QBank Wisdom Flashcards
(147 cards)
1
Q
Most commonly injured organ in blunt abdominal trauma
A
Spleen, evidence will be noticeable acutely on immediate CT scans.
2
Q
What is the name for firm, necrotic, classically insensate tissue classically formed on exposed tissue following burn wounds?
A
Eschar!
When eschar occurs circumferrentially on an extremity, it can restrict outward expansion of the compartment as edema occurs following the burn. ==> COMPARTMENT SYNDROME (which can be alleviated by performing an escharotomy)
3
Q
Clinical signs of compartment syndrome
A
- Deep pain out of proportion to injury
- PULSELESSNESS
- Paresthesias
- Cyanosis and pallor of affected extremities.
4
Q
Indications for open reduction of a fracture
A
“NO CAST”
- Nonunion
- Open fracture
- Compromise (neurovascular)
- Articular fracture (involving joint)
- Salter harris III, IV, V)
- Trauma
5
Q
How do you describe a fracture?
A
"BLT LARD": Bone Location (on bone) Type (of fracture) (open vs. closed, complete vs. incomplete, transverse vs. linear, etc.) Lengthening Angulation Rotation Displacement vs. non
ALSO, plan: open vs. closed reduction
"PLASTER OF PARIS" Plane Location Articular cartilage involvement Simple or comminuted Type (eg Colles') Extent Reason Open or closed Foreign bodies disPlacement Angulation Rotation Impaction Shortening
6
Q
Bone fracture types [for Star Wars fans] GO C3PO:
A
Greenstick Open Complete/ Closed/ Comminuted Partial Others
7
Q
What is tic douloureaux?
A
= Trigeminal neuralgia.
It manifests with short bursts of excrutiating, lancinating pain lasting from seconds to minutes in the distribution of V2 and V3. The etiology is most likely external compression of the trigeminal nerve.
8
Q
What kinds of surgery often lead to tongue palsy?
A
Tongue palsy can be caused by hypoglossal nerve CNXII injury.
Surgeries that risk this injury are BELOW THE MANDIBLE (such as for submandibular salivery gland tumor resection)
9
Q
Describe hoarseness as a post-op complication
A
Can result from injury to the recurrent laryngeal branches of the vagus nerve.
RISK FROM SURGERIES: on thyroids, parathyroids glands
10
Q
Which is the only branch of the trigeminal nerve with motor innervation?
A
V3, the mandibular division, which exit the cranium via the foramen ovale (of skull, not <3, dummy) and follow a deep course to innervate the muscles of mastication.
Jaw asymmetry can result from a unilateral paralysis of these muscles of mastication following damage to V3 on one side.
Injury to this nerve before it reaches the muscles of mastication would require very DEEP dissection!!!
11
Q
What is strabismus, and how does it come about?
A
Strabismus (improper alignment of the eye) can result from disorders of the extraocular muscles or of the nerves that innervate them (CNIII, CN IV, CNVI).
Brainstem lesions (as in CVAs) are most commonly responsible.
12
Q
What is a risk of axillary lymphadenectomy for the treatment of breast cancer?
A
An injury to the long thoracic nerve, which leads to winged scapula.
13
Q
How can you get an air embolism?
A
- Trauma patient who is on respirator
- From subclavian vein access
Can result in sudden collapse and cardiac arrest.
(?PFO necessary, ?A-line risk)
14
Q
How can you get an amniotic fluid embolism?
A
It occurs immediately after the rupture of the membranes. Not usually seen in early pregnancy.
15
Q
Classic presentation of a fat embolism
A
Dyspnea
Confusion
Petechiae in the upper part of body
Occurs after multiple fractures of long bones.
16
Q
How can you tell a hemothorax from a pleural effusoin on CXR?
A
CANNOT! Both are fluid collections in the potential pleural space, and are thus indistinguishable.
17
Q
Most common finding after blunt chest injury
A
Pulmonary contusion
CXR reveals opacities caused by hemorrhage in the involved lung segments.
18
Q
What could result from traumatic tracheobronchial disruption?
A
Pneumothorax
Mediastinal emphysema AND/OR
SubQ emphysema
19
Q
How do you identify a traumatic diaphragmatic rupture?
A
By herniation of abdominal contents (stomach, intestine, spleen) into thorax.
