Surgery Flashcards
(370 cards)
1
Q
What metabolic condition is an absolute contraindication to surgery?
A
DKA
2
Q
A malnourished pt needs to go to surgery; what’s the ideal course of action?
A
Oral feedings for 10 days; next best would be oral feeding for 5 days; then parenteral feeding for any time
3
Q
If someone needs surrey, when should they stop smoking?
A
8 wks before surgery (quitting closer increases bronchial secretions, and makes things worse)
4
Q
In terms of the heart, two things you don’t want to have if going to surgery?
A
JVD (EF less than 35%) or MI within 6 months
5
Q
Risk of parenteral nutrition?
A
Fungemia
6
Q
What are the 5 things you look at for the Child-Pugh score, and what is it used for?
A
Used to assess liver and how well the pt will be able to process anesthesia; A BEAP: Albumin (low), Bilirubin (elevations), Encephalopathy, Ascites, PT/PTT (elevation); (any 1 of these means a 40% chance of death)
7
Q
Fever on day 0, right after induction what do you do?
A
Dantrolene (likely malignant hyperthermia!)
8
Q
Fever on post op day 2, what is it/what do you do?
A
Pneumonia (wind); chest xray, abx
9
Q
Fever on post op day 7, what do you do?
A
ultrasound or CT scan (wound = cellulitis) to rule out abscess
10
Q
Fever on post op day 1, what is it/do you do?
A
atelectasis (wind); CXR (should be negative) and incentive spirometry
11
Q
Fever on post op day 3, what is it/do you do?
A
UTI (water); urinalysis and tx with antibiotics
12
Q
Fever on post op day 10, what is it/what do you do?
A
Abscess; U/S or CT scan, drain, abx
13
Q
Fever on post op day 5, what is it/what do you do?
A
DVT (walking); U/S, heparin
14
Q
What are the 5 W’s of post op fever and when do they typically occur?
A
Wind (atelectasis = day 1), Water (UTI = day 3), Walking (DVT = day 5), Wound (cellulitis/abscess = day 7/10; may also see bacteria right after surgery day 0), Wonder drugs (malignant hyperthermia = during surgery)
15
Q
Elderly post-op, X-ray shows dilated colon. Dx and tx (2)?
A
Ogilvie’s (pseudo-obstruction); place rectal tube, give pyridostigmine
16
Q
Treatment of MI after surgery?
A
Medical, PCI, NEVER tPA
17
Q
How do you diagnose an MI after CABG?
A
CKMB, NOT troponins
18
Q
When is it okay to put an IVC filter in for DVTs (2)?
A
When the next PE will kill them AND there’s a contraindication to anticoagulation
19
Q
A wound is leaking salmon-colored fluid, but the skin is intact. Dx and what do you do (2)?
A
Dehiscence; limit straining, elective OR
20
Q
Post-op, foley in place, 0 urine output?
A
Unkink the catheter
21
Q
Wound opens and intestines come out, dx and what do you do (3)?
A
Evisceration; warm saline dressing, bed rest, emergent OR
22
Q
Day 2 post-op: pt gets hypertensive, tachycardia, diaphoretic, and confused. Dx? Tx?
A
Delirium tremens; give benzos (lorazepam)
23
Q
Post-op, has urge to void, but can’t. Dx? What do you do?
A
Urinary retention (post op ileus of ureter/urethra vs BPH); in-and-out cath (post-void residual)
24
Q
Diagnose a pulmonary embolism?
A
CT scan (good kidneys); VQ scan (bad kidneys)
25
Post-op, low urine output, first step?
Give fluids (see if pre-renal vs intrinsic vs both)
26
Fistula causes (6ish)? What should you do?
FRIEND: foreign body; radiation; inflammation/infxn/IBD; epithelialization; neoplasm, distal obstruction; remove the fistula (LIFT procedure)
27
Painful jaundice, dx?
Gallstones
28
You dx primary sclerosing cholangitis with strictures. How do you treat?
Ursodeoxycholic acid to transplant. DO NOT stent PSC
29
What disease is associated with primary sclerosing cholangitis?
Ulcerative colitis
30
How do you diagnose cholangiocarcinoma?
ERCP with endoscopic biopsy (card says brushes?)
31
Thin-walled, distended gallbladder on US, what do you think?
painless jaundice caused by biliary cancer somewhere
32
What is Courvoisier's sign?
distended, palpable, painless gallbladder
33
How do you diagnose pancreatic cancer?
Endoscopic ultrasound (EUS) with biopsy
34
Treatment for choledocolithiasis?
ERCP
35
How do you diagnose primary sclerosing cholangitis?
MRCP (beads on a string); can do ERCP if MRCP equivocal
36
What will the US show in choledocolithiasis?
dilated ducts
37
Lots of D bili elevated, general cause?
Obstruction
38
You diagnose a stricture of the biliary tree. What do you do?
Stent it
39
Best test in working up esophageal cancer?
EGD with biopsy
40
First diagnosis step in GERD?
Empiric PPI
41
Best tx for achalasia?
Myotomy (dilatation and botox need repeating)
42
How do you diagnose Boerhaave's?
Gastrografin swallow (less irritating to mediastinum than barium); then barium; EGD if others are negative
43
Bird's beak esophagus on imaging = ?
Achalasia
44
Self limiting upper GI bleed caused by vomiting?
Mallory-Weiss tear
45
Esophageal cancer at the bottom of the esophagus is what type? Most common cause?
Adenocarcinoma; GERD
46
When is EGD the first step in GERD?
alarm symptoms = anemia, N/V, weight loss
47
1st step in working up esophageal cancer?
barium swallow (localizes cancer)
48
Esophageal cancer at the top of the esophagus is what type? What is a common cause?
Squamous cell carcinoma; smoking
49
Hernia that you see after a pt has surgery?
Ventral hernia
50
What will you see on KUB for small bowel obstruction?
air fluid level
51
Hernia that you see in baby boys?
