2020 Critical Care Surg ENT MSK Flashcards
Recusation fluids that in large quantity can give you hypo Ca?
Albumin
ABG with hyperK, lactate and hypo Ca – which fluids to give?
RBC
What indicates successful CPR?
Femoral pulse
ABG with metabolic acidosis with hyper Cl - Which fluid can cause this?
normal saline
What to give in ALS for PEA?
adrenaline
Major resp complication that is preventable post-surgery?
atelectasis
Which type of surgery carries the highest risk of pulmonary complication post-surgery?
upper GI surgery
Cause of reduced air entry bilateral post-operation?
atelectasis
Gabapentin mode of action?
Act on voltage-gated calcium channels
Name an atypical morphine?
buprenorphine
What is the most common symptom of aortic stenosis?
exertional dyspnoea
ASA grade for elective surgery for pt with controlled chronic hypertension?
ASA 2
Calculate anion gap (know the formula)?
(Na+ + K+) – (Cl- + HCO3-)
Indication of HHS?
Moderate ketonemia, ph <7.3, bicarb <15
SAH ECG?
massive T wave inversion
What to do first for a pregnant lady with seizure?
test BGL first
Lady with UTI sxs – what test to do first?
Beta -hcg
Largest radiation to ovaries:
- Lumbar spine xray?
- Pelvis xray?
- CT head?
- Mammography?
= pelvic xray?
Choice of imaging in PE question for pregnant lady in the third trimester based on imaging pathways?
VQ scan
What do you do after decompression of tension pneumothorax?
Insert chest drain
At what % blood loss do you see low BP?
> 30%
Absolute contraindication for anticoagulation?
ischemic stroke 1 month ago
Reason for non-contrast CT in suspected stroke?
= To rule out haemorrhagic stroke first
What to do with pt with chest pain with neurological sx?
= CT contrast first - suspect aortic dissection
Children acute pain control?
fentanyl IV
The head injury in a patient with a lucid interval. Whats the diagnosis?
Extradural haematoma
Difference between tension pneumothorax and cardiac tamponade?
absent breath sound
Which bacteria for infective endocarditis in naive valve vs. IVDU?
strep for naïve valve and staph aureus for IVDU
IE which side of the heart?
tricuspid valve incompetence
bacterial sinusitis - what to treat with?
treat with broad-spectrum abx
Man who has clear runny nose after a footy game, now confused and feeling not himself. What are you worried about?
CSF fluid leak
Management of sinusitis only 7 day?
Give nasal saline
Mx of nose fracture?
wait for 7-10 days then fix if needed
Avoid Manipulation at initial presentation: Avoid attempting to realign or reposition the fractured nose immediately, as this may exacerbate the injury or cause further complications.
The first thing to do in tracheostomy patient with airway issue?
Follow the guideline or suctions
Cognitive impaired patient with ear wax - mx?
wax softeners
The diabetic patient had a fall - cause?
peripheral neuropathy
Tumour Marker for pancreatic cancer?
CA19-9
Which disorder is caused by absence of ganglion myenteric plexus?
achalasia
Risk of bowel prep?
dehydration
Management of glue ear in a 4-year-old aboriginal with more than 25db hear loss?
Mild hearing loss (21 - 30 dB)
1. Continue to review regularly
2. Use and recommend strategies to improve
quality of communication
Ensure ongoing audiological, language and
educational support
Refer for ENT assessment
If school age, recommend classroom amplification
Refer for speech therapy if concerned about
language development
Management of blocked ear in a woman with normal otoscopy exam?
= Urgent Audiogram
Post auricular redness - diagnosis?
Acute mastoiditis
Immediate management OSA truck driver?
CPAP
Post-op patient has low RR, what is the reason?
Opioid toxicity
Medication for bradycardia and hypotension?
atropine
Sign of acute sepsis (qSofa)?
New confusion
DIC management?
cryoprecipitate
Which one is a surgical emergency in septic patient?
infected obstructed kidney
Placement of arterial line for coagulopathy - which vessel?
femoral line
How to reduce CPP in patient who has high ICP?
Give hypertonic saline to bring ICP down.
Nimodipine is used for what?
To prevent vasospasm in pts with SAH
Which anti-coagulant for antiphospholipid syndrome during pregnancy?
LMWH
What is the first symptom of systemic scleroderma?
Raynaud
How to remove ingested razors from stomach?
upper GI removal via upper GI scope
What to do in a patient with post thyroidectomy with perioral paraesthesia?
hypocalcaemia - give Ca
Cyst that move with hands movement?
ganglion cyst
Best med for post-operative pain control? & its MOA?
