UWORLD Flashcards
Pt complains of popping sound followed by severe pain at the time of injury when his foot was fixed and was twisted. PE reveals localized tenderness on medial side of knee. THis is a meniscal tear. What is the “bucket handle” tears and “McMurray’s sign”?
“bucket handle tears” -locking of the knee joint on extension
McMurray’s sign: palpable or audible snap occurring while slowly extending the leg at the knee from full flexion while simultaneously applying tibial torsion.
Pt complains of popping sound followed by severe pain at the time of injury when his foot was fixed and was twisted. PE reveals localized tenderness on medial side of knee. THis is a meniscal tear. What is the “bucket handle” tears and “McMurray’s sign”?
“bucket handle tears” -locking of the knee joint on extension
McMurray’s sign: palpable or audible snap occurring while slowly extending the leg at the knee from full flexion while simultaneously applying tibial torsion.
Medial collateral ligament injury is assoc with abduction injury to the knee. What test will help in clinical diagnosis
valgus stress test (when you move the knee laterally)
Lateral collateral ligament is rare and would be seen in adduction injury to the knee. What test can clinically diagnose it
varus stress test
Respiratory Quotient = CO2 produced/rate of O2 uptake
An RQ close to 1 –>
An RQ at 0.8 –>
An RQ at 0.7 –>
An RQ close to 1 –> carbohydrates major nutrient oxidized
An RQ at 0.8 –> protein
An RQ at 0.7 –> lipid
Sepsis is a hypermetabolic, hypercatabolic state wherein both fat and protein are broken down in addition to gluose. Respiratory quotient in a septic patient is? >1, = 1,
amt of O2 consumed =
PaO2-PvO2
Someone with winged scapula post axillary lymphadenectomy for treatment of breast cancer due to?
injury to long thoracic nerve.
Someone with winged scapula post axillary lymphadenectomy for treatment of breast cancer due to?
injury to long thoracic nerve.
What is torus palatinus
a congenital condition characterized by chronic growth on hard palate. It is a benign bony growth located on midline suture of hard palate. More common in younger patients, women and Asians. No medical or surgical therapy required unless symptomatic or interferes with speech or eating
What’s the most reliable means of monitoring adequacy of circulation in a circumferentially burned limb?
serial exam using doppler US flow meter
Respiratory Quotient = CO2 produced/rate of O2 uptake
An RQ close to 1 –>
An RQ at 0.8 –>
An RQ at 0.7 –>
An RQ close to 1 –> carbohydrates major nutrient oxidized
An RQ at 0.8 –> protein
An RQ at 0.7 –> lipid
amt of O2 consumed =
PaO2-PvO2
Tx rxn: anaphylactic rxn presents with rapid onset of shock, angioedema/urticaria, and resp distress w/in a few secs of transfusion. Caused by?
Caused by recipient anti-IgA abs in someone with IgA def
Someone with winged scapula post axillary lymphadenectomy for treatment of breast cancer due to?
injury to long thoracic nerve.
Someone with pulsatile groin mass below the inguinal ligament with anterior thigh pain 2/2 to compression of femoral nerve. Suspect.
femoral artery aneurysm
What is torus palatinus
a congenital condition characterized by chronic growth on hard palate. It is a benign bony growth located on midline suture of hard palate. More common in younger patients, women and Asians. No medical or surgical therapy required unless symptomatic or interferes with speech or eating
A change in which parameter is the FIRST indicator of hypovolemia?
HR goes up and peripheral vasoconstriction occur to maintain BP w/in normal
Tx rxn: Febrile nonhemolytic is most common that presents with fever and chills w/in 1-6 hrs of tx. Caused by?
cytokine accumulation during blood storage
Tx rxn: acute hemolytic presents with fever, flank pain, hemoglobinuria, renal failure and DIC. Usu occurs w/in 1 hr of tx. What test to order? Caused by?
Test: positive direct Coombs test
Caused by ABO incompatibility
Tx rxn: delayed hemolytic rxn presents with mild fever and hemolytic anemia w/in 2-10 days after transfusion. What tests are positive. Caused by?
