Surgery Clerkship Flashcards
1
Q
What is the most common carpal bone fracture?
A
Scaphoid fracture
2
Q
FOOSH causing wrist hyperextension or axial compression should be concerning for?
A
Scaphoid fracture
3
Q
What physical exam finding is seen with scaphoid fracture?
A
Tenderness in anatomical snuffbox
4
Q
Patient presents after FOOSH and is found to have tenderness in his anatomical snuffbox. The X-ray does not demonstrate fractures.
What to do next?
A
Thumb spica and re-image in 7-10 days OR confirm with CT or MRI of the wrist.
X-ray at the time of scaphoid fractures has low sensitivity. Therefore, even if the initial x-ray is negative, CT scan or MRI of the wrist is recommended to confirm. As an alternative, the wrist can be immobilized with a thumb spica splint and can be re-imaged in 7-10 days.
5
Q
For patients involved in serious deceleration traumas, e.g. MVAs or falls from greater than 10 feet, physicians should have high caution for?
A
Blunt aortic trauma
Blurt aortic injury carries a high mortality rate, making expeditious detection and treatment critical.
6
Q
What is the most common complication for anterior shoulder dislocations?
A
Axial nerve injury
7
Q
The radial nerve is frequently injured with ____?
A
Humeral mid-shaft fractures
8
Q
Scapular winging?
A
Damage to the long thoracic nerve which innervates the serratus anterior muscle
9
Q
Respiratory distress
Neurologic disfunction or confusion
Petechial rash
A
Fat embolism syndrome
Think of this with fracture of large marrow-containing bones like the femurs or pelvis, s/p ortho surgery, and pancreatitis.
10
Q
Amenorrhea, abdominal/pelvic pain, vaginal bleeding, positive B-hcg
A
Ectopic pregnancy
11
Q
Sudden-onset, severe, unilateral lower abdominal pain, nausea and vomiting
Unilateral, tender adnexal mass
A
Ovarian torsion
12
Q
Sudden-onset, severe, unilateral lower abdominal pain immediately following strenuous or sexual activity
A
Ruptured ovarian cyst
13
Q
Blunt thoracic trauma.
Tachypnea, tachycardia, and hypoxia within 24 hours of the trauma.
Chest wall bruising.
Decreased breath sounds on side of injury.
A
Pulmonary contusion
14
Q
Preoperative evaluation of the surgical patient: what is the number one limiting factor prior to surgery? (3)
A
History of cardiovascular disease
- EF below 35%
- Recent MI. Must defer surgery 6 months and stress patient during the interval.
- CHF. Must medically optimize the patient with ACE inhibitors, beta blockers, and spironolactone to decrease mortality.
15
Q
True or False: patients should quit smoking prior to surgery.
A
True.
Patients should quit smoking 6-8 weeks prior to surgery and use nicotine patches if needed in the meantime.
16
Q
Who should get PFTs done as part of preoperative evaluation? (2)
A
- Patients with known lung disease
2. Patients who have significant smoking history
17
Q
True or False: Dialysis patients should not have surgery.
A
False. If the patient is on dialysis, dialyze the patient 24 hours prior to surgery.
18
Q
72 y/o man undergoing femoro-popliteal bypass for severe left leg claudication which causes unbearable pain with exercise.
The patient has PMH of T2DM and remote appendectomy.
What preoperative testing is recommended?
a. BMP only
b. BMP + EKG
c. BMP + EKG + PFTs
d. BMP + EKG + exercise stress test
e. BMP + EKG + thallium stress test
A
E. BMP + EKG + thallium stress test
Vascular surgery is very high risk surgery. This patient has two significant risk factors for a cardiac event: DM and age >70. Therefore, the patient needs a thorough workup including a tress test. Since the patient has claudication in his leg, exercise stress testing is not recommended. Non-exercise stress testing is recommended.
19
Q
What are the ABCs of trauma assessment? (3)
A
Airway - assess and secure airway (orotracheal tubes are the best way to maintain airway in patients without facial trauma. Patients with facial trauma require a cricothyroidotomy. Patients with cervical since injury still need an orotracheal tube. This should be performed with flexible bronchoscopy to reduce risk of further c-spine injury.
