DIP Episode 163 - USMLE Step 2CK Rapid Review Series 19 (Surgery, Abdomen)
Topic
Abdominal trauma management; GI bleeding and obstruction; Acute abdominal processes (appendicitis, cholecystitis)...
Key Takeaway
The approach to acute abdominal pathology requires a systematic algorithm: assess stability first in trauma, prioritize imaging based on clinical signs of peritonitis, and remember that many common surgical conditions have specific, high-yield differential diagnoses or complications (e.g., AAA repair complications, pseudo-obstruction).
Episode Notes
Source / episode info
- Episode: 163
- Title: Divine Intervention Episode 163 – USMLE Step 2 CK Rapid Review Series 19 (Surgery, Abdomen).
- Published: 2019-09-28
- Source: Episode page
One-liner
This episode provides a rapid review of critical abdominal topics, covering trauma algorithms and signs of peritonitis, retroperitoneal hemorrhage management, urological emergencies like bladder rupture, acute GI processes (appendicitis, cholecystitis), vascular catastrophes (AAA, mesenteric ischemia), and common surgical pitfalls (pseudo-obstruction, fistula formation).
High-yield summary
- Abdominal Trauma: If signs of peritonitis (e.g., rebound tenderness) are present, proceed immediately to exploratory laparotomy (X-Lap); otherwise, CT scan is preferred if the patient is stable.
- GI Bleeding: In suspected PUD bleeding, the most likely source vessel is the gastroepiploic artery (GDA); massive hemorrhage requires fluid resuscitation and potential surgery.
- AAA Management: The biggest risk factor is smoking; screening guidelines include men > 65 years old with a history of smoking or family history, using an abdominal ultrasound cutoff of 5.5 cm.
- Acute Cholecystitis: If the patient is critically ill (e.g., septic/ICU), initial management should be percutaneous cholecystostomy stenting rather than immediate laparoscopic cholecystectomy.
- Bowel Obstruction: Differentiate between mechanical obstruction (adhesions, hernia) and colonic pseudo-obstruction syndrome (massive distension without an identifiable cause); treatment for the latter involves neostigmine or rectal tube decompression.
Learning objectives
- Describe the appropriate surgical algorithm for blunt abdominal trauma based on stability and signs of peritonitis.
- Identify the key differential diagnoses and management steps for acute GI bleeding (e.g., PUD) and bowel obstruction.
- Recognize high-risk populations and screening criteria for Abdominal Aortic Aneurysm (AAA).
- Differentiate between mechanical small bowel obstruction and colonic pseudo-obstruction syndrome, and outline appropriate initial management.
- Master the diagnosis and treatment of acute cholecystitis versus choledocholithiasis/cholangitis using imaging modalities (US vs MRCP vs ERCP).
Board exam buzzwords
| Condition | Key Finding | Association | Board Exam Tip |
| AAA | Pulsatile abdominal mass; Calcification anterior to vertebrae. | Smoking, Age > 65 years old. | Screening is mandatory in high-risk men (smokers/age). Cutoff: 5.5 cm. |
| Acute Cholecystitis | RUQ pain, fever, leukocytosis; Ultrasound shows thickened wall. | Initial management for critically ill patients. | Use percutaneous cholecystostomy stenting first if the patient is unstable or septic. |
| Colonic Pseudo-obstruction | Massive colonic distension (Ogilvie's); No mechanical obstruction found. | Neostigmine administration; Rectal decompression. | Distinguish from true SBO/LBO by lack of physical blockage on imaging. |
| PID | Lower abdominal pain, vaginal discharge, adnexal tenderness. | Neisseria gonorrhoeae and Chlamydia trachomatis. | Treatment requires broad-spectrum IV antibiotics (e.g., Ceftriaxone + Doxycycline). |
Rapid review table
| Topic | Key Point | Context | Exam Relevance |
| Abdominal Trauma | Peritonitis signs mandate immediate surgery. | Rebound tenderness, guarding, rigidity. | Do not wait for CT scan if peritonitis is present; go straight to X-Lap. |
| PUD Bleeding | Gastroepiploic artery (GDA) bleed is common and severe. | Acute onset of massive GI bleeding/melena. | Remember the GDA as a primary source vessel on board exams. |
| AAA Screening | Men > 65 years old, smoker, or family history. | Abdominal ultrasound screening; cutoff diameter: 5.5 cm. | This is a classic preventative screening question. |
| Acute Cholecystitis | Initial management in critically ill patients. | Septic/ICU setting. | Prioritize percutaneous cholecystostomy over immediate surgery due to patient instability. |
Board-speak -> diagnosis
| Board-speak / Vignette phrase | Diagnosis / Concept | Why it fits |
| Patient with blunt abdominal trauma and signs of peritonitis/rebound tenderness. | Acute Abdominal Trauma requiring surgery | Peritonitis mandates immediate surgical exploration (X-Lap), regardless of imaging results. |
| History of smoking, male > 65 years old, presenting with acute abdominal pain. | Abdominal Aortic Aneurysm (AAA) | High-risk demographic for AAA; screening is mandatory in this population. |
| Patient post-cardiac catheterization develops back pain and hypotension. | Retroperitoneal Hemorrhage | Catheterization can disrupt retroperitoneal vessels, leading to bleeding requiring angiography/embolization. |
| A patient with chronic colitis presents with severe abdominal distension but no mechanical obstruction. | Colonic Pseudo-obstruction Syndrome (Ogilvie's) | The colon is dilated and gas-filled without a physical blockage; requires decompression (neostigmine). |
| Female presenting with lower abdominal pain, vaginal discharge, and adnexal tenderness. | Pelvic Inflammatory Disease (PID) | Classic triad of symptoms; treatment requires broad-spectrum IV antibiotics covering N. gonorrhoeae and C. trachomatis. |
| A patient undergoing hemodialysis develops a pulsatile mass in the arm. | Arteriovenous (AV) Fistula | High output state associated with dialysis access, leading to increased cardiac demand. |
Differential diagnosis / distinguishing features
Bowel Obstruction
| Key Features | Distinguishing Findings | Next Step |
| Small Bowel Obstruction (SBO) | Vomiting, abdominal distension; X-ray shows dilated small bowel loops. | NPO, IV fluids, NG decompression. Surgical intervention if failure to improve. |
| Colonic Pseudo-obstruction | Massive colonic dilation (Ogilvie's); No mechanical cause found on imaging. | Neostigmine or rectal tube decompression; supportive care. |
Bladder Rupture
| Key Features | Distinguishing Findings | Next Step |
| Intraperitoneal rupture | Diffuse abdominal pain, signs of peritonitis (peritoneum involved). | Immediate surgical consultation (Urology) for repair. |
| Extraperitoneal rupture | Localized pain at the bladder neck/trigone; no diffuse peritonitis. | Conservative management: Foley catheterization and observation. |
Management pearls
- Trauma: If signs of peritonitis are present, do not delay surgery for CT imaging; proceed directly to exploratory laparotomy (X-Lap).
- GI Bleeding: In suspected PUD bleeding, the most common source vessel is the gastroepiploic artery (GDA); massive hemorrhage requires aggressive resuscitation and potential surgical intervention.
- AAA Screening: For men > 65 years old who smoke or have a family history of AAA, perform an abdominal ultrasound screening; repair is indicated if the diameter reaches 5.5 cm or grows rapidly.
- Acute Cholecystitis (Critically Ill): If the patient is septic or unstable, initial management should be percutaneous cholecystostomy stenting to decompress the gallbladder before definitive surgery.
Don't miss
Integration & clinical reasoning
- Trauma & Peritonitis: The presence of peritonitis is the single most critical finding in abdominal trauma, overriding all other diagnostic steps and mandating immediate surgical intervention.
