Step 2 Surgery Flashcards
What cord damage are pts at risk of with degenerative joint disease in the cervical spine? What are the S/S?
Central Cord Syndrome: weakness pronounced in the upper > lower extremities from damage to central corticospinal tracks (leading to arm predominant sympt) and lateral decussating spinothalamic tracks (causing specifically loss of pain and temp).
Older pts are at risk with DJD with injury involving hyper flexion of the neck.
Dx: pt with a hx of blunt chest trauma, elevated jugular veins, hypotension unresponsive to IV fluids, distant heart sounds.
Why do some have Normal or abnormal Cxray?
Trmt?
Acute pericardial tamponade.
Normal Xray if ACUTE b/c it only takes 100-200 mL of fluid to cause symptx of pericardial tamponade. VS Chronic fluid build up (2/2 malignancy or renal probs) giving the pericardium time to stretch and retain more fluid (1-2L). Fluid compresses chambers to cause decrease blood flow into the heart (causing JVD) and poor CO (refractory hypotension)
Immediate surgical pericardotomy or pericardiocentesis
What do the S/S of suspected intraperitoneal bleed look like 2/2 blunt abdominal trauma? Which 2 organs are MC causing the bleeding? How would you manage the pt?
Abdominal distention, abdominal ecchymoses, and hypoactive BS = S/S
Spleen/Liver
Use fluid resuscitation first. If unstable, use FAST (focused assessment with sonogram for trauma) to assess the heptorenal, splenorenal, or infra peritoneal areas for free fluid. If non-confirmatory, Diagnostic Peritoneal Lavagae (DPL) can be done. If the pt is STABLE, a CT can be done in place of this. If any of the above is positive = ex lap
Tracheal deviation could be from what three things? With distended neck veins, what two things could it be? W/ suspected TPnthx, what do you do first? What if they remain hemodynamically compromised s/p your first step?
Tracheal deviation could result from opposite side TPnthx or hemothorax or sam sided lung collapse.
W/ distended neck veins, cardiac tamponade or Tpnthx.
Immediate needle decompression in the 2nd/3rd intercostal space in midclavicular line or 5th intercostal space in midaxillary line. Chest tube placement THEN follows.
Do a FAST to look for missed pericardial tamponade if still unstable.
S/P surgery a pt has hyperactive reflexes after needing multiple transfusions, what electrolyte abnormality is suspected? Why?
Hypocalcemia 2/2 citrate in transfused blood will bind the calcium.
Sarcoid can also present with diffuse interstitial infiltrates, uveitis, erythem nodosum, and patchy rales….T/F?
True
Three causes of RUQ pain s/p cholecystectomy?
1) Sphincter of Oddi Dysfunction - seen with increased manometry reading of sphincter
2) Retained Common Bile Duct Stones
3) Functional Pain = dx of exclusion
Pts with AF should be risk stratified with what system? How do you manage respective levels?
CHADS2 = CHF/Hypertension/Age>75/DM/Stroke or TIA (2 pts)
For 0 pts = no anticoag or aspirin
For 1 pt = anticoag or aspirin
For 2 or more = anticoag
Anticoag = warfarin, Rivaroxaban Dabigatran, Apixaban
ARDS is caused by? Respiratory trmt re: PEEP and TV?
Inflammatory mediators from local or systemic sepsis, trauma or inflammation. This causes increased alveolar capillary permeability and bilateral fluffy infiltrates.
Mechanical ventilation with a PEEP from 5 - 15 may be necessary with a TV of 6ml/kg. Watch out for barotrauma or PNThx.
What kind of tremor increases at the very end of goal-directed activities like reaching for an object, drinking from a glass, finger-to-nose testing?>
Essential tremor - give propanolol
During the work-up of hyperthyroidism, what is your best initial medication mgmt for the symptomatic pt?
Propanolol to help control symptoms while you work them up. Want a radio iodine uptake study unless pregnant, then would start PTU instead.
Child with headaches and hypertension with a to-fro murmur auscultated in the CVA, MC’ly = ?
Fibromuscular Dysplasia - can hear the venous hum at the CVA 2/2 well-developed collaterals. Right renal artery is usually more affected. See string of beads on angiography.
All hemodynamically unstable pt with penetrating abdominal trauma warrant?
Immediate exploratory laparotomy
MC Causes of osteo in kids? Other causes? What is they had a prosthesis?
Stap Aureus = MCC. Others = GBS and E. Coli in infants and Strep Pyogenes in children. Strep Epidermitis if prothesis present.
Pulsatile mass in the right groin area?
