Aortic & Peripheral Artery Disease

Question 1

PAD

Answer 1

1. Acute Limb ischemia in the setting of chronic PAD often occurs less dramatically than in patient with WITHOUT PAD. Emergency intervention is necessary (embolectomy, thrombolysis, & endovascular)
2. ABI index to confirm presence of PAD ( >1.3 = calcified & incompressible vessel; 1 = normal; <0.6= claudication; <0.4= ischemia/reset pain)

Question 2

Lower extremely arterial injury

Answer 2

1. Hard signs of vascular injury includes ( pulsatile bleeding, bruits/thrills, hematoma at site of injury, & distal ischemia/absent of pulses/cool extremely) require urgent surgical exploration of the wound
2. Soft signs of vascular injury includes (history of hemorrhage, no pulses, bone injury & neurologic abnormality) require injured extremity index (ABI), CT scan/angiography, or Duplex doppler US.

Question 3

Atrial fibrillation

Answer 3

Irregularly irregular

Question 4

Premature ventricular complex (PVC)

Answer 4

Widen QRS

Question 5

Ventricular aneurysm

Answer 5

ST elevation

Question 6

Ischemia

Answer 6

1. ST elevation
2. ST depression
3. Inverted T wave

Question 7

Infraction

Answer 7

Q wave

Question 8

Pericarditis

Answer 8

ST elevation throughout leads

Question 9

Right Bundle Branch Block (RBBB)

Answer 9

1. Wide QRS

2. R-R in V1 or V2

Question 10

Left Bundle Branch Block (LBBB)

Answer 10

1. Wide QRS

2. R-R in V5 or V6

Question 11

Aortic dissection

Answer 11

Sign:

1. Tearing chest pain that radiates to the back/neck/abdomen
2. Asymmetrical pulses between arms/ Hypotension/ aortic regurgitation
3. X-ray shows: widened mediastinum ( widened cardiac silhouette) & pleural effusion (due to hemothorax)
4. CT scan: intimal flap (double aortic lumen) (CTA)
5. Episodes of syncope (> 20mm Hg variation in SPB between arms)

Treatment:

1. Medical (Sodium nitroprusside, Beta blockers, morphine)
2. Emergent surgical repair for ascending dissection

Risk factor:

1. HTN
2. Connective tissue disease (Marfan syndrome)
3. Cocaine use
4. BLUNT AORTIC INJURY (incomplete rupture= tear of intima/ tear of intima & media/ psuedocoarctation; complete rupture)

Complication:

1. Stroke
2. Aortic regurgitation
3. Pericaridal effusion/temponade
4. MI

DIAGNOSIS:

1. CTA (stable) —> MR-A (more time consuming)
2. TEE (unstable patient & with kidney disease)

Types:
1. Type A: ascending aorta dissection that rupture in pericardial space & lead to pericardial temponade & cardiogenic shock (signs: chest pain, syncope, stroke, MI, hypotension, aortic regurgitation, asymmetrical pulses/ upper extremity)

Associated with:
1. Turner syndrome ( bicuspid aortic valve/ aortic coarctation & HTN)

Question 12

Pulmonary embolism

Answer 12

Sign:

1. Chest pain (pleuritic) with Hypotension & JVD
2. Tachycardia
3. SOB
4. Elevated D-dimer
5. Pleural effusion

Question 13

Blunt thoracic aortic injury (BTAI)

Answer 13

Causes:
1. Blunt chest trauma (car accident, fall from heights)

Sign:
1. Incomplete rupture
*tear to intima
*tear to intima & media
*psuedocoarctation (upper extremity HTN & lower
extremity hypotension)
2. Complete rupture

Symptoms:

1. Upper extremity HTN/lower extremity hypotension
2. Hoarseness of voice (compression on recurrent laryngeal nerve)

Initial diagnosis:
1. Chest x-ray: widen mediastinum & left-sided hemothorax (effusion) & abnormal aortic contour

Confirm diagnosis:

1. Stable patient: CT angiography (CTA)
2. Unstable patient/hypotension: Transesophaheal Echocardiography (TEE)

Question 14

Indication of amputation

Answer 14

Signs:

1. Non-revascularizable limb ischemia
2. Unsalvageable soft-tissue damage
3. Life-threatening infection (infected gangrene)

Example:
1. Patient with PAD & gangrene with signs of infection —> perform amputation to remove infectious source & prevent sepsis

Question 15

AAA rupture

Answer 15

Risk factor associated with AAA:

1. Smoking
2. Advanced age >60
3. male
4. HTN
5. History of atherosclerosis

*note: uncontrolled diabetes does not contribute to AAA

Sign:

1. Abdominal pulsatile mass
2. Hypotension
3. Bruits/ tenderness between epigastrium/periumbilicus

Symptoms:

1. Abdominal/flank/back/groin pain
2. Ecchymosis (hematoma) at flank
3. limb ischemia
4. Pulsatile mass

Investigation:

1. X-ray: perivertebral aortic calcification (extensive atherosclerosis)

Diagnosis:

1. Abdominal U/S = unstable
2. Abdominal CT = stable

Treatment:
1. Surgical repair (endovascular)

*Note: bowel ischemia/infraction is a complication of AAA repair

Note:

1. Femoral & popliteal aneurysms are associated with AAA —> present as pulsatile mass that compress (nerve/vein) & lead to thrombosis & ischemia
2. Ruptured AAA: acute onset of severe abdominal or flank pain + syncope +pulsatile abdominal mass + flank/abdominal hematoma

Question 16

Leriche syndrome (aortoiliac occlusion)

Answer 16

Sign:

1. Claudication of buttocks, hip, thigh
2. Absent of femoral pulse + symmetric atrophy of lower extremity muscles (due to ischemia)
3. Impotence

Question 17

Ankylosing spondylitis

Answer 17

1. Associated with aortic regurgitation

Sign of AS:

1. Chronic back pain
2. Impaired spinal mobility
3. Bilateral heal pain

Question 18

Shock

Answer 18

Tachycardia + hypotension

Question 19

Central venous pressure (CVP) measured by central venous catheter

Answer 19

1. Pressure at the superior vena cava, where the tip of catheter is located
2. Equal to the right-atrial pressure = preload

Note:

1. Low CVP (LOW PRELOAD)—> hypovolemic or distributive shock
2. High CVP (high preload) —> cardiogenic & obstructive

Note:

1. Hypovolemic shock = hemorrhage
2. Distributive shock = anaphylaxis
3. Cardiogenic shock = Blunt cardiac injury
4. Obstructive shock = cardiac tamponade, PE, pneumothorax

Question 20

Cardiovascular contraindication to pregnancy

Answer 20

1. Symptomatic mitral stenosis
2. Symptomatic aortic stenosis
3. Symptomatic heart failure with LVEF <30%
4. Pulmonary arterial hypertension
5. Bicuspid aortic valve with ascending aorta enlargement >50mm

Hemodynamic changes:

1. Increase in blood volume up to 50% increase in CO by second trimester
2. Stenotic valvular disease poorly tolerated than regurg. Disease.

Treatment:
1. Percutaneous mitral intervention should be performed prior to pregnancy

Question 21

infective endocarditis

Answer 21

Heart failure is leading cause of death in patient with infective endocarditis
(Acute heart failure —> aortic/mitral regurg. )

Signs of Infective endocarditis:

1. Fever
2. Leukocytosis
3. Mitral valve vegetation

Sign of heart failure:

1. SOB
2. Pulmonary edema
3. Bilateral lower extremity edema

Question 22

Left ventricular outflow tract obstruction (LVOT) in hypertrophic cardiomyopathy

Answer 22

Standing & valsalva strain phase:

1. Decrease LV volume
2. Worsen obstruction & accentuate murmur

Squatting & leg raises & handgrip:

1. Increase LV volume
2. Lessens obstruction & decrease murmur

Treatment:

1. High LV end diastolic blood volume (preload) is improved by hydration & low heart rate & avoid venous dilator (nitroglycin)
2. High LV end systolic blood volume is improved by low stroke volume & low contractility

Question 23

Mitral regurgitation

Answer 23

1. Mitral valve repair is recommended in patients with Ejection fraction of 30%-60%, asymptomatic, or symptomatic

Question 24

Arteriovenous fistula & hemodialysis

Answer 24

1. Access between cephalic vein & radial artery
2. The fistula forms an enlarged vein, which serves as an access point (for hemodialysis) & facilitates adequate blood flow to/from the hemodialysis machine
3. AV fistula can lead to hemodynamic changes
   
   • decrease afterload (by decreasing SVR)
   • increase preload (increasing RAP; venous return)
   • increase CO (by decrease SVR & increase venous Return)
4. Marked changes in these parameters can lead to high-output heart failure

Note:

1. An AV-fistula allows blood to bypass the high-resistance systemic capillaries, resulting in decreased systemic vascular resistance (afterload), increased venous reture (preload), & increased cardiac output.
2. A large AV-fistula can lead to high-output heart failure

Question 25

Primary adrenal insufficiency (adrenal crisis) (hypoaldosteronism)

Answer 25

Def:
1. Autoimmune destruction of all 3 layers of adrenal cortex ( aldosterone, cortisol, & androgen)

Sign:

1. Hypotension & shock
2. N/V & abdominal pain
3. Fatigue, Fever & generalized weakness, weight loss
4. Lab: hyponatremia & hypoglycemia & peripheral eosinophilia

Adrenal crisis:
1. Caused by surgery, endoscopy, infection, injury —> manifist as hypotension & shock that are refractory to volume resuscitation & poorly responding to vasopressor

Treatment:

1. Hydrocortisone
2. Dexamethasone
3. Rapid IV volume repletion

Question 26

Mitral valve stenosis

Answer 26

Sign:

1. Progressive SOB with exertion —> can be at rest
2. Swelling ankles
3. Diastolic murmur that rumble
4. Normal LV diastolic pressure; increased pulmonary pressure

Signs:

1. Increase CVP (increase preload)
   * JVD
   * Hepatomegaly
   * Lower extremity edema
2. Increase PCWP
   * Orthopnea
   * Paroxysmal nocturnal dyspnea
   * hemoptysis
3. Decrease CO
   * dyspnea
   * fatigue

Question 27

Malignant pericardial effusion

Answer 27

1. Large & prone to recurrence
2. Acute management includes: pericardiocentesis
3. They require prevention of re-accumulation, either by pericardial window or prolonged catheter drainage.
4. Metastasis from breast, lung, GI

Note:

1. Malignancy (lung cancer) is a common cause of pericardial effusion, appears in chest X-ray as enlarged cardiac silhouette with clear lung.
2. Echocardiography is used to confirm the diagnosis, evaluate for sign of subacute tamponade, & guide pericardiocentesis

Question 28

Blunt chest trauma/Injury

Answer 28

1. Hemodynamic unstable
   * resuscitation
   * evaluation ( chest X-ray, eFAST, ECG
   * Ex: chest tube for pneumothorax
   * operating room
2. Hemodynamic stable
   * chest x-ray, eFAST, ECG, CT scan
   * Normal= discharge

Question 29

Cardiac temponade

Answer 29

Sign:

1. Increased PCWP
2. Decreased CO
3. Increased SVR
4. Increased RAP
5. Can develop after coronary artery disease

Diagnosis:
1. Urgent echocardiography should be performed in patient with suspected cardiac tamponade for definitive management

Question 30

Central venous catheter (CVC)

Answer 30

1. To administer medications (pressors, or hypertonic saline) or difficult vascular access, or need for long term medication (chemo)
2. Preferred entry point: internal jugular vein & subclavian (assisted by U/S and landmarks)
3. Tip of catheter is ideally placed in superior vena cava, & avoid placement at smaller vessels (subclavian, jagular or azygous)
   * predispose to venous perforation & lung puncture (lead to pneumothorax) & myocardial perforation (lead to pericardial tamponade)
4. Portable chest x-ray is performed immediately following CVC to recognized mis-placed catheter
   
   • correct location: angle between trachea & mainstem bronchus
5. Do not try more than 3 times !!!!!!

Question 31

Pleural effusion

Answer 31

Manage pleural effusion:

1. Conservative therapy (observation): Small + after 1-2 days of coronary artery bypass + no respiratory symptoms
2. Chest tube insertion/ thoracocentesis/fluid analysis: large + symptomatic pleural effusion

Question 32

Echocardiography

Answer 32

1. To diagnose prosthetic valve dysfunction ( either, stenotic, regurgitation, Infective endocarditis)
2. Allow visualization of the valve & surrounding anatomy

Question 33

Exercise stress test

Answer 33

1. To assess stable angina ( chest pain with exertion & improves with rest)

Question 34

Dehiscence can lead to mediastinitis

Answer 34

Types:

1. Soft tissue (muscle, skin) dehiscence : require local wound care or debridement followed by primary closure.
2. Sternal dehiscence: is surgical emergency & require sternal re-wiring to prevent cardiac trauma.