- GI Bleeding & Vascular Anatomy: Understanding the anatomy of bleeding vessels (GDA) helps predict the source of massive GI hemorrhage, which can be rapidly fatal if not addressed surgically.
- Bowel Function vs. Structure: Differentiating between a true mechanical obstruction (SBO/LBO) and functional pseudo-obstruction syndrome is crucial for appropriate management (surgery vs. neostigmine).
OMM / COMLEX integration
- Acute Abdomen/Sepsis: In any unstable or acutely ill abdominal presentation (e.g., perforated viscus, severe sepsis), standard emergency management takes priority over OMT. The focus remains on resuscitation, source control (surgery), and antibiotics.
- GI Bleeding: Hemodynamic instability from massive GI bleeding requires immediate blood product transfusion and surgical intervention; OMT is not a primary treatment modality for acute hemorrhage.
Concept connections / cross-references
- For detailed information on the pathophysiology of bowel obstructions, see [ Episode 14 ].
- The principles of broad-spectrum antibiotic coverage are reinforced in discussions regarding sepsis and abdominal infections, such as those covered in [ Episode 28 ].
High-yield association table
| Condition | Association | Mechanism | Clinical Significance |
| AAA | Smoking; Age > 65 years old. | Atherosclerosis/Degeneration of the aortic wall. | High-risk screening population requiring prophylactic ultrasound and potential repair. |
| Acute Cholecystitis | Critically ill patient (septic, unstable). | Difficulty with general anesthesia/laparoscopy. | Initial management should be percutaneous cholecystostomy stenting to stabilize the patient first. |
| Colonic Pseudo-obstruction | Neostigmine; Rectal decompression. | Functional ileus or paralytic bowel state (Ogilvie's). | Requires supportive care and agents that stimulate gut motility, not surgical intervention initially. |
| AAA Repair | Enteroenteric fistula formation. | Anastomotic leak/inflammation between the bowel and the repair site. | Can mimic colon cancer; context of recent AAA surgery is key to diagnosis. |
Key terms glossary
| Term | Definition | Context | Example |
| Peritonitis | Inflammation of the peritoneum (lining of the abdominal cavity). | Abdominal trauma, perforated viscus. | Rebound tenderness and guarding are signs of peritonitis. |
| Colonic Pseudo-obstruction | Functional bowel obstruction without a mechanical cause. | Ogilvie's syndrome; severe ileus. | Treated with neostigmine or rectal decompression, not surgery. |
| Gastroepiploic Artery (GDA) | Major blood vessel supplying the lateral colon wall. | Peptic ulcer disease bleeding. | Bleeding from this artery is a common and life-threatening source of GI hemorrhage. |
| MRCP | Magnetic Resonance Cholangiopancreatography. | Evaluation of biliary/pancreatic ducts. | Preferred over RUQ ultrasound for diagnosing choledocholithiasis due to superior visualization. |
Study optimization
| Topic | Study Approach | Priority | Resources |
| Abdominal Trauma | Master the algorithm: Stability -> Peritonitis signs -> Imaging/Surgery. | High (Must memorize flow chart). | Review trauma protocols and classic exam vignettes. |
| GI Bleeding & Obstruction | Create comparison tables for differential diagnoses (e.g., SBO vs Pseudo-obstruction; Acute vs Chronic Cholecystitis). | Medium-High (Focus on initial management steps). | Use board question banks to test specific vessels (GDA) and drugs (Neostigmine). |
| Vascular Emergencies | Memorize AAA risk factors, screening guidelines, and post-repair complications. | High (Classic high-yield topic). | Review vascular anatomy and the pathophysiology of aneurysm formation. |
Question pattern recognition
- Trauma/Peritonitis: Signs of peritonitis (rebound tenderness) are an absolute indication for immediate exploratory laparotomy; do not delay with CT imaging.
- AAA Screening: The classic screening scenario involves a male smoker > 65 years old, requiring abdominal ultrasound if the diameter \ge 5.5 cm or growth is rapid.
- Acute Cholecystitis Management: If the patient is septic/unstable, initial management must be percutaneous cholecystostomy stenting to stabilize them before definitive surgery.
Test yourself
Common mistakes to avoid
Common traps
Original transcript with highlights
Original transcript with highlights
Okay, welcome. My name is Divine, I'm a resident. This is episode 163, believe of the Divine intervention podcasts. And this podcast I'm going to title this USM List app to see here a bit review. I will go ahead and call this series 19, I think. And it's going to be focused on surgery. Because again, I've got a lot of requests for that over the last couple of weeks. And this one is going to be focused very specifically on the abdomen. Because again, right, abdomen is very high yield. I mean, probably constitutes like, I don't know, like, 15, 20% of the surgery show. So I will just run, you know, very rapidly go through some high yield abdominal concepts. Now, first of all, I guess I'll go ahead and mention right. What if they give you a question about a person that sustains up any training trouble to the abdomen? What's always your first step? Well, exploratory laparotomy, right? You don't like think twice, you just take the person straight for X-Lap. What if a person has like blond trauma to the abdomen? What is your next step? The thing is, typically you have to kind of skip a few steps, because they will give you more information in the question. When you see like a blond abdominal trauma question, right? The first thing is, they will usually tell you the person has like a reboundal guardian. The person has a reboundal guardian, right? They obviously have signs of peritonitis. On that those circumstances, your next step will be to, you know, proceed to X-Lap, right?
Once you see signs of peritonitis, you don't have to think twice, you go for X-Lap. If the person doesn't have a reboundal guardian, then you just kind of have to ask yourself, is this person stable or is this person unstable? The patient is stable, then you can do like a CT scan of the abdomen. You give you a lot of information. You can even be able to stop there. Because you'll just give you a ton more information than the other stuff. But if the patient is unstable, right? Then you want to consider going with a fast scan on your test. If a fast scan is not available, you can do something called like a diagnostic repair to Nio Lovage, or do again, essentially no one does that in the real world. But if a person is unstable and they have blond abdominal trauma, and they have no signs of peritonitis, you can consider doing a fast scan. If a fast scan is not there, then you can choose the DPL. Another thing is, if the fast scan is equivocal, right? Then you want to consider getting a diagnostic repair to Nio Lovage as well, right? And again, if that fast scan or DPL or whatever is positive, right? Let's see, you see blond or whatever, right? Then you need to go ahead and proceed with the surgery. So that's just something, again, high yield. That's a very high yield algorithm to keep in mind. It's just one of those things you're going to show up on your test. Okay.
Now, what if they give you a question about a patient that, um, recently on the went, like a cardiac catheterization for like an R-seeing fart, and then they tell you that hours later this patient starts completing a back pain, and this patient is like kind of like hypotensive kind of unstable. What's your diagnosis there? Well, I hope you're thinking about like a retroperitoneal hemorrhage, right? Retroperitoneal, like him, a tumor, retroperitoneal hemorrhage. On those circumstances, you absolutely want to, you know, perform angiography with embolization. That'll be the right next step in management for your test. Now, what if they give you a question about a patient that, you know, was in a pretty bad, like, what will be your accident? And then this patient, they tell you that the urine output has been like very minimal over the last couple of hours. And then they tell you that this patient, um, on physical exam, he has like a supropubic tenderness to bowel patient. Like, also, propubic fullness. That's another word they'd love to use on exams. Now, what kind of diagnosis should you be considering? Well, I hope you're thinking about like, like urinary tension, right? Like this patient essentially may have like a cut-eye quinoa syndrome. Although, remember that one other thing that could present this one in BM Es is a person that has like metastatic cancer.
