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Clinical Medicine > Surgery > Flashcards

Surgery Flashcards

1
Q

Q001. assessing the airway

A

A001. patient conscious and speaking ��> airway present

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2
Q

Q002. airway procedures

A

A002. in the field ��> cricothyroidotomy

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3
Q

Q003. signs of shock

A

A003. systolic pressure < 90mmHg; fast feeble pulse; low urinary output in patient who is cold, pale, shivering, sweating, thirsty

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4
Q

Q004. traumatic causes of shock

A

A004. bleeding

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5
Q

Q005. hemorrhagic shock Vs. pericardial tamponade Vs. tension pneumothorax

A

A005. hemorrhage ��> CVP is low (empty veins); cardiac tamponade and tension pneumothorax ��> CVP high (distended neck veins); pericardial tamponade ��> no respiratory distress; tension pneumothorax ��> severe respiratory distress, unilateral loss of breath sounds, hyperresonance and mediastinum/tracheal deviation

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6
Q

Q006. hemorrhagic shock in penetrating injuries management

A

A006. surgical intervention first to stop the bleeding then volume replacement

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7
Q

Q007. non�hemorrhagic shock management

A

A007. fluid replacement first with 2L of Ringer followed by packed red cells until urine is 0.5�2ml/kg/h and CVP does not exceed 15mmHg

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8
Q

Q008. pericardial tamponade shock management

A

A008. clinical diagnosis, don�t order x�rays, if unclear order sonogram; prompt evacuation of pericardial sac by pericardiocentesis, tube, pericardial window or open thoracotomy; fluids and red cells while evacuation is being done

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9
Q

Q009. tension pneumothorax shock management

A

A009. clinical diagnosis, don�t order x�rays or wait blood gases;; big needle or IV catheter into pleural space;; follow with chest tube connected to underwater seal

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10
Q

Q010. preferred route of fluid resuscitation in shock

A

A010. 2 16�gauge peripheral IV lines

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11
Q

Q011. types of head trauma

A

A011. penetrating

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12
Q

Q012. head trauma + loss of consciousness

A

A012. CT of head required to rule out hematoma

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13
Q

Q013. base of skull fracture

A

A013. signs are raccoon eyes, rhinorrhea, otorrhea, ecchymosis behind ear; no antibiotics indicated; cervical spine CT to assess integrity; if has loss consciousness ��> head CT; if signs of base fracture ��> neck CT also

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14
Q

Q014. neurologic damage from trauma

A

A014. from initial blow, or later hematoma or increased intracranial pressure; treat hematoma with surgery; treat pressure with drugs (diuretics)

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15
Q

Q015. acute epidural hematoma

A

A015. sequence of trauma, unconsciousness, lucid interval, gradual coma, fixed dilated pupil, contralateral hemiparesis; CT shows biconvex, lens�shaped hematoma; cure is emergency craniotomy

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16
Q

Q016. acute subdural hematoma

A

A016. sequence of trauma, unconsciousness, lucid interval, gradual coma mcuh more severe; CT shows semilunar hematoma; if midline deviated ��> craniotomy; else ��> treat increased intracranial pressure

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17
Q

Q017. diffuse axonal injury from head trauma

A

A017. CT shows blurring of gray�white matter interface and small punctuate hemorrhages; if no hematoma, no surgery; decrease ICP

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18
Q

Q018. chronic subdural hematoma

A

A018. in elderly or severe alcoholics

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19
Q

Q019. penetrating neck trauma exploration indications

A

A019. expanding hematoma; deteriorating vital signs; esophageal or tracheal injury (coughing, hemoptysis); gunshot to middle neck

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20
Q

Q020. neck gunshot wounds

A

A020. middle zone ��> exploration; upper zone ��> arteriogram; base of neck ��> arteriogram, esophagogram (barium), esophagoscopy, and bronchoscopy before surgery

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21
Q

Q021. neck stab wounds

A

A021. if upper and middle zones in asymptomatic patients ��> observation

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22
Q

Q022. blunt neck trauma

A

A022. if neurologic deficits or pain to local palpation of cervical spine ��> cervical spine CT

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23
Q

Q023. types of chest trauma

A

A023. rib fracture; pneumothorax; hemothorax; blunt trauma; sucking chest wounds; flail chest; pulmonary contusion; myocardial contusion; traumatic rupture of diaphragm, aorta, trachea or bronchus; air and fat embolism

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24
Q

Q024. rib fracture

A

A024. can be deadly in elderly

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25
Q

Q025. plain pneumothorax

A

A025. penetrating trauma due to broken rib or weapon; moderate shortness of breath, unilateral absence of breath sounds and hyperresonance; do chest x�ray, place chest tube, connect to underwater seal

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26
Q

Q026. hemothorax

A

A026. penetrating trauma due to broken rib or weapon

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27
Q

Q027. blunt chest trauma

A

A027. monitor hidden injuries; blood gases,; chest x�ray,; cardiac enzymes,; ECG

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28
Q

Q028. sucking chest wound

A

A028. flap sucks air in with inspiration and closes in expiration

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29
Q

Q029. flail chest

A

A029. multiple rib fracture with paradoxical breathing; treat lung contusion with fluid restriction, colloid solutions and diuretics

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30
Q

Q030. pulmonary contusion

A

A030. appears immediately or within 48 hours ��> deteriorating blood gases and white�out of lungs on x�ray; treat with fluid restriction, colloids and diuretics

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31
Q

Q031. myocardial contusion

A

A031. suspect it in sternal fractures

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32
Q

Q032. traumatic rupture of diaphragm

A

A032. bowel in chest on left side by physical exam and x�ray

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33
Q

Q033. traumatic rupture of aorta

A

A033. hidden injury due to at junction of arch and descending aorta; due to deceleration injury; asymptomatic until rupture occurs; suspect it if first rib, scapula or sternum are fractured; first procedure is x�ray; if normal mediastinum ��> transesophageal echo, CT or MRI angio; if wide mediastinum ��> aortogram if noninvasive tests are inconclusive; needs prompt surgical repair

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34
Q

Q034. traumatic rupture of trachea or major bronchus

A

A034. suggested by subcutaneous emphysema or large air leak from chest tube

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35
Q

Q035. air embolism

A

A035. seen as sudden death in intubated trauma patients; also from supraclavicular node biopsy, central venous lines, CVP lines that disconnect; do cardiac massage with left side down; prevent with Trendelenburg position

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36
Q

Q036. fat embolism

A

A036. multiple trauma patient with long�bone fractures; petechial rash in axilla and neck; fever, tachycardia and respiratory distress; treatment is respiratory support

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37
Q

Q037. types of abdominal trauma

A

A037. gunshot wounds

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38
Q

Q038. gunshot wound to abdomen

A

A038. any entry or exit below nipple line is considered to involve abdomen

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39
Q

Q039. stab wound to abdomen

A

A039. if penetration is evident (protruding viscera), hemodynamic instability or peritoneal irritation��> exploratory laparotomy; else ��> digital exploration; if equivocal ��> CT scan

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40
Q

Q040. signs of internal bleeding after blunt trauma

A

A040. same as shock; hypotension,; fast pulse,; low CVP and urine,; pale,; cold,; anxious,; shivering,; sweating,; thirsty

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41
Q

Q041. body compartments where internal bleeding can cause shock

A

A041. needs appriximate 1,500ml loss of blood for shock; potential places ��> abdomen, thighs, pelvis; places easily detectable ��> lungs, pericardium, neck, arms and legs; not possible ��> head

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42
Q

Q042. to determine abdominal internal bleeding after blunt trauma

A

A042. suspect in multiple trauma patient with normal chest x�ray, no evidence of pelvic or femur fracture who develops signs of shock

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43
Q

Q043. intraabdominal bleeding diagnosis

A

A043. CT scan determines presence, severity and site of bleeding; if hemodynamically unstable ��> do diagnosis while resuscitating with peritoneal lavage or sonogram; if positive ��> exploratory laparotomy

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44
Q

Q044. ruptured spleen

A

A044. most common source of significant intraabdominal bleeding in blunt trauma; hints are ruptured lower left ribs; try to repair, not remove; if removal is needed ��> postoperative immunization against encapsulated bugs

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45
Q

Q045. intraoperative coagulopathy after abdominal trauma

A

A045. treated with platelet packs and fresh�frozen plasma

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46
Q

Q046. abdominal compartment syndrome

A

A046. abdominal surgical wound cannot be closed in surgery or opens up in postoperative

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47
Q

Q047. pelvic fractures

A

A047. pelvic hematomas are usually left alone if not expanding; have to rule out associated injuries (rectal exam, bladder, pelvic exam and urethra in men); diagnosis is with signs of shock in patient with pelvic fracture who is not bleeding elsewhere; blood transfusions necessary but external fixation Vs. arteriographic embolization Vs. surgery is controversial

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48
Q

Q048. urologic injuries

A

A048. penetrating trauma

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49
Q

Q049. hallmark of urologic injuries

A

A049. hematuria in trauma patient

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50
Q

Q050. urethral traumatic injury

A

A050. usually result of pelvic fracture; almost exclusively in men with blood at the meatus, scrotal hematoma, not able to void, high�riding prostate on exam; Foley catheter should not be inserted but retrograde urethegram done instead; anterior injuries are repaired immediately, posterior are delayed

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51
Q

Q051. bladder traumatic injury

A

A051. associated with pelvic fracture, diagnosed by retrograde cystogram which must include postvoid film; surgical repair is done

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52
Q

Q052. renal traumatic injury

A

A052. usually associated with lower rib fracture

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53
Q

Q053. scrotal hematoma

A

A053. can attain alarming size but no specific intervention needed unless sonogram shows ruptured testicle

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54
Q

Q054. fracture of the penis

A

A054. usually due to sex with woman on top; sudden pain, large shaft hematoma and normal glans; emergency surgery required to prevent impotence

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55
Q

Q055. penetrating injury to extremities considerations

A

A055. determine whether there�s vascular injury or not

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56
Q

Q056. combined injuries of arteries, nerves and bone

A

A056. first do bone,; then vascular repair,; then nerve,; finally a fasciotomy (to prevent compartment syndrome)

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57
Q

Q057. crushing injury of extremities

A

A057. risks ��> hyperkalemia (do fluid correction), myoglobinemia, myoglobinuria, renal failure and compartment syndrome

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58
Q

Q058. chemical burns

A

A058. massive irrigation to remove offending ageng

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59
Q

Q059. electrical burns

A

A059. always deeper than they appear; may involve myoglobinemia, myoglobinuria and renal failure; orthopedic injuries due to massive muscle contraction

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60
Q

Q060. respiratory burns

A

A060. smoke inhalation in fires

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61
Q

Q061. rule of nines for adults

A

A061. head and arms ��> 9% each

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62
Q

Q062. rule of nines for babies

A

A062. head ��> 18%

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63
Q

Q063. Parkland formula

A

A063. kg X % of burn X 4cc RL + 2L D5W; first 1/2 in first 8h, the rest in next 16h; on day 2 ��> half of day 1