Investigate:
1. CT scan of chest

Management:

1. Surgical debridement
2. Tissue culture (require for identifying proper AB)
3. Empiric IV antibiotics

Note:

1. Mediastinitis is a complication of cardiovascular surgery.
2. Lead to infection of deep tissue + systemic symptoms (fever, tachycardia) + chest pain + chest wall edema/crepitus (feel crackle with palpation)+ purulent discharge
3. Copious drainage from sternal wound —> require Chest imaging (CT) —-> shows fluid collection

Question 35

Left ventricular aneurysm

Answer 35

1. Is a late complication (several months) of transmural MI
2. Sign: deep Q wave & elevated ST segment (ECG)
3. Diagnosis via echocardiogram (thin & dyskinetic myocardial wall)
4. Progressive left ventricular enlargement & dyskinetic wall motion leading to heart failure (JVD, pulmonary crackles)/angina/systemic embolization

Question 36

Hemorrhagic shock

Answer 36

Signs:

1. Hypotension
2. Tachycardia
3. Diaphoresis

Question 37

Blunt chest trauma

Answer 37

1. Hemodynamic stable
   (Abnormal finding on evaluation, chest x-ray, ECG)
2. Hemodynamic unstable
   (Resuscitation & evaluation via eFAST, chest CT scan, ECG). —> REQUIRES: thoracotomy

Question 38

Avascular necrosis (osteonecrosis, aseptic necrosis) of the femoral head

Answer 38

• osteonecrosis is common with Sickle cell disease
  1. Reduced perfusion of the femoral head & collapse of periarticular bone

Sign:

1. Hip pain/ reduced range of motion
2. Groin pain on weight bearing
3. Pain on hip abduction & internal rotation
4. No erythema, swelling, or point tenderness
5. Normal WBCs, ESR, CRP
6. Crescent sign seen at later stage in MRI
7. X-ray: subchondral lucency & loss of the normal spherical contour of the femoral head
8. X-ray: joint space is preserved & no osteophyte

Question 39

Osteomyelitis (hematogenous)

Answer 39

• associated with Staph. Aurues & salmonella in children

Signs:

1. Fever
2. Fatigue
3. Elevated ESR, CPR
4. Bone tenderness, swelling, erythema , pain

Diagnosis
1. X-ray shows tissue swelling & periosteal elevation

Treatment :

1. Surgical debridement
2. Antibiotics

Question 40

Slipped capital femoral epiphysis (SCFE)

Answer 40

• Associated with obesity & adolescence (obese teenager) (limited hip flexion & internal rotation)

Sign:

1. Dull hip Pain
2. Altered gait
3. Referred knee pain
4. Limited internal rotation of the hip
5. Complication: avascular necrosis & osteoarthritis
6. Symptoms: foot to point laterally, & thigh abduction & external rotation with passive hip flexion

Question 41

Femoral neck fracture or inter-trochanter hip fracture

Answer 41

1. Common in elderly after an acute fall

Signs following a fall:

1. Leg shortened, abducted (gluteal medius) & externally rotated (iliopsoas)
2. Severe pain on range of motion
3. X-ray: shortening & angulation of femoral neck

Also with :
1. Anterior hip dislocation which occurs with severe trauma ( e.g., industrial accident, motor vehicle collision-MVC)

Diagnosis:
1. X-ray

Question 42

Hip fracture

Answer 42

1. Intra-capsular (femoral head or neck): less echymosis & high avascular necrosis
2. Extra-capsular (trochanteric or subtrochanteric): high risk of displacement & visible ecchymosis

Treatment:
1. Surgical correction: open reduction with internal fixation

Question 43

Posterior hip dislocation

Answer 43

1. Associated with axial force on the femur (dashboard injury)

Signs:

1. Adduction
2. Internal rotation at the hip
3. Neurologic manifistation due to involvement of sciatic nerve (impaired dorsiflexion)

Treatment:
1. Requires reduction within 6 hours of injury

Complication:
1. Osteonecrosis of the femoral head (ONFH) due to delayed reduction

Question 44

Paget disease leads to osteosarcoma

Answer 44

1. Paget disease is associated with bone remodeling & increase risk of osteosarcoma

Prevalence:

1. In children: osteosarcoma develops in metaphysis of long bone
2. In adults >40: osteosarcoma develops at sites of damaged bones

Signs of osteosarcoma (distal femur):

1. Codman triangle (periosteal elevation)
2. Sunburst periosteal reaction
3. Moth-eaten lytic lesions (destructive bone lesion)
4. Pain + soft tissue swelling + hallmarks

Question 45

Lyme arthritis

Answer 45

1. Associated with borrelia burgdorferi infection

Signs:

1. Mono-articular arthritis of the knee
2. Develops after months/years after tick exposure
3. Erosion of joint cartilage or bone

Question 46

Osteoarthritis

Answer 46

Symptoms:

1. Joint pain worse with activity & weight-bearing
2. Pain radiates to groin, thigh, buttocks and lateral hip region
3. No synovitis (no warmth, no redness)
4. Brief stiffness with prolonged rest

Signs:

1. Inflammatory destruction of articular cartilage, often involves several joints (knee, hip)
2. Imaging: shows thickening of subchondral bone, joint space narrowing & formation of osteophytes

Affects:

1. Hip
2. Knee
3. Hands, (rarely elbow)

Signs:

1. Osteophytes
2. Joint space narrowing
3. Subcondrial sclerosis
4. Subcondrial cysts

Treatment:

1. Non-pharm: exercise, weight loss
2. If symptoms persist: Topical or oral NSAIDs (duloxetin, tramadol, topical capsaicin) or injectable glucocorticoids
3. If symptoms persist, surgery (total knee arthroplasty) or chronic pain management (nonsurgical candidates)

Question 47

Stress fracture

Answer 47

Signs:

1. Overuse injury to bone caused by repetitive stress (running on pavement)
2. Associated with peroisteal elevation (codman triangle), cortical thickening (with fracture line) & sclerosis
3. Rare in femur
4. Common in tibia & fibula

Question 48

Septic bursitis

Answer 48

Note:

1. During a joint or brusal aspiration or injection, introduction of skin flora may result in septic bursitis or septic arthritis, presenting as a worsening pain several days following the procedure.
2. Diagnostic aspiration of the joint or bursa is necessary to assess for infection

Associated with:
1. Injection of medication (corticosteroid) in the bursa region with introduction of staph. Aureus/strept.pyrogen) into deep structure

Signs: (several days after injection/procedure)

1. Painful + localized bursal swelling with erythema & warmth
2. Fever + chills + myalgias
3. Septic brusitis can develop into septic arthritis

Treatment:
1. Image-guided (U/S) aspiration

Question 49

Acute pain management in patients with opioid use disorder

Answer 49

Pain control: (open fracture & poly-trauma)

1. Maximize non-opioid medication (acetaminophen & NSAIDS & ketorolac)
2. Use regional anasthesia
3. For severe pain: Add IV short-acting opioids as needed (morophine) (short period 3-5 days)

Question 50

Osteoid osteoma (OO) = benign bone-forming tumor

Answer 50

Signs: (occurs in adolescence boys)

1. Proximal femur & spine
2. Pain: (worse at night, relieved by NSAIDS, unrelated to activity) = usually back pain
3. No systemic symptoms
4. X-ray: small, round lucency
5. Treatment: NSAID, monitor for spontaneous resolution

Question 51

Ankylosis spondylitis

Answer 51

Signs:

1. Chronic, progressive back pain (worse with rest & at night)
2. Pain improved with activity
3. Spinal stiffness (bamboo-pattern spine)

Question 52

Vertebral disc herniation

Answer 52

Signs:

1. Nerve root compression result in back pain
2. Acute pain, radicular, worse with flexion
3. Associated with abnormal sensory & motor findings
4. Positive straight-leg raising test (radicular pain from 30-60 degree indicates sciatic nerve root compression)

Question 53

Pre-patellar-bursitis

Answer 53

1. Associated with occupation requiring repetitive kneeling (landscaping/ gardening, plumbing)

Sign:

1. Acute knee pain & tenderness
2. Localized Swelling anterior to patella
3. Erythema

Diagnosis:

1. Bursal fluid Aspiration (cell count, gram stain, & culture)
2. No infection: treat with NSAIDs
3. Infection: drainage + antibiotics

Question 54

Patellar fracture

Answer 54

Signs: (fall from heights)

1. Acute swelling
2. Tenderness
3. Inability to extend knee

Question 55

Infectious (septic) arthritis

Answer 55

Signs:

1. Acute pain
2. Joint effusion
3. Fever
4. Swelling involves joint space
5. Pain with active & passive motion

Question 56

Patellar tendinitis

Answer 56

Signs:

1. Episodic pain at the inferior patella & patellar tendon
2. Seen in athletes in jumping sports or occupation with repetitive, forceful knee extension
3. X-ray: thickening of the patellar tendon

Question 57

Spondylolisthesis

Answer 57

1. Associated with anterior slippage of vertebral body ( L5 slips over S1) due to bilateral defects of the pars interarticularis (spondylolysis)
2. Repetitive back extension & rotation (gymnastics, divers) & adolescence growth spur

Signs:

1. Low back pain that is worse with lumbar extension
2. Radiculopathy as slippage progress (compress on spine; radiating pain, numbness, weakness)
3. Palpable step-off present !
4. X-ray: lumbar visible at lateral view

Treatment:

1. Modify activity
2. Neurologic deficits >90 days (obtain MRI of spine & surgical consultation)

Question 58

Spondylolysis

Answer 58

1. Associated with fracture of the pars interarticularis due to overuse injury (unilateral or bilateral)
2. Bilateral injury leads to spondylolisthesis

Question 59

Risk factor of avascular necrosis (osteonecrosis)

Answer 59

Risk factors:

1. Femoral head or neck fracture
2. Hip anterior dislocation
3. Glucocorticoids
4. Alcohol
5. Sickle cell disease
6. Systemic lupus erythematous

Signs:

1. Chronic groin pain
2. Decrease range of motion
3. X-ray shows: flattening/collapse of femoral head & patchy sclerosis
4. MRI: can be used if x-ray is not diagnostic: shows boundary between normal & ischemic bone

Question 60

Displaced supracondylar fracture of the humerus

Answer 60

Sign:

1. Fall on outstretched hand
2. Hold injury arm on flexed position & winces when touched & not moving arm
3. Posterior displacement of the distal humerus fragment
4. entrap of brachial artery & median nerve by the anteriorly displaced proximal humerus

Question 61

Radial head subluxation (nursemaid’s elbow)

Answer 61

1. Common in pre-school children
2. Caused by swinging or pulling a child by the arm

Sign:

1. Hold arm in pronation against chest
2. Avoid any movement

Treatment:
1. Closed reduction by forearm hyper-pronation (hear a pop indicates successful reduction)

Question 62

Colles fracture (distal radius fracture; dinner-fork deformity)

Answer 62

1. Associated with fall on outstretched hand & common in elderly
2. Can compress
   * radial artery (lead to absent pulse, delayed capillary refill)
   * median nerve (lead to acute carpal tunnel syndrome

Signs:

1. Severe wrist pain
2. Bruised & swollen

Treatment:
1. Closed reduction in the ED

Question 63

Post-amputation pain

Answer 63

Types:

1. Acute stump pain (tissue/nerve injury + severe pain lasts 1-3 weeks)
2. Ischemic pain ( swelling & skin discoloration + wound breakdown)
3. Post-traumatic neuroma ( weeks-months after amputation + altered local sensation + decrease pain with anesthetic injection)
4. phantom limb pain (usually within 1 week + intermittent cramp/ burning felt in distal limb)

Question 64

Tophaceous gout

Answer 64

1. Affects the olecranon bursa
2. Gout can affect the superficial bursea (olecranon & prepatellar)

Causing:

1. Acute bursitis: painful + inflammation changes+ Erythema, warmth, swelling
2. Chronic bursitis: no pain+ large, rounded, fluctuant swelling/effusion
3. Bursal tophus: no pain+ slowly enlarging, hard mass + chronic inflammation that leads to + bone erosion/overhanging edges of cortical bone

Risk factor for tophus formation:

1. Gout
2. Chronic kidney disease

Question 65

Osteosarcoma

Answer 65

1. Bone malignancy in adolescence (affects femur)
2. Or as malignant transformation due to paget disease in adults > 65 (affects axial skeleton)

Signs:
1. X-ray shows: periosteal reaction results in sunburst or codman triangle (destruction of trabecular & cortical bone with formation of new periosteal bone)

Question 66

Fat embolism syndrome (FES)

Answer 66

1. Occurs 24-72 hours after inciting event ( fracture, orthopedic surgery, pancreatitis)
2. Release fat into venous circulation
3. Lead to cerebral embolism

Signs:

1. Triads (respiratory distress, neurologic dysfunction/confusion, & petechial rash)
   * obstruction of pulmonary circulation: tachypnea, hypoxemia,
   * obstruction of cerebral circulation: confusion, visual field defect, unilateral arm weakness

Treatment:

1. Immobilization of fracture
2. Supportive care (mechanical ventilation)

Question 67

Signs of traumatic arterial injury

Answer 67

Hard signs ( require immediate surgery)

1. Distal limb ischemia (paralysis, pain, pallor, poikilothermy)
2. Absent distal pulse
3. Active hemorrhage & rapidly expanding hematoma
4. Bruit or thrill at site of injury

Soft signs ( require further imaging)

1. Diminished distal pulse
2. Unexpected HTN
3. Stable hematoma
4. Documented hemorrhage at time of injury
5. Associated neurologic deficit

Note:

1. Presence of hard sign after rib fracture indicates arterial injury & require immediate surgical intervention
2. Presence of soft sign after rib fracture suggest arterial injury have occurred & require further imaging ( CT angiogram)

Question 68

Clavicle fracture

Answer 68

1. Middle third of clavicle overlies the brachial plexus & subclavian artery/vein in the thoracic outlet

Question 69

Greenstick fracture (radius) (distal forearm fracture)

Answer 69

1. Common in children
2. Typically occur after a fall on outstretched hand
3. Because children have strong periosteum, fracture is limited in one bone (radius)

Sign:

1. Pain
2. Swelling
3. Limited range of motion

Treatment:

1. Immobilization
2. No long term complication

Question 70

Buckle fracture (incomplete radial fracture)

Answer 70

1. Common in children
2. Occurs in the distal radius &/or ulna due to fall on outstretched hand
3. X-ray is diagnostic & shows tiny bulging/bending of the bony cortex

Sign:

1. Pain over fractured area
2. Tenderness over fractured area
3. Limited range of motion (impaired thumb movement due to radial injury)
4. No swelling

Treatment:

