Pestana questions

Question 1

How do you manage linear skull fractures if they are closed (no overlying wound)

Answer 1

leave alone

Question 2

Urethral injury occurs almost exclusively in men, and is typically associated with a pelvic fracture, and may present with blood at the meatus. more complete clinical picture might include a scrotal hematoma, for posterior injuries the sensation of wanting to void but not being able to, and a “high riding” prostate on rectal exam . . . what should be done

Answer 2

retrograde urethrogram

Question 3

Intertrochanteric fx of hip are less likely to lead to avascular necrosis and are usually treated how

Answer 3

ORIF with post op anticoagulation

Question 4

Femoral neck fx, particularly if displaced compromise the very tenuous blood supply of the femoral head. Faster healing and earlier mobilization can be achieved how?

Answer 4

by replacing the femoral head with a prosthesis

Question 5

While repairing an elevator shaft, a 39 year old worker falls from a height of 2 stories, landing on his feet. Both calcanei are obviously fractured. Further evaluation should include x rays of what?

Answer 5

Thoracic and lumbar spine

Question 6

This is a squamous cell carcinoma that is found in the classic setting of many years of healing and breaking down, such as seen in untreated third degree burns that underwent spontantous healing, or in chronic draining sinuses secondary to osteomyelisis

Answer 6

Marjolin ulcer

Question 7

treatment for complete arterial occlusion of lower extremity

Answer 7

-embolectomy with Fogarty catheter and fasciotomy should be added if several hours have passed before revascularization

Question 8

Most testicular cancers are exquisitely radiosensitive and also respond to what type of chemo

Answer 8

platinum based chemo

Question 9

A pedestrian is hit by a car. He arrives in the ER in coma. He has clear fluid dripping from the left ear and a dark bruise behind his ear and over his left mastoid area. As he is being taken to the CT scanner for a scan of the head, you would recommend what?

Answer 9

The CT be extended to include his neck

Question 10

A 31 year old woman crashes her car against a bridge. She has multiple injuries, including upper and lower extremity fractures. Her Blood pressure is 135/75, and her pulse rate is 82. ON physical exam she has a rigid, tender abdomen with guarding and rebound on all quadrants. What is the next step in management?

Answer 10

Exploratory Laparotomy

Question 11

A 22 year old man is shot twice in the abdomen with a .22 handgun. One entry wound lies to the left of the umbilicus, with the bullet lodged in the right psoas muscle. The second entry wound is just above the pubis, and that bullet is in the middle of his abdomen. He has gross hematuria. Evaluation of the hematuria would best be done by what?

Answer 11

exploratory laparotomy

Question 12

53 year old women come in because of a breast mass. Two days ago she noticed a lump on self exam. She has a 2 cm firm nontender mass in the left breast, which is movable within the breast. She has no prior history of breast disease, but she is well-read and well-informed patient who gets regular screening mammograms and is due for her next one in 3 months. The next step in management is what?

Answer 12

Do mammographically or sonographically guided core biopsies

Question 13

What urinary output are we shooting for when replacing fluids in a severely burned patient?

Answer 13

1 or 2 mL/kg/hr

Question 14

3 hours ago, a 72 kg man sustained second and third degree flame burns to an estimated 35% of his body surface. Ringer lactate without sugar has been infused at a rate of 1 L/hr, and his urinary output has been measured by an indwelling catheter. In those first 3 hours his urinary output was 290, 315, and 350 mL/h. Based on that info, you should?

Answer 14

decrease the rate of fluid administration

Question 15

Genu Valgus (knock-knee) is normal between what ages and no treatment is needed?

Answer 15

4 and 8

Question 16

A 68 year old woman arrives in the ER with a clinically obvious fx of the radius and a possible dislocation of the ulnar stylus process. When questioned about the trauma that caused the injury, the woman reports that there was none: She attempted to lift a heavy bag of groceries and “my arm broke”. you immediately suspect what?

Answer 16

Metastatic osteolytic cancer

Question 17

A 21 year old male has had multiple problems while in the ICU recovering from a laparotomy for a gunshot wound. Initially, his chest x-rays and respiratory function were normal, but he now has bilateral pulmonary infiltrates and a PO2 of 65 while breathing 40% oxygen. There is no evidence of congestive heart failure. The diagnosis and appropriate therapy are what?

Answer 17

• Adult respiratory distress syndrome (ARDS)

- Positive expiratory pressure (PEEP)

Question 18

All abdominal hernias should be electively repaired to avoid the risk of intestinal obstruction and strangulation . . what are the exceptions?

Answer 18

• Umbilical hernias in patients younger than 2-5 years of age (they may close by themselves)
• Esophageal sliding hiatal hernias (which are not “true” hernias)

Question 19

A 42 year old, right handed man has a history of progressive speech difficulties and right hemiparesis for 5 months. He has had progressively severe headaches for the last 2 months, which are worse in the mornings. At the time of admission he is confused and vomiting and has blurred vision, papilledema, and diplopia. Shortly thereafter, his BP goes up to 190/110 and he develops bradycardia. The rise in his BP is due to what?