So you can be like a guy with a histroprostic cancer that has against supropubic fullness, or a lady that has a history of, um, breast cancer and supropubic fullness. I mean, obviously, the person is having like, you know, signs and symptoms of like a spinal cord compression. The first thing you'd want to do under those circumstances is to give IV dexamethasol. But if all the problem a person has is like urinary tension, then your next step is actually to, uh, perform a bladder catheterization. That's one thing that shows up, you know, quite commonly on exams, and you won't keep in mind. Now, the thing is, one, I guess, let me just go ahead and I mentioned this. What if you get a question about a patient? And they tell you that this patient has a rupture of the bladder, right? And they tell you that, oh, the person has rupture like the neck of the bladder or the tri-good of the bladder. Um, what's your diagnosis? What would you want to do next as like your management step? Well, you can actually treat this conservatively, right? So I remember for purposes of step 2 CK, you want to know how to differentiate between a person that has ruptured the bladder, um, like an intrapere tonal rupture, or a person that has had like an extra peritoneal bladder rupture, right? So the intrapere tonal kind in general, that tends to, um, be like for the dumb of the bladder, right? And those people tend to have like just like diffuse pain, signs of peritonitis. They feel pretty crappy, right?
And in general for that, you just take them straight to surgery, call your friendly urologist. But the extra peritoneal one is more along like the bladder neck or like the blood, like the tri-good of the bladder. Um, for the most part, again, like I said, you can treat them on operatively, you don't need to do anything fancy. Um, in fact, sometimes you can just insert a fully catheter, you know, keep it in for a couple of days, and the patient gets better. Um, and usually, right, these people don't have like the diffuse, the abdominal pain and rebound and garden, and all that stuff. And then, what if they give you an exam question, and they talk about a patient that, you know, was recently like in an accident, like a motor vehicle accident, and this patient is completely of like left shoulder pain. Uh, what diagnosis are you thinking about? Well, I hope you're thinking about like, uh, like a ruptured spleen, right? I remember, right, there's something called a curbsine. It's like a person having like shoulder pain, uh, whenever you have like some issue that's irritating the diaphragm, like a ruptured spleen or like a sub-frenic abscess, right? So the thing is, when people have like ruptured spleen, right, that can irritate the diaphragm on the left, and that can cause a refect pain to the shoulder, right?
That's known as curbsine, K-he-H-R, not like Steve Kerr, as in the Golden State Warriors coach, uh, but curbsine, K-he-H-K-E-H-R, um, so they'll have like a refect pain to the shoulder. Um, so those are, in fact, really like, if a person has like, you know, like, uh, a blonde abdominal trauma to the abdomen, uh, they very likely have a splinic rupture. If you were, if they give you like a very non-specific question without much in the well of a cluzo-hint, uh, think about a rupture of the spleen. I remember the spleen, right? Again, it's the most commonly ruptured organa when a person has like, blonde injury to the abdomen, and really there are many things that can cause clipps-plinic rupture, right? Like abdominal trauma, if a person who has chest trauma that involves like the lower ribs, that can also puncture the spleen, and remember, right, if a person has spleen-ic issues, uh, you know, you want to try to see if you can treat it non-operatively, uh, but again, if, if the person, you know, by some unfortunate stroke of, uh, events, uh, you have to remove the person's spleen, don't forget to, uh, vaccinate that person against like, shin organisms, or it's like, strip new moh each floor under nice serum and ingedatives. Uh, that's a classic thing that your friends, or the, or the USMLE, are love to test.
Um, and then, right, if, I'm just sort of walking through the abdomen, if you're looking at the liver regularly, the liver is like the second most commonly, like, uh, injured organ in a person that has a blunt abdominal trauma, right? And again, it can have like, right shoulder pain, um, if you think above the liver, right, the diaphragm, right? The diaphragm can rupture, right? And that can also be like a sick malay of a blunt abdominal trauma, um, although typically, right, from imaging, you'll show you like abdominal contents in the thoracic cavity, when you see that, think about a diaphragmatic rupture, and hopefully, right, you know that that typically happens on the left, right? Not on the right, uh, because the liver kind of protects things on the right side, right? But the, uh, there's really nothing protecting the diaphragm on the left side. So most times when people have a blunt abdominal trauma, and you have a rupture of the diaphragm, that almost always happens in the setting of, uh, that almost always happens in the setting of, um, uh, like usually happens on the left. And I guess since I'm talking about the diaphragm now, uh, if they describe a person that, you know, recently had some kind of abdominal surgery, and then this person is completely over like, this person has been having like fever, and this person has been having like abdominal pain, and it's been going on for like days and days and days.
Um, under those circumstances, you really do want to think about, uh, something called, uh, a sub-frenic abscess, okay? That's a pretty classic presentation on NV Me exams. And then remember that if a person has a diaphragmatic rupture, right? So if you describe again a newborn, and they show you imaging, and you see like abdominal contents, or you see like abdominal folds in the, in the thoracic cavity, one of those circumstances is a really, really hope, that you're thinking about a diaphragmatic hernia. And remember that the occasionally test the Bos word, embryologic pathophysiology behind the diaphragmatic hernia, right? Uh, it arises from a failure of a formation of the, uh, a chloroparietonial membrane, right? And again, you see divine, oh, that's so much. How do I remember that again? Chloroparietonial, I love embryology. And the old used makes sense, right? Chloroparietonial membrane is a membrane that separates the plural cavity and the peritonial cavity, okay? So that's a nice way to keep that, uh, keep that straight in your, in your mind. And then let's see, let me look at other abdominal organs in my mind. Uh, let's say like the pancreas, right? Like a person can get like, uh, again in the setting of injury, right? If a person has like a motor vehicle accident, it's with a like, lurch forward and hit the abdomen, or they can give this in like a child that has a big gastric pain, from like a bicycle, like hand-duel bar injury.
Um, under those circumstances, uh, think about injury to the pancreas. Uh, those people will classically have like, elevations in lipes. Remember, lipes, elevations are more sensitive than amylase elevations, uh, for the diagnosis of a pancreatitis. And then, uh, since I'm also talking about hand-duel bars, right? If they describe a kid, you know, that has had like, like a hand-duel bar injury, and this kid is kind of like having like drops in his hemoglobin, completely of like, epigastric pain, sometimes it can be back pain, and immediately, like, oh, when I've done an example, they say a falsatel mass, um, under those circumstances, sometimes the movement would like billions vomitting. Um, again, it would be like an acute issue. Under those circumstances, you really don't want to think about some kind of, uh, abdominal hematoma, right? The classic presentation of abdominal hematomas on MBM exams. Another thing that, uh, another way of abdominal hematoma, we present on a test is, they can give you a question about like, uh, like a person that, uh, was recently studied on like, warframe, right? For some kind of, I don't know, like, quagglopathy.
So you study on warframe, and then they start, completely of like, epigastric pain, and if a person, see for example, right, has like a peptic ulcer disease, and then they tell you that the person becomes like, profoundly hyper, like suddenly becomes like, profoundly hypotenuse, losing a ton of blood, um, or, you know, maybe they won't see losing a ton of blood, but they'll show you like a hemoglobin that has gotten acutely low. The patient is profoundly hypotenuse, completely of like severe, severe, severe abdominal pain. Um, under those circumstances, I would really want you again to think about, uh, the condition of a, like, a peptic ulcer, right? Um, and if they ask you for the blood vessel, that is likely bleeding, the one I really want you to pick on you exam, is the gastro-doantinolary, okay? Go ahead and pick the gastro-doantinolary, uh, they love to test that stuff all the time on MDM exams, and actually I've seen that in the real world, and actually, I've actually seen that clinically. You may say, oh, the GDA is, uh, it's nothing too bad, uh, I should, I worry about this. Uh, I promise you, if a, if a person has a GDA bleed, you better call your GI doctor, pronto, right? That thing is rapidly fatal, if it's not treated. The GDA can bleed, bleed, bleed, bleed, bleed, like, I never used to respect the GDA until, like, soy clinically. So, it's just one of those things you don't want to mess around with.