1. Pain control
2. Heal within few weeks without complication

Question 71

Avascular bone necrosis

Answer 71

1. In children, is associated with the hip ( Legg-Calve-Perthes disease)
2. Signs: chronic joint pain & decrease of motion
3. X-ray: subchondral fracture & flattened, collapsed epiphysis

Question 72

Greater trochanter pain syndrome (trochanteric bursitis)

Answer 72

Risk factors:

1. Women
2. Age > 50
3. Obesity
4. Low back or lower extremity disorders ( scoliosis, osteoarthritis, planter fasciitis)

Signs:

1. Chronic lateral hip pain
2. Pain is worse with hip flexion or lying on affected side

Diagnosis:

1. Focal tenderness over trochanter
2. X-ray to rule out hip joint pathology
3. U/S shows degeneration of tendons or tendonitis

Treatment:

1. Activity modification
2. NSAIDS
3. Local Corticosteroid injection

Question 73

Salter harris type III ( juvenile Tillaux fracture)

Answer 73

1. Common in adolescence
2. Fracture of the distal tibial epiphysis & lateral physis (growth plate)
3. Injury to physis can lead to growth arrest & lead to persistence limb-length discrepancy

Question 74

Pes anserinus pain syndrome (anserine brusitis)

Answer 74

Pes anserinus : (attached point at medial knee)

1. Semitendenous tendon
2. Gracilis tendon
3. Sartorious tendon

Sign:

1. Medial knee pain
2. Overuse, abnormal gait, trauma
3. Pain at antero-medial tibia/ tenderness over the medial tibial chondyle or just below the joint line

Management:

1. Quadriceps strengthening exercise
2. NSAIDs

Question 75

Hip fracture due to fall & development of MI

Answer 75

1. Older patients with hip fracture should undergo definitive surgical correction as soon as possible.
2. Surgery may be delayed up to 72 hours to evaluate surgical risk & insure medical stability

Management:

1. ECG
2. Cardiac markers
3. Chest X-ray

Question 76

Leg- calve-perthes disease

Answer 76

1. Idiopathic avascular necrosis

Signs:

1. Children 3-12
2. Hip pain + limp + avoid weight bearing on affected limb
3. Limited abduction + internal rotation
4. Positive trendelenburg sign
5. X-ray: femoral head flattening, fragmented, sclerosis
6. MRI: avascular necrosis of femoral head
7. Treatment: surgical repair

Question 77

Ganglionic cyst

Answer 77

Is a connective tissue out-pouching, arising from tendon sheaths, joint capsule, or bursea

Signs:

1. Round, Mobile, Non-tender, firm cyst on dorsal of wrist
2. Transilluminate light
3. Intact grip strength

Treatment:

1. Observation: asymptomatic cyst- spontaneous resolve
2. Needle aspiration: recurrence

Question 78

Plantar fasciitis

Answer 78

1. Degeneration of planter aponeurosis (& its insertion at calcaneus due to overuse)
2. Heel pain with standing or walking

Signs:

1. Heel pain + worse with walking/standing & weight bearing
2. Pain elicited with dorsiflexion of toes
3. X-ray shows heel spurs

Treatment:
1. Padded heal insert

Question 79

Phantom limb pain (PLP)

Answer 79

1. Common following extremity amputation

Signs:

1. Shooting/burning pain at area that has been amputated
2. Pain is worse with urination/defecation

Treatment:
1. Multimodal pain control regimen (pharmacology & therapeutic)

• Antidepressant (tricyclic), anti-epileptic (gabapentin), NMDA antagonist (ketamine), analgesics (acetaminophen, opioids)

Question 80

Deep vein thrombosis (DVT)

Answer 80

1. Evaluate with duplex ultrasonography

2. Pain & swelling at effected lower extremity

Question 81

Post-traumatic neuroma

Answer 81

1. Regrowth of nerve fibers into tangled mass of unmylienated nerve endings

Sings:

1. Pain relieved with local anesthesia injection
2. Pain is exacerbated with palpation or percussion

Question 82

Lumbosacral radiculopathy (L5, S1)

Answer 82

1. Shooting pain radiates to foot
2. Associated with back pain
3. Symptoms exacerbated with range of motion testing (straight leg raising test)

Question 83

Acute glenohumoral dislocation

Answer 83

1. Blow to abducted/raised arm (play basketball)
2. Fall on outstretched hand
3. Violent muscle contraction (seizure)

Sign:

1. Anterior dislocation: arm held in abducted/external rotation. Anterior prominence of humeral head
2. Posterior dislocation: arm held in adducted/internal rotation. Loss of anterior contour, prominence of coracoid & acromion.

Manage:

1. Close reduction, surgical repair
2. Immobilization, progressive rehabilitation

Complication:

1. Fracture (glenoid, proximal humerus, clavicle)
2. Rotator cuff injury
3. Recurrence dislocation

Question 84

Osteomyelitis vs septic arthritis

Answer 84

1. Osteomyelitis: due to contamination of an open fracture fragment or contagious extension from a local wound. Infection of the bone. Infection of the end of long bone.
2. Septic arthritis: traumatic contamination by a penetrating wound. Infection of the cartilage, synovial fluid. Infection of the joint.

Question 85

Compartment syndrome

Answer 85

Caused by:

1. Trauma
2. Prolonged compression
3. Reperfusion after revascularization of acute ischemic limb

Signs:

Early (common)

1. Pain out of proportion to injury
2. Pain increase with passive stretch
3. Rapidly increasing & tense swelling
4. Paresthesia (pins & needle)

Late (uncommon):

1. Decrease sensation
2. Motor weakness (within hours)
3. Paralysis (late)
4. Decrease distal pulses

Treatment:

1. Needle Manometry to measure pressure (< 30 mmHg)
2. Fasciotomy (surgery)

Question 86

Cellulitis

Answer 86

Early signs:
1. Pain, redness, swelling, heat

Late sign:

1. Redness travels
2. Pain is worsen
3. More swelling & skin is tight

Manage:

1. Elevate leg
2. Ice pack

Question 87

Tarsal tunnel syndrome

Answer 87

1. Posterior tibial nerve compression beneath the flexor retinaculum in the medial ankle.

Signs:

1. Burning pain or numbness in the posteromedial ankle, heel, sole & toes (sharp, shooting pain,pins / needle pain
2. Elicited by tapping on the nerve (Tinel sign)

Question 88

Giant cell tumor

Answer 88

1. Benign tumor, but locally destructive
2. Common in epiphysis of long bone
3. Occur in young adults or older adults with paget disease

Sign:

1. Progressive pain
2. Swelling, stiffness
3. Maybe, pulmonary metastasis or malignant transformation

Diagnosis:
1. X-ray/ CT/MRI + Biopsy: soap-bubble appearance = eccentric lytic bone lesion + multi-nucleated giant cells (osteoclast interspersed with sheets of mononuclear stromal cells)

Treatment:

1. Surgery (intra-lesional curettage or excision)
2. To shrink the tumor = denosumab against RANKL

Question 89

Myositis ossificans

Answer 89

1. Heterotropic bone formation

Sign:

1. Intramuscular mass with pain, swelling/induration
2. Days to weeks following injury
3. Quadriceps & brachialis
4. Labs: elevated alkaline phosphatase, ESR, CRP
5. X-ray: periosteal bone reaction, calcification with radiolucent center

Management:

1. ROM exercise & NSAID (indomethacin)
2. Surgical excision

Question 90

Intra-peritoneal bladder rupture (at dome)

Answer 90

Signs:

1. Blunt lower abdominal trauma
2. Inability to void (urine go to peritoneal space)
3. Abdominal distention with ascites ( increase abdominal girth + dull percussion with fluid wave)
4. Elevated BUN & Creatinine ( due to peritoneal reabsorption)
5. Acute onset
6. Positive FAST for intra-peritoneal fee-fluid
7. Chemical peritonitis

Diagnosis:
1. Retrograde cystography

Question 91

Severe cirrhosis (alcoholic liver disease)

Answer 91

Signs:

1. Ascites ( abdominal girth + dull percussion with fluid wave)
2. Low serum albumin
3. Progressive pattern of ascites symptoms

Question 92

Acute kidney injury

Answer 92

1. Develop from rhabdomyolysis (short term alcohol intoxication + long term alcohol abuse)

Signs:

1. Elevated BUN & Creatinine
2. No ascites
3. Dark urine

Question 93

Perforation

Answer 93

1. Systemic inflammatory response ( fever, tachycardia)

2. Peritonitis (abdominal rigidity)

Question 94

Splenic injury ( laceration ) due to blunt abdominal trauma

Answer 94

Signs:

1. Abdominal distention
2. Hemorrhagic shock ( tachycardia + hypotension)
3. LUQ pain

Question 95

Evaluation of blood in urine (red urine)

Answer 95

1. Urinalysis
   = > 3 RBC/hpf : hematuria
   = 0-2 RBC/hpf : hemoglobinuria (intravascular hemolysis + decrease Hb &haptoglobin) or myoglobinuria (rhabdomyolysis + increase CK+ muscle ache)
2. CBC: to assess severity of anemia/fatigue

Question 96

Glomerulonephritis

Answer 96

Signs:

1. HTN
2. Proteinuria
3. Urinary RBC casts

Diagnose:
1. Serum complement level

Question 97

Infection (UTI)

Answer 97

Sign:

1. Dysuria
2. Pyuria

Diagnosis:
1. Urine culture

Question 98

Prosthetic valve

Answer 98

Signs:

1. Infective endocarditis
2. Fever
3. New murmur
4. Maybe hematuria & proteinuria ( due to IE- associated acute kidney injury)

Question 99

Posterior Urethral injury (male)

Answer 99

1. Caused by pelvic fracture (signs: adducted, internally rotated, & perineal bruising)

Signs:

1. Blood in the urethral meatus
2. High-riding prostate
3. Inability to void
4. Perineal bruising

Diagnosis:
1. Retrograde urethrography (diagnosed via extravasation of contrast from urethra)

Treatment:
1. Temporary urinary diversion via supra-pubic catheter, followed by delayed repair

Note:
1. Never start with catheterization because it can convert urethral tear into laceration

Question 100

Anterior urethral injury (male)

Answer 100

Sign:

1. Penile fracture
2. Straddle injury

Treatment:
1. Repaired urgently within 24 hours

Question 101

Renal or peri-nephritic abscess

Answer 101

Signs:

1. Insidious flank pain
2. Systemic symptoms (fever, fatigue, diaphoresis, weight loss)
3. Urinalysis (pyuria, bacteriuria, proteinuria)
4. History of UTI or extra-renal infection (bacteremia)

Diagnosis:
1. CT or US: enlarged kidney with central, hypo-dense fluid collection

Treatment:

1. Antibiotics
2. Percutaneous drainage

Question 102

Acute interstitial nephritis

Answer 102

1. Can cause acute kidney injury
2. Caused by drugs: methicillin, NSAIDs, rifampin

Signs:

1. Fever
2. Rash
3. Pyuria
4. Urine eosinophilia with WBC casts

Treatment:
1. Resolves spontaneously

Question 103

Acute papillary necrosis

Answer 103

1. Causes AKI

Signs:

1. Fever
2. Flank pain
3. Hematuria
4. History of analgesic overuse or sickle cell anemia

Question 104

Renal cell carcinoma

Answer 104

Signs:

1. Weight loss
2. Fever
3. Anemia
4. Hematuria
5. Flank pain/mass

Question 105

Renal tuberculosis

Answer 105

1. Due to hematogenous spread of miliary tuberculosis
2. Lead to abscess formation or glomerulonephritis

Signs:

1. Pyuria (WBC)
2. Hematuria (RBC)
3. Urinary casts
4. Lower UTI symptoms

Question 106

Pre-renal acute kidney injury (AKI)

Answer 106

1. No underlying kidney disease
2. Caused by intravascular volume depletion (due to preoperative infection or intra-operative blood loss)

Signs:

1. Decrease urine output (oliguria < 500mL)
2. Increase BUN:CR ratio (20:1)
3. Increase serum creatinine (due to volume depletion = decrease renal perfusion =decrease GFR)
4. Unremarkable urine sediment (absent of casts, cell, or protein)
5. Tachycardia, hypotension

Treatment:
1. Intravenous isotonic fluid (normal saline) to restore renal perfusion

Question 107

Volume overload

Answer 107

1. JVD
2. Lung crackles
3. Pulmonary edema
4. Hypoxia

• note:
  1. Similar to recurrent flash pulmonary edema (with no lower extremity edema)

Question 108

Renal artery stenosis (RAS) (Reno-vascular disease)

Answer 108

1. HTN-related symptoms
2. Severe HTN & recurrent flash pulmonary edema (JVD & pulmonary crackles, without lower extremity edema) suggest RAS
3. Associated symptoms include: chronic kidney disease, secondary hyper-aldosteronism (hypo-kalemia, elevated serum bicarbonate)

Signs:

1. Asymmetrical renal size (>1.5 cm)
2. Abdominal bruits
3. Unexplained rise in serum creatinine (>30%) after starting ACE inhibitor or ARBs
4. Urinalysis is bland
5. Imaging (renal ultrasound with doppler): unexplained atrophic kidney

Question 109

Post-operative urinary retention

Answer 109

1. Urine retention is a common post-operative complication
2. Risk factor: (male, elderly, hernia repair, joint arthroplasty, anorectal operation, prolonged anesthesia, excessive fluid administration, use of opioid, anti-cholinergic)

Signs:

1. Hypertension
2. Tachycardia
3. Supra-pubic discomfort/fullness (elicit with palpation)

Diagnose:

1. Portable bladder ultrasound
2. Urinary catheterization performed if (> 600 mL on U/S)

Question 110

Anterior bladder wall rupture

Answer 110

Sign:

1. Gross hematuria
2. Supra-pubic pain/tenderness
3. Inability to void
4. Negative FAST for intra-peritoneal fee-fluid

Question 111

Hydronephrosis

Answer 111

1. Swelling of one or 2 kidneys due to inability to drain urine & urine build up
2. Causing dilation of renal pelvis
3. Indicates urinary obstruction
4. Treat with: ureteral stent placement

Question 112

Posterior urethral valves (PUV)

Answer 112

1. Newborn + abdominal distention + poor urine output + respiratory distress (oligohydromnias = subsequent lung hypoplasia)
2. Diagnosis: renal/bladder US

Question 113

Evaluation of acute kidney injury

Answer 113

Evidence of volume depletion:

Yes; Improve with IV-fluid (yes; pre-renal)
No; Urinalysis & microscopy (normal; exclude renal obstruction; post-renal)

abnormal; (intrinsic)

1. hematuria +/- proteinuria (evaluate for glomerulonephritis; inflammation)
2. Pyuria ( evaluate for Acute Interstitial Nephritis; antibiotics)
3. Granular casts (muddy brown) +/- epithelial cells (evaluate for acute tubular necrosis; intraoperative hypotension )

Question 114

Varicocele

Answer 114

Primary:

1. Compression of left renal vein between SMA & Aorta
2. Incompetent venous valve
3. Presentation: Bag of warms mass; pubertal onset; left-sided; decompression when supine
4. Management: reassurance & observation

Secondary:

1. Extrinsic compression of IVC (renal or retroperitoneal mass)
2. Venous thrombus lead to venous compression
3. Presentation: bag of warms; pre-pubertal onset; right-sided; persists when supine
4. Management: Abdominal US

Question 115

Testicular cancer

Answer 115

1. Male; 15-35 years
2. Present with painless, & firm testicular mass
3. Management: surgical orchiectomy
4. Avoid biopsy due to tumor seeding

Question 116

Epididymitis

Answer 116

1. Infectious case of scrotal swelling & pain

2. Management: urine culture

Question 117

Bladder cancer

Answer 117

1. Present with: old patient + hydronephrosis + painless hematuria + voiding symptoms
2. Diagnosis: cystoscopy + biopsy + CT abdomen (staging)

Notes:

1. Hydronephrosis: associated with flank pain + increase creatinine level
2. Voiding symptoms: dysuria + frequency
3. Hematuria: due to tumor growth+ new vessels bleeding

Question 118

Acute hyponatremia (<48 hrs)

Answer 118

• risk of brain herniation (cellular swelling, & cerebral edema)

Signs:

• sodium <130 mEq/L
• signs of elevated intracranial pressure (ICP) (headache, N, confusion)

Treated:
- hypertonic 3% saline

Question 119

Acute adrenal insufficiency

Answer 119

Signs:

• hyponatremia
• hyperkalemia
• severe hypotension
• confusion
• N/V
• weakness

Treatment:

• dexamethasone
• hydrocortisone

Question 120

Hydronephrosis

Answer 120

Signs:

• N/V
• HTN
• unilateral flank pain
• initially relieved by pain killer
• Normal Creatinine level
• later, causes costovertebral angle tenderness + non/radiating back pain

Occurs with:
-ureter injury after hysterectomy

Question 121

Pyelonephritis

Answer 121

Signs:

• costoveretebral angle tenderness
• fever
• chills
• elevated creatinine level

Occurs with:
- complication of foley catheter

Question 122

Nephrolithiasis

Answer 122

Signs:

• unilateral back pain, radiates to groin
• N/V
• Hematuria

Question 123

Urethral stricture (fibrotic narrowing)

Answer 123

Signs:

• urine retention
• decrease spraying stream
• incomplete emptying of bladder
• post-void residual volume is high

Diagnosis:
- urethrography

Treatment:

• urethral dilation
• urethroplasty

Question 124

CT abdomen / pelvis

Answer 124

-for renal injury

Signs:

• flank pain with ecchymosis
• Costo-vertebral tenderness
• hematuria

Question 125

Polycystic kidney disease (Autosomal dominant)

Answer 125

Signs:

• HTN
• Hematuria
• recurrent flank pain
• 30-40 ages

Diagnosis:
- U/S shows multiple cysts in kidney

Treatment:
-supportive (vasopressin-2 receptor antagonist: Tolvaptan; slow disease progression)

Question 126

Chronic kidney disease (decrease GFR)

Answer 126

Results in:

• decrease 1.25 DH vitamin D = decrease Ca
• decrease phosphate filtration = increase Phosphate

Causes:
- Increase PTH (secondary hyperparathyrodism)

Output:
-inadequate treatment: osteitis fibrosa cystica (a form of renal osteodystrophy) ( high PTH, High bone turnover, decrease mineralization with fibrosis, increase fracture risk)

• excessive treatment: adynamic bone disease ( low PTH, low bone turnover, decrease cellularity & mineralization, increase fracture risk)
• optimal treatment: normal bone turnover

Note:
- femoral fracture in CKD raise suspicion for secondary hyperparathyrodism

Question 127

Lung abscess

Answer 127

Sign:

• alcohol use
• foul smelling sputum
• Fever
• Leukocytosis
• cavity infiltrate with air-fluid level
• fever, night sweat, weight loss, cough with putrid sputum

Caused by:

• aspiration of (oropharangeal) anaerobic bacteria
• due to periods of swallowing difficulty & LOC (ALCOHOL USE)

Diagnosis:

• CT
• X-ray
• shows consolidation (inflammatory exudate & edema)
• abscess (air-fluid level)

Treatment:
-ampicillin-sulbactam

Question 128

Acute lung rejection

Answer 128

Signs:

• fever
• cough
• dyspnea

Confirmed:
- chest x-ray: shows perihilar opacities & interstitial edema

Diagnosis:

• lavage
• biopsy

Treatment:
- high dose glucocorticoid

Question 129

Hemothorax vs tension pneumothorax vs diaphragm rupture vs lung atelectasis vs lung contusion vs flail chest vs fat emboli vs myocardial contusion

Answer 129

Hemothorax:

• hypotension - tachycardia -tachypnea
• decreased (diminished) breath sound
• dullness on percussion
• contralateral tracheal deviation
• treat: tube thoracotomy

Tension pneumothorax:

• hypotension - tachycardia -tachypnea
• absent breath sound
• hyper-resonance on percussion
• contralateral tracheal deviation
• air leakage into mediastinum & pleural space

Diaphragm rupture:

• no hypotension -no tachycardia
• Decrease breath sound
• Tracheal deviation
• diagnosis: visualize with (intra-thoracic nasogastric tube)

Lung atelectasis (alveolar collapse) & lung contusion (alveolar edema)

• tachycardia -tachypnea -no hypotension
• decrease breath sound
• dullness to percuss

Flail chest:

• tachypnea -hypoxia
• respiratory distress
• impaired generation of negative (intrathoracic) inspiratory pressure
• tidal volume decrease & work of breathing increase (become fatigue & develops respiratory failure = requires mechanical ventilation)
• requires mechanical positive pressure ventilation
• lead to lung contusion, atelectasis, hypoxia (due to poor ventilation )
• fracture of > 3 adjacent ribs in > 2 positions

Fat emboli:

• associated with long bones
• occlude pulmonary capillaries & lead to hypoxia
• associated with neurological deficits
• occurs within 24-72 hours
• signs: 1. Respiratory distress; 2. Neurological deficits; 3. Rash

Myocardial contusion:
- result in cardiogenic pulmonary edema & hypoxia

Question 130

Venous air embolism (VAE)

Answer 130

-Develops after removal of central venous catheter (CVC)

Signs:

• respiratory distress
• ventilation/perfusion mismatch
• hypoxemia
• obstructive shock
• cardiac arrest

Management:

• left lateral decubitus or left lateral trendelnburg (left lateral decubitus with head down) = traps the VAE into lateral wall of the right ventricle = prevent right ventricle outflow tract obstruction
• high flow oxygen = shrink VAE as it allow absorption of nitrogen

Question 131

Sleeping position and clinical correlation

Answer 131

Prone:
- for atelectasis

Supine:
-arterial air embolism (prevent travel to brain)

Left lateral decubitus:
- venous air embolism (help VAE to move to lateral wall of right ventricle & prevent RVOTO

Right lateral decubitus: (Normal)
- encourage movement of air into right ventricle outflow tract to pulmonary

Semi-recumbent
-lower risk for ventilator acquired pneumonia in incubated patients in mechanical ventilation

Question 132

Post-operative pneumonia

Answer 132

Prevention:

1. Incentive spirometry
2. Deep breathing exercise
3. Continuous positive airway pressure (expensive)

Question 133

Hemodynamic measures in shock

Answer 133

1. PCWP: left sided preload
2. CI: LV output
3. SVR: afterload
4. CVP: right-sided preload
5. SvO2:

Hypovolemic shock: (increase ejection fraction)

1. PCWP: low
2. CI: low
3. SVR: high
4. CVP: low
5. SvO2: low

Cardiogenic shock: (myocardial contusion)

1. PCWP: high
2. CI: low
3. SVR: high
4. CVP: high
5. SvO2: low

Obstructive shock:

1. PCWP: low
2. CI: low
3. SVR: high
4. CVP: high
5. SvO2: low

Distributive shock:

1. PCWP: low
2. CI: high
3. SVR: low
4. CVP: low
5. SvO2: high

Question 134

Hypovolemic shock & mechanical ventilation & sedatives

Answer 134

• positive pressure mechanical ventilation causes acute increase in the intra-thoracic pressure
• in case of hypovolemic shock ( decrease CVP): initiation of mechanical ventilation can cause acute loss of right-ventricular preload, loss of Cardiac output & cardiac arrest.
• sedatives can lead to relax of venous vessels & loss of venous return (hypotension)

Question 135

Isolated rib fracture

Answer 135

Causes:

1. Shallow breathing
2. Atelectasis (increase risk for pneumonia)

Manage:

1. Adequate analgesia
2. Pulmonary toilet
3. Incentive spirometry

Question 136

Septic shock

Answer 136

Signs:

• hypotension
• tachycardia
• fever
• low urine output

Caused by:
-pneumonia

Manage:

1. restore adequate tissue perfusion + identify underlying infection —> via: Crystalloid (1. lactate ringer (IV); 2. Normal saline 0.9%)
2. Continuously monitor patient to prevent volume overload ( pulmonary edema, hypoxia, or until pressure is not improved)
3. Next step, use Norepinephrine (vasopressor) to improve perfusion.

Question 137

Isotonic solution (0.9%)

Answer 137

• used in case of metabolic acidosis that is developed due to lactic acidosis (tissue hypoperfusion)

Question 138

Acute respiratory distress syndrome (ARDS)

Answer 138

Types of lung injury:

1. Direct: pneumonia or inhalation
2. Indirect: sepsis, pancreatitis, or trauma

Signs:

1. Within 1 week
2. X-ray shows bilateral alveolar opacities
3. Exclusion of cardiac failure or volume overload

Diagnosis:

1. ECG
2. Troponin I
3. B-type natriuretic peptide
4. Bedside TTE

Question 139

Lung cancer

Answer 139

Bronchial carcinoid tumors:

1. Young + nonsmoker
2. Airway obstruction ( dyspnea + wheezing + post-obstructive pneumonia) or hemoptysis
3. Mass with an endobronchial component

Small cell carcinoma

1. Former or active heavy smoker
2. Bulky hilar or mediastinal mass

Squamous cell carcinoma:

1. Former or active heavy smoker
2. Central cavitation (heterogenous density) due to tumor necrosis

Question 140

Diaphragmatic paralysis

Answer 140

Caused by:

1. Phrenic nerve injury (surgery)
2. Viral ( Herpes zoster, poliomyelitis)
3. Neurological ( ALS, GBS)

Signs:

• dyspnea on exertion
• orthopnea
• paradoxical breathing movement (abdomen moving inward during inspiration)

Diagnosis:
-paradoxical movement of diaphragm/abdomen during brisk inspiration (fluoroscopic sniff test) (abdomen goes inward instead of outward during inspiration)

Question 141

Aspiration pneumonia with subsequent lung abscess

Answer 141

Caused by:

• impaired consciousness (alcohol, drug, seizure)
• swallowing difficulty (Parkinson disease)

Signs:

• Systemic system
• cough (yellow sputum)
• x-ray: cavity infiltrate

Note:
- similar to lung cancer, however , in cancer no yellow sputum

Question 142

Ludwig angina

Answer 142

-cellulitis of submandibular & sublingual spaces

Signs:
- airway obstruction ( drooling, tripod position, can’t lay flat)

Question 143

Chemical pneumonitis

Answer 143

• within minutes to hours after aspiration of gastric acid that burns the lower respiratory tract

Treat:

• supportively
• oropharyngeal suction

Question 144

Bacterial aspiration pneumonia

Answer 144

1. Within days to weeks after aspiration of oropharyngeal or gastric microbes

Treat:
1. Antibiotics

Question 145

Massive pulmonary embolism

Answer 145

Signs:

• hypotension
• right heart strain = right bundle branch block
• JVD

Diagnosis:
-CT angiography

Immediate death occurs

Question 146

Rib fracture location & associate injuries

Answer 146

1-3 ribs: subclavian, brachial plexus, mediastinal vessels (aorta)

3-6: cardiovascular

9-12 ribs: intraabdominal: liver, spleen, kidney (11-12) —> detected via CT scan of abdomen (with contrast to visualize blush/extravasation) in hemodynamically stable patient (SBP >90)

Question 147

Pulmonary embolism

Answer 147

Signs:

• sudden dyspnea
• tachycardia
• nonproductive cough
• mild hypoxia

Diagnosis:

• CT angiography (stable)
• TTE (unstable; massive PE with syncope, shock)

Manage:

• IVC filter
• anticoagulation

Question 148

Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu) (HHT)

Answer 148

Signs:

• hemoptysis
• epistaxis
• pulmonary bruits
• nodular lung lesions
• anemia (iron deficiency; microcytic)

