Surgery Flashcards Preview

Step 2 > Surgery > Flashcards

Flashcards in Surgery Deck (304):
1

What agent is given to patients with extreme hypotension (low BP) during heart surgery that eventually requires bypass?

Methylene Blue

MOA: inhibits guanylate cyclase and production of cGMP --> reduced responsiveness of vasodilators (nitric oxide)

2

Internal vs External Carotid resistance via Doppler?

*External: when not using somatic (muscles) parts of body, the blood vessels are vasoconstricted to restrict blood flow when it's not needed there. This is why high initial pressure on doppler followed by sharp drop-off. (picked up on doppler)
Supplies face muscles (somatic areas)

*Internal: blood flow to visceral organs needs to be high at all times. This is why there is high (loud) diastolic phase during doppler b/c blood flow is still high (picked up on doppler)
These vessels feed important organs (brain, kidney) and will have high flow

3

During carotid endarterectomy, where do you clamp vessels?

When closing up, what order do you release the vessels to assess for bleeding?

Clamp proximal and distal to place of operating (common carotid and both internal & external carotids)

1) Open distal artery first (common carotid portion furthest from head) to assess for any bleeding from suture site
2) Then release the external carotid artery --> if there is any residual gunk/plaque, you don't want it going to the brain and stroking the patient. Going down the external carotid to face is less damaging.
3) Release internal carotid artery last!!

4

What can be given to prevent contrast-induced nephropathy in people w/ renal insufficiency?

What 2 things should be avoided?

Aceytlcysteine w/ plenty of IV fluids

Avoid volume depletion and NSAIDs

5

How many days before surgery do you need to d/c Warfarin?

3-4 days pre-op

*Switch from warfarin to either heparin/LMWH until surgery than start either again 12 hrs post-op and maintained until INR >2

6

How long before a surgery should you stop smoking?

at least 4 weeks pre-op (6-8 weeks)

7

Cause of fever immediately after initiation of anesthesia?

Malignant hyperthermia

Tx: Dantrolene, 100% O2, cooling blankets

8

Common cause of fever post-op day 0-1?

Atelectasis or pneumonia

9

Patient post-op develops a fever on post-op day #1 and it persists for 2-3 days?

Pneumonia

10

Fever presenting post-op day 3-5?

Post-op UTI

UTI: 3 letters - 3rd days after see fever
DVT: V is roman numeral for 5 - 5 days after see fever
Wound: W for week (1)
Deep Abscess: 4 letters + 9 letters = 13 (9-13 days)

11

How many days after operation do you see fever from wound infection?

5-8 days

12

Maintenance fluid calculation?

4-2-1 rule
or
wt (kg) + 40 = mL/hr

13

Adequate urine output?

0.5 mL/kg/hr (30mL/hr)

14

Maintenance IV fluid of choice for adults? children?

Adults: D5 1/2 NS + 20 mEq KCl/L
Children: D5 1/4 NS + 20 mEq KCl/L

15

Composition of 0.9 NS?

Na: 154
K: 0
Osm: 308
pH: 6.0
Cl: 154

16

Composition of extracellular fluid?

Osm: 290
Na: 140
K: 4.5
Cl: 108
pH: 7.4
Lactate: 5

17

Composition of LR?

Osm: 273
Na: 130
K: 4
Cl: 110
HCO3: 27
Ca: 3
pH: 6.5
Lactate: 28

18

Composition of D5W?

Osm: 252
Na: 0
K: 0
Glucose: 50g/L
pH: 4.5

19

Composition of D5 1/2 NS?

Osm: 450
Na: 77
K: 0
Cl: 77
Glu: 50

20

Composition of PlasmaLyte?

Osm: 294
Na: 140
K: 5
Cl: 98
pH: 7.4

21

Name for chronic leg discoloration from chronic venous insufficiency?

Lipodermatosclerosis or venous stasis dermatitis

22

What are better for moisture retention and delivery of medications - creams or ointments?

Ointments

23

What is Leriche syndrome?

Aortoiliac occlusive disease --> form of peripheral artery disease involving bifurcation of abdominal aorta

Triad:
1) B/L hip/buttock/thigh claudication (worse w/ walking)
2) Decreased/absent femoral pulses
3) **Impotence --> if not present, not Leriche!

24

What is Leriche syndrome?

Aortoiliac occlusive disease --> form of peripheral artery disease involving bifurcation of abdominal aorta

Triad:
1) Buttock/thigh claudication
2) Decreased/absent femoral pulses
3) Impotence

25

6 P's of Compartment Syndrome?

Pain, Pallor, Paresthesia, Paralysis, Poiklothermia, Pulseless

26

Daily protein needs for TPN?

25 kcal/kg/day or 1-1.5 g/kg/day

27

3 common causes of appendicitis?

Bowel fecalith
Lymphoid hyperplasia (viral infection) - children
Tumor

28

Testing modality for children w/ suspected appendicitis? Women? Men?

Children and women --> Ultrasound
Most adults over 50 --> CT scan

29

2 pre-op treatments for appendicitis?

Crystalloid fluid
Abx: cefazolin + metronidazole

30

First step in appendectomy?

Ligate appendicular artery (branch off of ileocecal from SMA)

31

Borders of inguinal canal?

Roof: fibers of internal oblique & transversus abdominus
Floor: inguinal ligament
Anterior: external oblique aponeurosis
Posterior: transversalis fascia

32

Borders of Hasselbach's triangle?

Lateral border of rectus abdominus
Inferior epigastric artery
Inguinal ligament

33

What congenital defects allows indirect inguinal hernias to occur?

Patent processus vaginalis

34

Borders of femoral canal?

Anterior: inguinal ligament
Posterior: Cooper's ligament (periosteum of superior pubic ramus)
Medial: lacunar ligament
Lateral: femoral vein

35

3 stages of hernia progression?

Reducible
Incarcerated (non-reducible --> leads to lymphatic and venous obstruction in the loop of bowel --> overtime leads to compression and obstruction of arterial flow to loop of bowel)
Strangulated (ischemic/necrotic bowel from lack of blood supply)

36

Drug commonly avoided due to Sphincter of Oddi spasm?

Morphine (tested but not practiced)

37

Term for air located in the gallbladder?

Emphysematous Cholecystitis

38

Charcot's triad?



Reynold's pentad?

1) Fever & chills
2) RUQ pain
3) Jaundice
*Also see increased ALP
**Seen in acute ascending cholangitis**

Charcot triad + hypotension & mental status changes

39

What is triangle of Calot?

Area where ligation of cystic artery and duct occur for gallbladder removal

"3 C's"
1) Cystic duct
2) Common hepatic duct (BEFORE cystic duct joins)
3) Cystic artery

40

Common feature of R-sided colon cancer?

Fe-def anemia

*Microcytic anemia in older adult (>50) = colorectal cancer until proven otherwise (also think GI bleed)

41

Common feature of L-sided colon cancer?

Bowel changes

Pencil-thin stools, constipation, diarrhea

42

Best initial test for colorectal cancer?

DRE --> if (+) then to colonoscopy

43

In adults, 3 most common causes for small bowel obstruction?

Adhesions (prior abdominal surgery)
Hernias
Tumors (suspect w/ no prior abd surgeries or hernias)

44

How do gallstones get into the small bowel and cause obstruction?

Cholecystoenteric FISTULA forms (b/w gallbladder and small bowel) and allows passage of large gallstones into bowel --> obstruct the ileocecal valve

45

X-ray findings for gallbladder fistula?

Air in biliary tree
Possible radio-opaque mass in RLQ

46

2 common causes for large bowel obstruction?

Tumors
Volvulus

47

Bilious vomiting in newborn?

Malrotation of midgut volvulus until proven otherwise!

48

Causes for bowel obstruction in children?

Volvulus, intussusception, hernias

If they don't pass meconium:
At all = CF
During initial 24 hrs = Hirschsprung's disease

49

Common complication of bowel obstruction?

Vomiting --> hypokalemic, hypochloremic metabolic alkalosis

Hypokalemic b/c the alkalosis causes H+ to efflux from cells for buffer --> K+ moves into cells as H+ moves out --> drop in K+ level

50

X-ray findings for small bowel obstruction?

Dilated loops of small bowel
"Step-ladder" appearance --> air-fluid levels

51

Treatment for SBO?

"Suck & Drip"
1) NPO
2) NG tube to suck out all gas in GI tract
3) Aggressive IV hydration w/ IV crystalloid
4) Foley placed to monitor urine output for hydration status
5) Correct electrolyte imbalances

*Surgery is only needed w/ complete obstruction or clinical/radiographic signs of ischemia, necrosis, or perforation

52

Most common area for AAA?

Best method of testing?

Below renal artery bifurcation (no vasa vasorum causes weakening in arterial wall)

CT scan

53

What size do AAA become surgical candidates?

>5.5cm diameter

54

Femoral triangle?

Lateral border: sartorius muscle
Medial border: adductor longus muscle
Superior border: inguinal ligament

55

Treatment for large bowel obstruction?

Enema, decompression w/ rectal tube, colonoscopy

56

Name for acute colonic pseudo-obstruction causing dilation of colon without any actual mechanical obstruction?

