random 1/16/17 Flashcards
1
Q
umbilical hernia vs omphalocele vs gastroschisis
A
covered by skin
covered by peritoneum
not covered
2
Q
umbilical hernia path pres dx tx
A
incomplete closure of ab muscles around umbilical ring at birth
assoc w premie, af am, hypothyroid, ehlers danlo, beckwith wiedeman syndrome
soft nontender bulge covered by Skin protruding during crying coughing straining etc, may have small intestines omentum etc
easily reducible usually, little risk of incarceration or strangulation
clinical dx
spontaneous reduction by concentric fibrosis and scarring if small usually
if large (^1.5cm) or other medical issues may not reduce - surgery around age 5 if persisting or earlier if problematic
3
Q
gastroschisis
define
tx
A
evisceration of bowel with no covering membrane, red, right of umbilical cord
surgical emergency
4
Q
omphalocele
define
tx
A
protrusion of abdominal contents at base of umbilicus, covered by peritoneum without skin
immediate surgical repair for survival
5
Q
umbilical granuloma
pres
tx
A
usually after umbilical cord cut, soft moist pink pedunculated friable
silver nitrate
6
Q
tf
surgery usually required for umbilical hernia
A
f
usually reduces via concentric fibrosis wo incarceration or strangulation
-surg if not closed about age 5 (higher risk if large ^1.5cm or other medical issues) or earlier if problematic
-surg for omphalocele, gastroschisis
-silver nitrate for umbilical granuloma
7
Q
how to know if aortic arch is widened on cxr
A
obscures left pulmonary artery/hilum
8
Q
blunt aortic injury
path
pres
dx
A
mva or fall from height 10+ feet
not very specific htn tachyc anxiety
cxr mediastinal widening, maybe r trach dev, left mainstem bronchus depression
ct angio if cxr and hx equivocal
9
Q
tf
mediastinal widening w myocardial contusion
A
f
tachyc
maybe see rib fractures
10
Q
most common cxr finding after blunt chest injury
A
hemorrhagic lung opacities from pulmonary contusion
11
Q
traumatic diaphragmatic rupture on cxr
A
herniation of abdominal contents into thorax
12
Q
tf
any patient w blunt deceleration trauma (mva, fall 10 plus feet) gets cxr
A
t
mus ro aortic injury
13
Q
anterior bursae of knee
A
- suprapatellar bursa between quad tendon and distal femur, continuous w joint capsule
- prepatellar bursa subcutaneously
- deep infrapatellar bursa between patellar tendon amd proximal tibia
- subcutaneous infrapatellar bursa
14
Q
define bursa
A
synovial sac to alleviate friction at bony prominences and ligamentous attachments
15
Q
pain w rom w inflamed bursa
A
active rom often painful
passive rom often not, less pressure on bursa
16
Q
prepatellar bursitis aka
A
housemaid’s knee
17
Q
pres
dx
tx
acute prepatellar bursitis
A
acute pain and tenderness anterieor knee in kneeling job
aspirate for cell count and gram stain (also crystals but less common) (acute prepatellar bursitis often infectious, staph aureus, from penetrating trauma, repeat friction, or extension of local cellulitis… other bursites usually not infectious…)
if cx positive drain and systemic abx
if cx neg activity mod, nsaids
18
Q
patellar fx
path
pres
A
direct blow or sudden force under load (fall from height)
pain swelling tenderness inability to extend knee
19
Q
patellofemoral pain gender preference
A
female
more valgus, maltracking
20
Q
extra axial well-circumscribed or round enhancing dural-based mass on brain mri think...
A
meningioma
may also calcify and appear hyperdense on non-con ct
21
Q
meningioma path pres dx tx
A
benign primary tumor of meningiothelial cells
middleage elderly woman
if large enough for mass eddect - headache, focal weakness numbness, seizure
extra axial
well-circumscribed or round, enhancing, dural-based, mass on brain mri (may also calcify and appear hyperdense on noncon head ct)
confirm intraoperatively (surg resection for symptomatic pts)
22
Q
when to consider chemo for brain cancer
A
combo w resection amd radiation for highly malignant brain tumors (glioblastoma multiforme, medulloastoma…) or highly sensitive mets (eg testicular germ cell tumor..)