Breathing - proper ventilation to maintain O2 saturation above 90%.
Circulation - insert 2 large-bore IVs into the patient and begin aggressive fluid resuscitation to prevent hypovolemic shock.
20
Q
27 y/o man
Severe abdominal pain radiating to back after car accident.
Abdomen hurts after colliding with the steering wheel.
After 2 days in the hospital, he develops a large ecchymosis on his right flank.
Most likely diagnosis?
A
Hemorrhagic pancreatitis
Bruising on the flank suggests retroperitoneal damage. This is where blood collects in pancreatitis. Pseudocysts may develop 6-8 weeks after pancreatitis. Renal trauma and aortic trauma do not present with ecchymosis.
21
Q
What does free air under the diaphragm indicate?
A
Perforation of bowel
22
Q
What is the best initial test to evaluate for free air under the diaphragm?
A
Upright CXR
23
Q
Best test for evaluating for intraabdominal bleeding?
A
FAST scan (ultrasound)
24
Q
When do you add CT scan to FAST scan?
A
When you want to evaluate retroperitoneal bleed or if you suspect splenic rupture in spite of negative FAST
25
Hemodynamically unstable patients need?
Exploratory laparotomy
26
What is ileus?
Nonmechanical etiology for lack of peristalsis in the GI tract
27
29 y/o woman presents to ED.
Sudden onset left-sided chest pain.
Difficulty breathing.
Only medication is birth control pills.
Smoked 1 pack of cigarettes per day for the past 10 years.
HR 120. RR 24.
Physical exam: diminished breath sounds on the left. Trachea deviated to the right.
a. pericardial tamponade
b. pulmonary embolus
c. tension pneumothorax
d. hemothorax
c. tension pneumothorax
Tension PTX presents with diminished breath sounds on one side and tracheal deviation. PE does not give tracheal deviation although it does have chest pain and tachycardia.
The patients' risk for PTX is that she is a smoker. It is likely that she has a pleural bleb that burst due to her smoking hx.
28
Most effective treatment for pericardial tamponade?
Pericardiocentesis
29
How to treat PTX?
Chest tube placement
30
How to treat tension pneumothorax?
Immediate needle decompression followed by chest tube placement.
31
How to treat hemothorax?
Chest tube drainage and possible thoracotomy
32
Trachea deviating away from involved lung?
Tension PTX
33
Trachea deviating towards involved lung?
Atelectasis
34
18 y/o boy is hit with a car while riding his bike.
Presents with severe groin pain after falling.
PE reveals blood at the urethral meatus and a high-riding prostate.
What to do next?
a. place foley catheter
b. retrograde urethrogram
c. empiric abx
d. CBC and electrolytes
e. discharge patient with reassurance
b. retrograde urethrogram
Patient has urethral disruption that needs evaluation.
A kidney, ureters, and bladder x-ray followed by a retrograde urethrogram must be conducted prior to any other tests. Placing a foley catheter without such imaging modality can lead to further urethral damage.
The step after urethrogram is a foley catheter placement to aid in urination.
35
75 y/o man
Hx of A. fib, CAD, HLD.
Presents with abdominal pain worse after eating.
Pain is 10/10. No peritoneal signs present.
Lab shows WBC of 15 with neutrophil predominance and decreased bicarbonate.
What is the most appropriate next step?
a. CT of the abdomen
b. angiography
c. LFTs
d. colonoscopy
e. ABX
b. angiography
This patient is suffering from acute mesenteric ischemia. The patient presents with complaints of abdominal pain that is severe and out of proportion to physical findings.
Most common risk factor is atrial fibrillation which can cause emboli to occlude vessels.
Labs may show increased lactic acid and leukocytosis.
Angiography is done prior to surgery as quickly as possible to avoid perforation. Colonoscopy may lead to perforation.
36
What is the most appropriate therapy for acute mesenteric ischemia?
Emergent laparotomy.