20
Q
Colonic malignancy typically presents with…
A
Anemia
Constipation
Weight loss
(older patient group)
21
Q
Complicated pyelonephritis typically presents with…
A
Fever
Flank pain
Sometimes dysuria
22
Q
IBD usually presents with…
A
Prolonged episodes of diarrhea and fever.
23
Q
Parasitic colitis typically presents…
A
acutely after travel to endemic areal, with many episodes of diarrhea (predomoinant sx) and fever.
24
Q
What is paradoxical aciduria? What context is it encountered in?
A
You are vomiting H+, and paradoxically peeing out H+ too.
In the context of metabolic alkalosis from loss of H+, Cl-, and fluid (dehydration) from vomiting up gastric contents, where you have lost H+ and have HCO3- excess, the kidney paradoxically compensates for dehydration by excreting H+ and K+ to conserve sodium (and thus water), in an attempt to preserve intravascular volume. The renal excretion of H+ on top of the loss of gastric H+ further leads to increase pH and metabolic alkalosis.
NOTE: Normally, the kidneys would excrete bicarbonate to reduce pH; however, as the dehydration becomes more severe, kidney’s drive to retain Na+ predominates.
25
What are some causes of serum hypertonicity?
Hyperglycemia from DM
Mannitol
Hypernatremia
26
Why does hyperglycemia lead to hyperkalemia?
Hyperglycemia leads to serum hypertonicity, which leads to H2O shift from intra- to extra cellular compartments.
Loss of intracellular H2O leads to increase intracellular K+, favoring a gradient for K+ to move out of cells.
Also, as H2O exits the cell, "solvent drag" sweeps K+ along.
27
What are some dysrrythmias/ECG findings of HYPOkalemia?
```
T-wave flattening/inversion
ST segment depression
U-waves
Prolonged QT
V tachycardia
```
28
What are some dysrrythmias/ECG findings of HYPERkalemia?
Peaked T waves
Wide QRS
V-fibrillation
29
In wound healing, what is the order in which cells arrive to wound site?
Platelets
PMNs (neutrophils)
Macrophages
Fibroblasts
30
What defines the clinical syndrome of shock?
Inadequate TISSUE PERFUSION to maintain CELLULAR METABOLISM
I.e. Loss of balance between these two components such that metabolism requirements outstrip perfusion (be it O2 delivery, other nutrient delivery, or toxin/CO2 removal)
31
What is one of the main issues in hypovolemic shock?
Inadequate blood volume leads to decreased venous return (i.e. decreased preload), which leads to decreased cardiac output and decreased tissue perfusion.
32
What is a distinguishing feature of cardiogenic shock?
In cardiogenic shock, there is increased central venous pressure because of inadequate cardiac pump performance, which leads to blood backing up into the venous system.
33
What is neurogenic shock?
Loss of sympathetic tone leading to peripheral vasodilation can result in relative hypovolemia and decreased cardiac performance.
This can be the result of vasovagal response, cervicothoracic spinal cord injury, or spinal anesthesia.
Hypotension and vasodilation leading to maldistibutive perfusion results in deranged cellular metabolism.
34
Which types of shock involve decreased SVR and vasodilation?
Neurogenic and septic.
35
List causes of obstructive shock
```
Tension pneumothorax
Cardiac tamponade
Massive pulmonary embolism
Venous air embolism
Severe cardiac valvular stenosis
```
36
Which is the only type of shock in which cardiac output may be increased?
Euvolemic septic shock
37
What are causes of cardiac arrest?
