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Surgery Shelf > Surgery Notes > Flashcards

Surgery Notes Flashcards

1
Q

When pt has good renal function, PE can be diagnosed via CT scan. How is PE diagnosed in pt with poor renal function?

A

V/Q scan

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2
Q

GERD pt doesn’t want meds — what do you do?

A

Nissen fundoplication

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3
Q

How do you evaluate for ureteral injury following traumatic pelvic fracture?

A

IV pyelogram preoperatively

-OR-

Methylene blue intraoperatively

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4
Q

Herniation of abdominal contents through the internal inguinal ring due to congenital patent processus vaginalis

A

Indirect inguinal hernia

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5
Q

Pt presents 3 days s/p lap chole with severe RUQ pain and a fluid collection. What is the first step in workup?

A

Fluid aspiration and analysis

[determine if blood, enteric contents, or bile]

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6
Q

Oligohydramnios, no urine output on first day of life, elevated creatinine, dx?

A

Posterior urethral valves

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7
Q

Rumbling diastolic murmur with opening snap

A

Mitral stenosis

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8
Q

How long do you give clopidogrel for a drug eluting stent

A

1 year

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9
Q

Succinylcholine can cause what electrolyte abnormality in burn and spinal cord injury patients? How does this manifest on EKG?

A

Hyperkalemia

Peaked T waves and shortened QT interval

[eventually, as hyperkalemia worsens, there is progressive lengthening of PR interval and QRS duration, the P wave may disappear, and ultimately the QRS widens further to a sine wave pattern]

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10
Q

Etiology of anterior cord syndrome

A

Almost always caused by a spinal artery occlusion (typically the artery of Adamkiewicz from a AAA), the infarct occurs in the front half of the cord

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11
Q

Holosystolic murmur that occludes both S1 and S2 at the cardiac apex that radiates to axilla

A

Mitral regurgitation

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12
Q

2 cardiac risk factors that are outright contraindications to non-cardiac surgery

A

EF <35% (75% chance of perioperative MI)

MI within last 6 months (40% chance of mortality at 3 months vs. 6% at 6 months)

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13
Q

Reynold’s pentad for ascending cholangitis

A 
Jaundice
Fever
Abdominal pain
Shock
Altered mental status
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14
Q

Tx for acute epidural hematoma

A

Craniotomy and evacuation

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15
Q

What imaging study should be obtained FIRST in those with suspected small bowel obstruction?

A

Acute abdominal series

[includes upright CXR to look for pneumoperitoneum, upright abdomen to see air-fluid levels, and supine abdomen which best shows bowel dilation; Classic findings of SBO are ladder-like dilated loops of bowel with air fluid levels]

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16
Q

5 W’s of post-op fever

A 
Wind — Atelectasis, PNA
Water — UTI
Walking — DVT
Wound — Infection, abscess
Wonder drugs
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17
Q

When should smoking cessation be done in relation to surgery?

A

8 weeks prior to surgery — because congestion initially worsens on quitting

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18
Q

70 y/o F presents with LUQ pain. US reveals calcified lesion in LUQ. Most likely dx?

A. AAA
B. Accessory spleen
C. Colorectal carcinoma of splenic flexure
D. Mesenteric ischemia
E. Splenic artery aneurysm
A

E. Splenic artery aneurysm

[these are the most common splanchnic aneurysms and often present with concentric calcification on imaging. They most often occur during childbearing years (d/t fibromuscular dysplasia) or later in life (d/t portal HTN). Surgical intervention indicated when symptomatic, present in childbearing years, or greater than 2 cm in size]

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19
Q

Tx for patients with CAD affecting 1-2 vessels

A

Angioplasty (PCI/stenting) + Clopidogrel

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20
Q

A 67 y/o female presents with complaints of a lump in her breast. PE reveals 2 cm mass in upper outer quadrant and 1 cm mass in lower inner quadrant, both in left breast. The 2cm mass is firm and appears fixed to underlying tissue; bx reveals invasive ductal carcinoma. Most appropriat management is:

A. B/l mastectomy
B. Lumpectomy with SLND
C. Radical mastectomy
D. SLND
E. Simple mastectomy with SLND
A

E. Simple mastectomy with SLND

[breast conserving therapy is contraindicated in multicentric disease with 2+ primary tumors in separate quadrants of the breast such that they cannot be encompassed in a single excision]

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21
Q

Wet vs. dry macular degeneration

A

Both present with chronic, progressive, central vision loss (peripheral is spared). Differentiate types via simple retinal exam

Wet (20%) — shows blood/fluid, tx with laser

Dry (80%) — shows Drusen/pigment changes, tx with supportive care

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22
Q

Transient synovitis is on the differential for septic hip. It’s synovial inflammation up to 4 weeks after URI or GI viral illness. It is differentiated from septic hip bc there is no fever or leukocytosis, and xray is normal. Tx is supportive. When differentiating this from septic joint, the ______ criteria can also be used — in which the more criteria you have, the higher risk for septic joint

A

Kocher

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23
Q

Pearly skin lesion that’s non-healing and bleeds easily

A

Basal cell carcinoma

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24
Q

Intraparenchymal hemorrhages are bleeds within the brain parenchyma itself. This occurs most often at what location?

A

Caudate and putamen

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25
Q

If a baby has persistent or worsening jaundice after 2 weeks of age, consider the dx of biliary atresia. Labs will show a direct hyperbilirubinemia. What is the hierarchy of testing?

A

Start with Ultrasound + LFTs

If unsure, do HIDA scan after 5-7 days of phenobarbital stimulation

If still unsure, can do liver biopsy and/or intraoperative cholangiogram

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26
Q

Hx of blunt trauma and you note pulsus paradoxus > 10 mmHg

A

Cardiac tamponade

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27
Q

When do you operate on a pancreatic pseudocyst?

A

6 weeks or 6 cm

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28
Q

T/F: Teratomas are typically benign in females and malignant in males

A

True

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29
Q

Tx for hemorrhoids grade I-IV

A

Grade I = conservative therapy with warm sitz baths and high fiber diet

Grade II = non-surgical removal procedure such as rubber band ligation

Grade III and IV = surgical hemorrhoidectomy (closed = most common, but can be done open)

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30
Q

Burn with blisters that have broken open, glossy pink, and blanches with pressure

A. Deep partial
B. Epiderma
C. Fourth degree
D. Full thickness
E. Superficial partial
A

E. Superficial partial

[epidermal burns do not blister. Superficial and deep partial are painful, but superficial blanche while deep do not]

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31
Q

_________ ________ syndrome can result after a chronic obstruction to a portion of the intestines causing bacterial overgrowth due to stasis within the obstructed limb. Bacterial overgrowth may be patchy, confined to distal small intestine, or located in inaccessible sites and may therefore be missed. The bacteria will bind with ____________ and decrease its absorption into the body, leading to megaloblastic anemia

A

Blind loop syndrome; Vitamin B12

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32
Q

1st step in working up esophageal cancer

A

Barium swallow

[however, BEST test in working up esophageal cancer is EGD with biopsy]

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33
Q

Upper vs. lower motor neuron symptoms

A

Upper = spastic paralysis, hyperreflexia, upward going Babinski

Lower = flaccid paralysis, hyporeflexia

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34
Q

Boot-shaped heart on CXR, association with Downs syndrome or DiGeorge syndrome

A

Tetralogy of Fallot

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35
Q

What type of imaging should be done if you are concerned for CBD perforation following an ERCP?

A

Nuclear medicine hepatobiliary scan

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36
Q

Galeazzi fracture bony deformity

A

Radius breaks, ulna dislocates

[occurs with downward blow against upward turned radius]

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37
Q

Hernia that contains Meckel’s diverticulum

A

Littre’s hernia

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38
Q

3 classifications of gallstones

A

Cholesterol

Black pigment (calcium bilirubinate)

Brown pigment (calcium salts of unconjugated bilirubin)

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39
Q

Causes of high anion gap metabolic acidosis

A

MUDPILES

Methanol
Uremia
DKA
Paraldehyde
Isoniazid
Lactic acidosis
Ethylene glycol
Salicylates
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40
Q

Relationship between postmenopausal SERM therapy and breast cancer

A

SERMs have been shown to REDUCE the incidence of invasive breast cancer in women who are post-menopausal and have increased lifetime risk for breast cancer

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41
Q

Blunt trauma to the abdomen — what is the next step?

A

FAST scan

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42
Q

Tx for 3rd degree burn to anterior thigh

A

Silver sulfadiazine

Early mobilization

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43
Q

What type of surgeries are highest risk for DVT/PE?

