Surgery: UWorld

Question 1

What is the most common bone in the body to be affected by stress fractures?

Answer 1

The tibia

Stress fractures classically occur in the anterior part of the middle third of the tibia in patients involved in jumping sports and the posteromedial part of the distal third of the tibia in runners. X-rays are frequently normal during the initial evaluation.

Question 2

Dyspnea, hemoptysis, subcutaneous emphysema, audible crepitus on cardiac auscultation (Hamman sign), and sternal tenderness are all characteristic of what diagnosis?

Answer 2

Tracheobronchial tear

Question 3

What is a good modality for evaluating cardiac systolic and diastolic functions, cardiac valves, and pericardial effusions?

Answer 3

Transthoracic echocardiography

Question 4

Following splenectomy, patients are at increased risk for sepsis secondary to which 3 bacteria?

Answer 4

1. Streptococcus pneumoniae
2. Neisseria Meningitidis
3. Haemophilus influenzae

Splenectomy increases the risk of sepsis secondary to encapsulated bacteria. Pneumococcal vaccine boosters are required every 5 years. The spleen plays an important role in immune surveillance. As blood flows through it, antigens are samples by dendritic cells and presented to helper T-cells, which subsequently activate B-cells to differentiate into antibody-secreting plasma cells. In the absence of specific antibodies, phagocytes are unable to recognize and engulf encapsulated organisms, thereby allowing these organisms to multiply unchecked in the circulation.

Question 5

What is the first step in management of a suspected urethral injury?

Answer 5

Retrograde urethrogram

The procedure can be used both to determine whether damage to the urethra has occurred and to determine the location of such damage within the urethra. Foley catheterization in the presence of a urethral injury will predispose the patient to abscess formation and worsening of the urethral damage.

Question 6

What classically presents with dull abdominal pain and possibly bloody diarrhea acutely following abdominal aortic aneurysm repair

Answer 6

Colonic ischemia

Colonic ischemia follows up to 7% of such procedures due to interference of blood flow to the distal left colon. Common causes include loss of collateral circulation, manipulation of vessels with surgical instruments, prolonged aortic clamping and impaired blood flow through the inferior mesenteric artery.

Question 7

What is characterized by early satiety, nausea, nonbilious vomiting, and weightloss?

Answer 7

Gastric outlet obstruction

Question 8

What are the 3 main organs injured by blunt abdominal trauma?

Answer 8

Spleen, liver, and kidney

Evaluation with exploratory laparotomy.

Question 9

CT scan of the head showing numerous minute punctuate hemorrhages with blurring of the gray-white matter interface is characteristic of what?

Answer 9

Diffuse axonal injury

This is the most significant cause of morbidity in patients with traumatic brain injuries. It is frequently due to traumatic deceleration injury and results in vegetative state.

Question 10

What effect on risk of postoperative atelectasis does moving from supine to sitting have?

Answer 10

Moving from supine to sitting can increase the functional residual capacity by 20-35% and thus can help prevent postoperative atelectasis

Question 11

What is the gold standard for evaluating known peripheral artery disease (PAD) because it is highly sensitive and specific for determining the specific vessels involved?

Answer 11

Contrast arteriography

It is an invasive procedure requiring arterial puncture and the use of contrast dye. Arteriography is best reserved for an unclear diagnosis or when planning invasive interventions.

Question 12

Air seen under the diaphragm (between liver and diaphragm for example) is of greatest concern for what?

Answer 12

Perforated peptic ulcer

No other diagnostic studies are required for this surgical emergency, and surgery consultation must be obtained immediately.

Question 13

What should be suspected in all adult patients with blunt chest trauma who present with persistent jugular venous distension, tachy cardia, and hypotension despite aggressive fluid resuscitation?

Answer 13

Acute cardiac tamponade

Chest x-ray findings typically reveal a normal cardiac silhouette without tension pneumothroax.

Question 14

Why is mechanical ventilation risky in a patient with hypovolemic shock?

Answer 14

It may cause circulatory collapse

Positive pressure mechanical ventilation increases intrathoracic pressure, which decreases venous return to the heart and thereby decreases the ventricular preload. This effect may cause circulatory collapse if the patient’s intravascular volume is not replaced before mechanical ventilation is attempted.

Question 15

Syringomyelia classically presents with what?

Answer 15

Central cord syndrome

This is characterized by impaired strength and pain/temperature sensation in the upper extremities (or having a cape-like distribution), with preservation of dorsal column function. Syringomyelia is a generic term referring to a disorder in which a cyst or cavity forms within the spinal cord that can expand and elongate over time, destroying the spinal cord.

Question 16

In evaluating a patient with a shoulder injury, a positive drop arm sign (arm drops rapidly from 90 degree abduction) is indicative of what?

Answer 16

Rotator cuff tear

The rotator cuff is formed by the tendons of the supraspinatus, infraspinatus, teres minor, and subscapularis. The supraspinatus is most commonly injured, due to repeated bouts of ischemia near its insertion on the humerus induced by compression between the humerus and the acromion. The drop arm test is a maneuver that can help to diagnose a rotator cuff tear. Here, the patient’s arm is abducted passively to greater than 90 degrees, and the patient is then asked to lower the arm slowly. With a complete rotator cuff tearm the patient will be unable to lower the arm smoothly and it will appear to drop rapidly from near the 90 degree position.

Question 17

What is the management of a patient with pulmonary contusions?

Answer 17

Close monitoring and intubation with mechanical ventilation in severe instances

Question 18

Foot ulcers occuring on the plantar surface of the foot under points of greatest pressure, such as under the head of the first metatarsal bone are classically caused by what?

Answer 18

Peripheral neuropathy, microvascular insufficiency and immunosuppression

All three are present in diabetics. Diabetic foot ulcers typically occur on the sole of the foot on high-pressure weight bearing sites, such as below the head of the first metatarsal.

Question 19

What is the diagnostic study of choice in a patient with suspected esophageal perforation?

Answer 19

Gastrografin-contrast esophagography

This demonstrates contrast leakage at the site of the perforation.

Question 20

What is the most common infectious agent in acute bacterial parotitis?

Answer 20

Staphylococcus aureus

Parotitis is an inflammation of one or both parotid glands. This post-operative complication can be prevented with adequate fluid hydration and oral hygiene.

Question 21

Abdominal pain and bloody diarrhea following an abdominal aortic aneurysm repair is concerning for what?

Answer 21

Bowel ischemia or infarction

Bowel ischemia is one known complication (1-7%) incidence of abdominal aortic aneurysm repair. It results from inadequate colonic collateral arterial perfusion to the left and sigmoid colon after loss of the inferior mesenteric artery during aortic graft placement.

Question 22

How is acute appendicitis diagnosed?

Answer 22

It is a clinical diagnosis

Question 23

What is the most common cause of lower gastrointestinal hemorrhage in an elderly patient?

Answer 23

Diverticulosis

Bleeding from diverticulosis is typically painless. Diverticulosis should be distinguished from diverticulitis, which is characterized by abdominal pain and infectious symptoms, usually without associated bleeding.

Question 24

What should be suspected in patients with a history of blunt trauma (motor vehicle accident), abnormal chest x-ray, left lower lung opacity, elevated hemidiaphragm, and mediastinal deviation?

Answer 24

Diaphragmatic rupture

Children can have delayed presentation with expansion of the diaphragmatic defect and herniation of abdominal organs.

Question 25

When a wound fails to heal after a prolonged period, biopsies should be obtained to ensure that the ulcer has not degenerated into what?

Answer 25

Squamous cell carcinoma *When SCC arises within a burn wound, these ulcers are known as Marjolin ulcers.*

Question 26

Loss of motor function, pain, and temperature, but intact proprioception is characteristic of what?

Answer 26

Anterior cord syndrome *This is commonly associated with a burst fracture of the vertebra and is characterized by loss of motor function, pain, and temperature below the lesion. Proprioception remains intact.*

Question 27

A biconvex hematoma on head CT scan is diagnostic of what?

Answer 27

Epidural hematoma

Question 28

Non bleeding varices are managed with what?

Answer 28

Nonselective beta-adrenergic antagonists such as propranolol *Such therapy can reduce the risk of bleeding by up to half.*

Question 29

What is given pre-operatively to patients with mild hemophilia A?