Hs and Ts
- Hypovolemia (tx = IV fluid resuscitation, blood transfusion, control bleeding)
- Hypoxia (tx = oxygen, proper ventilation, good CPR technique, and hyperbaric oxygen if cyanide or CO poisoning)
- Hydrogen ions (acidosis - lactic, DKA, salycylate, ethanol, TCA, etc.) (tx = proper ventilation, good CPR technique, buffers like bicarb, emergent hemodyalisis)
- Hyperkalemia (tx = Ca++ administration to stabilize cardiomyocyte electrochem potentials and thus prevent fatal arrythmias; nebulized salbutamol, IV insulin usually with glucose and bicarb to drive K+ into cells; loop diuretics like furosemide to spill potassium in urine or sodium polustyrene sulfonate to bind K+ to excrete in stool; emergent hemodyalisis)
- Hypokalemia (tx = give IV K+)
- Hypothermia, core temp <35°C (tx = cardiac bypass, irrigation of body cavities with warm fluids, or warmed IV fluids)
- Hyperglycemia, such as DKA (correct acidosis)
- Hypoglycemia (tx = IV glucose)
Ts
- Tanlets or toxins (tricyclic antidepressants, phenothiazides, beta blockers, calcium channel blockers, cocaine, digoxin, aspirin, paracetamol/acetaminophen) (tx = specific antidotes, fluids for volume expansion, vasopressors, Na+ bicarb for TCAs, glucagon or Ca++ for CCBs, benzos for cocaine, or cardiopulmonary bypass)
- Tamponade (cardiac) (tx= pericardiocentesis)
- Tension pneumothorax (tx = needle decompression thoracotomy
- Thrombosis (myocardial infarction) (tx = rescucitate, MONA, antiplatelet therapy, thrombolytic therapy, or percutaneous coronary intervention)
- Thromboembolism (i.e. Hemodynamically significant pulmonary embolism) (tx = thrombolytics or thrombolectomy; prognosis is poor)
- Trauma (hard blow to the chest at precise moment in cardiac cycle, commotio cordis)
38
Hs and Ts of cardiac arrest, briefly
| Six and SIX!
Hs: hypovolemia, hydrogen ions, hyper/hypoglycemia, hypo/hyperkalemia, hypoxia, hypothermia
Ts: tablets/toxins, tamponade, tension pneumothorax, thrombosis (MI), thromboembolism (PE), trauma
39
What information can you get from a pulmonary artery catheter?
1. LA and LV preload pressures
2. Cardiac output
3. Mixed venous oxygen saturation
4. Systemic vascular resistance (SVR) and pulmonary vascular resistance (PVR)
40
Which are the important steps in the initial management of massive hemoptysis (>600mL/day or rate >100mL/hr)?
1. Establish an adequate patent airway (biggest risk is asphyxiation, not exanguination).
2. Maintains adequate ventilation and gas exchange.
3. Ensure hemodynamic stability.
4. Place patients with bleeding lung in dependent position (lateral position).
5. Bronchoscopy is the initial procedure of choice to identify/localize the bleeding site and attempt early therapeutic intervention (suctioning ability to improve visualization, balloon tamponade, electrocautery).
41
What are immediate causes of post-operative fever (0-2 hrs)?
Prior trauma/infection
Blood products
Malignant hyperthermia
42
Acute causes of post-operative fever (24hrs - 1 week)?
- Nosocomial infections
- Surgical site infections due to Group A strep or Clostridium perfringens
- Non-infectious (MI, PE, DVT)
43
Subacute causes of postoperative fever (1 week-1 mo)
- SSI due to organisms other than group A strep or clostridium perfringens
- C. difficile (pseudomembranous colitis)
- Drug fever
- PE/DVT
44
Delayed causes of post-operative fever (> 1mo)
- Viral infections (ex. from blood products)''
- Infective endocarditis.
- SSIs due to indolent organisms
45
What is the pathophysiology of a febrile nonhemolytic transfusion reaction? How is it different from an acute hemolytic reaction?
The bottom line is the CYTOKINES in the transfused blood products.
In a FEBRILE, NONHEMOLYTIC transfusion reaction, when red cells and plasma are separated from whole blood, small amounts of residual plasma and/or leukocyte debris may remain in the red cell concentrate. During blood storage, these leukocytes release CYTOKINES that when transfused can cause transient fevers, chills, and malaise, WITHOUT hemolysis, within 1-6 hours of transfusion.
Manage by stopping the transfusion, rule out other serious causes of fever (such as acute hemolytic reaction ) and give antipyretics.
Acute hemolytic transfusion reaction immune-mediates because of ABO incompatibility, signs include fever, hypotension, anxiety, and tea-colored urine (with late signs of generalized bleeding (DIC) and hypotension).
46
Which signs usually accompany a drug fever?
"Wonder drugs!" This is a diagnosis of exclusion.
Most often accompanied by RASH and peripheral eosinophelia.
Typically occurs 1-2 weeks after medication administration.
47
What are the signs that characterize malignant hyperthermia?
In essence, this is a HYPERCATABOLIC state that usually develops within 1 hours of exposure to causative agents (inhaled anesthetics, succ.). Signs include:
- HIGH fever (>40C/104F).