So, this is just, I guess, pro tip for, like, if you're, like, an intern or resident, and if you suspect that a person has, like, peptic ulcer disease, and then they kind of, like, start crumping, or start having, like, GI bleak-style symptoms, call your gastro-doantinolary, just, ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha ha I'm really really really really really want to give a actually give a ivy fluids right so you give a ton of ivy fluids give a lot of fluid resuscitation and then you can consider like giving like blood products if the patient is not responding to the ivy fluid and then obviously want to go ahead and consider surgery under those circumstances and if a person right presents with like right low accords and pain and all that stuff right what are you thinking about that's obviously already that pain decidedes and then they may ask you for like your next step in money to be in fried on MDME exams the thing is your next step in money can kind of depends on the particulars of the question right so let's sort of talk through that a real quick right so if for example they give you a question right so let's sort of talk through that a real quick right so if for example they give you a question right so let's sort of talk through that a real quick right
so if for example they give you a question right so let's sort of talk through that a real quick right so if for example they give you a question right so let's sort of talk through that a real quick right so if for example they give you a question right so let's sort of talk through that a real quick right so if for example they give you a question right so if for for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for exam
ple they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for example they give you a question right so if for yes you want to think about appendicitis but one of the things I would strongly encourage you to think about is like a so as a abscess that's a classic presentation of so as abscesses on NV Me exams they will try to you know really try hard to trick you that it's appendicitis but it may be a so as abscess you may say okay divine how do I know the difference between these two well here's a trick you can use on your test one trick you can use this for person has a cut up appendicitis I mean look at the name a cut up appendicitis yes symptoms tend to show up acutely right you think to have acute symptoms but if a person has like a so as abscess the symptoms tend to like brew and get like progressively worse over a couple of days right that's one nice way to differentiate that on your test that is also one of the reasons why for person presents with a cut up appendicitis especially if they are stable right you know you want to go ahead especially if you're stable and they're like an adult you want to consider getting like a CT scan of the abdomen right we get a CT scan of the abdomen with contrast when you do that that can help you delete like many different appendicitis pathologies because depending on the appendicitis pathology that tells you what yo
u're supposed to do right so if for example again you say like you know like the regular good old appendicitis then under those circumstances right you go ahead and perform like like an appendectomy usually everyone does like a laparoscopic appendectomy although you can also do an open appendectomy and typically right you want to give anti-biotics as well where you want to give like a ton ton ton of anti-biotics especially like an anti-biotic that covers like GI flour right so like you can give like C-Purple's metronidazole or you can give like a first generation cephalosporing like the surgically beloved anceph if you're like every surgeon they love anceph they have like this anceph fetish but basically right cephalzolin right is anceph so you give cephalzolin and then you give metronidazole because the metronidazole help you cover or help you cover anaerobic now they give you a question right in the detail you that oh you see like the you know this person has like you know classic signs of appendicitis and then you notice that the appendicitis has pipherythed on imaging right then on that those circumstances you want to you know proceed to like very quick very rapid appendectomy uh because it's fairly a life threatening right so that's one big thing when you keep at the back of your mind and then one thing is if you see like an abscess in the appendix right so the person has like an appendicitis abscess um let me try to trick you to do like an immediate appendectomy that's the wrong thing to do on exams that's the wrong thing to do on exams the right thing to do an exam if a person has an appendicitis abscess is to actually go ahead and uh give antibiotics right during the abscess on the like some kind of imaging guidance and then weeks afterwards you can then go ahead and uh perform an appendectomy okay that's very high up to no in general uh doing doing an appende
ctomy like acutely in the setting of an appendicitis abscess is not a great idea on on NV Me exams so I'll go ahead and tell you that that's something very very I used to know for the purposes of tests and then um again remember your different signs would have been decided right so like there's like saw sign um there's like roughs inside there's like up to reader sign right so up to reader sign internally with the low extremity depression like grids and pain and all that stuff remember like you might bring this point all those signs are really to find them uh pretty clearly in the in the mainstream or surgery review video so I'm gonna go ahead and move on from that so that I don't uh I don't uh burn uh burn too much time on that and remember if they ask you for the pathophysiology behind uh like uh appendicitis you want to think about a person you know potentially having like um like uh with a thicker lift right that's obstructing uh uh the appendicitis aluminum and then you have like steasies of badness behind that and then you get into trouble with an infection um some thank you can also have like like just something that sort of sets them off like an inflammatory process uh that kind of like sets things off and then you have inflammation around the appendix right um although if they give you a question about a female or a complete sort of like right low accords and pain um very high fevers strong lucocytosis um and then they tell you that the beta ECG is positive when you examine um I would strongly encourage you to you know consider um um like a ruptured ectopic pregnancy as your diagnosis right that's that's a ruptured ectopic until proven otherwise uh so you want to be careful with that on exams and then if they give you a question right about a patient that you know has like a histral like let's say they tell you this patient like recently had an MI or this pati
ent patient recently had uh like they tell you that oh on exam like on a quotation of the chest or your tina knee kg you notice that a person has like an irregularly irregular interval uh that's you know that's pretty classic for like acute mesentericus schemia right um classically it's like the super mesenteric artery that's all screwed up um when you see that you want to go ahead and get like some kind of a geography um and if the person has uh if the person's beginning to have like bowel is schemia then you may need to and then you may need to you know go ahead and resect us some sections about remember acute mesentericus schemia is acute right um chronic mesentericus schemia is chronic so those people have like weight loss they will have like very like you know like long-standing symptoms um they'll tell you that whenever they eat it hurts a ton and typically when it usually hurts a turn like in the left upper quadrant because if you remember from uh I don't know from like an army or whatever um people tend to have like uh uh like the what the left upper quadrant like the splinic fracture it tends to be like a watershed area right so uh people uh if a person has like systemic hypertension uh then those people tend to get like problems in the in the left upper quadrant because it's kind of like at the uh like the distal end of a profusion from the inferior mesenteric artery and also the superior mesenteric artery right so that's a big thing you want to keep at the back of your mind and then if they give you a question about a patient that has like a long history of like osreative colitis and then you tell you that over the last uh you know two days this patient can come down like severe abdominal pain his abdomen is like severely distended on a on physical exam the patient has like rebound or guardian and then they show you an image in a you see that the transverse
colon is like massively diluted um on that those circumstances you want to think about a toxic metocolon um your next step in management is going to be exploratory laparadon right uh you want to decompress that bowel because that person can die relatively quickly two other things that can cause that toxic make a colon in the end exam it can be a person that has cdf remember uh toxic make a colon can be like a very nasty nasty complication of cdf and then if they describe a person from like a developing country you know completely of like severe abdominal pain um and again having like massive distension of the abdomen like a toxic make a colon style picture think about triplanosomal cruziate as the potentially inciting cause on the those circumstances and then if they give you a question like about a female presence with like severe lower abdominal pain vaginal discharge bilateral adnexal tenderness right you want to go ahead and think about like pelvic inflammatory disease right on that those of circumstances um typically right you go ahead and give like broad spectrum IV antibiotic therapy and typically the bugs you want to cover like um nice urgunaria and aclamydia right so you want to give things like a septraxol and zythromycin or septraxol plus doxycycline right so those are big things you want to keep on the back of your mind um you may see divine you're talking about p.i.d.