Femoral artery aneurysm - below the inguinal ligament. It may be associated with AAA; it’s the 2nd MC aneurysm following popliteal aneurysm.
Stroke on the non-dominant parietal cortex most likely causes a pt that does what?
Hemineglect
Man presenting with a hx of being sick, unilateral lymphadenopathy, “hot potato voice”, and deviated uvula = dx? Mgmt?
Peritonsilar abscess 2/2 tonsillitis. Needle peritonsillar aspiration
What are pts with Hasimoto’s Thyroiditis at risk for x60? What does it look like on U/s?
Lymphoma of the thyroid; pseudo cystic pattern on U/S - present with compressive symptoms, don ought sign on CT (wrapping around trachea) can be missed by needle aspiration so a core biopsy is necessary
Hypothyroidism increases the risk of what additional lab findings?
Hyperlipidemia, hyponatremia, and asymptomatic elevation in CK and LFT’s.
What PE signs would differentiate SBO from paralytic ileus?
Auscultated tinkling and visible peristaltic waves
What drug do you give to decrease dermatitis herpetiformis?
Dapsone
Pts with prolonged QT are at increased risk of syncope, ventricular arrhythmias (torsades) and sudden cardiac death - trmt for those asympotmatic and symptomatic?
All its should receive Beta blockers and specifically avoid potassium channel blockers (could worsen the QT prolongation). If symptomatic, long-term pacemaker placement should be considered
Syndrome with sudden death, congenital sensorineural deafness, and QT interval of 600 = ?
Jervell and Lange-Nielsen
Metabolic causes of prolonged QT?
Hypocalcemia, Hypokalemia, and Hypomagnesemia
Kawasaki Disease Dx:
Fever >5 days + 4 of the following:
- bilateral nonexudative conjunctivitis
- mucositis (fissured/injected lips, injected parynx, and strawberry tongue)
- cervical lymphadenopathy with at least one LN being > 1.5 cm
- erythematous polymorphous rash
- extremity edema or erythema
Trmt = aspiring + IVIG; also get baseline Echo with repeat in 6-8 weeks; also watch out for Reye’s Syndrome (hepatic encephalopathy 2/2 aspirin)
Complications = coronary artery aneurysms and MI’s
Acromegaly has what feared complication? Other complications? What’s the excessive factor that leads to bone and soft tissue overgrowth?
Congestive Cardiac Failure - 2/2 insulin-like GF I (IGF-I)
Other complications = hypertension, respiratory causes, and malignancy
A widened pre vertebral space with drooling, truisms (can’t open mouth fully), muffled/hoarse voice = beware of? MCpathogens?
Retropharyngeal Abscess! Polymicrobial with strep. progenies and staph aureas. Presents with hx of recent infxn.
Exposure to dirt/sand where cats and dogs have been with a new onset of erythematous papule with subsequent serpiginous, reddish brown elevated lesions in an ascending track makes you think of?
Cutaneous Larva Migrans = Ancylostoma Braziliense
Acalculous cholecystits RF’s?
Hospitalized its with extensive burns, severe trauma, prolonged TPN, prolonged fasting, and mechanical ventilation.
Think of this whenever you have an isolated and asymmetric arthritis in the presence of urethritis, conjunctivitis, or mouth ulcers…What else might you see on PE? Trmt?
Reactive Arthritis = seronegative spondyloarthropathy - affects knee and sacroilliac joints MC’ly. Enthestitis might also present (tendon insertion pain). Sterile synovial analysis.
Give NSAIDS
MCC of vitreous hemorrhage?
Diabetic retinopathy. Will see poor visibility of the funds, floating debris, dark red glow, only light perceived by pt.
What to do if myasthenia gravis pt doesn’t respond first to pyridostigmine/neostigmine? What would you give to induce remission?
Then can move to corticosteroids. Only use plasmapheresis to (a) stabilize the patient before thymectomy or (b) myasthenia crisis
Steroids or thymectomy
Chronic malabsorptive diarrhea (steatorrhea, flatulence, abd distention), protein losing enteropathy, weight loss, migratory non-deforming arthitis, lymphadenopathy, and low grade fever = ? See on bx?
Whipple’s Disease 2/2 Tropheryma Whippelii - dx with small intestinal biopsy and PCR - would show PAS-positive macrophages containing non-acid fast gram positive bacilli.
Pt with suspected lung cancer and hypertension, hypokalemia, elevated blood glucose, and proximal muscle wasting = ?
Small-cell lung cancer producing ectopic ACTH - high levels of cortisol can work on the mineralocorticoid receptor to cause hypertension and hypokalemia.
