Shelf Flashcards
How could you distinguish pericardial tamponade from tension pneumothorax?
CVP is high in both conditions.
In pericardial tamponade, there is NO respiratory distress.
What is the definition of shock
Systolic BP less than 90.
UOP less than 0.5mL/kg/hr
Fast feeble pulse
Trauma: shock is due to bleeding (most common), pericardial tamponade or tension pneumothorax. If shock is due to bleeding, CVP is low. If shock is due to pericardial tamponade or tension pneumothorax, CVP is high.
Circulatory collapse in flushed, “pink and warm” patient with signs of shock is concerning for
Vasomotor shock - seen in anaphylaxis and high spinal cord transaction.
A linear skull fracture that is closed with no overlying wound is….
Left alone
Rhinnorhea, otorrhea, raccoon eyes, ecchymosis behind ear concerning for
Base of skull fracture
Spinal cord injury
Primary - initial insult
Secondary - occurs in minutes to hours following the insult and involves spinal cord edema that leads to central hemorrhagic necrosis.
Management: ensure secure airway and Hemodynamic stability, next bladder catherization to ensure no acute urine retention.
Rule out vascular injury in clavicle fracture with:
Angiogram - examine subclavian artery
Brachial plexus is also at risk.
Clavicle injuries:
Middle third of clavicle:
Distal third:
Middle third: Brace, rest, ice
Distal third of clavicle: open reduction and internal fixation
Valgus stress test for MCL
Repeat. Only perform arthroscopy if MRI is inconclusive.
If PCWP increases in response to infusion but there is no sig change in BP in the setting of an accident, consider:
Myocardial contusion – meaning compromises LV function. Next step is urgent echocardiogram.
What rules against hypovolemic shock in this case is that hypovolemic shock has low starting PWCP.
Uncomplicated diverticulitis:
Bowel rest, oral antibiotics, observation. Hospitalize if elderly, immunosuppressed or have elevated Leukocytosis.
Complicated diverticulitis:
Drainage percutaneously if collection is greater than 3cm. Less than 3cm, treat with IV antibiotics and observation.
If after 5 days from drainage there is no symptom resolution, surgery for drainage and debridement.
Doppler pressure of ______ is threshold for escharotomy
25-40.
If escharotomy provides no relief, consider fasciotomy.
A patient with focal neurological signs and acute head trauma should get:
Emergency craniotomy
Tracheobronchial separation is treated with;
Surgery
No risk of adenal insufficiency in pt on prednisone of 5mg or less.
Repeat.
Children with blunt trauma to the abdomen who present with Epigastric pain and repetitive vomiting are concerning for…
Management:
Duodenal hematoma
Management: NG suction and parenteral nutrition. Most duodenal hematomas resolve in 1-2 weeks. The hematoma is between the sub mucosal and muscular layers. If conservative management fails, then laparotomy or laparoscopy.
A man over the age of 60 with back pain, hypotension, syncope is concerning for…
Abdominal aortic aneurysm rupture. If a RUPTURED AAA is suspected, he should be taken to the operating room right away.
Needle shaped crystals on urinalysis indicate
Uric acid stones. These stones must be evaluated by CT scan or IV pyelography because they are radiolucent.
Stones less than 0.6cm can pass with IV hydration and analgesia.
Colonoscopy should not be performed in setting of acute pathology because of increased risk of
Bowel perforation
If an esophageal rupture is suspected, management is:
Confirm diagnosis with water-soluble esophagogram. Then attempt primary closure and drainage of mediastinum (mutually left-sided pleural effusion) within 6 hours to avoid mediastinitis.
CXR in esophageal rupture demonstrates pleural effusion, pneumomediastinum, and/or pneumothorax.
Patients with a positive psoas sign concerning for appendiceal abscess (these patients usually have symptoms of appendicitis for over 5 days) should be manages with
IV antibiotics, bowel rest, and (if appropriate) Percutaneous drainage. They should have an INTERVAL appendectomy in 6-8 weeks because complication rate of immediate surgery is high.