23
Q
when to consider ct cap for brain cancer
A
when visceral primary suspected cause of brain mets (multiple ring-enhancing lesions at gray-white junction (intraaxial))
24
Q
typical appearance of brain mets on… mri? ct?
A
multiple ring-enhancing lesions at gray-white junction (intraaxial)
25
multiple ring-enhancing lesions at gray-white junction (intraaxial)
think...
metastasis to brain
26
indication for whole brain radiation
widely metastatic brain disease
27
ddx for anterior mediastinal mass
```
4 Ts
thymoma
thyroid neoplasm
teratoma (and other germ cell tumors)
terrible lymphoma
```
28
serum hormone levels in germ cell tumors
seminoma - 1/3 have ele b-hcg but usually normal afp
non-seminoma (yolk sac tumor, choriocarcinoma, embryonal carcinoma, mixed) - ele afp, some ele b-hcg
29
anterior mediastinal mass
w elevated afp amd b-hcg
think...
non-seminoma germ cell tumor (yolk sac tumor, choriocarcinoma, embryonal carcinoma, mixed) - ele afp, some ele b-hcg
(seminoma - 1/3 have ele b-hcg but usually normal afp)
30
how long can surgery for femoral neck fracture be delayed to stabilize acute comorbid medical problems
72hrs
| longer risks further medical complication and less likely return to previous functional status
31
the 2 lobes of the parotid gland are separated by...
the facial nerve
32
hoarseness can result from surgery on...
thyroid or parathyroid glands
| if recurrent laryngeal branches of vagus injured
33
tic doloroux
distribution
etiology
2nd and 3rd trigeminal branches (V2 V3)
| external compression of trigeminal probably
34
tongue palsy can be caused by surgery...
in the submandibular region
| if hypoglossal XII injured
35
jaw assymmetry can result from unilateral injury to
V3 which innervates muscles of mastication
| exits foramen ovale and follows deep course to mastication muscles, so deep dissection needed to injure
36
strabismus results from what nerve injury
lr6so4ao3
extraocular muscles
abducens trochlear occulomotor
37
winged scapula a complication of this surg...
axillary lymphadenectomy for breast cancer if long thoracic nerve injured
38
2 most important exam findings for compartment syndrome
pain w pasilsive stretch
paresthesias
(and swollen, tense, inc pressure)
39
are paresthesias an early or late compartment syndrome symptom?
early
| from sensory nerve ischemia
40
```
tf
dec sensation
motor weakness
paralysis
dec distal pulses
```
are common findings in compartment syndrome
f
uncommon findings
pain out of proportion, pain w passive stretch, paresthesias, tense swelling
are earlier more common findings
41
causes of compartment syndrome
direct trauma
prolongued compression
reperfusion after ischemia
42
tf
| compartment syndrome responds well to narcotics
f
43
tf
| paresthesias count as neurologic deficit in context of compartment syndrome
f
paresthesias early from sensory nerve ischemia
but neurologic deficits (dec sensation, motor weakness) arise later
44
tf
| pallor is required to dx compartment syndrome
f
| uncommon, not required
45
what does pallor signify in compartment syndrome and is it required for diagnosis
arterial occlusion
| not required, uncommon, late finding
46
tf most compartment syndrome pts have dec distal pulses
f
most intact pulses
uncommon
not required for dx
47
most critical prognostic factor for compartment syndrome amd what does it mean for disgnostic method
time to fasciotomy
| so in high risk pt (eg limb revascularization) don't wait to measure compartment pressures - go straight to fasciotomy
48
tf
| elevation and ice recommended for compartment syndrome
f
for inflammation
just keep cs at level of torso
49
differentiate compartment syndrome from dvt
cs more acute, severe, paresthesias, pallor rare but pallor if vascular component
dvt more insidious onset, no neuro sx, red and hot because vein occluded
50
diverticulitis on ct
inflammatory soft tissue stranding and colonic wall thickening
51
proportion of uncomplicated vs complicated diverticulitis
75%
| 25%
52
manage uncomplicated diverticulitis
bowel rest
oral abx
observation
but for elderly immunosuppressed significant fever or leukocytosis or significant comorbidities - admit amd iv abx
53
define complicated diverticulitis
| and manage
abscess
perf
obstruction
fistula
fluid collection v3cm iv abx and obs
w surg if sx worsen
fluid collection ^3cm ct guided percutaneous drainage, if sx not controlled in 5 days surgical drainage and debridement, sigmoid resection for fistulas perfs w peritonitis obstruction recurrent diverticulitis
54
define
initial
total
terminal hematuria
at start if void
throughout void
at end of void
55
ddx for terminal hematuria
lower collecting system (bladder, prostate)
- urothelial cancer
- cystitis (infection vs radiation)
- urolithiasis
- bph
- prostate cancer
56
6 indications for cystoscopy
- gross hematuria w no evidence of glomerular disease or infection
- microscopic hematuria w no ev kf glom dz or inf but inc risk of cancer (^40 male smoker...)
