Surgery Flashcards
What is the initial step in management in any patient with acute trauma or change in mental status?
assess and establish an airway (if necessary)
What is the best initial way to establish an airway in a trauma/ change in mental status patient?
orotracheal intubation
What is the best initial way to establish an airway in a trauma pt with cervical spine injury?
use of flexible bronchoscope
but can also perform orotracheal intubation with manual cervical immobilization
What is the best initial way to establish an airway in a trauma pt with extensive facial trauma and/ or bleeding into the airway?
cricothyroidotomy
can also perform percutaneous tracheostomy
What is the best initial step in management of a trauma or mental status change pt with an oxygen saturation of less than 90%?
obtain arterial blood gas (ABG)
as well as determined likely cause of hypoxia
A pt presenting after a chest trauma with hypotension, distended neck veins, elevated CVP (central venous pressure), enlarged heart on CXR, electrical alternans on EKG, pulsus paradoxus and normal breath sounds most likely suffers from …
Pericardial Tamponade
What is the best initial treatment for pericardial tamponade?
pericardiocentesis
place needle to remove fluid
What is the next best step in management for a pt with pericardial tamponade if pericardiocentesis is unsuccessful?
pericardial window
A pt presenting after chest trauma with hypotension, distended neck veins, elevated CVP (central venous pressure), difficulty breathing, tracheal deviation, absent breath sounds and hyper-resonance to percussion most likely suffers from …
Tension Pneumothorax
What is the best initial treatment for a pt with tension pneumothorax?
insert large bore needle or IV catheter into pleural space (at second intercostal space) followed by chest tube placement
What is the best way to control the site of the bleeding in an abdominal trauma (or any trauma)?
apply direct pressure to visible sites
avoid blind clamping or tourniquet
What is the best next step in the management of a pt with abdominal trauma and hypovolemic shock who is hemodynamically unstable?
fluid resuscitation (2 large bore IVs in periphery and/or central venous access)
(if pt responds promptly, then unlikely still bleeding)
What are the five things that should be done in preparation for an immediate exploratory laparotomy in a trauma pt?
- setup 2 large bore IV lines
- give floods and blood
- type and screen
- insert foley catheter
- administer IV antibiotics
What is the best way to provide fluid resuscitation in a child (less than 6 years old) who is hemodynamically unstable with poor access?
intraosseous cannulation in proximal tibia (with Ringer’s lactate at 20 ml/kg)
A pt presenting with hypotension, tachycardia, is warm and flushed and has a recent history of medication use (penicillin)/ spinal anesthesia/ exposure to allergen (bee sting) most likely suffers from …
Vasomotor Shock (Distributive Shock)
What is the first step in management of a pt presenting with vasomotor shock (distributive shock)?
vasoconstrictors and fluids
True or False. An object embedded in a pt should be removed in the emergency room or at the scene of the accident.
False
all impaled objects are to be removed in the OR under a controlled setting
What is the next step in management of a pt with an asymptomatic head injury that lead to a closed skull fracture (linear skull fracture) and scalp laceration?
clean laceration
surgery is not needed
What is the next step in management of a pt with an asymptomatic head injury that lead to a comminuted, depressed fracture and scalp laceration?
Surgical repair/ craniotomy (for comminuted/ depressed skull fracture)
What is the best initial step in management of a pt with head trauma and loss of consciousness (or other symptoms) and normal neuro exam?
CT of head and neck without contrast
if normal, can discharge with 24 hour supervision
What medications should be given to all patients with open skull fractures? (2)
- tetanus toxoid
2. prophylactic antibiotics
A pt presenting with ecchymosis around both eyes, ecchymosis behind the ear or clear fluid dripping from the ear or nose after a head trauma most likely suffers from …
Basal Skull Fracture
raccoon eye- ecchymosis around eyes; Battle’s sign- ecchymosis behind ear
What is the best management for a pt presenting with signs/ symptoms of basal skull fracture?
CT scan of head and neck (shows basal skull fracture)
no treatment of CSF leak needed
A pt presents with a head injury to the side of the head (temporal region) resulting in brief loss of consciousness and then return to baseline and CT scan shows a lens shaped hemorrhage in the brain most likely suffers from …
Epidural Hematoma
middle meningeal artery damage
What is the best initial step in management of a pt with CT confirmed epidural hematoma?
Emergency Craniotomy
prevent sudden deterioration
A pt presents with a head injury resulting in fluctuating consciousness (gradual headaches, memory loss, personality changes, dementia, confusion, drowsiness) and CT scan shows semilunar, crescent shaped hematoma most likely suffers from …
Subdural Hematoma
bridging veins
What is the best treatment for a pt with CT confirmed subdural hematoma without midline displacement?
