LESSONS LEARNED: WEEK 1

Question 1

When this reaction occurs, pts can experience a variety of symptoms including dyspnea, flank pain, renal failure, DIC, and possibly death.

Answer 1

Acute hemolytic transfusion reaction

Question 2

A syndrome characterized by respiratory distress associated at times with hypoxemia, cyanosis, fever, and new infiltrates on chest xray that develop w/in 6 hours of transfusion of any blood products.

Answer 2

Transfusion related acute lung injury

TRALI is a syndrome characterized by neutrophil priming and activation within the lung parenchyma following exposure to inflammatory components in donor blood products which leads to diffuse endotherlial dysfunction and non cardiogenic pulmonary edema. Pts often present with acute onset dyspnea, hypoxemia, fever, and cyanosis post transfusion/within minutes to hours

Question 3

What is the next best step in a pt who sustained injuries from a MVA, is having ab pain, is hemodynamically unstable, and on imaging shows signs of a hemoperitoneum?

Answer 3

Exploratory Laparotomy

Pts who suffer from blunt abdominal trauma may have a splenic laceration or rupture. In stable pts, minor splenic injuries can be tx’d nonoperatively but in unstable pts, repair/splenectomy is indicated.

Question 4

A pt who sustained a C7/T1 subluxation and sensation and touch is absent below the midchest, why might the pt be hypotensive/the bp does not improve even with transfusions?

Answer 4

Neurogenic Shock due to spinal cord injury.
The neurogenic shock following a TBI or spinal cord injury due

Question 5

Obese female w/worsening headache, it is somewhat releived with standing, and has some vision changes and papilledema on ocular exam. What are you concerned for?

Answer 5

Idiopathic intracranial hypertension,
confirm w/lumbar puncture

Question 6

What margins are we looking at for first time excision of a BCC?

Answer 6

5mm-1cm

Question 7

In peripheral artery disease, what is normally an indicator for amputation?

Answer 7

Gangrene

Question 8

What can you use to assess a pt’s risk of MACCE (major adverse cardiovasc and cerebrocasc events) perioperatively?

Answer 8

Revised Cardiac Risk Index or the American College of Surgeons National Surgical Quality Improvement Program

Question 9

Explain the diff between thrombosis and embolism

Answer 9

Thrombosis is when a blood clot, or thrombus, forms in a blood vessel. An embolus is when a clot, fat, air bubble, or other feature travels through blood vessels, with a risk of lodging elsewhere. Both can block blood flow and increase the risk of a heart attack or stroke.

Embolism=ACUTE symptoms
Thrombosis=more chronic, insidious worsening

Question 10

What can you sue to help calculate risk of bleeding with anticoagulation?

Answer 10

HAS-BLED score

Question 11

Why might anticoagulation with heparin be prederable in pts with hx of recent surgery or malignancy?

Answer 11

Heparin has a short half life and has greater ease of reversal of anticoag (readily available reversal agent)

Question 12

Most likely cause of new irregular cardiac rythm is a pt who sustained a MVA

Answer 12

Blunt Cardiac Injury

Always be on the look out for tamponade and hypovolemic shock in these pts tho

Question 13

Why are pts with OSA at risk for cor pulmonale?

Answer 13

Because pts w/OSA (untreated) may develop pulmonary htn tht leads to cor pulmonale

Question 14

Hypercapnia that is not compensated (evident by acidemia) and hypoxemia in the setting of resp distress indicates _______________________ and requires ________________________ to manage/tx

Answer 14

respiratory failure–> intubate, ventilate

Question 15

What changes on PO2, PCO2, and A-a gradient can ou expect in a pt w/hypoventilation?

Answer 15

DECREASE PO2
INCREASE PCO2 (you may see acidosis)
NORMAL A-a on ABG

Etiologies: obesity hypoventilation syndrome, central vercous system depressants, and neuromuscular disorders impacting the diaphragm

Question 16

Bowel sounds in the lungs fields in a pt who sustained a MVA is concerning for…

Answer 16

Diaphragm rupture due to sudden increase in intraabdominal pressure

Question 17

Common causes of post-op fever

Answer 17

atelectasis, pneumonia, UTI, surg site infection, intrathoracic or intraabdominal infections related to surgery

Question 18

transmural inflammation of gi tract

Answer 18

crohn disease

Question 19

autosomal dominant genetic syndrome resulting from the biallelic loss of function of the PAC gene. It is charaterized by the presence of thousands of adenomatous polyps arizing after puberty.

