Surgery Flashcards
1
Q
What agent is given to patients with extreme hypotension (low BP) during heart surgery that eventually requires bypass?
A
Methylene Blue
MOA: inhibits guanylate cyclase and production of cGMP –> reduced responsiveness of vasodilators (nitric oxide)
2
Q
Internal vs External Carotid resistance via Doppler?
A
*External: when not using somatic (muscles) parts of body, the blood vessels are vasoconstricted to restrict blood flow when it’s not needed there. This is why high initial pressure on doppler followed by sharp drop-off. (picked up on doppler)
Supplies face muscles (somatic areas)
*Internal: blood flow to visceral organs needs to be high at all times. This is why there is high (loud) diastolic phase during doppler b/c blood flow is still high (picked up on doppler)
These vessels feed important organs (brain, kidney) and will have high flow
3
Q
During carotid endarterectomy, where do you clamp vessels?
When closing up, what order do you release the vessels to assess for bleeding?
A
Clamp proximal and distal to place of operating (common carotid and both internal & external carotids)
1) Open distal artery first (common carotid portion furthest from head) to assess for any bleeding from suture site
2) Then release the external carotid artery –> if there is any residual gunk/plaque, you don’t want it going to the brain and stroking the patient. Going down the external carotid to face is less damaging.
3) Release internal carotid artery last!!
4
Q
What can be given to prevent contrast-induced nephropathy in people w/ renal insufficiency?
What 2 things should be avoided?
A
Aceytlcysteine w/ plenty of IV fluids
Avoid volume depletion and NSAIDs
5
Q
How many days before surgery do you need to d/c Warfarin?
A
3-4 days pre-op
*Switch from warfarin to either heparin/LMWH until surgery than start either again 12 hrs post-op and maintained until INR >2
6
Q
How long before a surgery should you stop smoking?
A
at least 4 weeks pre-op (6-8 weeks)
7
Q
Cause of fever immediately after initiation of anesthesia?
A
Malignant hyperthermia
Tx: Dantrolene, 100% O2, cooling blankets
8
Q
Common cause of fever post-op day 0-1?
A
Atelectasis or pneumonia
9
Q
Patient post-op develops a fever on post-op day #1 and it persists for 2-3 days?
A
Pneumonia
10
Q
Fever presenting post-op day 3-5?
A
Post-op UTI
UTI: 3 letters - 3rd days after see fever
DVT: V is roman numeral for 5 - 5 days after see fever
Wound: W for week (1)
Deep Abscess: 4 letters + 9 letters = 13 (9-13 days)
11
Q
How many days after operation do you see fever from wound infection?
A
5-8 days
12
Q
Maintenance fluid calculation?
A
4-2-1 rule
or
wt (kg) + 40 = mL/hr
13
Q
Adequate urine output?
A
0.5 mL/kg/hr (30mL/hr)
14
Q
Maintenance IV fluid of choice for adults? children?
A
Adults: D5 1/2 NS + 20 mEq KCl/L
Children: D5 1/4 NS + 20 mEq KCl/L
15
Q
Composition of 0.9 NS?
A
Na: 154 K: 0 Osm: 308 pH: 6.0 Cl: 154
16
Q
Composition of extracellular fluid?
A
Osm: 290 Na: 140 K: 4.5 Cl: 108 pH: 7.4 Lactate: 5
17
Q
Composition of LR?
A
Osm: 273 Na: 130 K: 4 Cl: 110 HCO3: 27 Ca: 3 pH: 6.5 Lactate: 28
18
Q
Composition of D5W?
A
Osm: 252 Na: 0 K: 0 Glucose: 50g/L pH: 4.5
19
Q
Composition of D5 1/2 NS?
A
Osm: 450 Na: 77 K: 0 Cl: 77 Glu: 50
20
Q
Composition of PlasmaLyte?
A
Osm: 294 Na: 140 K: 5 Cl: 98 pH: 7.4
21
Q
Name for chronic leg discoloration from chronic venous insufficiency?
A
Lipodermatosclerosis or venous stasis dermatitis
22
Q
What are better for moisture retention and delivery of medications - creams or ointments?
A
Ointments
23
Q
What is Leriche syndrome?
A
Aortoiliac occlusive disease –> form of peripheral artery disease involving bifurcation of abdominal aorta
Triad:
1) B/L hip/buttock/thigh claudication (worse w/ walking)
2) Decreased/absent femoral pulses
3) **Impotence –> if not present, not Leriche!
24
Q
What is Leriche syndrome?
A
Aortoiliac occlusive disease –> form of peripheral artery disease involving bifurcation of abdominal aorta
Triad:
1) Buttock/thigh claudication
2) Decreased/absent femoral pulses
3) Impotence
25
6 P's of Compartment Syndrome?
Pain, Pallor, Paresthesia, Paralysis, Poiklothermia, Pulseless
26
Daily protein needs for TPN?
25 kcal/kg/day or 1-1.5 g/kg/day
27
3 common causes of appendicitis?
Bowel fecalith
Lymphoid hyperplasia (viral infection) - children
Tumor
28
Testing modality for children w/ suspected appendicitis? Women? Men?
Children and women --> Ultrasound
| Most adults over 50 --> CT scan
29
2 pre-op treatments for appendicitis?
Crystalloid fluid
| Abx: cefazolin + metronidazole
30
First step in appendectomy?
Ligate appendicular artery (branch off of ileocecal from SMA)
31
Borders of inguinal canal?
Roof: fibers of internal oblique & transversus abdominus
Floor: inguinal ligament
Anterior: external oblique aponeurosis
Posterior: transversalis fascia
32
Borders of Hasselbach's triangle?
Lateral border of rectus abdominus
Inferior epigastric artery
Inguinal ligament
33
What congenital defects allows indirect inguinal hernias to occur?
Patent processus vaginalis
34
Borders of femoral canal?
Anterior: inguinal ligament
Posterior: Cooper's ligament (periosteum of superior pubic ramus)
Medial: lacunar ligament
Lateral: femoral vein
35
3 stages of hernia progression?
Reducible
Incarcerated (non-reducible --> leads to lymphatic and venous obstruction in the loop of bowel --> overtime leads to compression and obstruction of arterial flow to loop of bowel)
Strangulated (ischemic/necrotic bowel from lack of blood supply)
36
Drug commonly avoided due to Sphincter of Oddi spasm?
Morphine (tested but not practiced)
37
Term for air located in the gallbladder?
Emphysematous Cholecystitis
38
Charcot's triad?
Reynold's pentad?
1) Fever & chills
2) RUQ pain
3) Jaundice
* Also see increased ALP
* *Seen in acute ascending cholangitis**
Charcot triad + hypotension & mental status changes
39
What is triangle of Calot?
Area where ligation of cystic artery and duct occur for gallbladder removal
"3 C's"
1) Cystic duct
2) Common hepatic duct (BEFORE cystic duct joins)
3) Cystic artery
40
Common feature of R-sided colon cancer?
Fe-def anemia
*Microcytic anemia in older adult (>50) = colorectal cancer until proven otherwise (also think GI bleed)
41
Common feature of L-sided colon cancer?
Bowel changes
Pencil-thin stools, constipation, diarrhea
42
Best initial test for colorectal cancer?
DRE --> if (+) then to colonoscopy
43
In adults, 3 most common causes for small bowel obstruction?
Adhesions (prior abdominal surgery)
Hernias
Tumors (suspect w/ no prior abd surgeries or hernias)
44
How do gallstones get into the small bowel and cause obstruction?
Cholecystoenteric FISTULA forms (b/w gallbladder and small bowel) and allows passage of large gallstones into bowel --> obstruct the ileocecal valve
45
X-ray findings for gallbladder fistula?
Air in biliary tree
| Possible radio-opaque mass in RLQ
46
2 common causes for large bowel obstruction?
Tumors
| Volvulus
47
Bilious vomiting in newborn?
Malrotation of midgut volvulus until proven otherwise!
48
Causes for bowel obstruction in children?
Volvulus, intussusception, hernias
If they don't pass meconium:
At all = CF
During initial 24 hrs = Hirschsprung's disease
49
Common complication of bowel obstruction?
Vomiting --> hypokalemic, hypochloremic metabolic alkalosis
Hypokalemic b/c the alkalosis causes H+ to efflux from cells for buffer --> K+ moves into cells as H+ moves out --> drop in K+ level
50
X-ray findings for small bowel obstruction?
Dilated loops of small bowel
| "Step-ladder" appearance --> air-fluid levels
51
Treatment for SBO?
"Suck & Drip"
1) NPO
2) NG tube to suck out all gas in GI tract
3) Aggressive IV hydration w/ IV crystalloid
4) Foley placed to monitor urine output for hydration status
5) Correct electrolyte imbalances
*Surgery is only needed w/ complete obstruction or clinical/radiographic signs of ischemia, necrosis, or perforation
52
Most common area for AAA?
Best method of testing?
Below renal artery bifurcation (no vasa vasorum causes weakening in arterial wall)
CT scan
53
What size do AAA become surgical candidates?
>5.5cm diameter
54
Femoral triangle?
