Surgery: UWorld Flashcards
1
Q
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?
A
Anterior dislocation
1
Q
What is the most common bone in the body to be affected by stress fractures?
A
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.
2
Q
What does a steady state respiratory quotient (RQ) close to 1.0 indicate?
A
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.
2
Q
Dyspnea, hemoptysis, subcutaneous emphysema, audible crepitus on cardiac auscultation (Hamman sign), and sternal tenderness are all characteristic of what diagnosis?
A
Tracheobronchial tear
3
Q
What is a good modality for evaluating cardiac systolic and diastolic functions, cardiac valves, and pericardial effusions?
A
Transthoracic echocardiography
4
Q
Hip, groin, or knee pain plus an antalgic gait in a boy between age 4 and 10 is a classic presentation of what?
A
Legg-Calve-Perthes disease (Idiopathic avascular necrosis of the femoral capital epiphysis)
4
Q
How do you confirm the diagnosis of retroperitoneal hemorrhage from an extension of a local vascular hematoma secondary to cardiac catheterization?
A
Non-contrast abdominal CT scan
Treatment is largely supportive. Patients who develop neurologic deficits in the ipsilateral extremity require urgent decompression of the hematoma.
4
Q
Postprandial abdominal cramps, weakness, light-headedness, and diaphoresis in the setting of a recent partial gastrectomy are suggestive of what diagnosis?
A
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.
4
Q
Following splenectomy, patients are at increased risk for sepsis secondary to which 3 bacteria?
A
- Streptococcus pneumoniae
- Neisseria Meningitidis
- 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.
5
Q
Persistent pneumothorax and significant air leak following chest tube placement in a patient who has sustained blunt chest trauma suggests what?
A
Tracheobronchial rupture
Other findings include pneumomediastinum and subcutaneous emphysema.
5
Q
What is the first step in management of a suspected urethral injury?
A
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.
6
Q
Patients with blunt trauma should undergo what initial evaluation for intraperitoneal hemorrhage?
A
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.
6
Q
What classically presents with dull abdominal pain and possibly bloody diarrhea acutely following abdominal aortic aneurysm repair
A
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.
7
Q
What artery is commonly injured in a supracondylar fracture of the humerus (commonly seen in children)?
A
Brachial artery
7
Q
What is the treatment for acute mediastinitis?
A
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%.
7
Q
What is the preferred treatment of ruptured appendicitis with a contained abscess (appear stable >5 days after onset of symptoms)?
A
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.
7
Q
What is characterized by early satiety, nausea, nonbilious vomiting, and weightloss?
A
Gastric outlet obstruction
8
Q
What are the 3 main organs injured by blunt abdominal trauma?
A
Spleen, liver, and kidney
Evaluation with exploratory laparotomy.
9
Q
- What muscles of the leg are innervated by the tibial nerve?
- The tibial nerve provides sensation to what region of the leg?
A
- 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
- The tibial nerve provides sensation to the leg (except medial side) and plantar foot
9
Q
CT scan of the head showing numerous minute punctuate hemorrhages with blurring of the gray-white matter interface is characteristic of what?
A
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.
10
Q
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?
A
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.
10
Q
What effect on risk of postoperative atelectasis does moving from supine to sitting have?
A
Moving from supine to sitting can increase the functional residual capacity by 20-35% and thus can help prevent postoperative atelectasis
11
Q
What is the final stage of compartment syndrome in which the dead muscle has been replaced by fibrous tissue?
A
Volkmann’s ischemic contracture
11
Q
Deep lacerations to the axillary region and axillary lymphadenectomy are common causes of injury to what nerve?
A
Long thoracic nerve
Damage causes scapular winging.
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?
Contrast arteriography
## Footnote
*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.*
12
Air seen under the diaphragm (between liver and diaphragm for example) is of greatest concern for what?
Perforated peptic ulcer
*No other diagnostic studies are required for this surgical emergency, and surgery consultation must be obtained immediately.*
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?