37
What are the most common locations for mesenteric infarction?
Splenic and hepatic flexures
38
MI referred pain?
Left chest, jaw, and left arm
39
Gall bladder referred pain?
Right shoulder/scapula
40
Pancreas referred pain?
Back pain
41
Pharynx referred pain?
Ears
42
Prostate referred pain?
Tip of penis/perineum
43
Appendix referred pain?
Right lower abdominal quadrant
44
Esophagus referred pain?
Substernal chest pain
45
Pyelonephritis, nephrolithiasis referred pain?
Costovertebral angle
46
What is boerhaave syndrome?
Full-thickness tear of the esophagus secondary to retching.
47
How does esophageal perforation happen?
Rapid increase in intraesophageal pressure with negative intrathoracic pressure caused by vomiting.
48
Severe and acute onset of excruciating retrosternal chest pain.
Pain swallowing.
Positive hamman sign
Pain radiating to left shoulder
Esophageal perforation
49
What is hamman sign?
Crunching heard upon palpation of thorax due to subcutaneous emphysema
50
Most common cause of esophageal perforation?
Iatrogenic. Upper endoscopy
51
Mallory-weiss syndrome vs boerhaave syndrome?
Mallory-weiss syndrome is a mucosal tear of the esophageal. Boerhaave is a full thickness tear (perforation).
52
True or False: Barium swallow should be used to diagnose esophageal perforation
FALSE
Barium is caustic to tissues and cannot be used with perforations.
53
What is the most accurate test for diagnosing esophageal perforation?
Esophogram with diatrizoate meglumine and diatrizoate sodium. This will show leakage of contrast outside of esophagus. Barium swallow is contraindicated in evaluating perforations as it is caustic to tissues.
54
How do you treat esophageal perforation (boerhaave syndrome)?
Surgical exploration with debridement of the mediastinum and closure of the perforation.
Mediastinitis is a complication that carries a very high mortality rate. Debridement of the mediastinum is essential
55
How do you treat mallory-weiss syndrome?
Supportive care
56
Gastric perforation is most commonly seen 2/2 to what?
Peptic ulcer disease
57
How do you treat gastric perforation? (4 steps)
1. make patient NPO
2. place NG tube
3. Medical management (broad-spectrum ABX, IV fluids)
4. Emergent surgery (exploratory and repair of perforation)
58
True or False: acute appendicitis presents with pain that originates in the right lower quadrant and beings to localize to the umbilical region
FALSE
It's the opposite. It usually presents with umbilical region pain that later begins to localize to the right lower quadrant.
59
What is contraindicated with diverticulitis? (2)
Barium enema and colonoscopy due to increased incidence of perforation.
60
Abdominal pain that radiates to the back has 2 emergent conditions. What are they?
1. pancreatitis
| 2. aortic dissection
61
Best test for diagnosing acute pancreatitis? Most sensitive? Most specific?
CT scan, amylase, lipase
62
How do you treat acute pancreatitis?
Aggressive IV fluids and NPO until symptoms resolve
63
How do you treat diverticulitis?
ABX for first attack. Surgical resection if it recurs or perforates.
64
Signs of small bowel obstruction?
Failure to pass stool and gas.
HYPERactive bowel sounds.
Nausea, vomiting, and abdominal pain.
65
What is a significant risk factor for small bowel obstruction?
Past abdominal surgery is a very significant risk factor as adhesions can form from surgery.
66
How do you treat bowel obstruction? (4 steps)
1. make patient NPO
2. place NG tube with suction
3. medical management (IV fluids to replace volume lost via third spacing)
4. surgical decompression (if complete obstruction or lack of improvement with medical management)
67
What is the most accurate test for fecal incontinence?
anorectal manometry
68
What is a comminuted fracture?
A fracture in which the bone gets broken into multiple pieces. Most commonly caused by crush injuries.
69
What is a stress fracture?
A complete fracture from repetitive insults to the bone. Most common stress fracture is of the metatarsals. Vignette may describe an athlete with persistent pain.
