Surgery - Kap Flashcards
1
Q
Male pt has pneumaturia and fecaluria. Dx and studies?
A
GI fustulas (colovesical most common, but also enterocolic, colocolonic, vaginal-colonic).
Usually in sigmoid
Usually caused by diverticulitis, sigmoid cancer
Studies - CT scan to confirm presence of inflammatory diverticular mass
2
Q
Pt falls and tries to catch themself with an outstretched arm. Type of fx and management?
A
Colles’ fracture - dorsally displaced, angulated fx of the distal radius and ulnar styloid
Managment - short armed cast to immobilize the wrist while allowing elbow mobility - provides for good QOL.
3
Q
Pt gave birth a few weeks ago and has had ongoing rectal pain ever since. Extreme pain with defecation and bright red blood. Dx and location of lesion?
A
Anal fissure
Syx - exquisite pain and minimal bright red bleeding, pain with coughing and sitting
Usually young female, can have anal pruritus
Location - posterior to midline, distal to dentate line
10% are anterior to midline
Most common cause - constipation with hard stools, childbirth, Crohn’s
Management - warm water after BM, analgesics, stool softners, high-fiber diet
4
Q
Pt is 3 days post op and develops acute abdominal pain and distention. PE - distended. Studies - minimally dilated small bowel, max dilated large bowel. Dx and management?
A
Dx - colonic pseudo obstruction (Ogilvie syndrome). Caused by symp/parasymp imbalance
Common in post op period
Exacerbated by narcotics and electrolyte imbalance
Management - 2 mg neostigmine slowly
5
Q
Male pt has chills, fevers, low back/perineal pain, and urinary hesitancy. Dx and Tx?
A
Acute prostatis Generalized athralgia/myalgias common PE - prostate tender, warm, swollen E. coli or Chlamydia Tx - Quinolones (ofloxacin 4-6 weeks)
6
Q
Atrial fib is at risk of which GI injury?
A
Mesenteric thromboembolism
Early cases - angio
Late cases - exploratory laparotomy
Pain out of proportion to exam
7
Q
What is a clean-contaminated surgery and what is the risk of a post surgery infection.
A
Clean contaminated - created in a sterile environment but involves entry into the respiratory, GI, or genital systems with limited spillage from that system
Risk of infection - 3-5%
8
Q
2 weeks post a GI surgery pt presents with obstruction. Cause and best way to Dx?
A
Obstruction due to adhesions
CT scan
9
Q
Elderly pt has a fall and presents in pain with one leg appearing shorter and externally rotated. Management?
A
Displaced femoral neck fracture
Replace femoral head with metal prosthesis
The fractured head is at significant risk for avascular necrosis.
10
Q
A CHF pt cannot maintain an erection. What should he be given?
A
A vacuum device
NEVER give sildenafil in a CHF pt especially when they are taking nitrates
11
Q
Best way to prevent postop pneumonia in a pt with multiple RF’s?
A
Anything that encourages lung expansion: Incentive spirometry, deep breathing, PEEP
RF’s: age, smoking, pulm dz, poor health, long surgery
12
Q
AAA Pt post op 1 day presents with bloody diarrhea. Dx?
A
Bowel ischemia
Especially in AAA
13
Q
What should be done immediately after placing a central line?
A
CXR to confirm placement in to the subclavian vein.
14
Q
Pt has free air on CT. What do you do?
A
exploratory lap
15
Q
Pelvic fx pt has localized pain, urinary retention, and hematuria
A
Extraperitoneal bladder injury
Contusion or rupture of the neck, anterior wall, or anteriolateral wall of bladder
16
Q
Initial management for a renal failure pt with DVT
A
Warfarin + heparin
warfarin causes procoagulable state in first 48 hours
17
Q
Cause of edema, stasis dermatitis, and venous ulcerations
A
Venous insufficiency, valve incompetence
18
Q
4 weeks post MI pt presents with periumbilical pain out of proportion to exam, leukocytosis, high Hgb, High amylase, and metabolic acidosis. Dx?
A
Acute mesenteric ischemia
Caused by cardiac emboli
Confirm with CT angio
Tx - embolectomy, abx, and anticoags
19
Q
Locations in the colon most sensitive to ischemia?
A
Splenic flexure
Rectosigmoid junction
20
Q
Male pt has dysuria, frequency, urgency, painless hematuria. Rectal exam and U/A negative. Now what?
A
High risk of bladder cancer
Perform cystoscopy with bx
Bladder cancer frequently presents with painless hematuria
21
Q
Appropriate meds for conscious sedation of a child?
A
po or pr midazolam or diazepam
Pt is able to maintain airway, reflexes, and response to physical stimuli
Indicated when a pt hasn’t fasted (ie trauma)
22
Q
Most common COD in a transfusion reaction?
A
febrile hemolytic transfusion rxn (low HCT)
Caused by ABO mismatch
Ab mediated hemolysis -> fever, tachy, anemia, and hemoglobinuria
Tx with IVF, diuresis, sodium bicarb, and vasopressors
23
Q
What should be done to correct a medial meniscus tear?
A
Acute - PT and NSAIDS
Chronic - Arthroscopic evaluation and intervention
24
Q
What do you do when you can’t Foley a pt that has urinary retention?
A
Suprapubic tube placement
25
LLQ pain
Diverticulitis
| Often require sigmoidectomy after the acute flair is over
26
Main concern after reducing a supracondylar fracture?
Vascular and nerve injury (brachial a. and/or median n.)
27
Premature infant with feeding intolerance, thrombocytopenia, and air in the loops of the bowel. Dx?
Necrotizing enterocolitis
| air in the bowel is pathognomonic
28
Lab findings in primary hyperparathyroidism
```
High PTH
Hypercalcemia
Hypophosphatemia
Elevated urine calcium
"Stones, bones, abd groans, and psych moans"
```
29
What is an appropriate surgery for a breast lump >4cm in diameter?
Mastectomy, too large for a lumpectomy
| Also do axillary node sampling to determine post op systemic therapy
30
Charcots triad
Fever, RUQ pain, jaundice
| Dx - cholangitis
31
RUQ pain - for stones. CCK stimulation revealed EF <35%. Dx?
Chole dyskinesia
32
During lap chole, adhesions surrounding the liver and gallbladder. Dx?
Fitz-Hugh-Curtis Syndrome
| Intra abdominal dissemination of PID
33
Cholangiocarcinoma at the confluence of the R and L hepatic ducts?
Klatskin tumor
34
Etiology of bacterial cholangitis?
E. coli, Klebsiella, Pseudomonas, enterococci, proteus
35
Which landmarks demarcate the R and L hepatic lobes?
The gallbladder fossa and the IVC
36
where is the CBD in the hepatoduodenal ligament?
Usually CBD is lateral
Hepatic a medial
Portal v. posterior
37
Tx for pt that is morbidly obese with GERD or Barrets?
Gastric bypass with Roux N-Y gastrojejunostomy
38
What is the main cause of gastric bypass failure despite the repair being intact?
High volume intake of high calorie liquids
39
Potential micronutrient deficiencies from gastric bypass?
Fe deficiency from duodenal bypass (microcytic anemia)
| B12 deficiency from lack of IF (macrocytic anemia)
40
Most likely site for colon volvulus?
Sigmoid
Presents with abd distention and obstruction. KUB reveal tire sign
Tx - decompression with sigmoidectomy
41
How do you tx a pt that has had 2 or more divirticulitis flairs requiring hospitalization?
Sigmoid resection after resolution of the acute flair
42
Blood supply to the gallbladder?
Cystic a. (from the R hepatic a.)
43
Gallbaldder secretion is stimulated by?
CCK
| cystic duct -> CBD -> ampulla of Vater (controlled by sphincter of Oddi)
44
Where does the bile that is stored in the gallbladder come from?
The liver
| Pancreatic bile stays in the pancreatic duct
45
What joins the cystic duct to form the CBD?
Common hepatic duct
46
What prevents the reflux of bile into the gallblader?
The spiral Valves of Heister
47
Borders of the triangle of Calot?
Cystic duct - lateral
Common hepatic duct - medial
Liver edge - superior
The cystic a. courses through this triangle
48
gallstones in the gallbladder
Cholithiasis
49
Stones in the common bile duct
Choledocholithiasis
| Major cause of pancreatitis
50
What causes biliary colic pain?
When CCK stimulates the gallbladder to contract it contracts down on the stone and there is either partial or total occlusion of the duct
51
gallstones are made of?
Cholesterol (75%)
Calcium bilirubinate (pigmented)
or a mix
Occurs when bile is supersaturated with cholesterol or cirrhosis/hemolysis (pigmented)
52
Infection of the bile ducts extending into the liver?
Cholangitis
| RUQ pain, fever, jaundice
53
Gallbladder dz presenting with elevated LFTs?
Choledocholithiasis
Stones in the common bile duct
Can cause gallstone pancreatitis
54
NIH Criteria for bariatric surgery
BMI>40 or >35 + comorbids (DM, HTN, OSA)
No metabolic abn causing weight gain
attempted and failed weight loss
Psychologically stable w/o eating disorders
55
What is dumping syndrome?
Post gastric bypass ingestion of concentrated sweets
Occurs due to bypassing of the intestines
abd cramps, n/v, flushing
56
Risks of gastric bypass surgery?
```
Dumping syndrome
Intestinal anastomoses
Ulcers
Strictures
Internal hernias
```
57
Chronic alcoholic presents with acute pancreatitis plus free air. Dx?
```
Perforated viscus (ulcer)
Emergency lap
```
58
Management of SIADH?
Fluid restrict and diuresis
| if this fails, ADH antagonist (demeclocycline, lithium)
59
Child has recurrent unilateral nosebleeds that are now malodorous
Foreign body
60
How do you manage a diverticulitis pt presenting in sepsis
IVF, abx
| Surgically remove the sigmoid
61
A herniated lumbar disk is identified on MRI. How do you manage?
Pain control and monitor for spontaneous resolution
Surgical intervention is required if neurologic syx progress
Emergency intervention in cauda equina syndrome
62
What happens in nonocclusive mesenteric ischemia (NOMI)?
alternating narrowing and dilation of mesenteric a. causing hypoperfusion of small bowel
Elderly pt with diffuse abd pain following hypotensive episode
63
mid 40's male has a UTI that improves with abx but quickly returns after d/c. Dx?
Prostatic abscess
PE - tender prostate with a fluctuant mass
Tx - evacuation followed by abx
64
Graft vs. host is mediated by which cells?
Donor T cells
65
Cholangitis pt develops a liver abscess. Now what?
Percutaneous drainage of the pyogenic liver abscess
66
How do you diagnose congenital hip dislocation?
PE and U/S
| Tx - Pavlik harness with splinting in abduction x 6 mo
67
Tx for acute prostatitis
Fluoroquinolones 4-6 wks
68
Hypotension, tachycardia, low urine output
Cardiogenic shock
| B1 agonist - dobutamine
69
Why is a bx of a prostate helpful
The gleason score determines severity and therefore need for surgery
70
DM has bx of nasal mucosa revealing thrombosed vessels with multiple broad non-septate hyphae with right angle branches. Dx and management?
Mucormycosis
| Amphotericin B and debridement
71
Surgical management of thyroid follicular cancer?
Total thyroidectomy plus post op radioactive iodine
High hematogenous metastasis risk
Radioactive iodine destroys the remaining malignant cells, but only succesful if these cells aren't competing with normal tissue
72
Workup for a scrotal hematoma due to trauma?
