Surgery Notes Flashcards
When pt has good renal function, PE can be diagnosed via CT scan. How is PE diagnosed in pt with poor renal function?
V/Q scan
GERD pt doesn’t want meds — what do you do?
Nissen fundoplication
How do you evaluate for ureteral injury following traumatic pelvic fracture?
IV pyelogram preoperatively
-OR-
Methylene blue intraoperatively
Herniation of abdominal contents through the internal inguinal ring due to congenital patent processus vaginalis
Indirect inguinal hernia
Pt presents 3 days s/p lap chole with severe RUQ pain and a fluid collection. What is the first step in workup?
Fluid aspiration and analysis
[determine if blood, enteric contents, or bile]
Oligohydramnios, no urine output on first day of life, elevated creatinine, dx?
Posterior urethral valves
Rumbling diastolic murmur with opening snap
Mitral stenosis
How long do you give clopidogrel for a drug eluting stent
1 year
Succinylcholine can cause what electrolyte abnormality in burn and spinal cord injury patients? How does this manifest on EKG?
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]
Etiology of anterior cord syndrome
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
Holosystolic murmur that occludes both S1 and S2 at the cardiac apex that radiates to axilla
Mitral regurgitation
2 cardiac risk factors that are outright contraindications to non-cardiac surgery
EF <35% (75% chance of perioperative MI)
MI within last 6 months (40% chance of mortality at 3 months vs. 6% at 6 months)
Reynold’s pentad for ascending cholangitis
Jaundice Fever Abdominal pain Shock Altered mental status
Tx for acute epidural hematoma
Craniotomy and evacuation
What imaging study should be obtained FIRST in those with suspected small bowel obstruction?
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]
5 W’s of post-op fever
Wind — Atelectasis, PNA Water — UTI Walking — DVT Wound — Infection, abscess Wonder drugs
When should smoking cessation be done in relation to surgery?
8 weeks prior to surgery — because congestion initially worsens on quitting
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
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]
Tx for patients with CAD affecting 1-2 vessels
Angioplasty (PCI/stenting) + Clopidogrel
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
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]
Wet vs. dry macular degeneration
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
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
Kocher
Pearly skin lesion that’s non-healing and bleeds easily
Basal cell carcinoma
Intraparenchymal hemorrhages are bleeds within the brain parenchyma itself. This occurs most often at what location?
Caudate and putamen
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?
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
Hx of blunt trauma and you note pulsus paradoxus > 10 mmHg
Cardiac tamponade
When do you operate on a pancreatic pseudocyst?
6 weeks or 6 cm
T/F: Teratomas are typically benign in females and malignant in males
True
Tx for hemorrhoids grade I-IV
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)
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
E. Superficial partial
[epidermal burns do not blister. Superficial and deep partial are painful, but superficial blanche while deep do not]
_________ ________ 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
Blind loop syndrome; Vitamin B12
1st step in working up esophageal cancer
Barium swallow
[however, BEST test in working up esophageal cancer is EGD with biopsy]
Upper vs. lower motor neuron symptoms
Upper = spastic paralysis, hyperreflexia, upward going Babinski
Lower = flaccid paralysis, hyporeflexia
Boot-shaped heart on CXR, association with Downs syndrome or DiGeorge syndrome
Tetralogy of Fallot
What type of imaging should be done if you are concerned for CBD perforation following an ERCP?
Nuclear medicine hepatobiliary scan
Galeazzi fracture bony deformity
Radius breaks, ulna dislocates
[occurs with downward blow against upward turned radius]
Hernia that contains Meckel’s diverticulum
Littre’s hernia
3 classifications of gallstones
Cholesterol
Black pigment (calcium bilirubinate)
Brown pigment (calcium salts of unconjugated bilirubin)
Causes of high anion gap metabolic acidosis
MUDPILES
Methanol Uremia DKA Paraldehyde Isoniazid Lactic acidosis Ethylene glycol Salicylates
Relationship between postmenopausal SERM therapy and breast cancer
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
Blunt trauma to the abdomen — what is the next step?
FAST scan
Tx for 3rd degree burn to anterior thigh
Silver sulfadiazine
Early mobilization
What type of surgeries are highest risk for DVT/PE?