Test: positive direct Coombs test, positive new antibody screen
Caused by anamnestic antibody response
Hemorrhagic shock can be divded into 4 categories depending on amt of blood loss.
Class IV
> 40% (>2000 ml)
HR > 140
BP markedly decreased
Tx rxn: urticarial/allergic presents with urticaria, flushing, angioedema and pruitis within 2-3 hrs of tx. Caused by
Caused by recipient IgE antibodies and mast cell activation
Tx rxn: Transfusion-related acute lung injury presents with resp distress and signs of noncardiogenic pulmonary edema w/in 6 hrs of tx. Caused by?
Caused by donor anti-leukocyte abs
Hypoxemia can be caused by reduced inspired O2 tension, hypoventilation, diffusion limitation, shunt, and V/Q mismatch. What is characteristic of alveolar hypoventilation?
respiratory acidosis
normal A-a gradient
Nerve damage from wearing crutches
radial nerve
Hemorrhagic shock can be divded into 4 categories depending on amt of blood loss.
Class I
72
BP normal
After MVC, someone develops dyspnea, tacypnea, chest pain, hypoxemia that worsened by fluids and patchy irregular alveolar infiltrates on chest x-ray. Suspect?
pulmonary contusion
Whistling noise during respiration after rhinoplasty? Suspect?
nasal septal perforation likely from septal hematoma
Hemorrhagic shock can be divded into 4 categories depending on amt of blood loss.
Class IV
> 40% (>2000 ml)
HR > 140
BP markedly decreased
Cricothyroidectomy should be converted to formal tracheostomy if MV is needed past 5-7 days. Why?
high incidence of tracheal stenosis
A-a gradient is normal when it’s
Pulmonary Embolism
Atelectasis
Pleural effusion
Pulmonary edema
There is a decrease in PCO2 (respiratory alkalosis) due to compensatory hyperventilation
Persistent pneumothorax and significant air leak following chest tube placement in a pt who has sustained blunt chest trauma suggests?
tracheobronchial rupture. (normally right main bronchus)
Trismus (inability to open the mouth normally), limited cervical extension, neck pain, fever… suspect
retropharyngeal abscess -usual source is from local penetrating trauma. In order to fully evaluate the extent of the infection, do a CT of the neck and/or lateral radiographs of the neck which may show lordosis of cervical spine with gas and swelling in retropharygneal area. Treatment is IV abx and urgent drainage of abscess
4 T’s for ddx for anterior mediasinum mass.
- thymoma
- teratoma
- thyroid neoplasm
- terrible lymphoma
After MVC, someone develops dyspnea, tacypnea, chest pain, hypoxemia that worsened by fluids and patchy irregular alveolar infiltrates on chest x-ray. Suspect?
pulmonary contusion
Whistling noise during respiration after rhinoplasty? Suspect?
nasal septal perforation likely from septal hematoma
What fixes paradoxical movement in flail chest?
positive pressure mech ventilation by replacing the normal negative intrapleural pressure during spon vent with positive intrapleural press
Cricothyroidectomy should be converted to formal tracheostomy if MV is needed past 5-7 days. Why?
high incidence of tracheal stenosis
What are some common causes of gastric outlet obstruction?
- malignancy
- PUD
- chrohn
- strictures 2/2 to ingestion of caustic agents
- gastric bezoars
Persistent pneumothorax and significant air leak following chest tube placement in a pt who has sustained blunt chest trauma suggests?
tracheobronchial rupture. (normally right main bronchus)
Trismus (inability to open the mouth normally), limited cervical extension, neck pain, fever… suspect
retropharyngeal abscess -usual source is from local penetrating trauma. In order to fully evaluate the extent of the infection, do a CT of the neck and/or lateral radiographs of the neck which may show lordosis of cervical spine with gas and swelling in retropharygneal area. Treatment is IV abx and urgent drainage of abscess
Blunt abd trauma –> delayed onset hypotension, LUQ abd pain, left shoulder pain (kehr sign). If hemo stable, do what? If not hemo stable, do what?