70
True or False: Stress fractures are diagnosed with X-rays
FALSE.
X-rays do not show stress fractures. CT or MRI must be conducted in order for dx.
71
What is a compression fracture?
Fracture of the vertebra in the setting of osteoporosis
72
What is a pathologic fracture?
A fracture that occurs from minimal trauma to the bone that is weakened by disease (eg. cancer, multiple myeloma, paget disease, osteoporosis, etc)
Vignette may be an older person who fractures a rib from coughing.
73
What is an open fracture?
A fracture where the injury causes a broken bone to pierce through the skin
74
How do you treat an open fracture?
SURGERY. Surgery is always the right answer. Open fractures are associated with high rates of bacterial infection to the surrounding tissue.
75
Arm held to side with externally rotated forearm with severe pain
Anterior shoulder dislocation
76
Arm is medially rotated and held to the side with severe pain
Posterior shoulder dislocation
77
What to rule out in setting of clavicular fracture?
Subclavian artery or brachial plexus injury
78
What is trigger finger?
Stenosis of the tendon sheath leading to finger that is acutely flexed and painful. It can make a popping sound when pulled free. Treated with steroid injections before even considering surgery.
79
What is dupuytren contracture? How do you treat it?
It is a condition more common in men over age 40 where the palmar fascia becomes constricted and the hand can no longer be properly extended. Surgery is the only effective therapy.
80
66 y/o man. Bilateral leg pain of several months duration.
Worse when he walks. Improves when he sits. Leaning forward alleviates the pain. He is not a smoker.
What is the most likely dx? What diagnostic study to do?
Most likely spinal stenosis. Send for spine MRI.
81
What is compartment syndrome?
Compression of nerves, blood vessels, and muscle inside a closed space. This can also be within a cast after setting a fracture.
82
What are the 6 signs of compartment syndrome?
1. pain (most commonly the first symptom)
2. pallor (lack of blood flow causes pale skin)
3. paresthesia (pins and needles)
4. paralysis (inability to move the limb)
5. pulselessness (lack of distal pulses)
6. poikilothermia (cold to the touch)
83
How do you treat compartment syndrome?
Immediate fasciotomy must be done to relieve pressure before necrosis occurs.
84
How do you treat MCL or LCL injury?
Surgical repair
85
How do you treat ACL injury?
Arthroscopic repair
86
How do you treat PCL injury?
Arthroscopic repair
87
How do you treat meniscal injury? (knee)
Arthroscopic repair
88
What is the unhappy triad of knee injuries?
ACL, MCL, and medial meniscus
(Imagine taking a blow to the lateral side of your leg. This is much more common than blow to the medial aspect of the leg)
89
Management of AAA?
3-4 cm: US every 2-3 years
4-5.5 cm: US or CT every 6-12 months
>5.5 cm: surgical repair
90
What is #1 risk factor for aortic dissection?
HTN
91
Sudden onset tearing chest pain radiating to back.
+/- Asymmetric BP in right and left arms.
Aortic dissection
92
Diagnostic test of choice for suspected aortic dissection?
TEE is the fastest and used if the patient is clinically unstable. If stable, MRA is the diagnostic test of choice (magnetic resonance angiogram)
93
How to treat aortic dissection?
Ascending dissection - emergent surgery and BP control
| Descending dissection - BP control
94
True or False: use vasodilators to control BP in aortic dissections
FALSE!!
Vasodilators should never be used alone for aortic dissections. They can cause reflex tachycardia which can increase shearing forces
95
What medical management is first-line for controlling BP in aortic dissection?
Beta-blockers.
The weak spot can extend with each beat, extending the tear. Control BP and HR with b-blockers
96
Postoperative fever W's? (5)
```
Wind (atelectasis or pneumonia)
Water (UTI)
Walking (DVT/PE)
Wound (wound infection, cellulitis)
Wonder drugs (drug fever)
```
97
POD 1-2 fever?
Atelectasis or postoperative pneumonia
98
POD 3-5 fever?
UTI
99
POD 5-7 fever?
DVT, PE, or thrombophlebitis of IV access lines
100
POD 7 fever?
