surg

Question 1

A drop in the platelet count by >50% or a new thrombus within 5-10 days of initiating heparin should raise suspicion for heparin-induced thrombocytopenia (HIT)

If HIT is suspected what is management??

Answer 1

discontinue heparin and anticoagulation should be initiated with a nonheparin medication (eg, argatroban, fondaparinux).

Question 2

Patients with a septal hematoma require prompt ??

Answer 2

incision and drainage

Question 3

Presentation includes inspiratory stridor that is worse in the supine position and exacerbated by feeding or upper respiratory illnesses; prone positioning improves symptoms. The diagnosis is confirmed with visualization of the larynx, typically by flexible fiberoptic laryngoscopy

Answer 3

Laryngomalacia, which causes chronic stridor in infants, is typified by “floppy” supraglottic structures that collapse during inspiration.

Question 4

​​​​​​​ Patients with ??? classically have the triad of respiratory distress (eg, tachypnea, hypoxemia), neurologic dysfunction (eg, confusion), and a petechial rash; however, the rash is present in less than half of cases. The condition can occur 24-72 hours following fracture or surgical manipulation of bones that contain abundant marrow (eg, femur, pelvis)

Answer 4

fat embolism syndrome (FES)

Question 5

this imaging modality has a sensitivity of up to 97% in the detection of pancreatic cancer and can be used for staging purposes and preoperative planning.

Answer 5

abdominal CT

Question 6

classically affects boys age 3-12, with peak incidence at age 6.

Patients typically have an antalgic gait (avoids weight bearing on the affected side due to pain) and dull, chronic lower extremity pain of insidious onset. The pain may affect the hip directly or present as referred thigh or knee pain, as in this patient. Diagnosis requires a high index of suspicion as initial x-rays may be normal

Answer 6

Legg-Calvé-Perthes disease (LCP)

Question 7

patient’s acute onset of severe flank pain, syncope, and hemodynamic instability is concerning for ????

ypically occurs in patients age >60 and is more common in smokers, men, and those with a history of atherosclerosis or connective tissue disease.

Answer 7

ruptured abdominal aortic aneurysm (AAA).

Question 8

Erythema nodosum presents with tender, nonpruritic, erythematous, or violaceous nodules measuring 2-3 cm and usually located on the shins. It has a strong association with ???

Answer 8

inflammatory bowel disease (IBD), especially Crohn disease

Question 9

Peripherally inserted central catheters increase the risk of upper extremity ???. The risk is greatest in hospitalized patients, particularly those with malignancy or other hypercoagulable state. Manifestations include arm swelling, erythema, and pain.

Answer 9

DVT

The diagnosis is made with duplex ultrasonography. Treatment with 3 months of anticoagulation is required.

Question 10

Mediastinal masses are categorized according to their compartments (ie, anterior, middle, posterior). The middle compartment contains the heart and great vessels, trachea and main bronchi, esophagus, pericardium, and lymph nodes. Middle compartment masses may include ????, which arise from congenital, anomalous budding of the foregut and can cause chest discomfort and nonspecific respiratory symptoms.

Answer 10

bronchogenic cysts

**thymoma and thymus located in anterior mediastinum

Question 11

workup of a suspicious breast mass (eg, unilateral, firm, fixed, causing nipple retraction) in males is ??

Answer 11

same in men as in women: imaging (eg, mammography, ultrasound) is performed first, followed by tissue sampling (eg, core biopsy).

Question 12

??? transfusion reaction is an uncommon, life-threatening reaction which causes fever, flank pain, and hemoglobinuria within 1 hour of transfusion initiation. Continued hemolysis can lead to acute renal failure, disseminated intravascular coagulation, and shock

Answer 12

Acute hemolytic: due to transfusion of mismatched blood (eg, ABO incompatibility)

Question 13

Acquired ??? results from the oxidization of iron in hemoglobin, which is most commonly due to topical anesthetic agents or dapsone. It presents with hypoxia, a characteristic pulse oximetry reading of ~85%, and a large oxygen saturation gap.

Answer 13

methemoglobinemia

Because methemoglobin absorbs light at distinct wavelengths, pulse oximetry commonly is ~85% (as seen in this patient) regardless of the true oxygen saturation. In parallel, blood gas analysis frequently returns a falsely elevated result for oxygen saturation (eg, 99% in this patient) as it provides an estimate based only on the PaO2, not on effective hemoglobin-oxygen binding. These inaccurate readings create the large oxygen saturation gap.

Question 14

Vitamin ?? deficiency is usually due to inadequate dietary intake, intestinal malabsorption, or hepatocellular disease. An acutely ill patient with underlying liver disease can become deficient in 7-10 days. Laboratory studies usually show prolonged prothrombin time followed by prolonged partial thromboplastin time.

Answer 14

K

Question 15

??? is characterized by the triad of bilateral hip, thigh, and buttock claudication; impotence; and absent or diminished femoral pulses (often with symmetric atrophy of the bilateral lower extremities due to chronic ischemia).

Answer 15

Aortoiliac occlusion (Leriche syndrome)

Question 16

which cardiac mass can produce cytokines (eg, IL-6) that lead to systemic inflammation (evidenced by an elevated erythrocyte sedimentation rate) and constitutional symptoms (eg, fever, weight loss).

Answer 16

cardiac myxomas in the LA

Question 17

Patients with trauma following rapid deceleration are at risk for blunt thoracic aortic injury. Signs may include upper extremity hypertension with lower extremity hypotension (pseudocoarctation) and/or a hoarse voice (left recurrent laryngeal nerve stretching).

what is the best test/choice for imaging??

Answer 17

​​​​​​​CT angiography of the chest is highly sensitive and specific for thoracic aortic injury and is readily available.

ECHO is not as good

Question 18

Pain is the most common manifestation of abdominal aortic aneurysm (AAA), and it can vary according to aneurysm location. Proximal AAA tends to cause upper abdominal, flank, or back pain. In symptomatic, hemodynamically stable patients, the diagnosis is best made by ??

Answer 18

abdominal CT

hemodynamically unstable = U/S and surgery

Question 19

patient has fever, chills, leukocytosis with left shift, new arrhythmia, and a pericardial effusion on echocardiography. This presentation is most concerning for ???

Answer 19

purulent pericarditis

Question 20

Purulent pericarditis is an acute, rapidly fatal infection most commonly caused by hematogenous spread of Staphylococcus aureus. Urgent echocardiography-guided ??? is essential for confirmation of the diagnosis and treatment

Answer 20

pericardiocentesis

Question 21

??? can occur as a local vascular complication of cardiac catheterization, and often presents with sudden hemodynamic instability and ipsilateral flank or back pain. Diagnosis is confirmed with non-contrast CT scan of abdomen and pelvis or abdominal ultrasonography. Treatment is usually supportive with bed rest, intensive monitoring, and intravenous fluids and/or blood transfusion.

