Surgery Flashcards
acute mediastinitis is a possible complication of cardiac surgery usually due to what
what is presentation
intraoperative wound contamination
fever, tachy, cehst pain, leukocytosis and wound drainage post op
serum phos in vitamin D def
low
what is a common precipitating event to ischemic colitis
repair of AAA
what helps achalasia position wise
upright position
what age does child need surgery if umbilical hernia persists
5 or so
pts with penetrating trauma who have what need urgent exploratory lap
hemodynamic instab
peritonitis
evisceration
or blood from NG tube
managment of amputation and reimplantation
limb or digit wrapped in sterile gauze, moistened with sterile saline and placed in plastic bag on ice to ED
what can be injured in a supracondylar fracture of the humerus
brachial artery
median nerve injury
AE dapsone
hemolytic anemia (check G6PD)
PE showing an abdominal succussion splash
pyloric stricture
dysphagia, halitosis, and fullness of the throat in pts over 60
zenker diverticulum
if have persistent hemoptysis and initial bronchoscopy doesnt work to localize source what is next
pulmonary arteriography
clinical features of pulmonary contusion
presents within 24 hours of blunt thoracic trauma with
tachypnea, tachy, hypoxia
management of complicated gallstone diseas like cholecyst, choledoch, or gallstone panc
choleccystectomy within 72 hours
SBO where is location: colicky abdominal pain, delayed vomiting, prominent abdonminal distension, constipation, hyperactive BS and dilated loops of bowel on x ray
mid or distal
CT scan showing ruptured aorta with blood collection in the adventitial layer is what
ruptured AAA
soft signs of extremity vasular trauma
history of hemorrhage
diminished pulse
bone injury
neuro abnormality
tx: injured extremity index (if under 0.9 then CT)
CT scan with angiography
duplux doppler US
steps in cervical spine trauma after a fall in pt that is hypoxic and hypopneic
stabilize spine
assess airway, if above C3 can cause immediate paralysis and lower C lesions can damage phrenic nerve
orotracheal intubation unless massive facial trauma
Afib after CABG
normal or nah?
treatment
15-40% get it, usually self limited and resolves within 24 hours
can use BBor amiodarone
only anticoags and or cardoversion if lasts over 24 hours
suspected scaphoid fracture managment
xray at time of injury is low sensitivity
CT scan or MRI to confirm
or
immobilize with splint and repeat imaging in 7-10 days
scrotal mass that decreases with supine position and increases with standin/valsalva maneuvers
varicocele (dilation of pampiniform plexus)
management in flail chest
what can occur often
pain control and supplemental oxygen early
resp failure can occur from pulmonary contusion leading to edema/blood in the alveoli and intubation with mechanical PPV is req in many pts
tibial nerve supplies what muscles and what actions and sensation
posterior compartment of thigh and leg and plantar muscles of foot
flexion of knee and digits and plantar flexion of foot
sensation to leg (except medial side) and plantar foot
cause of acalculous cholecystitis and what patients is it seen in
idiopathic and seen in pts with sever underlying illness:
dehydration, ischemia, burns, severe trauma, post op state
same signs and sx as acute cholecystitis
stasis dermatitis most classically involves what
the medial leg below the knee and above the medial malleolus
anterior spinal cord syndrome can occur in what surgery
thoracic aortic aneurysm repair (reduced radiuclar artery flow like in artery of adamkieqicz)
penile fracutre is rupture of what
corpus cavernosum from teari in tunica albuginea
for pts involved in MVA or falls from over 10 feet physicians must have high suspicion for what
blunt aortic injury
pt had blunt trauma in MVA then persistent pneumothorax despite chest tube placement and pneumomediatstinum and subcut emphysema
tracheobronchial perforation secondary to blunt thoracic trauma
confirm dx with Ct scan, bronchoscopy or surgical exploration
managment of clavicular fractures
all need neurovascular exam to r/o injury to subclavian artery and brachial plexus
post op measures used to decrease the risk of pneumonia
lung expansion
spirometry, deep breathing exercises, continous positive airway pressure
spirometry most effective
greatest danger in massive hemoptysis
what position to put pt
asphyxiation bc of airway flooding with blood
place pt in lateral position to avoid blood collection in opp lung