Once this is diagnosed, what is treatment?

Ogilvie syndrome (often in elderly w/ extra-abdominal surgery)

Tx: Neostigmine (potent cholinesterase (-) & parasympathetic agonist that stimulates colonic contraction and subsequent decompression of the bowel)

57

What is blood supply of internal & external hemorrhoids and which are painful?

Internal: dilated superior rectal plexus located ABOVE dentate line and NOT painful

External: dilated inferior rectal plexus loctated BELOW dentate line and YES are painful

58

Management of hemorrhoids?

Conservative (sitz baths, stool softeners, high fiber diet)

Surgical management:
Internal: rubber band ligation
External: hemorrhoidectomy

59

What condition should you suspect w/ an anal fissure, perianal abscess, or anorectal fistula fail to heal?

Crohn's disease

60

What is Goodsall's rule of anorectal fistulas?

Anterior fistulas connect w/ rectum in a straight line
Posterior fistulas go towards a midline internal opening in the rectum

61

During organ transplantation, in what organ are antigenic reactions (acute, hyper acute, delayed) not very common?
What is most common complication?

Liver

*Most common cause of early functional deterioration is technical problems w/ biliary & vascular anastomoses --> if they appear normal, then do liver biopsies to confirm organ rejection

62

Risk factors for squamous cell carcinoma of the mouth? Common precursor lesions?

Smoking & alcohol
Erythroplakia & leukoplakia

63

Firm, non-tender mass in front of L ear present for 4 months w/ limited mobility and not fixed to deep tissues or to overlying skin. FNA is done, but indeterminate. What do you suspect? Next best step?

Parotid tumor (pleomorphic adenoma or adenoid cystic tumor)

Next step: superficial parotidectomy w/ sparing of facial nerve
*Repeat biopsies are NOT advised b/c of potential damage to facial nerve from scar tissue formation

64

Fever, perineal pain, irritative urinary symptoms, very tender prostate on exam? Tx?

Acute Prostatitis

Tx: Fluoroquinolones 4-6 weeks (broad G(-) & (+) coverage)

65

R hip pain radiating down femur to the knee. Hx Crohn's w/ recent flair controlled w/ prednisone for 2 weeks. Pain worse on exertion & relieved w/ NSAIDs. Limited ROM w/ R hip, especially w/ external rotation. X-ray shows dulling of femoral head only. What is next step in diagnosis?

Avascular necrosis of femoral head secondary to exogenous steroid use!

*Femoral head especially at risk due to poor blood supply (medial fem circumflex via profunda femoris)

66

What is a Pringle maneuver?

Hemostats used to clamp the Portal Triad in hepatoduodenal ligament to control possible liver bleeding.

If done and bleeding still persists in RUQ --> think hepatic vein or IVC behind the liver

67

In someone with epidural hematoma that suddenly becomes unresponsive, what is the definitive management?

Surgical evacuation of the hematoma

68

Elderly at risk for what types of fractures? Why? Best initial test?

Femoral fractures (hip fracture due to FALLS! - underlying cormorbidities also)

Diag test --> X-ray of hip/femur

69

What is an absolute indication for CT scan to the head?

Loss of consciousness secondary to head trauma

WITHOUT contrast - contrast reserved for mass lesions in the brain

70

When is contrast used for head CT's?

Suspecting mass lesions in head

71

Method for eliminating pyogenic liver abscess?

Amebic liver abscess?

Pyogenic abscess --> percutaneous drainage (Abx won't touch it!)

Amebic abscess --> metronidazole (E. histolytica) & then percutaneous drainage if no resolution w/ Abx

72

Pt w/ recent pituitary surgery for prolactinoma develops lethargy, confusion, and becomes comatose. Her urine output is elevated and is receiving modest IV fluids. What is the cause? Treatment?

Central diabetes insipidus --> damage to other parts of anterior/posterior pituitary & their hormones
- Lack of ADH = massive/rapid water loss via kidneys causes hypernatremia (causes CNS symptoms)
- Tx: IV fluids and desmopressin (ADH-analouge)

73

Patient is actively bleeding per rectum. A NG tube is placed & aspiration reveals clear, green fluid w/o blood. How does this help you identify location of GI bleed?

If aspirate is clear = bleed is DISTAL to Ligament of Trietz (where duodenum becomes jejunum)

74

X-ray findings of SBO + air in biliary tree (pneumobilia) is indicative of what?

Gallstone ileus in ileocecal valve from gallbladder-small bowel fistula

Common sequela after acute cholecystitis

75

2 complications of femoral fractures. What signs do you see with each?

Fat emboli --> usually several days after fracture and see respiratory failure

Hypovolemic shock --> massive blood loss into thigh cavities

76

Common complication after acute pancreatitis seen w/ high fevers and leukocytosis?

Pancreatic abscess

CT scan of abdomen to locate abscess for drainage

77

What is cause for pneumaturia (peeing bubbles) and fecaluria?
What test would confirm?
What are 3 most common causes?

Colovesical fistula (colon & bladder)
CT scan to confirm
1) Diverticulitis 2) Sigmoid cancer 3) Bladder cancer

78

Someone vomiting bright red blood. What is first step in management? Second? Third?

1) Examine mouth & nose --> r/o epistaxis!!!
2) Lavage gastric contents via NG tube
3) Upper Endoscopy

79

Best treatment for acute ascending cholangitis?

1st: supportive care + broad-spectrum Abx

2nd: ERCP
Evaluates biliary obstruction & is both diagnostic & therapeutic (decompression of dilated common bile ducts)

80

Best treatment for acute ascending cholangitis?

ERCP --> evaluates biliary obstruction & is both diagnostic & therapeutic (decompression of dilated common bile ducts)

81

What nerves are at risk for damage in inguinal hernia repairs?

Iliohypogastric, ILIOINGUINAL, genitofemoral (genital branch), lateral femoral cutaneous

82

5 indications for surgery on GI tract?

1) Bleeding
2) Perforation
3) Obstruction
4) Retractable symptoms
5) Neoplasm

83

Triad of lab findings indicating the need for a Damage Control Situation (stopping operation to stabilize patient for several hrs before returning to surgery)?

1) Hypothermia (5mmol)
2) Coagulopathy (increased PT/INR & PTT)
3) Acidosis (low pH & lactate >5mmol)

84

Most common malignant tumor in appendix?

Carcinoid tumor

85

Purpose of the large colon?

Water absorption

86

Aside from niacin deficiency, what condition causes diarrhea, dermatitis, dementia?

Carcinoid syndrome (from decreased niacin production)

87

What are the signs of carcinoid syndrome?

"Be FDR"

Bronchospasm
*Flushing (skin - early & frequent)
Diarrhea
R-sided heart failure (valve failure - tricuspid)

88

What lab test is used for carcinoid tumors?

Treatment for carcinoid?

5-hydroxyindolacetic acid (HIAA)

Tx: octreotide (somatostatin analogue)

89

2 most common causes for fistula formation?

Diverticulosis & cancer

90

Newly-developed Fe-deficiency anemia in postmenopausal woman or older man?

Colorectal cancer

91

Triad often seen w/ diverticulitis?

Fever
LLQ pain/diffuse abd pain
Leukocytosis

92

What tests are contraindicated in suspected diverticulitis?

Barium enema, colonoscopy --> risk of perforation

93

Consider this diagnosis in patient w/ atypical chest pain (normal cardiac exam) and symptoms of GERD?

Hiatal hernia

94

What unique structure is found in males inguinal canal? females inguinal canal?

Males: spermatic cord w/ vas deferens
Females: round ligament of uterus

95

Why is shoulder pain a common complaint post-laparoscopy?

CO2 used for insufflation can irritate the diaphragm (direct pressure or cell death from temp changes) --> referred pain via phrenic nerve

96

What abdominal test/procedure is strictly therapeutic?

ERCP

97

24 yo woman who recently gave birth presents w/ extreme rectal pain when defecating and bright red blood on toilet paper. She feels pain when coughing and it's relieved when standing. Where is most common location of this lesion?

Anal fissure --> Posterior midline BELOW dentate line

98

In a person w/ claudication, what disease process are thinking and what is next best test? What limit denotes disease?

Peripheral vascular disease (arterial occlusive disease)

*Ankle-brachial index (ABI) --> measures systolic BP in ankle divided by brachial artery via Doppler

ABI

99

In a person w/ claudication, what disease process are thinking and what is next best test?

Peripheral vascular disease (arterial occlusive disease)

*Ankle-brachial index (ABI) --> measures systolic BP in ankle divided by brachial artery via Doppler

100

Allogenic bone marrow graft to someone results in fever, diarrhea, generalized rash, cough, jaundice, and intestinal bleeding. What is the cause and complication of the marrow transplant?

Graft-vs-host disease (GVHD)

T lymphocytes (cytotoxic T cells & NK cells) of the donor tissue attacks the immunocompromised host! Symptoms in stem are classic

101

CT scan shows small bowel thickening w/ air in the bowel wall (pneumatosis intestinalis/coli) w/ hx of CHF, CAD. What is it?

