Uworld Flashcards
if suspect variceal hemorrhage, do what before getting EGD?
place 2 large bore IV catheter for fluid resuscitation
give IV octreotide and abx
THEN EGD
the most likely diagnosis in a patient with abdominal pain following a traumatic injury and abd. XR with gas-filled loops in small and large intestine + gastric dilation
paralytic ileus
ileus is commonly due to ?
other causes?
retroperitoneal/abdominal hemorrhage or inflammation, intestinal ischemia, e-lyte abnormalities
perforated PUD should be diagnosed with ? which may show ?
upright XR of chest and abd
would show free intraperitoneal air under the diaphragm
hidradenitis suppurativa vs pilonidal disease
HD: multiple, recurrent painful nodules in the axillae, inguinal folds and perineal areas
PD: single fluctuant mass midline in gluteal clefts
painful active range of motion but normal passive range of motion think ?
bursitis
prepatellar bursitis may be cause by S. aureus
episodic pain at the inferior patella and patellar tendon, think?
patellar tendinitis
chronic anterior knee pain worse with activity or prolonged sitting, think what condition?
patellofemoral pain syndrome
3-4% of patients with spinal cord injuries will develop post-traumatic ?
syringomyelia
enlargement of central canal of the SC due to CSF retention
cervical spondylosis results from ?
disc degeneration in pts over 40
may develop stenosis, resulting in neuro deficits
atelectasis will show what on ABG?
hypoxemia, hypocapnia and respiratory alkalosis
supracondylar fracture of humerus most commonly happens from what injury?
complications?
FOOSH branchial artery injury median n. injury cubitus varus deformity compartment syndrome Volkmann ischemic contracture
common first sign of burn wound infection
change in wound appearance/loss of viable graft
other findings: temp less than 97.7 or greater than 102.2, tachy greater than 90, tachypnea greater than 30, hypotension (refract) systolic less than 90, oliguria, hyperglycemia, thrombocytopenia, AMS
common bugs in burn wound infections
treatment?
immediate: G+ (s. aureus)
5+ days: G-/fungi (pseudomonas, candida)
pip/tazo or carbapenem + vanc (MRSA) +/- aminoglycoside (pseudomonas)
treatment of duodenal hematoma
decompression with NG tube; may need surgery or percutaneous drainage
ddx of anterior neck mass (4 “Ts”)
if B-hCG elevated, think ?
if B-hCG and a-FP elevated think ?
thymoma, teratoma, thyroid neoplasm, terrible lymphoma
B-hCG elevated in 1/3 of seminomas
both elevated think nonseminomatous/mixed germ cell tumor
nonseminomatous forms of germ cell tumors
yolk sac, embryonal, choriocarcinoma
if pt presents with insidious onset constant gnawing epigastric pain worse at night, anorexia/weight loss, jaundice, think ?
pancreatic adenocarcinoma
jaundice from extrahepatic biliary obstruction
pancreatic cancer is diagnosed with ? if jaundice present and ? if no jaundice
US (head tumor)
CT (body/tail tumor)
ischemic colitis typically affects what areas?
“watershed” areas: splenic flexure (SMA/IMA) and rectosigmoid junction (sigmoid/SRA)
clinical feature ischemic colitis
mild pain/tenderness
hematochezia, diarrhea
metabolic (lactic) acidosis
dx ischemic colitis
CT scan: thick bowel wall, double halo sign, pneumatosis coli
colonoscopy
management ischemic colitis
IVF, bowel rest, IV abx, colon resection
a life-threateneing form of acute cholecystitis due to infection with gas-forming bacteria (Clostridium, E. coli)
emphysematous cholecystitis
may see air-fluid levels, gas in the GB wall, pneumobilia
tx with emergent cholecystectomy + IV abx (amp + sulbactam)
what clavicular fractures may require ORIF?
fractures of the distal 1/3rd
FFP may be indicated in hemoptysis if INR is greater than ?