pelvic inflammatory disease in a surgery in a surgery podcast you think uh some obi gang pathology is a shop on the test well i'll hope you're saying yes to that um the thing is the surgery shelf um the people that write it are really ingenious to to be honest with you because i mean like there's obi gang on this on the surgery shelf there is um dermatology on the surgery there's a pharmacology on the surgery shelf there's pediatrics on the surgery shelf there's internal medicine in the surgery shelf um really to be honest with you i find the surgery shelf to probably be a little more challenging to prepare for a compared to like the internal medicine shelf for example at least that was certainly the case for me uh during my 30th of med school and then if a person has like uh you know like uh um p.i.d and then they tell you that oh this person starts completing of like creatopocodran p and under those circumstances you obviously want to think about the phetiochitis syndrome where they've had like an extension of the infection to the hepatic capsule right that's a classic thing again that tends to show up on the exams and then one of the high-yield thing uh guess maybe as you mentioned i kind of skip that one i was talking about appendicitis remember i said that if a person has appendicitis right and you know they have like um they have like the classic findings you don't need to do any imaging you can just eat them straight to surgery but if a patient has like if the if the if the mb is trying to get you to pick an imaging test kind of look at the population you're dealing with right obviously if it's a child or it's uh it's a pregnant female uh getting a cat's kind of the abdomen with contrast maybe it may not be the smartest idea in the world so on that those circumstances you want to go ahead and uh get like an ultrasound of the abdomen right um in those population
s but for pretty much everyone else you can get a CT scan of the abdomen with IV contrast and then wouldn't they give you a question about a patient that um you know is uh coming into the hospital um and this patient you know is like stable well they have like abdominal pain and you plan to get like a CT scan of the abdomen with a contrast and then the ask for the next and this person is like a diabetic and the ask for like the next best step in management um one of the if there's an answer that involves you know like uh stopping the use of midformin uh you probably want to go ahead and do that because remember right midformin can cause a lactic acidosis in people that have like chronic kidney disease or people that have like acute kidney injury or in people that are getting like anything that can injure the kidney right so if for example a person is like profoundly hypotensive and they have like a pre-rinally ki where a person is getting like contrast for some kind of abdominal procedure uh I mean for some kind of abdominal complaint uh you want to go ahead and discontinue um midformin in those populations uh that can cause like severe severe severe problems in those patients right so you don't want to because lactic acidosis is actually deadly right so you don't you don't want to do uh you want to try to avoid that if you can and then what if they give you a question about like a smoker you know this person has spoke for like a long time and then this person is presenting like severe um severe like meet up abdominal pain or they can present like severe back pain um and then this person is like profoundly hypotensive and then the metelial do they really do this these days I mean everyone has memorized this crap so they don't do that anymore but occasionally you can see that the person has like a pulse of telemusics don't know the exam if you see that right you really
want to think about a triple A right so an abdominal eorica aneurysm uh that has ruptured um sometimes one of the things they can give you is they can tell you that oh they notice um uh the notice like calcifications anterior to the anterior to the vertebral bodies um whenever you see that that's something that's the drip to the other sign uh that's classic for like either ruptured or an impending like a soon to ruptured triple A right and obviously right if a person you know if you suspect the bad bad bad triple A you want to go ahead and take the percentage of surgery um because that thing is rapidly fatal I mean the mortality from non-stickings like more than 50 percent even when you you know do everything right um so you want to take that percentage of surgery as quickly as possible I mean if the if they're trying to get you to do some kind of diagnostic testing on the mbmm the only thing you can consider getting for those people is uh you can get like an abdominal ultrasound um you can use that you know find the triple A and then go ahead and fix it and in terms of fixes right for triple A uh you can consider getting like uh you know you can do like open surgical repair or you can do like endovascular aneurysmore or repair like an IVAR um the thing is both of them have pretty equaler outcomes um but again remember I think I may have said this in a like a podcast I made a while ago uh but this is something that your friends at the mbmm are beginning to like you know test quite a bit um like complications of like triple E repair right there are three big ones you want to keep at the back of your mind they love to shop a lot on exams one is an euro and taric fistula so it can be a person that you know has like a micrositic anemia like weeks to months after like a triple E repair uh then you want to consider that maybe this person has found the fistula between the o
rder and some part of the GI tract right so they are like slowly chinglaught uh into the GI tract um that can cause like it can be like a micrositic anemia that kind of looks like oh this person has colon cancer but the thing that they will try to trick you right obviously they will give you colon cancer as an answer choice there um don't pick colon cancer the the thing is you want to that's why again I tell people that you cannot just memorize a random crap for the USML exam so there's not a good strategy for success right because the thing is if you see micrositic anemia in a person that is past age of 50 right the first thing you should be thinking about on a name game is colon cancer right so oh let's go ahead and get a colon also pure whatever but no no bit a smart thing to do here but if they give you context right it's the context that ultimately matters on any USML exam if they give you the context of like recent history of like a ruptured triple A or like triple A surgery or like triple A in the vascular repair uh then and the person has like a micrositic anemia they give you that context don't pick colon cancer you believe that's an answer representing to you pick an auroenteric vestula right that's a more likely answer choice on uh more likely correct answer choice on your exams so that's the first complication second complication is um if a person has like actually I'll go ahead and talk about four complications one of the one does just drop to my mind um if a person has an auroenterica uh you know and you're a triple E repair right one thing that at the end the description that a person is like paraplegic or has like urinary retention after surgery um you want to think about like uh uh you want to think about like uh uh like uh ischemia of the spinal cord uh typically it arises from like problems with the other of a dhamcoids which is a branch of the abdo
minal of the abdominal aorta um so if you see paraplegia like urinary retention or like what I kind of a corner style symptoms after like a triple E repair uh think about like an infarction of the other of a dhamcoids do typically say something in the question about like multiple episodes of like uh ischemia of like profound hypertension uh during the surgery if you see that think about other of a dhamcoids involvement I remember the other of a dhamcoids tend to supply the anterior to third of the spinal cord so uh again a triple E repair can be integrated on an inbemic exam with anterior spinal artery syndrome uh so that's a big thing you want to keep at the back of your mind and then a third complication you want to keep abreast of is uh if you describe like a patient with like rising creatinine after like a triple E repair this person has probably just had like a schemia of the kidneys during the other case uh that's again a classic thing that shows up on exams and then one sneaky one that I'm almost certain is not in most resources that people study um is this thing called uh an endolique an endolique right so you'll describe a person you know that has a history of like a triple E repair and then they may tell you that um this person you know has been having like uh like the hemoglobin has been like slowly dropping uh person has like micrositic anemia stals symptoms and usually for this kind of question they may not give you an auroant terric vestular as an answer choice but they may tell you that all like on angiography or like CT scan of the abdomen are the notice that when you give like contrast you're seeing contrast go beyond like the margins of the excluded aneurysm if you see those you really want to think about an endolique uh there are many different types of endoliques is like type one to type five but I'm fairly certain that is beyond the scope of uh ac
tually I'm not it's not a matter of being fairly certain you know what you can never say 100% for anything um I'm like 99.9% sure that that is beyond the scope of the step to ck exam so I'm gonna go ahead and skip that there's like a type one type two type three type four type five endolique but I think that's a little too much so I'm gonna go ahead and skip that uh I'm not gonna talk about that right now and obviously right for triply you want to remember the biggest risk factor right the biggest risk factor for triply is a smoking right and remember the screening guidelines right if a person is more than 65 if it's a man not women to map right in general women are not screened for triply I have no idea why that's the I mean some women are screened but those are like some super specialized guidelines that again I will be shocked if you saw your step two ck exam but in general women are not screened for triply still boggles my mind to this day but in general for men um if you've smoked and you're more than the age of 65 you do deserve like a one-time abdominal ultrasound and the cutoff number you want to remember right is five and a half centimeters if you find a triply and it's one and five and a half centimeters you go ahead and fix the go ahead and fix the triply or another thing is if a person has a triply and it's grown by like half a centimeter in six months or like a centimeter in a year then under those circumstances again want to go ahead and fix that if a person has like a triply that is symptomatic you also want to go ahead and fix that as surgically although one other thing you want to keep in mind is if a person is above the age of 50 and you have a family history of a triply those people also deserve like the one-time abdominal ultrasound for triply screening that's like a sneaky one you can throw on your exam although that's probably a little more commo