Scrotal sonogram - suspicion of a testicular, epididymal, or vascular compromise requiring surgery
73
following an anorectal procedure pt presents with contant soiling of the underwear. Dx?
Fistula-in-ano
PE - small opening on the anus with granulation tissue and a fistulous tract.
Rule out malignancy and/or necrosis with sigmoidoscopy
Tx - fistulotomy
74
Which two ocular tumors can require enucleation?
Retinoblastoma
| Melanoma - can still metastasis up to 20 years later
75
How do you decide if a pt should be intubated?
If their GCS is <8
76
Vomiting + chest pain + sub q emphysema
Meckler triad -> perf esophagus
sub q emphysema = air under the skin
Dx with Gastrografin swallow study - demonstrates contrast extravasating from the esophageal lumen. Nontoxic to the surrounding structures, unlike barium
77
What is a beneficial medical tx in a pt with hyperPTH and Serum Ca2+ ~12?
Estrogen-progestin therapy
| beneficial in postmenopausal women, reduces bone resorption (increase bond density and decreases serum Ca2+)
78
5 P's of compartment syndrome
```
Pain
Pallor
Parethesia
Poikilothermia
Pulselessness
Time to decompress the wound surgically
```
79
What causes a direct inguinal hernia?
Defect in the posterior wall (transversalis fascia)
RF's - age, male, obese
Fever and unreducible suggest that the bowel is strangulated
80
8 hrs following removal of a prolactinoma a pt becomes comatose. Shes received 800 mL IVF and UO is 600 mL. Dx?
Diabetes insipidous
| Check serum salt level
81
unilateral intrascrotal pain, swelling fever. Pain relieved by lifting the testes
Epidiymitis
Usually caused by chlamydia
Tx - Azithro, doxy, or tetracycline
82
Young male presents with unilateral testiticular pain that is not relieved by lifting the testes
Testicular torsion
83
Pt is unable to extend wrist and sensation is compromised in the thumb and forefingers
Radial n. palsy
| Common in humerous fx
84
Elderly pt becomes senile after a minor fall 2 weeks ago
Chronic subdural hematoma
| Tearing of bridging veins
85
When would you see post op ileus
4-5 days after an abdominal operation
Dx with Xray or CT - see air in the bowel rather than obstruction
Keep pt NPO and insert an NG tube to decompress
86
Primary Sclerosing cholangitis is highly associated with?
IBD, especially ulcerative colitis
87
PSC increases the risk for?
Cholangiocarcinoma
| Colon cancer
88
Pt with elevated cortisol that is not suppressed by high dose dexamethasone. Dx?
Ectopic ACTH production
Consitent with small cell carcinoma of the lung.
Requires radiation and chemo
89
Kissing lesion in the stomach reveals high grade lymphoma. What is important to know prior to selecting treatment?
Depth and invasion of the tumor into the gastric wall
If it has invaded the entire depth, the organ will perf with chemo alone
Surgery is preferred when it is full thickness
90
Flank pain radiating to the inner thigh + hematuria is?
Nephrolithiasis
Xray
Unless pt has crohn's -> more likely to have uric acid and calcium oxalate stones, get a CT w/o contrast
91
Pt has radial n. pain that is reproduced when holding her thumb inside of her fist and forcing the wrist into ulnar deviation. Dx?
Tenosynovitis of the abductor or extensor tendons of the thumb (de Quervain's tenosynovitis)
Finkelstein test
92
Pt has absent pedal pulses and is opnely bleeding following a trauma but there is no fx. What do you do next?
Exploratory surgery
93
If a pt has weak distal pulses in the setting of a fx without bleeding, what do you do next?
Splint the fx and CT angio of the limb to identify where the vascular injury is
94
An impotent pt is able to get erections o/n. Dx and management?
Organic impotence
| augment iwht sildenafil, tadalafil, vardenafil
95
What should be given intraoperatively to a pt that has been on steroids for a long time
Intraoperative steroids
| given to avoid adrenal crisis secondary to HPA suppression
96
When knees hit the dashboard in a MVA what should you be worried about?
Posterior dslocation of the hips
| Avascular necrosis
97
Long standing HCV and cirrhosis predisposes a person to? What level should be checked?
Hepatocellular carcinoma
| alpha fetoprotein
98
What is the pathophys of dumping syndrome
Rapid gastric emptying
undigested food enters the duodenum
generally have hypoglycemia
99
pt with sclerosing cholangitis is at risk of developing?
cholangiocarcinoma
| Klatskin tumor at the confluence of the hepatic ducts
100
Prostate cancer was confirmed by u/s guided biopsy. Now what?
Radical prostatectomy
101
Pt has a painless testicular mass that transilluminates. Now what?
Nothing. It's a simple cyst and will resolve
102
Most common cause of fever 1 day s/p surgery
Atelectasis
| Encourage incentive spirometry and deep breathing
103
Most common cause of fever 3 day s/p surgery
UTI
104
Most common cause of fever 5 day s/p surgery
DVT
105
Most common cause of fever 7 day s/p surgery
incisional infection
106
Most common cause of fever 10-15 day s/p surgery
deep abscess
107
How do you tx ascending cholangitis?
emergency ERCP
| LCC is urgent, but not emergent
108
When do you start looking for Barrett's?
Pt >50 with GERD >5years
109
Pt >50 with flattened stool and blood
Left sided colon cancer
110
How do you treat early breast cancer?
Lumpectomy + sentinel LN bx + adjuvant radiation + tamoxifen (if ER +)
111
Pt with chronic UC presents with a dilated and distended transverse colon
Toxic megacolon
Complication of UC
Tx - supportive care + sbx
May require a total colectomy
112
Common complication after a AAA repair?
Ischemic colitits
Occurs when IMA is covered by the aortic graft
Presents with bloody diarrhea and leukocytosis
Almost always requires resection
113
Preggo that dies due to syx similar to aortic diseciton?
Disection of visceral aneurysm
Splenic a. aneurysms tend to rupture during pregnancy
Should be repaired in all women of childbearing age
114
Weight lifter has arm swelling when he holds his arm over head
Thoracic outlet syndrome
Can be neurologic arterial or venous in etiology
Venous -> edema and venous engorgement
Weight lifting -> hypertrophy of the anterior scaline m. and subclavian v. becomes pinched between the muscle and clavicle
Tx - surgery
115
Burn pt develops excessive edema under the burn
Eschar
Con lead to compartment syndrome
Tx - decompress the eschar (escharotomy) to prevent limb loss
116
Post seizure, pt has shoulder pain but AP Xrays are negative. Returns the next day clutching her injured arm over her chest
Posterior dislocation of the should
NEED AP AND AXILLARY views
Typically only see posterior dislocation in MVA, seizure and electrocution
117
Closed skin fx with weak distal pulses. You need a
CT angio - vascular injury is an emergency
118
Signs of rhabdo
Creatanine Kinase elevated
Hyperkalemia
Tx - emergency dialysis
Suspect a crush injury
119
Pt develops scrotal abscess
surgically drain
| ensures complete drainage of fluid
120
This pt with epigastric blunt trauma
Pancreatic injury
| Elevated amylase, lipase
121
Pt with vomiting, chest pain, subQ emphysema
Esophageal perf (Boerhaave syndrome)
Full thickness transmural perf (vs, Mallory-Weiss, tear of the inner layer)
Dx with Gastrografin swallow study (water based and nontoxic)
Tx - thoracotomy, or NPO IVF and abx
122
Pt that frequently wears heels has exquisite pain between the third and fourth toes
Morton neuroma
| Tx - avoid heels, or surgery to remove the neuroma
123
Management of an ACL
Average person - knee immobilization and rehab, surgery if failure
Athletes require surgery
124
Former alcoholic and smoker has a nontender firm nonfluctuant mass x 6 months in his neck. Most likely?
Met cancer until proven otherwise
Most likely Squamous cell from the lung or GI (primary pharyngeal is suspicious here)
Work up - panendoscopy, FNA, CT or MRI
125
How do you evaluate a pt with blood at the urethral meatus?
Retrograde urethrogram
Never cath
Associated with pelvic fx, get a CT
126
Management of acute abdomen
Exp Lap
127
Management of acute epididymitis
Scrotal elevation + abx
Younger male - G/Ch
Older - UTI organisms
128
After a fall, pt is clutching arm in external rotation as if about to shake hands. Shoulder looks square
Anterior dislocation
| Often has numbness over the axillary n. area
129
Pt is unable to flatten their hand out and has palpable fascial nodules
Dupuytren contracture
| Fibrotic dz of the palmar fascia causing shortening and thickening of the palms
130
How long do you observe a umbilical hernia in a child?
For 2 years, most will spontaneously close by age 2
| Exception is if the baby becomes symptomatic
131
Woman has unilateral bloody nipple discharge and MRI is negative for masses. Now what?
Galactography
| Look for intraductal papilloma
132
BPH pt is still symptomatic while taking tamsulosin. What can be added?
Finasteride, (or dutasteride but this drug is pricy
| 5alpha reductase inhibitor reduces presence on dihydrotestoerone -> prostate should shrink after 6 mo of treatment
133
Pt had a previous GI surgery that resulted in an untreated ulcer, now has severe halitosis and diarrhea
Gastrojejunocolic fistula
| gastric ulcer eroded into jejunum -> fecal contents into the stomach
134
How long after induction of anesthesia can a pt demonstrate malignant hyperthermia?
Up to 30 minutes, especially when succinylcholine is used
| Give dantrolene
135
Pt has pneumaturia (air in urine), be suspicious for
Colovesical fistula
| Get a CT
136
High Alk Phos
High total bili
Angemia
Guiac + stool
Duodenal tumor obstructing the common bile duct (most likely at the ampulla of Vater)
137
Primary hyperparathyroidism causes which electrolyte abnormalities?
Hypercalcemia
Hypophosphatemia
Syx - Stones, bones, abdominal groans, psych moans)
138
Smoker with progressive dysphagia (meat -> mashed potatoes)
Squamous cell carcinoma of the esophagus
| RF's - smoking, drinking
139
Workup for SBO?
Clinical Dx based on syx and hypoactive/high pitched bowle sounds
Abd Xray to r/o free air. Dilated loops of bowel confirms dx of SBO
140
Best option for GERD pt that has failed PPI's
Lap Nissen Fudoplication
141
Diagnositc test for Meckel diverticulum?
Technetium pertechnetate scan
| Radioisotope has high affinity for gastric mucosa allowing visualiation of the ectopic tissue
142
How do you diagnose Venous insufficiency?
Ultrasound
143
Complication of penile foreskin being retracted for a long period of time
Paraphimosis
The foreskin acts as a tourniquet around the penis
Medical emergency - must reduce the foreskin by adding pressure
Occurs after catheter placement if foreskin is not replaced over the glans
144
Baby fails to pass meconium in first 36 hours, distended abdomen, no stool in rectum
```
Hirschprug dz (aganglionosis)
Dx - rectal bx that is devoid of ganglion cells
Tx - surgical resection of the aganglionic segment
```
145
Pt has a non-healing punched out ulcer on the skin
Skin cancer
| Dx with bx of the edge of the lesion, need to assess the interface with normal skin
146
Consequence of prolonged urinary retention
B/l hydronephrosis
147
What is the pringle maneuver?
