Pestanas Flashcards
When is the use of a fiberoptic bronchoscope mandatory for securing an airway?
If there is a subcutaneous emphysema in the neck (indicating a tracheobronchial injury).
describe BP, pulse, and urinary output in shock. How will the patient appear (5)?
BP - below 90 systolic, UO -
Describe hemorrhage, pericardial tamponade, and tension pneumo as causes of shock in terms of CVP, respiratory state, and relevant clinical signs.
Hemorrhage - CVP low
Pericardial tamponade - CVP high, Hx of trauma to the chest.
Tension pneumo - CVP high, Hx of trauma to the chest, respiratory distress, and tracheal deviation
What is the first step in the treatment of hemorrhagic shock (after ABCs), describe the process (3)
1) fluid resuscitation with Ringer’s.
2) attain UO of 0.5-2.0ml/kg/hr
3) maintain CVP
What is indicated in a patient with head trauma who became uncoscious?
CT head
What are some clinical signs of basal skull fractures (4)? What is indicated? What must procedure must be avoided?
1) Racoon eyes, rhinorrhea, otorrhea, ecchymosis behind ears
2) CT head and c-spine
3) do not intubate nasally
Describe an acute epidural hematoma in terms of sequence of events (4), clinical signs (3), radiographical findings, and treatment
1) sequence: head trauma -> unconscious -> lucid interval -> coma
2) clinical signs: fixed and dilated pupil, contralateral hemiparesis, decerebrate posture
3) radiology: biconvex lense-shaped hematoma
4) Tx: craniotomy
Describe acute subdural hematoma in terms of sequence, radiologic findings, and treatment (5)
1) sequence: head trauma -> no lucid interval -> unconscious/coma
2) rad: cresent-shaped hematoma
3) Tx: monitor ICP, hyperventilate (PaCO2
Describe chronic subdural hematoma in terms of population, sequence, and Tx
1) population: old or alcoholic
2) sequence: mental function deteriorate over days to weeks as hematoma forms
3) Tx: surgical evacuation
Describe spinal hemisection (from knife blade) in terms of clinical findings (2). What is another name for this injury?
Brown-Sequard injury
1) loss of pain and temp sensation (ST tract) distal to lesion on contralateral side
2) loss of proprioception (DC tract) and paralysis (motor) on ipsilateral side
Describe anterior cord syndrome in terms of clinical findings (2) and mechanism
mechanism: burst fracture
1) loss of motor and pain and temp sensation bilaterally
2) maintain vibration and proprioceptive sensation
Pt is elderly, suffers forced hyperextension of neck in car crash. Only finding is paralysis and burning pain in the upper extremity. What is the Dx?
Central cord syndrome
What is the course during rib fracture in the elderly (4). How is it treated (2)?
1) course: pain -> hypoventilation -> atelectasis -> pneumonia
2) Tx: local nerve block or epidural catheter
How can pneumothorax and hemothorax be differentiated via percussion?
pneumo - hyperresonant
hemo - dull
When is surgery required for a hemothorax? Why is it typically not required?
1) needed if >1500ml recovered from chest tube, or >600ml over 6hours.
2) typically not needed as lungs (low pressure source) are source of bleed and bleeding stops spontaneously
What is the clinical sign for flail chest? What is the concern of the associated pulmonary contussion? What else needs to be considered given the large impact of trauma?
1) paradoxic breathing
2) pulmonary contussion sensitive to fluid overload - fluid restrict and consider diuresis
3) consider traumatic transection of aorta given trauma history
What is the radiographic sign for a pulmonary contusion?
white out
How are suspect myocardial contusions monitored? when should they be suspected? What is the treatment?
1) EKG and troponins
2) suspect in sternal fractures
3) Tx: monitor for arrhythmias, treat if present
When is aortic rupture suspected (3)?
1) deceleration injury
2) fractures of sternum, first rib, scapula
3) wide mediastinum on CXR
What is the DDx for subcutaneous emphysema (3)?
1) tracheobronchial injury
2) tension pneumo
3) esophageal rupture
what are the signs of fat embolism (6)?
1) Hx positive for long bone fracture, patchy infiltrates on CXR
2) SOB -> respiratory distress
3) hypoxemia
4) petechia
5) tachycardia
6) low platelets
What investigation is required for gunshot wounds to the abdomen?
exploratory laparotomy
What 3 signs indicate the need for exploratory laparotomy in a stab victim?
1) protruding viscera
2) hemodynamic instability
3) peritonitis
What 2 diagnostic tests can be used to assess for intra-abdominal bleeding in the hemodynamically unstable trauma patient? What is the next step following a positive finding?