NMDA receptor antagonist - Ketamine
Definitive treatment of limb ischemia?
Arteriography - Angioplasty and Stenting.
What type of cancer might migratory thrombophlebitis suggest?
Migratory thrombophlebitis, also known as Trousseau’s syndrome, is often associated with pancreatic cancer.
Trousseau’s syndrome is a paraneoplastic phenomenon where recurrent, migratory blood clots form in superficial veins, often moving from one site to another. It occurs due to the hypercoagulable state created by certain cancers, especially those of the gastrointestinal tract and pancreas.
What is a sign of ureter obstruction on imaging?
Hydronephrosis
A common sign of ureteral obstruction on imaging is hydronephrosis, which is the swelling or dilation of the renal pelvis and calyces due to a buildup of urine. This occurs when urine is unable to drain past the obstruction, causing pressure to build up in the kidney.
Imaging Signs:
Ultrasound - Hydronephrosis: Dilated renal pelvis and calyces.
What is the best measurement for acute liver failure post paracetamol toxicity?
Key markers to assess liver function and prognosis:
1. Serum Arterial Lactate - Elevated lactate (>3.5 mmol/L after fluid resuscitation) indicates poor perfusion and liver dysfunction, often used as a key criterion in King’s College criteria for liver transplantation.
2. INR - A rising INR (particularly >1.5) reflects impaired liver synthetic function and coagulopathy, which is a hallmark of acute liver failure.
3. Serum Bilirubin - While not as sensitive as lactate or INR, rising bilirubin levels can reflect worsening liver dysfunction.
4. ALT & AST - Extremely elevated ALT/AST levels are seen early in paracetamol toxicity, but their decline does not necessarily indicate improvement in liver function as hepatocyte necrosis progresses.
Patient had BP 77/40 after fluid IV resus – what do you do?
Add vasopressor
Dx of fever, drooling in a patient who was vaccinated? - A: Epiglottitis
B: Croup
C: Peritonsillar abscess
The most likely diagnosis for a patient presenting with fever and drooling, particularly if they were vaccinated, is epiglottitis (A).
What is the lymphatic drainage of the anus?
What are the signs on clinical examination of a massive haemothorax?
The signs of a massive hemothorax on clinical examination are primarily due to the accumulation of a large volume of blood in the pleural space, which compresses the lung and can cause hypovolemic shock.
Which clear fluid is contraindication?
- A: Coke
- B: Lemonade
- C: Water
- D: Milk and tea
The clear fluid that is a contraindication (for example, before surgery or anesthesia) in your list is likely tea with milk.
- Milk is not considered a clear fluid because it contains fat and proteins, which delay gastric emptying and increase the risk of aspiration during anesthesia.
- Water, lemonade, and tea (without milk) are considered clear fluids and are generally allowed up to 2 hours before surgery in most guidelines. These fluids leave the stomach quickly and are less likely to cause complications during anesthesia.
- Coke (carbonated beverages) is sometimes allowed but may not be preferred close to surgery because carbonation can cause bloating or increase gastric contents, though it is technically still a clear liquid.
What is the bird beak sign?
Bird-beak sign: dilation of the proximal esophagus with stenosis of the gastroesophageal junction seen on Esophageal barium swallow: supportive and/or confirmatory test for Achalasia
A patient develops erectile dysfunction post proctectomy surgery. Which nerve is likely to have been damaged?
splanchnic nerve
A patient develope hyponatraemia post TURP surgery. What is the cause?
= Glycine Usage
- Glycine Solution: During TURP, a glycine solution (often 1.5% glycine) is used as a bladder irrigation fluid. This solution helps to maintain visibility in the surgical field by flushing out blood and debris
- Absorption of Glycine: The glycine solution can be absorbed into the bloodstream during surgery, especially if there is significant bleeding or prolonged irrigation.
- Hyponatremia: Glycine is a hypotonic solution compared to the blood plasma, and its absorption can lead to dilutional hyponatremia. This condition occurs when the absorbed fluid dilutes the sodium concentration in the blood, leading to lower sodium levels.
A young man presents with abdominal pain which improves on defecation. What is the diagnosis?
In a young man with IBS, it’s common for symptoms such as abdominal pain to improve after defecation. This is a characteristic feature of IBS.
Symptoms of IBS:
1. Abdominal Pain: Often relieved by defecation or passing gas. The pain may vary in intensity and is typically associated with changes in bowel habits.
2. Altered Bowel Habits: This can include diarrhea (IBS-D), constipation (IBS-C), or a combination of both (IBS-M).
3. Bloating and Gas: These symptoms can accompany the abdominal pain.
Mechanism - Pain Relief After Defecation: In IBS, the act of defecation can alleviate abdominal pain because it relieves pressure in the colon and reduces bloating. The colon’s response to normal bowel movements helps alleviate discomfort.
