UW Surgery Flashcards

Question

In cervical spine trauma (patient fell and landed on neck), paralysis of what is your main concern?

Answer 1

The diaphragm - the diaphragm is innervated by C3-C5 (“C3, C4, C5 keeps the diaphragm alive!”), so if injury occurs at these roots, patients may have immediate diaphragmatic paralysis - if patient is injured below C5, a delayed diaphragmatic paralysis may occur due to ascending edema *signs to look for: Hypercapnic respiratory failure and use of accessory muscles (intubate!)

Answer 2

4,500- 11,000 (4.5- 11k)

Answer 3

PANCREATIC ADENOCARCINOMA - early satiety, intractable N/V, weight loss-> gastric outlet obstruction (can be cancer- 80%, peptic ulcer dz, bezoar, gastric polyps, etc.). In this case, pancreatic cancer is invading the duodenum * succussion splash= “splash” heard on abdominal auscultation when rocking the patient back and forth at the hips- suggests retained food in stomach - new-onset diabetes in an old person suggests pancreatic cancer (the pancreas stops producing adequate insulin) - K+ is low and bicarb high (metabolic alkalosis) due to vomiting (loss of H+, Cl-, K+ from the stomach-> alkalosis and hypOkalemia)

Answer 4

Solid mass of indigestible material (hair, foreign objects) that can cause blockage *rare, most people will have an underlying motility disorder (gastroparesis) or prior gastric surgery

Answer 5

Having an endoscopy done | If a tube is going down your esophagus, there is risk that the tube will perforate the esophagus if not done right

Answer 6

``` ESOPHAGEAL PERFORATION (due to the endoscopy with biopsy) —> chest/ back pain, systemic inflammatory response, and pleural effusion due to leaked esophageal contents ``` Confirm with ESOPHAGOGRAPHY WITH WATER-SOLUBLE CONTRAST- the best way to confirm esophageal perforation (can see the contrast escape the perf) Treat with EMERGENT SURGERY (debridement and repair)

Answer 7

Needle thoracostomy He had a tension pneumothorax (air in right pleural space-> dec right lung sounds and trachea is deviated left bc air from the outside pushes the trachea in the opposite direction) -This is a complication of central line placement (from the right subclavian, you can knick the right lung)

Answer 8

About 8.5-10

Answer 9

70-110 (fasting) <120 (2 hrs postprandial/ after food) *in the hospital, we’re okay with it being higher like to 180

Answer 10

Adrenal insufficiency She has Cushing’s features (central obesity and moon face) and is on chronic glucocorticoids (Prednisone for SLE)—> suppresses hypothalamus-pituitary-adrenal axis. These patients may not respond well to acute stressors (surgery) and need higher doses of glucocorticoids (cortisol) during these times. ``` *Normally adrenal glands make: G-> mineralcorticoids (aldosterone) F-> glucocorticoids (cortisol) R-> sex hormones (androgens) In adrenal gland insufficiency, they’re not working to make aldosterone + cortisol (*lack of aldosterone can-> hypOnatremia and Hyperkalemia). Treat with IV hydrocortisone or dexamethasone (give them back what they’re lacking) and fluid support. ```

Answer 11

CVA tenderness! | Lateral to vertebrae, below rib cage

Answer 12

Nephrolithiasis (kidney stone)/ ureteral stone

Answer 13

Tamsulosin, or similar alpha 1 antagonist *Alpha-1 causes urinary sphincter contraction-> urinary retention Block alpha-1-> urinary sphincter relaxation-> decreases ureteral pressure, facilitating stone passage **drugs like Bethanacol (anticholinergic that treats urinary retention/ helps you pee) would not work bc the receptors are in the bladder, but not the ureters **also give hydration and pain meds (analgesics)

Answer 14

Zenker diverticulum Spasm/ poor relaxation of cricopharyngeal muscles during swallowing (usually in an old man)—> false diverticulum (outpouching of mucosa in esophageal wall)—> food gets stuck in the pouch—> bad breath, regurg of food, dysphasia, voice change

Answer 15

Bad breath | May be due to retained food in a Zenker diverticulum, for example

Answer 16

Diagnose: swallow study Treat: surgery (circiopharyngeus muscle is divided and diverticulum is either removed (diverticulectomy) or combined with the esophageal lumen (diverticulotomy))

Answer 17

Bleeding in the biliary tree (blood mixes with bile) *typically seen following abdominal surgery or trauma

Answer 18

Mallory-Weiss tear (Longitudinal mucosal tear at the GE junction) *note: AST:ALT > 2:1 indicates alcoholic hepatitis He keeps vomiting, so makes sense that this caused an esophageal tear-> bleeding *NOT esophageal rupture (Boorhave), as this would present with air in mediastinum, chest pain, maybe pleural effusion *NOT ruptured esophageal varices, as this would have shown up on the endoscopy 3 days ago

Answer 19

Mallory-Weiss: longitudinal tear at GE junction of esophagus due to sudden increase in intraabdominal pressure- severe vomiting/ rethcing (alcoholics, bulemics), abdominal trauma, or hiatal hernia Can lead to... Boerhaave syndrome: rupture of esophagus (can also be caused as a complication of endoscopy and will cause subcutaneous emphysema/ air under chest, maybe pleural effusion)

Answer 20

Gastric cancer * Chinese people have increased risk for GI cancer (salty MSG-filled food) * The microcytic anemia= iron deficiency anemia (from GI bleed- tumor vessels ooze into gastric lumen) * Hepatomegaly and high liver enzymes explained by Mets to liver

Answer 21

Perianal abscess (Bacterial infection of anal crypt gland) * Both constipation and anal sex are risk factors * Treat with incision and drainage to avoid progression to a fistula

Answer 22

Splenic laceration *spleen= most commonly injured organ in blunt abdominal trauma

Answer 23

Topical Lidocaine (pain relief) and topical vasodilators like Nifedipine/ CCB or Nitroglycerin (decrease pressure in and increase blood flow to area to promote healing) *If refractory (medical management fails), then do surgery (lateral sphincterotomy, fissure excision)

Answer 24

CT scan of the abdomen

Answer 25

Colonoscopy with biopsies (Crohn’s would show transmural inflammation, cobblestone appearance, skip lesions. Ulcerative Colitis would show continuous ulcerations and pseudo polyps of the distal colon/ rectum)

Answer 26

A stool marker for inflammatory diarrhea *can check it to confirm an IBD flare, for example

Answer 27

Low FODMAP diet (Fermentable, Oligosaccharides, Disaccharides, Monosaccharides, And Polyols) *Basically- don’t eat too many simple sugars that are poorly absorbed in the small intestine

Answer 28

Biliary atresia (Fibrosis of extrahepatic bile ducts) * Usually present at 2-8 weeks * Total and DIRECT bilirubin will be high * GGT (gamma-glutamyl transpeptidase) and alk phos will be high from bile duct destruction * Reticulocyte count in normal, since there’s no hemolysis going on **Although you may think hemolytic disease of the newborn, this would not explain the absent gallbladder and pale stools

Answer 29

X-ray of the colon with contrast dye *can use it for diagnosis of diverticulosis (not diverticulitis bc the dye can further irritate the inflamed colon!), etc.

Answer 30

ZE (Zollinger-Ellison) syndrome= gastrin-secreting tumor in pancreas or duodenum —> excess release of stomach acid—> multiple ulcers + inactivation of pancreatic enzymes (bc normally the basic environment of the duodenum activates them)—> malabsorption and diarrhea

Answer 31

Pancreatic pseudocyst (encapsulated area of fluid/ tissue/ debris that causes an inflammatory response) ``` Endoscopic drainage (you do this only for patients with bad symptoms from it) ```

Answer 32

You don’t! *Only 20% of patients with gallstones get symptoms

Answer 33

Recommend a high-fiber diet (30 grams of fiber/ day), hydration, reduction in fat and alcohol intake, regular exercise Can also give stool softeners (*remember that chronic constipation/ straining is why you get bleeding hemorrhoids in the first place)

Answer 34

Hepatocellular carcinoma (HCC) that metastasized to the spine *High AFP means HCC or testicular cancer (HCC more likely due to the fact that he’s from another country where hep B and C are more prominent and has high liver enzymes too)

Answer 35

CT of the abdomen (you need to see that pancreas—she may have pancreatic cancer!) * smoking + epigastric pain in an old person—> be suspicious of pancreatic cancer. CT is the 1st line test to check for it. * she has normal labs and no dilation of the bile ducts, so not likely to be a gallbladder pathology.

Answer 36

SIBO (small intestinal bacterial overgrowth) * common complication of gastric bypass surgery—the blind loop of intestine can allow for excessive bacterial growth (conditions that alter intestinal motility like DM can also cause this) * often causes nutritional deficiencies, including vit B12-> macrocytic anemia

Answer 37

Colon cancer that metastasized to the liver

Answer 38

Get an abdominal Ultrasound * This sounds like biliary colic and a RUQ U/S is the first test for gallstones (cholecystitis)! * Would show gallbladder wall thickening, edema, pericholecystic fluid aka fluid around the gallbladder

Answer 39

Perforated peptic ulcer * CAD means the patient is prob taking Aspirin, which blocks GI protective prostaglandins-> inc risk for peptic ulcer dz * air under the diaphragm (pneumoperitoneum) is concerning for perforated viscus (a perfed organ- in this case, due to full-thickness erosion of an ulcer through the stomach or duodenal wall) * a perforated gut-> peritonitis (tenderness w/ guarding), risk of sepsis! Surgery is indicated immediately

Answer 40

Inflammation and distention of the gallbladder due to a gallstone obstructing the cystic duct *typical symptoms: RUQ pain, fever, leukocytosis (high WBC count)

Answer 41

When a RUQ ultrasound is inconclusive

Answer 42

Laparoscopic cholecystectomy within 72 hrs

Answer 43

Do surgery to take out the gallbladder (cholecystectomy within 72 hrs) *although fibrates can contribute to the formation of gallstones, having symptomatic gallstones is indication for surgery

Answer 44

Small bowel obstruction (SBO) due to fibrotic intestinal stricture *strictures are a complication of Crohn’s disease (severe inflammation) (Stricture= abnormal narrowing of intestine)

Answer 45

Pyloric stricture (gastric outlet obstruction) *succession splash= sloshing sound on auscultation that means there's retained gas/ fluid in the stomach

Answer 46

Generalized swelling

Answer 47

1. Trauma from a paracentesis (needle drainage of ascites fluid, this bleeding resolves on its own) 2. Underlying malignancy (like hepatocellular carcinoma- tumor growth disrupts nearby blood vessels) **if cancer is a concern, do abdominal imaging, measure AFP (revised in HCC), and cytologic analysis of the ascitic fluid

Answer 48

Acute mediastinitis - complication from cardiac surgery due to intraoperative wound contamination - presents with fever + chest pain + leukocytosis + mediastinal widening on CXR - treat with drainage, surgical debridement, and prolonged antibiotic therapy (*despite treatment, there’s a 10-15% death rate with this complication)

Answer 49

Copper deficiency - occurs in patients with gastric bypass, chronic malabsorption, or zinc excess (competes with copper for absorption in the GI tract) - symptoms are similar to vitamin B12 deficiency + hypochromic microcytic anemia, hair loss, skin depigmentation, hepatosplenomegaly, edema, and osteoporosis - diagnose w/ low serum copper and ceruloplasmin (copper-carrying enzyme) - treat with copper supplements and discontinuation of zinc

Answer 50

Nasopharyngeal carcinoma - tumor associated with EBV, in China - tumor obstructs nasopharynx—> nasal congestion/ nosebleeds, headache, facial numbness (invades para-cavernous sinus), and/or ear infection (invades Eustachian tube), spreads to cervical lymph nodes

Answer 51

DIC (disseminated Intravascular coagulation) * Seen after severe trauma, sepsis, malignancy, Ob/gyn complications (due to exposure of tissue factor and release of procoagulant proteins/ phospholipids) * *Would have prolonged PT and PTT, thrombocytopenia (low platelets since they’re used up) * Inappropriate activation of the coagulation cascade (coag factors and platelets get used up where they shouldn’t be, so bleeding happens from IV sites and mucosal surfaces) * Organ failure may also be seen (ex: bleeding out so lack of blood to kidneys-> reduced urine output despite fluids given)

Answer 52

Osteosarcoma * Retinoblastoma is associated with osteosarcoma * Concentric layers of reactive bone= sunburst pattern * lifting of periosteum (outer layer of bone)

Answer 53

“Frozen shoulder” -fibrosis and contracture of the glenohumeral joint capsule-> decreased passive range of motion

Answer 54

Cholecystectomy (take the gallbladder out now that she’s stable to prevent another episode of gallbladder pancreatitis) *would do ERCP to relieve the obstruction if the patient had cholangitis, CBD obstruction/ dilation, or increasing LFT’s

Answer 55

Gallstone pancreatitis *some studies have shown this has a 95% positive predictive value for predicting gallstone pancreatitis (also expect elevated LFTs, alk phos, and lipase)

Answer 56

When UltraSound is inconclusive (need this extra test to determine if there’s cholecystitis)

Answer 57

IT (iliotibial) band syndrome - overuse injury-> poorly localized lateral knee pain, esp with flexion of the knee * NOT lateral meniscus injury- this is caused by acute trauma rather than overuse-> catching, popping, or locking of the knee with movement

Answer 58

Celiac disease—> malabsorption of fat-soluble vitamins (A, K, E, and D)—> low vitamin D= low calcium—> secondary hyperparathyroidism (PTH will rise to try to compensate and raise calcium levels)—> more breakdown of bone

Answer 59

Hyperthyroidism | Everything is sped up so there is increased bone turnover

Answer 60

HIGH pH: calcium or ammonium magnesium phosphate (struvite) LOW pH: uric acid or cysteine

Answer 61

Necrotizing fasciitis - presents with pain out of proportion, signs of tissue necrosis (crepitus, purulent/ pus drainage, or CT showing gas in deep tissues), and systemic signs (hypotension) - most commonly from group A strep - requires antibiotics + surgical debridement

Answer 62

Lactated Ringers | Isotonic balanced solution, meaning it contains near-physiologic levels of chloride, potassium, and calcium

Answer 63

6 months *orchiopexy is indicated after this point to reduce complications associated with cryptorchidism (undescended testicles) such as testicular torsion, infertility, and testicular malignancy

Answer 64

CT or MRI to confirm fracture OR Repeat X-ray in 7-10 days *X-ray at the time of injury has a low specificity for scaphoid fracture. Repeat the X-ray so the inflammation shows up (cost effective) or do MRI (faster, may allow for earlier return to normal activity)

Answer 65

Right lobe (right bronchus is more vertical than the left, so aspiration is more likely down this tube) *if sitting/ standing, will go to right lower lobe. If laying down, will go to posterior right upper or lower lobe (depends on gravity).

Answer 66

Excisional biopsy *A mole is suspicious for melanoma if it appears different from other (“ugly duckling sign”), itches or bleeds, or develops nodularity. (Does not have to meet at least one of the ABCDE criteria: Asymmetry, Border irregularity, Color variation, Diameter >6mm, or Evolving)

Answer 67

If lesion is small or suspicion for melanoma is high—> Wide excisional biopsy If lesion is large or suspicion for melanoma is low—> Punch biopsy **never do a shave biopsy for suspected melanoma—checking for depth of invasion is important!

Answer 68

Thyroid storm Treatment: - Beta-blockers like Propanolol (block sympathetic effects and conversion of T4-> active T3) - PTU (block TH synthesis and conversion of T4-> active T3) - Glucocorticoids (block conversion of T4-> active T3) - life-threatening thyrotoxicosis triggered by surgery (or trauma, childbirth, infection, etc.) - symptoms: tachy, arrhythmias, HTN, high fever, tremor, altered mental status *high CK, BUN, Cr possibly due to rhabdo (which would cause intrinsic AKI from myoglobinuria) (not sure?)

Answer 69

Refeeding syndrome - this occurs when chronically malnourished people (anorexia nervosa, malignancy) are reintroduced to nutrients - > glucose spike-> HUGE increase in insulin (body wants to store up all it can since it’s so deprived of calories)-> electrolyte imbalances (low phosphorus, low K+, low Mg)-> cardiac arrhythmias, rhabdo, seizures, death

Answer 70

NO Fluoroquinolones increase collagen degradation-> aortic aneurysm rupture (also: Achilles’ tendon rupture and retinal detachment) * avoid in patients with known aortic aneurysm or with risk factors (Marfans, Ehlers-Danlos, advanced atherosclerotic disease, uncontrolled HTN) * *QT prolongation is another adverse affect

Answer 71

5-aminosalicylic acid medications (5-ASA) (such as mesalamine, sulfasalazine, and balsalazide) *Mesealamine enemas (suppositories that you push up the rectum) are preferred in patients with UC confided to the rectosigmoid. For more extensive dz, oral 5-ASA meds are recommended.

Answer 72

Needle thoracostomy (make a small incision in chest wall for drainage, can place chest tube) This is a tension pneumothorax Air from injured lung comes into pleural space-> high intrathoracic pressure-> compresses vena cava-> backs up blood so that neck veins are distended but there’s less cardiac return -there is also a mediastinal shift (trachea pushed away) **do NOT do emergent thoracotomy (completely opening up chest)—this is a last resort to resuscitate a trauma or cardiac arrest patient

Answer 73

An incomplete fracture involving only one side of the bone

Answer 74

Most likely fractured ribs w/ intercostal vessel injury-> hemothorax (bleeding into pleural space) *always think of intrathoracic hemorrhage when you have blunt chest trauma + hypovolemic shock! (His vitals show low BP, tachy, and he also has flat neck veins due to bleeding out)

Answer 75

Squamous cell carcinoma (SCC) *remember that this is keratinized and ugly and is seen more often in people on chronic immunosuppressive therapy!

Answer 76

Biopsy it -Evolving leukoplakia in the oral cavity requires biopsy (even if done before). Tobacco= no 1 risk factor for oral squamous cell carcinoma.

Answer 77

Get a CT of the abdomen - This is describing migratory superficial thrombophlebitis aka Trousseau syndrome (superficial venous thrombosis at unusual sites like the arm and chest) - Associated with PANCREATIC CA

Answer 78

Chronic pancreatitis Pancreatic enzyme supplementation - pancreas is damaged (from recurrent pancreatitis and fibrosis)-> cannot make pancreatic enzymes to help digest-> malabsorption of fat-> steatorrhea (stools that float) - postprandial (after eating) epigastric pain can become continuous - give them the pancreatic enzymes they are missing to improve symptoms

Answer 79

Clinical observation only (As long as it’s small to moderately sized, post-op day 1 or 2, and not associated with respiratory symptoms) *About half of CABG patients develop a pleural effusion after (usually on the left). This is the body’s reaction to cutting into the pleura and disrupting lymphatic channels and such.

Answer 80

Cholangiocarcinoma (cancer of the bile ducts) - Remember that ulcerative colitis is associated with primary sclerosing cholangitis (inflammation/ fibrosis of intra and extrahepatic bile ducts), which increases risk for cholangiocarcinoma - Presents with signs of biliary obstruction (RUQ pain, jaundice, dark urine) and weight loss is a sign of cancer * bile duct obstruction (in this case from tumor)-> no bile going into duodenum and out into feces, more into blood and eventually to urine-> pale stools, dark urine

Answer 81

CEA (tumor marker)

Answer 82

Inflammation and fibrosis of the intrahepatic and extrahepatic bile ducts (*vs. primary biliary cholangitis, which is autoimmune destruction of the intraheptic bile ducts) Associated with ulcerative colitis (UC) (90%)! Having this means you’re at increased risk for cholangiocarcinoma (cancer of bile ducts)

Answer 83

If there are signs of Urosepsis (fever, chills, tachy), AKI, complete obstruction OR Stone >10 mm

Answer 84

Alpha blockers (Tamsulosin) *remember alpha-1 causes urinary retention and contracts the ureters. Block alpha-> dilate/ open up the ureters for easier passage of the stone

Answer 85

Abdominal ultrasound - this sounds like AAA (abdominal aortic aneurysm) - symptoms: severe abdominal/flank/groin pain, pulsatile mass, flank ecchymoses, limb ischemia * you would get a CT abdomen instead of U/S if he were hemodynamically stable and you had time

Answer 86

Foreign body aspiration - use history! He’s a 1 year old playing legos - aspiration occurs in right lung (right bronchus is more vertical, easier for stuff to go down) - wheezing and decreased breath sounds on affected side are characteristic - hyperresonance and hyperexpansion indicate air trapping (he can’t breathe well due to that lego prob causing some atelectasis/ collapsing some alveoli)

Answer 87

