Surgery shelf Flashcards
Diaphoretic, pale, cold, shivering, anxious BP<90, PR: 120
Hypovolemic shock
Causes of shock in trauma setting
- Bleeding
- Pericardial Tamponade
- Tension Pneumothorax
Cardinal sign for pericardial tamponade or tension pneumothorax
Big distended veins in the neck ( elevated JVD/CVP)
Trauma patient with BP 60/40, PR: 150, Absent breath sounds on one side, hyperresonant to percussion, elevated JVD/CVP, tracheal deviation
Tension Pneumothorax
How to fluid resucitate
2 big 16 gauge catheters in both arms or puncture at the femoral vein. 1 or 2L of ringers lactate
Whats the access point for a child who you cant get peripheral IV access on
intraosseus cannulation of the proximal tibia
Trauma patient with high CVP, normal breathing, BP<80/50, PR: 150, no tracheal deviation, sweating, diaphoretic, shivering, cold and pale
Pericardial Tamponade
Management of Pericardial Tamponade
Pericardiocentensis, pericardial window, pericardial tube, mediasternotomy (decompress pericardial sac). In the meantime of placing these things give patient fluid
Management for Tension Pneumothorax
Big bore needle in the pleural space to be followed by chest tube.
Types of shock in the non trauma setting
- Bleeding
- Cardiogenic shock
- Vasomotor shock
Patient with severe chest pain, cold, diaphoretic, BP 8-/65, PR:130, Neck veins are distended, shortness of breath
Cardiogenic shock from massive MI
Patient with BP 75/20, PR:150, warm and flushed, CVP is low
Vasomotor shock (sudden loss of peripheral vascular tone)
Management of linear skull fracture
No therapy for the linear skull fracture but clean and close the scalp laceration
Management for Trauma Patient with head trauma who has loss consciousness
CT scan of head
Racoon eyes, rhinnorhea, clear fluid leaking from the ear, ecchymosis behind the ear
Base of the skull fracture
Trauma patient, Lucid interval, fixed dilated pupil, contralateral hemiparesis
Acute epidural hematoma
How do you treat ICP
Elevate head, Hyperventilation, osmotic diuresis, mannitol
Indications for surgery in neck injuries
- Rapid deteriorting patient
- Gun shot wounds to the middle neck
- Penetrating injuries to important veesel (expanding hematoma, spitting up blood)
Patient stabbed in the back, paralysis and loss of proprioception on ipsilateral below legion and loss of pain and temperture contralateral below lesion
Brown Sequard syndrome (hemisection)
Patient sustains burst fracture of vetebral bodies, loss of motor function, loss of pain and temperature bilaterally. Vibratory sense remains normal
Anterior Cord syndrome
Patient hyperextends their neck, develops burning and paralysis bilaterally on both upper extremities. Motor function of legs are normal
Central Cord syndrome
Management of rib fracture in old patient
local Nerve block
Management of pnuemothorax
Chest x-ray then chest tube. (2nd intercostal space in front of chest)
Explain management of hemothorax
- Use chest tube if there is a small amount of fluid (<600)
2. Use thoractomy if there is a large amount of fluid retained from chest tube (1000cc)
Severe deceleration injury, chest trauma, BP 80/40, PR: 150, widened mediatstinum
Aortic dissection
Paradoxically breathing is a sign of
Flial chest
Managment for pulmonary contusion
Fluid restriction, diuretics, monitor ABG
Reasons for air and emphysema in the chest and lower neck
- Tension pneumothorax
- Tracheal bronchial injury
- Endoscopy–> esophageal rupture
sudden death in a trauma patient
Air embolism
Patient with multiple long bone fractures, Petechial rashes, fever, tachycardia, hypoxemia, bilateral patchy infiltrate, low platelets
Fat embolism
Management for gun shot wound to the abdomen
Exploratory laparotomy
Management for acute abdomen
Exploratory laparotomy
Signs of acute abdomen
Abdominal pain, rebound tenderness, guarding in all quadrants
Trauma patient in shock, CVP is low and no evidence of bleeding anywhere but the abdomen. WHats the managment
Direct peritoneal lavage or sonogram in the ER
Trauma patient that is hemodynamically stable, no evidence of bleeding anywhere but the abdomen. What is the managment
CT scan of abdomen
Most common site of compartment syndrome
Forearm and lower leg
What are the concerns in a crushing injury
Myoglobinemia/myoglobinuria and hemoglobinemia/hemoglobinuria. Also monitor levels of serum potassium. Renal failure. Compartment syndrome
What do you monitor in a patient with respiratory burn
Monitor ABG and Carboxyhemoglobin
Whats the formula for fluid rescucitation for burns on day 1
wgt in kg x % of burn x 4
How do you adjust fluids on the second day of a burn
half of the fluids from day 1
Whats the rate to start at in a burn patient for fluid resuscitation
1000cc/hr
What should be a normal hourly urinary output
1cc/kg/hr….so anywhere from half your body weight to 2 times your body weight
Managment from bite of black widow spider
IV calcium gluconate
Symptom of bite from black widow spider