What is the best fluid option for post-op ileus?
For managing post-operative ileus, the best fluid option is generally normal saline (0.9% sodium chloride).
1. Normal Saline (0.9% Sodium Chloride):
- Isotonic: It has a similar osmolarity to that of plasma, which helps maintain fluid balance without causing significant shifts in electrolyte levels.
- Restores Volume: It effectively restores intravascular volume and can help manage dehydration that may occur due to decreased oral intake or ongoing gastrointestinal losses.
- Avoids Electrolyte Imbalances: Unlike some other fluids, normal saline does not contain significant amounts of electrolytes that could exacerbate imbalances.
A female presents with sudden onset of severe abdominal pain but she had a soft mildly tender abdomen on examination. She is a diabetic and smoker. What is the diagnosis?
Acute mesenteric ischemia
What is the main electrolyte disorder associated with refeeding syndrome? Why?
As the body continues to experience starvation, existing phosphorous stores are depleted to sustain metabolic activity, leading to hypophosphatemia, widely observed in patients with refeeding syndrome. In refeeding syndrome, long-term starvation may have already depleted the body of phosphorous stores.
What is the management for DVT?
therapeuticIV heparin
A patient presents with a non-healing ulcer. What investigation needs to be performed?
An edge biopsy of an ulcer is a diagnostic procedure used to evaluate the tissue at the margins of an ulcer to determine if there is any underlying pathology, such as malignancy or infection. This type of biopsy is particularly important when there is suspicion of cancer or other serious conditions that might not be evident from the ulcer surface alone.
A female patient has had an abscess like mass in the outer quadrant of her breast drained. What should you do next?
- A: Cytology
- B: Surgery
- C: Excision
- D: Do nothing
After draining an abscess-like mass in the outer quadrant of the breast, the appropriate next step is often to ensure proper follow-up and evaluation to rule out any underlying malignancy. Given the context, the best course of action would typically be:
C: Excision
Hypotensive patient post MVA with seatbelt injury, CT showed nil intraperitoneal blood and has ileus. What is the diagnosis?
In a hypotensive patient who has been involved in a motor vehicle accident (MVA) and has a seatbelt injury with a CT scan showing no intraperitoneal blood but with ileus, the diagnosis to consider is likely mesenteric injury.
What is the Rovsing’s definition?
Rovsing’s sign is a clinical sign used to help diagnose appendicitis. Rovsing’s sign is considered positive when palpation of the left lower quadrant (LLQ) of the abdomen causes pain in the right lower quadrant (RLQ). This sign suggests inflammation in the appendix, typically indicative of appendicitis.
Which antibiotics are best for a patient with E.coli urosepsis?
= Amox & Gent
What drugs can you give cholinergic side effects?
Which is the best vasopressor for cardiogenic shock?
Dobutamine for cardiogenic shock
What would determine ongoing management of someone with chronic tonsilitis?
- A: Fatigue
- B: Asymmetry of tonsils
= B: Asymmetry of tonsils - suggests either peritonsillar abscess or suspected tonsillar malignancy - either way these are an indications for possible tonsillectomy
Which syndrome is there a strong link to in patients with medullary carcinoma?
- Family hx of MENs
Medullary thyroid carcinoma (MTC) is a type of thyroid cancer that can have a strong association with family history and is often linked to Multiple Endocrine Neoplasia (MEN) syndromes.
Medullary Thyroid Carcinoma (MTC) - Characteristics
- Origin: MTC arises from parafollicular C cells of the thyroid gland, which produce calcitonin.
- Clinical Presentation: It can present as a thyroid nodule or mass, often with elevated levels of calcitonin and carcinoembryonic antigen (CEA).
What is the best supported tx for COVID19 pt?
- Steroids
- High flow
- Intubate & ventilate
Steroids?
& ?
Rectus sheath hematoma CT, patient was on warfarin and had been coughing?
What medication would you give for a patient with metastatic disease to brain?
= Dexamethasone - Dexamethasone is commonly used to reduce edema and inflammation around brain metastases, which helps alleviate symptoms such as headache, nausea, and neurological deficits.
Management of abscess post appendicectomy?
Patients with perforated appendicitis have a longer hospital stay, and up to 25% will develop a postoperative abscess, or infection pocket that many times requires drainage.
How to remove ingested razors from stomach?
Endoscopic removal
Outline the management of lumbar spine disc herniation?
Gout management in renal failure?
= Same but lower doses or avoid colchicine altogether. Allopurinol is safe but reduce dose
What are the features of an ulnar nerve palsy?
