Surgery Flashcards
1
Q
Q001. assessing the airway
A
A001. patient conscious and speaking ��> airway present
2
Q
Q002. airway procedures
A
A002. in the field ��> cricothyroidotomy
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
4
Q
Q004. traumatic causes of shock
A
A004. bleeding
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
6
Q
Q006. hemorrhagic shock in penetrating injuries management
A
A006. surgical intervention first to stop the bleeding then volume replacement
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
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
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
10
Q
Q010. preferred route of fluid resuscitation in shock
A
A010. 2 16�gauge peripheral IV lines
11
Q
Q011. types of head trauma
A
A011. penetrating
12
Q
Q012. head trauma + loss of consciousness
A
A012. CT of head required to rule out hematoma
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
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)
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
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
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
18
Q
Q018. chronic subdural hematoma
A
A018. in elderly or severe alcoholics
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
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
21
Q
Q021. neck stab wounds
A
A021. if upper and middle zones in asymptomatic patients ��> observation
22
Q
Q022. blunt neck trauma
A
A022. if neurologic deficits or pain to local palpation of cervical spine ��> cervical spine CT
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
24
Q
Q024. rib fracture
A
A024. can be deadly in elderly
25
Q025. plain pneumothorax
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
26
Q026. hemothorax
A026. penetrating trauma due to broken rib or weapon
27
Q027. blunt chest trauma
A027. monitor hidden injuries; blood gases,; chest x�ray,; cardiac enzymes,; ECG
28
Q028. sucking chest wound
A028. flap sucks air in with inspiration and closes in expiration
29
Q029. flail chest
A029. multiple rib fracture with paradoxical breathing; treat lung contusion with fluid restriction, colloid solutions and diuretics
30
Q030. pulmonary contusion
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
31
Q031. myocardial contusion
A031. suspect it in sternal fractures
32
Q032. traumatic rupture of diaphragm
A032. bowel in chest on left side by physical exam and x�ray
33
Q033. traumatic rupture of aorta
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
34
Q034. traumatic rupture of trachea or major bronchus
A034. suggested by subcutaneous emphysema or large air leak from chest tube
35
Q035. air embolism
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
36
Q036. fat embolism
A036. multiple trauma patient with long�bone fractures; petechial rash in axilla and neck; fever, tachycardia and respiratory distress; treatment is respiratory support
37
Q037. types of abdominal trauma
A037. gunshot wounds
38
Q038. gunshot wound to abdomen
A038. any entry or exit below nipple line is considered to involve abdomen
39
Q039. stab wound to abdomen
A039. if penetration is evident (protruding viscera), hemodynamic instability or peritoneal irritation��> exploratory laparotomy; else ��> digital exploration; if equivocal ��> CT scan
40
Q040. signs of internal bleeding after blunt trauma
A040. same as shock; hypotension,; fast pulse,; low CVP and urine,; pale,; cold,; anxious,; shivering,; sweating,; thirsty
41
Q041. body compartments where internal bleeding can cause shock
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
42
Q042. to determine abdominal internal bleeding after blunt trauma
A042. suspect in multiple trauma patient with normal chest x�ray, no evidence of pelvic or femur fracture who develops signs of shock
43
Q043. intraabdominal bleeding diagnosis
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
44
Q044. ruptured spleen
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
45
Q045. intraoperative coagulopathy after abdominal trauma
A045. treated with platelet packs and fresh�frozen plasma
46
Q046. abdominal compartment syndrome
A046. abdominal surgical wound cannot be closed in surgery or opens up in postoperative
47
Q047. pelvic fractures
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
48
Q048. urologic injuries
A048. penetrating trauma
49
Q049. hallmark of urologic injuries
A049. hematuria in trauma patient
50
Q050. urethral traumatic injury
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
51
Q051. bladder traumatic injury
A051. associated with pelvic fracture, diagnosed by retrograde cystogram which must include postvoid film; surgical repair is done
52
Q052. renal traumatic injury
A052. usually associated with lower rib fracture
53
Q053. scrotal hematoma
A053. can attain alarming size but no specific intervention needed unless sonogram shows ruptured testicle
54
Q054. fracture of the penis
A054. usually due to sex with woman on top; sudden pain, large shaft hematoma and normal glans; emergency surgery required to prevent impotence
55
Q055. penetrating injury to extremities considerations
A055. determine whether there�s vascular injury or not
56
Q056. combined injuries of arteries, nerves and bone
A056. first do bone,; then vascular repair,; then nerve,; finally a fasciotomy (to prevent compartment syndrome)
57
Q057. crushing injury of extremities
A057. risks ��> hyperkalemia (do fluid correction), myoglobinemia, myoglobinuria, renal failure and compartment syndrome
58
Q058. chemical burns
A058. massive irrigation to remove offending ageng
59
Q059. electrical burns
A059. always deeper than they appear; may involve myoglobinemia, myoglobinuria and renal failure; orthopedic injuries due to massive muscle contraction
60
Q060. respiratory burns
A060. smoke inhalation in fires
61
Q061. rule of nines for adults
A061. head and arms ��> 9% each
62
Q062. rule of nines for babies
A062. head ��> 18%
63
Q063. Parkland formula
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
64
Q064. burn care
A064. topical silver sulfadiazine is agent of choice
65
Q065. tetanus prophylaxis
A065. required for all bites
66
Q066. dog bites
A066. considered provoked if dog was petted while eating or teased
67
Q067. snake bites
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
68
Q068. bee stings
A068. wheezing and rash may occur with hypotension; give 0.3�0.5ml epinephrine 1:1,000; remove stingers without squeezing
69
Q069. black widow spider bite
A069. the spider is black with red hourglass on belly; nausea, vomiting, generalized muscle cramps; treat with IV calcium gluconate