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64
Q

Q064. burn care

A

A064. topical silver sulfadiazine is agent of choice

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65
Q

Q065. tetanus prophylaxis

A

A065. required for all bites

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66
Q

Q066. dog bites

A

A066. considered provoked if dog was petted while eating or teased

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67
Q

Q067. snake bites

A

A067. severe local pain, swelling and discoloration within 30 minutes; draw blood for typing and cross match, coagulation stdies and liver/renal function; treat with antivenom; don�t make cruciate cuts, suck out venom, wrap with ice or apply tourniquet

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68
Q

Q068. bee stings

A

A068. wheezing and rash may occur with hypotension; give 0.3�0.5ml epinephrine 1:1,000; remove stingers without squeezing

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69
Q

Q069. black widow spider bite

A

A069. the spider is black with red hourglass on belly; nausea, vomiting, generalized muscle cramps; treat with IV calcium gluconate

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70
Q

Q070. brown recluse spider bite

A

A070. skin ulcer with necrotic center surrounded by halo of erythema

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71
Q

Q071. human bites

A

A071. bacteriollogically the dirtiest

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72
Q

Q072. orthopedic disorders in children

A

A072. dysplasia of the hip

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73
Q

Q073. developmental dysplasia of the hip

A

A073. uneven gluteal folds

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74
Q

Q074. Legg�Perthes disease

A

A074. avascular necrosis of capital femoral epiphysis occurs around age 6; limping, decreased hip motion, hip/knee pain, antalgic gait; diagnose with AP/lateral hip x�rays; treatment is controversial

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75
Q

Q075. slipped capital femoral epiphysis

A

A075. orthopedic emergency; chubby boy around 13, limping and with groin/knee pain, limited hip motion, flexed hip and thigh is externally rotated; diagnose with x�rays and treat with surgical pinning of femoral head

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76
Q

Q076. septic hip

A

A076. orthopedic emergency in little toddlers with history of febrile illness and refusal to move the hip

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77
Q

Q077. acute hematogenous osteomyelitis in children

A

A077. history of febrile illness with severe localized bone pain

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78
Q

Q078. genu varum

A

A078. bow legs normal up to age 3

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79
Q

Q079. genu valgus

A

A079. knock knee is normal between 4�8 years

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80
Q

Q080. Osgood�Schlatter disease

A

A080. osteochondrosis of tibial tubercle seen in teenagers with persistent pain over tibial tubercle aggravated by contraction of quadriceps

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81
Q

Q081. club foot

A

A081. seen at birth with feet turned inward

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82
Q

Q082. scoliosis in pediatrics

A

A082. seen mostly in adolescent girls

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83
Q

Q083. osteogenic sarcoma

A

A083. ages 10�25

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84
Q

Q084. Ewing sarcoma

A

A084. ages 5�15 and grows at diaphysis

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85
Q

Q085. metastatic bone tumors

A

A085. seen min adults from breast (lytic lesions) or prostate (blastic lesions)

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86
Q

Q086. multiple myeloma

A

A086. CRAB ��> hypercalcemia, renal failure, anemia, localized bone pain and lytic lesions on x�rays; increased total proteins with normal albumin; Bence�Jones protein; abnormal Igs by serum electrophoresis; infections; treat with chemo

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87
Q

Q087. soft tissue sarcomas

A

A087. firm, mass fixed to surrounding structures which metastasizes to lungs not lymph nodes; treat with wide local excision, radiotherapy and chemo

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88
Q

Q088. general considerations about fractures

A

A088. x�rays should include 2 views at 90 degrees to one another and include joints above and below fracture

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89
Q

Q089. clavicular fractures

A

A089. typically at junction of middle and distal third

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90
Q

Q090. anterior dislocation of the shoulder

A

A090. most common dislocation

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91
Q

Q091. posterior shoulder dislocation

A

A091. occurs after seizures or electrical burns

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92
Q

Q092. Colles fracture

A

A092. fall on outstretched hand results in painful and deformed wrist

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93
Q

Q093. Monteggia fracture

A

A093. diaphyseal fracture of proximal ulna with anterior dislocation of radial head results from direct blow to ulna

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94
Q

Q094. Galeazzi fracture

A

A094. fracture of distal third of radius from direct blow with dorsal dislocation of distal radioulnar joint

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95
Q

Q095. scaphoid fracture

A

A095. fall on outstretched hand

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96
Q

Q096. metacarpal neck fractures

A

A096. closed fist hits hard surface

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97
Q

Q097. hip fractures

A

A097. typically elderly who sustain fall

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98
Q

Q098. femoral neck fractures

A

A098. can compromise vasculature of femoral head

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99
Q

Q099. intratrochanteric fractures

A

A099. less likely to lead to avascular necrosis; treat with open reduction, pinning and anticoagulation to prevent DVT and pulmonary embolism

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100
Q

Q100. femoral shaft fracture

A

A100. treat with intramedullary fixation

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101
Q

Q101. knee injury

A

A101. has swelling; if no swelling, unlikely to be serious; MRI is best diagnosis

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102
Q

Q102. collateral ligament injury

A

A102. lateral blow displaces medial ligaments and vice versa

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103
Q

Q103. anterior cruciate ligament injury

A

A103. more common than posterior; knee pain and swelling; with flexed knee at 90 degrees, leg can be pulled anteriorly; treat sedentary patients with immobilization and rehab; treat athletes with arthroscopic reconstruction

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104
Q

Q104. posterior cruciate ligament injury

A

A104. knee pain and swelling; with flexed knee at 90 degrees, leg can be pulled posteriorly; treat sedentary patients with immobilization and rehab; treat athletes with arthroscopic reconstruction

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105
Q

Q105. meniscal tears

A

A105. presents with pain, swelling and click when knee is forcefully extended; best diagnosed with MRI; arthroscopic repair is done; complete meniscectomy leads to late development of degenerative arthritis

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106
Q

Q106. tibial stress fractures

A

A106. seen in young men subjected to forced marches

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107
Q

Q107. tibia and fibula fractures

A

A107. often when pedestrian is hit by car

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108
Q

Q108. rupture of Achilles tendon

A

A108. seen in out�of�shape middle�aged men subjected to severe strain; loud popping noise is heard and there’s loss of balance; there’s pain, swelling and limping and palpation reveals a gap; cast in equinus or surgery

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109
Q

Q109. fracture of ankle

A

A109. falling on inverted foot; AP, lateral and mortise x�rays are diagnostic; if displacement, open reduction and external fixation is needed

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110
Q

Q110. compartment syndrome

A

A110. orthopedic emergency frequently in forearm or lower leg precipitated by reperfusion after ischemia or crushing injury; there’s pain and limited use of extremity, compartment is tight, tender and painful; emergency fasciotomy is treatment

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111
Q

Q111. pain under cast

A

A111. orthopedic emergency requires removal of cast and examination of limb

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112
Q

Q112. open fracture

A

A112. orthopedic emergency requires cleaning in OR and suitable reduction within 6 hours from injury

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113
Q

Q113. posterior hip dislocation

A

A113. hip pain, leg is shortened, adducted and internally rotated; emergency reduction is needed to prevent avascular necrosis

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114
Q

Q114. gas gangrene

A

A114. penetrating dirty wounds; within 3 days patient looks ill; wound is tender, swollen, discolored and has gas crepitation; treat with IV penicillin, emergency surgical debridement, hyperbaric O2

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115
Q

Q115. radial nerve injury

A

A115. dorsiflexion is affected

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116
Q

Q116. popliteal artery injury

A

A116. due to posterior dislocation of knee; check pulses, Doppler and arteriogram; delayed restoration of flow requires prophylactic fasciotomy

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117
Q

Q117. carpal tunnel syndrome

A

A117. numbness and tingling in distribution of median nerve reproduced by tapping or pressing median nerve over carpal tunnel

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118
Q

Q118. trigger finger

A

A118. finger is acutely flexed and patient is unable to extend it

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119
Q

Q119. DeQuervain tenosynovitis

A

A119. due to holding baby’s head with wrist flexion and thumb extension

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120
Q

Q120. felon

A

A120. abscess in pulp of fingertip due to neglected penetrating injury

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121
Q

Q121. gamekeeper thumb

A

A121. injury of ulnar collateral ligament due to forced hyperextension of thumb

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122
Q

Q122. jersey finger

A

A122. injury to flexor tendon when finger is forcefully extended; when making a fist, the distal phalanx does not flex; manage with splinting

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123
Q

Q123. mallet finger

A

A123. extended finger is forcefully flexed and extensor tendon is ruptured

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124
Q

Q124. traumatically amputated digits

A

A124. surgically reattached when possible;; clean with sterile saline, wrap in saline moistured gauze and place in sealed plastic bag on bed of ice;; do not put antiseptic solutions, alcohol, dry ice or allow finger to freeze

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125
Q

Q125. lumbar disk herniation presentation

A

A125. at L4�L5 or L5�S1; months of vague aching discogenic pain (pressure on anterior spinal ligament) followed by neurogenic pain; precipitated by forced movement, coughing, sneezing, defecating; neurogenic pain feels like electric shock down leg

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126
Q

Q126. lumbar disk herniation diagnosis

A

A126. straight leg raising gives excruciating pain

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127
Q

Q127. lumbar disk herniation management

A

A127. initially bed rest for 3 weeks; pain control with nerve blocks; surgery if progressive muscle weakness; emergency surgery if cauda equina syndrome (distended bladder, flaccid rectal sphincter, perineal saddle anesthesia)

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128
Q

Q128. cauda equina syndrome

A

A128. distended bladder

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129
Q

Q129. ankylosing spondylitis

A

A129. progressive chronic back pain and morning stiffness worse at rest

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130
Q

Q130. metastatic malignancy

A

A130. progressive back pain worse at night and unrelieved by rest or position

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131
Q

Q131. diabetic ulcers

A

A131. indolent and located at pressure points

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132
Q

Q132. arterial insufficiency ulcers

A

A132. at the tip of the toes usually; they look dirty with a pale base devoid of granulation tissue; associated with absent pulses, trophic changes, claudication, rest pain; initial test is Doppler, then arteriogram; treat with surgical revascularization

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133
Q

Q133. venous stasis ulcers

A

A133. develops in chronically edematous indurated hyperpigmented skin of legs

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134
Q

Q134. foot ulcers

A

A134. need work up for diabetes and arteriosclerotic disease

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135
Q

Q135. Marjolin ulcer

A

A135. is a squamous cell carcinoma of the skin that develops in chronic leg ulcer from burns or osteomyelitis

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136
Q

Q136. plantar fasciitis

A

A136. sharp heel pain when stepping, worse in the morning; bony spur on x�ray and tenderness to palpation; resolves in 12�18 months; no surgery, just sumptomatic treatment

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137
Q

Q137. preop assessment: cardiac ��> ejection fraction

A

A137. below 35% poses too much risk

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138
Q

Q138. preop assessment: cardiac ��> JVD

A

A138. worst factor indicating cardiac risk

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139
Q

Q139. preop assessment: cardiac ��> MI

A

A139. next worst predictor of cardiac complications

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140
Q

Q140. preop assessment: cardiac risk factors

A

A140. JVD

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141
Q

Q141. preop assessment: pulmonary risk factors

A

A141. smoking (high PCO2) ��> quit smoking 8 weeks prior to surgery with intensive respiratory therapy; do FEV1 and if abnormal, blood gases