Observation
What is the best treatment for a pt with CT confirmed subdural hematoma with midline displacement?q
Emergency Craniotomy
A pt in a motor vehicle accident in which there was head trauma presenting deeply unconscious most likely suffers from …
Diffuse Axonal Injury
Acceleration-deceleration injury
What is the goal of therapy for a pt suffering from diffuse axonal injury (acceleration-decleration injury)?
prevent further damage from increased intracranial pressure (ICP)
A pt described as having briefly depressed consciousness after head trauma followed by improvement and then progressive drowsiness most likely suffers from …
elevated intracranial pressure
medical emergency
What should always be performed in a trauma/ mental status change patient before performing a lumbar puncture?
head CT to assess for increased intracranial pressure
if perform LP in setting of elevated ICP, pt will herniate and die
What are the first line treatment options for elevated intracranial pressure? (3)
- head elevation
- hyperventilation (vasoconstriction and decreases blood volume in brain)
- avoid fluid overload
What are the second line treatment options for elevated intracranial pressure? (2)
- mannitol (careful of reducing cerebral perfusion)
2. sedation/ hyperthermia (lowers oxygen demand)
What are four indications for abdominal surgery in the setting of an acute abdomen?
- peritonitis (excluding primary peritonitis)
- abdominal pain/ tenderness plus signs of sepsis
- acute intestinal ischemia
- pneumoperitoneum
What is primary peritonitis?
- spontaneous inflammation in kids with neprosis
2. adult with ascites and mild abdominal pain
What are the indications for medically treating a pt with an acute abdomen?
- primary peritonitis
- pancreatitis
- cholangitis
- urinary stones
- mimics of acute abdomen (lower lobe pneumonia, MI, pulmonary ebolism)
- ruptured ovarian cysts
A pt with history of diverticulitis/peptic ulcer/ crohn’s disease develops acute abdominal pain that is sudden, severe, constant and generalized, and the pain is excruciating with any movement most likely suffers from ….
Gastrointestinal Perforation
What is the best diagnostic test for gastrointestinal perforation?
erect CXR (shows free air under diaphragm or falciform ligament)
(can do left lateral decubitis X-ray if too sick to stand)
What is the treatment for gastrointestinal perforation?
NPO, IV fluid hydration, IV antibiotics and emergency surgery
A pt presenting with epigastric pain that wakes pt at night and is referred to the scapula most likely suffers from …
Peptic Ulcer
A pt develops pain in chest/ upper abdomen, dysphagia and/or odynophagia, and subcutaneous emphysema shortly after an endoscopy procedure most likley suffers from …
esophageal perforation
What is the diagnostic test of choice for esophageal perforation?
gastrografin contrast esophagram
What is the treatment for esophageal perforation?
emergent surgery
A pt presents with severe colicky pain, absence of flatus/feces, high pitched bowel sounds, nausea, vomiting and constant movement to find comfort in the setting of prior surgery/ elderly pt with weight loss and anemia or melanotic stools/ recurrent lower abdominal pain/ history of hernia/ sudden abdominal pain in elderly most likely suffers from …
Obstruction
secondary to adhesions/ tumor/ diverticulitis/ incarcerated hernia/ volvulus
What is the most accurate diagnostic tests for an abdominal obstruction?
CT scan of abdomen and pelvis (showing transition point- location at which the obstruction has occured)
What are two other diagnostic tests other than an abdominal CT that can be used in abdominal obstruction?
- CBC and lactate (elevated)
2. supine and erect abdominal X-ray (showing dilated loops of bowel, absence of gas in rectum)
An elderly pt presenting with sudden abdominal pain and has a bird’s beak sign on abdominal x-ray most likely suffers from …
Volvulus
What is the best treatment for abdominal obstruction?
NPO, nasogastric suction, IV fluids and emergency surgery
What is the best initial treatment for abdominal obstruction secondary to volvulus?
proctosigmoidoscopy with rigid instrument leaving rectal tube in place
What is the best treatment for recurrent abdominal obstruction secondary to volvulus?
sigmoid resection
What are the two contraindications for elective repair of abdominal hernias?
- umbilical hernia in kid (less than 2 years old)
2. esophageal sliding hiatal hernia
A middle aged/ elderly pt presents with fever, leukocytosis, acute left lower quadrant pain, peritoneal irritation in left lower quadrant and palpable tender mass most likely suffers from ..
Acute Diverticulitis
in woman, could be fallopian tube or ovaries
What is the most accurate diagnostic test for acute diverticulitis?
