Pestana Flashcards
What is tx for linear skull fracture?
if closed –> leave alone
if open (overlying wound) –> close wound
if comminuted or depressed –> OR
What is tx for rib fracture?
local nerve block and epidural catheter to prevent hypoventilation –> atelectasis
What is presentation of pulmonary contusion?
right away up to 48 hrs after chest trauma, high A-a gradient, hypoxemia, hypercapnea
have deteriorating blood gas and white out of lungs on CXR
What is the difference in how you manage gunshot vs knife wound to abdomen?
gunshot = always go straight for ex-lap, if RUQ only can do conservative w/ serial ab CT
stab = if clear penetration or peritoneal or instability do ex lap, otherwise can do digital exploration, if equivocal do CT
What do you do if intra-op develop coagulopathy?
empriric platelets and FFP
if also have hypotehrmia and acidosis –> terminate lap and pack
What do you need to do if patient w/ penetrating injury to extremities?
if no major vessels in vicinity –> do tetanus ppx and clean wound
if near major vessels and asymptomatic –> doppler or CTA
if obvious vascular injury –> surgical exploration
What are indications for topical agent for burn?
standard = silver sulfadiazine
if thick cartilage, eschar = mafenide acetate
if near eye = triple abx
When do you do early excision and grafting in burn?
burns
When can you expect that high degree of angulation will remodel in kid vs not remodel?
remodel everywhere except if in growth plate or supracondylar fracture of humerus
What is tx for clavicular fracture?
sling
only need open reduction and internal fixation if want for cosmetic reasons
What is tx for intertrochanteric fracture?
open reduction and internal fixation w/ post op anticoagulation b/c high risk DVT/PE
What is tx for femoral neck fracture?
replace femoral head w/ prosthesis for earlier mobilization
What is tx for compartment syndrome?
emergency fasciotomy
What is presentation of comparetment syndrome?
mcc in lower leg = 2/2 fracture w/ closed reduction
pt: pain and limited use of extremity, compartment feels tight and tender to palpation, excruciating pain w/ passive extension, pulses may be normal
What is mallet finger?
extended finger forcefully flxed in volleyball
- tip of finger repains flexed when hand extended
What is jersey finger?
injury to flexor tendor
when making fist, distal phalanx does not flex
What should you do before surgery if pt w/ severe nutritional depletion (loss 20% body wt, albumin
4-5 days of preop nutritional support preferably via gut
When are you likely to see peri-op MI?
during operation triggered by hypotension
or post-op in first 2-3 days
What is tx for MI in periop?
emergency angioplasty or coronary stent
do not use clot busters
What is typical presentation of post op PE?
POD7
pleuritc CP and SOB
What is tx for would dehiscence?
tape securely, bind abdomen, arrange for re-op
if peritoneal signs = evisceration and need emergency ab closure
What is tx for GI fistula (draining bowel contents from wound or drain site)?
fluid and electrolyte replacement, nutritional support, compulsive protection of ab wall (suction tubes, ostomy) to let nature heal fistula
What are some things that prevent healing in GI fistula?
FETID
- foreign body
- epithelialization
- tumor
- infection
- irradiated tissue
- IBD
- distal obstruction
What is the difference in presentation between external and internal hemorrhoids?
internal bleed –> tx rubber band ligation, only pain/itching if prolapse
external hurt –> tx surgery if conservative tx fails
What does NGT tell you about source of GI bleed?
if blood = upper source
if no blood and fluid is white = excludes above pylorus, may still want to do upper GI endoscopy
if no blood and fluid is green (bile) = above ligament of treitz excluded
What should you think if pt w/ LLQ pain, feer, leukocytosis, palpable tender mass? enxt step?
acute diverticulitis
next: do CT, start NPO, IVF, abx
most cool down w/ medical tx
What is tx for breast cancer in pregnancy?
do surgery but:
- no radiotherapy at any time in pregnany
- no chemo during first trimester
What happens to aldosterone when upright vs lying down in adrenal hyperplasia vs adenoma?
hyperplasia: more aldosterone when upright
adenoma: lack or response or lower when upright
What should you think if baby w/ excess salivation and NGT coils in upper chest?
if normal gas patern on XR –> blind pounch upper esophagus and fistula between lower esophagus and tracheobronchial tree
What should you suspect if baby with XR showing multiple dilated loops of small bowel and ground glass appearance in lower abdomen in setting of feeding intolerance and bilious vomiting? next step?
meconium ileus
next step = gastrografin enema to dx (microcolon and inspissated pellets of meconium in terminal ileum) and therapeutic
What is likely dx if baby w/ stridor, resp distress w/ crowing respiration during which hyperextends and some difficulty swallowing? What dx tests? tx?