Lateral border: sartorius muscle
Medial border: adductor longus muscle
Superior border: inguinal ligament
55
Treatment for large bowel obstruction?
Enema, decompression w/ rectal tube, colonoscopy
56
Name for acute colonic pseudo-obstruction causing dilation of colon without any actual mechanical obstruction?
Once this is diagnosed, what is treatment?
Ogilvie syndrome (often in elderly w/ extra-abdominal surgery)
Tx: Neostigmine (potent cholinesterase (-) & parasympathetic agonist that stimulates colonic contraction and subsequent decompression of the bowel)
57
What is blood supply of internal & external hemorrhoids and which are painful?
Internal: dilated superior rectal plexus located ABOVE dentate line and NOT painful
External: dilated inferior rectal plexus loctated BELOW dentate line and YES are painful
58
Management of hemorrhoids?
Conservative (sitz baths, stool softeners, high fiber diet)
Surgical management:
Internal: rubber band ligation
External: hemorrhoidectomy
59
What condition should you suspect w/ an anal fissure, perianal abscess, or anorectal fistula fail to heal?
Crohn's disease
60
What is Goodsall's rule of anorectal fistulas?
Anterior fistulas connect w/ rectum in a straight line
| Posterior fistulas go towards a midline internal opening in the rectum
61
During organ transplantation, in what organ are antigenic reactions (acute, hyper acute, delayed) not very common?
What is most common complication?
Liver
*Most common cause of early functional deterioration is technical problems w/ biliary & vascular anastomoses --> if they appear normal, then do liver biopsies to confirm organ rejection
62
Risk factors for squamous cell carcinoma of the mouth? Common precursor lesions?
Smoking & alcohol
| Erythroplakia & leukoplakia
63
Firm, non-tender mass in front of L ear present for 4 months w/ limited mobility and not fixed to deep tissues or to overlying skin. FNA is done, but indeterminate. What do you suspect? Next best step?
Parotid tumor (pleomorphic adenoma or adenoid cystic tumor)
Next step: superficial parotidectomy w/ sparing of facial nerve
*Repeat biopsies are NOT advised b/c of potential damage to facial nerve from scar tissue formation
64
Fever, perineal pain, irritative urinary symptoms, very tender prostate on exam? Tx?
Acute Prostatitis
Tx: Fluoroquinolones 4-6 weeks (broad G(-) & (+) coverage)
65
R hip pain radiating down femur to the knee. Hx Crohn's w/ recent flair controlled w/ prednisone for 2 weeks. Pain worse on exertion & relieved w/ NSAIDs. Limited ROM w/ R hip, especially w/ external rotation. X-ray shows dulling of femoral head only. What is next step in diagnosis?
Avascular necrosis of femoral head secondary to exogenous steroid use!
*Femoral head especially at risk due to poor blood supply (medial fem circumflex via profunda femoris)
66
What is a Pringle maneuver?
Hemostats used to clamp the Portal Triad in hepatoduodenal ligament to control possible liver bleeding.
If done and bleeding still persists in RUQ --> think hepatic vein or IVC behind the liver
67
In someone with epidural hematoma that suddenly becomes unresponsive, what is the definitive management?
Surgical evacuation of the hematoma
68
Elderly at risk for what types of fractures? Why? Best initial test?
Femoral fractures (hip fracture due to FALLS! - underlying cormorbidities also)
Diag test --> X-ray of hip/femur
69
What is an absolute indication for CT scan to the head?
Loss of consciousness secondary to head trauma
WITHOUT contrast - contrast reserved for mass lesions in the brain
70
When is contrast used for head CT's?
Suspecting mass lesions in head
71
Method for eliminating pyogenic liver abscess?
Amebic liver abscess?
Pyogenic abscess --> percutaneous drainage (Abx won't touch it!)
Amebic abscess --> metronidazole (E. histolytica) & then percutaneous drainage if no resolution w/ Abx
72
Pt w/ recent pituitary surgery for prolactinoma develops lethargy, confusion, and becomes comatose. Her urine output is elevated and is receiving modest IV fluids. What is the cause? Treatment?
Central diabetes insipidus --> damage to other parts of anterior/posterior pituitary & their hormones
- Lack of ADH = massive/rapid water loss via kidneys causes hypernatremia (causes CNS symptoms)
- Tx: IV fluids and desmopressin (ADH-analouge)
73
Patient is actively bleeding per rectum. A NG tube is placed & aspiration reveals clear, green fluid w/o blood. How does this help you identify location of GI bleed?
If aspirate is clear = bleed is DISTAL to Ligament of Trietz (where duodenum becomes jejunum)
74
X-ray findings of SBO + air in biliary tree (pneumobilia) is indicative of what?
Gallstone ileus in ileocecal valve from gallbladder-small bowel fistula
Common sequela after acute cholecystitis
75
2 complications of femoral fractures. What signs do you see with each?
Fat emboli --> usually several days after fracture and see respiratory failure
Hypovolemic shock --> massive blood loss into thigh cavities
76
Common complication after acute pancreatitis seen w/ high fevers and leukocytosis?
Pancreatic abscess
CT scan of abdomen to locate abscess for drainage
77
What is cause for pneumaturia (peeing bubbles) and fecaluria?
What test would confirm?
What are 3 most common causes?
Colovesical fistula (colon & bladder)
CT scan to confirm
1) Diverticulitis 2) Sigmoid cancer 3) Bladder cancer
78
Someone vomiting bright red blood. What is first step in management? Second? Third?
1) Examine mouth & nose --> r/o epistaxis!!!
2) Lavage gastric contents via NG tube
3) Upper Endoscopy
79
Best treatment for acute ascending cholangitis?
1st: supportive care + broad-spectrum Abx
2nd: ERCP
Evaluates biliary obstruction & is both diagnostic & therapeutic (decompression of dilated common bile ducts)
80
Best treatment for acute ascending cholangitis?
ERCP --> evaluates biliary obstruction & is both diagnostic & therapeutic (decompression of dilated common bile ducts)
81
What nerves are at risk for damage in inguinal hernia repairs?
Iliohypogastric, ILIOINGUINAL, genitofemoral (genital branch), lateral femoral cutaneous
82
5 indications for surgery on GI tract?
1) Bleeding
2) Perforation
3) Obstruction
4) Retractable symptoms
5) Neoplasm
83
Triad of lab findings indicating the need for a Damage Control Situation (stopping operation to stabilize patient for several hrs before returning to surgery)?
1) Hypothermia (5mmol)
2) Coagulopathy (increased PT/INR & PTT)
3) Acidosis (low pH & lactate >5mmol)
84
Most common malignant tumor in appendix?
Carcinoid tumor
85
Purpose of the large colon?
Water absorption
86
Aside from niacin deficiency, what condition causes diarrhea, dermatitis, dementia?
Carcinoid syndrome (from decreased niacin production)
87
What are the signs of carcinoid syndrome?
"Be FDR"
Bronchospasm
*Flushing (skin - early & frequent)
Diarrhea
R-sided heart failure (valve failure - tricuspid)
88
What lab test is used for carcinoid tumors?
Treatment for carcinoid?
5-hydroxyindolacetic acid (HIAA)
Tx: octreotide (somatostatin analogue)
89
2 most common causes for fistula formation?
Diverticulosis & cancer
90
Newly-developed Fe-deficiency anemia in postmenopausal woman or older man?
Colorectal cancer
91
Triad often seen w/ diverticulitis?
Fever
LLQ pain/diffuse abd pain
Leukocytosis
92
What tests are contraindicated in suspected diverticulitis?
Barium enema, colonoscopy --> risk of perforation
93
Consider this diagnosis in patient w/ atypical chest pain (normal cardiac exam) and symptoms of GERD?
Hiatal hernia
94
What unique structure is found in males inguinal canal? females inguinal canal?
Males: spermatic cord w/ vas deferens
Females: round ligament of uterus
95
Why is shoulder pain a common complaint post-laparoscopy?
CO2 used for insufflation can irritate the diaphragm (direct pressure or cell death from temp changes) --> referred pain via phrenic nerve
96
What abdominal test/procedure is strictly therapeutic?
ERCP
97
24 yo woman who recently gave birth presents w/ extreme rectal pain when defecating and bright red blood on toilet paper. She feels pain when coughing and it's relieved when standing. Where is most common location of this lesion?
Anal fissure --> Posterior midline BELOW dentate line
98
In a person w/ claudication, what disease process are thinking and what is next best test? What limit denotes disease?
Peripheral vascular disease (arterial occlusive disease)
*Ankle-brachial index (ABI) --> measures systolic BP in ankle divided by brachial artery via Doppler
ABI
99
In a person w/ claudication, what disease process are thinking and what is next best test?
Peripheral vascular disease (arterial occlusive disease)
*Ankle-brachial index (ABI) --> measures systolic BP in ankle divided by brachial artery via Doppler
100
Allogenic bone marrow graft to someone results in fever, diarrhea, generalized rash, cough, jaundice, and intestinal bleeding. What is the cause and complication of the marrow transplant?