subacute pain over the midline sacrococygeal with mucoid and blood drainage most likely has what
pionidal disease
treatment of pre-renal AKI
IV isotonic fluid
positive airway pressure is indicated in what fracture
flail chest
evaluation of hemoptysis if have massive bleeding do what
if stops bleed then what
if bleeding continues then what
secure the airway, breathing and circulation
- if stops bleeding then workup with CXR, coag studies, renal fnct, UA, rheum workup
- then CT scan +/- bronchoscopy
- then treat cause
if bleeding does no stop then
-straight to treating cause via bronchoscopic interventions, embolization or resection
bilateral cellulitis of the submandibular and sublingual spaces from infected mandibular molar
ludwig angina
see drooling
managment of small bowel obstruction
bowel rest, NG tube suction, IVF
surgical exploration for sinngs of complications
sudden onset severe unilateral lower abdominal pain immediately following strenusous or sexual activity in woman and US shows free pelvic free fluid
ruptured ovarian cyst
abdominal pain and hematochezia in old man with CAD getting AAA repair
colonic ischemia
spontaneous pneumothorax treatment if small or large
2 cm or smaller then observe and oxygen
if large and stable then needle aspiration or chest tube
steps of dx PAD
ABI first then arterial US bc less senstivie and specific, do in sx pts
preventing pre and post op bacterial parotitis
most common bug?
adequate fluid hydration and oral hygiene
staph aureus
treatment for anal fissures
higher fiber diet and fluids
stool softener
sitz baths
topical anesthetics and vasodilators like nifedipine and nitroglycerin
terminal hematuria with clots suggests what
bleeding within bladder or ureters and is concerning for urothelial cancer
what injury can cause posterior urethral injury and how to diagnose
pelvic fractures
retrograde urethrogram
atelectasis and oxygen co2 level
most severe when
ventilation perfusion mismatch leading to hypoxemia nad increased work of breathing
most severe during 2nd postoperative night
managment of splenic injury from BAT
hemodynamically stable, still risk factors
stable pts with AMS
hemodynam stable: FAST, if normal but high riskfeatures like anemia or guarding then CT
stable pts with AMS go straight to CT
dudoenal hematoma occurs after what and can lead to what
blunt abdominal trauma
can lead to partial or complete obstruction
24-36 hours after initial event get epigastric pain and comit from obstruction
epidural hematoma treatment in pt with focal deficits or signs of intracranial HTN
emergent neurosurgical hematoma evacuation
subacute post op fever timing and etiology
1 week to 1 month
SSI/cath infection
C diff
drug fever
PE/DVT
ingesting acid is risk factor for developing what
dx
tx
pyloric stricture
upper endoscopy
surgery
where to place needle thoracostomy in tension pneumo
f/u with what
2nd intercostal space in midclavicular line, if this fails then
fifth intercostal space in the midaxillary line
then do emergency tube thoracostomy
when would you do CT scan or US for suspected appendectomy
non classical symptoms
what does the LV do in hypovolemic shock
decreases in size bc of decrased filling volume so it increases its ejection fraction
PPV in hypovolemic shock
causes acute increase in intrathoracic pressure which in severly hypovolemic pt with low central venous pressure can collapse venous capacitance vessels like IVC and cut off venous return = sudden loss of RV preload
what provokes gilbert syndome
stress like infection, fasting, vig exercise, surgery
polymyalgia rheumatica
muscle pain and stiffness in shoulder and pelvic girdle
decreased ROM in shoulder, neck, hip
responds to glucocortiicoids
can be associated with temporal arteritis
when do you use bronchoscopy in hemoptysis
when have >600 mL/day or 100 mL/hr
delayed fever (>1month after surgery) usually caused by what
surigcal site infection
virus
fibrosis and contracture of the glenohumeral joint capsule. causes persistent pain along with decreased ROM in multiple planes
adhesive capsulitits
blunt abdominal trauma in hemodynamically stable pt that is not alert or normal mental status
what if normal metnal status
seriel abdominal exams +/- CT
if normal
FAST
- = seriel abdominal exams +/- CT
+ = CT scan abdomen
small pneumothoraces in clinically stable pt treatment
observation and supplemental oxygen
first step if pt is ID’d to have pulmonary TB
isolation
varicoceles are more common on which side and why?