``` Pulmonary contusion (Bruise on the lung due to chest trauma—since capillaries are damaged, blood and fluid accumulates in lung tissue and interferes with gas exchange, potentially leading to hypoxia) ``` *Tachycardia and high RR can be explained by pain and shallow breathing **often associated with rib fractures (though kids have more elastic chest walls so they won’t always fracture ribs)

Answer 88

Bladder disease (bladder cancer) - painless hematuria (due to cancer blood vessel formation) - you get total hematuria (blood during entire urinary stream) or terminal hematuria (blood just at end of urinary stream—if cancer is at neck/ bottom part of bladder) * risk factors: smoking, male, >40 * *he doesn’t have weight loss, but that’s prob just bc we’re catching it early—get a cystoscopy for diagnosis!

Answer 89

Endoscopy of the bladder via the urethra | *use this to aid in diagnosis of bladder cancer, for example

Answer 90

Pancreatic pseudocyst (encapsulated fluid collection of the pancreas, a complication of pancreatitis)

Answer 91

A globe (eyeball) laceration/ perforation

Answer 92

Intra-abdominal abscess (specifically right subphrenic abscess—below the diaphragm in the region of the liver) *Remember causes of post-op fever! “Wind, water, walking, wound” Post-op day 1–> atelectasis Post-op day 2-> pneumonia Post-op day 3-> UTI Post-op day 5-> DVT Post-op day 7-> wound infection Post-op day 10-15-> deep abscess (subphrenic, pelvic, subhepatic, etc.) **intra-abdominal abscesses are often associated with pleural effusion

Answer 93

``` “Wind, water, walking, wound” Post-op day 1–> atelectasis Post-op day 2-> pneumonia Post-op day 3-> UTI Post-op day 5-> DVT Post-op day 7-> wound infection Post-op day 10-15-> deep abscess (subphrenic, pelvic, subhepatic, etc.) ``` *”wonder drugs”= malignant hyperthermia (from halothane or succinylcholine) DURING surgery

Answer 94

``` “Wind, water, walking, wound” Post-op day 1–> atelectasis Post-op day 2-> pneumonia Post-op day 3-> UTI Post-op day 5-> DVT Post-op day 7-> wound infection Post-op day 10-15-> deep abscess (subphrenic, pelvic, subhepatic, etc.) ``` *”wonder drugs”= malignant hyperthermia (from halothane or succinylcholine) DURING surgery

Answer 95

Heparin-induced thrombocytopenia (HIT) - You can assume heparin was given since she underwent CABG - This is describing skin necrosis at the abdominal site where the patient is getting subcutaneous injections of heparin *HIT= bad reaction to heparin where it binds platelet factor 4 (hep-PF4) and antibodies are made against this complex. The antibodies destroy platelets (thrombocytopenia) and stick platelets together (clotting in the setting of anticoagulation).

Answer 96

Toxic shock syndrome (due to nasal packing) - Staph a.-> toxic shock syndrome toxin-1 release (superantigen)-> T-cell activation and massive cytokine release-> widespread vasodilation-> hypotension (tachy in attempt to compensate) - Other symptoms: sunburn rash, vomiting, diarrhea, inc neutrophils

Answer 97

Petechial rash

Answer 98

Venous air embolism (VAE) * Veins are susceptible to VAE due to their relatively low hydrostatic pressure (more collapsible). The VAE travels to the RV or further to the pulm arterioles, where it can cause obstructive shock and cardiac arrest. * think of this in a patient with sudden-onset respiratory distress after removal of a central venous catheter

Answer 99

Esophageal perforation (Boerhaave syndrome) - chest/back pain, fever, pleural effusion (from esophageal contents leaking into pleural space) in the setting of self-induced vomiting points to esophageal perf * emergent surgery!

Answer 100

Post-op ileus (bowel paralysis) *vs SBO- X-ray would show transition point (the obstruction) and dilated small bowel proximal/ leading up to that point

Answer 101

Avascular necrosis aka osteonecrosis (disruption of bone vasculature) - this is a complication of long-term glucocorticoid use - > progressive hip pain, reduced range of motion, joint instability *X-ray is normal in the first few months—MRI is more sensitive **his moon face and buffalo hump neck are signs of Cushing’s, which support chronic glucocorticoid use

Answer 102

Gallbladder stasis Normal person: eat food-> CCK release-> gallbladder contraction Person on TPN (total parenteral nutrition): IV nutrients-> directly delivered to bloodstream and does not go down GI tract, so no CCK release or gallbladder contraction-> promotes formation of bile sludge and gallstones

Answer 103

Hemobilia (bleeding into the biliary tract) - complication of recent liver biopsy - this upper GI bleed explains the melena, low Hb, reactive thrombocytosis - leukocytosis due to inflammation - high total bili due to bile duct obstruction (blood is obstructing the bile ducts, so bile backs up rather than being emptied into the GI tract) *note: liver abscess can occur after a liver biopsy and present with RUQ pain, leukocytosis, hyperbili if compressing biliary tree—but would NOT have upper GI bleed and would have fever too

Answer 104

Esophageal perforation (Boerhaave syndrome) * the leaked GI contents cause a systemic inflammatory response (fever, tachy) that can quickly progress to septic shock and death * confirm diagnosis with esophagography (barium swallow test) or CT scan w/ water-soluble contrast * give IV antibiotics and PPIs (acid would further irritate) and get an emergency surgical consult for debridement and repair! **vs Mallory-Weiss partial-thickness esophageal tear (assoc w/ hematemesis, do upper GI endoscopy to confirm, give PPI/ acid suppression, and most heal on their own)

Answer 105

Go to OR for fasciotomy (fascia is cut to relieve pressure and restore circulation) This is compartment syndrome! - caused by trauma, prolonged compression of an extremity, or after revascularization of an ischemic limb (inc pressure in compartment of leg-> impaired perfusion-> severe pain, necrosis of muscle cells, nerve injury) - presents with excruciating pain worse w/ passive movement - paresthesia from sensory nerve ischemia and intact pulses are early findings (though there’s variability in associated signs/ symptoms)

Answer 106

Doppler ultrasonography

Answer 107

Ruptured ovarian cyst -on Warfarin-> hemoperitoneum (internal bleeding in abdomen) from ruptured ovarian cyst-> hemodynamic instability (BP is low w/ tachy) and low hematocrit * NOT ovarian torsion bc that presents with sudden lower abdominal pain but not an acute abdomen on exam + drop in Hct * NOT ruptured ectopic pregnancy (last period 3 wks ago, so unlikely)

Answer 108

1. BMI >40 2. BMI >35 with comorbidity (T2DM, HTN, OSA, etc.) 3. BMI >30 with resistant T2DM or metabolic syndrome * Check that they’ve already tried weight loss by diet and exercise, check psych history and readiness to change, and review cardiac and pulm risk factors for surgery * *Patient does not have to try weight-loss meds first, though that is an option

Answer 109

Bladder rupture - abdominal trauma (hit abdomen after drinking and prob had a full bladder)-> intraperitoneal bladder rupture-> urine leaks into peritoneal cavity-> abdominal distention and ascites (inc BUN and Cr from peritoneal reabsorption) * peritonitis (guarding + rebound tenderness) doesn’t always happen bc urine is sterile (and he’s got alcohol in his system masking pain) * this is NOT a cirrhosis picture (it’s too acute + liver studies were normal + that wouldn’t explain his inability to pee)

Answer 110

``` Delayed emergence (return to consciousness) from anesthesia (>15 min) -due to drug effect, metabolic disorder, or neurologic disorder (often multifactorial) ``` *ABG shows hypoxic respiratory failure due to hypOventilation (low pH, high CO2, low O2). This along with bradycardia (low HR) and bradypnea (low RR) suggest prolonged medication effect

Answer 111

Ogilvie syndrome “Paralytic ileus of the colon” -recent diarrhea (from foodborne gastroenteritis)+ diuretics-> electrolyte imbalance (hypokalemia)-> colon ileus (since K+ is needed to move the gut) * treat w/ bowel rest (NPO) and rectal tube to decompress/ drain out feces so they don’t back up and lead to perf * *can also give Neostigmine if ready to perf (cecal diameter >12cm) (AChE inhibitor-> more AChe= more PNS rest and DIGEST so helps get the poop out)

Answer 112

Mohs microsurgery *if not on the face (not a cosmetically sensitive area), can do electrodessication and curettage or generic surgical excision

Answer 113

Medical management: oral hydration, pain control, tell patient to strain their urine <5mm-> pass spontaneously 6-10mm-> alpha-blockers can help them pass >10mm-> consult urology Also consult urology if patient has refractory pain, anuria (can’t pee), AKI, or signs of urosepsis

Answer 114

Bone biopsy When the ulcer is so deep you can feel the bone the risk of osteomyelitis is much greater!

Answer 115

Pneumothorax ``` Mechanical ventilation (positive pressure ventilation)-> pulmonary barotrauma-> alveolar rupture-> pneumothorax (air in pleural space) *this is a complication of mechanical ventilation and COPD’ers are at higher risk due to already having hyperinflation/ air trapping and blebs that can rupture ``` -rapid-onset hypoxemia, dec breath sounds on affected side, inc peak pressure (more resistance to air flow from the ventilator), and inc plateau pressure (dec compliance/ ability to expand) **don't confuse alveolar rupture-> pneumothorax with alveolar collapse-> atelectasis.

Answer 116

Chest tube Allow the air to escape from the pleural space and the lungs to re-expand

Answer 117

Her hypocalcemia is due to the blood transfusions (given that she had liver lacerations) - there is citrate in transfused blood that binds up calcium - normal liver: this does NOT cause hypocalcemia bc the liver rapidly metabolizes/ breaks down the citrate - bad liver: this can cause hypOcalcemia bc the liver isn’t breaking down citrate as well-> more citrate remains to bind up that calcium-> dec levels in the blood

Answer 118

Uncomplicated diverticulitis- bowel rest, oral antibiotics, observation (IV antibiotics if old, immunosuppressed, bad leukocytosis, comorbidities) Complicated diverticulitis (assoc w/ abscess)- <3 cm-> IV antibiotics and observation 4+ cm-> CT-guided percutaneous drainage (*if this fails then surgical drainage)

Answer 119

Patella dislocation - common in young athletes after quick, lateral movements on a flexed knee - exam shows reduced range of motion and lateral displacement of the patella out of the trochlea

Answer 120

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

Answer 121

Abdominal CT w/ oral contrast This is concerning for anastomotic leak (complication of gastric bypass surgery, GI contents leak into peritoneum) -fever, abdominal pain, tachycardia within 1 wk *requires urgent surgical repair

Answer 122

>3x the upper limit of normal

Answer 123

In the teeth roots This is Ludwig angina (cellulitis of the submandibular space/ floor of mouth) -occurs from dental infections *treat with IV antibiotics (ampicillin-sulbactam, clindamycin, etc.) and removal of inciting tooth

Answer 124

Surgically unblocking a blood vessel

Answer 125

No You evaluated the ABCs (airway, breathing, circulation). He’s talking and breathing, can maintain his own airway. No expanding hematoma or emphysema in the neck, so no need for intubation at this time.

Answer 126

``` Adrenal insufficiency (lack of aldosterone + cortisol) -he bled into and destroyed adrenal glands ``` *Initially presents like septic shock, responds well to steroid bolus since it’s due to lack of steroid (cortisol). Think of this in patients who respond to shock treatment at first but then relapse.

Answer 127

Send him home Linear skull fractures are left alone if closed! (If open, go to OR)

Answer 128

Acute subdural hematoma (poor prognosis) Lower the ICP (intracranial pressure) to prevent further damage at this point (Head elevation, hyperventilate, hypertonic saline or mannitol, HTN treatment)

Answer 129

Hemisection of the spinal cord (Brown-Sequard) -loss of ipsilateral motor (CST) and proprioception/ vibration (DC-ML), controlateral pain/ temp (STT)

Answer 130

1. Hemisection (Brown-Sequard)- loss of ipsilateral motor and proprioception/ vibration, loss of controlateral pain/ temp below the level of the lesion 2. Anterior cord syndrome- loss of motor + pain/ temp on both sides below the level of the lesion 3. Central cord syndrome- loss of pain/ temp on both sides in the upper extremities * ”cape-like distribution” * can be due to hyperextension of neck (ex: car crash) * can also cause paralysis and burning in upper extremities

Answer 131

Intercostal nerve block and analgesia (pain meds) by epidural catheter -control the pain, otherwise pain-> hypoventilation (hurts to breathe, so patient will take shallow breaths)-> atelectasis (collapse of alveoli)-> pneumonia (alveolar collapse allows for mucus plug formation and inc chance of infection)

Answer 132

Pulmonary contusion (bruising) *looks like ARDS but follows chest trauma (the lungs took a big blow and are bruised up/ capillaries bursted, impairing breathing function)

Answer 133

Exploratory laparotomy Required in gunshot wounds to abdomen!

Answer 134

Retrograde urethrogram

Answer 135

Tetanus prophylaxis *removal of the bullet is not necessary

Answer 136

Peripheral pulses and capillary filling -the concern in a circumferential burn in cut off blood supply!

Answer 137

Immediate excision and grafting -this is for limited (only in one area) 3rd degree burns

Answer 138

Developmental dysplasia of the hip | Ball and socket hip joint didn’t form properly...may require hip brace for 6 mo or so

Answer 139

No (can do closed reduction to ‘set’/ align the bone—even though it’s angulated, meaning it’s displaced/ not lined up to the point where the bone fragments are pointed different directions) Open reduction surgery is almost never the answer in kids—they have softer, flexible bones that easily heal back to normal. Where kids get into trouble and need surgery is when the fracture affects the growth plate.

