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Surgery Flashcards

1
Q

who is at the greatest risk for a hepatic adenoma

A

young women on prolonged oral contraception

  • most are fine
  • life-threatening complications can occur like malignant transformation or rupture can occur

-consider rupture in the setting on sudden-onset, severe right upper quadrant pain and signs of hemorrhagic shock

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2
Q

patient with puncture wound through shoe then gets osteomyelitis

A

pseudomonas osteomyelitis

-usually takes > 2 weeks

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3
Q

if pt has penetrating abdominal trauma, hemodynamic instability, peritonitis, evisceration, or impalement… whats your next step

A

exploratory laparotomy

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4
Q

how to manage uncomplicated renal stones (< 1 cm)

A

hydration, analgesics, alpha blockers

-list of alpha-blockers: tamsulosin and -osin

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5
Q

what is a potential complication of an epidural nerve block

-pt may present with progressive motor/sensory dysfunction, localized back pain, bladder/bowel dysfunction

A

spinal epidural hematoma

  • more common in older people taking antithrombotics
  • manage with urgent MRI and neurosurgical decompression
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6
Q

2 main signs that should prompt surgical exploration

A

free air on x-ray

clinical signs of peritonitis

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7
Q

what is malignant hyperthermia and when/how does it present

A
  • genetic mutation altering intracellular calcium triggered by volatile anesthetics, succinylcholine, excessive heat
  • manifests as: masseter/muscle rigidity, sinus tachy, hypercarbia, rhabdo, hyperkalemia, and late you’ll see hyperthermia
  • can occur during or even be delayed till after youre done with anesthesia
  • treat with respiratory/ventilation support, stop cessation of causative anesthetic, and dantrolene
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8
Q

what is a HIDA scan

A

aka. cholescintigraphy

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9
Q

most common symptom of pancreatic cancer and how do you test for it

A

insidious, continuous midepigastric pain that radiates to back/flanks and is worse with eating or lying down

-get abdominal CT as first step when suspected

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10
Q

cardiac myxoma

A

usually in LA

benign tumor but bits of it can embolize

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11
Q

tender, erythematous streaks proximal to wound

A

Lymphangitis

  • regional tender lymphadenopathy (lymphangitis)
  • systemic symptoms (fever, tachycardia)
  • usually due to strep pyogenes and MSSA
  • treat with cephalexin
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12
Q

what correlates to medullary thyroid cancer metastasis

A

neuroendocrine malignancy –> calcitonin secreting parafollicular C cells
calcitonin correlates to metastasis

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13
Q

how to manage osteoarthritis

A
  1. non-pharm –> exercise and weight loss
  2. topical or oral NSAIDs
  3. surgery or chronic pain management
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14
Q

how does the body get rid of low molecular weight heparin

A

renal removal

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15
Q

infection w/i retropharyngeal space can drain where..

A

into the superior mediastinum which can cause acute necrotizing mediastinitis

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16
Q

what is one of the first signs of IBD

A

toxic megacolon

  • systemic toxicity (fever, tachy, hypotension)
  • bloody diarrhea
  • abdominal distension/peritonitis
  • marked colonic distension on imaging
  • treat with bowel rest, NG suction, abx, corticosteroids if IBD is associated, surgery if unresponsive to med management
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17
Q

description of giant cell tumor

A

only epiphyseal tumor

looks like soap bubble on x-ray

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18
Q

acute knee pain associated with catching or reduced range of motion suggests what…

  • likely with crepitus too
  • acute popping sensation may occur
  • slow-onset joint effusion
A

meniscal tear

  • persistent symptoms should have eval with MRI
  • may need
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19
Q

how to initially manage patients with large surface area (> 20%) burns

A

extensive burns can lead to hypovolemic shock due to large release of proinflammatory mediators that increase vascular permeability and can cause third spacing of fluid
MANAGE WITH EXTENSIVE FLUID RESUSCITATION
-use parkland formula to figure out how much
-titrated to maintain adequate urine output
-put in urethral catheter to monitor

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20
Q

what is one of the earliest manifestations of autosomal dominant polycystic kidney disease

A

hypertension

  • likely results from cyst expansion leading to localized renal ischemia and consequent increase in renin production with activation of RAA axis
  • best treated with ACE inhibitors
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21
Q

biggest risk factor for pancreatic cancer

A

smoking

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22
Q

3 ways to assess for a melanoma

A
  1. ABCDE (more than 1 or 2 is suspicious) –> asymmetry, borders, color variation, diameter > 6mm, evolving appearance over time
  2. 7-point checklist (> 1 major or > 3 minor criteria is suspicious) –> MAJOR: change in size, shape, develops nodularity, or color MINOR: size > 7mm, local inflammation, crusting/bleeding, sensory symptoms like itching or bleeding
  3. ugly duckling sign –> one lesion significantly different from the others on the patient
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23
Q

if a patient has RA and then is slowly developing UMN and other nerve problems, what should come to your mind?

A

cervical myelopathy

  • atlantoaxial instability which can be made worse if a pt needs to be intubated
  • slowly progressive, spastic paraparesis involving upper and lower extremities, hyperreflexia, sensory changes, and a positive babinski sign
  • hoffman sign may also be positive
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24
Q

patient who develops acute abdominal pain, shock, and anemia in the setting of one of the following likely has what

  • hematologic malignancy
  • infection
  • systemic inflammatory disease
  • anticoagulation
A

atraumatic splenic rupture

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25
Q

how to search for epiglotitis

A

get lateral neck radiograph to look for enlarge epliglotti s

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26
Q

50% of pts get what after a coronary artery bypass graft operation

A

pleural effusion, usually on the left side
-if its small, occurs shortly after surgery (post op day 1 or 2), and creates no respiratory problems then you can just observe it to make sure it goes away on its own

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27
Q

initial diagnostic study for hemodynamically stable pts with aortic dissection

A

CT angiography – reveals intimal flap separating true and false lumens

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28
Q

ulcerated tonsillar lesion in pt with long smoking history

A

oropharyngeal squamous cell carcinoma

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29
Q

what are the signs of a necrotizing surgical site infection

A
  • pain, edema, erythema spreading beyond surgical site
  • systemic signs: fever, tachycardia, and hypotension
  • paresthesia or anesthesia at wound edges
  • purulent, cloudy-gray discharge (dishwater drainage)
  • subcutaneous gas or crepitus

-treat with parenteral abx and urgent surgical debridement

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30
Q

patient has intraperitoneal air on x-ray what do you think

A

possible peptic ulcer perforation and they need surgical exploration

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31
Q

classic triad for spinal epidural abscess and what is the progression

  • epidural anesthesia is a common trigger due to direct inoculation
  • if you suspect it then get spinal MRI
  • treat with surgical decompression and antibiotics
A
  1. fever
  2. focal/severe back pain
  3. neurologic findings (motor/sensory change, bowel/bladder dysfunction, paralysis)

progression: focal back pain –> nerve root pain –> motor weakness, sensory changes, bowel/bladder changes –> paralysis

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32
Q

patient comes in with kidney stone in urethra, at what size do you change management of stone?

A

stone size < 10mm –> medical management with hydration, pain control, alpha blockers, and strain urine (can be done outpatient)
-if that doesnt work/help or pt has uncontrolled pain with no stone passage in 4-6 weeks then get a urology consult

stone size > 10mm –> urology consult

  • note that most ureteral stones < 5mm in diameter pass spontaneously and alpha blockers can be used to help stones 6-10mm
  • if larger than 10mm, refractory pain, anuria, aki, urosepsis then consult urology
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33
Q

pt has abdominal/flank/groin pain, pulsatile mass, flank ecchymosis, and limb ischemia
what do you think

A

unstable abdominal aortic aneurysm

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34
Q

how do you work up a suspected aaa in a stable pt

A

CT scan

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35
Q

3 local complications of cardiac catheterization

A
  1. hematoma (possible mass)
  2. pseudoaneurysm (bulging pulsatile mass with systolic bruit)
  3. AV fistula (no mass with continuous bruit)
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36
Q

if a pt has celiac disease what should be an additional concern

A

osteoporosis due to vitamin D malabsorption

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37
Q

Patient presents with hypoxia, characteristic pulse ox of ~85% with a large oxygen saturation gap

A

Acquired Methemoglobinemia

  • results from oxidation of iron hemoglobin
  • due to topical anesthetic agents or dapsone
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38
Q

pilonidial cyst/disease

A
  • most frequently affects males age 15-30
  • obese individuals
  • most common symptom is a painful, fluctuant mass on the upper coccyx with mucoid, purulent, and bloody discharge
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39
Q

what is the best way to diagnose diverticulitis

A

abdominal CT with oral or IV contrast

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40
Q

whatre the surgical indications for pts with cerebellar hemorrhage

A
  1. signs of neurologic deterioration
  2. radiologic evidence of hemorrhage > 3mm
  3. brainstem compression
  4. obstructive hydrocephalus
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41
Q

patient had gastric bypass and then presents with abdominal pain, bloating, flatulence, malabsorption, weight loss, anemia, vitamin deficiency

A

small intestinal bacterial overgrowth

-dx with jejunal aspirate and culture > 10^3 or carbohydrate breath testing

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42
Q

what predisposes someone to small intestinal bacterial overgrowth

A

conditions that alter intestinal mobility

  • systemic sclerosis
  • diabetes

anatomy problems
-stricture

gastric/pancreatic secretions

  • atrophic gastritis
  • chronic pancreatitis
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43
Q

patient has whip-lash like injury in the setting of underlying cervical spondylosis… what do you think of

A

central cord syndrome

-presents only with upper extremity abnormalities

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44
Q

patient with post-op hypotension, distended JVD, and new onset right bundle branch block