Answer 29

Desmopressin (DDAVP) *This is given to prevent excessive bleeding. It indirectly increases factor VIII levels by causing vWF release from endothelial cells.*

Question 30

What is transesophageal echocardiography helpful in diagnosing?

Answer 30

Aortic dissection

Question 31

Surgery below the mandible, such as for a tumor of the submandibular salivary gland, would put one at risk for what type of injury?

Answer 31

Hypoglossal nerve injury resulting in tongue palsy

Question 32

What kind of tear of the medial meniscus leads to locking of the knee joint during terminal extension?

Answer 32

A bucket handle tear

Question 33

What is the difference between the presentation of bowel ischemia and bowel infarction?

Answer 33

1. Ischemia presents with sudden-onset severe poorly localized (visceral) midabdominal pain accompanied by nausea and vomiting but physical exam is unremarkable 2. Infarction presents like ischemia but also with peritoneal signs (tenderness to palpation with guarding and rebound) and bloody stool

Question 34

Injury to which nerve would cause loss of sensation of skin over the lateral three and a half fingers and lateral half of the palm?

Answer 34

Median nerve

Question 35

What is the next step in management of someone with clinical signs of scaphoid fracture but a negative X-ray?

Answer 35

Thumb immobilization in a spica cast and repeated X-rays in 7-10 days *It can take up to 10 days to show abnormalities on X-rays. Scaphoid fractures are particularly concerning because of the tenuous blood supply of the scaphoid, making the proximal fracture fragment vulnerable to avascular necrosis.*

Question 36

Severe pain, pain with passive range of motion, paresthesias, as well as pallor and paresis of the affected limb is all characteristic of what?

Answer 36

Compartment syndrome *The presence of pulses does not rule out compartment syndrome. Compartment syndrome may be caused by direct trauma (hemorrhage), prolonged compression of an extremity, or after revascularization of an acutely ischemic limb.*

Question 37

What is the treatment for compartment syndrome?

Answer 37

Urgent Fasciotomy

Question 38

What is the primary objective in the management of a rib fracture?

Answer 38

Pain relief *This will allow proper ventillation and prevent atelectasis and pneumonia.*

Question 39

All patients with penetrating injury and evidence of peritonitis or unstable hemodynamics need what?

Answer 39

Immediate laparotomy

Question 40

Uric acid stones, which are radiolucent, have to be evaluated by what?

Answer 40

CT of the abdomen or intravenous pyelography

Question 41

What is the treatment of choice for esophageal perforation?

Answer 41

1. Antibiotic therapy 2. Parenteral nutrition 3. Surgical repair

Question 42

What potentially lethal postoperative complication commonly presents with neausea, vomiting, abdominal pain, hypoglycemia, and hypotension often in the setting of steroid-dependence?

Answer 42

Acute adrenal insufficiency *Exogenous steroids depress pituitary-adrenal axis and a stressful situation can precipitate an acute adrenal insufficiency.*

Question 43

What are some signs of peritoneal irritation (peritoneal signs)?

Answer 43

1. Rebound tenderness 2. Abdominal guarding 3. Decreased bowel sounds

Question 44

What is characterized by sudden onset pain, pulselessness, pallor, paresthesias, and paralysis in the affected limb of a patient with a low likelyhood of compartment syndrome?

Answer 44

Arterial embolism (Arterial occlusion of an extremity) ## Footnote *In contrast, arterial thrombosis results in slow, progressive narrowing of the vascular lumen in the affected limb (symptoms have insidious onset), and pulses in patients with arterial thrombosis are usually diminished bilaterally.*

Question 45

What is a hydrocele?

Answer 45

Fluid collection within the processus or tunica vaginalis (the peritoneal projection that accompanies the testis during its descent into the scrotum)

Question 46

What results from lower extremity venous insufficiency due to valve incompetence?

Answer 46

1. Edema 2. Stasis dermatitis 3. Venous ulceration *Valvular incompetence results in pooling of venous blood and increased pressures in post capillary venules. This increased pressure damages capillaries causing loss of fluid, plasma proteins, and erythrocytes into the tissue. Erythrocyte extravasation causes hemosiderin deposition and the classic coloration of stasis dermatitis. Inflammation of venules and capillaries as well as fibrin deposition and platelet aggregation cause microvascular disease and ultimately ulcerations will occur. Such disease classically occurs on the medial leg superior to the medial malleolus.*

Question 47

Which meniscus is more commonly injured?

Answer 47

The medial meniscus is more commonly injured than the lateral meniscus

Question 48

What is the most effective strategy to prevent post-operative atelectasis?

Answer 48

Breathing exercies with incentive spirometer

Question 49

Hoarseness can result from thyroid/parathyroid surgery with injury to what?

Answer 49

Recurrent laryngeal branch of the vagus nerve

Question 50

What is the most common etiology of small bowel obstruction?

Answer 50

Adhesions (typically post-operative)

Question 51

What usually presents with nausea, vomiting, abdominal bloating, and dilated loops of bowel on abdominal x-ray?

Answer 51

Complete small bowel obstruction *Adhesions, typically post-operative, are the most common etiology.*

Question 52

What is the investigation of choice to diagnose an intraabdominal abscess?

Answer 52

CT scan

Question 53

Patients with blunt abdominal trauma and positive findings on focused assessment with sonography for trauma (FAST) require what?

Answer 53

Emergent exploratory laparotomy

Question 54

Epigastric tenderness and palpable crepitus in the suprasternal notch are characteristic of what?

Answer 54

Esophageal rupture *The retrosternal pain and crepitus in the suprasternal notch are the result of pneumomediastinum, which commonly occurs following rupture of the esophagus within the mediastinum.*

Question 55

What rare complication of aortic aneurysm surgery presents with abrupt onset of weakness and bowel/bladder dysfunction?

Answer 55

Spinal cord ischemia with lower spastic paraplegia *The spinal cord derives its blood supply from the anterior spinal artery (ASA) and two posterior spinal arteries, which originate from the vertebral artery. The ASA has several small arteries feeding into it that originate from radicular arteries in the vertebral artery, intercostal arteries, and sometimes the aorta. The thoracic spinal cord is particularly dependent on these radicular arteries and the most vulnerable to infarction.*

Question 56

Burning pain and paralysis in upper extremities with relative sparing of the lower extremities is characteristic of what?

Answer 56

Central cord syndrome *It is commonly seen in elderly secondary to a forced hyperextension type of injury to the neck.*

Question 57

What is the treatment for a patient with acute gastrointestinal perforation who is taking warfarin?

Answer 57

Emergent laparotomy with pre-operative administration of fresh frozen plasma

Question 58

Tachypnea, tachycardia, hypotension, mental changes, thrombocytopenia, and petechia in the setting of long bone fracture are characteristic of what?

Answer 58

Fat embolism

Question 59

In a young individual who presents with a fleshy immobile mass on the midline hard palate, the most likely diagnosis is what?

Answer 59

Torus palatinus This is a benign bony growth. It is thought to be due to both genetic and environmental factors and is more common in younger patients, women, and asians. No medical or surgical therapy is required unless the growth becomes symptomatic or interferes with speech or eating.

Question 60

Crohn disease and other intestinal diseases causing fat malabsorption increase the absorption of what?

Answer 60

Oxalate *Increased absorption is the most common cause of symptomatic hyperoxaluria and oxalate stone formation.*

Question 61

1. Positive trendelenburg sign (drooping of the contralateral hemipelvis below its normal horizontal level during monopedal stance) indicates weakness of which muscle(s)? 2. Which nerve innervates the affected muscle(s)?

Answer 61

1. Gluteus medius and minimus muscles 2. Superior gluteal nerve

Question 62

What kind of shoulder dislocation commonly occurs after a tonic-clonic seizure, with the patient holding the arm adducted and internally rotated?

Answer 62

Posterior dislocation ## Footnote *Neurovascular impairment is unusual.*

Question 63

Dyspnea, tachypnea, chest pain, hypoxemia worsened by intravascular volume expansion, and patchy, irregular alveolar infiltrates on chest x-ray are indicative of what?