n on step three like a person has like you know they're like more than 50 years old and did you have like a family history of a triply even if you've not smoked now those people deserve a one-time abdominal ultrasound to screen for a triply and then if they describe a question about if you give a question about like a young female right and she has like like studying on set if you have abdominal pain watch is like studying for an exam and then they tell you that all like weeks earlier she found like a cyst in an ultrasound yeah yeah yeah they want to think about ovarian torsion right one thing about ovarian torsion you want to go ahead and you know fix that surgically like detours the ovaries so that they don't get a skimmy of the ovaries the ovaries cannot survive for more than a few hours without an adequate blood supply usually right the big risk factor for like ovarian torsion is having like something that like box of the ovary right so like having a history of like PCOS for example or having a history of like a drumboids like a drumboid cysts right like a teratoma or having a history of like command of I think like some kind of ovarian cyst those all increase the presence risk for for a for ovarian torsion and then again they can try to trick you on an exam by putting like all like ovarian torsion as an answer choice or you can see like a rupture of like ovarian cysts as an answer choice the thing is before you ever pick rupture of an ovarian cysts as an answer choice you want to make sure that they see something about like free fluid selling the peritonium in the question if you see free fluid in the peritonium well the free fluid just doesn't just show from from nowhere it doesn't just appear out of the blue something must have rupture to cause that right so under those circumstances you know you go ahead and you go ahead and you know proceed to surgery because
those people have like signs and symptoms of of peritonitis and then if they give you a question about a patient you know that has had like this bulging abdominal mass for the longest time ever and then they didn't tell you that oh this person this mass in the presence abdomen is no longer reducible and the patient is complaining of like severe abdominal pain and all that badness that's a strong belief it hurts you you want to go ahead and fix that surgery because again that can cause a ball of skin you're like really really fast right then you don't want to you don't want to mess with that and then if a person you know comes in complain of like credible quadrant pain and they even have like shoulder pain and they have fevers and lucosytosis obviously that's acute colisistitis right under those circumstances you want to go ahead and get the right upper cordial ultrasound you will find classically an imaging right you'll find like you know like thickening of the you find like thickening of the of the of the ball bladder wall you may find like pericolicistic fluid if you see that you want to go ahead and proceed to an upperoscopic of colisistectomy and you give the patient like you know pretty adequate amounts of antibiotics and then if for example the red upper cordial ultrasound is equivocal right the next thing you want to consider is getting a high-discan right the high-discan it's a nuclear medicine study that's really a beautiful physiologic study but I'll probably defer that to another discussion but a high-discan is like soup if a high-discan is negative you don't have a basically if you don't see feeling of the gallbladder right then the person has the person has acute colisistitis but if you notice that the ball bladder fills in the process of getting a high-discan and the person does not have a acute colisistitis you've essentially ruled out a acute colisist
itis under those circumstances and if for example right a person has like a colisistitis and they tell you that you don't see an obstructing stone that is something called a ecal colisistitis to try to trick you on an MDME example asking for the next step in management they will give you an answer choice that says like lapproscopic acolicisectomy don't pick that answer choice you get it wrong the way you treat the way you treat a ecal colisistitis is by doing something called a percutaneous acolicis stostomy right because these patients are usually like super sick right like they're like ICU patients patients on TPN patients are ventilators right ecal colisistitis like colisistectomy like right now is never the right answer right you can do it later but really for the most part what you do right now is a percutaneous acolicis stostomy and then one of the things they could do on an MDME example is they can give you a question about a person that has um so one weird thing they may give you on exams they may give you a question about a patient you know that you know has like kind of like signs and symptoms of like a ecalisistitis this one you almost have to tell you the answer in the question although people tend to still get this one wrong it shows up really on the exams when he shows up most people get it wrong but basically right they can describe a person that you know has like signs and symptoms or ecalisistitis they go ahead and show you like uh well this person will have like almost like colisistitis plus right because usually the person has a ecalisistitis they typically just have like you know like red apple cordon pain they have fevers they have the lucositis and all that crap but if they give you like a presence that has like colisistitis plus wear they have all those like you know classic ulisistitis symptoms but then the person kind of looks like um and in f
act one way they may put the person kind of looks like a person that has extending colonitis right so they'll show you like red apple cordon pain but they have like fevers they'll have like profound jaundice um but then they will tell you that oh like on uh the when you get imaging the common buddha is not distantly like um that's weird right if you see that um think about something called miritsis syndrome typically when they're describing the image and findings they may tell you that or this person has like uh they will tell you that oh an obstructing stone is seen in the cystic duct or you notice that the common hepatic duct is diluted whenever you see that again you really want to think about miritsis syndrome essentially the thing that happens is these people have an obstructing stone in the cystic duct so that bulges the cystic duct as the cystic duct bulges it then compresses the common hepatic duct right and then when you compress the common hepatic duct you have like a conjugated hyperbular benenia and you have like profound jaundice right so that's a miritsis syndrome uh one complication that can actually happen with a miritsis syndrome is uh you may actually notice that the person has um something called a colisistocolydocophysi I think I'm pronouncing it right or I think I'm saying it right but I think that's right uh like a colisistocolydoc colisistocolydocophysiolo colisistocolydocophysiolo it's one of those things basically it's a connection between like the cystic duct and the common hepatic duct uh like a phisiala that forms uh if you see that again think about miritsis syndrome uh classicly on exams you can make the diagnosis of a redopropagion ultrasound but to be honest probably something that's probably a lot better in terms of diagnostic utility is an MRCP it's an MRCP so that's something you want to keep at the back of your mind and then um if a
person has um you know like your redopropagion being fever jaundice and then let's say they have profoundly hypotensive crazy high white count um you want to think about uh isanning colon giders right uh if you ask for your next bestekin management uh they'll try to trick you to get a redopropagion ultrasound on your test don't do that the thing you want to do on your exam is to go ahead and get uh an ERCP and ERCP is diagnostic and therapeutic right because those people they have like a stone obstructing the common bowel ducts right so this is uh this is a medical emergency right this is the one where you you know gling-gring your your uh gastroenterologies in the middle of the night call them out of sleep and get them to the hospital uh to fix this problem um it's a GI problem it's uh it's a gastroenterologist problem but it classically shows up quite commonly on on surgery and being exams so that's something again you want to keep at the back of your mind and then if a person has like um uh collido colethiasis right the typically will not have fevers right but you know they will have like redopropagion pain and they'll tell you that the person has like the elitio of the common bowel duct um so they won't have like the very sick picture that you see what is sending um typically again for that you can make the diagnosis by doing a redopropagion ultrasound if that's a quiver call you can proceed to an ERCP uh that's pretty helpful uh under those of circumstances and then um um um if a person has like blunt trauma to the abdomen right and uh the trauma involves the kidney um they will try really hard to try to get you to do an effect on an endemic exam don't do an effect on an endemic exam in general if the kidney is messed you want to try to like you know like use like non operative management that's typically a smart that's typically a smart thing to do um you don't
want to go ahead and like bring out a person's kidney cause in general when you rip out people's kidneys it tends to have like you know pretty bad morbidity and mortality even when people get like a kidney transplant um this is actually something high you know so pay attention here when people get kidney transplants they tend to keep the like the new kidney in like the I guess the transplanted kidney they tend to keep it in the uh you're going to keep it in the in the pelvic fossa uh they don't remove the bad kidneys that are there right because again uh there there's been a lot of studies that have shown like worse in morbidity and mortality when you take out a kidney that is like a dead kidney essentially right so you just want to live it in please don't mess with it just live it in please as is um and um what did they give you a question about a patient um whoa i didn't realize well this is i guess a 41 minutes already um for suppose that a rapid review podcast but i just want to kind of be a little comprehensive with the abdomen here uh what if they give you a question about a patient that you know it's had uh so i'll try to run this on pause so i'm sorry so if they give you a question about a patient you know that um has a history of like you know peritoneodalysis and then they tell you that this person is you know over the last two days this was in me like mild fevers so it won't be a crazy fever on mbm exams right so this is the way this will present like fever of like a hundred point i don't know it's seven like very mild fever right um this person has like you know has been kind of acting a little crazy um like person kind of has like ultra mental status um this person is complaining of like you know like a low grade abdominal pain if you see that uh you really want to think about um um spontaneous bacterial parietanitis the thing is your friends at the end