1) DPL
2) FAST scan
3) exploratory laparotomy
In the trauma setting, if the spleen is ruptured and a splenectomy is performed, what 3 vaccines should be provided to the patient?
1) H. influenze
2) pneumoccocus
3) meningococcus
- encapsulated bacteria
What population is almost exclusively subject to urethral injuries in trauma cases? What are these injuries associated with? What is the diagnostic test to confirm clinical suspicion? And what should not be attempted?
1) men
2) pelvic fractures
3) retrograde urethrogram
4) do not pass Foley
What are 2 rare sequelae of renal trauma?
1) CHF secondary to arteriovenous fisula formation
2) Renovascular hypertension secondary to renal artery stenosis
What are 5 concerns in crushing injuries, how are they treated?
1) hyperkalemia
2) myoglobinemia
3) myoglobinuria
4) renal failure
5) compartment syndrome
Tx: fluids, diuresis, alkalinize urine, fasciotomy
What are two indications of fluid resuscitation that should be monitored in burn victims, what are the target values?
1) UO of 1-2 ml/kg/hr
2) Avoid CVP >15mmHG
How does the rule of 9s change in a baby? what is an appropriate rate of fluid administration?
1) Head gets 2 9s, legs share 3 9s (not 4)
2) 20ml/kg/hr if burn >20% BSA
When is early excision and grafting an appropriate approach to burn care?
1) TBSA less than 20%
2) 3rd degree burns
What prophylactic treatment is provided in dog bites that are provoked or involve the face (2)?
1) tetanus prophylaxis (all bites)
2) Rabies prophylaxis (IgG and vaccine)
What are the clinical signs of a balck widow spider bite (2), what is the appropriate treatment?
1) N/V
2) generalized muscle weakness
3) Tx: IV calcium gluconate
How is development displasia of the hip treated in newborns?
abduction splinting with Pavlik harness for 6 months
What are the SSx of avascular necrosis of the capital femoral epiphysis (4)? what is another name for this disease? How is it treated?
1) SSx: antalgic gait, hip pain, insidious onset of limping, decreased hip motion
2) Legg-Calve-Perthes disease
3) Tx: casting and crutches to immobilize femoral head. Onset at age 6+
Describe the population affected by slipped capital femoral epiphysis. What is its treatment? What are the clinical signs (4)?
1) chubby 13 year old boys
2) pinning of femoral head, surgical emergency
3) SSx: groin pain, limp, inversion of a dangling affected foot, hip flexion results in external rotation.
After what age is genu varum a concern? What is the associated disease that causes it?
1) >3
2) Blount disease (failure of growth of medial proximal tibial growth plate)
In what age range is genu valgus normal
Ages 4-8
What is the order in which talipes equinovarus is corrected via serial casting (4)?
CAVE C: midfoot cavus A: forefoot adductus V: Hindfoot varus E: Hindfoot equinus
When is an ORIF indicated for fractures around growth plates in children?
ORIF if the fracture passes through the growth plate
What are radiographic signs of primary malignant bone tumors in young people (2)?
Sunburst pattern
Onion-skinning
What is the most common primary malignant bone tumor in the ages 10-25? What is the radiographic sign?
Osteogenic sarcoma
Sunburst pattern
What is the second most common primary malignant bone tumor in young patients? What is the radiographic sign?
Ewing sarcoma
Onion-skinning
What is the clinical presentation of a patient with an anterior dislocation of the shoulder? What nerve may be affected?
1) Hold arm adducted and externally rotated (“shaking hands”)
2) Axillary
What is the clinical presentation of a posteriorly dislocated shoulder?
1) hold arm adducted and internally rotated
Defensive wound, diaphyseal fracture of ulna, radial head is anteriorly dislocated. What is the Dx?
Monteggia fracture
Fracture to distal third of radius with distal dislocation of the distal radioulnar joint, what is the Dx?
Galeazzi fracture
What is the treatment for an undisplaced scaphoid fracture? For a displaced scaphoid fracture?
1) thumb spica
2) ORIF
What are two signs of a hip fracture?
1) leg shortened
2) leg externally rotated
What are two signs of posterior hip dislocation? What is important about its treatment?
1) leg shortened
2) leg internally rotated
3) Tx: must be prompt as blood supply at risk (AVN risk)
Describe Felon. What is the appropriate treatment?
Abscess in the pulp of the fingertip
surgical drainage to prevent increased pressure and necrosis
What sign is seen in Jersey finger?
Failure of flexion of distal phalynx on affected finger
What is seen in Mallet finger?
Inability to extend at DIP joint of affect finger. Tx: Cast
What is a Morton Neuroma? What is the cause, what is the treatment?
palpable neuroma between the third and forth toes in the common digital nerve. Caused by wearing pointed shoes. Treated conservatively.