Indirect hernia (through inguinal ring, often in to scrotum)
52
When do reducible, irreducible, and strangulated hernias go to surgery?
```
Reducible = elective
Incarcerated = urgent
Strangulated = emergent
```
53
Classic appendicitis presentation: what's the next step?
Surgery, not CT
54
Hernia that you see more in women?
Femoral (under the inguinal ligament)
55
Flushing, wheezing, diarrhea, what is the diagnosis and how do you test for it?
Carcinoid; 5-HIAA in urine (CT scan or octreotide scan as well)
56
Most common cause of small bowel obstruction, if pt has no prior surgery? Most common if pt has prior surgery? Name two other common causes.
Hernia; Adhesions; inflammatory bowel disease, cancers
57
Hernia you see in adult men?
Direct hernias (through the triangle - through transversals muscle)
58
Diagnose acute pancreatitis by?
Elevated lipase
59
Name the 3 most common causes of pancreatitis?
Alcohol, gallstones, and hypertriglyceridemia
60
Pancreatic pseudocyst: when do you operate?
6 wks or greater than or equal to 6 cm
61
Acute pancreatitis weeks ago, now early satiety?
pseudocyst, CT scan
62
Treatment of chronic pancreatitis?
Opiates (pain control - do not do surgery)
63
Antibiotic used in necrotizing pancreatitis? And when do you give it?
Meropenem - only if FNA proven infxn
64
Pt has fever, leukocytosis that fails to resolve days after pancreatitis, dx?
pancreatic abscess
65
Name 3 complications of acute pancreatitis that may require surgery
necrotizing pancreatitis, pancreatic abscess, pseudocysts
66
Pt has early satiety, ascited, dyspnea weeks after pancreatitis, dx?
Pseudocyst
67
Pt has falling hemoglobin, deteriorating, days after initial presentation of pancreatitis?
Necrotizing pancreatitis
68
When do you do a CT scan for a pt with high suspicion of pancreatitis (elevated lipase)?
CT scan if and only if no improvement after supportive treatment
69
How do you treat acute pancreatitis?
NPO, IVF, Analgesia (pancreatitis can cause positional chest pain)
70
Acronym for causes of pancreatitis?
G - Gallstones
E - EtOH
T - Trauma/Triglycerides
```
S - Steroids
M - Mumps
A - Autoimmune
S - Scorpion venom
H - Hyperlipidemia/Hypothermia/Hypercalcemia
E - ERCP/Emboli
D - Drugs
```
71
What do you see on US of cholecystitis (3)?
pericholecystic fluid, thickened gallbladder wall, gallstone
72
Ultrasound finding for choledocolithiasis?
Dilated ducts
73
Pancreatitis: what test can you get (gallbladder question)?
US, rule out gallstones as a cause
74
What do you do for cholangitis?
Emergent ERCP (also NPO, IVFs, IV Abx)
75
Risk factors for gallstones?
fat, female, forty, fertile, and Native American (5F's)
Hemolysis (pigmented gallstones)
76
Treat cholangitis with which abx (2)?
Metronidazole + ciprofloxacin
OR
amp + gentamycin + metronidazole
77
Best diagnostic test for cholecystitis?
HIDA scan (also called nuclear scan)
78
Treatment for choledocolithiasis?
ERCP and sphincterotomy (or straight to cholecystectomy)
79
Colicky abdominal pain is caused by what general thing?
Obstruction (cholelithiasis, nephrolithiasis)
80
Involuntary guarding is seen when? What should you do for this pt?
Peritonitis; Ex-lap
81
Image the RUQ with?
Ultrasound!
82
Image the LLQ with?
CT scan
83
Pain out of proportion to the physical exam, what do you think of?
Ischemia
84
Image the RLQ with?
CT scan
85
Colonoscopy of Ulcerative colitis shows?
continuous inflammation from rectum through colon
86
Treatment for familial adenomatous polyposis?
prophylactic colectomy
87
Bright red blood on toilet paper after bowel movement - most common diagnosis?
Hemorrhoids
88
Treatment for fistulas?
LIFT procedure = fistulotomy
89
Screening for anal cancer: how do you do it and to who?
anal pap; pts who have unreceptive sex, especially in HIV positive men
90
Ulcerative colitis, 8 years from diagnosis, what do you do?
Colonoscopy annually, prophylactic colectomy
91
1000s of colonic polyps by 20, what's the diagnosis?
familial adenomatous polyposis
92
Treatment for anal cancer?
Nigro protocol (not surgery!)
93
Biopsy of ulcerative colitis shows?
Superficial inflammation with crypt abscesses
94
Treatment for anal fissures?
Pastes or creams for pain and muscle tone relaxation (nitroglycerin paste, CCB paste) - can also use sitz bath or botox
95
___ is an abscessed hair follicle on someone with a hairy butt. How do you treat?
Pilonidal cyst (it is a congenital defect); incision and drainage, resection of the cyst
96
First test to diagnose peripheral vascular disease? How to interpret?
ankle brachial index; greater than 1.2 = hardening of vessels due to peripheral vascular disease; less than .89 is arterial disease
97
What type of ulcers would be found on sacrum? How to treat?
compression ulcers; roll patient, encourage out of bed (air mattresses are better for those who can't get out of bed)
98
Hairless leg, shiny or scaly legs, decreased pulses?
Peripheral vascular disease
99
What type of ulcer on medial malleolus?
Venous stasis
100
Ulcer that heals and breaks down over and over?
Marjolin ulcers (it is due to squamous cell carcinoma)
101
Best test for peripheral vascular disease?
Arteriogram
102
Ulcers on heels and toes, what type?
Diabetic neuropathic ulcers
103
Breast lump in a woman less than 30, what should you do?
Reassure and have them come back in 2-3 cycles
104
Treatment for localized breast cancer?
Mastectomy = Lumpectomy + Radiation
105
Breast lump in a woman that persists?
Ultrasound
106
Her2 neu negative, ER/PR positive. Premenopausal. Treatment? How would you treat for post menopausal?