Acute cardiac tamponade
*Chest x-ray findings typically reveal a normal cardiac silhouette without tension pneumothroax*.
14
What is the treatment for Legg-Calve-Perthes disease?
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.*
14
Why is mechanical ventilation risky in a patient with hypovolemic shock?
It may cause circulatory collapse
## Footnote
*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.*
15
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?*
Meniscal tear
*This is McMurray's sign*
15
When do duodenal hematomas most commonly occur?
Following direct blunt abdominal trauma
*More common in children*
15
Syringomyelia classically presents with what?
Central cord syndrome
## Footnote
*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.*
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?
Rotator cuff tear
## Footnote
*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.*
17
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?
Staph aureus
17
What condition is characterized by rapidly progressive bilateral cellulitis of the submandibular and sublingual spaces?
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.*
17
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?
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.*
17
What is the management of a patient with pulmonary contusions?
Close monitoring and intubation with mechanical ventilation in severe instances
19
What is the diagnostic study of choice in a patient with suspected esophageal perforation?
Gastrografin-contrast esophagography
*This demonstrates contrast leakage at the site of the perforation.*
20
What may mimic appendicitis by causing anorexia and midabdominal/right lower quadrant pain?
Meckel's diverticulitis
*Chills and other signs of sepsis typically do not occur.*
20
What is the most common infectious agent in acute bacterial parotitis?
Staphylococcus aureus
## Footnote
*Parotitis is an inflammation of one or both parotid glands. This post-operative complication can be prevented with adequate fluid hydration and oral hygiene.*
21
Abdominal pain and bloody diarrhea following an abdominal aortic aneurysm repair is concerning for what?
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.*
22
What muscles are innervated by the obturator nerve?
What portion of the leg recieves sensory innervation from the obturator nerve?
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
22
How is acute appendicitis diagnosed?
It is a clinical diagnosis
23
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?
Trochanteric bursitis
*This is inflammation of the bursa surrounding the insertion of the gluteus medius onto the femur's greater trochanter*.
23
What is the most common cause of lower gastrointestinal hemorrhage in an elderly patient?
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.*
24
What is the initial management of a patient with thermal inhalation injury to the upper airway?
Endotracheal intubation
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?
Diaphragmatic rupture
*Children can have delayed presentation with expansion of the diaphragmatic defect and herniation of abdominal organs.*
25
What test is used to confirm the diagnosis of esophageal perforation?
A water-soluble contrast esophagram
25
What typically presents with lower abdominal pain, malaise, low-grade fever and a tender pelvic mass on rectal examination?
Pelvic abscess
*Acute ruptured appendicitis may be complicated by pelvic abscess*.
25
Oliguria, azotemia, and an elevated BUN/creatinine ratio of \>20:1 in the post operative state most likely indicate what?
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.*
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?
Squamous cell carcinoma
*When SCC arises within a burn wound, these ulcers are known as Marjolin ulcers.*
26
Loss of motor function, pain, and temperature, but intact proprioception is characteristic of what?
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.*
27
A biconvex hematoma on head CT scan is diagnostic of what?
Epidural hematoma
28
All patients with a clavicular fracture should undergo what evaluation?
Neurovascular examination
This is to rule out injury to the underlying brachial plexus and subclavian artery
28
Absent bowel sounds with gaseous distention of both the small and large bowels is indicative of what?
Paralytic (adynamic) ileus
*This classically follows abdominal surgery but can also occur in cases of retroperitoneal hemorrhage associated with vertebral fracture.*
28
Non bleeding varices are managed with what?
Nonselective beta-adrenergic antagonists such as propranolol
*Such therapy can reduce the risk of bleeding by up to half.*
29
What is the most common etiology of small bowel obstruction?
Adhesions (typically post-operative)
29
What is given pre-operatively to patients with mild hemophilia A?
Desmopressin (DDAVP)
*This is given to prevent excessive bleeding. It indirectly increases factor VIII levels by causing vWF release from endothelial cells.*
30
What is transesophageal echocardiography helpful in diagnosing?