Clamping the portal triad in the hepatoduodenal ligament. Controls inflow (hepatic a., portal v. and CBD), but no effect on livers outflow. So, if bleeding persists after this suspect the hepatic v.'s which drain into the IVC
148
Most common cause of fever 10-15 days s/p a contaminated abd procedure?
Anastomotic disruption or
Deep abscess
Get a CT of the abdomen
149
Work up for pt with lower extremity claudication and decreased ABI
Get a peripheral artery duplex
Claudication is caused by arterial insufficiency
Need to see vascular surgery to revascularization or endovascular techniques
150
Management for b/l displacement of the malleoli
closed reduction and splint at 90degrees until they can see surgery, also soft tissue edema needs to resolve prior to surgery (urgent, not emergent)
Ultimately will require open reduction and internal fixation
151
Tx for BPH unresponsive to tamulosin
Finasteride (5alpha-reductase inhibitor)
| Prevents conversion of testorsterone to dihydrotestosterone
152
Management of a hypernatrimic pt?
Half normal saline (0.45%) + D5
| Note for every 3mEq increase in Na+= 1L of water deficit
153
Pt has organic erectile dysfunction
Determine amount of bioavailable testosterone (can be caused by hypogonadism; pt may also have decreased libido and osteoperosis)
If low start a trial of phosphodiesterase 5 inhibitor
154
Child in a trauma and we are unable to get a peripheral IV. What is the next best option?
IO in the proximal tibia
| Try to avoid damage to the growth plate
155
Unilateral pitting edema x years
| Audible femoral bruit and palpable thrill
Look for hx of penetrating trauma -> AVM
| Can develop significant venous HTN -> edema, varicose veins
156
At what point can prostate cancer screening be omitted?
When the pt has a life expectancy less than 10 years
| ie if more likely to die from other comorbidities
157
Days after liver transplant pt has elevated levels of GGT, alk phos, and bili
Get a U/S of the biliary tract and doppler of the vessels
Technical problems of anastomoses are most common cause of early deterioration in liver transplant
Antigenic reaction is less common in the liver
158
Dysphagia to solids and liquids + Barium swallow shows massively dilated proximal esophagus with narrow tapered appearance at the lower sphincter
Achlasia ("failure to relax)
"birds beak appearance"
Loss of inhibitory neurons in the lower esophageal sphincter
Idiopathic, Chagas, lymphoma, gastric carcinoma
159
Male >50 with rectal bleeding
Colon cancer until proven otherwise
| Need colonoscopy
160
Work up for PE
Spiral CT
Look for chest pain 1 wk after a major surgery
Tachycard, tachypnea, anxiety, diaphoresis, S2
ABG shows hypoxemia, hypocapneia, alkalosis
EKG normal
161
Solitary painless testicular mass
Testicular cancer
162
Testicular mass
| Bx - small cells with indistict borders, scant cytoplasm, sheets of crosded nuclei. Elevated alpha-fetoprotein
Embryonal carcinoma
163
Testicular mass +
| cytotrophoblastic, synctitophoblastic cells Elevated Bhcg
Choriocarcinoma
| Looks like chorionic villi
164
Testicular mass +
Nests of large, round clear cells with centrally placed nuclei resembling primary spermatocytes, elevated placental alk phos (PLAP)
Seminoma
Cause of more than half of testicular cancers
Presents in young men (20-40)
165
Testicular mass +
| Layers from all 3 germ layers
Teratoma
| May be bening (especially in the young) or malignant
166
Testicular mass +
| Papillary structures resemblin glomeruli (Schiller-Duval bodies), elevated Alpha-fetoprotein
Yolk sac carcinoma
167
Alcoholic with abd pain, n/v and b/l bruising along the flanks
Pancreatitis
b/l bruising on the flanks - Grey-Turner sign, caused by SubQ tacking of digested blood around the abdomen from the inflamed pancreas.
168
10-14 days Following tx for pancreatitis pt returns with high fever and leukocytosis
Pancreatic abscess
| Get CT of the abdomen to assess if the abscess can be drained
169
Male has a painless penile ulcer x months but not an STI
Squamous cell carcinoma
Most common penile cancer
Usually presents on the glans or foreskin
RF's: HPV, smoking, megma, phimosis, AIDs
Circumcision is protective
Dx with bx
Tx - penectomy
170
Pulstile mass at epigastrum + excruciating back pain?
Leaky AAA
Leaky blood in the retroperitoneal space can occur before a full dissection
>5 cm is high risk for dissection
171
Trauma pt is stable, but then dies very suddenly
Air emobolis
When > 120 mL of air enters the venous circulation within seconds.
Place pt in Tburg with left lateral decubitus position -> traps bubble in heart apex
172
Indications for CABG
- Signigicant Left main coronary artery stenosis
- 70% stenosis of the proximal LAD and proximal left circumflex a.
- 3 vessel disease
- Ongoing ischemia in symptomatic acute coronary syndrome not responsive to maximal nonsurgical therapy
173
Mastectomy is offered when a malignant mass is
>4cm
174
Early localized prostate cancer is id'd on bx, tx?
Prostatectomy
175
LLQ + tenderness + leukocytosis + fever
diverticulosis
| Colonoscopy is contra in the acute attack
176
Congenital biliary tree dilation causing mild RUQ in a young adult
Choledochal cyst
| Need surgical excision d/t increased risk of cholangiocarcinoma
177
First sign of hypermagnesmia
Loss of DTR's
| respiratory depression in extreme cases
178
Tx for asymptomatic hyponatremia?
Free water restriction
| Symptomatic when Na < 120 (HA, seizure, coma), this requires hypertonic saline infusion
179
Why are gastric bypass pts at increased risk for nephrolithiasis?
If a pt loses their ileum but colon is intact they are at increased risk of hyperoxaluria.
Fatty acids are absorbed in the terminal ileum allowing calcium and oxalate to form an insoluble (unabsorbalbe compound). When the ileum is bypassed, fatty acids combine with calcium in the colon, leaving oxalate soluble/absorbale. Also, unabsorbed fatty acids and bile in the colon promotes oxalate uptake in the colon
180
What finding confirms oliguria d/t hypovolemia
FENA <1% suggests prerenal etiology
| FENA = (urine NA x Sr Cr)/ (Sr Na x urine Cr) x 100
181
Post op pt has muscle spasms, hyperreflexia, tetany, but Ca2+ is NL
Mg deficiency
Common in malnourished pts and those with large GI fluid loses
EKG changes look like HYPERcalcemia (prolonged QT, T inversion, heart blocks)
182
Pt w/ LE claudication needs a cardiac eval to be cleared for surgery
Get a persantine thallium stress test
| He won't be able to acheive an exercise stress test with claudication
183
OD pt has tinnitus w/ mixed metabolic acidosis and respiratory alkalosis.
Aspirin/salicyclate intoxication
| Look for an increased anion gap
184
watery diarrhea + GERd x months
Get a serum gastrin
| Zollinger-Ellison syndome (gastrinoma)
185
Hepatitis with + ANA and anti-smooth muscle
autoimmune hepatitis
| Tx - steroids +/- azathioprine
186
Dysphagia with lesion in upper half of esophagus with hanging edges and luminal narrowing
squamous cell carcinoma of the Esophagous
upper half of esophagus = squamous cell
RF's - smoking, EtOH, achlasia, other cancer, lye ingestion
187
Multiparous woman with chronic constipation
Pelvic floor disfunction
Can cause urinary/fecal incontinence or constipation
Get an anorectal manometry
188
Why does acute pancreatitis increase risk of ARDS?
Circulating phospholipase
Active pancreatic enzymes are released when Exocrine tissue is damaged. Many of these (incl PLP) cause inflammation throughout the body
189
Pt with trach has bleeding from the trach. What is going on?
Tracheoinmominate artery fistula (50% mortality rate)
If bleeding stops - immediate fiberoptic exploration in OR
if bleeding is ongoing - inflate trach balloon for compression, reintubate with endotracheal tube, or remove trach and compress anteriorly with finger
190
How do you assess readiness for extubation?
```
MUST:
Correction of underlying pathology
Hemodynamic stability
Others:
Rapid shallow breathing index (rr:TV) 60-105
Negative inspiratory force>-20
Weaned off of PEEP
Minute ventilation < 10L/min
RR < 20
```
191
How do you manage a pt with a hemolytic reaction d/t an incompatible blood transfusion
Stop the transfusion
insert a foley, measure urine output hourly (Hgb causes renal damage)
Stimulate diuresis with mannitol and alkalinize urine with NaBicarb
192
Which anesthesia should be avoided in pts with abd distention due to air in the bowels?
NO
| Causes progressive distention in air-filed spaces during long procedures
193
Diagnostic criteria for ARDS
CXR with b/l pulmonary infiltrates
PaO2/FiO2 ratio < 200
Pulmonary wedge pressure <18
194
What are the physiologic changes in ARDS?
1. hypoxemia unresponsive to O2 levels
2. Decreased pulmonary compliance (stiff)
3. Decreased FRC
195
Which changes will shift the Hgb dissociation curve to the right and encourage tissue uptake of O2?
```
Acidosis
Increase in PaCO2
Elevation in temperature
High 2,3-DPG (increases with hypoxia)
Think of the changes in exercise that can meet tissue oxygen demand
```
196
Pt has respiratory acidosis due to hypercapneia and hypoxemia
Intubte
197
How do you manage a pt with TRALI?
Stop the transfusion and provide respiratory support
| Presents as ARDS, hypoxemia, CXR w/ b/l pulm infiltrates not due to volume overload
198
What is required when intubating a pt with subQ emphysema in the neck?
A fiberoptic bronchoscope
199
How do you treat hemorrhagic shock?
Fluid resuscitation
200
What is complicated diverticulitis?
Diverticulitis + perforation, abscess, or fistula
201
How do you manage a septic shock pt with complicated diverticulitis?
Fluid resuscitation
Broad spectrum abx
Surgical resection of sigmoid
202
How do you manage a septic shock pt with uncomplicated diverticulitis?
Admit
Fluids
IV abx
NPO (bowel rest)
203
What study should you order if you suspect Boerhaave syndrome
Gastrografin swallow
| Barium is toxic to the thoracic structures
204
Pt 5 days s/p abd surgery has drainage of pink fluid. Why?
Fascial dehiscence (wound won't look infected or dehisced)
Tape the wound securely and bind the abdomen
May eventually require elective fascial closure or hernia repair
If the wound eviscerates -> emergent surgery
205
Bloody diarrhea and anemia after AAA repair
Ischemic colitis
Occurs after AAA repair d/t occlusion of the inferior mesenteric a.
Dx with colonoscopy
Will require colon resection with colostomy to prevent sepsis
206
Pt has a radial n. palsy after reduction of a distal humerus fractures
Ortho to re-manipulate the fx
207
Pt has papillary m. rupture ~12 hrs after a MI. Manage?
Send to the OR
208
Pt has wasting of the intrinsic muscles of the hand
Ulnar n. injury
| Median is more sensory
209
What size margins are needed to excise a melanoma?
Depends on the depth of the lesion
Thin (<1mm thick) -> 1 cm margin
Intermediate (1-4mm) -> 2cm
Thick (>4mm) -> 2-3 cm
210
Treatment for alkali skin burns
Remove the agent and wash with large volumes of water
| May require surgical debridment
211
Chron's pt with deep ulcers
Pyoderma gangrenosum
Associated with IBD and other immune disorders
Tx - systemic steroids and immunosuppresants (ie cyclosporine)
212
Initial treatment of frostbite
Immersion in 40-44C water, elevation, abx, Tetanus toxoid
| May require debridment of necrotic tissue
213
Rapid progression of erythema and bullae concerning for?
