Surgery

Question 1

who is at the greatest risk for a hepatic adenoma

Answer 1

young women on prolonged oral contraception

• most are fine
• life-threatening complications can occur like malignant transformation or rupture can occur

-consider rupture in the setting on sudden-onset, severe right upper quadrant pain and signs of hemorrhagic shock

Question 2

patient with puncture wound through shoe then gets osteomyelitis

Answer 2

pseudomonas osteomyelitis

-usually takes > 2 weeks

Question 3

if pt has penetrating abdominal trauma, hemodynamic instability, peritonitis, evisceration, or impalement… whats your next step

Answer 3

exploratory laparotomy

Question 4

how to manage uncomplicated renal stones (< 1 cm)

Answer 4

hydration, analgesics, alpha blockers

-list of alpha-blockers: tamsulosin and -osin

Question 5

what is a potential complication of an epidural nerve block

-pt may present with progressive motor/sensory dysfunction, localized back pain, bladder/bowel dysfunction

Answer 5

spinal epidural hematoma

• more common in older people taking antithrombotics
• manage with urgent MRI and neurosurgical decompression

Question 6

2 main signs that should prompt surgical exploration

Answer 6

free air on x-ray

clinical signs of peritonitis

Question 7

what is malignant hyperthermia and when/how does it present

Answer 7

• genetic mutation altering intracellular calcium triggered by volatile anesthetics, succinylcholine, excessive heat
• manifests as: masseter/muscle rigidity, sinus tachy, hypercarbia, rhabdo, hyperkalemia, and late you’ll see hyperthermia
• can occur during or even be delayed till after youre done with anesthesia
• treat with respiratory/ventilation support, stop cessation of causative anesthetic, and dantrolene

Question 8

what is a HIDA scan

Answer 8

aka. cholescintigraphy

Question 9

most common symptom of pancreatic cancer and how do you test for it

Answer 9

insidious, continuous midepigastric pain that radiates to back/flanks and is worse with eating or lying down

-get abdominal CT as first step when suspected

Question 10

cardiac myxoma

Answer 10

usually in LA

benign tumor but bits of it can embolize

Question 11

tender, erythematous streaks proximal to wound

Answer 11

Lymphangitis

• regional tender lymphadenopathy (lymphangitis)
• systemic symptoms (fever, tachycardia)
• usually due to strep pyogenes and MSSA
• treat with cephalexin

Question 12

what correlates to medullary thyroid cancer metastasis

Answer 12

neuroendocrine malignancy –> calcitonin secreting parafollicular C cells
calcitonin correlates to metastasis

Question 13

how to manage osteoarthritis

Answer 13

1. non-pharm –> exercise and weight loss
2. topical or oral NSAIDs
3. surgery or chronic pain management

Question 14

how does the body get rid of low molecular weight heparin

Answer 14

renal removal

Question 15

infection w/i retropharyngeal space can drain where..

Answer 15

into the superior mediastinum which can cause acute necrotizing mediastinitis

Question 16

what is one of the first signs of IBD

Answer 16

toxic megacolon

• systemic toxicity (fever, tachy, hypotension)
• bloody diarrhea
• abdominal distension/peritonitis
• marked colonic distension on imaging
• treat with bowel rest, NG suction, abx, corticosteroids if IBD is associated, surgery if unresponsive to med management

Question 17

description of giant cell tumor

Answer 17

only epiphyseal tumor

looks like soap bubble on x-ray

Question 18

acute knee pain associated with catching or reduced range of motion suggests what…

• likely with crepitus too
• acute popping sensation may occur
• slow-onset joint effusion

Answer 18

meniscal tear

• persistent symptoms should have eval with MRI
• may need

Question 19

how to initially manage patients with large surface area (> 20%) burns

Answer 19

extensive burns can lead to hypovolemic shock due to large release of proinflammatory mediators that increase vascular permeability and can cause third spacing of fluid
MANAGE WITH EXTENSIVE FLUID RESUSCITATION
-use parkland formula to figure out how much
-titrated to maintain adequate urine output
-put in urethral catheter to monitor

Question 20

what is one of the earliest manifestations of autosomal dominant polycystic kidney disease

Answer 20

hypertension

• likely results from cyst expansion leading to localized renal ischemia and consequent increase in renin production with activation of RAA axis
• best treated with ACE inhibitors

Question 21

biggest risk factor for pancreatic cancer

Answer 21

smoking

Question 22

3 ways to assess for a melanoma

Answer 22

1. ABCDE (more than 1 or 2 is suspicious) –> asymmetry, borders, color variation, diameter > 6mm, evolving appearance over time
2. 7-point checklist (> 1 major or > 3 minor criteria is suspicious) –> MAJOR: change in size, shape, develops nodularity, or color MINOR: size > 7mm, local inflammation, crusting/bleeding, sensory symptoms like itching or bleeding
3. ugly duckling sign –> one lesion significantly different from the others on the patient

Question 23

if a patient has RA and then is slowly developing UMN and other nerve problems, what should come to your mind?

Answer 23

cervical myelopathy

• atlantoaxial instability which can be made worse if a pt needs to be intubated
• slowly progressive, spastic paraparesis involving upper and lower extremities, hyperreflexia, sensory changes, and a positive babinski sign
• hoffman sign may also be positive

Question 24

patient who develops acute abdominal pain, shock, and anemia in the setting of one of the following likely has what

• hematologic malignancy
• infection
• systemic inflammatory disease
• anticoagulation

Answer 24

atraumatic splenic rupture

Question 25

how to search for epiglotitis

Answer 25

get lateral neck radiograph to look for enlarge epliglotti s

Question 26

50% of pts get what after a coronary artery bypass graft operation

Answer 26

pleural effusion, usually on the left side -if its small, occurs shortly after surgery (post op day 1 or 2), and creates no respiratory problems then you can just observe it to make sure it goes away on its own

Question 27

initial diagnostic study for hemodynamically stable pts with aortic dissection

Answer 27

CT angiography -- reveals intimal flap separating true and false lumens

Question 28

ulcerated tonsillar lesion in pt with long smoking history

Answer 28

oropharyngeal squamous cell carcinoma

Question 29

what are the signs of a necrotizing surgical site infection

Answer 29

- pain, edema, erythema spreading beyond surgical site - systemic signs: fever, tachycardia, and hypotension - paresthesia or anesthesia at wound edges - purulent, cloudy-gray discharge (dishwater drainage) - subcutaneous gas or crepitus -treat with parenteral abx and urgent surgical debridement

Question 30

patient has intraperitoneal air on x-ray what do you think

Answer 30

possible peptic ulcer perforation and they need surgical exploration

Question 31

classic triad for spinal epidural abscess and what is the progression - epidural anesthesia is a common trigger due to direct inoculation - if you suspect it then get spinal MRI - treat with surgical decompression and antibiotics

Answer 31

1. fever 2. focal/severe back pain 3. neurologic findings (motor/sensory change, bowel/bladder dysfunction, paralysis) progression: focal back pain --> nerve root pain --> motor weakness, sensory changes, bowel/bladder changes --> paralysis

Question 32

patient comes in with kidney stone in urethra, at what size do you change management of stone?

