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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_102_библиотеки_им_акад_М_И_Перельмана
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MISCELLANEOUS
NEXT STEPS
1. BIOPSY (What kind of cancer is it?)
2. STAGING (Where is it? Has it spread?)
3. TREATMENT (How can we treat it?)
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CANCER
DIAGNOSIS & WORK-UP
NORMAL
CELL
CANCER
CELL
SURGERY
METASTASIS
CHEMOTHERAPY
RADIATION
DIABETES
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DIABETES MELLITUS TYPE 2
MISCELLANEOUS
NORMAL
FOOD
(GLUCOSE)
INSULIN
DIABETES
FOOD
(GLUCOSE)
FAT
GLUCOSE
ENTERS
CELL
NO GLUCOSE
CIRCULATES
GLUCOSE
CANNOT
ENTER CELL
GLUCOSE
CIRCULATES
MISCELLANEOUS
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ALTERNATING MEDICATIONS
FEVER CONTROL OR PAIN CONTROL
ACETAMINOPHEN
TYLENOL
IBUPROFEN
MOTRIN, ADVIL
BACTERIA vs VIRUS
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MISCELLANEOUS
BACTERIA
SINUS INFECTION
EAR INFECTION
THROAT INFECTION
LUNG INFECTION
VIRUS
SINUS INFECTION
EAR INFECTION
THROAT INFECTION
LUNG INFECTION
NO
ANTIBIOTICS
ANTIBIOTICS
MISCELLANEOUS
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CODE STATUS
CHEST COMPRESSION
SHOCK
VENTILATION
INTUBATION
SPIRITUAL
SUPPORT
FAMILY
SUPPORT
PAIN
CONTROL
DIGNITY
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SCRIPTING
SCRIPTING
e images in this book can be used in any way that may be helpful for the patient encounter. A few things are
important to keep in mind for eective patient communication:
• Use colloquial terms (e.g.: eardrum instead of tympanic membrane, blood clot instead of pulmonary embolism)
• Focus on the top three things that are pertinent. As clinicians, we know that there may be several dierentials that
we consider when making diagnoses. However, when talking with a patient, discuss only the most pertinent few.
• Compare the normal (“is is what it is supposed to look like”) to the abnormal (“is is what it looks like”)
• Address common misconceptions up front
• Discuss the medical lingo and explain what “patients” call it and what “medical professionals” call it.
• Use short sentences that are to the point.
Each patient encounter will be dierent. e same image may be used multiple times, yet explained in multiple
dierent ways. You may use the same image multiple times, yet explain it in multiple dierent ways. Some images
may be more useful than others. Below are very basic suggestions of how to use a particular image to talk with a
patient (each entry corresponds to a page in the book). Notice that each title is written in a colloquial language
with the medical terminology listed underneath. Notice also that the labels are also written in a very colloquial
language to simplify what is happening for a non- medical patient. Common misconceptions are in italics.
SKIN
Blood draw (Page 2)
A tourniquet plumps up your blood vessel (vein).
A needle is inserted directly into your vein. Blood
is removed. Once the needle is removed, there is no
direct access to the blood vessel. To get more blood,
a needle needs to be re- inserted. Clinicians oen call
this a “buttery” stick because the device looks like a
buttery.
Cut (Page 4)
Laceration
A cut is a break in the skin. Each cut is unique: where
it is, how big and how deep it is, how dirty it is, how
close it is to important structures like tendons, blood
vessels, and nerves. Some cuts require repair. An
abrasion occurs when the skin has rubbed against
something and is missing a layer. A puncture wound
occurs when there is a deep, narrow break in the skin.
IV (Page 3)
Intravenous insertion
A tourniquet plumps up your blood vessel (vein).
A needle, attached to a small piece of plastic, is
inserted directly into your vein. Once inside the vein,
the plastic is advanced and the needle is withdrawn.
Now, there is direct access to your blood vessels.
You can receive uids or medications through this
conduit. A needle does not need to be used again. e
needle does not stay in your blood vessel; only a exible
piece of plastic is le in your arm.