- Muscle rigidity
- Rhabdomyolisis
- Metabolic acidosis (from increased CO2 prodution and increased O2 consumption)
- Increased RR and HR.
- Hemodynamic instability.
48
What is the etiology of malignant hyperthermia?
Is usually cased by the volatile INHALED ANESTHETICS and the neuromuscular paralyzing agent succinylcholine. In susceptible individuals (this is an autosomal dominant inherited susceptibility), these drugs can induce a drastic and uncontrolled increase in skeletal muscle oxidative metabolism, which overwhelms the body's capacity to supply oxygen, remove carbon dioxide, and regulate body temperature, eventually leading to circulatory collapse and death if not treated quickly.
49
Which anesthetics are safe to use in a person known to be susceptible to malignant hyperthermia?
- Local anesthetic agents (the -caines, ex. lidocaine)
- Opiates (morphine, fentanyl)
- Ketamine
- Barbiturates
- Propofol
- Etomidate
- N2O (nitrous oxide)
- Benzos
The non-depolarizing muscle relaxants (the -iums, like rocuronium, cisatracurium) must be used for paralysis as opposed to succinylcholine.
50
How does a patient with PE present?
Pleuritic chest pain, tachypnea, dyspnea, tachycardia, and hypoxia.
51
What does the RQ mainly depend upon in a steady resting state?
Upon the proportions of metabolic fuels being oxidized for ATP production.
52
What does an RQ close to 1.0 indicate?
That carbohydrate is the major nutrient being utilized.
53
What does the RQ respresent?
It is the steady-state ratio of CO2 produced to O2 consumed per unit time.
RQ = CO2_eliminated/O2_consumed
It may be used to make assessments of the metabolism taking place in particular organs or in the body as a whole.
54
What is the normal RQ?
0.8
55
How does sepsis affect the RQ?
Sepsis is a hypermetabolic, hypercatabolic state wherein both body fat and protein are broken down in addition to glucose being oxidized.
Therefore, the RQ in a septic patient is typically less than 1.0.
56
What would the RQ tend to be in a patient being given a high-protein diet?
It would tend to be close to 0.8, since amino-acid oxidation becomes the predominant form of ATP production.
57
How does a high FiO2 affect the RQ?
If tissue oxygen delivery is adequate to prevent anaerobic metabolism, then the RQ will NOT be affected by the FiO2.
It is important to realize that increased O2 deliver to the tissues DOES NOT equate with increased O2 consumption by the tissues. The tissues consume only the amount of O2 that they need.
The RQ is calculated using the amount of O2 consumed (not delivered), which is determined by the difference in O2 content of the arterial and venous blood.
58
How is O2 consumption measured for calculation of RQ?
It is determined from the arteriovenous oxygen content difference (AVO2D).
59
How is CO2 production measured for calculation of RQ?
Using capnography (measurement of concentration or partial pressure of CO2 in respiratory gases) - i.e., the end-tidal CO2.
60
Does massive atelectasis affect the RQ?
Massive atelectasis could affect respiratory gas exchange and alter blood gases, but once a new steady state is achieved, the RQ value would still depend only upon the nature and proportions of metabolic fuels being oxidized.
THEREFORE, although the methods that we use to calculate the RQ (i.e. EtCO2 and ABGs/AVO2D) would be affected by atelectasis, the underlying O2 consumption and CO2 production by metabolism would be the same (unless the body is in such distress that it affects metabolism).
The bottom line is that the RQ is a metric for METABOLISM, specifically on the main fuel source for ATP production (not of respiration, paradoxically, even though we're depending on gases to tell us how the body is metabolizing).
61
How is the ankle-brachial index calculated?
ABI = higher ankle systolic pressure (PT/DP)/higher brachial artery systolic pressure(L vs. R).
Must calculate an ABI for each leg, but the denominator will always be the higher of the two brachial artery pressures.
62
For whom is one-time abdominal ultrasound screening for AAA recommended?
For men aged 65-75 with a history of smoking, but otherwise not needed to screen patient without suspicious symptoms.
63
How does joint swelling help you distinguish between meniscal tears and ligamentous tears at the knee?
Both are associated with a distinctly recalled acute knee injury, and both are often associated with a popping sensation.
However, with meniscal tears, joint swelling develops gradually and is often not noticeable until the next day. In contrast, with ligamentous tear, joint swelling occurs rapidly due to hemarthrosis.