A

massive pulmonary embolism

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45
Q

in a transfusion problem how do you tell the difference b/w TRALI and TACO

A

TRALI (transfusion related acute lung injury)

  • no JVD
  • normal ejection fraction
  • normal BNP

TACO (transfusion associated cardiac overload)

  • JVD present
  • possible S3 present
  • decreased ejection fraction
  • high BNP
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46
Q

if you suspect appendicitis in a non-pregnant adult then how do you diagnose it

A

abdominopelvic CT

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47
Q

cushing triad

A

used in late stages of acute head injury due to increased intracranial pressure

  1. hypertension
  2. bradycardia
  3. irregular respirations
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48
Q

If a trauma pt is presenting with blood loss but none is found intraperitonealy or pericardially then where do you look or what do you think of

A

pelvic fracture where the blood is “hidden” in the retroperitoneal space
-hemorrhagic shock is most common in trauma pts

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49
Q

mnemonic for lots of blood loss in trauma pt

A

blood on the floor and 4 more

  • external bleeding on the floor up to entire blood volume
  • chest: up to 40% of blood volume/hemithorax
  • abdomen (peritoneal cavity): up to entire blood volume
  • pelvis: up to entire blood volume and usually its hidden in the retroperitoneum
  • thigh: up to 1-2L of blood
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50
Q

patient has significant head trauma that leads to ipsilateral hemiparesis, ipsilateral mydriasis, and strabismus, contralateral hemianopsia, and altered mentation

A

transtentorial herniation of parahippocampal uncus

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51
Q

major risk factors for development of acute urinary retention (AUR)

  • dx with bladder ultrasound
  • pt presents with agitation, tachycardia, lower abdominal/suprapubic tenderness
A 
male sex
advanced age (>80)
history of BPH
history of neurologic disease 
surgery
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52
Q

patient has elevated alk phos and elevated GGT with mild focal dilations within both intra and extra-hepatic biliary ducts

A

primary sclerosing cholangitis
-associated with UC so patients should get colonoscopy

  • patients have fibrous obliteration of small bile ducts with concentric replacement by connective tissue in onion-skinning pattern
  • complications: biliary stricture, cholangitis/cholelithiasis, cholangiocarcinoma, colon cancer, biliary cancer, cholestasis (decreased fat-soluble vitamins, osteoporosis)
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53
Q

how does care change with a breast mass in pts above or below 30

A

below 30: ultrasound with maybe mammography then if simple cyst get needle aspiration if pt wants it, but if complex cyst/mass then get image-guided core biopsy

30 or above: mammography with maybe ultrasound then if suspicious for malignancy get core biopsy

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54
Q

patient with blunt trauma and renal injury

A

get CT of abdomen and pelvis

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55
Q

charcots triad vs reynolds pentad

A 
signs and symptoms suggesting obstructive ascending cholangitis (infection of biliary system)
TRIAD
1. RUQ pain
2. fever
3. jaundice

PENTAD

  1. shock (hypotension, tachycardia)
  2. altered mental status
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56
Q

patient presents with the following below, how do you diagnose them

  • jaundice, pruritis, acholic stools, dark urine
  • weight loss
  • RUQ pain
  • RUQ mass or hepatomegaly
  • increased direct bilirubin, ALP, GGT
A 
malignant biliary obstruction 
dx via 
-serum tumor markers: CEA, CA-19, AFP
-abdominal imaging: ultrasound, CT scan
-EUS or ERCP for tissue diagnosis if unclear
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57
Q

how to treat septic arthritis

A

IV abx and adequate drainage of purulent material via needle aspiration, arthroscopic irrigation, or open surgical drainage
note that serial procedures are often required to completely clear the infection

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58
Q

diabetic pt presents with fever, RUQ pain, nausea/vomiting, crepitus in abdominal wall adjacent to gall bladder
-additional risk factors are vascular compromise and immunosuppression

A

emphysematous cholycystitis

  • dx: air-fluid levels in gallbladder, gas in gallbladder wall, cultures with gas forming Clostridium or Ecoli, unconjugated hyperbilirubinemia, mildly elevated aminotransferases
  • treatment: emergent cholycystectomy with broad spectrum abx that include clostridium coverage (penicillin-tazobactam)
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59
Q

risk factors for different types of esophageal cancer and how to initially look for it

A

(distal esophagus) adenocarcinoma: uncontrolled GERD, obesity, male –> presents with solid food dysphagia

(proximal and mid esophagus) squamous cell carcinoma: smoking, alcohol, n-nitros containing foods (processed meat)

*do upper endoscopy for both with biopsies while CT and PET scan can be used for staging

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60
Q

hemobilia

A

bleeding into the biliary tract

  • rare cause of upper GI bleeding that usually occurs as complication of hepatic or biliopancreatic procedures
  • presents with RUQ pain, jaundice, and upper GI bleeding
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61
Q

how to manage hemothorax

A

tube thoracostomy is usually sufficient but pts need emergent thoractomy for extreme bleeding
-initial bloody output > 1,500mL or persistent hemorrhage > 200mL/hr for > 2hrs or continuous need for blood transfusion to maintain hemodynamic stability

*used to prevent exsanguination

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62
Q

compare and contrast basal cell carcinoma and squamous cell carcinoma

A

basal cell: pearly, flesh colored pink nodule with telangiectatic vessels is usually found on head or neck. most common skin malignancy

squamous cell: most common skin malignancy in pts on chronic immunosuppressive therapy or history of organ transplant or burn pts/sun exposure, very aggressive and can cause drainage

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63
Q

shin splints vs stress fracture

A

stress fracture will have point tenderness but shin splints will have diffuse tenderness on anterior shin

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64
Q

narrowed intercostal spaces and mediastinal shift toward problematic lung on x-ray

A

bronchial mucus plug

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65
Q

if pt has spinal cord compression due to spinal injury/malignancy/infection… what do you do

A
  • emergent MRI
  • IV glucocorticoids
  • neurosurgery +/- radiation oncology consult
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66
Q

patient with turners syndrome gets pregnant, what are they at increased risk for?

A

aortic dissection due to hemodynamic changes of pregnancy placing additional strain on aorta

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67
Q

lateral wrist pain, overuse syndrome involving tendons of abductor pollicis longus and extensor pollicis brevis
-occurs most commonly where tendons pass under extensor retinaculum in first dorsal compartment

A

de Quervain tendinopathy

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68
Q

patient has abdominal distension then has persistent bloody ascites found on multiple paracenteses suggests what

A

underlying malignancy

-most common is hepatocellular carcinoma

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69
Q

flank pain and hemodynamic instability

A

possible ruptured abdominal aortic aneurysm

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70
Q

how to test for PE in clinically stable patient

A

CT angiography

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71
Q

3 main components to glascow coma scale

A

eye opening
verbal response
motor response

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72
Q

how to treat pts with hypercalcemia due to immobilization

A

its due to increased osteoclastic bone resorption so giving bisphosphonates helps

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73
Q

ottawa ankle rules

A

tells you when to get plain radiographs of ankle with pain of malleolus
-point tenderness over posterior margin or tip of malleolus
OR
-inability to bear weight after injury and for 4 steps during medical evaluation

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74
Q

patient presents with leg injury and pain increased on passive stretch with parethesia

  • also pain out of proportion to injury
  • rapidly increasing and tense swelling
A

compartment syndrome

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75
Q

patient presents with insidious onset of flank pain and systemic symptoms (fever, weight loss)

  • usually with history of UTI or extrarenal infection (bacteremia) in last 2 months
  • urinalysis shows pyuria, bacteriuria, and proteinuria but can be normal
A

renal and perinephric abscesses

-urinalysis will be normal if abscess is not in contact with collecting ducts

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76
Q

pt with severe hypertensiona dn recurrent flash pulmonary edema in the setting of diffuse atherosclerosis suggests….

A

renal artery stenosis

  • associated findings: CKD, secondary hyperaldosteronism (hypokalemia, elevated serum bicarb)
  • dx with renal ultrasound with doppler
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77
Q

how to treat aortic dissection

A

pain control
IV beta blockers
maybe sodium nitroprusside (if SBP >120)
emergent surgical repair for ascending dissection

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78
Q

risk factors for atherosclerosis

A

diabetes
hypertension
smoking

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79
Q

if patient discusses occasional leg cramping what do you think of so what do you do

A

intermittent claudication
-ABI (ankle-brachial index) = SBP of dorsalis pedis or posterior tibial artery / SBP of brachial artery
-ABI Scores
less than 0.9 = PAD
0.91-1.3 = Normal
more than 1.3 = calcified and uncompressible vessels

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80
Q

expected labs with normal pressure hydrocephalus

A

ventriculomegaly with normal opening pressure on lumbar puncture

  • not all symptoms (wet, wobbly, wacky) may be present in early disease
  • can be due to secondary insults to brain: subarachnoid hemorrhage, trauma, meningitis all due to scarring of arachnoid granulations responsible for CSF
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81
Q

how to treat normal pressure hydrocephalus

A

ventriculoperitoneal shunting

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82
Q

chronic alcohol use disorders and postprandial epigastric pain should lead you to think of what and what do you see on paracentesis

A

chronic pancreatitis

-paracentesis: serosanguinis/yellow fluid with high amylase, high total protein, and low serum ascites albumin gradient

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83
Q

patient has a history of forceful retching then has epigastric/back/retrosternal pain, what are the two things on the top of your differential and describe them

A

Mallory-Weiss tear

  • mucosal tear
  • submucosal venous or arterial plexus bleeding
  • hematemesis (bright red or coffee ground appearance)
  • possible hypovolemia
  • upper GI is diagnostic and therapeutic to treat persistent bleeding
  • manage with acid suppression but most heal spontaneously

