Specialty Surgery-Uro, gyn, neuro, ortho

Question 1

Urology anatomy

1) where is Gerota’s Fascia
2) relation of renal vein, artery and renal pelvis to each other
3) relation of right renal artery to IVC
4) what vessels do the ureters cross over
5) which renal vein can be ligated from the IVC and why
6) relation of left renal vein and aorta
7) what does the epididymis connect to
8) MCC of acute renal insufficiency following surgery

Answer 1

1) around kidney
2) from anterior to posterior: renal vein anterior to artery anterior to renal pelivs (most posterior)
3) crosses posterior to IVC
4) iliac vessels
5) left renal vein can be ligated from IVC 2/2 increased collaterals (left adrenal vein, left gonadal vein and left ascending lumbar vein). RIght renal vein lacks collaterals
6) left renal vein crosses anteriorly to aorta
7) vas deferens
8) hypotension

Question 2

Kidney stones

1) MC type
2) which type can cause staghorn calculi (fill renal pelvis)
3) which type are increased in pts with terminal ileum resection and why
4) which type occur with proteus mirabilis (urease producing) infections
5) which are associated in a congenital reabsorption disorder
6) what pts are at inc risk of uric acid stones

Answer 2

1) Calcium oxalate (75%)
2) struvite stones
3) calcium oxalate bc increased oxalate absorption in colon since extra intra-intestinal fat is binding Ca
4) Struvite stones
5) Cysteine stones
6) ileostomies, gout and myeloproliferative disorders

Question 3

Kidney stones

1) which are radiopaque
2) which are radiolucent
3) indications for surgery
4) > what size unlikely to pass
5) surgical options

Answer 3

1) calcium oxalate, struvite
2) cystein and uric acid stones
3) intractable pain or infection, progressive obstruction or renal damage, solitary kidney
4) >6mm unlikely to pass.
5) ESWL (extra-corporeal shock wave lithrotripsy), ureteroscopy with stone extraction or placement of stent past obstruction, perc neph tube, open nephrolithotomy

Question 4

Testicular Cancer

1) T/F: #1 cancer killer in men 25-35 yo
2) sx
3) rx of testicular mass
4) are most testicular masses benign or malignant
5) dx and workup prior to surgery
6) what serum marker correlates to tumor bulk
7) MC type of tumor

Answer 4

1) true
2) painless hard mass
3) need to do orchiectomy through an inguinal incision (not trans-scrotal bc don’t want to disrupt lymphatics)- send testicle and attached mass for bx
4) Malignant
5) US, chest and abd CT to check for retroperitoneal and chest mets. Check B-HCG, AFP and LDH level
6) LDH
7) germ cell (90%)- seminoma or nonseminoma

Question 5

Testicular CA
1) T/F- undescended testicles (cryptorchidism) increase risk of testicular CA? if so, what type
2) MC type of testicular CA
3) Seminoma
a- what hormone is elevated in 10%
b- what hormone should not be elevated
c-rx
4) Nonseminomatous testicular cancer
a- types
b- serum markers that are elevated
c-rx

Answer 5

1) true- seminoma
2) seminoma
3) a-B-HCG; b-AFP; c-orchiectomy and retroperitoneal XRT for all stages. Seminoma is extremely sensitive to XRT.
-chemo (cisplatin, bleomycin, VP-16) for metastatic dz or bulky retroperitoneal dz, then resect
4) a-embyonal, teratoma (more likely to met to RP), choriocarcinoma, yolk sac
b- AFP and beta-HCG in 90%
c-orchiectomy and retroperitoneal node dissection for all stages. If Stage II or greater- chemo (cisplatin, bleomycin, VP-16) and resect after

Question 6

Prostate CA

1) MC site of organ
2) MC site of met and radiologic findings
3) dx and staging tests
4) complications of resection
5) rx for intracapsular tumor and no met (T1-2)
6) rx for extracapsular invasion or met
7) rx for stage Ia disease found with TURP

Answer 6

1) posterior lobe
2) bone- osteoblastic-> hyperdense areas on XR
3) transrectal bx, chest/abd/pelvis CT, PSA, alk phos, possible bone scan
4) impotence, incontinence, urethral strictures
5) XRT or radical prostatectomy + pelvic LN dissection (if lifespan>10yr) or nothing
6) XRT and androgen ablation (leuprolide is LH-RH blocker, flutamide is testosterone blocker, or bilateral orchiectomy)
7) nothing

Question 7

PSA and serum tests for prostate CA

1) how long after surgery does it take for PSA to return to 0. If it doesn’t return what test should you get
2) what is normal PSA
3) what else can increase PSA besides prostate CA
4) what is inc alk phos in a pt with prostate CA concerning for

Answer 7

1) 3weeks. if doesn’t return, get bone scan

2)

Question 8

Renal cell carcinoma (RCC, hypernephroma)

1) risk factor
2) sx
3) rx of mets and where does it met to
4) why can pts get erythrocytosis
5) rx
6) when may you consider partial nephrectomy
7) what about if growth in IVC

Answer 8

1) smoking
2) #1 primary tumor of kidney (15% calcified). sx- abd pain, mass, hematuria.
3) MC-lung. 1/3 have mets at dx. can do wedge resection of isolated lung or colon mets
4) inc erythropoietin-> HTN
5) radical nephrectomy with regional nodes (kidney, adrenal, fat, Gerota’s fascia and regional nodes), XRT and chemo.
6) only if pt will require dialysis after nephrectomy
7) can pull tumor thrombus out of IVC and still resect. Has predilection for growth in IVC

Question 9

Kidney CA

1) MC tumor in kidney
2) MC primary tumor
3) RCC paraneoplastic syndromes
4) rx of transitional cell CA of renal pelvis
5) oncocytomas- benign or malignant
6) angiomyopipomas- what are they and what disease do you see them with
7) components of Von Hippel-Lindau syndrome

