P A S T A N A S

Question 1

A 54 year old man involved in a high speed head on MVC is in coma. Both pupils are dilated and fixed. CT shows small, semilunar crescent-shaped intracranial hematoma hugging inside of skull. There is no deviation of his midline structures. What would help this patient the most?

Answer 1

Monitoring of ICP. This is acute subdural hematoma. If midline structures were deviated, craniotomy would help. If there is NO deviation, therapy centered on preventing further damage from subsequent increased ICP. Elevate head, hyperventilate, avoid fluid overload, and give mannitol or furosemide. Goal is PCO2 of 35. Sedation has been used to decrease brain activity (and oxygen demand). Hypothermia is currently suggested.

Question 2

A 54 year old man involved in a high speed head on MVC is in coma. He HAD lucid interval. Left fixed dilated pupil and right sided decerebrate posturing/hemiparesis. What is your tx?

Answer 2

Emergency craniotomy with hematoma evacuation and ligation of bleeding vessel. LP is contraindicated due to herniation risk. Size correlates with outcome.

Question 3

CT shows diffuse blurring of gray-white matter interface and multiple small punctate hemorrhages. What is your tx?

Answer 3

This is classic diffuse axonal injury –without hematoma, NO role for surgery *. Therapy directed at preventing further damage from increased ICP.

Question 4

Typical tx of hemothorax

Answer 4

Chest tube placed low. Surgery to stop bleeding is seldom rrequired UNLESS systemic vessel (typically INTERCOSTAL ARTERY) is source of bleeding and thoracotomy would be required.

Question 5

Tx of myocardial contusion

Answer 5

Focused on the complications, such as arrhythmias.

Question 6

A 35 y.o. man is shot in the thigh with a .22-caliber gun. The entrance wound is in the anterior, lateral aspect of his upper thigh and in x-rays the bullet can be seen embedded in the muscles posterolateral to the femur. The bone is in tact. In addition to cleaning of the entry wound, this man needs:

Answer 6

TETANUS PPX since no major vessels were in vicinity of injury tract. If penetration was near major vessels, Doppler studies or CT angio are done. If pt was symptomatic, surgical exploration/repair done.

Question 7

In a combined injury of arteries, nerves, AND bone, which one is done first?

Answer 7

Stabilize bone first THEN do delicate vascular repair which would otherwise be disrupted by rough handling necessary to put together a bone and leave the nerve for last. A fasciotomy should be added because prolonged ischemia could lead to compartment syndrome.

Question 8

A 39 y.o. woman accidentally drops hot iron on her thigh while doing the ironing. The shape of the iron is clearly delineated on her anterior, upper thigh, and the entire burned area is dry, white, leathery, and anesthetic. Local burn owound care would best be done with:

Answer 8

IMMEDIATE excision and grafting.

Question 9

Bit by a spider – present with N/V and severe generalized muscle cramps. Antidote?

Answer 9

Black widow spider bites get IV calcium gluconate. Muscle relaxants also help.

Question 10

Unprovoked dog bites/bites from wild animals immediately get what kind of ppx?

Answer 10

Rabies ppx – Immunoglobulin PLUS vaccine.

Question 11

Bit by a spider YESTERDAY. Now they have a skin ulcer with a necrotic center and surrounding halo of erythema. How do you treat them?

Answer 11

Dapsone. Surgical excision should be delayed until full extent of damage is evident – as much as one week. Skin grafting may be needed.

Question 12

In the neonatal unit, it is noted that a child has uneven gluteal folds. PE reveals that one of them can be easily dislocated posteriorly with a jerk and “click” and then returned to normal position with a “snapping” sound. The family is concerned because a previous child had same problem. Next step/tx?

Answer 12

SONOGRAM is diagnostic (don’t order X-rays bc hip is not calcified in newborn) and tx is abduction splitting with Pavlik harness for about 6 months. This is developmental dysplasia of hip.

Question 13

At what cobb angle do you consider bracing in scoliosis?

Answer 13

About 15-20 degrees or fast progression

Question 14

Tx of femoral neck fracture/intracapsular

Answer 14

Replacement with prosthesis. Particularly if displaced, as this compromises the tenuous blood supply of femoral head (e.g. AVN).

