Surgery

Question 1

When assessing a trauma for airway, what criteria are used to determine if the airway is patent?

Answer 1

Pt speaks full sentences, doesn’t use accessory muscles for breathing, has bilateral breath sounds

Question 2

When assessing a trauma for airway, what criteria are used to determine if the airway is Urgent?

Answer 2

Expanding hematoma or cutaneous emphysema is present

Question 3

When assessing a trauma for airway, what criteria are used to determine if the airway is emergent?

Answer 3

Pt has apnea, GCS<8, gurgling or gasping with breathing

Question 4

When assessing a trauma for breathing, what parameters are used to determine ventilation and oxygenation status?

Answer 4

Ventilation=CO2=pCO2

Oxygenation=O2=pO2 & SpO2

Question 5

When assessing a trauma for circulation, what criteria are used to determine if the patient is in shock?

Answer 5

• SysBP<90
• Urinary output<0.5cc/kg/hr
• Pt is pale, cool, and diaphoretic

Question 6

In hypotensive patients, what is the difference between cool and warm patients?

Answer 6

MAP=COxSVR

• Warm patients have some decrease in SVR (think sepsis, anaphylaxis, anesthesia, spinal trauma)
• Cold patients have some problem with CO (think tension pneumo, pericardial tamponade, hemorrhage)

Question 7

A patient comes into the trauma bay with JVD, normal heart, decrease breath sounds with hyperresonance and tracheal deviation, what is the next best step in management?

Answer 7

Needle decompression!
-This is a scenario that represents tension pneumothorax. This is a clinical Dx urgently and requires no further diagnostic workup, jump straight to treatment!

Question 8

A patient comes into the tauma bay with normal lung sounds, JVD, distant heart sounds, distant heart sounds, and pulsus paradoxus >10mmHg. What is the the most likely Dx?

Answer 8

Pericardial tamponade!

• To definitively diagnose get a FAST u/s and
• To Tx perform a pericardiocentesis.

Question 9

A patient comes to the trauma bay with flat jugular veins, normal heart and lung sounds, decreased Hgb, increased HR. Massive hemorrhaging is noted from the left lower extremity. What should be done on the way to the OR?

Answer 9

Apply pressure to the wound, give IV fluids, type and cross the patient’s blood, gain IV access via 2 large bore IVs, and give blood.

Question 10

A patient presents to the trauma bay w/ racoon eyes and battle sign with clear otorhea and rhinorrhea following head trauma. What is the next best step in management?

Answer 10

Get a CT scan!
This patient is concerning for a basilar skull fracture. Racoon eyes and battle sign are indicative of hematomas, battle sign is a hematoma behind the ears.

Question 11

A patient comes in to the trauma bay following massive head trauma. The patient lost consciousness during the ambulance ride but has now regained consciousness. Non-contrast CT scan shows a lens shaped bleed. What is the most likely diagnosis?

Answer 11

Epidural hematoma!
Next step is to treat this patient via craniotomy as untreated, this patient will likely slip into coma due to increased ICP. Epidural hematoma is one of few things that can cause loss of consciousness–>lucid interval–>coma–>death. Epidural hematoma is between skull and dura.

Question 12

A young patient comes to the trauma bay following massive head trauma and is unconscious. Head CT shows crescent shaped hematoma. What is the prognosis of this patient’s condition?

Answer 12

Poor!
This patient with a crescent shaped hematoma has a acute subdural hematoma. Treatment options are focused on relieving ICP and include hyperventilation, giving mannitol diuresis, and raising the bed angle to 30 degrees. Subdural hematomas are between the brain and the dura.

Question 13

An elderly patient is brought to the ED by her husband who reports strange behavior changes in the patient over the last few weeks. The patient had a minor fall and hit her head a few weeks ago but was fine at the time. Head CT shows a crescent shaped hematoma. What is the next best step in managing this patient’s condition?

Answer 13

Craniotomy!
This patient presents with features of chronic subdural hematoma. Chronic subdural hematoma is one of the few reversible causes of dementia and can be seen in elderly and alcoholic patients who undergo minor head trauma. Their brains are more vacuolated and are thus more likely to tear bridging veins that run between the cortex and venous sinuses.

Question 14

A patient comes into the trauma center unconscious after a rolling MVC and appears to have endured head trauma. CT scan shows blurring of the grey/white junctions. What is the prognosis for this patient’s condition?

Answer 14

Poor!
Grey white junctional blurring is indicative of diffuse axonal injury and essentially these patients will slip into a coma and die. Not much can be done.

Question 15

A 16 year old male loses consciousness during a particularly brutal hit during a football scrimage. On route to the trauma center he regains consciousness and his GCS is 15. He cannot remember the events immediately preceding the loss of consciousness. CT scan at the hospital shows no abnormalities. What is the most likely diagnosis?

Answer 15

Concussion!

This patient can likely go home if he has someone to observe him for mental status changes and keep him awake.

Question 16

A man gets hit over the head with a blunt object. He comes to the ED because of head trauma and has not had loss of consciousness. There is no scalp wound over the area. A CT scan shows a linear skull fracture with no sign of intracranial hematomas. What is the best next step in management?

Answer 16

Send him home!
Linear skull fractures are left alone if they are closed. If they are open they require wound closure. If they are comminuted of depressed, they have to be treated in the OR.

Question 17

What are the three zones of the neck?

Answer 17

Zone 2=middle of the neck
Zone 3=posterior to the mandible
Zone 1=below the middle of the neck to the level of the clavicles

Question 18

What are the hard signs when concerning neck trauma?

What are their significance?

Answer 18

• Airway-gurgling, stridor, loss of airway
• Vascular-Expanding hematoma, pulsatile bleeding, stroke, shock
• Hard signs indicate that the patient is unstable and needs to go to the OR immediately

Question 19

What are the soft signs when concerning neck trauma?

What are their significance?

Answer 19

Dysphonia, subcutaneous air/crepitance, any of the hard signs but milder
-In the abscence of hard signs, a patient with hard signs should undergo CT angio to determine the need for surgery or if we can just observe the patient.

Question 20

A pt is transported to the trauma center following a blunt neck trauma. The patient has signs of focal neurological deficit, erectile dysfunction, urinary and bowel incontinence as well as edema at the trauma site. What is the next best step in management of this patient?

Answer 20

IV Dexamethasone!
-This patient is likely experiencing cord compression. The compression isn’t caused by the trauma itself but rather the edema compressing upon the cord. IV steroids to limit the inflammation should help such a patient.

Question 21

A patient comes to the ED with a stab wound to the posterior neck and now has loss of proprioception and vibratory sensation throughout the body. What is the most likely diagnosis?

Answer 21

This patient likely has a posterior cord syndrome as the dorsal columns controlling proprioception and vibratory sensation were likely injured.

Question 22

A patient comes to the trauma center following a stab wound to the neck. He has ipsilateral loss of vibration and proprioception and motor function and contralateral loss of pain and temperature throughout the body. Upper limbs are areflexic and lower limbs are hyperreflexic. What is the most likely diagnosis?

Answer 22

Brown Sequard syndrome/hemisection through the cord

• Remember that the ALS decusates at the level of the cord, so spinal damage will always cause contralateral loss of pain and temp.
• Likewise, in cord lesions motor function is completely lost at the level of the lesion but hyperreflexia remains below the lesion.

Question 23

A patient comes to the ED due to sudden loss of motor functions throughout the body as well as loss of pain and temperature sensations. Hyperreflexia is noted in the lower extremities. Vibratory and proprioception remain intact. What is the most likely cause of this patient’s condition?

Answer 23

Spinal artery occlusion!

-This patient presents with an anterior cord syndrome, the most common cause of which are spinal artery occlusions.

Question 24

An elderly patient comes to the trauma bay with symptoms of paralysis and loss of pain and temperature sensation of her upper extremities. Her lower extremities are not involved. What likely caused these symptoms if they developed slowly over time causing loss of pain and temp before motor involvement? What is the likely cause if the onset of symptoms was sudden?

Answer 24

This patient presents with a central cord syndrome! The deficits are similar to anterior cord syndrome, however it typically involves only 1 dermatome, so a common presentation is deficit of the upper extemities sparing the lower extremity.

• If this progressed slowly with pain and temp sensatory involvement first, than we think about syringomyelia. The ALS is closer to the central canal, so we expect ALS involvement before motor involvement.
• If this progressed quickly, think about a fall with hyperextension of the neck, often seen with the elderly.

Question 25

A patient comes in to the trauma center following blunt chest trauma and has chest pain and shallow breathing. CXR shows evidence of multiple rib fractures. Pain control is begun to improve the patient's breathing. What potential complications are likely given this patient's history?

Answer 25

Complications associated with secondary penetrating trauma! -In the setting of rib fracture, the open ribs are basically little daggers open in the chest. Potential complications could be things like tension pneumo or hemothorax. Pain control is warranted as rib fractures themselves cause patients not to breath normally due to pain.

Question 26

A patient comes to the trauma center with dyspnea, hyperresonance, decreased breath sounds, decreased tactile fremitus and decreased whispered pectoriloquay following a penetrating trauma to the chest. CXR shows vertical lung shadow. Where should the physician place the thoracostamy?

Answer 26

Near the top of the lung! -This patient with a vertical lung shadow likely has a pneumothorax. Air doesn't respect gravity, so we see a vertical chest shadow, since air will rise, a superior thoracostamy placement is warranted to treat this condition.

Question 27

A patient comes to the trauma bay following penetrating trauma. The patient is dyspneic, has dullness to percussion, decreased breath sounds, and decreased tactile fremitus in the right lung. CXR shows a horizontal air fluid level in the right lung. A thoracostomy is performed at the lower lung borders. What should follow up for this patient consist of?

Answer 27

-This patient with a horizontal air fluid level in her right lung most likely has hemothorax. The treatment of hemothorax consists of placing a thoracostamy at the lower lung to drain the accumulated blood. -Follow up of these patients centers around determining if the bleed is from a peripheral artery, which will need surgical intervention, or from pulmonary vasculature, which will likely self resolve. In terms of thoracostomy blood drainage: -20cc/kg or 1500cc at once indicates peripheral arterial bleed-->surgery -Likewise, 3cc/kg/hr or 200cc/hr indicates peripheral arterial bleed-->surgery

Question 28

A patient comes to the traumabay with penetrating trauma to the right hemithorax. The patient is dyspneic and the wound is noted to suck in air when the patient inspires. What is the next best step in management of this patient?

Answer 28

Drape the wound in an occlusive dressing taped at three sides until thoracostomy is appropriate! -This patient with a wound that sucks in air on inspiration has a sucking chest wound. The diagnosis can be made upon visual inspection, but CXR can also be used. An occlusive dressing is useful as it stops air from being sucked in with inspiration. However, it is left partially open so that any air trying to escape can. Thoracostomy is often required at a later time.

Question 29

A patient is transported to the trauma center following massive blunt trauma. The patient has paradoxical chest wall motion-decreased diameter with inspiration and increased diameter with exhalation. CXR shows multiple rib fractures. What is the most appropriate treatment for this patient's condition?

Answer 29

Place the patient in binders with weights/plates! -This patient with paradoxical chest wall motion has flail chest. Diagnosis can be made with visual inspection and CXR showing multiple fractures in multiple locations. Tx is placing the patient in binders with weights/plates

Question 30

A patient is transported to the trauma center following massive blunt trauma to the chest. CXR on admission shows no abnormalities. However, 24 hours later, the patient complains of dyspnea and CXR shows massive white out of her left lung field. The patient is begun on PEEP and diuresis with furosemide. The patient is on fluid resuscitation with normal saline at 100cc/hr. What is the best next step in management of this patient?

Answer 30

Stop normal saline infusion! -This patient with white out of a lung field a day after blunt chest trauma is likely suffering from pulmonary contusion as a result of leaky capilaries subsequent to trauma. Daignosis is made based on visualization of "white out" on CXR a day or so following admission. These patients should be placed on PEEP, diuresis, and should be given colloids (blood, albumin) for fluid resuscitation instead of crystalloids (D5W, NS)

Question 31

A patient comes to the trauma center following massive blunt chest trauma. EKG shows abnormalities and troponins are elevated. What complication should be ruled out in this patient?

Answer 31

Pericardial tamponade! -A patient with EKG abnormalities and elevated troponins following chest trauma likely has myocardial contusion. Pericardial contusion is often a comorbid condition that is highly lethal and should be determined by doing a FAST u/s. Once acute complications are ruled out we essentially manage these people as if they had CHF and arrythmia with MONA-BASH (morphine, oxygen, nitrates, aspirin, beta blockers, ace-i, statin, heparin)

Question 32

A patient comes in to the trauma center following massive chest trauma. The patient has unequal pulses between the left and right arms and her mediastinum is widened on CXR. She has stage II renal failure. What should be done to diagnose her likely condition?

Answer 32

MRI or TEE! -This patient with massive chest trauma and widened mediastinum most likely has an aortic dissection, or atleast aortic dissection should be ruled out. CT angiogram is the usual mode of diagnosis, however, in patients with renal failure, contrast will cause further harm to the kidneys. MRI or TEE are alternative modes of reaching the same diagnosis. Most patients with aortic dissection will be dead on arrival as the ligamentum arteriosum dissects the aorta. In ones who aren't fully dissected but rather have an adventitial hematoma, surgery is required with IV beta blockers en route to surgery.

Question 33

A patient is transported to the trauma center following a gunshot wound to his right upper quadrant. The patient is hemodynamically stable. What is the next best step in management of this patient?

Answer 33

Close follow up of clinical signs and serial abdominal CTs! -This is a bit of a trick question. Gunshot wounds to the abdomen (anything below the nipple line) are usually managed with exploratory laparotomy. However, in select cases of low caliber gunshot wound to the R upper quadrant that are hemodynamically stable, we may suffice to just monitor them closely and get serial CTs.

Question 34

A patient undergoing abdominal surgery for multiple trauma requiring multiple transfusions develops coagulopathy (bleeding from any open surface). What should be done at this point? What conditions would temporarily shut down the surgery?

Answer 34

This patient should be treated with platelet packs and fresh frozen plasma. If in addition this patient develops hypothermia and acidosis, surgery should be terminated with packing of bleeding surfaces and temporary closure of any wounds.

Question 35

In patients with circumferential burns, what complications can be expected if the burn occurred on an extremity? The chest? What is the treatment of such complications?