Wound infections and cellulitis
101
POD 8-15 fever?
Drug fever or deep abscess
102
How to treat hospital-acquired pneumonia?
Zosyn (Tazobactam-piperacillin)
103
Postoperative. Severe hypoxia. Tachypnea. Accessory muscle use for ventilation. Hypercapnia. X-ray with bilateral pulmonary infiltrates without JVD
Dx? Treatment?
Acute respiratory distress syndrome (ARDS)
Treat with positive end expiratory pressure (PEEP)
104
Patient has PE and is placed on heparin and bridge to coumadin. Patient has 2nd PE while on coumadin. What next?
Must place IVC filter via inguinal catheterization.
105
What is a specific EKG finding for PE?
s1q3t3
However, this is seen in less than 10% of PE patients. It's specific but not sensitive
106
42 y/o. Constipated despite many laxatives. Last bowel movement 6 days ago.
PMH scleroderma, constipation. 1 yr hx of progressive abdominal distention.
38(100.4)/110/22/110.66
Abdomen distended with diffuse tenderness to deep palpation. Guarding and rebound. Hgb 12, WBC 14, abdominal X-ray shows dilation of colon and 12-cm cecum. No distention of small bowel.
Dx and tx?
Toxic mega-colon
Treat with laparotomy
107
What is reynold's pentad?
Dx for cholangitis
1. jaundice
2. fever
3. RUQ pain
4. mental status change
5. sepsis
108
Ventilation vs oxygenation?
What ventilator settings are controlled for ventilation? Oxygenation?
Ventilation is getting rid of CO2. Oxygenation is getting in O2.
Ventilation is manipulated with tidal volume and respiratory rate. Increasing tidal volume and increasing RR both decrease CO2.
Oxygenation is manipulated with FiO2 and PEEP.
109
Which lung cancer is associated with hypercalcemia?
Squamous cell carcinoma of the lung. (From release of PTHrP)
110
Which lung cancer is associated with SIADH?
Small cell (oat cell) carcinoma of the fun
111
What is the most common opportunistic agent in HIV-infected patients?
Cytomegalovirus
Associations: eosinophilic nuclear inclusions, small basophilic cytoplasmic inclusions. Owl eye. Esophageal ulceration. Colitis (bloody diarrhea).
112
Findings of VIPoma?
Vasoactive-inhibitory peptide-secreting tumor
WDHA
Water Diarrhea
Hypokalemia
Achlorhydria
It makes you have watery diarrhea which results in loss of potassium (hypokalemia). The achlorhydria is the reduction or cessation of stomach acid secretion.
113
30 y/o man. Painless, progressive enlargement of left testicle over the past 8 months.
No nodule.
Scrotum cannot be transilluminated.
What is likely dx?
a. epididymitis
b. hydrocele
c. indirect inguinal hernia
d. spermatocele
e. testicular tumor
e. testicular tumor
Epididymitis is painful
Hydrocele can transilluminate
Indirect inguinal hernia is not likely progressive over 8 months.
Spermatocele is painful liquid-filled nodule sitting above testicle.
Testicular tumor is most likely.
114
Pathophysiology of secondary HTN from renal artery stenosis?
Example is stenosis of right renal artery.
This causes increased renin activity at the right kidney which increases systemic angiotensin II levels. This causes increased aldosterone systemically which causes sodium retention and increased blood volume leading to hypertension. Angiotensin II also causes systemic vasoconstriction causing hypertension.
115
47 y/o previously healthy man.
2 week hx of progressive abdominal swelling.
PE shows distension and shifting dullness. Bowel sounds normal.
No tenderness, masses, or organomegaly.
Diagnostic paracentesis performed and yields 50mL of chylous/milky ascites.
Dx?
Lymphoma
Chylous ascites is an uncommon clinical finding that results from disruption of abdominal lymphatics. This is a sign of a lymphoma.
116
24 hr s/p solitary parathyroid adenoma resection.
42 y/o woman has perioral numbness and tingling.
Exam of incision site is normal.