Non-occlusive mesenteric ischemia (NOMI) --> vasoconstriction of mesenteric vessels OR hypoperfusion (shock) in stenosed vessels

102

What 2 broad categories must you consider w/ CT scan of small bowel inflammation w/ air in abdominal wall?

Mesenteric ischemia & infection (gas-producing organism)

103

What trauma situation warrants an exploratory laparotomy?

Gunshot wound to abdomen

104

3 complications of AAA repair?

1) Renal failure (atherosclerotic emboli of renal arteries, contrast-induced nephropathy, occlusion of renal arteries w/ graft)
2) Ischemic bowel (occlusion of IMA by graft-stent)
3) Spinal cord ischemia (disruption of artery of Adamkiewicz @ T12 --> causes anterior cord syndrome or paralysis of legs)

105

2 days post-op AAA repair, man develops abdominal pain w/ bloody diarrhea w/ falling Hgb & rising WBC count. Next best step? What is it?

Next step: urgent colonoscopy (gold standard to visualize cyanotic or shedding mucosa)

Ischemic colitis: complication of AAA repair b/c origin of IMA is covered by aortic graft. Don't have adequate collateral circulation via Marginal artery of Drummond from SMA
- Ischemia of descending and sigmoid colon (rectum spared b/c of different arterial supply than IMA)
**Blood diarrhea w/ leukocytosis in this setting = mesenteric ischemia

106

Next step in management for a person who sustains a closed fracture w/ weakened but present pulses?

CT angiogram --> have to assess possibility for VASCULAR injury

107

"Hard" signs indicating vascular injury and warranting immediate surgical exploration?

Active hemorrhage
Expanding hematoma
Pulse absence
Bruit or thrill
Distal ischemia (arteiral insufficiency --> pain, pallor, poikilothermia, paresthesias, paralysis, pulseless)

108

1 week hx of mass in scrotum that is painless, smooth, nonindurated and located above the testicle. Ultrasound reveals a cystic lesion w/o internal echoes in R epididymus. What is next best step?

No further management needed --> if asymptomatic, nothing else needed

Either spermatocele or epididymal cyst

109

Man feels a new budge in his groin that is causing him pain. He has a fever (100.4) and has mild R-sided erythema. A tender mass is felt at internal inguinal ring that is unaffected by cough or strain. What is next appropriate step?

Emergent surgical repair --> need to save the bowel or debride necrotic tissue

Hernia's are rarely painful

Painful, red, fever = incarcerated hernia

110

Most common cause of post-op decreasing urine output? What test helps confirm?

Hypovolemia (procedure w/ large blood loss) --> immediately after surgery the patient will "3rd space" the fluids given to them --> need about 3x as much fluid to maintain BP and urine output

Fluid challenge --> if hypovolemic, will have increased BP and urine output; if not, renal failure it is

111

A solitary thyroid nodule (2cm) w/ normal TSH levels is found. What is the next best step?

Fine needle aspiration (FNA) --> most thyroid nodules are BENIGN, but need to r/o cancer anyway

112

"Rule of 9's" for adult burn patients?

Estimated percentage of body surface area affected by the burn:
Anterior trunk: 18%
Posterior trunk: 18%
L leg (entire): 18%
R leg (entire): 18%
L arm (entire): 9%
R arm (entire): 9%
Head (entire): 9%

113

What is common cause of death in burn patients?

CO poisoning from inhaled smoke

*If unexpected neurologic symptoms occur --> get arterial carboxyhemoglobin level b/c pulse oximetry can be falsely elevated.

114

Pain on radial side of wrist & first dorsal compartment. Pain is reproduced by having patient hold their thumb inside their closed fist and forcing wrist into ulnar deviation. What is most likely diagnosis?

de Quervain's tenosynovitis --> tenosynovitis of extensor pollicus braves and abductor pollicus longus

*Pain on radial side of wrist & first dorsal compartment
*Pain reproduced by Finkelstein test (hold thumb inside closed fist and ulnar deviate hand)

115

Dysphagia starting w/ meat --> then other solids --> then soft foods --> liquids --> saliva. Smoking and drinking are risk factors?

Squamous cell carcinoma of esophagus

Smoking & drinking = squamous

116

72 yo woman w/ femoral neck fracture & affected leg appearing shorter and externally rotated. What is next best step in mgmt?

Replace femoral head w/ metal prosthesis

*The femoral head is tenuous & can easily develop avascular necrosis of femoral head

117

What is Nissen fundoplication and indications for performing this surgery?

Laparoscopic procedure that wraps the fundus of the stomach 360 degrees around the GE junction to "replace" or strengthen the lower esophageal sphincter.

Indications:
- GE reflux causing damage to lower esophagus (esophagitis)
- Refractory symptoms despite medical therapy
- Long term medical therapy is undesirable to younger patients

*Treatment of choice for pts w/ normal length and motility of esophagus

118

Complication of Billroth II procedure w/ severe diarrhea, wt loss, and severe halitosis?

What other gastric compliant usually associated w/ this?

Gastrojejunocolic fistula --> fecal contamination of gastric contents (halitosis!)

*Fistula develops from an UNTREATED marginal ULCER that develops in the antecolic anastomosis --> if left untreated, will eventually erode into jejunum allowing feces to pass back into stomach (halitosis & diarrhea)

119

Complication of Billroth II procedure w/ severe diarrhea, wt loss, and severe halitosis?

What other gastric compliant usually associated w/ this?

Gastrojejunocolic fistula --> fecal contamination of gastric contents (halitosis!)

*Fistula develops from an UNTREATED marginal ULCER that develops in the antecolic anastomosis --> if left untreated, will eventually erode into jejunum allowing feces to pass back into stomach (halitosis & diarrhea)

120

Posterior duodenal ulcers can cause massive bleeding from what vessel?

Gastroduodenal artery (lies posterior to duodenum)

121

What is Billroth II procedure?

What are the indications?

Greater curvature of stomach is connected to first part of jejunum in side-to-side manner. Often involves resection of antrum of stomach.

Indications:
1) Refractory peptic ulcer disease
2) Gastric adenocarcinoma

122

Explain Dumping syndrome?

What are signs?

What is treatment?

*Common post-gastrectomy syndrome (vagotomy or Billroth II)

*Hyper-osmolar chyme rapidly dumped into duodenum/small intestine (no pyloric regulation) --> causes fluid shifts from intravascular space into bowel --> results in combination of GI and vasomotor complaints

*S/S: sweating, dizziness, abd pain, diarrhea, palpitations, facial flushing all after eating

*Tx: smaller meals w/ less fat (dietary modification)

123

Which drains to inguinal lymph nodes - adenocarcinoma or squamous cell?

Squamous cell (skin cells)

124

85 yo diabetic on dialysis w/ chronic renal failure develops acute onset B/L facial & orbital swelling w/ loss of vision in R eye. Biopsy specimen of nasal/sinus mucosa shows multiple broad, nonseptate hyphae w/ right-angle branches. What is it? What is most appropriate treatment?

Mucormycosis (rhino-orbital mucormycosis) --> seen in debilitated and **diabetic** patients

Tx: immediate Amphotericin B & surgical debridement

125

What 2 tests are positive in ACL tear? What are 2 modes of treatment and which demographics fall into each category?

Anterior drawer & Lachman's test

Athletes: ACL surgical reconstruction
Sedentary people: immobilization w/ rehab

126

What nerve is most at risk for damage when the humerus is fractured in middle 1/3 or near jxn of middle and distal 1/3's? How would patient present?

Radial nerve (posterior cord of brachial plexus C6-T1)

**No wrist extension and numbness in dorsal aspects of thumb, index, & middle fingers

127

Anyone post-op lower extremity surgery (hip, knee) MUST be on what medication? Why?

*LMWH --> more specific binding potential than unfractionated heparin (more reliable effect on PTT)

High risk for DVT formation leading to PE --> LMWH most effective for DVT prophylaxis in this population

128

Describe a clean wound & its risk of infection?

Clean: created in sterile, non-traumatic environment & do not involve respiratory, GI, genital, urinary systems (physiologically colonized areas of body)

Risk of infection = 1-1.5%

129

Describe a contaminated wound and its risk of infection?

Contaminated: gross spillage from GI, resp, GU systems; wound resulting from recent trauma; outright violation of sterile technique in OR

Risk of infection = 10-15%

130

Describe a clean-contaminated wound and its risk of infection?

Clean-contaminated: created in sterile environment (OR) but involves entry into resp, GI, genital, or urinary systems but w/ limited/no spillage from that system (appendectomy for non-perfed appy w/ no spillage)

Risk of infection = 3-5%

131

Describe a contaminated wound and its risk of infection?

Contaminated: gross spillage from one of above systems; wound resulting from recent trauma; outright violation of sterile technique in OR

Risk of infection = 10-15%

132

Describe a dirty wound and its risk of infection?

Dirty: trauma that contains devitalized tissue or in the presence of established infection (e.g. debridement of gangrenous foot wound)

Risk of infection = 30-35%

133

After vagotomy, what happens to pylorus?