Necrotizing soft tissue infection
| Need immediate surgical intervention
214
What is Mohs surgery?
Resection of basal or SCC on the face with optimal cosmetic result
Resection in small increments with immediate frozen surgery analysis
Ensures clear margins
Takes longer
215
Pt gets a SCC following a thermal injury
Marjolin ulcer
| SCC is less common but more devastating d/t invasiveness and metastases
216
Bowen disease
In situ SCC
217
Erythroplasia of Qeyrat
SCC tumor of the penis
218
Tenosynovitis of the abductor or extensor tendons of the thumb
de Quervain tenosynovitis
| Seen in new moms
219
Tx of diaphragmatic rupture?
Emergency lap
Risk of vascular compromise in the hiatal hernia
Dx - air fluid level in on e side of the chest, NG tube coiling into the chest
220
Pain control for pts hospitalized with rib fx
Epidural
221
Tx of venous transection in a hemodynamically unstable pt
Ligation
| If pt were hemostable - suture, saphenous v. patches, synthetic interposition grafts
222
Management of a transected common bile duct
Unstable - T tube
| Stable - Roux-en Y choledochojejunostomy
223
TNF is a peptide hormone produced by?
Activated monocytes/macrophages
Key cytokine in GN shock/sepsis
Fxn: activate and recruit PMN's, increase vascular permeability
224
Post liver transplant. liver bx reveals paucity of bile ducts
Chronic rejection
| retransplant
225
What does a cross and match study in a transplant candidate
Studies if the recipient has circulating Ab's against donor HLA Ag
Studied by adding recipient serum and complement to donor lymphocytes
If a + cross-match is detected on donor T cells, transplant would cause a hyperacute rejection
226
Tumor lysis syndrome is mediated by
Cytotoxic T cells
| Hyperkalemia, hyperphos, hypocalcemia w/in 48 hours of starting chemo
227
MOA of cyclosporine
inhibits IL2 production from T helper cells -> no clonal expansion of cytotoxic T cells and no Ab production from B cells
228
Contraindication for a cardiac transplant
```
Increased pulmonary vascular resistance
Irreversible renal insufficiency
DM with end organ damage
Symptomatic extravascular dz
Current or recurrent malignancy (<2 yrs)
Non cardiac comorbidity that would limit survival (cirrhosis, COPD, infection, PUD, etc)
```
229
2 months post renal transplant pt has increased Cr, Decreased UO, fevers, tenderness over graft
Acute rejection episode
1wk-3months s/p transplant
Dx w/ bx
Tx w/ high dose steroids and anti-T cell Ab (OKT3)
230
Hemodynamically stable pt with acute abdomen
Get a CT scan
231
Hemodynamically unstable pt with acute abdomen
Get a FAST exam
| emergency lap if free fluid is found
232
Fever 10-15 days s/p abd surgery
Get a CT
| Anastomotic disruption or deep abscess
233
Epidural hematoma + unstable vital signs or neuro exam
Craniotolmy and hematoma evacuation
234
Hyperthyroidism pt has a thyroid scan with a single focus of increased isotope uptake
"hot nodule"
| iagnostic for a hyperfunctioning adenoma
235
Tx for adrenal insufficiency
Corticosteroids
| Bronzed diabetes
236
What does multifocal dz mean in breast cancer?
multiple tumors w/in 1 quadrant of the breast
| If the lesions are small compared to the size of the breast, pt may undergo conservation surgery
237
Tumor in the tail of the pancreas
Rash (necrolytic migrating erythema)
DM
Anemia
Glucagnoma
Dx - CT
Tx - surgical excision w/ distal pancreatectomy
Met is common
238
ACTH hypersecreting pituitary adenoma
Cushing dz
| Cotisol is suppressed w/ high-dose of dexamethasone
239
Management of a simple breast cyst
Reassurance and reexamine
Very low risk of malignancy, especially simple cysts
Complex cyst should be aspirated
240
When is a thoracotomy required?
hemothorax with:
Recovering >20mL/kg of blood when chest tube placed (or >1500mL at initial placement)
OR
Shock and persistent bleeding of more than 3mL/kg/h
241
PE finding in Achilles tendon rupture
Absence of plantar flexion on squeezing of the gastrocnemius m. in the prone position
Thompson Test
242
best initial test for mesenteric ischemia
CT scan
243
Tx for cardiogenic shock
Inotropic drugs
| Increases myocardial contractility to improve CO
244
Pt has dyspnea, peripheral edema, and coughing white sputum
Pulmonary edema secondary to CHF
| Give 100% O2, loop diuretics, nitrates, morphine
245
Following a blunt trauma pt has chest pain and a wide mediastinum on CXR. What study do you need?
Spiral CT
246
MOA of omeprazole
Inhibits parietal cell hydrogen potassium ATPase
247
Tx of ITP
Predinose, add IVIG if severe bleeding
| Splenectomy if poor medical management (<30k x 3 mo, or <10k x 6 weeks on high dose steroids)
248
Appendectomy pathology comes back as an appendiceal adenocarcinoma. Now what?
Need a R sided hemicolectomy
| 5 year survival is 55%
249
Tx for esophageal achalasia
Failure of relaxation of the lower esophagous
Tx - esophagmyotomy
If surgery not possible -> CCB's, nitrates, endoscopic dilation, botulinum
250
Definitive surgical treatment for Ulcerative Colitis
Total proctocolectomy with end ileostomy (older incontenint patients)
OR Total proctocolectomy with ileoanal pouch anastomosis
mucosectomy is not offered to pts without rectal dysplasia
251
Most common serious complication of an end colostomy?
Parastomal hernia
Occurs whent he stoma is placed lateral to the rectus abdominous m. (rather than through
Correct with relocation of the stoma or with a mesh
252
Painless jaundice + weight loss
Pancreatic cancer
| Get a contrast CT
253
Tx of a perf duodenal ulcer in a pt with no hx of PUD
Closure with an omental patch
| Vagotomy is only offered in pts with a long history of poor acid control
254
Management of an axonal shear injury in the brain
Keep the intracranial pressure low to prevent further damage
Elevate the head, hyperventalate, avoid fluid overload
This will preserve cerebral perfusion pressure
255
20-40 y/o female takes OCP's presents with RUQ pain and hypotensive
Ruptured Hepatic adenoma
Get a CT and emergency lap
If found incidentally, the adenoma will spontaneously regress after cessation of OCP's
256
What medications put a person at risk of DKA or hyperosmolar hyperglycemic state (HHS)
Drugs that affect carbohydrate metabolism:
Glucocorticoids
High dose thiazides
Sympathomimetics (dobutamine, terbutaline)
Second gen antipsychotics
257
When is valve replacement warranted in aoritc stenosis?
When the pt is symptomatic or the valve area is < 1 cm
258
What are good prognostic factors for a pt to be able to tolerate a lobectomy
FEV1 > 60% of predicted
259
Tx for small cell lung cancers
Chemo and radiation
260
Tx of empyema w/ glucose < 40mg and pH<7
Most advanced or chronic stage of empyema
| Thoracotomy w/ decortication to remove the purulent fluid. Abx therapy alone is not sufficient
261
Facial swelling and cyanosis when a pt bends over
SVC compression is almost always due to malignancy (90%)
| Bronchogenic most common
262
Tx for perf esophagus
confirm dx with gastrografin swallow
Health pt - repair perf and drain mediastinum
pt with motility disorder, stricture, malignancy - fix perf and underlying abnormality
pt with esophageal carcinoma - esophagectomy
if perf esophagus is dx'd late - proximal diversion (cervical esophagostomy or "spit fistula)
263
Management of a lung abscess
systemic abx
| if fails to resolve after 12 weeks -> percutaneous drainage
264
Initial tx of a descending aortic dissection
Bblocker - reduce rate of change in blood pressure and reduce shear on the aortic wall.
Can add nitroprusside
Take to urgery if there is evidence of end organ failure
265
pt has severe chest pain on swallowing and there are prolonged high amplitude contractions in the esophagus
Diffuse esophageal spasm (DES)
Etiology unk
Tx - myotomy
266
Kid swallowed alkaline cleaner. Manage?
Gastrografin swallow study
If perf present -> surgery
NPO until extent of damage determined
If severe give abx
267
Pt has pelvic fx + bloody urine
```
Bladder injury (+ urethral injury in males)
Do a retrograde cystogram + post-void films
Cystoscopy is was too invasive
```
268
Pt has a battle sign and CSF otorrhea
Suggest basal skull fx
| Get a CT that includes the neck to study the integrity of the cervical spine
269
Tx for central DI
IVF hydration
| desmopressin
270
Older pt with painless neck mass
Most likley SCC, met from another site (GI or respiratory)
271
Initial management of DVT?
Heparin
272
Best way to evaluate the L side of the colon for ischemia?
Sigmoidoscopy
273
<35 y/o Pt develops unilateral primary lymphedema
Lymphedema raecox
| > 35 years is lymphedema tarda
274
3 days s/p respair of AAA disection pt develops abd pain and bloody mucus per rectum
Ischemia of the L colon
275
When do pts with peripheral a. disease qualify for arterial reconstructive surgery
Pain at rest
| Gangrene
276
Tx for superficial/submucosal transitional cell carcinoma of the bladder
Local excision and topical chemo
| Look for man with hx of smoking
277
Flank pain radiating to the testicle
Proximal ureteral or renal pelvic obstuction
Common innervation of the testicle and renal pelvis
Expect microhematuria (30 RBC/hpf in sediment) on UA
278
Cause of kidney transplant rejection 1 month s/p transplant
Failure to suppress class II Ag recognition by the host
279
Most common opportunistic GI infection in HIV +. Presents with fever, crampy abdominal pain, and frequent (often bloody) stool
CMV
280
New onset of ecchymosis, low platlet count, but Bone marrow reveals increased megakaryocytes
Idiopathic thrombocytopenic purpura
| Caused by preformed Antiplatelet Ab
281
Femoral shaft fracture, sudden onset combative/disorientation, petechia over axillae
Fat embolism
282
Pt with anemia, unintentional weight loss, and low-pitched rumbing diastolic murmur best heard over the apex
Atrial myxoma
283
Paracentesis yielding milky chylous fluid
Lymphoma
284
Post menopausal woman w/ CT of ascites, multiple pelvic masses, omental thickening
Ovarian adenocarcinoma
285
smoker, coughing up blood, elevated serium calcium
SCC
| These cancer secrete PTH related peptide
286
Severe nosebleed with no obvious source on anterior rhinoscopy. Anterior nasal packing causes blood to now exit the mouth
Sphenopalantine a. bleed
287
Pre op pt has chronic occlusion of illiac and femoral v.
Give low dose heparin prophylaxis immediately prior to surgery
288
scleroderma pt with constipation x 6 days
Needs an exp lap
289
Pt with hx of breast cancer remission experiencing SOB, weight loss, pain in chest wall
Malignant pleural effusion
290
young female w/ hernia medial to the femoral v.
Femoral hernia
291
Older pt had hemorrhage during sigmoid colectomy 2 days ago. Pt can't void after removal of femoral catheter
Bladder outflow obstruction
292
1 day s/p parathyroidectomy pt has perioral numbness/tingling
Give IV Ca2+ gluconate
293
Sensation to pinprick is decreased bleow the nipples
Thoracic spine lesion
294
Renal a. stenosis causes HTN by
Increased serum aldosterone
295
When is extracorporeal shockwave lithotripsy indicated for nephrolithiasis?