Answer 140

Fat embolism that reached the brain Fat embolism: long bone fracture-> petechial rash, fever, tachy, low platelet count-> respiratory distress (low oxygen, patchy infiltrates)-> if fat droplets reach brain, coma + star-field MRI pattern

Answer 141

Compartment syndrome | Fasciotomy (surgically remove the fascia to relieve the pressure built up in the leg)

Answer 142

X-ray thoracic and lumbar spine If fall from height and land on feet, need to look at the lumbar spine in line of that incredible upward force

Answer 143

Fingertip abscess

Answer 144

Injury of the ulnar collateral ligament due to forced hyper-extension of the thumb

Answer 145

When you close your fist, finger is stuck up (cannot flex)

Answer 146

In both, when you open up a fist, the finger is stuck down (can’t extend) (*in Trigger finger if you forcefully extend it with the other hand, you hear a pop) Difference is: Mallet finger is a sports injury, Trigger finger is an inflammatory problem

Answer 147

Marjolin ulcer | Biopsy the ulcer edge

Answer 148

1. Lost 20% or more of body weight 2. Albumin <3 3. Anergy to skin antigens (lack of protein-> can’t make Ig) 4. Transferin <200 Do 7-10 days (or at least 4-5 days) of pre-op nutritional support before surgery

Answer 149

Hypotension (Blood loss-> low BP-> if already stenosis in coronary arteries and now you have general low blood flow to heart, the heart can suffer an MI)

Answer 150

``` Portacaval shunt (shunt between portal vein-> IVC) is the same idea as TIPS (shunt between portal vein-> hepatic vein). Since all the liver vessels (where detoxification happens) are being bypassed, ammonium can build up in the blood and lead to hepatic encephalopathy. ``` *This is a treatment that helps severe cirrhosis patients since the blood skips over the liver which is failing, so it prevents further portal HTN/ backing up of fluid...but a side effect is increased likelihood of hepatic encephalopathy.

Answer 151

Fluid replacement, nutritional support, protection of abdominal wall (To avoid sepsis and keep patient alive while nature heals the fistula)

Answer 152

NS (normal saline) with KCl * vomit-> loss of HCl and K+. This explains the low Cl and K+ and the metabolic alkalosis. * to treat hypokalemia, give back K+. Giving KCl will fix the low Cl and K+ problem.

Answer 153

SBO (small bowel obstruction), likely due to adhesions from previous abdominal surgeries NPO (bowel rest), NG tube, IV fluids (Hope for spontaneous resolution and monitor for signs of strangulation)

Answer 154

Internal hemorrhoids

Answer 155

Diverticulitis | CT scan

Answer 156

Acute edematous (inflammatory) pancreatitis *normal hematocrit rules out hemorrhagic pancreatitis

Answer 157

The same way you treat breast cancer in non-pregnant women (biopsy, cut it out, etc.), with 2 exceptions: 1. No radiation or hormonal manipulations 2. No chemo in the FIRST trimester

Answer 158

Gastrografin enema (to diagnose meconium ileus—baby prob has CF too and cannot pass meconium due to thick secretions) *Gastrografin is an X-ray with contrast/ dye that is water-soluble, less irritating than Barium enema. This is both diagnostic of meconium ileus (will see pellets of meconium in terminal ileum) and therapeutic (draws fluid in, helping to dissolve the meconium pellets).

Answer 159

Vascular ring (trachea and esophagus are encircled by a ring of abnormal blood vessels) Surgical division of abnormal blood vessel *presents similarly to tracheomalacia (soft/ underdeveloped tracheal rings that collapse on breathing) but there is ALSO difficulty swallowing (since the vascular ring encircles both the trachea and esophagus)

Answer 160

NO A minimum of FEV1=800mL is required! If you do the math, after taking out his right (bad) lung, he has 40% lung function. So take 40% of his FEV1 of 1,000= 400mL. This is less than 800, so he would not be able to survive with just his left lung.

Answer 161

Embolectomy w/ fogarty catheter (used to surgically remove the emboli) *if incomplete occlusion, may use fibrinolytics (clot busters)

Answer 162

Congenital—> surgical repair in 6 mo. (To avoid amblyopia where the brain turns off the competing signal and you go permanently blind in one eye) Acquired—> eyeglasses (usually a refraction problem) *of patch the good eye to allow the bad eye to catch up

Answer 163

Thyroglossal duct cyst (Remember, the thyroid in embryo migrates from the base of the tongue down to its usual position in the neck below thyroid cartilage and above the sternum. During this process, a fluid-filled cyst can form in the mid-neck.)

Answer 164

Panendoscopy (triple endoscopy) and biopsies -examine the pharynx/ larynx, upper trachea, and esophagus—this guy likely has squamous cell carcinoma of the mucosa

Answer 165

This is facial nerve injury secondary to trauma (edema is compressing the nerve) No treatment

Answer 166

Aortic stenosis-> valve replacement Mitral stenosis-> clip it (mitral commissurotomy, which means surgeon is cutting out the calcium deposits/ scar tissue to open the stenotic mitral valve) *why are these treatments different? Don’t know.

Answer 167

Metastasis (figure out if it’s present to know the direction you have to go with your treatment)

Answer 168

Aortic dissection

Answer 169

Waxy, raised lesion—> excised | Ulcer—> biopsy the edge

Answer 170

No—do it ASAP to avoid amblyopia (where brain turns off competing signals, resulting in permanent loss of vision in one eye)

Answer 171

Branchial cleft cyst | Can form during development of head/ neck structures

Answer 172

Acoustic nerve neuroma (Schwannoma)

Answer 173

Cavernous sinus thrombosis * trapped infection (sinusitis) that irritates blood vessels-> clot forms (rare complication) * Treat with IV antibiotics! and heparin/ anticoagulation (drainage of paranasal sinuses may or may not be indicated)

Answer 174

Trigeminal neuralgia | Carbamazepine

Answer 175

Acute epididymitis Do ultrasound (sonogram) and treat with antibiotics (<35 years get Ceftriaxone + Azithro or Doxy to cover Chlamydia/ Gonorrhea, >35 years get Ciprofloxacin to cover E. Coli)

Answer 176

Testicular torsion- no fever, testes “high riding with horizontal lie,” lifting scrotum does not relieve pain, treat with immediate surge Acute epididymitis- fever, testes in normal position, lifting scrotum relieves pain, treat with antibiotics (<35 years get Ceftriaxone + Azithro or Doxy to cover Chlamydia/ Gonorrhea, >35 years get Ciprofloxacin to cover E. Coli)

Answer 177

Ureteropelvic junction (UPJ) obstruction These patients already have some narrowing at the UPJ, but doesn’t cause a problem with normal peeing. Only causes a problem when they are peeing excessively (like after drinking), so that’s when it’s discovered. (*Same concept as angina doesn’t cause chest pain at rest, but does when exercising due to increased demand on the heart)

Answer 178

Platinum-based chemotherapy + radiation

Answer 179

Still have nocturnal erections—> psychogenic Sudden loss of erections—> trauma Gradual loss of erections (could get receptions but didn’t last long-> poor quality erections-> no erections)—> arteriosclerosis, DM, etc.

Answer 180

Steroid boluses

Answer 181

Cricothyroidotomy

Answer 182

Empty the pericardial sac (pericardiocentesis, pericardial window, tube, or open thoracotomy) This is pericardial tamponade (hypotension, distended neck veins, distant heart sounds)

Answer 183

Fracture of the base of the skull-> CSF leak *image the neck (CT) and take to neurosurgery

Answer 184

Arteriogram (X-ray w/ contrast to view vessels) -your main concern is the carotid artery for upper neck injuries

Answer 185

Reassure the parents he has a hyperactive cremasteric muscle (the muscle in the scrotal sac around the testes that moves the testes)

Answer 186

Exploratory laparotomy

Answer 187

Malignant tumor of the liver Measure alpha fetoprotein (AFP) *neuroblastoma of adrenal gland and Wilma tumor of kidney are NON-movable abdominal masses in kiddos

Answer 188

Core biopsy | FNA wouldn’t give you a big enough sample

Answer 189

Put her in the shower for at least 30 min before bringing her to the ED (Irrigate!)

Answer 190

1-2 mL/kg/hr

Answer 191

``` Genu Varum (bow legs)- normal until age 3 Genu Valgus (knock knees)- normal between ages 4-8 ```

Answer 192

Bone cancer (most likely metastatic osteolytic cancer, like from breast cancer) *this is a pathologic fracture- arm should not break from holding a bag of groceries! Most likely cancer. Although osteoporosis also means easy breaks, these folks usually fall (something a little more severe than just holding groceries) to get their fractures.

Answer 193

Internally rotated hip—> dislocated Externally rotated hip—> fractured

Answer 194

Dupuytren contracture (Fascia under skin is thick/ tight, pulls on hand so you can’t fully extend the fingers. More common in Norwegian ancestry. Steroids or collagenase injections may help.)

Answer 195

Diabetic neuropathy-> ulcer develops on pressure point-> fails to heal due to small vessel disease

Answer 196

1. Ascites 2. Encephalopathy 1. Albumin 2. INR 3. Bilirubin

Answer 197

ARDS (Acute Respiratory Distress Syndrome) * ARDS is not always a “white out” of the lung—often shows up as BILATERAL patchy pulmonary infiltrates with sudden increase in oxygen requirements * NOT pneumonia (he’s young so unlikely, only bad pneumonia will be bilateral, he has no other PNA symptoms, and ARDS is more likely following trauma)

Answer 198

This is wound dehiscence (leaking peritoneal fluid, even though wound looks intact). Tape and bind the wound securely and plan on surgical reclosure (otherwise can progress to evisceration, where skin opens up and the GI tract literally comes out of the skin at surgical site).

Answer 199

Left-sided (*vs. right-sided colon CA is more likely to involve anemia. The lumen is larger on the right, so less likely to cause obstruction-> thin stools)

Answer 200

Nothing- they may heal on their own within this age group.

Answer 201

Do an MRI- concerned about metastasis of breast cancer to vertebrae *persistent headache or back pain in a woman with breast cancer suggests metastasis (MRI is diagnostic)

Answer 202

Measure serum gastrin (non-responsive gastric ulcers are suspicious for ZE syndrome/ gastrinoma!) *Tumor in duodenum or pancreas-> too much gastric acid-> ulcers + inactivation of pancreatic enzymes-> malabsorptive, watery diarrhea

Answer 203

1. Duodenal atresia 2. Intestinal atresia 3. Annular pancreas 4. Malrotation * Duodenal atresia- failure to recannalize-> duodenum closes off (“double bubble” sign) * Intestinal atresia- vascular accident in utero/ disruption of SMA-> ischemic necrosis of fetal intestine-> bowel spirals up/ is narrowed/ blocked anywhere in intestine (“apple peel”, dilated loops of small bowel with air-fluid levels on X-ray) * Annular pancreas- abnormal rotations of ventral pancreatic bud-> pancreas encircles around duodenum * Malrotation- problem with midgut rotation during fetal development-> small intestine is positioned wrong/ clumped up on right side-> fibrous Ladd bands form and press on duodenum (can lead to Volvulus where intestine twists on itself)

Answer 204

Duodenal atresia- failure to recannalize-> duodenum closes off (“double bubble” sign)

Answer 205

Intestinal atresia- vascular accident in utero/ disruption of SMA-> ischemic necrosis of fetal intestine-> bowel spirals up/ is narrowed/ blocked anywhere in intestine (“apple peel”, dilated loops of small bowel with air-fluid levels on X-ray)

Answer 206

Annular pancreas- abnormal rotations of ventral pancreatic bud-> pancreas encircles around duodenum

Answer 207

Malrotation- problem with midgut rotation during fetal development-> small intestine is positioned wrong/ clumped up on right side-> fibrous Ladd bands form and press on duodenum (can lead to Volvulus where intestine twists on itself)

Answer 208

Shaken baby syndrome (call CPS)

Answer 209

Indomethacin (an NSAID) *Prostaglandins E1 and E2 kEEp the PDA open. NSAIDs close it.

Answer 210

Chronic constrictive pericarditis

Answer 211

Rupturing AAA (abdominal aortic aneurysm)

Answer 212

Metastatic melanoma *Note that the most common heart tumor is metastasis (from melanoma). Primary cardiac tumors are: myoxoma (LA tumor in adults, presents with syncope) and rhabdomyoma (in kids, associated with Tuberous Sclerosis)

Answer 213

Retinal detachment

Answer 214

Nasal foreign body (ex: he stuffed a lego up his nose)

Answer 215

Inner ear pathology

Answer 216

Brain cancer (morning headaches, weakness, speech difficulty, blurred vision, diplopia) Cushing’s reflex (tumor presses on brain-> inc ICP-> dec cerebral blood flow-> body responsds to this by increasing BP to try to get more blood to the brain-> reflex Brady)

Answer 217

Brain abscess | Do a CT scan of the head

Answer 218

Posterior urethral valves | Redundant tissue in the urethra obstructing urinary flow

Answer 219

Extracorporeal shock wave lithotripsy (ESWL) (Like an x-ray machine that shoots beams at you to break up the stone and help it pass) * it is >3mm, so unlikely to pass on its own * other options: endoscopic retrograde basket extraction, endoscopic retrograde laser vaporization of the stone, and open surgical removal (but these are not preferred over ESWL unless patient is pregnant or has a stone so big it’s in the centimeters and needs surgery, etc.)

Answer 220

Drain the blood (to prevent development of empyema)

Answer 221

Left diaphragmatic rupture *air-fluid levels in chest are consistent with bowel going up in chest through diaphragm hole

Answer 222

Provide temporary bowl coverage with an absorbable mesh (until swelling goes down and he can be closed up...this is abdominal compartment syndrome)

Answer 223

Retrograde cystogram including post-void films (shoot contrast/ dye up the urethra and take a picture after the patient urinates—should see most the dye come out, helps you evaluate damage to urethra and bladder) * it’s called “retrograde” cystogram bc the dye is injected up the urethra (opposite direction of pee going out the urethra) * *cystoscopy is a camera put up the bladder- don’t go sticking cameras up people’s bladders (invasive) until you have a better idea of what’s going on * *ultrasound of bladder may be helpful for showing fluid in pouch of Douglas, for example, but a cystogram is the best test here to track the fluid, see if it’s coming out of the bladder into the pelvis

Answer 224

Surgical exploration and repair *surgery is required if there is obvious vascular injury (absent pulses and/ or expanding hematoma)!

Answer 225

Provoked dog bites (ex: little girl pulls on dog’s tail so dog bites)—> no rabies ppx indicated (but monitor the dog for signs of rabies) *if bite is on the face, may consider starting rabies immunization (due to close proximity to brain) and discontinuing if dog shows no signs of having rabies Unprovoked dog bites or wild animal bites—> kill animal and examine brain for rabies. If animal is not available, do rabies ppx (Ig + vaccine)!

Answer 226

Slipped capital femoral epiphysis -Ortho emergency (usually in a chubby pre-teen). X-ray to diagnose. Surgery to treat and pin femoral head back in place.

Answer 227

Seizure or lightening strike (severe trauma)

Answer 228

Open reduction and internal fixation *Displaced (not aligned) fractures will often require surgery in adults (not kids- they have more flexible bones and surgery is usually indicated just when growth plate is involved). Also, note this guy is old and has a severe fracture (both malleoli- lateral and medial- broken, so he broke his ankle all the way across).

Answer 229

The neck (need to assess cervical spine)

Answer 230

MRI centered on L4-S1 (this is likely lumbar disc herniation!) *do pain control with nerve blocks