Does NOT contract anymore --> free passage of stomach contents to duodenum

134

What reverses effect of steroids on wound healing?

Vitamin A

135

Pt with progressive jaundice, high direct bilirubin, and high ALP. Sonogram shows dilated intra & extra hepatic ducts w/ a very distended, thin-walled gallbladder w/ NO stones present. What are you thinking? What's next best test?

Pancreatic cancer (head of pancreas)

CT scan of abdomen

136

Common locations for diabetic foot ulcers?

Dorsum of foot, heel, head of 1st metatarsal (pressure points)

Result from chronic pressure & microvascular compromise

137

What is Cushing's triad for increased ICP?

1) HTN
2) Bradycardia
3) Respiratory depression

138

44 yo man has vague RUQ pain for 1 mo. At age 21, had one eye enucleation "for a tumor." CT scan of abdomen shows multiple masses w/in the liver. What type of cancer is it?

Malignant melanoma!

*20+ years may elapse b/w primary tumor and metastatic manifestations

*Tyrosinase is tumor marker

139

Patient has a glass eye and liver full of multiple tumors
OR
Patient is missing a toe and has liver full of multiple metastasis

What is the cause of cancer??

Melanoma!

*Look or long periods of time (years) b/w primary and metastasis

140

Explain the Parkland Formula?

Used to calculate rate of fluid resuscitation for burn patients

Volume (cc) = 4 x wt (kg) x (%) total body area burn

Divide this # by 2

1/2 given in first 8 hours
1/2 given over next 16 hrs

Total volume of fluid given in initial 24 hrs

141

Bright red blood coating the stools & change in bowel habit (constipation) and stool caliber. Only experiences mild discomfort. What are you thinking?

Rectal cancer --> look for:
- Bright red blood coating outside of feces
- Change in bowel habit (constipation, diarrhea)
- Change in stool caliber (pencil-thin)

142

Rule of 9's for infant?

Entire head: 18%
Anterior torso: 18%
Posterior torso: 18%
Entire L leg: 14%
Entire R leg: 14%
Entire L arm: 9%
Entire R arm: 9%

143

Explain the Parkland Formula?

?Used to calculate rate of fluid resuscitation for burn patients

Volume (cc) = 4 x wt (kg) x (%) total body area burn

Divide this # by 2

1/2 given in first 8 hours
1/2 given over next 16 hrs

Total volume of fluid given in initial 24 hrs

144

What is stercoral perforation?

Bowel perforation due to pressure necrosis of a bowel wall from fecal mass that is hard and impacted

Increased intraluminal pressure eventually exceeds capillary perfusion pressure in bowel wall --> leads to ischemia, necrosis, and perforation

90% recto-sigmoid

145

Life threatening complication of stercoral bowel perforation?

Acute abdomen due to peritonitis

146

Describe pathogenesis of frostbite.

Tx?

What is protocol for rewarming?

Freezing & crystalizing of fluids in interstitial and cellular spaces from prolonged exposure to freezing temperatures. Lower temps cause vasoconstriction (to conserve blood supply to vital organs and preserve heat), leading to decrease in blood flow that can't deliver enough heat to tissues --> ice crystals and thrombus formation in capillaries and blood vessels

Tx: tPA (need to dissolve the already formed clots in the blood vessels)

Rewarming protocol: gradual rewarming over 30 minutes - 1 hr

147

Describe pathogenesis of electrical burns.

What complication can arise?

Tissue damage occurs from conversion of electric energy to heat, resulting in thermal injury, especially to internal tissues --> massive edema, thrombosis, muscle destruction occur

4th degree burns (full thickness burn of skin extending to muscle & bone) w/ charring of tissue

Complications:
**Rhabdomyolysis (muscle destruction)
**Compartment syndrome (edema, vein coagulation, muscle swelling) --> look for slow capillary refill, diminished peripheral pulses

*Important for what you don't see!

148

In a patient w/ a known infection and who is septic, what is most appropriate 1st step?

Debridement --> have to eliminate source of infection before pt will start to improve!

Debridement BEFORE IV fluids or Abx

149

Patient w/ hx of cardiac disease, regardless of age, require what before surgery?

- EKG
- Stress testing (exercise or Thallium) --> determines presence of ischemia on EKG
- ECHO (structural disease & EF) --> after ischemia identified on EKG, do this to see changes in myocardial tissue itself

150

In pre-op assessment, what is most important system to investigate? What 2 conditions are of most concern?

CV system

Recent MI & CHF (JVD, LE edema)

151

An ejection fraction below what value is at increased risk for complications w/ surgery?

EF < 35%

152

When is an EKG the only test needed prior to surgery?

Patient under 35 yo
No hx of cardiac disease

153

Patient w/ hx of cardiac disease, regardless of age, require what before surgery?

EKG
Stress testing (exercise or Thallium)
ECHO (structural disease & EF)

154

Which component of PFT's are necessary for pre-op testing in patient's w/ asthma, COPD, or smoking history?

Vital capacity --> it's VITAL for pre-op

155

What are you worried about in a patient who is post-op hip replacement w/ new onset chest pain and tachycardia about 5-7 days after surgery?

Pulmonary embolism

156

Dysuria, frequency, & urgency combined w/ painless hematuria is suspicious for what?

What assn is high with this pathology?

Bladder cancer

*Smoking hx w/ painless hematuria in older man = bladder cancer

157

What 2 scenarios are posterior shoulder dislocations common? Why? How does the patient present? What imaging is best for diagnosis?

Seizures & Electrocutions

MOA: massive contraction of all the muscles in the shoulder area is needed for a posterior dislocation

*Pt presents w/ I/L arm close to the body and hand resting on anterior chest wall

Axillary shoulder x-ray is best

158

In someone presenting w/ carpel tunnel syndrome, what is best initial test? What is a necessary test before surgery is performed?

Carpel tunnel syndrome: entrapment neuropathy of median nerve in carpel tunnel of wrist (flexor retinaculum)

Initial test: Wrist X-ray to r/o other pathology

Before surgery, need Electromyography (EEG) and nerve conduction studies to determine level of denervation of median nerve in hand

159

72 yo woman undergoes CABG after acute MI revealing 3 vessel blockage. 3 days after surgery, she develops acute onset abdominal pain w/ distention. Abd X-ray shows mild small bowel distention. NG tube reveals slight bilious fluid aspirated and sigmoidoscopy easily visualizes the distended segment of bowel. What is going on and why? Best next step?

Ogilvie syndrome: pseudo-obstruction in large bowel seen in older patients after invasive surgery
- Possibly due to narcotic use?

*Look for abd pain, dilated large bowel, N/V, distention in post-op period

Tx: Neostigmine (cholinesterase inhibitor that stimulates parasympathetics to increase colon contraction and decompress the colon)

160

Complication of chronic perianal/perirectal abscess? What is common symptoms of presentation?

Fistula-in-ano

Presents w/ constant soiling of underwear

Often see a scar in anus w/ a central opening where fluid drains

161

List some characteristics of tension pneumothorax.

What is immediate treatment?

Subcutaneous emphysema in neck
*Tracheal deviation to C/L side
*Hypotension, tachypnea, tachycardia
Absent breath sounds
High CVP
*Distended head/neck veins

Tx: Decompress w/ large bore needle inserted into 2nd intercostal space, midclavicular line.

162

Fracture common when falling on an outstretched hand?

Colles fracture: dorsally displaced, dorsally angulated fracture of distal radius w/ ulnar styloid

"Dinner-fork" deformity

Tx: SHORT arm cast --> immobilize the wrist & allow elbow mobility, providing great functional quality of life
The ulna is NOT unstable and elbow does NOT need to be immobilized

163

If there is a suspected gunshot, what tests are the fastest to confirm a gunshot wound?

If definite gunshot wound to the abdomen, what is next best step?

Plain & cross table X-ray --> then CT scan if stable


Exploratory laparotomy or diagnostic laparoscopy

164

When a person's knees hit the dashboard in MVA, what area do you suspect is injured? How would they appear on inspection? Best initial test?

Femoral dislocation/fracture
- Femur driven backwards and out of acetabulum, resulting in posterior dislocation of the hips
- Fragile blood supply of femoral heads that, if injured, can cause avascular necrosis of femoral head

On inspection --> affected leg appears shortened, adducted, and internally rotated

Best initial test --> x-ray of both hips

165

Abdominal distention, obstipation, vomiting, and hyperactive bowel sounds w/ someone who has had prior abdominal surgery. What is it? What's the cause? Next best step?

Bowel obstruction from adhesions (prior abd surgery)

Emergent exploratory laparotomy (incision in abd wall)

166

Painless hematuria in older person w/ smoking hx?

Bladder cancer until proven otherwise

Do more testing!

167

Man playing volleyball hears a "pop" from his ankle and falls to the ground. There is swelling in the back of his lower leg. He can put wt on the foot w/o pain, but can't take a step b/c it's painful. What is it? What test will prove it?

