UWorld 1 Flashcards
what type of shock is indicated by low CO, high PCWP and CVP, and low MAP
Cardiogenic (LV dysfunction gives high PCWP, RV dysfunction gives high CVP)
Describe hypovolemic shock in terms of CO, SVR, MAP, and CVP
High CO and SVR. Low MAP and CVP
Describe septic shock in terms of SVR, MAP, PCWP, and CVP
Low in all four metrics
Describe obstructive shock in terms of CO, SVR, MAP, PCWP, and CVP
Low CO, PCWP, and MAP, high SVR, CVP
Provide 4 examples of cardiogenic shock
contusion, MI, septal rupture, arrhythmia
Provide 3 examples of obstructive shock
cardiac tamponade, tension pneumo, massive hemothorax
Provide 3 examples of distributive shock
sepsis, anaphylaxis, neurogenic
What is Beck’s triad for cardiac tamponade
hypotension, high CVP, muffled heart sounds
Outline first 2 steps in treatment of cardiogenic shock
1) Fluid replacement until PCWP 15-20mmHG. 2) inoptropic agents to increase CO.
What is the best preventive measure against postoperative pneumonia
Incentive spirometry
A patient suffered a large deceleration injury. Hypertension was noted in the upper extremities, while hypotension was noted in the lower extremities. They are hoarse. What should be considered
Descending aortic rupture (with recurrent laryngeal nerve involvement)
A large air leak is noted after placement of a chest tube for a suspected pneumothorax. What should be considered with this finding?
Tracheobronchial rupture
Peritoneal irritation of the diaphragm can radiate where?
To the ipsilateral shoulder (phrenic nerve originates in C3-C5 nerve roots)
A patient has a marked decrease in systolic blood pressure, a HR >120, a RR of 40, and delayed cap refill following trauma. What class of hypovolemic shock is this?
Class III hypovolemic shock
Patient presents with fever, chills, and deep abdominal pain suggestive of retroperitoneal abscess following blunt trauma believed to have involved the pancreas. What is the appropriate treatment?
Percutneous drainage, culture fluid, debride surgically
What finding on xray is suggestive of gastric perforation
Free air under diaphragm
List 3 radiographic findings suggestive of aortic transection
Widened mediastinum, loss of aortic contour, tracheal deviation to the right, left-sided hemothorax
Provide a manifestation of esophageal rupture
subcutaneous emphysema, pneumomediastinum, pleural effusion
What are the radiographic findings of diaphragmatic rupture (2)
abdominal viscera in thorax, loss of diaphragmatic contour
What should you suspect in a patient with paradoxical thoracic wall movement following trauma and how would you correct it.
Flail chest. Correct with intubation and positive pressure ventilation (pain control and supplemental O2 also)
Differentiate blood produced from the GI tract vs the respiratory tract in a patient with hemoptysis
GI - blood is acidic, dark in colour, may contain food particles. Resp - blood is alkaline, bright red, and frothy.
What is the first step in mgmt of an event of atraumatic hemoptysis with suspect respiratory origin?
bronchoscopy - diagnostic, therapeutic, and aids in maintaining airway
What is the first step in managing a patient with suspected thermal injury to their upper airway
Intubate
Explain the clinical picture of biliary colic (3)
1) colicky pain post prandially 2) N/V 3) right shoulder or subscapular pain (referral).
Explain the clinical picture of acute cholecystitis (3)
1) pain is constant 2) fever 3) leukocytosis
A patient receives blood products during surgery and acquires a mild fever and rigors. What is the diagnosis and treatment
Dx: Acute febrile nonhemolytic transfusion reaction
Tx: Stop transfussion
What is the quickest way to reverse warfarin-induced anticoagulation in a patient with a suspected bleed in an emergency setting
Fresh frozen plasma (replenish vitamin K dependent clotting factors)
Describe the clinical features of Leriche syndrome (aortoiliac occlusion) (3)
1) claudication in hips, thigh, buttocks
2) impotence
3) symmetric atrophy of bilateral lower extremities
What drug should you provide a patient at increased risk of perioperative or post-operative MI?