Sever muscle contractions
Patient with nausea and vomiting, early satiety, abdominal distention, hyperresonant bowel sounds, tympany to percussion
Small bowel obstruction
New born child with uneven gluteal folds, hip can be displaced posteriorly with a snap. Runs in the family
Developmental dysplasia of the hip
Diagnostic test and management for developmental dysplasia
Sonogram and abduction splinting or have patient wear double diapers for about six months
6 year old patient, guarding with passive motion of the leg, knee pain, limping, less time on the affected leg
Avascular necrosis of the capital femoral epiphysis
13 yr old patient obese patient, pain in groin, limping, sole of foot pointing towards other foot, limited hip motion, when hip flexed leg goes into external rotation
slipped capital femoral epiphysis
Toddler with febrile illness a few days before problem started in the hip. Elevated sedimentation rate
Septic hip
Tenderness right over the tibial tubercle. No swelling in the knee
Osteochondrosis of the tibial tubercle
Baby born with both feet turned inward. Plantar flexion of the ankle
Club foot
Child falls with an extended arm and has a supracondylar frature of the humerus. What is the managment
Monitor the vascular supply
16 yr old patient low grade but constant pain in the distal femur for several months. X-ray shows a sunburst pattern,
osteogenic sarcoma
10 yr old consistent pain deep in the middle of thigh with periosteal skinning
ewing sarcoma
60 yr old patient with fatigue and pain in specific places on several bones. found to be anemic. multiple punched out lesions on x-ray
Multiple myleoma
Managment for fracture of clavicle
Figure of 8 device for 4-6 wks
Patient falls on an outstretched hand. Pain at the anatomical snuff box and wrist pain
Fracture of the scaphoid bone
Managment for scaphoid fracture
Thumb spica cast and x-ray 2 weeks later
If x rays show displacement of the scaphoid bone what is the management
Open reduction and external fixation
Management for femoral neck fracture of the hip
Prosthesis of femoral head
Management for intertrochanteric fracture of the hip
open reduction and pinning and post op anticoagulation
Management for femoral shaft fracture
intermedullary rod fixation
Management for gas gangrene
Penicillin and surgical debridement and hyperbaric oxygen treatment
Which nerve travels in the groove of the radius and causes an inability to dorsiflex the wrist
Radial nerve
Managment for carpel tunnel syndrome
Splint and NSAIDS
Managment for trigger finger
steroids
Predictors of operative risk
MI within 6 months Emergency operation age PVC and A.Fib Congestive heart failure (increase JVD
What causes malignant hyperthermia
Enzyme missing where succinylcholine couldnt be broken down
What drugs can lead to malignant hyperthemia
Halothane and succinylcholine
Management of malignant hyperthermia
IV Dantrolene
First postop day with fever of 102. Most common cause
atelectasis
3rd post op day with fever. Most common cause
UTI
5th post op day fever. Most common cause
DVT
7th post op day fever. Most common cause
Wound infection
10th post op day fever. Most common cause
Subphrenic abscess
Severe chest pain in a post op patient. Most common cause
MI or PE
What kind of testicular masses transilluminate with light and what is the management
hydrocele. reassurance and observation
Diagnostic test of choice for splenic injury
abdominal CT with contrast
Whats the risk factor for nasopharyngeal carcinoma and what race of people is this usual seen in
EBV virus and asians
Patient in a high speed accident with decreased breath sounds on the right, normal breath sounds on the left and hypotension. Chest tube placed. Multiple bruises over the chest wall and subcutaneous emphysema and pneumomediastinum
Trachealbronchial rupture
Patient has a history of crohns disease and comes in with an episode of left flank pain, hematuria and vomiting. Pain is relevied with analgesics. Whats the cause of the symptoms
Increased absorption of oxalate
What is the cause of intraluminal contents coming from the abdomen. Patient is afebrile and no signs of acute abdomen
GI tract fistula
What things prevent a fistula from healing
Foreign body Epithelization Tumor Infectious/irridiated tissue/inflammatory bowel disease Distal obstruction
Patient went out drinking one night and started vomiting repeatedly. First bile is coming up and then bright red blood is seen. What is the diagnosis
mallory weiss syndrome
Patient drinking heavily and drunk and starts vomiting repeatedly. A violent episode of vomiting sets in. Severe epigastric and substernal chest pain, diaphoretic, fever, leukocytosis is also seen. Whats the diagnosis
Esophageal perforation
Patient has an upper endoscopy for gastric cancer and is sent home. When the patient gets home he starts to feel ill. Fever, leukocytosis and sweating ensues. There is retrosternal chest pain. Subcutaneous emphysema is seen in the neck. What is the diagnosis