A

Orthopedic surgeries

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44
Q

Workup for suspected pheochromocytoma

A

24-hr urine metanephrines and catecholamines (VMA most sensitive)

If elevated, do CT or MRI

Confirm laterality with MIBG scan or adrenal vein sampling and resect

Pre treat patients with alpha blockade, then beta blockade before surgery

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45
Q

Most reliable method to determine the cause of ascites

A

Serum-ascites albumin gradient (SAAG)

Calculated by (serum albumin concentration) - (ascites albumin concentration)

If <1.1 g/dL — absence of portal HTN (biliary ascites, nephrotic syndrome, pancreatic ascites, peritoneal carcinomatosis, post-op lymphatic leak, serositis with CT disease, tuberculous peritonitis)

If >1.1 g/dL — presence of portal HTN (alcoholic hepatitis, Budd-Chiari syndrome, cardiac ascites, cirrhosis, fulminant liver failure, massive liver mets, myxedema, portal vein thrombosis)

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46
Q

Direct vs. indirect hernias relative to inferior epigastric vessels

A

Mnemonic: MD’s Lie

Medial to inferior epigastric vessels in Direct hernias

Lateral to inferior epigastric vessels in Indirect hernias

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47
Q

Dx of brain tumors

A

MRI to identify, biopsy to definitively dx

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48
Q

Dx and tx of arterial insufficiency ulcer

A

U/S, CT angiogram, stent vs bypass

Stop smoking

Cilostazol

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49
Q

Bovine valves vs. mechanical valves in valve replacement surgery

A

Bovine have <10 year duration but no anticoagulation is needed

Mechanical have 10-20 year duration, require anticoagulation - typically warfarin with goal INR 2.5-3.5

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50
Q

________ are LDH associated testicular tumors that are exquisitely sensitive to chemo and radiation

A

Seminoma

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51
Q

5 type classifications of gastric ulcer

A

Type I = gastric ulcer on lesser curvature near incisura

Type II = gastric ulcer on body of stomach in combo with duodenal ulcer

Type III = prepyloric gastric ulcer

Type IV = gastric ulcer that occurs high on lesser curve near GEJ

Type V = drug-induced (NSAIDs) that may occur anywhere in stomach

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52
Q

Herniation of abdominal contents through floor of Hesselbach’s triangle due to acquired defect in transversalis fascia from mechanical breakdown

A

Direct inguinal hernia

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53
Q

A 60 y/o female undergoes surgery for duodenal ulcer disease. Gallstones are noted at the time of the original operation. 8 days following surgery, she develops abdominal pain and RUQ tenderness. To determine if the gallbladder is the cause of her sxs, she should undergo which study?

A. Supine Xray
B. HIDA scan
C. Ultrasound
D. Erect Xray
E. Cholangiogram
A

B. HIDA scan

[not ultrasound bc that would show gallstones but fail to distinguish acute cholecystitis. A HIDA scan will fail to visualize the gallbladder if acute cholecystitis is present, thus confirming dx]

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54
Q

Management of achilles tendon tear

A

Casting cures within months

Surgery cures within weeks

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55
Q

A malnourished pt needs to go to surgery; what’s the best course of action?

A

Oral feedings x10 days > oral feedings for 5 days > parenteral feeding for any time

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56
Q

Developmental dysplasia of the hip means the hip is insufficiently deep so the femur head constantly pops out. How is this dx and tx?

A

Dx during well baby exam with clicking on hip flexion (barlow and ortolani)

Confirm dx with US at 4-6 weeks, as there is physiologic laxity at birth that may resolve

Tx with harness to keep femur approximated as joint grows out

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57
Q

Imaging study of choice with suspected diverticulitis

A

CT scan with IV contrast

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58
Q

Mitral stenosis can lead to CHF and afib. Treatment isn’t necessary until pt gets tired of the symptoms. What are tx options?

A

Commissurotomy (balloon dilation) or simply replacement of the valve

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59
Q

Impacted stone in gallbladder neck causing extrinsic compression of common hepatic duct

A

Mirrizzi syndrome

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60
Q

Risk of parenteral nutrition

A

Fungemia

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61
Q

Posterior fossa brain tumors

A

Medulloblastoma
Ependymoma
Schwannoma

[posterior fossa tumors more likely in kids]

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62
Q

Hodgkin disease is predominately a B-cell malignancy. Excisional LN bx is the best mode of dx for Hodgkin lymphoma. Reed sternberg cells (large cells with slightly basophilic cytoplasm and bilobed eosinophilic inclusion-like nucleoli) are pathognomonic. The Ann Arbor staging system is the most widely used and is based on the number of affected LNs, presence of B symptoms, and whether the disease crosses the diaphragm or not. What are the stages in the Ann Arbor system?

A

Stage I = localized to single node or extralymphatic site

Stage II = multiple LNs or limited extralymphatic site on same side of diaphragm

Stage III = more than 2 sites on both sides of diaphragm

Stage IV = diffuse or disseminated disease

Sub-stage A = no constitutional symptoms

Sub-stage B = constitutional symptoms (fever, night sweats, weight loss)

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63
Q

Management of hemodynamically unstable + pelvic fracture + bleed

A

Explore

Internal fixation

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64
Q

Risk of bladder cancer increases with smoking and exposure to aniline dyes (dry cleaning). An ultrasound could be chosen if there are obstructive symptoms, but the first and best test should be _________

A

A cystoscopy with biopsy

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65
Q

Splenectomy pts should be vaccinated against encapsulated organisms, preferably preoperatively, but if not given preop they can be given 2 weeks postop. What 3 vaccines should be given?

A

Pneumococcal (PCV)

Meningococcal (MCV4)

Haemophilus influenza type b (Hib)

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66
Q

Management of hemodynamically stable + pelvic fracture + bleed

A

Do NOT explore

External fixation

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67
Q

Billroth I vs. Billroth II

A

Billroth I = creation of gastroduodenostomy

Billroth II = gastrojejunostomy

[Either technique is indicated for peptic ulcer disease or gastric adenocarcinoma]

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68
Q

Blunt neck trauma + focal neurologic deficit. First step in management?

A

High dose dexamethasone

[Reduces edema and preserves neuro function]

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69
Q

Alkalinization of the stomach, gastrin, epinephrine, cholinergic agents (bethanecol), and alpha adrenergic agents (metoclopromide) _______ the resting pressure of the LES

A

Increase

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70
Q

Brain tumors may present with Cushing reflex — what does this mean?

A

Cushing reflex = bradycardia + HTN

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71
Q

Components of Child-Pugh score to ascertain functionality of the liver

A 
Encephalopathy
Ascites
Bilirubin
Albumin
INR
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72
Q

Which layer of the intestinal wall is most important in maintaining tensile strength and must be included when sewing intestinal anastomoses?

A

Submucosa

[due to collagen cross linking]

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73
Q

Baby with bilious vomiting and imaging shows double-bubble sign

A

DDx includes duodenal atresia, annular pancreas, malrotation

The chances are greater for malrotation if there is a normal gas pattern distally. Do a contrast enema followed by upper GI series. Malrotation can cause ischemia and must be r/o first.

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74
Q

What is the Pringle maneuver?

A

Compression of hepatoduodenal ligament, sealing the hepatic artery and portal vein

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75
Q

Acute limb ischemia presents with sudden onset of extremity that’s painful, pale, pulseless, paresthesias, paralysis, and poikilothermia (cold). You have 6 hours to fix it. Do an ultrasound or arteriogram to find the site of the lesion. What are the 3 choices of interventions for acute limb ischemia?

A

Embolectomy

Localized tPa

Heparin

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76
Q

An alcoholic Scandinavian male presents with palmar nodes and is unable to extend hand flat

A

Dupuytren’s contracture

[must be tx with surgery, splinting and NSAIDs don’t work]

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77
Q

In CABG procedure, the most significant vessel affected (usually the LAD) is connected to the __________ artery, while the others get the ________ vein

A

Internal mammary artery; great saphenous vein

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78
Q

Which is more likely associated with chromosomal abnormalities - Gastroschisis or Omphalocele?

A

Omphalocele — i.e., Beckwith-Wiedemann syndrome

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79
Q

What is trigger finger?

A

Stneosing tenosynovitis in which pt is unable to extend finger. When forced, there is a “pop”

Tx with splinting and NSAIDs or intraarticular injections

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80
Q

Esophageal cancer is often symptomatic only after it has blocked ___ of the lumen

A

2/3

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81
Q

Post-op fever day 2

A

Pneumonia

—Do CXR, treat for hospital acquired PNA (vancomycin and pip/tazo) while awaiting cultures

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82
Q

____________ is first line for medication therapy of prostate cancer. _________ are used if there is biochemical evidence of recurrence but not symptoms.

_________ is performed if refractory to medications. ______ is added to treatment if there is metastasis

A

GnRH analogs (Leuprolide); Anti-androgens (Flutamide)

Orchiectomy; radiation

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83
Q

Hemorrhage is a common cause of hypovolemic shock. Hemorrhage is further classified based on the amount of blood lost and there are characteristic symptoms associated with each class. Class ____ hemorrhage involves 30-40% blood volume loss, about 1500-2000 cc of blood, resulting in a significant drop in systolic BP and changes in mental status. HR is increased >120 bpm and RR is also markedly elevated. Urine output is decreased and cap refill is delayed

A

Class III

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84
Q

EGD shows dysplasia vs. cancer — what would you do in each case?