When the stone is > 1cm
If <1cm -> hydration and analgesics, alpha adrenergic blockers may also prevent bladder outlet obstruction and promote expulsion of the stone
296
When are percutaneous nephrostomy tubes indicated in nephrolithiasis
Unstable pt presenting with UTI and an obstructive stone
297
Management of an infant w/ b/l undescended testicles
Chorionic gonadotropin therapy x 1 month -> operative placement into the scrotom before age 2 if it has not occurred
298
Tx for testicular torsion
Orchiopexy of b/l testicles
Both testes have higher than normal risk of torsion so it is best to correct both at the same time
Most common in boys 12-18, present with pain and a high riding testicle
Occurs due to an abnormally narrowed testicular mesentery w/ tunica vaginalis surrounding the testis
Likely to save the testicle if surgery occurs w/in 4-6 hours
299
Tx of renal cell carcinoma
Radical nephrecotomy
| Not responsive to radiation or chemo
300
Initial management of BPH w/ recurrent UTI's?
TURP
also indicated in BPH pts with urinary retention, upper tract dilation, renal insufficiency, outflow obstruction, bladder stones
301
Initial management of uncomplicated BPH
alpha-adrenergic antagonists and/or 5 alpha reductase inhibitors
302
Management or ureter transection in an unstable pt
Place an external stent through the proximal ureteral stump w/ delayed reconstruction
303
Initial management for spinal cord injury
IV high dose steroids
| Been associated with better outcomes when given w/in 8 hours of injury
304
pt with head injury develops bradycardia, HTN, irregular respiratory pattern
"cushing triad" of increased intracranial pressure
Raise the head of the bed, propofol, hyperventilate (PCO2 to 30-35), mannitol
If persists -> burr hole or craniotomy
305
Athletic guy w/ chron's dz, presenting with leg pain. Decreased hip ROM
Avascular necrosis of femoral head due to steroid use
| Dx on MRI
306
How do you dx osteomyelitis in the early post op period?
Nuclear triphasic bone scan
307
Management of an open femur fx
Early irrigation and debridment, IV abx, fasciotomy, w/ internal or external fixation
Re-irrigate and debride in 1 wk to clear out all necrotic tissue
308
Peds pt w/ limp x weeks.
TTP over R thigh.
Xray R femoral head is small and denser than NL
Legg-Calve-Perthes (LCP) dz
Occurs ages 2-12 more common in boys, can be b/l
Caused by period of ischemia in proximal femoral epiphysis followed by revascularization
309
Peds pt with limp and pain in thigh or knee
Limited internal ROM in hip
Xray displacement of the metaphysis of the proximal femur
Slipped capital femoral epiphysis
Dissociation b/w epiphysis and metaphysis of proximal femur
Occurs in adolescents growth spurts, b/l in 1/3 of cases
310
Injury to the radial n. at the wrist would primarily cause?
Sensory abnormalities of the dorusm of the hand from ring finger to thumb and palmar surface of thumb
A more proximal radial n. injury would compromise wrist extension and forearm supination
311
Stable pt with displaced tibial shaft fx
Intramedullary nailing
| Plates are used when the fx is too proximal or distal for nailing
312
What are goal CPP and ICP?
CPP>70mmHg
| ICP <20mmHg
313
Most likely cause of a ring enhancing lesion in an otherwise healthy pt
metastatic dz
| Lung, breast, kidney, melanoma, GI
314
Pt w/ depressed skull fx has CSF draining from nose
Get immediate dural repair
315
Pt has worst HA of life and LP consistently yields blood. Now what?
Get a 4 vessel cerebral angiogram
| Tx - craniotomy w/ clipping of the aneurysm
316
Acutely increasing ICP causes?
Irregular respirations, bradycardia, increased blood pressure
Cushing triad
Papilledema is associated with chronic increases in ICP
317
Formula for burns
Kg x %BSA x 3-4cc (adults)
kg x %BSA x 2-4 cc (kids)
Give LR or normal saline
318
CRF pt has abn electrolytes and elevated BUN/Cr. What do they need before surgery?
Dialysis 24 hrs prior
319
BMI 67, frequent hospitalizations for panniculitis. Best long term management?
Gastric bypass
320
Tx for nasopharyngeal carcinoma
Chemoradiation
321
Tx of pleomorphic adenomas (mixed tumors) of the parotid gland
superficial parotidectomy w/ preservation of the facial n.
322
FEbrile kid with a small mass near the anterior border of the SCM
Branchial cleft remnant
| I&D acutely, completely excise when the infection has resolved
323
Management of a thyroglossal duct cyst
Excision of the cyst and central portion of the hyoid bone (Sistrunk procedure)
Simple excision of the cyst has a high recurrence rate
324
What is a thyroglossal cyst?
retention of an epithelial tract between the thyroid and its embryologic origin
Presents as a painless swelling in the midline of the neck that moves w/ swallowing
325
Tx of SCC of the tongue?
Partial glossectomy and b/l neck dissections
326
Post op hoarseness due to damage to?
The recurrent laryngeal n.
327
Management of acute epiglottitis
Emergent intubation in the OR
| Tracheostomy if unsuccessful
328
Adult with a neck mass
Malignancy until proven otherwise
| Do a FNA
329
24 hours after surgery pt has SOB, S3 and S4 but VS's are WNL
High-output CHF
330
Which lung cancer leads to secretion of ACTH and ADH
Small cell
331
T1DM Pt has a traumatic swelling of the ankle. Xray shows osteopenia and disorgzanization of the midtarasl and tarsometatarsal joints
Due to lack of normal joint sensation
332
10 days post surgery pt develops a cyanotic toe and thrombocytopenia
Heparin-induced thrombocytopenia
333
Work up for a kid presenting with a brainstem thrombus
Angio of the neck vessels
| In kids w/ recent trauma, dissection of the vertebral a. w/ distal embolization is likely
334
most common cause of unilateral bloody nipple discharge
Intraductal papilloma
Get a galactogram to guid the resection
Resection is curative
335
Management of Hyperosmolar hyperglycemia w/ hypokalemia
Half NS + K+ replacement IV
| Don't use regular saline because the mixture with K+ would be too hypertonic to correct the problem
336
Hearing loss due to tympanic rupture is?
A conductive hearing loss
The amplification system to the cochlea is disrupted
Weber test - sound will be louder in the affected ear (sensorineural loss would be opposite)
337
Management of advance inflammatory carcinoma
Neoadjuvant chemo followed by mastectomy
Inflammatory = ulcerating through the skin
Considered a palliative QoL treatment to remove the breast
338
Pt has lots of hematemasis and is getting hypotensive
Give IV NS prior to studies
339
Calf claudication + diminished distal pulses. Next?
ABI
| this is arterial pathology
340
PT w/ dysphagia, GERD, occ n/v. EGD stricture at GE junction and Barret's
Sliding hiatal hernia
341
Tx of neonate with low imperforate anus
Perineal operation
caused by failure of descent of the urorectal septum
Associated with esophageal atresia or tethered spinal cord
2 stage procedures (surgery + diverting ileostomy) are generally only needed in high imperforate anus due to risk of incontinence
342
Imperforate anus is associated with?
```
Congenital heart disease
esophageal atresia
abn of the lumbar spine
double urinary collection systems
hydronephrosis
```
343
Tx of ileal atresia
small bowel resection w/ anastamosis
344
Tx for duodenal obstruction secondary to annular pancrease
duodenoduodenostomy
| Basically a diversion of the pancreas. Resection is too extreme
345
Dx/Tx intussusception?
Air enema
346
Remnant of vitelline duct located 60 cm proximal to the ileocecal valve
Meckel diverticula
347
Recommendation for a pt with a family hx of adenomatous polyposis
Protocolectomy w/ an ileoanal reservoir
348
Management for heparin-induced throbocytopenia
stop all heparin (including LMWH), start non heparin anticoag (lepirudin, argatroban), and switch to po warfarin when platelet count back to >100k
HIT typically presents 5 days s/p starting heparin and drops platelets by 50% (<100k)
349
Assume significant bleeding in the early post op period is due to
Error in surgical operative field, that a vessel is still bleeding
Underlying coagulopathies are more likely to present during the surgery
350
Prolonged PTT
Factor VIII deficiency
351
Goldman's RF's for perioperative MI
MI w/in last 6 months
CHF (JVD, S3)
Age > 70
352
Elevated PTT
Increased Bleeding time
NL PT
Von Willebrand
| if inherited -> give DDAVP (vasopressin) as this stimulates release of vWF from storge sites
353
What fluids do you give to a pt with a massive transfussion
PRBC's + early administration of FFP and platelets
| Do not wait for laboratory values to confirm coagulopathy
354
How do you integrate feeding into a pt with a new jejunostomy
Start enteral feeding via the jejunostomy tube w/in 24 hours post op
The small bowel is able to return to normal fxn within hours, but the stomach is not
355
Post op pt develops a major retroperitoneal hematoma. How do you respond?
Immediately reverse heparin w/ a calculated dose of protamine and place a IVC filter
1 unite of protamine per 100 u of heparin
356
Pt looks like a PTX but on Xray has a hemidaiphragm
Traumatic diaphragmatic rupture
Almost always on the left
Tx - surgical repaire
357
Pt has a PTX that doesn't improve with a chest tube
Pt has tracheal or bronchial damage
| Happens when there is chest trauma and the glottis is closed
358
Warfarin pt is acutely bleeding
Give FFP
Works faster than vit K
Vit k takes 6-12 hours to start working, but should also be given
359
Pancreatic tumor w/ loose stools, facial rash, wt loss
VIPOMA
360
Pancreatic tumor w/ necrotizing migratory erythema
Glucagonoma
361
Pancreatic tumor w/ mild DM, steatorrhea, gallstones
Somatostatinoma
362
Pancreatic tumor with neuro findings (HA, lethargy, diplopia, blurred vision) especially w/ exercise or fasting
Insulinoma
363
Pancreatic tumor with flushing, diarrhea, wheezing, abd cramping, periperhal edeam
Carcinoid
364
GSW to the calf, swelling, pain with passive range of movement
Compartment syndrome
| Requires surgical decompression
365
On mammo, woman has multiple microcalcifications in the UOQ of the breast. No lump. Now what?
Needs a needle localized open biopsy
| FNa too likely to miss it
366
Colostomy site becomes indurated and crepitant
C. perfringens
367
Healthy adult w/ new HA's, hypokalemia and HTN
Aldosteronoma
368
Post surgery pt has PNA 5 days s/p surgery. GNR
Psuedomonas (HAP)
369
Management of Ogilvie syndrome
```
Correct electrolytes
Endoscopic decompression
IV neostigmine
If ischemic -> resect
Ogilvie = non mechanical pseudo-obstruction of the large intestine, typically seen in elderly post surgically
```
370
How do you transport a severed finger?
Wrap the finger in a moist gauze, put it in a plastic bag, place on a bed of ice
Must not dry out, be exposed to chemicals, or freeze
371
Graft vs. host dz is mediated by?
Donor T cells
| Rash, jaundice, diarrhea, intestinal bleeding, death
372
Risk of post op infection
Clean - 1-1.5%
Clean contaminated: 3-5%
Contaminated: 10-15%
Dirty: 30-35%
373
Medical therapy of PTH adenoma in pts that dont want surgery
Estrogen-progestin
Beneficial in post menopausal women because it reduces bone resorption, increases bone density, and decreases serum calcium
374
Months post LCC pt has colicky RUQ pain and jaundice
Iatrogenic stricutre of the common bile duct
| Stricture becomes infected causing cholangitis
375
How do you manage a porcelain gallbladder?
