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Level 2 Boards > Surgery and EM > Flashcards

Surgery and EM Flashcards

1
Q

Post surgery

Develops facial pain and inability to open mouth

Fever

Prevented by?

A

Suppurative parotitis

Avoid with hydration and oral hygiene

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2
Q

Glasgow Coma Scale

A

Less than 8 intubate

Motor Response
6 Follows commands
5 Localizes pain
4 Withdraws to pain
3 Flexion
2 Extension
1 None
Verbal Response
5 Oriented
4 Confused speech
3 Inappropriate words
2 Incomprehensible
1 None
Eye Opening response
4 Spontaneous
3 Opens to command
2 Opens to pain
1 None
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3
Q

Unilateral breath sounds on right after intubation

A

Right main stem bronchus cannulation

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4
Q

Shock

A

BP < 90

Fast and weak pulse

Pallor

Diaphoresis

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5
Q

Suspect Cardiac tamponade if

A

Hypotension
Muffled heart sounds
JVD

Confirm w/ ultrasound

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6
Q

Causes of shock (4)

A
  1. Hemorrhage
  2. Tension pneumothorax
  3. Cardiac tamponade
  4. Neurogenic shock
    - High spinal cord injury
    - Decreased total peripheral resistance
    - suspect after ruling out other three
    - Vasopressors and increased TPR
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7
Q

ABCDE

A 
Airway
Breathing
Circulation
Deformities
Exposure
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8
Q

Previously stable chest trauma becomes rapidly unstable suspect

A

Air embolism

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9
Q

New diastolic murmur in chest trauma suggests

A

Aortic dissection

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10
Q

Massive air leak in chest tube

A

Suggest tracheobronchial injury

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11
Q

Chest injury between nipples order

A

Echo for heart
CTA for aorta and its branches
Bronchoscopy for upper airways
Esophagograph/ esophagogram for esophagus

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12
Q

Gun shot wounds that require immediate laparotomy

A

Gun shot wounds below nipple (fourth intercostal space)

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13
Q

Separate body part what to do

A

Place in gauze moistened with saline

Sealed inside a plastic bag

Place on ice

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14
Q

Tx Increase cranial pressure

A

Head elevation
Hyperventilation
IV mannitol

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15
Q

Epidural hematuria due to what vessel

A

Middle meningeal artery

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16
Q

Subdural hematuria due to what vessel

A

Briding beins

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17
Q

Respiratory compromise in flail chest

A

Due to pulmonary contusion rather than flail chest

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18
Q

Tx Flail chest

A

Pain control
Positive pressure

Fixed in severe cases

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19
Q

Blunt trauma to first rib, scapula or sternum

A

Think strong bones

Associated with aortic disruption

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20
Q

What tests to do with pelvic fracture

A 
Rectal exam
Proctoscopy
Retrograde cystogram for bladder
Retrograde urethrogram 
Pelvic exam for vagina in women
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21
Q

Most common injury with blunt abdominal trauma

A

Spleen

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22
Q

Fractured left ribs 9-11

A

Spleen

If ruptured remove and give Pneumococcal and HiB and meningococcal vaccine)

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23
Q

Right lower rib fractures

A

Liver trauma

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24
Q

Child falls on handle bars

Epigastric pain
Bilious vomiting

Retroperitoneal air on X ray

A

Duodenum injury

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25
Q

Diaphragm ruptures on

A

Left side (since liver protects right)

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26
Q

Tx Pelvic fracture

A

External pelvic binders and angiographic embolization

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27
Q

Acute abdominal pain with blood in rectum

A

Mesenteric ischemia

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28
Q

McBurneys point

A

Appendicitis

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29
Q

Appendicitis tx

A

IV antibiotics
- cefoxitin
- cefazolin
plus metronidazole

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30
Q

Chemical burns

A

Copiously irrigation for 20-30 minutes before transferring to hospital

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31
Q

Complications of electrical burns

A

Rhabdomyolysis
Compartment syndrome

Thrombosis of blood vessels —> limb ischemia

Arrhythmias

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32
Q

Infection in burns caused by

A

Pseudomonas or Gram + occi

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33
Q

Abdominal pain

Rigid to palpation

Free air on Xray

A

Surgical exploration

Perforation

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34
Q

Formula for fluids

A

First 24 hours

4 x patient’s weight in kg x % BSA

body surface area

Give 50% of fluids over first 8 hours and remaining 50% over following 16 hrs

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35
Q

Measuring body percentage

A

Entire head 9%

Anterior torso 9%

Upper back 9%

Entire arm 9%

Anterior abdomen 9%

Lower back 9%

[Abdomen in total 36%]