Boerhaave syndrome

  • transmural tear
  • spillage of esophageal air/fluid into surrounding tissues
  • crepitus, crunching sound (Hamman sound)
  • odynophagia, dyspnea, fever, sepsis
  • CXR can show pneumothorax, pneumomediastinum, pleural effusion
  • esophagography or CT with water soluble contrast to confirm
  • manage with acid suppression, abx, NPO and emergency surgical consultation
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84
Q

patient has recent T2DM diagnosis, what are they now at a higher risk for

A

pancreatic cancer

25% of pancreatic cancer is heralded by recent < 2 year dx of DM

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85
Q

how to transport an amputated body part to be attached

A

transported by wrapping it in saline-moisturized gauze, sealing it in a plastic bag, and placing the bag in an ice water bath

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86
Q

what is a succussion splash

A

the noise of air and fluid moving around in an area likely due to an outlet obstruction and causing a backing up into the organ being discussed

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87
Q

splenic abscess triad and most common association

A
  1. fever
  2. leukocytosis
  3. LUQ pain
    - patients can develop left sided pleuritic chest pain, left pleuritic effusion, and splenomegaly
    - most common association: infective endocarditis
    - risk factors: hematogenous spread, immunosuppression, IV drug use, trauma, and hemoglobinopathies
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88
Q

more pain with knee flexion or pressing on the kneecap

A

patellofemoral pain syndrome

-first line treatment is to do quadriceps exercises

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89
Q

new baby presents b/w 2-8 weeks with jaundice, pale stools, small or absent gall bladder, what do they have and what labs do you expect

A

biliary atresia

  • high direct bilirubin, high GGT, and normal reticulocyte count
  • manage with surgical hepatoportoenterostomy (kasai procedure) or liver transplant
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90
Q

incidence of pancreatic cysts in aging population is 40% of people > 70, which is not really a problem cause usually they are low risk and not malignant but what would make you think it might be able to have a malignant transformation and how do you manage that

A
  • large size > 3cm
  • solid or calcific
  • main pancreatic duct involvement (ductal dilation)
  • thickened or irregular cyst wall

-manage with endoscopic ultrasound-guided biopsy and possibly surgical resection

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91
Q

what are the two most common causes of acute mesenteric ischemia

A
  1. cardiac embolic events with a.fib, valvular disease, or cardiovascular aneurysms
  2. acute thrombosis due to peripheral arterial disease or low cardiac output states

risk factors: atherosclerosis, embolic source, hypercoagulable disorders

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92
Q

what should you expect to see with acute mesenteric ischemia

A

pt present with: rapid onset of periumbilical pain, pain out of proportion to examination findings, and late onset of hematochezia

labs: leukocytosis, elevated hemoglobin, elevated amylase, and metabolic acidosis with elevated lactate
dx: CT preferred but can do MR angiography then do mesenteric angiography if diagnosis is unclear

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93
Q

after cardiac surgery pt describes clicking and shifting of chest (chest wall instability) when bending or moving upper extremities, what is this and what do you do

A

sternal dehiscence

  • surgical complication when 2 approximated edges of sternum separate
  • usually due to loosening or fracture of suture wire
  • if with infection its called mediastinitis
  • manage with surgical exploration and repair
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94
Q

laryngeal ulcer in a smoker… what do you think of

-pt presents with persistent hoarseness

A

squamous cell carcinoma

-make sure you get a laryngoscopy

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95
Q

how to manage pancreaticopleural fistula

A

bowel rest to help with fistula closure and possible ERCP with sphincterectomy or stent placement to help drain fluid through ampulla of vater instead of through fistula

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96
Q

ludwig angina

A

rapid, progressive cellulitis of submandibular space usually due to dental infections in mandibular molars that spread contiguously down the root of the tooth

  • usually polymicrobial with mixture of oral aerobic (viridans) and anaerobic bacteria
  • early intervention with IV abx usually helps prevent airway compromise
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97
Q

patient presents with shoulder pain, horner syndrome, arm pain, and/or hand weakness… what do you think of

A

superior pulmonary sulcus tumor

-get chest x-ray

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98
Q

how to manage pts with small spontaneous pneumothorax

A

observation and supplemental oxygen (regardless of O2 saturation) because it enhances the speed of resorption

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99
Q

how quickly can someone become vitamin K deficient

A

7-10 days

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100
Q

how to manage massive amounts of hemoptysis from pt (>600mL/day OR >100mL/hr)

A

secure airway and breathing but if bleeding continues then treat cause of bleeding via bronchoscopy, embolization, or resection
-if bleeding stops then manage like mild or moderate where you do a full workup first

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101
Q

when to do an urgent thoracotomy/surgical intervention for hemoptysis

A

pts with unilateral bleeding who continue to bleed even after bronchoscopy and/or arterial embolization

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102
Q

pt has hypophosphatemia (key finding!) plus other electrolyte abnormalities, muscle weakness, arrhythmias, and congestive heart failure… what do you think of

A

refeeding syndrome

  • due to reintroduction of nutrition in pts with chronic malnourishment
  • hypophosphatemia is due to increase insulin and cellular electrolyte uptake and the subsequent increase in phosphate utilization during glycolysis
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103
Q

aspiration pneumonitits vs aspiration pneumonia

A

aspiration pneumonitis

  • acute lung injury presents within hours secondary to chemical burn from aspiration of gastric contents
  • lung inflammation
  • can be asymptomatic or have decreased O2 with nonproductive cough
  • only treat with supportive care

aspiration pneumonia

  • infectious disease presents days after caused by aspiration of infected oropharyngeal secretions
  • pts present with productive cough
  • can lead to abscess formation
  • treat with abx (clinda or beta-lactam with beta-lactamase inhibitor)
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104
Q

all trauma pts should get what imaging

A
  1. portable chest and abdominal x-rays
  2. Focused Assessment with Sonography or Trauma (FAST)
  3. cervical spinal imaging (CT preferred)
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105
Q

indications for spinal CT

A
  1. high energy mechanism of injury
  2. neurological deficit
  3. spinal tenderness
  4. altered mental status
  5. intoxication
  6. distracting injury

*note that presence of single vertebral fracture (especially cervical) is an indication to image the entire spine because risk of additional spinal fracture increases 20%

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106
Q

what can trigger catecholamine surges in pts with pheochromocytomas (from adrenal medulla)

A

surgical procedures
induction of anesthesia
various medications (give alpha blockers before giving nonselective beta blockers)

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107
Q

what type of dislocation happens to an abducted externally rotated arm

A

anterior dislocation
-most commonly injured nerve is axillary which innervates teres minor and deltoid causing weakened shoulder abduction and decreased sensation in skin overlying lateral shoulder

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108
Q

common cause of postop fever (temp > 100.4)

A

due to cytokine release including IL-6 (pyretic) in response to tissue trauma, blood cell lysis, or bacterial endo/exotoxins

  • within hours = tissue trauma
  • 1+ weeks after surgery = bacterial infection
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109
Q

patient has some stressor then has increased unconjugated bilirubin but nothing else wrong

A

gilberts syndrome

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110
Q

pt presents < 24hrs after blunt thoracic trauma with tachypnea, tachycardia, hypoxia

  • pulm exam: rales and decreased breath sounds
  • CT scan or CXR with patchy alveolar infiltrates not restricted by anatomical borders
A

pulmonary contusion

-manage with pain control, pulmonary hygiene (incentive spirometry, chest PT), supplemental O2 and ventilatory support

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111
Q

if pt has blunt abdominal trauma with persistent nausea what do you think of

A

pancreatic duct injury

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112
Q

what are the indications for foot imaging (x-ray or MRI) with a diabetic foot ulcer

A
  1. deep (exposed bone or positive probe-to-bone testing)
  2. long-standing (present > 7-14 days)
  3. large ( > 2cm)
  4. associated with elevated ESR or CRP
  5. associated with adjacent soft tissue infection

*note –> always check for infection and osteomyelitis no matter what

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113
Q

explain everything about a varicocele

A

presentation: soft scrotal mass, bag of worms appearance, decreases in supine position, increases with standing and valsalva, subfertility, testicular atrophy

imaging (ultrasound): retrograde venous flow, tortuous anechoic tubules adjacent to testis, dilation of pampiniform plexus veins

treatment: gonadal vein ligation (in boys and young men with testicular atrophy), scrotal support and NSAIDs (older men who don’t want kids)

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114
Q

patient presents with duodenal and jejunal ulcers plus persistent diarrhea and fatty poop, what do you think of

A

zollinger-ellison

  • workup with endoscopy, CT/MRI, somatostatin receptor, scintigraphy for tumor localization
  • all the increased acid causes inactivation of pancreatic enzymes which can lead to malabsorption
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115
Q

what is a nissen fundoplication surgery used for

A

those with refractory GERD symptoms (anti-reflux surgery)

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116
Q

6 Ps of acute limb ischemia and how to manage it

A 
Pain
Pallor
Paresthesia
Pulselessness 
Poikilothermia (cool extremity)
Paralysis (late)

-manage with anticoagulation and thrombolysis/surgery

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117
Q

humerus fracture, what arteries and nerves are you worried about

A

proximal: Axillary nerve
mid-shaft: Radial nerve
distal: Median nerve, Brachial artery

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118
Q

patient with gallstone pancreatitis, fevers, RUQ pain, jaundice, altered mental status, and hypotension

A

acute cholangitis

-do ERCP to relieve biliary obstruction and prevent serious infectious complications

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119
Q

fever, RUQ pain, leukocytosis, altered LFTs
-dx with abdominal CT showing well-defined, hypoattenuating, rounded lesion often surrounded by peripherally enhancing abscess membrane