Indications for surgical intervention in chest trauma
1500mL of blood loss when chest tube inserted or greater than 600mL over 6 hours.
Dyspnea, tachypnea, chest pain, hypoxemia especially worsened by intravascular volume expansion with patchy, irregular alveolar infiltrates on CXR in the setting of Motor vehicle accident is concerning for
Pulmonary contusion
Petechiae, respiratory distress, and mental status changes 12-72 hours after long bone fracture is concerning for…
Fat emboli
Sudden hypotension, tachycardia, back pain following cardiac catherization is concerning for…
Retroperitoneal hematoma. Diagnose with CT of the abdomen and pelvis without contrast. Treatment is conservative. No surgery usually required.
The final sequel of compartment syndrome in the upper extremity after a fracture for example, is ___
Volkmann’s ischemic contracture where dead muscle is replaced by fibrous tissue.
Genu varus (bow legs) are normal until age 3. Beyond that age, they are concerning for ________ and can be managed by _____
Blount disease (disturbance of medial proximal tibial growth plate). Managed with surgery.
Osgood-Schlatter’s disease (_________) is treated with
Osteochondrosis of the tibial tubercle. Usually teenagers with persistent pain over tibial tubercle. Treat with immobilization of knee or cast for 4-6 weeks.
If a growth plate is bisected by a fracture, then appropriate management is
Open reduction and internal fixation to realign it perfectly. However, if the growth plate were intact and only lateral displacement occured, then closed reduction is acceptable.
Bone tumors in adults are usually metastatic
Investigate with bone scan first. Then follow up with x-rays. The exception to this is multiple myeloma where x-rays are preferred.
A shoulder dislocation that is held close to the body and internally rotated is the less common ______ dislocation of the shoulder
Posterior
Colles fracture, which occurs in fall on an outstretched arm in older woman (usually osteporotic) and results in a dorsally displaced radius is managed with ….
Referred to as “dinner fork” appearance.
Closed reduction and long arm cast
If scaphoid fracture x-Ray shows angulation and displacement, them open reduction and internal fixation is required. If only the history is positive and x-rays are non-concerning, then thumb spica cast.
Tenderness over anatomic snuff box is usually the clue.
Repeat
For trigger finger, first line therapy is …
Steroid injection
A mom who has been holding her baby often with wrist flexion and thumb extension is at risk for…
De Quervain’s tenosynovitis. The pain is on the radial side of the wrist. Can be reproduced with thumb in closed fist and ulnar deviation of wrist. Treatment: steroid injection.
For contracture where palmar facial nodules can be felt, the treatment is:
Surgery when it is causing disruption in normal activity.
The above condition is known as Dupuytren’s contracture.
An amputated digit should be cleaned with sterile saline and ww tapped in saline-moistening gauze, placed in sealed bag and transported on a bed of ice
Repeat.
An EF under 35% is a risk for peri-operative MI
Repeat
Do not use thrombolytics to treat MIs in the post-operative setting. CPK-MB is the most sensitive isozyme to pick up myocardial damage.
Repeat
Palpable or audible snap occurring while slowly extending the knee from full flexion while simultaneously applying tibial torsion with tenderness on medial side is concerning for…
Medial meniscus injury
A patient with a first time DVT should be started on heparin and transitioned to 3 months of Warfarin therapy with an INR goal of 2-3
Repeat
A joint replacement that becomes symptomatic 3 months afterward is likely to be? 6 months afterwards is likely to be?
3 months - Staph aureus
6 months - Staph epidermis (coagulase negative Staph)
In this disease marked by dysphagia, solids are swallowed more easly than liquids.
Achalasia.
Diagnosis: manometry
Treatment: repeated dilations or surgical myotomy (Heller myotomy)
Succussion splash is associated with _____
Pyloric stricture
Normal CXR findings do not rule out acute cardiac tamponade. In acute cardiac tamponade, the CXR is often normal because only a small amount of fluid is required in the pericardial sac to cause tamponade.