Lead to:

• mucocutaneous telangiectasia
• visceral organ Arteriovenous malformation

Diagnosis:
-x-ray: smooth & well-circumscribed nodular opacities

Treatment:
- pulmonary angiography followed by embolization (induces the blood to clot and block the flow of blood)

• AFTER 1-3 months, CT scan is performed to ensure complete blockage of pulmonary AVM

Question 149

Tracheo-bronchial injury

Answer 149

• in patients with thoracic trauma & extensive extra-pulmonary air (chest tube with persistent large air leak)

Signs:

• tension pneumothorax ( hypotension, deviated trachea, absent breath sound)
• crepitus ( crackling of the neck & chest skin)

Diagnosis:

• bronchoscopy
• operative repair

Question 150

Post-operative atelectasis

Answer 150

• seen on day 2 after a surgery and up to day 5.
• result from shallow breathing & weak cough due to pain

Signs:

• hypoxemia (low PO2)
• respiratory alkalosis

Prevent with:

• deep breathing exercise
• incentive spirometry
• adequate pain control
• directed coughing
• early mobilization

Manage:

• CPAP (continuous positive airway pressure) to help open collapsed alveoli
• atelectasis due to large mucus plugging requires (bronchoscopy)

Question 151

Following lung resection surgery

Answer 151

Predictor:

• FEV1
• diffuse lung carbon monoxide (DLCO)

Question 152

Acute hemolytic transfusion reaction (AHTR)

Answer 152

-develop within minutes to hours

Signs:

• fever
• hypotension
• flank pain
• hemoglobinuria
• DIC

Diagnosis:
-Coombs test

Question 153

Spontaneous pneumomediastinum

Answer 153

-tall, thin adolescent boy with asthma

Signs:

• acute chest pain
• SOB
• cough
• subcutaneous emphysema (crepitus, crackles in the neck and skin of chest)
• hamman sign

Diagnosis:
-x-ray: mediastinal gas

Manage:

• rest
• analgesia
• avoid valsalva maneuver

Question 154

Post-transplant lymphproliferative disorder (PTLD)

Answer 154

• occurs after receiving an organ transplant
• triggered by immunosuppressive medication (impairs cytotoxic T-cells, that lead to uncheck viral pathogens in donor tissue)

Question 155

Management of patients with burns

Answer 155

Steps:
- administer 100% oxygen

• early assessment of airways
• indicators of inhalation injury/oropharyngeal blistering = perform endotracheal intubation

** for stable patient: fibroptic laryngoscopy to visualize airways

Question 156

Hemorrhagic shock

Answer 156

Signs:

• hypotension
• tachycardia
• decrease capillary refill
• narrow pulse pressure (cool extremity)

Manage:
- 1:1:1 ratio of packed RBC + FFP + Platelets (to reduce coagulopathy)

• adjunct: antifibrolytic agent (within 3 hours) or topical hemostatic agent (kaolin-impregnated sponge, fibrin sealant dressing; to control external bleeding)

Question 157

Clinical feature of type 2 heparin-induced thrombocytopenia ( HIT)

Answer 157

Signs appear after 5 days of using heparin:

Signs:

• decrease platelet by 50%
• narcotic skin lesion at site of heparin injection
• arterial or venous thrombosis
• acute systemic reaction (anaphylactoid) after heparin

Diagnosis:
- serotonin release assay

Manage:

• stop heparin
• use direct thrombin inhibitor (argatroban; delay blood clotting) or fondaparinux (synthetic pentasaccharide)

-Warfarin can be used after platelet rise > 150,000, because if used as initial management it can lead to thrombus formation due to lowering protein C

Question 158

Transfusion reaction associated with hypotension

Answer 158

Anaphylaxis:

• Within seconds-minutes
• signs: shock, respiratory distress, angioedema/utecaria (rash)
• caused by: IgA antibodies
• manage: epinephrine, anti-histamine

Acute hemolysis:

• within minutes-hours (1 hr)
• signs: fever, hypotension, flank pain, hemoglobinuria, DIC
• Caused by: ABO incompatibility
• positive Coombs test

Urticarial:

• within hours (2-3 hours)
• sign: urticaria
• caused by IgE against blood components

Febrile non-hemolytic:

• within hours (1-6hrs)
• signs: fever, chills
• caused by: cytokine accumulation during blood storage

Transfusion-related acute lung injury: (TRALI)

• within minutes-hours (6 hrs)
• signs: respiratory distress (hypoxia, SOB), pulmonary edema, pulmonary infiltrates
• caused by: donor anti-leukocytes antibodies
• Manage: respiratory supportive care + transfusion stop

Bacterial sepsis:

• within minutes-hours
• signs: fever, chills, septic shock, DIC
• Caused by: bacterial contamination of donor product

Delayed hemolytic:

• within days to weeks
• signs: asymptomatic, hemolytic anemia, positive Coombs test, positive new antibody screen
• caused by: anamnestic antibody respond

Graft vs host reaction:

• within weeks
• sign: rash, fever, GI symptoms, pancytopenia
• caused by: donor T-lymphocytes

Question 159

Disseminated intravascular coagulation (DIC)

Answer 159

Question:

• decrease urine output
• oozing from IV site

Sign:

• bleeding
• hypotension, tachycardia (hemodynamic unstable)
• acute kidney & liver injury

Causes:

• sepsis
• severe traumatic injury
• malignancy
• obstetric complication

Pathophysiology:

• procoagulant excessively trigger coagulation cascade
• formation of fibrin or platelet rich thrombi & fibrinolysis
• bleeding & organ damage (kidney, lung)

Laboratory:

• increase D-dimer
• increase PT & PTT time (consumption of coagulation factor)
• decrease fibrinogen
• decrease platelet ( thrombocytopenia )
• hemolytic anemia (schistocytes)

Question 160

Acquired methoglobinemia

Answer 160

• anesthesia agent oxidize iron in hemoglobin (altered hemoglobin state)

Sign:

• hypoxia ( pulse oximetry 85%) (bluish discoloration of lips/fingertip)
• large oxygen saturation gap

Question 161

Bacterial pneumonia

Answer 161

• causes plueral effusion
• types:
  1) uncomplicated: small, sterile, resolve with antibiotics
  2) complicated (empyema): frank pus/bacteria, requires drainage via chest tube, and antibiotics

Question 162

Mucus plugging

Answer 162

-lead to large-volume atelectasis (lung collapse) due to airway obstruction.

Sign:

• absent of breath sound
• dullness to percuss

Diagnosis:
-x-ray: opacification of the affected lung area & mediastinal shifting towards the side of atelectasis

Question 163

Peripheral Inserted central catheter (PICC)

Answer 163

• lead to upper extremity deep venous thrombosis

Signs:
-arm swelling, pain, erythema

Diagnosis:
-duplex U/S

Manage:
-3 months of anti-coagulation

Question 164

Hemorrhagic shock (blood transfusion)

Answer 164

Management:

1) women of childbearing or young girls: group O-RH D negative blood
2) women past childbearing & men: group O-RH D positive blood

While waiting for type-specific blood

Question 165

Lethal triad in trauma patient

Answer 165

1) hypothermia
2) coagulopathy
3) acidosis

Question 166

Large-volume crystalloid resuscitation

Answer 166

• increase coagulopathy
• increase hypothermia
• increase mortality in patients
• balance crystalloid use: maintain a blood pressure that is sufficient for tissue perfusion

Question 167

Acute pulmonary embolism

Answer 167

Signs:

• right sided chest pain (pleuritic in nature)
• signs of VTE risk factors ( travel, surgery, swelling calf, OCP)

Diagnosis:
- CT pulmonary angiography

Question 168

Spontaneous pneumothorax

Answer 168

Feature:

• no previous history of lung disease
• thin, young men
• history of cystic fibrosis, COPD, smoking, marfan syndrome, thoracic endometriosis

Sign:

• chest pain, dyspnea
• decrease breath sound, decrease chest movement
• hyper-resonance to percussion

Imaging:

• visceral pleural line
• absent lung markings beyond pleural edge

Management:

• small (<2 cm): observation & oxygen administration
• large & stable: large bore needle aspiration (14 or 18) or chest tube

Question 169

Tension pneumothorax

Answer 169

Feature:

• life-threatening
• due to trauma or mechanical ventilation

Sign:

• chest pain, dyspnea
• decrease breath sound, decrease chest movement
• hyper-resonance to percussion
• hemodynamic instability
• tracheal deviation away from affected side

Imaging:

• visceral pleural line
• absent lung marking beyond pleural edge
• contralateral mediastinal shift
• ipsilateral hemi-diaphragm flattening

Management:
- urgent needle decompression or chest tube placement

Question 170

Head & neck squamous cell carcinoma (

Answer 170

• associated with alcohol & smoking

Sign:
- palpable cervical lymph node

Diagnosis:
-laryngopharyngoscopy

Question 171

Hemothorax

Answer 171

• bleeding > 1500 ml

Management:

• tube thoracotomy
• emergent thoracotomy for extreme bleeding (>2000ml) or continuous need for blood transfusion to maintain hemodynamic stability

Question 172

Ventilator-associated pneumonia

Answer 172

• develops > 48 hours after endotracheal intubation
• caused by: aspiration of microorganism from oropharynx or stomach into pulmonary parenchyma (caused by leakage around the cuff) (due to supine position or movement of tube)

Management:

• head of bed is elevated to 30-45 degree
• suction of subglottic secretion
• minimize tube movement
• limit use of gastric acid inhibitors (PPI, antacid..)

Question 173

Rectus sheath hematoma

Answer 173

• occur due to rupture of inferior epigastric artery from blunt trauma or forceful abdominal contraction (severe coughing)
• associated with patient receiving anti-coagulation drugs

Sign:

• acute abdominal pain
• palpable abdominal wall mass (does not move with movement)
• anemia
• leukocytosis

Diagnosis:
-abdominal CT

Management:

• stable: conservatively (serial CBC test, reversal of anticoagulation)
• unstable (shock) : angiography with embolization

Question 174

Anterior mediastinal mass

Answer 174

Types:

• thymoma
• teratoma (& other germ cell tumor)
• lymphoma
• thyroid neoplasm

thymoma

• middle-aged patients
• paraneoplastic syndrome ( Myasthenia Gravis; Abnormal anti-acetylcholine receptor antibodies; ptosis)
• normal AFP & Beta-hCG

teratoma (& other germ cell tumor)
-elevated AFP & Beta-hCG

lymphoma

• fever, weight loss, night sweat
• normal AFP & Beta-hCG

thyroid neoplasm

Seminoma:

• elevated Beta-hCG
• normal AFP

Question 175

Breast mass

Answer 175

Signs:

• unilateral
• firm
• fixed
• causing nipple retraction

Diagnosis:

1. Mammogram or U/s
2. Biopsy

Question 176

Acute graft vs host disease

Answer 176

• caused by donor T-lymphocytes attacking host antigens
• occurs within 100 days of transplant

Sign:

• rash
• abdominal pain
• profuse, watery diarrhea
• Hepatobiliary inflammation

Question 177

Vitamin k deficiency

Answer 177

• associated with coagulation factors (2, 7,9,10)

- cause bleeding due to coagulation factors deficiency

Question 178

Vitamin C deficiency

Answer 178

• cause bleeding due to vessel fragility

Question 179

Hemophilia A

Answer 179

• associated with coagulation factor 8

Question 180

Anti-platelet dysfunction

Answer 180

• caused by aspirin

- associated with Von Willebrand disease

Question 181

Horner syndrome

Answer 181

Sign:
-ipsilateral ptosis, miosis, anhidrosis

Associated with Pancoast (superior pulmonary sulcus tumor) tumor :

• shoulder pain
• Horner syndrome
• neurologic deficit (C8-T2) (atrophy/numbness of hand muscle)
• supraclavicular lymphadenopathy
• weight loss

Diagnosis:

• chest x-ray: mass in the lung apex (superior portion) (at superior sulcus)
• staging (TNM)
• biopsy

Question 182

Exudative effusion

Answer 182

Analysis:

• pleural protein/serum protein >0.5
• pleural LDH/serum LDH >0.6
• Pleural LDH > 2/3 upper limit of normal for serum LDH

Etiology:

• empyema ( purulent fluid, neutrophil-predominant, + gram stain/ culture)
• chylothorax ( milky white fluid, increase triglycerides)
• malignancy ( abnormal cytology)
• TB (+ acid-fast bacterial stain/culture

Caused by:

• increase capillary permeability
• disruption of thoracic duct (drainage)
• direct leakage of chyle/ lymphatic fluid into pleural cavity (chylothorax)

Management of chylothorax:

• drainage via thoracentesis
• drainage via chest tube placement
• limitation of dietary fat
• thoracic duct ligation

Question 183

Pulmonary contusion

Answer 183

-occurs 24 hours after thoracic trauma

Signs:

• tachypnea
• tachycardia
• hypoxia
• rales or decrease breathing sound
• CT or X-ray: irregular, non-lobular infiltrates (alveolar edema: ground-glass opacities)

Manage:

• pain control
• pulmonary hygiene ( incentive spirometry, Chest physio)
• oxygen & ventilation

Question 184

Blunt thoracic trauma

Answer 184

• injure the lung
• causing alveolar edema & hemorrhage (that is worsened by resuscitation)
• lead to dyspnea, tachycardia, hypoxemia

Question 185

Mediastinal compartment, structure & masses

Answer 185

Anterior compartment:

• structures: thymus, lymph node
• masses:
  1) thymoma
  2) lymphoma
  3) germ cell tumors ( teratoma, seminoma, & nonseminoma)
  4) thyroid tissue (ectopic, substernal goiter)

Middle compartment:

• Structures: lymph node, pericardium, heart & great vessels, trachea & main bronchi, esophagus
• masses:
  1) lymphadenopathy (sarcoidosis, lung cancer), lymphoma
  2) benign cystic masses ( pericardial cyst, bronchogenic cyst)
  3) vascular mass
  4) esophageal tumors