70
Q070. brown recluse spider bite
A070. skin ulcer with necrotic center surrounded by halo of erythema
71
Q071. human bites
A071. bacteriollogically the dirtiest
72
Q072. orthopedic disorders in children
A072. dysplasia of the hip
73
Q073. developmental dysplasia of the hip
A073. uneven gluteal folds
74
Q074. Legg�Perthes disease
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
75
Q075. slipped capital femoral epiphysis
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
76
Q076. septic hip
A076. orthopedic emergency in little toddlers with history of febrile illness and refusal to move the hip
77
Q077. acute hematogenous osteomyelitis in children
A077. history of febrile illness with severe localized bone pain
78
Q078. genu varum
A078. bow legs normal up to age 3
79
Q079. genu valgus
A079. knock knee is normal between 4�8 years
80
Q080. Osgood�Schlatter disease
A080. osteochondrosis of tibial tubercle seen in teenagers with persistent pain over tibial tubercle aggravated by contraction of quadriceps
81
Q081. club foot
A081. seen at birth with feet turned inward
82
Q082. scoliosis in pediatrics
A082. seen mostly in adolescent girls
83
Q083. osteogenic sarcoma
A083. ages 10�25
84
Q084. Ewing sarcoma
A084. ages 5�15 and grows at diaphysis
85
Q085. metastatic bone tumors
A085. seen min adults from breast (lytic lesions) or prostate (blastic lesions)
86
Q086. multiple myeloma
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
87
Q087. soft tissue sarcomas
A087. firm, mass fixed to surrounding structures which metastasizes to lungs not lymph nodes; treat with wide local excision, radiotherapy and chemo
88
Q088. general considerations about fractures
A088. x�rays should include 2 views at 90 degrees to one another and include joints above and below fracture
89
Q089. clavicular fractures
A089. typically at junction of middle and distal third
90
Q090. anterior dislocation of the shoulder
A090. most common dislocation
91
Q091. posterior shoulder dislocation
A091. occurs after seizures or electrical burns
92
Q092. Colles fracture
A092. fall on outstretched hand results in painful and deformed wrist
93
Q093. Monteggia fracture
A093. diaphyseal fracture of proximal ulna with anterior dislocation of radial head results from direct blow to ulna
94
Q094. Galeazzi fracture
A094. fracture of distal third of radius from direct blow with dorsal dislocation of distal radioulnar joint
95
Q095. scaphoid fracture
A095. fall on outstretched hand
96
Q096. metacarpal neck fractures
A096. closed fist hits hard surface
97
Q097. hip fractures
A097. typically elderly who sustain fall
98
Q098. femoral neck fractures
A098. can compromise vasculature of femoral head
99
Q099. intratrochanteric fractures
A099. less likely to lead to avascular necrosis; treat with open reduction, pinning and anticoagulation to prevent DVT and pulmonary embolism
100
Q100. femoral shaft fracture
A100. treat with intramedullary fixation
101
Q101. knee injury
A101. has swelling; if no swelling, unlikely to be serious; MRI is best diagnosis
102
Q102. collateral ligament injury
A102. lateral blow displaces medial ligaments and vice versa
103
Q103. anterior cruciate ligament injury
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
104
Q104. posterior cruciate ligament injury
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
105
Q105. meniscal tears
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
106
Q106. tibial stress fractures
A106. seen in young men subjected to forced marches
107
Q107. tibia and fibula fractures
A107. often when pedestrian is hit by car
108
Q108. rupture of Achilles tendon
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
109
Q109. fracture of ankle
A109. falling on inverted foot; AP, lateral and mortise x�rays are diagnostic; if displacement, open reduction and external fixation is needed
110
Q110. compartment syndrome
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
111
Q111. pain under cast
A111. orthopedic emergency requires removal of cast and examination of limb
112
Q112. open fracture
A112. orthopedic emergency requires cleaning in OR and suitable reduction within 6 hours from injury
113
Q113. posterior hip dislocation
A113. hip pain, leg is shortened, adducted and internally rotated; emergency reduction is needed to prevent avascular necrosis
114
Q114. gas gangrene
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
115
Q115. radial nerve injury
A115. dorsiflexion is affected
116
Q116. popliteal artery injury
A116. due to posterior dislocation of knee; check pulses, Doppler and arteriogram; delayed restoration of flow requires prophylactic fasciotomy
117
Q117. carpal tunnel syndrome
A117. numbness and tingling in distribution of median nerve reproduced by tapping or pressing median nerve over carpal tunnel
118
Q118. trigger finger
A118. finger is acutely flexed and patient is unable to extend it
119
Q119. DeQuervain tenosynovitis
A119. due to holding baby's head with wrist flexion and thumb extension
120
Q120. felon
A120. abscess in pulp of fingertip due to neglected penetrating injury
121
Q121. gamekeeper thumb
A121. injury of ulnar collateral ligament due to forced hyperextension of thumb
122
Q122. jersey finger
A122. injury to flexor tendon when finger is forcefully extended; when making a fist, the distal phalanx does not flex; manage with splinting
123
Q123. mallet finger
A123. extended finger is forcefully flexed and extensor tendon is ruptured
124
Q124. traumatically amputated digits
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
125
Q125. lumbar disk herniation presentation
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
126
Q126. lumbar disk herniation diagnosis
A126. straight leg raising gives excruciating pain
127
Q127. lumbar disk herniation management
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)
128
Q128. cauda equina syndrome
A128. distended bladder
129
Q129. ankylosing spondylitis
A129. progressive chronic back pain and morning stiffness worse at rest
130
Q130. metastatic malignancy
A130. progressive back pain worse at night and unrelieved by rest or position
131
Q131. diabetic ulcers
A131. indolent and located at pressure points
132
Q132. arterial insufficiency ulcers
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
133
Q133. venous stasis ulcers
A133. develops in chronically edematous indurated hyperpigmented skin of legs
134
Q134. foot ulcers
A134. need work up for diabetes and arteriosclerotic disease
135
Q135. Marjolin ulcer
A135. is a squamous cell carcinoma of the skin that develops in chronic leg ulcer from burns or osteomyelitis