Prophylactic cholecystectomy
| High risk to progress to gallbladder cancer
376
Coagulopathy pt develops hypothermia during a prolonged surgery
Terminate the surgery
| Pack the bleeding surfaces and temporarily close with towel clips
377
Work up for a SBO
Clinical exam
Xray
Esp Lap
378
Most accurate test for chronic pancreatitis
```
Secretin stimulation (90% specific)
Chronic pancreatitis pt will not be able to realease a large volume of bicarb rich pancreatic fluid
```
379
How do you dx ischemic colitis after a surgery?
Colonoscopy or flexible sigmoidoscopy
380
Describe Dobutamine
Inotropic agent of choice in cardiogenic shock
B1 agonist
Improves cardiac performance in pump failure by both positive inotropy and peripheral vasodilation
Only marginally increases myocardial O2 demand
381
How does increasing PEEP improve oxygenation?
By increasing functional residual capacity
| Keeps alveoli open at the end of expiration, increasing surface area for gas exchange
382
Tx of neurogenic shock (injury, bradycardia, hypotension)
```
IVF
Vasoconstrictors (DA, phenylephrine)
```
383
A pt with cholecystitis presents with Xray w/ multiple dilated loops of small bowel and air in the billiary tree
Gallstone ileus
A cholecstoenteric fistula is formed when a large stone erodes into the small bowel and lodges in the ileocecal valve
presents with air in the biliary tree (pneumobilia)
384
Woman finds unilateral rust colored discharge in her bra. Most likely?
Intraductal papilloma
385
Management of splenectomy pt presenting with PNA?
Ceftriaxone and Vanco
386
Dysphagia pt with smoking and drinking hx needs a
EGD
387
Workup for a AAA pt prior to elective surgery
EKG, stress test (radionucleide scan w/ thallium and dipyridamole)
388
Acutely ill pt w/ mild acidemia, low PCO2, NL PO2
GI loss of bicarb
389
3 day s/p MVA pt has abd Xray w/ a large gastric bubble
Duodenal hematoma
390
New stroke pt with intraparenchymal hemorrhage is most likely caused by?
HTN
391
Management of a stable pt w/ a small R sided PTX?
Observation
392
kiddo w/ 1 day hx of unilateral photophobia, decreased vision. Small vesicles w/ erythematous base on the eyelid skin and conjunctiva
HSV conjunctivitis
393
sudden onset of unilateral vision loss. Pallorof optic disc, macular edema, thin arterioles, sausage like narrowing of retinal v.
Central rentinal a. occlusion
394
Xray with air under the diaphragm needs a
Lap
395
Management of follicular neoplasm of they thyroid
Thyroidectomy
396
Febrile pt with LLQ pain, this is his second episode, needs a?
CT
397
30ish woman w/ 6 weeks hx of nervousness, sweating, weight loss. lump on side of neck. Thyroid scan only shows uptake in the nodule.
Toxic thyroid adenoma
398
Toxic megacolon goes with
Chron dz
399
Pt consents to a procedure, receives opiate premedication, and then panicks and says she doesn't want to do it.
Cancel the operation
400
New onset of bloody bowel movements x weeks, internal hemorrhoids on rectal exam. Now needs a?
Colonoscopy
401
If you suspect Carpal tunnel, order a?
Nerve conduction study
402
Pt has a large (4x7cm) cystadenoma in the tail of the pancreas. Now what?
Distal pancreatomy
403
Stab wound over chest, tachy, hypotensive, breat sounds absent on R, trachea midline, neck veins flat
Massive hemothorax
404
GCS 5, right pupil dilated, unresponsive, needs?
Intubation and hyperventilation (preserve CPP)
405
Which local anesthetic is known for a long duration?
Bupivacaine
406
Immeadiately post surgery pt is mildly acidodic, Low O2 and high PCO2
Reintubate and ventilate
407
Pt with pearly surface papule w/ telangiectasis on face
Basal cell carcinoma
408
Hidradenititis suprativa affects which glands?
Apocrine glands of the acilla, groin
409
Female becoming obese increases her risk of?
Cholecystitis
410
How does Indomethacin close a PDA?
Cyclooxygenase inhibition with increased norepinephrine release
411
CRF pt has a compression fx due to low Ca2+ and high Phos,
Secondary hyperparathyroidism (due to her renal failure
412
Afib pt with abd pain and stool + for blood
```
Exploratory celiotomy (likely mesenteric ischemia)
celiotomy is another word for laparotomy
```
413
Pt has RUQ mass, jaundice, -ve gallstones
Choledocal cyst
| Tx - reux en Y cystojejunostomy
414
1 wk hx of scleral icterus, nausea, R sided abdominal cramps 2 months s/p LCC w/o cholangiogram.
Choledocholithiasis
| Cystic duct stone was not seen w/o the cholangiogram
415
How do you manage a pt that you suspect has temporal arteritis
Prednisone and temporal a. bx immediately
416
Pt w/ hx of femur fx complicated by DVT presents with 6m hx of ulcer over medial malleolus, 2+ edema. Other leg is NL. Why?
Venous valvular insufficiency
417
Febrile pt with n/v, high pitched bowel sounds. Xray - multiple dilated loops of small bowel and gas w/in the small bowel lumen and w/in the liver
Cholecystoduodenal fistula with an impacted gallstone
418
Pt 2 years s/p radiation therapy for laryngeal cancer presents with stridor. bulky tumor involving the upper and middle neck b/l on exam. Mild acedemia, increased CO2. Now what?
Needs a trachesotomy
| Retention of CO2 is suggesting an impending respiratory collapse
419
After an I&D pt presents to ER in pain and with a surgical incision that is black
Needs surgical debridement
420
Pt is unable to extend his knee. Ligament stability is NL but ROM if 15-110degrees
Torn meniscus
| Remember sensation of popping and getting stuck
421
10 yr hx of intermittent palpitations, exacerbated by stress and caffeine. On exam, midsystolic click heard best at the apex
Mitral valve prolapse
422
Kid has fever on POD1, why?
Collapse of right middle lobe of lung from decreased inspiratory effort (POD 1 fever is ATELECTASIS)
423
What is the best indicator for adequate resuscitation in a trauma pt?
Urine output 30-40mL
424
Unrestrained driver w/ retrosternal and interscapular chest pain, Xray w/ wide medistinum
Rupture of thoracic aorta
425
Why do cancer pts get cachectic
Increased serum tumor necrosis factor concentration
426
Man being screened for ifertility, semen analysis is NL, but one side of his scrotum has an irregular ropy mass. Why infertile?
Varicocele
427
Older pt with multiple episodes of PNA and now developed halotosis. NL LFTs, CXR w/ scarring at the lung base
Pharyngoesophageal diverticulum (zenker's)
428
All gunshot wounds to the abdomen require a?
Exp lap
| Abdomen is from the nipple to the pubis
429
1st line test for dx'ing osteomyetitis in the post op period
Nuclear triphasic bone scan
| Bone bx is the gold standard, but can be done second
430
When do you send a SBO pt to surgery?
When there are signs of ischemia
431
when is escharotomy indicated for a burn pt?
When you see vascular compromise (low threshold)
432
What is a complication of using silver nitrate to treat a burn?
```
Electrolyte abn (Hyponatremia, hypokalemia, hypocalcemia, hypochloremia) and methemoglobinemia
Silver sulfadiazine causes neutropenia
Mafenide acetate casuses metabolic acidosis (inhibits carbonic anhydrase)
```
433
Pt has a tumor on the lips, it's most likely to be
Squamous cell carcinoma
| SCC tends to be lower ip and BCC tends to be upper lip
434
3 types of wound closures
```
Primary intention - edges of the wound are brought together and sealed with sutures
Secondary intention - leave the wound open w/o active intent to seal the wound (heals by re-epithelialization), reserved for highly contaminated wounds where primary repair would fail
Tertiarty intention (delayed primary closure) - treat medically until the wound can be grafted
```
435
Pt has a white patch at the dentist
Leukoplakia
5% progress to cancer
Tx - strict oral hygiene, avoid alcohol and tobacco
bx is reserved for thick lesions
436
Pt is getting a nose cancer removed and receiving a graft from his ear. This is a?
Composite tissue graft
These grafts contains tissue + epidermis + dermis, ideal for deep defects where other grafts would have a poor cosmetic outcome
437
Best way to assess for compartment syndrome?
Doppler (Pressure >40mmHg is diagnostic)
438
Pt presenting with >5 days of appendicitis syx, psoas sign
Appendiceal abscess
Caused by appendiceal rupture that remains in a contained abscess
Tx - IVF, abx, bowel rest, and "interval appendectomy" (pt returns in 6-8 weeks for appy on elective basis
439
Following a head trauma pt becomes progressively drowsy and weak on one side of body
Transtentorial (uncal) herniation (midline shift due to epidural hematoma)
Ipsi hemiparesis, ipsi mydriasis/strabismus (oculomotor n.), cpntra hemianopsia, altered mentation
440
How does atelectasis change the ABG?
respiratory alkalosis
Hypoxemia
hypocapneia
441
How do you treat dumping syndrome?
Dietary modification, diminishes over time
Common postgastrectomy complication, caused by loss of NL pyloric sphincter action and hypertonic gastric contents enter the duodenum
Consume frequent small meals, slowly
Avoid simple sugars
Increase fiber/protein
Drink fluids b/w meals, not during
442
Most common cause of impaired wound healing in a chronic alcoholic?
```
Nutritional deficiency (scurvy/vit C)
Cutaneous changes (coiled hair), gingivitis, impaired wound healing, arthralgia/malaise
Can progress to hemolytic anemia and edema
```
443
Most common cause of hypotension after a blunt abdominal trauma?
L side - spleen lac
| R side - liver lac
444
Female presents with sudden onset of RLQ pain and hematocrit is dropping
Ruptured ovarian cyst
445
Tx of anal fissures
```
Increased fiber and fluids
stool softeners
sitz baths
topical anesthetics
Vasodilators (nifedipine, nitroglycerine)
```
446
Pt develops a whistling noise during respiration following a rhinoplasty. Suspect?
Nasal septal perforation
| Probably from a septal hematoma
447
Young male presents with SOB. Mediastinal mass compressing the trachea. Serum + for AFP and bHcg
Mixed germ cell tumor
Seminoma - elevated BHCG
Nonseminomatous germ cell tumors - AFP
448
Differential for mediastinal mass
```
4 T's
Thymoma
Teratoma (and other germ cell tumors)
Thyroid neoplasm
Terrible lymphoma
```
449
Prime objective when managing a rib fx?
Adequate pain control
| Helps to prevent hypoventilation as it is associated with atelectasis and PNA
450
Pt with PMH of pancreatitis x wks ago presents with abdominal pain, vomiting, and pancreatic mass on CT
Pancreatic pseudocyst that is likely infected
Needs endoscopic drainage
Pts w/ minimal syx of pseudocysts can have expectant management
451
BUN:CR is > 20:1
Prerenal azotemia
| Needs fluids
452
MI pt has a new pansystolic murmur best heard over the apex
Get to the OR
Acute papillary m. rupture, common 3-5 days s/p MI
High mortality rate
New murmur, sudden drop in bp and acute HF
453
Why are blowout fx of the orbit an ophthalmological emergency?