if stable –> abdominal CT scan wtih IV contrast to look for splenic injury
if unstable –> urgent laparatomy
Gastrochisis is a protrusion of bright red intestines to the ___ side of a normal umbilicus without a membrane. What to do
RIGHT
surgical emergency
FOr any pt who suffers blunt deceleration trauma (MVA or fall from > 10 feet), what must be ruled out? What’s the initial screening test? and the most sensitive finding?
blunt aortic trauma must be ruled out and CXR is the initial screening test and widening of the mediastinum is the most sensitive finding.
Plain films of the foot show a hairline fracture of the shaft of the second metatarsal in someone who has had painin that foot that started wks again with activity and now with rest. Dx? What to do?
Stress aka hairline fracture
Treatment: rest, analgesia, and a hard-soled shoe
When do you actually give someone tetanus abs
any individual with a severe or dirty wound WITH really immunocompromised state or an unclear or incomplete immunization history
HOw does positive pressure MV worsen someone in hypovolemic shock that has not been adequately resuscitated?
-positive pressure MV increases intrathoracic pressure which decreases venous return to heart and thereby decreases ventricular preload. In someone who is already in hypovolemic shock, this can cause circulatory collapse unless volume adequately resuscitated
widened mediastinum large left-sided hemothorax deviation of mediastinum to the right disruption of aortic contour on cxr
-all signs of possible
aortic injury
can be confirmed with CT
Prosthetic joint infection: early vs delayed-onset infection
early-onset: w/in 3 months of primary arthroplasty; most common org is staph aureus; treat with implant removal/exchange
delayed-onset: > 3 mo after primary arthroplasty; most common org is staph epid; treat with implant removal/exchange
what characterizes post-operative cholestasis?
benign condition that often develops after a major surgery characterized by hypotension, extensive blood loss into tissues, and massive blood repalcement. Jaundice develops due to increased pigment load from tx, decreased liver function due to hypotension and decreased renal bilirubin excretion from tubular necrosis. Jaundice is evident by 2nd or 3rd day with bilirubin peaking by POD10
How to manage someone with duodenal hematoma (most commonly due to direct blunt abd trauma in children)
Usually self-resolving so manage with NG suction and parenteral nutrition. If fails, then surgery
How soon after surgery can you start anticoagulation in a patient who needs it
48-72 hrs post-surgery in hemodynamically stable pts
how does thoracic artery aneurysm repair lead to anterior spinal cord syndrome (loss of spinothalamic and corticospinal)
the artery that supplies the anterior spinal cord is the anterior spinal artery which is a branch of the artery of Adamkiewicz from the thoracic arota. Therefore, thoracic aortic surgery can result in reduced blood flow during aortic cross clamping or hypotension and lead to anterior spinal cord infarction
Bacterial infection usu bronchopneumonia or burn wound infection leading to sepsis is the leading complication of burn victims after adequate fluid resusc. which are the 2 most likely organisms involved
staph aureus
pseudomonas
How can one confirm fat embolism
presence of fat droplets in urine
presence of intra-arterial fat globules on fundoscopy
How do these interventions help with lowering ICP:
1) head elevation
2) sedation
3) IV mannitol
4) hyperventilation
5) removal of CSF
1) head elevation: increased venous outflow from the brain
2) sedation: decreased metabolic demand & control of HTN
3) IV mannitol: extraction of free water from brain tissue –> osmotic diuresis
4) hyperventilation: CO2 washout –> cerebral vasoconstriction
5) removal of CSF –> reduction of CSF volume/pressure
What’s the most common bone in the body to be affected by stress fractures
tibia (“shint splints” or medial tibial stress syndrome”)
Acute bacterial parotitis can occur in older pts post-surgery presenting as fever, leukocytosis and parotid inflammation. How to prevent? What’s the most common causative agent?