136
Q136. plantar fasciitis
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
137
Q137. preop assessment: cardiac ��> ejection fraction
A137. below 35% poses too much risk
138
Q138. preop assessment: cardiac ��> JVD
A138. worst factor indicating cardiac risk
139
Q139. preop assessment: cardiac ��> MI
A139. next worst predictor of cardiac complications
140
Q140. preop assessment: cardiac risk factors
A140. JVD
141
Q141. preop assessment: pulmonary risk factors
A141. smoking (high PCO2) ��> quit smoking 8 weeks prior to surgery with intensive respiratory therapy; do FEV1 and if abnormal, blood gases
142
Q142. preop assessment: hepatic risk factors
A142. 40% mortality ��> bilirubin > 2, albumin < 3, PT > 16, encephalopathy; 80% mortality ��> bilirubin > 4, albumin < 2, ammonia > 150mg/dL
143
Q143. preop assessment: nutritional risk factors
A143. 20% weight loss in 2 months
144
Q144. preop assessment: diabetic coma
A144. absolute contraindication to surgery
145
Q145. postoperative fever causes
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
146
Q146. postop complications
A146. fever
147
Q147. postop bacteremia
A147. 30�45 minutes of invsive procedures
148
Q148. postop atelectasis
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
149
Q149. postop deep abscess
A149. fever 2 10�15 days postop
150
Q150. periop MI
A150. chest pain only in 30%, the rest present with MI complications; treatment directed at complications; cannot use thrombolytic therapy
151
Q151. postop PE
A151. ABGs ��> hypoxemia, hypocapnia; diagnosis ��> MC is CT +� contrast (angio CT); gold standard is angiogram; use heparin
152
Q152. intraop aspiration
A152. leads to chemical acid injury; prevent with NPO and antacids before induction; treat with bronchoscopy lavage, bronchodilators and respiratory support
153
Q153. intraop tension pneumothorax
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
154
Q154. causes of disorientation/coma postop
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
155
Q155. postop oliguria/anuria
A155. urinary retention ��> feels need to void but can't
156
Q156. postop paralytic ileus
A156. after abdominal surgery; mild distention, no pain, absent bowel sounds; prolonged by hypokalemia
157
Q157. early mechanical bowel obstruction
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
158
Q158. Ogilvie syndrome
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"
159
Q159. postop wound complications
A159. wound dehiscence
160
Q160. wound dehiscence
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)
161
Q161. evisceration
A161. complication of wound dehiscence
162
Q162. GI fistula
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
163
Q163. postop hypernatremia
A163. if gradual ��> rapid volume repletion with slow tonicity ��> use D51/2 NS
164
Q164. water intoxication
A164. CNS symptoms of hyponatremia
165
Q165. hypokalemia
A165. from GI loss, loop diuretics, increased aldosterone, correction of DKA; correct at < 10mEq/h
166
Q166. hyperkalemia
A166. from renal failure, aldosterone antagonists, crush injuries, dead tissue, acidosis; treat with calcium (neutralize effects on membrane, fastest); dextrose/insulin; exchange resins; dialysis
167
Q167. mechanical intestinal obstruction
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
168
Q168. mechanical intestinal obstruction by hernia
A168. from incarcerated hernia
169
Q169. appendicitis
A169. anorexia followed by vague paeriumbilical pain
170
Q170. colonic polyps
A170. most malignant ��> familial polyposis, villous adenoma, adenomatous polyp; not premalignant ��> juvenile, Peutz�Jeghers, inflammatory and hyperplastic
171
Q171. indications for surgery in ulcerative colitis
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
172
Q172. hemorrhoids
A172. internal ��> painless bleed, rubber band ligation; external ��> painful; prolapsed internal ��> pain and itching; rule out cancer in all anorectal diseases
173
Q173. anal fissure
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
174
Q174. ischiorectal perirectal abscess
A174. fever, perirectal pain, no bowel movements; local inflamation signs; surgical drainage; if diabetic ��> necrosis ��> watch closely; rule out cancer in all anorectal disease
175
Q175. fistula in ano
A175. draining tract lateral to anus after ischiorectal abscess drainage
176
Q176. GI bleeding stats
A176. 75% upper GI, 25% colon or rectum; if young person with GI bleed ��> suspect upper; if elderly ��> can be from anywhere
177
Q177. GI bleed work�up
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
178
Q178. acute abdominal pain from perforation
A178. sudden onset severe constant generalized abdominal pain
179
Q179. acute abdominal pain from obstruction
A179. sudden onset colicky pain that is localized
180
Q180. acute abdominal pain from inflammation
A180. gradual onset constant that starts as ill�defined and then localizes
181
Q181. acute abdominal pain from ischemia
A181. severe sudden abdominal pain with blood in the lumen
182
Q182. primary peritonitis
A182. ascites along with mild generalized acute abdomen and equivocal findings
183
Q183. acute abdomen management
A183. exploratory laparotomy after ruling out:
184
Q184. mesenteric ischemia
A184. acute abdomen in patient with Afib or recent MI
185
Q185. pyogenic liver abscess
A185. complication of billiary tract disease, acute ascending cholangitis; fever, leukocytosis, tender liver; ultrasound or CT are diagnostic; treat with percutaneous drainage
186
Q186. amebic abscess of liver
A186. mexico connection
187
Q187. types of jaundice
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
188
Q188. billiary obstruction from stone
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
189
Q189. Courvoisier�Terrier sign
A189. large thin�walled distended gallbladder by ultrasound in malignant obstruction
190
Q190. causes of obstructive jaundice
A190. stone in common duct
191
Q191. obstructive jaundice by tumor work�up
A191. first ultrasound ��> dilated gallbladder ��> CT ��> adenocarcinoma of head of pancreas
192
Q192. ampulla of Vater cancer
A192. malignant obstructive jaundice
193
Q193. gallstone disease spectrum
A193. asymptomatic gallstone ��> billiary colic ��> acute cholecystitis ��> acute ascending cholangitis ��> obstructive jaundice ��> biliary pancreatitis
194
Q194. biliary colic
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
195
Q195. acute cholecystitis
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
196
Q196. acute ascending cholangitis
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
197
Q197. biliary pancreatitis