A

Dysplasia — local ablation

Cancer — resection

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85
Q

MCC of ulcer on malleolus

A

Venous stasis

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86
Q

Chronic cystic duct obstruction and gallbladder distention with clear mucoid fluid

A

Hydrops of gallbladder

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87
Q

Tx for GERD without alarm sxs

A

PPI

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88
Q

Patient presents with HTN and hypokalemia — what is your dx and what do you do next?

A

Get a renin-aldosterone level — could be primary hyperaldosteronism (Conn syndrome) if increased aldosterone/decreased renin; or secondary hyperaldosteronism (renovascular hypertension) if renin is driving aldosterone (approaches 1)

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89
Q

Antibiotic used in necrotizing pancreatitis

A

Meropenem

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90
Q

Other name for inguinal ligament

A

Poupart’s ligament

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91
Q

Options for prophylactic antibiotics for appendicitis prior to lap appy

A 
Cefotetan
Cefoxitin
Ampicillin/sulbactam
Cefazolin+metronidazole
Clindamycin+fluroquinolone/aztreonam
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92
Q

Paralytic ileus of the colon that occurs in elderly sedentary patients who become immobilized after surgery; colon will appear very dilated

A

Ogilvie syndrome

[Do a colonoscopy to r/o cancer and to decompress the abdomen; leave a rectal tube in place]

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93
Q

A right shift in the hemoglobin-oxygen dissociation curve means that there is a decrease in hemoglobin’s affinity for oxygen. What things cause a right shift of the hemoglobin-oxygen dissociation curve?

A 
Acidosis
High altitude
Increase in pCO2
Increase in temperature
Increase in metabolic needs

[A shift to the left means an increased affinity of hemoglobin for O2. Factors that cause a left shift include decreased metabolic needs, hypothermia, decreased pCO2, increased pH, decreased 2,3-DPG, and fetal hemoglobin]

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94
Q

46 y/o female is dx with LCIS that is ER+. The most appropriate recommendation is:

A. B/l modified radical mastectomy
B. Breast lumpectomy with SLND
C. Breast lumpectomy with negative margins
D. Partial mastectomy
E. Tamoxifen therapy and surveillance
A

E. Tamoxifen therapy and surveillance

[LCIS, unlike DCIS, is not a cancer or a premalignant lesion. It simply places pt at higher risk of developing breast cancer. Tamoxifen reduces this risk and preserves breast tissue]

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95
Q

48 y/o female in the ED presents with RUQ abdominal pain, jaundice, acholic stools, dark urine, and a fever. Total bilirubin is elevated and LFTs suggest biliary ductal obstruction. WBC is 12,000. You suspect acute cholangitis. What is the best first imaging study to order?

A

US abdomen

Combination of jaundice and fever may indicate nonobstructive process or obstructive one. US abdomen can quickly distinguish between these, does not involve radiation, and may provide additional info such as presence of gallstones, CBD stone, or pancreatic mass

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96
Q

Hourly fluid requirments

A

4/2/1 rule —

4 cc/kg for the first 10 kg
2 cc/kg for the next 10 kg
1 cc/kg for every kg over 20 kg

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97
Q

Post-op patient feels the need to void 6+ hours after surgery but can’t — what do you do?

A

In-and-out cath

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98
Q

Head trauma resulting in LOC followed by lucid interval

A

Epidural hematoma

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99
Q

Football player passes out after colliding with another player. What do you do?

A

CT scan. If negative, dx is concussion — send home

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100
Q

Crescendo-decrescendo murmur in systole

A

Aortic stenosis

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101
Q

Chapman points in 5th and 6th ICS on mid-clavicular line on right anteriorly

A

Liver

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102
Q

________ are brain tumors attached to the dura that are highly curable via resection; dx with CT showing connection to bone, and biopsy showing psammoma bodies

A

Meningiomas

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103
Q

Typical chemotherapy for breast cancer

A

Typically anthracycline based (Doxorubicin-Cyclophosphamide) + a taxane (Paclitaxel)

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104
Q

Best test for suspected coarctation

A

Arteriogram

But CTA or MRA can be sufficient

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105
Q

______ shock = loss of SVR from infection or anaphylaxis

A

Distributive

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106
Q

AR disorder resulting in increased conjugated bilirubin without elevation in LFTs

A

Dubin Johnson syndrome

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107
Q

_______ is a brain tumor found at the cerebellopontine angle. If it is bilateral, it is part of ______________ (syndrome)

A

Schwannoma; neurofibromatosis type II

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108
Q

Holosystolic murmur that radiates to axilla

A

Mitral regurg

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109
Q

Workup for Cushings

A

24-hr free cortisol level, confirmed by 1 mg low dose Dexamethasone suppression test

If cortisol is high, its Cushings. Follow up with ACTH level to distinguish adrenal (low ACTH) from extra-adrenal (high ACTH). If adrenal, spot it with CT/MRI of adrenals. If extra-adrenal, perform high dose dexamethasone suppression test to determine pituitary (suppresses) vs ectopic (no suppression)

If ectopic, find it with CT/MRI of the chest (lung Ca), abdomen (pancreatic Ca), then pelvis (adrenals)

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110
Q

Harsh holosystolic murmur, right-sided cardiac hypertrophy, increased right-sided pressures, failure to thrive, heart failure

A

VSD

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111
Q

Embolic occlusion of retinal artery presents with painless unilateral vision loss without any other stroke symptoms and possibly cherry-red spots on fovea. What is the tx?

A

Intra-arterial tPA

To buy time or to get clot further down the arterial tree to spare some vision, you can try to hyperventilate rebreathed CO2 to vasodilate arteries, and apply orbital pressure

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112
Q

Blood at the meatus, high-riding prostate — what test do you get?

A

Retrograde urethrogram

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113
Q

EGD shows metaplasia/Barrett’s/salmon — how tx?

A

High dose PPI

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114
Q

Tx and margins needed for melanoma with Breslow of 2-4 mm vs. >4 mm

A

2-4 mm = wide resection and SLND if tracer+, 2 cm margins

> 4mm = palliative chemo and radiation, debulking of tumor burden palliative only

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115
Q

Organophosphage toxicity manifests as SLUDGE — salivation, lacrimation, urination, defecation, GI upset, emesis. What is tx?

A

Atropine

Pralidoxime

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116
Q

Pt with hx of t(11;22) presents with mid-shaft bone pain and xray shows onion-skin pattern; tx is resection

A

Ewing’s sarcoma

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117
Q

Head trauma followed by LOC and retrograde amnesia

A

Concussion

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118
Q

Anticholinergic agents (atropine), glucagon, and secretin ______ the resting pressure of the LES

A

Decrease

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119
Q

Single large tortuous arteriole in the submucosa of the upper GI tract which does not undergo normal branching or a branch with caliber of 1-5mm. The lesion bleeds into the GI tract through a minute defect in the mucosa which is not a primary ulcer of mucosa, but an erosion likely caused in submucosal surface by protrusion of the pulsatile arteriole

A

Dieulafoy’s lesion

[approx. 75% occur in upper part of stomach within 6 cm of the GE junction, most commonly in lesser curvature]

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120
Q

__________ tenosynovitis may be caused by continued forced extension of the thumb (baby cradle, weights, etc) resulting in pain on thumb and hand when used

A

De Quervains

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121
Q

Inguinal hernia that contains elements of both direct and indirect inguinal hernia

A

Pantaloon hernia

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122
Q

Tx for BCC in the following locations:

Large lesion not on the face

Large lesion on an extremity

Any lesion on face

A

Large lesion not on the face = wide excision

Large lesion on an extremity = amputation

Any lesion on face = Mohs

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123
Q

Methanol (from moonshine) or ethylene glycol (from antifreeze) intoxication yield an anion gap acidosis and osmolar gap. Antifreeze has fluorescein which can be detected by Woods lamp of urine. Tx is _____ which inhibits conversion of either to their toxic metabolites

A

Fomepizole (or alcohol)

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124
Q

Chemotherapeutic often utilized in breast cancer that is associated with a dose-dependent irreversible CHF

A

Doxorubicin

_____________________________________________

Doxorubicin = dose-dependent irriversible CHF
Trastuzumab = dose-INdependent Reversible CHF
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125
Q

Signs/sxs/tx for black widow spider bite

A

Abdominal pain/pancreatitis

Give IV calcium gluconate

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126
Q

Diagnostic criteria for SIRS vs. Sepsis

A

SIRS involves 2 or more of the following: Temp >38C or <36C, HR >90, RR >20 or PaCO2 <32 mmHg, WBC >12,000 or <4000, or >10% immature neutrophils

Sepsis = SIRS + documented infection

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127
Q

Presentation of posterior shoulder dislocation

A

Usually only occurs with extreme muscle spasm (seizure or electrocution)

Arm position is adducted and internally rotated (protected wrist position)

[dx with xray, tx is relocation and sling]

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128
Q

Dx and management of aortic stenosis

A

Dx with echocardiogram

Tx with surgical replacement; TAVR and TAVI may be attempted in poor surgical candidates

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129
Q

How is bleeding in the brain reduced pharmacologically?