- recurrent uti
- obstructive sx w signs of stone or stricture
- irritative sx wo infection
- abnorm urine cytology or imaging
57
tf
| clots in urine think glomerular
f
clots rare w glomerular (diff from casts)
an get clots w bleeding from ureters or bladder...
58
initial hematuria (at start of void) think...
urethritis or trauma (catheter)
59
total hematuria (throughout void) think...
upper collecting system (kidneys, ureters)
- renal mass
- glomerulonephritis
- urolithiasis
- polycystic kidney disease
- pyelonephritis
- urothelial cancer
- trauma
60
tf
| urinary clots are typically seen in renal causes of hematuria
f
clots not the same as casts
can get clots w urethral or bladder cause of hematuria
61
```
chronic nsaids
episodic post prandial epigastric pain
followed by acute severe constant pain
think...
tx
```
perforated peptic ulcer
expect pneumoperitoneum on upright xr between liver diaphragm
```
ng suction
ivf
iv abx
iv ppi
definitive mgmt w urgent exploratory laparotomy
```
62
q waves on ecg indicate...
old mi
63
pneumoperitoneum on upright xr
next step is ct w oral con?
no
| already thinking per from xr, no need to repeat dx w ct
64
indications for upper gi endoscopy
upper gi bleed (hematemesis, melena)
| weeks after resolved perfed peptic ulcer to eval for cancer h pylori infection or healing
65
what does viscus refer to
an internal organ
| singular of viscera
66
what causes the classic coloration of venous stasis dermatitis
erythrocyte extravisation thru post-capillary venules and hemosiderin deposition
67
pathogenesis of venous stasis dermatitis
venous valvular incompetence, venous htn, fluid protein blood extravisation thru postcapillary venules
inflammation fibrin deposition platelet aggregation
microvascular dz, ulceration
68
xerosis
| define
dry skin
69
vocabulary of venous stasis signs and sc
xerosis (dry skin) early
| lipodermatosclerosis (inflammation of subq fat
ulcers
late)
70
stasis dermatitis most commonly involved what specific part of the body
medial leg between knee and inferior maleolus
71
raynaud disease /phenomenon
path
feared complication
arterial spasm in response to cold or emotional stress causing discoloration amd discomfort of distal digits
distal gangrene if severe
72
limb complications of neurosyphilis
tabes dorsalis - posterior spinal cord lesion causing dec sensation and proprioception of lowe extremities - paresthesias and ataxia
73
rivaroxaban
apixaban
fondaparinux
moa's
rivaroXaBAN
apiXaBAN
direct factor Xa inhibitors
fondaparinuX
indirect factor Xa inhibitor
74
argatroban
bivalirudin
dabigatran
moa's
argaTroBAN
bivalirudin
dabigaTran (oral)
thrombin (factor II) inhibitors
75
preferred long term oral anticoagulant in end stage renal dz
and moa
warfarin
vit k antag
(factors II VII IX X, proteins C and S
76
what clotting factors does heparin inhibit
XII XI IX
VII
X
II
(all a)
77
duration of anticoagulation after provoked dvt by surger
likely 3 mos
78
when to bridge to warfarin w ufh vs lmwh
ufh if end stage renal (lmwh ci - renally excreted)
79
how to bridge heparin to warfarin
4-5 days till inr 2-3 (start warfarin usually evening same day as heparin)
80
aspirin's role in dvt
none
| it's a platelet inhibitor, not involved w clotting cascade
81
when to start anticoagulation therapy postop in a hemodynamically stable pt
and does it inc risk of bleeding
48-72 hours
does not significantly inc risk of bleeding
82
why bridge ufh to warfarin - why not just keep heparin goimg
heparin is iv only
| so want to get to oral warfarin for discharge
83
mechanism of diaphragmatic rupture in blunt trauma
special presentation in kids
high intraabdominal pressures
or avulsion
-left more common because left posterolat diaphragm congenitally weak and lover protects right
some pts, kods especially, may have no s or s initially but delayed presentation mos yrs later w expansion of defect and herniation risk strangulation and high risk death
84
looks like diaphragm hernia on cxr, next diagnostic step?