A

pyogenic liver abscess

  • can result from direct spread from biliary tract or from hematogenous seeding of distal infection, particularly those involving the portal system (diverticulitis)
  • manage with blood cultures, abx, aspiration, and drainage
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120
Q

how is TPN usually administered

A

central venous catheter

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121
Q

free-living marine bacterium that causes food-borne illness (with what?) and wound infections which can be anything from mild to rapid-onset/severe necrotizing fasciitis with hemorrhagic bullous lesions and septic shock

A

Vibrio Vulnificus

  • food-borne via oysters
  • pts with liver disease: cirrhosis, viral hepatitis, hereditary hemochromatosis are at high risk for worse infections
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122
Q

what are the signs of a urethral injury

A
  • blood at the urethral meatus
  • high-riding prostate
  • resistance while trying to pass a foley catheter
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123
Q

pelvic fracture, gross hematuria, suprapubic pain/tenderness, difficulty voiding

A

extraperitoneal bladder wall rupture

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124
Q

adducted and internally rotated hip

A

posterior hip dislocation

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125
Q

pt has mechanical fall then has shortening and external rotation of one leg

A

Femoral neck or intertrochanteric fracture
OR
anterior hip dislocation (but less common)

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126
Q

how do pts with sudden onset pneumothoraxes present

A

tachycardia, tachypnea, hypoxemia, decreased or absent breath sounds on affected side

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127
Q

what arteries are most commonly affected by fibromuscular dysplasia

A

renal and internal carotid

  • pts present with hypertension and/or recurrent headaches
  • may find bruits on neck and abdomen
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128
Q

pt has hip pain and long-term steroid use, what do you think

A

long-term steroid use increases the likelihood of avascular necrosis

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129
Q

what is stool elastase a marker for

A

pancreatic exocrine function (low in chronic pancreatitis)

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130
Q

management of gallstones

A

asymptomatic: no treatment

typical biliary colic symptoms: elective laparoscopic cholecystectomy or possibly just give ursodeoxycholic acid in poor surgical candidates

complicated disease (acute cholecystitis, choledocholithiasis, gallstone pancreatitis): cholecystectomy within 72 hours

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131
Q

how to diagnose and treat an esophageal perforation

etiology: instrumentation (endoscopy), trauma, effort rupture (boerhaave syndrome), esophagitis (infectious/pills/caustic)

A

DX

  • chest x-ray or CT scan: widened mediastinum, pneumomediastinum, pneumothorax, pleural effusion (low pH and very high amylase maybe even with food particles)
  • CT scan: esophageal wall thickening, mediastinal fluid collection
  • esophagography with water-soluble contrast: leak from perforation

TX

  • NPO, IV abx, and PPI
  • emergency surgical consultation
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132
Q

what is used as a tumor marker for thyroid tumors

A

thyroglobulin (made by normal and malignant thyroid tissue)

-used as a tumor marker once thyroid tissue has been removed

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133
Q

patient presents within 1 week of having gastric bypass with fever, abdominal pain, tachypnea, and tachycardia… what do you think of

A

anastomotic leak

  • confirm with CT with contrast or upper GI
  • treat with urgent surgical repair
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134
Q

fibrotic intestinal stricture vs adynamic/paralytic ileus

A

both present with bilious emesis, severe abdominal pain, partial or incomplete obstruction, distension

  • fibrotic stricture usually presents in crohns pt or smoking history (anything to make you think lots of inflammation)
  • adynamic ileus presents with absent bowel sounds and gastric dilation/gas-filled loops of large and small intestine after insult stuns the bowel (intra-abdominal surgery or high-dose opioids)
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135
Q

patient has persistent clear unilateral rhinorrhea that increases with increased intracranial pressure (like bending over or bowel movements)…

A

CSF rhinorrhea

  • most often caused by head trauma
  • can result in meningitis
  • manage with bed rest, head elevation, avoidance of straining, lumbar drain placement, and surgical repair
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136
Q

aortic stenosis

  • criteria for severe
  • indications for surgery
A

Severe

  • aortic jet velocity > 4 m/sec OR
  • mean transvalvular pressure gradient > 40 mmHg
  • valve area usually < 1 1.0 cm2 but not required

Indications for valve replacement (severe AS + 1 of the following)

  • onset of symptoms (angina, syncope)
  • left ventricular ejection fraction < 50%
  • undergoing other cardiac surgery (CABG)
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137
Q

patient with spinal cord injury above T6… what do you worry about

A

possible autonomic dysreflexia

  • noxious stimuli below injury level trigger unregulated sympathetic response leading to severe hypertension
  • compensatory parasympathetic response above the lesion typically causes bradycardia
  • manage with removing noxious stimuli and treating hypertension
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138
Q

if pt has prerenal acute kidney injury what do you expect their BUN/creatintine ratio to be

A

> 20:1

also expect oliguria (< 500mL/day) and unremarkable urine sediment

139
Q

what is the most likely cause of acute epididymitis for those under vs over the age of 35

A

under 35 likely due to STD (chlamydia, gonorrhea)

over 35 likely due to bladder outlet obstruction (coliform bacteria)

140
Q

furuncle

A
  • skin abscess usually due to staph aureus
  • painful pustule or nodule and drains purulent material
  • kinda looks like a small pimple with a tiny white head
141
Q

intertrigo

A

due to candida infection and presents as well-defined, erythematous plaques with satellite vesicles or pustules in intertriginous and occluded skin areas

142
Q

how does a rectus sheath hematoma occur

A

occur due to rupture of inferior epigastric artery from blunt trauma or forceful abdominal contractions (severe coughing), particularly in those receiving anticoagulation therapy

143
Q

when to suspect acalculous cholecystitis

A
  • can lead to sepsis and death
  • fever and leukocytosis, most pts cant talk cause this usually happens in the severely ill
  • radiology: gallbladder wall thickening and distention with presence of pericholecystic fluid
  • immediately give antibiotics and do percutaneous cholecystostomy with abscess drainage if necessary
144
Q

how to treat acute vs chronic hyponatremia

A

ACUTE (< 48hrs)
-any symptoms give hypertonic 3% saline

CHRONIC (> 48hrs)

  • better tolerated
  • give hypertonic 3% saline only if sodium is < 120mEq/L

*hyponatremic pts are at risk for brain herniation

145
Q

how to differentiate epidermal inclusion cyst and lipoma

A

epidermal inclusion cyst: benign nodule containing squamous epithelium that produces keratin, can change in size and usually resolves spontaneously

lipoma: benign painless subq mass with normal overlying epidermis, usually soft and rubbery and irregular, do not regress or recur

146
Q

hepatic finding with a central stellate scar

A

focal nodular hyperplasia

-grows around blood source

147
Q

only major modifiable risk factor that affects severity and progression of Crohn disease

A

smoking

-tell all pts to stop smoking

148
Q

most common cause of nosocomial bloodstream infections

A

central venous catheters

-direct pathway for colonized skin organisms

149
Q

slowly enlarging abdominal mass that enlarges with valsalva, palpable fascial edges in nonobese pts, possible delayed presentation for months to years

A

incisional hernia

  • breakdown of prior fascial closure
  • risk factors: obesity, smoking, poor wound healing, vertical or midline incision, surgical site infection
  • dx with clinical symptoms or CT scan of abdomen
150
Q

explain the return to consciousness after anesthesia and what is delayed emergence

A
  • emergence w/i 15 mins
  • in tact protective reflexes (gag) w/i 30-60mins
  • delayed emergence: pt fails to regain consciousness w/i expected window due to 3 things
    1. drug effect of preop drugs
    2. metabolic disorder (hyper/hypo -glycemia, -thermia, or liver disease)
    3. neurologic disorder (stroke, seizure, or elevated icp)
151
Q

> 50yo obese woman presents with chronic lateral hip pain worse with abduction of leg and repetitive hip flexion (climbing stairs/walking uphill) or lying on affected side
-pt also has focal tnderness over trochanter… what is it and what do you do

A

Greater trochanteric pain syndrome (GTPS)

  • overuse syndrome involving tendons on gluteus medius and minimus where they run over greater trochanter (trochanteric bursitis)
  • x-ray to rule out hip joint pathology
  • ultrasound: degeneration of tendons, tendinosis

treatment

  • exercise, PT, activity modification
  • NSAIDs
  • corticosteroid injection
152
Q

how to manage diverticulitis (uncomplicated vs complicated)

A

Uncomplicated

  • stable: outpatient with bowel rest, oral abx, and observation
  • elderly/immunosupressed/high fever or leukocytosis/comorbidites: admit with IV abx

Complicated (diverticulitis + abscess, perforation, obstruction, or fistula)

  • fluid collection < 3cm treat with IV abx and observe then surgery if worse
  • fluid collection > 3cm treat with abx and CT-guided percutaneous drainage and if that doesnt help then do surgical drainage and debridement
153
Q

tachypnea, hypoxia, segment of chest wall that moves inward during inspiration… what do you think

A

flail chest

  • occurs when fracture of > 3 contiguous ribs in > 2 locations creates isolated chest wall segment (flail segment) that moves paradoxically (opposite) to rest of rib cage during respiration
  • impairs generation of negative intrathoracic pressure and causes ineffective ventilation
  • pulmonary contusion
  • atelectasis
154
Q

chronic mitral regurg surgical indications

A

Primary
-surgery if LVEF 30-60% (regardless of symptoms)

Secondary
-medical management, valve surgery rarely indicated

155
Q

intermittent solid food dysphagia most commonly in younger men with atopic conditions