Answer 35

- Circumferential burns of an extremity can lead to loss of distal blood supply of the extremity due to edema accumulating underneath the eschar. Therefore, these patients will need compulsive monitoring of peripheral pulses and capillary refill. - Similarly, circumferential burns of the chest can lead to difficulty breathing as the edema limits chest wall expansion. - The treatment of these complications is an escharotomy

Question 36

How does bone remodeling in children differ from adult bone remodeling following a fracture?

Answer 36

- Degrees of angulation that would be unacceptable in the adult may be okay in children following reduction and fixation. - Areas where children have special problems include supracondylar fractures of the humerus and fractures of any bone involving growth plates.

Question 37

What are clues that a penetrating abdominal trauma needs to go to the OR? What about a blunt abdominal trauma?

Answer 37

- Penetrating-Any gunshot wound below the nipple line (T4), pts with peritoneal signs, shock, bowel evisceration, or a probe that goes into the peritoneum. - Blunt-Blood on a FAST exam or blood or air on a CT scan.

Question 38

What 5 areas can hide enough blood that can cause a patient to exsanguinate(die by losing too much blood)?

Answer 38

Thighs, pelvis, abdomen, thorax, the floor

Question 39

A pt is brought to the trauma center following blunt abdominal trauma and is found to have blood and air in his abdomen following CT scan. Exploratory laparotomy is begun in the OR. Signs of a ruptured liver is present. What maneuver can the surgeon do to clear the field of blood while she repairs the liver?

Answer 39

Pringle maneuver, the temporary cutoff of the blood supply to the liver! -Lobectomy may be part of the repair of a ruptured liver. Liver rupture is the most common cause of abdominal bleed following trauma. The liver ruptures similarly to the aorta via dissection caused by the ligamentum teres (aortic dissection=ligamentum arteriosum)

Question 40

A pt is brought to the trauma center following abdominal trauma. The patient has several stab wounds, is in shock, and has areas of bowel evisceration. She is brought to the OR for ex lap and is found to have massive intrabdominal trauma to include a ruptured liver and spleen as well as stab wounds to small and large intestine. How should spleen injury be handled?

Answer 40

Splenectomy! -In a patient with massive trauma requiring multiple repairs to include spleen injuries, just chuck the spleen to save time as it isn't a vital organ. Post-op these patients will need vaccination against encapsulated organisms to include H. flu, S. pneumo, and N meningitides

Question 41

How should suspected rectal injury in a trauma be diagnosed? Suspected ureter injury?

Answer 41

- Rectal-proctoscope | - Ureter-IV pyelogram

Question 42

A patient comes in to the trauma center with a stab wound under the chest. Bowel sounds are heard at the level of the clavicle. CT scan shows loops of bowel in the chest. The patient is brought to the OR for ex lap and repair, what is the most likely diagnosis?

Answer 42

Ruptured diaphragm! | Tx with ex lap and repair

Question 43

A patient comes to the trauma center with a stab wound to the abdomen. Upright KUB shows air under the diaphragm. The patient is brought to the OR so that ex lap and repair can be done. Given the most likely diagnosis, what would CT scan most likely show?

Answer 43

Air at the apex of the belly! -This patient most likely has perforation of hollow viscera within the abdomen. Upright KUB will not usually be done, but it would show air under the diaphragm as the air rises to the top. CT scan will show air at the apex of the belly as the patient will be lying down. Tx is ex lap and repair.

Question 44

A pt is brought to the trauma center following being hit by a car while walking on the sidewalk. Hip rock produces diffuse pain and his hips move in differenct directions with pushing. CT scan shows a pelvic fracture. What is the best tx option for this patient?

Answer 44

External fixation! | -Pelvic fracture rarely requires surgery, believe it or not. The clinical signs and Dx are as outlined in the question.

Question 45

A patient comes to the trauma center with high riding prostate and blood at the penile meatus. A retrograde urethrogram shows evidence of urethral trauma. If this patient needs to pee, what should be done until his urethra is able to tolerate urination?

Answer 45

Use a suprapubic catheter! -Signs and dx or urethral trauma are as outlined in the question. Never use a urinary catheter in such patients as this will likely cause further urethral damage.

Question 46

How should chemical burns caused by ingestion be managed?

Answer 46

Serial CXRs, NPO, watch and wait acutely, later grade via endoscopy

Question 47

How should chemical burns caused by inhalation be managed? What are signs of more severe damage?

Answer 47

- Monitor these patients via ABGs, spO2, peak flow, bronchoscopy and intubate prophylactically as if their airway closes they will need a cric/trach. - Worse signs include stridor/soot or singing in the nares.

Question 48

What is the feared complication of electrical burns and how should is be managed?

Answer 48

Rhabdomyolysis! -Rhabdo is common as the bones conduct electricity so they heat up and cook the surrounding muscle. Monitor for rhabdo by checking CK, and creatinine. Tx rhabdo (no treatment for the electrical burn itself) with IV fluids and mannitol.

Question 49

A 70kg patient comes in to the trauma center with 3rd degree burns over 20% of his body, 1st degree burns over 15%, and 2nd degree burns over 30% of his body. How much fluids will this patient need over the next 24 hours?

Answer 49

4x70x50%=14,000mL=14L over the next 24 hours! -You split this up, giving 50% over the first 8 hours, and the rest over the next 16 hours. 1st degree burns don't count, so only use the 2nd and 3rd degree burns in the calculation.

Question 50

What are the s/s of a black widow bite and how would you treat it?

Answer 50

Abdominal pain that mimicks pancreatitis following a bite. Tx with IV calcium

Question 51

What are the s/s of a brown recluse bite and how would you treat it?

Answer 51

Bite-->ulcer-->necrosis | Tx with debridement and grafting

Question 52

What is the management and follow up of either a domesticated animal or human bite?

Answer 52

Irrigation, leave the wound open and give amox clav (augmentin). F/u with tetanus IG and tetanus toxoid vaccine if their last vaccination was atleast 5 years ago.

Question 53

What laboratory clue hints at possible alcohol intoxication?

Answer 53

Elevated olmolar gap in the face of normal sodium, glucose, and BUN levels! -remember that olmolal gap=2xNa+(glucose/18)+(BUN/2.8) and shouldn't be over 15. If you have an elevated gap but these parameters are normal, you likely have alcohol toxicity

Question 54

What is the treatment for an alcohol intoxication that doesn't cause an elevated anion gap? What about one that does?

Answer 54

- supportive treatment | - Fonepizole or EtOH

Question 55

What can be used to reverse acetiminophen toxicity?

Answer 55

N-acetyl cysteine

Question 56

What is the treatment of salicylate toxity?

Answer 56

Urine alkalinization and forced diuresis

Question 57

What is the treatment of cyanide toxicity caused by smoke inhalation? What is an option viable for cyanide toxicity caused by nitroprusside ingestion?

Answer 57

- Thiosulfate | - Amyl nitrate

Question 58

What agent treats the symptoms of organophosphate toxicity? What agent reverses organophosphate acetylcholinesterase inhibition?

Answer 58

- atropine | - pralidoxime

Question 59

``` Describe the following hand deformities: Duputyren contracture Felon Jersey finger Mallet finger ```

Answer 59

- Duputyren contracture-Norwegians, contracture of the palm of the hand and palmar fascial nodules - Felon-abscess in the pulp of a fingertip, pt will have fever and this requires urgent surgical drainage - Jersey finger-Distal fingertip won't flex when making fist (patient always pointing), caused by injury to flexor tendon - Mallet finger-Extensor tendon ruptured, patient can't extend affected digit.

Question 60

A patient recovering from a subtotal gastrectomy for gastric cancer with a gastroduodenal anastamosis begins draining 2 liters per day of green fluid. The patient has no abdominal pain, fever, or signs of peritoneal irritation. What is the most likely diagnosis?

Answer 60

The patient has developed a GI fistula! -Given the setting of surgery and spouting out green fluid, GI fistula is the most likely Dx in this patient. Management should include fluid replacement and nutritional support, and protection of the abdominal wall (suction tubes, ostomy bags) until the fistula heals on its own.

Question 61

When should you get a gastrograffin swallow?

Answer 61

Whenever you suspect esophageal full thickness perforation. This is most likely in cases of Boerhaave syndome. These patients will have fever & leukocytosis.

Question 62

A patient presents with colicky abdominal pain, protracted vomiting and no pasage of gas or feces in 3 days. Abdominal exam reveals a prior laparotomy scar from a prior gunshot wound, high pitched bowel sounds coinciding with the pain, and obvious distension. X rays show distended loops of small bowel with multiple air fluid levels. What is the next best step in management?

Answer 62

NPO, NG suction, and IV fluids -This patient likely has mechanical intestinal obstruction caused by adhesions from her previous laparotomy. Clinical course and treatment are as outlined. The goal with treatment is to watch and wait to see if it will resolve spontaneously and to see if there are any signs of strangulation. Surgery is done if such conservative management fails to relieve symptoms-within 24 hours in cases of complete obstruction, and within a few days in cases of partial obstruction.

Question 63

What parameters of CHF and MIs confer an increased risk for surgery?

Answer 63

Ejection fraction and timing since the MI! -An EF<35% confers a 75% chance of death. Likewise, MI within 3 mos of surgery confers a 40% chance of mortality, but waiting until 6 mos post MI reduces this risk to 6%. The Goldman Index is an indicator of cardiac risk (the more points, up to 53, the greater the risk of complication)

Question 64

Why is ventilation more important than oxygenation during surgery?

Answer 64

Ventilation is useful to relove acidosis during surgery. Oxygenation is relatively well controlled in the OR with oxygen masks etc.

Question 65

What lab values should be ordered in the preop evaluation of a patient with lung disease?

Answer 65

PFTs and ABGs to check for increased CO2 or decreased O2 indicating poor pulmonary status

Question 66

How long should patients stop smoking before surgery?

Answer 66

8 weeks

Question 67

What parameters should be checked preop for a patient with liver pathology?

Answer 67

``` Albumin (dec=bad) PT/PTT (inc) Total bilirubin (inc) ascites encephalopathy -1 of these raises surgical mortality rate to 40%, all of these means 100% mortality chance. Childs pugh score is an indicator of cirrhosis severity with 15=bad and 5=good ```

Question 68

When should prealbumin and CRP be checked preop?

Answer 68

In suspected cases of nutritional deficiency! -Think of patients who've lose 20% of their body weight in the last 3 months, albumin <3, skin anergy. Give these patients oral nutrition for atleast 10 days.

Question 69

What is a metabolic absolute contraindication to surgery?

Answer 69

DKA! | Give them IVF and insulin until anion gap resolves, these patients will die if they go to the OR.

Question 70

During surgery a patient develops fever. What treatment should be initiated?

Answer 70

O2, IVF, Dantrolene, and cooling! -Sudden fever after anesthesia is most likely to be malignant hyperthermia. This is why you ask about family history of anesthesia complications.

Question 71

What is the most likely diagnosis in a patient with fever immediately after a surgery?

Answer 71

Bacteremia! | -Get a blood Cx and start them on broad spectrum Abx. Prophylaxis would've been better sterility in the OR

Question 72

On POD 1 a patient develops fever. CXR is negative. What is the most likely diagnosis?

Answer 72

Atelectasis! | Prophylaxis would be incentive spirometry and getting these folks out of bed.

Question 73

On POD 2 a patient develops fever. CXR confirms a diagnosis of pneumonia. What is the next best step?

Answer 73

Start broad spectrum Abx with vanc zosyn! | Prophylaxis would've been incentive spirometry and getting these folks out of bed.

Question 74

POD 3 a patient develops fever. The patient's urine looks relatively cloudy and he's had a foley in since the operation. What is the next best step?

Answer 74

Get urine culture, urinalysis, and begin appropriate antibiotics! -This patient most likely has a UTI. This situation could've been prevented by removing the foley earlier.

Question 75

POD 5 a patient has a swollen tender leg and has developed fever. Lower extremity US shows evidence of DVT. What could have prevented this situation?

Answer 75

LMWH postop and getting out of bed! | -This patient likely has DVT. Tx with a heparin-warfarin bridge

Question 76

POD 5 a patient has hypoxia, hypercapnic respiratory alkalosis and fever. CXR shows evidence of plueral effusion. What treatment should be initiated?

Answer 76

Heparin to warfarin bridge! | -This patient likely had a PE. This situation could have been prevented with LMWH postop and getting out of bed.

Question 77

POD 7 a patient develops fever and tenderness around the suture site. What is the next best step in management?

Answer 77

US the wound to check for abscess! -US will be negative in a case of cellulitis and positive showing for the abscess in a case of abscess. For both you should start Abx, but incision and drainage should be done for abscess. Additionally abscess happen POD 7-14 and may be mistakenly thought of as unrelated to the surgery. These can be prophylaxed with OR sterility and patient hygiene around the surgical site.

Question 78

What labs/imaging should be used to rule out postop MI or PE in a chest pain patient?

Answer 78

MI-EKG troponins | PE-US spiral CT

Question 79

What are 4 causes of altered mental status during the postop period?

Answer 79

Delirium tremens-give benzos Electrolytes-dx with BMP Hypoxemia-give PEEP for ARDS Sundowning-give atypical antipsychotics

Question 80

What would KUB show for a case of postop ileus?

Answer 80

small AND large bowel dilation-give fluids, potassium, and make patient move

Question 81

What would KUB show for a case of postop obstruction?

Answer 81

Small OR large bowel dilation-get an NG tube, perform surgery

Question 82

What would KUB show for a case of Ogilvie syndrome?

Answer 82

Colonic dilation-get a rectal tube, stigmine, colonoscopy

Question 83

POD 10 a patient returns with a hernia and serosanguinous salmon colored drainage. What is the most likely Dx?

Answer 83

Dehiscence! | -Tx with binders, less straining, and reoperate electively

Question 84

POD 10 a patient returns with loops of bowel out of her open incision site. What is the best next step in management?

Answer 84

Go to the OR emergently and apply warm saline dressings! | -This is a case of exisceration. Never push the bowel back into the peritoneum! This will only make things worse.

Question 85

What are the most common causes of fistula?