Answer 63

Pulmonary contusions This would occur in the setting of blunt chest trauma. Pulmonary contusion is often not clinically evident immediately following an injury, and initial radiographic studies may be negative. Patients typically develop hypoxia and respiratory distress hours later as pulmonary edema sets in. Administration of large volumes of IV fluid may hasten this process. Pulmonary contusion complicates 30-75% of cases of severe blunt chest trauma.

Question 64

After blunt chest trauma, hemorrhagic shock associated with decreased breath sounds and dullness to percussion over one hemithorax and contralateral tracheal deviation is most likely due to what?

Answer 64

A large ipsilateral hemothorax *Each hemithorax is capable of holding up to 50% of the circulating blood volume. Tension pneumothorax would also produce hypotension, tachycardia, and tachypnea, with tracheal deviation but would reveal decreased breath sounds with _hyperresonance to percussion_ of the affected hemithorax.*

Question 65

What is the treatment of choice for acalculous cholecystitis in a critically ill patient?

Answer 65

The emergent treatment of choice is percutaneous cholecystostomy followed by cholecystectomy when the medical condition stabilizes

Question 66

What is the preferred way to establish an airway in an apneic patient with a cervical spine injury?

Answer 66

Orotracheal intubation with rapid sequence intubation (RSI) *This is the preferred route to manage unstable and apneic patients to protect the airway and provide oxygenation. 4 people are involved in RSI: one manually stabilizes the patient, one induces the patient with anesthesia, one applies cricoid pressure to prevent passive regurgitation until endotracheal tube placement is confirmed, and one places the endotracheal tube.*

Question 67

What is the treatment for penile fracture

Answer 67

Retrograde urethrogram followed by surgical exploration of the penis *Urethrogram is to assess for urethral injury. Surgery is to evacuate the hematoma and mend the torn tunica albuginea.*

Question 68

What results from disc degeneration in patients over age 40 and presents with neck pain and stiffness?

Answer 68

Cervical spondylosis *Patients may develop spinal stenosis, resulting in neurologic deficits.*

Question 69

What injury may be missed by CT scan during the first six hours following blunt trauma and if untreated can be complicated by a retroperitoneal abscess or pseudocyst?

Answer 69

Pancreatic injury (Contusion, crush injury, laceration, or transection) *Fever, chills, and deep abdominal pain suggest a retroperitoneal abscess.*

Question 70

What is typically asymptomatic (symptoms would include pain associated with fractures or with arthritis resulting from bone deformity) and diagnosed when an increased bone-specific alkaline phosphatase is discovered on routine laboratory testing (serum calcium and phosphorus are normal)?

Answer 70

Paget disease of the bone *Paget disease of the bone (osteitis deformans) is a disease of unkown etiology that is characterized by disordered bone remodeling. Specifically, osteoclast activity is increased leading to drastically enhanced bone resorption which results in accelerated osteoblast activity in an effort to rebuild the degraded bone. The result is formation of structurally inferior woven bone at various sites throughout the body. The woven bone formed in Paget disease lesions is larger than normal bone and is prone to bowing and fracture.*

Question 71

In case of an amputation injury, how should the amputated parts be preserved?

Answer 71

Wrapped in saline-moistened gauze, sealed in a plastic bag, and placed on ice

Question 72

Weakness and atrophy of the hypothenar and interosseous muscles characterize what palsy?

Answer 72

Klumpke's palsy *Damage to the lower trunk (C8 and T1) of the brachial plexus which primarily affects muscles innervated by the ulnar nerve. "Claw hand" deformity may also result.*

Question 73

1. What muscles are innervated by the femoral nerve? 2. The femoral nerve provides sensation for what part of the leg?

Answer 73

1. The femoral nerve innervates the muscles of the anterior compartment of the thigh, and is therfore responsible for knee extension and hip flexion 2. The femoral nerve provides sensation to the anterior thigh and medial leg via the saphenous branch

Question 74

What is the next investigational step in the work-up of a solitary pulmonary nodule detected on chest x-ray?

Answer 74

CT scan *The data obtained should be coupled with demographic data to determine the patient's risk of malignancy, which is necessary for determining further therapy*. *If malignancy is unlikely, serial CT scans for 2 years is appropriate. An indeterminate or suspicious finding on chest CT requires further investigation with biopsy or PET scan.*

Question 75

What presents as flank or abdominal pain radiating to the groin, along with nausea and vomiting?

Answer 75

Urinary calculi (Renal colic) *Unlike patients with an acute abdomen, patients with urinary stones are often writhing in pain and unable to sit still in the exam room. These patients do not have peritoneal irritation so movement does not worsen their pain.*

Question 76

What occurs when the gallbladder becomes distended as it contracts against an obstructed cystic duct?

Answer 76

Biliary colic *The pain is typically exacerbated by fatty meals and resolves completely between episodes. Fever and leukocytosis are not present.*

Question 77

What typically causes severe periumbilical abdominal pain out of proportion to findings on physical exam, and is accompanied by nausea, vomiting, and fecal blood?

Answer 77

Bowel ischemia

Question 78

In pediatric patients, what is the most common etiology of osteomyelitis?

Answer 78

Hematogenous seeding by Staph aureus *The infection tends to affect the metaphysis, with epiphyseal sparing. Radiographic evidence of osteomyelitis is subtle early in the course of the disease.*

Question 79

Patients who present with localized right lower quadrant findings have a high incidence of perforation with abscess formation when they present how long after symptom onset?

Answer 79

\>48hours: High risk of perforation into the peritoneal and retroperitoneal spaces, causing peritonitis or an abscess. Patients at this stage can have additional symptoms of fever, leukocytosis, reactive thrombocytosis \>5days: Likely have a contained abscess and appear more stable than patients who present within 72 hours of symptom onset.

Question 80

Absent bowel sounds with gaseous distention of both the small and large bowels is indicative of what?

Answer 80

Paralytic (adynamic) ileus *This classically follows abdominal surgery but can also occur in cases of retroperitoneal hemorrhage associated with vertebral fracture.*

Question 81

Atelectasis is a common postoperative complication that results from shallow breathing and weak cough due to pain, and is most common on what postop day(s) following abdominal or thoracoabdominal surgery?

Answer 81

POD#2-3

Question 82

1. All patients with smoke inhalation should be suspected to have what? 2. What is the appropriate treatment?

Answer 82

1. Acute carbon monoxide poisoning 2. 100% oxygen via a nonrebreather facemask

Question 83

What nerve is involved in tarsal tunnel syndrome?

Answer 83

Tibial nerve *The tibial nerve is compressed as it passes through the ankle. Tarsal tunnel syndrome is caused by a fracture of the bones around the ankle. Patients typically present with burning, numbness, and aching of the distal plantar (not dorsal) surface of the foot or toes that sometimes radiates up the calf.*

Question 84

All patients with a clavicular fracture should undergo what evaluation?

Answer 84

Neurovascular examination This is to rule out injury to the underlying brachial plexus and subclavian artery

Question 85

What is Cushing's reflex What does it indicate?

Answer 85

1. Hypertension, bradycardia, and respiratory depression 2. Elevated intracranial pressure

Question 86

Nasopharyngeal cancer (NPC) is most common in patients of Mediterranean and Far Eastern descent and is strongly associated with what?

Answer 86

Epstein-Barr virus infection *NPC is usually asymptomatic until disease is advanced; most NPC is metastatic at the time of diagnosis. Patients with NPC often present with recurrent otitis media (resulting from eustachian tube obstruction by tumor), recurrent epistaxis, and/or nasal obstruction.*

Question 87

Communicating hydroceles that persist beyond 12 months of age are unlikely to resolve spontaneously and put the patient at increased risk of what?

Answer 87

Indirect inguinal hernia *Surgical intervention is indicated in such cases.*

Question 88

What are 4 ways to lower intracranial pressure?

Answer 88

1. _Elevate head_: increases venous outflow from head 2. _Sedation_: Decreases metabolic demand and controls HTN 3. _IV Mannitol_: Extraction of free water out of brain tissue 4. _Hyperventilation_: CO2 washout, leading to cerebral vasoconstriction

Question 89

What is the most common cause of acute mesenteric ischemia?

Answer 89

An embolus from the heart

Question 90

Injury to the lower trunk of the brachial plexus (originating from C8 and T1) results in what?