Achilles tendon rupture

(+) Thompson test: inability of prone-positioned patient to plantar flex when gastrocnemius is squeezed

168

42 yo woman w/ LE itching w/ hx of Protein C deficiency & DVT. LE has 1+ non-pitting edema w/ dry, peeling, hyper pigmented skin. Her distal pulses are only weakly palpable. What is it? What's next most appropriate diagnostic modality?

Venous insufficiency --> likely post-thrombotic in etiology
- Lipodermatosclerosis or venous stasis dermatitis: skin changes that include hyper-pigmentation, dermatitis (itching, scaling), ulceration ultimately

Mgmt: LE duplex US imaging (assess venous obstruction) caused by thrombus formation & valvular insufficiency - (past surgery, standing a lot)

169

What is the only definitive treatment for an abscess anywhere in the body?

Drainage!

If you just use Abx, they will be useless!

170

Examiner is assessing a 52 yo for an inguinal hernia. As he places his finger in the external inguinal ring (superficial), where on the finger would you feel an indirect hernia & what defect accounts for this?

Where on the finger would you feel a direct hernia & what defect accounts for this?

Indirect: feel herniation on tip of the finger from a defect in the deep inguinal ring

Direct: feel herniation along lateral aspect of finger in external inguinal ring from a defect in the posterior wall of the inguinal canal (transversalis fascia)

171

Thin people w/ epigastric blunt trauma at risk for what type of injury?

Thin patients w/ epigastric blunt trauma --> pancreatic injury due to risk of compressing the pancreas against the spine causing parenchymal hemorrhage, ductal injury, or pancreatic transection.

Increased amylase & lipase

172

What is best method of management for patient with metastatic pancreatic cancer?

Chemotherapy

173

Most common transfusion reaction?

Febrile non-hemolytic transfusion reaction

*Leukocytes left over from isolated RBCs release cytokines in storage --> when given, they cause immune reaction

174

Most common transfusion reaction?

Febrile non-hemolytic transfusion reaction

175

Most common cause of death by transfusion?

Clerical error leading to ABO incompatibility

176

4 birds of thorax/mediastinum?

Va"GOOSE" (Vagus nerve)
Esopha"GOOSE" (Esophagus)
Azy"GOOSE" (Azygous vein)
Thoracic "DUCK" (Thoracic duct)

177

Someone receives PRBC's (correct type & cross), but after just several hours they develop a fever, back pain, tachycardia, diaphoresis, and falling Hgb & Hct. The urine in the Foley appears reddish. What is this? What is cause?

How to differentiate b/w hemolytic & non-hemolytic reaction?

Febrile hemolytic transfusion reaction --> antibody-mediated hemolysis leading to fever, tachycardia, anemia, and hemoglobinuria
- Tx: IVF & diuresis, NaHCO3 for urine, vasopressors

Look at HEMATOCRIT
Decreasing = hemolytic reaction

Non-hemolytic --> during ABO-compatible transfusions in which recipient antibodies attack donor WBCs

178

Difference b/w ABO-compatible & ABO-incompatible reactions?

HEMATOCRIT
- Decreased = hemolytic reaction (ABO incompatibility)

179

Blood is noted in urethral meatus of someone who had trauma to pelvis. What must be suspected and what is next best step?

Urethral injury --> Get retrograde urethrogram (dye squirted into bladder and patency of urethra visualized w/ KUB)

*Blood @ urethral meatus = retrograde urethrogram

**Do NOT use Foley catheter!!! (may worsen damage)**

180

1 yo w/ reducible umbilical hernia - what is treatment? What is max age when they resolve on their own?

If reducible & asymptomatic = do nothing (monitor)

If under 2 yo, the hernia may still close spontaneously!

181

Person with high fever & chills, RUQ pain, and elevated bilirubin levels w/ increased ALP. What is it? Most common cause? Tx?

*Cholangitis! --> Charcot triad (if mental status changes & hypotension = Reynold's pentad)

Obstruction of common bile duct most likely from stone from gallbladder (choledocholithiasis)

182

Does cholecystitis have jaundice?

NO

183

Person with high fever & chills, RUQ pain, and elevated bilirubin levels w/ increased ALP. What is it? Most common cause? Tx?

*Cholangitis! --> Charcot triad (if mental status changes = Reynold's pentad)

Obstruction of common bile duct most likely from stone from gallbladder (choledocholithiasis)

184

What pressures indicate compartment syndrome? What other factors point towards compartment syndrome?

Compartment pressures above 30-40 mmHg

6 P's: pain, pallor, poikilothermia, paresthesias, paralysis, pulselessness

185

Any fracture w/ diminished/absent pulses w/ normal compartment pressures suggests what? What is best initial test to confirm?

Arterial injury from fracture!

Angiography

186

In suspected skin cancer, what is best initial test?

Biopsy specimen at edge of lesion for diagnosis and staging

187

Fair skin individuals w/ sun exposure on the upper face are most at risk for what type of cancer?

Basal cell carcinoma

188

What is most likely cause for no urine output when there is normal perfusion pressure & pulses?

Kinked Foley catheter

*Common things are common!

189

Describe path of inferior alveolar nerve.

V3 of trigeminal nerve --> passes through mandibular foramen and exits both laterally and anteriorly to supply the lower chin and jaw

Decreased sensation over this area (lower chin & jaw) is diagnostic for mandibular fracture distal to entrance of the inferior alveolar nerve

190

What medication predisposes you to gastric ulcer?

Steroid use
- Blocks initial step in arachidonic acid pathway

*Start someone on H2(-) or PPI as prophylaxis

191

Someone recently admitted to hospital has been started on steroids for nerve issues. They suddenly develop epigastric pain & vomiting. Abd Xray shows pneumoperitoneum. What is likely diagnosis? Next best step?

Gastric ulcer w/ perforation

Next step: urgent exploratory laparotomy

192

Most common cause of one-sided bloody nipple discharge in women b/w 20-40 yo? Steps in management?

Most common cause of bloody nipple discharge in older patient (>40yo)?

Intraductal papilloma
Mgmt: don't show up on mammography due to small size; need to do galactogram

Intraductal carcinoma

193

Step of management in spinal cord injury?

1) Immobilize neck w/ neck collar
2) Put patient's body on hard surface to immobilize rest of the spine
3) W/in first 8 hours of injury, give high-dose corticosteroids (may speed recovery and return of motor function after injury)

194

Acute abdominal pain in LLQ?
Best diagnostic test?
Initial treatment?
Contraindicated?

Diverticulitis
Abdominal CT scan
NPO, IV fluids, antibiotics, pain control
Colonoscopy

195

4 F's for acute cholecystitis?

What is Murphy sign?

Fat, Forty, Female, Fertile

Inspiratory arrest on palpation of RUQ as diaphragm displaces the gallbladder towards the physician's hand --> increased pressure on the inflamed gallbladder results in pain, leading to a pause in inspiration

196

Type of injury common w/ fall onto outstretched hand? Are X-rays helpful? Next step in mgmt?

What is common complication of untreated scaphoid fracture?

Nondisplaced fracture of scaphoid bone

X-rays taken soon after will NOT show a fracture

Mgmt: thumb spica cast indicated for treatment

Avascular necrosis of scaphoid bone

197

In advanced breast cancers (large tumors fixed to chest wall or w/ extensive lymph node involvement), what is the preferred initial treatment course?

1) Preoperative chemotherapy to shrink the tumor
2) Surgical palliation

198

Sudden onset severe, tearing back pain in person w/ HTN & a pulsatile mass in epigastrium?

Rupturing AAA

199

Post-op ileus presents how many days after surgery? What type of surgery?

How does it differ from mechanical obstruction? Signs/symptoms?

Treatment?

4-5 days after abdominal surgery (manipulation of abdominal contents)

There is no distinct transition point (vs. mechanical) but still have same signs/symptoms and findings on abd x-ray

Tx: NPO + insertion of NG tube to decompress

200

49 yo woman w/ suspicious breast lump receives mammography and FNA, which does not identify any malignant cells. What is next appropriate step?

Core-needle biopsy

FNA results are only valuable when they are (+) for malignancy
A (-) FNA does NOT rule out cancer --> need further testing

201

Repeated episode of bilious, non-bloody vomiting in 23 yo male from food poisoning. Has L chest pain and a crunching sound is heard when palpating his chest. What is the diagnosis? What is most common cause? What is best test to confirm?

Boerhaave syndrome (perforated esophagus)
- Forceful vomiting (gastroenteritis, alcohol) results in transmural (full-thickness) tear and perforation of esophagus
- Usually @ L lateral position of distal esophagus (3-5 cm above GE junction)

Hamman's sign: mediastinal crunching on ausculation & indicates presence of pneumomediastinum

Most common cause = iatrogenic during upper endoscopy

Diagnosis: Gastrografin swallow study --> contrast extravasates from esophageal lumen
- Gastrografin is water-soluble & NOT toxic to mediastinal/thoracic structures (vs. barium)

202

What is Meckler's triad? What is it seen in?

1) Vomiting
2) Chest pain
3) Subcutaneous emphysema (palpated & heard crunching on auscultation) - Hamman's sign

Esophageal perforation (Boerhaave syndrome)

203

Person w/ gallstone pancreatitis, what is best course of treatment action?