Answer 32

stone size < 10mm --> medical management with hydration, pain control, alpha blockers, and strain urine (can be done outpatient) -if that doesnt work/help or pt has uncontrolled pain with no stone passage in 4-6 weeks then get a urology consult stone size > 10mm --> urology consult * note that most ureteral stones < 5mm in diameter pass spontaneously and alpha blockers can be used to help stones 6-10mm * if larger than 10mm, refractory pain, anuria, aki, urosepsis then consult urology

Question 33

pt has abdominal/flank/groin pain, pulsatile mass, flank ecchymosis, and limb ischemia what do you think

Answer 33

unstable abdominal aortic aneurysm

Question 34

how do you work up a suspected aaa in a stable pt

Answer 34

CT scan

Question 35

3 local complications of cardiac catheterization

Answer 35

1. hematoma (possible mass) 2. pseudoaneurysm (bulging pulsatile mass with systolic bruit) 3. AV fistula (no mass with continuous bruit)

Question 36

if a pt has celiac disease what should be an additional concern

Answer 36

osteoporosis due to vitamin D malabsorption

Question 37

Patient presents with hypoxia, characteristic pulse ox of ~85% with a large oxygen saturation gap

Answer 37

Acquired Methemoglobinemia - results from oxidation of iron hemoglobin - due to topical anesthetic agents or dapsone

Question 38

pilonidial cyst/disease

Answer 38

- most frequently affects males age 15-30 - obese individuals - most common symptom is a painful, fluctuant mass on the upper coccyx with mucoid, purulent, and bloody discharge

Question 39

what is the best way to diagnose diverticulitis

Answer 39

abdominal CT with oral or IV contrast

Question 40

whatre the surgical indications for pts with cerebellar hemorrhage

Answer 40

1. signs of neurologic deterioration 2. radiologic evidence of hemorrhage > 3mm 3. brainstem compression 4. obstructive hydrocephalus

Question 41

patient had gastric bypass and then presents with abdominal pain, bloating, flatulence, malabsorption, weight loss, anemia, vitamin deficiency

Answer 41

small intestinal bacterial overgrowth | -dx with jejunal aspirate and culture > 10^3 or carbohydrate breath testing

Question 42

what predisposes someone to small intestinal bacterial overgrowth

Answer 42

conditions that alter intestinal mobility - systemic sclerosis - diabetes anatomy problems -stricture gastric/pancreatic secretions - atrophic gastritis - chronic pancreatitis

Question 43

patient has whip-lash like injury in the setting of underlying cervical spondylosis... what do you think of

Answer 43

central cord syndrome | -presents only with upper extremity abnormalities

Question 44

patient with post-op hypotension, distended JVD, and new onset right bundle branch block

Answer 44

massive pulmonary embolism

Question 45

in a transfusion problem how do you tell the difference b/w TRALI and TACO

Answer 45

TRALI (transfusion related acute lung injury) - no JVD - normal ejection fraction - normal BNP TACO (transfusion associated cardiac overload) - JVD present - possible S3 present - decreased ejection fraction - high BNP

Question 46

if you suspect appendicitis in a non-pregnant adult then how do you diagnose it

Answer 46

abdominopelvic CT

Question 47

cushing triad

Answer 47

used in late stages of acute head injury due to increased intracranial pressure 1. hypertension 2. bradycardia 3. irregular respirations

Question 48

If a trauma pt is presenting with blood loss but none is found intraperitonealy or pericardially then where do you look or what do you think of

Answer 48

pelvic fracture where the blood is "hidden" in the retroperitoneal space -hemorrhagic shock is most common in trauma pts

Question 49

mnemonic for lots of blood loss in trauma pt

Answer 49

blood on the floor and 4 more - external bleeding on the floor up to entire blood volume - chest: up to 40% of blood volume/hemithorax - abdomen (peritoneal cavity): up to entire blood volume - pelvis: up to entire blood volume and usually its hidden in the retroperitoneum - thigh: up to 1-2L of blood

Question 50

patient has significant head trauma that leads to ipsilateral hemiparesis, ipsilateral mydriasis, and strabismus, contralateral hemianopsia, and altered mentation

Answer 50

transtentorial herniation of parahippocampal uncus

Question 51

major risk factors for development of acute urinary retention (AUR) - dx with bladder ultrasound - pt presents with agitation, tachycardia, lower abdominal/suprapubic tenderness

Answer 51

``` male sex advanced age (>80) history of BPH history of neurologic disease surgery ```

Question 52

patient has elevated alk phos and elevated GGT with mild focal dilations within both intra and extra-hepatic biliary ducts

Answer 52

primary sclerosing cholangitis -associated with UC so patients should get colonoscopy - patients have fibrous obliteration of small bile ducts with concentric replacement by connective tissue in onion-skinning pattern - complications: biliary stricture, cholangitis/cholelithiasis, cholangiocarcinoma, colon cancer, biliary cancer, cholestasis (decreased fat-soluble vitamins, osteoporosis)

Question 53

how does care change with a breast mass in pts above or below 30

Answer 53

below 30: ultrasound with maybe mammography then if simple cyst get needle aspiration if pt wants it, but if complex cyst/mass then get image-guided core biopsy 30 or above: mammography with maybe ultrasound then if suspicious for malignancy get core biopsy

Question 54

patient with blunt trauma and renal injury

Answer 54

get CT of abdomen and pelvis

Question 55

charcots triad vs reynolds pentad

Answer 55