= Inability to aBDuct fingers
Motor functions:
Two muscles of the anterior forearm – flexor carpi ulnaris and medial half of flexor digitorum profundus
Intrinsic muscles of the hand (apart from the thenar muscles and two lateral lumbricals)
Sensory functions: Medial one and half fingers and the associated palm area.
What is Meralgia paresthetica - which nerve?
Meralgia paresthetica is caused by the compression of one of the large sensory nerves in the leg — the lateral femoral cutaneous nerve. This nerve provides sensation to the skin along the outer thigh starting from the inguinal ligament and extending down toward the knee.
Source of bleeding in a trauma patient?
femur
What can build up in the space following a breast surgery? What is this called?
After breast cancer surgery, fluid may collect where tissue was removed. This swelling is called a seroma. It may resolve on its own over time, or it may need to be drained. Seromas may be uncomfortable and lengthen the patient’s recovery time, but they aren’t cancerous.
Seroma in post breast surgery
Which makes the PID worse?
- A: Ovulation
- B: UTI
- C: Pregnancy
Pelvic inflammatory disease (PID) can be exacerbated by various factors, but among the options provided, the one most likely to worsen PID is:
C: Pregnancy
Unilateral vocal cord nodule, with appearances similar to papilloma or SCC?
- List 6 differentials for benign vocal cord nodules?
Laryngeal carcinomas are almost always squamous cell cancers (SCC) - rregular, nodular, and/or ulcerative lesions
Patient presents with a midline lump in the neck which moves with swallowing and is central. What is the diagnosis?
Thyroglossal cyst
ECG with TCA toxicity features?
The ECG is a vital tool in the prompt diagnosis of poisoning with sodium-channel blocking medications such as tricyclic antidepressants (TCA), which cause CNS and cardiovascular toxicity in overdose in the form of seizures and ventricular dysrhythmias.
An ECG should be taken in all patients who present with a deliberate self-poisoning (or altered GCS of unknown aetiology) to screen for TCA overdose.
ECG Features of Sodium-Channel Blockade
1. Intraventricular conduction delay: QRS > 100 ms in lead II
2. Terminal R wave > 3 mm in aVR or R/S ratio > 0.7 in aVR
3. Patients with TCA overdose will also usually demonstrate sinus tachycardia secondary to muscarinic (M1) receptor blockade
7 Causes of metabolic acidosis with normal anion gap?
= Addison’s
What are the typical features of:
- Polymyositis?
- Dermatomyositis ?
Dermatomyositis (DM): an inflammatory myopathy characterized by progressive symmetrical proximal muscle weakness and distinctive skin findings
Would you use activated charcoal for lithium toxicity?
= NO. Activated charcoal is not effective for lithium toxicity. This is because lithium is a small ion that does not bind to activated charcoal effectively. Instead, the management of lithium toxicity primarily focuses on:
1. Hydration: To enhance renal elimination of lithium.
2. Hemodialysis: In severe cases of lithium toxicity, particularly when serum lithium levels are significantly elevated, renal function is impaired, or there are severe symptoms such as altered mental status or seizures.
Activated charcoal is commonly used in the ED for the management of acute oral poisonings or drug overdoses where the substance is known to bind to charcoal. It works by adsorbing the toxin in the gastrointestinal tract, preventing further absorption into the bloodstream.
Describe the Appearance of tympanosclerosis?
Tympanosclerosis = complication of Chronic suppurative otitis media
Tympanosclerosis appears as white, chalky patches or plaques on the tympanic membrane (eardrum). These areas are usually located on the surface of the eardrum or, less commonly, within the middle ear structures. The patches result from calcification and scarring, often following repeated ear infections or trauma to the eardrum, including after the placement of ventilation tubes.
Key features of tympanosclerosis include:
1. White or greyish plaques on the eardrum.
2. Opaqueness of the tympanic membrane, often with limited mobility.
In more severe cases, these plaques can extend to the ossicles and impair hearing function.
Tympanosclerosis is generally a benign finding but can sometimes be associated with hearing loss if the ossicles are involved.
What is the typical history of anal fissure vs. haemorrhoids?
- Internal Haemorrhoids: Painless unless prolapsed or thrombosed.
- External Haemorrhoids: More likely to be painful if thrombosed, with a visible swelling or lump near the anus.
The symptoms of haemorrhoids often worsen with activities that increase intra-abdominal pressure, such as straining, heavy lifting, or pregnancy.
Typical features of dermatomyositis?
Pt had PCA catheter inside for pain control, in severe pain now, his PCA catheter is out – what should you do next? Refer to PCA, give morphine?