Graft-vs-host disease (GVHD)
T lymphocytes (cytotoxic T cells & NK cells) of the donor tissue attacks the immunocompromised host! Symptoms in stem are classic
101
CT scan shows small bowel thickening w/ air in the bowel wall (pneumatosis intestinalis/coli) w/ hx of CHF, CAD. What is it?
Non-occlusive mesenteric ischemia (NOMI) --> vasoconstriction of mesenteric vessels OR hypoperfusion (shock) in stenosed vessels
102
What 2 broad categories must you consider w/ CT scan of small bowel inflammation w/ air in abdominal wall?
Mesenteric ischemia & infection (gas-producing organism)
103
What trauma situation warrants an exploratory laparotomy?
Gunshot wound to abdomen
104
3 complications of AAA repair?
1) Renal failure (atherosclerotic emboli of renal arteries, contrast-induced nephropathy, occlusion of renal arteries w/ graft)
2) Ischemic bowel (occlusion of IMA by graft-stent)
3) Spinal cord ischemia (disruption of artery of Adamkiewicz @ T12 --> causes anterior cord syndrome or paralysis of legs)
105
2 days post-op AAA repair, man develops abdominal pain w/ bloody diarrhea w/ falling Hgb & rising WBC count. Next best step? What is it?
Next step: urgent colonoscopy (gold standard to visualize cyanotic or shedding mucosa)
Ischemic colitis: complication of AAA repair b/c origin of IMA is covered by aortic graft. Don't have adequate collateral circulation via Marginal artery of Drummond from SMA
- Ischemia of descending and sigmoid colon (rectum spared b/c of different arterial supply than IMA)
* *Blood diarrhea w/ leukocytosis in this setting = mesenteric ischemia
106
Next step in management for a person who sustains a closed fracture w/ weakened but present pulses?
CT angiogram --> have to assess possibility for VASCULAR injury
107
"Hard" signs indicating vascular injury and warranting immediate surgical exploration?
```
Active hemorrhage
Expanding hematoma
Pulse absence
Bruit or thrill
Distal ischemia (arteiral insufficiency --> pain, pallor, poikilothermia, paresthesias, paralysis, pulseless)
```
108
1 week hx of mass in scrotum that is painless, smooth, nonindurated and located above the testicle. Ultrasound reveals a cystic lesion w/o internal echoes in R epididymus. What is next best step?
No further management needed --> if asymptomatic, nothing else needed
Either spermatocele or epididymal cyst
109
Man feels a new budge in his groin that is causing him pain. He has a fever (100.4) and has mild R-sided erythema. A tender mass is felt at internal inguinal ring that is unaffected by cough or strain. What is next appropriate step?
Emergent surgical repair --> need to save the bowel or debride necrotic tissue
Hernia's are rarely painful
Painful, red, fever = incarcerated hernia
110
Most common cause of post-op decreasing urine output? What test helps confirm?
Hypovolemia (procedure w/ large blood loss) --> immediately after surgery the patient will "3rd space" the fluids given to them --> need about 3x as much fluid to maintain BP and urine output
Fluid challenge --> if hypovolemic, will have increased BP and urine output; if not, renal failure it is
111
A solitary thyroid nodule (2cm) w/ normal TSH levels is found. What is the next best step?
Fine needle aspiration (FNA) --> most thyroid nodules are BENIGN, but need to r/o cancer anyway
112
"Rule of 9's" for adult burn patients?
```
Estimated percentage of body surface area affected by the burn:
Anterior trunk: 18%
Posterior trunk: 18%
L leg (entire): 18%
R leg (entire): 18%
L arm (entire): 9%
R arm (entire): 9%
Head (entire): 9%
```
113
What is common cause of death in burn patients?
CO poisoning from inhaled smoke
*If unexpected neurologic symptoms occur --> get arterial carboxyhemoglobin level b/c pulse oximetry can be falsely elevated.
114
Pain on radial side of wrist & first dorsal compartment. Pain is reproduced by having patient hold their thumb inside their closed fist and forcing wrist into ulnar deviation. What is most likely diagnosis?
de Quervain's tenosynovitis --> tenosynovitis of extensor pollicus braves and abductor pollicus longus
* Pain on radial side of wrist & first dorsal compartment
* Pain reproduced by Finkelstein test (hold thumb inside closed fist and ulnar deviate hand)
115
Dysphagia starting w/ meat --> then other solids --> then soft foods --> liquids --> saliva. Smoking and drinking are risk factors?
Squamous cell carcinoma of esophagus
Smoking & drinking = squamous
116
72 yo woman w/ femoral neck fracture & affected leg appearing shorter and externally rotated. What is next best step in mgmt?
Replace femoral head w/ metal prosthesis
*The femoral head is tenuous & can easily develop avascular necrosis of femoral head
117
What is Nissen fundoplication and indications for performing this surgery?
Laparoscopic procedure that wraps the fundus of the stomach 360 degrees around the GE junction to "replace" or strengthen the lower esophageal sphincter.
Indications:
- GE reflux causing damage to lower esophagus (esophagitis)
- Refractory symptoms despite medical therapy
- Long term medical therapy is undesirable to younger patients
*Treatment of choice for pts w/ normal length and motility of esophagus
118
Complication of Billroth II procedure w/ severe diarrhea, wt loss, and severe halitosis?
What other gastric compliant usually associated w/ this?
Gastrojejunocolic fistula --> fecal contamination of gastric contents (halitosis!)
*Fistula develops from an UNTREATED marginal ULCER that develops in the antecolic anastomosis --> if left untreated, will eventually erode into jejunum allowing feces to pass back into stomach (halitosis & diarrhea)
119
Complication of Billroth II procedure w/ severe diarrhea, wt loss, and severe halitosis?
What other gastric compliant usually associated w/ this?
Gastrojejunocolic fistula --> fecal contamination of gastric contents (halitosis!)
*Fistula develops from an UNTREATED marginal ULCER that develops in the antecolic anastomosis --> if left untreated, will eventually erode into jejunum allowing feces to pass back into stomach (halitosis & diarrhea)
120
Posterior duodenal ulcers can cause massive bleeding from what vessel?
Gastroduodenal artery (lies posterior to duodenum)
121
What is Billroth II procedure?
What are the indications?
Greater curvature of stomach is connected to first part of jejunum in side-to-side manner. Often involves resection of antrum of stomach.
Indications:
1) Refractory peptic ulcer disease
2) Gastric adenocarcinoma
122
Explain Dumping syndrome?
What are signs?
What is treatment?
* Common post-gastrectomy syndrome (vagotomy or Billroth II)
* Hyper-osmolar chyme rapidly dumped into duodenum/small intestine (no pyloric regulation) --> causes fluid shifts from intravascular space into bowel --> results in combination of GI and vasomotor complaints
* S/S: sweating, dizziness, abd pain, diarrhea, palpitations, facial flushing all after eating
* Tx: smaller meals w/ less fat (dietary modification)
123
Which drains to inguinal lymph nodes - adenocarcinoma or squamous cell?
Squamous cell (skin cells)
124
85 yo diabetic on dialysis w/ chronic renal failure develops acute onset B/L facial & orbital swelling w/ loss of vision in R eye. Biopsy specimen of nasal/sinus mucosa shows multiple broad, nonseptate hyphae w/ right-angle branches. What is it? What is most appropriate treatment?
Mucormycosis (rhino-orbital mucormycosis) --> seen in debilitated and **diabetic** patients
Tx: immediate Amphotericin B & surgical debridement
125
What 2 tests are positive in ACL tear? What are 2 modes of treatment and which demographics fall into each category?
Anterior drawer & Lachman's test
Athletes: ACL surgical reconstruction
Sedentary people: immobilization w/ rehab
126
What nerve is most at risk for damage when the humerus is fractured in middle 1/3 or near jxn of middle and distal 1/3's? How would patient present?
Radial nerve (posterior cord of brachial plexus C6-T1)
**No wrist extension and numbness in dorsal aspects of thumb, index, & middle fingers
127
Anyone post-op lower extremity surgery (hip, knee) MUST be on what medication? Why?
*LMWH --> more specific binding potential than unfractionated heparin (more reliable effect on PTT)
High risk for DVT formation leading to PE --> LMWH most effective for DVT prophylaxis in this population
128
Describe a clean wound & its risk of infection?
Clean: created in sterile, non-traumatic environment & do not involve respiratory, GI, genital, urinary systems (physiologically colonized areas of body)
Risk of infection = 1-1.5%
129
Describe a contaminated wound and its risk of infection?
Contaminated: gross spillage from GI, resp, GU systems; wound resulting from recent trauma; outright violation of sterile technique in OR
Risk of infection = 10-15%
130
Describe a clean-contaminated wound and its risk of infection?
Clean-contaminated: created in sterile environment (OR) but involves entry into resp, GI, genital, or urinary systems but w/ limited/no spillage from that system (appendectomy for non-perfed appy w/ no spillage)
Risk of infection = 3-5%
131
Describe a contaminated wound and its risk of infection?
Contaminated: gross spillage from one of above systems; wound resulting from recent trauma; outright violation of sterile technique in OR
Risk of infection = 10-15%
132
Describe a dirty wound and its risk of infection?
Dirty: trauma that contains devitalized tissue or in the presence of established infection (e.g. debridement of gangrenous foot wound)
Risk of infection = 30-35%
133
After vagotomy, what happens to pylorus?