A

eosinophilic esophagitis

  • untreated can cause esophageal stricture and food impaction
  • manage with dietary therapy, PPI, topical glucocorticoids
156
Q

middle mediastinal mass ddx

A
  • bronchogenic cysts
  • tracheal tumors
  • pericardial cysts
  • lymphoma
  • lymph node enlargement
  • aortic aneurysms
157
Q

anterior mediastinum masses

A

4Ts

  • thymoma
  • teratoma
  • thyroid neoplasm
  • terrible lymphoma
158
Q

amiodarone side effects

A

hepatic steatosis and cholestasis

159
Q

common causes of ischemic hepatitis (shock liver)

A
  • cardiac insults (MI, unstable arrythmias)
  • respiratory failure
  • hypovolemia
  • septic shock
160
Q

first step in a tension pneumothorax

A
  • needle thoracostomy in order to prevent cardiovascular collapse
  • precedes intubation cause intubation can actually cause cardiovascular collapse
161
Q

whats so interesting about a diaphragmatic rupture

A

usually children with traumatic diaphragmatic injury may initially have no symptoms but can present months to years later after progressive expansion of the diaphragmatic defect
-get CT of chest and abdomen

162
Q

what is a risk of being on chronic glucocortioid therapy if you are exposed to an acute stressor (surgery, illness, or trauma)

A

secondary adrenal insufficiency and can develop adrenal crisis

  • presents with hypotension and shock that is refractory to initial volume resuscitation
  • treat with IV hydrocortisone or dexamethasone with aggressive volume repletion
163
Q

how to treat chronic bacterial prostatitis

A

fluoroquinolones for 6 weeks

164
Q

how to treat a penile fracture

A
  • if pt presents with blood at meatus, dysuria, urinary retention then they need retrograde urethrography due to urethral injury
  • then after that they need urgent operative repair
165
Q

if you think someone might have a corneal abrasion (cause they had a high-velocity injury to the globe) but dont see it then what can you do

A

fluorescein instillation cause it may reveal an open globe laceration by extrusion of fluid through laceration

-in corneal defect itll be stained and appear yellow

166
Q

how to stage a gastric adenocarcinoma

A

after initial endoscopy/biopsy positive for adenocarcinoma

  1. get CT of abdomen and pelvis
  2. PET/CT, endoscopic ultrasound, laparoscopy, CT chest +/- paracentesis/peritoneal lavage
  • if limited stage then do surgical resection
  • if advanced stage then do chemo +/- palliative surgery
167
Q

how does benzo w/d present

A

agitation, tremors, perceptual changes, psychosis, elevated vital signs, delirium, and seizures
-symptoms present w/i 24-48hrs

168
Q

patient presents with shoulder pain (with abduction and external rotation) and weakness and has a positive drop arm test where pt cant bring arm down so it just falls
MRI can confirm dx

A

rotator cuff tear

169
Q

how to manage cat bites

A

-can cause pasteurella or any anaerobic bacteria

copious irrigation and cleaning
prophylactic amox/clav
tetanus booster as indicated
avoid closure

170
Q

how to deal with septic shock pt

A

secure airway, restore adequate tissue perfusion with normal saline
then identify underlying infection and treat it

171
Q

what is the pathophys of struvite kidney stones

A

increased urine ammonia production

  • pts have recurrent UTIs
  • stone removal usually required
172
Q

how does a peptic duodenal ulcer typically present

A

periodic epigastric pain relieved by meals

173
Q

meniere disease

A
  • caused by increased endolymphatic fluid volume or pressure in vestibular system
  • causes episodic vertigo and hearing loss as well as aural fullness/tinnitus lasting 20mins to 1 day
  • lack triggers
174
Q

what are the 4 types of post-amputation pain

A
  1. acute stump pain
    - tissue and nerve injury causing severe pain lasting 1-3 weeks
  2. ischemic pain
    - swelling, skin discoloration, wound breakdown, decrease in transcutaneous oxygen tension
  3. post-traumatic neuroma
    - weeks to months after amputation
    - focal tenderness, altered local sensation
    - decreased pain with anesthetic injection
  4. phantom limb pain
    - onset usually w/i 1 week
    - increased risk in pts with severe acute pain
    - intermittent crampting, burning felt in distal limb
175
Q

what is a charcot joint

A
  • aka neurogenic arthropathy
  • impaired sensation and proprioception
  • altered weight bearing and recurrent trauma
  • acute inflammatory response
  • causes impaired ambulation, foot and ankle deformity, mild pain
  • x-ray: bone and joint destruction, fragmentation, subluxation/dislocation
  • mange with mechanical offloading and correction of joint mechanics (casting, orthotics)
176
Q

what is most important to help a pt with an isolated rib racture and atelectasis

A

adequate pain control

-if you dont have this then you increase the risk of pneumonia (frequent complication of rib fractures)

177
Q

most common primary brain malignancy

A

glioblastoma

  • increased intracranial pressure
  • headaches, papilledema, change in personality
  • CT/MRI show butterfly appearance with possible central necrosis
178
Q

what should you look out for when giving a pt desmopressin

A

its an analogue of ADH so you could potentially induce SIADH

179
Q

what is the most common complication after an ERCP

A

acute pancreatitis

180
Q

for pts with penetrating abdominal trauma when is immediate exploratory laparotomy indicated

A
  1. hemodynamic instability (SBP < 90)
  2. peritonitis (rigidity, rebound tenderness)
  3. evisceration (externally exposed intestines)
181
Q

what is the most common type of liver cancer

A

metastasis from another primary source

182
Q

what are the hard signs indicating that due to extremity vascular trauma someone will need surgical exploration and fixation

A
  • observed pulsatile bleeding
  • presence of bruit/thrill over injury
  • expanding hematoma
  • signs of distal ischemia
  • hemodynamic instability

-if pt doesnt have tehse then do CT angiography for further evaluation

183
Q

spinal cord

A

Anterior

  • ascending: pain, temp, crude touch, pressure
  • descending: voluntary motor

Posterior
-ascending: pressure, vibration, fine touch, proprioception

184
Q

what are you concerned about in spinal cord lesions above T1

A

neurogenic shock due to interruption of descending sympathetic fibers
-unopposed parasympathetic stimulation causing hypotension, bradycardia, hypothermia

185
Q

most common cause of small-bowel obstruction

A

Adhesions
-ladd bands may be congenital in children but adhesions typically result from abdominal operations or inflammatory processes

186
Q

how does small-bowel obstruction present

A

depends on where the obstruction is

  • vomiting (causing hypokalemia, decreased oral intake, dehydration, and orthostasis)
  • proximal: early vomiting, abdominal discomfort, abnormal contrast filling on x-ray
  • mid/distal: colicky abdominal pain, delayed vomiting, prominent abdominal distension, constipation-obstipation, hyperactive bowel sounds, dilated loops of bowel on abdominal x-ray
187
Q

sphincter of oddi

A

muscular valve controlling flow of bile and pancreatic juice into duodenum

188
Q

how to treat acute colonic pseudoobstruction (ogilvie syndrome)

A

bowel rest and colonic decompression and aided by IV neostigmine

189
Q
  • patient with back pain increased with standing, walking, and lying on back
  • tenderness of affected level
  • first felt pain while moving boxes but had a negative straight leg test
A

vertebral compression fracture

-usually due to osteoporosis (decreased bone mineral density)

190
Q

besides malignant hyperthermia what is a big side effect of succinylcholine

A
  • its a depolarizing neuromuscular blockers
  • can cause life-threatening hyperkalemia in pts with condition leading to upregulation of postsynaptic acetylcholine receptors (skeletal muscle trauma, burn injury, stroke)

-these pts should use vecuronium or rocuronium (nondepolarizing neuromuscular blocking agents) instead

191
Q

how does von hippel-linau present

A
  • cerebellar and retinal hemangioblastomas
  • pheochromocytomas
  • renal cell carcinoma (clear cell subtype)
192
Q

how to tell the difference b/w small bowel obstruction and ileus

A

SBO- surgery was weeks to years ago, pts presents with distension and increased bowel sounds, small bowel dilation is present (not large bowel)

Ileus- recent surgery (hours to datys), metabolic (hypokalemia, or medication induced, pt presents with possible distention and reduced/absent bowel sounds, both small and large bowel dilation

193
Q

torus palatinus/mandibulari

A

chronic mass

  • benign bony growth (exostosis) at midline suture of hard palate or lingual surface of mandible
  • surgery is only indicated if mass becomes symptomatic somehow
194
Q

medullar thyroid carcinoma

A

rare neuroendocrine carcinoma of thyroid parafollicular C cells that can be sporadic or associaated with RET germline mutation (MEN2)

195
Q

patient with smoking history presents with nontender, solitary cervical lymph nodes (hard mass under mandible)

A

mucosal head and neck squamous cell carcinoma

196
Q

acute GVHD

A
  • usually within 100 days of transplant
    1. maculopapular rash: painful/confluent and may look like SJS
    2. profuse, watery diarrhea: secretory pattern with crampy abdominal pain, n/v
    3. liver inflammation: damage to biliary tract epithelium, leading to elevated bilirubin, alk phos, and transaminases
197
Q

patient with history of retinoblastoma has thigh pain, what do you think of

A

osteosarcoma

-retinoblastoma and osteosarcoma are linked by RB1 tumor suppressor gene

198
Q

what makes you worried about a parotid mass for malignancy

A

cranial nerve dysfunction (facial droop, facial numbness) increases concern for malignancy

199
Q

what is an angiosarcoma

A

rare malignant tumor derived from internal lining of blood vessels of lymphatic vessels

  • strongest risk factor for getting this is: past radiation therapy
  • breast cancer survivors with chronic lymphedema are also at risk
200
Q

what to think of if you have a circular 3rd degree burn that results in eschar formation..?