A

IV beta blockers to reduce systolic BP (<140/<90)

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130
Q

Most common congenital heart defect

A

VSD

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131
Q

Hemisection of spinal cord

A

Ipsilateral loss of motor and sensory below the lesion

Loss of pain sensation contralaterally

Lower motor neuron symptoms at level of injury
Upper motor neuron symptoms below

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132
Q

Abx for dog/cat/human bite

A

Amoxicillin-Clavulanate

[human bites also require surgical debridement — do not suture them closed!]

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133
Q

Hemorrhage is a common cause of hypovolemic shock. Hemorrhage is further classified based on the amount of blood lost and there are characteristic symptoms associated with each class. Class ____ hemorrhage involves more than 40% blood volume loss, greater than 2L of blood, leading to significant decrease in BP and mental status. Tachycardia is present often greater than 140 bpm. Urine output minimal or absent. Skin is cold and pale and cap refill is delayed

A

Class IV

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134
Q

SIRS involves 2 or more of the following: Temp >38C or <36C, HR >90, RR >20 or PaCO2 <32 mmHg, WBC >12,000 or <4000, or >10% immature neutrophils

Sepsis = SIRS + documented infection
______________________________________________________

Define severe sepsis vs. septic shock

A

Severe sepsis = sepsis + organ dysfunction or hypoperfusion (lactic acidosis, oliguria, or altered mental status)

Septic shock = sepsis + organ dysfunction + hypotension (systolic BP <90 or >90 with vasopressors)

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135
Q

Hemothorax caused by penetrating trauma presents with decreased lung sounds with dullness to percussion. An X-ray will show horizontal lung shadow with a meniscus. Treatment is typically just to place a chest tube and drain the blood. When does surgical exploration become necessary?

A

Surgical exploration (thoracotomy) for the source of the bleeding is required if the chest tube produces 1500+ mL (20cc/kg) on insertion OR 200 mL/hr (3cc/kg/hr)

[these findings indicate peripheral arterial bleeding which will not stop on its own]

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136
Q

_______ test is used to dx scoliosis, in which pt bends forward and asymmetric shoulders are diagnostic. Confirm with xrays

A

Adam’s

137
Q

Blood at the meatus + high-riding prostate following traumatic pelvic fracture indicates possible urethral injury. What must you do prior to inserting foley?

A

Retrograde urethrogram

138
Q

Epidural hematoma may present with signs of uncal herniation - what are these signs?

A

Ipsilateral fixed dilated pupil

Contralateral hemiparesis

139
Q

A 67 yo female presents with paresthesias in the limbs. Exam reveals loss of vibratory sense, positional sense, and sense of light touch in lower limbs. She is also found to have pernicious anemia. Endoscopy reveals an ulcer in the body of the stomach. What is the most likely dx?

A. Vit B12 excess
B. Deficiency of Vit K
C. Cancer of the stomach
D. Gastric sarcoma
E. Esophageal varices
A

C. Cancer of the stomach

[Pts with pernicious anemia have achlorhydria and an increased risk of developing gastric carcinoma. There is a deficinecy in Vit B12 that leads to megaloblastic anemia and neurologic involvement (subacute degeneration of the dorsal and lateral spinal columns)]

140
Q

Anterior Chapman’s point 6th ICS on the R

A

Gallbladder

141
Q

Fluids and management in pt with pulmonary contusion

A

Colloids (blood and albumin) for resuscitation (AVOID NS and LR which are crystalloids)

Use diuretics and PEEP

142
Q

______ imaging is indicated if there is a suspicion of necrotizing pancreatitis, but this shouldnot be done until after 72 hours of illness, and in patients with predicted severe disease or evidence of organ failure, associated fever, anda markedly elevated WBC.

A

CT

[CT imaging can also be done in pts with a suspicion of infected pseudocysts, but these take 7-10 days to develop]

143
Q

Rectal injury in pelvic fracture. Next step?

A

Proctoscope

144
Q

Colonoscopy guidelines in pt with UC

A

Colonoscopy q1y needed starting at year 8 from dx

145
Q

Surgical procedure involving resection of rectosigmoid colon with closure of rectal stump to form colostomy

A

Hartmann procedure

146
Q

An appendiceal wall >____ is considered thickened

A

> 6 mm

147
Q

Systolic crescendo-decrescendo murmur heard at left sternal border that radiates to the neck; most commonly presents with angina, but can present with syncope or CHF (worse px)

A

Aortic stenosis

148
Q

Tx for biliary atresia

A

Kasai procedure (hepatoportoenterostomy)

149
Q

Grading internal hemorrhoids

A

Grade I = hemorrhoids do not prolapse

Grade II = hemorrhoids prolapse with defecation but reduce spontaneously

Grade III = hemorrhoids prolapse on defecation and must be reduced manually

Grade IV = hemorrhoids are prolapsed and cannot be reduced manually

150
Q

FETID mnemonic for things that keep fistulas open

A 
F — foreign bodies
E — epithelialization
T — tumor
I — infection/irradiation/inflammatory bowel
D — distal obstruction
151
Q

Her2Neu-associated breast cancer is a tyrosine kinase associated with worse prognosis but provides targeted chemotherapeutic agent _________, which inhibits Her2Neu.

This chemotherapeutic is associated with what adverse effect?

A

Trastuzumab

Dose-independent reversible CHF (q3month echocardiograms required)

152
Q

How much albumin should be given for every liter of ascites removed after large volume paracentesis?

A

6-8 g of albumin/L of ascites removed

153
Q

Management of PDA in infancy

A

In term infants, usually self-resolve within 7 days

In preterm infants, often need to be closed using indomethacin or surgery

Use prostaglandins if PDA is needed for critical heart lesion

154
Q

Old person has a fall and gets rapidly worsening dementia, dx and next step?

A

Subdural hematoma; get a CT

155
Q

Young patient with lymphadenopathy and B symptoms (fever, night sweats, weight loss)

A

Hodgkin lymphoma

156
Q

What is considered the standard biopsy for the diagnosis of breast cancer?

A

Core-needle biopsy

[FNA is sufficient if ultrasound confirms its a cyst; excisional biopsy is done when it is obviously cancer]

157
Q

Tetanus prophylaxis recommendations for clean/minor wounds vs. contaminated or deep puncture wounds

A

For clean/minor wounds, tetanus toxoid should be given if the last booster was >10 years ago

For contaminated or deep puncture wounds, a booster should be given if pts last one was >5 years ago

158
Q

A normal ABI is 1.0-1.4. An ABI > 1.4 indicates calcification — this should be followed up with what test?

A

Toe-brachial index

159
Q

Pt with hx of Peutz Jeghers syndrome presents with colicky abdominal pain and moderate tenderness in RLQ with associated rebound. Most likely dx?

A. Appendicitis
B. Bowel ischemia
C. Colon adenocarcinoma
D. Intussusception
E. Volvulus
A

D. Intussusception

[about 50% of pts with PJS will have an intussusception during their lifetime, most often in small bowel, likely caused by hamartomatous polyps, and should be tx with polypectomy to prevent recurrence. PJS may also cause occlusion of lumen by polyps, abd pain caused by infarct, acute or chronic rectal bleeding from ulceration, and extrusion of polyps through the rectum]

160
Q

A normal ABI is 1.0-1.4. An ABI of 0.9-1.0 is equivocal and should be followed up with _________. Mild PVD is indicated by ABI of 0.8-0.9, moderate PVD is indicated by ABI of 0.4-0.8, and severe PVD is indicated by ABI of <0.4. PVD should be followed up with _____

A

Exercise ABI; U/S Doppler

161
Q

Patent ductus arteriosus results in connection between what 2 structures?

A

Aorta

Pulmonary artery

162
Q

Baby with bilious vomiting and imaging shows multiple air-fluid levels

A

Intestinal atresia

[caused by vascular accident in utero; ask about maternal cocaine use]

163
Q

Management of suspected CO poisoning

A

Obtain carboxyhemoglobin level (normal is <3% but smokers may have as much as 10%)

Tx is 100% FiO2 and hyperbaric

[NOTE that saturation of Hgb will appear normal on pulse ox!]