left side
bc gonadal vein on left drains to the left renal vein and can be compressed
atelectasis is most common postop day what
2 and 3
severe burn assocaited with extensive scar formation and a chronic non healing wound is what
SCC
this is a Marjolin ulcer
chest xray for PCP pneumonia what is often elevated in serum
bilateral interstitial infiltrates
serum LDH often elevated
the most important risk factor of a gallstone ileus
dx
tx
cholecystitis which predisposes to biliary-enteric adhesions
CT scan shows GB thickenink, pneumobilia (air in biliary tree) and stone
tx with remoing stone and +/- cholecystectomy
treatment of postoperative mediastinitis
drainage, surgical debridement with immediate closure and prolonged abx therapy
other studies considered in pts with blunt genitourinary trauma
radiographs for frx
US for testicle injury
retrograde cystouretrhrogram for urethral ainjury and bladder rutpure (these pts usually have gross hematuria, and difficult peeing and blood at meatus)
managment of ischemic colitis
IV fluids and bowel rest
abx with enteric coverage
colonic resection if necrosis develops
what kind of trauma causes diffuse axonal injury
accel/decel
pain location for mesenteric ischemia
periumbilical and hematochezia
gross hematuria based on stage of voiding at which it occurs
terminal
prostate, bladder neck or trigone, or posteior urethra
urothelial cancer, cystitis, urolithiasis, bph prostate cancer
hemodynamically unstable pt with pneumothorax treatment
immediate tube thoracostomy, if not available then urgent needle decompression
what part of the bladder if ruptured can lead to fluid into the peritoneum and cause acute chemical peritonitis
dome of the bladder (intraperit)
can cause referred pain to ipsilateral shoulder
stable pt with large pneumothoraces treatement
decompression with large bore needle in 2nd or 3rd ICS midclavicular line or at 5th ICS mid axillary line
what would you see in bladder rupture and diagnosis
gross hematuria nad possibly difficulty voiding
retrograde cystogram
what is elevated in a nonseminomatous germ cell tumor
elevated AFP and b-HCG
____ is episodic pain and tenderness at inferior patella and paterllar tedon. seen in athletes in jumping sports or occupations with repetitive forcefull knee extension
paterllar tendinitis
fistula in abdominal aortic aneurysm rutpure
can create an aortocaval fistula with IVC leading to venous congestion in retroperitoneal structures like bladder nad these viens in bladder can rupture and cause gross hematuria
ribs broken in flail chest
3 or more contiguous ribs fractured in 2 or more locations
treatment for emphysematous cholecystitis
emergent cholecystectomy
broad spectrum antibiotics with clostridium coverage (amp-sulbactam) also e coli
what is the most frequent cause of bloodstream infection in pts with intravasuclar devices
staph epidermidis
diagnosing pulmonary contusion
rales or decreased BS
CT scan or CXR with patch alveolar infiltrate not restricted by anatomical borders
meningioma found mainly in what pop
middle age to elderly women
thing meningioma and menses
SBO vs ileus which has increased BS
SBO start increased then go to absent
ileus has reduced/absent
ABI under .9 is dx for what
peripheral artery disease
pt: MVA then elevated JVP and tachycardia and hypotension
chest xray
pericardial tamponade
xray can show normal cardiac silhouette bc small amt pericardial fluid
treatment for dumping syndrome
small/freq meals
replace simple sugars with complex carbs
incorporate high fiber and protein rich food
testing for meniscal tear
thessaly test
-pt stands on 1 leg and knee flexed 20 degrees then internally and externally rotates on flexed knee
mcmurray test
passive knee flexion and extension while holding in internal or external rotation
pain, click, or catch indicates tear
ondansetron can contribute to what and how
serotonin receptor antagonist can contribute to constipation
when would you use ERCP in pancreatitis
when have cholangitis, visible CBD dilation/obstruction or increaseing liver enzyme elevels
infection within the retropharyngeal space drains where and can lead to what
drains inferiorly to the superior mediatstinum
spread to the carotid sheath can cause thrombosis of the internal jugular vein and deficits in CN 9-12
extension through the alar fascia into the danger space can rapidly transmit infx into posterior mediastinum to diaphragm
syringomyelia sx
decrased strength and diminished pain and temp sensation affecting the arms/hands or having a cape-like distribution