Answer 19

Familial adenomatous polyposis

Question 20

AD inheritence w/mutation in SMAD4 or BMPR1A genes general manifests w/in first two decades of life w/painless hematochezia and rectal bleeding due to polyps. Most often hamartomatous polyps.

Answer 20

Juvenile Polyposis Syndrome

Question 21

Pts w/UC should undergo colonoscopy screenings starting when?

Answer 21

8 yrs after dx

Question 22

Pts w/progressive dysphagia should undergo an EGD to evaluate. Who needs a barrium swallow test prior to the EGD?

Answer 22

Pts w/ hx suggesting a leson that is a risk for esophageal perforation like cancer, radiotherapy to esophagus, or clinical features of a zenker diverticulum.

Question 23

Pt w/ medhx of UC presenting w/ high fever, tachy, hypotn, leukocytosis, enlarged dialated bowel, and impaired colonic motility is concerning for…

Answer 23

Toxic megacolon

Question 24

Who is at risk for toxic megacolon?

Answer 24

Condition w/colonic inflammation including UC, crohn, infections including c.diff, enteric gram negative bacteria, cytomegalovirus, entamoeba histolytica, and ischemic injury

Question 25

Elderly pt presenting w/ abdominal pain, distention, constipation, and vomitting. Xray shows dialated air filled sigmoid colon and CT shows whirl of sigmoid colon around its mesenteric attachment. What is the cause?

Answer 25

Sigmoid volvulus, a rotation of the large bowel around its mesentery. Happens in elderly debilitated patients, casues large bowel obstruction.

Question 26

Charcot’s triad

Answer 26

Fever, RUQ pain, and jaundice–> CHOLANGITIS

Reynold’s pentad is charcot’s triad w/ shock and altered mental status tacked on

Question 27

What is cholangitis?

Answer 27

inflammation of the bile duct system commonly secondary to cholodocolethiasis

Question 28

Why doesn’t cholesystitis typically present w/jaundice?

Answer 28

Because it does not block the common bile duct

Question 29

Signs/symptoms of an esophageal perforation

Answer 29

mediastinitis and pleural effusion which present aschest pain, fever, tachycard/ypnea, diaphoresis, plueritic chest pain.

Question 30

How can you differentiate congenital biliary atresia from benign cause of neonatal jaundice?

Answer 30

Benign etiologies improve bt the second to third week of life whereas biliary atresia with persist and often worsen within the first 8 weeks of life

Question 31

What procedure do we use to treat congenital biliary atresia?

Answer 31

Kasai procedure (hepatoportoenterosotomy)

Question 32

Present with progressively worsening neonatal jaundice, pale stool, dark urine, poor weight gain, and in bad untreated cases cirrhosis, coagulopathy, and portal htn.

Answer 32

Congenital Biliary Atresia

Question 33

How do we differentiate pre vs post renal acute kidney injury?

Answer 33

FRactionally excrented sodium
prerenal is <1% and >2% un intrinsic kidney injury like in tubular necrosis

Question 34

How are urethral injuries evaluated?

Answer 34

Retrograde urethography

Question 35

True of False: tyroid malignancies typically do not excrete thyroxine

Answer 35

true, if you are looking at a nodule and the pt has increased T4, start thinking about a toxic adenoma not a carcinoma

Question 36

Pts who get a thyroidectomy are at risk for what?

Answer 36

Hypoparathyroidism and subsequent hypocalcenuka which results in perioral paresthesia, carpopedal spasm, laryngospasm, prolonged QT, Chvostek sign, and trousseau sign

Question 37

Chvostek sign

Answer 37

refers to a twitch of the facial muscles that occurs when gently tapping an individual’s cheek

Question 38

trousseaus sign

Answer 38

sign for latent tetany, a carpopedal spasm induced by ischemia secondary to the inflation of a sphygmomanometer cuff, commonly on an individual’s arm, to 20 mmHg over their systolic blood pressure for 3 minutes.

Question 39

Cut off point for hyponatremia

Answer 39

135

Question 40

Peaked t waves

Answer 40

hyperkalemia

Question 41

How do you start managing hyperkalemia?

Answer 41

Admin of iv calcium to prevent cardiac cell excitability and start meds that cause transfer of potassium out of the serium through the urine or stool (insulin, albuterol, sodium bicarb)

Question 42

Main causes of post op hypotension

Answer 42

bleeding, under rescuscitation during the procedure, adverse effects of medication, and sepsis