Posterior compartment:

• structures: neural tissues, vertebrae, lymph node
• masses:
  1) neurogenic tumors (schwannoma, neurofibroma), meningiocele
  2) spinal masses ( metastases)
  3) lymphoma

Question 186

Testicular cancer

Answer 186

Sign:

• painless testicular mass
• unilateral
• dull achy lower abdomen

Diagnosis:

• bilateral scrotal U/S
• tumor markers (LDH, Beta hCG, AFP)
• Radical inguinal orchiectomy (used to remove testicles with cancer)

Question 187

Chronic bacterial prostatitis

Answer 187

• caused by e.coli or coliform bacteria

Signs:

• urinary tract infection
• painful ejaculation
• prostatic tenderness (+/-)
• young or middle-aged man
• improves with short course of antibiotics (6 weeks of Fluoroquinolone/ciprofloxacin)
• bacteria & pyuria in urine

Question 188

Acute epididymitis

Answer 188

Etiology:

• less than 35 yrs: sexually transmitted (chlamydia, gonorrhea)
• more than 35 yrs: bladder outlet obstruction (coliform bacteria; e.coli)

Signs:

• unilateral, posterior testicular pain
• epididymal edema
• pain improves with testicular elevation
• dysuria & frequency with (coliform infection)

Diagnosis:
-NAAT for chlamydia & gonorrhea (nucleic acid amplificatio
test)
-urinalysis/ culture

Question 189

Priapism

Answer 189

Sign:

• prolonged & painful erection (more than 12 hours)
• seen with hematologic disorders ( altered blood viscosity, sickle cell disease, CML, Thalassemia, multiple myeloma)

Diagnosis:
-CBC

Management:

• aspirate blood from the corpora cavernosa
• intracavernous injection of phenylephrine

Question 190

Benign prostatic hyperplasia

Answer 190

Signs:

• urinary urgency
• straining to urinate
• sensation of incomplete bladder evacuation
• frequent nocturia

MANAGEMENT:

1) alpha-blockers
2) 5-alpha reductase inhibitor
3) Phosphodiesterase type 5 inhibitor
5) TURP

Note:
- transurethral resection of the prostate (TURP) is performed to reduce the size of prostate, however, after years the remaining part of prostate tissue can grow back & and block bladder and lead to BPH.

Question 191

Acute bacterial prostatitis

Answer 191

Signs:

• fever
• dysuria
• swollen prostate

Manage: (6 weeks course)

• fluoroquinolone (levofloxacin)
• Trimethoprim-sulfamethoxazole

Question 192

Varicocele

Answer 192

Sign:

• soft scrotal mass (bag of warms)
• increase with valsalva maneuver / standing
• decrease with supine position
• increase risk for: infertility & testicular atrophy (due to increase scrotal temp.)

Diagnosis:
-US: retrograde venous flow / dilation of pampiniform plexus vein (surrounding spermatic cord & testis)

Management:

1) boys/young men (with testicular atrophy/ change in semen) : gonadal vein ligation/embolization
2) older men (no desire for babies): scrotal support & NSAIDs

Question 193

Testicular torsion

Answer 193

• common in adolescence
• absent of fixation of testis to tunica vaginalis
• caused by twisting of spermatic cord = lead to testicular necrosis

Sign:

• testicular, abdominal & inguinal pain
• N/V
• horizontal testicular lie with elevated testicle (testicle in horizontal plane)
• absent cremasteric reflex
• swollen, erythematous scrotum
• pain worse with scrotum elevated
• scrotum does not transilluminate

Diagnosis:

• scrotal U/S with doppler: no blood flow & reactive hydrocele
• heterogenous echotexture ( testicular necrosis)

Management:

• surgical detorsion & fixation + exploration of the contralateral side
• manual detorsion (if immediate surgery not available)

Question 194

Fournier gangrene

Answer 194

• acute necrotic infection of the scrotum; penis; or perineum

Signs:

• crepitus in the perineum, scrotum & lower abdomen
• fever & hypotension
• leukocytosis, acidemia, renal insufficiency, coagulopathy

Management:

• antibiotics
• IV-fluid
• emergent surgery: early exploratory-laparotomy & debridement

Question 195

Benign prostatic hyperplasia vs. prostatic cancer

Answer 195

BPH:

• Risk factor: age>50
• affected part: central portion (transitional zone)
• examination:
  1. Symmetrical enlarged & smooth prostate
  2. Can have elevated Prostate-specific antigen (PSA)

Prostatic cancer:

• risk factor: age > 40, African American, family history, diet high in meat/low in vegetables
• affected part: peripheral portion
• examination :
  1) asymmetrically enlarged, nodules & firm prostate
  2) markedly elevated PSA

Question 196

Peyronie disease (PD)

Answer 196

• caused by blunt trauma to penis during sexual intercourse that lead to aberrant wound healing.
• lead to fibrosis of tunica albuginea of the penis

Signs:

• dorsal penile plaque (between glans/pubis)
• pain & curvature with erection

Management:

• reduce pain: NSAIDs
• reduce fibrosis: pentoxifylline
• increase collagenase: intra-lesional injection
• refractory cases: surgery

Question 197

Management of patient with burns

Answer 197

Steps:

1) stabilization ( A,B,C)
2) resuscitation ( IV-fluid)
3) urethral catheter ( foley catheter) (urine-output)
4) copious irrigation
5) gentle gauze debridement of the affected area
6) topical antibiotics
7) non-stick dressing

Question 198

Acute pyelonephritis

Answer 198

Signs:

• fever
• costvertebral angle tenderness
• leukocytosis
• urine: pyuria, bacteriuria, hematuria

Question 199

Penile fracture

Answer 199

• associated with crackling sound after sex with pain & rapid loss of erection

Signs:
- urethral injury ( blood at meatus, dysuria, urinary retention)

Diagnosis:
Retrograde urethrography

Question 200

Abdominal compartment syndrome

Answer 200

Caused by:

• excessive fluid resuscitation
• pathogen or surgery to intra-abdomen

Signs:

• tense, distended abdomen
• increase CVP ( venous compression, but decrease venous return & decrease CO)
• Increase ventilatory requirement ( increase intrathoracic pressure, elevated diaphragm = compress lung= high pressure during ventilation= peak inspiratory pressure)
• hypotension & tachycardia ( decrease venous return & decrease CO)
• decease urine output ( decrease intraabdominal organ perfusion)

Diagnosis:
- measurement of bladder pressure via foley catheter= estimate intraabdominal pressure

Manage:

• avoid over resuscitation with fluid
• decrease intraabdominal volume ( NG tube)
• increase intraabdominal compliance ( sedation)
• surgical decompression if IAP is > 25 mmHg ( laparotomy without fascial closure, allowing for an open abdomen)

Question 201

Ischemic colitis

Answer 201

Signs:

• abdominal pain
• bleeding (hematochezia)
• diarrhea
• leukocytosis
• lactic acidosis
• hypotension

Diagnosis:

• abdominal CT scan with contrast= thickened bowel with fat strand
• confirmed by: colonoscopy

Management:

• bowel rest + iv-fluid
• antibiotics
• colonic resection, if necrosis developed

Involved areas: “watershed area”

• splenic flexure ( SMA/IMA)
• Rectosigmoid junction ( Sigmoid artery & Superior rectal artery)

Question 202

Acute colonic pseudoobstruction (ogilvie syndrome)

Answer 202

Caused by:

• electrolytes imbalance
• surgery, neurologic disease, anticoagulation drugs
• recent infection

Signs:

• severe abdominal pain + distention
• vomiting
• obstipation

Diagnosis:

• CT abdomen: colonic dilation without anatomic obstruction
• x-ray: colonic dilation, normal haustra, non-dilated small bowel

Treatment:

• Bowel rest
• colonic decompression ( NG/rectal tube)
• neostigmine (iv)

Question 203

Trousseau syndrome ( migratory superficial thrombophlebitis)

Answer 203

• hypercoagulabe disorder
• inflammation of the veins due to blood clot
• associated with undiagnosed malignancy (occult visceral malignancy) (cancer): pancreas, lung, prostate, stomach, colon

Signs:
- thrombosis at unusual sites ( arm, chest)

Diagnosis:
- CT scan of abdomen

Question 204

Splenic abscess

Answer 204

Caused by:
-bacteremia from distant infection (infective endocarditis, cholecystitis)

Sign:

• LUQ pain (may radiate to the back)
• fever, chills
• (+/-) splenomegaly

Diagnosis:

• CT scan of the abdomen
• x-ray: elevated hemi-diaphragm ( left pleural effusion)

Manage:

• antibiotics
• splenectomy ( patient fail percutaneous aspiration)

Question 205

Radiation proctitis (RP)

Answer 205

• mucosal damage associated with pelvic radiation therapy

Acute RP:

• present < 8 weeks post-radiation
• diarrhea + tenesmus + mucus discharge

Chronic RP:

• present months/years post-radiation
• hematachezia, anemia, strictures

Diagnosis:
- colonoscopy: mucosal pallor, friability, telangiectasia confined to the rectum

Question 206

Zollinger-Ellison syndrome ( gastrin-producing tumor)

Answer 206

Signs:

• multiple refractory ulcers ( usually distal to duodenum)
• chronic diarrhea
• elevated serum gastrin (> 1000) ( causes diarrhea & steatorrhea due to inactivation of pancreatic enzymes; fat malabsorption)

Diagnosis:

• endoscopy (locate ulcer)
• CT or MRI (identify pancreatic tumor or metastasis)
• somatostatin receptor scintigraphy for tumor localization

Question 207

Polyarteritis nodosa (PAN)

Answer 207

Causes:
-inflammation, weakness, damage of arteries (lumen narrow & aneurysm —> organ ischemia & infraction due to decrease blood flow & thrombus formation)

• associated with kidney ( renal infraction) , & GI (mesenteric ischemia, bowel perforation)

Signs:

• loss of appetite
• sudden weight loss
• abdominal pain
• excessive fatigue
• fever
• muscle & joint ache

Diagnosis:
-Angiography : arteries with micro-aneurysms, irregular luminal narrowing, & distal occlusion

Question 208

Zinc

Answer 208

• absorbed in the duodenum & jejunum
• malabsorption (crohn’s and celiac diseases), bowel resection, gastric bypass, or poor nutritional intake can prevent absorption of zinc
• zinc associated with hair loss, and impaired tasting

Question 209

Steatorrhea (fat malabsorption)

Answer 209

Signs:
- voluminous, greasy, foul-smelling stool that are difficult to flush

Associated with:

• chronic pancreatitis due to alcohol abuse
• cystic fibrosis
• autoimmune pancreatitis
• pancreatic cancer
• crohn’s disease (small bowel)
• celiac disease
• Zollinger-Ellison syndrome
• Whipple disease

Management:
- pancreatic enzyme supplementation

Question 210

Mittelschmerz

Answer 210

• unilateral, mid-cycle pain prior to ovulation
• pain lasts hours to days
• no need for U/S

Question 211

Ectopic pregnancy

Answer 211

• amenorrhea, vaginal bleeding, abdomen/pelvic pain
• elevated beta hCG
• U/S: no intra-uterine pregnancy
• treat: methotrexate

Question 212

Ovarian torsion

Answer 212

• severe, sudden onset, unilateral, lower abdominal pain
• N/V
• unilateral, tender adnexal mass on examination
• U/S: enlarged ovary with decreased blood flow/ absent blood flow/absent doppler flow
• treat:
  1) laparoscopy with detorsion
  2) ovarian cystectomy (preserved ovaries)
  3) oophorectomy if necrosis or malignancy

Question 213

Ovarian cyst rupture

Answer 213

• severe, sudden onset, unilateral, lower abdominal pain
• associated with strenuous activity or sex
• abdominal rigidity, guarding rebound tenderness, referred shoulder pain
• U/S: pelvic free fluid (hemi-peritoneum)
• treat: NSAID & observation (non-urgent)

Question 214

Pelvic inflammatory disease (PID)

Answer 214

• fever, chills, vaginal discharge, abdomen/pelvic pain, cervical motion tenderness
• U/S: +/- tuboovarian abscess

Question 215

Palpable breast mass

Answer 215

younger than 30 years:

• U/S (+/-) mammogram
  1) simple cyst: needle aspiration if desire
  2) complex cyst/solid mass/irregular border: image-guided core biopsy

Older than 30 years:

• mammogram (+/-) U/S
• suspicious for malignancy: core biopsy

Question 216

Inflammatory breast cancer

Answer 216

Signs:

• rapid in onset (within months) & aggressive & metastasis
• painful
• Enlarged lymph nodes (underarm)
• retracted nipple/flattening
• itching
• edema, erythema, thickened skin dimpling & “orange-peel” breast

Diagnosis:

• mammogram +/- U/S
• biopsy (confirm diagnosis)

Question 217

Mastitis

Answer 217

Sign:

• pain, erythema, warmth
• fever
• rapidly improved with antibiotics
• involves women breast feeding
• if not improved with antibiotics, evaluate patient for inflammatory breast cancer or breast abscess ( tender & fluctuant mass)

Question 218

Fat necrosis

Answer 218

Sign:

• firm & irregular mass
• no nipple discharge & skin/nipple retraction
• history of trauma or surgery
• local ecchymosis
• calcification on mammogram
• biopsy: fat globules & foamy histiocytes (macrophages)
• reassurance & routine follow up

Question 219

Invasive ductal carcinoma

Answer 219

Signs:

• firm & irregular mass
• nipple discharge
• nipple retraction

Question 220

Lobular breast carcinoma

Question 221

Benign Intra-ductal papilloma

Answer 221

Signs

• nipple discharge (bloody or non-bloody)
• no breast mass
• unilateral

Diagnosis:

• mammography +/- U/S
• biopsy +/- excision

Question 222

Fibroadenoma

Answer 222

Sign:

• firm, round & mobile mass
• cyclic premenstrual tenderness ( feel pain before period)
• age < 30

Question 223

Management of breast pain (mastalgia)

Answer 223

Cyclical, bilateral & diffused:

1) mass: imaging
2) no mass: observation

Non-cyclical, unilateral, focal

1) mass: biopsy, referral to breast surgeon
2) no mass: imaging
- normal: observe
- abnormal: biopsy

Question 224

Breast cysts (benign)

Answer 224

Simple cyst:

• FNA for symptomatic: biopsy/imaging (bloody) & observation (non-bloody)
• non-bloody cyst: biopsy/imaging (recurrent/persistent) & no additional management (for resolved cyst)

Complex cyst:
-biopsy

Question 225

Small bowel obstruction

Answer 225

Signs:

• acute abdomen
• hyperactive & absent bowl sound
• N/V
• obstipation

Diagnosis:

• air fluid level
• dilated proximal colon & collapsed distal colon
• no air in rectum (colon)

Management:

• bowel rest + NG decompression
• emergency laparotomy ( to prevent bowel ischemia/perforation)

Question 226

Pectoralis minor

Answer 226

• distinguish the surgical level of axillary lymph node during axillary lymph node dissection

Question 227

Hypermetabolic response to severe burn

Answer 227

• arise within 5 days post injury

Signs:

• tachycardia
• hypertension
• fever
• hyperglycemia

Question 228

Frostbites

Answer 228

• Signs of ischemia ( decrease capillary refill, grey color, sensory loss)
• manage with warm water bath.
• if refractory, Perform angiography or technetium-99 scintigraphy ( identify thrombosis)

Question 229

Brown recluse spider bite

Answer 229

Signs:

• painful
• burning sensation
• deep skin ulcer that develops to necrosis & eschar
• provide support wound care only + cold packs

Question 230

Venamous Snake-bite

Answer 230

• systemic toxicity treat with: crotalidea polyvalent immune Fab
• normal laboratory & mild symptoms: observation, frequent coagulation studies, wound evaluation

Question 231

Hypercalcemia

Answer 231

• occurs in prolonged immobilization due to increase bone turnover
• treat: bisphosphonate (reduce hypecalcemia & bone turn over)

Question 232

Stress hyperglycemia

Answer 232

• increase blood glucose due to illness or injury

Mild elevation:
- no treatment

Massive elevation ( glucose > 180 or 200)

• lead to mortality
• treat: short acting insulin ( to lower glucose to 140-180)

Question 233

Evaluating thyroid nodules

Answer 233

Via TSH level & thyroid U/S

-High TSH: FNA

• Low TSH: radioactive iodine scintigraphy ( radionuclide thyroid scan)
  1) hypo-functional (cold) or intermediate nodule: FNA
  2) hyper-functional (hot) nodule (not malignant) : treat hyperthyrodism

Question 234

Hypocalcemia

Answer 234

• prolonged QT
• hypoparathyrodism
• post thyroidectomy
• high-volume blood transfusion (due to chelation of ionized calcium by citrate in transfused blood; hepatic dysfunction causes decreased clearance of citrate by the liver)
• signs: muscle cramp, anxiety, fatigue, poor sleep
• treat: IV calcium gluconate/chloride

Question 235

Intravenous fluid

Answer 235

Isotonic

1) lactate ringer solution
- volume resuscitation ( hypovolemia, shock, burnt victim)

2) 0.9 % normal saline
- volume resuscitation ( hypovolemia, shock)
- don’t give to burnt victim = develop hyperchloremic metabolic acidosis

3) albumin (5% or 25%)
- volume replacement
- treatment of spontaneous bacterial peritonitis or hepatorenal syndrome

Hypotonic

1) dextrose 5% in water
- water deficit

2) 0.45% (half-normal) saline
- water deficit

3) dextrose 5% in 0.45% (half-normal) saline
- maintain hydration

Hypertonic

1) 3% (hypertonic) saline
- severe, symptomatic hyponatremia

Question 236

Syndrome of inapproperiate ADH

Answer 236

-desmopressin can act like an analogue to ADH

Signs:

• mild hyponatremia: nausea & forgetfulness
• severe hyponatremia: seizure, coma
• euvolemia ( moist mucus membrane, no edema, no JVD)

Findings:

• hyponatremia
• serum osmolality (<275)
• urine osmolality (>100)
• urine sodium (>40)

Manage:

• fluid resuscitation +/- salt tablet
• severe hyponatremia: 3% (hypertonic) saline

Question 237

Indication for select pre-operative tests

Answer 237

1) ECG:
- history of coronary artery disease (CAD) or arrhythmia
- asymptomatic patients with risk of major adverse cardiovascular events (MACE >1%)

2) Chest radiograph:
- history of cardiopulmonary disease
- undergoing an upper abdominal/thoracic surgery

3) Hemoglobin
- history of anemia, & expected significant blood loss
- undergoing major surgery

4) Coagulation & platelets
- history of abnormal bleeding or anti-coagulant use
- liver disease, malignancy, planned spinal anesthesia

5) Creatinine & electrolytes
- history of kidney disease, cardiovascular-risk calculation
- use of medication ( ARB, ACE inhibitors, diuretic)

Question 238

Diabetic foot ulcer (causes neuropathic ulcers)

Answer 238

caused by:
- repeated pressure, friction or trauma

Risk factors:

• uncontrolled diabetes ( measure hemoglobin A1c)
• peripheral neuropathy ( loss of sensation)
• foot deformities or muscle atrophy
• End stage renal disease/ dialysis (ESRD)

Signs:

• located at the sole of foot at high-pressure points
• painless ulcer
• punched out appearance with necrotic base
• adjacent callus ( on pressure point, not painful, related to pressure)

Diagnosis:
- check hemoglobin A1c (controlled vs uncontrolled diabetes)

Question 239

Venous ulcer

Answer 239

Signs:

• located at the shin of leg above malleolus
• associated with edema & stasis dermatitis (venous eczema ; leak of blood from vein into skin)

Diagnosis:
-duplex U/S

Question 240

Penetrating abdominal trauma

Answer 240

Indication for immediate laparotomy:

• hemodynamically unstable (systolic BP < 90)
• peritonitis ( rigidity, rebound tenderness)
• evisceration (externally exposed intestine)
• impalement (+ remove necrotic tissue, hematoma, initiate negative pressure wound therapy)
• penetration of peritoneum & significant organ damage

Note:
- eFAST: can be performed before just to confirm the need of laparotomy ( presence of free-fluid)

Question 241

Tracheobronchial rupture ( bronchial rupture) = rapid accumulation of pleural air in despite presence of chest tube

Answer 241

-air escape with each breath

Signs:

• persistence pneumothorax
• RAPID large air leak (+ decrease in oxygen saturation) despite tube thoracotomy
• presence of air in pleural space (pneumothorax) + air under diaphragm (pneumomediastinum) + air trapped in tissue under skin (subcutaneous emphysema; crepitus)

Diagnosis:
-bronchoscopy

Manage:
- repair surgery

Question 242

Primary hyper-parathyrodism (PTH)

Answer 242

Etiology:

• parathyroid adenoma
• hyperplasia
• carcinoma
• MEN Type 1 & 2A

Symptoms:

• constipation + fatigue
• abdominal pain + renal stones+ bone pain

Diagnosis:

• hypercalcemia
• hypophosphatemia
• elevated PTH
• Increase 24-hours urinary calcium excretion

Indication for parathyroidectomy:

• age <50
• hypercalcemia with symptoms
• with complications: osteoporosis, nephrolithiasis, impaired renal function- GFR<60)

Question 243

Pheochromocytoma

Answer 243

Signs:

• pale + tachycardia+ hypertension occurrence after general anesthesia induction
• catecholamine surge due to anesthesia
• history of anxiety disorder, HTN, headache

Signs:

• headache, sweating , tachycardia
• resistance HTN or HTN + increased glucose
• family history of MEN 2, NF1, VHL

Diagnosis:

• urine or plasma metanephrine level
• confirmatory abdominal imaging for increase metanephrine

Management:
- pre-operative alpha blocker (7-14 days before surgery), before beta-blocker ( 2-3 days before surgery) to prevent catecholamine surge
-laparoscopic or open surgery for surgical resection
-

Question 244

Adrenal crisis

Answer 244

Development of hypotension (SB <90) despite IV-fluid bolus during surgery

Etiology:

• adrenal hemorrhage or infraction
• illness, injury, surgery in patient with adrenal insufficiency
• pituitary apoplexy

Signs:

• hypotension +shock + hypoglycemia
• N/V + abdominal pain
• fever + generalized weakness

Treat with:

• IV-hydrocortisone
• IV- dexamethasome
• rapid (aggressive) IV volume repletion

Question 245

Prolactin & amenorrhea

Answer 245

Hyperprolactinoma due to pituitary microadenoma

• increase prolactin
• inhibits GRH (Hypothalamus)
• decrease FSH & LH (anterior pituitary)
• decrease estrogen (ovaries)
• amenorrhea, an-ovulation, menopausal symptoms, infertility

Signs:

• hot flashes
• vaginal dryness & atrophy
• dyspareunia
• prolonged estrogen deficiency leads to osteoporosis (bone loss)

Manage:
-dopamine agonist

Question 246

Hemorrhagic shock areas causing hemodynamic instability

Answer 246

1) floor
2) chest
3) abdomen
4) pelvis/retroperitoneum
5) thigh

Question 247

Papillary thyroid cancer

Answer 247

Signs:

• (2) cm hypo-echoic nodules in one lobe of thyroid
• no enlargement of lymph node
• FNA biopsy: large cells with ground glass cytoplasm + pale nuclei containing inclusion bodies + central grooving consistent with papillary thyroid cancer

Management:

• FNA biopsy
• surgical resection (thyroidectomy)
• if recurrence is expected:
  1) radioactive iodine ablation (kill remaining thyroid tissue after thyroidectomy)
  2) thyroid hormone

Question 248

Tertiary hyperparathyroidism

Answer 248

Risk factor:

• chronic kidney disease (end stage renal disease-ESRD)
• chronic hypocalcemia, hyperphosphatemia ( result in more secretion of PTH)

Pathogenesis:

• parathyroid hyperplasia
• loss of feedback inhibition on PTH by calcium

Signs:

• increase calcium
• increase phosphorous
• increase increase PTH

Management:

• refractory to medical therapy
• parathyroidectomy

Question 249

Antibiotics prophylaxis for pre-operative surgery

Answer 249

Cardiac, neurological, orthopedic, vascular:

• skin flora: gram positive: strep., staph.,
• cefazolin (cephalosporin); vancomycin ; clindamycin

GI, genitourinary, gynecologic/obstetric, head/neck, thoracic:
- broader coverage

Question 250

Euthyroid sick syndrome ( low T3 syndrome)

Answer 250

-adaptive response to severe illness
Signs:
-EARLY: low T3, normal T4, normal TSH
-LATE: low T3, T4, TSH

Management:

• observe without treatment
• follow up testing when patient has returned to normal baseline

Question 251

Eosinophilic esophagitis

Answer 251

caused by:
- eosinophilic infiltration of the esophagus mucosa

Signs:

• food dysphagia
• refractory heartburn
• regurgitation
• food impaction

Diagnosis:

• endoscopy & esophagus biopsy (eosinophil: >15)
• rule out: achalasia, infection

Management:

• elimination diet
• PPI
• Topical glucocorticoids

Question 252

Colovesical fistula

Answer 252

• associated with diverticular disease, Crohn disease, malignancy
• abnormal connection between colon & bladder

Signs:

• pneumaturia (air in urine)
• fecaluria (stool in urine)
• recurrent urinary tract infection

Diagnosis:

• CT scan of the abdomen with oral or rectal contrast
• colonoscopy (exclude malignancy)

Management:
-surgical after resolution of infection

Question 253

Stress-induced ulcer

Answer 253

• associated with ICU
• risk factors: sepsis, coagulopathy, mechanical ventilation, traumatic spinal cord/brain injury, burns, high-dose corticosteroids

Signs:

• gross or occult GI bleeding (in stool)
• anemia

Question 254

Requirement for bariatric surgery

Answer 254

Requirements:

1) BMI > 40
2) BMI >35 + comorbidity ( T2D, HTN, sleep apnea)
3) BMI > 30 + resistant T2D or metabolic syndrome

Question 255

Metastasis to liver

Answer 255

• metastasis from: colon, pancreas, skin

Signs:

• weight loss
• anemia
• hepatomegaly
• cholestasis ( high bilirubin & Alkaline phosphatase)
• normal liver function test

Question 256

Evaluation of bilious emesis in neonates ( meconium ileus vs. Hirschsprung disease vs. malrotation vs. duodenal atresia)

Answer 256

Bilious emesis

• unstable (+ rigid abdomen): emergency laparotomy
• stable: abdominal X-ray
  1) free-air: emergency laparotomy

2) dilated loops of bowel:
- increase rectal tone &/or delayed passage of meconium: contrast enema: (microcolon: meconium ileus) or (rectosigmoid transition zone: Hirschsprung disease)

• normal rectal examination: upper GI series …….(+…)
  3) normal: upper GI series: right-sided ligament of trietz: malrotation
  4) double bubble sign: duodenal atresia

Note:
- malrotation with midgut volvulus causes intestinal perforation & necrosis, considered in patient with normal rectal examination & air-fluid level on x-ray.