Perineum 1%

Entire leg 18%

Head 9%
Torso 36%
Arm 9% 
Perineum 1%
Leg 18%
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36
Q

Burns what to use topically

A

Topical antimicrobials if no epidermis intact

Mafenide acetate (fulfamylon)

Silver sulfadiazine

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37
Q

Hypotension and vasopressors

A

Only give vasopressors once adequate fluid resuscitation

Cause vaso constriction of extremities and digital ischemia

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38
Q

Fever POD 1-3

A

Atelectasis

Pneumonia (day 3)

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39
Q

Fever POD 3-4

A

UTI

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40
Q

Fever POD 4-5

A

DVT

PE

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41
Q

Fever POD 7+

A

Surgical site infection

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42
Q

Pulseless electrical activity tx

A

CPR

Epinephrine
Vasopressin

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43
Q

Ventricular fibrillation tx or pulseless ventricular tachycardia

A

CPR

Defibrillate —> 
Defibrillate —>
Epinephrine —> 
Defibrillate —>
Amiodarone —>
Defibrillate —>
Epinephrine
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44
Q

Tx Supraventricular tachycardia

A

Unstable —> synchronized electrical cardiovesion

Stable —> vagal maneuvers

If resistant= adenosine

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45
Q

Tx Atrial fibrillation/ flutter

A

Unstable —> synchronized electrical cardioversion

If stable —> diltiazem or beta blocker

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46
Q

Hypovolemic shock

CO
PCWP
PVR
CVP

A

CO Down
PCWP Down
PVR Up
CVP Down

Trauma
Blood loss
Dehydration
Third spacing
Burns
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47
Q

Cardiogenic shock

CO
PCWP
PVR
CVP

A

CO Down
PCWP Up
PVR Up
CVP UP

CHF
Arrthymias
Structural heart disease
MI

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48
Q

PCWP

PVR

A

pulmonary wedge pressure= left atrial pressure

Peripheral vascular resistance

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49
Q

Obstructive shock

CO
PCWP
PVR
CVP

A

CO Down
PCWP Up or Down
PVR Up
CVP Up

Cardiac tamponade
Tension pneumothorax
Massive PE

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50
Q

Distributive shock

CO
PCWP
PVR
CVP

A

CO Up
PCWP Down
PVR Down
CVP Down

Septic
Anaphylactic

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51
Q

Hypothermia

A

32-35 passive rewarming

28-32 active rewarming, warm blankets, warm water (external)

<28 active internal rewarming, warm IV fluids

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52
Q

Hypothermia and death

A

Can not pronouced until rewarmed to 32 degrees

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53
Q

Tx bites

A

Amox-clav

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54
Q

Tx Black widow

A

Antivenin

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55
Q

Tx Brown recluse

A

Cold compresses to slow necrosis

Dapsone

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56
Q

Tx Scorpion sting

A

If neuromucular toxicity: antivenin

If not: benzodiazepines and analgesics

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57
Q

Tx Vibrio ulnificus

A

Severe necrotizing fasciitis and hemorrhagic bullous lesions

Increased in those with preexisting liver disease

Tx IV doxycycline and ceftriaxone

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58
Q

Tetanus algorithm

A

Clean minor wound
< 3 lifetime toxoids or > 10 years ago= Id (or Tdap)

other wise no prophylaxis

Other wounds

< 3 lifetime toxoids —> Td/Tdap + Tetanus Ig

Last toxid > 5 years —> Td (or Tdap)