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142
Q

Q142. preop assessment: hepatic risk factors

A

A142. 40% mortality ��> bilirubin > 2, albumin < 3, PT > 16, encephalopathy; 80% mortality ��> bilirubin > 4, albumin < 2, ammonia > 150mg/dL

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143
Q

Q143. preop assessment: nutritional risk factors

A

A143. 20% weight loss in 2 months

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144
Q

Q144. preop assessment: diabetic coma

A

A144. absolute contraindication to surgery

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145
Q

Q145. postoperative fever causes

A

A145. high fever ��> malignant hypertehermia, bacteremia; usual range fever; atelectasis, day 1; pneumonia, day 3; UTI, day 3; deep venous thrombophlebitis, day 5; wound infection, day 7; deep abscess, 2 weeks

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146
Q

Q146. postop complications

A

A146. fever

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147
Q

Q147. postop bacteremia

A

A147. 30�45 minutes of invsive procedures

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148
Q

Q148. postop atelectasis

A

A148. MCC in first day; rule out malignant hyperthermia and bacteremia; treat with ��> deep breathing and coughing, postural drainage, and if needed bronchoscopy; if uncorrected ��> pneumonia

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149
Q

Q149. postop deep abscess

A

A149. fever 2 10�15 days postop

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150
Q

Q150. periop MI

A

A150. chest pain only in 30%, the rest present with MI complications; treatment directed at complications; cannot use thrombolytic therapy

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151
Q

Q151. postop PE

A

A151. ABGs ��> hypoxemia, hypocapnia; diagnosis ��> MC is CT +� contrast (angio CT); gold standard is angiogram; use heparin

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152
Q

Q152. intraop aspiration

A

A152. leads to chemical acid injury; prevent with NPO and antacids before induction; treat with bronchoscopy lavage, bronchodilators and respiratory support

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153
Q

Q153. intraop tension pneumothorax

A

A153. from positive pressure breathing; decreased BP, increased CVP; if abdomen is open ��> decompress through diaphragm; else ��> needle through anterior chest with chest tube later

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154
Q

Q154. causes of disorientation/coma postop

A

A154. hypoxia ��> first thing to check with ABGs; ARDS ��> treat with PEEP, careful of barotrauma; delirium tremens ��> in alcoholics, treat with benzos or alcohol; hyponatremia ��> from high ADH and free water; may use hypertonic and osmotic diuretics; hypernatremia ��> from unreplaced water loss; ammonium ��> in cirrhotic patients with bleeding varices who goest for portocaval shunt

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155
Q

Q155. postop oliguria/anuria

A

A155. urinary retention ��> feels need to void but can’t

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156
Q

Q156. postop paralytic ileus

A

A156. after abdominal surgery; mild distention, no pain, absent bowel sounds; prolonged by hypokalemia

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157
Q

Q157. early mechanical bowel obstruction

A

A157. due to postop adhesions; paralytic ileus does not resolve; x�ray ��> dilated small bowel loops and air fluid levels; confirm with CT ��> proximally distended, distally collapsed bowel; surgical correction

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158
Q

Q158. Ogilvie syndrome

A

A158. paralytic ileus” of the colon; follows surgery other than abdominal; large abdominal distention; x�ray ��> massively dilated colon; colonoscopy to suck out gas; leave rectal tube in; cecostomy of colostomy may be needed”

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159
Q

Q159. postop wound complications

A

A159. wound dehiscence

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160
Q

Q160. wound dehiscence

A

A160. after open laparotomy; wound is intact but salmon�colored peritoneal fluid leaks out; tape the wound, bound the abdomen and careful mobilization and coughing; eventual re�operation for ventral hernia prevention or correction (not emergency)

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161
Q

Q161. evisceration

A

A161. complication of wound dehiscence

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162
Q

Q162. GI fistula

A

A162. bowel content leaks; sepsis if drains to cesspool; fluid/electrolyte loss, nutritional depletion and erosion of belly wall if they drain freely; treat with electrolyte replacement, nutrition beyond the fistula and ostomy bags until nature heals it; nature heals it if FETID not present ��> foreign body, epithelialization, tumor, infection, irradiation, IBD or distal obstruction

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163
Q

Q163. postop hypernatremia

A

A163. if gradual ��> rapid volume repletion with slow tonicity ��> use D51/2 NS

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164
Q

Q164. water intoxication

A

A164. CNS symptoms of hyponatremia

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165
Q

Q165. hypokalemia

A

A165. from GI loss, loop diuretics, increased aldosterone, correction of DKA; correct at < 10mEq/h

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166
Q

Q166. hyperkalemia

A

A166. from renal failure, aldosterone antagonists, crush injuries, dead tissue, acidosis; treat with calcium (neutralize effects on membrane, fastest); dextrose/insulin; exchange resins; dialysis

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167
Q

Q167. mechanical intestinal obstruction

A

A167. caused by adhesions in those with prior laparotomy; colick pain, vomiting, abdominal distention, no passage of gas or feces; x�ray ��> distended small bowel loops, air fluid levels; treatment ��> NPO, NG suction, IV fluids waiting for spontaneous correction; watch for strangulation ��> fever leukocytosis, peritonitis, sepsis

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168
Q

Q168. mechanical intestinal obstruction by hernia

A

A168. from incarcerated hernia

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169
Q

Q169. appendicitis

A

A169. anorexia followed by vague paeriumbilical pain

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170
Q

Q170. colonic polyps

A

A170. most malignant ��> familial polyposis, villous adenoma, adenomatous polyp; not premalignant ��> juvenile, Peutz�Jeghers, inflammatory and hyperplastic

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171
Q

Q171. indications for surgery in ulcerative colitis

A

A171. disease > 20 years; nutritional compromise; multiple hospitalizations; need for high�dose steroids or immunosuppresants; toxic megacolon (abdominal pain, fever, leukocytosis, distended colon); also need to remove all rectal mucosa

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172
Q

Q172. hemorrhoids

A

A172. internal ��> painless bleed, rubber band ligation; external ��> painful; prolapsed internal ��> pain and itching; rule out cancer in all anorectal diseases

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173
Q

Q173. anal fissure

A

A173. exquisite pain with defecation with blood; constipation from fear of bowel movement; may require physical exam under anesthesia; relax the tight sphincter with stool softener, topical nitroglycerin, botulin toxin or surgery; rule out cancer in all anorectal disease

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174
Q

Q174. ischiorectal perirectal abscess

A

A174. fever, perirectal pain, no bowel movements; local inflamation signs; surgical drainage; if diabetic ��> necrosis ��> watch closely; rule out cancer in all anorectal disease

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175
Q

Q175. fistula in ano

A

A175. draining tract lateral to anus after ischiorectal abscess drainage

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176
Q

Q176. GI bleeding stats

A

A176. 75% upper GI, 25% colon or rectum; if young person with GI bleed ��> suspect upper; if elderly ��> can be from anywhere

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177
Q

Q177. GI bleed work�up

A

A177. hematemesis or melena ��> start work�up with upper endoscopy; blood per rectum ��> NG tube; if blood retrieved ��> upper GI bleed ��> endoscopy; if no blood retrieved + white fluid ��> follow with endoscopy to exclude duodenum bleed; if no blood retrieved + billous fluid ��> no upper endoscopy needed; once upper GI bleed is excluded ��> exclude hemorrhoids ��> if excluded ��>; if high volume ��> angiography; if low volume ��> wait for bleeding to stop then colonoscopy, alternative ��> tagged RBC scan; if child ��> Meckel ��> technetium scan looking for ectopic gastric mucosa

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178
Q

Q178. acute abdominal pain from perforation

A

A178. sudden onset severe constant generalized abdominal pain

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179
Q

Q179. acute abdominal pain from obstruction

A

A179. sudden onset colicky pain that is localized

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180
Q

Q180. acute abdominal pain from inflammation

A

A180. gradual onset constant that starts as ill�defined and then localizes

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181
Q

Q181. acute abdominal pain from ischemia

A

A181. severe sudden abdominal pain with blood in the lumen

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182
Q

Q182. primary peritonitis

A

A182. ascites along with mild generalized acute abdomen and equivocal findings

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183
Q

Q183. acute abdomen management

A

A183. exploratory laparotomy after ruling out:

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184
Q

Q184. mesenteric ischemia

A

A184. acute abdomen in patient with Afib or recent MI

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185
Q

Q185. pyogenic liver abscess

A

A185. complication of billiary tract disease, acute ascending cholangitis; fever, leukocytosis, tender liver; ultrasound or CT are diagnostic; treat with percutaneous drainage

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186
Q

Q186. amebic abscess of liver

A

A186. mexico connection

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187
Q

Q187. types of jaundice

A

A187. hemolytic ��> unconjugated bilirubin < 6 or 8, no bilirubin in urine; hepatocellular ��> both fractions elevated, very high transaminases, modest AP; obstructive ��> both fractions elevated, modest transaminases and very high AP ��> do ultrasound

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188
Q

Q188. billiary obstruction from stone

A

A188. ultrasound may not find common duct stone, but stones in a nondistended gallbladder are seen; high alkaline phosphatase; after ultrasound, do ERCP for confirmation and stone removal; after ERCP ��> cholecystectomy

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189
Q

Q189. Courvoisier�Terrier sign

A

A189. large thin�walled distended gallbladder by ultrasound in malignant obstruction

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190
Q

Q190. causes of obstructive jaundice

A

A190. stone in common duct

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191
Q

Q191. obstructive jaundice by tumor work�up

A

A191. first ultrasound ��> dilated gallbladder ��> CT ��> adenocarcinoma of head of pancreas

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192
Q

Q192. ampulla of Vater cancer

A

A192. malignant obstructive jaundice

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193
Q

Q193. gallstone disease spectrum

A

A193. asymptomatic gallstone ��> billiary colic ��> acute cholecystitis ��> acute ascending cholangitis ��> obstructive jaundice ��> biliary pancreatitis

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194
Q

Q194. biliary colic

A

A194. stone temporarily obstructs cystic duct; colicky pain in RUQ radiates to right shoulder and back; triggered by fatty food, associated with nausea and vomit; no signs of peritoneal irritation or systemic inflammation; self�limited; diagnose with ultrasound; elective cholecystectomy is indicated

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195
Q

Q195. acute cholecystitis

A

A195. starts as biliary colic until inflammation of gallbladder occurs; pain becomes constant with fever and leukocytosis and peritoneal signs in RUQ; liver function tests mildly affected; ultrasound ��> gallstones, thick gallbladder, pericholecystic fluid; supportive and antibiotics to cool down then elective cholecystectomy; if doesn�t respond ��> emergency surgery

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196
Q

Q196. acute ascending cholangitis

A

A196. stone partially obstructs common bile duct with ascending infection; fever with chills, high WBCs with sepsis; some hyperbilirubinemia and markedly increased AP; treat with ERCP decompression or percutaneous transhepatic cholangiogram; then do cholecystectomy

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197
Q

Q197. biliary pancreatitis

A

A197. stone obstructs bile and pancreatic ducts at ampulla

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198
Q

Q198. acute edematous pancreatitis

A

A198. due to alcohol or gallstones; high amylase or lipase; key finding is high hematocrit; treat with NPO, rest and fluids

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199
Q

Q199. acute hemorrhagic pancreatitis

A

A199. alcohol or gallstones; lower hematocrit; high amylase or lipase; Ranson criteria ��> leukocytosis, hyperglycemia, hypocalcemia, increased BUN, metabolic acidosis, ARDS; do daily CTs to find abscesses and drain them