Question 15

Tx of intertrochanteric fractures

Answer 15

ORIF + anticoag bc the unavoidable immobilization ensures high risk of DVT and PE

Question 16

Pt is in the stretcher with the leg shortened, adducted and internally rotated after head on car collision. Emergency tx?

Answer 16

Emergency reduction of the hip – posterior dislocation could cause AVN.

Question 17

Describe a felon.

Answer 17

Abscess in the pulp of a fingertip caused by neglected penetrating injury. Because the pulp is a closed space with multiple fiscal trabecula, pressure can build up and lead to tissue necrosis, thus surgical drainage must be urgently done.

Question 18

Describe jersey finger.

Answer 18

Injury to flexor tendon sustained when flexed finger is forcefully extended. When making a fist, the distal phalanx of the injured finger does not flex with the others.

Question 19

Describe mallet fingers.

Answer 19

The extended finger is forcefully flexed, and the extensor tendon is ruptured. The tip of the affected finger remains flexed when the hand is extended, resembling a mallet.

Question 20

A cirrhotic patient goes into coma after performance of an emergency portocaval shunt for bleeding esophageal varices. The lab test most likely to reveal the reason for neurological deterioration is ?

Answer 20

Ammonium levels

Question 21

EF under what is prohibitive cardiac risk for non cardiac operations?

Answer 21

Under 35%.

Question 22

Worst single finding predicting high cardiac risk

Answer 22

JVD (indicates presence of CHF). If at all possible, tx with ACE-I, beta blockers, digitalis, and diuretics should precede surgery.

Question 23

Severe wound pain and very high fever within hours of surgery should alert you to the possibility of what?

Answer 23

GaS GANGRENE in the surgical wound

Question 24

8 days after a difficult hemigastrectomy and gastroduodenostomy for gastric ulcer, a pt begins to leak 2-3 liters of green fluid per day through right corner of his bilateral subcostal incision. He is afebrile and has no signs of an acute abdomen. The treatment plan should be based on:

Answer 24

Fluid replacement, nutritional support, and protection of abdominal wall. This is a fistula and nature will heal the fistula as long as there is no FETID to prevent it (Foreign body, Epithelialization, Tumor, Infection/Irradiated tissue/IBD, Distal obstruction).

Question 25

A pt with severe PUD develops pyloric obstruction and he has protracted vomiting of clear gastric contents w/o blood or bile for several days. Looks clinically dehydrated and serum electrolytes show sodium of 134, chloride 82, potassium 2.9, and bicarb 34. Rehydration best accomplished with?

Answer 25

Normal saline + added KCl.

Question 26

A 44 y.o. man has had colicky abdominal pain and protracted vomiting for several days. He has developed progressive, moderate abdominal distention and he has not had a BM or passed any gas for 5 days. He has high pitched bowel sounds that coincide with the colicky pain and his X-rays show distended loops of small bowel with air fluid levels. He is afebrile and has no signs of peritoneal irritation. 5 years ago he had an exalt for a gunshot wound of abdomen. AT this time the mainstay of therapy for this man should be?

Answer 26

NPO, NG suction, IV fluids and careful observation in case of spontaneous resolution. This is mechanical intestinal obstruction. Surgery is done if conservative mgmt is unsuccessful.

Question 27

A 49 y.o. obese woman presents with abdominal pain. She has a hx of 3 prior episodes LLQ abdominal pain for which she was briefly hospitalized and treated with abx. She began to feel discomfort 12 hours ago and now she has constant LLQ pain, tenderness and vaguely palpable mass in LLQ of abdomen. she has fever and leukocytosis . PE negative for OB-GYN pathology. Next dx step?

Answer 27

This is acute diverticulitis – CT is diagnostic. Start tx with NPO, IV fluids, abs. Emergency sx for those who don’t resolve.

Question 28

Slight elevation in INDIRECT bilirubin. No bile in the urine. Workup should involve?

Answer 28

What is chewing up the RBCs. This is hemolytic jaundice.