64
How does an MI classically present?
Crushing substernal chest pain radiating to the L shoulder and arm typically in a patient with risk factors such as smoking, diabetes, hyperlipidemia, and a + FamHx of CAD.
65
Are steroid injections indicated for fractures?
NO! They are appropriate for short-term treatment of joint inflammation and bursitis, but they are NOT appropriate for fractures because they can impede healing.
66
How would a person with radiation proctitis present?
Clinical features of : diarrhea, rectal bleeding, tenesmus, and incontinence. Later, strictures and fistulae may form.
67
What are the clinical features of C.Diff colitis (peudomembranous colitis? How is it diagnosed?
Sx: abdominal pain, fever, watery diarrhea.
Dx: colonoscopy, dececting toxin in stool with ELISA.
68
Which types of shoulder dislocations result in injury to the axillary nerve?
AnteroInferior dislocations.
69
Injury to which nerve causes paralysis of the deltoid and teres minor muscles as well as loss of sensation over the upper arm?
Axillary nerve
70
Which nerve is commonly injured by fractures of the humeral midshaft and by using improperly fitted crutches? Which are the resulting symptoms?
RADIAL NERVE
Sx: wrist drop (loss of innervation to muscles that extend the hand at the wrist) and sensory loss on the posterior arm, forearm, and lateral dorsal hand.
71
Which nerve is commonly injured by fractures of the medial epicondyle of the humerus of the humerus, or more distally by deep lacerations of the anterior wrist?
ULNAR NERVE
Sx: "claw hand" resulting from paralysis of most of the intrinsic muscles of the hand as well as sensory loss to the dorsal and ventral medial hand.
72
Where does the musculocutaneous nerve run? How is it commonly injured?
The musculocutaneous nerve arises from the lateral cord of the brachial plexus and innervates the biceps, brachialis, and coracobrachialis muscles.
It is NOT frequently injures by common forms of upper extremity trauma.
73
Which nerve is commonly injured by deep lacerations to the axillary region and axillary lymphadenectomy?
HINT: Often injured during radical mastectomies with lymphadenectomy.
LONG THORACIC NERVE
Damage causes SCAPULAR WINGING.
74
What is the purpose of a retrograde cystogram with post-void films?
Used for diagnosis of bladder injury. Bladder injury may occur following major trauma, especially pelvic fracture. Patients typically complain of gross hematuria.
75
When does posterior dislocation of the shoulder commonly occur?
After tonic-clonic seizures, with the patient holding the arm aDducted and internally rotated.
76
What is the classic triad of preeclampsia?
HTN
Proteinuria
Edema
77
What is the initial treatment of eclampsia?
Magnesium sulfate
Oxygen
Antihypertensives
Unfortunately, delivery is the only definitive treatment.
78
What is eclampsia?
The constellation of 3 symptoms of preeclampsia + seizures.
The patient can develop sx of headache, blurry vision, photophobia, abdominal pain, and altered mentation prior to the seizure that can persist afterwards.
79
What is the name for transient unilateral weakness following a tonic-clonic seizure that usually spontaneously resolves?
Todd's paralysis.
Note, adduction and internal oration of the arm is not seen with Todd's paralysis. These finding result from a posterior dislocation of the shoulder which can occur during tonic-clonic seizures.
80
How is the pain of biliary colic distinguishable from that of acute cholecystitis?
The pain of biliary colic is distinguished from that of acute cholecystitis by its intermittent nature and relation to meals as well as the absence of fever.
81
Which symptoms are indicative of peritoneal irritation ("peritoneal signs")?
Rebound tenderness
Abdominal guarding
Decreased bowel sounds
82
What is rebound tenderness?
It refers to pain upon abrupt removal of pressure rather than application of pressure to the abdomen. (The latter is referred to simply as abdominal tenderness.)
It represents aggravation of the parietal layer of peritoneum by stretching or moving as it "snaps" back into place. Often associated with PERITONITIS.
83
List some conditions that fall under the classification of "acute abdomen" (Sudden, severe abdominal pain of unclear etiology, that is
- Acute appendicitis
- Acute peptic ulcer and its complications.