A197. stone obstructs bile and pancreatic ducts at ampulla
198
Q198. acute edematous pancreatitis
A198. due to alcohol or gallstones; high amylase or lipase; key finding is high hematocrit; treat with NPO, rest and fluids
199
Q199. acute hemorrhagic pancreatitis
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
200
Q200. pancreatic abscess
A200. acute suppurative pancreatitis seen in CT after days of persistent fever and leukocytosis
201
Q201. pancreatic pseudocyst
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
Q202. glucagonoma
A202. hyperglycemia
203
Q203. esophageal atresia
A203. excessive salivation shortly after birth with choking on first feed
204
Q204. imperforated anus
A204. may be VACTER presentation
205
Q205. congenital diaphragmatic hernia
A205. always on the left; problem is lung hypoplasia with respiratory distress; intubate, ventilate, wait 3�4 days for lung maturation then surgery
206
Q206. gastroschisis Vs. omphalocele
A206. gastroschisis defect is to the right of the normal cord with loose bowels
207
Q207. double bubble sign
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
Q208. intestinal atresia
A208. multiple air�fluid levels throughout abdomen
209
Q209. necrotizing enterocolitis
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
Q210. meconium ileus
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
Q211. hypertrophic pyloric stenosis
A211. nonbilous projectile vomiting after feeding at 3 weeks
212
Q212. biliary atresia
A212. persistent progressive jaundice in 6�8 week baby
213
Q213. Hirchsprung
A213. chronic constipation
214
Q214. Meckel diverticulum / diverticulitis
A214. lower GI bleed in kid
215
Q215. vascular rings
A215. pressure on tracheobronchial tree and esophagus
216
Q216. atrial septal defect
A216. faint pulmonary flow systolic murmur
217
Q217. ventricular septal defect
A217. failure to thrive
218
Q218. patent ductus arteriosus
A218. bounding pulses
219
Q219. tetralogy of Fallot
A219. right to left shunt with cyanosis; bluish hue, clubbing and relieved by squatting; systolic ejection murmur, right ventricular hypertrophy
220
Q220. transposition of great vessels
A220. kept alive by ASD, VSD or PDA; immediate cyanosis
221
Q221. coin lesion and lung cancer work�up
A221. check previous x�ray
222
Q222. operability of lung cancer
A222. need aminimum FEV1 of 800
223
Q223. subclavian steal syndrome
A223. atherosclerotic stenotic plaque at origin of subclavian
224
Q224. abdominal aortic aneurysm
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
Q225. arteriosclerotic disease of lower extremities
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
Q226. atrial embolization
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
Q227. dissecting aortic aneurysm of thoracic aorta
A227. due to hypertension
228
Q228. amblyiopia
A228. interference with processing of images in first 6�7 years of life most commonly by strabismus
229
Q229. strabismus
A229. surgically correct to prevent amblyiopia
230
Q230. acute angle closure glaucoma
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
Q231. orbital cellulitis
A231. eyelids are inflammed
232
Q232. retinal detachment
A232. flashes of light and floaters in the eye
233
Q233. embolic occusion of retinal artery
A233. unilateral sudden loss of vision
234
Q234. thyroglosal duct cyst
A234. midline; pulling tongue out retracts the mass; surgical removal of cyst, middle segment of hyoid bone and track to base of tongue
235
Q235. brachial cleft cyst
A235. anterior edge of sternocleidomastoid
236
Q236. cystic hygroma
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
Q237. recently discovered enlarged lymph node
A237. complete history and physical + follow�up 3�4 weeks
238
Q238. persistent enlarged lymph node
A238. could be inflammatory but cancer has to be ruled out
239
Q239. squamous cell carcinoma of mucosa of head and neck
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
Q240. facial nerve tumor
A240. unilateral facial peripheral paralysis that is insidious
241
Q241. parotid tumor
A241. most are adenomas but predispose to malignant
242
Q242. cavernous sinus thrombosis
A242. diplopia in patient with sinusitis; emergency IV antibiotics, CT and drainage is required
243
Q243. epistaxis
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
Q244. parinaud syndrome
A244. tumor of pineal gland
245
Q245. neurogenic claudication
A245. back pain worsened by back extension or standing up, relieved by flexion or sitting down; diagnosis is spinal stenosis; do MRI
246
Q246. reflex sympathetic dystrophy
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
Q247. testicular torsion
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
Q248. acute epididymitis
A248. severe testicular pain of sudden onset
249
Q249. combined obstruction and infection of urinary tract
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
Q250. urologic diagnostic procedures
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
Q251. posterior urethral valves
A251. MCC for a newborn not urinating in first day
252
Q252. hypospadia
A252. urethral opening on ventral side of penis
253
Q253. vesicouretheral reflux
A253. signs of peylonephritis in a child
254
Q254. low implantation of urether
A254. normal voiding plus wet with urine all the time in girls but asymptomatic in boys
255
Q255. ureteropelvic junction obstruction
A255. normal diuresis is ok but large volume cannot handle it (teenage goes drinking)
256
Q256. renal cell carcinoma
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
Q257. cancer of bladder
A257. smoking predisposes; hematuria, irritative voiding symptoms; work�up ��> first IVP; best test is cystoscopy
258
Q258. prostatic cancer
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
Q259. testicular cancer
A259. painless testicular mass
260
Q260. urether stone
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
Q261. psychogenic impotence
A261. does not interfere with nighttime erections
262
Q262. hyperacute transplant rejection
A262. vascular thrombosis within minutes
263
Q263. acute transplant rejection
A263. 5 days � 3 months
264
Q264. chronic transplant rejection
A264. years after the transplant with insidious loss of function
265
Q265. what conditions is carpal tunnel syndrome related to
A265. DM
266
Q266. what is Charcot's triad associated with
A266. ascending cholangitis
267
Q267. what is Charcot's triad
A267. fever
268
Q268. what is ascending cholangitis
A268. infection of bile duct ��> sepsis and multiorgan failure
269
Q269. tx for ascending cholangitis
A269. Antibiotics and supportive care
270
Q270. what is the best way to dx stones in GB?