``` signs and symptoms suggesting obstructive ascending cholangitis (infection of biliary system) TRIAD 1. RUQ pain 2. fever 3. jaundice ``` PENTAD 4. shock (hypotension, tachycardia) 5. altered mental status

Question 56

patient presents with the following below, how do you diagnose them - jaundice, pruritis, acholic stools, dark urine - weight loss - RUQ pain - RUQ mass or hepatomegaly - increased direct bilirubin, ALP, GGT

Answer 56

``` malignant biliary obstruction dx via -serum tumor markers: CEA, CA-19, AFP -abdominal imaging: ultrasound, CT scan -EUS or ERCP for tissue diagnosis if unclear ```

Question 57

how to treat septic arthritis

Answer 57

IV abx and adequate drainage of purulent material via needle aspiration, arthroscopic irrigation, or open surgical drainage note that serial procedures are often required to completely clear the infection

Question 58

diabetic pt presents with fever, RUQ pain, nausea/vomiting, crepitus in abdominal wall adjacent to gall bladder -additional risk factors are vascular compromise and immunosuppression

Answer 58

emphysematous cholycystitis - dx: air-fluid levels in gallbladder, gas in gallbladder wall, cultures with gas forming Clostridium or Ecoli, unconjugated hyperbilirubinemia, mildly elevated aminotransferases - treatment: emergent cholycystectomy with broad spectrum abx that include clostridium coverage (penicillin-tazobactam)

Question 59

risk factors for different types of esophageal cancer and how to initially look for it

Answer 59

(distal esophagus) adenocarcinoma: uncontrolled GERD, obesity, male --> presents with solid food dysphagia (proximal and mid esophagus) squamous cell carcinoma: smoking, alcohol, n-nitros containing foods (processed meat) *do upper endoscopy for both with biopsies while CT and PET scan can be used for staging

Question 60

hemobilia

Answer 60

bleeding into the biliary tract - rare cause of upper GI bleeding that usually occurs as complication of hepatic or biliopancreatic procedures - presents with RUQ pain, jaundice, and upper GI bleeding

Question 61

how to manage hemothorax

Answer 61

tube thoracostomy is usually sufficient but pts need emergent thoractomy for extreme bleeding -initial bloody output > 1,500mL or persistent hemorrhage > 200mL/hr for > 2hrs or continuous need for blood transfusion to maintain hemodynamic stability *used to prevent exsanguination

Question 62

compare and contrast basal cell carcinoma and squamous cell carcinoma

Answer 62

basal cell: pearly, flesh colored pink nodule with telangiectatic vessels is usually found on head or neck. most common skin malignancy squamous cell: most common skin malignancy in pts on chronic immunosuppressive therapy or history of organ transplant or burn pts/sun exposure, very aggressive and can cause drainage

Question 63

shin splints vs stress fracture

Answer 63

stress fracture will have point tenderness but shin splints will have diffuse tenderness on anterior shin

Question 64

narrowed intercostal spaces and mediastinal shift toward problematic lung on x-ray

Answer 64

bronchial mucus plug

Question 65

if pt has spinal cord compression due to spinal injury/malignancy/infection... what do you do

Answer 65

- emergent MRI - IV glucocorticoids - neurosurgery +/- radiation oncology consult

Question 66

patient with turners syndrome gets pregnant, what are they at increased risk for?

Answer 66

aortic dissection due to hemodynamic changes of pregnancy placing additional strain on aorta

Question 67

lateral wrist pain, overuse syndrome involving tendons of abductor pollicis longus and extensor pollicis brevis -occurs most commonly where tendons pass under extensor retinaculum in first dorsal compartment

Answer 67

de Quervain tendinopathy

Question 68

patient has abdominal distension then has persistent bloody ascites found on multiple paracenteses suggests what

Answer 68

underlying malignancy | -most common is hepatocellular carcinoma

Question 69

flank pain and hemodynamic instability

Answer 69

possible ruptured abdominal aortic aneurysm

Question 70

how to test for PE in clinically stable patient

Answer 70

CT angiography

Question 71

3 main components to glascow coma scale

Answer 71

eye opening verbal response motor response

Question 72

how to treat pts with hypercalcemia due to immobilization

Answer 72

its due to increased osteoclastic bone resorption so giving bisphosphonates helps

Question 73

ottawa ankle rules

Answer 73

tells you when to get plain radiographs of ankle with pain of malleolus -point tenderness over posterior margin or tip of malleolus OR -inability to bear weight after injury and for 4 steps during medical evaluation

Question 74

patient presents with leg injury and pain increased on passive stretch with parethesia - also pain out of proportion to injury - rapidly increasing and tense swelling

Answer 74

compartment syndrome

Question 75

patient presents with insidious onset of flank pain and systemic symptoms (fever, weight loss) - usually with history of UTI or extrarenal infection (bacteremia) in last 2 months - urinalysis shows pyuria, bacteriuria, and proteinuria but can be normal

Answer 75

renal and perinephric abscesses | -urinalysis will be normal if abscess is not in contact with collecting ducts

Question 76

pt with severe hypertensiona dn recurrent flash pulmonary edema in the setting of diffuse atherosclerosis suggests....

Answer 76

renal artery stenosis - associated findings: CKD, secondary hyperaldosteronism (hypokalemia, elevated serum bicarb) - dx with renal ultrasound with doppler

Question 77

how to treat aortic dissection

Answer 77

pain control IV beta blockers maybe sodium nitroprusside (if SBP >120) emergent surgical repair for ascending dissection

Question 78

risk factors for atherosclerosis

Answer 78

diabetes hypertension smoking

Question 79

if patient discusses occasional leg cramping what do you think of so what do you do

Answer 79

intermittent claudication -ABI (ankle-brachial index) = SBP of dorsalis pedis or posterior tibial artery / SBP of brachial artery -ABI Scores less than 0.9 = PAD 0.91-1.3 = Normal more than 1.3 = calcified and uncompressible vessels

Question 80

expected labs with normal pressure hydrocephalus

Answer 80

ventriculomegaly with normal opening pressure on lumbar puncture - not all symptoms (wet, wobbly, wacky) may be present in early disease - can be due to secondary insults to brain: subarachnoid hemorrhage, trauma, meningitis all due to scarring of arachnoid granulations responsible for CSF

Question 81

how to treat normal pressure hydrocephalus

Answer 81

ventriculoperitoneal shunting

Question 82

chronic alcohol use disorders and postprandial epigastric pain should lead you to think of what and what do you see on paracentesis

Answer 82

chronic pancreatitis | -paracentesis: serosanguinis/yellow fluid with high amylase, high total protein, and low serum ascites albumin gradient

Question 83

patient has a history of forceful retching then has epigastric/back/retrosternal pain, what are the two things on the top of your differential and describe them

Answer 83

Mallory-Weiss tear - mucosal tear - submucosal venous or arterial plexus bleeding - hematemesis (bright red or coffee ground appearance) - possible hypovolemia - upper GI is diagnostic and therapeutic to treat persistent bleeding - manage with acid suppression but most heal spontaneously Boerhaave syndrome - transmural tear - spillage of esophageal air/fluid into surrounding tissues - crepitus, crunching sound (Hamman sound) - odynophagia, dyspnea, fever, sepsis - CXR can show pneumothorax, pneumomediastinum, pleural effusion - esophagography or CT with water soluble contrast to confirm - manage with acid suppression, abx, NPO and emergency surgical consultation

Question 84

patient has recent T2DM diagnosis, what are they now at a higher risk for

Answer 84

pancreatic cancer | 25% of pancreatic cancer is heralded by recent < 2 year dx of DM

Question 85

how to transport an amputated body part to be attached

Answer 85

transported by wrapping it in saline-moisturized gauze, sealing it in a plastic bag, and placing the bag in an ice water bath

Question 86

what is a succussion splash

Answer 86

the noise of air and fluid moving around in an area likely due to an outlet obstruction and causing a backing up into the organ being discussed

Question 87

splenic abscess triad and most common association

Answer 87