Does NOT contract anymore --> free passage of stomach contents to duodenum
134
What reverses effect of steroids on wound healing?
Vitamin A
135
Pt with progressive jaundice, high direct bilirubin, and high ALP. Sonogram shows dilated intra & extra hepatic ducts w/ a very distended, thin-walled gallbladder w/ NO stones present. What are you thinking? What's next best test?
Pancreatic cancer (head of pancreas)
CT scan of abdomen
136
Common locations for diabetic foot ulcers?
Dorsum of foot, heel, head of 1st metatarsal (pressure points)
Result from chronic pressure & microvascular compromise
137
What is Cushing's triad for increased ICP?
1) HTN
2) Bradycardia
3) Respiratory depression
138
44 yo man has vague RUQ pain for 1 mo. At age 21, had one eye enucleation "for a tumor." CT scan of abdomen shows multiple masses w/in the liver. What type of cancer is it?
Malignant melanoma!
* 20+ years may elapse b/w primary tumor and metastatic manifestations
* Tyrosinase is tumor marker
139
Patient has a glass eye and liver full of multiple tumors
OR
Patient is missing a toe and has liver full of multiple metastasis
What is the cause of cancer??
Melanoma!
*Look or long periods of time (years) b/w primary and metastasis
140
Explain the Parkland Formula?
Used to calculate rate of fluid resuscitation for burn patients
Volume (cc) = 4 x wt (kg) x (%) total body area burn
Divide this # by 2
1/2 given in first 8 hours
1/2 given over next 16 hrs
Total volume of fluid given in initial 24 hrs
141
Bright red blood coating the stools & change in bowel habit (constipation) and stool caliber. Only experiences mild discomfort. What are you thinking?
Rectal cancer --> look for:
- Bright red blood coating outside of feces
- Change in bowel habit (constipation, diarrhea)
- Change in stool caliber (pencil-thin)
142
Rule of 9's for infant?
```
Entire head: 18%
Anterior torso: 18%
Posterior torso: 18%
Entire L leg: 14%
Entire R leg: 14%
Entire L arm: 9%
Entire R arm: 9%
```
143
Explain the Parkland Formula?
?Used to calculate rate of fluid resuscitation for burn patients
Volume (cc) = 4 x wt (kg) x (%) total body area burn
Divide this # by 2
1/2 given in first 8 hours
1/2 given over next 16 hrs
Total volume of fluid given in initial 24 hrs
144
What is stercoral perforation?
Bowel perforation due to pressure necrosis of a bowel wall from fecal mass that is hard and impacted
Increased intraluminal pressure eventually exceeds capillary perfusion pressure in bowel wall --> leads to ischemia, necrosis, and perforation
90% recto-sigmoid
145
Life threatening complication of stercoral bowel perforation?
Acute abdomen due to peritonitis
146
Describe pathogenesis of frostbite.
Tx?
What is protocol for rewarming?
Freezing & crystalizing of fluids in interstitial and cellular spaces from prolonged exposure to freezing temperatures. Lower temps cause vasoconstriction (to conserve blood supply to vital organs and preserve heat), leading to decrease in blood flow that can't deliver enough heat to tissues --> ice crystals and thrombus formation in capillaries and blood vessels
Tx: tPA (need to dissolve the already formed clots in the blood vessels)
Rewarming protocol: gradual rewarming over 30 minutes - 1 hr
147
Describe pathogenesis of electrical burns.
What complication can arise?
Tissue damage occurs from conversion of electric energy to heat, resulting in thermal injury, especially to internal tissues --> massive edema, thrombosis, muscle destruction occur
4th degree burns (full thickness burn of skin extending to muscle & bone) w/ charring of tissue
Complications:
* *Rhabdomyolysis (muscle destruction)
* *Compartment syndrome (edema, vein coagulation, muscle swelling) --> look for slow capillary refill, diminished peripheral pulses
*Important for what you don't see!
148
In a patient w/ a known infection and who is septic, what is most appropriate 1st step?
Debridement --> have to eliminate source of infection before pt will start to improve!
Debridement BEFORE IV fluids or Abx
149
Patient w/ hx of cardiac disease, regardless of age, require what before surgery?
- EKG
- Stress testing (exercise or Thallium) --> determines presence of ischemia on EKG
- ECHO (structural disease & EF) --> after ischemia identified on EKG, do this to see changes in myocardial tissue itself
150
In pre-op assessment, what is most important system to investigate? What 2 conditions are of most concern?
CV system
Recent MI & CHF (JVD, LE edema)
151
An ejection fraction below what value is at increased risk for complications w/ surgery?
EF < 35%
152
When is an EKG the only test needed prior to surgery?
Patient under 35 yo
| No hx of cardiac disease
153
Patient w/ hx of cardiac disease, regardless of age, require what before surgery?
```
EKG
Stress testing (exercise or Thallium)
ECHO (structural disease & EF)
```
154
Which component of PFT's are necessary for pre-op testing in patient's w/ asthma, COPD, or smoking history?
Vital capacity --> it's VITAL for pre-op
155
What are you worried about in a patient who is post-op hip replacement w/ new onset chest pain and tachycardia about 5-7 days after surgery?
Pulmonary embolism
156
Dysuria, frequency, & urgency combined w/ painless hematuria is suspicious for what?
What assn is high with this pathology?
Bladder cancer
*Smoking hx w/ painless hematuria in older man = bladder cancer
157
What 2 scenarios are posterior shoulder dislocations common? Why? How does the patient present? What imaging is best for diagnosis?
Seizures & Electrocutions
MOA: massive contraction of all the muscles in the shoulder area is needed for a posterior dislocation
*Pt presents w/ I/L arm close to the body and hand resting on anterior chest wall
Axillary shoulder x-ray is best
158
In someone presenting w/ carpel tunnel syndrome, what is best initial test? What is a necessary test before surgery is performed?
Carpel tunnel syndrome: entrapment neuropathy of median nerve in carpel tunnel of wrist (flexor retinaculum)
Initial test: Wrist X-ray to r/o other pathology
Before surgery, need Electromyography (EEG) and nerve conduction studies to determine level of denervation of median nerve in hand
159
72 yo woman undergoes CABG after acute MI revealing 3 vessel blockage. 3 days after surgery, she develops acute onset abdominal pain w/ distention. Abd X-ray shows mild small bowel distention. NG tube reveals slight bilious fluid aspirated and sigmoidoscopy easily visualizes the distended segment of bowel. What is going on and why? Best next step?
Ogilvie syndrome: pseudo-obstruction in large bowel seen in older patients after invasive surgery
- Possibly due to narcotic use?
*Look for abd pain, dilated large bowel, N/V, distention in post-op period
Tx: Neostigmine (cholinesterase inhibitor that stimulates parasympathetics to increase colon contraction and decompress the colon)
160
Complication of chronic perianal/perirectal abscess? What is common symptoms of presentation?
Fistula-in-ano
Presents w/ constant soiling of underwear
Often see a scar in anus w/ a central opening where fluid drains
161
List some characteristics of tension pneumothorax.
What is immediate treatment?
```
Subcutaneous emphysema in neck
*Tracheal deviation to C/L side
*Hypotension, tachypnea, tachycardia
Absent breath sounds
High CVP
*Distended head/neck veins
```
Tx: Decompress w/ large bore needle inserted into 2nd intercostal space, midclavicular line.
162
Fracture common when falling on an outstretched hand?
Colles fracture: dorsally displaced, dorsally angulated fracture of distal radius w/ ulnar styloid
"Dinner-fork" deformity
Tx: SHORT arm cast --> immobilize the wrist & allow elbow mobility, providing great functional quality of life
The ulna is NOT unstable and elbow does NOT need to be immobilized
163
If there is a suspected gunshot, what tests are the fastest to confirm a gunshot wound?
If definite gunshot wound to the abdomen, what is next best step?
Plain & cross table X-ray --> then CT scan if stable
Exploratory laparotomy or diagnostic laparoscopy
164
When a person's knees hit the dashboard in MVA, what area do you suspect is injured? How would they appear on inspection? Best initial test?
Femoral dislocation/fracture
- Femur driven backwards and out of acetabulum, resulting in posterior dislocation of the hips
- Fragile blood supply of femoral heads that, if injured, can cause avascular necrosis of femoral head
On inspection --> affected leg appears shortened, adducted, and internally rotated
Best initial test --> x-ray of both hips
165
Abdominal distention, obstipation, vomiting, and hyperactive bowel sounds w/ someone who has had prior abdominal surgery. What is it? What's the cause? Next best step?
Bowel obstruction from adhesions (prior abd surgery)
Emergent exploratory laparotomy (incision in abd wall)
166
Painless hematuria in older person w/ smoking hx?
Bladder cancer until proven otherwise
Do more testing!
167
Man playing volleyball hears a "pop" from his ankle and falls to the ground. There is swelling in the back of his lower leg. He can put wt on the foot w/o pain, but can't take a step b/c it's painful. What is it? What test will prove it?
