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M3 - Clerkships > Surgery Clerkship > Flashcards

Surgery Clerkship Flashcards

1
Q

Desmopressin is analogue of what hormone?

A

antidiuretic hormone (ADH) - can cause hyponatremia by manifesting SIADH. Check serum electrolytes to check for hyponatremia

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2
Q

Solid liver masses - which one is this?
1. associated with anomalous arteries
2. arterial flow and central scar on imaging

A

Focal nodular hyperplasia

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3
Q

Solid liver masses - which one is this?
1. women in long term oral contraceptives
2. possible hemorrhage or malignant transformation

A

Hepatic adenoma

-well demarcated, hyperechoic lesions
-Needle biopsy is not recommended due to risk of bleeding, surgical excision is preferred

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4
Q

Solid liver masses - which one is this?
1. Systemic systems
2. chronic hepatitis or cirrhosis
3. Elevated alpha fetoprotein

A

Hepatocellular carcinoma

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5
Q

Solid liver masses - which one is this?
1. single/multiple lesions
2. known extrahepatic malignancy

A

Liver mets

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6
Q

What does elevated GGT (glutamyl trasnpeptidase) levels indicate?

A
  • along with elevated alkaline phosphatase it can mean biliary compression or obstruction
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7
Q

Hydatid cysts are caused by what?

A
  • found in the liver and caused by Echinococcus tapeworm infections.
  • Most often seen in immigrants or occasionally in individuals from the southwest who are exposed to sheep and dogs
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8
Q

Leriche Syndrome is a triad of what?

A
  1. Bilateral hip, thigh, and buttock claudication
  2. Absent or diminished femoral pulses: from the groin distally, often with symmetric atrophy of the bilateral lower extremities due to chronic ischemia
  3. Impotence: almost always present in men with this condition
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9
Q

Pheochromocytoma
1. classic triad
2. management prior to surgery

A
  1. episodic headache, sweating, and tachycardia
  2. since intraoperative catecholamine surges can precipitate hypertensive crisis, pheochromocytoma crisis (a condition characterized by labile blood pressures, high fever, and multiorgan failure), and fatal arrhythmias —-> appropriate adrenergic blockade is needed before sx.
    —- alpha adrenergic blockade should be administered first 7-14 days prior to sx then beta adrenergic blockade can be initiated 2-3 days prior to surgery
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10
Q

Types of rash in these conditions?
1. Toxic shock syndrome
2. Meningococcemia
3. Rocky mountain spotted fever
4. Scarlet Fever
5. Stevens Johnson Syndrome

A
  1. diffuse macular rash
  2. typically petechial
  3. macular initially then petechiae. Begins on extremities then centripetally
  4. Skin findings are preceded by a prodrome of fever, headache, vomiting, and sore throat – then 12-48 hours later theres fine, pink blanching papules on the neck and upper trunk and quickly generalize with flexural accentuation (rough, sandpaper like)
  5. mucocutaneous erythematous and purpuric macules that progress to necrosis and sloughing of epidermis
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11
Q

Major risk factors for ventilator associated pneumonia

A
  1. acid suppression (PPI, H2R blocker, antacid)
  2. Supine position
  3. Pooled subglottic secretions
  4. Paralysis and excessive sedation
  5. Excessive patient movement while intubated
  6. Frequent ventilator circut changes
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12
Q

A laryngeal ulcer in a smoker is likely what type of cancer?

A
  • Squamous cell carcinoma
  • comes with persistent hoarseness (>30 days) due to impaired vibration or movement of the vocal cords and fungating laryngeal mass
    -other symptoms: dysphagia, airway obstruction, referred otalgia (pain felt in the ear but originating from a nonotologic source – facilitated by either CN IX or CN X)
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13
Q

Ludwig Angina

A
  • Rapidly progressive cellulitis of the submandibular and sublingual spaces. Most cases arise from contiguous spread (rather than lymphatic) of polymicrobial dental infections in the mandibular molars
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14
Q

The primary source of head and neck SCC is usually from where?

A
  1. mucosal surfaces of the head and neck (nasopharynx, oral cavity, oropharynx, larynx)
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15
Q

what disease is this?
- Clinical presentations-
1. most pts asymptomatic until age 30-40
2. flank pain, hematuria
3. hypertension
4. palpable abdominal masses (usually bilatera)
5. chronic kidney disease

A

Autosomal dominant polycystic kidney disease
-flank pain and hematuria result from cyst rupture that can be triggered by activities involving bending and exertion (eg. yard work)

-HTN is typically early disease manifestation

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16
Q

Acute cellular rejection after transplant
1. Occurs at what point in time after transplant?
2. symptoms?
3. definitive diagnosis made by?
4. treatment?

A
  1. Within the first 3 months
  2. fevers, malaise, lethargy - some are asymptomatic - suspected based on LFT abnormalities
  3. biopsy
  4. high dose corticosteroids
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17
Q

Mechanical complications of acute myocardial infarction
1. Acute or within 3-5 days (2 possible things)
2. within 5 days or up to 2 weeks
3. Up to several months

A

1a. papillary muscle rupture/dysfunction
1b. interventricular septum rupture
2. Free wall rupture
3. Left ventricular aneurysm

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18
Q

What is the involved coronary artery for these?
1a. papillary muscle rupture/dysfunction
1b. interventricular septum rupture
2. Free wall rupture
3. Left ventricular aneurysm

A

1a. RCA
1b. LAD (apical septal) or RCA (basal septal)
2. LAD
3. LAD

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19
Q

What are the clinical findings for
1a. papillary muscle rupture/dysfunction
1b. interventricular septum rupture

A

1a. severe pulmonary edema, respiratory distress + new early systolic murmur + Hypotension/cardio shock
1b. chest pain, new holosystolic murmur, hypotension/cardio shock

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20
Q

What are the clinical findings for
1. Free wall rupture
2. Left ventricular aneurysm

A
  1. Chest pain + distant heart sounds + shock, rapid progression to cardiac arrest
  2. heart failure, angina, ventricular arrhythmias
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21
Q

What are the echo findings for these?
1a. papillary muscle rupture/dysfunction
1b. interventricular septum rupture
2. Free wall rupture
3. Left ventricular aneurysm

A

1a. Severe mitral regurgitation
1b. Left to right ventricular shunt
2. pericardial effusion with tamponade
3. thin and dyskinetic myocardial wall

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22
Q

What is pyoderma gangrenosum?

A
  1. form of neutrophilic dermatosis that starts with inflammatory papule, pustule, or nodule and progresses to form an expanding ulcer with a purulent or fibrinous base and an irregular, violaceous border
    —usually on trunk or lower extremities
    —30% are triggered by local trauma
    —risk increases in patients with underlying systemic inflammatory disorder
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23
Q

Bacterial pneumonia often causes pleural effusion - the type of effusion depends on how the pneumonia develops in the body.