A270. U/S (98�99% sensitivity); not the best way to dx stones in CBD, only 50% are visualized
271
Q271. what is ERCP
A271. way to visulaize CBD
272
Q272. dx of choledocolithiasis
A272. dilated CBD on U/S
273
Q273. how to manage a patient w gal
stones and pancreatitis
274
Q274. causes of LGI bleeds if >40 yo
A274. diverticulosis
275
Q275. dx of LGI bleed + pain
A275. ischemic bowel
276
Q276. how to localize LGI bleed
A276. colonoscopy
277
Q277. cause of overt LGI bleed in children
A277. meckel's diverticulum
278
Q278. cause of overt LGI bleed in 20�60 yo
A278. diverticulitis
279
Q279. cause of overt LGI bleed in >60 yo
A279. divertic
280
Q280. what is RBC scan
A280. used to dx bleeding if >.1 ml/min
281
Q281. advantage of mesenteric angiography
A281. 0.5�1.0 ml/min in order to be visualized... can see faster bleeds
282
Q282. common causes of overt LGI bleeds in children
A282. Meckel's diverticulum
283
Q283. common causes of LGI bleeds in 20�60 yo
A283. IBD
284
Q284. common causes of LGI bleeds in >60 yo
A284. neoplasm
285
Q285. when are maroon colored stools seen?
A285. LGI bleeds without rectum/anus involvment
286
Q286. features of a rectal bleed
A286. formed stool streaked with blood , or fresh blood at the end of a BM
287
Q287. what is mortality in head injury with hypoxia and hypotension?
A287. 0.75
288
Q288. how much is mortality increased in hypoxia?
A288. 2x
289
Q289. how to tx increased intracranial pressure?
what precautions must be taken?
290
Q290. which type of hematoma (subdural or epidural) is more common
A290. subdural
291
Q291. what does sluggish pupil dilation indicate
A291. early sign of temporal lobe hernaition
292
Q292. 1st step in managing SBO
A292. fluid resusc
293
Q293. complications of SBO
A293. strangulation
294
Q294. why is SBO so painful
A294. severe bowel distention ��> venous congestion, decreased bowel perf, necrosis; bowel ischemia 2/2 strangulation
295
Q295. what is an ileus
A295. distention from non�obstructive causes
296
Q296. gallstone ileus
A296. mechanical obstruction of SB b/c of large gallstone in bowel lumen
297
Q297. causes of SBO in child
A297. hernia
298
Q298. causes of SBO in adult
A298. tumor
299
Q299. presentation of SBO
A299. passage of intestinal lumenal contents ��> cramplike abdominal pain
300
Q300. association of BM with SBO
A300. usually BM at very start of obstruction, followed by increasdd peristalsis and
301
Q301. dx if there is stool on DRE of patient with SBO
A301. ileus, NOT mechanical obstruction
302
Q302. what is early post�op SBO
A302. sx that occur <40d following surgery; results from narrowed lumen, exact cause not known
303
Q303. w/u for post�op SBO
A303. CT to rule out infection
304
Q304. tx for post�op SBO
A304. supportive care
305
Q305. cause of chronic mesenteric ischemia
A305. occlussion of 2/3 BV
306
Q306. Dx of chronic mesenteric ischemia
A306. if no ATH, use arteriograpyhy
307
Q307. tx for chronic mesenteric ischemia
A307. revasc with antegrade aortomesenteric bypass/perivisceral aortic endarterectomy
308
Q308. when to operate on acute mesenteric ischemia
A308. this is a surgical emergency!
309
Q309. causes of acute mesenteric ischemia
A309. embolism in SMA or celiac artery
310
Q310. which part of the small intestines is spared in acute mesenteric ischemia? why?
A310. prox jejunum b/c of collaterals
311
Q311. tx for acute mesenteric ischemia
A311. embolectomy
312
Q312. when should a AAA be repaired
A312. 5cm
313
Q313. #1 cause of morbidity and mortality in AAA repair
A313. cardiac complications
314
Q314. how should AAA found on physical exam be confirmed
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
Q315. what are the 2 types of AAA repairs
benefits of each
316
Q316. disadvantages to EvAR
A316. rquire imaging f/u every 3�6 mos
317
Q317. presentation of AAA rupture
A317. back pain
318
Q318. management of acute pancreatitis
A318. resuscitative measures/supp O2
319
Q319. complications of acute pancreatitis
A319. hemorrhage
320
Q320. process of infected pancreatic necrosis
A320. 2/2 infx by bowel organisms
321
Q321. pancreatic abscess cause and tx
A321. accumulation of pus and infectious debris
322
Q322. tx of infectious pancreatic pseudocyst
A322. percutaneous/operative drainage
323
Q323. Ranson's criteria seen on admission
A323. WBC >16,000; glucose >200; age > 55yo; AST >250; LDH >350
324
Q324. Ranson's criteria following 48 hrs
A324. HCt fall by 10%
325
Q325. value of Ranson's criteria
A325. more criteria have more severe dz and increased risk of comlication and death
326
Q326. what indicates severe acute pancreatitis
A326. necrosis of pancreas; 50% have inx and increased microvasc permeability; �> increased volume los; decreased perfusion of kidneys, lungs, etc
327
Q327. when should a contrast�enhanced CT of the pancreas be done?