Answer 85

``` Foreign body Epithelialization Tumor Irradiation/Inflammation/IBD (Crohn's) Distal obstruction You will need to resect or divert the fistula. ```

Question 86

How can you easily distinguish between obstruction and renal failure in a oliguric postop patient?

Answer 86

Ask them is they have the urge to pee! - If they have urge-obstruction, get in and out cath and a bladder scan - If not-renal failure-after 500 cc bolus if they start producing urine they were just volume down, give fluids, if they don't then it's intrinsic renal disease. - If there is literally 0 output, it might be a mechanical kink in the foley, unkink it!

Question 87

A patient comes to your clinic complaining of retrosternal burning chest pain made worse with lying flat and eating spicey food. She states the pain is made better when she sits up and uses antacids. She describes episodes of "nocturnal asthma" some nights. What is the best test for diagnosis of this patient's condition and what would be the appropriate diagnostic workup if such a patient came in with concurrent nausea, vomiting weight loss or anemia?

Answer 87

Best test is 24 hour pH monitoring, if the patient came in with "alarm symptoms" (nausea, vomiting, weight loss, anemia) do EGD +Bx to rule out more severe pathology! -This patient has GERD, caused by a weakened LES-->acid reflux. Simply treat with a PPI. IF an EGD discovers metaplasia-high dose PPI; dysplasia-ablation; adenocarcinoma-resection. Severe GERD can be surgically managed via Nissen fundoplication.

Question 88

A patient comes in with postprandial N/V and a feeling of food being stuck in his throat after meals. What is the diagnostic workup and tx of this patient's condition?

Answer 88

Get a barium swallow (bird's beak), monometry (diagnostic), EGD+Bx (rule out psuedoachalasia) and tx with myotomy! -This patient likely has achalasia, caused by a failure of the LES to relax.

Question 89

A patient comes to your clinic complaining of dysphagia that has progressively gotten worse over the last 6 months. Barium swallow shows an area of esophageal stricture and EGD+Bx are concerning for malignancy. What is the most likely malignancy if the stricture is in the upper 1/3rd or the esophagus vs the lower 1/3rd of the esophagus?

Answer 89

Upper 1/3rd=squamous cell carcinoma(SCC); lower 1/3rd=adenocarcinoma! -SCC is most likely to be caused by smoking and drinking hot drinks whereas adenocarcinoma is most likely to be caused by GERD.

Question 90

A 20 year college student is brought to the ED by his roommate after he was found retching and vomiting blood. The patient had been to a large party that night and does not typically drink as much as he does this night. 2 large bore IVs are placed, IVFs are given, the patient is typed and crossed for potential transfusion, PPIs are given and GI is consulted. Shortly after arriving to the ED the patient stops vomiting blood. What is the most likely Dx?

Answer 90

Mallory Weiss tear! -These are superficial esophageal tears more common in "weekend warriors". Diagnostic workup is unnecessary, however you're going to treat this as a more severe incident until you confirm that the patient doesn't have something much more serious like Boorhaave's.

Question 91

A known bulimic patient comes to the ED with chest pain that began after an episode of vomiting. On examination, crepitance is heard throughout the entire chest, a "Hammond's Crunch" is heard with every heart beat and the patient has fever, leukocytosis and nonproductive cough. What is the next best step in management of this patient?

Answer 91

Get a gastrograffin swallow! -This patient has Boorhaave's syndrome caused by a transmural esophageal tear. This is most likely in "career vomiters" like bulimics, alcoholics. Gastrograffin swallow is the first diagnostic test, if this is negative get a barium swallow, if this is negative get an endoscopy. Remember that gastrograffin is caustic to the lungs.

Question 92

On POD 5 following C-section, a woman comes to the ED with colicky abdominal pain. Physical exam shows abdominal distension. She is admitted and over the next 2 days she becomes obstipated and no longer has bowel sounds on physical exam. She remains distended. What is the next best step in management of this patient?

Answer 92

Get and upright KUB or CT scan with contrast! -This is a case of small bowel obstruction most likely caused by adhesions (non-surgical cause is hernia). CT scan is particulary helpful here as it can be used to determine if the obstruction is complete or partial. Partial obstruction can be managed conservatively with NG tube and IVFs for three days, after which we go to surgery or unless the pain becomes peritoneal before then. The point is to wait and see if the incomplete obstruction will self resolve. Complete obstruction needs to be managed with surgery.

Question 93

Describe the patients and locations of these hernias: - Direct - Indirect - Femoral - Ventral

Answer 93

- Direct-Adults, an inguinal hernia that passes through the transversalis muscle - Indirect-Babies-an inguinal hernia that passes through the inguinal ring - Femoral-Females, herniation under the inguinal ligament - Ventral-Iatrogenic, common in the post-op period

Question 94

What are the surgical indications for these hernia characteristics: - Reducible - Incarcerated - Strangulated

Answer 94

- Reducible-elective surgery - Incarcerated-urgent surgery - Strangulated-emergent surgery

Question 95

A patient comes in with intolerable lower abdominal pain with radiation to the left lower quadrant (mcburney's point), anorexia, nausea and vomiting. What is the next best step in management?

Answer 95

-Surgery This patient has appendicitis. No further workup is needed, Dx is clinical. In practice, practitioners typically get a CT scan to confirm the Dx while the OR is prepped.

Question 96

A patient recently diagnosed with lung cancer comes to the ED looking flushed, with wheezing and diarrhea. KUB shows evidence of cardiac fibrosis and new metastasis to the liver. What laboratory test will confirm the Dx?

Answer 96

Urinary 5-HIAA! -This patient likely has carcinoid syndrome. Pathology is by the new mets outside of the liver producing serotonin. Metastasis must come from a primary lung or GI malignancy as these areas typically mask excess serotonin production by deactivating it. Once the malignancy mets outside these areas, the serotonin isn't dealth with properly and builds up-->serotonin syndrome. Treatment is by IDing the lesions with CT scan and resecting the tumors.

Question 97

A patient comes to the ED with abdominal pain that radiates to the back. The pain is positional and eases when she leans forward and gets worse when she lays back. She has associated nausea and vomiting. What are the best diagnostic steps to determine the most likely diagnosis and what tests can be used to determine the etiology of this condition?

Answer 97

This is most likely pancreatitis! - Get a lipase and amylase, if these are negative but pancreatitis is still heavy on the differential get a CT scan. Amylase is often negative so lipase is always better - To determine the etiology of pancreatitis, get a RUQ US and triglyceride panel (think stones, alcohol, hyperlipidemia in terms of etiology)

Question 98

A patient that came to the ED with positional epigastric pain that radiates to the back, especially when leaning back, and nausea vomiting is diagnosed with pancreatitis after elevations in lipase and US confirms stones at the Ampula of Vater. What is the appropriate management of this patient during this admission?

Answer 98

NPO, IVFs, IV pain control until symptoms of pancreatitis resolve!

Question 99

A patient that came to the ED with positional epigastric pain that radiates to the back, especially when leaning back, and nausea vomiting is diagnosed with pancreatitis after negative amylase and lipase but a positive abdominal scan. Abnormal lipid panel confirms the etiology as hyperlipidemia. She is started on NPO, IVFs, IV pain control. 1 day after admission this patient develops a sick as shit appearance and hypotension. What is the next appropriate step in management?

Answer 99

Send this patient to ICU, plan for a necrosectomy, and perform FNA to determine if the patient has developed a pancreatic infection necessitating carbapenems! -In a patient with confirmed pancreatitis who develops such a clinical appearance, you must have a high degree of suspicion of necrotizing pancreatitis. Necrotizing pancreatitis develops within hours to day.

Question 100

A patient that came to the ED with positional epigastric pain that radiates to the back, especially when leaning back, and nausea vomiting is diagnosed with pancreatitis after negative amylase and lipase but a positive abdominal scan. Abnormal lipid panel confirms the etiology as hyperlipidemia. She is started on NPO, IVFs, IV pain control. At an unspecified time after admission admission, this patient develops early satiety, weight loss, and increased abdominal pain. A CT scan is ordered and is concerning for psuedocyst. What is the management of this condition?

Answer 100

- If the cyst has been present <6 weeks AND is <6cm in size, it is uncomplicated, watch and wait - If the cyst has been present for >6 weeks OR is >6cm in size, it is complicated, drain that mofo

Question 101

A patient that came to the ED with positional epigastric pain that radiates to the back, especially when leaning back, and nausea vomiting is diagnosed with pancreatitis after elevations in lipase and US confirms stones at the Ampula of Vater. He is started on NPO, IVFs, IV pain control. 1 week after admission this patient's still haven't fully resolved and he develops fevers, leukocytosis, and is septic. What is the most likely Dx?

Answer 101

This patient most likely has a pancreatic abscess! | -The next best step is to start antibiotics and perform an incision and drainage

Question 102

What antibiotic regimens are appropriate for biliary tract infections?

Answer 102

You need gram - and anaerobic coverage - Ciprofloxacin+Metronidazole - Gentamycin+Metronidazole - Zosyin (pip-tazo) will work, but is poor antibiotic stewardship as it also convers gram +s, so it will be wrong on the test.

Question 103

A patient comes in colicky RUP pain that radiates to the shoulder and is worse with fatty meals. What is the best step in diagnosis?

Answer 103

Get a RUQ abdominal US! -This patient with colicky RUQ pain likely has cholelithiasis. Etiology is a mixed cholesterol (fat female fertile forty) or pigmented stone (hemolyisis). Tx includes elective cholecystectomy or ursodeoxycholic acid for poor surgical candidates

Question 104

A patient comes in with constant RUQ abdominal pain, positive murphy's sign, fever, and leukocytosis. RUQ US is negative, but HIDA scan shows a filing defect of the gallbladder distal to the cystic duct. What tx should be given to the patient?

Answer 104

NPO, IVFs, IV abx (gent+MTZ, cipro+MTZ) urgent cholecystectomy or cholecystotomy is this is a poor surgical candidate. -This patient has cholecystitis. Typically, these patients will have pericholycystic fluid, thickened gallbladder wall and visible gallstones on US, but in cases with high suscpiscion and a negative US, a HIDA scan will show a filling defect of the gallbladder at the level of the cystic duct.

Question 105

A patient has painful jaundice with a positive murphy sign, fever and leukocytosis. RUQ US shows dilation of the common bile duct. What is the most likely diagnosis in this patient?

Answer 105

Choleydocolithiasis! -Caused by stone in the common bile duct, these patients will have jaundice +/- hepatitis and pancreatitis (depends on the level of the stone). If the US is negative, MRCP is the next best diagnostic tool. Tx with NPO, IVFs, Abx (cipro+MTZ, Gent+MTZ), get urgent ERCP, and elective cholecystectomy.

Question 106

What is the ball valve effect in cases of choleydocolithiasis?

Answer 106

The stone is obstructing one day and not the next leading to up and down labs/symptoms that seems confusing! -Just remember that shit gets bad when they're obstructed, but better the next day when their not and the cycle repeats until you get that urgent ERCP. Same management as choledocolithiasis, don't be fooled.

Question 107

What are Charcot's triad and Renold's pentad for cholangitis?

Answer 107

- Charcot's-RUQ pain, jaundice, fever | - Reynold's-Charcot's+hypotension and altered mental status

Question 108

A patient comes in with RUQ pain, jaundice, fever, hypotension and altered mental status. RUQ US confirms the presence of common bile duct dilation and obstruction via stone. What is the treatment algorithm for this patient?

Answer 108

Emergent ERCP followed by urgent/elective cholecystectomy, give IVFs, IV Abx (cipro+MTZ, Gent+MTZ0 -This patient likely has cholangitis, the infected version of choledocolithiasis. Caused by gallstone in the common bile duct, but the occlusion has gone on long enough to lead to infection.

Question 109

What kind of findings should prompt you to get a colonoscopy?

Answer 109

- Iron deficiency bleeding in a postmenopausal woman or any man. - Change in stool caliber, weight loss, alternating bowel habits

Question 110

Describe the difference between "good" and "bad" colon polyps

Answer 110

- Good polyps are pedunculated, small, tubular, and have a stalk - Bad polyps are sessile, have no stalk, are large and villous.

Question 111

How would you treat familial adenomatous polyposis colon cancer?

Answer 111

Prophylactic colectomy! | -These patients will have 1000s of polyps on colonoscopy

Question 112

How often should a patient receive repeat colonoscopies given: - 1-2 polyps - Carcinoma in situ - frank dysplasia

Answer 112

- 1-2 polyps-q5 years - Carcinoma in situ-q 3 years - frank dysplasia-yearly

Question 113

What are the pt findings and treatments of internal and external hemorrhoids?

Answer 113

- Internal-bleeding but painless-get these banded - External-painful but bleedless-resect these. - Preparation H and sitz bath are first line treatments before those outlined above. Dx is made by visual inspection/anoscopy.

Question 114

How is the Dx of anal cancer made?

Answer 114

Anal pap smear showing evidence of HPV-->squamous cell carcinoma. -Be mindful of this in homosexual males, those with prior STD, anoreceptive sex. These patients need chemo and radiation.

Question 115

Wth is a pilonidal cyst?

Answer 115

Bruh, is that an abscessed hair follicle on your hair ass? | -More likely with family history, hairy ass. Clinical Dx, get incision and drainage.

Question 116

What are the 5 types of visceral abdominal pain?

Answer 116

- Obstructive - Inflammatory - Perforation - Ischemic - Referred

Question 117

Describe obstructive abdominal pain (visceral)

Answer 117

- Colicky pain, patient can't get comfortable. - Negative for leukocytosis, or fever - Think cholelithiasis, nephrolithiasis

Question 118

Describe inflammatory abdominal pain (visceral)

Answer 118

- Constant pain where patient can't get into a comfy position. - Positive for leukocytosis and fever - Think cholecystitis, pyelonephritis

Question 119

Describe abdominal pain due to perforation (visceral)

Answer 119

- Patient appears sick as shit, pain is constant and patient remains motionless - X-ray will be concerning for free air - Think PUD, Cancer, penetrating trauma

Question 120

Describe ischemic abdominal pain (visceral)

Answer 120

- Pain out of proportion to appearance, bloody bowel movements - S/s of sepsis - Think CAD, Afib, Mesenteric ischemia

Question 121

What organs may be involved in epigastric pain?

Answer 121

``` Heart Esophaguss Pancreas Aorta Stomach ```

Question 122

What organs may be affected in RUQ pain? What is the typical diagnostic modality?

Answer 122

``` Lung Diaphragm Liver Gallbladder/Biliary -Dx with US ```

Question 123

What organs may be affected in LUQ pain? What is the typical diagnostic modality?

Answer 123

Lung diaphragm Spleen -Dx with CT

Question 124

What organs may be affected in RLQ pain? What is the typical diagnostic modality?

Answer 124

``` Ovary Kidney Ureter Ovaries/Testes Appendix -Dx with CT ```

Question 125

What organs may be affected in LLQ pain? What is the typical diagnostic modality?

Answer 125

``` Kidney Ureter Ovaries/Testes Colonic diverticula -Dx with CT ```

Question 126

What are the layers of tissue from skin to bone (in terms of ulcers)?

Answer 126

``` Epidermis Dermis Fascia Tissue Bone ```

Question 127

What are the 4 stages of ulcer tissue involvement?