ct to confirm
85
diaphragmatic hernia on cxr
left lower lung opacity
(usually left because weaker there and liver protects right)
left elevated hemidiaphragm
mediastinal shift right
86
what about severe burns provides good substrate for infection
avascular
immunilogically poor
protein-rich
87
bugs in burns
staph a (g+) immidiately, from sweat glands and hair follicles
pseudomonas and candida (g- and fungi) 5 days out
88
systemic signs of burn wound sepsis
```
temp v36.5 (97.7)
^39. (102.2)
progressive tachyc ^90
progressive tachyp ^30
refractory hypot sbp v90
```
89
s and s of burn wound sepsis
oliguria, unexplained hyperglycemia, thrombocytopenia, ams
```
temp v36.5 (97.7)
^39. (102.2)
progressive tachyc ^90
progressive tachyp ^30
refractory hypot sbp v90
```
90
```
burn wound sepsis
pres
dx
expected bugs
tx
```
large area (^20% bsa high risk)
wound changing for worse eg getting deeper or failing skin graft
oliguria, hyperglycemia, thrombocytopenia, ams
t v36.5 97.7 ^39 102.2, tachyc tachyp hypot
wound cx ^10^5/g tissue
bx for histopath depth
staph a from sweat glands and follicles immediately
5 days out pseudomonas candida
broad abx piptazo carbapenem
vanc maybe for mrsa
aminoglycoside maybe for mdr pseudo
local wound care and debridement
91
tf
| CO exposure can cause a delayed neuropsych syndrome / ams
t
| sometimes it can
92
temp inc w drastic metabolic rate inc eg w large burn
up to 38.5 101.3
93
typically first signs of burn wound infection
change in appearance (getting deeper, necrotic)
| failed skin graft
94
pts of primary vs secondary pmeumothorax
prim - thin young men no hx
| sec - copders / lung dz
95
s and s
| tension pneumo vs spontaneous pneumo
hemodynamic instability and trachial deviation away
in addition to usual cp sob dec chest wall movement hyperresonance
96
tf
| spontaneous pneumothorax most often occurs at rest
t
spontaneous rupture of subpleural blebs
(thin male in 20's, marfan, smoker, thoracic endometriosis... all risks)
97
manage small primary spontaneous pneumothorax in medically stable pt
obs
| and supplemental o2 (speeds resorption of pneumo... how..?)
98
manage primary spontaneous pneumothorax
- obs and supplemental o2 to speed resorption if small pneumo clinically stable
- large bore needle (14 or 18 gage) decompression via 2nd or 3rd mid-axillary intercostal (sup border of rib) or 5th intercostal mid or ant axillary if large pneumo clinically stable
- emergent tube thoracostomy if possible otherwise needle decompression if hemodynamically unstable
99
when to get cct after cxr for suspected pneumothorax
don't usually
can if dx uncertain
or loculated pneumo suspected
or thoracostomy concern
100
when to consider VATS for pneumothorax
video assisted thorascopic surgery
for failure to reexpand ^90%
or recurrence
can patch or pleurodese
101
how might recent fever and sore throat in young athlete predispose to splenic laceration
could have been mono
splenomegaly
higher risk of laceration with blunt abdominal trauma
102
epidermal hematoma typically from trauma to this bone
sphenoid
(mma)
middle meningeal artery
103
epidural hematoma most common in what age group
children and adolescents
| from trauma
104
level of the diaphragm
up to 4th (nipple) thoracic dermatome on right and 5th (just below pec) on left w expiration
down to 12th thoracic dermatome w inspiration (posteriorly?)