Answer 9

1) mets from breast CA
2) renal cell CA
3) erythropoietin, PTHrp, ACTH, insulin
4) radical nephroureterectomy
5) benign
6) benign hamartomas, can occur with tuberous sclerosis
7) multifocal and recurrent RCC, renal cysts, CNS, tumors and pheochromocytomas

Question 10

Bladder CA

1) MC type
2) presentation
3) risk factors
4) dx
5) rx
6) cause of squamous cell CA of bladder

Answer 10

1) transitional cell CA
2) painless hematuria
3) smoking, aniline dyes, cyclophosphamide
4) cystoscopy
5) intravesical BCG or transurethral resection if muscle not involved (T1)
- if muscle wall invaded (T2+) : cystectomy with ileal conduit, chemo (MVAC: methotrexate, vinblastine, adriamycin/doxorubicin, and cisplatin) and XRT. Can also do reservoir or neoladder
- if mets: chemo
6) Schistosomiasis

Question 11

Testicular torsion

1) peak age
2) direction of torsion
3) rx

Answer 11

1) 15yo
2) toward midline
3) bilateral orchiopexy. if testical not viable, however, resect and do orchiopexy of C/L testis

Question 12

Ureteral trauma-techniques for end-to-end repair

Answer 12

spatulate ends, use absorbable suture to avoid stone formation, stent the ureter to avoid stenosis, place drains to identify and potentially help treat leaks
-avoid stripping the soft tissue on the ureter as it will compromise blood supply

Question 13

Benign prostatic hypertrophy

1) where does it arise (what zone?)
2) Initial therapy
3) surgical options and when to use
4) post-TURP syndrome and rx
5) T/F: most pts with TURP have retrograde ejaculation

Answer 13

1) transitional zone
2) alpha blockers- terazosin, doxazosin (relax smooth muscle)
5-alpha-reductase inhibitors- finasteride (inhibits the conversion of testosterone to dihydrotestosterone-> inhibits prostate hypertrophy)
3) for recurrent UTIs, gross hematuria, stones, renal insufficiency or failure of meds. Do TURP
4)hyponatremia 2/2 irrigation with water-> can precipitate seizures from cerebral edema. rx- careful correction of Na with diuresis
5) true

Question 14

Neurogenic bladder

1) MCC
2) sx
3) rx

Answer 14

1) spinal compression with nerve injury above T-12
2) urinates all the time
3) surgery to improve bladder resistance

Question 15

Neurogenic obstructive uropathy

1) sx
2) cause
3) rx

Answer 15

1) incomplete emptying
2) nerve injury below T-12, can occur with APR
3) intermittent catheterization

Question 16

Urinary Incontinence
1) stress incontinence
a- pathophysiology
b- rx
2) overflow incontinence
a- pathophysiology
b-rx

Answer 16

1) a- because of hypermobile urethra or loss of sphincter mechanism
b-kegel exercises, alpha-adrenergic agents, surgery for urethral suspension or pubovaginal sling
2) a- incomplete emptying of enlarged bladder. often caused by BPH obstruction-> distension and leakage
b-TURP

Question 17

Treatment of other urologic disorders

1) ureteropelvic obstruction
2) vesicoureteral reflux
3) ureteral duplication (MC urinary tract abdnormality)
4) ureterocele
5) polycystic kidney disease

Answer 17

1) pyeloplasty
2) reimplantation with long bladder portion
3) reimplantation if obstruction occurs
4) resect and reimplant if symptomatic
5) resect only if symptomatic

Question 18

Urologic defects

1) hypospadias- what is it and when to rx
2) epispadias- what is it and rx
3) Horseshoe kidney-complications and rx
4) Failure of closure of urachus- what is it/when does it occur and rx

Answer 18

1) ventral urethral opening. rx- repair at 6mo with penile skin
2) dorsal urethral opening. rx- surgery
3) complications-UTI, urolithiasis, hydronephrosis. rx- may need pyeloplasty
4) connection bw umbilicus and bladder fails to close- occurs in pts with bladder outlet obstructive disease (wet umbilicus). rx- resect sinus/cyst and closure of bladder, relieve outlet obstruction

Question 19

Urologic diseases

1) epididymitis- what can cause sterile epididymitis
2) varicocele- how does it develop and what should you be worried about?
3) spermatocele- what is it and rx
4) what should you suspect in adult with acute hydrocele
5) MCC of pneumaturia and dx

Answer 19

1) increased abdominal straining
2) worrisome for renal cell CA or for other retroperitoneal malignancy. (L gonadal vein inserts into L renal vein and obstruction by renal tumor causes varicocele)
3) fluid0filled cystic structure separate from and superior to the testis along the epididymis. rx- surgical removal if sx
4) tumor elsewhere (pevic, abdominal). they are translucent
5) diverticulitis and formation of colovesical fistula

Question 20

Urologic diseases

1) what are WBC casts seen with
2) what about RBC casts
3) sx/signs of interstitial nephritis
4) pregnancy rate after repair of vasectomy

Answer 20

1) pyelonephritis, glomerulonephritis
2) glomerulonephritis
3) fever, rash, arthralgias, eosinophils
4) 50% pregnancy rate

Question 21

Urologic diseases-

1) rx of SCC of penis
2) what can you use to check for urine leak
3) what to do if phimosis found at time of laparotomy

Answer 21

1) penectomy with 2-cm margin
2) indigo carmine or methylene blue
3) dorsal slit

Question 22

Priapism

1) rx
2) risk factors

Answer 22

1) aspiration of the corpus cavernosum with dilute epinephrine or phenylephrine. may need to create a communication through the glans with a scalpel
2) sickle-cell anemia, hypercoagulable states, trauma, intracorporeal injections for impotence

Question 23

Gynecology anatomy

1) function of round ligament
2) what does broad ligament contain
3) what does the infundibular ligament contain
4) function of the cardinal ligament

Answer 23

1) allows anteversion of the uterus
2) uterine vessels
3) ovarian artery, nerve and vein
4) holds cervix and vagina