Orthopedic surgeries
Workup for suspected pheochromocytoma
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
Most reliable method to determine the cause of ascites
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)
Direct vs. indirect hernias relative to inferior epigastric vessels
Mnemonic: MD’s Lie
Medial to inferior epigastric vessels in Direct hernias
Lateral to inferior epigastric vessels in Indirect hernias
Dx of brain tumors
MRI to identify, biopsy to definitively dx
Dx and tx of arterial insufficiency ulcer
U/S, CT angiogram, stent vs bypass
Stop smoking
Cilostazol
Bovine valves vs. mechanical valves in valve replacement surgery
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
________ are LDH associated testicular tumors that are exquisitely sensitive to chemo and radiation
Seminoma
5 type classifications of gastric ulcer
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
Herniation of abdominal contents through floor of Hesselbach’s triangle due to acquired defect in transversalis fascia from mechanical breakdown
Direct inguinal hernia
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
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]
Management of achilles tendon tear
Casting cures within months
Surgery cures within weeks
A malnourished pt needs to go to surgery; what’s the best course of action?
Oral feedings x10 days > oral feedings for 5 days > parenteral feeding for any time
Developmental dysplasia of the hip means the hip is insufficiently deep so the femur head constantly pops out. How is this dx and tx?
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
Imaging study of choice with suspected diverticulitis
CT scan with IV contrast
Mitral stenosis can lead to CHF and afib. Treatment isn’t necessary until pt gets tired of the symptoms. What are tx options?
Commissurotomy (balloon dilation) or simply replacement of the valve
Impacted stone in gallbladder neck causing extrinsic compression of common hepatic duct
Mirrizzi syndrome
Risk of parenteral nutrition
Fungemia
Posterior fossa brain tumors
Medulloblastoma
Ependymoma
Schwannoma
[posterior fossa tumors more likely in kids]
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?
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)
Management of hemodynamically unstable + pelvic fracture + bleed
Explore
Internal fixation
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 cystoscopy with biopsy
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?
Pneumococcal (PCV)
Meningococcal (MCV4)
Haemophilus influenza type b (Hib)
Management of hemodynamically stable + pelvic fracture + bleed
Do NOT explore
External fixation
Billroth I vs. Billroth II
Billroth I = creation of gastroduodenostomy
Billroth II = gastrojejunostomy
[Either technique is indicated for peptic ulcer disease or gastric adenocarcinoma]
Blunt neck trauma + focal neurologic deficit. First step in management?
High dose dexamethasone
[Reduces edema and preserves neuro function]
Alkalinization of the stomach, gastrin, epinephrine, cholinergic agents (bethanecol), and alpha adrenergic agents (metoclopromide) _______ the resting pressure of the LES
Increase
Brain tumors may present with Cushing reflex — what does this mean?
Cushing reflex = bradycardia + HTN
Components of Child-Pugh score to ascertain functionality of the liver
Encephalopathy Ascites Bilirubin Albumin INR
Which layer of the intestinal wall is most important in maintaining tensile strength and must be included when sewing intestinal anastomoses?
Submucosa
[due to collagen cross linking]
Baby with bilious vomiting and imaging shows double-bubble sign
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.
What is the Pringle maneuver?
Compression of hepatoduodenal ligament, sealing the hepatic artery and portal vein
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?
Embolectomy
Localized tPa
Heparin
An alcoholic Scandinavian male presents with palmar nodes and is unable to extend hand flat
Dupuytren’s contracture
[must be tx with surgery, splinting and NSAIDs don’t work]
In CABG procedure, the most significant vessel affected (usually the LAD) is connected to the __________ artery, while the others get the ________ vein
Internal mammary artery; great saphenous vein
Which is more likely associated with chromosomal abnormalities - Gastroschisis or Omphalocele?
Omphalocele — i.e., Beckwith-Wiedemann syndrome
What is trigger finger?
Stneosing tenosynovitis in which pt is unable to extend finger. When forced, there is a “pop”
Tx with splinting and NSAIDs or intraarticular injections
Esophageal cancer is often symptomatic only after it has blocked ___ of the lumen
2/3
Post-op fever day 2
Pneumonia
—Do CXR, treat for hospital acquired PNA (vancomycin and pip/tazo) while awaiting cultures
____________ 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
GnRH analogs (Leuprolide); Anti-androgens (Flutamide)
Orchiectomy; radiation
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
Class III
EGD shows dysplasia vs. cancer — what would you do in each case?
Dysplasia — local ablation
Cancer — resection
MCC of ulcer on malleolus
Venous stasis
Chronic cystic duct obstruction and gallbladder distention with clear mucoid fluid
Hydrops of gallbladder
Tx for GERD without alarm sxs
PPI
Patient presents with HTN and hypokalemia — what is your dx and what do you do next?