- adequate fluid hydration and oral hygiene can prevent
- Staph aureus
Leriche syndrome -triad of symptoms?
arterial occlusion at the bifurcation of aorta into common iliac arteries aka aortoiliac occlusion.
Triad: bilateral hip/thigh/buttock claudication, impotence, and symmetric atrophy of b/l LE due to chronic ischemia
Who is at greatest risk of Leriche syndrome/aortoiliac occlusion
men at high risk for atherosclerosis (e.g. smokers)
Congenital adhesions are called
Ladd’s bands
What are the most impt steps in management of lactic acidosis from septic shock?
IV normal saline with or without vasopressure therapy to maintain the intravascular pressure and abx to correct the underlying infection
Femoral nerve: motor and sensory functions?
motor: muscles of anterior compartment so impt for knee extension and hip flexion.
Sensation: anterior thigh and medial leg via the saphenous branch
Obturator nerve: motor and sensory functions?
motor: muscles of medial compartment so impt in adduction of thighs
sensation: medial thigh
What’s impt about moving pt from supine to sitting post-op
supine to sitting can increase the functional residual capacity by 20-35%.
What to do if someone needs urgent surgery and is on warfarin?
will need to reverse INR to lessen chances of bleeding excessively during surgery by giving infusion of FFP to restore vit K-dependent clotting factors.
define massive hemoptysis
> 600 ml of expectorated blood over a 24 hr period or a bleeding rate > 100 mL/hr
WHat’s initial management of someone with massive hemoptysis
- adequate airway
- aqequate ventilation and gas exchnage
- make sure hemo stable
- placed with bleeding lung in dependent postion to avoid blood collection of opposite lung
- bronchoscopy is initial procedure of choice as it can localize bleed, and can intervene therapeutically
positive drop arm sign when you passively abduct pt’s arm and then release and ask pt to lower it. instead of lowering it, it just drops down, signfying
rotator cuff tear
after gynecologic surgeries, a woman develops unexplained fever and you suspect thromboplebitis. How to treat?
- heparin
- abx
Pressure ulcers are caused by impaired blood flow leading to ischemia. Check CBC and blood cx as culturing will just get skin flora. Can do tissue biopsy to r/o marjolins ulcer. Best prevention is turning pt q2h. What are the 4 stages of pressure ulcers
stage 1 = skin intact but red and still blanches with pressure
stage 2 = blister or break in the dermis
stage 3 = subcutaneous destruction into the muscle
stage 4= involvement of joint or bone
adenocarcinoma of the lungs can cause pleural effusions characterized by
exudative with high hyaluronidase
Lung cancer assoc with hypercalcemia
squamous cell -PTHrp
Pt with shoulder pain, ptosis, constricted pupil and facial edema?
pancoast tumor/superior sulcus syndrome usu from small cell
pt with lung cancer with ptosis that is better after 1 min of upward gaze
lambert eaton assoc with small cell carcinoma from ab to presynaptic calcium channels
what is krukenberg cancer?
gastric cancer that has metasized to ovaries
What is virchow’s node
gastric cancer with swollen supraclavicular LNs
What is gastric lymphoma assoc with
HIV
What is MALT lymphoma assoc with
H. pylori and can be treated with triple therapy
What is blummer’s shelf
gastric cancer metastasis that can be felt on digital rectal exam.
What is sister mary joseph
gastric cancer with umbilical LNs
What is mentriers’
protein losing enteropathy on EGD can see enlarged rugae
Pt has bilious vomiting, post-prandial pain and recently lost 200 lbs.
SMA syndrome happens when 3rd part of duodenum is compressed by aorta and SMA. Treatment is nutrition.
Choledochal cysts can present as persistent jaundice in a newborn. What’s the diff btw type 1 and type 4
type 1 = fusiform dilatation of CBD -> treat with excision
type 4 = caroli’s disease when cysts are in intrahepatic ducts that will necessitate liver tx
TIPS can improve portal HTN but can worsen
hepatic encephalopathy by interrupting clearance of ammonia.
Post-op splenectomy can lead to thrombocytosis when plts are above 1,000,000. How to treat.