Serum Ca is 6.8, serum albumin normal.
Whats the next step?
a. observation
b. IV Mg
c. IV Calcitonin
d. IV calcium gluconate
e. oral vitamin D
d. IV calcium gluconate
For very low levels of hypocalcemia (less than 7.5), give IV calcium. Oral vitamin D and calcium can be used for mild hypocalcemia.
Low calcium risks systolic arrest.
117
Pathophysiology of charcot joints?
Loss of peripheral sensation and propioception leads to repetitive micro trauma to the joint in question. This damage goes unnoticed to the neuropathic patient and the resultant inflammatory resorption of the traumatized bone renders the region weak and susceptible to further trauma.
118
Omental thickening or omental caking is a radiologic finding suggestive of?
Metastatic tumors arising from the stomach, ovary, or colon.
119
24-hr Fluid resuscitation for burns?
Calculate for 50% total body surface burn on a 75kg man
4mL x BSA% x weight
4 x 50 x 75 = 200 x 75 = 15,000 = 15 L of Lactated Ringers
120
Patient shot in the calf with a bullet. X-ray demonstrates bullet still in the muscle. Vital signs stable. Patient has tense painful calf. Passive movement of great toe exacerbates patient's calf pain. What should you think of? How to tx?
Compartment syndrome
Treat with emergency fasciotomy
121
60 y/o woman s/p sigmoid resection and end colostomy for tx of diverticulitis with rupture.
Post-op night 1, she becomes confused, oliguric, and febrile. Tissues around the colostomy are indurated and crepitant. What is the most likely causal organism?
a. bacteroides fragilis
b. clostridium perfringens
c. escherichia coli
d. group A b-hemolytic streptococcus
e. staphylococcus aureus
b. clostridium perfringens
Because tissues are crepitant. Remember that C. perfringens is associated with crepitus.
Bacteroides fragilis is associated with intra-abdominal abscesses.
122
42 y/o patient admitted to hospital with piece of meat lodged in lower esophagus.
With considerable difficulty, the meat is removed by esophagoscope. That evening, the patient has a temperature of 38.3 (101 F). Which is the most appropriate diagnostic study?
a. CT chest
b. Neck x-rays
c. MRI chest
d. Repeated esophagoscopy
e. water-soluble contrast upper GI study
e. water-soluble contrast upper GI study
We are looking for an esophageal tear caused iatrogenically during the esophagoscopy. We don't want to use barium due to the inflammatory reaction it can cause if leaked outside of the GI tract.
123
What is Conn's syndrome?
Conn's syndrome is also known as primary aldosteronism. Hyperaldosteronism causes retention of sodium and potassium wasting. This results in HTN which can cause headaches and vision changes. Can also be asymptomatic HTN.
Other symptoms include muscular weakness, muscle spasms, tingling sensations, and excessive urination.
124
What is a common complication to be aware of for AV fistulas?
High-output heart failure. Blood takes the path of least resistance through the vistula. Clinical findings include JVD, S3, and S4.
125
What is high-output heart failure?
This is when cardiac output is higher than normal due to increased peripheral demand. There is circulatory overload which may lead to pulmonary edema secondary to an elevated diastolic pressure in the LV. These individuals usually have normal systolic functions but have symptoms of heart failure.
Seen with peripheral shunting, low-systemic vascular resistance, hyperthyroidism, beri-beri, carcinoid, paget's disease, and anemia.
126
42 y/o man brought to ED after MVA.
25 mph, car hit a tree.
Seat belt sign, head laceration. Lab studies and X-rays unremarkable.
3 days later, patient develops bilious vomiting that tests positive for blood. Patient is afebrile. Abdomen is non-tender but distended. CBC, BMP, amylase, and LFTs are normal. X-ray unremarkable.
CT abdomen is most likely to show?
a. acute cholecystitis
b. contained splenic rupture
c. duodenal hematoma
d. intrahepatic hematoma
e. splenic hematoma
c. duodenal hematoma
Presents 1-5 days after abdominal injury. Typically from MVA seatbelt injury. Happens when blunt force rapidly compresses duodenum against the vertebral column. Blood collects between the submucosal and muscular layers of the duodenum causing partial or complete obstruction.