Answer 90

Klumpke's palsy *This palsy primarily affects muscles innervated by the ulnar nerve, which supplies most of the intrinsic muscles of the hand. Weakness and atrophy of the hypothenar and interosseous muscles characterize this palsy, and "claw hand" deformity may also result. Injury to this trunk typically results from sudden upward pulling on the arm.*

Question 91

All hemodynamically unstable patients with penetrating abdominal trauma must undergo what immediately?

Answer 91

Exploratory laparotomy *To diagnose and treat the source of bleeding as well as to diagnose and treat perforation of any abdominal viscus in an effort to prevent sepsis.*

Question 92

What nerve is most commonly injured in conjunction with a humeral neck fracture?

Answer 92

Axillary nerve

Question 93

What is the imaging modality of choice for diagnosing urinary calculi?

Answer 93

Non-contrast spiral CT of abdomen and pelvis *Abdominal and palevic X-ray will identify radiopaque, calcium-containing stones. Other types of urinary stones, accounting for at least 15% of cases, are not visible on plain X-ray. Also this X-ray can miss small stones and gives no information about obstruction. An intravenous pyelogram (IVP) uses IV contrast and plain X-ray to visualize the urinary system. IVP was the test of choice in the past for diagnosing urinary stones, but because of the risk of contrast-related reactions with IVP, non-contrast CT is now preferred. Ultrasonography can be used if the patient is pregnant to reduce radiation exposure, however, this can also miss some small stones.*

Question 94

A popping sound, intense knee pain, and effusion at the time of injury is indicative of what?

Answer 94

Anterior cruciate ligament (ACL) tear

Question 95

What is the difference between the evaluation of a palpable breast abnormality in a patient under age 30 and a patient over age 30?

Answer 95

* \>30: Evaluation with ultrasound and mammogram * \<30: Evaluation with ultrasound only ## Footnote *In \<30 year olds, simple cysts can have needle aspiration (if desired), whereas complex cysts and solid masses require image guided core biopsies.*

Question 96

What usually presents with severe unilateral flank pain that radiates into the groin?

Answer 96

Acute renal colic

Question 97

What are 5 causes of immediate (within a few hours) postoperative fever?

Answer 97

1. Febrile nonhemolytic transfusion reaction 2. Prior infection or trauma 3. Inflammation due to surgery 4. Malignant hyperthermia 5. Medications

Question 98

What is a common cause of limp in otherwise healthy children?

Answer 98

Transient synovitis of the hip *There are no associated radiographic abnormalities.*

Question 99

What are the first physiologic changes when hemorrhage occurs?

Answer 99

Tachycardia and peripheral vascular constriction

Question 100

A cresentic collection on CT scan of the head is consistent with what?

Answer 100

Subdural hematoma

Question 101

Oliguria, azotemia, and an elevated BUN/creatinine ratio of \>20:1 in the post operative state most likely indicate what?

Answer 101

Acute pre-renal failure from hypovolemia *Urinary catheter obstruction should first be ruled out. The next step in the diagnosis/management of acute renal failure manifesting as oliguria or anuria is an IV fluid challenge.*

Question 102

What is characterized by the triad of bilateral hip, thigh, and buttock claudication, impotence and symmetric atrophy of the bilateral lower extremities due to chronic ischemia?

Answer 102

Leriche syndrome (aortoiliac occlusion) *This is occlusion at the bifurcation of the aorta into the common iliac arteries. The pulse is soft or absent bilaterally from the groin distally in this condition.*

Question 103

What motions does the tensor fascia lata contribute to?

Answer 103

Hip abduction and maintenance of knee extension *It spans from the iliac crest to the fascia lata.*

Question 104

What motion(s) does the quadratus lumborum contribute to?

Answer 104

Lateral flexion of the trunk and functions in rib cage fixation *It spans from the iliac crest to the 12th rib and the transverse processes of the first four lumbar vertebrae.*

Question 105

What treatment is required for a displaced scaphoid fracture?

Answer 105

Open reduction and internal fixation

Question 106

What is the most common cause of lower extremity edema?

Answer 106

Venous insufficiency (valvular incompetence) *It classically worsens throughout the day and resolves overnight when the patient is recumbent.*

Question 107

What typically presents with lower abdominal pain, malaise, low-grade fever and a tender pelvic mass on rectal examination?

Answer 107

Pelvic abscess *Acute ruptured appendicitis may be complicated by pelvic abscess*.

Question 108

1. What is the immediate management of splenic trauma in a hemodynamically unstable patient that responds to fluid administration? 2. What is the immediate management of splenic trauma in a hemodynamically unstable that does not respond to fluid administration?

Answer 108

1. Obtain abdominal CT scan 2. Emergent exploratory laparotomy In the case of CT scan-documented splenic injury, the decision for operative intervention is determined by the grade of the injury. If operative intervention is required, every effort is made to repair the spleen rather than remove it, especially in children. If removal is unavoidable, post-operative immunization against encapsulated bacteria is mandatory.

Question 109

Embolectomy in an extremity that occurs 4-6 hours after the onset of ischemia is associated with what risk?

Answer 109

Compartment syndrome *Extremities subjected to at least 4-6 hours of ischemia can suffer from both intracellular and interstitial edema upon reperfusion. When edema causes the pressure within a muscular fascial compartment to rise above 30 mmHg, compartment syndrome occurs leading to further ischemic injury to the confined tissues.*

Question 110

What is the standard treatment approach for complicated diverticulitis with abscess formation?

Answer 110

CT-guided percutaneous drainage *Fluid collection 3cm should initially be drained with CT-guided drainage. Surgical drainage can be attempted if percutaneous drainage fails to control symptoms by the fifth day.. Surgery with sigmoid resection is generally reserved for patients with fistulas, perforation with peritonitis, obstruction, or recurrent attacks of diverticulitis.*

Question 111

What test is used to confirm the diagnosis of esophageal perforation?

Answer 111

A water-soluble contrast esophagram

Question 112

What motion(s) does the psoas major contribute to?

Answer 112

Flexion and lateral rotation of the thigh *It spans from the transverse processes of the lumbar vertebrae to the lesser trochanter of the femur.*

Question 113

After securing the airway, breathing, and circulation, what is the next step in managing hemoptysis with active bleeding?

Answer 113

Bronchoscopy *This is the procedure of choice to identify the site of bleeding and attempt early therapeutic intervention.*

Question 114

After securing airway, breathing, and circulation, what is the next step in management of massive (\>600ml in 24hr or 100ml/hr) hemoptysis that is not currently bleeding?

Answer 114

Chest xray, CBC, coagulation studies, renal function, urinalysis, rheumatologic workup, and CT scan *Bronchoscopic interventions, embolization, or resection are the definitive treatments.*

Question 115

Hypotension, tachycardia, flat neck veins, confusion, and cold extremities despite IV fluid resuscitation in a trauma patient indicates what?

Answer 115

Hypovolemic/hemorrhagic shock

Question 116

What is the initial management of a patient with thermal inhalation injury to the upper airway?

Answer 116

Endotracheal intubation

Question 117

What typically presents with severe retrosternal chest pain and mediastinal free air on chest x-ray?

Answer 117

Esophageal rupture *It does **_not_** cause massive blood loss.*

Question 118

What is useful for patients with evidence of chronic GI blood loss who have had a negative upper and lower endoscopy?

Answer 118

Capsule endoscopy *This is used to examine the small bowel.*

Question 119

What differentiates inflammatory bowel (IBD) disease from colonic ischemia?

Answer 119

Relative to IBD, colonic ischemia has an acute onset and typically spares the rectum, involving only a segment of the colon

Question 120

What complication of acute pancreatitis presents with nausea, vomiting, and constant epigastric pain that radiates to the back?

Answer 120

Fat necrosis

Question 121

What condition is defined as a mechanically induced degenerative neuropathy commonly seen in runners that presents with pain between the third and fourth toes reproducible with palpation on physical examination?

Answer 121

Morton neuroma *Treatment is conservative with bilateral shoe inserts. Surgery is reserved for patients who fail conservative treatment.*

Question 122

What is characterized by weakness of the upper extremities and loss of pain and temperature sensation in a cape-like distribution over the neck, shoulders, upper arms and hands?