Aortic dissection
31
What potentially lethal postoperative complication commonly presents with neausea, vomiting, abdominal pain, hypoglycemia, and hypotension often in the setting of steroid-dependence?
Acute adrenal insufficiency
*Exogenous steroids depress pituitary-adrenal axis and a stressful situation can precipitate an acute adrenal insufficiency.*
31
What is the difference between the presentation of bowel ischemia and bowel infarction?
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
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?
Hypoglossal nerve injury resulting in tongue palsy
32
What kind of tear of the medial meniscus leads to locking of the knee joint during terminal extension?
A bucket handle tear
34
Severe pain, pain with passive range of motion, paresthesias, as well as pallor and paresis of the affected limb is all characteristic of what?
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.*
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?
Median nerve
35
What is the next step in management of someone with clinical signs of scaphoid fracture but a negative X-ray?
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.*
37
What is the treatment for compartment syndrome?
Urgent Fasciotomy
38
What is the primary objective in the management of a rib fracture?
Pain relief
*This will allow proper ventillation and prevent atelectasis and pneumonia.*
39
All patients with penetrating injury and evidence of peritonitis or unstable hemodynamics need what?
Immediate laparotomy
40
Uric acid stones, which are radiolucent, have to be evaluated by what?
CT of the abdomen or intravenous pyelography
41
What is the treatment of choice for esophageal perforation?
1. Antibiotic therapy
2. Parenteral nutrition
3. Surgical repair
43
What are some signs of peritoneal irritation (peritoneal signs)?
1. Rebound tenderness
2. Abdominal guarding
3. Decreased bowel sounds
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?
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.*
45
What is a hydrocele?
Fluid collection within the processus or tunica vaginalis (the peritoneal projection that accompanies the testis during its descent into the scrotum)
46
What results from lower extremity venous insufficiency due to valve incompetence?
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.*
47
Which meniscus is more commonly injured?
The medial meniscus is more commonly injured than the lateral meniscus
48
What is the most effective strategy to prevent post-operative atelectasis?
Breathing exercies with incentive spirometer
49
Hoarseness can result from thyroid/parathyroid surgery with injury to what?
Recurrent laryngeal branch of the vagus nerve
51
What usually presents with nausea, vomiting, abdominal bloating, and dilated loops of bowel on abdominal x-ray?
Complete small bowel obstruction
*Adhesions, typically post-operative, are the most common etiology.*
52
What is the investigation of choice to diagnose an intraabdominal abscess?
CT scan
53
Patients with blunt abdominal trauma and positive findings on focused assessment with sonography for trauma (FAST) require what?
Emergent exploratory laparotomy
54
Epigastric tenderness and palpable crepitus in the suprasternal notch are characteristic of what?
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.*
55
In pediatric patients, what is the most common etiology of osteomyelitis?
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.*
55
What rare complication of aortic aneurysm surgery presents with abrupt onset of weakness and bowel/bladder dysfunction?
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.*
56
Tachypnea, tachycardia, hypotension, mental changes, thrombocytopenia, and petechia in the setting of long bone fracture are characteristic of what?
Fat embolism
56
Burning pain and paralysis in upper extremities with relative sparing of the lower extremities is characteristic of what?
Central cord syndrome
*It is commonly seen in elderly secondary to a forced hyperextension type of injury to the neck.*
57
What is the treatment for a patient with acute gastrointestinal perforation who is taking warfarin?
Emergent laparotomy with pre-operative administration of fresh frozen plasma
59
What is the next investigational step in the work-up of a solitary pulmonary nodule detected on chest x-ray?
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.*
59
In case of an amputation injury, how should the amputated parts be preserved?
Wrapped in saline-moistened gauze, sealed in a plastic bag, and placed on ice
59
In a young individual who presents with a fleshy immobile mass on the midline hard palate, the most likely diagnosis is what?
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.
60
Crohn disease and other intestinal diseases causing fat malabsorption increase the absorption of what?