Question 24

1) best test for diagnosing disorders of the female genital tract
2) diagnosing pregnancy
a- at what point can you see most pregnancies on ultrasound
b- at what beta-HCG level is the gestational sac seen?
c- at what beta-HCG level is the fetal pole seen

Answer 24

1) ultrasound
2) a-around 6 weeks
b-1500
c-6000

Question 25

Abortions:

1) definition of Missed abortion
2) threatened abortion
3) Incomplete abortion

Answer 25

1) 1st trimester bleeding, closed os, positive sac on US, and no heart beat
2) 1st trimester bleeding, positive heart beat
3) tissue protrudes through os

Question 26

Ectopic pregnancy

1) signs/sx
2) risk factors

Answer 26

1) life threatening- significant shock and hemorrhage can occur. sx- acute abdominal pain, positive beta-HCG, negative ultrasound for sac, can also have missed period, vaginal bleeding, hypotension
2) previous tubal manipulation, PID, previous ectopic pregnancy

Question 27

Endometriosis

1) sx
2) MC site
3) rx
4) how to diagnose on endoscopy if causing rectal bleeding

Answer 27

1) dysmenorrhea, infertility, dyspareunia
2) ovaries MC, but can also involve rectum
3) OCPs
4) endoscopy shows blue mass

Question 28

Pelvic Inflammatory Disease
1) sx
2) risk factors
3) dx
4) rx
5) complications
6) visual/microscopic findings if cause is
a- HSV, b- HPV, c-Syphilis, d-Gonococcus

Answer 28

1) pain, N/V, fever, vaginal discharge. MC in first 1/2 of cycle
2) multiple sexual partners
3) cervical motion tenderness, cervical cultures, positive gram stain
4) ceftriaxone, doxycycline
5) persistent pain, infertility, ectopic pregnancy
6) a- vesicles; b-condylomata; c-positive dark-field microscopy, chancer; d- diplococci

Question 29

Mittelschmerz

1) cause
2) symptoms

Answer 29

1) rupture of graafian follicle

2) occurs 14 days after 1st day of menses-> pain that can be confused with appendicitis

Question 30

Vaginal Cancer

1) MC primary CA
2) Type of cancer caused by DES (diethylstilbestrol)
3) what is the rhabdosarcoma that occurs in young girls
4) rx for most vaginal cancers

Answer 30

1) squamous cell CA
2) clear cell CA of vagina
3) Botryoides
4) XRT

Question 31

Vulvar cancer

1) who is at risk
2) rx
3) what type is pre-malignant

Answer 31

1) elderly, nulliparous, obese.
2) usually unilateral
* if 2cm (stage II +)- radical vulvectomy (bilateral labia) with bilateral inguinal dissection, postop XRT if close margins (s VIN III or higher- premalignant (VIN= vulvar-intra-epithelial neoplasm

Question 32

Ovarian CA
1) sx
2) factors that decrease risk
3) factors that increase risk
4) Types- what is secreted and symptoms specific to
a-granulosa-theca
b-sertoli-Leydig
c-struma ovarii
d- choriocarcinoma
5) which type has the worst prognosis

Answer 32

1) abd/pelvic pain, change in stool or urinary habits, vaginal bleeding
2) OCPs, BTL
3) nulliparity, late menopause, early menarche
4) a-estrogen secreting, precocious puberty
b- androgens, masculinization
c- thyroid tissue
d- beta-HCG
5) clear cell type

Question 33

Ovarian CA

1) staging: describe stage I-IV
2) MC initial site of regional spread
3) rx

Answer 33

1) I- One or both ovaries only; II-limited to pelvis, III-spread throughout abdomen; V- distant mets
2) other ovary
3) debulking tumor can be effective; including omentectomy (helps chemo-XRT).
For all stages: total abdominal hysterectomy and BSO plus
-pelvic and para-aortic LN dissection
-omentectomy
-4 quadrant washout
-Chemo (cisplatin and paclitaxel=Taxol)

Question 34

1) leading cause of gynecologic death
2) Krukenberg tumor- where is primary tumor site and pathology findings
3) Meige’s syndrome- what is it and rx
4) MC malignant tumor of female genital tract

Answer 34

1) ovarian CA
2) stomach CA met to ovary with signet ring cells on path
3) pelvic ovarian fibroma that causes ascites and hydrothorax. rx- excision of tumor
4) endometrial tumor

Question 35

Endometrial CA

1) risk factors
2) T/F- uterine polyps have high chance of malignancy
3) typical presentation
4) subtypes with worst prognosis
5) rx

Answer 35

1) nulliparity, late 1st pregnancy, obesity, tamoxifen, unopposed estrogen
2) false, low chance (0.1%)
3) vaginal bleeding in post-menopausal woman
4) serous and papillary sybtypes
5) if stage I/II (endometrium or cervix)- do TAH and BSO or XRT. if stage III/IV (Vagina, peritoneum, ovary, bladder or rectum)- do TAH, BSO and XRT

Question 36

Cervical CA

1) 1st site for spread
2) associated HPV subtypes
3) MC type of CA
4) rx

Answer 36

1) obturator nodes
2) 16 and 18
3) squamous cell CA
4) microscopic dz without basement membrane invasion-> cone bx to remove dz
Stage I and IIa- TAH
Stage IIb to IV- XRT

Question 37

Ovarian cysts
1) Postmenopausal pt
a- reasons to do oophorectomy with intraop frozen sections
b- management if oophorectomy not initially indicated
2) Premenopausal pt rx

Answer 37

1) a- septated, has inc vascular flow on Doppler, has solid components, or has papillary projections. Do TAH if oarian CA
b- if none of above present, follow with US x 1 year –> if persists or gets larger-> manage as above
2) same as above, but consider histology and stage + if pt desires future pregnancy before doing TAH

Question 38

Rx of Incidental ovarian mass at the time of laparotomy for another procedure

Answer 38

1) biopsy mass, 4 quadrant wash, biopsy omentum, look for mets and bx, don’t perform oophorectomy