preservation of dorsal column function
burn wound sepsis odd changes
oliguria, hyperglycemia, thrombocytopenia and AMS
sings and sx suggestive of necrotizing surgical site infection
pain, edma, erythema beyone surgical site systemic signs paresthesia at edge of wound purulent cloudy-gray discharge subcut gas or crepitus
hard signs of extremity vascular trauma and treatment
observed pulsatile bleed
bruit/thrill over injury
expanding hematoma
sings distal ischemia
surgically explore
RUQ or epigastric pain with elevated aminotransfereases and alk phos. give morphine and makes worse
visualization of dilated CBD with no stones is big key
sphincter of oddi dysfunction bc causes contraction
ST depression on ECG indicate what
ischemia
urine sodium under 25
volume depletion
CHF
cirrhosis
chronic dysphagia to both solids and liquids, difficulty belching, and mild weight loss are all common manifestations of what
achalasia
what is given pre-operatively to patients with mild hemophilia A in order to prevent excessive bleeding
desmopressin
what injury is associated with aotic injury
rapid deceleration injury like MVA over 30 mph
falls from 10 ft or more
severe crush injury
alternative agents for PCP besides TMP-SMX
pentamidine
atovaquone
Trimethoprim + dapsone
clindamycin + primaquine
bugs in necrotizing fascitis
strep pyogenes
staph aureus
c perfringens
fractures of the middle third clavicle treated how
what obout distal third
middle, nonop ,with brace, rest and ice
distal third: open reduction and internal fixation
what other sx of tension pneumo that you know is diff from spont pneumothor
hemodynamic instability
tracheal deviation away from affected side
bilateral flaccid paralysis and loss of P and T below level of injury
then UMN signs develop over days to weeks
vibration and proprioception are preserved
anterior spinal cord syndrome
cerebellar dysfunction from alcoholic cerebellar degen features
progressive gait dysfunction
truncal ataxia
nystagmus
intention tremor or dysmetria (tremor when trying to touch target
impaired rapid alt movement (dysdiadochokinesia)
muscle hypotonia–> pendular knee reflex
what is required to diagnose a psoas abscess
treatment?
CT scan
drain and abx
what innervates quadriceps femoris, sartorius and pectineus and responisble for what action of knee and hip
femoral nerve
knee extension and hip flexion
metoclopramide is what
dopamine antagonist with promotility effects
treatement for ruptured AAA
exploratory abdominal surgery no time for laparoscopy
gold standard for diagnosis of sphincter of ODdi dysfunction is what and treatment
manometry
sphincterotomy is treatment of choice
gallstone pancreatitis should be suspected in pts who have evidence of pancreatitis with ALT over what
150
what is the most common complications of cardiac catheterization
how long after does occur
local vascular comp at insertion site like:
bleeding or hematoma, arterial dissection, acute thrombosis, pseudoaneurysm or AV fistula
usually 12 hours later
old pt with hip fracture should undergo definitive surgical correction as soon as reasonably possible but surgery ma be delayed up to ___ hours to evaluate surgical risk and ensure medical stability
72
extra axial well circumscribed round dural based mass on mri with calcifications is what and treatment
meningioma
benign so resect to cure
managment of blunt genitourinary trauma with renal injury and stable
GU exam
UA
contrast enhanced CT if have hematuria and stable
tx for pt with acalcuous cholecystitis
ABX and emergent cholecystectomy
pts who can’t have srgy do percutaneous drainage of GB with choleccytostomy
swelling of feed with dorsa of feet being affected and marked thickening and rigidity of the skin
lymphatic obstruction
how to diagnose GI perforation
upright x rahy of chest and abdomen
shows free air under diaphragm
complications of central venous cath tip placement in wrong spot
venous perforation
lung puncture —> pneumothorax
myocardial perf –> pericardial tamponade
most common cause of massive hemothorax are lacerations to what
lung parenchyma or damage to intercostal or internal mammary artery
pts with appendicits that have delayed presentation and longer duration of symptoms usually have what and how to diagnose
tx
appendiceal rupture with contained abscess
palpation will be negative but things like
psoas sign, obturator sign, and rectal exam may be positive, CT can confirm
tx: IV ABX, and drainage if needed. can get appendectomy electively 6-8 weeks later
cervical radiculopathy typically presents with what