Answer 127

1) nonblanching erythema 2) Epidermis+Dermis 3) Fascia 4) Bone/Muscle

Question 128

A bedridden patient has developed a stage 2 compression ulcer. What is the most likely location and how can these be prevented?

Answer 128

The most likely location of compression ulcers is the sacral area, roll these patients q2 hrs, get them out of bed (if possible) and get them an air mattress! - If this occurs at a nursing home, this is abuse. - Remember that stage 2 ulcers involve both the dermis and epidermis

Question 129

A diabetic patient comes in with stage 3 foot ulcers on the balls of her right foot. What pathological changes predispose to these changes?

Answer 129

Microvascular changes and neuropathy! - Dx this with a monofilament test. These patients need better BG control, elevate their legs, and this can progress toward the need for amputation. Give these patients good shoes and make them frequently inspect their feet for prophylaxis. - Stage 3 ulcers are down to the fascial layer.

Question 130

A patient with peripheral vascular disease comes in with stage 1 ulcers on the tips of her toes. On physical exam she has hairless legs (not too helpful with females is it?) scaley shins, and absent pulses. What is the most likely Dx?

Answer 130

Arterial insufficiency! - This arises due to macrovascular damage and most often presents on the tips of toes. Get ankle brachial index, US doppler, and angiogram on these patients for diagnosis. Stents and bypass are the treatment options - Remember that stage 1 ulcers indicate an area of nonblanching erythema.

Question 131

A patient presents with leg edema-->induration, hyperpigmentation and a stage 4 medial malleolus ulcer. Given the most likely Dx, what is the best treatment of this patient?

Answer 131

Give them compression stalkings, elevate their legs, and give them diuretics! - This is a case of venous insufficiency-->ulcer. Edema is from venous stasis. The most common location for these is the medial malleoli. The diagnosis is clinical. - Stage 4 ulcers are down to the muscle/bone. This patient would probably need a BKA, but the above treatment is the likely algorithm for more typical cases.

Question 132

A patient presents with an ulcer on a sinus tract in the chin that has heaped margins. Biopsy is suspiscious for malignancy and a wide resection of the tissue is planned. What is the most likely pathology for this condition?

Answer 132

Squamous Cell Carcinoma! -Ulcer leading into a sinus tract? Think Marjolin ulcer. Dx is with biopsy and Tx is with a wide resection. This is super rare and even the ortho doc forgot what it was called.

Question 133

What are the 3 major risk factors for developing breast cancer?

Answer 133

- Extra Estrogen-early menarche, late menopause, nulliparity, hormone replacement therapy (non-birth control) - Radiation-lymphomas - Bad genes-BRCA 1+2

Question 134

What are 3 signs concerning for overt breast cancer?

Answer 134

breast dimpling fixed axillary nodes large breast mass

Question 135

How often is breast cancer screening recommended?

Answer 135

q2 years starting at age 50 -Mammograms are less effective with patients <30yo as the breast tissue is more dense, US is more effective in those patients

Question 136

Given a positive mammogram when should you use core vs excisional biopsy?

Answer 136

Core biopsy is the standard, excisional biopsy is for when you have a very high degree of suspiscion that this is cancer

Question 137

For a patient <30yo with a breast mass describe appropriate management in the following scenarios: 1) Newly discovered lump 2) Persistent lump 3) Lump+cyst 4) Lump+cyst that has resolved 5) Any patient >30 with mass OR bloody OR recurrent

Answer 137

1) Newly discovered lump-wait 1-2 cycles 2) Persistent lump-Get US to determine mass or cyst 3) Lump+cyst-Perform FNA-bloody=cancer, puss=abscess, fluid=benign cyst 4) Lump+cyst that has resolved-Stop 5) Any patient >30 with mass OR bloody OR recurrent-go to the mommogram/Bx pathway.

Question 138

How are local breast malignancies managed?

Answer 138

Radiation and Surgery! - Perform a sentinal lymph node biopsy to determine if axillary lymph node dissection is necessary. - Conservative therapy with lumpectomy, radiation, and lymph node dissection are as effective as mastectomy for early localized lesions

Question 139

How are systemic breast malignancies managed?

Answer 139

-Chemo: Doxy/dona rubicin-cause dose dependant CHF Cyclophosphamide Paclitaxel -Targeted: Her2/Neu receptor+ -traztuzumab (reversible CHF), poor prognosis Her2/Neu receptor- -bevacizumab Estrogen/Progesterone receptors-Tomaxifen/Rolaxifen, aromatase inhibitors.

Question 140

Bonus points for breast cancer

Answer 140

- BRCA1/2 mutation-get prophylactic mastectomy or yearly mammogram/MRI - Tamoxifen causes DVTs and endometrial cancer because it is a breast estrogen receptor antagonist and uterine agonist, raloxifen only does breast antagonism so it doesn't have the DVT/endometrial cancer side effects.

Question 141

A newborn has gurgling, coughing, and bubbling with meals. Placement of an NG tube runs into resistance and an xray shows coiling of the tube. What is the most likely diagnosis?

Answer 141

Tracheo-esophageal fistula! | -These babies will need surgical repair. There are many variants

Question 142

A newborn literally has no asshole. What step can be taken to determine the treatment of this patient's condition?

Answer 142

Get an abdominal x-ray! -This is a case of imperforate anus. In mild disease bowel is up against but not connected to the anus but in severe disease bowel is seperated from the anus by a considerable distance. If disease is mild, fix it now surgically; if disease is medium, get a colostomy and reverse it before the child potty trains. This is a VACTERL disease

Question 143

Describe the differences between gastroschisis, omphalocele, and bladder exstophy

Answer 143

Diseases of the newborn! - Gastroschisis-R of midline, bowel not in membranous sac, tx with a surgical silo - Omphalocele-midline, bowel in membranous sac, tx with a surgical silo - Bladder exstrophy-midline, bladder (lack of bowel, red shiny, wet), surgery required

Question 144

A newborn has scaphoid abdomen (caved in) and bowel sounds in the chest. A chest x-ray confirms the diagnosis of Morgani(anterolateral) congenital diaphragmatic hernia. Surgery is planned to put the bowel back into the abdomen. What other consideration should be made for this child?

Answer 144

The kid likely has hypoplastic lungs! -Intubation and surfactant may be required. The bowel being in the chest didn't give the chance for the lungs to develop. Posterior congenital diaphragmatic hernia is called Bochdalek.

Question 145

An Xray of a newborn shows double sign. What additional signs would be diagnostic of: - Malrotation - Duodenal Atresia/Annular pancreas - Intestinal atresia

Answer 145

A doulbe bubble sign in an infant=biliary emesis - Malrotation-normal gas through the rest of the bowel, contrast enema-->upper GI series-->surgery - Duodenal Atresia/Annular pancreas-No gas through the rest of the bowel-->surgery - Intestinal atresia-caused from in utero infarcts, which are mostly from maternal cocaine abuse-->surgery.

Question 146

A premature infant has bloody bowel movements after his first feed, abdominal distension, and labs show decreased platelets. How can the diagnosis be made?

Answer 146

Get a babygram! -This patient likely has necrotizing enterocolitis, evident after 1st feed. X ray of the baby (babygram) shows pnuemotosis intestinalis. (air in the walls of the bowel). Tx this baby with NPO and TPN

Question 147

A newborn has failure to pass meconium and bilius emesis on day three of life. The patient's parents both have cystic fibrosis. A babygram shows a ground glass appearance and dilated loops of bowel. What is the treatment of this condition?

Answer 147

Gastrograffin enema! | -This patient likely has meconium ileus, common in neonates with cystic fibrosis.

Question 148

A 2 week old infant presents with postprandial projectile vomiting and PE reveals a olive shaped mass. The patient appears restless and hungry. An US shows a donut shape around the pyloris. What metabolic derrangements would you expect in such a patient?

Answer 148

Hypochloremia, hpokalemia, metabolic alkolosis! -This neonate has pyloric stenosis, evident within weeks of birth. The donut shape is relatively diagnostic, look up a picture. Give these patients IVFs, replenish electrolytes, and ultimately they need surgery to relieve the stenosis.

Question 149

A 7 week old infant looks jaundiced. What is the next best step in diagnosis?

Answer 149

give this baby phenobarbital and see if this stimulates the biliary tree and after 1 week get a HIDA scan! -This patient likely has biliary atresia which is apparent 6-8 weeks after birth. Tx is to remove the atretic segment of the biliary system.

Question 150

A neonate fails to pass meconium. KUB shows an area of dilated colon next to normal looking colon. What is the treatment of this condition, and what is an alternative patient presentation for this disease?

Answer 150

Remove the bad segment of bowel, this can present at any age with chronic diarrhea! -This patient likely has Hirschsprung disease caused by failure of innervation of the rest of the colon. The good section of bowel is the dilated segment on xray and the bad section is the normal appearing bowel distal to the dilated segment.

Question 151

A 2 month old neonate presents with abdominal pain, and stays in the fetal position. KUB shows a sausage shaped portion of bowel. What presentation would impart a poorer prognosis?

Answer 151

Currant jelly diarrhea! -This neonate has intusseception-->bowel ischemia. Currant jelly diarrhea is a poor prognostic factor as it means the bowel is beginning to slough off. Tx is with an air enema to undo the intusseception and resection of any necrotic segments of bowel.

Question 152

What lab value determines the risk of malignancy given a thyroid nodule?

Answer 152

TSH! - High risk=normal or high TSH - Low risk=low TSH

Question 153

Describe the workup of thyroid nodule given elevated or normal TSH (high cancer risk)

Answer 153

- Get and US - If nodule <1cm, it is small, watch and wait and get repeat US q6mos - If nodule >1cm, it is large, get FNA. If FNA shows cancer-surgery, not cancer-watch and wait and get repeat US q6mos, unsure-repeat FNA

Question 154

Describe the workup of thyroid nodule given low TSH (low cancer risk)

Answer 154

- Get radioactive iodine uptake - If nodule is cold (non-functioning) get US-->FNA: If FNA shows cancer-surgery, not cancer-watch and wait and get repeat US q6mos, unsure-repeat FNA - If nodule is hot (functioning) tx w/ meds, resect

Question 155

What follow up should be performed after gastrinoma treatment?

Answer 155

you need to rule out gastric cancer!

Question 156

What tests should be ordered to rule out exogenous insulin use or solfonylurea use?

Answer 156

- C-peptide-if low with high insulin-exogenous insulin use | - Solfonylurea screen for solyonylurea use (releases endogenous insulin)

Question 157

A patient presents with migratory necrolytic dermatitis. What tests should be ordered?

Answer 157

Glucagon level and CT scan. | -This finding is relatively specific for glucagonoma. Resect these tumors

Question 158

A patient with bone pain is found to have hypercalcemia, hypophosphatemia, and elevated parathyroid hormone. A sestamibi scan shows evidence of a parathyroid adenoma. Resection of the adenoma is planned. F/U should include concern for what possible metabolic derrangement?

Answer 158

Postop hypocalcemia! -This patient likely has primary hyperparathyroidism. As the hot nodule overproduces PTH the normal glands get smaller. So postop, the small glands may underproduce PTH until they regain full function, so you may need to give Ca2+ until the glands adapt.

Question 159

In a patient with red blood per rectum what finding based on NG tube suction excludes upper GI bleed as the source of bleeding?

Answer 159

No blood in the NG fluid and flluid is green/bile tinged! | This means bleeding has been excluded from the nose to the ligament of Trietz.

Question 160

A patient who receives a NG tube suction for GI bleed workup is found to have no blood and be white. What areas have been excluded as a source for the GI bleed?

Answer 160

Nose-->pylorus! | -The duodenum is still a potential source of this GI bleed, so upper GI endoscopy should follow.

Question 161

A 6 month old baby presents with 2 problems: 1-at times he has stridor, crowing respiration and respiratory distress, during which he hyperextends his neck; 2-He has difficulty swallowing. What 2 diagnostic tests should be ordered?

Answer 161

Barium swallow and bronchoscopy! -This patient likely has a vascular ring. Bronchoscopy will show tracheal compression and rule out tracheomalacia whereas barium swallow will show evidence of esophageal compression via an extrinsic source.

Question 162

A young woman presents with acute onset heart failure. She has fever and a new diastolic heart murmur. Her BP is 130/30. She admits to be a IV heroin abuser. What is the most likely Dx?

Answer 162

Acute aortic insufficiency! | -This is most common in young IV drug abusers. It requires emergency aortic valve replacement and long term antibiotics.

Question 163

How do you determine the operability of lung cancer?

Answer 163

- Central masses require pneumonectomy and peripheral masses can be treated with lobectomy - If the patient requires pneumonectomy determine the FEV1 and what proportion comes from the effective lung - If FEV1 preop is <800mL before operation, can't do pneumonectomy. If postop FEV1 would be <800mL, can't do pneumonectomy.

Question 164

A 40 year old patient with Afib comes in following sudden R leg pain. The pain is cold, pulseless, and paresthetic and he can't move it. What treatment should be done?

Answer 164

Embolectomy with fogarty catheter, fasciotomy is sever hours post pain onset -This patient likely has arterial embolization-->complete occlusion. US can localize the clot. In cases of incomplete occlusion, you can use clot busters to return circulation.

Question 165

A farmer presents with an indolent, raised and waxy skin mass over the bridge of his nose that has been slowly growing over the past 2 years. There are no enlarged lymph noes in the head and neck. What is an alternate description for the most likely diagnosis?

Answer 165

A nonhealing ulcer! -This patient likely has basal cell carcinoma. These lesions are highly resectable. The ulcerated form will have raised edges that need to be biopsied.

Question 166

A 4 year old boy is brought in with converged eyes which have developed over the last 3 months. What is the consequence of not treating this phenomenon?

Answer 166

Ambylopia! -This patient presents with strabismus. This can be instantly corrected with corrective lenses. Ambylopia is visual impairment caused by poor processing of images from the brain. In the case of strabismus, the brain will select a dominant eye and the visual center for the other eye will essentially shut off. Therefore, it is extremely important to correct strabismus.

Question 167

A 69 year old man who smokes and drinks has unilateral R sided earache and serous otitis media. Palpation in his mouth shows induration where the R eustachian tube opens into the pharynx. Panendoscopy shows tumors and CT scan shows the extent of the tumors. What should be avoided in diagnostic workup of these tumors?