Options for repair (Page 5)
Repairable lacerations can be xed using 4 dierent
methods: stitches, Steri- Strips, staples, and adhesive
glue. Abrasions usually do not require repair. ey
slowly ll in over time. Any time there is a break in the
skin, there will be some level of scarring. Clinicians try
to minimize any scarring using the appropriate repair
technique.
112 SCRIPTING
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Boil (Page 6)
Abscess
Just under our skin, hair follicles contain small
glands that secrete sebum. is keeps skin moist and
lubricated. When a hair follicle clogs up, the sebum
gets trapped under the skin. is forms an early
abscess. Sometimes early abscesses resolve on their
own. Other times, they need to be cut open with a
scalpel.
Paronychia (Page 8)
Your cuticle sits on top of the nail and helps protect
it. Sometimes, bacteria becomes trapped between
the cuticle and the nail. A localized infection, called
paronychia, develops. To treat a paronychia, simply
take a scalpel and li up the cuticle and drain this
collection of pus.
Supercial clot (Page 10)
Supercial thrombophlebitis
Veins return blood to the heart. Our bodies have
supercial veins and deeper veins. Sometimes a blood
clot develops in these veins. When the clot is in the
supercial vein, it causes local inammation of the wall
of the blood vessel. It usually occurs aer an IV has
been placed. It resolves with heat and time. However,
when the clot is in the deep vein, it can be dangerous. It
may break o and travel to vital organs, like the lungs.
MRSA (Page 7)
Methicillin- resistant Staphylococcus aureus (MRSA)
Our skin is covered with all types of bacteria; MRSA
is the name of just one of them. e bottom image
depicts how the skin gets infected. e le part of the
image depicts normal, intact skin. Here, bacteria on
the outside does not enter. e right part of the image
depicts broken skin. Here, bacteria enter and infect
underlying skin structures. MRSA commonly causes
skin ulceration, but can also cause an abscess.
Crushed nger (Page 9)
Subungual hematoma
When you crush the tip of your nger, blood vessels
under your nail burst. is causes a lot of pressure
and pain. To relieve some of this pressure, a small
instrument, called a trephinator, burns a small hole
through the nail. Blood drains out, and the pressure is
relieved.
Airway anatomy (Page 11)
When you breathe, air ows down past the epiglottis,
into your lungs. When you swallow food, the epiglottis
acts like a lid and shuts the opening of the airway. is
ensures that food goes into the esophagus, instead
of the lungs. When you have an allergic reaction or
angioedema, the tongue becomes swollen and blocks
your airway. When you have epiglottitis, your epiglottis
becomes swollen and blocks your airway. When you
aspirate, food goes down the wrong tube; it goes down
into the lungs instead of the esophagus.
EENT (Eye, ear, nose, throat)
Eye pain (Page 14)
Corneal abrasion & conjunctivitis
e surface of the eye is covered with the cornea (over
the eye) and the conjunctiva (on the inner surface of the
eyelids). e top image depicts the normal side view of
the eye. e bottom image depicts a problem with this
surface. e le part of the image depicts conjunctivitis.
is is where the conjunctiva becomes infected by a virus
or a bacteria. e right part of the image depicts a corneal
abrasion. is is a scratch on the cornea. A corneal ulcer
is a hole through the surface of the cornea.
Toothache (Page 15)
Dental caries vs dental abscess
e le image depicts a normal tooth. Notice that
the nerve sits deep inside the pulp. e right image
depicts an abnormal tooth. e le side of the image
shows a cracked tooth with an exposed nerve. is
causes a lot of pain. e right side of the image shows
a cavity that has invaded into the pulp. Bacteria in
your mouth travels down into your pulp and forms an
abscess.
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Nosebleed (Page 16)
Epistaxis
Many blood vessels lay just under the surface of the
nasal mucosa, right next to your nasal septum. Notice
how supercial these vessels are. Minor trauma
(picking the nose, bumping nose, dry air) can cause
a nosebleed. When you have a nose bleed, tilt your
head forward and pinch the area just under your bony
ridge. If this does not stop the bleeding, you may need
nasal packing. A packing puts direct and constant
pressure on the area that is bleeding deeper inside
the nose. You will go home with this packing. e
hole will close up over the next few days. Do not try
to remove the packing by yourself because it may cause
more damage.