Esophageal perforation due to an instrument
Whats the diagnostic order of tests for esophageal perforation
Gastrographing swallow–>barium swallow–>surgery
Whats the diagnostic test if your thinking its a stomach cancer
endoscopy and biopsy and then CT scan
Management of small bowel obstruction
NPO nasogastric suction and IV fluids. If the bowel doesnt clear then go to surgery
Patient comes in with colicky abdominal pain, abdominal distention, protracted vomiting, x-ray showing loops of bowel and air fluid levels, hasnt had a bowel movement or passed any gas, tampany to percussion. Patient is then put on NPO and has nasogastric suction. Patient then develops fever, leukocytosis, abdominal tenderness and guarding. What the diagnosis
Strangulation of the small bowel
Protracted diarrhea, episodes of flushing of face, expiratory wheezing, prominent jugular venous pulse recognized on her neck. What is the diagnosis
Carcinoid syndrome
Patient comes in with anorexia, vague periumbilical pain for a few hours that becomes sharp severe constant in the right lower quadrant. Leukocytosis, fever, guarding, rebound abdominal tenderness. What is the diagnosis
Acute appendicitis
If your thinking appendicitis what diagnostic test would you order
Either sonogram or CT scan
What is the classical presentation of a cancer of the colon on the right side
Anemia
Name polyps an order of premalignant to benign
Familial polyposis, villious adenomas, adenmatous polyp, juevnile polyps (benign)
Patient with Chronic ulcerative colitis, weighs 90lbs, over 40 hospital visits, severe abdominal pain, fever, leukocytosis, tender abdomen with muscle guarding and rebounding, distended transverse colon and gas in the bowel. Whats the next best step
Surgery. Colon resection
Female patient comes in with sever pain with defecation, blood streak stools, avoids defecating from pain, patient wouldnt let doctor exam them
Anal fistula
How does a anal fistula occur?
A tight sphincter is present which creates small tears in the anal mucosa then the blood supply gets cut off and the tears dont heal causing pain and bleeding
Chronic perianal fistula which was operated on and then things keep getting worse with multiple unhealing ulcers and purulent discharge. Whats the diagnosis
Crohns disease
Characteristics of sqamous cell carcinoma of the anus
mass protruding out of anus. associated with viral infection (HIV). metastsis to lymph nodes in abdomen and groin nodes
33 yr old Patient with 3 large bowel movement made up of dark red blood, sweating, pale, BP 90/70 PR 110. Patient just had a bloody bowel movement 20 min ago. What is the Next step in management?
Nasogastric tube aspiration looking for blood
7 yr old boy passes a large bloody bowel movement. What is the diagnosis and management
Meckels diverticulum. Technitium 99 scan is diagnostic
What 3 general groups of conditions cause abdominal pain or acute abdomen
- Perforation(sudden onset, constant pain, severe, generalized, guarding rebound tenderness, absent bowel sounds)
- Obstruction( sudden onset, colicky pain, localized)
- Inflammatory( gradual onset, constant pain, localized, guarding and rebound tenderness that localized, fever, leukocytosis)
Patient with cirrhoisis and ascites presents with generalized abdominal pain that started 12hrs ago. Moderate tenderness in all quadrants with some guarding and rebound tenderness with mild fever and leukocytosis. What is the diagnosis?
Primary bacterial peritonitis
Excruciating sudden onset of pain, rigid abdomen and lies motionless with absent bowel sounds. Free air under the diaphagram. What is the diagnosis
Perforation
alcoholic man presents with severe epigastric pain after alcohol intake, pain is constant and radiates to the back. Vomiting is present. What is the diagnosis
Acute pancreatitis
A 40 yr old obese mother of 6 children has severe right upper quadrant pain colicky in nature that radiated to the left shoulder and around the back. Has tenderness to deep palpation and rebound tenderness in the right upper quadrant. Nausea and vomiting is present. Constant pain. Fever and leukocytosis. Similar episodes with ingestion of fatty foods. What is the diagnosis
Acute cholecystitis
50 yr old man with right flank pain that radiates to the groin and has microscopic hematuria. What is the diagnosis
ureteral stone
What is the diagnostic test for diverticulitis
CT scan
82 yr old patient with colicky abdominal pain, severe abdominal distention, no gas, no stools, distended loops of small and large bowel, large air shadow (parots beak), nausea, vomiting, hyperactive bowel sounds, tympanic to percussion. What is the diagnosis
sigmoid volvulus
79 yr old man with A. Fib develops an acute abdomen. Develops acidosis and look sick. Silent abdomen with diffuse tenderness, trace of blood in stool, distension in small bowel up to the transverse colon. What is the diagnosis?