1.5
injury to the long thoracic nerve causes weakness of what muscle ? with impairments of ?
may happen during ?
the serratus anterior
extreme abduction (greater than 90 degrees) due to inability to rotate the scapula forward
penetrating trauma, med/sx procedures (chest tube placement)
succinylcholine is a ? that may cause life-threatening ? in what patients
use what instead?
depolarizing neuromuscular blocker
hyperkalemia
patients with up regulation of postsynaptic acetylcholine receptors (burns, sk. musc. trauma, stroke)
use rocuronium, vecuronium
blunt chest trauma presenting with tachycardia, hypotension, JVD
+/- pleural effusion +normal cardiac contours on CXR
think what?
acute pericardial tamponade
100-200mL is enough to compromise venous return (JVD) and cardiac output (^HR, dec. BP) while not changing the cardiac contours (pericardium is stiff)
aortoiliac occlusion (Leriche syndrome) causes chronic ischemia classic triad?
b/l hip, thigh, buttock claudication
impotence
symmetric atrophy of b/l LE
how does hyperventilating decrease ICP?
it lowers cerebral paCO2 resulting in rapid vasoconstriction
what testicular mass increases in size with valsalva and standing and does not transilluminate?
varicocele
(spermatocele will not change in size)
(hydrocele will transilluminate)
varicocele treatment
gonadal vein ligation (boys and y. adult males with testicular atrophy)
scrotal support and NSAIDs (older men)
the most common cause of ureteral injury
iatrogenic trauma during abdominal surgery
injury due to blunt trauma is relatively rare
urethral injury presents with ?
inability to pass a foley, blood at the meatus, high-riding prostate
extraperitoneal bladder injury (EPBI) presents how
localized pain in low abdomen/pelvis
gross hematuria
urinary retention
intraperitoneal bladder rupture presents how
diffuse abdominal tenderness, guarding, rebound tenderness (signs of chemical peritonitis)
there may be metabolic acidosis and elevated amylase in these GI conditions (hint: not pancreatitis)
severe SBO, bowel ischemia
may also have leukocytosis and ^hgb
due to infarction, perforation, or peritonitis
how to diagnosis acute mesenteric ischemia
CT (2nd: MRA)
only mesenteric angiography if dx unclear
presentation of transtentorial herniation of the parahippocampal uncus (uncal herniation)
ipsilat hemiparesis (compression of contralto crus cerebri)
ipsilat mydriasis (loss of PS innervation)
strabismus- down and out (compression of ipsilate oculomotor n.)
contralat homonymous hemianopsia (compression of ipsilat PCA)
AMS/coma (compression of reticular formation)
what is Cushing’s reflex?
what does it indicate?
HTN, bradycardia, respiratory depression
indicates ^ICP
what may you see on CT with diffuse axonal injury?
diffuse small bleeds at the grey-white matter junction
pts typically are in a coma and px is grim
rupture of the dome of the bladder may cause shoulder pain due to what mechanism?
irritation of the peritoneal lining of l or r hemidaphragm may cause referred pain to the ipsilat shoulder (Kehr sign) as sensory innervation to the shoulder originates form the C3-5 spinal roots which are also the origin of the phrenic nerve innervating the diaphragm
GI complaints (nausea, abdominal pain, diarrhea) and vasomotor symptoms (palpitations, hypotension, tachycardia) after meals in a post-gastrectomy patient, think ? how to manage?
dumping syndrome: rapid emptying of gastric contents into duodenum/sm. intestine due to pyloric sphincter dysfunction from injury in bypass surgery diet modifications (sm. meals)
prolonged QT interval, think ?
if shortened, think ?
hypocalcemia
hypercalcemia
myocardial contusion vs. myocardial rupture
contusion cause tachycardia, BBBs, or arrhythmia; classic injury is sternal fracture
rupture causes cardiac tamponade that presents with muffled heart sounds, hypotension, and distended neck veins; dx with US and tx with emergent sx
esophageal rupture is typically caused by ?
manifestations on CXR?
iatrogenic (EGDs) and esophagitis
rarely cause by blunt trauma
pneumomediastinum and pleural effusions
hemothorax may result from injury to ?
aorta, myocardium, hilar blood vessels or lung parenchyma
symptoms from shortness of breath to shock
persistent pneumothorax and significant air leak following chest tube placement in a blunt chest trauma pt, think ?
findings on CXR ?
tracheobronchial rupture
pneumomediastinum and subcutaneous emphysema
one of the most common solid organ injuries due to blunt abdominal trauma
manifests how?
hepatic laceration
hypotension, RUQ pain and bruising, free intraperitoneal fluid, R shoulder pain due to phrenic irritation
fever, leukocytosis, chest pain, mediastinal widening in a post-cardiac surgery patient, think ?
acute mediastinitis
tx with abx, drainage and surgical debridement
what is abdominal succession splash and what does it imply?