Answer 21

Retroperitoneal hematoma

Question 22

hemodynamics of thyroid storm involve ????, leading to hyperdynamic circulation and increased venous return to the heart. High-output heart failure quickly develops, leading to backup of pressure from the left ventricle with increased pulmonary capillary wedge pressure.

Answer 22

decreased systemic vascular resistance and increased cardiac output

Question 23

A ???? can develop as a complication of vascular access during cardiac catheterization. Patients typically have mild localized pain and swelling and a continuous bruit accompanied by a palpable thrill over the fistula site.

Answer 23

arteriovenous fistula

Question 24

???? is a complication of cardiac surgery characterized by separation of the bony edges of the sternum. Patients may report mild pain or sensation of chest wall instability and “clicking” with chest movement. The diagnosis can be made radiographically (eg, displaced sternal wire) or clinically; palpable rocking or clicking of the sternum confirms the diagnosis. Management involves urgent surgical exploration and repair.

Answer 24

Sternal dehiscence

Question 25

After initial stabilization, burn patients who require aggressive fluid resuscitation (eg, due to burns covering a large total body surface area) should undergo ??? as soon as possible.

Answer 25

urethral catheterization

fluid is titrated to maintain adequate urine output (goal: ≥0.5 mL/kg/hr), a marker of organ perfusion. For accurate monitoring of urine output in these patients, a urethral catheter (eg, Foley catheter) is required.

Question 26

Testicular torsion can present with acute testicular pain and swelling after mild trauma. The diagnosis may be made clinically; however, in patients in whom the diagnosis is unclear, a ??? can confirm the diagnosis and exclude other etiologies.

Answer 26

Doppler ultrasound of the scrotum

testicular torsion is a surgical emergency; up to 80% of patients with untreated torsion develop a nonviable testicle within 12 hours.

Question 27

Heterogeneous echotexture seen on US is a late finding indicating testicular ???, which develops after >12 hours of ischemia and can result in nonviability. Therefore, if testicular torsion is suspected, urgent urologic evaluation is indicated.

Answer 27

necrosis

Question 28

A solid, firm, nontender testicular mass should be considered testicular cancer until proven otherwise. A diagnostic workup generally includes bilateral scrotal ultrasound, serum tumor markers, and ???

Answer 28

radical inguinal orchiectomy.

Question 29

???? testicular tumors often cause feminization (eg, gynecomastia) due to the production of estrogen by tumor cells. This frequently causes secondary inhibition of FSH and LH. Serum tumor markers (eg, β-hCG, AFP) are not usually elevated.

Answer 29

Leydig cell

sertoli cell tumors are very rare but also can occasionally cause estrogen excretion

Question 30

??? often presents with symptoms of recurrent urinary tract infection, painful ejaculation, and/or prostatic tenderness in young or middle-aged men. Patients often have transient improvement of symptoms with short courses of antibiotics. Six weeks of a fluoroquinolone is generally required for eradication.

Answer 30

Chronic bacterial prostatitis

**some patients have NO prostate tenderness on exam

Question 31

??? is a life-threatening necrotizing fascitis that typically affects perineal, scrotal, and lower abdominal skin. Patients generally have rapid-onset swelling, tenderness, and crepitus of the affected region and significant systemic symptoms (eg, hypotension, high fever). Rapid surgical intervention is required to prevent death and should not be delayed for imaging.

Answer 31

Fournier gangrene

increased rx in DM and obese

Question 32

A varicocele is a tortuous dilation of the pampiniform plexus surrounding the spermatic cord and testis. It presents as a soft, irregular mass that increases in size with standing and Valsalva. The diagnosis is confirmed with ultrasound. Initial interventions include scrotal support and simple analgesics. Varicoceles are associated with increased risk for ???

Answer 32

infertility; for patients with testicular atrophy or changes in semen analysis, surgical venous ligation can improve fertility.

Question 33

Secondary ??? is a malignant endothelial tumor that develops 4-8 years after breast cancer therapy. Risk factors include radiation therapy and chronic lymphedema. Typical lesions are red, bruise-like plaques and purple papules and nodules. Timely biopsy is recommended for diagnosis because the cancer readily metastasizes.

Answer 33

angiosarcoma

Question 34

A mole may represent melanoma if it appears substantially different from others (“ugly duckling sign”), itches or bleeds, or develops ???. If melanoma is suspected, an excisional biopsy should be obtained.

Answer 34

nodularity

Question 35

Hidradenitis suppurativa is a chronic, relapsing condition characterized by inflamed nodules, subcutaneous abscesses, scarring, and sinus tract formation in intertriginous areas. Treatment IS ???

Answer 35

Prolonged treatment with topical (eg, clindamycin) or oral (eg, tetracycline) antibiotics

Question 36

Foot imaging (eg, x-ray, MRI) is generally recommended for all diabetic foot ulcers that are: Looking for ???

• deep (eg, exposed bone, positive probe-to-bone testing).
• long-standing (eg, present >7-14 days).
• large (eg, ≥2 cm).
• associated with elevated erythrocyte sedimentation rate/C-reactive protein.
• associated with adjacent soft tissue infection.

Answer 36

signs of osteomyelitis

Question 37

??? is the first-line treatment for nonmelanoma skin cancers that have a high risk for recurrence ex. Basal cell carcinoma on the face. It allows for the highest cure rate and maximal preservation of normal tissue, making it an ideal option for facial lesions.

Answer 37

Mohs micrographic surgery

This technique is characterized by sequential removal of thin skin layers with intraoperative microscopic margin inspection to ensure complete removal of the cancer.

Question 38

Initial management of pressure ulcers includes local wound care, ???, pain control, and nutritional support.

Answer 38

repositioning of the patient to reduce pressure

Question 39

??? dressings are commonly used for wounds that are infected, have just been freshly debrided, or have devitalized tissue or fibrinous slough at the base. They are typically performed twice a day and involve placing gauze that has been moistened (typically with saline) onto the wound. As the gauze dries, it adheres to the wound bed and, when it is removed, debrides devitalized tissue.

Answer 39

Wet-to-dry

Question 40

Once devitalized tissue is removed and the wound has healthy granulation tissue, wet-to-dry dressings should be discontinued, because they can nonselectively debride the delicate granulation tissue that serves as a base for epithelial migration (ie, reepithelization). Instead, ??? dressings should be used. Moist wounds heal faster than dry wounds because wound fluid contains factors that promote wound healing (eg, platelet-derived growth factor, fibroblast growth factor, matrix metalloproteases). In addition, a moist environment promotes reepithelization. Because of these benefits, wounds should also not be left open to the air and allowed to dry out

Answer 40

Nonadherent and moisture-retaining

Question 41

??? can cause atrophy of the small intrinsic muscles of the feet, leading to unopposed action of the large lower leg muscles, and clawing of the toes with hyperextension at the metatarsal-phalangeal joints. As a result, pressure is redistributed to the metatarsal heads, increasing susceptibility to callus formation, skin breakdown, and ulcer formation.