CT with contrast (abscess, free air, fat stranding)
What is absolutely contraindicated in a patient with acute diverticulitis?
colonoscopy
What is the treatment for diverticulitis if there are no peritoneal signs?
outpatient antibiotics
What is the treatment for diverticulitis if there is localized peritoneal signs and abscess?
admit pt, NPO, IV fluids, IV antibiotics, and CT guided percutaneous drainage of abscess
What is the treatment for diverticulitis if there is generalized peritonitis or perforation?
emergency surgery
What is the treatment for recurrent attacks of diverticulitis?
elective surgery
What are the risk factors for pancreatitis? (6)
- alcoholism
- gallstones
- meds (thiazides, furosemide, penatmidine, flagyl, tetratcycline)
- hypertriglyceridemia
- trauma
- Post ERCP
A pt presents with abdominal pain radiating to the back with associated nausea and vomiting in the setting of alcoholism/ gallstones/ hypertriglyceridemia/ post-ERCP most likely suffers from …
Acute Pancreatitis
What is the best initial test for suspected acute pancreatitis?
serum amylase and/or lipase (12-48 hours of symptoms)
urine amylase or lipase for 3rd-6th day
What are the signs that suggest hemorrhagic pancreatitis in a pt with pancreatitis presentation? (3)
- lowering hematocrit
- very high WBC (> 18,000), glucose, BUN
- hypocalcemia
What is the best initial treatment for acute pancreatitis?
NPO, nasogastric suction, IV fluids
What complication of pancreatitis can occur 10 days after onset of symptoms presenting with persistent fevers and high WBC count and what is the treatment?
abscess; surgical drainage
What complication of pancreatitis can occur 5 weeks after initial onset presenting with anorexia, pain and palpable mass and what is the treatment?
pseudocyst
- if painful and >6cm and > 6 weeks, surgical internal drainage or endoscopic drainage
- if infected, percutaneous external drainage
- if painless, no drainage
What are two major side effects of chronic pancreatitis?
- diabetes (give insulin)
2. steatorrhea (replace pancreatic enzymes)
A pt presents with anorexia developing into vague periumbilical pain that then becomes sharp, severe, constant and localized to the right lower quadrant, palpation of LLQ increases the pain felt in RLQ, fever, and leukocytosis (WBC 10,000-15,000) most likely suffers from …
Acute Appendicitis
What is the most accurate diagnostic test for acute appendicitis?
CT scan
What is the treatment for acute appendicitis?
IV antibiotics before appendectomy
if perforated, continue IV antibiotics until fever and WBC normalized
What are the indications for elective surgery in a patient with ulcerative colitis? (4)
- present more than 20 years (malignancy potential)
- multiple hospitalizations
- need chronic high dose steroids/ immunosuppressants
- toxic megacolon
A pt with history of ulcerative colitis who develops abdominal pain, fever, leukocytosis, epigastric tenderness, massively distended transvers colon on X-rays with gas within the colon wall most likely suffers from ….
Toxic Megacolon
A pt presenting with severe abdominal pain and the pain appears to be out of proportion to the physical exam, has signs of acidosis and sepsis most likely suffers from ….
Mesenteric Ischemia
What is the best initial step in management of a pt with suspected mesenteric ischemia?
- surgery (if diagnosed during, perform embolectomy and revascularization)
- angriography (if diagnosed during, give vasodilators or thrombolysis)
What is the best diagnostic test and treatment for intrabdominal absecess?
CBC and CT of abdomen/pelvis with contrast; surgical or percutaneous drainage and antibiotics
An obese, fecund women in her 40’s presents with recurrent episodes of abdominal pain, high alkaline phosphatase, dilated ducts on sonogram, nondilated gallbladder full of stones and direct hyperbilirubinemia most likely suffers from…
Obstructive Jaundice Caused by stones
What is the best initial diagnostic test for obstructive jaundice caused by stones?
sonogram
What is the confirmatory diagnostic test for obstructive jaundice caused by stones?
endoscopic ultrasound (EUS) or magnetic resonance cholangiopancreatography (MRCP)
What is the treatment for obstructive jaundice caused by stones?
endoscopic retrograde cholangiopancreatography (ERCP) followed by cholecystectomy
A pt presenting with progressively worsening jaundice, hyperbilirubinemia, and weight loss most likely suffers from….
Intrabdominal Tumor (adenocarcinoma of pancreas head/ ampulla of Vater, cholangiocarcinoma)
What is the best initial test for detecting a suspected intraabdominal tumor?
CT scan (if positive, obtain tissue diagnosis via endoscopic ultrasound/ EUS)
What is the next best step in management for detecting a suspected intraabdominal tumor if a CT scan is negative?