Question 257

Chronic pancreatitis

Answer 257

Signs:

• intermittent epigastric pain (radiate to the back) (worst with eating)
• nausea
• pancreatic atrophy & calcification
• history of alcohol abuse

Management:
- provide pancreatic enzyme supplement (amylase, lipase, protease)

Question 258

Subphrenic abscess (intra-abdominal abscess)

Answer 258

• accumulation of infected fluid between the diaphragm, liver, and spleen.
• associated with infection after surgery (appendectomy, splenectomy)
• should be suspected if fever & abdominal symptoms returns days after surgery

Signs:

• RUQ pain
• fever
• leukocytosis
• pulmonary manifistation ( hiccups, pleural effusion, SOB)

Diagnosis:
-CT (abdomen)

Management:

• antibiotics
• drainage

Question 259

Vascular ring (abnormal arch within aorta)

Answer 259

-encircle trachea or esophagus

Signs

• compression of trachea presents with stridor
• compression of esophagus presents with dysphagia, vomiting, recurrent food impaction

Question 260

Management of C. Difficile infection

Answer 260

Drugs:

1) vancomycin or fidaxomicin
- non/severe CDI ( symptoms: profuse watery diarrhea + abdominal pain)
- severe CDI (symptoms + leukocytosis >15,000 + Creatinine>1.5 )

2) Oral vancomycin & IV- metronidazole
- fulminant CDI ( severe CDI + either: hypotension/shock or illeus/megacolon)

3) Fecal microbiota transplantation or surgical intervention
- refractory CDI

Question 261

Enteral nutrition

Answer 261

• used right away for patient with moderate to severe burn

- benefits: stop the hyper-metabolic state, maintain gut integrity, reduce rate of sepsis, decrease mortality

Question 262

Pilonidal disease

Answer 262

-associate with: males., age 15-30, obese, sedentary

Signs:

• painful, fluctuant mass 4-5 cm in the intergluteal region
• mucoid, purulent or blood drainage

Question 263

Primary sclerosing cholangitis (PSC)

Answer 263

Signs:

• fatigue + pruritus
• associated with ulcerative colitis

Laboratory/imaging:

• cholangiography: dilated intrahepatic & extrahepatic bile duct
• increase bilirubin & alkaline phosphatase
• increase gamma-glutamyl transpeptidase

Lead to:

• biliary stricture
• cholangitis or cholelithiasis
• cholangiocarcinoma
• cholestasis

In patients with PSC:
- colonoscopy is performed to rule out associated Ulcerative colitis

• annual colonoscopy is performed in patients with PSC+UC to monitor risk for colon cancer

Question 264

Perforated viscus

Answer 264

• caused by duodenal ulcer = result in retroperitunium bleeding + free air
• caused by kidney laceration or pancreatic trauma = delayed retroperitunium bleeding + free fluid

Question 265

Surveillance after colon cancer resection

Answer 265

Stage 1:
-colonoscopy after 1 year, than after 3-5 years

Stage 2/3:

• colonoscopy after 1 year, than after 3-5 years
• CEA testing
• CT scan of chest, abdomen, pelvis

Stage 4:
- follow stage 2/3 + more frequent CT scan

Question 266

Perianal abscess

Answer 266

-associated with: constipation, intercourse
Sign:
- progressive worsening pain in anal region
- tender, fluctuant, erythematous mass + itching
- fever

Question 267

Colon cancer

Answer 267

Left sided:
-visible red bleeding with rectum

Right sided:
- occult bleeding + anemia

Question 268

Acute ischemic bowel

Question 269

Ischemic colitis

Answer 269

• complication of vascular surgery
• old
• atherosclerosis
• thickening of colonic wall
• cyanotic mucosa + hemorrhagic ulceration

Question 270

Visceral hemorrhage management

Answer 270

1) 2 IV-access
2) resuscitation
3) IV- octreotide
4) antibiotics

Stop bleeding:

• beta blocker
• endoscopic band ligation (1-2 weeks later)

Continued bleeding:

• balloon tamponade (temporary)
• TIPS or shunt surgery

Early re-bleeding:

• repeat endoscopy
• recurrent bleeding
• TIPS or Shunt

Question 271

Toxic megacolon

Answer 271

• present in patients with inflammatory bowel disease (Crohn’s or UC) (low grade fever, abdominal pain, bloody diarrhea)

Treat:
- IV corticosteroid ( methylprednisolone)

Question 272

Acute pancreatitis

Answer 272

• caused by alcohol or gallstone

- evaluate right upper quadrant by U/S

Question 273

Gallstone pancreatitis

Answer 273

• suspected in patient with alanine aminotransferase > 150

- treat with: cholecystectomy

Question 274

Toxic megacolon

Answer 274

1) CT scan shows colonic dilation > 6 cm

2) systemic toxicity ( fever, leukocytosis, hemodynamic instability)

Question 275

Zenker diverticulum

Answer 275

• foul smelling breath
• mass in neck when palpate
• recurrent pneumonia + dysphagia + regurgitation in elderly patient

Diagnosis:
-contrast esophagography

Treat:
- surgical (cricopharangeal myotomy +/- diverticulectomy)

Question 276

Esophagus perforation

Answer 276

• pleural effusion with yellow exudate + high amylase content or green fluid or low pH
• widened mediastinum

Diagnosis:

• water-soluble contrast CT scan
• esophogography

Question 277

Pancreatic psuedocyt

Answer 277

• encapsulated area ( enzyme-rich fluid, tissue, debris) around fat stranding
• previously diagnosed with acute pancreatitis

Treat:
- endoscopic drainage for symptomatic patient with abdominal pain , N/V, distention, discomfort

Question 278

Pyogenic liver abscess

Answer 278

Signs:

• fever
• leukocytosis
• RUQ pain
• altered liver function tests

Diagnosis:
-CT

Treat:

• blood culture
• antibiotics
• drainage
• aspiration

Question 279

Epidural hematoma

Answer 279

Signs:

• tear of middle meningeal artery
• skull fracture
• young patient
• elevated ICP ( headache, N/V, altered Mental status)

Question 280

Subdural hematoma

Answer 280

Signs:

• tear of bridging veins
• older patients or anti-thrombotic use
• acute SDH: coma
• chronic SDH: confusion + headache

Question 281

Subarchinoid hemorrhage

Answer 281

Signs:

• Sudden &B severe thunderclap headache
• loss of consciousness
• Meningism ( headache, neck stiffness, photophobia, N/V)

Question 282

Emergence from anesthesia

Answer 282

• most patient fully awake after 15 min

Residual effect of anesthesia leads to:

Delayed emergence:

• hypoactive state
• somnolence persisting > 30-60 min

Emergence delirium:
- hyperactive state

Treat:
- reassurance & reorient & observe : usually temporary & will resolve

Question 283

Copper (similar to effect of vitamin B12)

Answer 283

Signs:

• hair loss or brittle
• anemia or osteoporosis
• ataxia
• skin depigmentation

Question 284

In trauma of cervical spine

Answer 284

Manage:

• spinal immobilization + removal of helmet
• oxygen supplement

In hospital:

• orotracheal intubation
• in-line cervical stabilization
• CT scan of cervical spine

Question 285

Spinal cord injury

Answer 285

• high spinal cord injury (above C5) leads to hypercapnia respiratory failure due to diaphragm paralysis
• high speed motor accident: expansion of airbag leads to hyperextension of the neck; injury to C5 (C5-C6) —> This makes you reconsider CT scan of the thoracic & lumbar spine (imaging the entire spine)

Question 286

Untreated anterior shoulder dislocation

Answer 286

Sign:

• hand is abducted + externally rotated
• cause injury to axillary nerve (innervated teres minor & deltoid muscles)

Result in:
- decrease abduction + decrease sensation at the lateral shoulder

Question 287

High-speed motor accident management

Answer 287

1) chest & pelvic x-ray
2) FAST
3) CT of cervical spine ( before doing surgery: irrigation, fixation, because patient might require orotracheal intubation & neck manipulation) —> evaluate cervical spine injury

Question 288

Traumatic carotid injury ( carotid artery dissection)

Answer 288

Caused by:

• fall with object in mouth
• neck manipulation

Signs:

• aphasia (inability to speak or comprehend)
• thunderclap headache
• neck pain
• gradual onset of hemiplegia
• facial droop

Diagnosis:
- CT or MRI angiography

Question 289

Meningioma

Answer 289

Signs:

• hyperdense & calcified mass at the dural space of frontal lobe
• headache, seizure, focal weakness/numbness
• middle-elderly aged women
• benign

Treat:
- surgical resection

Question 290

Cuada equina syndrome can lead to spinal epidural hematoma

Answer 290

• caused by epidural block, lumbar puncture, spinal surgery
• common in older adult taking anti-thrombotic agents

Sings:

• slowly progressive motor & sensory dysfunction
• localized back pain
• bowel & bladder retention

Manage:
-urgent MRI + DECOMPRESSION

Question 291

Stroke due to intracranial hemorrhage

Answer 291

Signs:

• slurred speech
• dizziness
• weakness
• continuous hemorrhage lead to brain herniation (midline shift on CT scan, decerebrate posturing)
• brain herniation leads to respiratory failure (decrease ventilation)—> manage with intubate & mechanically ventilate

Question 292

Femoral nerve

Answer 292

• hip flexion & knee extension (hf/ke)

- sensation to anterior thigh & medial leg

Question 293

Loss of spinal cord function (injury to descending spinal tract)

Answer 293

Signs: (long standing reduce of sympathetic tone)

• hypotension + hypothermia (lack of peripheral vasoconstriction) + bradycardia
• areflexia, anesthesia, paralysis, distended bladder
• initial presentation: tachycardia/hypertension due to sympathetic stimulation (NE release)

Question 294

Thunderclap headache seen in

Answer 294

• subdural hematoma
• carotid dissection due to trauma
• pituitary apoplexy (hemorrhage or acute ischemia of pituitary; associated with large adenoma; headache, nausea, mental status, hypotension, bilateral visual field defect, ophthalmoplegia )
• severe-onset of headache + nausea + altered mental status

Question 295

Paroxysmal sympathetic hyperactivity (PSH)

Answer 295

Signs:

• tachycardia, hypertension, tachypnea
• fever, diaphoresis
• associated with traumatic brain injury
• lasts for 20-30 min
• triggered by bathing, repositioning, or spontaneous

Question 296

Spinal cord compression (cervical myelopathy)

Answer 296

Signs:

• weakness in upper & lower extremities
• atrophy of hand (loss of grip)
• neck stiffness + electric shock feeling when neck flexed (lhermitte sign)
• hyperreflexia of leg

Question 297

Reduce ICP

Answer 297

• mannitol or hypertonic saline
• elevated head
• sedation
• hyperventilation
• CSF removal
• decompression craniectomy

Question 298

Orbital floor fracture (muscle entrapment)

Answer 298

Signs:

• vertical diplopia
• restrictive upward eye movement

Question 299

Malignant hyperthermia

Answer 299

Signs:

• tachycardia
• dyspnea
• muscle rigidity
• myoglobinuria ( brown urine found in foley catheter)
• arise shortly after anesthesia induction

Question 300

Venous stasis ulcer

Answer 300

Signs:

• brawny skin discoloration (hemosiderin deposition)
• ulcer with well-vascularized granulation tissue (appears pink/red)

Scenario:

• venous ulcer —> developed cellulitis —> managed with sntibiotics & wet to dry dressing (commonly used for wound that are infected, have been freshly derided, devitalized tissue) —> (gauze soaked in saline, applied to wound, let dry, upon removal of gauze from wound, it takes out the devitalized tissue)
• when healthy granulation tissue forms, wet to dry dressing should be discontinued and substituted with (non-adherent, moisture-retaining dressing to promote healing)

Note:
- would should not be left open to air to let dry out; because moist wound heal faster than dry wound

Question 301

Diabetic foot ulcer

Answer 301

• history of uncontrolled diabetes
• loss of sensation (peripheral neuropathy)
• colonized by many microbes, complicated by osteomyelitis

Diagnosis:

• x-ray or MRI to assess for osteomyelitis
• ulcer with (increase ESR or CRP) requires imaging

Question 302

Basal cell carcinoma

Answer 302

Risk factors:

• fair skin
• sun
• radiation

Signs:

• skin colored, pearly nodule, +/- rolled borders
• telangiectasia appears
• central ulceration, local invasion

Diagnosis:
- shave, punch, excisional biopsy

Treat:
- 1st: surgical excision with 4 mm margin + MOHs micrographic surgery (for face & high-risk of recurrence)

-2nd: topical FU, topical imiquimod, C & E

Question 303

Keratocanthoma

Answer 303

Signs:

• rapidly growing nodules with ulceration & keratin plug
• shows spontaneous regression/resolution
• can progress to invasive squamous cell carcinoma

Manage:
- excisional biopsy with complete removal of lesion

Question 304

Melanoma

Answer 304

Signs: ( ABCDE)

• asymmetry
• border irregularity
• color variation
• diameter > 6 cm
• evolving appearance over time

Management:
- excisional biopsy

Question 305

Pyoderma gangrenosum

Answer 305

Signs:

• painful papules with discharge that progressively enlarge
• refractory to antiseptics
• women 40-60 years
• associated with: IBD, rheumatoid arthritis, malignancy

Diagnosis:

• exclusion of infection ulcer
• skin biopsy: shows mixed inflammation (neutrophils)

Manage:
- local or systemic glucocorticoids

Question 306

Pressure necrosis

Answer 306

-prolonged pressure over bony prominence

Question 307

Secondary angiosarcoma due to radiation

Answer 307

• purpuric nodules
• purpuric patches without distinct border
  Diagnosis: lesion biopsy

Question 308

Infantile hemangioma

Answer 308

• days to weeks after birth
• bright red soft raised plaques

Manage:
- beta-blocker (oral)

Question 309

Squamous cell carcinoma

Answer 309

• non-healing ulcer arise from chronic wound or scar
• aggressive, recurrence, local invasion, metastasis

Diagnose:
-biopsy

Question 310

Alcohol withdrawal treatment

Answer 310

• benzodiazepines

- for liver diseases: lorazepam