A

the eschar restricts venous and lymphatic drainage which then leads to acute compartment syndrome

201
Q

what to give pts prophylatically for surgery who are undergoing a clean surgery (no viscera/bowel will be cut)

A

need coverage against gram-positive skin flora with 1st or 2nd gen cephalosporin (cefazolin) or with vanc or clinda

*if its not clean based on surgical site but usually you need broader coverage

202
Q

most common malignancies in young men

A
  • testicular cancer
  • lymphoma
  • leukemia
203
Q

painless jaundice with weight loss, what do you think of

A

pancreatic cancer (adenocarcinoma)

204
Q

what is the BEST way to help prevent pulmonary complications before a surgery

A

incentive spirometry and deep breathing exercises

205
Q

what is a retrograde cystography

A

bladder is passively filled with water-soluble contrast then imaged (CT scan) to confirm dx of intraperitoneal rupture/bladder rupture

206
Q

patient with cirrhosis and NEW ONSET ascites, what do you think of

A

acute obstruction of portal or hepatic veins due to thrombus or hepatocellular carcinoma
-get abdominal ultrasound

207
Q

what screening is important in pts with cirrhosis of any kind

A

abdominal ultrasound every 6 months to evaluate for new onset Hepatocellular carcinoma

208
Q

if pt has basal cell carcinoma on their face or ears how do you get rid of it

A

Mohs micrographic surgery
-sequential removal of skin layers with microscopic inspection to confirm margins are clear of malignant tissue (has the highest cure rate)

209
Q

how to determine if cervical spine imaging should be performed
NEXUS low-risk criteria

A
  • neurologic deficit
  • spinal tenderness
  • altered mental status
  • intoxication
  • distracting injury
210
Q

patient has diabetic foot ulcer, when do you test for osteomyelitis (bone biopsy)

A
  1. positive probe-to-bone test
  2. ulcer larger tahn 2cm
  3. ulcer lasting > 1 week
    - note that fever, pain, elevated ESR, and sinus tract drainage may be present
211
Q

how to treat a meningioma

A

complete surgical resection

212
Q

what is the first step after pt has open-book pelvic fracture with disruption of the pelvic ring and anterior widening

A

they are at risk of life-threatening hemorrhage so the first step is to put on a pelvic binder to decrease pelvic volume and promote tamponade of venous bleeding

213
Q

what are the possible bladder symptoms of diverticulitis

A

urinary urgency, frequency, sterile pyuria (+ leukocyte esterase with - nitrite/bacteria) due to bladder irritation from adjacent sigmoid colon inflammation

214
Q

what lab valdue has a 95% positive predictive value for diagnosing gallstone pancreatitis and how do you manage these pts

A

ALT > 150 U/L

-early cholecystectomy is indicated in all pts who are medically stable enough to undergo surgery

215
Q

if pt has infected prothetic with coagulase-negative staph (epidermitis) then what do you expect compared to staph aureus

A
  • delayed onset
  • chronic pain
  • implant loosening
  • gait impairment
  • sinus tract formation
216
Q

how to confirm and treat bronchial rupture

A

bronchoscopy and treat with operative repair

217
Q

von hippel-lindau is associated with what

A

excess production of catecholamines due to pheochromocytomas

218
Q

patient with COPD has a secondary spontaneious pneumothorax … what do you think of

A

rupture of alveolar bleb (most common cause of acute respiratory symptoms in COPD pts)

219
Q

greatest risk factor for prostate cancer

A

advanced age

-approximately 30-80% of men older tahn 70 have histologic evidence of prostate cancer

220
Q

general diagnostic workup of solid, firm, nontender testicular mass

A

testicular cancer until proven otherwise

  • bilateral scrotal ultrasound
  • serum tumor markers
  • radical inguinal orchiectomy
221
Q

what does a fixed teardrop pupil indicate

A

open globe injury

222
Q

most common cancers causing liver metastases

A
  • GI tract
  • lung
  • breast
223
Q

patient with sickle cell and hip pain, what do you think of

A

avascular necrosis (osteonecrosis)

224
Q

pt presents with hematuria, renovascular congestion (enlarged kidney on imaging), elevated LDH with maybe AKI, and flank pain

A

renal vein thrombosis

-dx with CT or MR angiography or renal venography

225
Q

first step in diagnosing gastric cancer

A

EGD

-then you can do test for H pylori stool testing or anything else

226
Q

where should a central venous catheter be placed and why

A

ideal: lower superior vena cava
- if you do it in smaller veins it predisposes to venous perforation or pneumothorax
- get portable chest x-ray right after to make sure it was placed correctly if you dont use ultrasound guided CVC placement

227
Q

indications for open reduction and surgical exploration of fractures

A
  • open fractures
  • neurovascular compromise
  • significant displacement
228
Q

it you think a pt has wound dehiscence following a surgery what should your next step be

A

management is determined by extent of tissue involvement –> get imaging of the affected area

-usually after chest/sternal surgery

soft tissue: only superficial tissues, use local wound care or debridement followed by primary closure

sternal: separation of edges of sternum seen by clicking or rocking on palpation, surgical emergency and requires sternal rewiring to prevent cardiac trauma

229
Q

pt with intestine problem (or anything causing fat malabsorption) presents with nephrolithiasis, what do you think of

A

oxalate crystals in kidney cause gut probs usually increase its absorption

230
Q

how to manage venous air embolism

A
  • left lateral decubitus positioning to trap the VAE on the lateral wall of the right ventricle preventing RVOT obstruction and further embolization into pulmonary circulation
  • high-flow or hyperbaric oxygen to encourage absorption of air embolus
231
Q

what is a complication of thoracic aortic aneurysm repair and how does it present

A

anterior spinal cord ischemia

-distal, bilateral flaccid paralysis, loss of pain/temp and crude touch sensation and urinary retention

232
Q

what complication are burn pts at risk for especially if their burns cover > 20% of their surface area

  • pts present with temp, tachy, hypotension, oliguria, hyperglycemia, thrombocytopenia, and mental status changes
  • dx with quantitative wound culture and biopsy for histopathology
A

wound infections and sepsis

  • soon after injury: gram + sepsis
  • after 5 days: gram - and fungi
  • note that a change in burn wound appearance of the loss of skin graft is often the first sign on burn wound infection
233
Q

patient getting laparoscopic surgery gets CO2 insufflation then gets bradycardic, AV block, and sometimes even asystole… why?

A

increased intra-abdominal pressure stimulates stretch receptors on peritoneum that respond by triggering increase in vagal tone

234
Q

how to treat basal cell carcinoma

A

excisional biopsy with narrow margin

235
Q

how to diagnose a rotator cuff tear

A

MRI of area

-usually get treated with surgery (preferrably within 6 weeks of injury)

236
Q

how to visualize soft tissues

A

MRI

237
Q

how to treat tympanic membrane barotrauma

A

usually heals spontaneously within a few weeks

238
Q

postop hematoma in pt with no personal or family history

A

insufficient hemostasis

239
Q

variceal hemorrhage bleed algorithm

A
  1. place 2 large-bore IV catheters
  2. volume resuscitation, IV octreotide, antibiotics
  3. urgent endoscopic therapy of esophageal varices
  • if that stops the bleeding then give beta-blockers and do endoscopic band ligation 1-2 weeks later
  • if they continue to bleed do balloon tamponade temporarily then TIPS or shunt surgery
  • if they have early rebleeding then do endoscopic therapy again then TIPS or shunt surgery if needed
240
Q

if you see intraperitoneal free air on imaging what does this confirm?

A

bowel perforation which should prompt emergent surgical exploration
-presents as bowel contusion then mesenteric ischemia

241
Q

how to manage a peritonsillar abscess

A

IV abx therapy and urgent drainage of abscess

-pt will have deviation of uvula and unilateral lymphadenopathy

242
Q

most common causes of cirrhosis

A
  • alcohol abuse
  • chronic viral hepatitis
  • nonalcoholic fatty liver disease (hx of DM and obesity)

*note pts usually dont know they have cirrhosis until they get variceal bleeding or hepatocellular carcinoma

243
Q

what type of fluid resuscitation do you wanna use for burn patients

A

lactated ringer solution b/c it maintains a normal blood pH whereas normal saline can cause hyperchloremic metabolic acidosis

244
Q

what are the best predictors of postop outcomes following lung resection surgery

A

FEV1 and DLCO

245
Q

how to manage upper extremity DVT (usually within 7-14 days of PICC insertion)

A
  • dx with duplex ultrasonography

- treat with 3 months of anticoagulation

246
Q

how to help manage pts with AD polycystic kidney disease

A
  • treatment is mainly supportive

- vasopressin-2 receptor antagonist (tolvaptan) may slow progression in some pts

247
Q

benefits of neonatal circumcision

A

reduced risk of…

  • uti in first year of life
  • penile phimosis
  • cancer
  • inflammatory disorders in adulthood

-decreases risk of acquiring some (not all) stds

248
Q

what are the risk factors for head and neck squamous cell carcinoma and what do you think if a pt has it without these risk factors

A
  • presents as enlarged ulcerated tonsil with ipsilateral cervical adenopathy
  • risk factors: smoking and alcohol
  • if pt doesnt have these then look for HPV if pt is younger than expected (HPV-16)
249
Q

most sensitive test for medial collateral ligament tear

A

MRI

-pt will have medial knee and valgus laxity

250
Q

how to treat acute bacterial prostatitis

A

usually due to e.coli or proteus so treat for 6 weeks with…
-fluoroquinolone
OR
-TMP-SMX

251
Q

patient presents with abdominal pain, diarrhea, nausea, hypotension/tachycardia, dizziness/confusion, fatigue, diaphoresis about 15-30mins after meals
-usually after postgastrectomy