pain and paresthesias of the neck and arm along with upper extremity weakness
acute mesenteric ischemia is most commonly due to abrupt arterial occlusion from either of the following:
cardiac embolic events like afib or valve disease (IE) or cardiovascular aneurysms
acute thrombosis due to PAD or low CO states
treatment for varicocele
gonadal vein ligation
scrotal support and NSAIDs in older men who don’t want more children
acute cholecystitis without stones obstructing the cystic duct
acalculous cholecystitis
same signs and sx
complicated diverticulitis is diverticulitis with what and managment
abscess, perforation, obstrucation or fistula formation
-fluid uder 3 cm can be treated with IV abx and observation
> 3 cmfluid have CT guided percutaneous drainage
then surgical drain and debridement if this does not work
what nerve damaged in anterior shoulder dislocation
what m does it innervate and weakness with what
axillary
teres minor and deltoid
weak shouder abduction
AE TMP-SMX
rash, neutropenia, hyperkalemia, elevated transaminases
diagnsosing acalculous cholecystitis
imagin that shows GB wall thickening and distension and presence of pericholecystic fluid
pain out of proportion to injury, pain on pasive stretch, swelling and paresthesia
arterial pulses?
compartment syndrome
arterial pulses usually present
lab testing in acute mseneteric ischemia
leukocytosis, hemoconcentration, elevated amylase, and metabolic acidosis
decreased breath sounds at the right lung base with no wheezes or prolonged expiration and normal temp. Chest xray shows dense opacity at right lung base
dx?
atelectasis
____ following major thoracic trauma that presents with acute circulatory failure or neurological signs and tracheobronchial
air embolism
what kind of hernia is associated with af americans, premautre birth ehlers danlos and beckwith wiedeamann syndrome and hypothyroid
umbilical
managment of someone with acute pancreatitis from gallstones
cholecystectomy
platelet count greater than what provides adequate hemostasis for most invasive procedures
50,000/mm3
prostehetic joint infection bugs
under 3 months
3-12 months
>12 months
under 3 = staph aureus
3-12 = coagulase neg staph, propionibacterium, enterococci (PEC)
> 12 = staph aureus, gram neg rods, beta hemolytic strep
when does aspiration of gastric contents usually take place after surgery and sings?
within the first few hours after surgery
sx: sudden onset dyspnea, cough, fever, and rhonchi/crackles on exam
when do you do surgery for anal fissure
fissures that are refractory to medical managment
porgressive proximal muscle weakness and atrophy without pain or tenderness in LE muscles most common
normal ESR and CK
drug induced
glucocorticoid induced myopathy
DVT treatment with pt taht has ESRD
unfractionated heparin then warfarin
path of dumping syndrome
common postgastrectomy complication in 50% of pts
loss of normal action of pyloric sphincter, leads to rapid emptying of hypertonic gastric contents into the duodenum and SI
-fluid shift from intravascular space to SI, = hypotension and stim of autonomic reflexes and release of intestinal VIP
imaging for penile fracture
retrograde urethrogram when suspected urethral injury:
blood at meatus
hematuria
dysuria
urinary retention
most sensitive test to achalasia
manometry
intraperitoneal bladder rupture
rupture of the dome of the bladder
intraperitoneal urine leak with signs of chemical peritonitis (diffuse abdom tenderness, guarding and rebound)
most comon cause of acute liver failure
drug tox and acute viral hepatitis
bowel ischemia post AAA repair from what arteries lost
loss IMA during aortic graft placement
left and sigmoid colon perfusion lost
when would you add ccorticosteroids when treating PCP pneumonia
partial pressure of oxygen (PaO2) @ or under 70 mm hg or an A-a gradient of 35 or more
ABG in atelectasis
pH elevated, PO2 decreased, PCO2 decreased
acute post op fever
timing nad cause
24 hrs to 1 weeks
nosocomial infx
SSI
noninfection like MI, PE, DVT
emphysematous cholecystitis risk factors
take a VID for EC
vascular compromise
immunosupp
DM
lab values in acute mesenteric ischemia
leukocytosis, hemoconcentration, elevated amylase and metaboic acidosis
most common peripheral artery aneurysms
popliteal and femoral
impaired cough and shallow breathing following a abdominal or thoracoabominal surgery can lead to what
atelectasis
left sided abdominal pain with radiation to the shoulder, fever, and vomiting and free fluid not common
splenic infarct
nerve?