Answer 167

Open biopsy must be avoided during workup! - This patient likely has squamous cell carcinomal of the mucosa of the head and neck. It is typical of old smokers/drinkers. Often the first sign is a metastatic node in the neck. After triple endoscopy showing tumor, CT is done to evaluate the extent of the tumors. Open biopsy must be avoided as the treatment will be radical neck dissection-->resection and prior incision will likely interfere with treatment. Tx includes radiotherapy and platinum based chemotherapy. - Alternative presentations include persistent hoarseness, persistent painless ulcer in the floor of the mouth, and persistent unilateral earache.

Question 168

A patient comes in with hypertension and hypokalemia. The patient has a Aldosterone:renin ratio >20. What is the next best step in this workup?

Answer 168

Get a salt suppression test, if + get CT/MRI and adrenal vein sampling in preparation for tumor resection -This patient's findings are concerning for an adrenal tumor. Aldosterone:Renin ratio>20 means that aldosterone is not being secreted in response to renin, so think of adrenal masses

Question 169

An older guy with atherosclerosis presents with HTN and hypokalemia. He is found to have an aldosterone:renin ratio <10. Doppler indicates increased flow speed across the renal arteries and angiogram is concerning for renal artery stenosis (RAS). How would presentation and management of this condition differ if the patient were a woman?

Answer 169

- In women RAS often presents with concurrent fibromuscular dysplasia and stenting fixes the problem. - In men RAS presents in old guys with atherosclerosis ad they are managed medically. - Dx is made with aldo:renin reatio <10, US with doppler, and angiogram.

Question 170

A patient presents with episodic HTN, pain, palpitations, perspiration, and paroxysms. Urinary 24 hour metanephrines and VMA are elevated. CT scan identifies a 2 cm L sided adrenal tumor. Adrenal vein sampling is done to make sure we have the correct adrenal before resection can be planned. How should Tx procede?

Answer 170

The patient will need alpha blockade followed by beta blockade before resection! -This patient has a pheochromocytoma given the + 24 hr urinary VMA and metanephrines. Adrenergic blockade is necessary so that surgery doesn't cause a release of hormone during the surgery.

Question 171

A patient presents with HTN, DM, a buffalo hump, truncal obesity, and moon facies. A low dose dexamethasone suppression test fails to suppress cortisol release. ACTH levels are found to be decreased, what is the most likely diagnosis?

Answer 171

Primary adrenal tumor! -This patient has Cushing's syndrome. The patient should get CT/MRI and adrenal venous sampling to localize the tumor before resection is planned.

Question 172

A patient presents with HTN, DM, a buffalo hump, truncal obesity, and moon facies. A low dose dexamethasone suppression test fails to suppress cortisol release. ACTH levels are found to be elevated. What is the next best step?

Answer 172

Get a high dose dexamethasone suppresion test! -This patient has Cushing's. If the high dose test suppresses cortisol release, you have Cushing's dz-get and MRI of the pituitary and resect it. If the high dose test fails to suppress cortisol release, you have an ectopic cortisol releasing tumor-get a CT and plan your next more from there.

Question 173

A patient presents with HTN of the uper extremities but hypotension of the lower extremities with frequent claudication. What is the next best step in workup of this patient?

Answer 173

Get a chest xray and an angiogram! -This patient likely has coarctation of the aorta which is always distal to the branching of the great vessels. X ray will show rib notching. Tx is to resect and reanastamose the stenosed aorta.

Question 174

A 65 year old male smoker presents with a tender pulsatile mass. Abdominal US shows an abdominal aortic aneurysm. How should this condition be managed?

Answer 174

Management of AAA depends on size: - <3.5cm=q12mos screening - <4.5cm=q6 mos screening - >5.5cm or growing >0.5cmq6mos get surgery. - Surgery is also indicated if the patient presented with a tender pulsatile mass with back pain. In terms of surgical management, EVAR=open repair. - Remember that AAA is the byproduct of atherosclerosis.

Question 175

What are the 2 types of aortic dissection and how are they treated?

Answer 175

- Type A=ascending-Operate and consider replacing the aortic valve - Type B=descending-Manage medically with IV beta blockers

Question 176

A patient presents with tearing chest pain that radiates toward his back, asymetric BP between his arms, and a widened mediastinum. CT angiogram cannot be performed as the patient has ESRD, so a TEE is done which shoes evidence of a type A aortic dissection. What conditions commonly predispose to the patient's current condition?

Answer 176

Marfan syndrome and syphilis! | Remember that aortic dissection is often the byproduct of HTN.

Question 177

A patient had rheumatic fever at the age of 18 and presents today, at age 36, with shortness of breath, progressive dyspnea on exertion, orthopnea, paroxyslmal nocturnal dyspnea, cough, and hemoptysis. She appears cachectic and has atrial fibrillation and a low pitched diastolic rumbling murmur. What is the next best step in the workup?

Answer 177

Get echocardiogram! -This patient presents with mitral stenosis probably due to her old bout of rheumatic fever. Tx would be a surgical commissurotomy of the mitral valve to relieve the stenosis or a balloon valvuloplasty.

Question 178

Describe the difference between branchial cleft cysts and cystic hygroma

Answer 178

- Branchial cleft cysts occur along the anterior edge of the sternomastoid muscle anywhere from the tragus to the base of the neck. They are several centimeters in diameter and sometimes have a little opening and blind tract in the skin overlying them. - Cystic hygromas are found at the base of the neck and are large mushy ill defined masses that occupy the entire supraclavicular area. They often dive into the mediastinum requiring CT scan before surgical removal.

Question 179

A 62 year old man presents with a 1 year history of sudden onset episodes of vertigo, diplopia, dysarthria, and instability of gait. These symptoms invariably go away without therapy and are painless, leaving no neurological sequelae behind. What is the most likely diagnosis?

Answer 179

Transient ischemic attacks! The most common etiology is carotid artery stenosis or ulcerated plaque at the carotid bifurcation. Workup includes duplex carotid US. Tx includes carotid endartectomy but angioplasty and stent can be done if a filter is first deployed to prevent embolization of debris to the brain. The whole point is to prevent an actual stroke.

Question 180

A 60 year old man complains of sharp, severe, shooting pain of his face, "like a bolt of electricity". The pain is brought about by touching a specific area of his face and occurs multiple times a day with each episode lasting 60 seconds. The "trigger zone" is unshaven as he avoids touching it. An MRI rules out organic cause of disease. What is the most likely diagnosis?

Answer 180

Trigeminal neuralgia/tix douloureux! | -Treatment should be with anticonvulsants (carbamazapine). If this is unsuccesful radio frequency ablation can be tried.

Question 181

A 28 year old man presents with fever and pyuria and complains of testicular pain. The affected testis is in the normal position and appears swollen. Both the testis and cord are tender to palpation. Gently supporting and lifting the testis provides slight relief of pain. What is the most likely diagnosis?

Answer 181

Acute epididymitis! | -Give these patients antibiotics. US should be done to rule out testicular torsion as this obviously has high morbidity.

Question 182

A 16 year old girl goes out on her first beer drinking binge and shortly thereafter develops severe colicky flank pain. What is the most likely diagnosis?

Answer 182

Ureteropelvic junction obstruction!

Question 183

A patient with arteriosclerotic occlusive diesease reports gradual loss of erectile function. At first he got erections but they gradually lasted less long, became poor in quality and eventually disappeared altogether. The postage strip test proves that the erections aren't psychogenic (the perforations of the stamps didn't seperate) and that he has no nocturnal erections. What should be the first line treatment option for this patient?

Answer 183

Sildenafil (viagra) -vascular surgery, penis pumps, and prosthetics are also options but drugs are the least invasive and morbid option for this guy.

Question 184

Ten days after liver transplant, a patient has elevated GGT, alkaline phosphatase and bilirubin. What is the first step in workup?

Answer 184

Ultrasound and doppler studies! -In liver transplant, technical problems occur more often than rejection. Therefore, instead of giving a trial of steroid boluses, the first step in workup is getting US and doppler to rule out biliary obstruction (US) and venous thrombosis (doppler)

Question 185

What should be done in an emergency situation where intubation cannot be acheived in a timely manor and the patient is becoming anoxic?

Answer 185

Cricothyroidotomy!

Question 186

A young woman has been stabbed in the chest L of the sternum in the 4th intercostal space. Her BP is 80/50 and pulse is 110. Her face and neck veins are largely distended but she is breathing normally and has bilateral breath sounds. What is the best next step in management?

Answer 186

Empty the pericardial sac by the the most expedient means! -This patient has pericardial tamponade. If the diagnosis is unclear, you can do US but never do an xray at this point. You need to move quick to save this patient's life.

Question 187

A 3 year old child presents for her yearly checkup. A fixed s2 sound is heard incidently. What is the best diagnostic test for this anomally?

Answer 187

Echocardiogram! | -This patient likely has an ASD. Tx is closure with a device, open chest surgery is unnecessary.

Question 188

A 6 month old boy has failure to thrive. A murmur is heard and and echocardiogram shows evidence of CHF. The patient has Down's dz. What is the most likely diagnosis?

Answer 188

VSD! -The only other pediatric CT condition associated with Down's is tetralogy of fallot, which would present with much different symptomology. VSD often presents with an asymptomatic heart murmur, CHF and is diagnosed with echo. If the patient is asymptomatic, wait 1 year to see if the defect closes on its own. If the patient has outright CHF, you need surgery.

Question 189

A 1 year old boy presents for his 1 year checkup. Thw patient is found to have a continuous multi phasic murmur. A echocardiogram is concerning for patent ductus arteriosis. What medicine can be used to close the PDA?

Answer 189

Indomethicin! -In PDA there is a persistent connection b/w the aorta and pulm artery causing L-->R shunting. The murmur is not there. It used to be descrived as continuous and machine like but this became a buzzword so the new buzzword is continuous and multi phasic. If you see either of these, you know the Dx. Get an echo to be sure and indomethicin will close it.

Question 190

A baby is born looking blue. The pt is brought to the OR and transposition of the great arteries is discovered. What class of medicines will be beneficial to this baby?

Answer 190

Prostaglandins! -Transposition of the great arteries presents with blue babies that die without immediate intervention due to failure of the great vessels to twist during week 8 of development. Nongestational diabetics are at greatest risk of giving birth to babies with this defect. Prostaglandins are useful to keep the PDA patent until surgery corrects the defect.

Question 191

A 3 year old is brought in for looking blue. The patient has occasions when she is playing where she squats to regain her energy and get back to playing. The patient has Down's syndrome. What is CXR likely to show?

Answer 191

A boot shaped heart! -This patient likely has tetralogy of fallot. Alternative presentation would be a baby born blue. Echo is diagnostic. Surgery is corrective. Prostaglandins may be given to newborns to keep PDA patency.

Question 192

A neonate presents with a distended bladder after being unable to urinate for days. Pregnancy was accompanied by oligohydramnios. Pt has an elevated creatinine. What is the next best diagnostic step?

Answer 192

US-->Voidincy cystourethrogram (VCUG)-->Catheter/measure urinary output! -This is a case of posterior urethral valves! This congenital defect is caused redundant tissue in the neonate and leads to 0 urinary output. US will show hydronephrosis. A VCUG will show reflux and catheterization will show massive urinary output. The catheter is the temporary treatment but surgery remains the ultimate treatment.

Question 193

A newborn is peeing in his face. PE reveals a urethral opening on the dorsal surface of his penis. What should never be done to this patient?

Answer 193

Never do a circumcision! -This is a case of epispadias, an abnormally positioned urethral opening. Hypospadias is the same thing but on the ventral surface of the penis. If you circumcise this kid you have removed the skin the surgeon needs to use to reconstruct this kid's urethra. Not cool

Question 194

A 6 month old infant is brought in because she is "never not wet!". The patient goes to bed at appropriate intervals and seems to have appropriate toilet habits. However inspection of the child's diaper at any time reveals wetness. What is the diagnostic workup of this condition?

Answer 194

US-->VCUG-->Radionucleotide scan! -This patient has an ectopic ureter past the bladder sphincter. These don't happen in boys. US will not show hydronephrosis and VCUG will rule out reflux. A radionucleotide scan will reveal the diagnosis. Tx is reimplantation of the ureter to the correct position.

Question 195

A newly immigrated 3 year old boy from S. America is brought in to establish care. The boys parents describe recurrent UTIs. US reveals hydronephrosis. What is the next best step in management?

Answer 195

Get Voiding Cystourethrogram! -This is likely a case of vesiculouretero reflux. In developed countries these are typically diagnosed before birth by prenatal US. The reflux-->recurrent UTIs. Tx this condition with Abx and surgery.

Question 196

A newborn baby is brought in by his father who is worried that one his boy's testicles is in the canal instead of the testicle. On PE you can easily pull the testicle down and when it is let go it returns to the canal. What is the most likely diagnosis?

Answer 196

Hyperactive cremasteric muscle! -This patient has an undescended testicle because of hyperactive cremasteric muscle. This is a benign condition. On the other hand if we couldn't pull it down at all we would watch it to make sure it falls by age 1. If it didn't than we would need to get orchiopexy to fix it in its proper location.

Question 197

A 45 year old woman crashes her car into a pole and is brought to the ED with multiple extremity fractures, BP 135/70, P 83. On PE she has a rigid tender abdomen with guarding and rebound in all quadrants. What is the next best step in management?

Answer 197

Exploratory Laparotomy! | -This patient with blunt trauma and peritoneal signs needs an ex lap to determine the problem.

Question 198

The mother of a 1 month old brings him in because she has felt a mass in the baby's abdomen. On PE there is a RUQ mass that moves up and down with respiration. What is the most likely Dx?

Answer 198

Malignant liver tumor! - Ddx of newborn abdominal masses: 1) Liver tumor-moves with respiration, get alpha-fetoprotein 2) Wilm's tumor-deeper abdominal mass doesn't move with respiration. Adrenal tumor 3) Neuroblastoma in adrenal gland-deeper abdominal mass doesn't move with respiration. Poor prognosis

Question 199

A 53 yo woman comes in with a newly discovered breast lump. It is a 2cm firm nontender mass in the left breast that is mobile. She has no prior breast disease and due for her next screening mammogram in 3 months. What should be done next?

Answer 199

Get mammogram guided core biopsy! -Pt is over 30 with a newly found breast mass, get biopsy. Excisional biopsy is not warranted as there are no signs of frank cancer.

Question 200

A 45 yo man w/ CAD and CHF comes in with chest pain and syncope. PE reveals a systolic crescendo decrescendo murmur at the 2nd intercostal space along the R sternal border. The murmur is found to radiate to the carotid arteries. What is the most likely diagnosis?