Answer 122

Central cord syndrome *Patients may present with burn injuries on the hands due to loss of sensation.*

Question 123

What is characterized by inward motion of one side of the chest wall on inspiration that is corrected by positive pressure mechanical ventilation?

Answer 123

Flail chest *This occurs when multiple contiguous ribs are fractured resulting in an isolated segment of the thoracic wall that exhibits paradoxical motion during normal respiration.*

Question 124

What is the treatment for slipped capital femoral epiphysis?

Answer 124

Prompt surgical pinning of the slipped epiphysis where it lies *This is in order to lessen the risks of avascular necrosis of the femoral head and chondrolysis.*

Question 125

What classically presents insidiously with a combination of constant visceral epigastric pain radiating to the back, jaundice, anorexia, and weight loss?

Answer 125

Pancreatic cancer

Question 126

1. What is an ileus? 2. what is the most common cause of ileus?

Answer 126

1. An ileus is a functional defect in bowel motility without an associated physical obstruction. 2. Abdominal surgery is the most common cause

Question 127

What presents with dyspnea, confusion, and petechia in the upper part of the body and occurs after multiple fractures of long bones?

Answer 127

Fat embolism *Diagnosis can be confirmed by presence of fat droplets in urine or presence of intra-arterial fat globules on fundoscopy.*

Question 128

In a middle-aged adult, superficial unilateral hip pain that is exacerbated by external pressure to the upper lateral thigh (as when lying on the affected side in bed) suggests what?

Answer 128

Trochanteric bursitis *This is inflammation of the bursa surrounding the insertion of the gluteus medius onto the femur's greater trochanter*.

Question 129

The presence of tachypnea, tachycardia, distended neck veins, and tracheal deviation suggest what?

Answer 129

Tension pneumothorax

Question 130

What is a common iatrogenic complication of cardiac catheterization that presents with hypotension and tachycardia?

Answer 130

Hematoma formation *If above the injuinal ligament, the hematoma can extend directly into the retroperitoneal space and cause significant bleeding with hemodynamic instability.*

Question 131

What are 2 causes of delayed (\>1mo) postoperative fever?

Answer 131

1. Viral infections 2. Infection with indolent organisms

Question 132

Epigastric pain and vomiting following direct blunt abdominal trauma is the classic presentation of what?

Answer 132

Duodenal hematoma

Question 133

What is the most appropriate management of dumping syndrome?

Answer 133

Dietary modification *The symptoms usually diminish over time and dietary changes are helpful to control the symptoms. In resistant cases, octreotide (somatostatin analog) should be tried. Reconstructive surgery is reserved for intractable cases.*

Question 134

What muscles are innervated by the obturator nerve? What portion of the leg recieves sensory innervation from the obturator nerve?

Answer 134

1. The obturator nerve innervates the muscles of the medial compartment of the thigh (gracilis, adductor longus, adductor brevis, anterior portion of adductor magnus) and controls adduction of the thigh. 2. It provides sensation over the medial thigh

Question 135

What is the major cause of morbidity and mortality in patients with significant total body surface area burns?

Answer 135

Hypovolemic shock *In the setting of adequate initial fluid resuscitation, bacterial infection (usually bronchopneumonia or burn wound infection) leading to sepsis and septic shock is the leading complication.*

Question 136

Intravenous catheter infections are most commonly caused by what organisms?

Answer 136

Cutaneous organisms such as Staphlyococci *Femoral catheters carry a higher risk of causing bacteremia than subclavian catheters and may also cause gram-negative bacteremia*.

Question 137

What may mimic appendicitis by causing anorexia and midabdominal/right lower quadrant pain?

Answer 137

Meckel's diverticulitis *Chills and other signs of sepsis typically do not occur.*

Question 138

Anterior shoulder dislocation may cause injury to what nerve and artery?

Answer 138

Axillary nerve and artery

Question 139

What condition is characterized by rapidly progressive bilateral cellulitis of the submandibular and sublingual spaces?

Answer 139

Ludwig angina *The infection classically arises from an infected second or third mandibular molar; the organisms that typically cause the process are streptococcus and anaerobes. Asphyxiation is the most common cause of death in this disease.*

Question 140

What should one suspect when a patient develops a whistling noise during respiration following rhinoplasty?

Answer 140

Nasal septal perforation *This is likely the result of a septal hematoma.*

Question 141

What is often characterized by intermittent epigastric pain, nausea, vomiting, and right-sided shoulder or subscapular discomfort?

Answer 141

Biliary colic *The pain of biliary colic is distinguished from that of acute cholecystitis by its intermittent nature and relation to meals as well as the absence of fever.*

Question 142

What classically causes tachycardia, new bundle branch blocks or arrhythmias and is commonly associated with sternal fracture?

Answer 142

Myocardial contusion

Question 143

What causes upper and lower motor neuron deficits with no loss of sensory function?

Answer 143

Amyotrophic lateral sclerosis (ALS) *Twitching, muscle weakness, and cramping are common symptoms.*

Question 144

What are 5 causes of acute (24hrs-1wk) postoperative fever?

Answer 144

1. Nosocomial infection 2. Group A strep or Clostridium perfringens surgical site infections 3. Myocardial infarction 4. Pulmonary embolism 5. Deep vein thrombosis

Question 145

Severe radicular pain with a positive straight leg raise test is indicative of what?

Answer 145

Acute disk prolapse

Question 146

Unilateral subacute hip pain in a male child coupled with a progressive antalgic gait (limp), thigh muscle atrophy, decreased hip range of motion, and collapse of the ipsilateral femoral head on plain pelvic x-rays are findings suggestive of what?

Answer 146

Idiopathic avascular necrosis of the femoral capital epiphysis (Legg-Calve-Perthes disease)

Question 147

Patients with hemodynamic instability and suspected tension pneumothorax should have immediate treatment with what?

Answer 147

Needle thoracostomy prior to intubation *Intubation with positive ventilation usually exacerbates an existing pneumothorax.*

Question 148

What is the next step in management of a lower GI bleed where the source cannot be identified by colonoscopy?

Answer 148

Technetium-99 labeled erythrocyte scintigraphy ## Footnote *This study localizes the source of blood loss so that the region can be further evaluated and treated by colonoscopy.*

Question 149

Musculoskeletal infections, such as osteomyelitis or abscess, frequently result from hematogenous spread of organisms from another site, such as the skin. In such cases, what is the most common offending pathogen?

Answer 149

Staph aureus

Question 150

To provide adequate hemostasis for most invasive procedures, what must the platelet count be?

Answer 150

\>50,000/mm3

Question 151

What will an x-ray show in tension pneumothorax?

Answer 151

1. Deviation of the trachea and mediastinum away from the affected side of the chest 2. Increased lucency on the affected side of the chest

Question 152

What should be obtained in all patients who undergo central venous catheterization

Answer 152

Chest x-ray *To confirm proper placement of the catheter tip and absence of complications before administering drugs or other agents through the catheter.*

Question 153

When do duodenal hematomas most commonly occur?

Answer 153

Following direct blunt abdominal trauma *More common in children*

Question 154

What differentiates biliary colic from acute cholecystitis?

Answer 154

Biliary colic is intermittent, related to fatty meals, and not associated with fever

Question 155

What may result from hyperextension injuries, particularly in elderly patients with spondylosis, and is characterized by weakness that is more pronounced in the upper extremities than in the lower extremities and may be accompanied by a localized deficit in pain and temperature sensation?

Answer 155

Central cord syndrome *This is selective damage to the central portion of the anterior spinal cord, specifically the central protions of the corticospinal tracts and the decussating fibers of the lateral spinothalamic tract.*

Question 156

"Popeye sign" is produced by rupture of which tendon?

Answer 156

Long head of the biceps muscle *This sign is where the biceps muscle belly becomes prominent in the mid upper arm. Weakness with supination is prominent and forearm flexion is typically preserved.*

Question 157

How do Osteosarcoma and Ewing sarcoma tend to differ?

Answer 157

Osteosarcoma affects metaphyses of long bones whereas Ewing sarcoma affects diaphyses of long bones *Osteosarcoma is a primary bone cancer that produces a finding called Codman's triangle in the metaphyses of long bones and can be described as a "sunburst" pattern on x-ray. Ewing sarcoma is a primary bone cancer that causes "onion skinning" in the diaphyses of long bones*.