Conservative --> NPO, IV fluids, pain meds & wait for stone to pass

If this doesn't help in 3-4 days --> ERCP to relieve stone

204

Patient recently fell on shoulder & presents w/ arm held close to the body & forearm rotated outward, as if preparing to shake hands. There is small area of numbness over deltoid muscle. What is diagnosis?

Anterior shoulder dislocation

*Axillary nerve injury is a common complication

205

Common history finding that usually always found w/ acute appendicitis?

Anorexia

206

What do you suspect in a male who suffered trauma to perineum (lower abd/pelvis) or pelvic fracture? What is test of choice?

Urethral injury

Retrograde urethrogram

**NEVER place a Foley catheter until retrograde urethrogram is done to assess urethral injury

207

First step in a person w/ post-operative disorientation? Why?

Start supplemental O2 --> most lethal cause of post-op disorientation is hypoxia

**Transient hypoxia is not uncommon after surgery --> often breathe shallowly due to incisional pain & narcotic use

208

Anyone over 50 yo w/ bleeding out of anus needs what treatment?

Colonoscopy!

*If person is on anticoagulation, this will NOT cause normal colonic mucosa to bleed! Has to be a lesion present w/ a predisposition to bleed

209

Urinary retention from BPH can be triggered by what drugs? What is treatment?

OTC meds (may contain antihistamines and decongestant), nasal drops (contain alpha stimulating agents)

These lead to stimulation of alpha-adrenergic receptors --> further constrict the bladder neck --> big palpable bladder

210

Explain wound dehiscence? Treatment?

Serosanguineous (straw-colored clear fluid) fluid seeping through closed abdominal wound after surgery

Tx: remove 1 or 2 sutures in skin and explore w/ sterile glove to see if there is organ evisceration (trapping of abd viscera in wound)

211

What is wound evisceration and treatment?

Evisceration: herniation of abdominal viscera through wound formed by surgery

Tx: taken back to OR to fix abd contents and close wound properly

212

Cause of fever 10-15 days after surgery? How to r/o?

Deep abscess (pelvic or sub-phrenic)

CT scan

213

In trauma settings, infusions of large amounts of intra-operative fluids (LR, NS), what potential side effect must you watch for? How do you avoid this complication?

Abdominal compartment syndrome

Large IVF's cause severe edema in abdomen --> abdominal pressure >30mmHg means decreased venous return in IVC

Often in trauma settings, fluids are freely running --> need 3x crystalloid to replace blood volume, but most of fluids move to interstitial space

Tx: Temporary abdominal closure w/ absorbable mesh

214

What is Osgood-Schlatter disease? How to manage it?

Overuse injury of patellar tendon as the tibial tuberosity has not ossified and is more prone to microscopic avulsion fractures causing pain

Pain at tibial tubercle and patella AFTER repetitive exercise

Tx: conservative (rest, icing; exercise IS encouraged)

215

Appropriate management for malignant breast cancer > 4cm in diameter?

Mastectomy w/ axillary node sampling (sentinel node testing)

216

Appropriate management for malignant breast cancer

Lumpectomy, axillary sampling, and post-op radiation

217

What is Osgood-Schlatter disease? How to manage it?

Overuse injury of patellar tendon in tibial tuberosity as the tibial tuberosity has not ossified and is more prone to microscopic avulsion fractures causing pain

See pain in tibial tubercle and patella AFTER repetitive exercise

Tx: conservative (rest & icing; exercise is encouraged)

218

Appropriate management for malignant breast cancer > 4cm in diameter?

Mastectomy w/ axillary node sampling (sentinel node testing)

219

Early satiety, nausea, non-bilious vomiting, wt loss in patient w/ hx of acid ingestion? What physical exam finding helps diagnose?

Pyloric stricture

Abdominal succussion splash --> retained gastric material >3 hours after a meal will generate a splash sound & indicates presence of hollow viscus filled w/ both fluid & gas

220

Management of amputation injury?

Wrap digit in sterile gauze moistened w/ sterile saline & place in plastic bag --> bag then placed on ice and transported w/ patient to nearest ER (don't allow digit to freeze)

If done this way, digit viable for up to 24 hours

221

What is potential complication of thoracic aortic aneurysm surgery? How does it present?

Anterior spinal cord infarction
- Anterior spinal artery supplies anterior 2/3 of spinal cord (motor tracts, pain/temp sensation) --> dependent on radicular arteries (artery of Adamkiewicz)

S/S: abrupt onset B/L LE flaccid paralysis, loss of pain/temp BELOW level of spinal injury
- UMN signs develop over days-weeks

*Vibration & proprioception INTACT --> dorsal column of spinal cord not usually affected

222

Appropriate management for malignant breast cancer

Lumpectomy, axillary sampling, and post-op radiation

223

Most common causes of syringomyelia?
Pattern of symptoms?

Arnold Chiari malformations, spinal cord injury (whiplash injury)

S/S: "Cape-like" distribution --> decreased strength & diminished pain/temp affecting arms/hands
*NO loss of light touch, vibration, or position sense (dorsal columns intact)

224

Pt has MVA where he drank a lot of liquid before the crash. He sustained a direct blow to abdomen & pelvis & complains of diffuse abd pain that refers to his L shoulder. What GU injury is cause?

Bladder dome rupture --> only part of bladder covered by peritoneum & only injury that allows urine to leak into peritoneum --> this lets urine irritate diaphragm (shoulder pain)

225

Person is in MVA and has pneumothorax. After chest tubes are placed, he still has pneumothorax on CXR as well as pneumomediastinum (subQ emphysema). What is cause?

Tracheo-bronchial perfoartion secondary to blunt thoracic trauma

226

Man falls when riding his bicycle & one week later has fever, shaking chills, and deep abdominal pain. What do you suspect?

Retroperitoneal abscess --> likely due to pancreatic laceration from trauma

227

In massive hemoptysis, after securing airway, what is next best step?

First, place patient in dependent position (lateral position) to avoid blood collection in airways of opposite lung

Bronchoscopy to localize bleeding site, suction, and other therapeutic interventions

228

Acute onset back pain w/ hypotension?

Ruptured AAA

229

Man presents w/ sudden onset severe pain in the back of his neck and upper chest. He also has B/L leg weakness for past 2 hours. His blood pressure is 210/120 and CXR shows R-sided pleural effusion. What is diagnosis? What main risk factor? Diagnostic test for confirmation?

Acute aortic dissection
Risk factor = severe HTN
Dx test: CT w/ contrast OR transesophageal ECHO

*Dissection can extend into:
- Pericardium (tamponade)
- Spinal arteries (spinal cord ischemia --> lower extremity weakness)
- Pleural cavity (hemothroax --> looks like pleural effusion on CXR)

230

Early satiety, nausea, non-bilious vomiting, wt loss in patient w/ hx of acid ingestion? What physical exam finding helps diagnose?

Pyloric stricture

Abdominal succussion splash --> retained gastric material >3 hours after a meal will generate a splash sound & indicates presence of hollow viscus filled w/ both fluid & gas

231

Management of amputation injury?

Wrap digit in sterile gauze moistened w/ sterile saline & place in plastic bag --> bag then placed on ice and transported w/ patient to nearest ER (don't allow digit to freeze)

If done this way, digit viable for up to 24 hours

232

Patient in recent MVA who has new onset severe back pain w/ weakness and decreased pain sensation in both legs - what do you suspect and what is next step?

Traumatic spinal cord injury

Place urinary catheter to assess for urinary retention & prevent acute bladder distention/damage

233

Patient has DVT from reversible inciting event (e.g. surgery) in R distal part of femoral vein. What is most appropriate initial treatment?

Heparin started as bridge to Coumadin (goal INR 2-3)

*Goal of therapy is to prevent extension of the clot & development of future clots RATHER than lysis of the present clot!

*Surgery is primary risk factor (post-op immobilization)

234

Severe R-calf pain several hrs after leg surgery. Complains of burning sensation in back of R leg w/ his leg being swollen, tense, & extremely tender. His pain is worsened by passive R-knee extension. DP & PT pulses palpable B/L. What is likely diagnosis?

Soft-tissue swelling --> Compartment syndrome

**Common s/s:
*Pain out of proportion to injury (extreme)
*Paresthesias early (burning)
*Pain worsened on passive stretch
Rapidly increasing & tense swelling

235

How many lobes of parotid gland & what separates these lobes? What sign will be seen w/ damage to this nerve?

2 lobes (superficial and deep) - superficial accounts for 80% of gland

Facial nerve runs through parotid & divides it into 2 parts

I/L facial droop seen w/ damage to facial nerve

236

Most common complication seen post thyroidectomy? What signs do you see?

Hypocalcemia (primary hypoparathyroidism - removed w/ thyroid)

S/S: involuntary contractions (tetany) of lips, face, extremities; seizures
- Ckvostek sign (facial nerve tapping)
- Trousseau sign (tapping median nerve)

*Also prolongs QT interval on EKG

237

Immediate management of splenic rupture is determined by what factor?