in me right they realize that every human being has memorized um um svp in the context of like oh alcohol like a levere portal pressures all that crap i didn't do didn't they're really trying to curb doing that these days so one nicely represent svp on exams these days uh in the context of uh in the context of a person that has um like peritoneodalysis um under those circumstances your next step in money may not be as soon you know do parts and thesis and then you'll see more than the 250 neutral fields and then really for those things you want to go ahead and give a third generation several sporing like septriaxone or you want to give us like septal taxine um and then those people right they may require like fluoroquinolone prophylaxis afterwards um to kind of like decrease the risk of recurrence and remember that there are actually no differences in outcomes between like peritoneodalysis and uh and hemodalysis and remember that if a person is about to get a peritoneodalysis um you want to insert a dialysis catheter at at least a month before you initiate a peritoneodalysis if a person is getting like hemodalysis you need to insert an uh an at your v nostpistula um at least two months right before before you initiate the hemodalysis so that the fistula can mature you may see it divine uh what are all these weird things you're talking about i promise you these things are all high you to know yeah one of these like inocostins that you don't generally find in many resources or people tend to gloss over but it tends to be very high for exams right so that's something you want to keep at the back of your mind and if they give you a question about a patient you know that has had like a recent v fissula like instituted for for like uh possibly initiation of uh hemodalysis and then they describe that this person has been having like you know like um severe like you know like
mouth shape like okay let's not say severe but like chest pain like hypotension um the person has like crackles in the lungs and the person has like you know like heart failure stout symptoms but it tell you that oh the performance echocardiogram and the person's a EF is like 75% like some crazy number you want to think about high output heart failure right high output heart failure it's pretty classic in people that uh uh that's a classic presentation in people that uh um I getting like an AV fistula done uh for uh for hemodalysis uh many people are used to like the classic like we're stopped somewhere and then you develop an AV fistula afterwards like pulsatal mass in the arm and high output heart failure but the thing is the mbm is beginning to emphasize that so think about this uh AV fistula process for like hemodalysis that's a nice way to tend to prevent a presenter high output heart failure on exams and then other things you want to keep at the back of your mind right if a person has um um like uh projects disease right that can obviously also cause high output a heart failure um because the person's uh um boom already becomes like hypervascular that can be a classic presentation of a high output heart failure uh so I think I'm going to go ahead and stop here fingers is kind of going on for long but I think you know I've covered a lot of like high-yield stop that sort of touches on the abdomen like I've talked about the pancreas I mean obviously if a person has pancreatitis right like MPO, IV fluids, being controlled um remember that a pancreatic pseudosis can shop like weeks after like abdominal pain uh fullness of the abdomen, epigastric tenderness, think about a pancreatic pseudocyst I mean generally giving antibiotics is not smart for pancreatitis right um and then if the detail you that a person has like uh you know like chronic epigastric pain like fat m
alabsorption and then they show you like imaging and you see like all those white dots in the world of the pancreas now that's chronic pancreatitis the biggest risk factor for chronic pancreatitis is alcoholism on exams right so that's something I want to keep in mind so yes I think I've talked about like most parts of the GI tract um well I guess I didn't talk about diverticulitis right so like lymph lower quadrant pain um in an old person um and fevers, leukocyteosis uh you want to go ahead and get a CT scan of the abdomen with IV contrast um and uh you treat it with antibiotics and then weeks after the person has been treated they need to get a colonoscopy that's a high yield thing you want to keep in mind for exams and um remember that if a person you know has a histone diverticulitis and then they tell you that you're now noticing like poop or like air in the person's urine the person has formed this thing called a coloe vesicle fistula that's a classic thing that tends to shop on on the USMLE exams and then if a person has like you know like severe abdominal pain and they show you like a coffee bean sign and the head of the coffee bean is oriented towards like the red upper quadrant that person has uh has a sigmoid voluvelous um if the person has if you see like imaging and the head of the coffee bean is oriented towards like the left upper quadrant and that person has a sickle voluvelous right so you don't want to mix those two up on your test and then if they give you a question about you know like some old guy chronic abdominal pain I mean not not chronic abdominal pain but this guy is like old has like really bad abdominal pain and he tells you that his abdomen is like severely distended and he's not passing gas or whatever and then they tell you that all the colon is all distended and all that stuff I want to think about a colonic pseudo obstruction that's
classicly known as an ogovic syndrome your next step in management of other circumstances is uh you can give like a neo-stigmin remember a neo-stigmin is an acetylcholine estrizin he better so that will raise the levels of acetylcholine and that can decompress the bowel uh you can also try to like insert like a rectal tube to like literally like soak out all the air out of the colon and relieve the person's obstruction it's called a colonic pseudo obstruction because the person has like signs and symptoms of an obstruction but the colon is not distended and then remember right if they give you a question about a person that has had like you know I don't know it appendectomy in the past or the person has had like a C section in the past and then this person presents with like you know like bilios vomited in abdominal pain uh they they're not passing gas or poop you want to think about a small bowel obstruction right and obviously right the biggest risk factor for a small bowel obstruction is uh is uh adhesions from prior surgery where remember the second most common cause of a small bowel obstruction is like a hernia and then the third most common cause is a cancer right we're just obviously bad um so those are things you want to keep at the back of your mind um so yeah I think I've talked about most parts of the GI tract um yeah at least those are all the ideas that seem to be falling into my mind right now uh so as I do at the end of every podcast uh sorry again I know this is a rapid review podcast my apologies that it's long but again I want that to just give you like a very good abdomen review so that you're like oh if you're using to this podcast you can knock out most of the abdomen questions you get on your exam um so as I do at the end of every podcast I do offer one of one tutoring for like many exams right so like step one step two CK step two C S step three
um uh if you're a med student like the pre-clinical med school exams 30-ish-off exams of a tutoring for all those things and then I do this thing called like longitudinal tutoring where if you're like a first year second year or third year or tutor even for like your shelf exam or like your block exams but at the same time I tutor you like longitudinal for your for your associated uh USMLE exam uh that's like coming up uh so if you're like a first or second year tutor for step one at the same time um again every pre-much everyone have done this without being like wildly successful on the USMLE exams so if that's something I'm interested in I feel free to reach out to me um I think that's something that uh many people have found to be extremely helpful and then I do this um booster USMLE courses for step one it's 20 hours for subduc exams they're for its 10 hours each um where again it's something that is ideal like if you're at the end of your prep or you feel like good with your knowledge based in general um I use a Q&A format to like integrate like multiple disciplines for you and sort of like cover most of the high-yield topics you're very likely seeing you exam um again most people have done this we have done this for a couple of months most people have done this with they found it to be extremely helpful um so if that's something I'm interested in I feel free to again to reach out to me and then if you're you know like a resident and you need to do info like the internal medicine intrudin exam or internal medicine board exam or the pediatrics like intrudin exam or the pediatric board exams I go for tutoring for all those things um and then if you're a college student and you need to do it for like Gen-CAM, O-CAM, Physics, Bio-CAM, Astrology,ophysiology of a tutor for all those things as well and then um uh if your are a resident applying to residency so like an
ERAS application or a college student applying to medical school so an AMCA application I don't for like one-on-one like I guess you can call it like a vaccine or coaching for that so like rec letters personal statements, mock interviews, editing applications um I have again I have a ton of experience with that most of the people have worked with that much that they have first choice uh some of the their second or third choices above really for the most but pretty much everyone have worked with as much that their first choice um and um I've been on the admissions committee of the top two med school for you know for like a year so I have a lot of experience reading like thousands of high quality applications so if you need any of those things feel free to reach out to me have a wonderful rest of your day uh God bless you I'll see you in the next podcast thank you
Practice questions — USMLE style
Question 1 — Surgery/Trauma
A 45-year-old male sustains blunt abdominal trauma following a motor vehicle accident. Initial vital signs show stable blood pressure and heart rate, and he is alert and oriented. On physical examination, the patient has no signs of peritonitis (e.g., guarding or rebound tenderness). The initial management plan includes obtaining a CT scan of the abdomen with IV contrast to further evaluate for internal injuries. Which of the following findings would necessitate immediate surgical intervention regardless of the patient's hemodynamic stability?