SERM = Tamoxifen; Aromatase inhibitor
107
Doxorubicin//danorubicin side effects?
Irreversible and dose-dependent CHF
108
Woman less than 30 with a breast mass on ultrasound, what should you do?
Biopsy
109
Her2 neu positive, ER/PR negative, post-menopausal. Treatment?
Trastuzumab
110
Woman less than 30 with a cyst on US, what's the next step?
drain, FNA
111
What's the screening timing for breast cancer?
50q2 (USPSTF) or 40q2 (ACOG)
112
Woman less than 30 with a cyst that recurs, what should you do?
Biopsy
113
When should you do a mammogram and core needle breast biopsy in a woman with a breast mass (4)?
Greater than 30 OR US shows mass OR Aspirate is bloody OR cyst recurs after aspiration
114
Trastuzumab side effects?
Reversible and dose-independent CHF
115
What are the side effects of tamoxifen vs raloxifene?
Tamox: better, increase DVT risk, increase Endo cancer
Ralox: worse, decresase DVT risk, decrease endo cancer
(tamoxifen is an ER agonist in the uterus and an antagonist in the breast)
116
What's the first test performed on a large trauma victim?
FAST (ultrasound)
117
JVD, Distant heart sounds, no lung sounds, hypotension = ?
Tension pneumothorax
118
JVD, distant heart sounds, crackles on lungs, hypotension = ?
cardiogenic shock (echocardiogram)
119
JVD, distant heart sounds, clear lungs, hypotension = ?
Beck's triad = pericardial tamponade
120
Hypotension in the setting of fever, tachypnea, and a chest XR positive for pneumonia, what type of shock? How do you treat (3)?
vasomotor shock (aka distributive shock); fluids, antibiotics and give pressors
121
MAP = __ x __
CO x SVR (or TPR)
122
CO = ___ x ___
HR x SV
123
Stroke volume is based on __ and __
preload and contractility
124
CT scan shows crescent shaped bleed - dx? How do you tx if acute? How do you treat if chronic?
Subdural hematoma; decrease ICP; craniotomy and drain it
125
Name 4 ways you can decrease ICP?
Elevate the head of bed, hyperventilate, mannitol, ventriculostomy
126
Large motor vehicle accident, coma, blurring of grey-white matter, dx?
Diffuse axonal injury
127
CT scan shows lens shaped bleed - dx? How do you tx?
Epidural hematoma; craniectomy
128
Football player passes out after colliding with another player - what do you do?
CT scan; if negative, call it a concussion and send him home - rest needed with gradual return
129
Pt with raccoon eyes likely has what?
basilar skull fracture
130
Old person has a fall and gets rapidly worsening dementia, what do they likely have? What should you do?
Subdural hematoma; CT scan
131
Young skier collides with tree. At first they are passed out, then regains consciousness and goes out again. What do they have?
Epidural hematoma (walk-talk-and-die)
132
Mechanism of injury that gives an old demented person a subdural?
simple falls (atrophy of brain and tense bridge veins predispose)
133
Stable wound to the neck just under the mandible (zone 3). What do you order?
Arteriogram
134
Old person with hyperextension injury, now can't feel pain or temperature, has loss of motor in upper extremities. Dx?
Central cord syndrome
135
Left sided weakness and loss of proprioception, right sided loss of pain and temperature after a gunshot wound?
Brown-Sequard = hemisection of spinal cord
136
How do you treat a tension pneumothorax?
Needle decompression
137
How do you diagnose a pneumothorax?
CXR shows vertical lung shadow
138
How do you treat a sucking chest wound?
Occlusive dressing (taped on 3 sides) - this is caused by a penetrating trauma from the outside (aka not a rib)
139
How do you diagnose a myocardial contusion?
ECG and troponins
140
You see a sternal fracture, scapular fracture, or flail chest. Name 3 things you should be worried about.
Myocardial contusion, pulmonary contusion, aortic dissection
141
How do you treat a pulmonary contusion?
Diuresis, avoid large volume fluids (can also use PEEP to help push fluid back in to capillaries)
142
Paradoxical wall motion on respiration, what does the pt have?
Flail chest (caused by blunt trauma - 2 or more ribs broken in 2 or more places)
143
How do you treat a pneumothorax?
chest tube; thoracostomy
144
If the hemothorax produces greater than 1500ccc on initial drain, what should you do?
Cut the chest open = thoracotomy (they are likely bleeding from a large artery)
145
How do you treat a hemothorax? What does it look like on CXR?
Chest tube, thoracostomy; horizontal lung shadow
146
How do you diagnose an aortic dissection?
CTA! (cxr may show widening of the mediastinum)
147
When does pulmonary contusion often occur with regards to the traumatic event?
24-48 hours after trauma
148
Blunt trauma to the abdomen, next step?
FAST
149
Rectal injury in pelvic fracture. Next step?
Protoscope (then may need surgery)
150
Blood at the urethral meatus, high riding prostate. What test do you get?
Retrograde urethrogram (RUG)
151
What do you do before a splenectomy?
Vaccinate against encapsulated organisms
152
Maneuver to stop liver hemorrhage? What are you compressing?
Pringle maneuver (compression of the hepatoduodenal ligament - contains the portal vein and hepatic artery and CBD)
153
22 Caliber revolver shot a fat guy; what do you do?
Explore the wound, FAST
154
Gunshot wound below T4 gets what?
Ex Lap
155
Options to treat bleeding spleen?
Repair if able (capsule), resect if necessary
156
Crepitus on hip rocking = ?
pelvic fracture
157
With a pelvic hematoma, what should you do?
Transfuse, do NOT explore (can also do IR guided embolization)
158
With urethral injury, how do you treat?
Surgery; suprapubic catheter (NO foley!)
159
Circumferential burn, now pt has no distal pulses. What do you do?
Escharotomy (remove eschar because it is compressing vessels in extremity) - can be done at bedside because eschar has no sensation
160
A child swallows lye - what do you do?