Answer 200

Aortic stenosis! -This is a typical presentation, aortic stenosis is caused by calcifications and the typical patient is the old guy with atherosclerosis. Dx is with echo and Tx is with valve replacement. TAVI/TAVR is a potential nonsurgical option for some patients.

Question 201

A 22 yo old IV drug abuser receiving a checkup is found to have a holosystolic apical murmur that radiates toward the axilla. What event would be likely to have caused such a murmur in a 55yo man?

Answer 201

Infarction-->papillary muscle rupture or chorda tendenae rupture! -This patient has mitral regurgitation. This is the typical murmur, it is commonly caused by infection 9IV drug use) or infarction. Dx is by echo and Tx is with a valve replacement

Question 202

A patient presents with acute devastating tearing chest pain that radiates to his back. He is found to have asymetric BP b/w his arms. CT angiogram shows a widened mediastinum and is concerning for aortic dissection. What type of murmur is most likely if this dissection is Type A(before the great vessels)?

Answer 202

Aortic regurgitation! -Aortic regurgitation can be caused by infxn, infarction, or dissection. It can present acutely with a devastated patient or chronically with an insidious presentation. The murmur is a decrescendo diastolic border at the 4th intercostal space along the L sternal border. Dx is by echo and Tx is with valve replacement. FU issue is whether or not to get CABG, if the aortic valve is affected than the coronaries are likely to be as well.

Question 203

A patient with is found to have a diastolic rumbling murmur with opening snap best heard at the apex. What history and comorbid conditions are likely in such a patient?

Answer 203

Hx of rheumatic heart dz, pt has CHF and Afib! -This is a common picture of mitral stenosis, almost exclusively caused rheumatic heart dz, look for the immigrant. Dx w/echo and Tx medically and with baloon valveotomy. Valve replacement is typically held off for as long as possible as these patients are typically young and valves only last so long (organic=<10years; mechanical=10-20yrs requiring permanent warfarin anticoag, INR 2.5-3.5). You can only enter the chest 3 times.

Question 204

What is the diagnostic workup of CAD?

Answer 204

- First get a EKG to rule out STEMI. Next get troponins to rule out NSTEMI. Lastly get a stress test to rule out symptomatic CAD. If any of these are + you're getting a L. hearth catheterization. - Tx is with stent+clopidogrel for 1-2 small vessel dz or CABG for 3+ or large vessel dz. CABG-use L internal mammary artery for important vessels and saphenous vein grafts for other vessels

Question 205

What are the 2 most common causes of ambylopia?

Answer 205

Untreated strabismus or congenital cataracts

Question 206

How are congenital and acquired cases of strabismus treated?

Answer 206

Our goal is to prevent abylopia! - Congenital-requires surgery within 6 months - Acquired-Patch the good eye or get glasses that fix it

Question 207

A newborn is born with a milky cloudy white plaque in the front of the eye. What most likely caused this situation?

Answer 207

A TORCH infection! -This is a case of congenital cataract. If not present at birth think galactossemia. These are treated with resection, failure to resect-->ambylopia

Question 208

A newborn is found to have a all white retina and lacks a red reflex. What gene mutation likely exists in this patient?

Answer 208

Rb gene mutation! -This patient has a retinoblastoma. Tx is surgical (remove affected eye. Never get radiation as this-->second hit for unnafected eye. FU issue is to check for osteosarcoma as rb mutation causes osteosarcoma as well.

Question 209

What agent should be used for gonarrhea prophylaxis?

Answer 209

Topical erythromycin! -Silver nitrate was used in the past. It doesn't prevent gonorrheal conjunctivitis and causes a chemical conjunctivitis-->nonpurulent bilateral discharge within first 24 hours of birth

Question 210

A neonate has bilateral purulent discharge from the eyes on day 3. What agent should be given?

Answer 210

Ceftriaxone! -This is the typical scenario of gonarrheal conjunctivits. It presents within day 2-7 with bilateral purulent discharge. Topical erythromycin can prevent this if you know mom has gonarrhea. Remember to culture this on chocalate agar and get PCR to ID the organism.

Question 211

A 8 day old newborn is brought in for occular discharge. The discharge began yesterday as a mucoid discharge affecting the left eye but has evolved to become a bilateral purulent discharge. What tx should be given?

Answer 211

Oral erythromycin! -This is a case of chlamydia conjunctivitis. You will get cultures and PCR. Chlamydia cannot be prophylaxed unfortunately. FU issue is to check the baby for pneumonia.

Question 212

What agents reduce the duration of HSV conjunctivitis?

Answer 212

Acyclovir/gancyclovir

Question 213

How is a bacterial neonatal conjunctivitis generally treated?

Answer 213

Treat presumptively for gonorrhea (ceftriaxone) & chlamydia (oral erythromycin) until culture directs treatment.

Question 214

A patient presents with a headache, pain in her R eye, a nonreactive pupil and a rigid R eyeball. Further questioning reveals that she has had repeat bouts of pain and pressure of her R eye when she is in low lit environments. What agent should be strictly avoided in this patient?

Answer 214

Atropine! -This patient has closed/narrow angle glaucoma. Pupillary dilation-->dec outflow-->inc ocular pressure-->non-reactive pupil. By the time this gets to the non-reactive pupil it's a surgical emergency. Dx is by getting occular pressures and clinically. Tx with alpha agonists and beta blockers. Never give these people atropine

Question 215

A patient presents with an inflammatory process of the eye region. What is the most important thing to determine before proceeding?

Answer 215

Can they move their eye! -In periorbital cellulitis, eye movement determines the course. If eye movement is preserved we can just get antibiotics. If not, we need a CT scan to find an abscess and I&D must be performed on any abscess. Furthermore if this situation arises in a diabetic we must be mindful of mucormycosis, the patient may need amphotericin.

Question 216

A 25 year girl comes in with a peice of metal in her eyes after being out shooting guns without eye protection. After extensive irrigation, what modality can be used to make sure that there is no leftover debris or potential nidus for abscess?

Answer 216

Flourecin dye! -This is a typical scenario for corneal abrasion. Irrigation should be performed and flourecin dye is used to determine whether or not we got all the debris and if there is a nidus for abscess formation. If there are, surgery becomes the cure

Question 217

A patient comes in following a MVC and complains of not being able to see out of one eye. When asked he states that there appears to be a curtain over his right eyes vision. This does not come and go What is the next best step in management?

Answer 217

Ophthomologic exam! -You should see retinal detachment! This is a common complication of severe trauma or hypertensive crisis. Dx is clinical and tx is basically to spot weld this with a laser. Curtain vision loss=severe, mild=seeing floaters. If the vision loss is not constant think amorousis fugax

Question 218

A patient presents following severeal episodes of painless vision loss affecting one eye at a time. On PE the patient has no FNDs. The patient is given intraarterial TPA and hyperventilation. What finding on PE is pathognomnic for this condition?

Answer 218

Foveal cherry red spots! -This is a case of amorosis fugax/retinal artery inclusion which presents with episodes of painless unilateral vision loss. This is basically an eye stroke. Dx is clinical. Tx is hyperventilation, and application of pressure on the eye until TPA can be administered.

Question 219

A 65 yo diabetic presents with chronic progressive vision loss, decreased night vision and visible white spot in the L eye. What is the treatment of this condition?

Answer 219

Surgery! -This is a case of cataracts-old diabetic with a visible white plaque in the eye-->progressive vision loss and loss of night vision. Dx is clinical.

Question 220

Describe the differences between wet and dry macular degeneration

Answer 220

Macular degeneration presents with chronic progressive CENTRAL vision loss. - Wet is from blood fluid and is treated with a laser - Dry is from aging/accumulation of drusen. You'll see eye pigment change. There is no treatment.

Question 221

What is the appropriate fluid infusion rate for a patient whose burns exceed 20% body surface area? What is the desired urine output in a patient with severe burns/

Answer 221

- Start at 1L/hr of LR and adjust as needed to produce the desired urinary output. - 1-2ml/kg/hr while avoiding a CVP over 15mmHg

Question 222

At what ages are knock knee (genu valgus) and bowlegs (genu varum) normal?

Answer 222

- knock knee is normal between 4-8, no Tx is necessary - bowlegs is normal up to age 3. After age 3 pt may have blount dz (disturbance of medial proximal tibial groth plate) which requires surgery

Question 223

A 68yo woman comes in with a radius and ulnar fracture after literally just lifting up a grocery bag. What should you suspect?

Answer 223

A metastatic osteolytic cancer. These are common from the breast in women and blastic cancers are common from the prostate in men.

Question 224

A farmer comes in with a pearly skin lesion of his nose that has been slowly growing over the past 3 years. It has regular borders and doesn't have color changes. What is the best diagnostic step?

Answer 224

Get excisional biopsy! -This sounds like basal cell carcinoma. Get excisional biopsy to confirm. Face lesions=Moh's surgery; mild limb dz=excisional bx is the cure; aggressive limb lesions=amputation. Alternatively this could've been a nonhealing ulcer that easily bleeds.

Question 225

A naval officer comes in with a hyperpigmented lower lip lesions. What is the most likely Dx?

Answer 225

Squamous cell carcinoma. Get excisional biopsy to confirm. Face lesions=Moh's surgery; mild limb dz=excisional bx is the cure; aggressive limb lesions=amputation. Alternatively this could've been a nonhealing ulcer w/o bleeding or a well defined red papule

Question 226

What criteria lead to suspicion for melanoma.

Answer 226

Melanoma can present as a jet black hairless lesion. all other lesions suspicious for melanoma can be judged by the ABCDE criteria: - Asymmetry - Border irregularity - Color changes - Diameter >5mm - Evolving

Question 227

How is the diagnosis of melanoma made?

Answer 227

- Punch biopsy for large lesions not suspiscious for melanoma - Excisional biopsy for small lesions suspiscious for melanoma

Question 228

How does tx vary based on the size of melanoma lesion?

Answer 228

<0.5 mm-excisional bx with 0.5mm margins - 1-2 mm-excisional bx and sentinal lymph node dissection with 1 cm margins - 2-4 mm-same as above with 2 cm margins - >4 mm-chemo and radiation (metastatic dz)

Question 229

A patient presents with a "thunderclap" headache that he describes as the worst headache he's ever had in his life. His neck is also stiff. What is the most likely Dx?

Answer 229

Subarachnoid hemorrhage! - Get a non contrast head CT. These are caused by berry aneurysmal rupture. If the CT is negative but youre still suspiscious get a LP which will show xanthrochromia. MR/CT angiogram will show the defect. Tx is symptom dependent: 1) bleeding-CCBs, BBs, coiling, clipping 2) hydrocephalus-Serial LPs, VP shunt 3) seizures-prophylaxis 4) vasospasm-prophylaxis with CCBs, tx with vasopressors.

Question 230

A patient presents with headache, NV and inability to use the left side of his body. Non contrast CT is concerning for intraparenchymal hemorrhage. How should this be treated?

Answer 230

- Decrease ICP-give mannitol, elevate the head of the bed, hyperventilate - Craniotomy to evacuate hematoma is sx progress.

Question 231

How should all intracranial blleds be followed up?

Answer 231

Serial CTs to determine if the blood mass is expanding.

Question 232

What pt populations do craniopharyngioma and meduloblastoma affect?

Answer 232

- Craniopharyngioma-Kids, calcification of the sella turcica | - meduloblastoma-kids

Question 233

What pt populations do epindymoma meningioma and glioblastoma affects?

Answer 233

-adults, meningioma has a good prognosis, seen as calcified lesion connected to the dura. Glioblastoma is seen as a ring enhancing lesion and bat's wing deformity.

Question 234

A 54 yo woman presents with complaints of several episodes of severe calf pain that come and go throughout the day. On physical exam she has shiny shins, loss of leg hair, absent dorsalis pedis pulses bilaterally, and cold feet. What is the next best step in workup?

Answer 234

Get an ankle brachial index (ABI)! -This patient has peripheral vascular, more common in women. The risk factors are the same as those for CAD: HTN, DM, smoking, hyperlipidemia. Any ankle brachial index <1 indicates dz with <0.4 indicating severe disease. If ABI is positive get US doppler and then CT angiogram. Tx is by angioplasty, stenting and bypass. Stent can be used for plaques above the knee or small lesions but bypass is typically used for everything else. You want these patients followed basically like a CAD patient: B blocker, ACEi, A1C<7, smoking cessation, statin, aspirin, clopidogrel. In severe dz cilostazel and pentoxyphline can be used to tx symptoms but they do not treat the dz.

Question 235

A patient presents complaining of the acute onset of leg pain. Her L leg appears cold, and pale. She cannot move the L lower leg and she describes the sensation of paresthesias in her toes. US doppler and angiogram are concerning for claudication at the level of the calf. She had a heart catheterization yesterday for CHF symptoms. What is the most likely Dx?

Answer 235

Acute limb ischemia! -In heart catheterizations, cholesterol emboli are a common complication. Other scenarios would be a patient with Afib or just a thrombus in someone with peripheral vascular dz. Tx is by embolectomy and administration of TPA.

Question 236

A 72 yo man comes in complaining of hesitancy, frequency and failure to fully empty his bladder. A digital rectal exam reveals an enlarged firm nodular prostate. What laboratory value would be most concerning given this patient's presentation?

Answer 236

An elevated prostate specific antigen (PSA)! -This is a case of prostate cancer, commonly found in old men over 70. Most people die with prostate cancer instead of because of prostate cancer so screenings are no longer recommended. Patients have sx similar to BPH: hesitancy, urinary retention, frequency. You should get a PSA and if this elevated go for the transrectal biopsy. Resection is curative but orchiectomy also works as the mass grows in response to androgens. Medications that can be used include flutanide (anti-androgen) and leuprolide (GnRH anolog, preferred). Choose the tx with the least morbidity since prostate cancer isn't likely the thing that will kill them. FU with serial PSAs-any future elevation indicates recurrence. Recurrence without sx-flutanide; recurrence with sx-radiation

Question 237

A patient presents with painless hematuria and sx of urinary hesitancy, frequency, and failure to empty. What is the most likely Dx?

Answer 237

Bladder cancer! -The other common cause of painless hematuria is renal cell carcinoma but this doesn't present with obstructive Sx. Get and US 1st but the best test is cystoscopy+Bx. Tx is transurethral resection+cisplatin based chemo. FU with increased surveillance

Question 238

A 22 yo bike rider comes in with a newly discovered testicular mass. On examination the mass doesn't transilluminate. US shows a 3mm R testicular mass. What should never be done in this situation?