Repeat.
What therapy is available for persistent Primary Raynaud’s?
Calcium Chanel blocker
Digoxin,Verapamil, adenosine should NOT be used in WPW. They increase AV node refractory period thus favoring accessory pathway and placing at risk of V-Fib. Instead use anti-arrhythmic like procainamide.
Repeat
In hypothermia, ________ (EKG changes) seen
J Osborne Waves
All mechanical obstructions caused by incarcerated hernias undergo surgical repair
Repeat
A small bowel carcinoid tumor with liver metastases that causes diarrhea, flushing of the face, wheezing, R sided heart valvular damage (jugular venous pulse)
Carcinoid syndrome
24 hour 5-hydroxyindolacetic acid
For rectal cancers, management may include:
Pre-op chemotherapy and radiation
Treat primary peritonitis with a single bacterial agent with
Antibiotics. No surgery.
Acute hemorrhagic pancreatitis is more severe and is marked by lower hematocrit, at presentation: elevated WBC count, elevated blood glucose, low serum calcium
Repeat
After ____ weeks of observation, pancreatic pseudocysts must be drained percutaneously.
6 weeks. Chance of rupture, bleeding, or secondary infection increases precipitously at this point.
Treatment of acalculous cholecystitis
Antibiotics and Percutaneous cholecystostomy. Definitive therapy is cholecystectomy.
In acute cholecystitis, perform cholecystectomy within 72 hours
Repeat
To diagnose a ureteral stone use which imaging study?
Non-contrast CT of the abdomen and pelvis
SIRS criteria
Temp under 95 or over 100.4
RR greater than 20
HR greater than 90
WBC count greater than 12K, less than 4K or greater than 10% bands
Penile fracture
Emergent retrograde urethrogram to assess for urethral injury and then emergent surgical exploration.
Pituitary MRI
Adrenal CT
Repeat
DO NOT drain an amebic abscess. You must treat it with oral metronidazole regardless of its size.
Repeat
A SBP over _____ is considered adequate response to fluids.
100
A 4 week history of fatigue and exercise intolerance and Dyspnea. HR of 130, BP of 150/90, and global hypokinesis of LV and left atrium with EF of 35% with signs of A - Fib is concerning for…
Tachycardia-mediated cardiomyopathy. Treatment: rate or rhythm control is critical
In high risk patients (________ and ______), a solitary pulmonary nodule which is defined as a nodule in middle or lateral lung less than ___cm is managed by _____
Over 40 years old, smokers
Less than 3 cm
Managed by CT chest followed by fine needle aspiration
Note bronchoscopy is NOT good for peripheral lesion.
Livedo reticular is can be associated with cholesterol emboli.
Treatment: supportive and statins.
Repeat
TB is associated with upper lobe cavitary lesions
Repeat
Sodium bicarbonate is given in TCA overdose to mitigate the effects of the TCA on myocardial sodium channels - to prevent QRS widening. Other supportive therapy for TCA overdose is oxygenation, intubation, IV Fluids, active charcoal within 2 hours of ingestion.
Give Sodium bicarbonate if QRS interval is greater than 100msec
Repeat
A positive VDRL but negative FTA-ABS, thrombocytopenia, prolonged PTT and history of two miscarriages in a pregnant woman suggests
Anti-phospholipid antibody syndrome and should be treated with LMWH.
Administration of EPO side effects in chronic renal disease
Worsening HTN, headaches, flu-like illness
Secondary amyloidosis can be treated with:
To diagnose primary amyloidosis, you can perform
Colchicine
Abdominal fat pad biopsy - amyloidosis.
If a patient presents with MGUS it is ____ appropriate to perform metastatic bone survey (metastatic bone x-rays) looking for lytic lesions. MGUS patients will have less than 3g/dL of protein and less than 10% plasma cells in their bone marrow.
It is appropriate.