MRCP (magnetic resonance cholangiopancreatography)
if positive, obtain tissue diagnosis via ERCP/ endoscopic retrograde cholangiopancreatography
A pt presents with brief colicky pain in the right upper quadrant radiating to the right shoulder and back, triggered by fatty foods, without signs of systemic infection or peritoneal irritation most likely suffers from …
Biliary Colic
Temporary occlusion of cystic duct by gallstone
What is the diagnostic test and treatment for biliary colic?
Sonogram; elective cholecystectomy
A pt presenting with constant right upper quadrant pain, peritoneal irritation, fever, leukocytosis, pain on palpating of the RUQ during inhalation most likely suffers from ….
Acute Cholecystitis
Persistent occlusion of cystic duct
What is the diagnostic test for suspected acute cholecystitis?
Sonogram showing gallstone, thick walled gallbladder, pericholecystic fluid
What is the treatment for acute cholecystitis?
Nasogastric suction, NPO, IV fluids, antibiotics followed by cholecystectomy (6-12 weeks after presentation)
(Emergency cholecystectomy if generalized peritonitis or emphysematous cholecystitis suggestive of perforation/ gangrene)
A pt presents with high fever, very high WBC count, jaundice, abdominal pain (RUQ), altered mental status, shock, high alkaline phosphatase, elevated total bilirubin and direct bilirubin, elevated transaminases most likely suffer from …
Acute Ascending Cholangitis
Obstruction of common duct and ascending infection
What is the treatment for acute ascending Cholangitis?
IV antibiotics and emergency decompression of common duct (ERCP > percutaneous transhepatic cholangiogram/ PTC) followed by cholecystectomy
What is the best initial test for fecal incontinence (involuntary bowel content passage for at least one month in pt older than 3 years old)?
Flexible sigmoidoscopy or anoscopy
What is the most accurate test for fecal incontinence?
Anorectal manometry
What is the best initial treatment for fecal incontinence?
Bulking agents (fiber) with biofeedback techniques (muscle strengthening exercise control exercise)
What is the next best step in management of pt with fecal incontinence if bulking agents and biofeedback techniques are unsuccessful?
Endoscopic injection of dextranomer/ hyaluronic acid (to create pseudo-sphincter)
(If fails, colorectal surgery)
What are the four hepatic derangements that must be considered preoperatively before performing surgery on a pt?
- Bilirubin (>2)
- Albumin (16)
- Encephalopathy/ altered mental status
(If there is more than one present, no surgery)
What are patients with severe COPD (FEV1
Post-operative pneumonia (because ineffective cough leading to inability to clear secretions)
What are cardiac risk factors that need to be assessed pre-operatively before surgery? (4)
- Ejection fraction
What should be done in smokers prior to non-emergent surgery?
- Pulmonary function test (PFTs to evaluate FEV1)
(If FEV1 abnormal, obtain blood gas) - Smoking cessation for 8 weeks prior
What are the four nutritional risk factors that need to be assessed and modified prior to non-emergent surgery?
- Loss of 20% body weight over several months
2. Albumin (
What are the criterion and their associated point value used in cardiac risk index in noncardiac surgery?
- Age >70 (5)
- MI within 6 months (10)
- Ventricular gallop/ JVD/ signs of heart failure (11)
- Significant aortic stenosis (3)
- Arrhythmia other than sinus/premature atrial contractions (7)
- more than 5 premature ventricular contractions per minute (7)
- General medical conditions (pO2 50, K 50, creatinine > 3, elevated AST, chronic liver disorder, bed bound) (3)
- Emergency surgery (4)
- Intraperitoneal, intrathoracic, aortic surgery (3)
Level 1: 0-5; level 2: 6-12; level 3: 13-25; level 4: > 25
What is the cause of post-operative fever that starts on post-op day 1 and what is the best initial diagnostic test to confirm the diagnosis?
Wind (atelectasis); chest X-ray
Tx: incentive spirometry
What is the cause of post-operative fever that develops on post-op day 3 and what is the best initial diagnostic test to confirm the diagnosis?
Water (UTIs); urinalaysis and urine culture
Pneumonia; chest x-ray, sputum culture
(Tx: antibiotics)
What is the cause of post-operative fever that starts on post-op day 5 and what is the diagnostic test that confirms that diagnosis?
Walking (DVT/ thrombophlebitis); Doppler of lower extremity
Tx: anticoagulation
What is the cause of post-operative fever that starts on post-op day 7 and what is the diagnostic test to confirm the diagnosis?
Wound (wound infections); complete physical exam and CT scan
Tx: antibiotics for cellulitis, incision and drainage for abscess
What is the next best step in management of a pt who develops post-operative disorientation? (2)
- Obtain arterial blood gas (to assess for hypoxia which is most lethal cause)
- Blood cultures and CBC (to assess sepsis)
What is the next best step in management for a pt who has fecal, gastric or duodenal leakage from surgical wound post-operatively?