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200
Q

Q200. pancreatic abscess

A

A200. acute suppurative pancreatitis seen in CT after days of persistent fever and leukocytosis

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201
Q

Q201. pancreatic pseudocyst

A

A201. late sequela of acute pancreatitis or pancreatic trauma; collection of pancreatic secretions outside the ducts seen in CT or ultrasound; cysts < 6cm or < 6 weeks ��> conservative management for resolution; cysts > 6cm or > 6 weeks ��> percutaneous, surgical or endoscopic drainage

202
Q

Q202. glucagonoma

A

A202. hyperglycemia

203
Q

Q203. esophageal atresia

A

A203. excessive salivation shortly after birth with choking on first feed

204
Q

Q204. imperforated anus

A

A204. may be VACTER presentation

205
Q

Q205. congenital diaphragmatic hernia

A

A205. always on the left; problem is lung hypoplasia with respiratory distress; intubate, ventilate, wait 3�4 days for lung maturation then surgery

206
Q

Q206. gastroschisis Vs. omphalocele

A

A206. gastroschisis defect is to the right of the normal cord with loose bowels

207
Q

Q207. double bubble sign

A

A207. air�fluid level in stomach to the left; air�fluid level in first portion of duodenum to the right; nor air in distal bowels; present in duodenal atresia, annular pancreas and malrotation

208
Q

Q208. intestinal atresia

A

A208. multiple air�fluid levels throughout abdomen

209
Q

Q209. necrotizing enterocolitis

A

A209. premature infant; first feeding causes intolerance, abdominal distention, thrombocytopenia and sepsis; treat with broad�spectrum antibiotics; indications for surgery ��> abdominal wall erythema, air in portal vein, pneumatosis, pneumoperitoneum

210
Q

Q210. meconium ileus

A

A210. babies with cystic fibrosis; feeding intolerance and bilious vomiting; x�ray ��> multiple dilated loops of small bowel; gastrofin enema ��> microcolon, meconium pellets; diagnose and treat with gastrografin enema

211
Q

Q211. hypertrophic pyloric stenosis

A

A211. nonbilous projectile vomiting after feeding at 3 weeks

212
Q

Q212. biliary atresia

A

A212. persistent progressive jaundice in 6�8 week baby

213
Q

Q213. Hirchsprung

A

A213. chronic constipation

214
Q

Q214. Meckel diverticulum / diverticulitis

A

A214. lower GI bleed in kid

215
Q

Q215. vascular rings

A

A215. pressure on tracheobronchial tree and esophagus

216
Q

Q216. atrial septal defect

A

A216. faint pulmonary flow systolic murmur

217
Q

Q217. ventricular septal defect

A

A217. failure to thrive

218
Q

Q218. patent ductus arteriosus

A

A218. bounding pulses

219
Q

Q219. tetralogy of Fallot

A

A219. right to left shunt with cyanosis; bluish hue, clubbing and relieved by squatting; systolic ejection murmur, right ventricular hypertrophy

220
Q

Q220. transposition of great vessels

A

A220. kept alive by ASD, VSD or PDA; immediate cyanosis

221
Q

Q221. coin lesion and lung cancer work�up

A

A221. check previous x�ray

222
Q

Q222. operability of lung cancer

A

A222. need aminimum FEV1 of 800

223
Q

Q223. subclavian steal syndrome

A

A223. atherosclerotic stenotic plaque at origin of subclavian

224
Q

Q224. abdominal aortic aneurysm

A

A224. pulsatile mass between xiphoid and umbilicus; coincidental finding on x�ray, ultrasound or CT; < 4cm ��> observation; > 5�6 cm ��> repair; if tender ��> will rupture soon ��> repair

225
Q

Q225. arteriosclerotic disease of lower extremities

A

A225. presentation ��> intermittent claudication, shiny atrophic skin, no hair, no peripheral pulses, rest pain, ulceration and gangrene; if doesn’t interfere with daily activities ��> cessation of smoking, exercise and cilostazol; if severe ��> Doppler for pressure gradient; if no gradient ��> not amenable to surgery; if gradient ��> arteriogram looking for areas of stenosis and good distal vessels; if short stenotic segments ��> stents; if large stenotic segments ��> bypass graft of sequential stent

226
Q

Q226. atrial embolization

A

A226. from atrial fibrillation or recent MI (mural thrombus); pain, pale, poikilothermic, pulseless paresthetic, paralytic lower extremity; do Doppler; if incomplete obstruction ��> thrombolytics; if complete ��> embolectomy with Fogarty catheter + fasciotomy

227
Q

Q227. dissecting aortic aneurysm of thoracic aorta

A

A227. due to hypertension

228
Q

Q228. amblyiopia

A

A228. interference with processing of images in first 6�7 years of life most commonly by strabismus

229
Q

Q229. strabismus

A

A229. surgically correct to prevent amblyiopia

230
Q

Q230. acute angle closure glaucoma

A

A230. severe eye pain or frontal headache typically in the evening; halos around lights; pupil is dilated and does not respond to light; cloudy cornea; eye is very hard; emergency treatment with acetazolamide, topical betablockers, alpha2 agonists; then emergency laser surgery

231
Q

Q231. orbital cellulitis

A

A231. eyelids are inflammed

232
Q

Q232. retinal detachment

A

A232. flashes of light and floaters in the eye

233
Q

Q233. embolic occusion of retinal artery

A

A233. unilateral sudden loss of vision

234
Q

Q234. thyroglosal duct cyst

A

A234. midline; pulling tongue out retracts the mass; surgical removal of cyst, middle segment of hyoid bone and track to base of tongue

235
Q

Q235. brachial cleft cyst

A

A235. anterior edge of sternocleidomastoid

236
Q

Q236. cystic hygroma

A

A236. at the base of neck; large, mushy, ill�defined mass occupies entire supraclavicular area; often extend into chest and mediastinum; CT before surgery is mandatory

237
Q

Q237. recently discovered enlarged lymph node

A

A237. complete history and physical + follow�up 3�4 weeks

238
Q

Q238. persistent enlarged lymph node

A

A238. could be inflammatory but cancer has to be ruled out

239
Q

Q239. squamous cell carcinoma of mucosa of head and neck

A

A239. smokers, drinkers, rotten teeth, AIDS; persistent hoarseness; persistent painless ulcer at floor of the mouth; persistent unilateral earache; do triple panendoscopy; FNA may be done but not open biopsy; treatment ��> resection, radical neck dissection, radio, chemo

240
Q

Q240. facial nerve tumor

A

A240. unilateral facial peripheral paralysis that is insidious

241
Q

Q241. parotid tumor

A

A241. most are adenomas but predispose to malignant

242
Q

Q242. cavernous sinus thrombosis

A

A242. diplopia in patient with sinusitis; emergency IV antibiotics, CT and drainage is required

243
Q

Q243. epistaxis

A

A243. in children, may be from nose picking; treat with phenylephrine and local pressure; in adolescents ��> cocaine abuse (posterior packing needed) or nasopharyngeal angiofribroma (surgical excision); in elderly or hypertensives ��> can be life�threatening; control BP and posterior packing

244
Q

Q244. parinaud syndrome

A

A244. tumor of pineal gland

245
Q

Q245. neurogenic claudication

A

A245. back pain worsened by back extension or standing up, relieved by flexion or sitting down; diagnosis is spinal stenosis; do MRI

246
Q

Q246. reflex sympathetic dystrophy

A

A246. causalgia develops after crushing injury; constant burning pain does not respond to analgesics; extremity is cold, cyanotic and moist; diagnosis ��> successful sympathetic block; management ��> surgical sympathectomy

247
Q

Q247. testicular torsion

A

A247. adolescents with testicular pain of sudden onset; no fever, pyuria or history of mumps; testicle is tender but cord is not; clinical diagnosis, don�t do tests; emergency surgery required

248
Q

Q248. acute epididymitis

A

A248. severe testicular pain of sudden onset

249
Q

Q249. combined obstruction and infection of urinary tract

A

A249. urologic emergency because it can lead to kidney destruction in hours; suddenly develops fever, chills and flank pain; treat with IV antibiotics and decompression above the obstruction

250
Q

Q250. urologic diagnostic procedures

A

A250. IV pyelogram; looks at kidneys, ureters and some bladder; contraindicated if creatinine >2; CT ��> renal tumors and stones; sonogram ��> to look for dilation and obstruction; cytoscopy ��> to look at bladder mucosa for cancer

251
Q

Q251. posterior urethral valves

A

A251. MCC for a newborn not urinating in first day

252
Q

Q252. hypospadia

A

A252. urethral opening on ventral side of penis

253
Q

Q253. vesicouretheral reflux

A

A253. signs of peylonephritis in a child

254
Q

Q254. low implantation of urether

A

A254. normal voiding plus wet with urine all the time in girls but asymptomatic in boys

255
Q

Q255. ureteropelvic junction obstruction

A

A255. normal diuresis is ok but large volume cannot handle it (teenage goes drinking)

256
Q

Q256. renal cell carcinoma

A

A256. hematuria, flank pain, flank mass; hypercalcemia, erythocytosis, elevated liver enzymes; work�up ��> IVP shows mass; US shows solid, not cystic mass; CT may be first study shows heterogenous solid mass

257
Q

Q257. cancer of bladder

A

A257. smoking predisposes; hematuria, irritative voiding symptoms; work�up ��> first IVP; best test is cystoscopy

258
Q

Q258. prostatic cancer

A

A258. rock hard nodule on rectal exam and high PSA; diagnosis ��> transrectal needle biopsy guided by sonogram; CT for extent of involvement; widespread bone metastasis ��> androgen ablation, orchiectomy, flutamide

259
Q

Q259. testicular cancer

A

A259. painless testicular mass

260
Q

Q260. urether stone

A

A260. < 3mm can pass spontaneously with analgesic and fluids; > 7mm needs intervention with shock wave lithotripsy or more invasive such as; basket extraction, sonic probes, laser

261
Q

Q261. psychogenic impotence

A

A261. does not interfere with nighttime erections

262
Q

Q262. hyperacute transplant rejection

A

A262. vascular thrombosis within minutes

263
Q

Q263. acute transplant rejection

A

A263. 5 days � 3 months

264
Q

Q264. chronic transplant rejection

A

A264. years after the transplant with insidious loss of function

265
Q

Q265. what conditions is carpal tunnel syndrome related to

A

A265. DM

266
Q

Q266. what is Charcot’s triad associated with

A

A266. ascending cholangitis

267
Q

Q267. what is Charcot’s triad

A

A267. fever

268
Q

Q268. what is ascending cholangitis

A

A268. infection of bile duct ��> sepsis and multiorgan failure

269
Q

Q269. tx for ascending cholangitis

A

A269. Antibiotics and supportive care

270
Q

Q270. what is the best way to dx stones in GB?