The most common manifestation of rheumatic heart disease is…
Mitral stenosis (Loud S1 and mid-diastolic rumble)
Zollinger-Ellison works by causing pancreatic enzyme inactivation due to overproduction of stomach acid. Zollinger Ellison does NOT cause pancreatic enzyme deficiency.
Repeat
Polycythemia Vera tends to increase all 3 bloodlines. It’s median age is 60.
If there are blanching papules on a mucous membrane, consider AVMs secondary to hereditary telangiectasias (Osler-Weber-Rendu syndrome).
Repeat
A single pre-operative dose of antibiotics no more than 1 hour before procedure is effective in reducing adverse outcomes
Repeat
A patient who has claudication can have their cardiac risk eve lactation performed by pharmacologically and also have an echocardiogram if they have high cardiac disease risk. They are not a candidate for exercise stress testing due to peripheral vascular disease
Repeat
Respiratory alkalosis and metabolic acidosis and tinnitus are pathognomonic for aspirin toxicity
Repeat
A patient with HIT should stop heparin and be placed on lepirudin which can be used as a bridge to warfarin.
Repeat
A prolonged APTT but normal PT and normal bleeding time and platelet count are concerning for
VWD. Von Willebrand’s disease. The disease is marked by lack of response to ristocetin. Giving cryoprecipitate helps to improve with coagulation.
Patient with polycythemia Vera should get ____ before surgery for qualitative platelet deficiency.
Fresh frozen plasma
Patients with acute exacerbation of COPD should be treated with: _______
If their respiratory status becomes a concern, the first step is to:
Short-acting Bronchodilators, glucorticoids, and antibiotics.
First step: Non-invasive positive pressure ventilation. If the patient fails NIPPV after 2 hours (develops profound acidosis – less than 7.1, develops poor mental status or hemodynamic instability) then consider mechanical ventilation.
Sudden painless loss of vision particularly in someone with Cardiovascular disease risk factors is concerning for _______
Management: _____
Mechanism: ____
Central retinal artery occlusion.
Management: Ocular massage and high flow oxygen.
Mechanism: Emboli
Signs of sepsis, deep abdominal pain, fever, and chills a week after a blunt abdominal injury with initially clear CT scan is suggestive of
Pancreatic laceration. (Retro peritoneal abscess). Treatment: emergency. Immediate percutaneous drainage with culture of the fluid and then surgical debridement.
Note that splenic injury usually does not have any signs of sepsis, shows up on CT and is more associated with hypotension.
Chest pain that is sharp, focal, non-radiating, worsens with inspiration and movement and can be induced by Palpation on exam is consistent with:
Costochondritis. Reproducible chest pain on physical exam suggests Musculoskeletal origin.
Treat for cyanide poisoning too in smoke inhalation. With hydroxocobalamin or sodium thiosulfate or nitrites (nitrites will induce methemoglobin).
Cyanide impairs oxygen utilization in tissues and causes state of anaerobic metabolism leading to lactic acidosis.
Repeat
Viral myocarditis causes dilated cardiomyopathy. Dilated ventricles with diffuse hypokinesia on echo.
Repeat
Hypopigmented areas that do not tan
Tinea versicolor
Hemophilia A management
Mild hemophilia A - treat with DDAVP
Severe hemophilia A - treat with AMICAR (e-aminocaprioic acid - inhibits finrinolysis) and DDAVP
Large transfusions can cause deficiency of factors:
Factors V and VIII, the lability factors.
Heparin is reversed with protamine
Repeat
Patients who have TPN after being severely malnourished are at risk of refeeding syndrome. (Hypokalemia and hypophosphatemia). Refeeding occurs when these patients are administered glucose.
Repeat
Transfusion of clotting factors should occur on call to the OR. Based on half life of factor VII.
Repeat
UTI is the most common post-op infection
Repeat
What is associated with osteitis fibrosa cystica?
Primary hyperparathyroidism
Type IV RTA is marked by:
Non-gap metabolic acidosis and hyperkalemia.
What is the appropriate management of a transfusion reaction?