auscultating a “splash” sound when rocking pt back and forth by hips 3+ hrs after meal
implies both fluid and gas in stomach, there is gastric outlet obstruction
anterior spinal cord infarction typically presents with ?
spinal shock: bilateral flaccid paralysis + loss of pain/temp below level of injury
UMN symptoms (spasticity and hyperreflexia) develop over days-weeks
vibration and proprioception are usually preserved
anterior spinal cord infarction is a potential complication of what surgery?
thoracic aortic aneurysm surgery
ischemic stroke tends to present with neurologic deficits on what side compared to lesion?
contralateral
an exploratory laparotomy is indicated in a patient with a penetrating abdominal wound in what situations ?
indicated if pt is unstable, if peritonitis or have evisceration of organs, or blood from a NG tube or on rectal exam
combank: +FAST or DPL, free air/diaphragm rupture, contrast imaging with ruptured GIT, intraperitoneal bladder injury, severe solid organ injury
soft signs: acidosis, ^WBC, persistent pain, tachy
clinical features of pre-renal injury
how to manage
serum Cr ^50%, decreased UOP, BUN/Cr greater than 20:1, FEN less than 1
treat with IV fluids to restore renal perfusion
intrinsic AKI due to acute interstitial nephritis (AIN) is commonly caused by ?
clinical features?
B-lactam abx (pip/tazo)
leukocytes on UA, skin rash
Factor Xa inhibitors
direct:
rivararoxaban (Xarelto)
apixaban (Eliquis)
indirect: fondaparinux (Arixtra)
Direct Thrombin Inhibitors
argatroban
bivalirudin (Angiomax)
dabigatran (Pradaxa)
what anticoagulants are contraindicated in ESRD?
LMWH (enoxaparin (Lovenox))
rivararoxaban (and assumably other Xa inhibitors and direct thrombin inhibitors)
IV UNFRACTIONATED heparin is ok
brain mets vs meningioma
brain mets typically present as multiple ring enhancing lesions at the grey-white junction (intra-axial), look for origin with CT of chest, abdomen and pelvis
meningioma presents as extra-axial well circumscribed dural based mass, although benign treat with surgical resection as it can cause headaches, seizure, focal neuro deficits
when is chemotherapy appropriate for brain tumors?
may be coupled with resection and radiation for highly malignant primary brain tumors (GBM, medulloblastoma) or highly chemosensitive mets (from testicular germ cell tumor)
when is radiation appropriate for brain tumors?
whole brain radiation if diffuse metastatic brain disease
focused tumor radiation (stereotactic radiosurgery) for partially resected or unresectable meningiomas
Lactated Ringers composition
why is it a good choice in the trauma setting?
130 mEq Na+, 109 mEq Cl-. 28 mEq lactate, 4 mEq K+, 3 mEq Ca+ (NS: 154 mEq Cl- and Na+)
lactate is converted to bicarb and can buffer the hypovolemia-induced metabolic acidosis
crystalloids vs colloids
crystalloids have e-lyte composition similar to plasma (LR, NS)
colloids include blood products, albumin, hetastarch, hespan: greater ability to stay IV, given if pt doesn’t respond to crystalloids (2-3 L)
treatment for gastric adenocarcinoma in antrum
subtotal gastrectomy (removes distal 3/4 of stomach) need total gastrectomy if tumor is located in body or fundus of stomach (then Roux-en-Y to esophagus)
Shock classifications
Class I: up to 750 mL blood loss (15%), normal vitals, some anxiety
Class II: 750-1500 mL (15-30%), HR 100-120, RR 20-24, anxiety, normal SBO, decrease PP, +/- delayed cap refill
Class III: 1500-2000 mL (30-40%, drop in SBP, HR 120+, RR^, UOP decreased, delayed cap refill
Class IV: 2L+ (40%), AMS, dec. BP, HR 140+, UOP minimal/absent, delayed cap refill
succinylcholine can cause hyperkalemia in what pts?
what will you see on EKG?
burn and SCI pts
peaked T waves, shortened QT interval
later progressive lengthening of PR interval and QRS duration
P wave may eventually disappear and ultimately the QRS widens to a sine pattern
goals in treating a spontaneous pneumothorax
(1) eliminate air from the pleural space
(2) reduce air leakage
(3) heal the pleural fistula
(4) re-expand the lung
(5) prevent future occurrences
bronchoscopy useful in hemoptysis patient how so ?
localizing bleeding site, provide suctioning to improve visualization, and other therapy (balloon tamponade, electrocautery)