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)
Antibiotic used in necrotizing pancreatitis
Meropenem
Other name for inguinal ligament
Poupart’s ligament
Options for prophylactic antibiotics for appendicitis prior to lap appy
Cefotetan Cefoxitin Ampicillin/sulbactam Cefazolin+metronidazole Clindamycin+fluroquinolone/aztreonam
Paralytic ileus of the colon that occurs in elderly sedentary patients who become immobilized after surgery; colon will appear very dilated
Ogilvie syndrome
[Do a colonoscopy to r/o cancer and to decompress the abdomen; leave a rectal tube in place]
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?
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]
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
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]
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?
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
Hourly fluid requirments
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
Post-op patient feels the need to void 6+ hours after surgery but can’t — what do you do?
In-and-out cath
Head trauma resulting in LOC followed by lucid interval
Epidural hematoma
Football player passes out after colliding with another player. What do you do?
CT scan. If negative, dx is concussion — send home
Crescendo-decrescendo murmur in systole
Aortic stenosis
________ 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
Meningiomas
Typical chemotherapy for breast cancer
Typically anthracycline based (Doxorubicin-Cyclophosphamide) + a taxane (Paclitaxel)
Best test for suspected coarctation
Arteriogram
But CTA or MRA can be sufficient
______ shock = loss of SVR from infection or anaphylaxis
Distributive
AR disorder resulting in increased conjugated bilirubin without elevation in LFTs
Dubin Johnson syndrome
_______ is a brain tumor found at the cerebellopontine angle. If it is bilateral, it is part of ______________ (syndrome)
Schwannoma; neurofibromatosis type II
Holosystolic murmur that radiates to axilla
Mitral regurg
Workup for Cushings
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)
Harsh holosystolic murmur, right-sided cardiac hypertrophy, increased right-sided pressures, failure to thrive, heart failure
VSD
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?
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
Blood at the meatus, high-riding prostate — what test do you get?
Retrograde urethrogram
EGD shows metaplasia/Barrett’s/salmon — how tx?
High dose PPI
Tx and margins needed for melanoma with Breslow of 2-4 mm vs. >4 mm
2-4 mm = wide resection and SLND if tracer+, 2 cm margins
> 4mm = palliative chemo and radiation, debulking of tumor burden palliative only
Organophosphage toxicity manifests as SLUDGE — salivation, lacrimation, urination, defecation, GI upset, emesis. What is tx?
Atropine
Pralidoxime
Pt with hx of t(11;22) presents with mid-shaft bone pain and xray shows onion-skin pattern; tx is resection
Ewing’s sarcoma
Head trauma followed by LOC and retrograde amnesia
Concussion
Anticholinergic agents (atropine), glucagon, and secretin ______ the resting pressure of the LES
Decrease
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
Dieulafoy’s lesion
[approx. 75% occur in upper part of stomach within 6 cm of the GE junction, most commonly in lesser curvature]
__________ tenosynovitis may be caused by continued forced extension of the thumb (baby cradle, weights, etc) resulting in pain on thumb and hand when used
De Quervains
Inguinal hernia that contains elements of both direct and indirect inguinal hernia
Pantaloon hernia
Tx for BCC in the following locations:
Large lesion not on the face
Large lesion on an extremity
Any lesion on face
Large lesion not on the face = wide excision
Large lesion on an extremity = amputation
Any lesion on face = Mohs
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
Fomepizole (or alcohol)
Chemotherapeutic often utilized in breast cancer that is associated with a dose-dependent irreversible CHF
Doxorubicin
_____________________________________________
Doxorubicin = dose-dependent irriversible CHF Trastuzumab = dose-INdependent Reversible CHF
Signs/sxs/tx for black widow spider bite
Abdominal pain/pancreatitis
Give IV calcium gluconate
Diagnostic criteria for SIRS vs. Sepsis
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
Presentation of posterior shoulder dislocation
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]
Dx and management of aortic stenosis
Dx with echocardiogram
Tx with surgical replacement; TAVR and TAVI may be attempted in poor surgical candidates
How is bleeding in the brain reduced pharmacologically?
IV beta blockers to reduce systolic BP (<140/<90)
Most common congenital heart defect
VSD
Hemisection of spinal cord
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
Abx for dog/cat/human bite
Amoxicillin-Clavulanate
[human bites also require surgical debridement — do not suture them closed!]
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
Class IV
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
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)
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?
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]
_______ test is used to dx scoliosis, in which pt bends forward and asymmetric shoulders are diagnostic. Confirm with xrays
Adam’s
Blood at the meatus + high-riding prostate following traumatic pelvic fracture indicates possible urethral injury. What must you do prior to inserting foley?