Mesenteric ischemia
Whats the blood marker for hepatocellular carcinoma
Alpha feto protein
Patient develops vague right upper quadrant discomfort, palpable liver with nodularity, CEA within normal limits after cholecystectomy. Now the CEA is 2 times above upper limits. What is the diagnosis
Metastatic cance of liver
Diagnostic test for liver cancer
CT scan
What are the two kinds of liver abscess?
- Pyogenic liver abscess (due to biliary traact disease)
2. Amebic abscess of liver ( due to infection from mexico)
Whats the treatment for an amebic abcess of the liver?
metronidazole
Whats the prophalyaxis for malaria for a patient going to india?
Mefloquin
What is the diagnostic test for a patient with obstructive jaundice?
Sonogram
What does a big distended thin walled gallbladder suggest to you?
Cancer of the gallbladder
Patient presents with signs of obstructive jaundice and distended thin walled gallbladder, anemia and blood in the stools. What is the diagnosis
Cancer of the ampula of vater
Whats the diagnostic test for any biliary tract disease
sonogram
What are the three things that confirm the diagnosis of acute cholecystitis
- Stones in the gallbladder
- Distended thick walled gallbladder
- Pericholecystic fluid
Whats the management for acute ascending cholangitis
ERCP
If a person has acute cholecystitis and you want to wait before you do surgery, whats the management?
Antiobiotics, IV fluids, nasogastric suction
In the setting of pancreatitis what does a low hematocrit mean
hemorrhagic pancreatitis
In the setting of pancreatitis what does a high hematocrit mean
edematous pancreatitis
Patient presents with acute hemorrhagic pancreatitis. They are treated and sent to the ICU. 2 weeks later the patient develops a febrile illness with fever and leukocytosis. What is the most likely diagnosis
Pancreatic abscess
Alcoholic Patient comes in with ill defined upper abdominal discomfort, early satiety, large epigastric mass that is deep within abdomen and hard to define. Was discharged from the hospital 5 weeks ago for treatment of acute pancreatitis
Pancreatic psuedocyst
Patient comes in with a calcified pancreas on CT scan, constant severe epigastric pain that goes straight through to the back, steatorrhea and diabetes. What is the diagnosis
Chronic pancreatitis
Patient comes in with a 12x10x7cm mass in left breast for seven years and slowly growing. Not attached to the chest wall and is firm and rubbery. No axillary nodes present. Whats the diagnosis
cystosarcoma phyllodes. Has malignant potential
35 yr old patient comes in with a 10 yr history of Multiple painful lumps on both breast that seems to come and go with her period. She now has a firm round 2 cm mass that has been present for 6 weeks. What is the diagnosis and management
fibrocystic disease. Mammogram and aspiration of the cyst
Patient comes in with Bloody discharge from right nipple on and off for several months. What is the diagnosis and management
Intraductal papilloma. Mammogram
Patient has a red swollen breast without tenderness. No fever or leukocytosis. Orange peel appearance. What is the diagnosis
Inflammatory cancer of the breast
What would a mammogram show to get you thinking about breast cancer
irregular density, fine microcalcifications, wasnt present on previous films
Which cancer is most likely known to be bilateral
Lobular cancer of the breast
Whats the management for inflammatory cancer of the breast
Radiation and chemotherapy first to reduce the cancer then mastectomy
Which breast cancer has no potential to metastasize
Ductal carcinoma insitu
Which breast cancer patients needs chemotherapy
Premenopausal or distant metastasis
Which breast cancer patients need tamoxifen treatment
post menopausal women or women who are receptor positive
What is the diagnostic test to do for a patient with possible bone metastasis
Bone scan
Patient has severe migratory necrolytic dermatitis for several years that hasnt responded to treatment. She also has Mild stomatitis and mild diabetes mellitus. What is the diagnosis?
glucagonoma
Patient comes in with hypertension that wasn’t present 3 yrs ago. She is not taken any medictions. Her sodium level is 145, bicarbonate is 28, and potassium is 2.7. What is the diagnosis?