Question 29

Elevations in direct AND indirect bilirubin, very high transaminases, with modest elevation of alk phos. Most common cause?

Answer 29

HEPATITIS – > get serologies. Hepatocellular jaundice!

Question 30

Elevations in direct AND direct bilirubin, modest elevation of transaminases, VERY HIGH alk phase. First step i workup?

Answer 30

Obstructive jaundice –> sonogram. Look for the dilation of biliary ducts as well as further clues as to nature of obstructive process.

Question 31

What is courvoisier-terrier sign?

Answer 31

Large thin walled distended gallbladder identified in MALIGNANT obstruction of CBD.

Question 32

What should you suspect in patient with jaundice, anemia, and positive blood in stools?

Answer 32

Cancer in pancreatic ampulla causing obstructive jaundice. It bleeds into the lumen just like any other mucosal malignancy. ENDOSCOPY should be the first test.

Question 33

What is nesidioblastosis?

Answer 33

Devastating hypersecretion of insulin in newborn requiring 95% pancreatectomy

Question 34

If a patient has severe migratory necrolytic dermatitis, glossitis, and stomatitis, what kind of tumor do you suspec?

Answer 34

Glucagonoma. CT scan locates tumor and resection is curative. Somatostatin and streptozocin can help those with metastatic, inoperable dz.

Question 35

A 45 y.o. man comes into ER with pale, pulseless, paresthetic, painful and paralytic LE. Condition began suddenly 2 hrs ago. PE shows no pulses anywhere in that LE which also feels cold to palpation. Pulse at the wrist in 95 bpm, grossly irregular. Treatment for tis man will be based on use of:

Answer 35

Fogarty catheters. Uregent eval and tx should be completed w/i 6 hrs. Doppler studies will locate point of obstruction. Early incomplete occlusion may be tx with clot busters. Embolecyomy with Fogarty catheters is done for complete obstructions and fasciotomy should be added if several hours have passed before revascularization.

Question 36

72 y.o. chronic smoker with severe COPD is found to have central hilar mass on CXR. Bronchoscopy and bx estblish dx of SCC of lung. His FEV1 is 1100 and VQ scan shows 60% of Pulm function comes from affected lung. In order to determine operability this man needs:

Answer 36

No further tests – he is NOT surgical candidate. Operability of lung CA predicted on residual function after resection assuming pneumonectomy (central lesion) is required. For lobectomy function is less of an issue (peripheral lesions). A minimum FEV1 of 800 mL is needed*. If clinical findings suggest this may be limiting, FTs done. Treat with chemo + radiation.

Question 37

16 y.o. presents with large, mushy ill-defined mass that occupies the entire supraclavicular area. What should you do first?

Answer 37

CT scan before attempted surgical removal as cystic hygromas often extend deeper into the chest.

Question 38

A 35 y.o. woman has dysnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, cough, and hemoptysis. She had these progressive sx for about 5 yrs. she looks thi and cchectic and she has a fib and a low-pitched, rumblign disstolic apical murmur. At age 15 she had rheumatic fever. Surgery has been recommended. Teh preferred procedure would be :

Answer 38

Mitral commisurrotomy to open a stenotic mitral valve.

Question 39

A 61 y.o. chrnic smoker has episode of hemoptysis. CXR shows central hilar mass. Bronchoscopy and biopsies establish dx of SCC of lung. His FEV1 is 1900 and VQ scan sows 35% of pulm function comes from affected lung. Further workup should:

Answer 39

Be directed at evaluating presence or absence of mets. Potential cure by surgical removal of lung cfancer depends on mets. Hilar mets can be removed with pneumonectomy but nodal mets at carina or mediastinum preclude curative resection. CT scan may identify nodal mets and more recently addition of PET scanning has helped define presence of actively growing tumor in enlarged nodes. Endobronchial ultrasoudn is a more invasive option to sample mediastinal nodes. Cervical mediastinal exploration is rarely needed. Mets to other lung or liver should also be evident on CT.

Question 40

A 73 y.o. man has sudden onset of severe tearing chest pain that radiates to back and migraates down shortly after its onset. His BP is 220/110, and he has unequal pulses in UE and a wide mediastinum on CXR. Dx best estab with?