Answer 41

Motor neuropathy

​​​​​​​Sensory, autonomic, and motor neuropathy can all contribute to plantar foot ulcer formation in patients with diabetic neuropathy. Motor neuropathy can cause intrinsic foot muscle atrophy, toe clawing, and abnormal redistribution of pressure to the metatarsal heads.

​​​​​​​Autonomic neuropathy causes loss of autonomic tone in the arteriolar and capillary circulation, leading to shunting of blood from the arterioles to the veins and decreased tissue perfusion.

Question 42

Circumferential, full-thickness burns can result in the formation of constrictive eschar bands. When profound edema from aggressive fluid resuscitation and increased capillary permeability occur together, vascular compromise can result. TX?

Answer 42

Immediate release of the burned skin (ie, escharotomy) is required to restore perfusion.

CUT an incision through the burned skin until subcutaneous fat is observed and skin tension is released

Question 43

Does increasing FiO2 for ARDS help oxygenation?

Answer 43

NO

Fluid from pulmonary edema fills the alveoli and facilitates alveolar collapse. Alveolar ventilation (V) is zero, which results in an extreme ventilation/perfusion (V/Q) mismatch (right-to-left intrapulmonary shunting), causing hypoxemia. Because diffuse pulmonary edema prevents air from reaching the alveoli throughout much of the lungs (eg, >50%), an increase in the fraction of inspired O2 (FiO2) does not correct the hypoxemia.

Question 44

??? is the mainstay of rib fracture management to prevent the associated complications of atelectasis and pneumonia

Answer 44

Adequate pain control

Question 45

Acute lung transplant rejection (ALTR) typically occurs within 6 months of transplant and may present with progressive dyspnea and cough accompanied by low-grade fever, hypoxemia, and chest x-ray revealing perihilar opacities and interstitial edema. Because pulmonary infection can have a similar clinical presentation and the treatment for ALTR (ie, high-dose glucocorticoids) could markedly worsen an infection, ??? should be performed in the diagnostic workup of ALTR.

Answer 45

bronchoalveolar lavage and lung biopsy

Question 46

Myopia, or nearsightedness, is characterized by increased anterior-posterior diameter of the eye, causing blurred distance vision. High myopia (≥6 diopters of correction) increases the risk of ???

Answer 46

retinal detachment and macular degeneration

Question 47

Open globe laceration (OGL) is typically caused by small, high-velocity particles sent airborne by power tools, explosions, lawn mowers, or motor vehicle accidents. Large OGL may present with globe deformity, extrusion of vitreous or iris, or a visible entry wound. Other manifestations include a ??? pupil, asymmetric anterior chamber depth, loss of visual acuity or afferent pupillary response, and reduced intraocular pressure.

Answer 47

peaked or teardrop pupil

Question 48

moa of increased oxalate causing stones in Crohn’s disease patients??

Answer 48

Under normal circumstances, calcium binds oxalate in the gut and prevents its absorption. In patients with fat malabsorption, calcium is preferentially bound by fat leaving oxalate unbound and free to be absorbed into the bloodstream. Failure to adequately absorb bile salts in states of fat malabsorption also cause decreased bile salt reabsorption in the small intestine. Excess bile salts may damage the colonic mucosa and contribute to increased oxalate absorption

Question 49

Blunt trauma to a full bladder can cause it to rupture at the weakest point, the dome. Diversion of urine from the urinary tract (eg, inability to void) into the peritoneal cavity can cause urinary ascites and increased ??? from peritoneal reabsorption.

Answer 49

blood urea nitrogen and creatinine

Question 50

Patients with ??? develop hydronephrosis; however, symptoms can be masked initially by postoperative pain medications (post GYN surg). With continued obstruction, patients have nonradiating back pain and costovertebral angle tenderness. Because only 1 ureter is affected, patients typically have normal renal function (eg, normal creatinine and urinalysis); however, irreversible renal damage can occur if the obstruction is untreated. Diagnosis can be made by renal ultrasound. Treatment is surgical correction of the obstruction (eg, suture removal).

Answer 50

ureteral obstruction

Question 51

Contributing factors to acute kidney injury (AKI) in hospitalized patients include administration of potentially nephrotoxic agents (eg, intraarterial contrast, antibiotics) and intraoperative hypotension in patients undergoing surgery. In patients without evidence of volume depletion, ??? should be initially obtained to help determine the etiology of AKI.

Answer 51

urinalysis and urine microscopy

Question 52

Severe vomiting characteristically causes hypokalemic, hypochloremic metabolic alkalosis. The metabolic alkalosis is initiated by loss of gastric H+, worsened by hypovolemia-induced activation of the renin-angiotensin-aldosterone system, and perpetuated by profound total body Cl- depletion leading to hypochloremia and impaired renal bicarbonate excretion. Urine Na+ and Cl- are ??? due to total body depletion and aldosterone-mediated renal tubular reabsorption.

Answer 52

low

Repletion of volume and Cl- with normal saline corrects the metabolic alkalosis (saline responsive).

Question 53

Immediate postsurgical fever occurs within hours of the operation and is usually due to ???? Acute (1-7 days postoperatively) and subacute (7-28 days postoperatively) fever is generally driven by infections.

Answer 53

Postoperative fever is generally mediated by cytokine release in response to tissue trauma, blood cell lysis, or infection.

Question 54

??? are the most common causes of osteomyelitis in children with sickle cell disease. Therefore, empiric antibiotics should include antistaphylococcal (eg, clindamycin) and gram-negative (eg, ceftriaxone) coverage

Answer 54

Staphylococcus aureus and Salmonella

Question 55

???? are the most common cause of catheter-related bloodstream infection.

Answer 55

Coagulase-negative staphylococci (CoNS)

Question 56

3 most common bugs causing infection from central venous catheters???

Answer 56

Coagulase-negative staphylococci, Staph aureus, and Candida

Question 57

n patients with severe burn injuries, ??? reduces the risk of burn wound infections.

*most effacacious

Answer 57

early excision of necrotic tissue and wound closure (eg, skin grafting)

Question 58

Budding yeast in the blood culture of a hospitalized patient should raise suspicion for candidemia, requiring empiric antifungal treatment, ????, and evaluation for metastatic foci (eg, ophthalmologic examination). Although Candida is a normal skin commensal, its presence on blood culture should never be considered a contaminant.

Answer 58

removal of central lines

Question 59

Catheter-related bloodstream infections occur approximately once per year in patients with tunneled hemodialysis catheters. Most cases present with systemic signs of infection (eg, fever, malaise, chills) without localizing symptoms. The catheter site frequently appears normal. Initial therapy usually includes antibiotics, fluid resuscitation, and ????

Answer 59

removal of the dialysis catheter.

Question 60

???2 bugs??? are responsible for most deep infections following puncture wounds.