164
Q

Imaging of choice when pt presents with painless jaundice

A

CT abdomen

[better visualization of the pancreas]

165
Q

_______ shock is asociated with cardiac tamponade or PE

A

Obstructive

166
Q

Disease occurring in teenage athletes that presents as painful knee with swelling over tibial tubercle. The athlete has 2 options — stop exercising (curative) or play through it. If they play through it, there may be a palpable nodule. There is no permanent sequelae but it hurts

A

Osgood-Schlatter disease (aka Osteochondrosis)

167
Q

Structures included in hepatoduodenal ligament

A

Proper hepatic artery
Portal vein
Common bile duct

168
Q

Most common malignancy associated with chylous ascites

A

Lymphoma

169
Q

Penetrating neck trauma that presents with any one of the “hard signs” is an indication to go to surgery. What are the hard signs from an airway, vessel, and digestive perspective?

A

Airway = gurgling, stridor, apnea

Vessels = expanding hematoma, pulsatile bleeding, frank shock, stroke

Digestive = frank mediastinitis

170
Q

Hepatic hemangioma

Thrombocytopenia

Consumptive coagulopathy

A

Kasabach-Merritt syndrome

171
Q

Among the parameters used to diagnose shock are a systolic blood pressure of ________ or urine output of ________, or clinical signs of shock (pale, cool, diaphoretic, etc)

A

<90 mmHg

<0.5 cc/kg/hr

172
Q

Mets to the brain usually make it through the medium caliber vessels and get stuck as a single or multiple lesions at the grey-white border. What are the 3 most common cancers that metastasize to the brain?

A

Lung > Prostate/Breast > Colon

173
Q

High-pitched blowing murmur that’s decrescendo, best heard in diastole at 4th intercostal space at left sternal border; other signs include widened pulse pressure, water-hammer pulses, pistol-shot pulses, and head bobbing

A

Aortic insufficiency

174
Q

Tetralogy of Fallot is most common cyanotic defect in children and is an endocardial cushion defect. What are the 4 findings?

A

Overriding aorta
Pulmonary stenosis
Right ventricular hypertrophy
Ventricular septal defect

175
Q

75 y/o presents with painless loss of vision in L eye that he noticed when he woke up this morning. Hx is significant for cardiovascular disease and smoking. On PE there is afferent pupillary defect and dilated fundoscopic exam shows cherry red spot and pale “ground glass” retina. Carotid bruits bilaterally. Pulses weak in lower extremities. Which of the following is next best step?

A. Anterior chamber paracentesis
B. Methylprednisolone
C. Ocular massage
D. Orbital MRI
E. tPA
A

C. Ocular massage

[this is acute central retinal artery occlusion. Repeated pressure for 10-15 seconds on orbit improves retinal blood flow and may allow embolus to move downstream to restore blood flow to some of retina. Other tx include acetazolamide and eye drops to lower intraocular pressure and allow increased blood flow. TPA can be given w/i 4-6 hours, but since he woke with sxs, we don’t know timing. Anterior chamber paracentesis is second line if massage doesnt work]

176
Q

Chapman point in intercostal spaces between ribs 2-3 close to sternum anteriorly, and on middle of transverse processes of T2 posteriorly

A

Esophagus

177
Q

How do you work up a suspected renovascular hypertension (secondary hyperaldosteronism)?

A

Aldosterone:renin ratio (approaches 1)

Ultrasound with Doppler

Definitive dx with angiogram, but this should only be done when intervention is planned (i.e., young female with fibromuscular dysplasia)

178
Q

Most common cyanotic heart defect in newborns

A

Transposition of great vessels

179
Q

Malnutrition is identified by a loss of body weight >20% in a few months, an albumin of _____, or anergy to skin antigens

A

<3

180
Q

Tx and margins needed for melanoma with Breslow of <0.5 mm vs. 1-2 mm

A

<0.5 mm = local resection with 0.5cm margins

1-2 mm = wide resection and SLND if tracer+, 1cm margins

181
Q

How is primary sclerosing cholangitis diagnosed?

A

MRCP

[not ERCP!!!]

182
Q

The fluid of choice for resuscitation in the trauma patient is LR — what is contained in LR and why is it the top choice in this scenario?

A 
130 mEq Na+
109 mEq Cl-
28 mEq lactate
4 mEq K+
3 mEq Ca+

It is isotonic and the lactate is converted to bicarb which buffers hypovolemia-induced metabolic acidosis that occurs with shock

183
Q

Hip fractures present with shortened leg and external rotation. How are these managed when they involve femoral head vs. intertrochanteric vs. shaft?

A

Femoral head involvement requires femoral prosthesis due to femoral neck having tenuous vascular supply

Intertrochanteric fracture gets ORIF with plates

Shaft fracture gets rods

184
Q

What injuries should you go looking for if a pt presents with traumatic flail chest, scapular fracture, or sternal fracture?

A

Pulmonary contusion
Myocardial contusion
Aortic dissection

185
Q

Pt with chest pain s/p MI and CABG procedure 2 days prior —what test do you order?

A

Creatine kinase

186
Q

To prevent vasospasm (acute infarct after subarachnoid hemorrhage), the pt needs what pharmacologic intervention?

A

Calcium channel blockers

[if vasospasm occurs, blood pressure msut be increased to maintain perfusion]

187
Q

Post-op patient with some, but low, urine output — what do you do?

A

500cc fluid bolus — if dehydrated, urine output will increase slightly with bolus. If it doesn’t, there’s some sort of intrinsic renal failure requiring further workup

188
Q

What color are gallstones on MRCP

A

Black

MRCPs are down with T2 weighted imaging with fat suppression where only fluid appears hyperintense (white) and stones are hypointense (black)

189
Q

Most common cause of hydatid disease

A

Echinococcus granulosus

[indicated by calcifications in the wall of a liver cyst; cysts can rupture and result in anaphylactic shock. Tx with mebendazole/albendazole]

190
Q

Small bowel resection with a primary anastomosis — the most appropriate classification of this wound is:

A. Clean
B. Clean contaminated
C. Contaminated
D. Gross contaminated

A

B. Clean contaminated [sterile wounds that require opening of a non-sterile hollow viscus organ without significant spillage of infectious contents]

[Clean wounds are depicted by sterile environments with no source of infection present other than potential skin contaminants. Contaminated wounds are accidental wounds that involve violation of sterile fields or gross spillage of infectious content into previously sterile field. Gross contaminated wounds include traumatic wounds that have significant delay in attaining treatment, oftentimes including necrosis or frank purulence]

191
Q

T/F: surgery is curative for Crohns

A

False — surgery can be curative for UC, but not Crohns

192
Q

Retinal detachment can occur spontaneously or following major trauma. The pt will either complain of floaters (indicating minor disease) or of a veil or cloud on top of their visual picture (indicating severe disease). What is the tx?

A

Laser — spot “welds” the retina back into place. Vision is compromised from there on, but without tx they will lose all vision

193
Q

Treatment of gastric adenocarcinoma in the body or fundus of the stomach

A

Total gastrectomy

[entire stomach is removed and a Roux-en-Y limb is sewn directly to the esophagus]

194
Q

Orthopedic emergency that can occur in adolescents who are either obese or in growth spurt; they complain of sudden onset hip or knee pain. Dx is confirmed via frog-leg position xray and surgery is required to tx

A

Slipped capital femoral epiphysis

195
Q

Splenectomy pts are more susceptible to encapsulated organisms — what are 4 common ones?

A

Salmonella
S.pneumonia
H.influenzae
N.meningitidis

196
Q

A ____ hernia occurs when only the antimesenteric wall of a hollow abdominal organ becomes incarcerated in an inguinal hernia

A

Richter’s hernia

[especially dangerous and difficult to dx because bowel ischemia may occur without the presentation of bowel obstruction]

197
Q

Wound ______ occurs when skin is intact but fascia has failed; dressings soaked with salmon-colored fluid

A

Dehiscence

198
Q

Test done for corneal abrasion

A

Fluorescein dye test

199
Q

4 stages of ulcers

A

Stage I = Nonblanching erythema

Stage II = Epidermis and Partial dermis

Stage III = Through Epidermis and Dermis

Stage IV = Muscle or bone

200
Q

LES can’t relax = achalasia; food gets stuck. Dx by barium swallow or definitively with manometry. What are treatment options?

A

Dilate with balloon
Relax with botox
Cut sphincter with Heller myotomy (best option)

201
Q

The zone method for managing penetrating neck trauma is less often used nowadays than performing a simple CT angiogram, but it is still utilized in many centers. What is the first step in management in a stable patient with a zone I vs. zone II vs. zone III penetrating neck trauma?

A

Zone I = angiogram

Zone II = exploration

Zone III = esophagram, bronchogram, arteriogram

202
Q

First line therapy for carpal tunnel

A

NSAIDs

[not splinting!]

203
Q

How is pancreatic cancer diagnosed?