Oxalate
*Increased absorption is the most common cause of symptomatic hyperoxaluria and oxalate stone formation.*
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)?
1. Gluteus medius and minimus muscles
2. Superior gluteal nerve
62
What kind of shoulder dislocation commonly occurs after a tonic-clonic seizure, with the patient holding the arm adducted and internally rotated?
Posterior dislocation
## Footnote
*Neurovascular impairment is unusual.*
63
What is the preferred way to establish an airway in an apneic patient with a cervical spine injury?
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.*
63
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?
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.*
63
Dyspnea, tachypnea, chest pain, hypoxemia worsened by intravascular volume expansion, and patchy, irregular alveolar infiltrates on chest x-ray are indicative of what?
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.
65
What is the treatment of choice for acalculous cholecystitis in a critically ill patient?
The emergent treatment of choice is percutaneous cholecystostomy followed by cholecystectomy when the medical condition stabilizes
67
What is the treatment for penile fracture
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.*
68
What results from disc degeneration in patients over age 40 and presents with neck pain and stiffness?
Cervical spondylosis
*Patients may develop spinal stenosis, resulting in neurologic deficits.*
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?
Pancreatic injury (Contusion, crush injury, laceration, or transection)
*Fever, chills, and deep abdominal pain suggest a retroperitoneal abscess.*
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)?
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.*
72
Weakness and atrophy of the hypothenar and interosseous muscles characterize what palsy?
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.*
73
1. What muscles are innervated by the femoral nerve?
2. The femoral nerve provides sensation for what part of the leg?
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
75
What presents as flank or abdominal pain radiating to the groin, along with nausea and vomiting?
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.*
76
What occurs when the gallbladder becomes distended as it contracts against an obstructed cystic duct?
Biliary colic
*The pain is typically exacerbated by fatty meals and resolves completely between episodes. Fever and leukocytosis are not present.*
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?
Bowel ischemia
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?
\>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.
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?
POD#2-3
82
1. All patients with smoke inhalation should be suspected to have what?
2. What is the appropriate treatment?
1. Acute carbon monoxide poisoning
2. 100% oxygen via a nonrebreather facemask
83
What nerve is involved in tarsal tunnel syndrome?
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.*
85
What is Cushing's reflex
What does it indicate?
1. Hypertension, bradycardia, and respiratory depression
2. Elevated intracranial pressure
86
Nasopharyngeal cancer (NPC) is most common in patients of Mediterranean and Far Eastern descent and is strongly associated with what?
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.*
87
What are the first physiologic changes when hemorrhage occurs?
Tachycardia and peripheral vascular constriction
87
Communicating hydroceles that persist beyond 12 months of age are unlikely to resolve spontaneously and put the patient at increased risk of what?
Indirect inguinal hernia
*Surgical intervention is indicated in such cases.*
88
What are 4 ways to lower intracranial pressure?
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
89
What is the most common cause of acute mesenteric ischemia?
An embolus from the heart
90
All hemodynamically unstable patients with penetrating abdominal trauma must undergo what immediately?
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.*
90
Injury to the lower trunk of the brachial plexus (originating from C8 and T1) results in what?
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.*
92
What is the imaging modality of choice for diagnosing urinary calculi?
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.*
92
What nerve is most commonly injured in conjunction with a humeral neck fracture?
Axillary nerve
94
A popping sound, intense knee pain, and effusion at the time of injury is indicative of what?
Anterior cruciate ligament (ACL) tear
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?
* \>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.*
96
What usually presents with severe unilateral flank pain that radiates into the groin?
Acute renal colic
97
What are 5 causes of immediate (within a few hours) postoperative fever?
1. Febrile nonhemolytic transfusion reaction
2. Prior infection or trauma
3. Inflammation due to surgery
4. Malignant hyperthermia
5. Medications
98
What is a common cause of limp in otherwise healthy children?
Transient synovitis of the hip
*There are no associated radiographic abnormalities.*
100
A cresentic collection on CT scan of the head is consistent with what?