Othersie —> no prophylaxis

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59
Q

toxicity tx

A

EDTA
Dimercaprol
Succinmer

LEADS

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60
Q

SE Aminoglycosides

A

Gentimicin
Neomycin

Ototoxicity
Nephrotoxicity (acute tubular necrosis)

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61
Q

Amiodarone SE

A

Acute:
AV block
Hypotension
Bradycardia

Chronic:
Pulmonary fibrosis
Arrhythmias
Corneal deposition

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62
Q

Cyclophosphamide SE

A

Myelosuppression
Hemorrhagic cystitis
Bladder cancer

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63
Q

SE Furosemide

A

Ototoxicity
Hypokalemia
Nephritis
Gout

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64
Q

SE Gemfibrozil

A

Myositis

Reversible increase in LFTs

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65
Q

SE Metformin

A

Lactic acidosis

AKI
Dehydration
Sepsis

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66
Q

SE Methotrexate

A

Hepatic fibrosis
Pneumonitis
Anemia

67
Q

SE Vincristien

A

Peripheral neuropathy

Paralytic ileus

68
Q

Vitamin deficiency

Dermatitis
ALopecia
Enteritis

Adrenal insufficiency

A

Vit B5 pantothenate

69
Q

Vitamin deficiency

Peripheral neuropathy
Anemia
Convulsions

A

Vit B6 pyridoxine

70
Q

Megaloblastic anemia deficiency of

A

Folic acid more common

Liver stores of B12

71
Q

Vitamin deficiency

Impaired taste
Impaired wound healing
Alopecia

72
Q

Abdominal pain

Metabolic acidosis

Elevated amylase
Elevated glucose

A

Bowel ischemia

73
Q

Provides best assessment of postoperative pulmonary morbidity in patient with lung cancer and resection

74
Q

How does hyperventilation lower ICP

A

Cerebral vasoconstriction

75
Q

How does head elevated change ICP

A

Increased venous outflow from head

76
Q

New onset hyperglycemia in elderly patient with temporal wasting

A

Pancreatic adenocarcionma

Due to islet cell destruction with tumor invasion

77
Q

Bluish hugh behind ear drum

Hearing decreasing over time

Can hear better in noisy room

A

Otosclerosis

78
Q

Fever chills dysphagia

Drooling
Muffled voice

Tongue is posteriorly displaced and superior

Submandibular area is tender with palpable crepitus

A

Ludwig angina

Rapidly progressive cellulitis of submandibular space

From Dental infxn commonly

79
Q

Seen with Black widow bites

A

Muscle pain
Abdominal rigidity
Muscle cramps

80
Q

Gastric dilation on x ray

A

Paralytic ileus

81
Q

Pelvic fracture with pelvic ring distruption what to do

A

Can cause life threatening hemorrhage from vascular injury

Plevic binder application to decrease pelvic volume and promote tamponade of bleeding

82
Q

Turner syndrome

Sudden severe chest pain
Constant pain

Sinus tachycardia

Pregnant

A

Aortic dissection

83
Q

Giving blood products develops difficulty breathing

Transfusion stopped now what?

A

Transfusion related acute lung injury (TRALI)

Respiratory supportive care only

84
Q

Prophylaxis coverage for heart surgery

A

Cephalosporins 1st 2nd
- Cefazolin

Allergy to pencillin

  • Vancomycin
  • Clindamycin
85
Q

Pruritus
Bloody stools occasionally

RUQ pain
Fever
Jaundice

A

Primary sclerosing cholangitis

Fibrosis and stricturing of the medium and large intra and extrahepatic bile ducts

Associated with UC

86
Q

Primary biliary cholangitis

  • MOA
  • Elevated
  • Two features
  • Seen in
A

Immune response against intrahepatic bile ducts

Elevated Alk phos
Jaundice
Pruritius

Common in females

87
Q

Sudden onset headache
Neck pain
Vomiting
Low grade fever

A

Subarachnoid hemorrhage

CT scan

88
Q

Blunt chest trauma

Pneumothorax tx

Pneumothorax reaccumulates and creptius

A

Bronchial rupture

89
Q

Absence of gallbladder

Direct bilirubin
GGT
Reticulocyte count

A

Biliary atresia

Direct bilirubin: increased
GGT: increased
Reticulocyte: normal

90
Q

Thymoma located

A

Anterior mediastinum

Myasthenia gravis symptoms

91
Q

Neuroblastoma in chest located

A

Posterior mediastinum

92
Q

Esophageal leiomyomas located

A

Posterior mediastinum

Submucosal

Asymptomatic

93
Q

Mass in middle of mediastinum

Recent infxn

A

Bronchogenic cyst

94
Q

Thyroglobulin

A

Precursor to active Thyroid hormones (T3 T4)