–differentiate uncomplicated vs complicated

A
  1. Uncomplicated - sterile exudate in pleural space. pH >= 7.2 with glucose >= 60 mg/dL
    —WBCs <= 50,000 and LDH <= 1,000 units/L
    –culture is negative
    –tx is antibiotics
  2. Complicated (exudative) - bacterial invasion of pleural space. pH < 7.2 with glucose < 60 mg/dL
    —WBCs > 50,000 and LDH >1,000
    –culture is positive or FALSELY negative
    –tx antibiotics and drainage
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24
Q

How are complicated parapneumonic effusions different from empyemas?

A

Empyemas have gross pus or bacteria on gram stain.

-most complicated effusions and ALL empyemas require drainage in addition to antibiotics

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25
Q

What are the 6 Ps of acute limb ischemia?

A
  1. Pain
  2. Pallor
  3. Paresthesia
  4. Pulselessness
  5. Poikilothermia
  6. Paralysis

*these patients do not have PAD and develop acute limb ischemia typically due to arterial embolus from Afib. Those with existing PAD who develop acute on chronic limb ischemia often lack these 6 Ps or develop them more slowly bc those with PAD have collateral circulation which form in response to progressive accumulation of atherosclerosis

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26
Q

Aspiration: chemical pneumonitis vs aspiration pneumonia
1. onset
2. manifestations
3. management

A

Chemical pneumonitis
1. sudden: within minutes or hours
2. abrupt dyspnea, cough, hypoxemia;;; low grade fever, diffuse crackles/wheezes, infiltrate in dependent portion of lung
3. supportive care, oropharyngeal suction

Aspiration pneumonia
1. indolent: few days to weeks
2. fever, cough with putrid sputum, infiltrate in dependent portion of lung
3. Antibiotics that target pathogens

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27
Q

Bacterial endophthalmitis
1. etiology
2. clinical features

A
  1. Bacterial infection of the aqueous humor or vitreous
  2. decreased vision with eye discomfort, conjunctival injection and edema, purulent haziness or layering of leukocytes in anterior chamber
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28
Q

Post of fever (acute)
1. 1-2 days
2. 3-5 days
3. 4-6 days
4. 5-7 days
5. 7+ days

A
  1. wind - atelectasis, pneumonia
  2. water - UTI
  3. walking: DVT
  4. wound -
  5. wonder drugs
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29
Q

Catheter related bloodstream infection typically occurs at what point after catheter insertion?

A
  1. > 48 hours
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30
Q

Primary sclerosing cholangitis

  1. symptoms
  2. labs that are diagnostics
  3. pathology
  4. diseases it is associated with?
A
  1. asymptomatic at 1st but then fatigue and pruritus
  2. increased alkaline phosphatase and gamma-glutamyl transpeptidase
  3. fibrous obliteration of small bile ducts, with concentric replacement by connective tissue in onion skin pattern
  4. IBD and ulcerative colitis
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31
Q

Acute mesenteric ischemia
1. symptoms
2. lab results
3. risk factors
4. etiology

A
  1. rapid onset of periumbilical pain (severe), pain out of proportion to exam findings, hematochezia is a late finding
  2. leukocytosis, elevated hemoglobin, elevated amylase, and metabolic acidossi (increased lactate)
  3. atherosclerosis, embolic sources, hypercoagulable disorder
  4. cardiac embolic events in the setting of Afib, valvular disease, or cardiovascular aneurysms –> can lead to embolus in mesenteric arteries
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32
Q

argatroban
1. mechanism of action

A
  1. acts by reversibly binding to the catalytic thrombin active site, thus inhibiting activation of factors V, VIII and XIII (the coagulant factors), as well as preventing fibrin formation and platelet aggregation
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33
Q

manifestations of superior pulmonary sulcus tumor (5)

A
  1. shoulder pain
  2. Horner syndrome (ipsilateral ptosis, miosis, endopthalmos and anhidrosis)
  3. Neurologic symptoms in the arm (invasion of C8-T2 nerves)
  4. Supraclavicular lymphadenopathy
  5. weight loss
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34
Q
  1. what imaging is done to confirm diagnosis of testicular torsion
  2. What anatomical differences can be seen in testicle
  3. Other symptoms
A
  1. Doppler ultrasound of the scrotum
  2. Horizontal testicular lie with elevated testicle
  3. Testicular, inguinal, abdominal pain ;; nausea, vomiting;; absent cremasteric reflex, swollen, erythematous scrotum
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35
Q

Stress factures
1. xray results
2. management

A
  1. usually negative xray in the first 2-3 weeks
  2. analgesia and reduced weight bearing; referral to ortho surgeon for high risk fracture
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36
Q

What are the 6 risk predictors in RCRI (revised cardiac risk index)

A
  1. high risk surgery (eg. vascular, intrathoracic)
  2. ischemic heart disease
  3. history of congestive heart failure
  4. history of cerebrovascular disease (stroke or TIA)
  5. Diabetes mellitus treated with insulin
  6. Preoperative creatinine >2 mg/dL

0-1 factor: low risk of cardiac death/nonfatal cardiac arrest/or nonfatal MI

> = 2 factors: elevated risk of cardiac death/nonfatal cardiac arrest/or nonfatal MI

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37
Q
  1. What testing occurs for low risk RCRI (0-1) before surgery
  2. What about for >=2 RCRI
A
  1. This person can undergo surgery without further testing
  2. further preop eval requires assessment of cardiac functional capacity (the ability to perform >= 4 metabolic equivalents)

—> patients who can do >= 4 METs can proceed to sx w/out further eval
—> patients who can only do <4 METs require further consideration

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38
Q

CARDIAC STRESS TESTING: When is exercise based testing recommended over pharmacologic based testing?

A

Cardiac stress testing - only necessary if cardiac intervention will impact surgical/perioperative management (e.g. postponing elective surgery for revascularization)

  1. pharmacologic based testing is used when patients are not likely to have an adequate exercise workload (<4 METs)
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39
Q

What is considered <4 METs and >= 4 METs

A

<4 METs =
-eat, dress, use toilet
-walk indoors in the house
-do light housework (e.g. vacuuming)

> =4 METs =
-climb a flight of stairs
-run for a short distance
-do yardwork
-participate in golf, tennis, or dancing

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40
Q

Pulmonary contusion
1. clinical features
2. diagnosis
3. management

A
  1. presents <24 hours after blunt thoracic trauma, tachypnea, tachycardia, hypoxia
  2. Rales/decreased breath sounds
    — CT scan* or CXR with patchy alveolar infiltrate not restricted by anatomic borders
  3. pain control, incentive spirometry, chest PT, supplemental oxygen and ventilatory support
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41
Q

What is euthyroid sick syndrome?