Answer 238

Never do a FNA! -This is a case of testicular cancer, FNA will seed the cancer in new spots. Orchiectomy is both diagnostic and curative as there really aren't benign testicular masses. FU marker is based on what kind of mass was found: Seminoma-LDH Endodermal-AFP Non-choriocarcinoma-beta HCG teratoma-malignant in males, look for mets!

Question 239

A patient presents complaining of painless hematuria and occasional flank pain. PE is significant for a palpable renal mass. CT scan shows a renal mass. What must be avoided in this patient?

Answer 239

Never do a FNA! -This is a case of renal cell carcinoma. CBC anomalies may include erythrocytosis or anemia depending on whether or not the tumor produces EPO. Nephrectomy is both diagnostic and curative. FNA will seed the cancer, similar to testicular cancer.

Question 240

A 50 yo M presents with urinary retention and frequency. DRE reveals a smmooth rubbery prostate. What is the next best step?

Answer 240

Get UA and UCx to rule out infection! -This is a case of BPH, common in dudes>50 presenting with obstructive sx. Smooth and rubbery=not cancer, firm nodular=prostate cancer on DRE. Tx is with tamsulosin (alpha blocker) and finaasteride (5alpha reductase i) and may require transurethral resection in severe cases. FU for obstructive uropathy with catheters, if catheters don't work you have to get transurethral resection.

Question 241

A patient complains of inability to get an erection. Further questioning reveals stress in his sexual relationship. What is the next best test?

Answer 241

Do the nighttime stamp test! -This is a case of erectile dysfunction. Sounds like ya boi needs a new girl, but maybe the stamps don't break and he really does have medical and not psychogenic ED. If so he needs viagra but other options include pumps and prosthesis. Don't let him take nitrates+viagra

Question 242

A patient presents with spontaneous onset of testicular pain. He doesn't appear to have fever or look sickly. Patient stays in horizontal lie and elevation of the sack causes pain. What is the next best step in Dx?

Answer 242

Get an US+doppler! -If this is positive for reduced flow we know this is testicular torsion. Patient will be in horizontal lie and will have pain on elevation of the sack. Tx is to untwist the testicle and tac is down with orchipexy.

Question 243

A 28 yo patient presents with spontaneous onset of testicular pain and is in vertical like and has relief of the pain with elevation of the testicle. Doppler US shows normal testicular flow. What is the best tx for this patient?

Answer 243

Ceftriaxone and Azithromycin! -This patient presents with epididymitis-verical lie and relief of testicular pain with sac elevation. In patients <35 think STD so treat for chlamydia and gonorrhea with ceftriaxone and azithromycin. Pts >55 think Ecoli and use a floroquinolone.

Question 244

A patient presents with fever and flank pain radiating to the groin. On PE he has no CVA tenderness. DRE causes severe tenderness. Urine culture and urinalysis are suspiscious for infection and shows no urinary casts.. What is the most likely diagnosis?

Answer 244

Bacterial Prostatitis! -These patients will present with symptoms similar to pyelonephritis but not have CVA tenderness or urinary casts. DRE exam produces severe tenderness. There is bacterial and inflammatory versions. Ucx and UA will determine tx-bacterial-give Abx; inflammaotroy-give NSAIDS. Never repeat the DRE as it can potentially seed the bacteria into the bloodstream-->bacteremia.

Question 245

What is the Tx of nephrolithiasis based on the following stone sizes: - <0.5cm - <0.7cm - <1.5cm - >3cm

Answer 245

- <0.5cm-IVFs and pain control - <0.7cm-same+a CCB - <1.5cm-same+stent or lithotrypsy - >3cm-surgery.

Question 246

Where are Ewing's sarcoma and Osteosarcoma typically located at on Xray?

Answer 246

These are pediatric bone tumors - Ewing's-midshaft has an onion skinning appearance - Osteosarcoma-distal femur, has a sunburst pattern and is associated with the Rb gene and retinoblastoma.

Question 247

What is the difference between mallet finger and trigger finger?

Answer 247

They will both present as constant finger flexion. - Mallet finger-extensor tendon tear. Tx with splint+NSAIDs-->articular steroids-->surgery - Trigger finger-stenosing synovitis. Pop when the finger is forced into extension.

Question 248

A patient presents with thumb pain. She is a new mother. With a fist with the thumb inside she gets pain with extension in the direction of the 5th digit. What is the most likely diagnosis?

Answer 248

Dequervain synovitis! -Common in mom's who lift babies all day or a dude who lifts too many weights. Dx is with pain on fist thumb twist motion. Tx with splint+NSAIDs-->articular steroids, no use of surgery.

Question 249

What position will the arm take in anterior and posterior shoulder dislocations?

Answer 249

- These both happen as a result of trauma but posterior dislocations are more likely to be a part of severe trauma such as in seizures or lightning strikes. - Anterior dislocation-Abducted shoulder with external arm rotation "shaking hands position" - Posterior dislocation-Abducted shoulder with internal arm rotation - Dx both with x ray and Tx is relocation+sling

Question 250

What is the typical patient that presents with a Colle's fracture?

Answer 250

An old lady with osteoporosis who falls! | -The lady will have a dorsally displaced wrist as she fell on her outstreched hand. Dx with xray and get cast/surgery

Question 251

What are the differences b/w Monteggia and Galleazi fractures?

Answer 251

They are both caused by downward blows to the forearm. In Monteggia the ulna is fractured and the radius dislocates. In Galleazi the radius is fractured and the ulna is dislocated. Either way get an xray and Tx with surgery vs cast.

Question 252

What area is in pain following a scaphoid fracture?

Answer 252

The anatomic snuff box! -Caused by a fall on an outstretched hand. Xray will be normal at first but show the broken bone later so just get the cast as soon as you suspect these.

Question 253

What is the usual cause of a boxer's fracture?

Answer 253

Some dipshit punching a wall-->fracture of the 4th and 5th digits.

Question 254

An old lady with osteoporosis presents to the ED following a MVC with a shortened and externally rotated R femur. Suspecting hip fracture you get an xray. How will the x ray results determine treatment?

Answer 254

Treatement depends on the hip fx location: - Femoral head fx-prosthesis - intratrochanteric-plates - shaft-rods - open-emergency washout

Question 255

What is the best diagnostic test for collateral ligament tears?

Answer 255

Get an MRI for ACL, PCL, MCL, or LCL tears.

Question 256

A patient presents with knee pain and extension of the knee produces an audible clicking sound. What is the most likely Dx?

Answer 256

Meniscus tear! | -Get an MRI of the knee and perform arthroscopic knee repair

Question 257

What will xray show on a stress fracture?

Answer 257

Nothing at first! Later it will be positive | -Typical of a "weekend warrior" in terms of exercise. Get these folks cast and crutches.

Question 258

A patient is brought to the ED after jumping from the Savannah bridge. X ray shows tibial/fibial fracture. What other situation commonly produces these fractures?

Answer 258

Pedestrian vs car! -In a tib fib fracture get an xray and cast/surgery. In any scenario where the tibia breaks the fibula will as well as it wasn't meant to hold weight.

Question 259

A patient was running and heard a pop and is now limping before her presentation to the ED. A gap is palpated where her achilles should be. What is the duration of healing if the patient gets a cast or surgery?

Answer 259

Cast-months, Surgery-weeks | -This is an achilles tendon tear.

Question 260

A 79 yo woman has a firm movable 3 cm mass in her left breast which has been present for 4 months. She was seen elsewhere and she brings a report saying her mammogram is not diagnostic of cancer but cannot rule it out either. What is the next best step in mgmt?

Answer 260

Get a radiographically guided core biopsy!

Question 261

A 63 yo woman has a 4cm breast mass under the nipple and areola of her R breast. The mass occupies most of her breast. Multiple core biopsies at an outside facility prove the diagnosis of infiltrating ductal carcinoma. She has no other lesions and exam of the axilla is negative. What role does surgery play in her treatment?

Answer 261

She will need a mastectomy and sentinel node axillary sampling! -Small lesions located far away from the nipple and areola get lumpectomy-->radiotherapy. Large lesions located near the areola and or nipple require mastectomy. If axillary lymph nodes aren't palpable get a sentinel node biopsy. If axillary nodes are palpable resect all axillary nodes.

Question 262

A 33 yo woman with back pain for the past 3 weeks is found to have two well circumscribed thoracic spinal areas of tenderness to palpation. She had a lumpectomy for breast cancer a year ago followed by chemo and radiation. She is currently on tamoxifen. How should this patient's problem be diagnosed?

Answer 262

Get an MRI! -Persistent headache or back pain in women with recent breast cancer suggests metastasis. MRI is diagnostic and these can be radiated or resected. The vertebral pedicles are the favorite location in the spine.

Question 263

A 2 wk old baby girl has brotracted vomiting of green fluid. Xray shows a double bubble sign with normal gas pattern beyond. What is the most likely diagnosis?

Answer 263

malrotation! -Protracted vomiting of green fluid and double bubble sign in a newborn should be concerning for duodenal atresia, annular pancreas and malrotation. If in addition to the double bubble there is normal gas pattern beyond than the chances of malrotation is higher.

Question 264

A 62 yo man has dyspnea on exertion, hepatomegally and ascites. Heart catheterization shows heart pressures with a square root sign and equalization. What is the most likely diagnosis?

Answer 264

Chronic constrictive pericarditis! -This is a classic picture of chronic constrictive pericarditis. Not sure if anything else will cause the square root sign and equalization on cardiac catheterization.

Question 265

A 32 yo M has physical exam findings concerning for heart disease. Echo is done and shows a 5 cm solid tumor growing out of the wall of the L ventricle. The patient has surgical removal of a pigmented back lesion 3 years ago but has been otherwise healthy. What is the most likely diagnosis?

Answer 265

Metastatic melanoma! -Metastatic melanoma is a champion of metastasizing to weird places (i.e. outside of liver lung brain bone lymph) and has no predictable time table.

Question 266

A 57 yo myopic man goes to his ophthomologist because he has been seeing floaters over the past 5 days. They began as one or two but now there appears to be a "snowstorm". Infact he describes a dark cloud over his visual field now. These symptoms only affect his R eye. What is the most likely dx?

Answer 266

Retinal detachment! | -Tx is with emergency laser "spot welding"

Question 267

A 2 yo boy is brought in because pus is running out of his nose. There is foul smelling fluid running out of his L nostril. The mother says this has been going on for about a week. What is the most likely diagnosis?

Answer 267

Nasal foreign body! | -Unilateral wheezing, earache, or rhinorrhea in a child-think foreign body

Question 268

A 42 yo R handed man has a hx of progressive speech difficulties and right hemiparesis for 5 months. He has progressively severe headaches for the past 2 months which are worse in the mornings. At admission he is confused and vomiting and has blurred vision, papilledema, and diplopia. Shortly thereafter his BP goes up to 190/110 and he develops bradycardia. What is the rise in his blood pressure due to?

Answer 268

Cushing reflex-a compensatory response to preserve brain perfusion! -This patient has a brain tumor compressing on a clinically silent brain area. Sx will be progressive headache worse in mornings and eventually signs of increased ICP: blurred vision, papilledema, projectile vomiting, bradycardia, HTN. MRI is the preferred study and high dose steroids are used until surgery can be performed.

Question 269

A 23 yo man comes in with otitis media and mastoiditis and is placed on appropriate Abx. 2 weeks later he returns complaining of severe headache, seizures, blurred vision, and projectile vomiting. He has had a fever for the past week. What is the most likely diagnosis?

Answer 269

Brain abscess! | -Get a head CT. MRI is not required as the typical appearance on CT is enough for diagnosis. Tx with surgical resection.

Question 270

A newborn baby boy has not urinated during the first 18 hours of life. Physical exam shows a normal urethral meatus and a distended bladder. What is the most likely diagnosis?

Answer 270

Posterior urethral valves! Newborn boys who can't pee should raise concern for posterior urethral valves (most common) or urethral meatal stenosis (2nd most common)

Question 271

DRE reveals a 1.5cm rock hard prostatic mass in a 65 yo man. His PSA is normal. What is the best next step in management?

Answer 271

Get a transrectal needle biopsy of the mass! In cases of prostate cancer a needle biopsy will be diagnostic. CT will help define the extent when planning surgery/radiation.

Question 272

The CT of a 59 yo woman with severe ureteral colic shows a 7mm stone at the ureteropelvic junction. What should the patient be treated with?

Answer 272

Lithotripsy! -stones<3mm can usually be managed conservatively but >7mm needs some kind of active management, lithotripsy being the most common.

Question 273

A 25 yo M is stabbed in the right chest. He states that he feels short of breath. PE shows no breath sounds at the right base and only faint sounds at the apex. CXR confirms R hemothorax. What is the next best step in management?

Answer 273

Chest tube placement! -Hemothorax seldom requires surgery as the lungs are a low pressure system and will autocoagulate. However, if more than 1500mL of blood initially upon placement or 600mL over the ensuing 6 hours is collected, surgery may be indicated as a systemic artery, such as an intercostal artery, may have been hit.

Question 274

A 23 yo w who sustained multiple injuries in a MVC is in shock upon admision. She is given fluids but she has a grossly tender and distended abdomen. FAST exam confirms that the abdomen is filled with blood. Ex lap is undertaken and the surgery has a prolonged course due to her multiple injuries. In the OR she receives 12 unites LR and 6 of packed red cells. Closure cannot happen as the edges are too swollen. How should the surgeons proceed?

Answer 274

Provide temporary bowel coverage with an absorbable mesh or nonabsorbable plastic! -This is a case of abdominal compartment syndrome. The tissues are just too swollen at this time but you can't leave the abdomen open, so temporary coverage is necessary until the swelling goes down enough for closure to occur. This may also present on POD2 when a patient's sutures rip open.

Question 275

A 22 yo woman loses control of an ATV and iscrushed by it during her accident. She comes to the ER with signs of obvious pelvic fracture. A foley catheter recovers bloody urine. The best way to evaluate her urological injury would be?

Answer 275

Retrograde cystogram including postvoid films! -Postvoid films are necessary to see extraperitoneal leaks at the base of the bladder that might be obscured by a bladder full of dye. These can be treated with a foley catheter. Intraperitoneal bladder leaks require surgical repair with a suprapubic cystostomy.

Question 276

A 29 yo W is shot in her upper thigh. X ray shows the bullet lodged in the muscles. There is an expanding hematoma below the entry wound and no pulses distal to the injury. Next step in management should be?

Answer 276

Get doppler studies! | -then you can get CT angio.

Question 277

An obese 13 yo boy has been limping and complaining of persisten L knee pain for several weeks. He gives no Hx of trauma. On PE his knee is not swollen and it appears to be normal. However, he has limited hip motion. He sits on the examination table with the sole of his L foot pointing to the R, and when his L his is passively flexed it goes into external rotation and cannot be rotated internally. What is the most likely Dx?