Produced by normal thyroid tissue

95
Q

Diffuse cerebral edema Tx

A

Elevated intracranial pressure

Elevate head
Hyperventilation
Hypertonic saline

96
Q

Give to reverse warfarin elevated INR

A

Prothrombin complex concentrate
(concentrate of Vit K dependent cofactors)

IV vit K

97
Q

Small pneumothorax tx

98
Q

Extensive burns what fluids

A

Isotonic crystalloid solution

- Lactated ringers

99
Q

Transfusion related acute lung injury vs transfusion associated circulatory overload

A

TRALI

  • Bilateral infiltrate
  • No JVD
  • Crackles
  • Normal EF
  • Normal BNP

TACO

  • Bilateral infiltrate
  • JVD
  • Crackles
  • Decreased EF
  • High BNP
100
Q

Risk factors ventilator associated pneumonia

A 
Acid suppression (PPI)
Supine position
Pooled subglottic secretions
Paralysis &amp; excessive sedation
Excessive patient movement while intubated
Frequent ventilator circuit changes
101
Q

Steps for adenocarcinoma of the stomach

A

Diagnosis by endoscopy and biopsy

Then CT abdomen and pelvis

PET/CT
CT chest
paracentesis

Limited= surgical resection

Advanced= chemo

102
Q

SE succinylcholine

A

Depolarizing neuromuscular blocker

Triggers influx of sodium ions and efflux of potassium ions

Cardiac arrhythmia
Severe hyperkalemia

103
Q

Black purple patch that develop on abdomen after CABG

Receiving heparin

A

Antibodies against platelet component

Heparin induced thrombocytopenia

104
Q

Trouble seeing at night

Opacification of lens

A

Cataracts

Surgically remove lens

105
Q

Lower extremity tingling and numbness

Hair loss

Gait ataxia

Loss of vibration and position

Skin depigment

Microcytic anemia

A

Copper deficiency

106
Q

SE corticosteriods (6)

A 
Acute mania
Immunosuppression
Thin skin
Osteoporosis
Easy bruising
Myopathies
107
Q

Tx Benzo overdose

A

Flumazenil

108
Q

Tx Malignant htn

A

Nitroprusside

109
Q

Macrocytic megaloblastic anemia with neurologic symptoms

A

Vit B12 deficiency

110
Q

Macrocytic megaloblastic anemia without neuro symtoms

A

Folate deficiency

111
Q

Calculating fluid repletion in burn patients

A

24 hr fluids = 4 x kg x %BSA

112
Q

Acceptable urine output in trauma patient

113
Q

Acceptable urine output in stable patient

114
Q

Decreased CO
Decreased PCWP
Increased PVR

A

Hypovolemic shock

Fluid and blood repletion

115
Q

Decreased CO
Increased PCWP
Increased PVR

A

Cardiogenic or obstructive shock

Tx Identify cause
Inotrpes (dobutamine)

116
Q

Increased CO
Decreased PCWP
Decreased PVR

A

Distrubitve shock

Septic
Anaphylactic

117
Q

Supportive tx ARDS

A

Low tidal volume ventilation

118
Q

3 large bloody stools
Mild abdominal cramps

Radiation therapy for hysterectomy for cervical cancer 12 months ago

Anemia

Mucosal pallor
Friability
Multiple telangiectasias which are confined to rectum

A

Radiation proctitis

Acute <= 8 weeks

  • direct mucosal damage
  • diarrhea, minimal bleeding
  • Antidiarrheals (loperamide)
  • Butyrate enemas
Chronic > 3 months to years
- severe bleeding
- strictures with constipation, and rectal pain
- multiple telangiectasias
- mucosal pallor &amp; friability
Tx Endoscopic thermal coagulation 
Sucralfate or glucocorticoid enemas
119
Q