Inferior rectus entrapment (upward gaze is affected and enophthalmos
May need emergent surgery
454
Cholangitis pt should receive a?
ERCP - diagnostic and therapeutic
| Elective LCC after
455
Management for a symptomatic epidural hematoma
Emergent neurosurgical hematological excavation
Caused by tearing of the middle meningeal a.
If severe enough, uncal herniation can cause ipsi CN III palsy and hemiparesis
456
4 days s/p LCC pt presents with distention and has not passed gas
Ileus (prolonged post op ileud (PPI) when syx are 3-5 days s/p operation
Think ileus when surgery is recent (hours to days) vs SBO where surgery is weeks to years ago
Ileus will have hypoactive BS
Caused by: splanchnic n. sympathetic tone, local inflammatory mediators, opiate analgesics
Dx - Abdominal Xray
Prevent w/ epidural anesthesia, minimally invasive surgery, and perioperative IVF
457
Obstipation is?
Failure to pass flatus or stool
458
Gnawing epigastric pain that is worse at night, anorexia/weight loss, jaundice
Pancreatic cancer
459
Periodic epigastric pain relieved by meals
Peptic/duodenal ulcer
460
How do you tx a penile fx?
Urologic emergency requiring urgen operative repair
Any pt with evidence of a urethral injury (blood at meatus, dysuria, or urinary retention) need a retrograde urethrogram first
461
RUQ pain, imaging reveals distended gallbladder w/ gas in the gallbladder wall and lumen. No gas in biliary tree
Emphysematous cholecystitis
Can be life threatening, more commin in immunocompromised (incl. DM)
Caused by infection of the gallbladder wall w/ gas-forming bacteria
Requires emergent cholecystectomy
Confirm w/ CT demonstrating air-fluid level in the gallbladder
462
Teen presents with fever, sore throat, earache. Exam - can't open jaw all the way, pooling of saliva, unilateral enlarged tonsil with deviation of the uvula
Peritonsillar abscess (quinsy)
Tx - needle aspiration or I and D + abx
caused by acute bacterial infection b/w the tonsil and pharyngeal muscles
463
Direct Inguinal hernias are due to a defect in
The posterior wall of the inguinal canal
464
MI pts need a stress test
5-7 days s/p MI to identify if there is ischemia
| Test must be submaximal stress test until pt is 10-14 days s/p MI
465
What heodynamic changes are seen in hypovolemic shock?
Decreased - preload, CO
Increased - vascular resistance, HR, EF
on exam - hypotension, tachycardia, cold extremities, flat veins
466
s/p cardiac surgery, pt has fever, chest pain, leukocytosis , and wide mediastinum
Acute mediastinitis
Requires drainage, surgical debridment and prolonged abx therapy
Caused by intraoperative wound contamination
467
newborn w/ defect at linea alba covered by skin
umbilical hernia
| Observe for resolution by 5
468
Newborn w/ defect to the righ of the umbilical cord, not covered by membrane or skin, contains bowel
Gastroschisis
| Immediate surgery after birth
469
New born with midline abdominal wall defect covered by peritoneum
Omphalocele
| Immediate surgery after birth
470
Teenager presents with jaundice 3 days s/p appendectomy
Gilbert syndrom
Disorder of bilirubin glucoronidation, due to decreased activity of the UDP-glucuronosyltransferase
Reccurrent jaundice precipitated by stress
Eleveted unconjugated bili, but NL LFTs
471
ICU pt 5 days s/p surgery with CT showing distended gallbaladder w/o stones w/ some pericholecystic fluid
Acolculous cholecystitis
Seen in the critically ill
presents similarily to cholecystitis
Tx - abx, percutaneous cholecystostomy w/ elective cholecystectomy when the condition stabilizes
472
Removal of a recurrent parotid mass puts pt at risk of?
Facial n. palsy, facial droop
473
Critically ill ICU pt's blood cultures grow coag negative sphylococci
Likely due to an intravascular device
474
Pt with a penetrating abdominal trauma + syx of abdominal injury needs a?
Exp Lap
| Abd injury = hemodynamically unstable, peritonitis, evisceration, blood in ng tube or rectal
475
Pt is asked to lower his arm, but as it gets below horizontal it suddenly drops. Painful
Rotator cuff tear
| Get MRI to confirm dx
476
Diverticulitis pt w/ CT showing rim-enhancing perisigmoid fluid collection.
Complicated diverticulitis (abscess formation)
Tx - percutaneous abscess drainage under CT guidance
If percutaneous drainage fails -> surgical drainage
477
when does a scaphoid fx need surgery?
If it's displaced
| Non displaced can be splinted w/ wrist immobilization, need close follow up to r/o osteonecrosis of the proximal segment
478
Post trauma, pt has abd pain and shoulder pain. No evidence of shoulder trauma. Hemodynamically stable. Be suspicious of?
Bladder dome rupture
Can be seen on CT
Pt will have abd pain and referred shoulder pain d/t urine leak into the periotneal cavity (chemical peritonitis)
479
Burns or chronically inflammed skin is at risk of developing?
Squamous cell carcinoma
SCC from chronic wounds tends to be more aggressive
SCC from a burn = Marjolin ulcer
480
Nasopharyngeal carcinoma is associated with?
Epstein-Barr virus
associated with China, Africa, and middle east
presents as nasal congestions w/ epistaxis, HA, CN palsies, otitis media
Early spread to the cervical lymph nodes
481
s/p trauma pt is hemodynamically stable but tachypnic, hypoxic and Xray reveals patchy alveolar infiltrate
Pulmonary contusion
Bruising of the lung, causing intra-alveolar hemorrhage and edema
w/ or w/o rib fx
CT - patchy irregulat alveolar infiltrate
complication of blunt trauma
482
Pt has blood at the end of urination
Bladder or prostatic damage
| Terminal hematuria + clots = urothelial cancer of the bladder
483
Blood at the beginning of urination
Urethral damage
484
Blood throughout urinaiton
Damage in kidney or ureters
| Clots are not seen in renal causes
485
tx of gallstone ileus
Surgical removal of the stone and cholecystectomy
486
Scrotal mass x months, does not transilluminate, increases in size w/ standing
Varicocele (dilation of the pampiniform plexus v.'s surrounding the spermatic cord)
More common on the L because the spermatic v. drains into the L renal v. whcih can be compressed as it basses between the sMA and the aorta
487
hours following a femoral endartectomy pt presents with a swollen lower extremity
Ischemia-reperfusion syndrome
A type of compartment syndrome
fasciotomy if >30 mmHg
488
Pt with a retropharyngeal abscess is at risk of developing?
Necrotizing mediastinitis
489
Penetrating injury to the thigh + evidence of vascular injury requires?
exp lap
490
Anterior shoulder dislocation is associated with damage to?
The axillary nerve
weak shoulder abduction
axillary n. inn teres minor and deltoid, sensation to lateral shoulder
491
How does hyperventilation decrease ICP?
Cerebral vasoconstriction (decreased cerebral blood flow)
492
signs of femoral n. palsy
reduced knee extension
| decreased sensation over medial and lower thigh
493
What causes an increased pulmonary cap wedge pressure?
PCWP measures the pressure in LA, so anything that would inhibit CO (MI, HTN, valve dz, cardiomyopathy, toxin, metabolic disorder, or myocarditis)
Increased PCWP associated w/ cardiogenic shock
494
Alcoholic has had pancreatitis but now has oily stools w/ NL LFTs and Alk Phos
Pancreatic insufficiency
495
Pt w/ 2m hx of intermittent gross hematuria, fatigue, and weight loss. N prostate.
Renal cell carcinoma
| Can have secondary hyperparathyroidism
496
GSW to thigh, popliteal, post tib, and dorsalis pedis pulses absent. Femur fx is reduced. What do you do next?
Exp lap. Vascular compromise due to absent pedal pulses. Don't do imaging
497
Trauma pt with flank pain and gross hematuria, hemodynamically stable
CT of abdomen and kidneys
498
Smoker, prerenal azotemia. Renal U/S shows a 14cm L kidney and 7 cm R kidney. Why does he have HTN and renal atrophy?
Renal a. stenosis
499
1 yr hx of progressive difficulty swallowing, intermittent vomiting of undigested food, and cough more severe at night.
Xray - air fluid level in posterior mediastinum at level of cardiac silhouette
Manometry - NL lower esophageal sphincter pressure, absent lower esophageal relaxation
Achlasia
500
woman w/ 48 hr onset of sharp pain in upper outer quadrent of R breast, gradually resolving.
Exam - tender area w/ no mass
Reassurance
501
Pt w/ R lower abdominal pain radiating to R groin x 7 days, fever, anorexia
PE - Increased pain w/ hip extension, flexion decreases pain
```
Psoas abscess
Get CT of abdomen and pelvis
PE manuever = psoas sign
Look for recent hx of skin infection (distant or intraabdominal)
RF - HIV, IVDU, DM, Crohn dz
Tx - drain + abx
```
502
pt s/p thyroidectomy presents w/ anxiety, muscle cramps, poor sleep, long QT interval
Hypocalcemia s/t hypoparathyroidism
503
What do you need to dx flail chest
Xray w/ 3 or more contiguous rib fx in 2 or more location (need a floating segment)
504
Pt gets dyspnea, hypotension, and tachy after placement of a subclavian central venous line
suspect a tension PTX
505
R ant thigh pain worse with walking. pulsatile mass in R groin
R femoral a. aneurysm
| associated with AAA
506
Middle aged woman, new onset of HA's and unilateral weakness
| CT - well-circumscribed partitally calcified mass
Meningioma
Benign, lie close to the dura
Tx - surgical resection is curative for most
507
POD 4 pt develops fever, tachy, hypotension, poor urine output
```
Septic shock
Give IVF (normal saline is a crystalloid restores volume as adequately as albumin but is much cheaper) and vasopressors to restore tissue perfusion
```
508
What do you recommend for a PAD pt w/ a ABI of 0.8
Recommend a walking program
509
hours post surgery pt had decreased urine output but good bp?
Give saline bolus to increase output
| Urine is the endpoint for resuscitation
510
Pt receives multiple unites of pRBC's intraoperatively but no FFP, presents with bleedign
thrombocytopenia
511
Pt experiences multiple DVT's despite heparin anticoagulation
Antithrombin III deficiency
512
surgeon can't hold pickups, numbness over ring and little fingers
PE - loss of intrinsic hand m. but no loss of reflexes
C8 nerve root
513
Chronic pancreatitis pt presents with steatorrhea and high glucose
Needs insulin therapy
| Entering pancreatic insufficiency
514
ITP pt plt count is 20k despite steroid therapy and IVIG. BM bx shows normal megakaryocytes Now what?
Splenectomy
515
Infant, jelly like stool, periodically brings knees to chest, elongated abdominal mass
Intsusscipation
| Needs contrast or air enema
516
4m hx of progressive hearing loss, ringing in same ear, an dunsteadiness with walking. Weber localizes to unaffected ear
Acoustic neuroma (vestibular schwannoma)
517
Which measurement is the best way to predict if a pt will require a pneumonectomy prior to surgery?
FEV1
518
Best way to assess cervical trauma?
Lateral x ray
519
PUD pt tx w/ omeprazole, presents w/ n/v x 1 day
Hemodynamically stable
distended abdomen with borborygmi in epigastric area and succussion splash. Why?