A
  1. low total and free T3 levels with normal T4 and TSH (early on but then later all is low)
    –high circulating levels of glucocorticoids and inflammatory cytokines
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42
Q

hematuria, voiding symptoms (dysuria, frequency), and/or hydronephrosis with flank pain —> more likely indicates

A
  1. bladder cancer - get urgent cytoscopy
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43
Q

When invasive infection is suspected in patients with burn injuries, empiric antibiotic therapy is required —> covering what organisms? (name organisms and drug used)

A
  1. gram positive skin flora organisms
  2. gram negative organisms

**piperacillin-tazobactam or a carbapenem (gram neg)
+ **vancomycin (gram pos)

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44
Q

Diagnosis of plantar fasciitis is achieved with?

A
  1. tenderness at insertion of plantar fascia (at heel and hindfoot)
  2. pain with dorsiflexion of toes
  3. presence of heel spurs on x-ray (but this is low sensitivity or specificity)
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45
Q

How should patients taking warfarin who require anticoagulation reversal (like for urgent surgery) be managed? (3)

A
  1. stop warfarin
  2. patients should get prothrombin complex concentrate (PCC), concentrate of vitamin K dependent
  3. IV vitamin K
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46
Q

Primary biliary cholangitis (PBC) vs Primary sclerosing cholangitis (PSC)

  1. what is the difference
  2. patients typically are..
A

PBC
1. Immune response against intrahepatic bile ducts that promotes cholestasis. Acute cholangitis is rare bc PBC is intrahepatic
2. Much more common in women and rarely associated with UC.

PSC
1. fibrosis and stricturing of the medium and large intra- and extrahepatic bile ducts promoting cholestasis and acute cholangitis.
2. Most commonly in men and associated with ulcerative colitis

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47
Q

Pilonidal disease
1. what is it
2. who does it affect
3. tx

A
  1. a fluctuant mass 4-5 cm cephalad to the anus in the intergluteal region w/associated mucoid, purulent, or bloody drainage. This is when a edematous infected hair follicle in the intergluteal region becomes occluded and infection spreads subcutaneously and forms abscess.
  2. young males, obese individuals, sedentary lifestyles – age 15-30
  3. drainage of abscess followed by excision of sinus tracts.
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48
Q

Febrile Nonhemolytic transfusion reaction
1. Symptoms
2. Pathophysiology

A
  1. mild fever, rigors, myalgias, nausea (depends on severity)
  2. The presence of preformed antibodies to donor leukocyte antigens and occasionally from cytokines in the plasma component of the transfused sample
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49
Q

Acute hemolytic transfusion reaction
1. symptoms
2. pathophysiology

A
  1. hemolysis, ESRD, DIC, hypotension
  2. mismatch between donor and recipient blood groups, caused by native recipient immunoglobulins against the donor antigen. Tx begins with immediate discontinuation of transfusion.
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50
Q

Anaphylactic Transfusion reaction
1. Symptoms
2. Pathophysiology

A
  1. Flushing, itching, nausea, vomiting, diarrhea, bronchospasm, SOB, angioedema, and in severe cases airway obstruction and distributive shock
  2. When transfused blood contains antigen against which the recipient has preformed IgE antibodies –> leads to severe type I (immediate) hypersensitivity reaction with diffuse mast cell degranulation and histamine release
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51
Q

Delayed hemolytic transfusion reaction (DHTR)
1. symptoms
2. pathophysiology

A
  1. anemia, jaundice, and fatigue may occur 1-10 days following transfusion
  2. Recipient develops antibodies against donor antigens 1-10 days after transfusion.
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52
Q

Transfusion related acute lung injury (TRALI)
1. symptoms
2. pathophysiology

A
  1. noncardiogenic pulmonary edema. Fever, dyspnea, severe hypoxemia, and shock
  2. Occurs within 6 hours -immune mediated reaction usually against transfusion of platelets or plasma
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53
Q

Methemoglobinemia
1. Symptoms
2. Pathophysiology
3. Treatment

A
  1. SOB, fatigue, lethargy, light headedness, and in severe cases arrhythmia, seizure, and multisystem organ failure. Blood appears darkened (chocolate color) on gross visualization.
  2. When an abnormal fraction of Hg in the blood exists in the ferric (Fe3+) form (methemoglobin). Methemoglobin cannot effectively bind oxygen. This typically occurs because of exposure to an oxidant stressor such as anesthetic, nitrate, or dapsone.
  3. Supplemental oxygen + IV methylene blue
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54
Q

Cushing reflex
- what is it?
- pathophysiology?

A
  1. Systemic HTN, bradycardia, and irregular respirations observed during periods of increased intracranial pressure, often in the setting of impending herniation
  2. MAP rises in setting of intracranial bleeding to maintain cerebral perfusion pressure. - With increased MAP, carotid baroreceptors trigger reflex bradycardia as an autoregulatory response. Irregular respirations occur bc of compression of pons and medulla.
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55
Q

What is the first line medication for aortic dissection?

A
  1. Labetalol - antihypertensive used to decrease BP to prevent further progression of the dissection flap. Goal of decreased heart rate to 60/min and BP to less than 100-120 mmHg systolic and 60-80 mmHg diastolic
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56
Q

What is the most predictive factor of the severity of the resulting aspiration pneumonia?

A
  1. Small volume simple fluid aspiration may be resorbed by the lung without consequence but LARGE VOLUME ASPIRATION may sufficiently impair gas exchange and result in refractory hypoxia.
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57
Q

Cholangiocarcinoma
1. symptoms
2. Diagnosis steps

A
  1. abdominal pain, weight loss, nausea, jaundice, and pruritus + dark urine or light pale stools
  2. Imaging of abdomen (CT scan or MRI) + ERCP for direct visualization of the lesion and bile duct scrapings or biopsy can occur for definitive diagnosis
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58
Q

VIPoma
1. symptoms
2. cause

A
  1. chronic and profound watery diarrhea, electrolyte disturbances (hypokalemia, hypercalcemia), achlorhydria, alkalosis, flushing, and vasodilation
  2. Endocrine neoplasia that produces vasoactive intestinal peptide (VIP) -potent vasodilator, regulates smooth muscle activity, epithelial cell secretion, and blood flow in the gastrointestinal tract
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59
Q

Gastrinoma
1. symptoms
2. what does it cause

A
  1. associated with zollinger-ellison syndrome: Can lead to recurrent/chronic duodenal or jejunal ulcers, which can present with abdominal pain, diarrhea secondary to malabsorption, and possible hematemesis, melena, or hematochezia
  2. excessive production of acid by the gastric parietal cells
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60
Q

Glucagonoma
1. symptoms
2. what does it cause

A
  1. nonspecific and include mild DM, paraneoplastic rash, weight loss
  2. Increases serum glucose concentration
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61
Q

Insulinoma
1. symptoms
2. what does it cause

A
  1. hypoglycemia - neurologic (agitation, headache, blurry vision, diplopia, tremor), autonomic (diaphoresis, tremor, nausea, vomiting, cramping, tachy, anxiety), nonspecific (fatigue, weakness, lethargy)
  2. neoplasm of pancreatic islet cells that functionally produces insulin in a dysregulated manner
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62
Q

Somatostatinoma
1. symptoms
2. what does it cause

A
  1. weight loss, mild DM, steatorrhea (fat excretion in stool), and achlorhydria
  2. increased somatostatin release (somatostatin prevents (inhibits) the release of pancreatic hormones, including insulin, glucagon and gastrin, and pancreatic enzymes that aid in digestion)
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63
Q

Crohn disease is common risk factor for what type of calculi?