Observe for perf/aspiration and likely scope (do NOT neutralize with acid) (irrigation?)
161
A chemist working in a lab pours some solution on his hand and it starts to burn, what do you do?
Irrigate vigorously!
162
Pt is struck by lightning. What 2 things should you check?
ECG to look for arrythmia; CK to look for muscle breakdown you can't see (bones conduct electricity and will burn the neighboring muscles)
163
3rd degree burn on the anterior thigh. What medical therapy do you give?
Silver sulfadiazine (ppx) and early mobilization
164
Man trapped in a burning building has singed nose hairs and soot in mouth. What do you do?
Intubate - a burn will respond with edema and you can lose the airway!
165
Pt has posterior shoulder dislocation - name 2 causes of this. How does it occur?
Electrical burn (lightning strike or high voltage lines) or seizure; nervous system causes muscles to contract with such great force that shoulder gets dislocated
166
Snakebite victim comes in with swollen, painful extremity turning purple. What do you do?
Give pt anti-venom!
167
A pt gets stung by a bee, gets hypotension, wheezing, and becomes flushed. Tx?
SubQ Epi (anaphylaxis!!)
168
Man comes in with a bite on chest, says he got it from a girl he just met. Tx?
Amoxicillin/clavulanate (ampicillin/sulbactam works too)
169
If a wild dog bites a little girl, what should you do?
Capture it, kill it and biopsy it; if can't cath give IgG and vaccine
170
If a domesticated dog bites a little girl, what should you do?
Observe dog
171
What bite causes pancreatitis?
Black widow spider bite
172
A girl gets stung by a bee, pincer is removed. The sting site is a little red. Next step?
Observe (bee stings don't have venom - only problematic when they cause anaphylaxis)
173
How do you treat a black widow spider bite?
IV calcium
174
What bite causes a necrotic ulcer with ring of erythema? How do you tx?
Brown recluse spider (see them in the South - think attics and old boxes); Wide debridement and skin grafts
175
Acetaminophen toxicity leads to?
Hepatic failure
176
How do you treat salicylate toxicity?
Alkalinize the urine
177
Treatment for acetaminophen toxicity?
N-Acetyl-Cysteine
178
Cherry red skin, cherry red blood, smoke inhalation = which toxin? How do you treat?
Cyanide; Thiosulfate
179
Smoke inhalation, 100% pulse ox, confused, nausea- what do you do?
100% FiO2 (ABG is ok too)
180
Lacrimation, rhinorrhea, defectaiton, urination, salivation...what is the toxin? How do you treat (3)?
Organophosphate; Decontamination, atropine, pralidoxime
181
Urine bag glowing under a special lamp - toxin?
Ethylene glycol
182
Two meds you give to an organophosphate poisoning?
Atropine (first), pralidoxime (second)
183
How do you treat ethylene glycol toxicity?
Fomepizole
184
Intestines are out of newborn, in the midline, and are contained in a sac. What's the dx? How do you treat?
Omphalocele; give a silo
185
What 3 other things should you look for in a pt with necrotizing enterocolitis?
Intraventricular hemorrhage (US with doppler); Retinopathy of prematurity (optho exam); Bronchopulmonary dysplasia
186
If you find an imperforate anus in a newborn, what do you do next?
Up-side-down babygram (XR)
187
Scaphoid abdomen and bowel sounds in the chest in a newborn, what's the diagnosis?
Diaphragmatic hernia
188
Coiled NG tube in an esophagus in a newborn, what's the dx? What should you do before surgery?
Esophageal atresia; look for VACTERL! (vertebra, anus, cardiac, trachea, esophagus, renal, limb)
189
Premature neonate develops bloody diarrhea, what's the dx? How do you confirm?
Necrotizing enterocolitis; XR
190
XR findings in necrotizing enterocolitis?
Pneumatosis intestinalis (air in the wall of the bowel)
191
Intestines are out of newborn, they are to the R of midline, and have no membrane - dx? Tx?
Gastroschisis; give a silo
192
Bilious vomiting in vignette, a double-bubble with multiple air fluid levels on XR image?
Intestinal atresia (vascular accident - can be caused by mom doing cocaine)
193
You diagnosed pyloric stenosis, now what do you do?
Assess for electrolyte abnormalities, fix those, then fix the pylorus (myotomy)
194
How do you diagnose biliary atresia?
HIDA scan after 1 wk of phenobarbital
195
Treatment for intussusception?
Air enema
196
Failure to pass meconium, X-ray shows dilated proximal colon and distal normal colon - dx? Tx?
Hirschsprung's; remove the "normal" looking bad colon segment
197
Currant jelly diarrhea in a child, pain relieved by fetal position; dx and how do you dx it? Tx?
Intussusception; Dx with KUB first (sausage shaped mass) then air enema, which is also the tx; may need resection of dead bowel
198
Pt has paroxysms of pain, pressure, palpitations, and perspiration - what's the dx and how do you dx it? Tx?
pheochromocytoma; 24hr urinary VMA and metanephrines (can do MIBG scan - which is taken up by neuroblastoma cells); tx with alpha blockade, then beta blockade, then resection (to prevent catecholamine surge)
199
Old man with hypertension and a bruit over his renal artery - what's the diagnosis? Tx?
Renovascular HTN; medical mgmt with high dose Ace-I/ARBs or aldosterone antagonists
200
What's the Aldosterone:Renin ratio in renal artery stenosis? Conn's syndrome?
RAS: less than 10
| Conn's (hyperaldosteronism): greater than 20
201
Child with claudication but does not turn blue - what's the dx?
Coarctation of aorta (rib notching would only be seen in an adult because it takes time to develop)
202
HTN and Hypokalemia points to which diagnosis?
Conn's (primary hyperaldosteronism)
203
A question about HTN and they show you a close up of a rib, what's the dx?
Coarctation of the aorta
204
First treatment of pheochromocytoma?
Alpha blockade!
205
1st step in diagnosing primary hyperaldosteronism?