Scarring and fibrosis of the duodenal ulcer crater
520
Pt w/ vomiting and substernal chest pain radiating to back, hypotensive, blunting of L costophrenic angle
Esophagography - extravasation into the mediastium and L pleural cavity. IVF and abx are started. Now?
Exp thoracotomy
521
Healthy young female. asyx. Patchy hilar infiltrate on xray
Sarcoidosis
522
3wk old infant presents with jaundice, high total bili and direct bili
Biliary atresia
| Occurs due to a clogged extrahepatic duct. Presents in first 6 weeks of life
523
2 yrs s/p LCC pt presents w/ RUQ pain, elevated LFTS and alk phos, U/s -ve for stones, and tx w/ opioids make syx worse
Sphincter of Oddi dysfunction
Causes biliary colic due to dyskinesia and stenosis of the sphincter of Oddi
Dx with manometry
tx sphincterotomy
524
Pt who had ingested acid months ago presents w/ early satiety, n, nonbillious vomiting, weight loss
Pyloric stricture causing gastric outlet obstruction
Pyloric stricture d/t acid ingestions
Other RF's - gastric malignancy, PUD, Crhon's, gastric bezoars
525
What is succussion splash?
PE finding where stethescope is placed over the abdoment and the pt is rocked side to side. Retained material (>3 hrs after a meal) will generate a splash suggesting the organs are filled with fluid and gas
526
5 days after a burn pt is at risk of
infection with GN organisms and fungi
527
Shortly after a burn pt is at risk of?
Infection with GP organisms
528
SIRS criteria
```
<36.5C or >39C
Tachy >90/m
tachypnea >30/m
hypotension SBP <90 mmHg
Also oliguria, hyperglycemia, thrombocytopenia, AMS
```
529
Middle aged adult w/ superficial unilateral hip pain exacerbated by pressure on the lateral thigh (ie lying on your side_
Trochanteric bursitis
Inflammation of the bursa surrounding the insertion of the gluteus medius onto the femur's greater trochanter
Caused by overuse/frictional forces
530
management of a stress fx?
Rest and analgesics
Can have a negative xray for up to 6 wks
commonly affects second metatarsal
5th metatarsal is at increased risk of non union and may require an ortho referral
531
Hypocalcemia and Hyperphosphatemia w/ NL renal fxn
Hypoparathyroidism
| Causes - post-surgical, autoimmune and non-autoimmune parathyroid destruction, defective Ca2+ sensing receptor
532
Pt presents with a mass on the hard palate of the mouth that is immobile and has a bony hard consistency. Been there for years
Torus Palatinus
Conginetal, associated with the young, women, and Asians
Surgey is only indicated if the pt becomes syx (interfers w/ eating, speech)
533
Pt has classing PE findings of appendicitis and high WBC
Get a lap appy
| No need to confirm with CT. Only need CT if pt does not have classic syx/findings
534
Pt has massive hemoptysis
>600mL/24hr OR
100mL/hr
What do you do?
Get an airway
Place the source of the bleeding low
Bronchoscopy to indentify the site and attempt intervention
535
Years after a MVA, pt presents with weakness and sensory loss of upper extremities. Wasting of small hand m. and impaired pain/temperature sensation b/l
Syringomyelia
Can develop post-traumatically (often whiplash) w/ syx developing months to years later
Caused by enlargement of the central canal of the spinal cord d/t CSF retention
dx - MRI
536
surgical wound with, purulent cloudy-gray discharge
Necrotizing surgical infection
Needs debridment and abx
"dishwater drainage"
typically polymicrobial and more common in DM pts
537
b/l hip, thigh, buttock claudication
impotence
symmetic atrophy of b/l lower extremities d/t ischemia
```
Aortoiliac occlusion (Leriche syndrome)
Occlusion at the bifucation of the aorta in to the common iliac a.'s
```
538
hours after cardiac catherterization pt has sudden hemodynamic instability and flank or back pain
Retroperitoneal hematoma
Once stable, do a non contrast CT of abdomen/pelvis or abdominal U/S
Tx - supportive (bed rest, monitoring, IVF, transfussion)
539
Tall skinny guy gets a PTX
Primary spontaneous PTX (PSP)
| IF stable, obs/oxygen
540
Old demented guy on POD 8 develops pain and swelling of the left angle of his jaw
Acute bacterial parotitis
Caused by inadequate fluid hydration and oral hygiene
Staph aureus
541
Septic joint in a prosthesis is caused by?
Staph aureus - presents in first 3 months of replacement, acute pain, fever
Staph epi - 3-12 months since surgery, presents with chronic pain, gait impairment, loose implant, sinus tract formation
542
New onset SOB, diastolic rumbling murmur best heard over apex
Mitral stenosis
543
How do NSAIDS cause ARF?
Inhibit synthesis of prostacyclin
544
Jehovahs witness needs emergent surgery but H&H is very low
Do the surgery w/o transfusion
545
kid w/ continuous murmur over the pulmonary area and bounding peripheral pulses
Patent ductus arteriosis
546
Chemo pt has a RA catheter placed. 10 days later his RUE is twice the size as the LUE and U/S shows occlusion of the R axillary and subclavian v.'s. Why?
Complication of the R atrial catheter
| Not related to the cancer
547
RF for unilateral temporary vision loss?
Carotid stenosis
| needs a doppler
548
Extensive 1st degree burn (sunburn) needs
Obs
549
```
Post op pt has:
pH 7.25
PCO2 55
PO2 75
Why?
```
Ventilatory insufficiency
550
What is a cornual pregnancy?
AKA interstitial pregnancy
Considered an ectopic pregnancy
Located outside of the uterus in the part of the fallopian tube that penetrates the muscular layer of the uterus
Can also mean that the fetus is implanted in one of the two horns of a bicornate uterus
551
What hormone changes are expected in a pt with a hot thyroid nodules
Decreased TSH
Increased T3/T4
Nodule is making T3/T4 causing suppression of TSH (hyperfunctioning nodule)
552
You find a thyroid lump. What do you do?
If TSH NL or high - FNA
If TSH low - radionuclide scan
Cold nodule - FNA
Hot nodule - check T4/T3
553
Dysphagia pt has a swallow study showing tapered distal esophageal stricture w/ moderate dilation of the proximal esophagus. Now what?
EGD and bx
554
2 hours s/p transfusion pt develops chills and fever. Why?
Preformed Ab (donor) to Leukocyte Ag (host)
555
ABG findings in atelectasis
```
Respiratory alkalosis
Hypocapnia
Hypoxemia
Atelectasis -> decreased lung volumes -> V/Q mismatch -> hypoxemia -> pt hyperventilates to pull up oxygen -> respiratory alkalosis due to blowing off CO2
PE has a similar ABG
```
556
The splenic flexure is the watershed betweent the?
Superior and inferior mesenteric a.
557
The rectosigmoid junction is the watershed between the?
sigmoid a. and superior rectal a.
558
Tenderness over medial aspect of knee.
| Pt standing, knee bent slightly, internal rotation of the knee elicits a locking sensation and significant sharp pain
```
Medial meniscus tear
Thessaly test
Confirm w/ MRI
If syx mild - rest it
If syx persistent - surgery
```
559
You suspect bladder injury and perotineal signs are present
Intraperitoneal bladder injury - typically rupture of the dome of the bladder.
Extraperitoneal presents w/ high riding prostate, blood at meatus but not peritoneal signs
560
Why should succinylcholine be avoided in pts with crush injury?
Life threatening hyperkalemia
Crush pts have cell death and can already be hyperkalemic
Succinylcholine depolarizes NM cells by triggering influx of Na and efflux of K
So, K from cell death and from NM depolarization can be super dangerous
Instead use a non depolarizing agent (vecuronium, rocuronium)
561
Why is O2 supplementation give to guys with Primary spontaneous PTX?
Supplemental oxygen aids spontaneous resorption
562
Pt develops jaundice after requiring several units of pRBCs
| Hi total and direct bili
Overproduction of bilirubin d/t rBC breakdown
563
Physiologic change in PHTN
Increased pulmonary vascular resistance
564
Ab against thyroid peroxidase is most commonly associated with
Chronic lymphocytic thyroiditis (Hashimoto dz)
565
Pt w/ prosthetic heart valve and schistocytes presenting w/ pallor fatigue needs
pRBCs
566
L sided chest pain
Absent breath sounds, dullness to percussion
CXR - L sided pleural effusion and peripheral soft tissue density
Bx dimorphic malignant cells; spindle cells w/ may mitotic figures and buboidal epithelial cells. What was this guy exposed to?
Asbestos
567
Construction worker
| cellulitis of the dorsum of the hand x 2 days
Group A strep
568
Bloody nipple discharge expressed from one nipple
Intraductal papilloma
569
Pt w/ flap laceration s/t bite that extends into the Sub Q fat. Avulsed skin is cyanotic, no bleeding
Debridment and application of a sterile dressing to the open wound
secondary closure
570
Cholesterol emboli in a branch of the retinal a. is d/t?
Carotid plaque
571
Why does a varicocele cause decreased fertility?
Increased scrotal termperature
| Can lead to a low sperm count
572
Pt on a vent has developed ARDS and on abx for polymicrobial findings in bronchial washings
CXR cavitory lesion in the R upper lobe. What is it?
Lung abscess
573
Chemo pt has pain of the extremities and ribs. Pain not well managed on codeine and amitriptyline
Try oxycodone
574
Breast bx comes back as invasive estrogen + . Now what?
Resection of the bx site
575
GERD pt
CXR - air fluid level posterior to cardiac silhouette
Barium swallow - proximal stomach herniating through esophageal hiatus
Now what?
EGD
576
Dysphagia, chest painduring meals x months
GERD x yrs
Only taking in liquids because they regurg food
Why?
Stricture of the distal esophagus
| RF's - gerd, acid ingestion, anything that will scar the esophagus
577
When it comes to aneurysms, what is the best predictor that the pt will develop HF?
The size of the abnormality
578
Tx for pt w/ HTN s/t hyperaldosterone
Spironolactone
Ald:renin ratio is increased
Adrenal mass on CT
579
UC pt develops jaudice, high total and direct bili, narrowing a biliary ducts d/t?
PSC
580
kid w/ 2 wk hx of severe hip and knee pain w/ limp
| abductio is decreased
Slipped capital femoral epiphysis
| fx is through the growth plate -> avascular necrosis
581
kid <10 y/o 2 wks s/p URI presents w/ a 2 day hx of limp. Pain over the hip, elevated ESR
Toxic (transient) synovitis
Dx of exclusion
Tx - rest, NSAIDS
582
Pt has diarrhea s/t excessive constipation related to opioid use. She needs?
Enemas
583
Healthy adult found in a deep stupor, Hypertensive
| Left hemiparesis, early decerebrate posturing
Ruptured intracerebral aneurysm
584
Pt has a cool foot, no pedal pulses, pulsatile mass in popliteal fossae. next step?
Arteriography w/ runoff
585
Hx of VSD, HF, cyanosis
Eisenmenger syndrome
586
12 y/o w/ weakness, pallor, black, shiny stools x 5 days. Microcytic anemia.
Scintigram - technetium shows RLQ separate fromthe activity in the stomach kidneys and bladder
Meckel diverticulum
587
Hepatic mass w/ central scar on CT (incidental finding)
Focal nodular hyperplasia
Benign
No further testing needed
588
See a wicked anal growth in a HIV positive guy do a
Bx