- Acute cholecystitis
- Acute pancreatitis
- Acute intestinal ischemia
- Diabetic Ketoacidosis
- Acute Diverticulitis
- Ectopic Pregnancy with tubal rupture
- Ovarian torsion
- Acute peritonitis (including hollow viscus perforation)
- Acute ureteric colic
- Bowel volvulus
- Acute pyelonephritis
- Adrenal crisis
- Biliary colic
- Abdominal aortic aneurysm
- Hemoperitoneum
- Ruptured spleen
- Kidney Stone
84
Which clinical exam finding is highly indicative of bowel ischemia?
Severe abdominal pain (often periumbilical) out of proportion to findings on physical exam. May be accompanied by nausea, vomiting, and fecal blood.
85
Describe how Chron's disease affects the absorption of the following substances:
- Bile salts
- Fatty acids/fat
- Oxalate
- Bile salt recycling in the small bowel is DECREASED
- Fatty acid absorption in the small bowel is DECREASED
- Oxalate absorption in
86
When a patient presents with a bawny edematous cutaneous plaque with a "peu d'orange" appearance overlying a breast mass, what is the first step in management?
Since clinically, inflammatory breast cancer cannot be differentiated from an infectious process (such as a breast abscess) with 100% certainty, a BIOPSY for HISTOLOGY should be done first to exclude or confirm the diagnosis.
87
Which patients are at risk for mastitis? How would you manage them?
Younger lactating women.
Upon diagnosis of mastitis, patients should be treated with an abx that cover Staph and should be encouraged to continue breastfeeding or breast pumping from the affected breast.
88
How does intraductal papilloma typically present? Is this a benign or malignant process?
Intermittent bloody discharge from one nipple.
BENIGN breast disease most common in pre/perimenopausal women.
Masses are generally not appreciated since the abnormality is small (usually < 2mm), soft, and located directly beneath the nipple/areola.
89
How do fibrocystic changes of the breast present?
This benign condition is common in PREMENOPAUSAL women.
Presents with BILATERAL breast pain associated with cystic changes of the breasts. Symptoms vary clinically with the menstrual cycle, and on exam, LUMPINESS of the breasts is appreciated.
90
A solitary, painless, firm, and mobile breast lump of about 2cm in size in a young woman (15-25) that does not change with the menstrual cycle, is most likely....
.... a FIBROADENOMA, a benign condition of the breast most common in young women.
91
Which age group is ductal carcinoma in situ (DCIS) most commonly seen in?
In POSTMENOPAUSAL WOMEN.
DCIS is usually discovered as an incidental finding on mammography. If presenting symptomatically, the most common symptom are nipple discharge and breast mass.
92
What are the histologic characteristics that are diagnostic for DCIS?
Cellular abnormalities of the ductal epithelium that do NOT penetrate the basement membrane.
93
How can you tell galactorrhea from other causes of nipple discharge?
Galactorrhea in non-breastfeeding women results from hyperprolactinemia, which is a hormonal imbalance, and as such, affects both breasts/nipples equally, resulting in BILATERAL nipple discharge.
Intraductal papilloma, DCIS, and Paget's disease of the breast all typically cause UNILATERAL nipple discharge, because these are focal processes.
94
What is Paget's disease of the breast?
A form of breast cancer that characteristically presents with eczematous changes of the nipple and areola.
The first symptom is usually an eczema-like rash. The skin of the nipple and areola may be red, itchy and inflamed. After a period of time, the skin may become flaky or scaly.
The diagnosis is confirmed histologically.
(Not to be confused with Paget's disease of the bone, chronic disorder in which excessive breakdown and formation of bone, followed by disorganized bone remodeling, leads to enlarged and misshapen bones. This causes affected bone to weaken, resulting in pain, misshapen bones, fractures, and arthritis in the joints near the affected bones.)
95
Which medication do you give for an opiate overdose?
Nalaxon, a mu-receptor (opiod receptor) competitive antagonist with a rapid onset of action.
96
How is ileus defined?
As a FUNCTIONAL defect in bowel motility without an associated obstruction.
97
What are signs and symptoms of postop ileus?
Nausea/Vomiting
Abdominal distention
Obstipation (failure to pass flatus/stool)
Hypoactive/absent bowel sounds
98
How do bowel sounds help you differentiate between postoperative ileus and a mechanical bowel obstruction?
Ileus presents with hypoactive/absent bowel sounds.
In contrast, a mechanical bowel obstruction causes hyperactive or "tinkling" bowel sounds.
99
Which factors contribute to post-op ileus?