Answer 60

Staphylococcus aureus and Pseudomonas aeruginosa

Question 61

Patients with plantar puncture wounds through footwear are at risk for ??? osteomyelitis.

Answer 61

Pseudomonas aeruginosa

Question 62

Any penetrating wound below the ??? can involve the intraabdominal organs. Patients with penetrating abdominal trauma and any of the following indications—hemodynamic instability, peritonitis, evisceration—should undergo immediate exploratory laparotomy.

Answer 62

fourth thoracic dermatome (ie, nipple level)

~4th rib

Question 63

??? can present with unexplained fever and diffuse or right upper quadrant (RUQ) abdominal pain. Other findings can include jaundice, RUQ mass, leukocytosis, or abnormal liver function tests (normal results do not exclude the diagnosis). It is most often seen in hospitalized patients who are critically ill. Common predisposing conditions include recent surgery (particularly cardiopulmonary, aortic, or abdominal), severe trauma, extensive burns, sepsis or shock, prolonged fasting or total parenteral nutrition, or critical illness requiring mechanical intubation.

Answer 63

Acalculous cholecystitis

These conditions likely cause gallbladder stasis or ischemia with local inflammation that can lead to gallbladder distension, necrosis, and secondary bacterial infection.

Question 64

??? most frequently affects males age 15-30, particularly obese individuals, those with sedentary lifestyles or occupations, and those with deep gluteal clefts. The most common presenting symptoms include a painful, fluctuant mass 4-5 cm cephalad to the anus in the intergluteal region with associated mucoid, purulent, or bloody drainage.

Answer 64

Pilonidal disease

VS. perianal abscess presents with fever, malaise, anal pain, and a tender, erythematous bulge at the anal verge. This patient is afebrile, and his pain and swelling are located superior to the anus over the coccyx (4-5 cm cephalad to the anus).

Question 65

??? malignancy most often occurs in those who have fibropolycystic liver disease or primary sclerosing cholangitis due to underlying ulcerative colitis. Most cases present with subacute right upper quadrant pain, weight loss, and signs of biliary obstruction such as jaundice, cholestatic liver enzyme pattern, and dilation of the intrahepatic or common bile duct.

Answer 65

Cholangiocarcinoma

Question 66

serum markers in cholangiocarcinoma vs. hepatocellular carcinoma of the liver

Answer 66

cholangiocarcinoma (↑ CEA/CA 19-9, normal AFP) vs. hepatocellular carcinoma (normal CEA and CA-19, sometimes ↑ AFP).

colon cancer also has these markers, but look for hx of UC or primary sclerosing cholangitis for cholangiocarcinoma

Question 67

The first step in the treatment of acute upper gastrointestinal bleeding is ????

Answer 67

to establish vascular access with 2 large-bore intravenous catheters to initiate resuscitation with intravenous fluids.

Question 68

patient who received aggressive fluid resuscitation for trauma and severe burns now has a tensely distended abdomen and evidence of intraabdominal organ dysfunction (ie, renal dysfunction with decreasing urine output). This presentation is most concerning for ???

also key finding is high peak inspiratory pressures (diaphragmatic elevation compressing lungs)

Answer 68

abdominal compartment syndrome (ACS)

should prompt measurement of bladder pressure, which estimates intraabdominal pressure (IAP)

Question 69

Regardless of the underlying etiology, acute cholangitis is treated with intravenous fluid, antibiotics, and urgent ???

Answer 69

biliary drainage using endoscopic retrograde cholangiopancreatography (ERCP), with a sphincterotomy and/or a biliary stent is used to facilitate the flow of bile.

Once the patient has recovered from acute cholangitis, complete surgical excision of the biliary cyst should be performed to reduce the risk of developing cholangiocarcinoma.

Question 70

Acalculous cholecystitis occurs in critically ill patients. The clinical presentation may be similar to calculous cholecystitis, though assessment may be difficult due to the underlying illness. Imaging studies show gallbladder wall thickening and distension and pericholecystic fluid. The emergency treatment of choice is antibiotics and ????, followed by cholecystectomy when the medical condition stabilizes.

Answer 70

percutaneous cholecystostomy

Question 71

Trousseau syndrome is a hypercoagulability disorder presenting with recurrent and migratory superficial thrombophlebitis at unusual sites (eg, arm, chest area). It is usually associated with an occult visceral malignancy such as ???? (most common), stomach, lung, or prostate carcinoma.

Answer 71

pancreatic

Question 72

Dumping syndrome is a common postgastrectomy complication characterized by gastrointestinal (eg, nausea, diarrhea, abdominal cramps) and vasomotor (eg, palpitations, diaphoresis) symptoms. The diagnosis is primarily clinical. The symptoms can be controlled with ??? and usually diminish over time

Answer 72

dietary modification (eg, avoiding simple sugars)

• Consume small, frequent meals, and eat slowly
• Avoid simple sugars
• Increase fiber and protein intake
• Drink fluids between rather than during meals

Question 73

patient has typical clinical features of early ??? including gastrointestinal (eg, nausea, diarrhea, abdominal cramps) and vasomotor (eg, palpitations, diaphoresis) symptoms. It is a common postgastrectomy complication, occurring in up to 50% of patients. It is caused by loss of the normal action of the pyloric sphincter due to injury or surgical bypass and leads to rapid emptying of hypertonic gastric contents into the duodenum and small intestine. This causes fluid shifts from the intravascular space to the small intestine, leading to hypotension, stimulation of autonomic (sympathetic) reflexes, and release of intestinal vasoactive polypeptides.

Answer 73

dumping syndrome (DS)

Question 74

total parenteral nutrition (ie used in some Crohn’s patients) predisposes to gallstones how ???

Answer 74

In patients on total parenteral nutrition or prolonged fasting, the normal stimulus for CCK release and gallbladder contraction is absent. This leads to biliary stasis and promotes the formation of bile sludge and gallstones.

Question 75

??? typically affects patients with recent travel from endemic regions (eg, Asia, Africa, South America). It is often asymptomatic but may cause pulmonary (eg, cough, eosinophilic pneumonitis) or intestinal (eg, abdominal pain, nausea/vomiting, malnutrition) manifestations. Complications include obstruction of the small bowel or hepatobiliary tree (eg, cholangitis, pancreatitis). Treatment includes albendazole or mebendazole.

Answer 75

Ascariasis

ascaris lumbricoides roundworm

Question 76

patient with abdominal pain and distension, high-pitched bowel sounds, obstipation, and imaging demonstrating small bowel dilation with air-fluid levels has a ???

Answer 76

small bowel obstruction (SBO).

Question 77

elderly patient with weeklong symptoms of likely diverticulitis (eg, vague lower abdominal discomfort, anorexia, constipation) experienced sudden, severe abdominal pain that temporarily improved and then spread to his entire abdomen. This presentation, now accompanied by fever and peritonitis (eg, guarding, rebound tenderness), is most consistent with ????.