- need to r/o tracheomalacia for resp sx w/ bronchoscopy
do barium swallow –> shows extrinsic compression = vascular ring
tx: surgery divides smaller of two aortic rach
How do you determine operability of lung cancer?
minimum FEV1 of 800 is needed
determine FEV1 determine fraction from each lung by VQ scan, if less than 800 would be lest do not do pneumonectomy
What is tx for aterial embolization to extremity from AFib clot?
urgent eval w/in 6 hrs
- do doppler
- early incomplete occlusion –> clot buster
complete –> embolectomy w/ fogarty catheter
if severe hrs have passed, do fasciotomy
What is presentation of basal cell? what loctations?
waxy raised lesion
prefers upper face, slow growing
What should you think if smoker w/ rotten teeth prsents w/ painless ulcer in floor of mouth and persistent U/L headache?
think squamous cell carcinoma of mucosae
dx: do triple endoscopy and bx
What is etiology / tx if pt w/ trauma has normal facial nerve function at time of asmission and later develops paralysis?
2/2 swelling/edema
will resolve spontaneously
what is likely dx/tx for pt w/ hx rheumatic fever and progressive DOE, orthopnea, PND, cough, hemoptysis, Afib?
likely mitral stenosis causing atrial enlargement and back up pulm edema into lungs
dx: echo
tx: repair w/ surgical commissurotomy or balloon valvuloplasty
What type of mets will be curable w/ pneumonectomy? which will not?
curable = hilar mets
nodal mets at carina or mediastinum do not allow curative resection
What is next step if suspect aortic dissection?
CTA/spiral CT = best test
also could do MRA or TEE
What is dx step if suspect nonhealing ulcer is skin cancer?
full thickness bx at edge of lesion
What is presentation of branchial cleft cyst?
anterior edge of sternomastoid muscle
can have little opening/dimple and blind tract in skin
What is presentation of cystic hygroma?
at base of neck, large mushy ill-defined mass
occupies entire supraclavicular area
seems to extend deeper into chest
must do CT
What is presentation of acute epidydimitis? next step?
testicle and cord are swollen and painful (vs torsion no pain in cord)
fever, pyruia
tx: abx and do US to r/o torsion
What should you think if pt w/ normal urine output but drinks for first time and colicky flank pain?
ureteropelvic junction obstruction = gets obstructed w/ large volume diuresis
What is main tx for seminoma?
- surgical excision
+ platinum based chemo for mets
What is next step for penetrating trauma to upper zone, middle zone, and base of neck?
upper: ateriogram
middle: surgical exploration if sx of hematoma, worsening tials, coughing or spitting blood
base of neck: arteriography, esophagogram, esophagoscopy, bronchoscopy before surgery
What is next step if pt w/ blunt trauma to abdomen and sx of peritoneal irritation?
exploratory laparotomy
What is next step for penetrating ab injury causing hematuria?
exploratory lap and repair
What should you think if baby w ab mass that moves up and down with respiration?
malignant liver tumor –> hepatoblastoma or HCC
check AFP
tx: resect
What should you think if baby w/ deep ab mass that is nonmobile? next?
wilms from kidney or neuroblastoma in adrenal
dx: CT or MRI
tx: surgical resction
What is next step for 55 yo woman w/ palpable breast mass?
mammo or US guided core bx
When is genu varum (bow) and genu valgus (knock-knee) normal?
genu varum = normal to 3, after = blount dz
genu valgus = normal 4-8yo
What should you suspect if pt had knees hit dashboard in car collision now w/ hip pain, leg sohortened, adducted, internally rotated?
posterior dislocation of hip
need to do emergent reduction to avoid avascular necrosis
What is de quervain tenosynovitis?
young mother, forced wrist flexion and thumb extension
complain of pain radial wrist, reproduce by holding thumb in closed fist and deviating wrist to ulnar
tx: steroidd injection
What is dupuytren contracture?
contract palm of hand, palmar fascial nodules
What is usual presentation of UTI post-op?