Question 39

Abnormal Uterine bleeding

1) rx if < 40yo and anovulation
2) rx if leiomyoma (uterine fibroid) in 40yo

Answer 39

1) rx- clomiphene citrate
2) rx- GnRH agonists
3) CA or menopause-> need bx

Question 40

Other Gynecologic considerations

1) C/I to estrogen therapy
2) how does endocrine endometrial polyp present
3) effect on uterine fibroids (Leiomyoma) on fertility and sx
4) MC vaginal tumor
5) Rx for ovarian torsion
6) rx for adnexal torsion with vascular necrosis

Answer 40

1) endometrial CA, thromboembolic dz, undiagnosed vaginal bleeding, breast CA
2) progressively heavier menses
3) under hormonal influence-> recurrent abortions, infertility, bleeding
4) invasion from surrounding or distant structure
5) remove torsion and check for viability
6) adnexectomy

Question 41

Other Gynecologic conditions
1) Hydatidiform mole
a- malignancy risk
b- origin of complete mole
c- rx
2) toxic shock syndrome- sx and cause
3) rx of ruptured tuboovarian abscess
4) dx and rx of ovarian vein thrombosis
5) postpartum pelvic thrombophlebitis- sx and rx

Answer 41

1) a- partial mole has malignancy risk
b- paternal origin
c- chemo (Methotrexate)
2) fever, erythema, diffuse desquamation, N/V. associated with highly absorbant tampon
3) perc drainage
4) dx- CT scan; rx- heparin
5) can lead to ovarian vein, IVC and hepatic vein thrombosis, get liver failure with ascites after pregnancy. Rx- heparin and abx

Question 42

Neurosurgery

1) Name the arteries of circle of willis
2) MC location of aneurysms of circle of willis

Answer 42

1) 2x vertebral arteries come together to for basilar artery which branches into 2 x posterior cerebral arteries. Posterior communicating arteries connect the middle cerebral arteries to the posterior cerebral arteries and the anterior cerebral arteries branch off middle cerebral arteries and connect to each other through 1 anterior communicating artery
2) 30% at anterior communicating artery, 25% at middle cerebral artery and 25% at posterior communicating artery. 2% at basilar artery and vertebral arteries.

Question 43

Nerve injury: define the following:

1) Neurapraxia
2) Axonotmesis
3) Neurotmesis
4) rate of nerve regeneration
5) nodes of Ranvier

Answer 43

1) no axonal injury (temporary loss of fnc, foot falls asleep)
2) disruption of axon with preservation of axon sheath, will improve
3) disruption of axon and axon sheath (whole nerve is disrupted), may need surgery for recovery
4) 1mm/day
5) bare sections, allow salutatory conduction

Question 44

Antidiuretic hormone
1) what is release controlled by
2) released in response to what?
3) actions
4) Diabetes insibidus
a- sx
b-causes
c-rx
5) SIADH
a- sx
b-cause
c- rx

Answer 44

1) supraoptic nucleus of hypothalamus, which descends into the posterior pituitary gland
2) high plasma osmolarity
3) ADH increases water absorption in collecting ducts of kidneys
4) a- inc UOP, dec Urine specific gravity, inc serum NA and inc serum osmolarity
b- can occur with ETOH and head injury-> dec ADH
c-DDAVP, free water
5) dec UOP, concentrated urine, dec serum Na and osmolarity.
b- can occur with head injury. Inc ADH
c- fluid restriction, then diuresis

Question 45

Causes of neurologic hemorrhage
1) Arteriovenous malformation
a- presentation
b- rx
2) Cerebral anneurysms
a- presentation
b- where do they occur
c-rx

Answer 45

1) a- pt 40, bleeding, mass effect, seizures or infarcts.
b-occur at branch points in artery. Most off middle cerebral artery
c-place coils then clip and resect aneurysm

Question 46

Neurologic hemorrhage
1) Subdural hematoma
a- CT findings
b-what vessels are damaged
c-rx
2) Epidural hematoma
a- CT findings
b- what vessel is damaged
c- classic presentation
d- rx
3) which has higher mortality

Answer 46

1) a- crescent shape on head CT and conforms to brain
b- torn bridging vessels
c- operate for significant neuro degeneration or mass effect (shift>1cm)
2) a- lens shape on head CT, pushes brain away
b- middle meningeal artery
c- lose consciousness, have lucid interval and then lose consciousness again
d- operate for significant neuro degeneration or mass effect (shift >0.5cm)
3) subdural has higher mortality than epidural

Question 47

Neurologic hemorrhage
1) Subarachnoid hemorrhage
a- cause
b- sx
c- rx
2) Intracerebral hematomas
a- MC location
b-rx
3) symptoms of inc ICP
4) signs of inc ICP
5) Cushing's triad

Answer 47

1) a- nontraumatic cerebral aneurysms (50% middle cerebral artery) and AVMs. can also result after trauma
b-nuchal rigidity, severe headache, photophobia, neurologic defects
c-isolate aneurysm from systemic circulation (ie-clip), max cerebral perfusion to overcome vasospasm, prevent rebleeding. Use hypovolemia and Ca-channel blockers to overcome vasospasm. OR if neurologically intact only
2) a-temboral lobe; b- drain large ones that cause focal deficits
3) stupor, HA, N/V, stiff neck
4) hypertension, HR lability, slow respirations, intermittent bradycardia is sign of impending herniation
5) hypertension, bradycardia, slow respiratory rate.