Differentiate patellofemoral stress syndrome vs. patellar tendonitis, and traction apophysitis…
PFS is seen in runners and is exacerbated by walking down-hill or down stairs but X ray shows nothing. PT shows point tenderness just on the inferior pole of the patella. And the last is the true Osgood-Schlatter disease where rapid development causes traction/pulling of an immature tubercle causing it to lift up or fragment.
Treat with stretching, NSAIDS, and rest
Trmt of Lambert Eaton?
Plasmapharesis and immunosuppressive therapy.
*Wouldn’t see myasthenia gravis in a pt with lung cancer sympt
Pts with mullerian a genesis have a blind ended vagina and normal uterus/ovaries and female phenotype with XX genotype. Why can’t it be androgen insensitivity, 5-alpha reductase def?
These both have XY genotype.
How does Nocardia appear on gram stain and who is at risk? Trmt/proph?
It’s a gram positive partially acid fast filaments -(crooked/branching beads). AIDS, lymphoma, or transplant pts are at risk - props/trmt = Bactrim
Hyperkalemia + non-anion gap metabolic acidosis with very mild/mod renal insufficiency = ? Associated disease? Problem with what?
This is Type 4 RTA = hyperkalemic non-anion gap metabolic acidosis 2/2 to dysfunction in the distal collecting tubule (where aldosterone acts) so H+ and K+ are retained 2/2 to commonly associated DM which causes juxtaglomerular damage resulting in hyporenin hypoaldosteronism.
Loop diuretics cause what electrolyte imbalance? Laxative abuse?
Hypokalemia and metabolic alkalosis
Hypokalemia and non-anion metabolic acidosis
T/F - can go straight to surgery with classic appendicitis?
True - only get CT if not classic presentation
When to get a plasma exchange in pt with MS?
If refractory to high-dose corticosteroids
trmt of Mumps?
Supportive
What distinguishes Folate and B12 def?
MMA and homocystein elevated in B12 but only homocysteine in folate. Also, folate can become depleted faster (3-4mo) vs. 3-4 yrs with B12. Strict vegetarians are at risk of B12 def.
Eczema Herpeticum = ?
Primary herpes simplex virus that is associated with atopic dermatitis. Numerous umbilicated vesicles over the area of the healing atopic dermatitis are typical with fever and adenopathy.
*THIS CAN BE LIFE THREATENING IN INFANTS - give acyclovir
Ataxia, dysarthria, scoliosis, hammer toes = ? MCC of death?
Friedreich’s Ataxia - Concentric Hypertrophic Cardiomyopathy
Pain from duodenal ulcers _____ with food vs. gastritis and gastric ulcers?
decreases
Bullous myringitis?
Serous filled blisters on the tympanic membrane
Best trmt for molluscum contagiosum?
Curettage and application of liquid nitrogen
Miliaria = ?
Heat rash - superficial aggregated small vesicles, papules, or pustules over the trunk which are associated with burning and itching - commonly seen in people living in warm moist climates.
Management of Pancreatic Pseudocyst?
It normally resolves spontaneously but should be drained if it becomes infected, lasts for > 6 weeks, or is > 5cm in diameter. Feared complication is it erodes into blood vessel.
Watch out for this in a post-op pt with decreased urinary output, abdominal pain, elevated BUN and Cr…? Trmt?
Post-operative Urinary Retention = common complication of surgery and anesthesia. Increased risk with age and high fluid intake.
Get a potable bladder scan. Next step would be to cath the pt.
Norepinephrine use in a hypovolemic patient can cause what 3 problems?
Vasoconstriction in tips of distal extremities, renal failure, and mesenteric ischemia.
Rapid onset of severe pain and vision loss in one eye, headache, seeing halos around lights, injected eye and the pupil is dilated and not responsive ?
Acute Angle Glaucoma
Tartrate resistant acid phosphatase stain + CD11c marker = ?
Hairy Cell Leukemia (enlarged spleen seen)
What kind of seizure would be provoked by hyperventilation?
Absence seizure - EEG shows spike and wave form
Juvenille Myoclonic epilepsy is seen in whom?
Mostly kids in the morning after being sleep deprived and have unilateral or bilateral myoclonus
Huntington’s Chorea has what characteristic feature on CT?
Atrophy of the caudate
How does thyroglobulin help you in the work up of thyroid disease?
If there is low uptake on the RAIU scan, elevated levels of thyroglobulin will tell you if it’s an endogenous process vs. low levels meaning it’s coming from an exogenous source