A
  1. oxalate
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64
Q
  1. What do Leydig cell tumors secrete?
  2. Where do they arise from?
A
  1. produce sex hormones in response to LH. Generally secrete androgens in men but can also secrete estrogens in states of dysregulation
  2. Leydig tumors arise from interstitial cells of the testicle
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65
Q

What type of thyroid carcinoma is associated with MEN familial association, hematogenous/lymphatic spread

-arises from parafollicular C cells and produces calcitonin
-often arises insidiously and is typically asymptomatic until a nodule is of palpable size

A

Medullary thyroid carcinoma

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Perfectly
66
Q
  1. What is the most common type of thyroid cancer and its histology??
  2. second most common and its histology?
A
  1. Papillary carcinoma - empty appearing nuclei with central clearing, nuclear grooves, and psammoma bodies in histology
  2. Follicular carcinoma - neoplastic cells are noted to invade the surrounding capsule
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67
Q
  1. What is the rare, aggressive thyroid malignancy?
  2. On exam what do you find
A
  1. anaplastic carcinoma - invades local structures like esophagus and trachea
  2. “hard, woody mass” can be palpable, dysphagia, or hoarseness
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68
Q

Secondary hyperparathyroidism
1. PTH levels
2. Calcium levels
3. Phosphate levels

A
  1. increased
  2. decreased
  3. increased

*due to inability of the kidney to excrete phosphate (ESRD) - and inability to produce active vitamin D which results in hypocalcemia –> leads to upregulation of PTH

69
Q

Primary hyperparathyroidism
1. PTH levels
2. Calcium levels
3. Phosphate levels

A
  1. increased
  2. increased
  3. decreased

-due to parathyroid adenoma, hyperplasia, or carcinoma

70
Q

Phenoxybenzamine
1. Mechanism of action/purpose

A
  1. alpha adrenergic blocker - It is used to treat high blood pressure (hypertension) due to a disease called pheochromocytoma

Alpha 1 receptors are the classic postsynaptic alpha receptors and are found on vascular smooth muscle. They determine both arteriolar resistance and venous capacitance, and thus BP. Alpha 2 receptors are found both in the brain and in the periphery. In the brain stem, they modulate sympathetic outflow.

71
Q

Aortic stenosis - location best heard of murmur and description

A
  1. best heard at the upper right sternal border and radiates to carotid arteries
  2. crescendo-decrescendo systolic murmur
72
Q

Tricuspid Regurgitation - location best heard of murmur and description

A
  1. Best heard a lower left sternal border
  2. holosystolic murmur
73
Q

Ventricular Septal Defect - location best heard of murmur and description

A
  1. lower left sternal border
  2. holosystolic murmur - present at birth
74
Q

Holosystolic apical murmur heard with radiation to axilla

A

Mitral regurgitation

75
Q

Empyema
1. common organisms
2. clinical features
3. management

A
  1. oral anaerobic bacteria, strep pneumo, staph aureas
  2. symptoms of pneumonia, insidious presentation, weight loss, lab evidence of inflammation
  3. chest tube drainage (empyema is free flowing), intrapleural fibrinolytic drugs, surgery for highly fibrotic loculated effusions
76
Q

What constitutes a massive PE?

A
  1. PE complicated by hypotension and/or acute right heart strain (such as jugular venous distention + RBBB on ECG)

-dyspnea and pleuritic chest pain are common symptoms of segmental PE

-Syncope tends to occur only in massive PE

77
Q

How is gastric cancer diagnosis usually established?

A
  1. EGD (esophagogastroduodenoscopy) - to visualize the stomach and obtain biopsy samples
  2. exam can also show epigastric pain that worsens with eating and weight loss. Proximal stomach tumors may cause dysphagia and postprandial nausea and vomiting

–CT abdomen is usually normal in early gastric cancer so not used initially but can be used to look for mets

78
Q

Alcohol withdrawal syndrome
–what occurs –
1. 6-24 hrs since last drink
2. 12-48 hrs
3. 48-96 hrs

A
  1. anxiety, insomnia, tremors, diaphoresis, palpitations, GI upset, intact orientation
  2. seizures, hallucinations
  3. Delirium tremens (confusion, agitation, fever, tachy, HTN, diaphoresis, hallucinations)
79
Q

HCC is a common complication of cirrhosis - what is recommended to not miss HCC diagnosis

A
  1. screening with abdominal ultrasound every 6 months - in patients with cirrhosis
  • often presents with liver decompensation (new onset ascites, variceal bleeding)
80
Q
  1. What type of hip dislocation has occured when leg appears shortened and internally rotated?
  2. what is a common complication of this?
A
  1. posterior hip dislocation
  2. sciatic nerve injury and arterial injury with avascular necrosis of the femoral head
81
Q

Gilbert Syndrome
1. pathogenesis
2. clinical findings
3. Diagnosis

A
  1. decreased hepatic UDP glucuronosyltransferase activity –> leads to decreased conjugation of bilirubin
  2. recurrent episodes of mild jaundice, provoked by stress (febrile illness, fasting, dehydration, vigorous exercise, menstruation, surgery)
  3. increased unconjugated bilirubin

**the more severe form is Crigler-Najjar syndrome (w/almost complete absence of UDP glucuronosyltransferase)

82
Q

Dubin Johnson Syndrome
1. pathogenesis

A
  1. Inability to excrete conjugated bilirubin out of the liver. Liver has black pigment.

**Other similar dx is Rotor syndrome: but this does not have black liver

83
Q

Ventilator associated pneumonia (VAP)
1. when does it occur
2. pathophysiology
3. symptoms that makes you suspicious about VAP
4. How to confirm this dx

A
  1. > = 48 hours after intubation
  2. aspiration of oropharyngeal or gastric secretions after intubation
  3. new pulmonary infiltrate, increased respiratory secretions, signs of worsened respiratory status (worsening oxygenation, lower tidal volumes, and increased inspiratory pressure), systemic signs of infection (fever, leukocytosis, and tachy)
  4. Sampling of lower respiratory tract (noninvasive endotracheal aspiration or invasive bronchoalveolar lavage)
84
Q

POUR (postop urinary retention) -
1. what factors are associated with POUR
2. POUR should prompt what imaging?