Aldo:Renin ratio (will be greater than 20)
206
Young woman with hypertension and a bruit over her renal artery - what's the diagnosis? Tx?
Fibromuscular dysplasia; stent it!
207
Pt with recent gastrectomy presents with abdominal pain, diarrhea, nausea, hypotension/tachycardia, dizziness/confusion, fatigue and diaphoresis 15-30 minutes after meals. What is the dx? Pathogenesis? Tx?
Dumping syndrome; due to loss of normal action by pyloric sphincter causing rapid emptying of hypertonic gastric contents in to duodenum and small intestine - leads to fluid shift from intravascular to intestine leading to hypotension, stimulation of autonomic reflexes, and release of intestinal vasoactive peptides; tx with small/frequent meals, replacing simple sugars with complex carbs, and high fiber and protein rich foods
208
You see a cushingoid pt - what should you ask about in your history?
prednisone
209
Passing out with low glucose, C-peptide high and on sulfonylurea, but med screen negative - dx?
Insulinoma
210
You see the words "migratory necrolytic dermatitis" - what's the diagnosis?
Glucagonoma
211
In the setting of Cushing's syndrome, the ACTH is low, what's the dx?
Primary adrenal tumor
212
In the setting of Cushing's the ACTH is high, what test is next?
High-dose dexamethasone suppression test
213
When do you biopsy a thyroid nodule?
When there is a mass with either a cold nodule on RAIU or if there is normal thyroid function
214
Low dose dexamethasone suppression test fails to suppress - what's the dx?
Cushing's syndrome (not disease)
215
You feel a thyroid nodule, first step?
TSH/FT4
216
Many nasty virulent ulcers refractory to treatment, what's the dx?
Gastrinoma (Zollinger-Ellison syndrome)
217
Holosystolic murmur that radiates to the axilla is?
Mitral regurgitation
218
You want to assess if the pt is having a post-op heart attack on a CABG pt - what do you do?
CKMB
219
How long do you give clopidogrel for with a drug eluting stent?
One year
220
Aortic stenosis is treated with?
Valve replacement (TAVR or TAVI = transcatheter aortic valve implantation/replacement)
221
When you replace the aortic valve, what test is required first?
Left heart cath; may need a CABG also
222
Crescendo-decrescendo murmur in systole, what's the dx?
Aortic stenosis
223
Which coronary diseases get CABG?
3+ vessels or a left mainstem equivalent
224
Diastolic rumbling with opening snap, what's the dx?
Mitral stenosis
225
You hear a murmur and the test wants you to order a diagnostic test. You get?
Echo
226
What causes fixed split S2?
Atrial septal defect
227
You want to close the PDA, what do you give? Open?
indomethacin; prostaglandins
228
Cyanotic congenital heart disease at age 3 = ?
Tetralogy (all the others are immediate at birth)
229
Holosystolic murmur in an adult; what's the diagnosis? In a neonate?
Mitral regurg; VSD
230
When do you treat a ventricular septal defect, and how do you choose what time to fix it?
All VSDs must be closed by year 1; if CHF, failure to thrive, or dyspnea, close immediately
231
Mom has diabetes and the question is about congenital heart disease - dx?
Transposition of the great vessels
232
Treatment for a descending aortic dissection? ascending?
Medical mgmt = keep systolic bp less than 120 (MAP 60-65); Emergent surgery
233
How do you screen for AAA and who gets screened?
U/S abdomen; men older than 65 who have ever smoked
234
Tearing chest pain that radiates to the back in a pt who is very hypertensive, dx?
Aortic dissection
235
How do you diagnose an aortic dissection (2)?
start with CXR; CT Angiogram is best
236
If the creatinine is elevated, how do you diagnose an aortic dissection?
TEE then MRI if TEE not available (CTA no good b/c of contrast)
237
Biggest risk factor for AAA?
Smoking
238
What's definitive tx for acute severe glaucoma? What meds can you give to help? What should you avoid?
Laser drill; constrict pupil with alpha agonists and beta antagonists (activate alpha and block beta!); avoid atropine!!
239
AAA - at what values do you need to act?
greater than 5.5 cm or growing greater than 0.5 cm/year
240
How do you diagnose peripheral vascular disease?
ABIs then U/S then arteriogram
241
Pt with tender, pulsatile abdominal mass, what should you do?
Emergent surgery (AAA)
242
You're thinking hydronephrosis vs hydroureter - what test do you get?
Ultrasound
243
What are the 5 P's of acute limb ischemia?
pain, pulselessness, poikilothermic (cold), paresthesias, pale
244
Which PVD can be stented?
In femoral artery and short lesions (less than 3cm)
245
PVD non medical mgmt (3)
control risk factors, smoking cessation, exercise
246
What ABI is normal? When is it severe?
normal = 0.9-1.2; Severe is less than 0.5 (greater than 1.2 is unable to assess)
247
How do you diagnose acute glaucoma?
Increased ocular pressures
248
Intense colicky pain after a teenager first experiments with alcohol, what's the dx?
Ureteropelvic junction obstruction
249
CT scan of the kidneys - when do you use contrast and when do you not?
IV contrast for trauma - checking for leaks
| Non-contrast for stones!
250
A person in a MVA has floaters in their vision; likely dx?
Retinal detachment (look with opthalmoscope)
251
Swelling of the eye, inability to move the eyeball, fever, leukocytosis - dx? How to diagnose? Tx?
orbital cellulitis; CT scan; emergent surgery
252
Carpenter doing metal work without eyewear complains of scratches in their eye - dx and how do you diagnose it? Tx?
Corneal abrasion; fluoresceine dye; irrigate a lot and surgery or medical mgmt if needed
253
What's definitive tx for acute severe glaucoma? What meds can you give to help? What should you avoid?
Laser drill; constrict pupil with alpha agonists and beta antagonists (activate alpha and block beta!); avoid atropine!!
254
If you have cataracts on the first day of life, what is the most likely cause?