105
must consider both chest and abdominal trauma w gunshot wound at what level
anywhere nipples or below (t4 dermatome or lower) - diaphragm can get up there with expiration
106
possible abdominal trauama after gunshot wound, pt hemodynamically unstable, best procedural next step?
what if stable?
fast focused assessment w sonography for trauma
(for hemoperitonium, peritoneal effusion, pericardial effusion)
if pos
exploratory laparotomy for any gsw hemodynamically unstable, peritonitis, or organ evisceration
if equivocal
dpl diagnostic peritoneal lavage
if neg
look for other reasons for hemorrhage - pelvic... long bone fx... - and stabilize
-ct when stable
if stable w neg us or diagnostic peritoneal lavage, ct to determine need for exploratory laparotomy
107
dpl diagnostic peritoneal lavage done in hemodynamically ____ pts w ____ abdominal trauma w inconclusive ____
unstable
blunt abdominal trauma
inconclusive fast focused assessment w sonography for trauma
108
reverse warfarin for emergent laparotmomy
ffp
| vit k not fast enough... relies on synth of new vit k dependent clotting factors ii vii ix x by liver
109
treat acute bowel perf from afib thrown clot infarct perf
```
ng tube decompression
ivf
iv abx
ffp to reverse warfarin
emergency laparotomy
```
110
tf
| preop transfusion is often required for pt w chronic anemia
f
usually not
generally, tissue oxygen delivery not deficient till hb v7
consider risk factors for ischemia and anticipated operative blood loss
111
when is desmopressin ddavp given preoperatively
pt had hemophilia a
| (ddavp indirectly inc factor viii by releasing vwf from endothelial cells
112
penile fracture is a fx of the...
corpus cabernosum
| w tear in tunica albuginea which envelopes it
113
detumescence
subsiding of swelling, tension, or sexual arousal
114
presentation of penile fracture
audible snap when erect
detumescence
pain ranging w severity of fx
hematoma bends shaft
115
manage penile fracture
emergent urologic surgery
| too many complications with medical mgmt... erectile dysfunction, painful erections, etc
116
when to get retrograde urethrogram for penile fracture
urethral injury suspected
| blood at meatus, hematuria, dysuria, urinary retention
117
normal serum calcium
8.4-10.2
118
normal serum phosphorus
3.0-4.5
119
describe neuromuscular irritability from hypocalcemia
```
perioral tingling and numbness
muscle cramps
tetany
carpopedal spasms
seizures
qt prolongation
```
120
which is symptomatically worse, acute or chronic hypocalcemia
acute
can be very symptomatic even with small decrease if fast enough
chronic may be asymptomatic at a quite low number
121
causes of primary hypoparathyroidism
```
post surgical
autoimmune
congenital (digeorge eg)
defective ca receptors on pt gland
infiltrative dz eg hemochromatosis wilson's neck irradiation
```
122
what is subtotal parathyroidectomy moat commonly done for
eg removal of 3.5/4 parathyroid glands for parathyroid hyperplasia
123
3 drugs that cause vitamin D deficiency
phenytoin
carbamazepine
rifampin
by inducing cytp450 in liver, breaking vit d into imactive metabolites
124
kidney function in vit d metab
1a-hydroxylase converts 25hydroxy to 1,25dihydroxyvitamin d
ca resorb
phos excrete
failure gives hypocalcemia hyperphosphatemia and seconday hyperparathyroidism
125
Treat AFib after CABG
BB or Amio
Usually resolves v24 hours
If persists, then start thinking about cardioversion and anticoagulation
126
Eval bunt genitouronary trauma
UA -- for hematuria basically
CT AP if hemodynamically stable
IV Pyelogram before Surgery if hemodynamically unstable