foot eversion
sensation overlateral leg and dorsum of foot
superficial peroneal nerve
in blunt abdominal trauma if have right shoulder pain from what
Hepatic laceration has hemorrhage that irritates the phrenic nerve
necrotizing surgical site infections occur more commolnly in what pts and what bugs
treatement?
pts with diabets usually poymicrobial
emergency early surgical exploration with debridement
also broad spectrum abx
if cannot abduct over 90 degrees what nerve and m may be compromised
long thoracic
serratus anterior
when do you not need an xray for CVC placement
if use US guided CVC placement
acute necrotizing mediastintis can be from spread from where and sx and tx
spread from retropharyngeal abscess
fever, chest pain, dyspnea, odynophagia
need surgical intervention
most essential managment of pt with rib fracture that has atelectasis and hypovent an dpneumoina
pain control
primaquine AE
methemoglbinemia, hemolytic anemia
fluid filled cyst of head of epididymis that presents as painless mass at the superior pole of the testis
spermatocele
burn wound sepsis is associated with what systemic findings
temp above 102 or below 98
tachycardia
tachypnea
hypotension
first 15 degrees of abduction shoulder
15-90 degrees
muscles
first 15 = supraspinatous
deloid = rest
what is cerebral angiography a useful diagnostic tool for
ID cerebral aneurysms and AV malformations
criteria for long term home oxygen therapy in pts with progresive hypoxemia from COPD
1) resting arterial oxygen tension of 55 mm hg or less (PaO2) or pulse ox at or under 88%
2) PaO2 at or under 59 or SaO2 at or under 89% in pts with cor pulmonale, evidence of R heart failure or hematocrit under 55%
hematocrit with rupruted ovarian cyst
referred pain
chest pain?
decresed
to shoulder
pleuritic
pts on long term glucocorticoid therapy who have cushingoid features are at high risk for what
adrenal crisis
can be seen in 3 weeks in pts taking 20 or more mg/day of prednisone
SBO where is location: early vomiting, abdominal discomfort, and abnormal contast filling on x-ray
proximal
what is almost always present in an extraperitoneal bladder injury?
pelvic fracture and gross hematuria
sometimes urinary retention
IV corticosteroids may be indicated in pts with intracranial HTN due to what
brain tumor or abscess
JVD with PE?