** free air is typically visible on abdominal imaging (eg, upright x-ray, CT scan).

Answer 77

diverticular perforation

Question 78

Patients with ???? of the gastrointestinal tract in the setting of ongoing inflammation (eg, diverticulitis) often have a classic pain sequence:

• Moment of perforation: sudden, severe pain (± vomiting, lightheadedness or syncope)
• After perforation to 2 hours: temporary relief or decreased pain as the inflamed organ decompresses
• >2 hours after perforation: generalized, constant pain due to peritonitis (± sepsis/septic shock)

Answer 78

free perforation

Question 79

Burn victims frequently develop intravascular volume depletion and require aggressive resuscitation with crystalloid solutions. ??? solution, a balanced fluid, is preferred because it contains near-physiologic levels of electrolytes and includes a buffer that helps correct acidosis and maintain normal blood pH.

Answer 79

Lactated Ringer

Normal saline is associated with the development of hyperchloremic metabolic acidosis.

Question 80

Prophylactic antibiotics reduce surgical site infections and are indicated when there is a high risk of infection or when infection would lead to significant morbidity/mortality. Patients undergoing clean procedures (ie, without infection or viscus entry) should receive coverage against gram-positive skin flora, ideally with a ???

Answer 80

first- or second-generation cephalosporin (eg, cefazolin) or, alternatively, with vancomycin or clindamycin.

Question 81

Constant (≥1 month) or progressive hoarseness is often related to a vocal cord lesion and requires evaluation by laryngoscopy. This patient with irregular, exophytic growths in clusters on the surfaces of his vocal cords likely has laryngeal papillomas due to recurrent ??

Answer 81

respiratory papillomatosis (RRP)

laryngeal papillomas are caused by human papillomavirus (HPV) subtypes 6 and 11. the mainstay of treatment remains surgical debridement, and patients often require many procedures.

Question 82

Serum ???? measurements are used as a tumor marker once the normally functioning thyroid tissue is removed in patients with thyroid cancer

Answer 82

thyroglobulin

Thyroglobulin (Tg) is the precursor to active thyroid hormones (T3 and T4) and is produced by normal thyroid tissue or differentiated (ie, papillary, follicular) thyroid cancer.

Question 83

??? is a benign, noninflammatory swelling of the salivary glands. It can result from overaccumulation of secretory granules in acinar cells (possibly due to abnormal autonomic innervation) in patients with chronic alcohol use, bulimia, or malnutrition. It can also result from fatty infiltration of the glands in patients with diabetes mellitus or liver disease.

Answer 83

Sialadenosis

Question 84

If a patient develops a whistling noise during respiration following rhinoplasty, one should suspect ??? likely resulting from a septal hematoma.

Answer 84

nasal septal perforation

complications are common after rhinoplasty

Question 85

Medullary thyroid cancer arises from the calcitonin-secreting parafollicular C cells. Serum ??? levels correlate with the risk of metastasis and recurrence, and are measured serially following surgery.

Answer 85

calcitonin

Question 86

An enlarged, ulcerated tonsil with ipsilateral cervical adenopathy is likely oropharyngeal (head and neck) squamous cell carcinoma. ??? is the likely etiology in the absence of traditional risk factors (smoking, alcohol).

Answer 86

Human papillomavirus

Question 87

Retropharyngeal abscess presents with neck pain, odynophagia, and fever following penetrating trauma to the posterior pharynx. Infection within the retropharyngeal space can extend where???

Answer 87

Extension through the alar fascia into the “danger” space can transmit infection into the posterior mediastinum and result in acute necrotizing mediastinitis.

Question 88

A ??? can occur after head trauma and result in episodic vertigo triggered by sudden pressure changes (eg, Valsalva maneuvers) or loud noises (Tullio phenomenon).

Answer 88

perilymphatic fistula

Question 89

Nasopharyngeal carcinoma is associated with ??? and occurs most commonly in those from Asia (particularly southern China) and parts of Africa and the Middle East. Manifestations include nasal congestion with epistaxis, headaches, cranial nerve palsies, and otitis media. Early spread to the cervical lymph nodes is common.

Answer 89

reactivation of Epstein-Barr virus

Question 90

In a patient with risk factors for malignancy, ear pain with a normal ear examination may be referred from the base of the tongue or hypopharynx/larynx. Associated cervical adenopathy makes ??? the most likely diagnosis. .

Answer 90

head and neck squamous cell carcinoma

The most common causes of referred otalgia are dental disease and temporomandibular joint disorders. However, referred otalgia is commonly a presenting symptom of mucosal head and neck squamous cell carcinoma (HNSCC), especially in an older patient with a history of smoking, alcohol use, occupational exposure to welding fumes, and cervical lymphadenopathy

Question 91

This patient with an enlarging fluid collection (ballotable neck swelling) developing after thyroidectomy likely has an expanding neck hematoma. An expanding neck hematoma is life-threatening due to the potential for airway obstruction, either from direct airway compression or from vascular compression causing venous congestion leading to laryngeal edema

Tx??

Answer 91

immediete wound exploration and drainage

Question 92

Peritonsillar abscess is characterized by fever, pharyngeal pain, and dysphagia. Examination findings include trismus, muffled voice, and swelling of the soft palate with deviation of the uvula. Treatment involves ???

Answer 92

needle aspiration or incision and drainage plus antibiotic therapy.

Question 93

Surveillance after colon cancer resection ??

Answer 93

for stage I: Colonoscopy in 1 yr & then every 3-5 yr

greaters stage = more tests; scans, CEA level

Question 94

Acute ??? is characterized by inflammation and distension of the gallbladder due to obstruction of the cystic duct by a gallstone. Typical features include acute right upper quadrant pain and tenderness, fever, and leukocytosis. Palpation (or an ultrasound probe) under the costal margin at the midclavicular line may elicit acute tenderness, especially during inspiration (Murphy sign).

Answer 94

cholecystitis

Question 95

??? commonly presents subacutely with fever and lower abdominal or flank pain radiating to the groin. The main sign is: abdominal pain with hip extension, can often be detected on examination. CT scans are required to confirm the diagnosis

Answer 95

Psoas abscess

drainage with antibiotics is the mainstay of therapy.

Question 96

patients with HCC are often asymptomatic. Therefore, in any patient with cirrhosis, screening abdominal ultrasound is recommended every ??? to evaluate for new-onset HCC.

Answer 96

6 months

Question 97

??? is the best diagnostic test for diagnosing acute diverticulitis and differentiating it from other causes of abdominal pain.