Subdural hematoma
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?
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.*
103
What motions does the tensor fascia lata contribute to?
Hip abduction and maintenance of knee extension
*It spans from the iliac crest to the fascia lata.*
104
What treatment is required for a displaced scaphoid fracture?
Open reduction and internal fixation
104
What motion(s) does the quadratus lumborum contribute to?
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.*
106
What is the most common cause of lower extremity edema?
Venous insufficiency (valvular incompetence)
*It classically worsens throughout the day and resolves overnight when the patient is recumbent.*
108
Embolectomy in an extremity that occurs 4-6 hours after the onset of ischemia is associated with what risk?
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.*
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?
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.
110
What is the standard treatment approach for complicated diverticulitis with abscess formation?
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.*
112
What motion(s) does the psoas major contribute to?
Flexion and lateral rotation of the thigh
*It spans from the transverse processes of the lumbar vertebrae to the lesser trochanter of the femur.*
113
After securing the airway, breathing, and circulation, what is the next step in managing hemoptysis with active bleeding?
Bronchoscopy
*This is the procedure of choice to identify the site of bleeding and attempt early therapeutic intervention.*
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?
Chest xray, CBC, coagulation studies, renal function, urinalysis, rheumatologic workup, and CT scan
*Bronchoscopic interventions, embolization, or resection are the definitive treatments.*
115
Hypotension, tachycardia, flat neck veins, confusion, and cold extremities despite IV fluid resuscitation in a trauma patient indicates what?
Hypovolemic/hemorrhagic shock
117
What typically presents with severe retrosternal chest pain and mediastinal free air on chest x-ray?
Esophageal rupture
*It does **_not_** cause massive blood loss.*
118
What is useful for patients with evidence of chronic GI blood loss who have had a negative upper and lower endoscopy?
Capsule endoscopy
*This is used to examine the small bowel.*
119
What is the treatment for slipped capital femoral epiphysis?
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.*
119
What differentiates inflammatory bowel (IBD) disease from colonic ischemia?
Relative to IBD, colonic ischemia has an acute onset and typically spares the rectum, involving only a segment of the colon
120
What complication of acute pancreatitis presents with nausea, vomiting, and constant epigastric pain that radiates to the back?
Fat necrosis
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?
Morton neuroma
*Treatment is conservative with bilateral shoe inserts. Surgery is reserved for patients who fail conservative treatment.*
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?
Central cord syndrome
*Patients may present with burn injuries on the hands due to loss of sensation.*
123
What is characterized by inward motion of one side of the chest wall on inspiration that is corrected by positive pressure mechanical ventilation?
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.*
125
What classically presents insidiously with a combination of constant visceral epigastric pain radiating to the back, jaundice, anorexia, and weight loss?
Pancreatic cancer
126
1. What is an ileus?
2. what is the most common cause of ileus?
1. An ileus is a functional defect in bowel motility without an associated physical obstruction.
2. Abdominal surgery is the most common cause
127
What presents with dyspnea, confusion, and petechia in the upper part of the body and occurs after multiple fractures of long bones?
Fat embolism
*Diagnosis can be confirmed by presence of fat droplets in urine or presence of intra-arterial fat globules on fundoscopy.*
129
The presence of tachypnea, tachycardia, distended neck veins, and tracheal deviation suggest what?
Tension pneumothorax
130
What is a common iatrogenic complication of cardiac catheterization that presents with hypotension and tachycardia?
Hematoma formation
*If above the injuinal ligament, the hematoma can extend directly into the retroperitoneal space and cause significant bleeding with hemodynamic instability.*
131
What are 2 causes of delayed (\>1mo) postoperative fever?
1. Viral infections
2. Infection with indolent organisms
132
Epigastric pain and vomiting following direct blunt abdominal trauma is the classic presentation of what?
Duodenal hematoma
133
What is the most appropriate management of dumping syndrome?
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.*
135
What is the major cause of morbidity and mortality in patients with significant total body surface area burns?