1. fever 2. leukocytosis 3. LUQ pain - patients can develop left sided pleuritic chest pain, left pleuritic effusion, and splenomegaly - most common association: infective endocarditis - risk factors: hematogenous spread, immunosuppression, IV drug use, trauma, and hemoglobinopathies

Question 88

more pain with knee flexion or pressing on the kneecap

Answer 88

patellofemoral pain syndrome | -first line treatment is to do quadriceps exercises

Question 89

new baby presents b/w 2-8 weeks with jaundice, pale stools, small or absent gall bladder, what do they have and what labs do you expect

Answer 89

biliary atresia - high direct bilirubin, high GGT, and normal reticulocyte count - manage with surgical hepatoportoenterostomy (kasai procedure) or liver transplant

Question 90

incidence of pancreatic cysts in aging population is 40% of people > 70, which is not really a problem cause usually they are low risk and not malignant but what would make you think it might be able to have a malignant transformation and how do you manage that

Answer 90

- large size > 3cm - solid or calcific - main pancreatic duct involvement (ductal dilation) - thickened or irregular cyst wall -manage with endoscopic ultrasound-guided biopsy and possibly surgical resection

Question 91

what are the two most common causes of acute mesenteric ischemia

Answer 91

1. cardiac embolic events with a.fib, valvular disease, or cardiovascular aneurysms 2. acute thrombosis due to peripheral arterial disease or low cardiac output states risk factors: atherosclerosis, embolic source, hypercoagulable disorders

Question 92

what should you expect to see with acute mesenteric ischemia

Answer 92

pt present with: rapid onset of periumbilical pain, pain out of proportion to examination findings, and late onset of hematochezia labs: leukocytosis, elevated hemoglobin, elevated amylase, and metabolic acidosis with elevated lactate dx: CT preferred but can do MR angiography then do mesenteric angiography if diagnosis is unclear

Question 93

after cardiac surgery pt describes clicking and shifting of chest (chest wall instability) when bending or moving upper extremities, what is this and what do you do

Answer 93

sternal dehiscence - surgical complication when 2 approximated edges of sternum separate - usually due to loosening or fracture of suture wire - if with infection its called mediastinitis - manage with surgical exploration and repair

Question 94

laryngeal ulcer in a smoker... what do you think of | -pt presents with persistent hoarseness

Answer 94

squamous cell carcinoma | -make sure you get a laryngoscopy

Question 95

how to manage pancreaticopleural fistula

Answer 95

bowel rest to help with fistula closure and possible ERCP with sphincterectomy or stent placement to help drain fluid through ampulla of vater instead of through fistula

Question 96

ludwig angina

Answer 96

rapid, progressive cellulitis of submandibular space usually due to dental infections in mandibular molars that spread contiguously down the root of the tooth - usually polymicrobial with mixture of oral aerobic (viridans) and anaerobic bacteria - early intervention with IV abx usually helps prevent airway compromise

Question 97

patient presents with shoulder pain, horner syndrome, arm pain, and/or hand weakness... what do you think of

Answer 97

superior pulmonary sulcus tumor | -get chest x-ray

Question 98

how to manage pts with small spontaneous pneumothorax

Answer 98

observation and supplemental oxygen (regardless of O2 saturation) because it enhances the speed of resorption

Question 99

how quickly can someone become vitamin K deficient

Answer 99

7-10 days

Question 100

how to manage massive amounts of hemoptysis from pt (>600mL/day OR >100mL/hr)

Answer 100

secure airway and breathing but if bleeding continues then treat cause of bleeding via bronchoscopy, embolization, or resection -if bleeding stops then manage like mild or moderate where you do a full workup first

Question 101

when to do an urgent thoracotomy/surgical intervention for hemoptysis

Answer 101

pts with unilateral bleeding who continue to bleed even after bronchoscopy and/or arterial embolization

Question 102

pt has hypophosphatemia (key finding!) plus other electrolyte abnormalities, muscle weakness, arrhythmias, and congestive heart failure... what do you think of

Answer 102

refeeding syndrome - due to reintroduction of nutrition in pts with chronic malnourishment - hypophosphatemia is due to increase insulin and cellular electrolyte uptake and the subsequent increase in phosphate utilization during glycolysis

Question 103

aspiration pneumonitits vs aspiration pneumonia

Answer 103

aspiration pneumonitis - acute lung injury presents within hours secondary to chemical burn from aspiration of gastric contents - lung inflammation - can be asymptomatic or have decreased O2 with nonproductive cough - only treat with supportive care aspiration pneumonia - infectious disease presents days after caused by aspiration of infected oropharyngeal secretions - pts present with productive cough - can lead to abscess formation - treat with abx (clinda or beta-lactam with beta-lactamase inhibitor)

Question 104

all trauma pts should get what imaging

Answer 104

1. portable chest and abdominal x-rays 2. Focused Assessment with Sonography or Trauma (FAST) 3. cervical spinal imaging (CT preferred)

Question 105

indications for spinal CT

Answer 105

1. high energy mechanism of injury 2. neurological deficit 3. spinal tenderness 4. altered mental status 5. intoxication 6. distracting injury *note that presence of single vertebral fracture (especially cervical) is an indication to image the entire spine because risk of additional spinal fracture increases 20%

Question 106

what can trigger catecholamine surges in pts with pheochromocytomas (from adrenal medulla)

Answer 106

surgical procedures induction of anesthesia various medications (give alpha blockers before giving nonselective beta blockers)

Question 107

what type of dislocation happens to an abducted externally rotated arm

Answer 107

anterior dislocation -most commonly injured nerve is axillary which innervates teres minor and deltoid causing weakened shoulder abduction and decreased sensation in skin overlying lateral shoulder

Question 108

common cause of postop fever (temp > 100.4)

Answer 108

due to cytokine release including IL-6 (pyretic) in response to tissue trauma, blood cell lysis, or bacterial endo/exotoxins - within hours = tissue trauma - 1+ weeks after surgery = bacterial infection

Question 109

patient has some stressor then has increased unconjugated bilirubin but nothing else wrong

Answer 109

gilberts syndrome

Question 110

pt presents < 24hrs after blunt thoracic trauma with tachypnea, tachycardia, hypoxia - pulm exam: rales and decreased breath sounds - CT scan or CXR with patchy alveolar infiltrates not restricted by anatomical borders

Answer 110

pulmonary contusion | -manage with pain control, pulmonary hygiene (incentive spirometry, chest PT), supplemental O2 and ventilatory support

Question 111

if pt has blunt abdominal trauma with persistent nausea what do you think of

Answer 111

pancreatic duct injury

Question 112

what are the indications for foot imaging (x-ray or MRI) with a diabetic foot ulcer

Answer 112

1. deep (exposed bone or positive probe-to-bone testing) 2. long-standing (present > 7-14 days) 3. large ( > 2cm) 4. associated with elevated ESR or CRP 5. associated with adjacent soft tissue infection *note --> always check for infection and osteomyelitis no matter what

Question 113

explain everything about a varicocele

Answer 113

presentation: soft scrotal mass, bag of worms appearance, decreases in supine position, increases with standing and valsalva, subfertility, testicular atrophy imaging (ultrasound): retrograde venous flow, tortuous anechoic tubules adjacent to testis, dilation of pampiniform plexus veins treatment: gonadal vein ligation (in boys and young men with testicular atrophy), scrotal support and NSAIDs (older men who don't want kids)

Question 114

patient presents with duodenal and jejunal ulcers plus persistent diarrhea and fatty poop, what do you think of

Answer 114

zollinger-ellison - workup with endoscopy, CT/MRI, somatostatin receptor, scintigraphy for tumor localization - all the increased acid causes inactivation of pancreatic enzymes which can lead to malabsorption

Question 115

what is a nissen fundoplication surgery used for

Answer 115

those with refractory GERD symptoms (anti-reflux surgery)

Question 116

6 Ps of acute limb ischemia and how to manage it

Answer 116