Hemodynamic status & response to IV fluids:
If stable = abdominal CT scan
Non-stable = emergent exploratory laparotomy

238

What is potential complication of thoracic aortic aneurysm surgery? How does it present?

Anterior spinal cord infarction

S/S: abrupt onset B/L flaccid paralysis, loss of pain/temp BELOW level of spinal injury
- UMN signs develop over days-weeks

*Vibration & proprioception are preserved --> dorsal column of spinal cord not usually affected

239

What is potential complication of thoracic aortic aneurysm surgery? How does it present?

Anterior spinal cord infarction
- Anterior spinal artery supplies anterior 2/3 of spinal cord (motor tracts, pain/temp sensation) --> dependent on radicular arteries (artery of Adamkiewicz)

S/S: abrupt onset B/L flaccid paralysis, loss of pain/temp BELOW level of spinal injury
- UMN signs develop over days-weeks

*Vibration & proprioception are preserved --> dorsal column of spinal cord not usually affected

240

3 common signs seen w/ splenic injury?

Test to confirm?

Delayed onset hypotension
LUQ pain
L shoulder pain (irritation of diaphragm)

Abd CT w/ contrast

241

U/L hip pain in middle-aged adult that is worsened by external pressure to upper lateral thigh (lying on affected side of bed). What is it?

Trochanteric bursitis

242

Signs of burn/smoke inhalation injury to upper airway or lungs?

When to intubate?

Burns on face
Singed eyebrows
Oropharyngeal inflammation/blistering
Carbon-containing sputum
Stridor
Carboxyhemoglobin >10%

*One or more indicates EARLY intubation to prevent upper airway obstruction by EDEMA that develops later on

243

Most common causes of syringomyelia?
Pattern of symptoms?

Arnold Chiari malformations, spinal cord injury (whiplash injury)

S/S: "Cape-like" distribution --> decreased strength & diminished pain/temp affecting arms/hands
*NO loss of light touch, vibration, or position sense (dorsal columns intact)

244

Pt has MVA where he drank a lot of liquid. He sustained a direct blow to abdomen & pelvis & complains of diffuse abd pain that refers to his L shoulder. What GU injury is cause?

Bladder dome rupture --> only part of bladder covered by peritoneum & only injury that allows urine to leak into peritoneum --> this lets urine irritate diaphragm

245

Describe febrile non-hemolytic transfusion reaction and how long after surgery it's seen?

When RBC & plasma are separated from whole blood, a small amount of residual leukocytes may remain in RBC concentrate --> during blood storage, these leukocytes release cytokines --> when blood is transfused, it causes transient fever, chills, malaise w/o hemolysis

Seen 1-6 hours AFTER surgery

246

Person is in MVA and has pneumothorax. After chest tubes are placed, he still has pneumothorax on CXR as well as pneumomediastinum (subQ emphysema). What is cause?

Tracheobronchial perfoartion secondary to blunt thoracic trauma

247

What are 2 complications of supracondylar fractures of humerus?

In pediatric population, what is mechanism of injury?

Entrapment of:
1) Brachial artery (no distal pulses)
2) Median nerve

Fall on an outstretched arm (also for Colles & scaphoid fracture)

248

Complication of abdominal surgery or retroperitoneal hemorrhage associated w/ vertebral fracture?

Paralytic ileus

On x-ray --> distention of both small & large bowels

249

Man falls when riding his bicycle & one week later has fever, shaking chills, and deep abdominal pain. What do you suspect?

Retroperitoneal abscess --> likely due to pancreatic laceration from trauma

250

What are the 3 components and grades of Glascow Coma Scale (GCS)?

1) Eye opening
Spontaneous (4)
To Verbal Command (3)
To Pain (2)
None (1)

2) Verbal response
Oriented (5)
Disoriented/Confused (4)
Inappropriate words (3)
Incomprehensible sounds (2)
None (1)

3) Motor Response
Obeys (6)
Localizes (5)
Withdraws (4)
Flexion posturing - decorticate (3)
Extension posturing - decerebrate (2)
None (1)

251

Patient develops whistling noise during respiration following rhinoplasty. What do you suspect?

Nasal septal perforation --> resulting from septal hematoma

252

How to differentiate b/w arterial thrombus & embolus?

Origin of emboli?

Embolus --> SUDDEN onset & severe; distal pulses diminished

Emboli originate from heart -> MI or AFib

253

When is post-op atelectasis the worst?

What blood gas values do you see?

Worst on post-op day 2

Collapsing alveoli --> V/Q mismatch --> causes hypoxemia & increased work of breathing (dyspnea, tachypnea)

For compensation for hypoxemia --> patients hyperventilate & develop resp alkalosis (high pH) w/ decreased PaCO2

254

When is post-op atelectasis the worst?

What blood gas values do you see?

Worst on post-op day 2

Collapsing alveoli --> V/Q mismatch --> causes hypoxemia & increased work of breathing (dyspnea, tachypnea)

For compensation for hypoxemia --> patients hyperventilate & develop resp alkalosis w/ decreased PaCO2

255

Complication of cardiac cath that presents w/ sudden hemodynamic instability and I/L flank or back pain. What imaging test is recommended?

Retro-peritoneal hematoma from local vascular access site used in legs (femoral) for the cath

CT w/o contrast

256

What is most important aspect of managing a rib fracture?

Adequate pain relief/analgesia (opiates/NSAIDs or intercostal nerve blocks)

Rib fractures associated w/ significant pain --> causes hypoventilation --> atelectasis & pneumonia

257

What is squamous cell carcinoma arising from a burn wound called?

Marjolin's ulcer

258

Describe flail chest?

Paradoxical thoracic wall movements occurring when multiple contiguous ribs are fractured in 2+ places --> this segment of ribs lose their continuity w/ remainder of thoracic wall
*Isolated segment has paradoxical inward motion on inspiration & outward motion on expiration

*PPV replaces normal (-) intrapleural pressure w/ (+) intrapleural during inspiration --> the flail chest motion is reversed back to physiologic motion

259

(+) arm drop test used to evaluate what injury?

What muscle commonly is affected?

Rotator cuff tear

Supraspinatus --> due to repeated bouts of ischemia near its insertion on humerus induced by compression b/w the humerus & the acromion

260

Name several risk factors for developing Marjolin's ulcer?

BURNS, osteomyelitis ulcers, venous stasis ulcers, chronic inflammation, scarred skin

261

Patient in recent MVA who has new onset severe back pain w/ weakness and decreased pain sensation in both legs - what do you suspect and what is next step?

Traumatic spinal cord injury

Place urinary catheter to assess for urinary retention & prevent acute bladder distention/damage

262

Patient has DVT from reversible inciting event (e.g. surgery) in R distal part of femoral vein. What is most appropriate initial treatment?

Heparin started as bridge to Coumadin (goal INR 2-3)

*Goal of therapy is to prevent extension of the clot & development of future clots rather than lysis of the present clot!

*Surgery is primary risk factor (post-op immobilization)

263

How many lobes of parotid gland & what separates these lobes? What sign will be seen w/ damage to this nerve?

2 lobes (superficial and deep) - superficial accounts for 80% of gland

Facial nerve runs through parotid & divides it in 2 parts

I/L facial droop seen w/ damage to facial nerve

264

Most common complication seen post thyroidectomy? What signs do you see?

Hypocalcemia (hypoparathyroidism - removed w/ thyroid)

S/S: involuntary contractions (tetany) of lips, face, extremities; seizures

*Also prolongs QT interval on EKG

265

Immediate management of splenic rupture is determined by what factor?

Hemodynamic status & response to IV fluids:
If stable = abdominal CT scan
Non-stable = emergent exploratory laparotomy

266

Why is chronic steroid use such a big deal w/ surgery?

How to ID person on chronic steroid use?

Chronic (>3 weeks) steroid use (>20mg) will suppress that HPA axis --> decreased ACTH hormone release --> decreased endogenous cortisol release during stress situations (SURGERY)
**Require a higher dose ("stress dose") of short-term glucocorticoids during the acute condition (surgery)

Cushingoid features: buffalo hump, central obesity, moon face (plethoric)

267

Blunt deceleration trauma (high-speed MVA or fall from >10feet) is common cause for what injuries?

What findings suggest these entities?

Aortic injury (transection/dissection)
**Signs:
Widened mediastinum
L-sided hemothorax
Deviation of mediastinum to R side
Disruption of normal aortic contour on CXR

Pulmonary contusion
**Signs
Hypoxia
Resp distress
B/L lower infiltrates on CXR
Large volumes of IVF may hasten process

268

High-speed MVA common cause for what injury?

What findings suggest this?

Aortic injury (transection/dissection)

**Signs:
Widened mediastinum
L-sided hemothorax
Deviation of mediastinum to R side
Disruption of normal aortic contour on CXR

269

3 common signs seen w/ splenic injury?

Delayed onset hypotension
LUQ pain
L shoulder pain

270

3 common signs seen w/ splenic injury?

Test to confirm?

Delayed onset hypotension
LUQ pain
L shoulder pain

Abd CT w/ contrast

271

First step in tx of esophageal varices?