A
  1. increasing age, male sex (patient factors) ;; hernia repair, joint arthroplasty, or anorectal operations (type of surgery);; prolonged anesthesia, excessive fluid administration, use of meds that impair bladder (anesthetic factors)
  2. bladder ultrasound
85
Q
  1. etiology: malignancy + primary tumors of lung, breast, GI, lymphoma, melanoma
  2. Clinical features: progressive dyspnea, chest fullness, fatigue + ECG shows decreased QRS voltage + CXR showed enlarged cardiac silhouette (water bottle sign) and clear lung fields + Echo shows large effusion and signs of tamponade

— what is this? + how to treat

A
  1. malignant pericardial effusion
  • pericardiocentesis
    -prolonged drainage for prevention of recurrence
86
Q

Erythema nodosum
1. clinical features
2. associated with what other dx
3. what type of reaction

A
  1. painful, erythematous nodules on shins in setting of inflammatory bowel disease (chronic diarrhea, abdominal pain, weight loss)
  2. more commonly occurs in Crohn disease
  3. delayed type Hypersensitivity reaction
87
Q

-Prosthetic valve dysfunction (PVD) -
What type of regurgitation occurs with bioprosthetic vs mechanical?

A
  1. Bioprosthetic typically has transvalvular regurgitation (regurgitation through the valve) - due to cusp degeneration or occasionally valvular thrombus that impairs valve closure
  2. Mechanical typically has paravalvular leak (regurgitation around the valve) - results from dehiscence of the valve from the aortic or mitral annulus … often due to annular degeneration or underlying infective endocarditis
88
Q

Hydatid cyst vs Amebic liver abscess (both on liver)

  1. differentiate the two
A

A: Hydatid cyst - is due to Echinococcus granulosus. Humans contract the infection from close and intimate contact with dogs which are the definitive hosts in the tapeworm’s lifecycle. Cause UNILOCULAR (eggshell calcification) cystic lesions that can occur in any organ (liver, lung, muscle, bone) - smaller daughter cysts may be present. Usually found incidentally or due to cysts compressing surrounding tissues.
— tx: surgical resection

B: Amebic liver abscess is due to Entamoeba histolytica (a parasite). This would cause fever and R upper quadrant pain that develops within weeks of intestinal amebiasis. (no eggshell calcifications)

89
Q

What is the single most important prognostic factor for breast cancer?

A

Tumor stage based on TNM staging
** (T-tumor size;;; N - regional lymph node involvement;;; M - presence of distant mets)

90
Q

Fluoroquinolones (levofloxacin, moxifloxacin, ciprofloxacin)

  1. mechanism of action
  2. what adverse effects can it be known for?
A
  1. increases cell matrix metalloproteases leading to increased collagen degradation
  2. Achilles tendon rupture, retinal detachment, and aortic aneurysm rupture
91
Q

Acute Adrenal Insufficiency (adrenal crisis)
1. etiology
2. clinical features
3. treatment

A
  1. adrenal hemorrhage or infarction, illness/injury/sx in patient with chronic adrenal insufficiency, pituitary apoplexy
  2. hypotension, shock, N/V, abdominal pain, fever, generalized weakness
  3. Hydrocortisone or dexamethasone (to replace cortisol) + rapid IV volume repletion
92
Q

Neuropathic (Charcot) Arthropathy
1. pathophysiology and causes
2. clinical manifestations (acute and chronic)
3. management

A
  1. Repetitive bone and joint trauma due to impaired sensation/proprioception (DM most common or posterior column disease)
  2. Acute - inflammatory erythema, warmth, and edema of the foot, xrays often normal

Chronic - bone deformities, neuropathic ulcers, cellulitis, osteomyelitis

  1. Acute - foot case to reduce edema and offload weight bearing

chronic - orthotic footwear, infection management, surgical realignment

93
Q

What is treatment of choice for alcohol withdrawal

A
  1. benzodiazepenes
    - lorazepam is preferred agent due to intermediate half-life, lack of active metabolites, and availability in IV form
94
Q
  1. In what patients is acalculous cholecystitis found?
  2. What is treatment?
A
  1. patients who have experienced severe trauma, recent surgery, critical illness, and/or prolonged fasting or parenteral nutrition bc all these things cause gallbladder stasis and ischemia leading to distension, necrosis, and secondary bacterial infection
  2. antibiotics and percutaneous cholecystostomy
95
Q

Patient who has tensely distended abdomen with evidence of intraabdominal organ dysfunction it is most concerning for abdominal compartment syndrome (ACS)

-This should prompt what analysis?

A
  1. measurement of bladder pressure because this estimates intraabdominal pressure (IAP)
  • temporizing measures: avoid fluids, decrease abdominal volume with NG tube, increase abdominal wall compliance with sedation
    -definitive treatment: surgical decompression
96
Q

What happens to H+ , K+, and Cl-, bicarb in severe vomiting

A
  1. with vomiting there is significant loss of gastric H+ from the body –> this reduces amount of carbonic acid (H2CO3) buffer in body resulting in increase in bicarbonate (HCO3-) - metabolic alkalosis is initiated with increased serum HCO3-
  2. Vomiting also causes loss of water and salt (NaCl) - more loss of Cl than Na (HYPOCHLOREMIC)
  3. Volume loss activates RAAS system - this stimulates Na reabsorption in distal tubules at the expense of H+ and K+ (HYPOKALEMIA) - worsens metabolic alkalosis

*urine chloride is low bc there is body depletion. Although Cl is absorbed with Na in ascending tubule — it is not enough to combat the Cl lost in vomiting. Cl is needed for HCO3- excretion so this hypochloremia further perpetuates metabolic alkalosis

97
Q

Refeeding Syndrome
1. when does this occur?
2. What changes to electrolytes occur?

A
  1. After reintroduction of nutrition in patients with malnourishment
  2. Hypophosphatemia, Hypokalemia, hypomagnesium, muscle weakness, and arrhythmias are some of the possible changes

-reintroduction of carbs leads to increased insulin secretion which stimulates the cellular uptake of electrolytes (ie. phosphate, potassium, magnesium) and increases phosphate utilization during glycolysis (eg. formation of ATP) –> eventually leads to phosphate deletion

98
Q

Acute bacterial prostatitis (ABP)
1. symptoms
2. caused by
3. treatment

A
  1. fever, dysuria, leukocytosis, and tender swollen prostate
  2. Colonic pathogens (E. coli, proteus species) - these contaminate urethra and subsequently enter prostate via intraprostatic urinary reflex
  3. Suprapubic catheter is generally required for decompression (urethral catheters can lead to sepsis if they dislodge bacteria from infected prostate) + prolonged (6 week) treatment with a fluoroquinolone (e.g. levofloxacin) or TMP-SMX
99
Q

Trousseau Syndrome
1. pathology?
2. symptoms
3. Associated with what?

A

AKA - migratory superficial thrombophlebitis

  1. Hypercoagulable disorder that usually presents with unexplained superficial venous thrombosis at unusual sites
  2. Lesions appear inflamed, reddened lines or lumps in the fat under the skin
  3. Associated with pancreatic cancer most commonly but also cancer of the lung, prostate, stomach, and colon, and acute leukemias
100
Q

Plantar Fasciitis
1. Symptoms
2. Diagnosis can be done with what presentations
3. Treatment

A
  1. Pain at plantar aspect of the heel and hindfoot. Worse with weight bearing
  2. Tenderness at insertion of plantar fascia, pain with dorsiflexion of toes, Presence of heel spurs on x-ray
  3. Activity modification, stretching, heel pads/orthotics
101
Q

Hypocalcemia can cause what symptoms?