Question 48

Spinal Cord Injury
1) rx of injury with deficit
2) signs of complete cord transection
3) SPinal shock
a- sx
b-what injury causes it
c-rx

Answer 48

1) high-dose steroids -> decrease swelling
2) areflexia, flaccidity, anesthesia and autonomic paralysis below the level of the lesion
3)a- hypotension, normal or slow heart rate and warm extremities
b- injury above T5 (loss of sympathetic tone)
c- fluids, many need phenylephrine drip (alpha agonist)

Question 49

Spinal Cord Injury
1) Anterior spinal artery syndrome
a- MC cause
b- sx
c-what functions are preserved
2) Brown-Sequard syndrome
a- cause
b- sx
3) Central Cord syndrome
a- cause
b-Sx
4) Cauda equina syndrome. a- sx b- cause

Answer 49

1) a- acutely ruptured cervical disk
b- BL loss of motor pain and temperature sensation below level of the lesion
c- preservation of position-vibratory sensation and light touch. Only 10% recover to ambulate
2) a- incomplete cord transection (hemisection of cord), commonly 2/2 penetrating injury
b- loss of ipsilateral motor and contralateral pain/temperature below level of lesion. about 90% recover to ambulate
3) a- hyperflexion of cervical spine
b- B/L loss of motor pain and temperature in upper extremities with lower extremities spared.
4) a-pain and weakness in lower extremities;
b- due to compression of lumbar nerve roots

Question 50

Spinal Cord: what tract carries
1) pain and temperature sensory neurons
2) motor neurons
What roots carry
3) sensory fibers, generally afferent
4) motor neuron fibers, generally efferent

Answer 50

1) spinothalamic tract
2) corticospinal tract and Rubrospinal tract
3) Dorsal nerve roots;
4) ventral nerve roots

Question 51

Name the spinal Cord syndrome/injury

1) BL loss of motor pain and temperature sensation below level of the lesion, preservation of position-vibratory sensation and light touch
2) B/L loss of motor pain and temperature in upper extremities with lower extremities spared.
3) loss of ipsilateral motor and contralateral pain/temperature below level of lesion. about 90% recover to ambulate
4) pain and weakness in lower extremities

Answer 51

1) Anterior Spinal artery syndrome
2) Central Cord syndrome
3) Brown-Sequard (cord hemi-section)
4) cauda equina syndrome

Question 52

Brian tumors
1)- sx
2) MC location in adults
3) MC location in children
4) a-MC primary brain tumor in adults and overall
b- MC subtype and prognosis
5) MC brain tumor in children
6) MC metastatic brain tumor in children
7) Acoustic neuroma
a- where does it arise from; b- sx; c- rx

Answer 52

1) HA, seizure, progressive neuro deficit, persistent vomiting
2) 2/3 supratentorial
3) 2/3 infratentorial
4) a- Gliomas; b- Glioma multiforme, uniformly fatal
5) medulloblastoma
6) neuroblastoma
7) a- CN 8 at cerebellopontine angle.
b- hearing loss, unsteadiness, vertigo, N/V
c- surgery

Question 53

Spine tumors
1) MC tumor
2) Benign or malignant: 
a- spinal tumors overall
b- intradural tumors
c- extradural tumors
3) how to test for paraganglioma

Answer 53

1) neurofibroma
2) a- benign, b- benign, c- malignant
3) check for urine metanephrines

Question 54

Pediatric neurosurgery
1) intraventricular hemorrhage (subependymal)
a- who gets it and cause
b-risk factors
c- sx
d-rx
2) Myelomeningocele
a) cause
b) MC location

Answer 54

1) a-premature infants 2/2 to rupture of fragile vessels in germinal matrix
b-ECMO, cyanotic congenital heart disease
c- bulging fontanelle, neuro deficits, hypotension, dec Hct
d-ventricular catheter for drainage and prevention of hydrocephalus
2) a-neural cord defect-> herniation of spinal cord and nerve roots through defect in vertebra
b- Lumbar region

Question 55

Neuro

1) Wernicke’s area- where is it and functions controlled for there
2) What about Broca’s area

Answer 55

1) in temporal lobe. controls speech comprehension

2) in posterior part of anterior lobe. speech motor generated here

Question 56

Neuro

1) Dx and rx for?: Pituitary adenoma, undergoing XRT, pt now in shock
2) which cervical nerve roots innervate the diaphragm
3) what cells act as brain macrophages

Answer 56

1) Dx: pituitary apoplexy. Rx: steroids
2) C3-5
3) microglial cells

Question 57

Cranial nerves: Name nerves I-XII and their function

Answer 57

CN I: olfactory, smell
CN II: Optic- sight
CN III: oculomotor- motor to eye
CN IV: Trochlear- superior oblique (eye)
CN V: Trigeminal ( ophthalamic, maxillary and mandibular branches)- sensation to face and muscles of mastication
CN VI: Abducens (lateral rectus- eye)
CN VII: Facial- motor to face, taste to anterior 2/3 of tongue
CN VIII: Vestibulocochlear: hearing and balance
CN IX: Glossopharyngeal- taste to posterior 1/3 of tongue, swallowing muscles
CN X: Vagus
CN XI: Accessory- trapezius and sternocleidomastoid
CN XII: hypoglossal- tongue motor

Question 58

Orthopedics

1) fnc of osteoblasts
2) fnc of osteoclasts
3) stages of bone healing
4) how does cartilage receive nutrients

Answer 58

1) synthesize nonmineralized bone cortex
2) reabsorb bone
3) 1) inflammation; 2) soft callus formation; 3) mineralization of the callus; 4) remodeling of the callus
4) osmotic migration from synovial fluid

Question 59

Salter Harris Classification of fractures

1) difference bw type I and II fx and how to rx
2) type III, IV and V difference and rx

Answer 59

1) type I is epiphysiolysis of growth plate without fracture, type 2 is same as 1 but with metaphyseal fracture fragment. Both have good prognosis and rx with CLOSED REDUCTION and splinting
2) III, IV and V all cross the epiphyseal plate and can affect the growth plate of the bone-> need ORIF
type III- fx thru growth plate and epiphysis; type IV is thru growth plate, epiphysis and metaphysis; type V is crush injury of growth plate without fx

Question 60

Fractures

1) which are associated with avascular necrosis (AVN)
2) which are associated with nonunion
3) which have greatest risk of compartment syndrome
4) biggest risk factor for nonunion

Answer 60

1) scaphoid, femoral neck, talus
2) clavicle, 5th metatarsal fx (Jones’ fx)
3) supracondylar humerus, tibia
4) smoking