TORCH infxn
255
Purulent eye discharge, bilateral, 2-5 days into life, what should you have used for ppx?
```
topical erythromycin (used to use silver nitrate, may still?)
(can ppx for gonorrhea only)
```
256
Mucopurlent eye discharge, unilateral, 7-12 days into life, what's the dx?
Chlamydia
257
Purulent discharge, bilateral, 2-5 days into life, what would gram stain show? What would it show for a mucuopurulent discharge unilateral 7-12 days into life?
gram negative diplococci; nothing (chlamydia is intracellular)
258
What do you do about congenital cataracts?
Remove them before amblyopia sets in (amblyopia is cortical blindness)
259
You see what looks like melanoma on the face that is small - what should you do? What if it was on the arms? What if it is on the back but is very large?
Punch biopsy; excisional biopsy; punch biopsy (in melanoma, wide excisional bx is preferred but punch is ok if large or on the face)
260
How do you treat epididymitis (2)?
If less than 40, more likely Gc/Chla = ceftriaxone and doxy
| If greater than 40, more likely e coli = cipro
261
Melanoma greater than 4mm deep gets?
Debulking, palliation
262
Melanoma 2-4mm deep gets what? 1-2mm deep? Less than 0.5mm?
Wide excision and sentinal lymph node biopsy (2cm margins); wide resection and SLND bx (1cm margins); local resection
263
Squamous cell caricnoma, small, on an extremity gets?
excisional biopsy (excisional if small and not on face; incisional if large OR on face)
264
A head CT scan shows blood between the cisterns, dx?
subarachnoid hemorrhage
265
Teenager with a non traumatic knee pain. Diagnosis and how?
Slipped capital femoral epiphysis; XR (frog leg)
266
A pt presents with progressively worsening dementia after a fall; what's the dx?
Chronic subdural hemorrhage
267
Worst headache of their life, sudden onset, not responsive to morphine, dx? What do you do?
Subarachnoid hemorrhage; non con head CT
268
A pt presents with stroke like symptoms. A non con CT shows a bleed. What should you do?
Keep the MAP less than 110 with esmolol
269
Child with a brain tumor has metastasis to the spine. What's the dx?
Medulloblastoma
270
What do you do to treat metastatic lung cancer to the brain?
Whole brain radiation
271
CT scan shows a knot attached to the skull, digging into the parenchyma, dx?
Meningioma
272
How do you treat De Quervain's tenosynovitis and where are they symptomatic?
Tendonitis of the thumb = thumb pain; treat with NSAIDs, then splinting/NSAIDs, then steroids (surgery doesn't help since it's an inflammatory disease)
273
CT scan shows a mass that crosses midline. Dx?
Glioblastoma multiforme
274
What's the FIRST test when trying to identify a brain cancer?
CT scan
275
Pathology shows psammoma bodies; dx?
Meningioma
276
CT scan shows multiple brain lesions; dx?
Metastatic disease
277
One kind of testicular cancer is really sensitive to chemo and radiation - what is it?
Seminoma
278
You see asymptomatic hematuria in a pt without any bleeding disorder, what's the dx? How do you assess?
bladder cancer; cystoscopy (can do US if there are obstructive signs)
279
Young person falls on to hand and has pain snuff box - dx? Tx (2)?
```
Scaphoid fracture (XR will be normal on day 1 and show necrosis on day 3); cast if normal xr on day 1; ORIF if fracture on day 1
(tenuous blood supply to distal scaphoid)
```
280
You know you shouldn't, but you screened for prostate cancer and got an elevated PSA. Next step?
biopsy (transrectal = transurethral)
281
How do you treat hip fractures depending on where the fracture is (3)?
```
All ORIF (closed for poor surgical candidates);
Femoral head = hip replacement
Intertrochanteric = plates
Shaft = rods
```
282
First step to diagnose a testicular cancer?
Transillumination (should fail to transilluminate if it is cancer)
283
How do you treat ACL or PCL tear?
```
athletes = surgical repair
non-athletes = conservative
```
284
How do you diagnose with imaging knee injuries?
MRI (can also use MRI for achilles tendon tear - though can be just clinically dx'd)
285
How do you treat collateral ligament tears?
One ligament = hinge cast
| Multiple ligaments = surgery
286
Oligohydramnios, no urine output on first day of life, elevated creatinine, what's the dx? How do you tx?
Posterior urethral valves; surgery for resection and reimplantation (but first catheter to relieve pressure)
287
A girl who is able to void, is toilet trained, but leaks constantly anyway - dx? How do you dx (3)?
Ectopic ureter (aka low implantation of the ureter); first get US (no hydronephrosis), then VCUG (rules out reflux), then radionucleide scan
288
Pt who is out of shape does a lot of activity and ends up with pinpoint tibia pain - dx? How to diagnose? How to treat?
Stress fracture; XR (normal on day 1, fracture on day 7); cast and crutches even if the XR is normal
289
How do you treat small bowel obstruction (4)?
Bowel rest, NG tube suction, IV fluids, surgical exploration (if severe = hemodynamic instability, guarding, leukocytosis, significant metabolic acidosis)
290
How do you manage a small spontaneous pneumothorax (less than or equal to 2cm)?
Supplemental oxygen and observation (oxygen enhances the speed of resorption)
291
Any pyelo in a child should prompt investigation for what?
Vesicoureteral reflux
292
You want to diagnose vesicoureteral reflux, what test do you get?
(after getting U/S first!) VCUG
293
Intense colicky pain after a teenager first experiments with alcohol, what's the dx?
Ureteropelvic junction obstruction
294
CT scan of the kidneys - when do you use contrast and when do you not?
IV contrast for trauma - checking for leaks
| Non-contrast for stones!
295
Tender prostate means? Tx?
prostatitis; cipro
296
Flank pain and hematuria - dx? How to diagnose?
Kidney stone; non-con CT
297
Sudden onset pain without urgent frequency or dysuria, without bacteriuria without fever, chills, n/v - testicle is in horizontal lie and there is pain with elevation - dx?