A

A270. U/S (98�99% sensitivity); not the best way to dx stones in CBD, only 50% are visualized

271
Q

Q271. what is ERCP

A

A271. way to visulaize CBD

272
Q

Q272. dx of choledocolithiasis

A

A272. dilated CBD on U/S

273
Q

Q273. how to manage a patient w gal

A

stones and pancreatitis

274
Q

Q274. causes of LGI bleeds if >40 yo

A

A274. diverticulosis

275
Q

Q275. dx of LGI bleed + pain

A

A275. ischemic bowel

276
Q

Q276. how to localize LGI bleed

A

A276. colonoscopy

277
Q

Q277. cause of overt LGI bleed in children

A

A277. meckel’s diverticulum

278
Q

Q278. cause of overt LGI bleed in 20�60 yo

A

A278. diverticulitis

279
Q

Q279. cause of overt LGI bleed in >60 yo

A

A279. divertic

280
Q

Q280. what is RBC scan

A

A280. used to dx bleeding if >.1 ml/min

281
Q

Q281. advantage of mesenteric angiography

A

A281. 0.5�1.0 ml/min in order to be visualized… can see faster bleeds

282
Q

Q282. common causes of overt LGI bleeds in children

A

A282. Meckel’s diverticulum

283
Q

Q283. common causes of LGI bleeds in 20�60 yo

A

A283. IBD

284
Q

Q284. common causes of LGI bleeds in >60 yo

A

A284. neoplasm

285
Q

Q285. when are maroon colored stools seen?

A

A285. LGI bleeds without rectum/anus involvment

286
Q

Q286. features of a rectal bleed

A

A286. formed stool streaked with blood , or fresh blood at the end of a BM

287
Q

Q287. what is mortality in head injury with hypoxia and hypotension?

A

A287. 0.75

288
Q

Q288. how much is mortality increased in hypoxia?

A

A288. 2x

289
Q

Q289. how to tx increased intracranial pressure?

A

what precautions must be taken?

290
Q

Q290. which type of hematoma (subdural or epidural) is more common

A

A290. subdural

291
Q

Q291. what does sluggish pupil dilation indicate

A

A291. early sign of temporal lobe hernaition

292
Q

Q292. 1st step in managing SBO

A

A292. fluid resusc

293
Q

Q293. complications of SBO

A

A293. strangulation

294
Q

Q294. why is SBO so painful

A

A294. severe bowel distention ��> venous congestion, decreased bowel perf, necrosis; bowel ischemia 2/2 strangulation

295
Q

Q295. what is an ileus

A

A295. distention from non�obstructive causes

296
Q

Q296. gallstone ileus

A

A296. mechanical obstruction of SB b/c of large gallstone in bowel lumen

297
Q

Q297. causes of SBO in child

A

A297. hernia

298
Q

Q298. causes of SBO in adult

A

A298. tumor

299
Q

Q299. presentation of SBO

A

A299. passage of intestinal lumenal contents ��> cramplike abdominal pain

300
Q

Q300. association of BM with SBO

A

A300. usually BM at very start of obstruction, followed by increasdd peristalsis and

301
Q

Q301. dx if there is stool on DRE of patient with SBO

A

A301. ileus, NOT mechanical obstruction

302
Q

Q302. what is early post�op SBO

A

A302. sx that occur <40d following surgery; results from narrowed lumen, exact cause not known

303
Q

Q303. w/u for post�op SBO

A

A303. CT to rule out infection

304
Q

Q304. tx for post�op SBO

A

A304. supportive care

305
Q

Q305. cause of chronic mesenteric ischemia

A

A305. occlussion of 2/3 BV

306
Q

Q306. Dx of chronic mesenteric ischemia

A

A306. if no ATH, use arteriograpyhy

307
Q

Q307. tx for chronic mesenteric ischemia

A

A307. revasc with antegrade aortomesenteric bypass/perivisceral aortic endarterectomy

308
Q

Q308. when to operate on acute mesenteric ischemia

A

A308. this is a surgical emergency!

309
Q

Q309. causes of acute mesenteric ischemia

A

A309. embolism in SMA or celiac artery

310
Q

Q310. which part of the small intestines is spared in acute mesenteric ischemia? why?

A

A310. prox jejunum b/c of collaterals

311
Q

Q311. tx for acute mesenteric ischemia

A

A311. embolectomy

312
Q

Q312. when should a AAA be repaired

A

A312. 5cm

313
Q

Q313. #1 cause of morbidity and mortality in AAA repair

A

A313. cardiac complications

314
Q

Q314. how should AAA found on physical exam be confirmed

A

A314. CT scan; don’t use arteriography b/c it just shows the lumen of BV, can’t dx aneurysm from this, although it will help to plan the operation

315
Q

Q315. what are the 2 types of AAA repairs

A

benefits of each

316
Q

Q316. disadvantages to EvAR

A

A316. rquire imaging f/u every 3�6 mos

317
Q

Q317. presentation of AAA rupture

A

A317. back pain

318
Q

Q318. management of acute pancreatitis

A

A318. resuscitative measures/supp O2

319
Q

Q319. complications of acute pancreatitis

A

A319. hemorrhage

320
Q

Q320. process of infected pancreatic necrosis

A

A320. 2/2 infx by bowel organisms

321
Q

Q321. pancreatic abscess cause and tx

A

A321. accumulation of pus and infectious debris

322
Q

Q322. tx of infectious pancreatic pseudocyst

A

A322. percutaneous/operative drainage

323
Q

Q323. Ranson’s criteria seen on admission

A

A323. WBC >16,000; glucose >200; age > 55yo; AST >250; LDH >350

324
Q

Q324. Ranson’s criteria following 48 hrs

A

A324. HCt fall by 10%

325
Q

Q325. value of Ranson’s criteria

A

A325. more criteria have more severe dz and increased risk of comlication and death

326
Q

Q326. what indicates severe acute pancreatitis

A

A326. necrosis of pancreas; 50% have inx and increased microvasc permeability; �> increased volume los; decreased perfusion of kidneys, lungs, etc

327
Q

Q327. when should a contrast�enhanced CT of the pancreas be done?

A

A327. if pancreatitis dx is in question

328
Q

Q328. what, if seen on CT, wouldu indicate severe dz and increased risk of complications

A

A328. 2+ extrapancreatic fluid collections or necrosis of >50% of pancreas

329
Q

Q329. management of necrotizing pancreatitis

A

A329. 50% of time,; complicate by infection, so must adminster proph Antibiotics when necrosis is confirmed on CT

330
Q

Q330. how should gallstone pancreatitis be treated?

A

A330. cholecystectomy after pancreatitis has resolved

331
Q

Q331. which Antibiotics penetrate pancreas

A

A331. imipenem

332
Q

Q332. Tx for carotid artery dz

A

A332. surgery should always be done on sx side 1st, if both are affected

333
Q

Q333. when should elective CEA be done

A

A333. if 60% stenosis is seen, unless patient is high risk

334
Q

Q334. what is complication o fCEA or medical management of carotid artery dz

A

A334. stroke can occur with either

335
Q

Q335. how is amt of stenosis determined in carotid artery dz

A

A335. US; if that is unclear, do MR angiogram, carotid angiogram or CT reconstruction angiogram

336
Q

Q336. what are risk factors for CEA

A

A336. prior radiation to the neck

337
Q

Q337. what is a short term tx for carotid artery dz

A

A337. stent

338
Q

Q338. When should barium enema be used in dx diverticulitis

A

A338. never� there is sig risk involved with intraeritoneal leakage of barium

339
Q

Q339. dx of diverticulitis

A

A339. CT scan will show colonic wall thickening, mesenteric fat stranding; can see diverticulae

340
Q

Q340. complications of diverticulitis

A

A340. perforation

341
Q

Q341. tx of abscesses from diverticulitis

A

A341. if small, Antibiotics; if big, CT�guided drainage + Antibiotics; if no imrpovement after 72 hrs, surgery

342
Q

Q342. if there is an increased risk of recurrence with diverticulitis, management?

A

A342. elective surgical resection with primary anastamosis even if prior flare�up was treated conservatively

343
Q

Q343. how should uncomplicated diverticulitis be treated?

A

A343. monitor hydration, give IV Antibiotics, bowel rest and observation

344
Q

Q344. how should complicated diverticulitis be treated?

A

A344. surgical resection

345
Q

Q345. what is fascial dehiscence?

A

A345. disruption of fascial closure within 3 days of operation, with or without operation

346
Q

Q346. complications of fascial dehiscence

A

A346. enterocutaneous fistula

347
Q

Q347. risk factors for fascial dehiscence

A

A347. failure of surgical technique, anesthetic relaxation; >70 yo; DM; infx; malnutrition; pulm dz

348
Q

Q348. tx of fascial dehiscence

A

A348. wound care

349
Q

Q349. time frame that fascial dehiscence is most likely to occur?

A

A349. up to 3 weeks following surgery, after that, fibrous scar formation has enough strengthh to prevent evisceration

350
Q

Q350. vitamins involved in wound healing

A

A350. vitamin c, a, b6; (collagen cross linking)

351
Q

Q351. tx of ptx

A

A351. tube thoracostomy/needle aspiration

352
Q

Q352. difference btwn primary and 2ndary spontaneous ptx

A

A352. 1ary: from spont rupture of blebs; 2ndary: from bullous emphysematous dz, CF, CA, PCP, necrotizing infx, copd

353
Q

Q353. sx of tension ptx

A

A353. dyspnea

354
Q

Q354. tx perf of duo ulcers

A

A354. if no h/o prior ulcers or + HP, omental patch closure and HP tx; if + h/o prior ulcers and � HP, highly selective vagotomy

355
Q

Q355. tx of perf gastric ulcer

A

A355. + closure of perf or excise/resect ulcer w 1ary repair or Billroth I/II

356
Q

Q356. tx of obstructing gastric ulcer

A

A356. antretomy and Whipple

357
Q

Q357. are H2 blockers or PPIs more effective in tx ulcers

A

A357. PPIs

358
Q

Q358. string sign

A

A358. seen in hypertrophic pyloric stenosis, showing narrowed pylorus

359
Q

Q359. stack of coins sign

A

A359. intestinal obstruction

360
Q

Q360. tx for intussusception

A

A360. radiographic reduction; if fails, open surgery

361
Q

Q361. incision through previous scar� good or bad?

A

A361. good. promotes wound healing

362
Q

Q362. featuress of large bowel ischemia

A

A362. minimal pain

363
Q

Q363. when should a colectomy be done on a patient with UC

A

A363. 10�20 yrs with dz… (after 10 yrs, CA risk increases 4x)

364
Q

Q364. complication of typhoid fever

A

A364. Peyer’s patches bleed /perf in 2�3rd week following sx

365
Q

Q365. how to stop intractable bleeding

A

A365. use laparoscopic towels to pack abdomen

366
Q

Q366. what is seen on EKG of patient with high Mg?

A

how can it be reversed

367
Q

Q367. what is seen with low Na on EKG

A

A367. nothing

368
Q

Q368. what is seen with low K on EKG

A

A368. flattened T waves and U waves

369
Q

Q369. when is succussion splash seen in the abdomen

A

A369. any sort of obstruction

370
Q

Q370. what are the most common causes of pyloric obstruction

A

A370. duo ulcer

371
Q

Q371. how is mild Na deficiency tx?

A

severe Na defic?

372
Q

Q372. how is ARDS monitored

A

A372. ABG

373
Q

Q373. surgery = physiological stress

A

A373. surgery = physiological stress

374
Q

Q374. benefits of enteral feeding

A

A374. preserves gut mucosal mass and nml gut flora

375
Q

Q375. benefits of parenteral feedings

A

A375. good for rapid administration

376
Q

Q376. what happens if TPN is suddenly DCd?