Answer 97

Abdominal CT scan

Question 98

Patients with ??? present with abdominal pain (usually lower left quadrant), fever, nausea/vomiting, and leukocytosis. Some (10%-15%) have urinary urgency, frequency, or dysuria due to bladder irritation from an inflamed sigmoid colon. Abdominal CT scan (oral and intravenous contrast) is the best diagnostic test

Answer 98

diverticulitis

Question 99

??? is recommended for complicated diverticulitis with abscess formation (​​​​​​​5-cm rim-enhancing perisigmoid fluid collection)

Answer 99

CT-guided percutaneous drainage

Sigmoid resection is generally reserved for patients with fistulas, perforation with peritonitis, obstruction, or recurrent attacks of diverticulitis

Question 100

CT scan of the abdomen with intravenous and oral contrast can identify features typical of ???:

• Colonic dilatation >6 cm (diagnostic)
• Loss of normal haustral pattern
• Irregular mucosal pattern, with areas of ulceration alternating with areas of edema

Answer 100

toxic megacolon

Question 101

patient with 6 weeks of lower abdominal pain, bloody diarrhea, and fecal urgency likely has undiagnosed inflammatory bowel disease (IBD). However, for the past 2 days, he has had worsening symptoms, abdominal distension and tenderness, leukocytosis, and systemic toxicity (eg, fever, hypotension, tachycardia). This presentation is concerning for ????, which can complicate IBD, often early in the disease (eg, initial presentation).

Answer 101

toxic megacolon (TM)

Question 102

Patients with ??? typically experience sudden onset of severe periumbilical pain that appears to be out of proportion to examination findings. It is commonly due to abrupt arterial occlusion from cardiac embolic events (eg, ventricular thromboembolism). Laboratory studies typically show leukocytosis, elevated hemoglobin (hemoconcentration), elevated amylase, and metabolic acidosis due to increased serum lactate levels. In this patient, metabolic acidosis is suggested by the very low bicarbonate level.

Answer 102

acute mesenteric ischemia

Question 103

which finding?

what management??

Answer 103

intraperitoneal free air. The free air establishes the diagnosis of perforated viscus, which warrants immediate surgical exploration

Question 104

Inadvertent damage to vagal nerve [CN X] branches can occur during Nissen fundoplication, a surgical procedure used to treat gastroesophageal reflux disease. This may result in ????, a disorder that causes bloating, early satiety, postprandial emesis, food aversion, and weight loss. A scintigraphic gastric emptying scan is diagnostic in the absence of obstruction (eg, negative esophagogastroduodenoscopy ± small bowel imaging).

Answer 104

gastroparesis

Nissen fundoplication, a surgical procedure used to treat gastroesophageal reflux disease. During this procedure, the fundus is folded and sewn around the lower esophageal sphincter to decrease the amount of gastric acid that refluxes into the esophagus.

Question 105

patient developed abdominal pain and absent bowel sounds following a traumatic injury. Abdominal x-ray demonstrates gastric dilation and gas-filled loops of both the small and large intestines, suggesting ??

Answer 105

paralytic (adynamic) ileus.

Contributors to the pathophysiology of ileus include irritation and temporary paralysis of the abdominal sympathetic and parasympathetic nervous system, local release of inflammatory mediators, and opioid analgesic use.

Question 106

Patients who undergo Roux-en-Y gastric bypass are at risk for multiple vitamin deficiencies. Fat-soluble vitamins and vitamin B12 deficiency are most common, but vitamin ?? deficiency can occur in the setting of poor postoperative diet. It is associated with ecchymosis, petechiae, poor wound healing, perifollicular hemorrhage, coiled hairs, and gingivitis; platelet count, prothrombin time, and partial thromboplastin time will be normal.

Answer 106

Vitamin C deficiency

Question 107

Features that distinguish biliary colic from cholecystitis are ??? and absence of abdominal tenderness, fever, and leukocytosis.

Answer 107

pain resolution within 4-6 hours

Ingestion of a large (usually fatty) meal stimulates gallbladder contraction. The intra-gallbladder pressure increases on gallbladder contraction against an obstructed cystic duct and causes pain. Subsequent gallbladder relaxation allows the stone to fall back from the duct with subsequent pain resolution.

Question 108

biliary colic can have reffered pain where???

Answer 108

right-sided shoulder/subscapular discomfort

Question 109

Approximately 1 day after sustaining blunt abdominal trauma (BAT), this patient has fever, diffuse abdominal tenderness with epigastric guarding, and retroperitoneal free air on imaging. This delayed presentation is concerning for a perforated viscus within the retroperitoneum, most likely where ????

Answer 109

duodenal tear

Question 110

??? is a common complication of cholecystectomy and occurs due to the overly rapid release of bile into the intestines, where it overwhelms the resorptive capacity of the terminal ileum and spills into the colon, resulting in secretory (fasting) diarrhea.

Answer 110

Bile acid diarrhea

Bile-acid binding resins (eg, cholestyramine, colestipol, colesevelam) are first-line therapy.

Question 111

??? is primarily used for suspected choledocholithiasis, which generally causes abdominal pain, nausea/vomiting, and laboratory abnormalities (eg, elevated transaminases, bilirubin, and alkaline phosphatase).

Answer 111

Endoscopic retrograde cholangiopancreatography

Question 112

??? is primarily used to exclude cholecystitis in patients with suggestive symptoms (eg, severe right upper quadrant pain, fever, tachycardia, leukocytosis with left shift) but no gallbladder inflammation or biliary obstruction on ultrasound.

Answer 112

HIDA scan

Question 113

patient has been receiving aggressive fluid resuscitation in the setting of acute pancreatitis, an inflammatory condition that can cause abdominal swelling from visceral edema, intraabdominal third spacing of fluids, and ileus (evidenced by decreased bowel sounds). Now, he has a tensely distended abdomen and clinical signs concerning for ????, including difficulty breathing and basilar atelectasis (from diaphragmatic elevation causing lung compression) and decreased urine output (from increased intraabdominal pressure reducing renal perfusion).

Answer 113

abdominal compartment syndrome (ACS)

Question 114

Occult gastrointestinal bleeding usually presents with unexplained iron deficiency anemia and/or a positive fecal occult blood test. Initial workup includes ????; small bowel evaluation (eg, video capsule endoscopy, deep enteroscopy) may be required if initial tests are unrevealing. The presence of hemorrhoids should not preclude this evaluation.

Answer 114

colonoscopy and upper endoscopy

Question 115

Anal fissures present with pain and rectal bleeding on defecation. Treatment includes increased fiber and fluid intake, stool softeners, sitz baths, and ???(2 more)

Answer 115

topical anesthetics and vasodilators (eg, nifedipine, nitroglycerin)

Question 116

??? should be suspected in patients who develop worsening abdominal pain, unstable vital signs, or signs (eg, fever, leukocytosis) of infection 7-10 days after onset of acute necrotizing pancreatitis. CT scan of the abdomen demonstrating gas within the pancreatic necrotic collection is diagnostic.