Hyperaldosteronism
Lady comes in who is thin hyperactive and has episodes of severe pounding headaches with pallor. What is the diagnosis
pheochromocytoma
Patient with severe HTN for 2 yrs that doesnt respond to medications. Bruit is heard in the abdominal area or flank. What is the diagnosis
Renal vascular HTN
What are the three diagnosis that can be made for a baby who on the first day of life vomits green fluid with feeding and has a double bubble sign
- Duodenal atresia
- Annular pancreas
- Malrotation( has air fluid levels beyond double bubble)
Whats the diagnostic test for malrotation
Barium enema
Infant has green vomiting after feeding and has many air fluid levels. What is the diagnosis
Intestinal atresia
Premature infant with Feeding intolerance, abdominal distension, and drop in platelets. What is the diagnosis?
necrotizing enterolytics
3 week old baby with projectile vomiting with no bile in it and follows each feeding. Visible peristalic waves and palpable olive mass in right upper quadrant. What is the diagnosis?
Pyloric stenosis
8 week old baby with progressive jaundice that is mainly conjugated bilirubin. What is the diagnosis?
biliary atresia
2 month old baby comes in with chronic constipation. Exam shows abdominal distention with loops of bowel throughout. What is the diagnosis?
Aganglionic megacolon
Currant jelly stools is the buzz word for???
Intersucception
Which heart defect has a fixed split S2
ASD
3 month old baby hospitalized for failre to thrive has a pansystolic murmur best heard at the left sternal boarder with increasing pulmonary vascular markings. What is the diagnosis?
VSD
premature baby has trouble feeding and pulmonary congestion. On physical exam the patient is noted to have a machine like murmur and bounding pulses. What is the diagnosis?
PDA
What is the management for PDA and when would you use it
Indomethacin and when there is no pulmonary congestion/failure present
72 yr old patient comes in with a history of angina and exertional syncopal episodes. loud harsh systolic murmur at the right 2nd intercostal space and radiates to the left sternal border. What is the diagnosis
Aortenic stenosis
Patient comes in with a 10 history of a wide pulse pressure blowing high pitched dialstolic murmur best heard at 2nd intercostal space and along the left sternal border. Left ventricular dilation is also noted. What is the diagnosis?
Chronic Aortic regurgitation
26 yr old drug addict develops CHF over a few days. Loud dialstolic murmur at the right 2nd intercostal space. Physical exam was normal. What is the diagnosis
Acute Aortic regurgitation
Patient comes in with dyspnea on exertion, orthopnea, paroxysmal nocturnia dyspnea, cough and hemoptysis, she has had these symptoms for over 5yrs. She looks thin and cachetic and has A. Fib with a low pitched rumbling dialstolic apical murmur. Had rheumatic fever when she was 12. What is the diagnosis
Mitral stenosis
55 yr old lady has Mitral valve prolapse and has developed exertional dyspnea, orthopnea, and A. Fib. She has a apical high pitched systolic murmur that radiates to the axilla. What is the diagnosis?
Mitral regurgitation
Patient comes in with progressive unstable disabling angina that does not respond to medications. Brother and father died of MI before 50. Patient is obese. What is the management
Cardiac catherization
55 yr old man progressive unstable disabling angina that does not respond to medications. Brother and father died of MI before 50. Lifestyle high cholesterol type 2 diabetes and obese. cath shows 70% occlussion of 3 vessels with good distal vessels. Ejection fraction is 65%. What is the management
CABG
What is the cardiac index?
Makes cardiac output per body surface. Should be around 3
What does Left ventricular end dialstolic pressure to you
It tells you how much volume is in the ventricle. If the number is high then there is cardiac insufficiency with propelling the fluid forward. If it is low then there isnt enough fluid in the vascular tree.
In the lung which kind of lesion is cancerous between calcified and noncalcified?
noncalcified
How do you remove a central mass in lung cancer
pneumonectomy
What level does your FEV need to be at to treat cancer with pneumonectomy in a patient with chronic respiratory problems? How would you calculate it?
- FEV1 of 800.
2. You calculate by taking the FEV and remove from that how much oxygen is coming from the affected lung.
Patient who is left handed when doing strenous work causes his hand to become cold and tingling with pain in the forearm. He also has vertigo blurred vision and difficulty articulating his speech. Angiogram show reversal of flow from vetebral artery
Subclavian steal syndrome
What size does an abdominal aneurysm have to be for elective surgery?
6cm
What would you do for an abdominal aneurysm that is 4cm?
Watchful waiting(observation)
What diagnostic test would you use for an abdominal aortic aneurysm?
Sonogram
68 yr old man comes in with excruciating back pain that began suddenly,he is diaphoretic and has a BP systolic of 90 and 8cm pulsatile mass palpated in the abdomen. What is the next step in management?
Surgical intervention
60 yr old retired man comes in who has claudication(pain with walking but relieved with rest) with walking more than 15 blocks. Whats the next step in management?
Walk as much as you can then rest. If the patient smokes help them stop smoking
severe pain in his right calf when he walks 2 blocks. Pain stops when he rest. He does not smoke and he can not retire at the moment. What is the next step in management?
