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AAA is defined as >

3cm. Definitely operate when > 5.5cm. Weigh risks and benefits when 4 - 5.5cm. Surveillance every 6 months to 3 years when 3 - 4 cm.


Why patients with AAA can get gross hematuria

Retroperitoneal rupture -> aortocaval fistula -> severe venous distension in bladder -> venous rupture in bladder


ABG in atelectasis

Respiratory alkalosis, hypocapnea and hypoxemia


Strategies to reduce post-op pulmonary complications

Stop smoking, control COPD, treat respiratory infection pre-op, spirometry, pain management and early mobilization.


Physical exam findings used to diagnose coma

Pupillary light reflex, EOM, corneal reflexes and posturing.


Mechanism of post-op ileus

Increased splanchnic nerve tone, local inflammatory mediator release and use of narcotic analgesics.


Metoclopramide mechanism of action

DA antagonist that causes LES contraction and gastric emptying.


Differential for an anterior mediastinal mass

"The terrible T's": teratoma, thymoma, thyroid neoplasm and terrible lymphoma.


AFP and beta-hCG in seminomas vs. non-seminomas

AFP is almost always normal in seminomas. The beta-hCG is variable in both types of tumors.


Area of the bladder most susceptible to rupture.

The dome. This was where the urachus originated in embryonic life and is an area of weaker tissue.


Definition of a massive hemothorax

> 1.5L


Muscles innervated by the axillary nerve

Deltoid and teres minor


Management of a stable patient with a contained appendiceal abscess for > 5 days.

IV abx, bowel rest and percutaneous drainage with elective appendectomy 6-8 weeks later.


When is surgery indicated for diverticulitis?

Fluid collection > 3cm can go for percutaneous drainage or surgery. Also, if symptoms are not controlled with bowel rest and antibiotics by day 5, surgery is indicated.


Pressure threshold to perform an escharotomy in a burn patient or fasciotomy in a patient with compartment syndrome



Management of a duodenal hematoma

Diagnose with contrast CT. Treat with NG suction and TPN. Most will resolve with this alone by 1-2 weeks.


Management of a first-time provoked DVT

Heparin to warfarin bridge 48-72 hours post-op. Warfarin for at least 3 months.


Physical exam for patients with trochanteric bursitis

Pain with direct pressure, resisted abduction and external rotation of the hip


Physical exam for patients with hip OA

Pain with internal rotation


Complications of the two different types of hip fractures

Intracapsular fractures have a higher chance of avascular necrosis. Extra capsular fractures have a greater need for implant devices.


How long can you delay repair of a hip fracture to medically stabilize you patient?

Up to 72 hours.


Danger space of head and neck infections

The retropharyngeal space is between the alar and prevertebral fascia, which drains directly into the mediastinum and can cause mediastinitis.


Ludwig's angina

Infection of the submandibular space that begins in the floor of the mouth and spreads to the sublingual space


Major complication of parapharyngeal head and neck infections

Carotid sheath involvement


Risk factors for post-op pulmonary complications

Smoking, COPD, age > 50, thoracoabdominal surgery, surgery > 3 hours and poor general health.


Next step if incentive spirometry fails to improve post-op pulmonary function



#1 risk factor for development of aortic dissection



How long does it take for strictures to develop after ingestion of acid?

6-12 weeks


How long does it take for a diabetic to develop gastroparesis?

10 years


Treatment of acalculus cholecystitis

Antibiotics + percutaneous cholecystostomy until medical condition improves, then cholecystectomy.


Tetanus prophylaxis guidelines

3+ toxoid doses = repeat toxoid vaccine if clean or minor wound and last dose was 10+ years ago. If wound is dirty or severe, repeat toxoid vaccine if last dose was 5+ years ago.


Definition of massive hemoptysis and management of these patients. Management of patients with mild-moderate hemoptysis?

> 600mL/day or >100mL/hour. These patients get bronchoscopy with therapeutic interventions. If this doesn't work move to pulmonary arteriography. If embolization doesn't work, urgent surgical thoracotomy. Patients with mild or moderate hemoptysis can first have a CT chest.


SBO patients who go to the OR emergently

Those who do not improve with bowel rest, NG tube, pain control and correction of metabolic derangement and become unstable. Also those who develop signs/symptoms of strangulation.


SBO patients that can be managed conservatively

Stable patients can get a small-bowel follow-through study done if they have a partial obstruction and fail conservative management.


When should you be concerned about post-op adrenal suppression

When patients have been taking 20+ mg prednisone for > 3 weeks, have Cushingoid features and recently received etomidate.


Diagnosing pancreatic cancer in the head vs. tail and body?

Head = u/s. Tail/body = CT.


Common cause of nasal septum perforation after septoplasty

Septal hematoma expansion


Treatment for most cases of ischemic colitis

Bowel rest, fluids and IV antibiotics. Surgery if there is perforation.


Colonoscopy of patients with ischemic colitis

Sharply demarcated areas of hemorrhagic ulcerations and cyanotic mucosa.