Answer 231

``` Morton neuroma (inflammation of colon digital nerve from dumb pointy shoes) ```

Answer 232

Treat his CHF! JVD is the single worst cardiac risk factor in surgery. Get the CHF under control, then go on with surgery.

Answer 233

Get a CT angiogram (spiral CT) and start on heparin This is a PE! *note: low CO2 is due to hyperventilation (blowing off CO2) associated with PE

Answer 234

The catheter is plugged or kinked

Answer 235

D5 1/2NS (5% Dextrose in half Normal Saline) *this is a hypOtonic solution and will bring down Na+ levels at an appropriate slow rate

Answer 236

Laparoscopic Nissan fundoplication (surgery where the upper stomach is pulled and wrapped around the esophagus to form a tight “sphincter” in place of the loose LES) *do this GERD surgery if patient has ulceration, stenosis, or dysplasic changes

Answer 237

Get him into surgery! Incarcerated hernia (can’t push bk in place, opposite of reducible) + fever and high WBCs= strangulation. Surgery is needed since blood supply is being cut off to the bowel!

Answer 238

Anal fissure *Believed to be due to a tight sphincter. Exam may need to be done under anesthesia. Initial therapy options include stool softeners, topical Nitroglycerin or Diltiazem ointment(CCB) (vasodilate to promote blood flow and healing to the area), local Botulinum toxin injection (relax sphincter).

Answer 239

Radioactively labeled technetium scan *anytime you see blood per rectum in a kid—> think Meckel diverticulum!!

Answer 240

Mesenteric ischemia (Clot thrown to SMA) *The acidosis is lactic acidosis due to sepsis/ end-organ damage (organ is not being perfused well, so doesn’t have the oxygen from blood to carry out aerobic respiratory...must do anaerobic with lactic acid byproduct)

Answer 241

Pancreatic abscess - fever and WBC count about 10 days after pancreatitis (a complication of it) * IR (interventional radiology) will drain it

Answer 242

Cystosarcoma phyllodes tumor of the breast * seen in late 20’s * large, grow over many years (“leaf-like” outgrowths) * most are benign, but have malignant potential so must remove them

Answer 243

- seen in 30s-40s - multiple lumps/ cysts that come and go with menstrual cycles - diffuse

Answer 244

Radiologically guided core biopsy *Don’t just do a mammogram—do a diagnostic mammogram with biopsy. Always biopsy a breast mass! Cannot assume the trauma caused fat necrosis of the breast, the end.

Answer 245

Extracorporeal membrane oxygenation (ECMO) (Like a heart-lung bypass machine used in open heart surgery. Uses a pump to circulate blood through an artificial lung back into the bloodstream.)

Answer 246

Surgery This is necrotizing enterocolitis (premature baby with immature immune system-> necrosis of intestinal mucosa) * We initially treat with NPO, antibiotics, IV fluids, IV nutrition * If baby develops abdominal wall erythema, air in portal vein, intestinal pneumatosis (gas in bowel wall), or pneumoperitoneum (intestinal necrosis and perforation), must do surgery!!

Answer 247

CT head to look for intracranial bleeding to suggest subarachnoid hemorrhage (usually due to ruptured berry aneurysm and presents as thunderclap headache/ “worst headache of my life”)

Answer 248

Brain tumor at the base of the frontal lobe (Foster-Kennedy syndrome)

Answer 249

Renal Cell Carcinoma (RCC) *note: high LFTs may be due to metastasis to liver

Answer 250

Triple antibiotic ointment *Silver sulfadiazine is a topical antibiotic to prevent infection. But triple antibiotic ointment is used instead for burns near the eyes, as silver is irritating to the eyes.

Answer 251

Cystoscopy (camera up bladder) *This is suspicious for bladder cancer

Answer 252

Order IV antibiotics for the patient, keep them hospitalized and place nephrostomy tube to drain (this is pyelonephritis aka kidney infection)

Answer 253

Venous statis ulcer *do Duplex scan of patients veins, advise use of compression stockings

Answer 254

Post-op water intoxication Stress/ pain from surgery-> ADH release-> too much water retention-> dilutes the concentration of Na+-> hypoNa+

Answer 255

Ogilvie syndrome Treat with colonoscopy and placement of rectal tube (drain the feces so they don’t keep building up and result in eventual perforation of colon) -A poorly understood paralytic ileus of the colon, often seen in elderly sedentary patients (dementia, in nursing home) who have become further immobilized (fracture). It is a psuedo-obstruction where nothing is mechanically blocking the colon, but it is “frozen.”

Answer 256

1. Ankle-brachial index (comparison of BP is upper vs. lower extremities) 2. Doppler studies (ultrasound that measures the velocity of blood flow) 3. CT angio (provides more info/ better picture of the stenosis going on in the vessels)

Answer 257

Hepatic adenoma - Benign liver tumor that is rare, but linked to OCP use - Do a CT to confirm - Treat with emergency surgery (goal is to remove prior to rupture, which can lead to massive intraabdominal bleed *sounds like that’s what this girl has)

Answer 258

Coarctation of the aorta CT angio

Answer 259

Ependymoma (Cancer of ependymal cells, which line the ventricles of the brain-> hydrocephalus) *Knee-chest position opens up flow of CSF, relieving their headache

Answer 260

Transfusion-related acute lung injury (TRALI) Stop the transfusion and do respiratory supportive care -Rare, but potentially fatal transfusion reaction where neutrophils get activated by the transfused blood and and damage pulmonary microvasculature-> inflammatory pulmonary edema (The donor blood has anti-leukocyte antibodies against recipient neutrophils and pulmonary endothelial cells, which causes damage. Basically, the donor blood has antibodies in it that attacks pulmonary cells and leads to an ARDS picture.) * Presents as respiratory distress, hypotension, and pulmonary infiltrates during blood transfusion * Risk factors: smoking, alcohol, critical illness

Answer 261

Testicular examination and if there is a mass-> scrotal ultrasound This is likely testicular cancer that metastasized to the lungs *retroperitoneal lymph nodes (up at the aorta, near where it bifurcates—testes descend from there in embryo) are often affected—> compression of nearby structures (nerve roots, psoas muscle)—> dull back pain

Answer 262

Flail chest Multiple rib fractures (>3 in >2 locations)-> piece gets sucked in on inhalation and protrudes out on exhalation, so this flail segment moves paradoxically (opposite) to the rest of the rib cage when breathing * How do this mess up respiration? 1) Impairs negative intrathoracic pressure during inspiration and increased dead space during expiration-> ineffective ventilation 2) Can cause pulmonary contusion (bruising/ ruptured capillaries)-> alveolar hemorrhage and edema-> impaired oxygen diffusion/ gas exchange 3) Pain from fractures-> shallow breathing-> atelectasis

Answer 263

Drop it Myocardial contusion (heart took a blow and it bruised)-> myocardial dysfunction and cardiogenic shock-> hypotension from forward heart failure

Answer 264

Crystalloid- LR and NS (lactated ringers and normal saline) Colloid- blood and albumin

Answer 265

Pelvic fracture *Hemorrhagic shock is the most common shock in trauma. Pelvic bleeds can hide int eh retroperitoneum.

Answer 266

Hemorrhage shock Mnemonic to survey areas where large blood loss can occur in trauma: “Blood on the floor and 4 more” - External bleeding (“on the floor”) - Internal bleeding (“4 more”): 1. Chest 2. Abdomen 3. Pelvis 4. Thigh

Answer 267

Aspiration pneumonitis (Acute lung injury due to aspiration of acidic stomach contents-> inflammatory reaction in lungs) - witnessed aspiration event (vomiting during intubation)-> hypoxemia and bilateral lung infiltrates in hrs * resolves in a day or two with supportive care **NOT the same as aspiration pneumonia—occurs in people with impaired consciousness (alcoholic, epileptic, dementia pt) that inhale oropharyngeal secretions-> fever + cough days (not hrs) later, treat with CAP antibiotics

Answer 268

Wells score >4 means PE is likely * May start on empiric anticoagulation (if in moderate-severe distress and have no contraindications) before diagnostic test * Do CT angio to diagnose

Answer 269

Ischemic colitis - Impaired blood flow to bowel (usually IMA and seen in old ppl with pre-existing atherosclerotic vascular dz) - Abdominal pain and bloody diarrhea following a vascular procedure - CT: thickening of bowel wall. Colonoscopy: cyanotic mucosa and hemorrhagic ulcers

Answer 270

Acute mesenteric ischemia - Often due to cardiac embolic events (thrown clot in the setting of a-fib, valvular dz, or cardiovascular aneurysms) - Sudden periumbilical pain out of proportion to exam findings - Do CT angio - Start on broad-spectrum antibiotics * Bicarb is low= metabolic acidosis (from end-organ/ bowel damage-> lactic acidosis)

Answer 271

Zinc deficiency

Answer 272

Get an EKG, cardiac markers, and CXR - He has a hip fracture (painful, shortened and externally rotated), so you need to correct with surgery - But FIRST you need to evaluate if surgery is safe for him...palpitations could be due to a-fib, decreased breath sounds on the right could be due to pleural effusion, crackles on the left with SOB and cough could be due to pulmonary edema or pneumonia...you need to order some heart/ lung tests to determine pre-op risk!

Answer 273

Get a bladder ultrasound -Acute urinary retention (post-op urinary retention is a thing—anesthesia and opioids can cause nerves to the bladder to “freeze up”) -Elderly, agitated, suprapubic tenderness (plus has BPH already) -Foley catheter insertion is diagnostic and therapeutic

Answer 274

Squamous cell carcinoma (SCC) -specifically, it is a Marjolin ulcer- SCC arising within a burn wound (dirty looking ulcer with heaped edges that has broken down and healed many times over the years) * SCC is associated with UV exposure and also chronically wounded/ scarred/ inflamed skin * *SCC arising in chronic wounds tends to be more aggressive, so early intervention is key

Answer 275

Spinal cord infarction/ ischemia - This is a devastating complication of thoracic aortic aneurysm (TAA) repair (happens in 5-15% of TAA repairs) where blood flow to the spinal cord (segmental arteries-> anterior spinal arteries, ASA) is disrupted—> anterior cord syndrome. - Loss of motor + pain/ temp on both sides below the site of the injury

Answer 276

Oropharyngeal squamous cell carcinoma (SCC) A tonsil ulcer in a smoker is likely due to SCC! * Tobacco use is a huge risk factor! (Along with alcohol and immunocompromised status) * *HPV is the cause in non-smoking patients

Answer 277

Painful swallowing

Answer 278

Chronic bacterial prostatitis -recurrent UTI symptoms, pain with ejaculation, and bacteriuria (Usually in young or middle-aged guys who smokes or has DM, caused by E.Coli) *NOT chronic urethritis (this is usually caused by an STD organism and causes urethral discharge)

Answer 279

MCL (medial collateral ligament) tear * with aBduction (pulling leg lateral) you are putting stress on the MCL (medial) * an MRI is the most sensitive test, but reserved for patients being considered for surgery (serious athletes)—uncomplicated MLC tears can be managed with RICE (rest, ice, compression, elevation) and no surgery

Answer 280

Atelectasis (collapsed alveoli due to impaired cough and shallow breathing from pain) - PO2 65 is low-> hypoxia - PCO2 35 is low-> hyperventilation (the hypoxia stimulates rapid breathing...but it is shallow causing atelectasis) *incentive spirometry to prevent this!

Answer 281

Surgical resection This is a meningioma (benign primary brain tumor of meningothelial cells, seen most often in women). If large enough to cause mass effect-> neuro symptoms such as headache, seizure, focal weakness/ numbness. *described as well-circumscribed, dural-based, calcified

Answer 282

Central cord syndrome - Often caused by hyperextension injury (head forced back from expanded airbag) in patients with preexisting cervical spine degenerative changes (cervical spondylosis) - Loss of pain/ temp in upper extremities in “cape-like” distribution (path where STT crosses is affected) - If large lesion, can also cause weakness in upper extremities (CST affected)

Answer 283

Get a comprehensive dietary history -BMI <18.5, distress over not running, and stress fracture are suggestive of Anorexia nervosa (Anorexic patients are at higher risk for fractures due to decreased bone mineral density) *initial management for stress fractures include rest, pain meds, stabilization with splint or brace if needed- not surgery (reserved for severe/ not healing fractures or severe pain despite conservative treatment)

Answer 284

An infected hair follicle with abscess

Answer 285

Neurofibromatosis type II | Includes bilateral vestibular Schwannomas. Congenital cataracts are another finding.

Answer 286

``` Pituitary apoplexy (Hemorrhage into the sella turcica due to a large pituitary adenoma pressing on blood supply) ``` - She had a pituitary adenoma (prolactioma), now presenting with headache, ptosis, vision changes. - Why shock (super low BP)? There is usually loss of ALL pituitary function. Loss of ACTH is most critical-> adrenal crisis (acute adrenal insufficiency). No cortisol to maintain vascular tone-> severe hypotension and distributive shock. * *hypoglycemia can also occur from lack of cortisol (which normally raises blood glucose by causing insulin resistance)

Answer 287

Get a renal ultrasound with Doppler -severe HTN + flash pulmonary edema in the setting of atherosclerosis suggests RENAL ARTERY STENOSIS * stenosed renal arteries-> lack of blood to kidneys-> activation of RAAS-> inc BP * *backing up of fluid to lungs, esp given he has diastolic HF and CO is decreased

Answer 288

FEV1 *FEV1 (amount of air you can breathe out forcefully in 1 min) and DCLO (diffusion capacity of the lung for carbon monoxide) are the best predictors of post-op outcomes following lung resection surgery

Answer 289

Endotracheal intubation Secure that airway before edema closes it up!

Answer 290

Acalculous cholecystitis (Acute inflammation of the gallbladder w/o gallstones) - seen in critically ill patients and patients with surgery (cardiopulmonary, aortic, abdominal), trauma, burns, sepsis, shock, etc. - presents as unexplained fever + leukocytosis + RUQ pain

Answer 291

Blunt cardiac injury - Hypotensive + tachy= shock - Bruises over anterior chest - HIGH central venous pressure (CVP)= high preload (consistent with cardiogenic or obstructive shock) (**low CVP/ preload would indicate hypovolemic or distributive shock) - When you give him fluid-> CVP/ preload goes up more/ does not improve

Answer 292

CT angio (to look at the subclavian artery, which runs under the clavicle in the thoracic outlet) Clavicle fractures are common in athletes who fall on their shoulder or outstretched hand. - Absent distal pulses or bruit at injury site—> immediate surgery. - Stable hematoma (as in this patient), reduced pulse, hemorrhage at time of injury, or neuro deficit (brachial plexus affected)—> vascular imaging (CTA) to further evaluate the injury. - None of above-> conservative (rest, ice, sling or figure 8 bandage only)

Answer 293

Splenic abscess - Fever + tender splenomegaly - Rare, potentially life-threatening complication of bacteremia from a distant infection (infective endocarditis, cholecystitis) * Diagnose with CT abdomen * Give antibiotics and do splenectomy

Answer 294

Acute cholecystitis -She has RUQ pain, fever, leukocytosis (*left shift= there’s an infection so the bone marrow is working in overdrive to produce more WBCs, so releases them into the blood before they are fully mature) (Remember Charcots triad: RUQ pain, jaundice, fever)

Answer 295

“Left shift" means there’s a lot of young, immature WBCs (suggests infection/ inflammation) -Infection/ inflammation-> bone marrow works in overdrive to produce more WBCs, so releases some into the blood early before they are fully mature

Answer 296

A gallstone lodging in the cystic duct | This is the first event that gives way to E.Coli ascending and causing inflammation and infection in the gallbladder

Answer 297

Otosclerosis (Abnormal growth of stapes/ middle ear bone due to imbalance of bone resorption-> stiffening and fixation that impairs transmission of sound from the tympanic membrane to the cochlea) - conductive hearing loss in a young woman (due to fixation of stapes) * may worsen in pregnancy

Answer 298

Conductive hearing loss Weber’s: louder on affected side (right)—> conductive (bc the conductive obstruction in the ear canal blocks out outside sound) Rinne’s: bone conduction > air conduction—> conductive

Answer 299

Osteomyelitis (get a X-ray or MRI even if no pain)

Answer 300

Bloody discharge

Answer 301

Urethral injury-> retrograde urethrogram *almost always in men, presents with blood at urethral meatus, scrotal hematoma, high-riding prostate Bladder injury-> retrograde cystogram w/ post-void films Renal injury-> CT abdomen *often due to rib fractures since the kidneys sit right below the ribs

Answer 302

IV hypertonic (3%) saline -She has SEVERE (<120) hypOnatremia and symptomatic (she is having mild symptoms, which include headache and confusion *severe symptoms would be seizure, coma, and respiratory arrest from the cerebral edema), so you give hypertonic saline (this is the only indication for it) * How did she get hypOnatremia? Likely due to hypOtonic IV fluids (0.45% saline) + SIADH (common for excess ADH to be released post-surgery due to stress/ pain)-> more water retention-> dec [Na+] * *It is acute (<48 hrs), so rapidly correct (brain hasn’t adapted to this new baseline so low risk fo osmotic demyelination syndrome) to prevent brain herniation from the rapid brain swelling!

Answer 303

Give a bolus of isotonic saline (0.9% NS) (for volume resuscitation) -His oliguria (low urinary output) is likely due to pre-renal AKI 2/2 Intravascular volume depletion Intraoperative blood loos-> decreased perfusion to kidneys-> pre-renal AKI *BUN/Cr ratio= 80/2= 40. This is high (>20:1), which is consistent with pre-renal AKI (slowed blood flow-> BUN has more time to get reabsorbed at the PCT).

Answer 304

Low urinary output | <500 mL of urine over 24 hrs

Answer 305

Alcoholism Sialadenosis= benign, non-inflammatory swelling of the salivary glands (seen in alcoholism, bulimia, and malnutrition)

Answer 306

(Benign salivary neoplasm) | Painless UNILATERAL enlargement of the parotid gland (usually a distinct mass is palpated)

Answer 307

Renal artery stenosis | Secondary cause of HTN

Answer 308

Abdominal CT This is likely pancreatic adenocarcinoma (cancer at head of the pancreas-> obstructive jaundice explaining the dilated bile ducts, high T. Bili, alk phos, ALT, AST)

Answer 309

Start heparin infusion (and core measures) -This presentation is consistent with unstable angina or NSTEMI (if the troponin level is elevated over 6-12 hrs when you trend it) - Give antiplatelet agents (ASA, clopidogrel) and anticoagulation (heparin) to prevent additional plaque thrombosis - Give beta-blockers to decrease myocardial oxygen demand and arrhythmia risk - Give nitrates to reduce myocardial oxygen demand and relieve ischemic pain - Give statins to stabilize plaques

Answer 310

Splenic abscess -Rare, potentially life-threatening complication of bacteremia from a distant infection (including cholecystitis) * diagnose with CT abdomen * treat with antibiotics + splenectomy (aspiration usually doesn’t cut it)

Answer 311

Open-angle glaucoma Glucocorticoids (his eye drops for uveitis) cause lens swelling-> impaired aqueous humor outflow * Diagnose with tonometry (measuring IOP) * Leads to loss of peripheral vision

Answer 312

CT abdomen and pelvis w/o contrast - This is a retroperitoneal hematoma (femoral artery puncture where they went in for the cath procedure-> bleeding into retroperitoneal space) * treatment is usually supportive with bed rest, IV fluids, and/or blood transfusion

Answer 313

Yes *can think of it as your body is trying to clot in a dissection (tear in aortic intima-> bleeding into aortic wall) and D-dimer is a fibrin split product from clotting

Answer 314

Renal vein thrombosis - due to hypercoagulable state (cancer, trauma, nephrotic syndrome) * confirm diagnosis with CT or MR angiography or renal venography

Answer 315

Plantar fasciitis - inflammation of the plantar aponeurosis (thick band of tissue that connects the calcaneus/ heel bone to the toes and supports the arch of the foot) * initial management includes activity modification (avoid going barefoot), stretching exercises, padded heel inserts

Answer 316

Hypoaldosteronism (Acute adrenal insufficiency/ adrenal crisis) - primary adrenal insufficiency-> autoimmune destruction of all 3 layers of the adrenal cortex (deficiency of aldosterone, cortisol, and androgens) - hypOnatremia (due to low aldosterone) - hypoglycemia (due to low cortisol) - eosinophilia (glucocorticoids normally decrease eosinophils) - acutely stressful events (endoscopy, surgery, injury, infection) in patients with chronic adrenal insufficiency can precipitate adrenal crisis-> severe hypotension and shock *treat with rapid volume depletion and hydrocortisone or dexamethasone

Answer 317

Esophageal perforation - He likely was drinking at the party (alcoholic) and repeatedly vomiting-> Boerhaave syndrome * GI contents leak into mediastinum-> widened mediastinum and/or into the pleural space-> pleural effusion * systemic inflammatory response to the GI contents-> fever + tachycardia (can progress to septic shock and death) *high amylase in pleural fluid means (1) esophageal rupture, (2) pancreatitis, or (3) malignancy Why isn’t this pancreatitis (also can cause unilateral high amylase pleural effusion)? Would NOT cause chest pain (would cause epigastric pain radiating to the back) or wide mediastinum

Answer 318

1. Primary survey= ABCs (Airway, Breathing, Circulation) | 2. Imaging following primary survey= portable chest and pelvic x-rays, FAST exam, and cervical spine imaging (CT)

Answer 319

CT of the cervical spine *do this for patients with high-energy mechanisms of injury (like car crash victims) and patients with neuro deficit, spinal tenderness, altered mental status, intoxication, or distracting injury

Answer 320

IV 0.9% NaCl (normal saline) - developed pneumonia (post-op fever and SOB)-> septic shock * low pH and low CO2= metabolic acidosis, likely due to lactic acidosis in the setting of septic shock * give aggressive IV fluids (NS or LR) prior to giving vasopressor to restore adequate tissue perfusion

Answer 321

MAJOR: 1. Positive blood cultures (bacteremia with staph a, strep viridans, or enterococcus) 2. Echo showing valvular vegetations MINOR: 1. Predisposing condition (already have an abnormal valve or IV drug user) 2. Fever (>100.4) 3. Embolic phenomenon (septic arterial or pulmonary emboli, intracranial hemorrhage, Janeway lesions) 4. Immunologic phenomenon (glomerulonephritis, Osler nodes, Roth spots, rheumatoid factor) 5. Positive culture not meeting major criteria * 2 MAJOR or 1 MAJOR + 3 MINOR= for sure endocarditis * 1 MAJOR + 1 MINOR or 3 MINOR= possible endocarditis

Answer 322

Staph aureus

Answer 323

Tension pneumothorax - trauma-> air comes in-> collapses the lung - air pushes trachea to opposite side (right pneumothorax, so trachea deviated to left) * percussion would be hyperresonant (trapped air) and fremitus decreased (collapsed lung= no air= no vibration) * you would place a right-sided chest tube to allow the air to escape and lung to re-expand

Answer 324

Bronchoscopy (Camera down bronchi of lungs) - chest tube with persistent large air leak suggests tracheobronchial injury (from his thoracic trauma) - get a bronchoscopy to confirm before surgical repair

Answer 325

Perilymphatic fistula - Rare and debilitating complication of head trauma - Leakage of endolymph from semicircular canals and cochlea into surrounding tissues-> progressive sensorineural hearing loss (damage to cochlear hair cells from loss of endolymph) and episodes of vertigo with nystagmus (triggered by pressure changes like Valsalva/ bearing down or going up in elevation) *advise to limit activities that increase inner ear pressure and refer to ENT for further management **NOT Ménière’s disease- this also presents with episodes of vertigo and hearing loss, but episodes last 20 min- 24 hrs and lack specific triggers

Answer 326

Get a serum gastrin concentration to check for gastrinoma/ ZE syndrome (gastrin 110-1,000) *make sure pt has been off PPI therapy for 1 wk when measuring (bc PPIs block acid-> inc gastrin release by neg fdbk) - duodenum or pancreatic tumor-> too much gastrin-> too much release of acid-> ulcers * can occur as part of MEN 1 (“pans of pitted pears”= pancreatic, pituitary, and parathyroid tumors)

Answer 327

Bladder cancer * although it can present as painless hematuria, bladder cancer can also cause voiding symptoms (due to invasion in the bladder, reducing bladder volume or causing detrusor muscle over activity) * hematuria (can be gross throughout stream or microscopic) is due to friable blood vessels that feed the tumor * suprapubic pain can occur in advanced tumors that penetrate the muscle and invade surrounding soft tissue/ nerves **consider this bc of smoking hx + ruled out UTI (no bacteria, leuk est, or nitrites in urine)! Do cystoscopy.