Retrograde urethrogram
Epidural hematoma may present with signs of uncal herniation - what are these signs?
Ipsilateral fixed dilated pupil
Contralateral hemiparesis
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
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)]
Anterior Chapman’s point 6th ICS on the R
Gallbladder
Fluids and management in pt with pulmonary contusion
Colloids (blood and albumin) for resuscitation (AVOID NS and LR which are crystalloids)
Use diuretics and PEEP
______ 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.
CT
[CT imaging can also be done in pts with a suspicion of infected pseudocysts, but these take 7-10 days to develop]
Rectal injury in pelvic fracture. Next step?
Proctoscope
Colonoscopy guidelines in pt with UC
Colonoscopy q1y needed starting at year 8 from dx
Surgical procedure involving resection of rectosigmoid colon with closure of rectal stump to form colostomy
Hartmann procedure
An appendiceal wall >____ is considered thickened
> 6 mm
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)
Aortic stenosis
Tx for biliary atresia
Kasai procedure (hepatoportoenterostomy)
Grading internal hemorrhoids
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
FETID mnemonic for things that keep fistulas open
F — foreign bodies E — epithelialization T — tumor I — infection/irradiation/inflammatory bowel D — distal obstruction
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?
Trastuzumab
Dose-independent reversible CHF (q3month echocardiograms required)
How much albumin should be given for every liter of ascites removed after large volume paracentesis?
6-8 g of albumin/L of ascites removed
Management of PDA in infancy
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
Old person has a fall and gets rapidly worsening dementia, dx and next step?
Subdural hematoma; get a CT
Young patient with lymphadenopathy and B symptoms (fever, night sweats, weight loss)
Hodgkin lymphoma
What is considered the standard biopsy for the diagnosis of breast cancer?
Core-needle biopsy
[FNA is sufficient if ultrasound confirms its a cyst; excisional biopsy is done when it is obviously cancer]
Tetanus prophylaxis recommendations for clean/minor wounds vs. contaminated or deep puncture wounds
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
A normal ABI is 1.0-1.4. An ABI > 1.4 indicates calcification — this should be followed up with what test?
Toe-brachial index
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
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]
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 _____
Exercise ABI; U/S Doppler
Patent ductus arteriosus results in connection between what 2 structures?
Aorta
Pulmonary artery
Baby with bilious vomiting and imaging shows multiple air-fluid levels
Intestinal atresia
[caused by vascular accident in utero; ask about maternal cocaine use]
Management of suspected CO poisoning
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!]
Imaging of choice when pt presents with painless jaundice
CT abdomen
[better visualization of the pancreas]
_______ shock is asociated with cardiac tamponade or PE
Obstructive
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
Osgood-Schlatter disease (aka Osteochondrosis)
Structures included in hepatoduodenal ligament
Proper hepatic artery
Portal vein
Common bile duct
Most common malignancy associated with chylous ascites
Lymphoma
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?
Airway = gurgling, stridor, apnea
Vessels = expanding hematoma, pulsatile bleeding, frank shock, stroke
Digestive = frank mediastinitis
Hepatic hemangioma
Thrombocytopenia
Consumptive coagulopathy
Kasabach-Merritt syndrome
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)
<90 mmHg
<0.5 cc/kg/hr
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?
Lung > Prostate/Breast > Colon
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
Aortic insufficiency
Tetralogy of Fallot is most common cyanotic defect in children and is an endocardial cushion defect. What are the 4 findings?
Overriding aorta
Pulmonary stenosis
Right ventricular hypertrophy
Ventricular septal defect
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
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]
Chapman point in intercostal spaces between ribs 2-3 close to sternum anteriorly, and on middle of transverse processes of T2 posteriorly
Esophagus
How do you work up a suspected renovascular hypertension (secondary hyperaldosteronism)?
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)
Most common cyanotic heart defect in newborns
Transposition of great vessels
Malnutrition is identified by a loss of body weight >20% in a few months, an albumin of _____, or anergy to skin antigens
<3
Tx and margins needed for melanoma with Breslow of <0.5 mm vs. 1-2 mm
<0.5 mm = local resection with 0.5cm margins
1-2 mm = wide resection and SLND if tracer+, 1cm margins
How is primary sclerosing cholangitis diagnosed?
MRCP
[not ERCP!!!]
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?
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
Hip fractures present with shortened leg and external rotation. How are these managed when they involve femoral head vs. intertrochanteric vs. shaft?