A327. if pancreatitis dx is in question
328
Q328. what, if seen on CT, wouldu indicate severe dz and increased risk of complications
A328. 2+ extrapancreatic fluid collections or necrosis of >50% of pancreas
329
Q329. management of necrotizing pancreatitis
A329. 50% of time,; complicate by infection, so must adminster proph Antibiotics when necrosis is confirmed on CT
330
Q330. how should gallstone pancreatitis be treated?
A330. cholecystectomy after pancreatitis has resolved
331
Q331. which Antibiotics penetrate pancreas
A331. imipenem
332
Q332. Tx for carotid artery dz
A332. surgery should always be done on sx side 1st, if both are affected
333
Q333. when should elective CEA be done
A333. if 60% stenosis is seen, unless patient is high risk
334
Q334. what is complication o fCEA or medical management of carotid artery dz
A334. stroke can occur with either
335
Q335. how is amt of stenosis determined in carotid artery dz
A335. US; if that is unclear, do MR angiogram, carotid angiogram or CT reconstruction angiogram
336
Q336. what are risk factors for CEA
A336. prior radiation to the neck
337
Q337. what is a short term tx for carotid artery dz
A337. stent
338
Q338. When should barium enema be used in dx diverticulitis
A338. never� there is sig risk involved with intraeritoneal leakage of barium
339
Q339. dx of diverticulitis
A339. CT scan will show colonic wall thickening, mesenteric fat stranding; can see diverticulae
340
Q340. complications of diverticulitis
A340. perforation
341
Q341. tx of abscesses from diverticulitis
A341. if small, Antibiotics; if big, CT�guided drainage + Antibiotics; if no imrpovement after 72 hrs, surgery
342
Q342. if there is an increased risk of recurrence with diverticulitis, management?
A342. elective surgical resection with primary anastamosis even if prior flare�up was treated conservatively
343
Q343. how should uncomplicated diverticulitis be treated?
A343. monitor hydration, give IV Antibiotics, bowel rest and observation
344
Q344. how should complicated diverticulitis be treated?
A344. surgical resection
345
Q345. what is fascial dehiscence?
A345. disruption of fascial closure within 3 days of operation, with or without operation
346
Q346. complications of fascial dehiscence
A346. enterocutaneous fistula
347
Q347. risk factors for fascial dehiscence
A347. failure of surgical technique, anesthetic relaxation; >70 yo; DM; infx; malnutrition; pulm dz
348
Q348. tx of fascial dehiscence
A348. wound care
349
Q349. time frame that fascial dehiscence is most likely to occur?
A349. up to 3 weeks following surgery, after that, fibrous scar formation has enough strengthh to prevent evisceration
350
Q350. vitamins involved in wound healing
A350. vitamin c, a, b6; (collagen cross linking)
351
Q351. tx of ptx
A351. tube thoracostomy/needle aspiration
352
Q352. difference btwn primary and 2ndary spontaneous ptx
A352. 1ary: from spont rupture of blebs; 2ndary: from bullous emphysematous dz, CF, CA, PCP, necrotizing infx, copd
353
Q353. sx of tension ptx
A353. dyspnea
354
Q354. tx perf of duo ulcers
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
Q355. tx of perf gastric ulcer
A355. + closure of perf or excise/resect ulcer w 1ary repair or Billroth I/II
356
Q356. tx of obstructing gastric ulcer
A356. antretomy and Whipple
357
Q357. are H2 blockers or PPIs more effective in tx ulcers
A357. PPIs
358
Q358. string sign
A358. seen in hypertrophic pyloric stenosis, showing narrowed pylorus
359
Q359. stack of coins sign
A359. intestinal obstruction
360
Q360. tx for intussusception
A360. radiographic reduction; if fails, open surgery
361
Q361. incision through previous scar� good or bad?
A361. good. promotes wound healing
362
Q362. featuress of large bowel ischemia
A362. minimal pain
363
Q363. when should a colectomy be done on a patient with UC
A363. 10�20 yrs with dz... (after 10 yrs, CA risk increases 4x)
364
Q364. complication of typhoid fever
A364. Peyer's patches bleed /perf in 2�3rd week following sx
365
Q365. how to stop intractable bleeding
A365. use laparoscopic towels to pack abdomen
366
Q366. what is seen on EKG of patient with high Mg?
how can it be reversed
367
Q367. what is seen with low Na on EKG
A367. nothing
368
Q368. what is seen with low K on EKG
A368. flattened T waves and U waves
369
Q369. when is succussion splash seen in the abdomen
A369. any sort of obstruction
370
Q370. what are the most common causes of pyloric obstruction
A370. duo ulcer
371
Q371. how is mild Na deficiency tx?
severe Na defic?
372
Q372. how is ARDS monitored
A372. ABG
373
Q373. surgery = physiological stress
A373. surgery = physiological stress
374
Q374. benefits of enteral feeding
A374. preserves gut mucosal mass and nml gut flora
375
Q375. benefits of parenteral feedings
A375. good for rapid administration
376
Q376. what happens if TPN is suddenly DCd?