Achilles tendon rupture
(+) Thompson test: inability of prone-positioned patient to plantar flex when gastrocnemius is squeezed
168
42 yo woman w/ LE itching w/ hx of Protein C deficiency & DVT. LE has 1+ non-pitting edema w/ dry, peeling, hyper pigmented skin. Her distal pulses are only weakly palpable. What is it? What's next most appropriate diagnostic modality?
Venous insufficiency --> likely post-thrombotic in etiology
- Lipodermatosclerosis or venous stasis dermatitis: skin changes that include hyper-pigmentation, dermatitis (itching, scaling), ulceration ultimately
Mgmt: LE duplex US imaging (assess venous obstruction) caused by thrombus formation & valvular insufficiency - (past surgery, standing a lot)
169
What is the only definitive treatment for an abscess anywhere in the body?
Drainage!
If you just use Abx, they will be useless!
170
Examiner is assessing a 52 yo for an inguinal hernia. As he places his finger in the external inguinal ring (superficial), where on the finger would you feel an indirect hernia & what defect accounts for this?
Where on the finger would you feel a direct hernia & what defect accounts for this?
Indirect: feel herniation on tip of the finger from a defect in the deep inguinal ring
Direct: feel herniation along lateral aspect of finger in external inguinal ring from a defect in the posterior wall of the inguinal canal (transversalis fascia)
171
Thin people w/ epigastric blunt trauma at risk for what type of injury?
Thin patients w/ epigastric blunt trauma --> pancreatic injury due to risk of compressing the pancreas against the spine causing parenchymal hemorrhage, ductal injury, or pancreatic transection.
Increased amylase & lipase
172
What is best method of management for patient with metastatic pancreatic cancer?
Chemotherapy
173
Most common transfusion reaction?
Febrile non-hemolytic transfusion reaction
*Leukocytes left over from isolated RBCs release cytokines in storage --> when given, they cause immune reaction
174
Most common transfusion reaction?
Febrile non-hemolytic transfusion reaction
175
Most common cause of death by transfusion?
Clerical error leading to ABO incompatibility
176
4 birds of thorax/mediastinum?
Va"GOOSE" (Vagus nerve)
Esopha"GOOSE" (Esophagus)
Azy"GOOSE" (Azygous vein)
Thoracic "DUCK" (Thoracic duct)
177
Someone receives PRBC's (correct type & cross), but after just several hours they develop a fever, back pain, tachycardia, diaphoresis, and falling Hgb & Hct. The urine in the Foley appears reddish. What is this? What is cause?
How to differentiate b/w hemolytic & non-hemolytic reaction?
Febrile hemolytic transfusion reaction --> antibody-mediated hemolysis leading to fever, tachycardia, anemia, and hemoglobinuria
- Tx: IVF & diuresis, NaHCO3 for urine, vasopressors
Look at HEMATOCRIT
Decreasing = hemolytic reaction
Non-hemolytic --> during ABO-compatible transfusions in which recipient antibodies attack donor WBCs
178
Difference b/w ABO-compatible & ABO-incompatible reactions?
HEMATOCRIT
| - Decreased = hemolytic reaction (ABO incompatibility)
179
Blood is noted in urethral meatus of someone who had trauma to pelvis. What must be suspected and what is next best step?
Urethral injury --> Get retrograde urethrogram (dye squirted into bladder and patency of urethra visualized w/ KUB)
*Blood @ urethral meatus = retrograde urethrogram
**Do NOT use Foley catheter!!! (may worsen damage)**
180
1 yo w/ reducible umbilical hernia - what is treatment? What is max age when they resolve on their own?
If reducible & asymptomatic = do nothing (monitor)
If under 2 yo, the hernia may still close spontaneously!
181
Person with high fever & chills, RUQ pain, and elevated bilirubin levels w/ increased ALP. What is it? Most common cause? Tx?
*Cholangitis! --> Charcot triad (if mental status changes & hypotension = Reynold's pentad)
Obstruction of common bile duct most likely from stone from gallbladder (choledocholithiasis)
182
Does cholecystitis have jaundice?
NO
183
Person with high fever & chills, RUQ pain, and elevated bilirubin levels w/ increased ALP. What is it? Most common cause? Tx?
*Cholangitis! --> Charcot triad (if mental status changes = Reynold's pentad)
Obstruction of common bile duct most likely from stone from gallbladder (choledocholithiasis)
184
What pressures indicate compartment syndrome? What other factors point towards compartment syndrome?
Compartment pressures above 30-40 mmHg
6 P's: pain, pallor, poikilothermia, paresthesias, paralysis, pulselessness
185
Any fracture w/ diminished/absent pulses w/ normal compartment pressures suggests what? What is best initial test to confirm?
Arterial injury from fracture!
Angiography
186
In suspected skin cancer, what is best initial test?
Biopsy specimen at edge of lesion for diagnosis and staging
187
Fair skin individuals w/ sun exposure on the upper face are most at risk for what type of cancer?
Basal cell carcinoma
188
What is most likely cause for no urine output when there is normal perfusion pressure & pulses?
Kinked Foley catheter
*Common things are common!
189
Describe path of inferior alveolar nerve.
V3 of trigeminal nerve --> passes through mandibular foramen and exits both laterally and anteriorly to supply the lower chin and jaw
Decreased sensation over this area (lower chin & jaw) is diagnostic for mandibular fracture distal to entrance of the inferior alveolar nerve
190
What medication predisposes you to gastric ulcer?
Steroid use
- Blocks initial step in arachidonic acid pathway
*Start someone on H2(-) or PPI as prophylaxis
191
Someone recently admitted to hospital has been started on steroids for nerve issues. They suddenly develop epigastric pain & vomiting. Abd Xray shows pneumoperitoneum. What is likely diagnosis? Next best step?
Gastric ulcer w/ perforation
Next step: urgent exploratory laparotomy
192
Most common cause of one-sided bloody nipple discharge in women b/w 20-40 yo? Steps in management?
Most common cause of bloody nipple discharge in older patient (>40yo)?
Intraductal papilloma
Mgmt: don't show up on mammography due to small size; need to do galactogram
Intraductal carcinoma
193
Step of management in spinal cord injury?
1) Immobilize neck w/ neck collar
2) Put patient's body on hard surface to immobilize rest of the spine
3) W/in first 8 hours of injury, give high-dose corticosteroids (may speed recovery and return of motor function after injury)
194
Acute abdominal pain in LLQ?
Best diagnostic test?
Initial treatment?
Contraindicated?
Diverticulitis
Abdominal CT scan
NPO, IV fluids, antibiotics, pain control
Colonoscopy
195
4 F's for acute cholecystitis?
What is Murphy sign?
Fat, Forty, Female, Fertile
Inspiratory arrest on palpation of RUQ as diaphragm displaces the gallbladder towards the physician's hand --> increased pressure on the inflamed gallbladder results in pain, leading to a pause in inspiration
196
Type of injury common w/ fall onto outstretched hand? Are X-rays helpful? Next step in mgmt?
What is common complication of untreated scaphoid fracture?
Nondisplaced fracture of scaphoid bone
X-rays taken soon after will NOT show a fracture
Mgmt: thumb spica cast indicated for treatment
Avascular necrosis of scaphoid bone
197
In advanced breast cancers (large tumors fixed to chest wall or w/ extensive lymph node involvement), what is the preferred initial treatment course?
1) Preoperative chemotherapy to shrink the tumor
| 2) Surgical palliation
198
Sudden onset severe, tearing back pain in person w/ HTN & a pulsatile mass in epigastrium?
Rupturing AAA
199
Post-op ileus presents how many days after surgery? What type of surgery?
How does it differ from mechanical obstruction? Signs/symptoms?
Treatment?
4-5 days after abdominal surgery (manipulation of abdominal contents)
There is no distinct transition point (vs. mechanical) but still have same signs/symptoms and findings on abd x-ray
Tx: NPO + insertion of NG tube to decompress
200
49 yo woman w/ suspicious breast lump receives mammography and FNA, which does not identify any malignant cells. What is next appropriate step?
Core-needle biopsy
FNA results are only valuable when they are (+) for malignancy
A (-) FNA does NOT rule out cancer --> need further testing
201
Repeated episode of bilious, non-bloody vomiting in 23 yo male from food poisoning. Has L chest pain and a crunching sound is heard when palpating his chest. What is the diagnosis? What is most common cause? What is best test to confirm?
Boerhaave syndrome (perforated esophagus)
- Forceful vomiting (gastroenteritis, alcohol) results in transmural (full-thickness) tear and perforation of esophagus
- Usually @ L lateral position of distal esophagus (3-5 cm above GE junction)
Hamman's sign: mediastinal crunching on ausculation & indicates presence of pneumomediastinum
Most common cause = iatrogenic during upper endoscopy
Diagnosis: Gastrografin swallow study --> contrast extravasates from esophageal lumen
- Gastrografin is water-soluble & NOT toxic to mediastinal/thoracic structures (vs. barium)
202
What is Meckler's triad? What is it seen in?
1) Vomiting
2) Chest pain
3) Subcutaneous emphysema (palpated & heard crunching on auscultation) - Hamman's sign
Esophageal perforation (Boerhaave syndrome)
203
Person w/ gallstone pancreatitis, what is best course of treatment action?