Femoral head involvement requires femoral prosthesis due to femoral neck having tenuous vascular supply
Intertrochanteric fracture gets ORIF with plates
Shaft fracture gets rods
What injuries should you go looking for if a pt presents with traumatic flail chest, scapular fracture, or sternal fracture?
Pulmonary contusion
Myocardial contusion
Aortic dissection
Pt with chest pain s/p MI and CABG procedure 2 days prior —what test do you order?
Creatine kinase
To prevent vasospasm (acute infarct after subarachnoid hemorrhage), the pt needs what pharmacologic intervention?
Calcium channel blockers
[if vasospasm occurs, blood pressure msut be increased to maintain perfusion]
Post-op patient with some, but low, urine output — what do you do?
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
What color are gallstones on MRCP
Black
MRCPs are down with T2 weighted imaging with fat suppression where only fluid appears hyperintense (white) and stones are hypointense (black)
Most common cause of hydatid disease
Echinococcus granulosus
[indicated by calcifications in the wall of a liver cyst; cysts can rupture and result in anaphylactic shock. Tx with mebendazole/albendazole]
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
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]
T/F: surgery is curative for Crohns
False — surgery can be curative for UC, but not Crohns
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?
Laser — spot “welds” the retina back into place. Vision is compromised from there on, but without tx they will lose all vision
Treatment of gastric adenocarcinoma in the body or fundus of the stomach
Total gastrectomy
[entire stomach is removed and a Roux-en-Y limb is sewn directly to the esophagus]
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
Slipped capital femoral epiphysis
Splenectomy pts are more susceptible to encapsulated organisms — what are 4 common ones?
Salmonella
S.pneumonia
H.influenzae
N.meningitidis
A ____ hernia occurs when only the antimesenteric wall of a hollow abdominal organ becomes incarcerated in an inguinal hernia
Richter’s hernia
[especially dangerous and difficult to dx because bowel ischemia may occur without the presentation of bowel obstruction]
Wound ______ occurs when skin is intact but fascia has failed; dressings soaked with salmon-colored fluid
Dehiscence
Test done for corneal abrasion
Fluorescein dye test
4 stages of ulcers
Stage I = Nonblanching erythema
Stage II = Epidermis and Partial dermis
Stage III = Through Epidermis and Dermis
Stage IV = Muscle or bone
LES can’t relax = achalasia; food gets stuck. Dx by barium swallow or definitively with manometry. What are treatment options?
Dilate with balloon
Relax with botox
Cut sphincter with Heller myotomy (best option)
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?
Zone I = angiogram
Zone II = exploration
Zone III = esophagram, bronchogram, arteriogram
First line therapy for carpal tunnel
NSAIDs
[not splinting!]
How is pancreatic cancer diagnosed?
Endoscopic ultrasound with biopsy
ERCP
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]
________ syndrome = hepatic venous outflow obstruction
Budd-Chiari syndrome
[causes include polycythemia vera, factor V leiden mutation, thrombocytosis, protein C and S, antithrombin III, antiphospholipid antibody syndrome]
Abscess found in pulp of fingertip, typically following a penetrating injury. It’s trapped inside a fascial plane so is exquisitely tender
Felon
Worst cardiac prognostic risk factor on Goldman index
JVD
[other factors include MI w/i 6 months, arrhythmia, age >70]
2 causes of renovascular hypertension
Bilateral renal artery stenosis
Fibromuscular dysplasia
Inguinal hernia containing the vermiform appendix
Amyand hernia (aka appendiceal hernia)
On examining a pediatric patient you hear bowel sounds over the lungs and note a scaphoid abdomen. The baby is dyspneic. Diagnosis?
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]
Pt presents with GERD followeed by progressive dysphagia to solids then liquids, you suspect cancer. What is your next step in dx?
Barium swallow — don’t do EGD right away — must identify safety to avoid perforation
Confirm with EGD and Bx
Assess stage with CT scan
Patient presents with “thunderclap” headache described as the worst headache of their life. Most likely dx?
Subarachnoid hemorrhage
Elderly pt with osteoporosis falls resulting in Colle’s fracture — what does that mean?
Dorsally displaced radius, looks like dinner fork (2 prongs sticking up)
Dx with xray and cast it
Kehr’s sign
Shoulder pain from diaphragmatic irritation following trauma (indicative of ruptured diaphragm)
Tx for acute subdural hematoma
Craniotomy if midline shift noted on CT
Otherwise the goal is to decrease ICP with elevation, hyperventilation, and mannitol
Autosomal dominant disorder of which there are 2 major manifestations: pigmented mucocutaneous macules and multiple hamartomatous GI polyps
Peutz-Jeghers syndrome
Neuro manifestations of central cord syndrome
Loss of pain and temp in cape-like distribution (usually hands and arms)
Absorbable suture
Vicryl Polydioxanone (PDS) Dexon Chromic Catgut
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?