A

A376. rebound hypoglycemia,; give D10W when TPN is suddennly DCd

377
Q

Q377. what does surgery do to fluid levels

A

A377. following surgery, increased cortisol levels ��> increased sugar in serum ��> increased urine output

378
Q

Q378. what TPN additive is good for liver encephalopathy

A

A378. lactulose

379
Q

Q379. how is AAA dx?

A

A379. U/S then CT scan to det true size

380
Q

Q380. A patient is diagnosed with invasive ductal adenocarcinoma. What is the most important factor in the staging of this patient�s cancer?

A

A380. Lymph Node Involvement

381
Q

Q381. Which nerve, if damaged in an axillary dissection, will result in only a sensory deficit?

A

A381. Intercostobrachial nerve

382
Q

Q382. What cancer drug can cause pulmonary fibrosis?

A

A382. Bleomycin

383
Q

Q383. A 59�yo male presents with complaints of recurrent UTIs. On further questioning, it sounds as if the patient is also experiencing pneumaturia. What is the most likely underlying cause for this patient�s symptoms?

A

A383. Diverticulitis; (Colorectal fistula is also a cause, but is very rare)

384
Q

Q384. What is considered the triangle of Calot in GB surgery?

A

A384. Cystic Duct,; Common Hepatic Duct,; Cystic Artery

385
Q

Q385. A 73�yo female presents with nausea, vomiting, obstipation and abdominal distention. She is afibrile, with slight tachycardia and a distended abdomen without peritoneal signs. She has no History of surgery. What is the most likely cause of this patient�s bowel obstruction?

A

A385. Gallstone Ileus

386
Q

Q386. A critically ill hemodynamically unstable intubated patient on vasopressors with History of recent MI and long ICU course begins having fevers. Labs are: WBC 19,000, AST 100, ALT 45, ALK Phos 345, total bilirubin 3.0, direct bilirubin 2.8. Abdominal ultrasound shows no stones in the gallbladder. Dx?; What is next step in Tx given patient�s condition?

A

A386. Dx: Acute Acalculous Cholecystitis; (due to biliary sludge secondary to inactivity of the biliary tree. It is seen in critically ill patients with prolonged periods of fasting or Parenteral nutrition, or in patients with multiple transfusions or trauma patients); Tx: Percutaneous Cholecystostomy; (until patient is stable enough to undergo a cholecystectomy)

387
Q

Q387. Type of Shock:; An 18�yo male restrained driver with tachycardia, hypotension, and a rigid abdomen

A

A387. Hypovolemic shock

388
Q

Q388. Type of Shock:; An 80�yo nursing home resident, febrile, unresponsive, hypotensive, with gram�negative rods cultured in urine.

A

A388. Distributive shock

389
Q

Q389. Type of Shock:; A 16�yo male victim of a motor vehicle crash with hypotension, bradycardia and the inability to move or feel both lower extremities

A

A389. Neurogenic shock; (seen in patients with spinal cord injuries; caused by a decrease in sympathetic output; CO, CVP, PCWP and SVR are all decreased)

390
Q

Q390. Type of Shock:; A 67�yo male in the medical ICU on 15L of oxygen by facemask, hypotension and crackles in the bases of both lungs

A

A390. Cardiogenic shock

391
Q

Q391. What is Duke�s staging for Colon Cancer (A�D)?

A

A391. A: limited to Mucosa

392
Q

Q392. What is the proper medical Tx (post�colectomy) for Duke�s stage C Colon Cancer?

A

What common cancer Tx is not used in colon cancer?

393
Q

Q393. What is the Diagnostic Test for patients with Rectal Cancer?

A

What is the adjuvant Tx for T3�T4 Rectal Cancer? (2)

394
Q

Q394. A 52�yo female presents with 5�day history of increasing LLQ pain, N/V and fever. Two previous episodes of the pain were treated with Antibiotics. She is tachycardic, has LLQ pain and diffuse peritoneal signs. A CT shows air in the abdomen. Dx?; Next step?

A

A394. Dx: Perforated Diverticulum

395
Q

Q395. A 27�yo male presents with severe RLQ and testicular pain that began 5 hours ago. The pain is the worst he has ever experienced and is assoc with nausea. He is writhing in pain and cannot hold still as you talk to him. He is afebrile and has a WBC of 10,300. Diagnostic test?; Dx?

A

A395. Diagnostic test: Urinalysis

396
Q

Q396. An 80�yo female presents with vomiting 5 times that day which was thick and brown in appearance. She also complains of severe abdominal pain that began the previous night and has gotten worse and that she has had no BM or flatus throughout the day. She has no History of previous surgery and underwent a colonoscopy 1 month ago for chronic constipation, which elicited normal results. What is the most likely cause of this bowel obstruction?

A

A396. Sigmoid Volvulus

397
Q

Q397. How is Total Body Water calculated in men and women?

A

A397. Men: 60% of body weight

398
Q

Q398. A patient�s recent blood glucose levels have been high at 500 mg/dL. This morning her sodium was 134 mmol/L. What is the corrected sodium level? (Eqn)

A

A398. (Na + [glucose � 100] x 0.016) =

399
Q

Q399. How is plasma osmolality calculated? (Eqn)

A

An osmolar gap is present if the measured and calculated osmolarity differ by how much?

400
Q

Q400. What causes a bluish discoloration of the periumbilical area?

A

What is another sign of this?

401
Q

Q401. Dx for the triad of HTN, bradycardia and irregular respirations?

A

A401. Dx: increased ICP

402
Q

Q402. Dx for calf pain on forced dorsiflexion of the foot in patient (Homan�s sign)

A

A402. Dx: DVT

403
Q

Q403. What are the two signs of a basilar skull fracture?

A

A403. Raccoon Eyes and Battle�s sign (ecchymosis over the mastoid process)

404
Q

Q404. What is Budd�Chiari syndrome?

A

A404. Thrombosis of hepatic veins

405
Q

Q405. MC indication for surgery with Crohn�s Dz?

A

A405. Small Bowel Obstruction

406
Q

Q406. MC vessel involved in a bleeding duodenal ulcer?

A

A406. Gastroduodenal artery

407
Q

Q407. MC bacteria in stool?

A

A407. Bacteroides fragilis (�B. frag�)

408
Q

Q408. MC electrolyte deficiency causing Ileus?

A

A408. Hypokalemia

409
Q

Q409. MC cause of Large Bowel Obstruction

A

A409. Colon Cancer

410
Q

Q410. MC type of Volvulus?

A

A410. Sigmoid volvulus

411
Q

Q411. MC bacteria causing UTI?

A

A411. E. coli

412
Q

Q412. MC benign tumor of the liver?

A

A412. Hemangioma

413
Q

Q413. A 55�yo man presents with a 20�year History of heartburn. During endoscopy a Biopsy demonstrates a high�grade columnar dysplasia consistent with Barrett�s esophagus. What is the most appropriate Tx?

A

A413. Esophageal resection

414
Q

Q414. What is the most important part of the surgical correction of Zenker�s diverticulum?

A

A414. Myotomy of the Cricopharyngeus muscle

415
Q

Q415. What are two main causes of non�anion gap metabolic acidosis?

A

How can you tell which is the problem?

416
Q

Q416. What is a common cause of post�op tachyarrhythmia?

A

What is the Tx?

417
Q

Q417. What is the next step in a patient presenting with a confirmed Acute MI?

A

(2 possible)

418
Q

Q418. A 60�yo female is post�op on mechanical ventilation. Her blood chemistry shows a Respiratory Acidosis. What initial change in the ventilator is most appropriate?

A

What (2) vent changes are used to improve the patient�s oxygenation?

419
Q

Q419. What do the thyroid labs look like in Graves Disease?

A

A419. Decreased TSH

420
Q

Q420. How does Secondary Hyper� and Hypo� thyroidism present in labs of TSH and T�4?

A

A420. Hyper: Increased TSH

421
Q

Q421. What is the most serious complication following surgical treatment for a Thyroidectomy?

A

A421. Recurrent Nerve Damage

422
Q

Q422. What is the first step in diagnosing a mass on the thyroid?

A

What is the difference between a Hot and Cold lesion?

423
Q

Q423. After performing a VMA for a pheochromocytoma, what imaging exam is most specific in localizing the lesion?

A

A423. MIBG (a NE analog)

424
Q

Q424. A 42�yo female was victim of a MVA and has been in the ICU for 2 weeks. She has been stable and on a vent for ARDS. She then suddenly gets acute hypotension (80/42) in addition to WBC of 9,000, HCT = 33%, Na = 130, K = 5.3, Cl = 110. You give the patient 2L of crystalloids but the vitals remain unchanged. A NE drip is started and the BP remains in the 80s/40s. What is the likely cause of this patient�s hypotension?

A

A424. Acute Adrenal Insufficiency; (Addisonian crisis: considered in any patient with unexplained hypotension that does not respond to fluid or pressors; occurs when the normal response of glutocorticoid release is impaired, most often in patients with long�term steroid use experiencing the stress of illness or surgery)

425
Q

Q425. What is the disasterous complication of a Supracondylar fracture of the Humerus?

A

A425. Volkmann�s Contracture

426
Q

Q426. What nerve and artery travel along the mid�Humeral shaft and can be damaged in a fracture to that area?

A

A426. Radial nerve

427
Q

Q427. Where is the MC place for a Mallory�Weiss tear?

A

A427. In the Stomach near the GE junction

428
Q

Q428. What is the most proven risk factor of Pancreas cancer?

A

What is the best initial diagnostic test?

429
Q

Q429. Why is a posterior hip dislocation an emergency?

A

A429. To avoid Posterior Avascular Necrosis

430
Q

Q430. What is the ECG sign with Primary Hyperparathyroidism?

A

A430. Shortened QT on ECG

431
Q

Q431. What is the required margin of resection for a melanoma of the following size:

A
  1. In situ
432
Q

Q432. What is used to Dx Achalasia?

A

A432. Esophageal Manometry

433
Q

Q433. A 54�yo male presents with angina�like chest pain that is usually assoc with stress and is relieved by nitrates. He is worked�up for an MI, but his troponin and ECG are normal. Dx?

A

A433. Diffuse Esophageal Spasm

434
Q

Q434. What is the MCC of an acute appendicitis?

A

A434. Lymphoid Hyperplasia

435
Q

Q435. What type of portal system shunt decreases the risk of developing encephalopathy?

A

A435. Warren distal Splenorectal shunt

436
Q

Q436. After undergoing a portal shunt procedure one week ago, the patient has become confused and combative. His breathing is unlabored and vitals are normal, but there is a foul smell to his breath and he has asterixis. Dx?; What is seen in the blood sample?

A

A436. Dx: Hepatic Encephalopathy

437
Q

Q437. What is the cause of hypotension in Septic shock?

A

A437. Cytokines from the inflammatory response cause loss of systemic vascular resistance

438
Q

Q438. Infant presents with excessive salivation and repeated episodes of coughing, choking and cyanosis. Dx?

A

A438. Dx: Esophageal Atresia

439
Q

Q439. Infant is vomiting and on abdominal films there is a �soap bubble� sign in the ileum. Dx?