``` Pain Pallor Paresthesia Pulselessness Poikilothermia (cool extremity) Paralysis (late) ``` -manage with anticoagulation and thrombolysis/surgery

Question 117

humerus fracture, what arteries and nerves are you worried about

Answer 117

proximal: Axillary nerve mid-shaft: Radial nerve distal: Median nerve, Brachial artery

Question 118

patient with gallstone pancreatitis, fevers, RUQ pain, jaundice, altered mental status, and hypotension

Answer 118

acute cholangitis | -do ERCP to relieve biliary obstruction and prevent serious infectious complications

Question 119

fever, RUQ pain, leukocytosis, altered LFTs -dx with abdominal CT showing well-defined, hypoattenuating, rounded lesion often surrounded by peripherally enhancing abscess membrane

Answer 119

pyogenic liver abscess - can result from direct spread from biliary tract or from hematogenous seeding of distal infection, particularly those involving the portal system (diverticulitis) - manage with blood cultures, abx, aspiration, and drainage

Question 120

how is TPN usually administered

Answer 120

central venous catheter

Question 121

free-living marine bacterium that causes food-borne illness (with what?) and wound infections which can be anything from mild to rapid-onset/severe necrotizing fasciitis with hemorrhagic bullous lesions and septic shock

Answer 121

Vibrio Vulnificus - food-borne via oysters - pts with liver disease: cirrhosis, viral hepatitis, hereditary hemochromatosis are at high risk for worse infections

Question 122

what are the signs of a urethral injury

Answer 122

- blood at the urethral meatus - high-riding prostate - resistance while trying to pass a foley catheter

Question 123

pelvic fracture, gross hematuria, suprapubic pain/tenderness, difficulty voiding

Answer 123

extraperitoneal bladder wall rupture

Question 124

adducted and internally rotated hip

Answer 124

posterior hip dislocation

Question 125

pt has mechanical fall then has shortening and external rotation of one leg

Answer 125

Femoral neck or intertrochanteric fracture OR anterior hip dislocation (but less common)

Question 126

how do pts with sudden onset pneumothoraxes present

Answer 126

tachycardia, tachypnea, hypoxemia, decreased or absent breath sounds on affected side

Question 127

what arteries are most commonly affected by fibromuscular dysplasia

Answer 127

renal and internal carotid - pts present with hypertension and/or recurrent headaches - may find bruits on neck and abdomen

Question 128

pt has hip pain and long-term steroid use, what do you think

Answer 128

long-term steroid use increases the likelihood of avascular necrosis

Question 129

what is stool elastase a marker for

Answer 129

pancreatic exocrine function (low in chronic pancreatitis)