Question 61

Lower extremity nerves- describe action of:

1) Obterator nerve
2) Superior gluteal nerve
3) Inferior gluteal nerve
4) femoral nerve

Answer 61

1) hip adduction
2) hip abduction
3) hip extension
4) knee extension

Question 62

Lumbar Disc herniation
1) presenting sx
2) what herniates
3) what level of nerves are affected
symptoms associated with
4) L2-3 disc herniation
5) L3-4 disc herniation
6) L4-5 disc herniation
7) L5-S1 disc herniation
8) Dx
9) rx

Answer 62

1) back pain, sciatica
2) nucleus pulposus
3) nerve root compression affects 1 nerve root below disck
4) L3 nerve compression-> weak hip flexion
5) L4 compression-> week knee extension (quadriceps) and weak patellar reflex
6) L5 compression-> weak dorsiflexion (foot drop), dec sensation in big toe web space
7) S1 compression-> weak plantar flexion and achilles reflex, dec sensation in lateral foot
8) MRI if neuro sx
9) NSAIDS, heat and rest. surgery if substantial/progressive neuro defect or disc fragments herniated into cord

Question 63

Terminal branches of brachial plexus: what they innervate

1) Ulnar nerve: a- motor; b-sensory; c-defect associated with injury
2) Median nerve: a-motor, b-sensory
3) Radial nerve
4) axillary nerve
5) musculocutaneous nerve
6) which is involved in carpal tunnel syndrome

Answer 63

1) a-intrinsic muscles of hand, finger abduction (Spread fingers), wrist flexion
b-all of 4th and 1/2 of 5th fingers, back of hand
c- claw hand
2) a-thumb apposition (OK sign), finger flexors,
b- palm and 1st 3 and 1/2 of 4th fingers on palmar side
3) a-wrist extension, finger extension, thumb extension and triceps. NO hand muscles
b- 1st 3 and 1/4 4th finger on dorsal side
4) motor to deltoid (abduction
5) motor to biceps, brachialis and coracobrachialis

Question 64

Cervical radiculopathy: symptoms with

1) C1-4 nerve compression
2) C5 nerve compression
3) C6 compression
4) C7 compression
5) C8 compression

Answer 64

1) neck and scalp pain
2) weak deltoid and biceps, weak biceps reflex
3) weak deltoid, biceps and wrist extensors. weak biceps and brachioradialis reflexes
4) weak triceps and triceps reflex
5) weak triceps and triceps reflex, weak intrinsic muscles of hand and wrist flexion

Question 65

Spine levels controlled by

1) radial nerve
2) median nerve
3) ulnar nerve
4) musculocutaneous nerve
5) axillary nerve
6) WHere are the: a- radial nerve roots on brachial plexus, b- ulnar nerve roots

Answer 65

1) C5-8
2) C6-T1
3) C8-T1
4) C5-C7
5) C5-6
6) a- superior portion; b- inferior portion

Question 66

Ortho: Upper extremity
1) rx of clavicle fracture
2) shoulder dislocation
a- if anterior: what might get injured and rx
b- if posterior: what might get injured and rx
c- which direction of dislocation is MC
3) rx and risk of injury of? with acromioclavicular separation
4) scapula fx- rx
5) Midshaft humeral fx
6) Supracondylar humeral fx in adults
7) supracondylar humeral fx in children

Answer 66

1) sling (risk of vascular impingement
2) a- axillary nerve. rx- closed reduction
b- axillary artery. rx- closed reduction
c- 90% are anterior
3) sling- risk of brachia plexus and subclavian injury
4) sling, unless glenoid fossa involved-> need internal fixation
5) sling
6) ORIF
7) nondisplaced-> closed reduction; displaced-> ORIF

Question 67

Ortho fractures

1) What is Colles fx: a- mech of injury, b- injured bone, c-rx
2) Nursemaid’s elbow- a- mech of injury, b- injured bone, c-rx
3) rx of combined radial and ulnar fx in a) adults, b) children

Answer 67

1) a-fall on outstretched hand, b- distal radius, c-closed reduction
2) subluxation of radius at elbow caused by pulling on extended, pronated arm. Rx- closed reduction
3) a-ORIF, b-closed reduction

Question 68

Ortho fx

1) Scaphoid dx- sx and rx
2) Volkmann’s contracture- a) pathophysiology; b) precursing fx and artery injury; c) nerve most affected. d) rx

Answer 68

1) snuffbox tenderness. rx- cast to elbow, may need fixation bc risk of avascular necrosis
2) a, b) suprachondylar humerous fx-> occluded anterior interoseous artery-> closed reduction of humerous-> artery reopens and reperfusion injury/edema-> forearm compartment syndrome (Flexor compartment most effected);
c- median nerve
d- rx- forearm fasciotomies

Question 69

Ortho
1) how to perform forearm fasciotomy
2) Dupuytren's contracture
a- associated diseases
b-Sx/anatomy affected
c- rx
3) Carpal tunnel syndrome
a- nerve effected, b- rx

Answer 69

1) open volar and dorsal compartments
2) a- DM, ETOH; b- progressive proliferation of palmar fascia of hand-> contractures that usually effect 4th and 5th digits (can’t extend fingers)
c- rx: NSAIDS, steroid injections, excision of involved fascia if significant
3) a-median nerve compression by transverse carpal ligament. b-splint, NSAIDs, steroid injections. if that fails-> Transverse carpal ligament release

Question 70

Ortho
1) Trigger finger: a- pathophysiology; b-rx
2) Suppurative tenosynovitis
a- pathophysiology
b- 4 classic signs
c- rx
3) rotator cuff tears- a- muscles affected; b-rx

Answer 70

1) a-tenosynovitis of flexor tendon catches at the MCP joint when trying to extend finger.
b- splint, tendon sheath steroid injections (not tendon itself!). If fails->release pulley system at MCP joint
2) a-infection spreads along flexor tendon sheaths of digits (can destroy sheath)
b- tendon sheath tenderness, pain with passive motion, swelling along sheath, semi-flexed posture of involved digit
c-midaxial longitudinal I&D
3) a-supraspinatus, infraspinatus, teres minor and subscapularis
b- acutely- sling + conservative rx. surgical repair if pt needs to retain high activity level or if ADL affected

Question 71

Ortho

1) what is Paronychia and rx
2) What is a Felon and rx

Answer 71

1) infection under nail bed, painful. rx- abx, remove nail if purulent
2) infection in terminal joint space of finger. rx- incision over tip of finger and along medial and lateral aspects to prevent necrosis of finger tip.