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.*
136
Intravenous catheter infections are most commonly caused by what organisms?
Cutaneous organisms such as Staphlyococci
*Femoral catheters carry a higher risk of causing bacteremia than subclavian catheters and may also cause gram-negative bacteremia*.
138
Anterior shoulder dislocation may cause injury to what nerve and artery?
Axillary nerve and artery
140
What should one suspect when a patient develops a whistling noise during respiration following rhinoplasty?
Nasal septal perforation
*This is likely the result of a septal hematoma.*
141
What classically causes tachycardia, new bundle branch blocks or arrhythmias and is commonly associated with sternal fracture?
Myocardial contusion
141
What is often characterized by intermittent epigastric pain, nausea, vomiting, and right-sided shoulder or subscapular discomfort?
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.*
143
Severe radicular pain with a positive straight leg raise test is indicative of what?
Acute disk prolapse
143
What causes upper and lower motor neuron deficits with no loss of sensory function?
Amyotrophic lateral sclerosis (ALS)
*Twitching, muscle weakness, and cramping are common symptoms.*
144
What are 5 causes of acute (24hrs-1wk) postoperative fever?
1. Nosocomial infection
2. Group A strep or Clostridium perfringens surgical site infections
3. Myocardial infarction
4. Pulmonary embolism
5. Deep vein thrombosis
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?
Idiopathic avascular necrosis of the femoral capital epiphysis (Legg-Calve-Perthes disease)
147
Patients with hemodynamic instability and suspected tension pneumothorax should have immediate treatment with what?
Needle thoracostomy prior to intubation
*Intubation with positive ventilation usually exacerbates an existing pneumothorax.*
148
What is the next step in management of a lower GI bleed where the source cannot be identified by colonoscopy?
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.*
150
To provide adequate hemostasis for most invasive procedures, what must the platelet count be?
\>50,000/mm3
151
What will an x-ray show in tension pneumothorax?
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
152
What should be obtained in all patients who undergo central venous catheterization
Chest x-ray
*To confirm proper placement of the catheter tip and absence of complications before administering drugs or other agents through the catheter.*
154
What differentiates biliary colic from acute cholecystitis?
Biliary colic is intermittent, related to fatty meals, and not associated with fever
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?
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.*
156
"Popeye sign" is produced by rupture of which tendon?
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.*
157
How do Osteosarcoma and Ewing sarcoma tend to differ?
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*.
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?
Pulmonary contusion
*Symptoms usually develop in the first 24 hours.*
160
The tendons of which 4 muscles compose the rotator cuff?
1. Supraspinatus
2. Infraspinatus
3. Teres minor
4. Subscapularis
162
What is most commonly responsible for strabismus (improper alignment of the eyes)?
Brainstem lesions
*It can result from disorders of the extraocular muscles or of the nerves that innervate them (CN III, IV, VI).*
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?
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.*
165
What noninvasive test is helpful in determining the exact vessels involved in peripheral artery disease (PAD)?
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.*
166
Which metatarsal is most commonly affected by stress fractures?
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.*
167
Parotid surgery involving the deep lobe of the parotid gland carries a significant risk of what?
Facial nerve (CN VII) palsy resulting in facial droop
168
What is the management of esophageal perforation?
Primary closure of the esophagus and drainage of the mediastinum must be attempted within 6 hours to prevent the development of mediastinitis
169
Slipped capital femoral epiphysis is common in what demographic?
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.*
171
What are the most common peripheral artery aneurysms?
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.*
172
What are 5 causes of subacute (1wk-1mo) postoperative fever?
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
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?
1. Eye opening
2. Verbal response
3. Motor response
175
What can occur during significant head trauma and leads to ipsilateral hemiparesis, ipsilateral mydriasis and strabismus, contralateral hemianopsia, and altered mentation.
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.*
176
What is the most common cause of spinal cord ischemia and infarction?