Answer 277

Slipped capital femoral epiphysis! -This is an orthopedic emergency. The typical patient is a chubby or loanky boy around age 13. They complain of groin/knee pain. When the legs are dangling the sole of the affected foot points toward the other. There is limited hip motion and when the hip is flexed the thigh externally rotates and cannot internally rotate. Xray is diagnostic and the head of the femur must be surgically pinned back in place.

Question 278

A 45 yo W attempts to lift a heavy object and suddenly has very severe back and posterior L leg pain which she describes as a bolt of electricity. The pain is aggravated by coughing or straining and it becomes excruciating if her leg is raised while extended. Bladder function, rectal sphincter tone, and perineal sensation are normal. The diagnostic and therapeutic plan should be?

Answer 278

MRI of L4-S1; pain control with nerve blocks! -This is a common scenario for lumbar disc herniation, which often happens in the 40s. MRI makes the diagnosis and spontaneous resolution is the rule. However, this process is very painful so nerve blocks are given to get the patient back in their daily groove.

Question 279

A 58 yo W first noted scleral icterus 5 weeks ago. Now her jaundice has progressed so that her entire body appears yellow and she has mild itching all over. She also reports vague constant upper abdominal and back pain and a 10 poung weight loss. The lab reports a total bilirubin of 29 most of which is conjugated (direct). Transaminases are minimally elevated and alk phos is about 5x the upper limit of normal. RUQ US shows a thin walled massively dilated gallbladder without stones. What is the next best step in diagnosis?

Answer 279

Get an abdominal CT! A thin walled dilated gallbladder on US suggests obstructive jaundice caused by tumor. 3 cancers are typical: adenocarcinoma of the head of the pancreas, adenocarcinoma of the ampulla of Vater, or cholangiocarcinoma of the common duct itself. Significant weight loss and constant back pain suggest a large pancreatic tumor, which should be visible on CT. MRCP is the next test if those clues are absent or CT is negative. Biopsy is by tumor location: CT guided percutaneous for large pancreatic mass, endoscopic for ampullary mass, ERCP and brushings for ductal neoplasm, or endoscopic US for tiny tumors within the head of the pancreas.

Question 280

A 27 yo immigrant from El Salvador has a 14 x 12 x 9 cm mass in her L breast. It has been present for 7 years and has slowly grown to its present size. The ass is firm, rubbery, and completely movable and unattached to the overlying skin or chest wall. Therea re no palpable axillary lymph nodes. What is the most likely Dx?

Answer 280

Cystosarcoma phyllodes! -There are seen in the late 20s. They grow over years to become large and replace and distort the entire breast although they don't invade or become fixed. Most are benign but they have the potential to become outright malignant sarcomas. Core or incisional biopsy is needed and removal is mandatory.

Question 281

A 54 yo W seeks help because she noticed a mass in her L breast. She was actually not in the habit of doing regular self exams but she was accidentally hit with a tennis rackit and that brought attention to the area. She has a 3.5 cm hard deep freely movable mass and some superficial bruising. What is the next best step in management?

Answer 281

Get radiologically guided core biopsies! -Breast cancer should be suspected in any woman with a palpable breast mass and the index of suspicion goes up with the patient's age. Other strong indicators of cancer include: ill defined fixed mass, retraction of overlying skin, orange peel skin, recent retraction of the nipple, eczematoid lesions of the areaola, reddish orange peel skin over the mass, and palpable axillary nodes. A history of trauma does not rule out cancer.

Question 282

A pregnant woman has a sonogram done to learn the gender of the baby. The sonographer reports that a congenital diphragmatic hernia is present in the fetus. It is already predictable that the baby will be born with severe problems. What consideration should this provoke for the baby?

Answer 282

The baby will likely be born with L sided hypoplastic lung! -Congenital diaphragmatic hernia is always on the left and the bowel will be up in the chest. The real problem is not the mechanical one but the hyppoplastic lung that still has fetal type circulation. Repair must be delayed 3-4 days to allow maturation. Babies are in respiratory distress and need endotracheal intubation, low pressure ventilation, sedation and NG suction. Difficult cases may require extracorporeal membrane oxygenation (ECMO). Many patients currently are diagnosed before birth by sonogram.

Question 283

A middle aged man is brought into the ER with extremely severe abdominal pain of sudden onset. He is thrashing around, trying to get off the stretcher, while his wife attempts to restrain him. What is the most likely diagnosis?

Answer 283

A stone impacted in his ureter! -Acute abdominal pain caused by obstruction of a narrow duct (ureter, cystci, common bile duct) has sudden onset of very severe colicky pain, with typical location and radiation according to the source. The patient moves constantly seeking a positon of comfort. There are few physical findings and they are limited to the area where the process is.

Question 284

In the course of a mugging, a 27 yo M is repeatedly kicked in the abdoen. When he is examined in the ER he has a BP of 85/55 and a pulse rate of 110 with a CVP of 1. 2 L of lactated ringers are infused over 20 mins via two 16 guage catheters, one in each arm. His BP promptly responds and by the time packed red cells arrive he is hemodynamically stable. He has no signs of peritoneal irritation on physical exam. What is the next best step in management?

Answer 284

Get an abdominal CT! -You need to evaluate this guy for internal bleeding and CT is the best option since he is hemodynamically stable. If the guy didn't stabilize this would be a case where we'd have to go straight to surgery.

Question 285

10 days after a patient receives a cadaveric renal transplant, the new kidney's function begins to deteriorate. A percutaneous bipsy report of the graft reads "signs of acute rejection". What medications should this patient receive?

Answer 285

Antithymocyte serum and a steroid bolus! | -This is a case of acute rejection, which is common after day 5 post transplant.

Question 286

A 66 yo obese W comes in because of a chronic ulcer that she says "does not hurt but it does not heal either". She has been applying antibiotic creams to no avail. Physical examination shows a 3.5cm ulcer just above the medial malleolus with a granulating bed surrounded by chronically edematous indurated and hyperpigmented skin. Her obesity precludes any reliable PE of her leg veins of her peripheral pulses. How should her initial plan and treatment proceed?

Answer 286

Duplex scan the patient's veins and use support stockings measured to fit her! -Venous stasis ulcers develop in chronically edematous, indurated, and hyperpigmented skin above the medial malleolus. The ulcer is painless with granulating bed. The patient has varicose veins and suffers from frequent bouts of cellulitis. Duplex scan is useful in the workup. Tx revolves around physical support to keep the veins empty, such as support stockings. Surgery may be required and endovascular ablation with laser or radiofrequency may also be used.

Question 287

A 17 yo boy has been having RLQ pain for 2 days. He says the pain began at that location and has been gradually been getting worse. On PE he has tenderness to deep palpation and mild rebound on both the RLQ and LLQ. Temp is 38 and WBC cound is 8500. He is terribly hungry but his parents are afraid to feed him. What is the next best step in management?

Answer 287

CT abdomen! -Any doubtful presentations of appendicitis should get a CT to confirm the diagnosis. Classically appendicitis presents with modest fever and leukocytosis (10-15000) with neutrophilia and aimmature forms.

Question 288

A 23 yo W has a tubal ligation done under general anesthesia by a vaginal approach. Something goes wrong in the postop pediod and within a few hours she is in coma. Her records of medications and fluid administrations have been lost, and all we know for sure is that at the time of anesthetic induction her serum sodium concentration was 142mEq/L and is now 118mEq/L. What likely caused this situation?

Answer 288

Water retention! -This is apotential postsurgical scenario as internal bleeding causes fluid loss and the body is forced to retain water-->hyponatremia. The other common scenario-->hyponatremia would be SIADH.

Question 289

A 34 yo W develops abdominal pain and shortly thereafter faints. When seen in the ER she has regained consciousness but is very weak, with profuse perspiration and a BP of 85/50. Her hgb is 8 and her abdomen is distended. There is no hx of trauma. Thinking about the possibility of an ectopic pregnancy, she is asked about her GYN hx. She is quite sure she is not pregnant because she is on birth control pills, which she has faithfully taken since she was a teenager. What is the most likely Dx?

Answer 289

Hepatic adenoma! -Hepatic adenomas may arise as a complication of birth control pills and are important because they have a tendency to rupture and bleed massively inside the adbomen. CT scan is diagnostic, emergency surgery is required.

Question 290

A 12 yo girl has a PE done prior to her acceptance at a summer camp. There is a faint heart murmur that triggers her referral to a pediatric cardiologist. The specialist instantly recognizes a faint pulmonary flow systolic murmur and a fixed split second heart sound. Upon direct questioning the family reports that indeed the girl has frequent colds and respiratory infections. What would you expect and echocardiogram to show?

Answer 290

Atrial septal defect! -Atrial septal defect has very minor, low pressure, low volume shunt. Pts typically grow into late infancy before it is recognized. A faint pulmonary flow systolic murmur and fixed split second heart sound are characteristic. A hx of frequent colds is elicited. Echo is diagnostic. Closure can be achieved surgically or by cardiac catheterization.

Question 291

A pediatric neurosurgeon takes a peek into his office waiting room and sees a child on hands and knees holding his head lower than his torso. What is the most likely Dx?

Answer 291

Ependymoma! -Brain tumors in children are usually in the posterior fossa. medulloblastoma is the most common type. It arises in the cerebellum and gives the classic cerebellar sx such as stumbling and truncal ataxia. The 2nd most common type is ependymoma. Some of those pivot on a pedicle, and affected children often assume the knee-chest position to open the flow of CSF and relieve their headache.

Question 292

``` A 52-year-old woman with well-controlled type 2 diabetes mellitus is brought to the emergency department 24 hours after the onset of abdominal pain. She has vomited three times in the emergency department. She appears toxic. She is 157 cm (5 ft 2 in) tall and weighs 95 kg (210 lb); BMI is 38 kg/m2. Her temperature is 39.5°C (103.1°F), pulse is 120/min, respirations are 28/min, and blood pressure is 160/90 mm Hg. Examination shows scleral icterus. Breath sounds are decreased over the lower lung fields bilaterally. The abdomen is mildly tender; bowel sounds are normal. Rectal examination shows no abnormalities. Laboratory studies show: Hemoglobin 12.6 g/dL Leukocyte count 16,000/mm3 Segmented neutrophils 70% Bands 10% Lymphocytes 20% Serum Na+ 130 mEq/L Cl− 90 mEq/L K+ 5.0 mEq/L HCO3− 14 mEq/L Glucose 600 mg/dL Bilirubin Total 5.2 mg/dL Direct 2.0 mg/dL Alkaline phosphatase 350 U/L AST 300 U/L Amylase 100 U/L What is the most likely diagnosis? ```

Answer 292

Cholangitis, ascending! -She has the Gall stones Risk Factors "Forty, Female, Fatty" which can be complicated by Cholangitis. And by Exclusion. The Acute Picture Rules out Amebic Liver Abscess and Chronic Cholecystitis and Biliary Cirrhosis. The Normal Amylase rules out Acute Pancreatitis and the Fever and Leukocytosis rules out Pancreatic Cancer. and the Hepatitis presents Sub-acutely which is not the case here.

Question 293

67 y/o postal worker comes to physician 1 day after 5 min. episode of weakness and numbness in right (dominant) hand while at work. No visual problems, headache, weakness, numbness in lower-extremities. Currently ASx. Smoke 1 PPD 45 years. He has not seen a physician in 40 years. Pulse 85 bpm, irregular, BP 140/90. Lungs are CTA. Pulses palpable. Carotids bruit heard bilaterally. Heart sounds normal except frequent premature beats. Neuro exam shows no abnormalities. An EKG shows normal sinus rhythm with multiple atrial premature contractions. Best next step?

Answer 293

TIA = Carotid Doppler! | -Without clear indications, there's no role for ECHO/ECG/MRA/CTA until a full blown stroke has occurred.

Question 294

pt brought to ER after gunshot to calf, writhing in pain, temp is 98.6, RR=16,BP: 110/76. exam shows 1 cm entrance wound over medial aspect of posterior right calf with no exit wound. calf is tense and tender to palpation. passive movement of the great toe exacerbates the patient's calf pain. peripheral pulses are normal. capillary refill time is 2 seconds. senation intact. Xrays show 1 cm bullet in medial aspect of posterior calf. what's best next step?

Answer 294

" passive movement of the great toe exacerbates the patient's calf pain" is the key piece of information there. He's got compartment syndrome. Peripheral pulses can be completely normal till late into the progression of compartment syndrome, so don't depend on the presence or absence of peripheral pulse to guide you. This guy needs an emergent fasciotomy (choice E).

Question 295

Twelve hours after undergoing drainage of a pancreatic abscess, a 52-year-old man with alcoholism becomes bradycardic and hypoxic and requires intubation and mechanical ventilation. He weighs 70kg (154 lb). The ventilator is set at an Fi02 of 100%, tidal volume of 1000ml, and positive end-expiratory pressure of 2.5cm H20. Arterial blood gas analysis shows pH 7.36 PCO2 40mm Hg P02 48mm Hg What is the most appropriate next step in management?

Answer 295

I think pt has ARDS so I’ll go with H (incr PEEP)

Question 296

An 18 YOW comes to the physican for advice about screenin with a fam hx of colon ca. She has the APC gene.2 polyps are seen on colonoscopy. Best long term treatment?

Answer 296

prctocolectomy with ileoanal reservoir. Almost certainly will get Ca at some point

Question 297

52 YOW has back pain with hx of treatment for breast cancer 5 years ago. Decreases sensitivity below nipples. Hyperreflexive and decr strength with + babinski in legs, arms are normal. Where is the lesion?

Answer 297

Thoracic spinal cord: T10 is nipples

Question 298

The driver of an automobile is brought into ED after head on MVC at 50 mph. He has mid chest tenderness. All diagnostic tests are norma, except an XR of the chest which shows a widened mediatinum. NExt step?

Answer 298

Aortic arch arteriogram

Question 299

12 hours after rod stabilization of a femoral fracture, 27 YO homeless ,an has sudden onset of combativeness and disorientation. HR 120, RR 24, BP 140/85. Exam shows petichiae over axila. Most likely cause?

Answer 299

Fat embolism

Question 300

A 45 YOm has daily temps to 100.9 and 15 lb wt loss over 3 m. he has pallor, normal vitals and normal CV and P exams except a low pitched disatolic rumble at the apex that dissappears when he lies on his R side. Hb is 10. Most liekly dx?

Answer 300

Atrial myxoma ( cancer picture with diastolic rumble)