Presentation of gastric distension, abdominal pain, bilious vomiting, anorexia, dehydration.
X-ray is non-specific. CT can confirm diagnosis.
Management involving decompression with NGT and parenteral nutrition. Surgery or percutaneous drainage can be considered if non-operative management fails.
127
What is radionuclide scan with thallium and dipyridamole?
This is the pharmacologic stress test that is performed when exercise stress test is contraindicated (e.g. abdominal aortic aneurysm)
128
True or False: any female with abdominal pain and previous hx of ovarian cyst or diagnosis of cyst at the presentation should be considered tortious until proven otherwise.
TRUE
Exploratory laparotomy is the treatment. Can't treat conservatively as we must assume that it's torsion.
129
Do amide or ester local anesthetics last longer?
Amides last longer.
The amides are intermediate to long acting while esters are short acting. Amides all last 3-6 hours but bupivicaine lasts the longest at 4-7 hours.
130
52 y/o woman. BRBPR for 2 weeks.
10 yr hx of HLD treated with simvastatin.
Vitals are normal.
Cardiopulmonary PE is normal.
Abdominal exam is normal.
Rectal exam shows internal hemorrhoids that prolapse and are manually reducible.
Hgb 13, WBC 6.5, serum cholesterol 210.
What next?
a. CT abdomen
b. technetium 99m scan
c. docusate sodium therapy
d. colonoscopy
e. hemorrhoidectomy
d. colonoscopy
While hemorrhoids can definitely cause BRBPR, a 52 y/o woman presenting with lower GI bleed needs a colonoscopy to rule out cancer.
131
Finding suggestive of ruptured bronchus?
Crepitus
132
Previously healthy 42 y/o woman. 2 day hx of right knee pain and inability to extend the right nee.
Symptoms began when he was getting up from a low chair. 37C. Examination of the knee shows tenderness to palpation along the medial joint line and a joint effusion. Ligament stability is normal. ROM is 15-110 degrees. X-ray is unremarkable.
Likely Dx?
a. ACL injury
b. bursitis
c. chondromalacia
d. collateral ligament injury
e. patellar dislocation
f. patellar tendon rupture
g. PCL injury
h. torn meniscus
h. torn meniscus
Tenderness along medial joint line with effusion.
Getting up from a low position is a classic presentation.
133
68 y/o man has had recurrent stridor for 2 hrs. 2 years ago, he had radiation therapy for laryngeal cancer. Examination shows bulky tumor involving the upper and middle neck bilaterally.
ABG while breathing 100% oxygen shows:
pH 7.32, PCO2 52, PO2 55, HCO3 17
Next step in management?
a. placement of an esophageal airway
b. bronchoscopy
c. neck irradiation
d. tracheostomy
e. laryngectomy
d. tracheostomy
Tumor has likely returned. Tracheostomy below the lesion to maintain airway is the next step.
134
Which study to confirm diagnosis of carpal tunnel syndrome?
a. X-rays of hands and wrists
b. electromyography
c. MRI of hands and wrists
d. arthroscopy of the wrist joints
e. nerve conduction studies
e. nerve conduction studies
135
56 y/o woman. 3 mo hx of sweating, nervousness, tremors, tachycardia, and hunger. Symptoms are worsened by fasting.
Selective angiography shows 1-cm tumor in the tail of the pancreas. Which of the following is the most likely diagnosis?
a. carcinoid
b. glucagonoma
c. insulinoma
d. somatostatinoma
e. vipoma
c. insulinoma
These symptoms are of hypoglycemia. Insulinoma causes hypoglycemia :(
136
77 y/o woman brought to the ED with fever and vomiting for 2 days. She is alert but unable to give a hx. She asks repeatedly for a drink of water.
Temp is 101.5F and BP is 100/60.
PE shows distended, non-tender abdomen with sparse high-pitched bowel sounds.