Observation if pt stable, not febrile, no signs of systemic involvement
(Correct dehydration and electrolyte imbalance as occurs)
A pt develops a fever greater than 104 degrees shortly after the onset of anesthetic (halothane or succinylcholine) most likely suffers from ….
Malignant hyperthermia
What is the treatment for malignant hyperthermia and possible complication?
Tx with IV dantrolene, 100% oxygen, correct acidosis, cooling blankets
Complication: myoglobin uric
What is the cause of post-operative fever that starts on post-op day 10-15 and what is the diagnostic test to confirm the diagnosis?
Deep abscess (subphrenic, pelvic, subhepatic); CT scan
Tx: percutaneous radiologically guided drainage
A pt who develops fever on post-op day 7, tachycardia, shortness of breath, hypoxia, and an increased A-a gradient most likely suffers from ….
Pulmonary embolism
Dx: CT angiogram; Tx: anticoagulate with heparin, IVC filter if recurrent
A pt develops fever, shortness of breath, hypoxia, infiltrate on x-ray and fever post-operatively most likely suffers from….
Aspiration pneumonia
Tx: lavage, remove gastric contents, bronchodilators, respiratory support
A pt develops fever, positive pressure breathing, becomes progressively more difficult to bag, blood pressure steadily declines and CVP steadily rises during a surgery most likely suffers from…
Intraoperative tension pneumothorax
Tx: insert needle to decompress and place chest tube
A pt develops fever, bilateral pulmonary infiltrates, respiratory distress and hypoxia with no evidence of CHF post-operatively most likely suffers from…
Acute Respiratory Distress Syndrome (ARDS)
Tx: positive end expiratory pressure/ PEEP
A pt develops fever, tachycardia, hyperthermia, hypertension, and altered mental status 2-3 days after surgery most likely suffers from…
Delirium tremens
Tx: benzos and watch for seizures and rhabdomyolysis
What is the initial step in management of a pediatric pt with a congenital anomaly that requires surgery?
Rule out other associated congenital conditions (VACTER: vertebral, anal, cardiac, tracheal, esophageal, renal, radial)
- Echo (assess for cardiac)
- Rectal exam (assess for anal)
- X-ray (assess for vertebral, radial)
- Sonogram (assess for renal)
An infant is found to have excessive salivation shortly after birth and choking spells with first feeding attempts most likely suffers from …
Esophageal Atresia
What is the diagnostic test and treatment for esophageal atresia?
Dx: nasogastric tube coiled in upper chest on CXR
Tx: surgical repair; gastrostomy to protect lungs if surgery delayed
An infant is found to have an absence of flatus and stool at birth and no anal canal on exam most likely suffers from…
Anal atresia
What is the best initial step in management for anal atresia?
Assess for fistula (vagina, perineum)
- if present, delay surgery until further growth but before toilet training
- if not present, colostomy
An infant that has dysphagia at birth and found to have loops of bowl in the left chest on CXR most likely suffers from …
Congenital Diaphragmatic Hernia
Due to hypoplastic lung
What is the treatment for Congential Diaphragmatic Hernia?
Endotracheal intubation, low pressure ventilation, sedation and nasogastric suction followed by surgical repair 3-4 days to allow lung maturation
What is the treatment for an infant with a small gastroschisis/ omphalocele defect?
close primarily
What is the treatment for an infant with a large gastroschisis/ omphalocele defect?
silastic silo (protect bowel), manual replacement of bowel daily, TPN (for nutrition bc bowel dysfunctional) and IV antibiotics
What is the best initial step in the management of an infant with exstrophy of the urinary bladder (abdominal wall defect over pubis)?
transfer to center for surgical repair within first 1-2 days of life
What are the three infant/ congenital diseases that can result in a “double bubble” sign on abdominal X-ray/ imaging?
- duodenal atresia
- malrotation (most dangerous)
- annular pancreas
An infant that presents with vomiting of greenish liquid material and has multiple air-fluid levels throughout the abdomen most likely suffers from …
Intestinal Atresia
(vascular accident in utero)
(tx: surgery)
A premature infant with feeding intolerance when first fed, abdominal distension and rapidly dropping platelets most likely suffers from ..
Necrotizing Enterocolitis
due to E. Coli and klebsiella pneumoniae
What is the treatment for Necrotizing enterocolitis?