Doppler studies looking for pressure gradient
When you perform a doppler exam looking for a pressure gradient, if there is no gradient found what does that tell you?
That tells you that there is disease in the small vessels in which there is nothing you can do about
When you perform a doppler exam looking for a pressure gradient, if there is a pressure gradient found what is the next step in management?
Arteriogram to show where the obstruction is
Patient cant sleep, pain in right calf which keeps him from sleep, pain goes away if he dangles the leg, leg was pale lying down but deep purple when he dangles them, no palpable pulses
Arterioocclusive disease with rest pain
Patient comes in the ER witha Pale cold pulseless painful and paralytic parasethic lower extremity. Begain suddenly. Pulse is irregular. What is the diagnosis and management?
Sudden occlusive disease. Get a doppler study then embolectomy
Patient comes in with sudden onset of severe tearing chest pain that migrates down after onset BP220/110 unequal pulses on upper extremity and widened mediastinum. Cardiac enzymes are negative. What is the diagnosisa and management?
Aortic dissection and do a spiral CT scan or TEE
If the aortic dissection is in the ascending aorta what is the management?
Emergency surgery
If the aortic dissection is in the descending aorta what is the management
Medical management
60 yr old patient comes in with an indolent raised waxy 1cm skin mass on the bridge of the nose. No enlarge lymphnodes in the head or neck. What is the diagnosis?
Basal cell carcinoma
72 yr old patient comes in with a Non healing indolent punched out clean looking 2 cm ulcers over the left dimple that has slowly becoming larger over the last 3 years. No enlarged lymph nodes in the head or neck. What is the diagnosis?
Basal cell carcinoma
Where do basal cell skin carcinomas occur
Above the lip
Where do squamous cell skin carcinomas occur
Below the lip
non healing indolent 1.5cm ulcer on the lower lip that has been enlarging for the past 8months. What is the diagnosis
Squamous cell carcinoma
What is the management for skin cancers
Start with full thickness skin biopsy
What is strabmismus
Crossed eyed
What is the management for strabismus an a child born with it
Surgical correction
What is the management for stabismus for a child who develops it around age 3
Glasses
A mother brings her baby in to see you. On exam one Pupil is white and one is black. What is the diagnosis
Retinoblastoma
Female Patient comes in with extremely severe frontal headache that started about an hour ago. She had just left the movie where she watched two movies. In the parking lot she saw halos around the lights. On Exam the pupil show mid dilation and doesnt react to light, corneas are cloudy and greenish and the eyes feel hard as a rock. What is the diagnosis
Acute angle closure glaucoma
What is the management for acute angle closure glaucoma
Surgery and in the meantime medical management like mannitol
32 yr old woman comes in with swollen, red, hot, tender eyelids on the left eye. Has fever and leukocytosis. pupil is dilated and fixed and very limited motion of left eye. What is the diagnosis?
Orbital cellulitits
A kid splashes drano in his eye and is screaming in intense pain. What is the next step in management?
Massive irrigation of the eye.
Patient comes in and says he sees Flashes of light at night when his eyes are closed and floaters during the day and a cloud at the top of his visual field. What is the diagnosis?
Retinal detachment
Patient has a sudden loss of sight in his right eye. What is the diagnosis?
Embolic occlusion of the retinal artery
What is the management for embolic occlusion of the retinal artery?
Rush to hospital for surgery and while in route breath in bag and have someone pushing on your eye and letting go repeatedly.
What eye issue will you have with longstanding diabetes?
retinopathy
Unilateral sensorinueral hearing loss should alert you to what?
Carcinoma of the 8th cranial nerve
Patient comes in with a big mass in front of the ear. There is no pain present and no signs of facial nerve symptoms. What is the diagnosis?
pleomorphic adenoma of parotid gland
65 yr old pain has 4cm hard mass in front of left ear and present for 6 months. Constant pain in the area and gradual progression of facial nerve paralysis and enlarged lymph node in the neck. What is the diagnosis
Parotid malignant tumor
62 yr old patint comes in complaining of dizziness and the room spins around him. What is the diagnosis?
Inner ear problem
52 yr old right handed man comes in with transient episodes of weakness, blurred vision and difficulty expressing hisself. This was sudden onset and lasted a few minutes and then resolved. The patient has no headache. What is the diagnosis
TIA
What is the next best step in management of TIA
Duplex scanning study
61 yr old patient presents with 1 yr history of episodes of vertigo, diplopia, blurred vision, dysarthria and instability of gait that last several minutes with sudden onset with no associated headache. What is the diagnosis
Vetebral ischemia
diabetic patient with right 3rd nerve paralysis and contralateral hemiparesis. This was sudden onset with no associated headache. Symptoms have lasted for 7 days. What is the diagnosis
Stroke
What is the diagnostic test to see a brain tumor
MRI
How do you treat paplliedema in a patient with a brain tumor
Dexamethasone
What does the cushing reflex indicate
Extremely high ICP
What is the cushing triad
ICP, High blood pressure and bradycardia
What is the first line of therapy for prolactinoma
Bromocriptine
What is the management for acromegaly?