yes bc of pulnonary vascular resistance and R side HF
treatment of pilonidal disease
drain abscess and collect debris followed by excision of sinus tracts
ope closure too
treatment for postpericardiotomy syndome
NSAIDs or steroids bc immune reaction
rotator cuff muslces
supraspinatous (MC injury)
infraspinatus
teres minor
subscapularis
pt with subacute shoulder pain on abduction most likely has what
rotator cuff tendinopathy
from repetitive activity above shoulder heigt
most common cause of syringomyelia are what
arnold chiari malformations and prior spinal cord injuries
fever and abdominal pain radiating to groin and pain with hip extension
psoas abscess
nerve damaged in humeral mid shaft fracture
radial nerve
uncal herniation lesions and cause
compression contralat crus cerebri = ipsilat hemiparesis
compression ipsilateral CN III = loss paraymp innervation (mydriasis, down and out gaze)
compression ipsilat PCA = contralat homnymous hemianopsia
compression of reticular formation = Altered consciousness, coma
atelectasiss occurs often after what surgery
abdominal and thoracoabdominal procedures
abdominal pain, diarrhea, nausea, hypotension/tachycardia, dizziness/confusion, fatigue, diaphoresis 15-30 minutes after meals
dumping syndrome
differential diagnosis for an anterior mediastinal mass includes what
4 Ts
thymoma, teratoma, thyroid neoplasm, terrible lymphoma
teratoma (and other germ cell tumors)
treatment for peritonsillar abscess
needle aspiration or I and D plus antibiotic therapy to cover GAS and anerobes
clinical presentation of bowel ischemia
abdominal pain and blood diarrhea
fever and leukocytosis may also be present
pt: use of NSAIDs and several day history of episodic postprandial epigastric pain followed by acute onset severe constant pain =
perforated peptic ulcer
urgent exploratory lap
pt is hemodynamically unstable after blunt abdominal trauma and FAST is inconclusive, what should you do next
diagnostic peritoneal lavage
managment of duodenal hematoma
decompression by NG tube, and possible parenteral nutrition
treatment of acute adrenal insufficiency
hydrocortisone or dexamethaasone
high flow IVF
spontaneous pneumothorax pts
thin young men or underlying lung disease like COPD
diagnostic requirements of acute liver failure
ALT and AST in 1000 or more
signs of hepatic encephalopathy
synthetic liver dysfunction (INR at or above 1.5)
if arterial puncture site is above where then a hematoma can extend into the retroperitoneal space
and what are clx features
and diagnosing it
and treatment
above inguinal ligament
hemodynamic instability and flank or back pain
confirm with non contrast CT scan of A and P or abdominal US
supportive treatment usually
unilateral LE edema that worsens when the leg is dependent (pt at work) and improves with leg elevation (when pt sleeping)
pathophys
venous valvular incompetence
decreases intravscular volume bc fluid out of caps into interstiial fluid and stimulates kidney to retain water which makes even worse
myocaredial contusion classically causes what
tachycardia, new BBB or arrhytmia
often see sternal fx
HF and angina several months following an MI with possible ventricular arrhythmia and systemic embolization
left ventricular aneurysm
immediately after a severe burn, what organisms dominate, then 5 days later what does
gram positive at first like staph aureus
5 days later gram negs like pseudomonas and candida
fracture of surgical neck of humerus may cause what
axillary nerve injury
femoral nerve provides sensation to what
anterior thigh and medial leg via saphenous branch
what is the most common nonsurgical hypoparathyroidism
lab findings
autoimmune
hypocalcemia, and hyperphosphatemia in presence of normal renal function
ECG shows persisten ST elevation and deep Q waves
LV aneurysm
pain out of proportion to clinical findings is first presenting sx and worsening pain may occur with passive stretch of affected muscle compartment
acute compartment syndrome
pts on what meds are at increaesd risk for hemoperitoneum from a ruptured ovarian cyst
anticoagulation
AE atovaquone
GI distress, rash
eval of hyponatremia: urine osmolality under 100
primary polydipsia
malnutrition (beer drinkers phenom)
urethral injury
blood at urethral meatus, high riding prostate
echo shoes thin and dyskinetic myocardial wall
LV aneursym
opoid withdrawal has signs of what activation
sypathetic nervous system
management of a stress fractutre
reduce weight bearing for 4-6 weeks
blood at urethral meauts, eccyhmosis of scrotum and high riding prostate
posteior urehtral injury
infection with nasopharyngeo carcinoma
epstein barr
what is cushings reflex and what does it mean
HTN, bradycardia and resp depression (BRH)
incresed ICP
what infection considered in ventilator associated pneumonia
pseudomonas
what pts most get pilnidal disease