- A) Mild ecchymosis over the flank area
- B) A positive FAST exam (Focused Assessment with Sonography for Trauma)
- C) Evidence of a diaphragmatic rupture on CT scan
- D) Localized tenderness in the right upper quadrant
Answer: B. The presence of signs of peritonitis, such as those indicated by a positive FAST exam suggesting free fluid or visceral injury, mandates immediate exploratory laparotomy (X-Lap). In blunt abdominal trauma, if there are clear signs of peritoneal irritation, surgical exploration is required immediately because the risk of intra-abdominal catastrophe outweighs the risks associated with surgery. If the patient is stable and has no signs of peritonitis, further imaging like CT can be utilized first.
Question 2 — Surgery/Vascular Emergencies
A 68-year-old male smoker presents to the emergency department after being found by EMS complaining of severe back pain and generalized abdominal discomfort. He has a history of hypertension. Physical examination reveals no obvious source of bleeding, but imaging suggests an expanding retroperitoneal hematoma. The patient is hypotensive and tachycardic. What is the most appropriate immediate next step in management?
- A) Immediate exploratory laparotomy
- B) Administration of tranexamic acid and fluid resuscitation
- C) Angiography with embolization
- D) Emergent placement of a nasogastric tube for decompression
Answer: C. The clinical picture—a patient with abdominal pain, hypotension, and signs suggestive of retroperitoneal hemorrhage following hypertension/smoking history—is highly suspicious for an acute abdominal aortic aneurysm (AAA) rupture. In this life-threatening emergency, the definitive diagnostic and therapeutic step is angiography followed by embolization to control bleeding sources before surgical repair can be planned or performed.
Question 3 — Gastroenterology/Inflammation
A 28-year-old female presents with a three-day history of increasing abdominal pain, fever, and leukocytosis. Physical examination reveals localized tenderness in the right lower quadrant (RLQ). Imaging suggests inflammation involving the appendix. However, the patient's symptoms are progressive and worsening over several days, unlike typical acute appendicitis which tends to present acutely. Which diagnosis is most likely, given the progression of symptoms and clinical context?
- A) Acute diverticulitis
- B) Perforated ectopic pregnancy
- C) Appendiceal abscess formation
- D) Toxic megacolon
Answer: C. While localized RLQ pain suggests appendicitis, the key differentiating factor provided in the transcript is the progression of symptoms over several days. A developing abscess (appendiceal abscess) often presents with a more gradual worsening of abdominal pain and systemic signs compared to the acute onset typical of simple appendicitis. Furthermore, an abscess requires drainage/antibiotics before definitive surgery, making it a critical distinction for management planning on board exams.
Question 4 — Urology/Surgical Management
A 75-year-old male with a history of chronic urinary retention and mild abdominal trauma presents to the emergency department. On physical exam, he has marked suprapubic fullness and diffuse abdominal tenderness. Imaging confirms a rupture at the bladder neck. The patient is hemodynamically stable and does not exhibit signs of generalized peritonitis or severe systemic illness. What is the most appropriate initial management strategy?
- A) Immediate surgical repair by urology
- B) Placement of an indwelling Foley catheter for several days
- C) Administration of IV dexamethasone to reduce inflammation
- D) Emergent CT scan of the pelvis with contrast
Answer: B. The location of the rupture (at the bladder neck or trigone, which is extraperitoneal) and the patient's stable condition allow for conservative management. For extraperitoneal bladder ruptures, simple urinary catheterization can often manage the injury effectively over several days, allowing the tissue to heal without immediate operative intervention. Immediate surgery is reserved for intrapelvic ruptures or cases with signs of severe peritonitis.
Quick fire review
What is the immediate management step for any patient presenting with blunt abdominal trauma?
Assume injury; proceed immediately to exploratory laparotomy (X-Lap) unless stable and lacking peritonitis signs.
If a patient has blunt abdominal trauma but is hemodynamically stable and lacks peritoneal signs, what imaging study is preferred?
CT scan of the abdomen with IV contrast.
What specific finding on physical exam suggests urinary retention or bladder outlet obstruction (e.g., in spinal cord compression)?
Suprapubic fullness/tenderness.
What are the two main types of bladder rupture, and how do they guide management?
Intraperitoneal (diffuse peritonitis -> surgery) vs. Extraperitoneal (bladder neck/trigone -> often conservative/catheterization).
What is the classic finding associated with a ruptured spleen causing referred shoulder pain?
Kehr's sign.
Which blood vessel bleed, if suspected in PUD, requires immediate attention due to its rapid fatality potential?
The gastroduodenal artery (GDA).
If a patient has an appendicitis abscess, what is the correct management sequence on exams?
Antibiotics + Image-guided drainage first; delay definitive appendectomy until later.
What embryological failure leads to diaphragmatic hernia?
Failure of formation of the pleuroperitoneal membrane.
In a patient with acute pancreatitis, which enzyme elevation is more sensitive for diagnosis (Lipase vs Amylase)?
Lipase.
For suspected ruptured AAA, what are two classic physical exam findings to look for?
Pulsatile abdominal mass and calcifications anterior to the vertebral bodies (suggesting pseudoaneurysm/rupture).
What is the primary antibiotic regimen recommended for Pelvic Inflammatory Disease (PID)?
Broad-spectrum IV antibiotics, typically Ceftriaxone + Doxycycline.
If a patient has acute cholecystitis but no obstructing stone, what non-surgical procedure should be performed?
Percutaneous cholecystostomy.
What is the primary risk factor for AAA and the recommended screening age/size cutoff in men?
Smoking; >65 years old with a diameter of 1.5–5.5 cm.
If a patient has signs of acute mesenteric ischemia, what diagnostic study should be performed?
Angiography (or CT angiography).
Quick recall / Anki-style questions
What embryological failure leads to diaphragmatic hernia?
Failure of formation of the pleuroperitoneal membrane.
In a patient with acute pancreatitis, which enzyme elevation is more sensitive for diagnosis (Lipase vs Amylase)?
Lipase.
For suspected ruptured AAA, what are two classic physical exam findings to look for?
Pulsatile abdominal mass and calcifications anterior to the vertebral bodies (suggesting pseudoaneurysm/rupture).
What is the primary antibiotic regimen recommended for Pelvic Inflammatory Disease (PID)?
Broad-spectrum IV antibiotics, typically Ceftriaxone + Doxycycline.
If a patient has acute cholecystitis but no obstructing stone, what non-surgical procedure should be performed?
Percutaneous cholecystostomy.
What is the primary risk factor for AAA and the recommended screening age/size cutoff in men?
Smoking; >65 years old with a diameter of 1.5–5.5 cm.
If a patient has signs of acute mesenteric ischemia, what diagnostic study should be performed?
Angiography (or CT angiography).