Inner ear infection (Page 18)
Otitis media
e le image depicts normal ear anatomy. Notice
the position of the eardrum and the Eustachian
tube that connects the ear to the nose. Because of
this connection, ear pain is oen accompanied
by nasal and throat symptoms. e image on the
right depicts otitis media or an inner ear infection.
Here, uid accumulates in the area and causes the
eardrum to bulge.
Sinus infection (Page 17)
Sinusitis
e sinuses are hollow cavities in your face. e le
image depicts a normal sinus. Notice that the sinus
drains into your nasal cavity and then out through
your nose. e right image depicts sinusitis. Here, the
nasal cavities become swollen and block the normal
drainage of the sinus. Fluid builds up and accumulates
in the sinuses and becomes infected.
Swimmer’s ear (Page 19)
Otitis externa
e le image depicts normal ear anatomy. Notice
that your ear canal curves around the side of your
face. Sometimes, water gets trapped inside and causes
an infection. e right image depicts an outer ear
infection. Here, the ear canal becomes irritated and
pus forms and drains out of the ear.
Sore throat (Page 20)
Strep pharyngitis & peritonsillar abscess (PTA)
e le image depicts a normal tonsil. It hides
between the folds of your throat. e structure
that hangs in the middle is called the uvula. e
right image depicts an infected tonsil. Notice that
the tonsil becomes covered with pus and becomes
enlarged and “angry.” is is strep throat. Sometimes,
the infection spreads beyond the tonsils and into the
nearby tissues. Here, it can form into an abscess. is
causes the uvula to shi le. When you develop an
infection in your throat, your lymph nodes along the
side of your neck become swollen as your body ghts
o the infection.
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CARDIOPULMONARY
Bronchitis vs pneumonia (Page 22)
Both bronchitis and pneumonia present
similarly: cough, wheezing, shortness of breath.
e le image depicts bronchitis. Notice that there
is a problem with the tubes of your airway. ey
either ll up with mucus, causing a productive
cough, OR they spasm and cause wheezing. e
right image depicts pneumonia. Notice that there
is a problem with your lung tissue itself. Here, the
tissue gets infected. Sometimes a chest x- ray can help
dierentiate the two.
Blood clot (Page 24)
Deep vein thrombosis (DVT) & pulmonary
embolism (PE)
Veins return blood back to your heart and lungs. e
le side depicts normal venous return. e right side
depicts a blood clot that forms in one of the deep veins
of your leg. is causes the leg to swell. Sometimes, a
small piece, called an embolism, breaks o and travels
to the lungs. When it gets to the lungs, it is called a
pulmonary embolism. Here, it blocks oxygen exchange
in the lung tissue. e lung tissue dies from the lack of
oxygen. is is called a lung infarct.
Emphysema (Page 23)
Chronic obstructive pulmonary disease (COPD)
e le image depicts a normal lung. Notice that air
moves down the airway. It travels to the alveoli and
oxygen gets dropped o, where it then circulates in the
bloodstream. Normally, airow is smooth. e right
image depicts a lung with COPD. Notice that the walls of
the alveoli are destroyed. Airow through the airways is
not smooth. Instead, muscles that surround the airways
spasm and cause bumpy airow and poor oxygen
exchange. Also, airways ll up with mucus and interfere
with oxygen exchange.
Swollen legs (Page 25)
Pedal edema
Veins have valves that return blood back to your heart.
e le side depicts normal blood return. Notice the
valve opens to allow blood to pass and then closes
to prevent backow. is process repeats to bring
blood back to the heart. e right image depicts pedal
edema. Notice that the valves don’t open and close
properly. Blood pools at the feet. is extra uid
then seeps into the subcutaneous tissue and causes a
“doughy” swelling to the legs.
Heart attack (Page 26)
Myocardial infarction (MI)
e heart is a muscle and needs oxygen just like any
other muscle of your body. Coronary arteries supply
this oxygen to the heart muscle. Sometimes, the
coronary artery gets clogged. When oxygen doesn’t
reach the muscle, it dies. is is a heart attack.