Stress fracture management

Diagnose with x-ray. If x-rays are negative and suspicion is still high, may do MRI or bone scan. Manage with rest, pain control, hard-sole shoe and light activity. Plaster casting if conservative management fails. Surgery if the 5th metatarsal is involved.


Most commonly involved bone in stress fractures

2nd metatarsal


Management of a patient with a possible fat embolism

Confirm diagnosis with fat droplets in the urine or on fundoscopy 12-72 hours after surgery. Serial x-rays within 24-48 hours of onset of symptoms may show progressive pulmonary infiltrates. Treat with respiratory support.


Gold standard for evaluation of mesenteric ischemia

Mesenteric angiography


Labs in patients with Paget's disease

Elevated alk phos and normal Ca and PO4


Cause of acute circulatory collapse in an intubated patient with PTX?

Increased intrathoracic pressure further decreases venous return to the right heart.


When is nasotracheal intubation contraindicated?

Apnea, hypopnea and basilar skull fractures.


When is needle cricothyroidotomy preferred to surgical cricothyroidotomy in an urgent airway situation?



When to convert cricothyroidotomy to a tracheostomy?

5-7 days, this will prevent tracheal stenosis


Normal respiratory quotient

Moles CO2 produced by fuel / moles O2 required to oxidize 1 mole of substrate. In normal individuals this = 0.8. 1.0 = too much carbohydrate, too much CO2 generation and it will be more difficult to wean a patient from a ventilator.


Timeline for post-op fevers

0-2 hours (immediate): prior trauma/infection, blood productions (1-6 hours), malignant hyperthermia.

1-7 days (acute): nosocomial infections (48 hours), SSI (GAS or C. perfringens), atelectasis (2-5 days), MI, PE, DVT

7-30 days (subacute): SSI (other organisms), catheter site infection, C. difficile, drug fever (anticonvulsants, allopurinol or antibiotics like beta-lactams and sulfonamides), DVT, PE

>30 days (delayed): viral infection, SSI (indolent organisms)


Carboxyhemoglobin level when you are concerned about a patient's airway



Why are steroids contraindicated in severely burned patients

They are diabetogenic and immunosuppressive, increasing their risk for metabolic derangement and infections, respectively.


Benign breast lesion that does not fluctuate with the menstrual cycle like fibrocystic changes do.



Causes of alveolar hypoventilation and respiratory acidosis

COPD, OSA, obesity hypoventilation syndrome, scoliosis, Myasthenia Gravis, Lambert Eaton, Guillan-Barre, anesthesia, narcotics, sedatives, brain stem lesion, stroke or meningitis.


Normal A-a gradient


Blood at the urethral meatus with a normal prostate exam and history of straddle injury.

Anterior urethral injury (anterior to urogenital diaphragm) is more common with blunt trauma or instrumentation.


Blood at the urethral meatus with difficulty voiding after an accident, high riding prostate and scrotal hematoma.

Posterior urethral injury is associate with pelvic fracture.


Most common causes of hypoparathyroidism

#1 - surgical, #2 - autoimmune, #3 - DiGeorge syndrome, #4 - defective Ca-sensing receptor, #5 - infiltrative disease like hemochromatosis, Wilson's and neck irradiation


Drugs that can cause vitamin D deficiency

P450 inducers like phenytoin, carbamazepine and rifampin


SIRS criteria

2 of the following:

T > 38.5C (101.3F) or 90

RR > 20

WBC > 12 or 10% bands

+source = sepsis

+oliguria, confusion = MODS

+hypotension = septic shock


Hypermetabolic changes that occur in the first week after a severe burn injury

Hyperglycemia, muscle wasting, protein loss and increased energy expenditure.


Most common causes of syringomyelia and Arnold-Chiari malformations?

Prior spinal cord injury


Why are more cardiologists doing catheterizations in the radial artery instead of femoral?

A puncture site above the inguinal ligament can cause a hematoma with retroperitoneal extension and cause hemodynamic instability.


How do diagnose a retroperitoneal hematoma

Non-contrast CT abdomen and pelvis


A patient presents with tachycardia, a new bundle branch block and a sternal fracture after an MVA. What is causing his symptoms?

Myocardial contusion


When are patients with a reperfused limb at significant risk for compartment syndrome

If the ischemia lasted greater than 4-6 hours, leading to significant soft tissue swelling and edema.


Interpretation of ABIs

1.3 or greater = calcified and non-compressible vessels, should prompt additional vascular studies (duplex u/s, CTA, MRA, angiography)

0.9 - 1.3 = normal

0.5 - 0.9 = moderate ischemia, consult vascular surgery


Structures at risk in supracondylar fracture of the humerus

Brachial artery and ulnar nerve


Management of post-CABG mediastintis

Diagnosed clinically by fever, tachycardia, chest pain, leukocytosis and sternal wound drainage.

Treated with surgical debridement and prolonged antibiotic therapy.


Management of post-CABG a-fib

Rate control with beta-blockers or amiodarone. Anticoagulation and cardioversion if lasting > 24 hours.


Post pericardotomy syndrome

Autoimmune fever, leukocytosis, tachycardia and chest pain a few weeks after the procedure.