Answer 328

Acute graft-vs-host disease (Donor cells attack body cells) -T-cell (particularly CD8+ cytotoxic) immune-mediated condition that affects up to 50% of patients who undergo bone marrow transplantation (T-cells recognize foreign antigen and mount immune response) -symptoms: maculopapular rash, jaundice, diarrhea, hepatosplenomegaly (this patient has rash + profuse watery diarrhea)

Answer 329

Swallow study with contrast esophagography (To diagnose Zenker diverticulum) *recurrent aspiration PNA is common in these patients

Answer 330

Carpal tunnel syndrome - compression of the median nerve as it passes through the carpal tunnel * this is the most common mononeuropathy in ESDR patients on dialysis due to dialysis-related amyloidosis (beta-2 microglobulin deposited in carpel tunnel) **NOT subclavian steal syndrome, as this would affect the entire arm, not just lateral hands

Answer 331

Symptomatic treatment only (Tylenol) and close observation - immediate post-op fever within hrs of surgery is due to cytokine release in response to tissue trauma, blood cell lysis (mismatched blood products), or bacterial toxins (drug reactions) * acute (1-7 days post-op) and subacute (7-28 days post-op) fever is usually due to infections

Answer 332

The cancer came back (recurrence of thyroid malignancy) - remember that thyroglobulin (Tg) is a precursor to TH (T3, T4) - patients who got their thyroid gland taken out should not have residual thyroid tissue, so elevated Tg means recurrent differentiated thyroid cancer (we use it as a tumor marker)

Answer 333

``` Incisional hernia (Occurs due to breakdown of prior fascial closure) ``` *most common in patients who are obese (increased intraabdominal pressure) and prior vertical or midline incision from surgery (increased tissue tension)

Answer 334

Testicular torsion Doppler ultrasound of the scrotum (*usually a clinical dx, but U/S can confirm it) -expect to see reduced/ absent blood flow or twisting of the spermatic cord

Answer 335

Complicated parapneumonic effusion or empyema (Pleural effusion 2/2 bacterial PNA) -exudative with low glucose (<60), low pH (<7.2), and high protein * uncomplicated-> sterile fluid * complicated-> fluid infected w/ bacteria * empyema-> collection of pus in pleural space (abscess of the lungs) *loculated means fibrotic scar tissue forms within the pleural cavity (in complicated and empyema)

Answer 336

Urinary catheterization (and DC amitriptyline) - amitriptyline-induced urinary retention (TCA w/ anticholinergic properties. Side effect of this is urinary retention “full as a flask” due to reduced detrusor muscle contractility and urethral sphincter relaxation.) * post-void urinary cath that shows >50 mL of urine is diagnostic of urinary retention and therapeutic

Answer 337

Refer for surgical mitral valve repair indications for mitral valve repair: - LVEF 30-60% * may also consider when: - LVEF <30% and symptomatic and surgery is likely to be successful - LVEF >60% and asymptomatic and surgery is likely to be successful in preventing the condition from worsening

Answer 338

CT scan of abdomen

Answer 339

Due to pancreatic beta-cell dysfunction

Answer 340

Fat necrosis of the breast (Benign condition associated with breast surgery/ reconstruction and trauma) Reassurance and normal routine follow-up

Answer 341

1. Urinalysis (to r/o UTI and glomerulonephritis and confirm hematuria) 2. Cystoscopy (camera up the bladder to visualize bladder wall and biopsy/ resect suspicious lesions) 3. CT abdomen (to visualize the kidney and look for metastasis)

Answer 342

Bladder cancer

Answer 343

NSAIDs (and continue moderate physical activity) - this is low back pain due to lumbar strain * symptoms usually resolve within a few wks

Answer 344

Postoperative atelectasis -abdominal pain following surgery-> shallow breathing bc it hurts (restricted chest expansion)-> low tidal volume w/ alveolar collapse * does not always come along with fever * causes hypoxemia (V/Q mismatch-> hyperventilation to compensate-> blow off more CO2, so ABG would show dec CO2= respiratory alkalosis)

Answer 345

HIGH A-a GRADIENT: 1. V/Q mismatch 2. Diffusion abnormality 3. Shunt (*does not correct with 100% O2) NORMAL A-a GRADIENT: 4. High altitude 5. Hypoventilation

Answer 346

Rotator cuff (supraspinatus) tear * diagnose with MRI * treat with surgery

Answer 347

(Acute) Cardiac tamponade - blunt cardiac injury from the crash-> blood rapidly accumulates in the pericardial sac, restricting filling of the heart-> hypotension, elevated JVP, muffled heart sounds (*Beck’s triad, though muffled heart sounds are seen in few patients) * CXR with globular cardiac silhouette= subacute cardiac tamponade (a slower process due to malignancy, renal failure, etc. where the heart has time to adapt by stretching out) vs. normal cardiac silhouette in this patient

Answer 348

Avascular necrosis (Osteonecrosis of the proximal left femoral head) * occlusion of end arteries supplying the femoral head-> necrosis of periarticular bone (bone around the joint) and cartilage * common in sickle cell patients due to disruption of microcirculation in the bone * seen in adults, rarely kids, due to reduced blood supply (kids have an extra artery- the fovea artery- supplying this area, but it obliterates later in life) * presentation: hip pain + reduced range of motion + normal x-rays

Answer 349

Exploratory laparotomy

Answer 350

Yes—they can be Due to increased scrotal temperatures (pooling of venous blood in testes creates heat, which is less than optimal for sperm production and motility)

Answer 351

Varicocele - soft scrotal mass (“bag of worms”) due to varicose veins of the testes - increases with standing and decreases with laying down (due to gravity) - the pooling of blood in the veins creates heat, which is less than optimal for sperm production and motility * men who don’t desire fertility-> conservative treatment with NSAIDs + scrotal support * men who desire fertility-> surgical venous ligation or embolization

Answer 352

Febrile nonhemolytic transfusion reaction - occurs in minutes to hours (usually 1-6 hrs) - cytokines in the stored donor blood make the person sick or preformed antibodies against WBC parts- but not attacking enough to cause hemolysis

Answer 353

Ulnar nerve

Answer 354

Pinky and ring finger-> ULNAR nerve Other 3 /12 digits, including thumb-> MEDIAN nerve

Answer 355

Contrast enema (barium or air enema) (*shows and un-inverts the intussusception)

Answer 356

Esophagoscopy (endoscopy) and biopsy -even though this sounds like achalasia, you need to r/o cancer (cancer can cause esophageal strictures)

Answer 357

Due to thrombocytopenia * remember: packed RBCs, platelets, and plasma should be transfused in a 1:1:1 ratio * he was given a bunch of RBCs, no platelets to aid in clotting, so he is bleeding out

Answer 358

Surgical exploration of the right femoral artery (Absent popliteal, posterior tibial, and dorsalis pedis pulses= all branch off the femoral artery) *in traumatic injuries, here’s your order of repair: bone-> vessels-> nerves (start with bone bc reduction may displace and damage vasculature)

Answer 359

Bone-> vessels-> nerves | *start with bone bc reduction may displace and damage vasculature

Answer 360

No | *even though CT scans are often ordered to confirm, it is a clinical dx

Answer 361

Pulmonary contusion

Answer 362

Bacterial overgrowth (SIBO) -poor movement of intestinal contents (decreased gastric acid and motility)-> allows certain intestinal bacteria to grow excessively

Answer 363

Tracheobronchial injury | like a ruptured bronchus

Answer 364

Strangulated inguinal hernia -presents as a painful hernia (mass) + fever + leukocytosis-> peritonitis and sepsis

Answer 365

Biliary atresia *most the bili is direct= conjugated (so not a conjugation issue) - destruction of extrahepatic biliary ducts (decreased bile flow) * no. 1 reason for pediatric liver transplantation

Answer 366

Pancreatic insufficiency (lack of pancreatic enzymes) in the setting of chronic pancreatitis * amylase/ lipase may be normal (in CHRONIC pancreatitis the pancreas is shot, so not a lot of amylase/ lipase for pancreatic cells to release) * ferritin is an acute phase protein, so elevated during inflammation * lack of AST, ALT elevation= non-cirrhotic liver, which r/o hemochromatosis

Answer 367

Sarcoidosis

Answer 368

Smoking cessation and graded exercise program

Answer 369

Renal cell carcinoma (RCC) - classic triad: (1) painless hematuria, (2) flank pain, (3) abdominal mass - PTHrP-> hypercalcemia and hypophosphatemia

Answer 370

Malignant hyperthermia * can occur up to 12 hrs after exposure to a causative drug (not just during surgery) * halothane or succinylcholine-> triggers massive release of calcium from defective RyR receptors on the SR-> tons of ATP gets generated to pump all that excess calcium that’s been released back into the SR (for muscle relaxation) and this generates heat

Answer 371

(Lateral) X-ray *MRI and CT (more sensitive and more expensive) can be used later as follow-up tests to a positive screen for cervical injury

Answer 372

When a surgeon opens up the skull

Answer 373

Acoustic neuroma (vestibular Schwannoma) * Rinne: air conduction > bone conduction= sensorineural hearing loss (Weber: sound would localize to good ear side) * can enlarge at the cerebellopontine angle-> impingement of CN 7 and 8

Answer 374

Insulinoma *increased c-peptide= endogenous source

Answer 375

Upper extremity DVT * young athletes are at risk due to hypertrophy of scalene/ subclavius muscles from weight lifting and damage to the axillosubclavian vein due to repetitive arm motions * congenital abnormalities (cervical rib) can also increase risk * presentation: swelling, heaviness, pain * diagnosis: Doppler or duplex U/S * treatment: thrombolysis and/or 3 mo of anticoagulation

Answer 376

Acute limb ischemia * Remember the 6 P’s: Pallor, Pain, Pulselessness, Paresthesias, Paralysis, Polar (cold) * Occlusion due to embolism (thrown clot) in the setting of a-fib (palpitations, irregular rhythm) or rupture of an atherosclerotic plaque in the setting of PAD (claudication) *Start anticoagulation with IV heparin!

Answer 377

Immediately start anticoagulation (IV heparin)! *other tests that may be helpful AFTER in the work-up: ankle-brachial index (ABI), echo (TTE), CT angio of lower extremities

Answer 378

Ventilator-associated PNA (VAP) - sub-type of hospital-associated PNA (HAP) that occurs >48 hrs after intubation - presents with: increased respiratory secretions, new pulmonary infiltrates, worsening oxygenation, signs of infection (fever/ leukocytosis/ tachycardia) * confirm diagnosis with sampling of the respiratory tract (noninvasive w/ endotracheal aspiration or invasive w/ bronchoalveolar lavage) * treat like HAP (broad-spectrum + psuedomonas + MRSA coverage)

Answer 379

Compartment syndrome - excessive swelling/ fluid accumulation in a compartment-> pressure build up to the point that blood flow is impaired (restriction of venous and lymphatic drainage) - pain out of proportion, tissue tension, ischemia-> necrosis

Answer 380

Polymicrobial (usually a mixture of gram (+): staph a., strep pyogenes and gram (-): pseudomonas)

Answer 381

Contiguous spread | The wound is touching the bone, so the infection is transmitted to this underneath layer

Answer 382

Congenital umbilical hernia Observation only *These hernias usually close spontaneously as the rectus abdominis muscles grow together and fasciae layers fuse. Defer surgery until age 5 if it persists (usually if it is large >1.5 cm).

Answer 383

Colonic ischemia (ischemic colitis) * hypovolemia-> ischemia most commonly at the splenic flexure= watershed area of the colon furthest away from the SMA * acute abdominal pain + GI bleed (why? Don’t know- maybe bowel necrosis damages surrounding capillaries) following hypotension. CT shows thickened bowel wall and colonoscopy confirms the diagnosis.

Answer 384

Spinal epidural abscess (due to direct inoculation with the epidural) -several days of fever + progressive neuro symptoms: focal back pain-> nerve root pain-> motor weakness, sensory changes, bowel/ bladder dysfunction-> paralysis * get an urgent MRI spine * treat with surgical decompression and antibiotics

Answer 385

DVT (deep vein thrombosis) due to recent surgery (provoked) Give unfractionated heparin followed by warfarin (for at least 3 mo.) *LMWH is not recommended in end-stage renal dz!

Answer 386

Prescribe amoxicillin/ clavulanate (Augmentin) -Cat bite protocol: Tetanus booster if last one was >5 year ago, avoid closure (nope...don’t go suturing it up), and prophylactic Augmentin (the majority of CAT bites will become infected with Pasteurella or anaerobes otherwise *cats worse than dogs)

Answer 387

Ascariasis (Ascaris lumbricoides) *a parasitic roundworm - from Indonesia - SBO (small bowel dilation w/ air-fluid levels) - eosinophils * may cause pulmonary or GI symptoms * complications: obstruction of small bowel or hepatobiliary tree * treat with albendazole

Answer 388

Sign of obstruction (SBO) - when the bowel is obstructed, it gets tired of pushing the stuff so the liquid (white) goes to the bottom and air (black) rises * SBO in the lungs-> think abscess

Answer 389

1. Leg shortened, adducted, and internally rotated—> POSTERIOR DISLOCATION (*More common than anterior dislocation! Usually in head-on collisions when knee strikes dashboard) 2. Leg shortened, aBducted, and internally rotated—> ANTERIOR DISLOCATION 3. Leg shortened and externally rotated—> FRACTURED (broken hip) **just remember: Dislocated-> internally rotated. Broken-> externally rotated.

Answer 390

Internally rotated *memory trick: "ID (like identification) and EF (like efff step 2)": for Internal rotation= Dislocation & External rotation= Fracture

Answer 391

Externally rotated *memory trick: "ID (like identification) and EF (like efff step 2)": Internally rotated= Dislocated, Externally rotated= Fractured

Answer 392

Posterior hip dislocation - head-on car crash (high-velocity trauma) - shortened and internally rotated hip - complication= sciatic nerve injury-> weakness of knee flexion (sciatic nerve), ankle dorsiflexion (common fibular nerve), and decreased ankle reflex (tibial nerve)

Answer 393

Echinococcus granulosus - dog tapeworm (humans get it from consumption of food/ water contaminated with dog feces) - tapeworm eggs hatch in the small intestine and spread to the liver and cysts cause GI symptoms

Answer 394

Syringomyelia - disruption of CSF drainage from central canal-> formation of fluid-filled cavity (syrinx) - affects STT crossing-> loss of pain and temp in “cape like distribution” * associated with Arnold-Chiari type I (cerebral tonsils extend into foramen magnum), inflammatory disorders, tumors, and trauma

Answer 395

Major burns-> massive release of pro-inflammatory mediators that increase vascular permeability-> 3rd-spacing of fluid (fluid leaks from capillaries and goes into space where it shouldn’t be)-> hypovolemic shock

Answer 396

Urethral catheterization -no. 1 priority is A,B,Cs (airway, breathing, circulation) and resuscitation (IV fluids) to prevent hypovolemic shock 2/2 pro-inflammatory mediators and third spacing -after this, we immediately place a Foley catheter for accurate monitoring of urine output! WHY? To know how much fluid to give the burn patient. Goal= hourly urine output of 1-2 mL(cc’s)/kg/hr (*rule of 9’s and Parklaran formula: 4*kg*%BSA isn’t really used anymore in real life)

Answer 397

Perforated peptic ulcer | Emergency exploratory surgery Consult surgery, start IV PPI + antibiotics, and give fluids

Answer 398

Fluorescein staining - high-velocity injury-> be worried about corneal abrasion and open globe laceration (*can occasionally penetrate the globe) - this staining allows you to see scratches on the cornea (appear yellow)

Answer 399

Paraesophageal Hiatal hernia

Answer 400

Pulmonary contusion - bruising to lungs * looks kinda like ARDS, but due to blunt thoracic trauma-> alveolar hemorrhage and edema (may take up to 24 hrs for edema to accumulate and show up on CT) *NOT fat embolism—femur fracture + SOB are suspicious for it, but would also present with petechial rash and confusion 12-72 hrs after injury

Answer 401

SOB (tachypnea, hypoxemia), petechial rash, and confusion in the setting of a femur/ long bone fracture 12-72 hrs after injury

Answer 402

Large pericardial effusion-> Cardiac tamponade - recent URI (pericardial effusions are often idiopathic, but can be triggered by viral illness), SOB, elevated JVP (fluid around the heart is restricting it from filling/ pumping, so blood backs up), clear lungs, large cardiac silhouette on CXR * Beck’s triad: (1) hypotension, (2) elevated JVP, (3) muffled heart sounds - “water bottle” shaped heart

Answer 403

Heart is surrounded by fluid (in pericardial sac)-> restricting filling and therefore pumping of the heart-> just like heart sounds may sound distant, the PMI may be hard to palpate since the heart isn’t pumping as well

Answer 404

Epididymitis-> pain improves with elevation of scrotum Testicular torsion-> pain worsens with elevation of scrotum

Answer 405

Nope- usually see absence of the cremasteric reflex

Answer 406

EKG-> normal or nonspecific ST and T-wave changes CXR-> widening of the mediastinum CT angio or TEE-> definitive diagnosis that yep, you’ve got aortic dissection

Answer 407

Acute ascending aortic dissection * syncope likely due to the fact that some blood is leaking into the aortic wall rather than perfusing organs- the brain * CT here is showing both ascending and descending parts of the aorta (cut at a level where both are in the picture)- notice the intimal flap

Answer 408

- IV beta blockers (like Esmolol) (*plus or minus Nitroprusside if SBP >120) - emergency surgery if type A dissection (ascending aorta) - pain control (Morphine)

Answer 409

Get a TTE (echo) -This sound like blunt cardiac injury (BCI) Blunt chest trauma-> persistent tachy + new arrhythmia (The injury to the heart can cause myocardial edema, hemorrhage, necrosis-> structural, ischemic, and electrical complications) *you need to do continuous cardiac monitoring for 24-48 hrs! (Most life-threatening arrhythmias occur during this time)

Answer 410

``` Intracerebral hemorrhage (ICH) Due to ruptured AV malformation ``` - ICH presents with progressive headache, N/V, and altered mental status over minutes to hours. - In young patients, it is often due to AV malformation (artery directly anastomoses with veins w/o capillaries in between). The high-pressure system can lead to aneurysm formation and spontaneous bleeding. May cause recurrent headache, seizure, or focal neuro deficits (includes hyperreflexia).