A

Endoscopic ultrasound with biopsy

204
Q

ERCP

A

Endoscopic retrograde cholangiopancreatography

[endoscope guided into duodenum, allowing for instruments to be passed into bile and pancreatic ducts; these are then opacified by injection fo contrast medium and radiologically visualized]

205
Q

________ syndrome = hepatic venous outflow obstruction

A

Budd-Chiari syndrome

[causes include polycythemia vera, factor V leiden mutation, thrombocytosis, protein C and S, antithrombin III, antiphospholipid antibody syndrome]

206
Q

Abscess found in pulp of fingertip, typically following a penetrating injury. It’s trapped inside a fascial plane so is exquisitely tender

A

Felon

207
Q

Worst cardiac prognostic risk factor on Goldman index

A

JVD

[other factors include MI w/i 6 months, arrhythmia, age >70]

208
Q

2 causes of renovascular hypertension

A

Bilateral renal artery stenosis

Fibromuscular dysplasia

209
Q

Inguinal hernia containing the vermiform appendix

A

Amyand hernia (aka appendiceal hernia)

210
Q

On examining a pediatric patient you hear bowel sounds over the lungs and note a scaphoid abdomen. The baby is dyspneic. Diagnosis?

A

Congenital diaphragmatic hernia

[caused by holes in the diaphragm. These are most commonly posterior (Bochdalek most common), but can be anterolateral (Morgagni). The problem is not the hernia, but the hypoplastic lung that must be intubated and ventilated for baby’s survival]

211
Q

Pt presents with GERD followeed by progressive dysphagia to solids then liquids, you suspect cancer. What is your next step in dx?

A

Barium swallow — don’t do EGD right away — must identify safety to avoid perforation

Confirm with EGD and Bx

Assess stage with CT scan

212
Q

Patient presents with “thunderclap” headache described as the worst headache of their life. Most likely dx?

A

Subarachnoid hemorrhage

213
Q

Elderly pt with osteoporosis falls resulting in Colle’s fracture — what does that mean?

A

Dorsally displaced radius, looks like dinner fork (2 prongs sticking up)

Dx with xray and cast it

214
Q

Kehr’s sign

A

Shoulder pain from diaphragmatic irritation following trauma (indicative of ruptured diaphragm)

215
Q

Tx for acute subdural hematoma

A

Craniotomy if midline shift noted on CT

Otherwise the goal is to decrease ICP with elevation, hyperventilation, and mannitol

216
Q

Autosomal dominant disorder of which there are 2 major manifestations: pigmented mucocutaneous macules and multiple hamartomatous GI polyps

A

Peutz-Jeghers syndrome

217
Q

Neuro manifestations of central cord syndrome

A

Loss of pain and temp in cape-like distribution (usually hands and arms)

218
Q

Absorbable suture

A 
Vicryl
Polydioxanone (PDS)
Dexon
Chromic
Catgut
219
Q

Patient presents from a movie theater with eye pain, headache, and rigid eyeball. There are halos and corneal clouding. The pupil is dilated and nonreactive to light. What is the dx and what do you do?

A

Dx = acute narrow angle glaucoma

Tx = alpha-2 agonists, beta blockers, diuretic (acetazolamide)
[NEVER give atropine!]

[acute narrow angle glaucoma is caused by fluid being trapped in the anterior chamber. When pupil dilates, pressure builds up and pupil cannot constrict back down.]

220
Q

Parkland formula to calculate fluid rescusitation in burn pts

A

(Body weight in kg) x (% BSA burned) x (4 cc of LR)

The first half is given in 8 hrs and the second half is given in 16 hrs

221
Q

A _____ inguinal hernia is defined as a hernia containing a hollow retroperitoneal organ, most commonly the bladder or colon

A

Sliding

222
Q

All subarachnoid hemorrhage pts need to have _______ prophylaxis

A

Seizure

[any standard antiepileptic can be given; Phenytoin, valproate, levetiracetam are all good choices]

223
Q

Anatomic structure that holds the aortic arch in place

A

Ligamentum arteriosum

224
Q

VACTERL anomalies

A 
Vertebral (X ray)
Anal (imperforate)
Cardiac (echo)
Tracheal
Esophageal
Renal (US)
Limbs (thumbs in particular)
225
Q

_______ score is created based on transrectal biopsy for prostate cancer

A

Gleason

226
Q

Treatment of gastric adenocarcinoma in the antrum of the stomach

A

Subtotal gastrectomy

[removal of distal 3/4 of stomach]

227
Q

Autoimmune disease associated with destruction of extrahepatic and intrahepatic bile ducts

A

Primary sclerosing cholangitis

228
Q

Don’t operate on anyone with DKA. What steps must you take to manage DKA prior to operating?

A

Control BG with hydration/insulin

Ensure urine output before attempting surgery

229
Q

You diagnose primary sclerosing cholangitis with strictures. What do you do?

A

Ursodeoxycholic acid to transplant

[do NOT stent PSC]

230
Q

Blood products used to tx hemophilia B

A

Factor IX

[hemophilia B = factor IX deficiency]

231
Q

Old person with hyperextension injury, now can’t feel pain or temperature, has loss of motor in the upper extremities. Dx?

A

Central cord syndrome

232
Q

5 P’s of pheochromocytoma

A 
Paroxysms of pressure (HTN)
Palpitations
Perspiration
Pain (pounding headache)
Pallor
233
Q

An out of shape weekend warrior presents with pinpoint tibia pain. X-ray is normal. What do you do?

A

Cast it, repeat xray in 2 weeks

[this is likely a stress fracture; xray is usually normal for 2 weeks]

234
Q

Tx for adenocarcinoma of the appendix

A

Right hemicolectomy

235
Q

Nonabsorbable

A

Nylon
Silk
Stainless steel
Prolene

236
Q

Presentation of anterior shoulder dislocation

A

Arm abducted and externally rotated (shaking hands position)

Deltoid paresthesia (axillary nerve damage)

[dx with xray, tx with relocation and sling]

237
Q

Borders of Hesselbach’s triangle

A

Inguinal ligament
Lateral border of rectus abdominis muscle
Inferior epigastric vessels

238
Q

Chapman point at 6th intercostal space on the L about one inch lateral to SC joint

A

Stomach peristalsis

239
Q

Best diagnostic strategies for BCC in the following locations:

Small lesion not on face

Large lesion not on face

Any lesion on face

A

Small lesion not on face = excisional bx (also tx)

Large lesion not on face = incisional bx

Any lesion on face = incisional bx

240
Q

Continuous machine-like murmur

A

PDA

241
Q

Tx of suspected scaphoid fracture if x-ray negative vs. x-ray positive

A

X-ray negative — cast it! xray may turn positive later

X-ray positive — ORIF

242
Q

Acromegaly is a growth hormone secreting tumor that presents as enlarging non-long bones. There may also be associated HTN and DM. What test is utilized in dx?

A

Glucose suppression test — which will fail to decrease GH

F/u with MRI

243
Q

A pt with Hemophilia A is scheduled for surgery. What is the most important blood product to have available in case of intraoperative bleeding?

A

Cryoprecipitate

[Hemophilia A = factor VIII deficiency; Cryoprecipitate is rich in factor VIII and fibrinogen which will help coagulation in these pts]

244
Q

Tx of bladder cancer

A

Since most are superficial without invasion, you can do transurethral resection + BCG or Cisplatin based chemotherapy

245
Q

T/F: Well-demarcated red papule in sun exposed area is most often a SCC. Diagnostic and treatment strategies mirror that of basal cell carcinoma.

A

True

246
Q

When is right hemicolectomy indicated in the case of appendiceal carcinoid?

A

When tumor is >1.5 cm

[If there are no signs of tumor spread and tumor is less than 1.5 cm, just an appendectomy can be performed]

247
Q

A compartment syndrome may develop after circumfirential full-thickness burns. What is the first step in treatment?

A

Escharotomy

[should inadequate perfusion persist despite escharotomy, a fasciotomy may need to be performed. However, these are not typically done along with the initial escharotomy]

248
Q

Tx for aortic dissections when they are ascending (type A) vs. descending (type B)

A

Ascending = operate (may need to replace aortic valve)

Descending = medically (IV beta blockade)

249
Q

When is EGD the first step in GERD?

A

Alarm symptoms — anemia, N/V, weight loss

250
Q

Post-op patient with paralytic ileus that has not resolved by day 5-7 — what is the next step?