POD3
What is usual presentation of wound infection post op?
POD 7, erythema, warmth, tenderness
What is presentation of L colon vs L colon?
R colon = anemia, occult blood
L colon = bloody bowel movement, narrow stool caliber, blood coats outside of stool
What is tx for pyogenic liver abscess 2/2 ascending cholangitis?
percutanoues drainage
When do you do lumpectomy vs mastectomy for breast cancer?
lumpectomy: if small, far from nipple
mastectmoy: large tumor under nipple and areola, if occupies most ofsmall breast
What is next step if pt w/ hx of breat cancer and persistent back pain?
do MRI and resect or radiate
What should you think if baby w/ green vomiting and multiple air fluid levels in abdomen?
intestinal atresia 2/2 vascular accident
What should you think if baby w/ green vomiting and double bubble?
malrotation: normal gas beyond, do contrast enema or upper GI study
duodenal atresia: double bubble only
annular pancreas: double bubble only
What is presentation of chronic constrictive pericarditis? findings on cardiac cath?
DOE, hepatomegaly, ascites
square root sign and equalization of pressures on cath
What is presentation of retinal detachment? tx?
flashes aof light and floaters
no pain
tx: emergency laser spot welding
At what point do you allow stones to pass vs use shock wave lithotripsy?
allow to pass =
What should you do next if cant insert IV in adult but need to give IVF? what about kid
adult = percutaneous femoral vein cath or saphenous cut down
kid
How do you dx bladder injury in ab trauma?
retrograde cystogram including postvoid films to see etraperitoneal leaks at base of bladder
What is a complication of b/l comminuted femoral shaft fractures?
may produce enough internal blood loss to lead to shock –> should place in external fixation while patient is stabilized
What is tx when break both malleoli?
open reduction and internal fixation
What is surgical tx for longstanding GERD?
nissen fundoplication
plus give radiofreq ablation if severe dysplastic changes
What should you think if young woman w/ pain w/ defection and blood streaks covering stool w/ fear of pain so avoid BMs? tx?
anal fissure
do exam under anesthesia and topical CCB (diltiazem)
What should you think if pt presents with jaundice and US w/ large thing walled distended gallbladder? next step?
= courvoisier-terrier sign = sign of malignancy (pancreatic, ampulla of vater adenoCA, or cholangiocarcinoma)
next step = do CT
What should you do if pt w/ jaundice and courvoisier sign on US w/ negative CT?
do mrcp to show smaller tumors
What should you think if pt w/ fever and leukocytosis 10 days after onset of pancreatitis? dx? tx?
pancreatic abscess
- do CT
- tx: percutaneous radiological drainage
What is tx for congenital diaphragmatic hernia?
- delay repair 3-4 days to allow lung maturation
- in meant time do ET intubation, low pressure ventialation, may require ECMO
What is likely dx if premature infant w/ feeding intolerance, ab distension and rapid dropping platelet count? tx?
necrotizing enterocolitis
tx: stop ffeds, abx, IVF, IV nutrition
immediate surgical intervention if ab wall erythema, air in portal vein,, intestinal pneumatosis, or pneumoperitoneum
What is likely etiology if pt w/ sudden onset acute generalized pain?
perforation
What is next step if pt w/ kidney transplant and signs of acute rejection?
steroid bolus = first line
if unsuccesssful give antithymocyte serum
What is work up for hematuria?
- first CT for cancer
- if negative and high suspicion do cystoscopy
What is next step if pt w/ kidney stone now w/ fever and flank pain?
urgen nephrostomy tube or stent placement + IV abx = combo of obstruction and infection
What is likely dx if older pt s/p surgery presents w/ ab distension and massively dilated colon? tx?
ogilvie syndrome
tx: colonoscopy, suck air out, place long rectal tube
What kind of brain pathology presents w/ kids who do knee-chest position?
ependymoma = to open flow of CSF and relieve HA