Fracture ribs 1-3

A

Subclavian vessels
Brachial plexus
Mediastinal vessels (aorta)

120
Q

Fracture ribs 3-6

A

Cardiovascular

121
Q

Fracture ribs 9-12

A

Intraabdominal

Liver (right)
Spleen (left)
Kidney (posterior ribs 11 & 12)

122
Q

Surgery of AAA

Develop LLQ pain and bloody diarrhea

Gross blood on rectal exam

Thickening of colon at rectosigmoid junction

Ulceration in same area, but colon above and below is normal

A

Ischemic colitis

Form of mesenteric ischemia limited to colon

123
Q

Melena
RUQ pain
Vomiting

Had liver biopsy 5 days ago

Hypotensive
Slight fever
Jaundice

Anemia
Elevated platelets
Leukocytosis
Elevated bilirubin

A

Hemobilia

Bleeding into biliary tract

Rare cause of Upper GI bleeding

124
Q

Elderly patient chronic constipation that has slowly progressive abdominal distension over 3 days

A

Sigmoid volvulus

Closed loop obstruction

Dilated inverted U shaped loop

125
Q

Brain image with dark brain tissue with white/gray mass in center

A

Hemorrhage

Surgery

126
Q

Decreased systemic vascualr resistance

A

Distributive shock

127
Q

Cause of hypovolemic shock

A

Decrease right ventricular preload

128
Q

Increase in pulmonary vascular resistance

A

PE can cause cardiac arrest due to rapid increase in pulmonary vascular resistance

Leading to acute right side heart failure

129
Q

Multiple lesion in liver check what

A

Colonoscopy

130
Q

Endophthalmitis

A

Bacterial or fungal infection within the eye, particularly the vitreous part

occurs 6 weeks post surgery

Pain and decreased visual acuity

Swollen eyelids and conjunctiva
Corneal edema
Hypopyon (inflammatory cells in anterior chamber)

131
Q

Conjunctivitis

A 
Excessive tearing
Burning sensation
Mild pain
Conjunctival
Eyelid edema

Vision not affected

132
Q

Uveitis

A

Viral or parasitic infection within the eye

Blurred vision
Moderate pain
Conjunctival injection
Constricted pupils*

May see keratic precipitates (mutton fat) and iris nodules

HLA-B27 related conditions

133
Q

Cavernous sinus thrombosis

A

Proptosis (protrusion of eye)
Ophthalmoplegia (inability to move eye muscles)
Chemosis (swelling and edema of conjunctiva)
Visual loss

134
Q

Post operation
N/V

Tachycardia
HTN
Fever

Delirious
Fine tremor
Mild lid lag

A

Thyroid storm

Tx Propranolol
Propylthiouracil

135
Q

Bilious vomiting
Abdominal pain
Passage of gas but no stool for 2 days

Crohns disease

A

SBO due to fibrotic stricture

136
Q

Adynamic ileus

A

Small bowel motility is disrupted

Leading to intestinal dilation, obstipation and bilious emesis

Presents similarly to SBO

But only develops after exposure to an insult that “Stuns” the bowl

  • Surgery
  • high dose opioids
137
Q

D dimer elevation

A

Presence of fibrin degradation products

138
Q

Infection of retropharyngeal space can spread where

A

Superior mediastinum

Acute necrotizing mediastinitis

139
Q

Increasing abdominal pain for the past several hours

Worsened by cough or movement

Fullness with tenderness and guarding just lateral to the umbilicus on the left side