A

Dumping syndrome

  • rapid emptying of hypertonic gastric contents
  • caused by loss of normal action of pyloric sphincter due to injury or surgical bypass
  • manage with small/frequent meals, replace simple sugars with complex carbs, incorporate high-fiber and protein-rich foods
252
Q

patient with thoracic trauma and extensive extrapulmonary air (chest tube with persistent large air leak)

A

likely tracheobronchial injury

-get bronchoscopy to confirm dx before operative repair

253
Q

upper extremity DVT risk factors and presentation

A

risk factors: central venous catheters, repeptitive arm motions (baseball pitching), weight lifting, malignancy

manifestations: acute arm edema, heaviness, pain, erythema, dilated subq collateral veins in chest/upper extremity, pulmonary embolism

254
Q

if pt has decline in renal function with addition of ACE inhibitors what do you think of

A

renal artery stenosis

-dx made with renal vascular imaging (renal doppler u/s)

255
Q

recurrent peptic ulcer disease with multiple ulcers and jejunal ulceration suggest what…

A

zollinger-ellison syndrome (gastrinoma)

256
Q

first step in dx of esophageal cancer based on age…

A
  • younger pts under 50 start with barium swallow

- older pts over 50 OR younger with alarm symptoms have endoscopy right away

257
Q

what abx to give for breast abscess

A

dicloxacillin or cephalexin

258
Q

diabetic foot infections most likely get the bone how…

A

polymicrobial (gram + and - and anaerobic bacteria) via contiguous spread from the wound

259
Q

how to treat stress hyperglycemia (usually due to sepsis, burns, or major trauma/hemorrhage)
-occurs due to stress triggering cortisol and catecholamines increasing glycogenolysis and gluconeogenesis

A
  • minimization of glucose in IV fluids

- insulin to maintain blood glucose at 140-180 mg/dL

260
Q

classic fat embolism syndrome triad

A
  1. respiratory distress (hypoxemia, dyspnea, tachypnea, tachycardia)
  2. neurologic dysfunction (confusion, visual field defects)
  3. petechial rash

*note: immediate CXR is normal but after 24-48hrs youll see bilateral pulmonary infiltrates

261
Q

what form of imaging is required for pancreatic lesions

A

CT scan of abdomen has sensitivity > 90%

262
Q

how to confirm a ganglion cyst

A

transillumination of mass

263
Q

how to manage pts with primary hyperparathyroidism

A

-parathyroid imaging and parathyroidectomy

  • hypercalcemia with elevated PTH
  • parathyroidectomy recommended for symptomatic pts (nephrolithiasis)
  • younger pts < 50 are likely to have complications during lifetime and should be offered surgery
264
Q

what is a main cause of atelectasis as a postop complication

-pts present with hypoxia (low pO2) which increases respiratory rate causing low pCO2

A

shallow breathing and weak cough due to pain

  • usually occurs on postop day.2 or 3
  • pts need adequate pain control, deep-breathing exercises, directed coughing, early mobilization, and incentive spirometry to help decrease incidence
265
Q

pathophys of peyronie disease

A

acquired disorder with fibrosis of tunica albuginea of penis (dorsal nodules/plaques)
-restricts expansion and flexibility during erections

266
Q

risk factors for splenic abscess

  • usually presents with persistent fever, LUQ pain, anorexia, weight loss
  • dx made with CT scan of abdomen
A
  • immunocompromised
  • hematologic malignancy
  • DM

-treat with abx plus splenectomy is usually needed cause most pts fail percutaneous aspiration (due to presence of occult microabscesses)

267
Q

how to manage AAA 3-5.5cm large

A

lifestyle modification (smoking cessation is best)

268
Q

patient presents with murmur after permanent pacemaker placement

A

tricuspid regurgitation

  • adverse effect of pacemaker
  • can cause cor pulmonale
269
Q

what is a characteristic image finding in pts with entamoeba histolytica

A

single, subcapsular, low-density lesion in the right lobe of the liver cause it has more blood supply than the left

-dx made with serology (needle aspiration not needed)

270
Q

when to think about scurvy (vitamin C deficiency)

A
  • common in alcoholism
  • usually within 3 months of vitamin C deficient diet
  • presents with the following
    1. cutaneous manifestations: follicular hyperkeratosis, perifollicular hemorrhage, ecchymosis, petechiae, coiled hairs
    2. gingivitis: receded gums that bleed easily and dental caries
    3. impaired wound healing
    4. systemic symptoms: arthralgias, malaise, weakness
271
Q

what is a size of lung nodule that independently correlates with > 50% malignant probability

A

2cm or larger

-always biopsy and

272
Q

when to manage a stress fracture why referring to ortho

A

for fracture at high risk of malunion

-ex: anterior tibial cortex, 5th metatarsal

273
Q

what is fournier gangrene (presents as rapid onset skin infection of lower abdomen, scrotum, and perineum with crepitus and significant systemic manifestations like hypotension, high fever and leukocytosis)
-DO SURGERY RIGHT AWAY

A

life-threatening necrotizing fasciitis

  • quickly progresses to sepsis and death without intervention
  • occur in the setting of cutaneous breakdowns in perianal/genital region that allow portal entry of polymicrobial colonic or urogenital organisms
  • spreads along subQ fat via fascial planes
274
Q

how to empirically treat human bite wounds

A

aerobic and anaerobic oral organsims so give amox-clav

275
Q

if a patient is on long term total parenteral nutrition what should you look out for

A

TPN can cause gallbladder stasis and predisposes to gallstone formation and bile sludging, both of which may lead to cholecystitis

276
Q

patient with any enlarging ballotable neck swelling near an incision should be dealt with how

A

its likely a hematoma and is life threatening cause it can become a lethal upper airway obstruction
-immediately drain the hematoma and explore the wound in the OR to control the source of bleeding and see if a endotracheal tube is needed or not

277
Q

how to describe hypoventilation based on lab values

A

normal A-a gradient and respiratory acidosis

278
Q

what is a surgical cricothyrotomy

A

when you trach their neck to make sure you have airway access if endotracheal intubation doesnt work

279
Q

patient get a bite then develops a small ulcer, what do you think of

A

brown recluse spider bite
-over the course of a few days a deep skin ulcer develops with erythematous halo and a necrotic center, which can progress to an eschar

280
Q

at what platelet count should you be okay to put someone on warfarin

A

> 150,000

-if its below dont put them on it yet

281
Q

how to diagnostically evaluate heparin-induced thrombocytopenia

A
  • serotonin release assay is the gold standard confirmatory test
  • start treatment in suspected cases prior to confirmatory tests
282
Q

greater trochanteric pain syndrome

A

overuse syndrome involving tendons of gluteus medius and minimus at greater trochanter

  • chronic lateral hip pain
  • treat with exercise, pt, nsaids, and steroid injections
283
Q

indications for bariatric surgery

A

BMI > 40
BMI > 35 with serious comorbidity (T2DM, hypertension, OSA)
BMI > 30 with resistant T2DM or metabolic syndrome

284
Q

what is radiation proctitis (acute vs chronic)

-colonoscopy demonstrates mucosal pallor, friability, and telangiectasias confined to the rectum

A
  • caused my mucosal damage associated with pelvic radiation therapy
  • acute RP presents < 8weeks post-radiation with diarrhea, tenesmus, and mucus discharge
  • chronic RP occurs months to years after radiation, resulting in hematochezia, anemia, and possibly strictures
285
Q

tender, nonpurpuric, erythematous, or violaceous nodules measuring 2-3 cm and usually located on shins

A

erythema nodosum

-associated with IBD (especially crohn disease)

286
Q

how to confirm a posterior urethral injury

A

retrograde urethrography

-pt will present with blood at the urethral meatus and a high-riding prostate

287
Q

CT with gall bladder that looks calcified on the outside

A

porcelain gallbaladder

-associated with increased risk for gallbladder adenocarcinoma and usually requires cholecystectomy

288
Q

what to give a patient on warfarin who emergently needs surgery

A

prothrombin complex concentrate and IV vitamin K

-if PCC is unavailable you can give fresh frozen plasma

289
Q

if an old fracture or break hasnt come back together yet what might they have

A

chronic osteomyelitis

  • pt presents with: intermittent pain/swelling and sinus tract formation
  • open bone biopsy for assessment and treat with surgical debridement of infected and necrotic bone
290
Q

what type of tumor produces EPO

A

renal cell carcinoma

291
Q

patient presents with oropharyngeal infection (pharyngitis or tonsillitis)
-leads to local invasion of lateral pharyngeal wall and infection of neurovascular bundle (especially internal jugular vein)

A

Lemierre syndrome

  • caused by Fusobacterium necrophorum
  • thrombosis of the vein allows dissemination of septic emboli to distal sites
292
Q

trousseau syndrome

A
  • hypercoagulability disorder
  • recurrent and migratory superficial thrombophlebitis at unusual sites (arm, chest)
  • usually associated with occult visceral malignancy: pancreatic is most common, stomach, lung, or prostate carcinoma
293
Q

when preoperatively should pts getting a pheochromocytoma removed take alpha blockers

A

7-14 days prior to surgery followed by beta blockers 2-3 days prior to surgery

*never give beta without alpha blockers first cause otherwise you can cause a hypertensive crisis

294
Q

how to manage atrial flutter

A
  • results from large reentrant circuit involving cavotricuspid isthmus of right atrium
  • risk for arterial thromboembolism so pts should be on chronic anticoagulation
295
Q

triad of aortoiliac occlusion (Leriche syndrome)