Discontinue transfusion. Fluids and mannitol because transfusion reactions are marked by hypotension and oliguria due to increased hemoglobin load in kidney.
Steroids DO NoT have a role in transfusion management.
If someone is bleeding from a tracheostomy, management is: ___
If actively bleeding, intubate.
If bleeding has stopped, fiberoptic evaluation.
Nitrous oxide should NOT be used in procedures with air-filled spaces (e.g. Bowel obstruction with distension) because it can cause progressive distention of air-filled spaces.
Repeat
In what direction does chronic hypoxia and blood banking shift the oxygen dissociation curve?
It shifts the dissociation curve to the left.
PEEP works by increasing FRC
Repeat
Treatment of neurogenic shock:
- Fluid bolus and then vasoconstrictors like phenylephrine and dopamine.
To mitigate against the effects of myoglobin, alkalinize urine.
Repeat.
Middle aged woman with point muscle tenderness and fatigue especially exercise with otherwise normal physical exam and normal ESR is concerning for…
Fibromyalgia
Treatment: Exercise, sleep, tricyclic anti-depressants
The most common cause of REVERSIBLE restrictive cardiomyopathy is
Hemachromatosis
Contact lens and involvement of the cornea is associated with
Pseudomonas keratitis
Treatment: remove lens. Topical Broad spectrum antibiotics
Hemodynamically unstable patients with an inconclusive FAST should get:
DPL Before deciding on need for laparotomy. If DPL is negative, stabilize and the CT scan.
Prophylaxis for MAC in HIV positive patients with low CD4 count (less than 50) is:
Azithromycin
On the other hand, treatment of MAC is Ethambuthol and clarithromycin
Fibrinolytic therapy or streptokinase is not appropriate for management of patient with recent motor vehicle accident. Instead if such a patient has an empyema that fails chest tube drainage, the next step is ….
Surgery
What drug is a class IC ant-arrhythmic that can be used sometimes to treat A-Fib in addition to it’s standard use for SVTs. This drug causes QRS prolongation at faster rates by what mechanism?
Flecainide. Blocking sodium channels.
Managing hepatic encephalopathy
Treat underlying cause (volume depletion, electrolyte abnormalities)
Lower serum ammonia (using lactulose and lactitol)
If a patient has herpes encephalitis, give him/her acyclovir first recalling that seizures can be attributed to the encephalitis.
Repeat.
PMN greater than _____ is concerning for SBP in ascites fluid.
250/mm^3
Treatment: 3rd generation cephalosporin
Mycoplasma pneumoniae can present with extra pulmonary symptoms like skin rash (erythema multiforme). It’s indolent course also tends to be marked by NON-PRODUCTIVE COUGH
Repeat
If colonoscopy does not demonstrate a bleeding source and the patient continues bleeding, arteriogram or labeled scintigraphy is in order. If they stop bleeding, small bowel studies are appropriate.
Repeat
A patient with sternal fracture is at risk for …
Myocardial contusion and aortic rupture.
Management: Myocardial contusion - manage with EKG and Troponins and control arrhythmias as they develop. If CXR shows widened mediastinum concerning for aortic rupture, perform spiral CT scan. If spiral CT is negative and you are still concerned for aortic rupture, get an aortogram.
Masses in a young female on OCPs are likely to be _______
Management regardless of size is:
Hepatocellular adenomas
Management: discontinue OCPs and complete CT scan in 3-6 months.
A patient who has symptoms concerning for cholangitis and has an elevated right diaphragm on x-ray especially in the setting of cholangiocarcinoma probably has
Liver abscess
In a patient who is unstable and has a bleeding duodenal ulcer, the appropriate management is:
Oversewing the ulcer, performing a pyloroplasty and a vagotomy due to reduced mortality.
Ceftizox is a ____ generation cephalosporin with NO coverage of what important bacterial agent?
3rd generation cephalosporin with NO coverage of pseudomonas.
The main treatment for Candida is ____. Ketoconazole is also moderately effective but must be avoided in what medical condition ______.