A

Tx?

440
Q

Q440. What bacteria are worrisome after a spenectomy?

A

A440. Encapsulated bacteria; (Strep pneumonia, H. influnzae, Meningococcus)

441
Q

Q441. What is a common cause of sudden or unexplained hyperglycemia on a post�op patient on TPN?

A

A441. Infection

442
Q

Q442. What complication related to TPN may cause a patient to get a HCO3 of 30 and go into Respiratory Failure?

A

A442. Increased CO2 production

443
Q

Q443. What is an appropriate test if you suspect Clostridium Difficile?

A

A443. Stool Toxin Assay

444
Q

Q444. Aside from trauma, what are (2) other causes of Hypovolemic shock?

A

A444. Small Bowel Obstruction and Pancreatitis

445
Q

Q445. What neurologic condition may develop if low sodium is corrected too rapidly?

A

What (2) problems can cause a greater risk of this occurring in the patient?

446
Q

Q446. What can be a devastating outcome of correcting a Hypernatremic patient too rapidly?

A

A446. Cerebral edema

447
Q

Q447. A 12�yo child presents with pain and inflammation over the ball of his left foot and red streaks extending up the inner aspect of his leg. He removed a wood splinter from his foot the previous day. What is the most likely bug?

A

A447. Streptococcus

448
Q

Q448. A 3�yo presents with a non�tender abdominal mass. What is the MCC of extracranial solid tumors seen in children?

A

First step?

449
Q

Q449. A 3�yo child presents with an abdominal mass, HTN and hematuria. Dx?; Diagnostic test?

A

A449. Dx: Wilm�s Tumor

450
Q

Q450. A 3�yo presents with abdominal distention and a RUQ mass that moves with respiration. Dx?

A

Diagnostic test?

451
Q

Q451. A 3�yo presents with a sacrococcygeal mass. Dx?

A

A451. Dx: Teratoma; (most common site in children, followed by mediastinum)

452
Q

Q452. What is the leading cause of death following a carotid endarterectomy?

A

A452. MI

453
Q

Q453. What drug is most beneficial in closing a Crohn�s fistula?

A

A453. Infliximab

454
Q

Q454. A patient with a history of Ulcerative Colitis has fever, tachycardia, a distended abdomen and a dilated transverse colon. Dx?; Tx?

A

A454. Dx: Toxic Megacolon; Tx: NPO, Nasogastric decompression, IV antibiotic and IV steroids for 48 hours, then Surgery if problem persists; (colonic decompression should not be attempted b/c it can lead to perforation)

455
Q

Q455. What is the MCC of a mediastinal tumor?

A

What systemic condition is classically assoc with it?

456
Q

Q456. Dx: patient presents with caf� au lait pigmentation and neurofibromas of the GI tract

A

A456. Von Recklinghausen Dz

457
Q

Q457. MC site of sarcoma metastasis?

A

A457. Lungs

458
Q

Q458. MCC of Acute Mesenteric Ischemia?

A

Chronic Mesenteric Ischemia?

459
Q

Q459. A 43�yo male presents with acute onset of chest pain since an episode of vomiting 6 hours ago. He has decreased breath sounds on the left and a mild left pleural effusion. Dx?

A

Diagnostic test?

460
Q

Q460. What is the Chemotherapy treatment for Melanoma in Stage III?

A

Stage IV?

461
Q

Q461. A 57�yo asymptomatic male is noted to have a prostate that is normal in shape and size on rectal examination. His PSA is 18 (nml < 2.5). What is the best next step for this patient?

A

A461. Transrectal US exam with prostate Biopsy

462
Q

Q462. A 72�yo man has a lower abdominal mass and constantly dribbles urine. Dx?

A

What is the best next step?

463
Q

Q463. What unusual lab value can be elevated with a Small Bowel Obstruction?

A

A463. Serum Amylase

464
Q

Q464. A 67�yo male presents with N/V 25 days post� appendectomy. He is afebrile, the abdomen is tender and distended. His WBC is 18,00, Na is 140, K is 4.2, Cl is 105 and Bicarb is 14. Dx?; Diagnostic test?; Tx?

A

A464. Dx: Anion Gap Acidosis secondary to Lactic Acid reflecting Ischemic Bowel

465
Q

Q465. A 34�yo diabetic woman complains of a 6�month History of numbness and pain in her right hand and thumb that wakes her up at night. Dx?

A

Tx? (2 together)

466
Q

Q466. A 42�yo woman presents with persistent epigastric and back pain, Leukocytosis and a serum amylase of 1,300. Dx?; Initial Tx?

A

A466. Dx: Biliary Pancreatitis

467
Q

Q467. Dx: Fever, intermittent RUQ pain and Jaundice

A

A467. Cholangitis

468
Q

Q468. Dx: Persistent abdominal pain, RUQ tenderness and leukocytosis

A

A468. Acute Cholecystitis

469
Q

Q469. A 52�yo alcoholic with cirrhosis presents with acute hematemesis. Bleeding esophageal varicies are found on UGI endoscopy. Tx?

A

A469. Tx: Endoscopic Sclerotherapy

470
Q

Q470. What is the management of a patient presenting with Melena?

A

(2 steps)

471
Q

Q471. A 75�yo man develops hematochezia and presents with hemodynamic instability. His vital improve slightly with PRBC. What is the next step in Management? (3 together)

A

A471. 1. NG tube

472
Q

Q472. What is the most common site of occlusion with Claudication?

A

A472. Superficial Femoral Artery

473
Q

Q473. A 22�yo hemodynamically stable, intoxicated man presents with stab wounds to the left throacoabdominal region and abdomen. What are the next steps in management? (4 steps)

A

A473. Initially Observe for 24 � 48 hours:; 1. CXR (to look for pneumothorax, hemothorax and free air in the abdomen); 2. Wound exploration and Peritoneal Lavage; 3. Then repeat the study in 6 hours to make sure no changes are seen; 4. if changes: Diagnostic Laparoscopy to insure bowel is not punctured

474
Q

Q474. A 24�yo male complains of colicky intermittent umbilical and RLQ abdominal pain of 24 hours, anorexia and nausea. He is afebrile. Dx?

A

A474. Gastroenteritis; (not appendicitis, b/c appendicitis does not present with intermittent pain)

475
Q

Q475. A 58�yo woman has acute chest pain and dyspnea post� operatively. The results from cardiopulmonary and abdominal exams are nonspecific. She has a minimally elevated leukocyte count and normal cardiac enzyme levels. Arterial blood gas studies indicate respiratory alkalosis and hypoxemia. CXR and ECG show no pathology. Dx?

A

Next step?

476
Q

Q476. Ten days after undergoing liver transplantation, a patient’s levels of gamma�glutamyl transferase (GGT), alkaline phosphatase, and bilirubin begin to rise. What is the most appropriate next step in diagnosis?

A

A476. Ultrasound of biliary tract and Doppler studies of the anastomosed vessels; (in all other transplants aside from the liver, it would be considered acute rejection and biopsies should be taken)

477
Q

Q477. What are the (2) rules for Breast cancer in a pregnant woman?

A

A477. The treatment of breast cancer in a pregnant woman should be the same as that in a nonpregnant woman, except for two restrictions:; 1. no chemotherapy during the first trimester; 2. no radiation therapy during the pregnancy

478
Q

Q478. A 62�year�old man reports an episode of gross, painless hematuria. There is no history of trauma. The man does not smoke and has had no other symptoms referable to the urinary tract. Physical examination, including rectal examination, is unremarkable. His serum creatinine is 0.8 mg/dL, and, except for the presence of many red cells, his urinalysis is normal and shows no red cell casts. His hematocrit is 46%. What are the most appropriate initial steps in the workup?; (2)

A

A478. 1. Intravenous pyelogram (IVP); 2. Cystoscopy; (Although most patients with hematuria have benign disease, silent hematuria can be due to renal, ureteral, or bladder cancer, and these malignant processes must be effectively ruled out. IVP will visualize kidney and ureteral tumors, but is not reliable enough to rule out bladder cancer. Direct visualization of the bladder mucosa by cystoscopy is the only way to rule out bladder cancer)

479
Q

Q479. A 45�year�old man with alcoholic cirrhosis is bleeding from a duodenal ulcer. He has required 6 units of blood over the past 8 hours, and all conservative measures to stop the bleeding, including irrigation with cold saline, IV vasopressin, and endoscopic use of the laser have failed. At the time of admission, when he had received only one unit of blood, showed a bilirubin of 4.5 mg/dL, a prothrombin time of 22 seconds, and a serum albumin of 1.8 g/dL. He was mentally clear when he came in, but has since then developed encephalopathy and is now in a coma. What best describes his operative risk?

A

A479. Prohibitive regardless of attempts to improve his condition

480
Q

Q480. A 22�year�old convenience store clerk is shot once with a .38 caliber revolver. The entry wound is in the left midclavicular line, 2 inches below the nipple. There is no exit wound. He is hemodynamically stable. A chest x�ray film shows a small pneumothorax on the left, and demonstrates the bullet to be lodged in the left paraspinal muscles. In addition to the appropriate treatment for the pneumothorax, what will this patient most likely need?

A

A480. Any gunshot wound below the nipples involves the abdomen, and such is the case here. The management of all gunshot wounds of the abdomen requires Exploratory Laparotomy

481
Q

Q481. A 68�year�old man is brought to the emergency department with excruciating back pain that began suddenly 45 minutes ago. The pain is constant and is not exacerbated by sneezing or coughing. He is diaphoretic and has a systolic blood pressure of 90 mm Hg. There is an 8�cm pulsatile mass deep in his epigastrium, above the umbilicus. A chest x�ray film is unremarkable. Two years ago, he was diagnosed with prostatic cancer and was treated with orchiectomy and radiation. At that time, his blood pressure was normal, and he had a 6�cm, asymptomatic abdominal aortic aneurysm for which he declined treatment. What is the most likely diagnosis?

A

A481. Rupturing abdominal aortic aneurysm; (Abdominal aortic aneurysms have a high incidence of rupture once they reach or exceed a size of 6 cm. Often, the first manifestation is excruciating back pain, as the blood leaks into the retroperitoneal space before the aneurysm blows out into the peritoneal cavity. The combination of a big aneurysm and sudden severe back pain should always lead to this presumptive diagnosis)

482
Q

Q482. A 55�year�old woman has been known for years to have mitral valve prolapse. She has now developed exertional dyspnea, orthopnea, and atrial fibrillation. She has an apical, high�pitched, holosystolic heart murmur that radiates to the axilla and back. Because of her deterioration, surgery has been recommended. What is the most appropriate procedure?

A

A482. Mitral valve annuloplasty; (Whenever possible, repair of the native mitral valve is preferable to replacement. The way to repair an insufficient valve is to tighten the annulus, bringing the leaflets closer to one another)

483
Q

Q483. A 23�year�old woman seeks help for exquisite pain with defecation and blood streaks on the outside of her stools, which she has been having for several weeks. She has no fever or leukocytosis. Physical examination done under spinal anesthesia, confirmed the suspected diagnosis, and she is placed on stool softeners and appropriate topical agents, but without success. She is willing to undergo more aggressive treatment. What is the most appropriate next step? (3 possible)

A

A483. 1. Lateral Internal Sphincterotomy; 2. Forceful Dilation under anesthesia; 3. Botulinum toxin Injections; (The clinical picture is classic for anal fissure, which is perpetuated by the fact that the anal sphincter is too tight.”)”