Answer 19

-A compensatory response to preserve brain perfusion (Cushing reflex)

Question 20

On a routine physical exam, a 65 year old man is found to have a 1.5 cm, rock-hard mass in his prostate. His PSA is normal for his age. The next step in management is to do what?

Answer 20

Do a transrectal needle biopsy of the mass

Question 21

The preferred route of fluid resuscitation in the trauma setting is 2 peripheral IV lines, 16-gauge. If they cannot be inserted, percutaneous femoral vein catheter or saphenous vein cut-downs are alternative. In children under 6 years of age, what is the alternate route?

Answer 21

Intraosseus cannulation of the proximal tibia

Question 22

a 77 year old man becomes “senile” over a period of 3 or 4 weeks. He used to be active and made an excellent living writing fiction and movie scripts. Now he stares at the wall all day long, barely recognizes his family, and is “a completely different person”. Two weeks before the mental changes began, he fell from a horse but apparently sustained no serious injuries. You expect a CT scan of his head to show what?

Answer 22

Chronic subdural hematoma

Question 23

A 22 year old woman loses control of an all-terrain vehicle, falls to the ground, and then is crushed . She arrives to the ER with stable vital signs but obvious physical evidence of a pelvis fracture. When a Foley catheter is inserted, it recovers bloody urine. The best way to evaluate her urological injury would be what?

Answer 23

Retrograde cystogram including post-void films

Question 24

During a hunting trip, a young man is bitten by a coyote. The bite drew blood, but the flow was easily stopped by local pressure. The animal was captured and brought alive to the authorities. The need for rabies prophylaxis in this patient should be determine by what?

Answer 24

Killing the animal and examining the brain

Question 25

Anal fissure happens to young women. They have exquisite pain with defacation and blood streaks covering the stools. The fear of pain is so intense that they avoid bowel movements (and get constipated) and sometimes refuse proper physical examination of the area. Exam may need to be done under anesthesia. A tight sphincter is believed to cause and perpetuate the problem, thus therapy is directed at relaxing it . . describe possible therapies

Answer 25

• Stool softeners, topical nitroglycerin, local injection of botox, forceful dilatation, or lateral internal sphincterotomy.
• Calcium channel blockers such as diltiazum ointment 2% TID topically for 6 weeks have had an 80-90% success rate as compared to only 50% success for botulinum toxin

Question 26

A 58 year old woman first noticed scleral icterus 5 weeks ago. Jaundice has been steadily progressing and not her entire body looks yellow and she has mild itching all over. She also reports vague, constant upper abdominal and back pain and a 10-pound weight loss. The lab reports a total bilirubin of 29, most of which is conjugated (direct) bilirubin. Transaminases are minimally elevated and alk phos is about 5x upper limit of normal. An US of her right upper abdomen shows a thin-walled massively dilated gallbladder without stones. The next diagnostic procedure should be what?

Answer 26

CT of upper abdomen

Question 27

a 27 year old immigrant from El Salvador has a 14 by 12 by 9 cm mass in her left breast. It has been present for 7 years and has slowly grown to its present size. The mass is firm, rubbery, and completely movable, and it is not attached to overlying skin or the chest wall. There are no palpable axillary nodes. The most likely diagnosis is what?

Answer 27

Cystosarcoma phyllodes

Question 28

A 54 year old woman seeks help because she noticed a mass in her left breast. She was actually not in the habit of doing breast self exams, but she was accidentally hit with a tennis racket and that brought to her attention to the area. She has a 3.5 cm, hard, deep, freely movable mass and some superficial bruising. The next step in management should be what?

Answer 28

Radiographically guided core biopsies

Question 29

Imaging when you suspect a subarachnoid bleed

Answer 29

• Workup begins with CT scan looking for blood in subarachnoid space and follows with arteriogram to locate the aneurysm
• Spinal tap can identify old blood or small amounts of current blood, but it should NEVER be the first test . . always start with a CT

Question 30

A 58 year old homeless man has been having intermittent hematuria for a year and a half but has not looked for help because “they treat me like trash in the ER.” Finally he is forced to go when he develop flank pain. Workup shows a flank mass, hypercalcemia, erythrocytosis, and elevated liver enzymes. CT scan shows a heterogenic tumor that has grown into the lumen of the vena cava. this is the full blown picture of what?

Answer 30

Renal cell carcinoma

Question 31

The diagnosis of intraabdominal bleeding can be made most accurately how?

Answer 31

CT scan

-The patient with minor internal injuries who responds promptly to fluid resuscitation does not need surgery

Question 32

10 days after a patient receives a cadaveric renal transplant, the new kidney’s function begins to deteriorate. A percutaneous biopsy report of the graft reads, “signs of acute rejection.”. management should be?

Answer 32

Antithymocyte serum and steroid bolus

Question 33

a 59 year old man has a ureteral stone impacted just above the point where the ureter empties into the bladder. CT scan shows the stone to measure 3 mm. Although he is having colicky pain, it is relatively mild and he is not nauseous or vomiting. A decision is made to give him plenty of fluids and pain medication, and let him pass the stone. At 3:00 am, his doctor gets a call informing him that the patient has developed chills, a fever spike to 105, and flank pain. The doctor order IV antibiotics over the phone. What else should he do?

Answer 33

-Go to the hospital right now and place a nephrostomy tube