Question 130

management of gallstones

Answer 130

asymptomatic: no treatment typical biliary colic symptoms: elective laparoscopic cholecystectomy or possibly just give ursodeoxycholic acid in poor surgical candidates complicated disease (acute cholecystitis, choledocholithiasis, gallstone pancreatitis): cholecystectomy within 72 hours

Question 131

how to diagnose and treat an esophageal perforation etiology: instrumentation (endoscopy), trauma, effort rupture (boerhaave syndrome), esophagitis (infectious/pills/caustic)

Answer 131

DX - chest x-ray or CT scan: widened mediastinum, pneumomediastinum, pneumothorax, pleural effusion (low pH and very high amylase maybe even with food particles) - CT scan: esophageal wall thickening, mediastinal fluid collection - esophagography with water-soluble contrast: leak from perforation TX - NPO, IV abx, and PPI - emergency surgical consultation

Question 132

what is used as a tumor marker for thyroid tumors

Answer 132

thyroglobulin (made by normal and malignant thyroid tissue) | -used as a tumor marker once thyroid tissue has been removed

Question 133

patient presents within 1 week of having gastric bypass with fever, abdominal pain, tachypnea, and tachycardia... what do you think of

Answer 133

anastomotic leak - confirm with CT with contrast or upper GI - treat with urgent surgical repair

Question 134

fibrotic intestinal stricture vs adynamic/paralytic ileus

Answer 134

both present with bilious emesis, severe abdominal pain, partial or incomplete obstruction, distension - fibrotic stricture usually presents in crohns pt or smoking history (anything to make you think lots of inflammation) - adynamic ileus presents with absent bowel sounds and gastric dilation/gas-filled loops of large and small intestine after insult stuns the bowel (intra-abdominal surgery or high-dose opioids)

Question 135

patient has persistent clear unilateral rhinorrhea that increases with increased intracranial pressure (like bending over or bowel movements)...

Answer 135

CSF rhinorrhea - most often caused by head trauma - can result in meningitis - manage with bed rest, head elevation, avoidance of straining, lumbar drain placement, and surgical repair

Question 136

aortic stenosis - criteria for severe - indications for surgery

Answer 136

Severe - aortic jet velocity > 4 m/sec OR - mean transvalvular pressure gradient > 40 mmHg - valve area usually < 1 1.0 cm2 but not required Indications for valve replacement (severe AS + 1 of the following) - onset of symptoms (angina, syncope) - left ventricular ejection fraction < 50% - undergoing other cardiac surgery (CABG)

Question 137

patient with spinal cord injury above T6... what do you worry about

Answer 137

possible autonomic dysreflexia - noxious stimuli below injury level trigger unregulated sympathetic response leading to severe hypertension - compensatory parasympathetic response above the lesion typically causes bradycardia - manage with removing noxious stimuli and treating hypertension

Question 138

if pt has prerenal acute kidney injury what do you expect their BUN/creatintine ratio to be

Answer 138

> 20:1 | also expect oliguria (< 500mL/day) and unremarkable urine sediment

Question 139

what is the most likely cause of acute epididymitis for those under vs over the age of 35

Answer 139

under 35 likely due to STD (chlamydia, gonorrhea) over 35 likely due to bladder outlet obstruction (coliform bacteria)

Question 140

furuncle

Answer 140

- skin abscess usually due to staph aureus - painful pustule or nodule and drains purulent material - kinda looks like a small pimple with a tiny white head

Question 141

intertrigo

Answer 141

due to candida infection and presents as well-defined, erythematous plaques with satellite vesicles or pustules in intertriginous and occluded skin areas

Question 142

how does a rectus sheath hematoma occur

Answer 142

occur due to rupture of inferior epigastric artery from blunt trauma or forceful abdominal contractions (severe coughing), particularly in those receiving anticoagulation therapy

Question 143

when to suspect acalculous cholecystitis

Answer 143

- can lead to sepsis and death - fever and leukocytosis, most pts cant talk cause this usually happens in the severely ill - radiology: gallbladder wall thickening and distention with presence of pericholecystic fluid - immediately give antibiotics and do percutaneous cholecystostomy with abscess drainage if necessary

Question 144

how to treat acute vs chronic hyponatremia

Answer 144

ACUTE (< 48hrs) -any symptoms give hypertonic 3% saline CHRONIC (> 48hrs) - better tolerated - give hypertonic 3% saline only if sodium is < 120mEq/L *hyponatremic pts are at risk for brain herniation

Question 145

how to differentiate epidermal inclusion cyst and lipoma

Answer 145

epidermal inclusion cyst: benign nodule containing squamous epithelium that produces keratin, can change in size and usually resolves spontaneously lipoma: benign painless subq mass with normal overlying epidermis, usually soft and rubbery and irregular, do not regress or recur

Question 146

hepatic finding with a central stellate scar

Answer 146

focal nodular hyperplasia | -grows around blood source

Question 147

only major modifiable risk factor that affects severity and progression of Crohn disease

Answer 147

smoking | -tell all pts to stop smoking

Question 148

most common cause of nosocomial bloodstream infections

Answer 148

central venous catheters | -direct pathway for colonized skin organisms

Question 149

slowly enlarging abdominal mass that enlarges with valsalva, palpable fascial edges in nonobese pts, possible delayed presentation for months to years

Answer 149

incisional hernia - breakdown of prior fascial closure - risk factors: obesity, smoking, poor wound healing, vertical or midline incision, surgical site infection - dx with clinical symptoms or CT scan of abdomen

Question 150

explain the return to consciousness after anesthesia and what is delayed emergence

Answer 150

- emergence w/i 15 mins - in tact protective reflexes (gag) w/i 30-60mins - delayed emergence: pt fails to regain consciousness w/i expected window due to 3 things 1. drug effect of preop drugs 2. metabolic disorder (hyper/hypo -glycemia, -thermia, or liver disease) 3. neurologic disorder (stroke, seizure, or elevated icp)

Question 151

> 50yo obese woman presents with chronic lateral hip pain worse with abduction of leg and repetitive hip flexion (climbing stairs/walking uphill) or lying on affected side -pt also has focal tnderness over trochanter... what is it and what do you do

Answer 151

Greater trochanteric pain syndrome (GTPS) - overuse syndrome involving tendons on gluteus medius and minimus where they run over greater trochanter (trochanteric bursitis) - x-ray to rule out hip joint pathology - ultrasound: degeneration of tendons, tendinosis treatment - exercise, PT, activity modification - NSAIDs - corticosteroid injection