1) Establish vascular access (2 large bore IV needles or central line)

2) After vasc access, control bleeding (vasoconstrictors), octreotide, somatostatin

272

Signs of burn/smoke inhalation injury to upper airway or lungs?

When to intubate?

Burns on face
Singed eyebrows
Oropharyngeal inflammation/blistering
Carbon-containing sputum
Stridor
Carboxyhemoglobin >10%

*One or more indicates early intubation to prevent upper airway obstruction by edema that develops later on

273

Acute mediastinitis can be a complication of what surgery? What signs point to it? What is best treatment?

Cardiac surgery from intra-op wound contamination

Signs:
- Post-op fever
- Tachycardia
- Chest pain
- High WBC
**Sternal wound drainage or purulent discharge
*Widened mediastinum on CXR

Tx:
- Drainage
- Surgical debridement w/ immediate closure
- Prolonged antibiotics

274

Name 2 ways burns contribute to compartment syndrome?

1) Massive edema occurs over following days w/in these compartments --> look for 6 P's

2) If an eschar (firm necrotic tissue on exposed burn wounds) forms circumferentially on an extremity, it can restrict outward expansion of compartment as edema occurs --> perform escharotomy & if symptoms don't resolve, then perform fasciotomy

275

Describe febrile non-hemolytic transfusion reaction and how long after surgery it's seen?

When RBC & plasma are separated from whole blood, a small amount of residual leukocytes may remain in RBC concentrate --> during blood storage, these leukocytes release cytokines --> when blood is transfused, it causes transient fever, chills, malaise w/o hemolysis

Seen 1-6 hours AFTER surgery

276

Name 3 potential causes for post-op fever 1-6 hours after surgery?

Malignant hyperthermia
Febrile non-hemolytic transfusion reaction
Prior infection/trauma

277

What are 2 complications of supracondylar fractures of humerus?

In pediatric population, what is mechanism of injury?

Entrapment of:
1) Brachial artery (no distal pulses)
2) Median nerve

Fall on an outstretched arm (also for Colles fracture)

278

Complication of abdominal surgery or retroperitoneal hemorrhage associated w/ vertebral fracture?

Paralytic ileus

On x-ray --> distention of both small & large bowels

279

Why is anterior leg pain commonly seen w/ femoral artery aneurysms?

What else is also usually seen w/ femoral artery aneurysms?

Compression of femoral nerve (runs lateral to artery) by aneurysm

AAA usually associated

280

Person has blunt abdominal trauma - what is initial best exam?

If (-) then what?
If (+) then what?

1) FAST exam (Focused Assessment w/ Sonogram for Trauma)

If FAST is (-) --> diagnostic peritoneal lavage to determine presence of intra-abdominal bleed (10mL blood)

If FAST is (+) --> laparotomy

281

Man twists his leg while playing basketball and hears a popping sound in his knee. 2 weeks later, his R knee is swollen and tender along medial side. Snapping can be felt in R knee on tibial torsion w/ knee flexed at 90 degrees. What is it?

Medial meniscus tear

- Injured during forceful twisting on knee w/ foot planted
- "Popping" sound heard w/ severe pain @ time of injury
(+) McMurray sign (tibial torsion w/ knee at 90 degrees)

282

How to differentiate b/w arterial thrombus & embolus?

Origin of emboli?

Embolus --> SUDDENLY onset & severe; distal pulses diminished

Emboli originate from heart -> MI or AFib

283

Initial steps in person w/ post-op oliguria?

1) change Foley
2) if prerenal azotemia suspected - IV fluids

284

When is post-op atelectasis the worst?

What blood gas values do you see?

Worst on post-op day 2

Collapsing alveoli --> V/Q mismatch --> causes hypoxemia & increased work of breathing (dyspnea, tachypnea)

For compensation for hypoxemia --> patients hyperventilate & develop resp alkalosis w/ decreased PaCO2

285

Swelling in meniscal injury vs ligament injury?

Meniscal: gradual swelling not noticed until next day

Ligament: rapid/immediate swelling from hemathroses

286

Complication of cardiac cath that presents w/ sudden hemodynamic instability and I/L flank or back pain. What imaging test is recommended?

Retro peritoneal hematoma from local vascular access site used in legs (femoral) for the cath

CT w/o contrast

287

What is most important aspect of managing a rib fracture?

Adequate pain relief/analgesia (opiates/NSAIDs or intercostal nerve blocks)

Rib fractures associated w/ significant pain --> causes hypoventilation --> atelectasis & pneumonia

288

What type of neck infection has the greatest risk for mediastinal spread?

Retropharyngeal abscess

289

Describe flail chest?

Paradoxical thoracic wall movements occurring when multiple contiguous ribs are fractured in 2+ places --> this segment of ribs lose their continuity w/ remainder of thoracic wall
*Isolated segment has paradoxical inward motion on inspiration & outward motion on expiration

*PPV replaces normal (-) intrapleural pressure w/ (+) intrapleural during inspiration --> the flail chest motion is reversed back to physiologic motion

290

(+) arm drop test used to evaluate what injury?

What muscle commonly is affected?

Rotator cuff tear

Supraspinatus --> due to repeated bouts of ischemia near its insertion on humerus induced by compression b/w the humerus & the acromion

291

Pain out of proportion w/ findings (2 things)?

Mesenteric ischemia
Compartment syndrome

292

Blunt abdominal trauma (mostly from MVA) frequently injure what 2 organs?

Free intra-peritoneal fluid should raise suspicion for what organ rupture?

Liver & spleen


Spleen

293

Blunt abdominal trauma (mostly from MVA) frequently injure what 2 organs?

Free intra-peritoneal fluid should raise suspicion for what organ rupture?

Liver & spleen


Spleen

294

What are 2 common risk factors for mesenteric ischemia?
What is classic presentation?
What lab finding is common?
Diagnostic test of choice?

1) Atherosclerotic disease (peripheral vascular disease)
2) AFib

SUDDEN onset severe periumbilical pain that is out of proportion w/ exam findings

Metabolic acidosis --> increased lactate

Mesenteric angiography is gold standard (CT angiography as alternate)

295

Child w/ direct trauma to his chest has epigastric pain w/ repeated vomiting immediately after the trauma. What is it? What is most appropriate step in management?

Duodenal obstruction --> following trauma, blood collects b/w submucosal and muscular layers of duodenum causing obstruction. Epigastric pain and vomiting due to failure to pass gastric secretions past obstructing hematoma.

Most resolve spontaneously in 1-2 weeks

*Tx: nasogastric suction & parenteral nutrition

296

In SBO, conservative mgmt usually tried first (NPO, NG tube suction, pain control, IVF's, correction of metabolic problems). What physical signs indicate this treatment has not helped & strangulation in imminent? What is next best step?

Impending strangulation signs --> fever, tachycardia, leukocytosis, metabolic acidosis (lactate)
- No peritoneal signs = no frank bowel necrosis yet

*Emergent surgical exploration to reverse cause of SBO

297

What is Morton's neuroma?

Mechanically induced neuropathic degeneration

S/S:
- Numbness
- Burning of toes
- Aching
- Burning in distal forefoot radiating forward from metatarsal heads to the 3-4th toes

*Pain b/w 3rd and 4th toes on plantar surface & a clicking sensation (Mulder sign) when simultaneously palpating this space & squeezing the metatarsal heads

Tx: b/l shoe inserts

298

Vital signs of someone in a trauma initially were 95/60 and pulse 120. He is struggling for respirations. You give him IV fluids and his BP increases to 160/90 and pulse drops to 50. What must you consider? What is complication(s)?

Cushing reflex --> HTN, bradycardia, resp depression
*Indicates increased ICP

The increased ICP can cause uncal herniation!
*I/L oculomotor (CN3) palsy --> mydriasis, strabismus
*I/L posterior cerebral artery --> C/L homonymous hemianopsia
*C/L cerebral peduncle --> I/L hemiparesis

299

Forceful abduction and external rotation of an arm causes what injury? What nerve is most commonly damaged?

Anterior shoulder dislocation

Axillary nerve --> courses around medial undersurface of humeral head, through the quadrangular space and can be injured by antero-inferior shoulder dislocations
*Paralysis of deltoid & teres minor muscles
*Loss of sensation over lateral upper arm

300

Person sustains penetrating chest wound and is hypotensive. Receives plenty of IV fluid and PRBCs. After rehydration, the pressure is still hypotensive. What 2 etiologies must you consider? Way to differentiate?

Tension pneumothorax or Pericardial tamponade
*CVP will be HIGH in both

*Re-expanded lung NOT pneumothorax

301

What often masks pericardial tamponade?

Massive blood loss --> substantial hypotension from blood loss masks hypotension from tamponade

302

In a person with acute abdomen who needs a laparotomy, what is the quickest way to reverse the warfarin they are on?

FFP

303

Person has abscess formation in sigmoid colon from diverticulitis. What is the cutoff size-wise for percutaneous drainage?

Larger than 3cm --> drained by CT-guided percutaneous drainage

304

Most common electrolyte abnormality after transfusion of large blood volume?

S/S?

Hypocalcemia
Citrate binders in the PRBCs

S/S: hyperactive DTRs