1. Increased splanchnic nerve SYMPATHETIC tone following violation of the peritoneum
2. Local release of inflammatory mediator.
3. Post-operative narcotic (opiate) analgesics, which contribute to poor bowel motility by causing disordered peristalsis.
100
How would a patient with gastroparesis due to poor glucose control and enteric neuropathy present?
Early satiety
Nausea
Postprandial vomiting
However, as you can see, these symptoms can be seen in patients with many types of GI complaints and/or past GI surgery.
101
What is the most common cause of post-operative small bowel obstruction?
ADHESIONS!!!
102
Which are the two most common causes of acute pancreatitis?
Gallstones
Alcohol
*** Usually biliary pancreatitis if no history of alcohol abuse.
(also, hypertriglyceridemia and recent ERCP)
103
How do you treat acute pancreatitis?
Primarily supportive - IV fluids, NG tube suction, NPO, and analgesia.
ABx are also usually indicated.
Monitor Ca++ and Mg++ and replace as needed.
104
Which is the preferred initial test for identifying gallstones?
Ultrasound (sensitivity 72-84%, spec 99%).
Of note, CT actually has a pretty bad sensitivity (52%), since most stones are isodense with bile and not easily visible on CT.
105
Which traumatic processes can lead to a pneumomediastinum?
Esophageal rupture
| Bronchial rupture
106
Which is the test indicated for diagnosing an esophageal rupture?
WATER-soluble contrast esophagography.
107
Which signs and symptoms are usually seen in myocardial contusion?
HINT - you can see all three on ECG
Tachycardia
New bundle branch block
Arrythmia
ALSO, a sternal fracture is a common associated finding.
108
Irritation to the diaphragm usually results in pain referred to the....
SHOULDER
109
In a patient who experienced blunt trauma who is presenting with SOB, vomiting, abdominal pain, and pain referred to the shoulder, what should you worry about? Which test can help you diagnose this?
DIAPHRAGMATIC RUPTURE.
CXR and other radiographic studies will classically demonstrate abdominal viscera above the diaphragm and loss of the diaphragmatic contour.
110
Which are presentations of a bronchial rupture?
HINT: Where can the air go?
Bronchial rupture is a rare complication of severe blunt thoracic trauma.
- Pneumothorax (that does NOT resolve with chest tube placement)
- Pneumomediastinum
- SubQ emphysema
111
How do you treat a stress (hairline) fracture of the metatarsals?
Rest
Analgesia
Hard-soled shoe
112
Which is the most commonly involved metatarsal when stress/hairline fracture?
The SECOND metatarsal, because it is subjected to significant extremes of loading during gait.
113
When would you get a bone scan or an MRI to diagnose a hairline/stress fracture?
To make the diagnosis when plain radiographs are unable to demonstrate the fracture.
114
Which are changes in knee function seen in patients with meniscal injury?
- Joint line tenderness
- Loss of smooth flexion or extension
- Inability to move forward and backward while squatting
- Effusion
115
When is brachial artery injury typically seen?
How does it present?
(HINT: 5 Ps)
The brachial artery is often injured in supracondylar fractures of the humerus (often seen in children).
Signs and sx are those of limb ischemia - 5 Ps - pain, pallor, pulsenesness, paresthesias, and pressure.
116
In a patient with loss of sensation of the skin over lateral three and 1/2 fingers and lateral half of the palm, which nerve is injured?
MEDIAN nerve.
117
In patient with wrist drop, which nerve is injured?
Radial nerve.
118
In patient with claw hand, which nerve is injured?
Ulnar nerve
119
In a patient with a small pulsatile mass in the groin area, what should you also look for?
A large pulsatile mass in the abdomen!
Femoral artery aneurysms (peripheral artery aneurysms) are frequently associated with AAAs.
120
Which are the two most common peripheral artery aneurysm sites?
Popliteal artery > Femoral artery
121
Which medication do you give for an opiate overdose?
Nalaxon, a mu-receptor (opiod receptor) competitive antagonist with a rapid onset of action.
122
How is ileus defined?
As a FUNCTIONAL defect in bowel motility without an associated obstruction.
123
What are signs and symptoms of postop ileus?
Nausea/Vomiting
Abdominal distention
Obstipation (failure to pass flatus/stool)
Hypoactive/absent bowel sounds
124
How do bowel sounds help you differentiate between postoperative ileus and a mechanical bowel obstruction?