Surgery to repair thoracic and thoracoabdominal aortic aneurysms
178
What nerve is at risk of being injured by fracture of the medial epicondyle of the humerus?
Ulnar nerve
## Footnote
*Symptoms include "claw hand" and sensory loss on the dorsal and ventral medial hand.*
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?
1. Appendicitis
2. Gynecologic
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?
Aortic rupture
182
A head CT scan showing a semilunar hematoma is characteristic of what?
A subdural hematoma
184
Paraplegia, variable sensory loss, and urinary/fecal incontinence is characteristic of what?
Cauda equine syndrome
185
What is the first step in evaluating a patient with suspected peripheral artery disease?
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.*
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?
Meniscal tear
*Becuase the meniscus is not directly perfused, effusion following injury typically is not clinically apparent for many hours following the injury.*
188
Acute pain and swelling of the midline sacrococcygeal skin and subcutaneous tissues are most commonly due to What?
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.*
190
What is the therapy for deep vein thrombosis (DVT)?
Heparin acutely and warfarin for _\>_3 months with an INR goal of 2-3
191
What are the early symptoms of carbon monoxide poisoning?
1. Agitation
2. Confusion
3. Somnolence
192
Transient unilateral weakness following a tonic-clonic seizure that usually spontaneously resolves is indicative of what?
Todd paralysis
194
How does one confirm the diagnosis of esophageal rupture?
Water-soluble contrast esophagography
195
Elevated amylase, lipase, and WBC, as well as mild azotemia and hypocalcemia are indicative of what?
Acute pancreatitis
*CT scan can be used to confirm the diagnosis of pancreatitis.*
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?
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.*
198
Damage to what vessel(s) results in an epidural hematoma?
Middle meningeal artery
199
How will a patient with an anterior shoulder dislocation hold their arm?
Slightly abducted and externally rotated
200
A portosystemic shunt connects the portal venous system to the systemic venous system. This can be accomplished surgically or with what procedure?
TIPS procedure
*These procedures are considered a last resort in variceal bleeding unresponsive to medical and endoscopic interventions.*
201
What is the gold standard for evaluating mesenteric ischemia?
Mesenteric angiography
*Patients with this disease present with severe abdominal pain after eating, and a relatively normal abdominal exam.*
203
What nerve is the most commonly injured in association with fracture of midshaft humerus?
Radial nerve
*Ulnar nerve is also a common nerve injury in association with humeral fracture. Its injury would cause a claw hand.*
204
What is Volkmann's ischemic contracture?
The final result of compartment syndrome in which the dead muscle has been replaced by fibrous tissue.
205
Hydrocele can be differentiated from other testicular masses by what?
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.*
206
What has a classic presentation of unconsciousness followed by a lucid interval, followed by a gradual deterioration of consciousness?
Acute epidural hematoma
*Head CT scan is diagnostic and shows a biconvex hematoma.*
207
Which rotator cuff tendon is most commonly injured?
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.*
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?
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.*
209
What is the treatment for an isolated duodenal hematoma?
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.*
210
Predisposition for renal cell carcinoma is seen in what Syndrome?
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.*
212
What effect on intracranial pressure does short-term hyperventilation have?
It decreases intracranial pressure
*It does this by causing cerebral washout of CO2, leading to vasoconstriction and decreased cerebral blood flow*
213
What motion(s) does the quadriceps femoris muscles contribute to?
Leg extension at the knee and the rectus femoris also functions as a hip flexor
214
Radial nerve compression from trauma most commonly occurs where?
In the forearm
*It results in hand weakness and decreased handgrip.*
216
What should be the next step in managing a patient with suspected tension pneumothorax?
Emergent needle thoracostomy
*Performing a chest radiograph for confirmation may lead to an unacceptable delay in treatment.*
217
Right upper quadrant pain, fever, and leukocytosis is typical for what?
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.*
218
Intermittent bloody discharge from one nipple, usually without an appreciable mass is the classic presentation of what?
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.*
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?