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.]
Parkland formula to calculate fluid rescusitation in burn pts
(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
A _____ inguinal hernia is defined as a hernia containing a hollow retroperitoneal organ, most commonly the bladder or colon
Sliding
All subarachnoid hemorrhage pts need to have _______ prophylaxis
Seizure
[any standard antiepileptic can be given; Phenytoin, valproate, levetiracetam are all good choices]
Anatomic structure that holds the aortic arch in place
Ligamentum arteriosum
VACTERL anomalies
Vertebral (X ray) Anal (imperforate) Cardiac (echo) Tracheal Esophageal Renal (US) Limbs (thumbs in particular)
_______ score is created based on transrectal biopsy for prostate cancer
Gleason
Treatment of gastric adenocarcinoma in the antrum of the stomach
Subtotal gastrectomy
[removal of distal 3/4 of stomach]
Autoimmune disease associated with destruction of extrahepatic and intrahepatic bile ducts
Primary sclerosing cholangitis
Don’t operate on anyone with DKA. What steps must you take to manage DKA prior to operating?
Control BG with hydration/insulin
Ensure urine output before attempting surgery
You diagnose primary sclerosing cholangitis with strictures. What do you do?
Ursodeoxycholic acid to transplant
[do NOT stent PSC]
Blood products used to tx hemophilia B
Factor IX
[hemophilia B = factor IX deficiency]
Old person with hyperextension injury, now can’t feel pain or temperature, has loss of motor in the upper extremities. Dx?
Central cord syndrome
5 P’s of pheochromocytoma
Paroxysms of pressure (HTN) Palpitations Perspiration Pain (pounding headache) Pallor
An out of shape weekend warrior presents with pinpoint tibia pain. X-ray is normal. What do you do?
Cast it, repeat xray in 2 weeks
[this is likely a stress fracture; xray is usually normal for 2 weeks]
Tx for adenocarcinoma of the appendix
Right hemicolectomy
Nonabsorbable
Nylon
Silk
Stainless steel
Prolene
Presentation of anterior shoulder dislocation
Arm abducted and externally rotated (shaking hands position)
Deltoid paresthesia (axillary nerve damage)
[dx with xray, tx with relocation and sling]
Borders of Hesselbach’s triangle
Inguinal ligament
Lateral border of rectus abdominis muscle
Inferior epigastric vessels
Chapman point at 6th intercostal space on the L about one inch lateral to SC joint
Stomach peristalsis
Best diagnostic strategies for BCC in the following locations:
Small lesion not on face
Large lesion not on face
Any lesion on face
Small lesion not on face = excisional bx (also tx)
Large lesion not on face = incisional bx
Any lesion on face = incisional bx
Continuous machine-like murmur
PDA
Tx of suspected scaphoid fracture if x-ray negative vs. x-ray positive
X-ray negative — cast it! xray may turn positive later
X-ray positive — ORIF
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?
Glucose suppression test — which will fail to decrease GH
F/u with MRI
A pt with Hemophilia A is scheduled for surgery. What is the most important blood product to have available in case of intraoperative bleeding?
Cryoprecipitate
[Hemophilia A = factor VIII deficiency; Cryoprecipitate is rich in factor VIII and fibrinogen which will help coagulation in these pts]
Tx of bladder cancer
Since most are superficial without invasion, you can do transurethral resection + BCG or Cisplatin based chemotherapy
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.
True
When is right hemicolectomy indicated in the case of appendiceal carcinoid?
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]
A compartment syndrome may develop after circumfirential full-thickness burns. What is the first step in treatment?
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]
Tx for aortic dissections when they are ascending (type A) vs. descending (type B)
Ascending = operate (may need to replace aortic valve)
Descending = medically (IV beta blockade)
When is EGD the first step in GERD?
Alarm symptoms — anemia, N/V, weight loss
Post-op patient with paralytic ileus that has not resolved by day 5-7 — what is the next step?