Anemia
Leukocytosis

A

Rectus sheath hematoma

Rupture of inferior epigastric artery

Patient receiving anticoagulation therapy

140
Q

Tx Staphylococcal toxic shock syndrome

A

Vancomycin plus clindamycin

141
Q

Tx Necrotizing otitis externa

A

Pseudomonas

Tx Ciprofloxacin

Granulation tissue

142
Q

Slurred speech
Unsteady gait
Drowsiness

Normal pupil size

A. Benzo overdose
B. Lithium toxicity
C. Opioid intoxication
D. Phenytoin toxicity
E. Serotonin syndrome
A

A. Benzo overdose

143
Q

Horizontal nystagmus
Cerebellar ataxia
Confusion

A

Phenytoin toxicity

144
Q

IV naloxone

A

potent opioid antagonist used for patients with opioid intoxication

145
Q

Burns

Develops fever
Tachycardia
HTN

No infection

A

Hypermetabolic state

5 days post injury

Triggered by profound release of inflammatory mediators from damaged tissue

Leading to increased levels of catecholamines and glucocorticoids

146
Q

GI bleeding from no identifiable source on upper and lower endoscopy

A

Bleeding in the distal duodenum, jejunum or ileum not well visualized

Due to vascular malformations in bowel wall (angiodysplasias)

Calcific aortic stenosis

147
Q

Five Whys analysis

A

Root cause anaylsis

Also systematically assess the general safety culture at the hospital

148
Q

Fialure modes and effects analysis (FMEA) (6)

A

Form multidisciplinary team

Define process to be studied

Develop a flowchart

Analyze error risk at each step

Identify potential corrective actions

Implement plan

149
Q

Pill overdose

Facial flushing
Dry mouth
Prolonged QRS

Tx

A

Tricyclic antidepressant

TCA can block cardiac fast sodium channels

Tx: Sodium bicarbonate

150
Q

Atropine fixes what type of overdose

A

Organophosphate toxicity

Salivation
Lacrimation 
Urination
Diarrhea 
Bradycardia
151
Q

Calcium chloride tx for

A

Severe hyperkalemia

152
Q

Hypo and hyperpigmented skin in patchy areas

Hyperkeratosis and scaling on palms and soles

Worsening burning and tingling sensation in hands and feet

Works outdoors on fences

A

Arsenic poisoning

Pressure tx wood
Contaminated water (wells)
Pesticides/ insecticides

QTC prolongation
Garlic breath

Tx Dimercaprol
DMSA

153
Q

Sodium bicarbonate MOA in helping overdose

A

Will alleviate depressant action on myocardial sodium channels

154
Q

Hypotension
Heart sounds muffled
Low glucose

Overdose on
A. Amitriptyline
B. Clonidine
C. Digoxin
D. Diltiazem
E. Metoprolol
A

E. metoprolol

Beta blocker toxicity

Prolonged PR interval

155
Q

N/V
Confusion
Changes in color vision

Everything is yellow

A

Digoxin toxicity

156
Q

Confused
Flank pain

Foley catheter place urine is red with calcium oxalate crystals

Hypocalcemia
AKI
Metabolic acidosis

A

Ethylene glycol poisoning

Tx Fomepizole

157
Q

Organophosphate poisoning tx

A

Remove clothing

Atropine

Pralidoxime

158
Q

Physostigmine

A

Acetylcholinesterase inhibitor

Tx anticholinergic toxicity
Flushing, mydriasis, anhidrosis, fever, urinary retention

159
Q

House fire what can you inhale

A 
Hydrogen cyanide (cyanide poisoning)
Tx: Hydroxocobalamin

Carbon monoxide

160
Q

Parenteral nutrition makes you at risk for

A

Central line associated bloodstream infection

161
Q

Suicide attempt

Abdominal pain
Coffee ground emesis
Dark green Diarrhea

Hypotension
Lethargic

Abdomen tender to palpation

A

Acute iron poisoning

Anion gap metabolic acidosis

Radiopaque pills on x ray

Tx Deferoxamine

[Acetaminophen toxicity, GI bleeding uncommon]

162
Q

Suicide attempt

Hyperthermia
Flushing
Tachycardia
Hypotension
Altered mental status

Decreased bowel sounds

A

Tricyclic antidepressant

163
Q

32 female

Vision impairment in right eye, blurry after takin hot shower

Occasional headaches in past

Dizziness and clumsiness over past 6 months

A

Multiple sclerosis

Worsened by heat exposure

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