Answer 411

Cardiac myxoma (Fragment of the LA tumor embolized to the brain-> stroke) * middiastolic rumble at cardiac apex= sounds like mitral stenosis * the reduced cardiac output from the tumor getting in the way can also cause syncope * some myxomas produce cytokines (IL-6)-> systemic symptoms (elevated ESR, fever, weight loss)

Answer 412

Surgically resect the LA tumor -To reduce risk of embolization (a fragment of the tumor can get thrown to the brain-> stroke or cause another acute ischemia to a limb or mesentery) and sudden cardiac death (from low cardiac output since tumor is taking up space)

Answer 413

Ischemia of the bowel - bowel ischemia is a complication of abdominal aortic aneurysm repair (1-7%) - bleeding from IMA during aortic graft placement-> inadequate perfusion of left and sigmoid colon (not enough colonic collateral arterial perfusion) - presents with abdominal pain (esp LLQ) + bloody diarrhea, may also get fever + leukocytosis

Answer 414

Hypovolemic shock (due to internal hemorrhage)-> decreased preload to the heart-> cardiac arrest *Why right after ventilation? Positive pressure mechanical ventilation-> acute increase in intrathoracic pressure-> collapse of IVC-> worsens venous return to heart (so this on top of hypoveolemic tipped him over- loss of RV preload-> loss of CO-> cardiac arrest)

Answer 415

Von Hippel-Lindau syndrome - AD mutation in VHL tumor suppressor gene on chromosome 3-> retinal and cerebellar hemangioblastomas, Pheochromocytoma, RCC * NOT AD polycystic kidney disease—although this can cause HTN (excess renin release) and intracranial hemorrhage, the intracranial hemorrhage would be due to cerebral berry aneurysms, not hemangioblastomas.

Answer 416

Peritoneal stretch receptors sense high intraabdominal pressure-> trigger vagal (PNS) tone-> dec HR (can cause severe brady, AV block, or even asystole) *why is CO2 injected into the abdomen the first place? This is done routinely in laproscopic surgeries to create more space for the surgeon to work with (for optimal maneuvering of instruments and visibility of structures).

Answer 417

De Quervain tendinitis (inflammation of the tendon of the thumb) (Finkelstein test= pain with adduction of wrist with fingers closed over thumb)

Answer 418

Bacterial or fungal infection of the eye *most common form is post-op endophthalmitis (presents with pain, swelling, decreased visual acuity within 6 wks after surgery)

Answer 419

Post-op endophthalmitis | bacterial or fungal infection of the eye

Answer 420

Acute necrotizing mediastinitis

Answer 421

Rest and analgesics (Tylenol) (**NSAIDs could delay healing time) - stress fractures most common in athletes - 2nd metatarsal is the most commonly injured - treat conservatively (2nd, 3rd, and 4th metatarsals/ middle toes have surrounding toes to serve as a “splint”)—unless you fracture the 5th metatarsal (pinky toe), then cast it (more likely to get nonunion/ unhealed bone)

Answer 422

CT the abdomen (*you’d also be right to say FAST exam is the next step, but intraabdominal injury is likely so you’ll be getting a CT anyways) - you gotta be worried about left-sided lower rib fractures injuring the spleen! * fractures of ribs 9-12 can cause intraabdominal injuries

Answer 423

Subclavian vessels, brachial plexus, mediastinal vessels (like the aorta)

Answer 424

Cardiovascular damage

Answer 425

Intraabdominal organ damage: Right side-> liver Left side-> spleen Posterior ribs 11, 12-> kidneys

Answer 426

Pulmonary injury

Answer 427

1. Give alpha-blocker 7-14 days prior to surgery (*Phenoxybenzamine, an irreversible and non-selective alpha blocker is preferred, but selective alpha-1 blockers like Terazosin can also be used) 2. Give beta-blocker 2-3 days prior to surgery **Remember: alpha blocker before beta blocker. Why? Block alpha-1-> block vasoconstriction-> vasodilate/ dec BP. Then beta blocker-> lower HR. If beta blocker were to be given 1st: block beta-2-> block vasodilation-> vasoconstriction/ inc BP-> precipitation of HTN crisis.

Answer 428

Urgent surgical exploration of the wound - “hard signs” of extremity vascular trauma: 1. Observed pulsatile bleeding 2. Presence of a bruit or thrill over the injury 3. Expanding hematoma 4. Signs of distal ischemia (absent pulses, cool extremities) - any of these^ signs (with or w/o hemodynamic instability) mean urgent surgery is indicated! Don’t wait on imaging unless area of damage is unclear. - if no “hard signs,” look for “soft signs” including history of hemorrhage, reduced pulses, bony injury, and neuro abnormality. Do (1) injured extremity index (similar to ankle-brachial index to compare systolic pressures) and (2) CTA.

Answer 429

1. Observed pulsatile bleeding 2. Presence of a bruit or thrill over the injury 3. Expanding hematoma 4. Signs of distal ischemia (absent pulses, cool extremities)

Answer 430

Blunt aortic injury - seen in accidents with rapid deceleration (car crashes where you slam against the air bag, falling off a roof and landing on pavement) - due to fixed descending aorta (pulled back) and mobile ascending aorta (pulled forward) - may initially appear stable (normotensive to hypertensive due to sympathetic response) but they got a life-threatening injury!! - get a CXR (widening mediastinum, abnormal aortic contour, and/or left-sided hemothorax/ effusion)

Answer 431

Abdominal U/S -We recommend abdominal U/S screening every 6 months in patient with cirrhosis! Why? Although ascites is often due to the cirrhosis, new-onset ascites can be an indication of obstruction of the portal or hepatic veins due to thrombus or HCC (hepatocellular carcinoma).

Answer 432

1. Significantly decreases (10-fold) UTIs in infancy (1st yr of life) 2. Decreases risk of penile cancer (likely due to less phimosis, meaning there’s no foreskin constricting and preventing retraction) 3. Decreases risk of certain penile inflammatory disorders (balantis) 4. Decreases risk of some STIs (HPV, HIV) * risks/ complications (<1%) include infection, inadequate skin removal, and urethral injury

Answer 433

Central cord syndrome - most common in elderly patients who already have stenosis of the cervical spinal canal (cervical spondylosis aka osteoarthritis of the vertebrae) + have a hyperextension injury (whiplash in car crash) - pain/ temp broken on both sides in “cape-like distribution” + paralysis and burning pain in upper extremities

Answer 434

Yes (according to UW it used to not be required, but now we do it for confirmation before cutting on someone) If child or pregnant mom—> RUQ U/S Anyone else—> CT abdomen and pelvis

Answer 435

To guide your diagnosis and treatment of suspected APPENDICITIS

Answer 436

Antibiotics + appendectomy within 12 hrs

Answer 437

If stable, contained abscess—> Antibiotics + percutanous drainage If unstable, free perforation, diffuse intraabdominal contamination—> Antibiotics + emergency appendectomy

Answer 438

SBO 2/2 incarcerated (not reducible) hernia of the groin - abdominal distention, high-pitched abd sounds, and air-fluid levels suggest SBO - fullness/ tenderness of right groin area suggest hernia (protrusion of bowel through weakened abdominal wall) *why high BUN and Cr? Vomiting-> dehydration (dry mucous membranes)-> pre-renal AKI

Answer 439

Incarcerated hernia- not reducible (you cannot push it back in place) Strangulated hernia- cut off blood supply

Answer 440

Bisphosphonate-related osteonecrosis of the jaw

Answer 441

CT scan the brain - this is subarachnoid hemorrhage (SAH), which you diagnosis by CT! (or LP showing xanthochromia if CT is inconclusive but still high clinical suspicion) - due to rupture of saccular (berry) aneurysm-> sudden thunderclap headache (“worse headache of my life”) - associated with vomiting, photophobia, neck pain/ stiffness (due to bleed irritates meninges) * NOT meningitis- this also presents with fever, stiff neck, severe headache...but symptoms come on more gradually, not so fast. * even if it were meningitis, it would be a good idea to get that CT before your LP (even though no papilledema, neuro deficit, etc.) to r/o SAH since they present so similarly

Answer 442

Recommend surgical removal *lung nodules >0.8-cm have a decent chance of being malignant—biopsy or surgically remove them **this is clearly a lung tumor (smoker, large at 2-cm, irregular borders), but if it were unclear, follow-up with a PET (positron emission tomography) scan

Answer 443

Posterior shoulder dislocation * although anterior shoulder dislocations are more common, posterior dislocations occur in seizures + lightening strikes * adduction + internal rotation-> posterior dislocation

Answer 444

1. Adduction + internal rotation—> POSTERIOR dislocation | 2. ABduction + internal rotation—> ANTERIOR dislocation

Answer 445

Get an echo Cardiac tamponade - a rare early complication of CABG - rapid accumulation of blood in pericardial space leads to cardiogenic shock: hypotension, low urine output (less blood to kidneys= less urine produced), cool extremities - Beck’s traid: hypotension, elevated JVP, distant heart sounds The give-away here is equalization of intracardiac diastolic pressures! (All 20)

Answer 446

Renal cell carcinoma (RCC) - smoker, hard flank mass, systemic symptoms * do an abdominal CT with and w/o contrast

Answer 447

Peyronie disease - condition (affecting 5% of men) that arises due to repetitive blunt trauma to the penis during sex with aberrant (abnormal) wound healing-> fibrous plaques in tunica albuginea-> pain + distortion of penis shape (makes sex difficult) * usually resolves in 1-2 years. If not, give NSAIDs for pain, Pentoxifylline to reduce fibrosis, and/or collagenase injections. Surgery if refractory.

Answer 448

CMV (cytomegalovirus) colitis - transplant patients at higher risk - can present with malaise, fever, abdominal pain, vomiting, and/or bloody diarrhea - atypical lymphocytes are seen (*also seen in EBV, but EBV is associated with malignancies—nasopharyngeal and non-Hodgkin’s—not colitis) - ulcers on colonoscopy (biopsy to diagnose)

Answer 449

ARDS 2/2 sepsis from nec fasc -ARDS-> inflammatory response that causes capillary leakage and diffuse pulmonary edema

Answer 450

Osteoporosis - vertebral point tenderness (localized pain) after a non traumatic even in an old person= vertebral compression fracture, most likely due to dec bone density from osteoporosis * NOT disc herniation- this presents with lumbosacral radiculopathy-> radiating pain

Answer 451

Insufficient hemostasis -in someone with no family hx of bleeding disorders, the most common reason for hematoma is just insufficient hemostasis (not enough anti-clotting took place to stop the bleeding)!

Answer 452

1. Bronchogenic cyst—> MIDDLE mediastinum 2. Thymoma—> ANTERIOR mediastinum 3. All neurogenic tumors (meningocele, enteric cysts, lymphomas, diaphragmatic hernias , esophageal hernias, esophageal tumors, aortic aneurysms)—> POSTERIOR mediastinum

Answer 453

Shock liver aka ischemic hepatitis - can occur due to cardiac insults (MI, V-tach, cardiogenic shock), hypovolemic shock, septic shock, or respiratory failure—> hepatic necrosis (*mostly in zone 3 of the liver lobules—in the middle, furthest from oxygen supply from the hepatic artery and portal vein) - see LFTs >1,000 after an insult

Answer 454

Retrograde cystogram (Catheter up the urethra-> to bladder and inject water-soluble contrast dye and get imaging w/ CT) -trauma + suprapubic tenderness + intraperitoneal free fluid (urine) + hematuria= bladder rupture (also suspicious due to “widening of the pubic symphysis” on imaging) **note: if bleeding at urethral meatus, you suspect pelvic fracture w/ injury to the urethra or bladder...so you do retrograde urethrogram (if normal) followed by retrograde cystogram. But his signs all point to bladder rupture, so a cystogram is the best next step.

Answer 455

Ex lap (exploratory laparotomy) Do not get imaging...do not pass go...do not collect $200...get your patient to the OR!

Answer 456

Get a FAST exam

Answer 457

Unstable patient—> exploratory laparotomy Stable patient—> CT abdomen/ pelvis (always better to get a good picture of what’s going on before you cut if you have that luxury)

Answer 458

Unstable patient—> diagnostic peritoneal lavage (DPL) or CT abdomen/ pelvis (look for other potential sources of hemorrhage) Stable patient—> CT abdomen/ pelvis

Answer 459

Immobilization - causes increased osteoClast activity-> more bone breakdown-> higher calcium released into the blood * Bisphosphonates (cause osteoC apoptosis) can help prevent this *his hypercalcemia is NOT due to rhabdo—that resolved weeks ago with treatment

Answer 460

When it looks like you have LOW calcium, but you also have LOW albumin (got to make sure the hypocalcemia is real) -for every change in albumin by 1 (every 1 below the 4), change calcium in the opposite direction (+0.8)

Answer 461

Primary hyperparathyroidism -high PTH (800), high calcium (11.8), low phosphorus (2.2) [*remember the normals: PTH 10-54, Ca 8.5-10, P 3-4.5] - excess resorption of calcium from bones-> net increase in calcium excretion by the kidneys (explains high urinary calcium and calcium kidney stones) * do parathyroid imaging and refer for parathyroidectomy (surgery is done for patients with symptomatic hypercalcemia or complications such as kidney stones—young patients (<50) at higher risk)

Answer 462

Do renal vascular imaging (U/S) -looking for renal artery stenosis * although renal artery stenosis usually occurs in old men due to atherosclerosis, it also can occur in kidney transplant patients within 2 yrs of the transplant...due to operative abnormalities (trauma during organ placement, abnormal suture placement), viral infection (CMV, BK virus), and atherosclerosis of the donor renal artery. * renal artery stenosis (of any cause)-> resistant HTN and decline in renal function after given ACE inhibitors (Lisinopril) **do angioplasty (surgical procedure to open up the vessel, possibly place stent)

Answer 463

Abdominal x-ray suggestive of it, plus 3+ of the following: 1. Fever >100.4 (38 C) 2. HR >120 3. WBCs >10,500 4. Anemia *IBD patients at increased risk

Answer 464

- IV fluids - Broad-spectrum antibiotics - Bowel rest (NG tube decompression) - IV corticosteroids if IBD-induced

Answer 465

Patellofemoral pain syndrome (PFPS) Recommend quadriceps (and hip aBductor) strengthening exercises - poorly localized anterior knee pain - one of the most common causes of chronic knee pain in young women (related to overuse) *”pain with extension of knee and compression of patella into trochlear groove”= patellofemoral compression test

Answer 466

Excisional biopsy *only consider punch biopsy if the melanoma is super large

Answer 467

Aortic dissection - She has Turner syndrome (X0) - Cardiac manifestations: coarctation of the aorta, bicuspid aortic valve, and HTN. All these increase risk for aortic dissection. - Hemodynamic changes of pregnancy (inc blood volume) put extra stress on the aorta and further increase risk of dissection. *Many Turner’s patients are infertile (due to streaked ovaries/ not properly formed), but can get pregnant usually by in vitro fertilization. However, pregnancy can be dangerous in these patients due to risk of aortic dissection.

Answer 468

Febrile nonhemolytic transfusion reaction -WBCs release cytokines in stored blood products. These cytokines from the donor blood make the person sick (fever, chills, headache). *fever occurring immediately (within a few hrs) after surgery is due to: prior infection/ trauma, inflammation from surgery, malignant hyperthermia, anesthetic meds, or blood products.

Answer 469

Ileus Morphine - Ileus= functional defect in bowel motility w/o an associated physical obstruction (bowel is frozen up) - common after abdominal surgeries, but if >3-5 days, it’s termed prolonged/ “pathologic” post-op ileus - Morphine (opiate) causes decreased GI motility (constipation), which worsens this problem * NOT SBO—this causes hyperactive (not hyperactive) bowel sounds and usually presents weeks-years after surgeries due to adhesions (not right after surgery) * Metoclopramide will NOT worsen ileus—it has pro-motility effects (is contraindicated in some cases of SBO since this will promote contraction against the obstruction). Ondansatron would worsen ileus, as it can cause constipation.