A

Upright KUB and/or contrast swallow CT

If it is a bowel obstruction, take to OR

251
Q

After abdominal trauma and confirmed intraabdominal hemorrhage, you perform the Pringle maneuver - compressing the hepatoduodenal ligament and thus sealing the hepatic artery and portal vein. However, there is continued bleeding - this indicates transection of the ______ _____

A

Hepatic vein

252
Q

Testicular endodermal sinus tumors can be followed with _____, while choriocarcinomas can be followed with ____

A

AFP; beta HCG

253
Q

The diagnosis of carpal tunnel is clinical. Initial treatment is splinting and NSAIDs. If that fails, next is intraarticular steroids. Ultimate tx is surgical release. Before going to the OR, obtain an ________ to confirm the dx

A

Electromyography

254
Q

Post-op fever day 7+

A

Wound infection

[if erythematous and warm it’s cellulitis - tx with abx. If erythematous, warm, and boggy - drain the abscess. If unknown, do US]

255
Q

In sliding hiatal hernia, the _____ of the stomach is displaced into the ______ mediastinum

A

Cardia; posterior

256
Q

Brain tumor common in children in the 4th ventricle causing an obstructive hydrocephalus; may present with history of child curling into a ball as this relieves the obstruction and the symptoms

A

Ependymoma

257
Q

Hormone that is a potent stimulator of gallbladder contraction

A

CCK

258
Q

Healthy active athlete with knee pain and a click on full extension

A

Meniscal tear

Use MRI to confirm and arthroscopic repair to remove as little as possible to avoid resultant arthritis

259
Q

Causes of post-op altered mental status

A

Hypoxia — give O2

ARDS — give PEEP

Delirium tremens — give benzos

Electrolytes and hypoglycemia — get a CMP and replace

Sundowning — give atypical antipsychotics

260
Q

Test used to screen for AAA vs. Test used to track changes in AAA

A

Screening = Ultrasound

Track changes = CT scan

[Do not use angiogram. Screen men over age of 65 who have smoked at some point in their lifetime with ultrasound]

261
Q

Post-op fever day 5

A

DVT/PE

Positive finding is 2 cm greater on one leg compared to other. Ultrasound to Dx. Anticoagulate with LMWH bridge to warfarin. Prophylaxis with early mobilization and heparins

262
Q

Wounds that are left open to heal by granulation and contraction are termed to heal by ______ _____

A

Secondary intention

263
Q

Accessory ducts directly from the liver bed into the gallbladder

A

Ducts of luschka

264
Q

Minimal urine output for an adult patient

A

0.5 cc/kg/hr

265
Q

3 requirements to qualify for CABG procedure

A
  1. Blood vessels have a 70% stenosis
  2. LAD affected or 3+ vessel disease
  3. There is good LV function OR reperfusion will restore ventricular function
266
Q

Dx and management of orbital cellulitis vs. periorbital cellulitis

A

Periorbital cellulitis = inflammation of eye area (Tx with abx)

Orbital cellulitis = inflammation of eye area + extraocular mm. paralysis (Tx: Get CT scan to confirm, then perform surgery)

267
Q

Lund-Browder chart or “rule of nines” method for estimating burn size in adults

A 
Anterior trunk = 18%
Posterior trunk = 18%
Each lower extremity = 18%
Each upper extremity = 9%
Head = 9%
268
Q

Estrogen and progesterone receptor positivity in breast cancer allows for endocrine therapy. What are preferred therapies in premenopausal vs. postmenopausal women?

A

Premenopausal:
Tamoxifen (stronger, causes DVT, risk of endometrial cancer)
Raloxifene (weaker, no DVT, no risk of endometrial cancer)

Postmenopausal:
Aromatase inhibitors like anastrozole

269
Q

______ ______ injury occurs in the setting of angular trauma such as spinning in a car struck on an angle. This produces blurring of the grey-white matter that’s best seen on MRI. Little can be done other than to manage ICP until the pt comes out of the coma

A

Diffuse axonal injury

270
Q

Best diagnostic test in pt complaining of GERD

A

24-hour pH monitoring

271
Q

Safest way to manage acute cholecystitis in a patient who is otherwise a poor surgical candidate

A

Percutaneous insertion of cholecystostomy tube

[Provides immediate decompression of the inflamed gallbladder thereby delaying definitive management until patient is stabilized. Once decompressed, cholecystography can be performed through the tube after resolution of cholecystitis. Free passage of contrast into the duodenum means there is no cystic duct obstruction and the tube may be removed. If gallstones appear as a source of obstruction, cholecystectomy should be performed once pt is medically stable]

272
Q

Pt with suspected aortic dissection requires imaging, but CT angiogram is contraindicated due to renal failure. What are your 2 options?

A

TEE

MRI

[both are considered equivalent options]

273
Q

Salicylate toxicity presents early on with tinnitus, vertigo, and hyperventilation; later with anion gap metabolic acidosis, altered mental status, and hyperpyrexia. What is tx?

A

Alkalinization of urine and forced diuresis

274
Q

In a pt with cirrhosis, the _____ score can be used to ascertain functionality of the liver

A

Child-Pugh

275
Q

Tx for H pylori

A

PPI + 2 antibiotics (usually Clarithromycin + amoxicillin OR Clarithromycin + metronidazole)

Sometimes Bismuth used as adjunct

276
Q

Smoke inhalation is far more common than medication induced Cyanide poisoning (such as nitroprusside). Cyanide converts all metabolism to anaerobic despite adequate O2. Coma, seizures, hypotension, and heart block are late symptoms. Look for cherry-red skin color and cherry-red arterial blood. What is first line therapy?

A

Thiosulfate

[the second line therapy is amyl nitrate which may worsen CO poisoning]

277
Q

Early sepsis is a physiologically hyperdynamic, hypermetabolic state representing a surge of catecholamines, cortisol, and other stress-related hormones. What are the 3 most common earliest clinical manifestations of sepsis?

A

Altered mental status

Tachypnea that leads to respiratory alkalosis

Flushed skin

278
Q

Pt complains of intermittent “veil” dropping over his eye and obstructing vision, but then vision returns — what is the dx?

A

Amaurosis fugax (indicates impending retinal artery occlusion)

[If this was constant, not transient — it is retinal detachment]

279
Q

Cherry-red skin, cherry-red blood, smoke inhalation — what toxin?

A

Cyanide

280
Q

5 P’s of critical limb ischemia

A 
Pain
Pallor
Paresthesia
Paralysis
Pulselessness
281
Q

MRCP

A

Magnetic resonance cholangiopancreatography

282
Q

Septic hip can occur at any age, though usually in toddlers, during febrile illness with complaints of joint pain. How is this dx and tx?

A

X-ray first, then joint aspiration with gram stain and culture

Tx with drainage and abx

283
Q

24 y/o male presents to ED with right sided head pain after being hit with blunt object by his roommate. Vital signs show BP of 139/91, HR 88, RR 12. PE reveals mild confusion, left upper and lower extremity weakness. Most likely dx?

A. Epidural hematoma
B. Intracerebral hemorrhage
C. Ischemic stroke
D. Subarachnoid hemorrhage
E. Subdural hematoma
A

A. Epidural hematoma

[commonly occurs after fracture or heavy blow to temporal bone, resulting in LOC followed by lucid interval, then deterioration which may include headache, vomiting, drowsiness, confusion, aphasia, seizures, and hemiparesis. CT will show biconvex disk that does not cross suture lines]

284
Q

You diagnose Conn syndrome in a pt with HTN, hypokalemia, and an increased aldosterone/decreased renin. What do you do next?

A

CT scan to find the tumor

Adrenal vein sampling to lateralize

Resect

285
Q

Causes of gallstone formation

A

Cholesterol supersaturation

Accelerated crystal nucleation

Gallbladder hypomotility

286
Q

Diagnostic study of choice in pt with suspected perforated duodenal ulcer

A

Upright CXR

[demonstrates free air below diaphragm in about 70-75% of pts presenting with perforated duodenal ulcer. A CT scan would show free fluid and free air but takes longer to perform and may delay definitive tx]

287
Q

Teenager with nontraumatic knee pain. Diagnosis and how?