Give aspirin (anti-plt)
Post-splenectomy vaccines
s. pneumo
h influenzae
n meningitides
(also post-op penicillin -impt in immune function)
+ Casoni skin test and liver cysts and eosinophilia
echinococcus
will do surgery to remove cysts but be careful of anaphy rxn and give albendazole
which deficiency is assoc with carcinoid tumor
niacin deficiency bc tryptophan is used to make niacin and is used to make all the excess serotonin instead
niacin is assoc with the Ds: diarrhea, dermatitis, death, dementia
List the 3 Light’s criteria to determine if an effusion is exudative or not.
Pleural fluid protein/Serum protein > 0.5
Pleural fluid LDH/Serum LDH > 0.6
Pleural fluid LDH > 2/3 upper limit of normal
How to calculate basal energy expenditure in males and females
males: 25 kcal/kg/day
females: 22 kcal/kg/day
Pt with recent h/o of skin infection presenting with fever and abdominal pain radiating to the groin and pain with hip extension points to what dx? How to dx and treat?
psoas abscess which can occur either hematologic seeding from a distant infection or from direct extension of an intraabdominal infection (diverticulitis, osteomyeltis)
Risk factors: HIV, IV drug use, diabetes, Chrohns
Dx: CT scan of abdomen & pelvis; blood and abscess cxs
Treatment: Drainage and broad spectrum abxs
In supracondylar fracture, one should worry about brachial artery or median nerve injury. Compartment syndrome is concerning as well although rare. What can compartment syndrome lead to/?
Volkman contracture which is permanent flexion contracture of the hand at the wrist, resulting in a claw-like deformity of the hand and fingers. Passive extension of fingers is restricted and painful. Volkmann’s Ischemic Contracture is the direct result of undiagnosed Compartment Syndrome. It is excruciatingly painful and disabling
What to suspect when a pt presents with recent cardiac cath, anticoagulation with heparin, sudden onset of hypotension, tachycardia, flat neck veins and back pain? How to diagnose and treat?
retroperitoneal hematoma due to bleeding from arterial access site that usu occurs w/n 12 hrs of catheterization.
Dx is confirmed with NON-contrast CT or ultrasound
Treatment is bed rest, IV fluids or blood tx
Which part of the bladder is the only region covered by peritoneum and can cause referred pain to left shoulder (kehr sign)?
dome of the bladder
How to treat penile fracture?
emergent urethrogram to assess for urethral injury and emergent surgery to evacuate the hematoma to mend the torn tunica albuginea
Pts who take daily prednisone >/- 20 mg for > 3 wks are at high risk of adrenal insufficiency when in stressful conditions like surgery. Impt to give stress dose of steroids during the acute stressful condition. What are some clinical clues that may suggest perioperative adrenal insufficiency?
- unexplained nausea/vomiting, abd pain
- hyponatremia, hyperkalemia
- hypoglycemia
- hypotension
Acute mediastinitis is a possible complication of cardiac surgery that is usually due to intraop wound contamination. What is typical presentation? What can you see on xray? How to dx and treat?
presentation: usu w/in 14d with fever, tachycardia, chest pain, leukocytosis, sternal wound drainage or purulent discharge
CXR: may show widened mediastinum
Dx is clinically made
Treatment is drainage, surgical debridement wtih immediate closure and abx therapy.
AF can occur after CABG but is usually self-limiting with resolution
rate control best with beta blockers or amiodarone
> 24 hrs of AF, can consider anticoagulation and/or cardioversion
Post-thyroidectomy is the most common cause of hypoparathyroidism. What is the second most common case of primary hypoparathyroidism?
autoimmune
nasopharyngeal carcinoma is an undifferentiated carcinma of squamous cell origin that is usu asymp until too late. They often present with recurrent otitis media (due to tumor obstructing eustacian tube), recurrent epistaxis, and/or nasal obstruction. This is strongly assoc with what virus and what social risk factors
strongly assoc with EBV
assoc with smoking and chronic nitrosamine consumption (salted fish)