Answer 116

Infected pancreatic necrosis

Question 117

She was gaining weight well as an infant likely due to being on an all-liquid diet (requiring less esophagus distension). With the introduction of solid foods (around age 6 months), dysphagia became more pronounced and the patient’s growth rate slowed due to increasing reliance on solid foods for her caloric needs. She had recurrent food impactions at the site of esophageal compression, seen on fluoroscopic esophagography at around the level of the aortic arch (eg, T3-T4). Her episodes of middle-lobe pneumonia were possibly due to aspiration.

what is the cause??

Answer 117

Vascular rings encompass congenital malformations of the aortic arch system that encircle the trachea and/or esophagus and cause compressive symptoms. Tracheal compression leads to biphasic stridor that increases with increased work of breathing (eg, crying, feeding).

Vascular rings can also present with esophageal compression symptoms, as in this patient with severe solid-food dysphagia.

CT scan can delineate the anatomy forming the vascular ring and evaluate associated tracheal abnormalities.

Question 118

??? is a rare cause of upper gastrointestinal bleeding that usually occurs as a complication of hepatic or biliopancreatic procedures. It presents with right upper quadrant pain, jaundice, and upper gastrointestinal bleeding.

Answer 118

Hemobilia (bleeding into the biliary tract)

Question 119

Clostridioides difficile infections can occasionally be complicated by ???, which usually presents with severe systemic symptoms (eg, high fever, tachycardia), leukocytosis, abdominal distension, and significant colonic distension on abdominal radiograph. Suspicion is often raised when a patient with C difficile infection stops having diarrhea and symptoms clinically worsen.

Answer 119

toxic megacolon

Question 120

patient with Clostridioides (formerly Clostridium) difficile infection (CDI) has worsening abdominal pain, signs of peritonitis, and severe colonic dilation (ie, toxic megacolon) despite appropriate medical management. The best next step is ??? to evaluate for colonic necrosis or perforation and to treat (eg, resect, lavage) the diseased colon.

Answer 120

laparotomy

clinical indicators warrant surgical evaluation:

• Signs of peritonitis: Diffuse abdominal tenderness, rebound tenderness (ie, tenderness with release of palpation pressure)
• Colonic dilation: Megacolon (ie, colonic diameter >6 cm) on abdominal x-ray, with associated loss of smooth muscular tone (eg, decreased diarrhea)
• Increased serum lactate: Possible marker of colonic ischemia

Question 121

Patients with inflammatory bowel disease (IBD) are at highest risk of developing toxic megacolon (TM) early in the disease, sometimes at initial presentation. Patients with IBD-induced TM should receive ??

Answer 121

intravenous corticosteroids

Other management includes supportive care (eg, intravenous fluids, electrolyte repletion), bowel rest and decompression (eg, nasogastric tube), and broad-spectrum antibiotics. Nonoperative management is often successful; however, surgical intervention (eg, subtotal colectomy with end-ileostomy) may be required if symptoms fail to improve.

Question 122

?? may lead to fracture nonunion. Common symptoms include intermittent pain and swelling and sinus tract formation. Diagnosis is suggested by this patient’s x-ray, which shows fragmentation of the bone and ragged, irregular fracture lines.

Answer 122

Chronic osteomyelitis

Open bone biopsy is recommended for microbiologic assessment, and treatment requires surgical debridement of the infected and necrotic bone

Question 123

Post-traumatic neuromas are due to the transection of nerve fibers and form over several weeks to months following injury or amputation. They cause pain with local pressure that can complicate fittings for amputational prosthetics. Injection of a local anesthetic can provide transient pain relief and confirm the diagnosis. Management typically involves ???

Answer 123

excision of the neuroma.

Question 124

A Salter-Harris type III (juvenile Tillaux fracture) is characterized by fracture of the distal tibial epiphysis and lateral physis (ie, growth plate) and most commonly occurs in adolescents when the physis is partially fused. Injury to the growth plate can cause ???

Answer 124

growth arrest and lead to persistent limb-length discrepancy

Question 125

tx for phantom limb pain ??

Answer 125

Treatment of PLP is typically multimodal and may include:

• pharmacotherapy: antidepressants (eg, tricyclics), antiepileptics (eg, gabapentin), N-methyl-d-aspartate (NMDA) receptor antagonists (eg, ketamine), and analgesics (eg, acetaminophen, opioids).
• adjuvant therapies: biofeedback, cognitive behavioral therapy, and mirror therapy (ie, using a mirror to watch the reflection of the residual limb moving at the location of the absent limb).

Question 126

??? should be suspected in patients with back pain who have pain worse at night and unrelieved with rest, and focal vertebral tenderness.

Answer 126

Vertebral metastasis

Other features may include neurologic deficits, unexpected weight loss, and hypercalcemia. The most common cancers associated with vertebral metastasis include prostate, breast, kidney, thyroid, and non–small cell lung cancer, as well as non-Hodgkin lymphoma.

Question 127

posterior tibial fracture (tibia goes posterior) requires what work-up

Answer 127

ankle-brachial index to rule out vascular injury to posterior lying popliteal artery

+ Duplex US

+ palpation of popliteal and distal pulses

Question 128

Older patients with hip fracture should undergo definitive surgical correction as soon as reasonably possible. However, surgery may be delayed up to 72 hours to evaluate surgical risk and ensure medical stability.

what tests??

Answer 128

Echo, cardiac markers, chest x-ray

depends on what the patient is presenting with

Question 129

Chronic neuropathic (Charcot) arthropathy is characterized by bone deformities resulting from repetitive trauma to the foot and ankle. what is the pathogenesis??

Answer 129

It develops in patients who have impaired sensation and joint proprioception (eg, diabetic peripheral neuropathy) that prevent the patient from adjusting weight bearing to avoid mechanically induced wear and tear.

Question 130

??? can present in either of 2 stages:

• Acute: Characterized by inflammatory erythema, warmth, and edema of the foot 1-2 days after minor trauma. X-rays at this stage usually show only soft tissue swelling without bone involvement.
• Chronic: Characterized by bone deformities noted on x-ray that typically include osseous fragmentation, new bone formation, and subluxation/dislocation predominantly in the mid and hind foot. Other common signs are loss of the metatarsal heads (pencil pointing) with osteopenia and phalangeal osteolysis. These changes often lead to neuropathic ulcers, arch collapse (rocker bottom feet), and callus formation.

Answer 130

Neuropathic arthropathy

Question 131

fat embolism syndrome (FES) occurs when fracture of a large, marrow-rich bone (eg, the femur) releases fat into the ?? circulation.

Answer 131

venous

*can affect both pulmonary and CNS system

Question 132

??? is a benign but locally destructive neoplasm that is most common at the epiphysis of long bones in young adults. Most patients have local manifestations (eg, pain, swelling), but pulmonary metastasis and malignant transformation may occur. X-ray shows an eccentric lytic lesion, often resembling soap bubbles. The diagnosis is confirmed with biopsy, and surgery is first-line treatment.