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.*
221
What is characterized by hypotension, tachycardia, elevated systemic venous pressure and pulsus paradoxus (\>10mmHg drop in blood systolic blood pressure on inspiration)?
Cardiac tamponade
*Emergent pericardiocentesis is indicated.*
222
What can occur following cardiac surgery and present with fever, chest pain, leukocytosis, and mediastinal widening on chest x-ray?
Acute mediastinitis
*This is a serious condition that requires drainage, surgical debridement, and prolonged antibiotic therapy.*
223
What is characterized clinically by diarrhea, rectal bleeding, tenesmus (constant feeling of needing to defecate despite an empty colon) and incontinence?
Radiation proctitis
*Later, strictures and fistulae may form.*
224
Idiopathic avascular necrosis of the femoral capital epiphysis is called what?
Legg-Calve-Perthes disease
This condition most commonly affects boys between ages 4 and 10, with a peak incidence between 5 and 7
225
What is the most common complication seen post thyroidectomy?
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.*
226
How will a patient with a posterior shoulder dislocation hold their arm?
Adducted and internally rotated
227
1. What muscles are innervated by the common peroneal nerve?
2. The common peroneal nerve provides sensation to what region of the leg?
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
228
What is the treatment for a pancreatic abscess?
Immediate placement of a percutaneous drainage catheter, culture of the drained fluid, and ultimately surgical debridement
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?
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.*
230
Patients who present with acute onset of back pain and profound hypotension should be evaluated for a presumptive diagnosis of what?
Ruptured abdominal aortic aneurysm
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?
Syringomyelia
*Whiplash is often the inciting injury. The condition involves enlargement of the central canal of the spinal cord due to CSF retention.*
232
Ipsilateral motor and proprioception loss and contralateral pain loss below a certain level is characteristic of what?
Brown Sequard syndrome
*This is acute hemisection of the spinal cord. Symptoms occur below the level of the lesion.*
233
What is the investigation of choice in diagnosing suspected splenic injury?
Abdominal CT with IV contrast.
234
What must be ruled out for any patient who suffers blunt deceleration trauma (moving vehicle accident or a fall from \>10 feet)?
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.*
235
Tension pneumothorax is an emergency situation that can be diagnosed clinically and requires immediate what?
Needle thoracostomy
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?
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.*
237
What treatment is recommended for all nondisplaced scaphoid fractures (fractures with
Wrist immobilization for 6-10 weeks
238
What test(s) can confirm suspicion for myocardial contusion?
Cardiac markers and EKG
*Cardiac markers are often elevated and EKG may show new left bundle branch block or dysrhythmia.*
239
A biconvex collection on CT scan of the head is consistent with what?
Epidural hematoma
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?
Fat necrosis
*No treatment is indicated.*
241
Intraabdominal pathology causing pain in one or both shoulders suggests what?
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*.
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?
Tension pneumothorax
*Needle thoracostomy should be done emergently; performing a chest radiograph for confirmation may lead to an unacceptable delay in treatment.*
243
What is the first step in evaluating a patient with suspected peripheral artery disease (PAD)?
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.*
244
What is the treatment for subluxation of the radial head?
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.*
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?
Posterior urethral injury
246
Any gunshot wound below which intercostal space is considered to involve the abdomen and requires an exploratory laparotomy in unstable patients?
4th intercostal space (Level of the nipple)
247
What is the treatment of mastitis that is associated with breast-feeding?
1. Analgesics
2. Antibiotics
3. Continuation of breast-feeding from affected breast
248
What is characterized by intensive wound pain, decreased sensitivity at the edges of the wound, cloudy-gray discharge, and sometimes crepitus?
Necrotizing surgical infection
*Early surgical exploration is essential*
249
When squamous cell carcinoma arises within a burn wound, these ulcers are known as what?
Marjolin ulcers
250
What can confirm the diagnosis of diaphragmatic rupture in a patient with a suggestive chest x-ray?
Chest CT of chest and abdomen
*CT is more sensitive than x-ray and is the definitive diagnostic modality.*