A376. rebound hypoglycemia,; give D10W when TPN is suddennly DCd
377
Q377. what does surgery do to fluid levels
A377. following surgery, increased cortisol levels ��> increased sugar in serum ��> increased urine output
378
Q378. what TPN additive is good for liver encephalopathy
A378. lactulose
379
Q379. how is AAA dx?
A379. U/S then CT scan to det true size
380
Q380. A patient is diagnosed with invasive ductal adenocarcinoma. What is the most important factor in the staging of this patient�s cancer?
A380. Lymph Node Involvement
381
Q381. Which nerve, if damaged in an axillary dissection, will result in only a sensory deficit?
A381. Intercostobrachial nerve
382
Q382. What cancer drug can cause pulmonary fibrosis?
A382. Bleomycin
383
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?
A383. Diverticulitis; (Colorectal fistula is also a cause, but is very rare)
384
Q384. What is considered the triangle of Calot in GB surgery?
A384. Cystic Duct,; Common Hepatic Duct,; Cystic Artery
385
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?
A385. Gallstone Ileus
386
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?
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
Q387. Type of Shock:; An 18�yo male restrained driver with tachycardia, hypotension, and a rigid abdomen
A387. Hypovolemic shock
388
Q388. Type of Shock:; An 80�yo nursing home resident, febrile, unresponsive, hypotensive, with gram�negative rods cultured in urine.
A388. Distributive shock
389
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
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
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
A390. Cardiogenic shock
391
Q391. What is Duke�s staging for Colon Cancer (A�D)?
A391. A: limited to Mucosa
392
Q392. What is the proper medical Tx (post�colectomy) for Duke�s stage C Colon Cancer?
What common cancer Tx is not used in colon cancer?
393
Q393. What is the Diagnostic Test for patients with Rectal Cancer?
What is the adjuvant Tx for T3�T4 Rectal Cancer? (2)
394
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?
A394. Dx: Perforated Diverticulum
395
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?
A395. Diagnostic test: Urinalysis
396
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?
A396. Sigmoid Volvulus
397
Q397. How is Total Body Water calculated in men and women?
A397. Men: 60% of body weight
398
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)
A398. (Na + [glucose � 100] x 0.016) =
399
Q399. How is plasma osmolality calculated? (Eqn)
An osmolar gap is present if the measured and calculated osmolarity differ by how much?
400
Q400. What causes a bluish discoloration of the periumbilical area?
What is another sign of this?
401
Q401. Dx for the triad of HTN, bradycardia and irregular respirations?
A401. Dx: increased ICP
402
Q402. Dx for calf pain on forced dorsiflexion of the foot in patient (Homan�s sign)
A402. Dx: DVT
403
Q403. What are the two signs of a basilar skull fracture?
A403. Raccoon Eyes and Battle�s sign (ecchymosis over the mastoid process)
404
Q404. What is Budd�Chiari syndrome?
A404. Thrombosis of hepatic veins
405
Q405. MC indication for surgery with Crohn�s Dz?
A405. Small Bowel Obstruction
406
Q406. MC vessel involved in a bleeding duodenal ulcer?
A406. Gastroduodenal artery
407
Q407. MC bacteria in stool?
A407. Bacteroides fragilis (�B. frag�)
408
Q408. MC electrolyte deficiency causing Ileus?
A408. Hypokalemia
409
Q409. MC cause of Large Bowel Obstruction
A409. Colon Cancer
410
Q410. MC type of Volvulus?
A410. Sigmoid volvulus
411
Q411. MC bacteria causing UTI?
A411. E. coli
412
Q412. MC benign tumor of the liver?
A412. Hemangioma
413
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?
A413. Esophageal resection
414
Q414. What is the most important part of the surgical correction of Zenker�s diverticulum?
A414. Myotomy of the Cricopharyngeus muscle
415
Q415. What are two main causes of non�anion gap metabolic acidosis?
How can you tell which is the problem?
416
Q416. What is a common cause of post�op tachyarrhythmia?
What is the Tx?
417
Q417. What is the next step in a patient presenting with a confirmed Acute MI?
(2 possible)
418
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?
What (2) vent changes are used to improve the patient�s oxygenation?
419
Q419. What do the thyroid labs look like in Graves Disease?
A419. Decreased TSH
420
Q420. How does Secondary Hyper� and Hypo� thyroidism present in labs of TSH and T�4?
A420. Hyper: Increased TSH
421
Q421. What is the most serious complication following surgical treatment for a Thyroidectomy?
A421. Recurrent Nerve Damage
422
Q422. What is the first step in diagnosing a mass on the thyroid?
What is the difference between a Hot and Cold lesion?
423
Q423. After performing a VMA for a pheochromocytoma, what imaging exam is most specific in localizing the lesion?
A423. MIBG (a NE analog)
424
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?
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
Q425. What is the disasterous complication of a Supracondylar fracture of the Humerus?
A425. Volkmann�s Contracture
426
Q426. What nerve and artery travel along the mid�Humeral shaft and can be damaged in a fracture to that area?
A426. Radial nerve
427
Q427. Where is the MC place for a Mallory�Weiss tear?
A427. In the Stomach near the GE junction
428
Q428. What is the most proven risk factor of Pancreas cancer?
What is the best initial diagnostic test?
429
Q429. Why is a posterior hip dislocation an emergency?
A429. To avoid Posterior Avascular Necrosis
430
Q430. What is the ECG sign with Primary Hyperparathyroidism?
A430. Shortened QT on ECG
431
Q431. What is the required margin of resection for a melanoma of the following size:
1. In situ
432
Q432. What is used to Dx Achalasia?
A432. Esophageal Manometry
433
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?