Conservative --> NPO, IV fluids, pain meds & wait for stone to pass
If this doesn't help in 3-4 days --> ERCP to relieve stone
204
Patient recently fell on shoulder & presents w/ arm held close to the body & forearm rotated outward, as if preparing to shake hands. There is small area of numbness over deltoid muscle. What is diagnosis?
Anterior shoulder dislocation
*Axillary nerve injury is a common complication
205
Common history finding that usually always found w/ acute appendicitis?
Anorexia
206
What do you suspect in a male who suffered trauma to perineum (lower abd/pelvis) or pelvic fracture? What is test of choice?
Urethral injury
Retrograde urethrogram
**NEVER place a Foley catheter until retrograde urethrogram is done to assess urethral injury
207
First step in a person w/ post-operative disorientation? Why?
Start supplemental O2 --> most lethal cause of post-op disorientation is hypoxia
**Transient hypoxia is not uncommon after surgery --> often breathe shallowly due to incisional pain & narcotic use
208
Anyone over 50 yo w/ bleeding out of anus needs what treatment?
Colonoscopy!
*If person is on anticoagulation, this will NOT cause normal colonic mucosa to bleed! Has to be a lesion present w/ a predisposition to bleed
209
Urinary retention from BPH can be triggered by what drugs? What is treatment?
OTC meds (may contain antihistamines and decongestant), nasal drops (contain alpha stimulating agents)
These lead to stimulation of alpha-adrenergic receptors --> further constrict the bladder neck --> big palpable bladder
210
Explain wound dehiscence? Treatment?
Serosanguineous (straw-colored clear fluid) fluid seeping through closed abdominal wound after surgery
Tx: remove 1 or 2 sutures in skin and explore w/ sterile glove to see if there is organ evisceration (trapping of abd viscera in wound)
211
What is wound evisceration and treatment?
Evisceration: herniation of abdominal viscera through wound formed by surgery
Tx: taken back to OR to fix abd contents and close wound properly
212
Cause of fever 10-15 days after surgery? How to r/o?
Deep abscess (pelvic or sub-phrenic)
CT scan
213
In trauma settings, infusions of large amounts of intra-operative fluids (LR, NS), what potential side effect must you watch for? How do you avoid this complication?
Abdominal compartment syndrome
Large IVF's cause severe edema in abdomen --> abdominal pressure >30mmHg means decreased venous return in IVC
Often in trauma settings, fluids are freely running --> need 3x crystalloid to replace blood volume, but most of fluids move to interstitial space
Tx: Temporary abdominal closure w/ absorbable mesh
214
What is Osgood-Schlatter disease? How to manage it?
Overuse injury of patellar tendon as the tibial tuberosity has not ossified and is more prone to microscopic avulsion fractures causing pain
Pain at tibial tubercle and patella AFTER repetitive exercise
Tx: conservative (rest, icing; exercise IS encouraged)
215
Appropriate management for malignant breast cancer > 4cm in diameter?
Mastectomy w/ axillary node sampling (sentinel node testing)
216
Appropriate management for malignant breast cancer
Lumpectomy, axillary sampling, and post-op radiation
217
What is Osgood-Schlatter disease? How to manage it?
Overuse injury of patellar tendon in tibial tuberosity as the tibial tuberosity has not ossified and is more prone to microscopic avulsion fractures causing pain
See pain in tibial tubercle and patella AFTER repetitive exercise
Tx: conservative (rest & icing; exercise is encouraged)
218
Appropriate management for malignant breast cancer > 4cm in diameter?
Mastectomy w/ axillary node sampling (sentinel node testing)
219
Early satiety, nausea, non-bilious vomiting, wt loss in patient w/ hx of acid ingestion? What physical exam finding helps diagnose?
Pyloric stricture
Abdominal succussion splash --> retained gastric material >3 hours after a meal will generate a splash sound & indicates presence of hollow viscus filled w/ both fluid & gas
220
Management of amputation injury?
Wrap digit in sterile gauze moistened w/ sterile saline & place in plastic bag --> bag then placed on ice and transported w/ patient to nearest ER (don't allow digit to freeze)
If done this way, digit viable for up to 24 hours
221
What is potential complication of thoracic aortic aneurysm surgery? How does it present?
Anterior spinal cord infarction
- Anterior spinal artery supplies anterior 2/3 of spinal cord (motor tracts, pain/temp sensation) --> dependent on radicular arteries (artery of Adamkiewicz)
S/S: abrupt onset B/L LE flaccid paralysis, loss of pain/temp BELOW level of spinal injury
- UMN signs develop over days-weeks
*Vibration & proprioception INTACT --> dorsal column of spinal cord not usually affected
222
Appropriate management for malignant breast cancer
Lumpectomy, axillary sampling, and post-op radiation
223
Most common causes of syringomyelia?
| Pattern of symptoms?
Arnold Chiari malformations, spinal cord injury (whiplash injury)
S/S: "Cape-like" distribution --> decreased strength & diminished pain/temp affecting arms/hands
*NO loss of light touch, vibration, or position sense (dorsal columns intact)
224
Pt has MVA where he drank a lot of liquid before the crash. He sustained a direct blow to abdomen & pelvis & complains of diffuse abd pain that refers to his L shoulder. What GU injury is cause?
Bladder dome rupture --> only part of bladder covered by peritoneum & only injury that allows urine to leak into peritoneum --> this lets urine irritate diaphragm (shoulder pain)
225
Person is in MVA and has pneumothorax. After chest tubes are placed, he still has pneumothorax on CXR as well as pneumomediastinum (subQ emphysema). What is cause?
Tracheo-bronchial perfoartion secondary to blunt thoracic trauma
226
Man falls when riding his bicycle & one week later has fever, shaking chills, and deep abdominal pain. What do you suspect?
Retroperitoneal abscess --> likely due to pancreatic laceration from trauma
227
In massive hemoptysis, after securing airway, what is next best step?
First, place patient in dependent position (lateral position) to avoid blood collection in airways of opposite lung
Bronchoscopy to localize bleeding site, suction, and other therapeutic interventions
228
Acute onset back pain w/ hypotension?
Ruptured AAA
229
Man presents w/ sudden onset severe pain in the back of his neck and upper chest. He also has B/L leg weakness for past 2 hours. His blood pressure is 210/120 and CXR shows R-sided pleural effusion. What is diagnosis? What main risk factor? Diagnostic test for confirmation?
Acute aortic dissection
Risk factor = severe HTN
Dx test: CT w/ contrast OR transesophageal ECHO
* Dissection can extend into:
- Pericardium (tamponade)
- Spinal arteries (spinal cord ischemia --> lower extremity weakness)
- Pleural cavity (hemothroax --> looks like pleural effusion on CXR)
230
Early satiety, nausea, non-bilious vomiting, wt loss in patient w/ hx of acid ingestion? What physical exam finding helps diagnose?
Pyloric stricture
Abdominal succussion splash --> retained gastric material >3 hours after a meal will generate a splash sound & indicates presence of hollow viscus filled w/ both fluid & gas
231
Management of amputation injury?
Wrap digit in sterile gauze moistened w/ sterile saline & place in plastic bag --> bag then placed on ice and transported w/ patient to nearest ER (don't allow digit to freeze)
If done this way, digit viable for up to 24 hours
232
Patient in recent MVA who has new onset severe back pain w/ weakness and decreased pain sensation in both legs - what do you suspect and what is next step?
Traumatic spinal cord injury
Place urinary catheter to assess for urinary retention & prevent acute bladder distention/damage
233
Patient has DVT from reversible inciting event (e.g. surgery) in R distal part of femoral vein. What is most appropriate initial treatment?
Heparin started as bridge to Coumadin (goal INR 2-3)
* Goal of therapy is to prevent extension of the clot & development of future clots RATHER than lysis of the present clot!
* Surgery is primary risk factor (post-op immobilization)
234
Severe R-calf pain several hrs after leg surgery. Complains of burning sensation in back of R leg w/ his leg being swollen, tense, & extremely tender. His pain is worsened by passive R-knee extension. DP & PT pulses palpable B/L. What is likely diagnosis?
Soft-tissue swelling --> Compartment syndrome
**Common s/s:
*Pain out of proportion to injury (extreme)
*Paresthesias early (burning)
*Pain worsened on passive stretch
Rapidly increasing & tense swelling
235
How many lobes of parotid gland & what separates these lobes? What sign will be seen w/ damage to this nerve?
2 lobes (superficial and deep) - superficial accounts for 80% of gland
Facial nerve runs through parotid & divides it into 2 parts
I/L facial droop seen w/ damage to facial nerve
236
Most common complication seen post thyroidectomy? What signs do you see?
Hypocalcemia (primary hypoparathyroidism - removed w/ thyroid)
S/S: involuntary contractions (tetany) of lips, face, extremities; seizures
- Ckvostek sign (facial nerve tapping)
- Trousseau sign (tapping median nerve)
*Also prolongs QT interval on EKG
237
Immediate management of splenic rupture is determined by what factor?