Question 152

how to manage diverticulitis (uncomplicated vs complicated)

Answer 152

Uncomplicated - stable: outpatient with bowel rest, oral abx, and observation - elderly/immunosupressed/high fever or leukocytosis/comorbidites: admit with IV abx Complicated (diverticulitis + abscess, perforation, obstruction, or fistula) - fluid collection < 3cm treat with IV abx and observe then surgery if worse - fluid collection > 3cm treat with abx and CT-guided percutaneous drainage and if that doesnt help then do surgical drainage and debridement

Question 153

tachypnea, hypoxia, segment of chest wall that moves inward during inspiration... what do you think

Answer 153

flail chest - occurs when fracture of > 3 contiguous ribs in > 2 locations creates isolated chest wall segment (flail segment) that moves paradoxically (opposite) to rest of rib cage during respiration - impairs generation of negative intrathoracic pressure and causes ineffective ventilation - pulmonary contusion - atelectasis

Question 154

chronic mitral regurg surgical indications

Answer 154

Primary -surgery if LVEF 30-60% (regardless of symptoms) Secondary -medical management, valve surgery rarely indicated

Question 155

intermittent solid food dysphagia most commonly in younger men with atopic conditions

Answer 155

eosinophilic esophagitis - untreated can cause esophageal stricture and food impaction - manage with dietary therapy, PPI, topical glucocorticoids

Question 156

middle mediastinal mass ddx

Answer 156

- bronchogenic cysts - tracheal tumors - pericardial cysts - lymphoma - lymph node enlargement - aortic aneurysms

Question 157

anterior mediastinum masses

Answer 157

4Ts - thymoma - teratoma - thyroid neoplasm - terrible lymphoma

Question 158

amiodarone side effects

Answer 158

hepatic steatosis and cholestasis

Question 159

common causes of ischemic hepatitis (shock liver)

Answer 159

- cardiac insults (MI, unstable arrythmias) - respiratory failure - hypovolemia - septic shock

Question 160

first step in a tension pneumothorax

Answer 160

- needle thoracostomy in order to prevent cardiovascular collapse - precedes intubation cause intubation can actually cause cardiovascular collapse

Question 161

whats so interesting about a diaphragmatic rupture

Answer 161

usually children with traumatic diaphragmatic injury may initially have no symptoms but can present months to years later after progressive expansion of the diaphragmatic defect -get CT of chest and abdomen

Question 162

what is a risk of being on chronic glucocortioid therapy if you are exposed to an acute stressor (surgery, illness, or trauma)

Answer 162

secondary adrenal insufficiency and can develop adrenal crisis - presents with hypotension and shock that is refractory to initial volume resuscitation - treat with IV hydrocortisone or dexamethasone with aggressive volume repletion

Question 163

how to treat chronic bacterial prostatitis

Answer 163

fluoroquinolones for 6 weeks

Question 164

how to treat a penile fracture

Answer 164

- if pt presents with blood at meatus, dysuria, urinary retention then they need retrograde urethrography due to urethral injury - then after that they need urgent operative repair

Question 165

if you think someone might have a corneal abrasion (cause they had a high-velocity injury to the globe) but dont see it then what can you do

Answer 165

fluorescein instillation cause it may reveal an open globe laceration by extrusion of fluid through laceration -in corneal defect itll be stained and appear yellow

Question 166

how to stage a gastric adenocarcinoma

Answer 166

after initial endoscopy/biopsy positive for adenocarcinoma 1. get CT of abdomen and pelvis 2. PET/CT, endoscopic ultrasound, laparoscopy, CT chest +/- paracentesis/peritoneal lavage - if limited stage then do surgical resection - if advanced stage then do chemo +/- palliative surgery

Question 167

how does benzo w/d present

Answer 167

agitation, tremors, perceptual changes, psychosis, elevated vital signs, delirium, and seizures -symptoms present w/i 24-48hrs

Question 168

patient presents with shoulder pain (with abduction and external rotation) and weakness and has a positive drop arm test where pt cant bring arm down so it just falls MRI can confirm dx

Answer 168

rotator cuff tear

Question 169

how to manage cat bites

Answer 169

-can cause pasteurella or any anaerobic bacteria copious irrigation and cleaning prophylactic amox/clav tetanus booster as indicated avoid closure

Question 170

how to deal with septic shock pt

Answer 170

secure airway, restore adequate tissue perfusion with normal saline then identify underlying infection and treat it

Question 171

what is the pathophys of struvite kidney stones

Answer 171

increased urine ammonia production - pts have recurrent UTIs - stone removal usually required

Question 172

how does a peptic duodenal ulcer typically present

Answer 172

periodic epigastric pain relieved by meals

Question 173

meniere disease

Answer 173

- caused by increased endolymphatic fluid volume or pressure in vestibular system - causes episodic vertigo and hearing loss as well as aural fullness/tinnitus lasting 20mins to 1 day - lack triggers

Question 174

what are the 4 types of post-amputation pain

Answer 174

1. acute stump pain - tissue and nerve injury causing severe pain lasting 1-3 weeks 2. ischemic pain - swelling, skin discoloration, wound breakdown, decrease in transcutaneous oxygen tension 3. post-traumatic neuroma - weeks to months after amputation - focal tenderness, altered local sensation - decreased pain with anesthetic injection 4. phantom limb pain - onset usually w/i 1 week - increased risk in pts with severe acute pain - intermittent crampting, burning felt in distal limb

Question 175

what is a charcot joint

Answer 175

- aka neurogenic arthropathy - impaired sensation and proprioception - altered weight bearing and recurrent trauma - acute inflammatory response - causes impaired ambulation, foot and ankle deformity, mild pain - x-ray: bone and joint destruction, fragmentation, subluxation/dislocation - mange with mechanical offloading and correction of joint mechanics (casting, orthotics)

Question 176

what is most important to help a pt with an isolated rib racture and atelectasis

Answer 176

adequate pain control | -if you dont have this then you increase the risk of pneumonia (frequent complication of rib fractures)

Question 177

most common primary brain malignancy

Answer 177

glioblastoma - increased intracranial pressure - headaches, papilledema, change in personality - CT/MRI show butterfly appearance with possible central necrosis