Metoprolol (beta blocker)
Provide the risk factors for atherosclerotic vascular disease (5)
DM, age, smoking, HTN, hyperlipidemia
Explain the respiratory quotient and provide values for carbohydrate, protein, and fat consumption. What does a high RQ indicate
RQ is the ratio of CO2 produced to O2 consumed, it is an assessment of metabolism
RQ carbs = 1.0, RQ protein = 0.8, RQ fat = 0.7
High RQ indicates excess carbohydrate metabolism
What would the anticipated RQ in a septic patient be (high, normal, or low)?
Low - metabolism of fats and proteins largely
Differentiate arterial embolism from arterial thrombosis (2)
1) Arterial embolism is a sudden and severe onset. AT has an insidious onset
2) AT typically presents with diminished pulses bilaterally
Explain the clinical picture of arterial embolism (6)
1) sudden and severe onset of pain
2) diminished or absent pulse
3) pallor
4) cool skin
5) neurologic deficits
6) muscle dysfunction
Which nerve is at highest risk during an anterior dislocation of the shoulder?
Axillary
Mid-shaft fracture of the humerus would affect what nerve and have what impact on the forearm/hand?
1) radial nerve
2) wrist drop and lack of sensation on doral-lateral portion of hand
List the five P’s of compartment syndrome (ischemic-reperfusion syndrome)
1) Pain
2) Paresthesias
3) Pallor
4) Pulselessness
5) Paralysis
What impact does positive pressure ventilation have on venous return
Reduces venous return by increasing intrathoracic pressure. Can exacerbate hypovolemic shock by reducing preload.
Outline the treatment for a patient who has suffered their first DVT
heparin for initial anti-coagulation, followed by 3 months of warfarin treatment with INR goal of 2-3. Objective is to prevent extension of clot, not thrombolysis.
Name two medications that can be used as thrombolytics in STEMIs or thrombotic strokes
tPA and streptokinase
Describe Vichow’s triad
stasis, hyper-coagulability, endothelial injury
Provide the diagnostic criteria for systemic inflammatory response syndrome (SIRS) (4)
1) Fever >38 or hypothemia 20
3) tachycardia, HR >90
4) leukocytosis (>12), leukopenia (10%)
Patient must meet 2 of 4 criteria
Differentiate SIRS, sepsis, and septic shock
SIRS - 2 of 4 diagnostic criteria met
Sepsis - SIRS due to infection
Septic Shock - sepsis with insufficient tissue perfusion and hypotension
What is the most common organism that causes infections in burn patients 1) prior to 1-week, 2) post 1-week
1) S. aureus
2) P. aeruginosa
Describe clinical findings of a tension pneumothorax (5)
1) tachypnea
2) tracheal deviation to unaffeccted side
3) High CVP
4) hyperresonance to percussion
5) tachycardia
What is the treatment for a tension pneumothorax?
Needle thoracostomy into 2nd intercostal space
What are characteristics of a lung nodule seen on CT that are consistent with malignancy? (4)
1) increasing size
2) irregular margins
3) irregular calcifications
4) cavitation
What study is used to evaluate solitary pulmonary nodules (SPN) detected on CXR?
CT scan
Which cranial nerve traverse the parotid gland
Facial
Surgery of the submandibular gland can result in which clinical feature
Tongue palsy due to damage to the hypoglossal nerve
Winged scapula can result due to what cancer procedure
Axillary lymphadenectomy for breast cancer
Describe the classic clinical presentation of renal colic
severe flank or abdominal pain radiating to the groin (scrotum or labia), accompanied by nausea and vomiting. Patient unable to sit still (unlike acute abdomen patient who is bothered by movement)
What is the best diagnostic test for urinary stones
CT Abdomen (visualize calcium and non-calcium stones)
What prevents post-op acute bacterial parotitis and what is the most common bacterial pathogen
1) adequate fluid intake and oral hygiene
2) S. aureus
Describe the characteristics of complete proximal bowel obstruction (3)
1) vomiting
2) abdominal discomfort
3) abnormal contrast filling on xray
Describe the characteristics of a mid or distal bowel obstruction (4)
1) colicky abdominal pain
2) vomiting
3) abdominal distension, dilated bowel on xray
4) constipation
Differentiate simple obstruction from strangulation
1) simple = luminal obstruction
2) strangulation = loss of blood supply
What is are the most common causes of small bowel obstruction (3)
adhesions»_space; Crohn’s > neoplasm
What are 4 common causes of melena
Upper GI bleed:
1) peptic ulcer disease
2) gastritis
3) esophagitis
4) mallory-weiss tear
What does a ‘drop test’ indicate wrt a patients arm
supraspinatus tear
Rupture of the long head of the bicep results in what clinical sign
Popeye’s sign
Expect weakness in supination
Describe Klumpke’s palsy
Results in claw hand due to damage of the lower brachial plexus which is the origin of the ulnar nerve. Results in claw hand.