- stop all feedings
- give broad spectrum antibiotics
- IV fluids and nutrition
- surgery if necrosis or perforation (abdominal wall erythema, portal vein gas, gas in bowel wall)
An infant with feeding intolerance, bilious vomiting and a family history of cystic fibrosis most likely suffers from …
Meconium Ileus
What are the diagnostic tests and their associated findings for meconium ileus?
- abdominal X-ray (multiple dilated loops of bowel, ground glass appearance in lower abdomen)
- gastrografin enema (microcolon and inspissated pellets of meconium in terminal ileum)
What is the treatment for Meconium Ileus?
gastrografin enema (draws fluid into bowel to dissolve pellets)
An infant aged 3 weeks presents with nonbilious projectile vomiting after each feeding, palpable olive sized mass in the RUQ and gastric peristalic waves most likely suffer from ..
Pyloric Stenosis
dx: sonogram
What is the treatment for pyloric stenosis?
- correct dehydration and associated hypochloremic, hypokalemic metabolic acidosis
- followed by pyloromyotomy
What is the electrolyte disturbance associated with pyloric stenosis?
hypochloremic, hypokalemic metabolic acidosis
A 6-8 week old infant presents with persistent, progressively increasing jaundice and elevated direct bilirubin most likely suffers from …
Biliary Atresia
What are the diagnostic tests for biliary atresia?
- serologies and sweat test (rule out other causes)
- HIDA scan after 1 week of phenobarbital
- if no bile at duodenum, surgical exploration
An infant presents with chronic constipation and rectal exam results in explosive expulsion of stool/flatus relieving abdominal distention most likely suffers from …
Hirschsprung Disease
aganglionic disease
What is the diagnostic test for Hirschsprung Disease?
full thickness biopsy of rectal mucosa
A 6-12 month old chubby, healthy looking infant presents with brief episodes of colicky abdominal pain that causes them to double up and squat, has a vague mass on right side of abdomen, an empty RLQ, and currant jelly stools most likely suffers from..
Intussusception
What is the diagnostic test and the treatment for intussusception?
barium or air enema (diagnostic and therapeutic)
surgery if unsuccessful
What is the most likely diagnosis for a pediatric pt (2 years old) presenting with lower GI bleeding (melena)?
Meckel Diverticulum (gastric mucosa in intestine)
What is the diagnostic test and the treatment for Meckel Diverticulum?
radioisotope scan (gastric mucosa in intestine); surgical resection
A pt who develops sepsis with a tender, swollen injury site with crepitus about 3 days after a deep penetrating or dirty wound most likely suffers from …
Gas gangrene
What is the treatment for gas gangrene?
large doses of IV penicillin and hyperbaric oxygen
What is the treatment for fractures that are not badly displaced or angulated?
closed reduction
What is the treatment for fractures that are severely displaced or angulated or can not be aligned?
open reduction and internal fixation
What is the treatment for an open fracture (broken bone is sticking out through a wound)?
wound debridement in OR and reduction within 6 hours of injury
A pt with an adducted arm and externally rotated forearm with numbness over the deltoid muscle after an trauma most likely suffers from …
Anterior dislocation of shoulder
axillary nerve is stretched
What is the best diagnostic test for detecting anterior dislocation of shoulder?
erect lateral and posterio-anterior (AP) X-rays
A pt with an adducted arm and internally rotated forearm and a history of recent seizure or electrical burn most likely suffers from …
Posterior dislocation of shoulder
What is the best diagnostic test for detecting posterior dislocation of shoulder?
axillary or scapular X-rays of shoulder
What is the best treatment for a clavicular fracture?
figure eight sling
What is the best treatment for a Colles’ fracture in an elderly pt who falls on outstretched hand resulting in painful wrist with a dinner fork deformity?
closed reduction and casting
What is the best treatment for a Monteggia fracture (direct blow to ulna) or Galeazzi fracture (direct blow to radius) resulting in a diaphyseal fracture with displaced dislocation of the nearby joint?
open reduction and internal fixation (for diaphyseal fracture) with closed reduction (for dislocated joint)
What is the best treatment for a scaphoid fracture in a pt who falls on outstretched hand resulting in persistent pain the anatomical snuffbox?
thumb spica cast
What is the best treatment for a femoral neck fracture in an elderly pt who sustains a fall and presents with externally rotated and shortened leg?
femoral head replacement (bc risk of avascular necrosis)
What is the best treatment for a intertrochanteric fracture in an elderly pt who sustains a fall and presents with externally rotated and shortened leg?
open reduction and pinning
What is the best treatment for a femoral shaft fracture in an elderly pt who sustains a fall and presents with externally rotated and shortened leg?
intramedullary rod fixation
surgery and cleaning within 6 hour due to massive blood loss potential
What is highly associated with femoral shaft fractures?
fat embolism
A women who awakens at night with an acutely flexed finger that snaps when forcibly extended most likely suffers from …. and the treatment is …
Trigger finger; steroid injection
A young mother carrying baby with a flex wrist and extended thumb to stabilize the baby’s head is likely to suffer from …. and the treatment is ….