```
Testicular torsion (clinical dx but can use doppler US showing no flow) - surgery!
(may have absence of cremaster reflex)
```
298
Sudden onset pain without urgent frequency or dysuria, without bacteriuria without fever, chills, n/v - testicle is in vertical lie and there is relief with elevation - dx?
Epididymitis (tenderness above the testes)
299
First step in working up erectile dysfunction?
Nighttime tumescence (if it breaks - you're having morning erections and problem is psych; if it doesn't break - organic problem)
300
Contraindication to sildenafil?
Nitrates! (causes dangerous hypotension when used together)
301
Test to diagnose testicular torsion?
US with doppler
302
How do you treat BPH in the chronic setting (1)? Acute (2)?
Finasteride (5-alpha reductase inhibitor); tamsulosin or doxazosin (alpha blockers)
303
How do you treat kidney stones based on their size?
Less than 5 mm = IVF and analgesia
Between = lithotripsy
Greater than 3cm = surgical (nephrostomy)
304
Tender prostate with sterile urinalysis means? How do you tx?
Sterile prostatitis; NSAIDs (or maybe Abx and alpha blockers)
305
How do you treat epididymitis (2)?
If less than 40, more likely Gc/Chla = ceftriaxone and doxy
| If greater than 40, more likely e coli = cipro
306
A young kid with fever and pain in any joint - dx and how do you dx?
Septic joint - arthrocentesis (gt 50,000 WBCs)
307
Tx for fracture in kids that does not involve the growth plate? That does involve the growth plate?
Cast; ORIF
308
Kid is 6 years old and has funky gait - dx?
Legg-calve-perthes disease
309
How do you make the diagnosis of scoliosis?
Adam's test (lean forward and see asymmetry)
310
Teenager with a non traumatic knee pain. Diagnosis and how?
Slipped capital femoral epiphysis; XR (frog leg)
311
Scandinavian man with a contracted hand, what's the diagnosis? How do you treat?
Duputryen's contracture; surgical release (fascial disease)
312
Pt has carpal tunnel - what do you try first?
NSAIDs (not splint, not steroids, not nerve conduction)
313
Abscess of nail pulp - what is it called and how do you treat?
Felon; Incision and drainage, antibiotics
314
What is it called and how do you treat the injury where the finger is unable to flex?
Jersey finger - splinting
315
When do you do nerve conduction velocity for carpal tunnel?
After everything else (NSAIDs, splinting, steroids) has failed and you're about to do surgery
316
Pop with forced flexion of a digit - dx? Tx?
Trigger finger; steroids
317
How do you treat De Quervain's tenosynovitis and where are they symptomatic?
Tendonitis of the thumb = thumb pain; treat with NSAIDs, then splinting/NSAIDs, then steroids (surgery doesn't help since it's an inflammatory disease)
318
Pt's holding arm adducted and externally rotated - what did they dislocate?
Anterior dislocation of shoulder (hand shaking position)
319
How does a a pt hold their arm after posterior dislocation of shoulder?
Adducted and Internally rotated
320
FOOSH where the radius is dorsally displaced is also called ___.
Colles' fracture
321
Which fracture is caused by upward block of a downward blow and what is fractured and what is dislocated? How do you tx?
Monteggia fracture = fractured ulna, dislocated radius
| tx with ORIF or casting depending on severity
322
Which fracture is caused by downward blow on a pronated arm and what is fractured and what is dislocated? How do you tx?
Galeazzi fracture = fractured radius, dislocated ulna
| tx with ORIF or casting depending on severity
323
What is fractured in a Boxer's fracture? How do you tx?
4th and 5th digit; casting
324
Young person falls on to hand and has pain snuff box - dx? Tx (2)?
```
Scaphoid fracture (XR will be normal on day 1 and show necrosis on day 3); cast if normal xr on day 1; ORIF if fracture on day 1
(tenuous blood supply to distal scaphoid)
```
325
Whole leg is shortened and externally rotated - what's the dx?
Hip fracture (major trauma in your; minor trauma in old/osteoporosis)
326
How do you treat hip fractures depending on where the fracture is (3)?
```
All ORIF (closed for poor surgical candidates);
Femoral head = hip replacement
Intertrochanteric = plates
Shaft = rods
```
327
Young healthy athlete with knee pain, and the knee clicks on full extension. No valgus/varus or anterior/posterior draw sign - dx? Tx?
Meniscal tear; athletes = arthroscopic repair; non-athletes = conservative
328
How do you diagnose with imaging knee injuries?
MRI
329
How do you treat collateral ligament tears?
One ligament = hinge cast
| Multiple ligaments = surgery
330
Reperfusion injury in the leg can lead to ___.
compartment syndrome (edema)
331
How do you treat compartments syndrome?
Fasciotomy
332
Pt who is out of shape does a lot of activity and ends up with pinpoint tibia pain - dx? How to diagnose? How to treat?
Stress fracture; XR (normal on day 1, fracture on day 7); cast and crutches even if the XR is normal
333
How do you treat small bowel obstruction (4)?
Bowel rest, NG tube suction, IV fluids, surgical exploration (if severe = hemodynamic instability, guarding, leukocytosis, significant metabolic acidosis)
334
How do you manage a small spontaneous pneumothorax (less than or equal to 2cm)?
Supplemental oxygen and observation (oxygen enhances the speed of resorption)
335
____ classically presents with acute-onset, severe, mid abdominal pain out of proportion to physical exam findings. How do you diagnose (3)?
Acute mesenteric ischemia; CT (preferred) or MR angiography (mesenteric angiography if diagnosis is unclear)
336
Name 3 risk factors for acute mesenteric ischemia
Atherosclerosis (acute on chronic); embolic source (thrombus, vegetations); hyper coagulable disorders
337
Persistent pneumothorax and significant air leak following chest tube placement in a pt who sustained blunt chest trauma suggests ___. Name two other findings.