What three organisms are most dangerous to a patient who has undergone a splenectomy
Encapsulated bacterial
1) S. pneumoniae
2) N. meningitidis
3) H. influenzae
What is the most common form of benign breast disease that presents with unilateral bloody discharge from the nipple
Intraductal papilloma
What information can differentiate fibrocystic breast changes from a fibroadenoma
fibrocystic changes vary based on menstrual cycle
Describe the findings for fibroadenoma (5)
1) benign
2) painless
3) firm
4) mobile
5) > 2cm
What commonly presents as pain and swelling of the midline sacrococcygeal skin and possible sinus tract. How is it treated?
1) pilonidal disease
2) drainage of abscess and excision of the sinus tract
Describe a varicocele (what structure does it affect, what is the result of transillumination, what accentuates the defect, significant findings on physical exam)
1) dilation of the pampiniform plexus of veins
2) negative transillumination
3) increases with increased intraabdominal pressure (Valsalva)
4) scrotum feels like “bag of worms”, dull pain in testis
Describe a hydrocele (what structure does it affect, what is the result of transillumination, what accentuates the defect)
1) fluid collection in tunica vaginalis
2) positive transillumination
3) may increase with valsalva
Describe a spermatocele (what structure does it affect, what is the result of transillumination, what accentuates the defect)
1) cyst with sperm in or near epididymis
2) positive transillumination
3) no change with valsalva
Describe a testicular neoplasm (3) and appropriate treatment
firm, non-tender, does no transilluminate
orchiectomy
Describe the clinical picture of a patient with a pulmonary contussion following trauma (3). What is seen on xray.
1) tachycardia
2) tachypnea
3) hypoxemia
4) patchy, irregular alveolar infiltrates
Describe the clinical picture of a fat embolism (5)
1) long bone fracture
2) tachycardia
3) tachypnea
4) mental changes
5) thrombocytopenia and petechiae
Differentiate hemithorax and tension pneumothorax based on CVP, volume status, percussion, and tracheal location
hemithorax - low CVP, signs of hypovolemia (hemorrhagic shock), dullness to percussion, tracheal may be slightly deviated to unaffected side
tension pneumo - high CVP, no signs of volume loss, hyper-ressonant to percussion, tracheal deviation to unaffected side obvious.
What vascular injury should be considered in a fall >10 ft
aortic rupture
What are the SSx and xray findings of aortic injury (5)
1) anxiety
2) tachycardia
3) hypertension (upper extremity, pseudocoarctation)
4) mediastinal widening
5) loss of aortic knob on xray
What are 3 clinical signs associated with pancreatic cancer
1) wt loss
2) jaundice (if cancer in head of pancreas)
3) epigastric pain radiating to the back
Differentiate duodenal ulcer from pancreatic cancer based on 2 clinical signs
duodenal ulcer - pain relieved with meals, wt loss not associated
How will PCWP and pO2be affected in a patient with pulmonary contusions who is being volume resuscitated
PCWP increases and pO2 decreases due to ongoing edema in the lungs hastened by fluid resuscitation
What are the effects of pulmonary contusion on blood pH and pCO2
pH is alkalotic, pCO2 is low - both due to hyperventilation
What would you expect the BUN/Cr ratio and the FeNa to be in prerenal azotemia in the post-op patient suffering from hypovolemia
BUN/Cr > 20, FeNa
How should prerenal azotemia be treated in a patient with suspect volume depletion following surgery
1) R/O catheter obstruction
2) Fluid challenge (provide IV bolus fluid) and monitor urine output
List the skin changes associated with peripheral vascular disease (4)
1) atrophic skin
2) shiny in appearance
3) loss of hair
4) poor healing of wounds or presence of ulcers
List some methods used to increase FRC of the lungs in the post-op patient (4)
1) elevating the head of the bed
2) ambulation
3) incentive spirometry
4) promoting coughing