Surgery or radiation
If you suspect cushing disease in a patient and you do a dexamethasone suppression test and the patient does suppress at low does, what does that tell you?
The patient does not have cushing disease
If you suspect cushing disease in a patient and you do a dexamethasone suppression test and the patient does not suppress at low doses but suppresses at high doses what does that tell you?
Pituitary adenoma
If you suspect cushing disease in a patient and you do a dexamethasone suppression test and the patient does not suppress at low or high doses, what does that tell you?
Paraneoplastic syndrome or adrenal adenoma
Young lady comes in with 6 month history of headache, vision loss, amenorrhea. Then Patient had a sudden headache and went into stupor, bilateral pallor of optic nerves. BP is 75/45. What is the diagnosis?
Pituitary apoplexy
Whats the next best step in management of pituitary apoplexy?
Steroids
Severe headaches begain 3 months ago and worst in the morning. Loss of upward gaze. What is the diagnosis?
Pineal tumor (Perinaud syndrome)
Where are adult brain tumors normally found
Above the tentorium
Where are child brain tumors normally found
below the tentorium
Patient comes in with severe headache, seizures and projectile vomiting over 2 weeks. Patient recent had mastoiditis. What is the diagnosis?
Brain abscess
What is the diagnostic study for a brain abscess?
CT scan
Patient comes in with constant severe back pain for 2 weeks and suddenly falls and cant get up. Patient is paralyzed below waist. 2 yr ago patient had a cancer of the breast treated with masectomy. What is the diagnosis?
Bone metastasis
45 yr old man comes in with aching back pain for several months. sudden onset of severe back pain from lifting. electrical shock shoot down legs worst with sneezing and straining. straight leg test gives excruciating pain. What is the diagnosis?
Disk herniation
Patient comes in with pain when walking that is relieved with rest. Has to sit down or bend over for the pain to go away. Patient can exercise if he is hunched over. Has normal pulses in his legs. What is the diagnosis?
Neurogenic claudication
What is the next best step in management of neurogenic claudication?
MRI
24 yr old man comes in with very severe pain of recent onset in the scrotum, fever and pyruria, cord is very tender. What is the diagnosis?
Acute epididymiditis
What is the next best step in management of acute epididymitidis?
sonogram
You diagnose a patient with pyelonephritis and give intravenous antibiotics. What is the next best step in management of the patient?
Urological workup (intavenous pyelogram or CT scan)
Patient comes in with fever and chils and dysuria diffuse low back pain and increased urinary frequency. On rectal exam there is a tender prostate. What is the diagnosis
Acute bacterial prostatitis
Male patient comes in with urgency frequency and burning pain with urination and Maladorus urine. On physical exam the prostate is not warm boggy or tender. What is the next best step in management?
IV antibiotics and cultures plus a Urological workup (IVP or sonogram)
6 yr old girl has trouble with potty training and is found wet with urine all the time. What is the diagnosis?
Low implantation of one of her ureters.
Whats the urological workup for a patient who comes in without trauma and has hematuria?
IVP first and then cystoscopy
62 yr old patient comes in with Hematuria, flank pain, flank mass. Has hypocalcemia elevated enzymes, erythrocytosis. What is the diagnosis?
Renal cell carcinoma
Whats the next step in management of a patient who has symptoms of renal cell carcinoma?
CT scan
65 yr old man is a chronic smoker which has had 3 instances with painless gross total hematuria. Has had irritating voiding symptoms with negative culture. What is the diagnosis?
Bladder carcinoma
Whats the management for a patient who has developed bone metastasis from prostate cancer?
orchiectomy or flutamide
25 yr old male comes in with a painless hard testicular mass. What is the diagnosis?
Testicular cancer
What is the management for testicular cancer
orchiectomy by the inguinal route
On pre-employment exam a chest x ray appears to show pulmonary metastasis from unknown tumor. Exam shows hard testicular mass. Past 6 months been losing weight for last 6 months. What is the management?
Orchiectomy and then chemotherapy
Management for BPH
Alpha blockers
Patient comes in complaining of air bubbles with urine. What is the diagnosis?
Fistula between GI tract and bladder commonly caused from diverticulitis
Patient has an organ transplant and soon as blood supply is reestablished the patient develops fever, dyspnea and hypoxia. What is the diagnosis?