Upright KUB and/or contrast swallow CT
If it is a bowel obstruction, take to OR
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 ______ _____
Hepatic vein
Testicular endodermal sinus tumors can be followed with _____, while choriocarcinomas can be followed with ____
AFP; beta HCG
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
Electromyography
Post-op fever day 7+
Wound infection
[if erythematous and warm it’s cellulitis - tx with abx. If erythematous, warm, and boggy - drain the abscess. If unknown, do US]
In sliding hiatal hernia, the _____ of the stomach is displaced into the ______ mediastinum
Cardia; posterior
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
Ependymoma
Hormone that is a potent stimulator of gallbladder contraction
CCK
Healthy active athlete with knee pain and a click on full extension
Meniscal tear
Use MRI to confirm and arthroscopic repair to remove as little as possible to avoid resultant arthritis
Causes of post-op altered mental status
Hypoxia — give O2
ARDS — give PEEP
Delirium tremens — give benzos
Electrolytes and hypoglycemia — get a CMP and replace
Sundowning — give atypical antipsychotics
Test used to screen for AAA vs. Test used to track changes in AAA
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]
Post-op fever day 5
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
Wounds that are left open to heal by granulation and contraction are termed to heal by ______ _____
Secondary intention
Accessory ducts directly from the liver bed into the gallbladder
Ducts of luschka
Minimal urine output for an adult patient
0.5 cc/kg/hr
3 requirements to qualify for CABG procedure
- Blood vessels have a 70% stenosis
- LAD affected or 3+ vessel disease
- There is good LV function OR reperfusion will restore ventricular function
Dx and management of orbital cellulitis vs. periorbital cellulitis
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)
Lund-Browder chart or “rule of nines” method for estimating burn size in adults
Anterior trunk = 18% Posterior trunk = 18% Each lower extremity = 18% Each upper extremity = 9% Head = 9%
Estrogen and progesterone receptor positivity in breast cancer allows for endocrine therapy. What are preferred therapies in premenopausal vs. postmenopausal women?
Premenopausal:
Tamoxifen (stronger, causes DVT, risk of endometrial cancer)
Raloxifene (weaker, no DVT, no risk of endometrial cancer)
Postmenopausal:
Aromatase inhibitors like anastrozole
______ ______ 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
Diffuse axonal injury
Best diagnostic test in pt complaining of GERD
24-hour pH monitoring
Safest way to manage acute cholecystitis in a patient who is otherwise a poor surgical candidate
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]
Pt with suspected aortic dissection requires imaging, but CT angiogram is contraindicated due to renal failure. What are your 2 options?
TEE
MRI
[both are considered equivalent options]
Salicylate toxicity presents early on with tinnitus, vertigo, and hyperventilation; later with anion gap metabolic acidosis, altered mental status, and hyperpyrexia. What is tx?
Alkalinization of urine and forced diuresis
In a pt with cirrhosis, the _____ score can be used to ascertain functionality of the liver
Child-Pugh
Tx for H pylori
PPI + 2 antibiotics (usually Clarithromycin + amoxicillin OR Clarithromycin + metronidazole)
Sometimes Bismuth used as adjunct
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?
Thiosulfate
[the second line therapy is amyl nitrate which may worsen CO poisoning]
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?
Altered mental status
Tachypnea that leads to respiratory alkalosis
Flushed skin
Pt complains of intermittent “veil” dropping over his eye and obstructing vision, but then vision returns — what is the dx?
Amaurosis fugax (indicates impending retinal artery occlusion)
[If this was constant, not transient — it is retinal detachment]
Cherry-red skin, cherry-red blood, smoke inhalation — what toxin?
Cyanide
5 P’s of critical limb ischemia
Pain Pallor Paresthesia Paralysis Pulselessness
MRCP
Magnetic resonance cholangiopancreatography
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?
X-ray first, then joint aspiration with gram stain and culture
Tx with drainage and abx
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. 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]
You diagnose Conn syndrome in a pt with HTN, hypokalemia, and an increased aldosterone/decreased renin. What do you do next?