A433. Diffuse Esophageal Spasm
434
Q434. What is the MCC of an acute appendicitis?
A434. Lymphoid Hyperplasia
435
Q435. What type of portal system shunt decreases the risk of developing encephalopathy?
A435. Warren distal Splenorectal shunt
436
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?
A436. Dx: Hepatic Encephalopathy
437
Q437. What is the cause of hypotension in Septic shock?
A437. Cytokines from the inflammatory response cause loss of systemic vascular resistance
438
Q438. Infant presents with excessive salivation and repeated episodes of coughing, choking and cyanosis. Dx?
A438. Dx: Esophageal Atresia
439
Q439. Infant is vomiting and on abdominal films there is a �soap bubble� sign in the ileum. Dx?
Tx?
440
Q440. What bacteria are worrisome after a spenectomy?
A440. Encapsulated bacteria; (Strep pneumonia, H. influnzae, Meningococcus)
441
Q441. What is a common cause of sudden or unexplained hyperglycemia on a post�op patient on TPN?
A441. Infection
442
Q442. What complication related to TPN may cause a patient to get a HCO3 of 30 and go into Respiratory Failure?
A442. Increased CO2 production
443
Q443. What is an appropriate test if you suspect Clostridium Difficile?
A443. Stool Toxin Assay
444
Q444. Aside from trauma, what are (2) other causes of Hypovolemic shock?
A444. Small Bowel Obstruction and Pancreatitis
445
Q445. What neurologic condition may develop if low sodium is corrected too rapidly?
What (2) problems can cause a greater risk of this occurring in the patient?
446
Q446. What can be a devastating outcome of correcting a Hypernatremic patient too rapidly?
A446. Cerebral edema
447
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?
A447. Streptococcus
448
Q448. A 3�yo presents with a non�tender abdominal mass. What is the MCC of extracranial solid tumors seen in children?
First step?
449
Q449. A 3�yo child presents with an abdominal mass, HTN and hematuria. Dx?; Diagnostic test?
A449. Dx: Wilm�s Tumor
450
Q450. A 3�yo presents with abdominal distention and a RUQ mass that moves with respiration. Dx?
Diagnostic test?
451
Q451. A 3�yo presents with a sacrococcygeal mass. Dx?
A451. Dx: Teratoma; (most common site in children, followed by mediastinum)
452
Q452. What is the leading cause of death following a carotid endarterectomy?
A452. MI
453
Q453. What drug is most beneficial in closing a Crohn�s fistula?
A453. Infliximab
454
Q454. A patient with a history of Ulcerative Colitis has fever, tachycardia, a distended abdomen and a dilated transverse colon. Dx?; Tx?
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
Q455. What is the MCC of a mediastinal tumor?
What systemic condition is classically assoc with it?
456
Q456. Dx: patient presents with caf� au lait pigmentation and neurofibromas of the GI tract
A456. Von Recklinghausen Dz
457
Q457. MC site of sarcoma metastasis?
A457. Lungs
458
Q458. MCC of Acute Mesenteric Ischemia?
Chronic Mesenteric Ischemia?
459
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?
Diagnostic test?
460
Q460. What is the Chemotherapy treatment for Melanoma in Stage III?
Stage IV?
461
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?
A461. Transrectal US exam with prostate Biopsy
462
Q462. A 72�yo man has a lower abdominal mass and constantly dribbles urine. Dx?
What is the best next step?
463
Q463. What unusual lab value can be elevated with a Small Bowel Obstruction?
A463. Serum Amylase
464
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?
A464. Dx: Anion Gap Acidosis secondary to Lactic Acid reflecting Ischemic Bowel
465
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?
Tx? (2 together)
466
Q466. A 42�yo woman presents with persistent epigastric and back pain, Leukocytosis and a serum amylase of 1,300. Dx?; Initial Tx?
A466. Dx: Biliary Pancreatitis
467
Q467. Dx: Fever, intermittent RUQ pain and Jaundice
A467. Cholangitis
468
Q468. Dx: Persistent abdominal pain, RUQ tenderness and leukocytosis
A468. Acute Cholecystitis
469
Q469. A 52�yo alcoholic with cirrhosis presents with acute hematemesis. Bleeding esophageal varicies are found on UGI endoscopy. Tx?
A469. Tx: Endoscopic Sclerotherapy
470
Q470. What is the management of a patient presenting with Melena?
(2 steps)
471
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)
A471. 1. NG tube
472
Q472. What is the most common site of occlusion with Claudication?
A472. Superficial Femoral Artery
473
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)
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
Q474. A 24�yo male complains of colicky intermittent umbilical and RLQ abdominal pain of 24 hours, anorexia and nausea. He is afebrile. Dx?
A474. Gastroenteritis; (not appendicitis, b/c appendicitis does not present with intermittent pain)
475
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?
Next step?
476
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?
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
Q477. What are the (2) rules for Breast cancer in a pregnant woman?
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
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)
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
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?
A479. Prohibitive regardless of attempts to improve his condition
480
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?
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
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?
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
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?
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
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)
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
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?
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
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?
A485. Dx: Causalgia; Diagnostic test: Sympathetic block; Tx: Sympathetectomy; (If sympathetic block relieves the symptoms, permanent cure will be obtained with surgical sympathectomy)
486
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?
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
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?
A487. Dx: Carpal Navicular fracture
488
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?
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
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?
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
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?"
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
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?"
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
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?
A492. Morton's Neuroma; (The location and circumstances are classic for Morton's neuroma, a benign neuroma of the third plantar interdigital nerve)
493
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?
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
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?
A494. Laparoscopic Nissen fundoplication
495
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?
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
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?
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
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?
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
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?"
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
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?
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
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?
A500. Lateral Collateral Ligament