De QUervain tenosynovitis; steroid injections
… is the contracture of the palm with palmar fascial nodules and is treated with ….
Dupuytren contracture; collagenase
if collagenase fails then surgery
A pt in a head-on car collision where their knees hit the dashboard who presents with an internally rotated and shortened leg most likely suffers from …. and is treated with …
Posterior dislocation of the hip; emergency reduction (to avoid avascular necrosis)
A pt who received a direct blow to one side of the knee joint in likely to suffer from …. and the treatment is …
medial/lateral collateral ligament injury
tx: casting if just 1 ligament, surgical repair if multiple
A pt presenting with swelling, knee pain and a positive anterior/ posterior draw sign most likely suffers from … and treatment is ….
Anterior/Posterior cruciate ligament injury
young athlete- arthroscopic repair
elderly- immoblization and rehabilitation
A pt presenting with prolonged knee pain, swelling and catching and locking during ambulation most likely suffers from … and treatment is …
meniscal injury; arthroscopic repair
A pt who is involved in military or cadet marches who presents with pain of the anterior portion of lower leg but has a negative X-ray initially most likely suffers from …. and the next best step in management is …..
Tibial stress injury; cast and no weight bearing with repeat x-ray in 2 weeks
A middle aged pt who overdose it at tennis/ basketball or a pt with history of fluoroquinolone use presents complaining of a sudden popping sound and limping most likely suffers from …. and treatment is ….
ruptured achilles tendon; casting in equinus position/ surgery
A pt with a history of rhematoid arthritis/ acromegaly/ hypothyroidism/ repetitive wrist movement presents with tingling and pain in the wrist, arm and last three fingers of the hands most likely suffers from ….
Carpal Tunnel Syndrome
compression of median nerve
What is the best initial test for carpal tunnel syndrome?
history and physical (including Phalen’s test- symptoms with wrist flexion and Tinel’s sign- symptoms with taping on flexor retinaculum)
What is the best initial treatment for carpal tunnel syndrome?
NSAIDs and splinting
followed by steroid injections and lastly surgery
A pt with a history of prolonged ischemia followed by repperfusion/ crushing injury/ trauma/cast who complains of excruiating pain with passive extension of the injured forearm/ leg, affected area feels tight, has tendernss to palpation and possibly loss of pulse in the extremity most likely suffers from …
compartment syndrome
What is the first step in management of a pt with compartment syndrome?
emergency fasciotomy
What is the best initial step in management of a pt with lumbar disc herniation?
anti-inflammatories (ibuprofen) and brief bed rest
(immediate surgical compression if cauda equina syndrome- bowel/bladder incontinence, flaccid anal sphincter, saddle anesthesia)
A pt presents with sudden onset severe back pain that began when lifting a heavy object, pain is sharp and radiates down his leg, is wrosened by coughing/ straining and improved with flexion of his legs, and straight leg raising produces excruciating pain most likely suffers from …
lumbar disc herniation
L4-L5 or L5-S1
What spinal area is likely affected if a patient has sluggish ankle reflex?
S1/S2
What spinal area is likely affectd if a patient has sluggish patellar reflex?
L4/L5
A male pt aged 30-40s presents with chronic back pain and morning stiffness that improves with activity, spinal x-ray shows fused sacroilliac joint and spicules bridging vertebral bodies (bamboo spine) and has a positive HLA-B27 antigen most likely suffers from …
Ankylosing spondylitis
tx: anti-inflammatory and physical therapy
An elderly pt presenting with progressive and constant back pain that is worse at night and unrelieved by rest, weight loss, hypercalcemia, elevated alkaline phosphatase and X-ray showing lytic/blastic lesions most likely suffers from …
Metastatic Malignancy
What metastatic malignancies are associated with blastic lesions on X-ray?
- prostate cancer
- breast cancer
(all others are lytic)
What is the initial best step in management of a pt with suspected metastatic malignancy?