CT scan to find the tumor
Adrenal vein sampling to lateralize
Resect
Causes of gallstone formation
Cholesterol supersaturation
Accelerated crystal nucleation
Gallbladder hypomotility
Diagnostic study of choice in pt with suspected perforated duodenal ulcer
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]
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
ACL
[Note: knee that is locked, extended, and hit from front will result in PCL tear]
Dx of subarachnoid hemorrhage
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)
Anterior fossa brain tumors
Oligo
Glioblastoma
Meningioma
[anterior fossa tumors more likely in adults]
GCS indication for intubation
GCS <8
A peripheral vascular disease lesion that is both in the femoral artery and <3cm can be tx with ______; everything else is tx with _____
Stenting; bypass
Pediatric pt with hx of retinoblastoma presents with femur/tib pain that shows sunburst pattern on xray; tx is resection
Osteogenic sarcoma
______ hernia = a ventral hernia occurring at the junction of the semilunar line and the lateral edge of the rectus muscle
Spigelian hernia
Tx for pediatric orthopedic fracture involving growth plate
Open reduction and internal fixation
Other scenarios where this is necessary include open fracture, comminuted or angular fracture
Post-op fever day 3
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
Most common cause of bowel obstruction in a pt with no surgical hx
Hernia
Intraoperative medication used to relax sphincter of Oddi in setting of CBD stones and also for intestinal smooth muscle relaxation to accommodate sizers/staplers
Glucagon
2 agents used on burn pts to prophylax against infection
Silver sulfadiazine
Mafenide
Post op fever day 1
Atelectasis
— Do a CXR and listen to lungs, if positive - give spirometry to improve ventilation. Usually best to do prophylactic spirometry
Complete transection of spinal cord
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
Torso hypertension + LE hypotension or claudication in a young adult + rib notching on CXR
Coarctation
Most common cause of intraabdominal hemorrhage
Liver rupture
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?
Ladd’s procedure
[disrupts the bands of Ladd which allow the surgeon to mobilize the right colon and cecum to reduce the malrotation]
Monteggia fracture bony deformity
Ulna breaks, radius dislocates
[mechanism of injury is usually a defensive injury where victim will use upward block against downward blow]
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
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]
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
Class II
First step in management after ingestion of caustic substance
EGD w/i 24 hrs to determine severity
Pt presents with RUQ pain, jaundice, fever, and altered mental status. Dx?
Cholangitis
Best test to diagnose an aortic dissection
CT angiogram
[looking for false lumen; can’t do CT angiogram in renal failure — so you do either TEE or MRI]
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?
Duodenal stump leak
Imaging test of choice for suspected kidney stone
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]
Kocher criteria can be used to gauge the risk of septic joint. What are the 4 criteria?
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
Acute vs. chronic causes of central cord syndrome
Acute = hyperextension of neck
Chronic = syrinx
Post-op fever day 7, what test do you order?
US or CT to r/o abscess
Murmurs due to ______ can be detected at any age; often determined due to fixed wide split S2
ASD
[Closure typically achieved via catheter directed device closure]
Tx of chronic pancreatitis
Opiates
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.
Class I
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”
Hypochloremic, hypokalemic metabolic alkalosis
Ultrasound
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
C. ECG
[MCC of death in lightening strike is cardiac arrest and/or dysrhythmia]
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
Medulloblastoma
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?
Legg-Calve-Perthe disease
Most common hernia in both men and women
Indirect inguinal
______ hernias carry highest risk of incarceration and strangulation and are more common in women than men
Femoral
Electrolyte abnormality that is a common cause of ileus
Hypokalemia
What are the 3 tests utilized in dx of Boerhaave’s, and in what order are they performed?
Gastrogafin swallow
Barium swallow
EGD
Tx for toxic megacolon d/t complication of C.diff colitis
Subtotal abdominal colectomy with end ileostomy
Layers of abdominal wall
Skin Subcutaneous fat Scarpa’s fascia External oblique muscle Internal oblique muscle Transversus abdominis muscle Transversalis fascia Peritoneum
If there’s a fever after anesthesia (typically halothane or succinylcholine) or a fever >104, assume malignant hyperthermia. What is the treatment/management?
Give Oxygen, Dantrolene, and cooling blankets
Follow with UA and watch for myoglobinuria
AAA screening guidelines for 3-4cm, 4-5cm, and 5-5.4cm
3-4 cm = screen q2years
4-5 cm = screen q1year
5-5.4 cm = screen q6months
What line divides the liver into right and left lobes?
Cantlie line
[runs from middle of gallbladder fossa anteriorly to the inferior vena cava posteriorly]
GERD with alarm symptoms, what do you do?
EGD
Premature baby with bloody diarrhea and pneumatosis intestinalis. Necrotizing enterocolitis is diagnosed. What do you do next?
NPO immediately
TPN and IV antibiotics
Hold off from surgery unless there’s no improvement or condition worsens
How is cholangiocarcinoma diagnosed?
ERCP with endoscopic brushes
What test is required prior to replacing aortic valve?
Left heart cath, may need CABG also
Neuro manifestations of anterior cord syndrome
Loss of motor and pain and temp
Sensation intact
[usually bilateral]
AAA cutoffs that indicate need for surgery
> 5.5 cm or growing >0.5 cm/6 months
Consequences of electrical burns
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