A
  1. parasthesia, hyperreflexia, tetany, or seizure

Labs show hypocalcemia, hyperphosphatemia, and low PTH level

102
Q

Type of shoulder pain
–> pain with abduction, external rotation
–> subacromial tenderness
–> normal range of motion but has positive impingement tests (Neers, Hawkins)

A

Rotator cuff impingement or tendinopathy

103
Q

Type of shoulder pain
–> anterior shoulder pain
–> pain with lifting, carrying, or overhead reaching
–> weakness (less common)

A

Biceps tendinopathy/rupture

103
Q

Type of shoulder pain
—> decreased passive and active range of motion
–> initial painful phase followed by stiffness > pain

A

Adhesive capsulitis (frozen shoulder)

103
Q

Type of shoulder pain
–> Lateral shoulder pain, decreased ROM, weakness with abduction and external rotation (positive drop arm test)
–> Age >40

A

Rotator cuff tear

Drop arm test: arm is held 90 degree abduction and released. Inability to hold arm steady suggests a tear.

104
Q

Type of shoulder pain
–> Uncommon and usually due to trauma
—> gradual onset of anterior or deep shoulder pain
—> Decreased active and passive abduction and external rotation

A

Glenohumeral osteoarthritis

105
Q

Pathophysiology of polyarteritis nodosa?

A
  1. fibrinoid necrosis of arterial wall–> leads to luminal narrowing and thrombosis –> tissue ischemia
  2. Internal/external elastic lamina drainage –> microaneurysm formation –> rupture and bleeding

*correlation with underlying hepatitis B/C (immune complexes)

106
Q

Clinical features of polyarteritis nodosa

A
  1. Constitutional: fever, weight loss, malaise
  2. Skin: nodules, livedo reticularis (makes skin look mottled in a net pattern), ulcers, purpura
  3. Renal: HTN, renal insufficiency, arterial aneurysms
  4. Nervous: headache, seizures, mononeuritis multiplex (type of peripheral neuropathy)
  5. GI: mesenteric ischemia/infarction
  6. MSK: myalgias, arthritis
107
Q

Diagnosis of polyarteritis nodosa?

A
  1. Negative ANCA and ANA
  2. Angio: microaneurysms & segmental/distal narrowing
  3. Tissue bx: nongranulomatous transmural inflammation
108
Q

Fibromuscular dysplasia
1. What is this?
2. most common in what type of patient?

A
  1. Can cause arterial narrowing, aneurysms, and ischemia/infarction (internal carotid artery and renal artery stenosis most often)
  2. Common in women (90%)

*It is common in renal arteries and may cause mesenteric ischemia due to involvement of splanchnic vessels

109
Q

Thromboangitis obliterans
1. what is this?
2. What patient population does it affect the most?

A
  1. Formation of inflammatory thrombi in distal extremities.
  2. Most commonly in young smokers
110
Q

Exudative effusions
1. Pleural protein/serum protein ratio?
2. Pleural LDH/serum LDH ratio is what?
3. Pleural LDH is at what level compared to normal serum LDH

A
  1. > 0.5
  2. > 0.6
  3. > 2/3 upper limit of normal for serum LDH
111
Q
  1. What is the most common complication post ERCP?
  2. what are the symptoms of this most common complication?
A
  1. pancreatitis - this is particularly prevalent in those with sphincter of Oddi dysfunction
  2. classic symptoms include: nausea, vomiting, epigastric pain that radiates to the back and worsens with eating, fever may happen

–> Dx occurs when patients have >= 2 of the following
*severe epigastric pain (often radiating to back)
*amylase or lipase >=3 times the upper limit of normal
*pancreatitis findings on imaging

112
Q

What type of drugs can treat greater trochanteric pain syndrome (trochanteric bursitis)?

A
  1. Initial tx includes local heat, activity modification, and NSAIDs
  2. Patients with persistent symptoms despite conservative therapy often benefit from local corticosteroid injection
113
Q

What imaging is used to confirm diagnosis of aortic dissection?

A

CT angiography of the aorta (CT aortography) - showing an intimal flap and double aortic lumen

114
Q

What is used to confirm the diagnosis and provide definitive treatment for testicular cancer?

A
  1. radical inguinal orchiectomy
115
Q

Graves ophthalmopathy
1. symptoms
2. pathophysiology

A
  1. ocular irritation, impaired extraocular motion, proptosis
  2. T cell activation and stimulation of orbital fibroblasts by TSH receptor autoantibodies leading to expansion of orbital tissues
116
Q

What should be suspected of patients when they are experiencing fever and abdominal symptoms several days after an abdominal operation?

A
  1. intra-abdominal abscess - this is significantly greater with lap appy than laparotmy
  • dx requires CT scan of abdomen
    -Tx is drainage and IV antibiotics
117
Q
  1. What are some signs that there is urethral injury in men?
  2. What imaging/procedure should men undergo to diagnose?
A
  1. blood at urethral meatus, high riding prostate on digital rectal exam, inability to void, perineal bruising.
  2. retrograde urethrography. - Urethral injury should be ruled out before retrograde cystography is done to check for bladder rupture after pelvic fracture
118
Q
  1. What is the difference between presentation of chemical pneumonitis vs aspiration pneumonia?
  2. Treatment?
A
  1. onset is different - chemical onset is within minutes or hours vs aspiration pneumonia takes few days to weeks
  2. Chemical - supportive care
    - aspiration pneumonia - antibiotics that target community acquired pneumonia pathogens (aerobic bacteria from upper airway) –> amoxicillin + azithromycin
119
Q
  1. observed pulsatile bleeding
  2. presence of bruit or thrill over injury
  3. expanding hematoma
  4. signs of distal ischemia (eg. absent pulses, cool extremities)
    –what are these hard signs of?

–> in the presence of these signs (with or without hemodynamic instability) ..it is indicative of need for what?

A

–> hard signs of vascular injury

–> need for urgent surgical repair and warrant immediate exploration. If area of damage is unclear, arteriography can be performed intraoperatively to clarify.

120
Q
  1. Septic arthritis is usually treated with what?
  2. A minority of patients have continued symptoms despite a few days of this initial treatment — this indicates infection with gram negative bacteria and require additional antibiotic which is?
A
  1. vancomycin
  2. third generation cephalosporin (ceftriaxone for example)
121
Q

What is Mittelschmerz?

A

Recurrent mild and unilateral mid-cycle pain prior to ovulation. Pain lasts hours to days

122
Q

Clinical presentation of ectopic pregnancy?