How is gout treated during an acute attack? What is provided for maintenance tretment?
1) indomethacin and colchicine
2) Allopurinol and probenicid
Provide some predictors of cardiac risk in the operative period (Goldman’s index) (7).
1) jugular venous distension
2) recent MI
3) rhythm other than sinus
4) age >70
5) emergency surgery
6) aortic valvular stenosis
7) poor medical condition
What 2 clinical signs and 3 lab values predict operative morality in a patient with liver disease?
1) encephalopathy
2) ascites
3) INR (PTT)
4) Albumin
5) bilirubin
What 3 findings are associated with malignant hyperthermia, how is it treated?
1) Hypercalcium
2) Hyperthermia
3) Acidosis
4) Tx: Dantolene, 100% O2, cooling blankets, correct acidosis
What are the causes of postop fever (6)? Provide them in the order they appear in the postop period.
1) atelectasis (pod 1)
2) pneumonia (pod 3)
3) UTI (pod 3)
4) DVT (pod 5)
5) wound infection (pod 7)
6) deep abscess (pod 10-15)
What are the SSx of PE (5)? When does it occur in the postop period? How is it diagnosed? How is it treated?
1) SSx: high CVP, SOB, hypoxia, tachycardia, diaphoretic
2) POD 7
3) Dx: pulmonary angio (gold standard), CT angio (most common)
4) Tx: heparin and warfarin
A patient goes into a coma after undergoing a portocaval shunt for bleeding esophageal varices. What is the Dx?
Ammonium intoxication
Describe Ogilvie syndrome. What is the affected population? What are the signs? How is it treated?
1) affects elderly sedentary patients post-operatively, described as paralytic ileus of the colon
2) Distend abdomen and distended colon on XR
3) Colonoscopy and placement of rectal tube
What is the calculation to determine the water deficit in hypernatremia?
For every 3meq/l Na above 140, 1 L of water lost
What causes hypernatremia of rapid onset? How is it treated? What is a clinical concern?
1) DI or osmotic diuresis
2) Tx: D5 1/3
3) Concern: CNS symptoms
How is hyponatremia of rapid onset treated? How is hyponatremia of insidious onset treated, what causes it?
1) Hypertonic saline - 3-5%
2) Water restriction
3) SIADH or post-op water intoxication
How is hyperkalemia of rapid onset treated?
1) acute treatment: 50% dextrose and insulin, IV calcium
2) corrective treatment: NG suction, dialysis
Describe the clinical signs, xray findings, diagnostic tools, and treatment for achalasia
1) Dysphagia worse with fluids than solids
2) Megaesophagus on xray
3) Manometry measurement
4) Tx: baloon dilatation via endoscopy
What is the causative agent in C. Diff enterocolitis? What are the best therapies?
1) cause: clindamycin
2) Tx: metronidazole, vancomycin
What are some therapies for anal fissures (5)?
1) stool softener
2) topical nitroglycerin
3) forceful dilatation
4) internal sphincterotomy
5) Calcium channel blockers
What is the most common cause of blood per rectum in a child? How should work-up commence? What are the histological changes seen?
1) Meckel’s diverticulum
2) Technetium scan
3) ectopic gastric mucosa
What are some SSx of abdominal pain caused by perforation (3)? What is a radiographic finding?
1) Sudden, constant, generalized pain
2) Patient reluctant to move
3) peitoneal signs - tenderness, guarding, rebound, silent abdomen
4) Free air under diaphragm
What are the SSx of abdominal pain cause by obstruction of a narrow duct (ureter, cystic, CBD) (2)?
1) colicky pain with typical radiation pattern
2) patient moves to find more comfortable position
What are the SSx of abdominal pain caused by an inflammatory process (4)?
1) pain is constant
2) generalized pain localizing to one location with typical radiation pattern
3) peritoneal signs present
4) fever and leukocytosis present
What is unique about abdominal pain caused by an ischemic process?
Only diseases that combine severe abdominal pain with blood in lumen of the gut
What are the radiographic signs of volvulus of the sigmoid (3)? How is it treated
1) air-fluid levels in small bowel
2) distended colon
3) large air-filled mass in RUQ with ‘parrot’s beak’ in the LLQ.
4) rigid proctosigmoidoscopy with insertion of rectal tube is curative.
Who is affected by amebic abscess of the liver? How is it treated? How is it diagnosed?
1) Mexicans
2) Tx: Metronidazole (not drainage)
3) Dx: clinical suspicion, treat empirically
What are 3 lab findings in obstructive jaundice
1) high total billi
2) High direct billi
3) high ALP
- normal or slightly high transaminases
How does the appearance of the gallbladder change with an obstruction caused by a stone vs an obstruction caused by a tumor?
stone - gallbladder is large and has thick wall
tumor - gallbladder is dilated and has thin wall
Describe the clinical picture of biliary colic (3). What is the Tx?