Question 72

Ortho - Lower extremity
1) Hip dislocation
a- MC direction
b- posterior disloc- sx, what can be injured and rx
c- anterior disloc- sx, what can be injured, and rx

Answer 72

1) a- posterior (90%)
b- internal rotation and adduction of leg. risk of sciatic nerve injury. rx- closed reduction
c- external rotation and abduction of leg. risk of femoral artery injury. rx- closed reduction

Question 73

Ortho - Lower extremity

1) rx of isolated anterior ring with minimal ischial displacement
2) rx of femoral shaft fx
3) rx of femoral neck fx

Answer 73

1) weight bearing as tolerated
2) ORIF with intramedullary rod
3) ORIF-> risk of avascular necrosis if open reduction delayed

Question 74

Ortho - Lower extremity
1) Lateral knee trauma: what can be injured
2) Anterior cruciate ligament injury
a-physical exam finding (what test is positive)
b-presentation and dx
c- rx
3) posterior cruciate ligament injury 
a- PE finding (what test positive)
b- presentation
c- rx

Answer 74

1) anterior cruciate ligament, posterior cruciate ligament and medial meniscus
2) a- positive anterior drawer test.
b- knee effusion and pain with pivoting action. MRI confirms dx
c- surgery if knee instability (reconstruction with patellar tendon or hamstring tendon). otherwise PT with leg-strengthening exercises
3) a-positive posterior drawer test, less common than ACL injury. b- knee pain and joint effusion
c-conservative therapy initially, then surgery if fails

Question 75

Collateral ligaments of the Knee
1) what injury can injure
a-Medial collateral ligament
b- lateral collateral ligament
2) rx of collateral ligament injury if a-small tear, b-big tear
3) what other injury is associated with MCL or LCL injury

Answer 75

1) a- lateral blow to knee
b- medial blow to knee
2) a- brace, b- surgery
3) injuries to corresponding meniscus

Question 76

Ortho Knee

1) rx of meniscus tears
2) what dx test is indicated with posterior knee dislocation and why
3) rx of patellar fx
4) rx of tibial plateau fx and tibia-fibula fx

Answer 76

1) arthroscopic repair or debridement
2) angiogram to r/o popliteal artery injury
3) long leg cast unless comminuted in which case need ORIF
4) ORIF fixation. Unless open-> external fixator until tissue heals

Question 77

Ortho ankle foot

1) if pt has pain and mass below popliteal fossa and ankle ecchymosis what is dx
2) Anke fx rx- which types need ORIF
3) Metatarsal fx rx
4) Calcaneus fx rx
5) Talus fx rx
6) nerve most commonly injured with lower extremity fasciotomy and sx
7) nerve affected that causes foot drop after lithotomy posn or long periods of crossed legs or fibula head fx

Answer 77

1) plantaris muscle rupture. mass= contracted plantaris)
2) cast and immobilization. Bimalleolar or trimalleolar fx need ORIF
3) cast immobilization ro brace for 6 weeks
4) if nondisplaced- cast and immobilize; ORIF if displaced
5) closed reduction, except ORIF if severely displaced
6) superficial peroneal nerve-> foot eversion
7) common peroneal nerve (foot-drop)

Question 78

Leg Compartments: name the arteries, nerves and muscles in each

1) Anterior
2) Lateral
3) Deep posterior
4) Superficial posterior

Answer 78

1) anterior tibial artery, deep peroneal nerve
muscles- anterior tibialis, extensor hallucis longus and digitorum longus, and communis
2) superficial peroneal nerve and peroneal muscles
3) posterior tibial artery, peroneal artery, tibial nerve.
muscles- felxor hallucis longus, flexor digitorum longus and posterior tibialis
4) sural nerve, muscles- gastrocneumis, soleus and plantaris

Question 79

Compartment Syndrome

1) most likely to occur in what compartment
2) can distal pulses be present
3) what pressure is considered abnormal
4) rx

Answer 79

1) anterior compartment of leg (get foot drop) after vascular compromise and then restoration of blood flow and subsequent reperfusion injury-> swelling
2) yes
3) >20-30 mmHG is abnormal
4) fasciotomy

Question 80

Pediatric ortho
1) Osteomyelitis
a- where does it occur
b- MC organism
c- dx and rx
2) Idiopathic adolescent scoliosis
a- MC affected area
b-rx- what angles need bracing and what need spinal fusion

Answer 80

1) a- in metaphysis of long bones in children
b- staph
c- dx- MRI, bone bx. Rx- I&D and abx
2) a-Right thoracic curve. prepubertal females
b- 20-45 degree angle need brace, >45 degrees or those likely to progress need spinal fusion

Question 81

Peds Ortho
1) Osgood-Schlatter disease
a-pathophysiology
b- common presentation
c-dx
d- rx
2) Legg-Calve-Perthes disease
a- pathophysiology and who gets it
b- sx
c- dx and rx

Answer 81

1) a- tibial tubercle apophysitis caused by traction injury from the quadriceps in adolescents 13-15y.
b-MC have pain in front of knee.
c-Xray with irregular shape or fragmenting of tibial tubercle
d- rx- mild sx-> activity limitation; severe sx-> cast 6wk followed by activity limitations
2) a-AVN of femoral head in kids 2+yo. can result from hypercoaguable state. BL in 10%
b-painful gait limp
c-X-ray: flattening of femoral head. rx- maintain range of motion with limited exercise-> femoral head will remodel without sequelae.
if femoral head not covered by the acetabulum-> surgery