A
  1. amenorrhea, abdominal/pelvic pain and vaginal bleeding
  2. positive beta hCG
123
Q
  1. Clinical presentation of ovarian torsion?
    -US findings
A
  1. sudden-onset, severe, unilateral lower abdominal pain, nausea and vomiting
  2. Unilateral, tender adnexal mass on examination

—on ultrasound: enlarged ovary with decreased or absent blood flow

124
Q

Clinical presentation of ruptured ovarian cyst?
–US findings

A
  1. sudden onset severe unilateral lower abdominal pain immediately following strenuous or sex - that becomes increasingly diffuse often radiating to shoulder due to phrenic nerve irritation
    - as blood fills abdominal cavity: peritoneal signs and hemodynamic instability

*rupture often occurs in women who have anticoagulation

  1. pelvic free fluid

*in ovulating women of reproductive age

125
Q

Clinical presentation of pelvic inflammatory disease?

A
  1. fever/chills, vaginal discharge, lower abdominal pain and cervical motion tenderness
126
Q

How does immobilization change calcium levels?

A
  1. Hypercalcemia – With immobilization there is more osteoclastic bone resorption. This is around 4 weeks of immobilization but those with chronic renal insufficiency may develop hypercalcemia in as little as 3 days

-Bisphosphonates inhibit osteoclastic bone resorption and are effective in treating hypercalcemia of immobilizaiton

127
Q

Angiosarcoma
1. What is the past medical history associated?
2. derived from what?
3. what does it look like?
4. dx is done via?

A
  1. Patients with breast cancer who underwent radiation or axillary LN dissection. (4-8 years after cancer therapy)
  2. Vascular endothelial cells
  3. Red, bruislike plaques on the breast, axilla, and/or upper arm - indistinct borders
  4. Biopsy.

-early surgical resection can be curative but it is an aggressive tumor that readily metastasizes

128
Q

X ray findings differences in SBO vs ileus

A
  1. SBO - air fluid levels, dilated proximal bowel, collapsed distal bowel, little/no air in colon/rectum
  2. Ileus - no transition point, dilated loops of bowel, air in colon/rectum
129
Q

Acute vs subacute cardiac tamoponade
1. rapidity of fluid accumulation
2. chest x ray findings

A
  1. Acute: minutes to hours
    –subacute: days to weeks
  2. Acute: normal cardiac silhouette
    —Subacute: enlarged, globular cardiac silhouette
130
Q

Sialadenosis
1. symptoms
2. pathology
3. Most often in what patients

A
  1. nontender, bilateral enlargement of parotid glands. Does not fluctuate and is not associated with eating.
  2. This is a benign swelling of salivary glands. Results from overaccumulation of secretory granules in acinar cells OR fatty infiltration of the glands
  3. Patients with chronic alcohol use, bulimia, or malnutrition (overaccum. of secretory granules in acinar cells)
    –OR–diabetics or those with liver disease
131
Q

How is pleural effusion different from empyema

A
  1. Pleural effusion - accumulation of fluid (transudate or exudate) in pleural space. Small to moderate and free flowing.
  2. Empyema - has frank pus or bacteria (by Gramstain) in the pleural space and requires drainage in addition to prolonged antibiotics. Moderate to large, free flowing or loculated
132
Q

Acute rotator cuff injury
1. diagnosis
2. treatment

A
  1. MRI, ultrasound
  2. PT, consider surgical repair
133
Q

Fibromuscular dysplasia
1. Physical exam findings
2. Diagnosis
3. Treatment

A
  1. Subauricular (below the ear) systolic bruit, abdominal bruit
  2. Imaging preferred (duplex US, CTA, MRA), catheter based arteriography
  3. Antihypertensives (ACE inhib or ARBs), Percutaneous transluminal angioplasty (PTA), surgery if PTA is unsuccesful
134
Q

Radiation proctitis
-differences between acute and chronic-
1. manifestations
2. timeline
3. endoscopic appearances
4 management

A

Acute
1. Diarrhea, mucus discharge, tenesmus, minimal bleeding
2. <= 8 weeks
3. severe erythema, edema, ulcers due to direct mucosal damage
4. antidiarrheals, butyrate enemas

Chronic
1. Severe bleeding, strictures with constipation and rectal pain.
2. >3 months to years
3. Multiple telangiectasias, mucosal pallor and friability
4. endoscopic thermal coagulation, sucralfate or glucocorticoid enemas

135
Q

Patient with AAA symptoms - hemodynamically stable
–what is the next step in management

A
  1. Obtain CT of abdomen
136
Q

Patient with AAA symptoms - hemodynamically UNSTABLE with unknown dx of AAA
–what is next step in management

A
  1. get obtained focused abdominal ultrasound to identify AAA
    - then get emergency repair
137
Q

Angle closure gluacoma
1. clinical features
2. diagnosis
3. treatment

A
  1. headache, ocular pain, nausea, decreased vision, conjunctival redness, corneal opacity, fixed, middilated pupil
  2. tonometry (measures intraocular pressure), gonioscopy (measures corneal angle)
  3. Topical therapy (timolol, pilocarpine, apraclonidine) + systemic therapy (acetazolamide) + laser iridotomy (facilitate aqueous outflow and provide definitive management)
138
Q

What are the risk factors for acute urinary retention (AUR)? (5)

A
  1. male sex
  2. advanced age
  3. history of BPH
  4. History of neurologic disease
  5. surgery
138
Q

Legg-Calve-Perthes Disease
1. pathogenesis
2. Clinical features
3. Diagnosis
4. Treatment

A
  1. idiopathic avascular necrosis of the femur
  2. Boys age 3-12; insidious hip pain, limp, restricted hip abduction, internal rotation, positive trendelenburg sign
  3. X ray - early may be normal but later will show femoral head flattening, fragmentation, sclerosis
    – MRI - avascular/necrotic femoral head
  4. Non-weight bearing, splinting/possible surgical repair
138
Q

Acute urinary retention
1. Diagnosis is confirmed with?
2. treatment?

A
  1. Bladder ultrasound demonstrating >= 300 mL of urine
  2. Insertion of foley catheter, urinalysis to rule out UTI
139
Q

Transient synovitis
1. symptoms
2. When does this develop?

A
  1. hip or knee pain and limp
  2. after a viral infection and resolves within 4 weeks
140
Q

Risk factors for diverticulitis

A
  1. increases with age
  2. obesity
  3. poor diet
  4. tobacco use
141
Q

What results in the urine are found with diverticulitis?

A
  1. mild irritative urinary symptoms (urgency, frequency)
  2. Sterile pyuria (eg. positive leukocyte esterase (suggests WBC in urine), negative nitrite (bacteria turn nitrates into nitrites))
142
Q

Surgical indications for severe chronic mitral valve regurgitation
1. Surgery if LVEF is …
2. Consider surgery if successful valve repair is highly likely such as —
—> asymptomatic and LVEF …
—> symptomatic and LVEF …

A
  1. 30-60% (regardless of symptoms)
  2. —> asymptomatic and LVEF >60%
    —> symptomatic and LVEF <30%
143
Q

What is normal ejection fraction?