Answer 40

Spiral CT scan enhanced with IV dye. Remember ascending gets surgery descending gets medical control of HTN in ICU.

Question 41

A 16 y.o. boy goes on a beer drinking binge for the first time in his life and shortly thereafter develops severe colicky flank pain. Classic scenario for?

Answer 41

Ureteropelvic junction obstruction. This anomaly allows normal UO to occur but if large diuresis occurs, narrow area cannot handle it.

Question 42

A pre-employment CXR shows large peripheral coin lesion in a 25 y.o. man. PE discloses hard testicular mass and orchiectomy by inguinal route provides dx of seminoma. Further tx for this young man should include:

Answer 42

Platinum chemo. BEcause benign testicular tumors are virtually non existent biopsy is always done with radical orchiectomy by inguinal route. Blood smaples taken preop for serum markers (alpha feto protein and beta HCG) usefu.l for F/U. Further sx for LN dissection may be done in some cases. Most are exquisitely radiosensitive and chemosensitive to platinum based chemo, even in advanced metastatic dz.

Question 43

10 days after cadaveric liver tx and initiation of standard immunosuppressive regimen, 55 y.o. recipient begins to have elevated levels of GGT, alk phos and bilirubin. W/u should start with?

Answer 43

U/s & Doppler. ACUTE REJECTION occurs >5 days nd usually within 3 mos. Episodes occur EVEN THOUGH pt is on maintenance immunosuppression. Signs of organ dysfunction suggest it and bx confirms. In case of liver, technical probelsm are more common than immunologic rejection. Thus first order of business when liver function deteriorates after tx (Rising GGT, alk phos, and bili) is to R/O biliary obstruction by US and vascular thrombosis by Doppler.

Question 44

First line of therapy for acute transplant rejection

Answer 44

Steroid boluses. If unsuccessful, anti-lymphocyte agents (OKT3) have been used but they are pretty toxic. Newer anti-thymocyte serum tolerated better.

Question 45

A 46 y.o. man involved in severe MVC arrives in ER unconscious with multiple facial fx, brisk bleeding into nose and mouth and gurgly, irregular and noisy breathing. Several attempts at endotracheal intubation have failed because blood obscures view and the nose does not have a lumen anymore. Five minutes have passed. It is time to do:

Answer 45

CRICOTHYROIDOTOMY. If for any reason intubation cannot be done in the usual manner and we are running out of time, a cricothyroidotomy may become necessar.y It is quickest and safest way to temporarily gain access before pt sustains anoxic injury.

Question 46

A young man is shot in upper part of neck. Eval of entrance and exit wounds indicates trajectory is all above level of angle of mandible. A steady trickle of blood fows from both wounds and it cannot be stopped with local pressure. His BP has been slowly fdeclining although he is not yet in shock. Further eval would best be done by:

Answer 46

Arteriogram. For GSW to upper zone, arteriographic dx and mgmt preferred. For gsw to base of neck, arteriography, esophagogram water-soluble followed by barium if negative, esophagoscopy, and bronchoscopy BEFORE surgery help decide the specific surgical approach.

Question 47

A pt who sustained penetrating injury of chest has been intubated and placed on a respirator and a chest tube has been placed in the appropriate pleural cavity. The patient has been hemodynamically stable throughout with no alarming signs of any kind, but then suddenly he goes into cardiac arrest. The most liekly cause of the cardiac arrest is:

Answer 47

Air embolism. should be suspected when sudden death occurs in chest trauma pt who is intubated and on respirator. It also happens when subclavian vein is opened to air (supraclavic node bx, central venous line placement, CVP lines that become DCed) also leading to suden collapse and cardiac arrest. Immediate mgmt includes carotid massage, with pt positioned left side down. PRevention includes trendelenburg psoition when great veins at base of neck are to be entered.

Question 48

Age when bowlegs is normal up to?

Answer 48

3. Persistent beyond age 3 is Blount dz for which surgery can be done (disturbance of medial prox tibial growth plate).

Question 49

Age hwen knock knees is normal up to?

Answer 49

4-8. No tx needed.