Question 158

A palpable or audible snap occuring while slowly extending the leg at the knee from full flexion while simultaneously applying tibial torsion is indicative of what? *What sign is this?*

Answer 158

Meniscal tear *This is McMurray's sign*

Question 159

What is characterized by tachypnea, tachycardia, and hypoxia, with decreased breath sounds on the affected side, and a chest x-ray revealing patchy irregular alveolar infiltrates?

Answer 159

Pulmonary contusion *Symptoms usually develop in the first 24 hours.*

Question 160

The tendons of which 4 muscles compose the rotator cuff?

Answer 160

1. Supraspinatus 2. Infraspinatus 3. Teres minor 4. Subscapularis

Question 161

What is the treatment for Legg-Calve-Perthes disease?

Answer 161

Conservative management with observation and bracing is the general treatment *Surgery may be indicated in cases where the femoral head is not well contained within the acetabulum.*

Question 162

What is most commonly responsible for strabismus (improper alignment of the eyes)?

Answer 162

Brainstem lesions *It can result from disorders of the extraocular muscles or of the nerves that innervate them (CN III, IV, VI).*

Question 163

What should be suspected in patients with evidence of injury to the anterior chest and hypotension but normal or elevated pulmonary capillary wedge pressure that worsens with fluid resuscitation, and a midline trachea?

Answer 163

Myocardial contusion *EKG should be obtained when there is concern for myocardial contusion because there may be an associated new left bundle branch block or dysrhythmia. Cardiac markers are often elevated. Potential complications include myocardial rupture, interventricular septum rupture, or valvular injury.*

Question 164

Deep lacerations to the axillary region and axillary lymphadenectomy are common causes of injury to what nerve?

Answer 164

Long thoracic nerve *Damage causes scapular winging.*

Question 165

What noninvasive test is helpful in determining the exact vessels involved in peripheral artery disease (PAD)?

Answer 165

Arterial duplex ultrasonography *It is less sensitive and specific for diagnosing PAD than is Ankle-brachial index (ABI) but can help identify the specific vessels responsible for symptoms once the diagnosis is made.*

Question 166

Which metatarsal is most commonly affected by stress fractures?

Answer 166

The 2nd metatarsal ## Footnote *The 2nd metatarsal is subjected to significant extremes of loading during gait. Patients present complaining of slow onset foot pain that initially only occurs with activity but later is present during rest as well. Point tenderness is present over the affected metatarsal on examination. Treatment of the 2nd, 3rd, and 4th metatarsals is conservative with rest, analgesia and a hard-soled shoe, because the surrounding metatarsals act as splints and nonunion is uncommon. Surgical intervention is reserved for fractures of the 5th metatarsal, such as Jones fractures, or for displaced fractures not amenable to closed reduction.*

Question 167

Parotid surgery involving the deep lobe of the parotid gland carries a significant risk of what?

Answer 167

Facial nerve (CN VII) palsy resulting in facial droop

Question 168

What is the management of esophageal perforation?

Answer 168

Primary closure of the esophagus and drainage of the mediastinum must be attempted within 6 hours to prevent the development of mediastinitis

Question 169

Slipped capital femoral epiphysis is common in what demographic?

Answer 169

Obsese adolescent boys *The physis (physical junction between the femoral head and neck) weakens during early adolescence because it is rapidly expanding and primarily composed of cartilage, which does not possess the strength of bone.*

Question 170

What is the final stage of compartment syndrome in which the dead muscle has been replaced by fibrous tissue?

Answer 170

Volkmann's ischemic contracture

Question 171

What are the most common peripheral artery aneurysms?

Answer 171

Popliteal and femoral artery aneurysms *They are frequently associated with abdominal aortic aneurysms. They manifest as pulsatile masses that can compress adjacent structures (nerves, veins) and can result in thrombosis and ischemia.*

Question 172

What are 5 causes of subacute (1wk-1mo) postoperative fever?

Answer 172

1. Catheter site infection (other than group A strep or clostridium perfringens) 2. Clostridium difficile 3. Drug fever 4. Pulmonary embolism 5. Deep vein thrombosis

Question 173

What are the 3 components of the Glasgow coma scale (GCS), which can predict the severity and prognosis of coma, during the primary survey?

Answer 173

1. Eye opening 2. Verbal response 3. Motor response

Question 174

What most commonly results from blunt trauma to the perineum (straddle injuries) or instrumentation of the urethra, and presents with perineal tenderness or hematoma, a normal prostate, and bleeding from the urethra?

Answer 174

Anterior urethral injury *This is the portion of the urethra distal to the urogenital diaphragm. Patients may not complain of inability to urinate, and delayed presentations may be complicated by sepsis secondary to extravasation of urine into the scrotum, perineum and/or abdominal wall.*

Question 175

What can occur during significant head trauma and leads to ipsilateral hemiparesis, ipsilateral mydriasis and strabismus, contralateral hemianopsia, and altered mentation.

Answer 175

Transtentorial herniation of the parahippocampal uncus *The uncus is the innermost part of the temporal lobe and herniates through the tentorium to cause pressure on the ipsilateral oculomotor nerve (mydriasis), ipsilateral posterior cerebral artery (contralateral homonymous hemianopsia), and contralateral cerebral peduncle against the edge of the tentorium.*

Question 176

What is the most common cause of spinal cord ischemia and infarction?

Answer 176

Surgery to repair thoracic and thoracoabdominal aortic aneurysms

Question 177

1. What muscles of the leg are innervated by the tibial nerve? 2. The tibial nerve provides sensation to what region of the leg?

Answer 177

1. The muscles of the posterior compartment of the thigh and leg, and the plantar muscles of the foot. These muscles control flexion of the knee and digits, and plantar flexion of the foot 2. The tibial nerve provides sensation to the leg (except medial side) and plantar foot

Question 178

What nerve is at risk of being injured by fracture of the medial epicondyle of the humerus?

Answer 178

Ulnar nerve ## Footnote *Symptoms include "claw hand" and sensory loss on the dorsal and ventral medial hand.*

Question 179

What is the preferred treatment of ruptured appendicitis with a contained abscess (appear stable \>5 days after onset of symptoms)?

Answer 179

Antibiotics, IV fluids, and bowel rest because surgery has been associated with a higher morbiditiy *A CT scan may reveal an abscess that can be percutaneously drained. Most patients will require an interval appendectomy 6-8 weeks later to prevent future appendicitis.*

Question 180

1. What is the most common etiology of pelvic abscess in men? 2. What is the most common etiology of pelvic abscess in women?

Answer 180

1. Appendicitis 2. Gynecologic

Question 181

Radiographic signs of mediastinal widening, depression of the left main bronchus, displacement of the trachea and esophagus to the right, and obliteration of the aortic knob shadow are consistent with what?

Answer 181

Aortic rupture

Question 182

A head CT scan showing a semilunar hematoma is characteristic of what?

Answer 182

A subdural hematoma

Question 183

What is the treatment for acute mediastinitis?

Answer 183

Drainage, surgical debridement, and prolonged antibiotic therapy. *Antibiotics alone do not appropriately treat mediastinitis. Even with appropriate treatment, acute mediastinitis has a mortality rate of 10-50%.*

Question 184

Paraplegia, variable sensory loss, and urinary/fecal incontinence is characteristic of what?

Answer 184

Cauda equine syndrome

Question 185

What is the first step in evaluating a patient with suspected peripheral artery disease?

Answer 185

Obtain an ankle-brachial index (ABI) to confirm the diagnosis *Patients with significant symptoms and normal ABI might have mild disease at rest and should undergo exercise testing with preexercise and post exercise ABI measurements to confirm diagnosis.*

Question 186

A popping sound and severe knee pain at the time of injury, followed by effusion a few hours to a day later is typical of what?

Answer 186

Meniscal tear *Becuase the meniscus is not directly perfused, effusion following injury typically is not clinically apparent for many hours following the injury.*

Question 187

What artery is commonly injured in a supracondylar fracture of the humerus (commonly seen in children)?

Answer 187

Brachial artery

Question 188

Acute pain and swelling of the midline sacrococcygeal skin and subcutaneous tissues are most commonly due to What?