Question 82

Peds Ortho
1) Slipped capital femoral epiphysis
a- MC sex and age
b- what is at risk of injury
c-X-ray findings
d- rx
2) Congenital dislocation of the hip
a- MC sex
b- rx
3) rx of clubfoot

Answer 82

1) a-males age 10-13.
b- AVN of femoral head, painful gait
c- widening and irregularity of epiphyseal plate
d- surgical pinning
2) a- females, b-Pavlik Harness, keeps legs abducted and femoral head reduced in acetabulum
3) serial casting

Question 83

Bone Tumors

1) MC bone tumor
2) rx of bone breast or prostate mets
3) MC primary malignant tumor of bone and rx
4) rx of pathologic fractures

Answer 83

1) #1 breast, #2 prostate
2) rx- internal fixation with imprending fx (>50% cortical involvement) followed by XRT
3) Multiple myeloma- rx- chemo if systemic. internal fixation for impending fx
4) treat with internal fixation. XRT can be used for pain releif.

Question 84

Bone Tumors:
1) Osteogenic sarcoma
a- MC age of presentation
b-X-ray findings
c- rx
2) Giant cell tumor
a- malignant or benign
b- rx

Answer 84

1) a- MC primary bone sarcoma, usually around knee. 80% in ptss triangle= periosteal reaction
c- limb-sparing resection, XRT and doxorubicin-based chemo can be used preop to increase chance of limb-sparing resection
2) a- benign but 30% risk of recurrence and has malignant degeneration risk
b-total resection +- XRT

Question 85

1) Name the benign bone tumors

2) rx

Answer 85

1) osteoid osteoma, endochondroma (may be able to observe), osteochondroma (resect only if cosmetic defect or sx), chondroblastoma, nonossifying fibroma (may observe) and fibrodysplasio
2) other than observation listed above. Can rx all with curretage +/- bone graft

Question 86

Spondylolisthesis

1) MC location
2) what is it
3) T/F: MCC of lumbar pain in adolescents

Answer 86

1) lumbar region
2) formed by subluxation or slip of one vertebral body over another
3) True (think gymnasts)

Question 87

1) Rx of cervical stenosis
2) rx of lumbar stenosis
3) What is a Torus fx
4) rx of open fx

Answer 87

1) surgical decompression if significant myelopathy present
2) surgical decompression for cases refractory to medical rx
3) Buckling of the metaphyseal cortex seen in children (ie- distal radius)
4) I&D, abx, fx stabilization and soft tissue coverage.

Question 88

Statistics:
1) name the type of error:
a- rejects null hypothesis incorrectly/ falsely assumes there is a difference when there isn’t
b- accepts the null hypothesis incorrectly. treatments are interpreted as equal when there is actually a difference
2) what is the MCC of type II error
3) what p-value rejects the null hypothesis

Answer 88

1) a- Type I error
b- Type II error
2) small sample size
3)

Question 89

Statistics:
Define-
1) Variance
2) parameter
3) mode vs. mean vs median

Answer 89

1) spread of data around a mean
2) population
3) mode= Most frequently occuring value
mean= average
median= middle value of a set of data (50th percentile)

Question 90

Trials and studies
1) what type avoids treatment biases
2) what type avoids observational biases
3) are the following prospective or retrospective:
a- cohort study, b- case-control study, c- RCT, d- double -blind controlled trial

Answer 90

1) RCT
2) Double-blinded controlled trail
3) prospective- cohort, RCT, double-blind
retrospective- case control

Question 91

How to compare quantitative variables

1) what tests use quantitative variables
2) what tests use qualitative variables

Answer 91

1) student’s T-test (2 independent groups- ie mean weight bw 2 goups), Paired t tests (Before and after groups- ie weight before and after timeframe), ANOVA (means for >2 groups)
2) nonparametric statistics (rase, sex, medications), Chi-squared test (2 groups with and without disease- ie obese patients and nonobese pts with and without DM), Kaplan-Meyer (small groups, estimates survival), relative risk (incidence in exposed/incidence in unexposed

Question 92

1) how to calculate relative risk
2) power of a test
3) what test should you use to estimate survival with small groups

Answer 92

1) incidence in exposed/incidence in unexposed
2) probability of making the correct conclusion= 1-prob of type II error. larger sample size increases power
3) Kaplan-Meyer

Question 93

1) what is positive predictive value
2) what is negative predictive value
3) what changes the predictive value of a test
4) are sensitivity and specificity changed by disease prevalence

Answer 93

1) likelihood that with a positive result the pt actually has the disease= true pos/ (True pos + false pos)
2) likelyhood that with a negative result the pt doesn’t have the disease= true neg/ (true neg + false neg)
3) disease prevalence
4) no, they are independent of prevalence

Question 94

1) how to calculate accuracy
2) what is National Surgical Quality Improvement Program (NSQIP)
3) what does the JCAHO prevention of wrong site/procedure/patient protocol involve

Answer 94

1) (true pos + true neg)/ (true pos + true neg +false pos +false neg)
2) collects outcome data to measure and improve surgical quality in the U.S. Outcomes reported as observed vs. expected rations
3) includes 1) preop verification of pt and procedure. 2) Operative site and side marking visible after pt prepped. 3) time out before incision verifying pt, procedure, position site + side and availability of implants or special requirements

Question 95

1) risk factors for retained object after surgery and MC object retained
2) define a sentinel event as it applies to JCAHO and what does hospital undergo to prevent future recurrences
3) what is the GAP protection technique

Answer 95

1) MC is sponge. RF- emergency procedure, unplanned change in procedure, obesity, towel used for closure
2) unexpected event involving death or serious injury or the risk thereof. Hospital undergoes root cause analysis to prevent and minimzie future occurences
3) Gaps in care (ie- change in caregiver, divisions of labor, shift changes, transfers) can lead to loss of information and error. Prevent by structured handoffs and checklists (face to face if possible), standardizing orders and reading back orders if verbal.