Supine X-ray of the abdomen shows multiple dilated loops of small bowel and gas within the small-bowel lumen and within the liver.
What's the most likely cause of these findings?
a. bacterial cholangitis caused by klebsiella pneumoniae
b. cholecystoduodenal fistula with an impacted gallstone
c. emphysematous cholecystitis with an intrahepatic perforation
d. perforated duodenal ulcer with a subhepatic abcess
e. pylephlebitis caused by sigmoid diverticulitis
b. cholecystoduodenal fistula with an impacted gallstone
Pneumobilia (gas within the biliary system) is suggestive of gallstone ileus. In this problem, this was described as gas within the liver.
137
What is a celiotomy?
Celiotomy is another word for laparotomy.
This is a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity.
138
What are howell-jolly bodies?
These are basophilic nuclear remnants (clusters of DNA) in erythrocytes that signify decreased or absent splenic function. A normal spleen will remove these inclusions during circulation.
139
True or False: urine output is a poor indicator for adequate fluid resuscitation in patients who need fluid replacement. You must track vital signs and capillary refill.
FALSE
Urine output is one of the best indications of adequate resuscitation.
140
27 y/o man brought to ED 25 minutes after MVA where he was the unrestrained driver.
On arrival, Glasgow Coma Scale was 5.
HR 150, RR 15, BP 165/90.
Right pupil is 6mm. Left pupil is 4mm.
There is minimal response to noxious stimuli.
Whats the most appropriate next step in management?
a. CT head
b. IV labetalol
c. Intubation and hyperventilation
d. EEG
e. lumbar puncture
c. intubation and hyperventilation
Remember the ABCs. Airway, breathing, circulation.
141
How to remember upper vs lower lip skin malignancies?
Per Dr. Sattar:
"memorizing all this is a bunch of B(asal)-S(quamous)"
Remember that upper lip malignancies are usually basal cell carcinomas and lower lip malignancies are usually squamous cell carcinomas.
142
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Previously healthy 15 y/o boy.
Sudden onset right-sided chest pain.
98.4/90/18/110.70
PE unremarkable.
X-rays of chest shows small, right PTX.
Which of the following is most appropriate for next step?
a. observation
b. PFTs
c. CT chest
d. V/Q scan
e. Bronchoscopy
```
a. observation
This is a small spontaneous pneumothorax. It is expected to resolve on its own within 3-5 days. Vitals look good on this patient.
143
Most common complications of supracondylar fracture of the humerus?
Neurovascular injury
Injury to brachial artery
Injury to median nerve
Must check distal pulses, perfusion, sensation, and motor.
144
Classic chest x-ray abnormalities for aortic rupture?
Widened mediastinum and left-sided hemothorax
Deviation of mediastinum to the right
145
How to lower intracranial pressure? (5)
1. head elevation - increasing venous outflow from the brain
2. sedation - decreasing metabolic demand and control of HTN
3. IV mannitol - extraction of free water from brain tissue via osmotic diuresis
4. hyperventilation - CO2 washout causing cerebral vasoconstriction
5. removal of CSF - reduction of CSF volume/pressure
146
How does hyperventilation decrease ICP?
Because the brain is an encased organ, relatively small changes in pressure can alter the ICP in important ways. The pressures in 3 distinct compartments of the brain - the brain parenchyma, the CSF, and cerebral blood flow, determine the overall ICP. Both brain parenchyma and CSF have relatively constant pressures except in certain circumstances, including space-occupying lesions and obstructions to CSF flow.
CBloodF is influenced by systemic blood pressure and is held constant over a fairly wide range of pressures by cerebrovascular auto regulation. However, the partial pressures of O2 and CO2 also play an important role in regulating CBF. In conditions such as stroke or trauma, these systems are disrupted and interventions may be required to lower ICP.
CBF is an important target for therapy, and paCO2 is a potent regulator of CBF (much greater than paO2). As levels of cerebral paCO2 rise, so does blood flow. Lowering cerebral arterial paCO2 through hyperventilation results in rapid vasoconstriction and a consequent decrease in ICP.