Answer 470

Recent surgery (hours to days)-> bowel “freezes up” Metabolic (like hypokalemia—since K+ is needed to contract the bowels) Medication induced

Answer 471

Ileus- recent surgery (hrs-days) SBO- past surgery (weeks-yrs) *due to adhesions

Answer 472

Ileus- possible distention + hypoactive bowel sounds SBO- distention + increased bowel sounds

Answer 473

Von Hippel-Lindau disease - AD mutation in VHL tumor suppressor gene on chromosome 3-> cerebellar and retinal hemangioblastomas, pehochromocytoma, and RCC (clear cell subtype) * renal cysts= pre-cancer to RCC *manage with eye/ retinal exams, plasma or urine metanephrines, MRI brain/ spine, MRI abdomen

Answer 474

``` Anorectal fistula (fistula in ano) Surgical evaluation (fistulotomy) ``` - perianal lesion, pain on defection, discharge - often due to rupture of a perianal abscess (forms a residual sinus tract)...or can be due to Crohn’s disease, radiation, atypical infections (lymphogranuloma venereum), or trauma *must correct, or else can get fecal incontinence

Answer 475

Urgent surgical consult - This is COMPLICATED SBO (risk of ischemia, strangulation, and necrosis) - She is hemodynamically unstable w/ metabolic acidosis (low bicarb) (lactic acidosis) * SBO often presents with high-pitched tinkles, but as it progresses, bowel sounds can decrease and even diminish altogether (if ischemia) * leukocytosis and amylase elevation can also be seen

Answer 476

EGD (endoscopy) -this is suspicious for gastric cancer (abdominal pain relieved with antacids, epigastric fullness, weight loss, Asian)

Answer 477

Duodenal tear (perforated viscus) -1 day after blunt abdominal trauma-> fever, diffuse abdominal tenderness, retroperitoneal free air on imaging (*delayed a day bc GI spillage is initially sequestered away from the intraperitoneal space)

Answer 478

“SAD PUCKER” ``` Suprarenal (adrenal) glands Aorta and IVC Duodenum Pancreases (head and body) Ureters Colon (ascending and descending) Kidneys Esophagus Rectum (mid-distal) ```

Answer 479

Get a x-ray of the spine - this is scoliosis (lateral S-shaped curvature of the thoracic and lumbar spine) - this deformity is most common in kids >10 during periods of rapid growth - x-ray to assess severity (Cobb angle) * most cases are mild (Cobb angle 10-30 degrees)-> monitor every 6 months * if moderate (Cobb angle 30-40 degrees)-> thoracolumbosacral spinal brace * if severe (Cobb angle 40-50 degrees)-> surgical fixation

Answer 480

Augmentin (Amoxicillin-clavulanate) *also leave the wound open to heal by secondary intention (closure-> high infection risk) * polymicrobial infections w/ aerobic and anaerobic oral flora (strep, staph,eikenella, H. Flu, beta-lactamase producing bugs) * Augmentin is used since it covers gram (+), gram (-), and anaerobic bugs (clavulanate= beta-lactamase inhibitor)

Answer 481

Do emergency laparotomy (to relieve the bowel obstruction) - This is COMPLETE SBO (tender mass at incision is likely an incisional hernia causing the obstruction—bowel gets trapped within the fascial defect) * no air in the rectum on x-ray * need to do surgery since she’s at risk for life-threatening complications otherwise (bowel ischemia or perforation)

Answer 482

Smoking! *People with HTN are more likely to get AAA’s, so we know HTN plays a role in AAA development. However, it is not known to play a role in AAA progression.

Answer 483

Hepatic adenoma * elevated alk phos + GGT means biliary obstruction/ compression * this is a benign tumor seen in young-middle aged women on OCPs (complications: growth, rupture, and malignant transformation)

Answer 484

1. Hepatic adenoma | 2. Focal nodular hyperplasia (FNH)

Answer 485

Subacute (not sudden) or chronic locking or popping sensation in the knee *remember, the meniscus is a C-shaped piece of cartilage on the shinbone (tibia) that cushions the shinbone and thigh bone (femur)

Answer 486

Older adults w/ osteoarthritis *causes swelling of the posterior knee and calf

Answer 487

Calcium-oxalate nephrolithiasis (kidney stones) -Crohn’s (terminal ileum involvement)-> fat malabsorption-> calcium gets bound up by fat instead of binding oxalate-> free oxalate precipitates out and forms calcium-oxalate kidney stones

Answer 488

You have a hemodynamically unstable patient (no time for CT) and FAST exam is unclear

Answer 489

Duplex ultrasonography DVT of right upper extremity - catheter placement increases DVT risk due to endothelial trauma during insertion or improper positioning - plus he has cancer, a hypercoagulable state * duplex U/S will look at the subclavian, axillary, and brachiocephalic veins * give 3 months anticoagulation (even though PE risk from upper extremity DVT is pretty low, about 6%)

Answer 490

1. Have a central catheter/ PICC (peripherally inserted central catheter) line placed 2. Young, athletic males 3. Thoracic outlet obstruction

Answer 491

3 months anticoagulation | PE risk is much lower compared to lower extremity DVT...but still 6%

Answer 492

Emergent thoracotomy (open up that chest) - hypovolemic shock (hypotension, tachycardia, flat neck veins) in the setting of trauma= hemorrhage until proven otherwise - lateral wounds can cause massive hemorrhage (>1,500 mL) from penetrating the lung and intercostal vessels -tube thoracostomy can manage most cases of hemothorax, but emergent thoracotomy is needed for massive bleeds: >Initially bloody output >1,500 >Persistent hemorrhage >200 mL/hr for >2 hrs or continuous need for transfusion

Answer 493

Esophageal perforation - blunt thoracic pressure can cause a sudden increase in intraesophageal pressure-> esophageal rupture - GI contents leak from the ruptured esophagus into pleural space-> pleural effusion (pleural fluid would be green, low pH, high amylase)

Answer 494

Bladder catheterization ``` This is anterior cord syndrome. Absent pinprick and temp= STT damaged. Absent motor= CST damaged. Vibration intact= DC-ML okay. Loss of everything but proprioception/ vibration below the level of the lesion (C5). ``` -This includes loss of bladder control. Cath to prevent bladder distention and possible injury. * Do NOT give ORAL steroids—as this patient should be kept NPO for surgery. You may do IV steroids (methylprednisolone) for spinal cord injury to reduce inflammation on the cord. * Do NOT intubate at this time—that’s overly aggressive given that he is breathing well and alert. C3, C4, C5 keeps the diaphragm alive, but he injured only C5.

Answer 495

Complicated parapneumonic effusions involve bacteria (vs. uncomplicated is sterile fluid). Low pH—> due to anaerobic utilization of glucose by neutrophils and bacteria. Low glucose—> bc bacteria consume it. High protein—> due to increased microvascular permeability.

Answer 496

Place them in respiratory isolation.

Answer 497

Bronchoscopy * can be used for lots of pulm things...TB, biopsy of tumors, to suck up sputum for a sample when blood cultures are negative and you can’t get a good regular sputum sample, to cauterize/ control bleeds since the vessels run with the alveoli (can put it down through ET tube if patient is intubated) * note: rupture of capillaries causes hemoptysis in TB. But, this guy is coughing up a massive amount of blood probably due to inflammation-> tissue necrosis and fragile vessels-> rupture of a larger bronchial or pulmonary vessel. **cricothyrotomy would not help bypass the bleeding, as the bleed is way down at the level of the alveoli.

Answer 498

Used to localize a bleed when there is persistent bleeding or initial bronchoscopy cannot localize the source *catheter through peripheral vein-> RA-> RV-> pulm arteries-> lungs (can use as a test for PE as well, but CTA is the gold standard)

Answer 499

Mild hypothermia—> tachycardia (the heart beats faster to pump more warm blood out to the body + vessels vasoconstrict to shunt blood to central organs for warmth + increased shivering) Moderate- severe hypothermia—> bradycardia (reaches a point where you are so cold pacemakers slow down and metabolic activity is slowed + decreased shivering)

Answer 500

Active rewarming *Although his HR is super low, warming to correct the underlying problem is most likely to help restore normal HR. Bradycardia 2/2 hypothermia is usually refractory to treatment with atropine and cardiac pacing.

Answer 501

Yes It is multiple little electrical signals delivered to the heart (an external pacemaker) to increase HR (in severe bradycardia)

Answer 502

Type 4 RTA Poorly controlled DM-> DCT becomes less responsive to Aldo= type 4 RTA-> not peeing as much K+, so will get high K+. Not peeing as much H+, so will get high H+= metabolic acidosis (low bicarb). *high Cr likely due to the DM too *Remember: Na-Cl-HCO3= 12 plus/minus 2 is normal. 10 is a normal anion gap metabolic acidosis, so it’s either a renal (RTA) or extrarenal (GI= diarrhea-> loss of bicarb) problem.

Answer 503

Leukemoid reaction (reaction to a severe infection), likely C-diff *how do you tell the difference between cancer and infection? High leuk alkaline phos-> infection! **when WBCs are super high like here they are 50,000 (not just like 12,000), it is usually c-diff or a blood cancer

Answer 504

CLL (chronic lymphocytic leukemia) - most common type of leukemia - presents with fatigue (can also have B symptoms—fevers, night sweats, weight loss—but absent here) - lymphocytosis= too many lymphocytes (naive CD8+) - peripheral smear would show small, mature lymphocytes with smudge cells * really high WBC count (50,000) means blood cancer or bad infection like c-diff. This has been chronic (2 months), plus they didn’t tell you leukocyte alkaline phos is elevated, so not an infection, it’s cancer. * the fact there’s lots of cells on peripheral smear (not LN biopsy), means leukemia not lymphoma.

Answer 505

Due to increased renin release * cyst expansion-> localized renal ischemia-> increased renin release (activates RAAS and causes a secondary hyperaldosteronism)-> HTN * *give ACE inhibitors

Answer 506

Yes Tendency toward acidic urine-> inc risk for uric acid kidney stones (nephrolithiasis)

Answer 507

Cricothyrotomy - This is epiglottitis (cellulitis of epiglottis and surrounding tissue) due to Candida (white plaques) * leaning forward= tripoding -He is having respiratory failure. Single failed attempt to endotracheal intubation—> surgical cricothyrotomy (bypasses epiglottal swelling and potential airway obstruction!)

Answer 508

CT abdomen *This presentation is suspicious for splenic injury...blunt chest/ abdominal trauma, evidence of hemorrhage (tachycardia), LUQ pain and left shoulder pain (referred pain from blood irritating the phrenic nerve). Splenic injury= #1 intraabdominal complication of blunt abdominal trauma. -He is hemodynamically stable + negative FAST exam + high suspicion for intraabdominal injury—> get a CT abdomen/ pelvis w/ contrast (**FAST doesn’t r/o bc it can miss early bleeding/ injuries like bowel perf that does produce detectable amounts of free fluid)

Answer 509

Sphincter of Oddi dysfunction (Sphincter of oddi= muscular valve controlling the flow of bile + pancreatic juice into the duodenum) * Dysfunction is due to dyskinesia or stenosis * Morphine (opioid) will worsen the pain by causing sphincter contraction *Diagnose with sphincter of oddi manometry

Answer 510

Incompetent pyloric sphincter (often following gastric surgery)-> retrograde flow of bile-rich duodenal fluid into the stomach and esophagus-> gastritis/ inflammation of stomach-> abdominal pain, vomiting, heartburn

Answer 511

Varicocele To prevent infertility -ropy scrotal mass that increases with bearing down, decreases with laying down when gravity isn’t against you= “bag of worms” varicocele * confirm dx with U/S showing dilation of the pampiniform plexus and retrograde venous flow * use scrotal support and NSAIDs to reduce discomfort * surgery (venous ligation) to prevent infertility (varicose veins-> pooling of blood-> too warm of an environment for sperm to thrive)

Answer 512

Cystoscopy (looking for bladder cancer) *if it is bladder CA, follow-up with abdominal CT for staging - painless hematuria (microscopic or gross) - hydronephrosis (bladder outlet obstruction-> back up of urine to ureters and kidneys-> elevated Cr) - voiding symptoms (due to obstructing tumor or detrusor muscle hyperactivity from it)

Answer 513

Emphysematous cholecystitis Urgent cholecystectomy! - RUQ pain, fever, gas in gallbladder wall or surrounding tissue - due to gas-forming organisms (Clostridium) - bacterial exotoxins-> hemolysis (low Hb, high indirect bili), tissue necrosis, septic shock, grangrenous cholecystitis and gallbladder perforation (if untreated)

Answer 514

``` CHF HTN Age 75+ DM Stroke/ TIA (worth 2 points) Vascular dz/ prior MI Age 65+ Sex is female ``` Score of 3+ —> anticoagulation (Score of 1-2 you may consider it) * max score= 9

Answer 515

Oral anticoagulation therapy - A-flutter (due to re-entry circuit in the cavotricuspid isthmus of the RA) is treated just like A-fib. - We often do cardioversion or ablation of the re-entry circuit to correct the arrhythmia, but must start with anticoagulation to avoid throwing a clot during these procedures. ``` *CHADS-VASC: CHF HTN Age 75+ DM Stroke/ TIA (worth 2 points) Vascular dz/ prior MI Age 65+ Sex is female -He has a score of 4, and with a score of 3+ you for sure do anticoagulation (1-2 is debatable). ```

Answer 516

Lymphangitis Cephalexin Cutaneous wound (cut)-> skin pathogens (group A strep, staph a.) enter the deep dermis and invade lymph channels-> tender, erythematous streaks from the wound to draining lymph nodes + systemic symptoms (fever) *this is NOT sporotrichosis (treated with Itraconazole), as this forms nodular lymphangitis (not streaks) over weeks (not days) and affects gardeners

Answer 517

Papillary muscle rupture (leading to mitral regurg) * this is a life-threatening complication of an MI that occurs 3-5 days later * murmur may be soft or in-audible so confirm dx with a TTE or TEE (echo)

Answer 518

Suppurative parotitis Prevent with hydration and oral hygiene - swelling and severe tenderness of parotid gland + fever + leukocytosis - more common in elderly, dementia patients (less likely to hydrate well and have good oral hygiene), and after surgery (NPO-> salivary stasis) - bacteria (usually staph a. from oral flora) travels to the parotid gland-> inflammation * get a U/S or CT scan to differentiate parotitis vs. parotid abscess and evaluate for salivary stones or neoplasms obstructing the duct * treat with broad-spectrum antibiotics, hydration, sialagogues (inc salivary flow), and massage

Answer 519

Transfusion-related acute lung injury (TRALI) - acute hypoxemic respiratory failure w/ bilateral pulm infiltrates during blood transfusion * no JVD + normal BNP= NOT transfusion-associated circulatory overload (TACO)

Answer 520

TACO will have JVD, S3, dec ejection fraction, and high BNP (TRALI will not) *BOTH will present with acute SOB and bilateral lung infiltrates within minutes-few hrs after blood transfusion

Answer 521

Ludwig angina (Rapidly progressive cellulitis of the submandibular and sublingual spaces) Be concerned about the patient’s airway - due to spread of dental infections (in mandibular molars) - problem threatening the airway + exam findings concerning for impending airway obstruction (drooling, can’t lay flat, tripod positioning)—> secure their airway regardless of O2 sat (can decompensated rapidly!)

Answer 522

Get a CXR (looking for Pancoast tumor aka superior pulmonary sulcus tumor) - smoker (*Pancoast tumors are in the apex/ periphery of the lung, so don’t present with SOB, hemoptysis until late) - right shoulder pain radiating to the arm (due to irritation of the brachial plexus) - right (ipsilateral) eye drooping (ptosis) and pupil constriction (miosis)= Horner syndrome (PAM= Ptosis, Anhydrosis, Miosis) (due to irritation of the brachial plexus) **NOT Myasthenia Gravis—also presents with ptosis and muscle weakness, but progressive shoulder pain radiating to the arm would be unusual

Answer 523

Squamous cell carcinoma of the lung or Adenocarcinoma of the lung *The term “Pancoast tumor” is given for the fact that it’s at the apex of the lung (comes along with specific symptoms for this reason—like shoulder pain + Horner’s syndrome from irritation of the brachial plexus and sympathetic chain)

Answer 524

Pancoast tumor

Answer 525

Surgical resection of the thyroid gland * follow it up with radioiodine ablation if the patient is high-risk for recurrence (large tumor, extrathyroidal invasion, lymph node metastasis, incomplete resection) * patient will need thyroid replacement for life

Answer 526

EGD (endoscopy) *can also r/o cancer

Answer 527

Carotid artery plaque | A piece breaks off and embolizes to the retinal artery

Answer 528

Sigmoidoscopy (to untwist) + placement of a rectal tube (to dec chance of recurrence in acute setting)

Answer 529

Enema | To help relieve the constipation

Answer 530

no further testing is required! This is Focal Nodular Hyperplasia (benign liver tumor w/ central scar) Managed conservatively—no malignant potential

Answer 531

Arteriography with runoff - Popliteal artery aneurysm-> acute limb ischemia due to thrombosis of aneurysm or acute thromboembolism - Runoff= visualization of vessels beyond the occlusion

Answer 532

Pyoderma gangrenosum

Answer 533

Immediate surgery (ex-lap) -this is a perforated viscus (organ)

Answer 534

Transfusion of packed RBCs * Hb 7 qualifies you for a blood transfusion * Schistocytes due to shearing of RBCs as they cross the artificial valve * no need for whole blood transfusion—no thrombocytopenia

Answer 535

Decreased bowel sounds-> ileus High-pitched bowel sounds-> SBO

Answer 536

Laryngeal squamous cell carcinoma - smoker w/ hoarseness * may also present with dysphagia (difficulty swallowing), airway obstruction, or referred pain to the ear

Answer 537

Biopsy This is a stupid Q—yes, you do ultrasound given that she’s 30 years old (dense breast tissue, U/S > mammogram), but the only test that will CONFIRM fibroadenoma is a core biopsy (only biopsy can confirm any palpable breast mass diagnosis)

Answer 538

Infective endocarditis -causing splenic abscess - fever + leukocytosis + upper left abdominal pain - seeding of septic emboli to the spleen - infective endocarditis more likely in a patient with MVP (or other valve problem)

Answer 539

Thrombosed external hemorrhoid - common symptoms of external (non-painful) hemorrhoids: itching, bleeding, anal discharge - thrombosis of external hemorrhoid -> feeling of fullness in perirectal area, pain, tenderness, visible purplish mass * treat w/ Sitz baths, stool softeners, and topical anesthetics

Answer 540

Prothrombin complex concentrate (concentrate of vitamin K-dependent factors: factors 2, 7, 9, 10) -acute abdomen (guarding, rebound tenderness), likely due to a perforated duodenal or gastric ulcer (upper abd pain relieved w/ antacids) - he’s on Warfarin w/ INR of 2.1 (2-3 is therapeutic range/ less clotting), but we don’t want less clotting/ more bleeding in the setting of an abdominal perf, so DC the Warfarin and give prothrombin complex concentrate! Also give IV vitamin K to help the liver make more clotting factors * If Prothrombin complex concentrate is not available, give FFP (fresh frozen plasma)—less effective

Answer 541

Platelet count 50,000 *>50,000 platelets is adequate for most clotting purposes

Answer 542

Malignant biliary obstruction (Pancreatic or biliary cancer/ cholangiocarcinoma) - hyperbilirubinemia is mainly conjugated (direct)= biliary obstruction - chronic painless jaundice + weight loss= biliary malignancy

Answer 543

Supplemental oxygen - he had a primary spontaneous pneumothorax (rupture of subpleural blebs) - small pneumo in a stable pt-> can manage w/ observation and supp O2 (regardless of O2 sat)

Answer 544

CT abdomen -likely pancreatic cancer in the tail of the pancreas (smoking, weight loss, insidious/ gradual back pain, normal neuro/ x-ray findings) - tumor in head of pancreas-> obstructive jaundice, steatorrhea, epigastric pain - tumor in tail of pancreas-> progressive, constant back pain worse at night when laying down

Answer 545

Gradual | Ex: insidious back pain= back pain came on gradually

Answer 546

Leriche syndrome (aka aortoiliac occulusion) Impotence - type of PAD with triad: (1) bilateral hip, thigh, and buttock claudication, (2) absent/ diminished femoral pulses, (3) impotence - men with atherosclerosis (smokers) at greatest risk

Answer 547

Give botulinum antitoxin - puncture wound (IV drug use w/ abscesses)-> entrance of Clostridium botulinum spores (wound botulism) - presents with symmetric descending neuro deficits, respiratory compromise, and autonomic dysfunction)

Answer 548

Adequate analgesia (pain meds) Control of pain in rib fractures is important so patients take deep, not shallow, breaths to prevent atelectasis and PNA *also encourage patient to use incentive spirometry

Answer 549

Brown recluse spider bite (Often are unrecognized initially, but then cause a skin ulcer at the site of the bite) Necrosis (necrotic center) and eschar *do basic wound management, often heals w/o scarring. Once the lesion is stable, may do debridement.