Heart failure (Page 28)
Congestive heart failure (CHF)
ink of your heart as a pump: It takes blood in and
pumps it out to the rest of your body. Sometimes,
your pump fails, and it cannot pump blood out to
the rest of the body. Because this incoming blood
does not get pumped out, it backs up in your lungs
and/ or legs.
Chest pain evaluation (Page 27)
When you have chest pain, you may be concerned
mainly about your heart. But remember, that your
pain may be caused by many other structures that are
nearby: the skin, the muscles, the lungs, the stomach,
the gallbladder, or the pancreas. Sometimes, we cannot
determine the exact cause of your chest pain but have
evaluated all of the structures in and around your chest.
Heart failure causes (Page 29)
Diastolic vs systolic disease
Heart failure occurs because of two processes. The
left image shows diastolic disease. Here, your blood
pressure is very high because your blood vessels
are very stiff and narrow. Your heart works really
hard to pump out blood against this resistance. At
first, it keeps up. But, after time, the heart muscle
gets really muscular. It has a hard time filling up
properly and also a hard time pumping out blood.
The right image depicts systolic disease. Here, your
heart is weak and dilated (usually because of a heart
attack). It just does not have the strength to pump
blood out.
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High blood pressure (Page 30)
Hypertension (HTN)
e le image depicts normal blood ow out of
the heart. Notice that the blood ows smoothly.
e right image depicts hypertension. Here, blood
ows out of the heart into a sti, narrow blood vessel.
is puts a strain on the heart. e heart muscle
enlarges and becomes muscular. You can actually see
this on an EKG.
Your blood pressure fluctuates throughout the day
(it is usually lowest while sleeping and highest in
the evening). It can increase based on emotions
(anger, excitement, nervousness). An isolated spike
is not concerning if it occurs without symptoms.
It can actually be dangerous to acutely lower your
blood pressure if you have no symptoms. It is the
general trend over time (weeks, months) that is
very important to prevent the consequences of
high blood pressure (kidney failure, stroke, heart
attack, etc.).
Irregular heart beat (Page 32)
Atrial brillation
e le image depicts the normal electrical impulses
that cause the heart to pump in a regular way. Notice the
impulse starts in one spot of the heart and then follows
in a regular, predictable pathway. is causes a regular,
rhythmic beat to the heart. e right image depicts
atrial brillation. Here, multiple spots re all at once.
is causes a very irregular beating of the heart. During
atrial brillation, the heart does not empty completely.
Clots form in the cavities of the heart. Sometimes, a
small piece of this clot breaks o and goes to the brain.
Here, it blocks a blood vessel and causes a stroke.
HTN + symptoms (Page 31)
Hypertensive urgency
So, when should you worry about high blood pressure?
When you have symptoms: severe headache/ strokelike symptoms, chest pain, shortness of breath,
abdominal pain, back pain, or foot pain. ese
symptoms tell us that your blood pressure is too high
and is causing strain and even damage to the organ.
Fluid around heart (Page 33)
Pericarditis vs pericardial eusion
e le image depicts the pericardium, a thin,
brous structure that surrounds the heart muscle.
e right image depicts an inammation of the
pericardium. is is called pericarditis. Sometimes,
this inammation causes uid to build up in the space
between the pericardium and the heart. is uid is
called a pericardial eusion. is can be dangerous
because this extra uid can compress the actual heart
muscle and block blood return to the heart.
Aortic dissection (Page 34)
e aorta is a big blood vessel that carries blood
from the heart to the rest of the body. It is made up
of several layers. Sometimes, the inner wall of the
aorta weakens and tears. is is because of high
blood pressure. Instead of going down the normal
tract, blood enters the wall of the aorta and “bleeds
into itself.”
Aortic aneurysm (Page 35)
e aorta is a big blood vessel that carries blood from
the heart to the rest of the body. Sometimes, the aorta
forms a balloon- like bulge. is is called an aneurysm.
Sometimes, the pressure gets too high, and the
aneurysm ruptures.
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