484
Q

Q484. A 42�year�old woman is thrown from the car which lands on her and crushes her. In the ER it is determined that she has a pelvic fracture, which is confirmed by portable x�rays done as she is being resuscitated. Her initial blood pressure is 50/30 mm Hg, and her pulse is 160/min and barely perceptible. Thirty minutes later, after 2 L Ringer’s lactate and 2 U packed cells have been infused, her pressure is only 70/50 mm Hg, and her pulse is 130/min. A sonogram done in the emergency department shows no intra�abdominal bleeding, and a diagnostic peritoneal lavage confirms that there is no blood in the abdomen. Rectal and vaginal exams show no injuries to those organs. There is no blood in her urine. What is the most appropriate next step in management?

A

A484. External fixation of the pelvis; (Pelvic fractures can bleed massively, and often the source is torn veins that are not easily controlled. Minimizing the motion of the bone fragments by external fixation can be helpful, and it will not make the situation worse)

485
Q

Q485. Several months after sustaining a crushing injury to his arm, a patient complains bitterly about constant, burning, agonizing pain in that arm, that does not respond to the usual analgesic medications. The pain in his arm is aggravated by the slightest stimulation of the area, such as rubbing from the shirt sleeves. The arm is cold, cyanotic, and moist, but it is not swollen. Pulses at the wrist are normal, and neurologic function of the three major nerves is intact. Dx?; Diagnostic test?; Tx?

A

A485. Dx: Causalgia; Diagnostic test: Sympathetic block; Tx: Sympathetectomy; (If sympathetic block relieves the symptoms, permanent cure will be obtained with surgical sympathectomy)

486
Q

Q486. A 71�year�old West Texas farmer of Irish ancestry has a nonhealing, indolent, punched out, clean�looking 2�cm ulcer over the left temple. The ulcer has been slowly growing over the past 3 years. There are no enlarged lymph nodes in the head and neck. Next step?

A

A486. Full thickness biopsy of the EDGE of the lesion; (The edge of the lesion offers the best information for the pathologist. A biopsy of the center of the lesion deprives the pathologist of all the clues that are found at the interface between the tumor and the normal skin, and in large lesions it runs the risk of sampling necrotic tumor that has outgrown its blood supply)

487
Q

Q487. A 35�year�old man falls on an outstretched hand and comes in complaining of wrist pain. He relates that he was not able to break the fall, and that the heel of his hand took the brunt of his full weight as it hit the pavement. On physical examination, he is distinctly tender to palpation over the anatomic snuff box. Anteroposterior and lateral x�rays are negative. What is the most likely diagnosis and most appropriate next step in management?

A

A487. Dx: Carpal Navicular fracture

488
Q

Q488. A 56�year�old man develops slow, progressive paralysis of the facial nerve on one side. It took several weeks for the full� blown paralysis to become obvious, and it has been present now for 3 months. It affects both the forehead and the lower face. He has no pain anywhere, and no palpable masses by physical examination. What is the most likely diagnosis?

A

A488. Facial nerve tumor; (Slowly developing paralysis on one side is suggestive of a tumor. Since there are no physical findings, such as pain or a mass, to place the tumor in the parotid gland, it must be impinging on the nerve itself at a more proximal location)

489
Q

Q489. A young mother complains of pain along the radial side of the wrist and the first dorsal compartment. She relates that the pain is often caused by the position of wrist flexion and simultaneous thumb extension that she assumes to carry the head of her baby. On physical examination, the pain is reproduced by asking her to hold her thumb inside her closed fist, and then forcing the wrist into ulnar deviation. What is the most likely diagnosis?

A

A489. Tenosynovitis of the abductor or extensor tendons of the thumb; (De Quervain’s tenosynovitis); (The clinical presentation is classic for De Quervain’s tenosynovitis, including the positive Finkelstein sign: the pain reproduced by ulnar deviation to stretch the affected tendons)

490
Q

Q490. A 44�year�old homeless woman presents to the emergency department because she is bleeding from the breast.” Physical examination shows a huge, fungating, ulcerated mass that occupies the entire right breast and is firmly attached to the chest wall. The right axilla is full of hard masses that are not movable either. Core biopsies of the breast are read as highly undifferentiated infiltrating ductal carcinoma, and assay for estrogen and progesterone receptors are negative. What is the most appropriate next step in management?”

A

A490. Radiation and chemotherapy; (Although this is an impressive, very advanced cancer with a poor prognosis, it can be expected to shrink significantly with local radiation plus systemic chemotherapy. It may do so to the point at which a palliative mastectomy becomes technically feasible, something that cannot be done at this time)

491
Q

Q491. A 54�year�old African American man, with a history of smoking and drinking, describes progressive dysphagia that began 3 months ago. He first noticed difficulty swallowing meat; it then progressed to other solid foods, then to soft foods, and now to liquids as well. He locates the place where the food sticks” at the lower end of the sternum. He has lost 30 pounds. What is the most appropriate first step in diagnosis?”

A

A491. Barium swallow; (The clinical picture is that of a cancer of the esophagus, and given his race and history of smoking and drinking, it is probably a squamous cell carcinoma. The description of where the dysphagia is felt suggests a low location, but such subjective feelings lack precision. The tumor will eventually be seen and biopsied by endoscopy, but the endoscopist will first want to know the exact location of the tumor and the degree to which the lumen is occluded. Otherwise, there is a high risk of instrumental perforation of the esophagus. The best way to obtain that information is to do a barium swallow)

492
Q

Q492. A 45�year�old woman, who wears high�heeled, pointed shoes, complains of pain in the forefoot after prolonged standing or walking. Occasionally, she also experiences numbness, a burning sensation, and tingling in the area. Physical examination shows no obvious deformities and a very tender spot in the third interspace, between the third and fourth toes. There is no redness, limitation of motion, or signs of inflammation. What is the most likely diagnosis?

A

A492. Morton’s Neuroma; (The location and circumstances are classic for Morton’s neuroma, a benign neuroma of the third plantar interdigital nerve)

493
Q

Q493. A 66�year�old woman picks up a bag of groceries out of the supermarket cart to place it in the trunk of her car. As she does so, she feels sharp, sudden pain in the middle of her arm, and her humerus suddenly breaks. She arrives at the emergency department cradling her arm; the deformity leaves no doubt that the bone is broken. What is the most likely reason for the fracture?

A

A493. Bony metastasis to the humerus from breast cancer; (A fracture from such trivial strain signifies a very weakened bone. In this age and gender, the most likely cause would be a lytic lesion from metastatic breast cancer. In a man, we would have suspected metastatic lung cancer � not prostate, because prostatic metastases are blastic rather than lytic)

494
Q

Q494. A 62�year�old man has had gastroesophageal reflux disease diagnosed by pH monitoring, and present for several years. He has been less than totally compliant with medical management, which he follows when the pain is bad, but discontinues when he feels better. Endoscopy and biopsies show severe peptic esophagitis, with Barrett’s esophagus and early dysplastic changes, but no overt carcinoma. Additional tests show good esophageal motility, with low pressure in the lower esophageal sphincter and normal gastric emptying. What is the most appropriate treatment at this time?

A

A494. Laparoscopic Nissen fundoplication

495
Q

Q495. A pedestrian is hit by a car. The paramedics report that he was unconscious at the site, and he arrives at the emergency department in coma, strapped to a head board with sandbags on either side of his head. Initial survey shows stable vital signs, and his pupils are of equal size and reactive to light. He is rapidly intubated by the nasotracheal route over a flexible bronchoscope and then sent for CT scans of the head. As he is being positioned on the table, it is noted that there is a sizable hematoma behind his right ear and that clear fluid is dripping from the ear canal. What is most advisable, considering this new finding?

A

A495. Extend the CT scan to include his neck; (The clinical findings are indicative of a fracture of the base of the skull, and thus he has sustained very significant trauma to the head. The integrity of the cervical spine has to be ascertained, and the CT that he is already going to have can be extended to include that area)

496
Q

Q496. During the performance of a supraclavicular node biopsy under local anesthesia, a hissing sound is suddenly heard, and the patient suddenly dies. At the time of the catastrophic event, the target node was under traction, and the final cut was being made blindly behind it to free it up completely. The patient, an otherwise healthy 24�year�old man, was inhaling at that moment. What has most likely caused this patient’s death?

A

A496. Major Vein injury with Air Embolism; (Major veins at the base of the neck have negative pressure during inspiration and, if injured at that moment, will suck air rather than bleed. The air embolism then leads to sudden death)

497
Q

Q497. A man who weighs 65 kg sustains second and third degree burns over both of his lower extremities when his pants catch on fire. When examined shortly thereafter, it is ascertained that virtually all of the skin from both groins to the tip of the toes, front and back, has been burned. According to the modified Parkland formula, what is the approximate total amount of IV fluid that he can be expected to require during the first 24 hours post�burn?

A

A497. 11,360 mL; (4 mL of Ringer’s lactate per kilogram of body weight, times the percentage of the body surface that has been burned; plus an additional 2000 mL of dextrose 5% in water to cover MAINTENANCE fluid needs. In the rule of nines,” each lower extremity represents 18% of the body surface. Thus, this patient has sustained a 36% body burn: 4 � 65 � 36 = 9360, plus 2000 = 11,360)”

498
Q

Q498. A 49�year�old woman has a firm, 2�cm mass in the right breast that has been present for 3 months. Mammogram has been read as cannot rule out cancer,” but it cannot diagnose cancer either. A fine�needle aspiration of the mass (FNA) and cytology do not identify any malignant cells. What is the most appropriate next step in management?”

A

A498. Core or Incisional Biopsies; (Negative findings do not have the same diagnostic value that positive findings have. If this had been a 19�year�old woman suspected of having a fibroadenoma, one would have been satisfied with negative imaging studies (in that age, a sonogram) or the negative FNA. But, at age 49, the risk of cancer is much higher. Given negative findings in the least invasive studies, one would feel compelled to move to more aggressive ways to obtain better tissue sampling)

499
Q

Q499. A 44�year�old woman has a palpable nodule in the right lobe of her thyroid gland. The nodule measures 2 cm and is firm. The rest of the thyroid gland cannot be felt and is not tender. She also describes losing weight in spite of a ravenous appetite, palpitations, and heat intolerance. She is thin, fidgety, and constantly moving, with moist skin and a pulse of 105/min. She has no exophthalmos or pretibial edema. Her TSH is reported as much lower than normal, and she has elevated levels of free T4. What is the most appropriate next step in diagnosis?

A

A499. Radionuclide Thyroid Scan; (the patient is hyperthyroid. She has no clinical signs of acute thyroiditis, and none of the other findings seen in Graves disease; however, she has a thyroid nodule, which raises the possibility of a hyperfunctioning adenoma (a hot” adenoma). If indeed she does, the scan will show that the nodule traps all the iodine, with suppression of the rest of the gland)”

500
Q

Q500. Patient hurts his knee, causing him the ability to bend his leg inward to a greater extent then normally possible. What structure is damaged?

A

A500. Lateral Collateral Ligament

Clinical Medicine (7 decks)

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