1) Colicky pain in the RUQ radiating to back and shoulder
2) Worse after meals (fatty meals), n/v
3) No peritoneal signs, no fever, no leukocytosis
4) elective cholecystectomy
What lab value is useful in differentiating edematous from hemorrhagic pancreatitis?
Hematocrit - high in edematous, low in hemorrhagic
What are the characteristics of a fibroadenoma of the breast (3)? How is it Dx?
1) firm
2) rubbery
3) motile
4) U/S or FNA
What are the characteristics of cystosarcoma phyllodes in the breast (3)? How are the Dx/Tx?
1) distorting growth over years
2) non-invasive
3) non-fixed (do have malignant potential)
4) core or incision biopsy
5) surgical resection
How is intraductal papilloma Dx/Tx?
1) ductogram (mamography to querry other lesions)
2) surgical resection
How does breast cancer treatment change in pregnancy (2)?
1) no chemo during first trimester
2) radiation deferred to post partum period
How is resectable breast cancer treated (differentiate small vs large lesions)? How are lymph nodes dealth with?
1) small - lumpectomy and radiation
2) large - total mastectomy
3) non-palpable lymph nodes - do SLN biopsy
4) palpable lymph nodes - resect
What are the 4 types of thyroid cancers? What is the most aggressive form?
1) Follicular (thyroidectomy, follow-up with radioactive iodine tests)
2) Medullary (thyroidectomy, foolw-up with calcitonin screen)
3) Papillary (slow, local resection)
4) Anaplastic (very aggressive, tracheostomy)
How does high-dose dexamethasone differentiate the origin of a tumor causing cushing’s?
1) if suppression occurs - pituitary adenoma
2) if suppression does not occur - adrenal adenoma
What is seen in Zollinger-Ellison disease (1)?
Multiple gastric ulcers (gastrinoma) refractory to med therapy
What is the VACTER constillation wrt congenital anomalies?
V - vertebral, A - anal, C - cardiac, T - tracheal, E - esophageal, R - radial
What is the DDx for green vomitting in a newborne (4)? What are the radiogrpahic fingings?
1) duodenal atresia - double-bubble
2) annular pancreas - double-bubble
3) malrotation - double-bubble and normal bowel gas pattern
4) intestinal atresia - air-fluid levels
What is seen in meconium ileus? Who does it affect? What is the treatment?
1) bilious vomiting, dilated small bowel on xray
2) CF patients
3) Gastrografin enema diagnostic and therapeutic
What are the SSx of L-R shunts (3)?
1) murmur
2) pulmonary vasculature overload
3) damaged pulmonary vasculature
How is patent ductus arteriosus treated in premature infants?
Indomethacin
What are the SSx of R-L shunts (3)?
1) murmur
2) diminished pulmonary vascular markings
3) Cyanosis
Describe subclavian steal. What are the symptoms (2)?
1) subclavian stenosis prior to the branching of the vertebral artery.
2) Arm claudication symptoms when exercised - cool, tingling, muscle pain
3) Posterior neurologic signs due to steal - vision and equilibrium symptoms
What are the 6 Ps of arterial embolization? What are 2 treatments?
Pale pulselessness pain poikilothermic paresthetic paralytic clot busters or embolectomy (with fasciotomy if >6hrs)
How does treatment of a dissecting aortic aneurysm change based on its location?
Ascending - repaired with surgery
Descending - repaired with hypertension control in the ICU
What are the 3 most common cellular origins of skin cancer in order.
1) Basal - slow growing, located on face above lips, can kill by local invasion, not likely to met, Mohs surgery
2) Squamous - lower lip area, timetable is months, wide margins or radiation required, spreads to region lymph nodes
3) Melanoma - ABCDE, less than 1mm deep require local excision, more than 1mm require wide resection and lymph screening, >4mm is likely lethal.
What is the appropriate treatment for acute angle closure glaucoma while awaiting corrective surgery (4)?
1) carbonic anhydrase inhibitors
2) topical beta-blockers
3) alpha-2-adrenergic agonists
4) Mannitol and pilocarpine
What is the DDx in a young adult with a nose bleed (2). How are they treated?
1) cocaine use with septal perforation- posterior packing
2) juvenile nasopharyngeal angiofibroma - surgical resection
What are the SSx of Meniere disease (3)?
1) vertigo
2) tinnitus
3) hearing loss
What are the medical therapies for BPH (2)?
1) alpha blockers - tamsulosin
2) 5-alpha reductase inhibitors - finasteride