A

Slipped-capital femoral epiphysis, dx with x-ray

288
Q

When the knee is locked, extended, and stress comes from behind, there will be a tear of the _______. This is common in football tackle injuries. Athletes get surgical repair while obese get casting

A

ACL

[Note: knee that is locked, extended, and hit from front will result in PCL tear]

289
Q

Dx of subarachnoid hemorrhage

A

CT scan without contrast

Will show +blood but outside the parenchyma and between the gyri. The best radiographic test is to obtain a MR angiogram or CT angiogram

An LP can also be donw to look for xanthochromia (old RBCs in CSF)

290
Q

Anterior fossa brain tumors

A

Oligo
Glioblastoma
Meningioma

[anterior fossa tumors more likely in adults]

291
Q

GCS indication for intubation

A

GCS <8

292
Q

A peripheral vascular disease lesion that is both in the femoral artery and <3cm can be tx with ______; everything else is tx with _____

A

Stenting; bypass

293
Q

Pediatric pt with hx of retinoblastoma presents with femur/tib pain that shows sunburst pattern on xray; tx is resection

A

Osteogenic sarcoma

294
Q

______ hernia = a ventral hernia occurring at the junction of the semilunar line and the lateral edge of the rectus muscle

A

Spigelian hernia

295
Q

Tx for pediatric orthopedic fracture involving growth plate

A

Open reduction and internal fixation

Other scenarios where this is necessary include open fracture, comminuted or angular fracture

296
Q

Post-op fever day 3

A

UTI

— Do U/A and urine culture. Always take foley out early if they can pee on their own. For catheter related UTI, start with Ceftriaxone

297
Q

Most common cause of bowel obstruction in a pt with no surgical hx

A

Hernia

298
Q

Intraoperative medication used to relax sphincter of Oddi in setting of CBD stones and also for intestinal smooth muscle relaxation to accommodate sizers/staplers

A

Glucagon

299
Q

2 agents used on burn pts to prophylax against infection

A

Silver sulfadiazine

Mafenide

300
Q

Post op fever day 1

A

Atelectasis

— Do a CXR and listen to lungs, if positive - give spirometry to improve ventilation. Usually best to do prophylactic spirometry

301
Q

Complete transection of spinal cord

A

Motor, pain, and sensory all lost below site of lesion

Lower motor neuron symptoms at level of lesion

Upper motor neuron symptoms below the lesion

302
Q

Torso hypertension + LE hypotension or claudication in a young adult + rib notching on CXR

A

Coarctation

303
Q

Most common cause of intraabdominal hemorrhage

A

Liver rupture

304
Q

Intestinal malrotation involves incomplete fetal rotation of the small bowel. As a result, intestinal malrotation is usually diagnosed in pediatric patients. Abdominal pain is often the predominant symptom. What is the gold standard tx?

A

Ladd’s procedure

[disrupts the bands of Ladd which allow the surgeon to mobilize the right colon and cecum to reduce the malrotation]

305
Q

Monteggia fracture bony deformity

A

Ulna breaks, radius dislocates

[mechanism of injury is usually a defensive injury where victim will use upward block against downward blow]

306
Q

A 28 y/o male is brought to the trauma unit by ambulance after a gun shot wound to the abdomen. Paramedics reveal he has been bleeding profusely and they have been applying pressure to the wound. BP is 60/40 and 1 L bolus of LR is given. Repeat vitals reveal BP of 65/42. Which of the following is most appropriate next step in management?

A. 1 unit O- blood
B. 1 L colloid bolus
C. 1 L crystalloid bolus
D. Dopamine
E. Norepinephrine
A

C. 1 L crystalloid bolus

[Trauma victims often require 2L crystalloids through one or two large-bore peripheral IVs. If there is no improvement after 2-3 L of crystalloid infusion, a colloid should be given — albumin, hetastarch, hespan, etc. Colloids have more ability to stay intravascularly than crystalloids]

307
Q

Hemorrhage is a common cause of hypovolemic shock. Hemorrhage is further classified based on the amount of blood lost and there are characteristic symptoms associated with each class. Class ____ hemorrhage involves 15-30% blood volume loss, approximately 750-1500 cc of blood, and manifests clinically with tachycardia, tachypnea, and a normal systolic BP with decreased pulse pressure. Symptoms may include cool/clammy skin, and cap refill may be delayed

A

Class II

308
Q

First step in management after ingestion of caustic substance

A

EGD w/i 24 hrs to determine severity

309
Q

Pt presents with RUQ pain, jaundice, fever, and altered mental status. Dx?

A

Cholangitis

310
Q

Best test to diagnose an aortic dissection

A

CT angiogram

[looking for false lumen; can’t do CT angiogram in renal failure — so you do either TEE or MRI]

311
Q

Pt on post-op day #7 following Billroth II procedure. Surgical drains were placed and previously noted to be serosanguinous. Now drainage appears bilious. What is the most likely cause?

A

Duodenal stump leak

312
Q

Imaging test of choice for suspected kidney stone

A

CT abdomen without contrast

[IV contrast is filtered by kidneys; since most stones are radio-opaque, you can see them without contrast. Contrast would simply fill kidney and ureters and may obscure the stone]

313
Q

Kocher criteria can be used to gauge the risk of septic joint. What are the 4 criteria?

A

Non-weight bearing

ESR >40

Fever > 38C

WBC > 12,000

Score of 1 = not septic joint
Score of 2 = not sure
Score of 3 = 93% septic joint
Score of 4 = 99% septic joint

314
Q

Acute vs. chronic causes of central cord syndrome

A

Acute = hyperextension of neck

Chronic = syrinx

315
Q

Post-op fever day 7, what test do you order?

A

US or CT to r/o abscess

316
Q

Murmurs due to ______ can be detected at any age; often determined due to fixed wide split S2

A

ASD

[Closure typically achieved via catheter directed device closure]

317
Q

Tx of chronic pancreatitis

A

Opiates

318
Q

Hemorrhage is a common cause of hypovolemic shock. Hemorrhage is further classified based on the amount of blood lost and there are characteristic symptoms associated with each class. Class ____ hemorrhage involves blood volume loss of up to 15% or approximately 750 cc of blood. Pts will have normal vitals including HR, BP, and pulse pressure. Symptoms may include anxiety.

A

Class I

319
Q

If a baby between 2-8 weeks of age who has not had any problems suddenly develops projectile vomiting after feeds, consider pyloric stenosis. A CMP will reveal ____________ which should prompt IVF for rehydration.

Definitive dx is made with _______ showing “donut sign”

A

Hypochloremic, hypokalemic metabolic alkalosis

Ultrasound

320
Q

A 26 y/o male presents to ED after being struck by lightening. He complains of shoulder pain and admits a brief LOC. VSS. He is alert and oriented but left shoulder is bare with some feathering burn marks on skin. There is otherwise no obvious blistering or other involved body regions. The most appropriate next diagnostic study is:

A. Creatine phosphokinase
B. CT of head without contrast
C. ECG
D. Plain film of shoulder
E. Serum myoglobin
A

C. ECG

[MCC of death in lightening strike is cardiac arrest and/or dysrhythmia]

321
Q

Highly malignant brain tumor that arises in 4th ventricle in children that seeds the subarachnoid space, which may lead to distal lesions in the cord; tx REQUIRES chemo, resection, and radiation

A

Medulloblastoma

322
Q

6 yo child presents with insidious onset knee pain and antalgic gait; xray reveals avascular necrosis of the hip. Tx is cast. What is dx?

A

Legg-Calve-Perthe disease

323
Q

Most common hernia in both men and women

A

Indirect inguinal

324
Q

______ hernias carry highest risk of incarceration and strangulation and are more common in women than men

A

Femoral

325
Q

Electrolyte abnormality that is a common cause of ileus

A

Hypokalemia

326
Q

What are the 3 tests utilized in dx of Boerhaave’s, and in what order are they performed?

A

Gastrogafin swallow
Barium swallow
EGD

327
Q

Tx for toxic megacolon d/t complication of C.diff colitis

A

Subtotal abdominal colectomy with end ileostomy

328
Q

Layers of abdominal wall

A 
Skin
Subcutaneous fat
Scarpa’s fascia
External oblique muscle
Internal oblique muscle
Transversus abdominis muscle
Transversalis fascia
Peritoneum
329
Q

If there’s a fever after anesthesia (typically halothane or succinylcholine) or a fever >104, assume malignant hyperthermia. What is the treatment/management?

A

Give Oxygen, Dantrolene, and cooling blankets

Follow with UA and watch for myoglobinuria

330
Q

AAA screening guidelines for 3-4cm, 4-5cm, and 5-5.4cm

A

3-4 cm = screen q2years

4-5 cm = screen q1year

5-5.4 cm = screen q6months

331
Q

What line divides the liver into right and left lobes?

A

Cantlie line

[runs from middle of gallbladder fossa anteriorly to the inferior vena cava posteriorly]

332
Q

GERD with alarm symptoms, what do you do?

A

EGD

333
Q

Premature baby with bloody diarrhea and pneumatosis intestinalis. Necrotizing enterocolitis is diagnosed. What do you do next?

A

NPO immediately
TPN and IV antibiotics

Hold off from surgery unless there’s no improvement or condition worsens

334
Q

How is cholangiocarcinoma diagnosed?

A

ERCP with endoscopic brushes

335
Q

What test is required prior to replacing aortic valve?

A

Left heart cath, may need CABG also

336
Q

Neuro manifestations of anterior cord syndrome

A

Loss of motor and pain and temp

Sensation intact

[usually bilateral]

337
Q

AAA cutoffs that indicate need for surgery

A

> 5.5 cm or growing >0.5 cm/6 months

338
Q

Consequences of electrical burns

A

Arrhythmias

Massive myoglobinuria (check CK, hydrate and give mannitol to avoid renal failure)

Muscle contractions can lead to posterior shoulder dislocations

Long-term sequelae include demyelination syndromes and cataracts

Surgery Shelf (2 decks)

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