Ileus presents with hypoactive/absent bowel sounds.
In contrast, a mechanical bowel obstruction causes hyperactive or "tinkling" bowel sounds.
125
Which factors contribute to post-op ileus?
1. Increased splanchnic nerve SYMPATHETIC tone following violation of the peritoneum
2. Local release of inflammatory mediator.
3. Post-operative narcotic (opiate) analgesics, which contribute to poor bowel motility by causing disordered peristalsis.
126
How would a patient with gastroparesis due to poor glucose control and enteric neuropathy present?
Early satiety
Nausea
Postprandial vomiting
However, as you can see, these symptoms can be seen in patients with many types of GI complaints and/or past GI surgery.
127
What is the most common cause of post-operative small bowel obstruction?
ADHESIONS!!!
128
Which are the two most common causes of acute pancreatitis?
Gallstones
Alcohol
*** Usually biliary pancreatitis if no history of alcohol abuse.
(also, hypertriglyceridemia and recent ERCP)
129
How do you treat acute pancreatitis?
Primarily supportive - IV fluids, NG tube suction, NPO, and analgesia.
ABx are also usually indicated.
Monitor Ca++ and Mg++ and replace as needed.
130
Which is the preferred initial test for identifying gallstones?
Ultrasound (sensitivity 72-84%, spec 99%).
Of note, CT actually has a pretty bad sensitivity (52%), since most stones are isodense with bile and not easily visible on CT.
131
Which traumatic processes can lead to a pneumomediastinum?
Esophageal rupture
| Bronchial rupture
132
Which is the test indicated for diagnosing an esophageal rupture?
WATER-soluble contrast esophagography.
133
Which signs and symptoms are usually seen in myocardial contusion?
HINT - you can see all three on ECG
Tachycardia
New bundle branch block
Arrythmia
ALSO, a sternal fracture is a common associated finding.
134
Irritation to the diaphragm usually results in pain referred to the....
SHOULDER
135
In a patient who experienced blunt trauma who is presenting with SOB, vomiting, abdominal pain, and pain referred to the shoulder, what should you worry about? Which test can help you diagnose this?
DIAPHRAGMATIC RUPTURE.
CXR and other radiographic studies will classically demonstrate abdominal viscera above the diaphragm and loss of the diaphragmatic contour.
136
Which are presentations of a bronchial rupture?
HINT: Where can the air go?
Bronchial rupture is a rare complication of severe blunt thoracic trauma.
- Pneumothorax (that does NOT resolve with chest tube placement)
- Pneumomediastinum
- SubQ emphysema
137
How do you treat a stress (hairline) fracture of the metatarsals?
Rest
Analgesia
Hard-soled shoe
138
Which is the most commonly involved metatarsal when stress/hairline fracture?
The SECOND metatarsal, because it is subjected to significant extremes of loading during gait.
139
When would you get a bone scan or an MRI to diagnose a hairline/stress fracture?
To make the diagnosis when plain radiographs are unable to demonstrate the fracture.
140
Which are changes in knee function seen in patients with meniscal injury?
- Joint line tenderness
- Loss of smooth flexion or extension
- Inability to move forward and backward while squatting
- Effusion
141
When is brachial artery injury typically seen?
How does it present?
(HINT: 5 Ps)
The brachial artery is often injured in supracondylar fractures of the humerus (often seen in children).
Signs and sx are those of limb ischemia - 5 Ps - pain, pallor, pulsenesness, paresthesias, and pressure.
142
In a patient with loss of sensation of the skin over lateral three and 1/2 fingers and lateral half of the palm, which nerve is injured?
MEDIAN nerve.
143
In patient with wrist drop, which nerve is injured?
Radial nerve.
144
In patient with claw hand, which nerve is injured?
Ulnar nerve
145
In a patient with a small pulsatile mass in the groin area, what should you also look for?
A large pulsatile mass in the abdomen!
Femoral artery aneurysms (peripheral artery aneurysms) are frequently associated with AAAs.
146
Which are the two most common peripheral artery aneurysm sites?
Popliteal artery
| Femoral artery
147
How can you tell a femoral hernia from an inguinal hernia?
Femoral hernias are below the inguinal ligament.
Direct inguinal hernias are above the inguinal ligament, and indirect inguinal hernias may descend into the scrotum.