Hyperacute rejection (preformed antibodies) due to incompatability with ABO blood groups
What is the management for acute transplant rejection?
Bolus of steroids
Whats the absolute contraindication for surgery?
DKA
What is the optimal method of feeding someone to increase nutrition
Enteral feeding(through the gut)
In pre-op evaluation what factors do you want to assess for severe liver failure
- Bilirubin
- PT
- Ammonia levels
What is Goldman index
Tells you the person who is at greatest risk for surgery
What are the most important factors for Goldmans index in order from most important to least important
- CHF (check ejection fraction)
- MI in the last 6months (EKG)
- Arrhythmia
- Old age
- Emergent surgery
- Aortic stenosis
What medications should a patient stop before surgery?
- Aspirin
- NSAIDS
- Metformin
- Warfarin (below 1.5)
Why would you check BUN and Cr before surgery
Because if uremia is present it can affect the function of platelets and cause an increase risk of bleeding (uremeic platelet dysfunction)
Which vent setting is important for weaning a patient off the ventilatior
Pressure support
What is the best test to evaluate a patient who is using a ventilator?
ABG
What is the value for the normal anion gap
8-12
What are the non anion gap acidosis
- Diarrhea
- RTA
- Diuretic abuse
If you have a metabolic acidosis what could be the cause?
- Vomiting
- Antacids
- Diuretics
- Hyperaldosteronism
- Barter syndrome
How can you differentiate between what is causing a metabolic alkalosis?
Look at the urine chloride. If it is below 20 then it is caused by vomiting or antacids, or diuretics. If it is aboive 20 then it is caused by hyperaldosteronism or barter syndrome
What could give you hypervolemia and hyponatremia?
- CHF
- Nephrotic syndrome
- Cirrhosis
What could give you hypovolemia and hyponatremia?
- Diuretics
2. Vomiting+free water
What could make you euvolemic and hyponatremic?
- SiADH
- Addisons
- Hypothyroidism
What is the rate to correct hyponatremia?
12-24mEQ/day
What causes these symptoms…. periorbital numbness, chvostek sign, prolonged QT interval
Hypocalcemia
What causes these symptoms…..Paralysis, ileus, ST depression, U waves
Hypokalemia
What causes these symptoms…. Peaked T waves and prolonged PR and QRS
Hyperkalemia
What causes these symptoms…. Bones, stones, groans, Shortened QT interval
Hypercalcemia
How do you treat hyperkalemia?
First calcium gluconate then insulin, glucose, albuterol, dialysis
What do you give for maintenace IV fluids
D5W and 1/2 normal saline +20KCl
What are the maintenace fluids for
up to 10kg–>
next 10kg–>
above 20kg
10kg–>100mL/kg/day
next 10kg–>50mL/kg/day
above 20kg–> 25mL/kg/day
What is the test to check for a patient with CO poisoning
Carboxyhemoglobin
You have a post-op patient with decrease platelets and increased clotting. What is the diagnosis
Heparin induced thrombocytopenia
How do you treat heparin induced thrombocytopenia
Agatroban or leparudin
What topical antibiotic for burns doesnt penetrate eschar and can cause leukopenia
silver sulfadiazine
What topical antibiotic for burns penetrates eschar but hurts like hell
malfinide
What topical antibiotic for burns doesnt penetrate eschar and causes hyponatremia and hypokalemia
Silver nitrate
What is the glascow coma scale number have to before to intubate?
GCS<8
What is the confirmatory test for pericardial tamponade
FAST scan
What are the components of the glascow coma scale?
eyes (4)
motor (6)
verbal(5)
Post-op day 7 patient has fever, pain at incision site, edema, induration but no drainage
Cellulitis
Patient comes in for a gyneological surgery and post -op she develops a fever that has an unknown cause. What are you thinking about?
Thrombophleblitis
What is marjolin ulcer?
Squamous cell carcinoma
What is lights criteria
Transudative if: LDHeffusion:LDHSerum<0.5
Where does adenocarcinoma like to metastazise to?
Liver, bone, brain, adrenals
What kind of effusion would an adenocarcinoma in the lung cause
Exudative with high hyaluronidase
Patient with kidney stones, constipation and malaise with low PTH and a central lung mass
Squamous cell carcinoma of the lung
Patient with shoulder pain, ptosis, constricted pupil, and facial edema?
Pancoast tumor from small cell cancer of the lung
What is MALT lyphoma associated with
H. Pylori
What are the complications of pancreatitis
- Hemorrhage
- Pseudocyst
- ARDS
- Abscess
What vitamin can you become deficient in if you have carcinoid syndrome?
niacin
What are the symptoms of niacin deficiency
Diarrhea, dementia, dermatitis
If you have Posy-op ileus what test should you run
You should check potassium. It would be low