Volume of blood required to cause symptoms in acute pericardial tamponade? Chronic?

Acute = 200mL

Chronic = 1-2L


Evaluation of hemoperitoneum in a stable vs. unstable patient involved in BLUNT trauma.

Unstable = FAST, then DPL if inconclusive

Stable = FAST, then CT abdomen/pelvis

***In penetrating trauma with signs of peritonitis or instability, all patients go directly to exploratory laparotomy.


Predisposing factors for emphysematous cholecystitis

Vascular compromise of the cystic artery, immunosuppression and gallstones


Management of emphysematous cholecystitis

Confirm with CT demonstrating air-fluid levels, gas in gallbladder wall and pneumobilia. Labs may show unconjugated hyperbilirubinemia due to clostridium-induced RBC hemolysis.

Treat with broad spectrum antibiotics and emergent cholecystectomy.


How to increase the FRC in the post-op period to prophylax against atelectasis

Have the patient in the upright position, incentive spirometry, chest physiotherapy and coughing.


Treatment of non-displaced scaphoid fractures? Displaced?

Non-displaced = wrist immobilization for 6-10 weeks

Displaced = ORIF


Work-up of a patient who suffers from a blunt deceleration injury to the chest

Screen for aortic injury with CXR. If equivocal, do chest CT and angiography.


Neurological risk when fixing a thoracic aortic aneurysm

Anterior cord syndrome from compromised blood flow from the artery of Adamkiewicz to the anterior spinal artery.


Risk factors for psoas abscess

HIV, diabetes, IVDU and Crohn's disease


Diagnosis of psoas abscess

CT scan is required.


Diagnostic test of choice for meniscal injury



Most common peripheral artery aneurysm site



Definition of oliguria

Less than 400cc or 6cc/kg urine per day


Management of patients with new onset oliguria

1) Check Foley 2) If pre-renal azotemia is suspected (BUN:Cr > 20:1 and FeNa


Who gets ECRP?

Patients with gallstone pancreatitis who have cholangitis, visible common bile duct dilation/obstruction and increasing liver enzymes.


Lab value that points towards gallstone pancreatitis

ALT > 150


Management of patients with suspect ischemic colitis vs. mesenteric ischemia?

Ischemic Colitis: CT to determine need for surgery (perforation, extensive bowel damage). If surgery is not needed, patients can be managed with IV fluids, abx and colonoscopy to confirm the diagnosis (pale mucosa, petechial bleeding, bluish hemorrhagic nodules or cyanotic mucosa with hemorrhage).

Mesenteric ischemia: mesenteric angiography is gold standard for diagnosis. Treatment is supportive (fluids, abx, NG tube).


Differences in mesenteric vs. colonic ischemia

Small bowel has late hematochezia and is usually due to thromboembolism where ischemic colitis is typically due to hypotension and has early hematochezia.


Pre-op thresholds for packed red cell or platelet transfusion?



How does DDAVP work?

Indirectly increases factor VIII levels by stimulating endothelial release of vWF.


Management of patients with walled off appendiceal abscess for > 5 days

IV abx, bowel rest and delayed appendectomy weeks later


When is bicarbonate given for acidosis



Fevers, chills and deep abdominal pain in a patient with abdominal trauma and negative CT a few weeks ago.

Pancreatic injuries can be easily missed by early CT and turn into pseudocysts with retroperitoneal abscess later on.


Lab that can be used to track response to treatment for nasopharyngeal carcinoma

EBV titer


Middle 1/3 vs. distal 1/3 clavicular fracture management

Middle fractures get a brace, rest and ice.

Distal fractures get ORIF due to risk of non-union.


Treatment of anal fissures

Diet modification (increase fiber), stool softeners and topical anesthetic. If these fail you can do a lateral sphincterotomy.


Management of bleeding esophageal varices

If bleeding is rapid, sclerotherapy with octreotide will cause the bleeding to stop quickly. For elective procedures, variceal banding is typically done. Balloon tamponade is only done as a temporary measure to keep the patient from exsanguinating while awaiting higher level of care.


Management of dumping syndrome.

Since it is due to hyperosmolar food entering the duodenum, loss of intravascular volume and reflex sympathetic stimulation, patients should eat small meals, avoid simple carbohydrates, increase fiber and protein and abstain from drinking fluid during meals.


Aortoiliac occlusion resulting in claudication, hip pain and impotence

Leriche syndrome


Penetrating wound beneath which intercostal requires exploratory laparotomy in an unstable patient?

4th intercostal


Congenital umbilical hernia associations

Hypothyroidism, Beckwith-Wiedemann syndrome, African-American race, premature birth and Ehlers-Danlos.


When is surgery recommended for congenital periumbilical hernias?

After age 5 and > 1.5cm in diameter.


X-ray findings seen in patients with ileus, SBO and Oglivie's

Ileus = gas-filled loops and air-fluid levels in large AND small bowel

SBO = area distal to obstruction is not distended

Ogilvie's = massively dilated colon without dilation of small bowel.


Time from initial trauma that ARDS is typically seen

24-48 hours