A

50% or higher

144
Q

Colovesical fistula
1. diagnosis
2. etiology

A
  1. CT scan of the abdomen with oral or rectal contrast (NOT IV) + colonoscopy to exclude colonic malignancy
  2. Diverticular disease (sigmoid most commonly), Crohn disease, Malignancy (colon, bladder, pelvic organs)
145
Q

Shortening and external rotation of leg - can be caused by what two issues?

A
  1. femoral neck or an intertrochanteric fracture
  2. Anterior hip dislocation (this is less common than fracture)

-X ray helps you decide

146
Q
  1. Function of succinylcholine
  2. What is it used for
  3. side effects
A
  1. depolarizing neuromuscular blocker that binds to post synaptic ACh receptors to trigger influx of NA ions and efflux of K ions. — temporary paralysis ensues
  2. Used during rapid sequence intubation
  3. can cause cardiac arrhythmia due to severe hyperkalemia
147
Q

Stress ulcers
1. most common in what kinds of patients
2. Risk factors

A
  1. patients in ICU - can cause occult or gross GI bleeding
  2. Shock , sepsis, coagulopathy, mechanical ventilation, traumatic spinal cord/brain injury, burns, and high dose corticosteroids
148
Q

Zollinger Ellison Syndrome
1. epidemiology
2. clinical features
3. Diagnosis
4. Workup

A
  1. 20-50 years old (possibly MEN1 - 20% of patients)
  2. multiple and refractory peptic ulcers, ulcers distal to duodenum, chronic diarrhea
  3. elevated serum gastrin (>1,000 pg/mL) in presence of normal gastric acid (pH<4). Inactivates pancreatic enzymes.
  4. Endoscopy
    - CT scan/MRI and somatostatin receptor scintigraphy for tumor localization
149
Q

What is the calf squeeze test (thompson test)

A

With the patient prone and the feet hanging off the table, the clinician squeezes the calf, shortening the gastrocnemius muscle. If the foot passively plantar flexes in response, the Achilles tendon is at least partially intact; the absence of passive plantar flexion indicates complete tendon rupture.

–plantar flexion indicates function of achilles tendon–

150
Q

Diagnostic test of choice for patients with suspected prosthetic valve endocarditis is what?

A

TRANSESOPHAGEAL ECHOCARDIOGRAPHY: visualizes vegetations and complications of infections

—Transthoracic echo has a lot of false negatives so not particularly good

151
Q

Ankylosing spondylitis
1. exam findings
2. complications
3. Lab association

A
  1. Arthritis, reduced chest expansion and spinal mobility, enthesitis (tenderness at tendon insertion sites), dactylitis, uveitis
  2. Osteoporosis, vertebral fractures, aortic regurgitaiton, cauda equina syndrome
  3. HLA-B27
152
Q

Chronic rejection of transplanted organ
1. timeline
2. pathology

A
  1. months to years
  2. CD4+ T lymphocyte response against donor peptides (like MHC) –> This T cell activation leads to cytokine production and both humoral and cellular hypersensitivity reactions (type II and IV)

–> results vascular atherosclerosis, smooth muscle proliferation with subsequent parenchymal fibrosis and atrophy of the transplanted organ

153
Q

Subclavian Steal Syndrome
1. Pathology
2. Physical exam

A
  1. Occurs secondary to stenosis of the subclavian artery proximal to origin of vertebral artery.
    —Movement and exertion of the affected upper extremity results in reversal of flow from ipsilateral vertebral artery into subclavian to supply upper extremity
  2. Dizziness, vertigo, imbalance, light headedness, hearing disturbances, Differential blood pressures between the affected and unaffected upper extremities with a greater than 15 mmHg difference between the two
    -subclavian bruit on auscultation
    -reduction or delay in radial pulse (ipsilateral)
154
Q

what is the most common organisms causing monomicrobial necrotizing fasciitis?

A
  1. step pyogenes (Group A)
155
Q

Aortic atheroembolism (Cholesterol embolization syndrome)
1. pathology
2. symptoms

A
  1. This is embolization of atherosclerotic plaque contents (e.g. cholesterol crystals) from a proximal large artery (e.g. aorta) to distal small arteries and arterioles
  2. localized inflammatory response, end organ damage, localized petechiae, livedo reticularis, and blue toe syndrome
156
Q

(BLANK) arise from existing cavitary lesions of the lung, such as those caused by previous infection, emphysematous blebs or bullae, or from cavitary squamous cell lung carcinoma

A
  1. aspergillomas (formation of fungal masses - aspergillus species)
    *lesion will be seen as round, solid nodule or mass within a larger lung cavity
157
Q

What is the most appropriate next step in management for a patient with a history of ulcerative colitis complicated by the development of colorectal cancer

A
  1. Proctocolectomy (removal of colon and rectum)
    – will remove cancer and curtail future risk for colorectal carcinoma
  • this is why we do not do segmental colectomy (since this would take out cancer but not remove future risk of cancer)
158
Q

What is normal urine output ranges in cc/kg/hr

A
  1. 0.5-2 cc/kg/hr (or 0.5-1)
159
Q

Diphenyhydramine
1. MOA
2. Purpose
3. side effects

A
  1. H1 receptor blocker
  2. Treatment of allergies, insomnia, and motion sickness
  3. Due to H1 receptor blockade, anticholinergic, and anti-alpha adrenergic effects
    – leads to dry mouth, urinary retention, constipation, hallucination, delirium, ataxia, flushed skin, visual disturbances, and sedation
160
Q

Isosorbide dinitrate
1. MOA
2. Purpose

A
  1. venous vasodilation, reducing cardiac preload
  2. used in tx of anginal chest pain in those with CAD, and in the treatment of heart failure
161
Q

Terazosin
1. MOA
2. Purpose

A
  1. alpha 1 antagonist
  2. Treatment of HTN and BPH. Serves to relax smooth muscle of the bladder neck and prostatic urethra resulting in improved urinary flow in the setting of BPH
162
Q

What color can cysts in the breast be?

A

clear, milky, yellow, green, or brown - all benign typical findings of fibrocystic disease

163
Q

Fibrocystic disease of the breast
1. patient population
2. Physical exam
3. malignancy

A
  1. premenopausal women over 35 years
  2. breast pain and lumps, presence of cysts, stromal fibrosis, and apocrine metaplasia on histology
  3. benign
164
Q

What is the most appropriate treatment for a patient presenting with increased intracranial pressure (ICP) related to underlying intracranial mets?

A
  1. corticosteroid therapy
    –Mets to the brain are associated with vasogenic edema which can lead to abnormal enlargement of the cerebellum which can impress on 4th ventricle and foramina of Magendie and Luschka (obstructive hydrocephalus)
165
Q

When would you choose bypass over percutaneous angioplasty?

A
  • When there is severe occlusion which requires surgical instead of endovascular tx
    -For bypass you need intact arteries that surround the location of occlusion

M3 - Clerkships (8 decks)

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