Amphotericin B
Ketoconazole must be avoided in liver disease.
Left ventricular failure is the most concerning risk factor for cardiac complications following vascular surgery.
Repeat
A sickle cell patient bleeding into the posterior chamber of the eye (in the absence of retinal detachment) can be managed by: _________
Future crises can occur with: __________
Manage bleeding in the eye in the absence of retinal detachment by observation.
Future crises can occur in the setting of alkalosis and hypoxemia.
Recall nerves in the feet are named for their actions on the toes. Extensors are on the top portion of the foot and are innervated by deep fibular nerve.
The flexors are in the posterior portion of the foot and are innervated by the TIBIAL NERVE. There is no posterior tibial nerve.
Repeat.
Pamidronate calcium bisphosphonate has what positive effect in multiple myeloma ___________
Reduces skeletal fractures, improving quality of life. Bisphosphonates inhibit osteoclastic action.
A liver cyst discovered on ultrasound shown to be hydatid disease should be managed by:
Laparotomy, cyst excision and peri-operative albendazole.
An long-term alcoholic patient who presents with gastric varices should have appropriate resuscitation to stop the bleeding and then have what resuscitation surgery?
Splenectomy - due to splenic vein thrombosis secondary to pancreatitis.
What is the best intervention for fibromuscular dysplasia of the renal arteries?
Percutaneous transluminal angioplasty (PTA)
Respiratory distress in the setting of spinal anesthesia is due to…
Centrally-induced mechanism secondary to decreased cardiac output
Paradoxical rhinorrhea is associated with CSF leakage from the Eustachian tube that leaks through the nose from the communication with the middle ear.
Repeat
Lacrimal gland is innervated by the facial nerve.
If facial nerve injury occurs and the stapes innervation is affected, huperacutism is what results! (NOT deafness).
Repeat.
For traumatic CSF leaks, management is:
No surgery required. Instead ELEVATE the head of the bed and then consider lumbar spinal drainage if the leak persists. Elevating the head of the bed reduces the intracranial pressure.
CF–absent bad deferens is the most likely cause for male infertility characterized by normal FSH, low sperm volume.
Repeat.
Breast tissue covers the medial third of serratus anterior.
Repeat.
A patient involved in a high speed motor vehicle collision with a CXR that shows multiple air fluid levels on the left is concerning for …
Traumatic diaphragmatic rupture. Management: Surgery.
An NG tube that shows up in the left chest is also a helpful hint.
A patient has an aortic rupture secondary to massive trauma (demonstrated by breaking a tough bone like scapula, first rib, or sternum) what is appropriate next step?
If he/she is stable, prior to establishing diagnosis, the first step would have been CXR to demonstrate widened mediastinum. Next a spiral CT and if the spiral CT were negative, aortogram or arteriogram. Once the diagnosis is confirmed by CT or aortogram/arteriogram, Management is emergency surgical repair.
Tetanus immunoglobulin should only be added for people who are UNINMMUNIZED or never in life received their full dose of tetanus toxoid before AND have a dirty or severe wound.
Repeat.
Back pain + syncope + hypotension in an elderly male is concerning for…
Abdominal aortic aneurysm rupture. Hematuria can also be a hint.
Sudden, severe lower extremity arterial pain is likely to be an embolus NOT a thrombus.
Repeat.
freely mobile, rubbery, breast mass in a woman around the age of 35 suggests FIBROADENOMA but mammography are appropriate first steps before advancing to core biopsy if there are signs of malignancy. Over the age of 30, mammography and ultrasound is preferred. Under the age of 30, ultrasound alone is a great first step.
Repeat
If there is a penile fracture, EVEN IF there is no blood at the meatus, do a retrograde urethrogram to rule out injury of the urethra.
Repeat.
What therapy has been shown to have effect in SEVERE septic shock?
Recombinant activated protein C
All patients with penetrating trauma (gunshot) to the abdomen who are Hemodynamically unstable need ex-lap immediately. DPL is only reserved for pts with blunt trauma
Repeat.