-men with atherosclerosis who smoke are at high risk for this

A
  • bilateral hip, thigh, and buttock claudication
  • impotence
  • absent or diminished femoral pulses (often with symmetric atrophy of bilateral lower extremities due to chronic ischemia)
296
Q

what is pituitary apoplexy

A

sudden hemorrhage into enlarged pituitary adenoma

  • pts present with sudden onset headache and visual disturbances
  • severe hypotension and distributive shock
297
Q

most common cause of a lung abscess

A

aspiration of oropharyngeal anaerobic bacteria

  • symptoms may look like TB with subacute fever, night sweats, weight loss, and cough with putrid sputum
  • x-ray reveals cavitary infiltrates often with air-fluid levels
298
Q

patient presents after cardiac surgery with what looks like an infection with chest pain… what do you think

A

acute mediastinitis

  • fever
  • chest pain
  • leukocytosis
  • mediastinal widening on x-ray

-requires drainage, surgical debridement, and prolonged antibiotic therapy

299
Q

pt presents with episodic headache, hypertension, hyperglycemia

A

pheochromocytoma

-measurement of urine or plasma metanephrines is initial step in diagnostic evaluation

300
Q

irregular scrotal mass that increases in size with valsalva and doesnt transilluminate

A

varicocele

301
Q

patient with lower and upper motor neuron signs… what do you do you think if its def not lou-gerigs

A

cervical myelopathy

-gait dysfunction is usually the first sign

302
Q

acute tonsillitis presentation

A
  • tonsillar erythema and exudates
  • tender anterior cervical nodes and palatal petechiae

*if pt has pooling of saliva (trismus) and uvular deviation then its more likely peritonsillar abscess

303
Q

how does a nonanion gap metabolic acidosis present

A
  • loss of bicarb

- can happen with pancreatic or small bowel leaks

304
Q

3 essential elements of informed consent

A
  • diagnosis
  • risks and benefits of both proposed treatment and alternatives
  • risk of refusing treatment
305
Q

what does the coffee bean sign mean on x-ray

A

volvulus

  • dilated, inverted, u-shaped loop of colon
  • patients without perforation or peritonitis can undergo flexible sigmoidoscopy to reduce twisted segment and avoid emergency surgery
306
Q

how does sigmoid volvulus present
risk factors: sigmoid colon redundancy (dilation/elongation from chronic constipation) and colonic dysmotility (underlying neurologic disorders)

A

presentation

  • slowly progressive abdominal discomfort/distension possibly with obstructive symptoms
  • abdomen distension and tympanic to percussion

imaging

  • x-ray: dilated, inverted u-shaped loop of colon (coffee bean sign)
  • CT scan: dilated sigmoid colon, mesenteric twisting (whirl sign)

management

  • endoscopic detorsion (flexible sigmoidoscopy) and elective sigmoid colectomy
  • emergency sigmoid colectomy if perforation/peritonitis present
307
Q

how to treat small bowel obstruction

A
  • NG tube for gastric decompression

- emergency laparotomy due to high risk of life-threatening complications (bowel ischemia, perforation)

308
Q

key finding in pts with otosclerosis (conductive hearing loss)

A

improvement of speech understanding in noisy environment

309
Q

what is the most common neuropathy in hemodialysis patients

A

carpal tunnel syndrome

  • 1/3 of pts get it
  • symptoms usually get worse during hemodialysis treatments
310
Q

how is hemodialysis access obtained

A

surgically creating AV fistula
-forms enlarged vein serving as access point and facilitates adequate blood flow to and from hemodialysis machine

note: if the AV fistula gets too big that can lead to high-output heart failure

311
Q

symptoms of primary adrenal insufficiency

A

main clinical features: hypotension and shock

fatigue, weight loss, abdominal pain, anorexia, and GI disturbance

312
Q

clinical indicators of thermal and smoke inhalation injuries

note: treat all these pts with high flow oxygen via non-rebreather mask with a low threshold for intubation (key reason to intubate is progressive airway edema)

A
  • burns of face
  • singeing of eyebrows
  • oropharyngeal inflammation
  • blistering or carbon deposits
  • carbonaceous sputum
  • stridor
  • carboxyhemoglobin level > 10%
  • history of confinement in burning building
313
Q

woman > 40yo with multiparity, vaginal delivery, and chronic constipation/straining

A

rectal prolapse

  • protruding rectal mass that occurs with valsalva
  • treatment is surgical
314
Q

how to treat cataracts (loss of acuity, glare, halos around lights, lens opacification, loss of red reflex)

A

surgical removal of lens with implantation of prosthetic lens

315
Q

patient presents with obliterative endarteritis and submucosal fibrosis (which stiffens the rectum and impairs its compliance) –> resulting in urgency and fecal incontinence

A

chronic radiation proctitis –> chronic tissue hypoxia results in neovascularization and telangiectasia formation (which are prone to hemorrhage)

316
Q

what should be considered in post-menopausal women with new-onset abdominal pain and/or concerning gastrointestinal symptoms

A

epithelial ovarian cancer

317
Q

HPV can cause what to the anus

A

anal squamous intraepithelial lesion which is a precursor to anal squamous cell carcinoma

  • small lesions can be treated topically with trichloroacetic acid
  • larger lesions managed with radiofrequency ablation
318
Q

sudden development of limb ischemia in pts with no previous problems

A

embolic arterial occlusion

-most arterial emboli are cardiac in origin

319
Q

constricting apple core mass on x-ray

A

most frequently associated with constriction of lumen of colon by stenosing ANNULAR COLORECTAL CARCINOMA
-most appropriate next step is proctocolectomy

320
Q

younger woman with hypertension and carotid stenosis

A

fibromuscular dysplasia of renal artery

321
Q

how to treat transitional cell carcinoma

A

endoscopic resection

322
Q

breast mass with clear brown fluid on aspiration

A

fibrocystic disease

-if its clear milky then its a galactocele

323
Q

what to look out for after radiation to bone

A

hypercalcemia and hypercalcemic crisis

324
Q

patient on steroid stops taking them then has severe hypotension unresponsive to LR or saline… what do you do

A

give IV steroids

325
Q

possible side effect of diphenhydramine

A

urine retention

326
Q

3cm cavity in upper lobe of lung with round 2cm mass in lumen in pt with hemoptysis, what do you think of

A

aspergilloma

327
Q

first step to examine for AAA in stable pt

A

bedside transabdominal ultrasound

328
Q

patient with rapidly progressive painful ulcer with purulent base and violaceous border following small local trauma like a bump or something
-they will also have some sort of underlying systemic inflammatory disorder

A

pyoderma gangrenosum

-usually get skin biopsy and treat with steroids

329
Q

patient presents with GI bleeding that cant be seen on endoscopy or colonoscopy and hes pretty old > 60

A

angiodysplasia

-associated with aortic stenosis which is associated with low levels of vWF multimers

330
Q

patients who undergo splenectomy should be given what drugs to take if they get a fever before theyve had their vaccinations

A

amox-clav

331
Q

what is the post burn injury hypermetabolic response

A
  • hachycardia, hypertension
  • increased gluconeogenesis and insulin resistance = hyperglycemia
  • increased basal metabolic rate = febrile
  • increased protein and lipid catabolism = increased lean muscle wasting

-treat: early excision and grafting, propranolol, insulin, nutrition, and anabolic steroids

332
Q

what can be an early sign of sepsis in burn pts

A

acute enteral feeding intolerance which can indicate end-organ hypoperfusion and dysfunction

333
Q

how to treat a calcaneal spur

A

incidental finding and do not require treatment

-they usually dont cause pain on their own

334
Q

what are you concerned about in a patient with a lung transplant

A

look for bronchiolitis obliterans

  • gradually progressive dyspnea, non-productive cough and an obstructive pattern (FEV1/FVC < 70%)
  • chronic lung transplant rejection
  • get bronchoalveolar lavage to rule out infection
  • biopsy will show submucosal lymphocytic infiltrate
335
Q

if someone has rhabdo, what are you nervous about

A

pts with rhabdo are likely to have hyperkalemia so avoid K-containing fluids

336
Q

patient with cholecystectomy then has unremitting diarrhea WITHOUT fever or leukocytosis

A

bile acid diarrhea

  • unresorbed bile acids spill into the colon, irritating the mucosa
  • secretory diarrhea (fasting diarrhea with nocturnal episodes)
  • unremarkable serum and stool studies
  • treat with bile acid binding resins (cholestyramine and colestipol)
337
Q

budesonide

A

used to treat microscopic colitis

338
Q

myositis ossificans

A

formation of lamellar bone in extraskeletal tissues

  • can be traumatic or neurogenic
  • pt presents with intramuscular mass, pain, swelling, induration days to weeks following the injury
  • increased Alk Phos, ESR, CRP
  • x-ray shows periosteal bone reaction and calcification with radiolucent center
  • treat with ROM exercise/NSAIDs or surgical excision
339
Q

what type of injury should make you think of an acute rotator cuff injury

A

acute glenohumeral dislocation

  • decreased abduction due to pain BUT in tact sensation
  • positive drop arm test- arm held in 90 degree abduction and released, inability to hold arm steady suggests a tear
340
Q

what is tertiary hyperparathyroidism

A
  • look for this in pts with CKD
  • chronic hypocalcemia and hyperphosphatemia
  • due to parathyroid hyperplasia and loss of feedback inhibition of PTH by calcium
  • VERY HIGH PTH
  • mild hypercalcemia and hyperphosphatemia
  • usually refractory to medical therapy
  • parathyroidectomy often needed
341
Q

how to treat a lung abscess

A

first-line: ampicillin-sulbactam, imipenem, or meropenem

alternate: clindamycin

342
Q

what is the landmark for distinguishing surgical levels of axillary lymph does during dissections

A

pectoralis minor muscle

343
Q

pt presents with general body pain and random vessels with signs of narrowing, thrombosis, and/or ischemia

A

polyarteritis nodosa

  • segmental, transmural inflammation of medium-sized arteries
  • usually kidney and gi tract are affected

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