Hemodynamic status & response to IV fluids:
If stable = abdominal CT scan
Non-stable = emergent exploratory laparotomy
238
What is potential complication of thoracic aortic aneurysm surgery? How does it present?
Anterior spinal cord infarction
S/S: abrupt onset B/L flaccid paralysis, loss of pain/temp BELOW level of spinal injury
- UMN signs develop over days-weeks
*Vibration & proprioception are preserved --> dorsal column of spinal cord not usually affected
239
What is potential complication of thoracic aortic aneurysm surgery? How does it present?
Anterior spinal cord infarction
- Anterior spinal artery supplies anterior 2/3 of spinal cord (motor tracts, pain/temp sensation) --> dependent on radicular arteries (artery of Adamkiewicz)
S/S: abrupt onset B/L flaccid paralysis, loss of pain/temp BELOW level of spinal injury
- UMN signs develop over days-weeks
*Vibration & proprioception are preserved --> dorsal column of spinal cord not usually affected
240
3 common signs seen w/ splenic injury?
Test to confirm?
Delayed onset hypotension
LUQ pain
L shoulder pain (irritation of diaphragm)
Abd CT w/ contrast
241
U/L hip pain in middle-aged adult that is worsened by external pressure to upper lateral thigh (lying on affected side of bed). What is it?
Trochanteric bursitis
242
Signs of burn/smoke inhalation injury to upper airway or lungs?
When to intubate?
```
Burns on face
Singed eyebrows
Oropharyngeal inflammation/blistering
Carbon-containing sputum
Stridor
Carboxyhemoglobin >10%
```
*One or more indicates EARLY intubation to prevent upper airway obstruction by EDEMA that develops later on
243
Most common causes of syringomyelia?
| Pattern of symptoms?
Arnold Chiari malformations, spinal cord injury (whiplash injury)
S/S: "Cape-like" distribution --> decreased strength & diminished pain/temp affecting arms/hands
*NO loss of light touch, vibration, or position sense (dorsal columns intact)
244
Pt has MVA where he drank a lot of liquid. He sustained a direct blow to abdomen & pelvis & complains of diffuse abd pain that refers to his L shoulder. What GU injury is cause?
Bladder dome rupture --> only part of bladder covered by peritoneum & only injury that allows urine to leak into peritoneum --> this lets urine irritate diaphragm
245
Describe febrile non-hemolytic transfusion reaction and how long after surgery it's seen?
When RBC & plasma are separated from whole blood, a small amount of residual leukocytes may remain in RBC concentrate --> during blood storage, these leukocytes release cytokines --> when blood is transfused, it causes transient fever, chills, malaise w/o hemolysis
Seen 1-6 hours AFTER surgery
246
Person is in MVA and has pneumothorax. After chest tubes are placed, he still has pneumothorax on CXR as well as pneumomediastinum (subQ emphysema). What is cause?
Tracheobronchial perfoartion secondary to blunt thoracic trauma
247
What are 2 complications of supracondylar fractures of humerus?
In pediatric population, what is mechanism of injury?
Entrapment of:
1) Brachial artery (no distal pulses)
2) Median nerve
Fall on an outstretched arm (also for Colles & scaphoid fracture)
248
Complication of abdominal surgery or retroperitoneal hemorrhage associated w/ vertebral fracture?
Paralytic ileus
On x-ray --> distention of both small & large bowels
249
Man falls when riding his bicycle & one week later has fever, shaking chills, and deep abdominal pain. What do you suspect?
Retroperitoneal abscess --> likely due to pancreatic laceration from trauma
250
What are the 3 components and grades of Glascow Coma Scale (GCS)?
```
1) Eye opening
Spontaneous (4)
To Verbal Command (3)
To Pain (2)
None (1)
```
```
2) Verbal response
Oriented (5)
Disoriented/Confused (4)
Inappropriate words (3)
Incomprehensible sounds (2)
None (1)
```
```
3) Motor Response
Obeys (6)
Localizes (5)
Withdraws (4)
Flexion posturing - decorticate (3)
Extension posturing - decerebrate (2)
None (1)
```
251
Patient develops whistling noise during respiration following rhinoplasty. What do you suspect?
Nasal septal perforation --> resulting from septal hematoma
252
How to differentiate b/w arterial thrombus & embolus?
Origin of emboli?
Embolus --> SUDDEN onset & severe; distal pulses diminished
Emboli originate from heart -> MI or AFib
253
When is post-op atelectasis the worst?
What blood gas values do you see?
Worst on post-op day 2
Collapsing alveoli --> V/Q mismatch --> causes hypoxemia & increased work of breathing (dyspnea, tachypnea)
For compensation for hypoxemia --> patients hyperventilate & develop resp alkalosis (high pH) w/ decreased PaCO2
254
When is post-op atelectasis the worst?
What blood gas values do you see?
Worst on post-op day 2
Collapsing alveoli --> V/Q mismatch --> causes hypoxemia & increased work of breathing (dyspnea, tachypnea)
For compensation for hypoxemia --> patients hyperventilate & develop resp alkalosis w/ decreased PaCO2
255
Complication of cardiac cath that presents w/ sudden hemodynamic instability and I/L flank or back pain. What imaging test is recommended?
Retro-peritoneal hematoma from local vascular access site used in legs (femoral) for the cath
CT w/o contrast
256
What is most important aspect of managing a rib fracture?
Adequate pain relief/analgesia (opiates/NSAIDs or intercostal nerve blocks)
Rib fractures associated w/ significant pain --> causes hypoventilation --> atelectasis & pneumonia
257
What is squamous cell carcinoma arising from a burn wound called?
Marjolin's ulcer
258
Describe flail chest?
Paradoxical thoracic wall movements occurring when multiple contiguous ribs are fractured in 2+ places --> this segment of ribs lose their continuity w/ remainder of thoracic wall
*Isolated segment has paradoxical inward motion on inspiration & outward motion on expiration
*PPV replaces normal (-) intrapleural pressure w/ (+) intrapleural during inspiration --> the flail chest motion is reversed back to physiologic motion
259
(+) arm drop test used to evaluate what injury?
What muscle commonly is affected?
Rotator cuff tear
Supraspinatus --> due to repeated bouts of ischemia near its insertion on humerus induced by compression b/w the humerus & the acromion
260
Name several risk factors for developing Marjolin's ulcer?
BURNS, osteomyelitis ulcers, venous stasis ulcers, chronic inflammation, scarred skin
261
Patient in recent MVA who has new onset severe back pain w/ weakness and decreased pain sensation in both legs - what do you suspect and what is next step?
Traumatic spinal cord injury
Place urinary catheter to assess for urinary retention & prevent acute bladder distention/damage
262
Patient has DVT from reversible inciting event (e.g. surgery) in R distal part of femoral vein. What is most appropriate initial treatment?
Heparin started as bridge to Coumadin (goal INR 2-3)
* Goal of therapy is to prevent extension of the clot & development of future clots rather than lysis of the present clot!
* Surgery is primary risk factor (post-op immobilization)
263
How many lobes of parotid gland & what separates these lobes? What sign will be seen w/ damage to this nerve?
2 lobes (superficial and deep) - superficial accounts for 80% of gland
Facial nerve runs through parotid & divides it in 2 parts
I/L facial droop seen w/ damage to facial nerve
264
Most common complication seen post thyroidectomy? What signs do you see?
Hypocalcemia (hypoparathyroidism - removed w/ thyroid)
S/S: involuntary contractions (tetany) of lips, face, extremities; seizures
*Also prolongs QT interval on EKG
265
Immediate management of splenic rupture is determined by what factor?
Hemodynamic status & response to IV fluids:
If stable = abdominal CT scan
Non-stable = emergent exploratory laparotomy
266
Why is chronic steroid use such a big deal w/ surgery?
How to ID person on chronic steroid use?
Chronic (>3 weeks) steroid use (>20mg) will suppress that HPA axis --> decreased ACTH hormone release --> decreased endogenous cortisol release during stress situations (SURGERY)
**Require a higher dose ("stress dose") of short-term glucocorticoids during the acute condition (surgery)
Cushingoid features: buffalo hump, central obesity, moon face (plethoric)
267
Blunt deceleration trauma (high-speed MVA or fall from >10feet) is common cause for what injuries?
What findings suggest these entities?
Aortic injury (transection/dissection)
**Signs:
Widened mediastinum
L-sided hemothorax
Deviation of mediastinum to R side
Disruption of normal aortic contour on CXR
```
Pulmonary contusion
**Signs
Hypoxia
Resp distress
B/L lower infiltrates on CXR
Large volumes of IVF may hasten process
```
268
High-speed MVA common cause for what injury?
What findings suggest this?
Aortic injury (transection/dissection)
```
**Signs:
Widened mediastinum
L-sided hemothorax
Deviation of mediastinum to R side
Disruption of normal aortic contour on CXR
```
269
3 common signs seen w/ splenic injury?
Delayed onset hypotension
LUQ pain
L shoulder pain
270
3 common signs seen w/ splenic injury?
Test to confirm?
Delayed onset hypotension
LUQ pain
L shoulder pain
Abd CT w/ contrast
271
First step in tx of esophageal varices?