Answer 550

``` Compartment syndrome (Likely the subtype: ischemia-reperfusion syndrome) ``` - pain out of proportion - pain worse with passive movement - rapidly increasing and tense swelling - paresthesia (early finding) * confirm by measuring compartment pressures (>30) * do urgent fasciotomy

Answer 551

DC the heparin and start argatroban -this is HIT (heparin induced thrombocytopenia)

Answer 552

Measure leg compartment pressures -this sounds like compartment syndrome! Confirm with compartment pressures (>30): delta pressure= diastolic BP- compartment pressure. If less than 30-> compartment syndrome. * pain out of proportion, pain worse with passive motion, rapidly increasing and tense swelling, and early paresthesia * do urgent fasciotomy (unless compartment pressures are falling and delta pressures are rising—they may be able to manage conservatively)

Answer 553

Plantar fasciitis - inflammation and degeneration of plantar aponeurosis (connects calcaneus/ heel bone to toes and supports the arch of the foot) - pain is worse when first stepping out of bed and with weight bearing - local point tenderness with dorsiflexion of the toes *x-ray may show calcifications in the proximal fascia (heel spurs)

Answer 554

Colonoscopy - anemia in old ppl is colon CA until proven otherwise! She has positive occult blood + anemia, so you need to follow-up with colonoscopy to check for cancer. * anosocpy is NOT the next best step...do this (like a Pap smear for the butt) to evaluate for INTERNAL hemorrhoids and anorectal pathology. She has external hemorrhoids and the main concern here is the likelihood of colon CA

Answer 555

Mixed germ cell tumor | Yolk sac tumor, choriocarcinoma, embryonal carcinoma

Answer 556

Thymoma Teratoma (and other germ cell tumors) Thyroid neoplasm Terrible lymphoma

Answer 557

AV fistula -complication of vascular procedures -inflammation-> AV fistula (abnormal connection between the artery and vein) can develop in the healing process (*the vein can be punctured on accident during needle insertion attempts to obtain femoral artery access-> opening in both vein and artery allows for a connection to form when the vessels heal) -continuous bruit w/ palpable thrill is key *confirm by ultrasound

Answer 558

Ultrasound *also, look out for mild localized pain, continuous bruit, and palpable thrill over the fistula site! **management of small AV fistulas= observation (for spontaneous closure) or U/S-guided compression. Management for large AV fistulas= surgery.

Answer 559

Acute mesenteric ischemia (“MI of the colon”) ``` Mesenteric angiography (CT looking at abdominal vessels) ``` - likely due to thrown clot from a-fib (esp since off her anticoags) - rapid-onset, pain out of proportion to exam findings, hematochezia (late complication) - labs show leukocytosis, lactic acidosis *treat with NG tube, IV fluids, anticoagulation, broad-spectrum antibiotics, surgery is some cases

Answer 560

Osteosarcoma - malignant proliferation of osteoBlasts - a complication of Pagets (which is osteoCs going crazy breaking down bone-> osteoBs going crazy trying to compensate but they do a sucky job of laying down bone so it is thick and fragile) - imaging shows destruction of bone, “sunburst” appearance, and “lifting of the periosteum” (Codman triangle)

Answer 561

CT abdomen and pelvis - blunt trauma w/ CVA tenderness + hematuria-> think renal injury * NOT retrograde cystourethrogram—that would be to evaluate for bladder and urethral injury

Answer 562

Fat embolism - long-bone fracture and TRIAD of neuro dysfunction (confusion) + petechial rash + respiratory distress (mimics ARDS) * can also occur after orthopedic surgery or pancreatitis -due to fat globules entering the bloodstream (fat emboli) **diagnosis is clinical and treatment is supportive. About half these patients require mechanical ventilation, but most end up making a full recovery

Answer 563

Surgical removal of the colon (part or all) + rectum -this is the surgery UC patients can get, which is curative

Answer 564

Methemoglobinemia -due to anesthetic use - some drugs (benzocaine, dapsone, nitrates) cause oxidation of iron in Hb (Fe2+-> Fe3+) so it cannot carry oxygen for delivery to tissues - large oxygen saturation gap: O2 sat reading is way different on pulse ox (85%) and ABG (99%) * treat by discontinuing the causative agent and giving methylene blue (reduces iron back from Fe3+-> Fe2+)

Answer 565

Alcohol withdrawal (Delirium Tremens) - late complication of alcohol withdrawal with severe agitation and fever * treat with Benzos and ICU care *Sketchy “hangover special” time after last drink: 8-12 hrs-> insomnia, anxiety, tremor, autonomic hyperactivity (high BP, HR) 12-48 hrs-> alcohol withdrawal seizures, hallucinations 48-96 hrs-> Delirium Tremens (fever, disorientation, severe agitation)

Answer 566

Sketchy “hangover special” time after last drink: 8-12 hrs-> insomnia, anxiety, tremor, autonomic hyperactivity (high BP, HR) 12-48 hrs-> alcohol withdrawal seizures, hallucinations 48-96 hrs-> Delirium Tremens (fever, disorientation, severe agitation)

Answer 567

``` Dumping syndrome (“rapid gastric emptying”) Dietary modification (smaller meals, eat complex carbs not simple table sugar, increase fiber and protein, drink fluid between meals not during meals) ``` -complication of gastrectomy (occurs in about half of patients) -malfunction of the pyloric sphincter (due to injury or surgical bypass)-> rapid emptying of stomach contents into the duodenum-> this not-fully-digested concentrated food mass triggers the body to move fluid from the bloodstream into the intestine in attempt to dilute the food -abdominal distention-> bloated, cramping, N/V, diarrhea -shift of fluid out of bloodstream-> loss of blood volume-> lightheadedness, tachycardia (These sxs occur in 10-30 min after eating) *also, rapid increase in sugar load absorption-> triggers the pancreas to pump out more insulin-> overreacts to this quick dumping-> hypoglycemia-> sweating, weakness, confusion, tremors (These sxs may occur in 1-3 hrs) * increased release of intestinal vasoactive peptides (GI hormones) also contributes to symptoms - Management: (1) diet modification (*usually controls symptoms)-> (2) meds to slow gastric emptying or block insulin release (Octreotide, acarbose)-> (3) tube feeding that bypasses upper GI tract (enteral jejunostomy) or surgical correction

Answer 568

5. 3 * technically, this is still a high K+ level bc 3.5-5 is normal, but its going down...we give K+ at this point to prevent hypokalemia (treating them with insulin-> brings K+ into cells)

Answer 569

Polycystic kidney disease (ADPKD) - most patients are asymptomatic until age 30-40! - flank pain, hematuria, HTN, palpable bilateral abdominal masses, urinary concentrating deficit (low specific gravity—likely due to tubular destruction) - flank pain + hematuria can result from cyst rupture (bending over to garden) - HTN-> renal dysfunction (high BUN, Cr)-> eventually leads to ESRD

Answer 570

Chest and sternal imaging (CT) -evidence of separation of the sternal surgical wound= dehiscence (fairly common complication from a CABG) - soft tissue dehiscence: superficial tissues (skin, muscle) separate—no signs of sternal instability or systemic illness, so you can just do local wound care or debridement w/ primary closure (suture it) - sternal dehiscence: the edges of the sternum separate—sternal instability (“clicking” or “rocking” on sternal palpation), so you need to do emergency surge to re-wire it back together to prevent cardiac trauma -MUST DO CT before anything else in a paitent with significant sternal wound discharge to r/o mediastinitis (deep tissue infection), as this is a surgical emergency!

Answer 571

Primary closure- suture it Secondary closure- let it heal up on its own

Answer 572

Mediastinitis (deep tissue infection) * due to contiguous (anatomical) spread of superficial infection or intraoperative deep tissue contamination * classically presents with systemic symptoms (fever, tachy), but may also get chest pain, chest wall crepitus, discharge, etc. * any patient with significant sternal wound drainage-> do CT scan (check chest and sternum for mediastinal fluid collections or pneumomediastinum) * to treat this would need to do emergency surgical debridement, tissue cultures, and empiric IV abx

Answer 573

Urethral stricture - narrowing of the urethra (more common in men) - commonly idiopathic, but can also occur 2/2 urethral trauma, infection, or radiotherapy - confirm with cystourethrogram - if severe, correct with urethral dilation or urethroplasy (surgical reconstruction of the urethra) *NOT detrusor (bladder muscle) overactivity, as this would cause urinary frequency and urgency

Answer 574

Pheochromocytoma -anesthesia-> catecholamine surge (consider patient’s history of HTN, anxiety, frequent headaches)

Answer 575

Fibromuscular dysplasia - developmental defect of blood vessel wall-> irregular thickening of med-large arteries, esp the renal artery and carotids-> secondary HTN (activation of RAAS) * systolic bruit under the right ear (subauricular)= thickening/ stenosis of the right internal carotid artery (vs. the carotid bulb in the neck, which is where atherosclerosis occurs in old ppl) **confirm w/ vascular imaging (U/S, CT, or MRI) and treat with ACE inhibitor (or angioplasty/ surgery)

Answer 576

Lateral neck radiograph (Showing enlarged epiglottis) - Infectious epiglottitis (cellulitis of epiglottis and surrounding tissues usually due to strep pneumo or H. Flu) - Diabetes, obesity, and URI are all risk factors

Answer 577

Abdominal x-ray (looking for colonic distention >6cm) -this is toxic megacolon 2/2 IBD (Ulcerative Colitis) * notice his unstable vitals...points you to a “toxic” picture—not just UC * diagnosis of toxic megacolon is made with imaging confirming colonic distension + systemic toxicity (fever, leukocytosis, hemodynamic instability) * do NOT do barium enema or colonoscopy (risk for perforation)

Answer 578

Surgical exploration and sternal fixation - this is sternal dehiscence (the edges of the bony sternum that were wired together have separated) - this is a surgical emergency! Otherwise, loose wire or bone fragments may lead to cardiac damage

Answer 579

Central venous catheter -they are the #1 source fo hospital acquired bloodstream infections! (Create a direct pathway for skin organisms like Candida to access the circulatory system) *a positive blood culture for Candida should NEVER be disregarded as a contaminant...search for a source!! (**the Sketchy video talks about how Candida is a common contaminant of SPUTUM cultures)

Answer 580

Internal hemorrhoids (not painful)-> rubber band ligation External hemorrhoids (painful)-> hemorrhoidectomy (under anesthesia...rubber band ligation would be too painful for them!) **also note, you try conservative measures 1st (stool softeners, more fiber, Sitz baths) unless patient is in a lot of pain due to external hemorrhoids, then remove them w/o prolonging their torture

Answer 581

“Hot tub folliculitis” Pseudomonas * get it from contaminated hot tubs (not adequately chlorinated) * self-limited, no treatment needed (if persist—can give an oral fluoroquinolone)

Answer 582

Mammogram -she is >30 years old, so always mammogram (plus or minus U/S) a palpable breast mass! (**had she been less then 30 years old, we would reassure and watch for a couple cycles-> U/S)

Answer 583

Core needle biopsy -cystic mass should go away with aspiration, so the fact that it persists warrants further work-up to r/o breast cancer (If bloody aspirate or persistent/ recurrent cyst—> go to biopsy)

Answer 584

Needle aspiration and antibiotics - this is acute mastitis (staph a.)-> breast abscess (fluctuant, tender, palpable mass) * drain and empiric abx (dicloxacillin, cephalexin)

Answer 585

Do a CT abdomen Unless the patient is a kid or pregnant woman-> do U/S of abdomen instead Then take to surgery (*note: although imaging used to be not required for an appendectomy, UW states that imaging is done now prior to surgery.)

Answer 586

If patient is stable: do cholecystectomy (take gallbladder out) If cholangitis (unstable), stone is stuck in CBD, or increasing LFTs: do ERCP to get the stone out-> let pancreas “cool down” bc inflammation complicates surgery-> cholecystectomy *note that gallstone pancreatitis does not mean the stone is for sure stuck in the common bile duct (CBD)! Stone may have been stuck in the CBD and passed like a drive-by, but still caused pancreatitis bc inflammation takes time to subside

Answer 587

Internally rotated-> Dislocated (And adducted-> posterior dislocation vs. aBducted-> anterior dislocation) Externally rotated-> Fractured (broken) **memory trick: “ID and EF” (ID like identification for Internally and Dislocated. EF like eff surgery for Externally and Fractured. To remember aBducted for anterior dislocation, remember Aliens ABduct people)

Answer 588

In the CBD (common bile duct) * this leads to an ascending gram (-) infection-> Charcot’s triad (RUQ pain, jaundice, fever/ chills) or Reynolds pentad (the triad + shock/ low BP, altered mental status) * *these patients are at risk for rapid sepsis and death (the liver has a rich blood supply)

Answer 589

Diagnostic mammogram w/ core biopsy

Answer 590

1. Reassurance and watch/ wait 2-3 cycles 2. If persists-> U/S (young women have dense breasts, so ultrasound is preferred over mammogram) 3. If U/S shows it is cystic-> elective needle aspiration. If U/S shows it is a mass (or complex cyst)-> image-guided core biopsy

Answer 591

When it is bloody (from FNA) or persists/ reoccurs

Answer 592

1. Cholecystitis (gallstone stuck in cystic duct) 2. Choledocholithiasis (gallstone stuck in CBD) 3. Gallstone pancreatitis (gallstone stuck in CBD far enough down where it is obstructing the main pancreatic duct) 4. Ascending cholangitis (gallstone stuck in CBD + there is an ascending gram neg infection)

Answer 593

``` Aortic dissection Blunt aortic injury Mediastinitis Esophageal rupture Aortic aneurysm Cardiac tamponade ```

Answer 594

Thyroid storm *severe stress (surgery, trauma, childbirth, illness)—> high HR, arrhythmia, high BP, high temp, tremor, altered MS

Answer 595

Ex lap (exploratory laboratory) ASAP

Answer 596

- Patient has peritonitis—> ex lap (*no need to get a FAST exam—get them to surgery!) - Patient is stable w/ positive FAST—> ex lap (*may do a CT first since stable so you got a little time) - Patient is unstable /w positive FAST—> ex lap - Patient is stable w/ negative FAST—> CT abdomen/ pelvis (if suspicious for abdominal injury) - Patient is unstable w/ negative FAST—> diagnostic peritoneal lavage (DPL) (*may do a CT, but prob don’t have time)

Answer 597

Ventilation: 1. Tv (tidal volume)- keep around 6 (4-8 to be exact) 2. RR (respiratory rate)- keep at 10-12 Oxygenation: 1. FiO2 (fraction inspired oxygen)- less than 60% 2. PEEP (positive end expiratory pressure)- around 5

Answer 598

Acute mastitis (inflammatory condition)

Answer 599

Periductal mastitis (inflammatory condition)

Answer 600

Mammary duct ectasia (inflammatory condition)

Answer 601

Fat necrosis (inflammatory condition)

Answer 602

Fibrocystic change (benign)

Answer 603

Intraductal papilloma

Answer 604

Fibroadenoma (benign)

Answer 605

Phyllodes tumor

Answer 606

1. DCIS (ducal carcinoma in situ) * malig proliferation of duct cells, calcifications (rarely a mass- so must biopsy to distinguish from benign fibrocystic change and fat necrosis), can “walk up” breast to become Paget dz of the breast 2. IDC (invasive ductal carcinoma) * invasive duct-like structures, mass plus/minus nipple retraction, subtypes (tubular, mucinous, medullary, or inflammatory) 3. LCIS (lobular carcinoma in situ) * malig proliferation of lobular cells, mass or calcification, cells spaced apart (lack of E-cadherin), Tamoxifen given 4. ILC (invasive lobular carcinoma) * invasive, single-file pattern

Answer 607

Carcinoma in situ (DCIS)—> lumpectomy + radiation + axillary LN dissection OR mastectomy + axillary LN dissection *LCIS (lobular carcinoma in situ)- we often do prophylactic bilateral mastectomy. Why? Removal of the tumor doesn’t decrease the chance of it turning invasive) ``` Invasive carcinoma (IDC, ILC)—> lumpectomy + radiation + axillary LN dissection + chemo (if node positive) + targeted therapy (like Tamoxifen, if estrogen receptor positive) OR mastectomy + axillary LN dissection + chemo (if node positive) + targeted therapy (like Tamoxifen, if estrogen receptor positive) ``` **when can you do lumpectomy + radiation as opposed to mastectomy? If the tumor is small and away from the nipple