Spinal X-ray (can also use MRI if neuro symptoms or bone scan)
An older, overweight patient presents with sharp heel pain that feels like a tack in the bottom of the foot every time their foot strikes the ground, pain is worse in the morning and resolves quickly, and may have bone spur on X-ray most likely suffers from…
Plantar fasciitis
tx: symptomatically; stretches
A female presenting with a palpable mass between the 3rd and 4th toes that is extremely tender and has a history of wearing high heels most likely suffers from …
Morton Neuroma
inflammation of common digital nerve at 3rd interspace
(tx: analgesics and appropriate footwear)
A male pt presenting with severe, sudden onset testicular pain without fever or pyuria, testis is swollen, exquistely tender, high riding and with a horizontal lie, and cremasteric reflex is absent most likely suffers from …
testicular torsion
what is the treatment for testicular torsion?
immediate surgical intervention with bilateral orchioplexy
dont wait for ultrasound
A male pt presenting with acute scrotal pain, fever, urinary symptoms, and pyuria most likely suffers from …
Acute epididymitis
obtain urinalysis and urine and/or discharge culture
What is the treatment for epididymitis?
males less than 35: ceftriaxone with doxycyline (for gonorrhea/ chlamydia)
elderly: levofloxacin (E.Coli)
What is the appropriate steps in management for a pt with urinary tract obstruction (urethral stone) and signs of infection (fever, chills, flank pain, elevated BUN and creatinine)? (3)
- immediate decompression of obstruction
- IV antibiotics
- ureteral stent or percutaneous nephrostomy
A newborn boy who does not urinate during the first day of life most likely suffers from … and what should be done as part of management?
Posterior urethral valve; catheterize to empty bladder and diagnose with voiding cystourethrogram
What should be avoided in a male newborn/infant with hypospadias (urethral opening on ventral side of penis)?
circumcision (bc foreskin needed for plastic reconstruction)
A child with hematuria from trivial trauma or with a urinary tract infection most likely suffers from …. until proven otherwise
undiagnosed congenital anomaly
dx reflux: voiding cystogram; give long term antibiotics if present
A girl who voids appropriately but is also found to be constantly wet from urinating into the vagina most likely suffers from …
low implantation of ureter
A teenager presents with colicky flank pain after drinking large volumes of beer/ beverage most likely suffers from …
Ureteropelvic junction obstruction
symptoms with diuresis
A pt presenting with visual disturbances, equilibrium dysfunction, and pain, numbness and tingling of the forearm with arm activity/exercises most likely suffers from …
Subclavian Steal Syndrome
arteriosclerotic stenotic plaque at origin of subclavian artery
What is the diagnostic test and treatment for subclavian steal syndrome?
angiography; bypass surgery
A pt presenting with pain, numbness and tingling of the forearm with arm activity/ exercises and no neurologic signs most likely suffers from …
Thoracic Outlet Syndrome
What is the best management for an asymptomatic abdominal aneurysm that is less than 5 cm?
serial annual imaging (to assess for growth)
What is the best management for an asymptomatic abdominal aneurysm that is 5 cm or larger?
elective repair
What is the best management for a tender abdominal aortic aneurysm?
urgent repair within a day (to prevent rupture)
What is the best management for hypotension and excruciating back pain in a pt with an abdominal aortic aneurysm?
emergent surgical repair (bc already leaking)
What is the most important intervention to prevent progression of thoracic aortic aneurysms?
blood pressure control
A pt presenting with pain in legs with exercise but relieved by rest and may have a history of smoking most likely suffers from ..
Arteriosclerotic Occlusive Disease of Lower Extremities
Claudication
What is the best step in management for arteriosclerotic occlusive disease of lower extremities if there is no significant affect on the patient’s lifestyle? (2)
- smoking cessation
2. cilostazol and aspirin
What is the best step in management for arteriosclerotic occlusive disease of lower extremities if pain is severe and has some affect on lifestyle?
diagnosis with doppler studies (ankle-brachial index
What is the best treatment for arteriosclerotic occlusive disease of lower extremities if there is disabling symptoms (affects work/ activities of daily living) or impending ischemia of extremity?
angioplasty and stenting (if more severe, bypass)
pain at rest is end-stage disease
A pt with history of atrial fibrillation or recent MI who has sudden onset painful, pale, cold, pulseless, paresthetic and paralytic lower extremity most likely suffers from…
arterial embolization of the extremity
dx: doppler studies
(tx: thrombolytics- early or embolectomy with fasciotomy)
A pt who develops fever, suprapubic tenderness, costoverterbral angle tenderness, signs of system infammation (elevated WBCs, hypotensions,etc) and has a catheter most likely suffers from ..
catheter-associated urinary tract infection
tx: prompt removal of catheter and antibiotics
What is the best way to prevent catheter-associated urinary tract infection in a pt with long term indwelling bladder catheterization?
intermittent catheterization
prophylactic antibiotics are not helpful
What is the initial best step in management of a patient with suspected central line associated bloodstream infection?
obtain blood cultures from catheter and another peripheral vein
(if same bacteria, then remove line and start antibiotics)