1) Establish vascular access (2 large bore IV needles or central line)
2) After vasc access, control bleeding (vasoconstrictors), octreotide, somatostatin
272
Signs of burn/smoke inhalation injury to upper airway or lungs?
When to intubate?
```
Burns on face
Singed eyebrows
Oropharyngeal inflammation/blistering
Carbon-containing sputum
Stridor
Carboxyhemoglobin >10%
```
*One or more indicates early intubation to prevent upper airway obstruction by edema that develops later on
273
Acute mediastinitis can be a complication of what surgery? What signs point to it? What is best treatment?
Cardiac surgery from intra-op wound contamination
Signs:
- Post-op fever
- Tachycardia
- Chest pain
- High WBC
* *Sternal wound drainage or purulent discharge
* Widened mediastinum on CXR
Tx:
- Drainage
- Surgical debridement w/ immediate closure
- Prolonged antibiotics
274
Name 2 ways burns contribute to compartment syndrome?
1) Massive edema occurs over following days w/in these compartments --> look for 6 P's
2) If an eschar (firm necrotic tissue on exposed burn wounds) forms circumferentially on an extremity, it can restrict outward expansion of compartment as edema occurs --> perform escharotomy & if symptoms don't resolve, then perform fasciotomy
275
Describe febrile non-hemolytic transfusion reaction and how long after surgery it's seen?
When RBC & plasma are separated from whole blood, a small amount of residual leukocytes may remain in RBC concentrate --> during blood storage, these leukocytes release cytokines --> when blood is transfused, it causes transient fever, chills, malaise w/o hemolysis
Seen 1-6 hours AFTER surgery
276
Name 3 potential causes for post-op fever 1-6 hours after surgery?
Malignant hyperthermia
Febrile non-hemolytic transfusion reaction
Prior infection/trauma
277
What are 2 complications of supracondylar fractures of humerus?
In pediatric population, what is mechanism of injury?
Entrapment of:
1) Brachial artery (no distal pulses)
2) Median nerve
Fall on an outstretched arm (also for Colles fracture)
278
Complication of abdominal surgery or retroperitoneal hemorrhage associated w/ vertebral fracture?
Paralytic ileus
On x-ray --> distention of both small & large bowels
279
Why is anterior leg pain commonly seen w/ femoral artery aneurysms?
What else is also usually seen w/ femoral artery aneurysms?
Compression of femoral nerve (runs lateral to artery) by aneurysm
AAA usually associated
280
Person has blunt abdominal trauma - what is initial best exam?
If (-) then what?
If (+) then what?
1) FAST exam (Focused Assessment w/ Sonogram for Trauma)
If FAST is (-) --> diagnostic peritoneal lavage to determine presence of intra-abdominal bleed (10mL blood)
If FAST is (+) --> laparotomy
281
Man twists his leg while playing basketball and hears a popping sound in his knee. 2 weeks later, his R knee is swollen and tender along medial side. Snapping can be felt in R knee on tibial torsion w/ knee flexed at 90 degrees. What is it?
Medial meniscus tear
- Injured during forceful twisting on knee w/ foot planted
- "Popping" sound heard w/ severe pain @ time of injury
(+) McMurray sign (tibial torsion w/ knee at 90 degrees)
282
How to differentiate b/w arterial thrombus & embolus?
Origin of emboli?
Embolus --> SUDDENLY onset & severe; distal pulses diminished
Emboli originate from heart -> MI or AFib
283
Initial steps in person w/ post-op oliguria?
1) change Foley
| 2) if prerenal azotemia suspected - IV fluids
284
When is post-op atelectasis the worst?
What blood gas values do you see?
Worst on post-op day 2
Collapsing alveoli --> V/Q mismatch --> causes hypoxemia & increased work of breathing (dyspnea, tachypnea)
For compensation for hypoxemia --> patients hyperventilate & develop resp alkalosis w/ decreased PaCO2
285
Swelling in meniscal injury vs ligament injury?
Meniscal: gradual swelling not noticed until next day
Ligament: rapid/immediate swelling from hemathroses
286
Complication of cardiac cath that presents w/ sudden hemodynamic instability and I/L flank or back pain. What imaging test is recommended?
Retro peritoneal hematoma from local vascular access site used in legs (femoral) for the cath
CT w/o contrast
287
What is most important aspect of managing a rib fracture?
Adequate pain relief/analgesia (opiates/NSAIDs or intercostal nerve blocks)
Rib fractures associated w/ significant pain --> causes hypoventilation --> atelectasis & pneumonia
288
What type of neck infection has the greatest risk for mediastinal spread?
Retropharyngeal abscess
289
Describe flail chest?
Paradoxical thoracic wall movements occurring when multiple contiguous ribs are fractured in 2+ places --> this segment of ribs lose their continuity w/ remainder of thoracic wall
*Isolated segment has paradoxical inward motion on inspiration & outward motion on expiration
*PPV replaces normal (-) intrapleural pressure w/ (+) intrapleural during inspiration --> the flail chest motion is reversed back to physiologic motion
290
(+) arm drop test used to evaluate what injury?
What muscle commonly is affected?
Rotator cuff tear
Supraspinatus --> due to repeated bouts of ischemia near its insertion on humerus induced by compression b/w the humerus & the acromion
291
Pain out of proportion w/ findings (2 things)?
Mesenteric ischemia
| Compartment syndrome
292
Blunt abdominal trauma (mostly from MVA) frequently injure what 2 organs?
Free intra-peritoneal fluid should raise suspicion for what organ rupture?
Liver & spleen
Spleen
293
Blunt abdominal trauma (mostly from MVA) frequently injure what 2 organs?
Free intra-peritoneal fluid should raise suspicion for what organ rupture?
Liver & spleen
Spleen
294
What are 2 common risk factors for mesenteric ischemia?
What is classic presentation?
What lab finding is common?
Diagnostic test of choice?
1) Atherosclerotic disease (peripheral vascular disease)
2) AFib
SUDDEN onset severe periumbilical pain that is out of proportion w/ exam findings
Metabolic acidosis --> increased lactate
Mesenteric angiography is gold standard (CT angiography as alternate)
295
Child w/ direct trauma to his chest has epigastric pain w/ repeated vomiting immediately after the trauma. What is it? What is most appropriate step in management?
Duodenal obstruction --> following trauma, blood collects b/w submucosal and muscular layers of duodenum causing obstruction. Epigastric pain and vomiting due to failure to pass gastric secretions past obstructing hematoma.
Most resolve spontaneously in 1-2 weeks
*Tx: nasogastric suction & parenteral nutrition
296
In SBO, conservative mgmt usually tried first (NPO, NG tube suction, pain control, IVF's, correction of metabolic problems). What physical signs indicate this treatment has not helped & strangulation in imminent? What is next best step?
Impending strangulation signs --> fever, tachycardia, leukocytosis, metabolic acidosis (lactate)
- No peritoneal signs = no frank bowel necrosis yet
*Emergent surgical exploration to reverse cause of SBO
297
What is Morton's neuroma?
Mechanically induced neuropathic degeneration
S/S:
- Numbness
- Burning of toes
- Aching
- Burning in distal forefoot radiating forward from metatarsal heads to the 3-4th toes
*Pain b/w 3rd and 4th toes on plantar surface & a clicking sensation (Mulder sign) when simultaneously palpating this space & squeezing the metatarsal heads
Tx: b/l shoe inserts
298
Vital signs of someone in a trauma initially were 95/60 and pulse 120. He is struggling for respirations. You give him IV fluids and his BP increases to 160/90 and pulse drops to 50. What must you consider? What is complication(s)?
Cushing reflex --> HTN, bradycardia, resp depression
*Indicates increased ICP
The increased ICP can cause uncal herniation!
* I/L oculomotor (CN3) palsy --> mydriasis, strabismus
* I/L posterior cerebral artery --> C/L homonymous hemianopsia
* C/L cerebral peduncle --> I/L hemiparesis
299
Forceful abduction and external rotation of an arm causes what injury? What nerve is most commonly damaged?
Anterior shoulder dislocation
Axillary nerve --> courses around medial undersurface of humeral head, through the quadrangular space and can be injured by antero-inferior shoulder dislocations
* Paralysis of deltoid & teres minor muscles
* Loss of sensation over lateral upper arm
300
Person sustains penetrating chest wound and is hypotensive. Receives plenty of IV fluid and PRBCs. After rehydration, the pressure is still hypotensive. What 2 etiologies must you consider? Way to differentiate?
Tension pneumothorax or Pericardial tamponade
*CVP will be HIGH in both
*Re-expanded lung NOT pneumothorax
301
What often masks pericardial tamponade?
Massive blood loss --> substantial hypotension from blood loss masks hypotension from tamponade
302
In a person with acute abdomen who needs a laparotomy, what is the quickest way to reverse the warfarin they are on?
FFP
303
Person has abscess formation in sigmoid colon from diverticulitis. What is the cutoff size-wise for percutaneous drainage?
Larger than 3cm --> drained by CT-guided percutaneous drainage
304
Most common electrolyte abnormality after transfusion of large blood volume?
S/S?
Hypocalcemia
Citrate binders in the PRBCs
S/S: hyperactive DTRs