Answer 188

Pilonidal disease *Pilonidal cysts are most prevalent in young males, particularly those with larger amounts of body hair. The precise etiology of pilonidal cysts and sinuses is not clearly described, but they are believed to develop following chronic activity involving sweating and friction of the skin overlying the coccyx within the superior gluteal cleft. Infection of hair follicles in this region may spread subcutaneously forming an abscess that then ruptures forming a pilonidal sinus tract. The chronic sinus tract may then collect hair and debris resulting in recurrent infections and foreign-body reactions. When the sinus becomes acutely infected, pain, swelling, and purulent discharge occur in the midline postsacral intergluteal region. Treatment is by drainage of abscesses and excision of the sinus tract.*

Question 189

Patients with blunt trauma should undergo what initial evaluation for intraperitoneal hemorrhage?

Answer 189

Focused assessment with sonography for trauma (FAST) *FAST can be done in a few minutes and has a high sensitivity and specificity for detecting hemoperitoneum, pericardial effusion, and intraperitoneal fluid.*

Question 190

What is the therapy for deep vein thrombosis (DVT)?

Answer 190

Heparin acutely and warfarin for _\>_3 months with an INR goal of 2-3

Question 191

What are the early symptoms of carbon monoxide poisoning?

Answer 191

1. Agitation 2. Confusion 3. Somnolence

Question 192

Transient unilateral weakness following a tonic-clonic seizure that usually spontaneously resolves is indicative of what?

Answer 192

Todd paralysis

Question 193

Persistent pneumothorax and significant air leak following chest tube placement in a patient who has sustained blunt chest trauma suggests what?

Answer 193

Tracheobronchial rupture *Other findings include pneumomediastinum and subcutaneous emphysema.*

Question 194

How does one confirm the diagnosis of esophageal rupture?

Answer 194

Water-soluble contrast esophagography

Question 195

Elevated amylase, lipase, and WBC, as well as mild azotemia and hypocalcemia are indicative of what?

Answer 195

Acute pancreatitis *CT scan can be used to confirm the diagnosis of pancreatitis.*

Question 196

Postprandial abdominal cramps, weakness, light-headedness, and diaphoresis in the setting of a recent partial gastrectomy are suggestive of what diagnosis?

Answer 196

Dumping syndrome *This is a common post-gastrectomy complication (up to 50% of patients with partial gastrectomy may experience this syndrome). The rate is lower for patients who underwent more conservative gastric surgery (IE proximal vagotomy). The pathophysiology of this condition involves rapid emptying of hypertonic gastric content into the duodenum and small intestine. This process leads to the fluid shift from intravascular space into the small intestine, release of intestinal vasoactive polypeptides, and stimulation of autonomic reflexes.*

Question 197

Imaging studies showing gall bladder distension, thickening of the gall bladder wall, and pericholecystic fluid, in the absence of calculi is characteristic of what diagnosis?

Answer 197

Acalculous cholecystitis *This occurs in critically ill patients and has a clinically vague presentation that is similar to calculous cholecystitis if the patient is able to interact.*

Question 198

Damage to what vessel(s) results in an epidural hematoma?

Answer 198

Middle meningeal artery

Question 199

How will a patient with an anterior shoulder dislocation hold their arm?

Answer 199

Slightly abducted and externally rotated

Question 200

A portosystemic shunt connects the portal venous system to the systemic venous system. This can be accomplished surgically or with what procedure?

Answer 200

TIPS procedure *These procedures are considered a last resort in variceal bleeding unresponsive to medical and endoscopic interventions.*

Question 201

What is the gold standard for evaluating mesenteric ischemia?

Answer 201

Mesenteric angiography *Patients with this disease present with severe abdominal pain after eating, and a relatively normal abdominal exam.*

Question 202

How do you confirm the diagnosis of retroperitoneal hemorrhage from an extension of a local vascular hematoma secondary to cardiac catheterization?

Answer 202

Non-contrast abdominal CT scan *Treatment is largely supportive. Patients who develop neurologic deficits in the ipsilateral extremity require urgent decompression of the hematoma.*

Question 203

What nerve is the most commonly injured in association with fracture of midshaft humerus?

Answer 203

Radial nerve *Ulnar nerve is also a common nerve injury in association with humeral fracture. Its injury would cause a claw hand.*

Question 204

What is Volkmann's ischemic contracture?

Answer 204

The final result of compartment syndrome in which the dead muscle has been replaced by fibrous tissue.

Question 205

Hydrocele can be differentiated from other testicular masses by what?

Answer 205

Transillumination *A hydrocele will transilluminate while other masses will not. Most hydroceles, both communicating and noncommunicating, will resolve spontaneously by the age of 12 months and can be safely observed during that period.*

Question 206

What has a classic presentation of unconsciousness followed by a lucid interval, followed by a gradual deterioration of consciousness?

Answer 206

Acute epidural hematoma *Head CT scan is diagnostic and shows a biconvex hematoma.*

Question 207

Which rotator cuff tendon is most commonly injured?

Answer 207

Supraspinatus tendon *This is due to repeated bouts of ischemia near its insertion on the humerus induced by compression between the humerus and the acromion.*

Question 208

Numbness and burning in the toes, aching, and burning in the distal forefoot that radiates forward from the metatarsal heads to the third and fourth toes are symptoms characteristic of what?

Answer 208

Morton Neuroma *This is a mechanically induced neuropathic degeneration. The symptoms are worsened by walking on hard surfaces and wearing tight or high-heeled shoes. Physical examination typically shows a clicking sensation (Mulder sign) when simultaneously palpating this space and squeezing the metatarsal joints.*

Question 209

What is the treatment for an isolated duodenal hematoma?

Answer 209

Conservative treatment with nasogastric suction and parenteral nutrition *Most hematomas will resolve spontaneously in 1-2 weeks. Surgery may be considered to evacuate the hematoma if this more conservative method fails.*

Question 210

Predisposition for renal cell carcinoma is seen in what Syndrome?

Answer 210

Von-Hippel-Lindau syndrome *This is an autosomal dominant genetic condition resulting from a mutation in the von-hippel-lindau tumor suppressor gene on chromosome 3p25. It is associated with central nervous system tumors, retinal hemangioblastomas, clear cell renal carcinoma, pheochromocytomas, pancreatic neuroendocrine tumors, pancreatic cysts, endolymphatic sac tumors, and epididymal papillary cystadenomas.*

Question 211

Hip, groin, or knee pain plus an antalgic gait in a boy between age 4 and 10 is a classic presentation of what?

Answer 211

Legg-Calve-Perthes disease (Idiopathic avascular necrosis of the femoral capital epiphysis)

Question 212

What effect on intracranial pressure does short-term hyperventilation have?

Answer 212

It decreases intracranial pressure *It does this by causing cerebral washout of CO₂, leading to vasoconstriction and decreased cerebral blood flow*

Question 213

What motion(s) does the quadriceps femoris muscles contribute to?

Answer 213

Leg extension at the knee and the rectus femoris also functions as a hip flexor

Question 214

Radial nerve compression from trauma most commonly occurs where?

Answer 214

In the forearm *It results in hand weakness and decreased handgrip.*

Question 215

What does a steady state respiratory quotient (RQ) close to 1.0 indicate?

Answer 215

A predominance of oxidation of carbohydrates and net lipogenesis *The RQ is the steady-state ratio of carbon dioxide (CO2) produced to oxygen (O2) consumed per unit time and may be used to make assessments of the metabolism taking place in particular organs or in the body as a whole. The RQ for protein and lipid as sole sources of energy are 0.8 and 0.7 respectively.*

Question 216

What should be the next step in managing a patient with suspected tension pneumothorax?

Answer 216

Emergent needle thoracostomy *Performing a chest radiograph for confirmation may lead to an unacceptable delay in treatment.*

Question 217

Right upper quadrant pain, fever, and leukocytosis is typical for what?

Answer 217

Acute cholecystitis *The majority of acute cholecystitis may be treated with observation and supportive care initially, followed by laparoscopic cholecystectomy within 72 hours during the same hospitalization.*

Question 218

Intermittent bloody discharge from one nipple, usually without an appreciable mass is the classic presentation of what?