15-30 year old young males, obese and sedentary lifestyles
what gallbladder path uses HIDA scan and when
cholecystitis when US inderterminate
preferred points of central venous access cath are where
internal jugular vein
subclavian vein
MC cause of ureteral injury
iatrogenic trauma during abdominal surgery
rare from blunt trauma but when happens its at ureteropelivc junction
-hematuria, fever, flank pain and hydronephrosis
diagnosing ischemic colitits
CT scan: colonic wall thickening, fat stranding
endoscopy: edematous and friable mucosa
hyponatremia
serum osmolality over 290
marked hyperglycemia
advanced RF
esophageal webs
most commonly located in the upper esophagus and only cause mild focal narrowing (dysphagia to solids but not liquids) IDA too plummer vinson
management of blunt genitourinary trauma in hemodynamically unstable pt with renal trauma eveidence
undergo IV pyelography prior to surgical evaluation
any penetrating wound below the ___ ICS is considered to involve the abdomen and requires what
4th
laparotomy in unstable pts
left sided hemothorax could cause what findings
some tracheal deviation to right and reduced breath sounds and dullness to percussion over involved side
pt with motor vehicle accident and chest x ray showing bowel loops within thoracic cavity and shift of mediatstinum suggest what and next step managment
diaphragmatic rutpure
Chest CT can confirm diagnosis
____ is chronic anterior knee pain and MC in women. PEripatellar pain worsened by activity or prolonged sitting
patellfemoral pain syndrome
erythema sweeling POOP to PE and CT scan showing air in deep tissue
necrotizing faciitis
initial stream hematuria
urethritis
trauma to urethra like foley cath
was is acute adrenal insufficiency characterized by
severe and often refract hypotension, vomiting, abdo pain and fever
hyponatremia and hyperkalemia (normal potassium in central AI)
RA often involves what joints
MCP
benign bony growth located on the midline suture of the hard palate
torus palantinus
genetic and environmentla
common in young women asians
nasal septal perforation is common following what surgery
presents how
rhinoplasty
post op whistling noise with respiration
perf from septal hematoma
what is common in occupations requirng repetivie kneeling and carpet laying and plumbing
prepatellar bursitis from staph aureus
aspirate and cell count and gram stain
if neg then NSAIDs and rest
if positive then drain and abx
bilateral lower extremity edema and stasis dermatitis is what
LE venous valvular incompetence
treating burn wound sepsis
pipe/tazo, carbapenum with vanco or aminoglycoside
axillary nerve injured during what humerus fracture
proximal
massive PE typically presents with what bp and neck veins
hypotension and distended neck veins
compartment pressure over ____nmm Hg or (diastolic - comparment pressure) under what indicates significant compartment syndrome
30
under 20-30
how to reduce warfarin anticoagulation
FFP
fever 1 week after surgery usually due to what
drug fever
surgical site infx
PE
leukocytosis with neutrophilic predominance is side effect of what med
systemic glucocorticoids
nerve?
foot dorsiflexion and toe extension and sensation where flip flops are
deep peroneal nerve
ideal placement of a central venous cath tip is where
lower superior vena cava
multiple, recurrent, painful nodules in the axillae, inguinal folds and perineal areas
hidradenitis suppurativa
ABI interpretation
abnormal, normal and low
- 90 or lower = abnormal
- 91-1.30 = normal
- 30 and over = calcified and uncompressible vessles, do more studies
symtomatic pancreatic pseudocyst treatment
endocsopic drainage
if no sx then expectant managment
fever occuring immediately (within a few hours) in the operative or postop period is typically due to what
prior infection or trauma, inflammation due to surgery, malignant hyperthermia, or meds or blood produts given prior to surgery
hip pain when pressure is applied as when sleeping and with external rotation or resisted abduction
from excess friction
trochanteric bursitis
hemodynamically stable pts with intraperitoneal fluid ID’d on FAST should have what done
CT scan of abdomen
can distinguish blood from urine or ascites and show site
obturator nerve innervates what comparment and muscles of thigh and action and sensation
medial compartment
gracillis adductor longus, adductor brevis, anterior portion of adductor magnus
adduction of thigh
sensation over medial thigh
AE pentamidine
nephrotox, hypotension, hypoglycemia, cardiac arrhythmias, pancreatitis, elevated transaminases
adrenal insufficieny and water stuff
presents with hypovolemia which leads to increased ADH and hyponatremia
this would concentrate urine
uncomplicated diverticulitis in stable patients can be managed how
outpatient setting with bowel rest, oral antibiotics and observation
if really old or CIP then hospital IV abx