Answer 132

Giant cell tumor of bone

Question 133

?? is characterized by anterolateral and superior displacement of the proximal femur along the physis (growth plate). It most commonly presents in adolescents with chronic hip pain. However, 15% of patients have only referred thigh or knee pain. Due to the referred nature of the pain, knee examination is normal. Characteristic findings on hip examination, however, include limited internal rotation, which causes the foot to point laterally, and thigh abduction and external rotation with passive hip flexion. ​​​​​​​

Answer 133

Slipped capital femoral epiphysis (SCFE)

*typically in obese

Bilateral hip x-rays are diagnostic and show a posteriorly displaced femoral head.

Question 134

??? can be diagnosed based on clinical and x-ray findings, with no need for additional diagnostic testing. This patient’s x-ray reveals osseous resorption, architectural foot disorganization, and midfoot arch collapse (ie, anatomical alignment between the intertarsal and tarsometatarsal articulations)

Answer 134

Chronic neuropathic arthropathy (complication of diabetic neuropathy)

Question 135

Sudden, forceful contraction of the quadriceps muscle can cause ???. Symptoms include an audible pop, rapid swelling, and inability to actively extend the knee against gravity. The patella rides low, with a palpable defect above the patella

Answer 135

rupture of the quadriceps–patellar tendon complex

diagnosis and extent of the injury can be assessed on MRI. Management of complete tears of the quadriceps tendon requires surgical intervention.

Question 136

??? is most common in obese, middle-aged adults, but it may also be seen in younger, well-conditioned individuals who participate in high-impact exercise or spend extended periods in bare feet. The pain is often worst when first standing from rest; it may lessen with activity but may again worsen after long periods of standing or walking. Physical examination typically shows tenderness at the calcaneus, especially with the toes passively dorsiflexed. Patients frequently have preexisting abnormalities of the arch (eg, pes planus, high arch)

Answer 136

Plantar fasciitis

Plantar fasciitis is characterized by inflammation and degeneration of the plantar aponeurosis (deep plantar fascia), a thick, fibrous band that extends from the calcaneus to the toes and supports the longitudinal arch of the foot. It is thought to be due to chronic overuse and repetitive microtrauma to the aponeurosis and its insertion point at the calcaneus.

Question 137

??? are typically seen in inexperienced athletes after initiation of a high-impact exercise program. Like plantar fasciitis, they cause pain at the heel that is worse with weight bearing. However, the pain can often be elicited by firm palpation at the sides of the heel (squeeze test).

Answer 137

Calcaneal stress fractures

Question 138

Plantar fasciitis initial management includes activity modification (eg, avoiding walking barefoot, reducing high-impact exercise), physical therapy (eg, fascial stretching, muscle strengthening exercises), and ??? , which reduce strain on the fascia. About 80% of patients recover within 1 year.

Calcaneal spurs are incidental and do not require treatment.

Answer 138

padded heel inserts

Question 139

??? cause pain and weakness at the shoulder. With the arm abducted over the head, the patient may be unable to lower the arm smoothly (drop arm test). An MRI scan can confirm the diagnosis.

Answer 139

Rotator cuff tears

Question 140

Osteonecrosis (aseptic necrosis) of the femoral head / avascular necrosis of the femoral head can have what x-ray finding ??

Answer 140

can be negative for months; MRI is better for diagnostic

Question 141

??? is most common in patients who perform repetitive arm movement above shoulder height. It presents with subacute pain on abduction. Impingement syndrome refers to compression of soft tissue structures between the humeral head and acromion and is a characteristic feature of this

Answer 141

Rotator cuff tendinopathy (RCT)

Question 142

Displaced supracondylar fractures of the humerus most commonly present after a fall onto an outstretched hand with posterior displacement of the distal humerus fragment. The anteriorly displaced proximal humerus fragment can entrap the ??? (2), which pass anterior to the humerus.

Answer 142

brachial artery and median nerve

Question 143

Stress fractures of the metatarsals are associated with a sudden increase in activity and are common in athletes and military recruits; the second metatarsal is most commonly injured. Initial treatment includes cessation of the offending activity and simple analgesics. Stress fractures of the ??? metatarsal are at increased risk for nonunion and warrant more aggressive treatment.

Answer 143

fifth (usually need casting or internal fixation)

Question 144

initial management of osteoarthritis of the knee includes weight loss, regular moderate activity, and topical or oral nonsteroidal anti-inflammatory drugs. In addition, exercises to strengthen ??? can reduce abnormal loading on the joint and protect the articular cartilage from further stress.

Answer 144

the quadriceps muscles

Question 145

Succinylcholine is a depolarizing neuromuscular blocker that can cause life-threatening ??? in patients with a condition leading to upregulation of postsynaptic acetylcholine receptors (eg, skeletal muscle trauma, burn injury, stroke). Nondepolarizing neuromuscular blocking agents (eg, vecuronium, rocuronium) should be used with these patients.

Answer 145

Succinylcholine is a depolarizing neuromuscular blocker that works by binding to postsynaptic acetylcholine receptors to trigger influx of sodium ions and efflux of potassium ions through ligand-gated ion channels; depolarization occurs and temporary paralysis ensues (delayed repolarization of the skeletal muscle membrane). Patient has experienced an extensive skeletal muscle crush injury, which places him at risk for hyperkalemia due to skeletal muscle cell lysis (rhabdomyolysis). In addition, skeletal muscle injury leads to upregulation of postsynaptic acetylcholine receptors, which can result in massive efflux of potassium following administration of succinylcholine. Other relevant conditions that cause upregulation of acetylcholine receptors include burn injury, disuse muscle atrophy, and denervation (eg, stroke, Guillain-Barré syndrome, critical illness polyneuropathy).

Question 146

On initial examination, mild swelling was noted, although compartment pressures were measured as normal. However, over the next 12 hours, reperfusion (due to relief of the compression) and likely fluid resuscitation led to increased edema, evidenced by tense swelling and pain (eg, grimacing) on passive manipulation on reexamination. This is indication of?

Answer 146

Compartment syndrome can arise multiple hours after injury as swelling progresses. Serial examinations are essential for timely diagnosis. When compartment syndrome is suspected (eg, tense swelling, pain with passive manipulation), emergency surgical consultation for fasciotomy should be obtained.

Question 147

??? can be caused by trauma or prolonged compression of an extremity or by revascularization procedures. Symptoms include severe pain that is worsened on passive range of motion, paresthesias, and sensory and motor deficits.

Answer 147

Compartment syndrome

The diagnosis is confirmed by measuring compartment pressures but can be made on clinical grounds in high-risk patients. Management includes urgent fasciotomy.

Question 148

Dorsal displacement of the radius (as occurs in Colles fracture) can result in compression of the ???, which enters the wrist through the carpal tunnel and provides sensation to the lateral 3½ digits and motor innervation to the thenar muscles (eg, opponens pollicis, abductor pollicis brevis).

Answer 148

median nerve