Answer 218

Intraductal papilloma *This is a benign breast disease. Masses are generally not appreciated in this condition, as the abnormality is small, soft, and located directly beneath the nipple.*

Question 219

What is likely the cause of fullness of the scrotum, and dull, aching pain in the testis, occuring more commonly on the left side, with a negative transillumination test?

Answer 219

Varicocele ## Footnote *A varicocele is a tortuous dilation of the pampiniform plexus of veins surrounding the spermatic cord and testis in the scrotum. It results from incompetence of the valves of the testicular vein and occurs most frequently on the left side, possibly because the left testicular vein enters the left renal vein inferiorly at a right angle thereby predisposing to impaired drainage.*

Question 220

What form of shoulder dislocation is most common and is usually caused by a direct blow or a fall onto an outstretched arm, after which the patient holds the arm slightly abducted and externally rotated?

Answer 220

Anterior dislocation

Question 221

What is characterized by hypotension, tachycardia, elevated systemic venous pressure and pulsus paradoxus (\>10mmHg drop in blood systolic blood pressure on inspiration)?

Answer 221

Cardiac tamponade *Emergent pericardiocentesis is indicated.*

Question 222

What can occur following cardiac surgery and present with fever, chest pain, leukocytosis, and mediastinal widening on chest x-ray?

Answer 222

Acute mediastinitis *This is a serious condition that requires drainage, surgical debridement, and prolonged antibiotic therapy.*

Question 223

What is characterized clinically by diarrhea, rectal bleeding, tenesmus (constant feeling of needing to defecate despite an empty colon) and incontinence?

Answer 223

Radiation proctitis *Later, strictures and fistulae may form.*

Question 224

Idiopathic avascular necrosis of the femoral capital epiphysis is called what?

Answer 224

Legg-Calve-Perthes disease This condition most commonly affects boys between ages 4 and 10, with a peak incidence between 5 and 7

Question 225

What is the most common complication seen post thyroidectomy?

Answer 225

Hypocalcemia *Patients may be asymptomatic at initial presentation (found incidentally) or may complain only of nonspecific symptoms (eg fatigue, anxiety, depression). Involuntary contractions (tetany) involving the lips, face, and extremities and seizures are seen in severe hypocalcemia. Electrocardiogram may show QT-interval prolongation.*

Question 226

How will a patient with a posterior shoulder dislocation hold their arm?

Answer 226

Adducted and internally rotated

Question 227

1. What muscles are innervated by the common peroneal nerve? 2. The common peroneal nerve provides sensation to what region of the leg?

Answer 227

1. The common peroneal nerve gives rise to the superficial and deep peroneal nerves which supply the muscles of the anterior and lateral leg 2. These nerves provide sensation to the anterolateral leg and dorsum of the foot

Question 228

What is the treatment for a pancreatic abscess?

Answer 228

Immediate placement of a percutaneous drainage catheter, culture of the drained fluid, and ultimately surgical debridement

Question 229

What is the treatment for circumferential full-thickness burns of an extremity with an eschar causing significant edema and constriction of the vascular supply and decreased peripheral pulses?

Answer 229

Escharotomy *Patients should be evaluated for clinical signs of adequate perfusion after escharotomy, and fasciotomy should be performed if there is no sign of relief.*

Question 230

Patients who present with acute onset of back pain and profound hypotension should be evaluated for a presumptive diagnosis of what?

Answer 230

Ruptured abdominal aortic aneurysm

Question 231

What develops in 3-4% of patients with spinal cord injuries, and presents months to years after injury with impaired strength and pain/temperature sensation in the upper extremities?

Answer 231

Syringomyelia *Whiplash is often the inciting injury. The condition involves enlargement of the central canal of the spinal cord due to CSF retention.*

Question 232

Ipsilateral motor and proprioception loss and contralateral pain loss below a certain level is characteristic of what?

Answer 232

Brown Sequard syndrome *This is acute hemisection of the spinal cord. Symptoms occur below the level of the lesion.*

Question 233

What is the investigation of choice in diagnosing suspected splenic injury?

Answer 233

Abdominal CT with IV contrast.

Question 234

What must be ruled out for any patient who suffers blunt deceleration trauma (moving vehicle accident or a fall from \>10 feet)?

Answer 234

Blunt aortic trauma must be ruled out *Chest x-ray is the initial screening test, and widening of the mediastinum is the most sensitive finding.*

Question 235

Tension pneumothorax is an emergency situation that can be diagnosed clinically and requires immediate what?

Answer 235

Needle thoracostomy

Question 236

What is an uncommon form of breast cancer that presents with an erythematous and edematous cutaneous plaque overlying a mass on the breast commonly with axillary lymphadenopathy?

Answer 236

Inflammatory breast cancer *Clinically, inflammatory breast cancer cannot be differentiated from an infectious process, such as a breast abscess, with 100% certainty. Therefore, a biopsy for histology should be done first to exclude or confirm that diagnosis. 1/4 of patients with this condition will have metastatic disease at the time of presentation.*

Question 237

What treatment is recommended for all nondisplaced scaphoid fractures (fractures with

Answer 237

Wrist immobilization for 6-10 weeks

Question 238

What test(s) can confirm suspicion for myocardial contusion?

Answer 238

Cardiac markers and EKG *Cardiac markers are often elevated and EKG may show new left bundle branch block or dysrhythmia.*

Question 239

A biconvex collection on CT scan of the head is consistent with what?

Answer 239

Epidural hematoma

Question 240

What shows clinical and radiographic findings similar to those seen in breast cancer (including skin or nipple retraction and calcifications on mammography), but biopsy reveals fat globules and foamy histiocytes?

Answer 240

Fat necrosis *No treatment is indicated.*

Question 241

Intraabdominal pathology causing pain in one or both shoulders suggests what?

Answer 241

Subdiaphragmatic peritonitis *Among the possible blunt traumatic bladder injuries, only an intraperitoneal rupture of the bladder dome could, by itself, cause a chemical peritonitis*. *Other lower urinary tract structures such as the bladder neck, anterior bladder, anterior urethra, and pseudomembranous urethra are all extraperitoneal*.

Question 242

What clinical diagnosis should be made for a trauma patient with decreased breath sounds and tracheal shift in the presence of hypotension and jugular venous distention?

Answer 242

Tension pneumothorax *Needle thoracostomy should be done emergently; performing a chest radiograph for confirmation may lead to an unacceptable delay in treatment.*

Question 243

What is the first step in evaluating a patient with suspected peripheral artery disease (PAD)?

Answer 243

Obtain an ankle-brachial index (ABI) using doppler to confirm the diagnosis ## Footnote *The ABI is the ration of the systolic blood pressure in the posterior tibial and dorsalis pedis arteries over the systolic blood pressure in the brachial artery. Ratios of 1 to 1.3 are considered normal, _\<_0.90 is abnormal.*

Question 244

What is the treatment for subluxation of the radial head?

Answer 244

Closed reduction by flexion and supination of the forearm *No post-reduction films are needed, since success is usually demonstrated by the infant/child who has resumed the use of previously unused extremity.*

Question 245

What is associated with pelvic fractures and presents with blood at the urethral meatus, a high riding prostate, scrotal hematoma, inability to void despite sensing an urge to void, and a palpably distended bladder?

Answer 245

Posterior urethral injury

Question 246

Any gunshot wound below which intercostal space is considered to involve the abdomen and requires an exploratory laparotomy in unstable patients?

Answer 246

4th intercostal space (Level of the nipple)

Question 247

What is the treatment of mastitis that is associated with breast-feeding?

Answer 247

1. Analgesics 2. Antibiotics 3. Continuation of breast-feeding from affected breast

Question 248

What is characterized by intensive wound pain, decreased sensitivity at the edges of the wound, cloudy-gray discharge, and sometimes crepitus?

Answer 248

Necrotizing surgical infection *Early surgical exploration is essential*

Question 249

When squamous cell carcinoma arises within a burn wound, these ulcers are known as what?

Answer 249

Marjolin ulcers

Question 250

What can confirm the diagnosis of diaphragmatic rupture in a patient with a suggestive chest x-ray?

Answer 250

Chest CT of chest and abdomen *CT is more sensitive than x-ray and is the definitive diagnostic modality.*