Tracheobronchial rupture; subcutaneous emphysema and pneumomediastinum
338
Name four cases of ileus
abdominal surgery; retroperitoneal/abdominal hemorrhage or inflammation; intestinal ischemia; electrolyte abnormalities
339
Describe xray findings in a pt with a paralytic ileus
Uniformly distended, gas-filled loops of both small and large intestines as well as gastric dilatation
340
What is the differential diagnosis for anterior mediastinal mass?
4 T's: thymoma, teratoma, thyroid neoplasm, terrible lymphoma
341
Abdominal succussion splash on physical exam points to which diagnosis?
Gastric outlet obstruction
342
Name 5 common causes of gastric outlet obstruction
gastric malignancy; peptic ulcer disease; Crohn's disease; strictures (w/pyloric stenosis) secondary to ingestion of caustic agents; gastric bezoars
343
Treatment for anal fissures include increased fiber and fluid intake, stool softeners, sitz baths, and these two other options (before moving on to surgical management)
```
topical anesthetics (lidocaine) and vasodilators (nifedipine! or nitroglycerin)
(the vasodilators reduce pressure in, and increase blood flow to the anal sphincter facilitating healing)
```
344
Males with evidence of urethral injury should undergo __. Name 4 of these indications
retrograde urethrogram; blood at the meatus, hematuria, dysuria, urinary retention
345
Patient comes in with penetrating abdominal trauma - name 4 criteria that demonstrate significant abdominal injury and are an indication for urgent exploratory laparatomy
hemodynamic instability
peritonitis (rebound tenderness, guarding)
evisceration (externally exposed intestines)
blood from a nasogastric tube or on rectal exam
346
Acute adrenal insufficiency is characterized by these 4 symptoms. Treatment includes __ or __ with aggressive __.
hypotension; vomiting; abdominal pain; fever; hydrocortisone or dexamethasone; fluid support
347
Knee injury; exam shows palpable locking or catching or clicking when the joint is extended under load, dx? How to confirm dx (2)?
Meniscal tear; MRI or arthroscopy
348
Rupture of this part of the bladder causes urine to leak into the peritoneal cavity and can lead to chemical peritonitis, which presents with these 2 symptoms.
Dome of the bladder; diffuse abdominal pain and guarding (can have referred shoulder pain as well)
349
Rupture of the anterior bladder wall and bladder neck is seen almost always with this injury. It leads to exztraperitoneal leakage of urine resulting in ___.
pelvic fracture; localized lower abdominal pain
350
The diagnosis of gastrointestinal perforation is confirmed with ___, which shows ___.
upright X-ray of the chest and abdomen; free intraperitoneal air under the diaphragm
351
A simple small bowel obstruction refers to what?
Luminal occlusion (strangulation refers to loss of blood supply to the bowel wall)
352
A sliding inguinal hernia is a direct/indirect hernia. It has a much higher risk of __ injury during repair than other hernias.
Indirect; colonic injury (this is because the posterior wall of the hernia sac is formed by a retroperitoneal organ (colon or bladder))
353
Asymptomatic pt is diagnosed with a femoral hernia. What should you do?
Surgical repair since there is a high risk of strangulation (associated with multigravida)
354
What is a Richter's hernia?
Hernia in which only one wall of the bowel is herniated - increased risk of strangulation and harder to diagnose (will not present with symptoms of SBO since there is still open lumen)
355
Genital branch of the genitofemoral nerve provides sensation to the __ and the __. The femoral branch of the genitofemoral nerve provides sensation to the __.
scrotum; cremasteric reflex; proximal medial thigh
356
The __ nerve supplies the gluteal region. The __ nerve provides sensation to the lateral thigh as low as the knee. The __ nerve provides sensation to the lower abdomen and medial thigh.
iliohypogastric; lateral femoral cutaneous nerve; ilioinguinal
357
Name 4 major predictors of adverse postoperative cardiac events
1) recent MI (within 1 month); 2) Unstable or severe angina; 3) Decompensated CHF; 4) significant arrhythmias
358
Most common cause of death 0-48 hours after STEMI?
Ventricular arrhythmia
359
At what time point post STEMI do you see ventricular septal or free wall rupture? What about Dressler syndrome (post-MI pericarditis)
4-5 days post MI; weeks to months after MI
360
What is the most significant risk factor for aortic dissection?
Hypertension
361
Name 3 common causes of large bowel obstruction
1) volvulus; 2) diverticulitis/ischemic strictures; 3) colorectal cancer
362
Necrolytic migratory erythema (annular (ring-like), erythematous erosions with blisters over the lower abdomen) is associated with which tumor?
Glucagonoma
363
MEN2A?
Pheochromocytoma, hyperparathyroidism, and medullary thyroid cancer
364
MEN1?
3Ps = parathyroid, pituitary, pancreatic tumors
365
Morton neuroma is a benign neuroma of the ___. How do you make diagnosis? Tx (2)?
3rd plantar interdigital nerve (causes numbness/burning/tingling btwn the 3rd and 4th toes); diagnosis is made by eliciting exquisite pain on palpation of that area; conservative tx = no high heels; surgery = removal of neurom
366
Every ___ mEq/L that serum sodium concentration os greater than normal = approximately __ L of water deficit
3; 1 (so a sodium of 152, means a deficit of 4L)
367
When is a sestamibi scan used?
To localized parathyroid adenomas (allows surgeon to use a less invasive approach)
368
Acute appendicitis is triggered by an obstruction in the appendiceal lumen - in adults, the obstruction is most common caused by ___. In children it is most often caused by ___.
fecalith; lymphoid hyperplasia (w/in the appendix triggered by antecedent viral infxn)
369
What is the unhappy triad and what causes it?
Medial meniscal tear, MCL tear, and ACL tear; caused by medially directed blow to the lateral knee (valgus stress!)
370
Acute bacterial prostatitis is most often caused by these 2 organisms. How do you treat?
E coli or chlamydia; fluoroquinolones (such as ofloxacin, levofloxacin, and cipro) for 4-6 wks)