Question 178

what should you look out for when giving a pt desmopressin

Answer 178

its an analogue of ADH so you could potentially induce SIADH

Question 179

what is the most common complication after an ERCP

Answer 179

acute pancreatitis

Question 180

for pts with penetrating abdominal trauma when is immediate exploratory laparotomy indicated

Answer 180

1. hemodynamic instability (SBP < 90) 2. peritonitis (rigidity, rebound tenderness) 3. evisceration (externally exposed intestines)

Question 181

what is the most common type of liver cancer

Answer 181

metastasis from another primary source

Question 182

what are the hard signs indicating that due to extremity vascular trauma someone will need surgical exploration and fixation

Answer 182

- observed pulsatile bleeding - presence of bruit/thrill over injury - expanding hematoma - signs of distal ischemia - hemodynamic instability -if pt doesnt have tehse then do CT angiography for further evaluation

Question 183

spinal cord

Answer 183

Anterior - ascending: pain, temp, crude touch, pressure - descending: voluntary motor Posterior -ascending: pressure, vibration, fine touch, proprioception

Question 184

what are you concerned about in spinal cord lesions above T1

Answer 184

neurogenic shock due to interruption of descending sympathetic fibers -unopposed parasympathetic stimulation causing hypotension, bradycardia, hypothermia

Question 185

most common cause of small-bowel obstruction

Answer 185

Adhesions -ladd bands may be congenital in children but adhesions typically result from abdominal operations or inflammatory processes

Question 186

how does small-bowel obstruction present

Answer 186

depends on where the obstruction is - vomiting (causing hypokalemia, decreased oral intake, dehydration, and orthostasis) - proximal: early vomiting, abdominal discomfort, abnormal contrast filling on x-ray - mid/distal: colicky abdominal pain, delayed vomiting, prominent abdominal distension, constipation-obstipation, hyperactive bowel sounds, dilated loops of bowel on abdominal x-ray

Question 187

sphincter of oddi

Answer 187

muscular valve controlling flow of bile and pancreatic juice into duodenum

Question 188

how to treat acute colonic pseudoobstruction (ogilvie syndrome)

Answer 188

bowel rest and colonic decompression and aided by IV neostigmine

Question 189

- patient with back pain increased with standing, walking, and lying on back - tenderness of affected level - first felt pain while moving boxes but had a negative straight leg test

Answer 189

vertebral compression fracture | -usually due to osteoporosis (decreased bone mineral density)

Question 190

besides malignant hyperthermia what is a big side effect of succinylcholine

Answer 190

- its a depolarizing neuromuscular blockers - can cause life-threatening hyperkalemia in pts with condition leading to upregulation of postsynaptic acetylcholine receptors (skeletal muscle trauma, burn injury, stroke) -these pts should use vecuronium or rocuronium (nondepolarizing neuromuscular blocking agents) instead

Question 191

how does von hippel-linau present

Answer 191

- cerebellar and retinal hemangioblastomas - pheochromocytomas - renal cell carcinoma (clear cell subtype)

Question 192

how to tell the difference b/w small bowel obstruction and ileus

Answer 192

SBO- surgery was weeks to years ago, pts presents with distension and increased bowel sounds, small bowel dilation is present (not large bowel) Ileus- recent surgery (hours to datys), metabolic (hypokalemia, or medication induced, pt presents with possible distention and reduced/absent bowel sounds, both small and large bowel dilation

Question 193

torus palatinus/mandibulari

Answer 193

chronic mass - benign bony growth (exostosis) at midline suture of hard palate or lingual surface of mandible - surgery is only indicated if mass becomes symptomatic somehow

Question 194

medullar thyroid carcinoma

Answer 194

rare neuroendocrine carcinoma of thyroid parafollicular C cells that can be sporadic or associaated with RET germline mutation (MEN2)

Question 195

patient with smoking history presents with nontender, solitary cervical lymph nodes (hard mass under mandible)

Answer 195

mucosal head and neck squamous cell carcinoma

Question 196

acute GVHD

Answer 196

- usually within 100 days of transplant 1. maculopapular rash: painful/confluent and may look like SJS 2. profuse, watery diarrhea: secretory pattern with crampy abdominal pain, n/v 3. liver inflammation: damage to biliary tract epithelium, leading to elevated bilirubin, alk phos, and transaminases

Question 197

patient with history of retinoblastoma has thigh pain, what do you think of

Answer 197

osteosarcoma | -retinoblastoma and osteosarcoma are linked by RB1 tumor suppressor gene

Question 198

what makes you worried about a parotid mass for malignancy

Answer 198

cranial nerve dysfunction (facial droop, facial numbness) increases concern for malignancy

Question 199

what is an angiosarcoma

Answer 199

rare malignant tumor derived from internal lining of blood vessels of lymphatic vessels - strongest risk factor for getting this is: past radiation therapy - breast cancer survivors with chronic lymphedema are also at risk

Question 200

what to think of if you have a circular 3rd degree burn that results in eschar formation..?

Answer 200

the eschar restricts venous and lymphatic drainage which then leads to acute compartment syndrome

Question 201

what to give pts prophylatically for surgery who are undergoing a clean surgery (no viscera/bowel will be cut)

Answer 201

need coverage against gram-positive skin flora with 1st or 2nd gen cephalosporin (cefazolin) or with vanc or clinda *if its not clean based on surgical site but usually you need broader coverage

Question 202

most common malignancies in young men

Answer 202

- testicular cancer - lymphoma - leukemia

Question 203

painless jaundice with weight loss, what do you think of

Answer 203

pancreatic cancer (adenocarcinoma)

Question 204

what is the BEST way to help prevent pulmonary complications before a surgery

Answer 204

incentive spirometry and deep breathing exercises

Question 205

what is a retrograde cystography

Answer 205

bladder is passively filled with water-soluble contrast then imaged (CT scan) to confirm dx of intraperitoneal rupture/bladder rupture

Question 206

patient with cirrhosis and NEW ONSET ascites, what do you think of

Answer 206

acute obstruction of portal or hepatic veins due to thrombus or hepatocellular carcinoma -get abdominal ultrasound

Question 207

what screening is important in pts with cirrhosis of any kind

Answer 207

abdominal ultrasound every 6 months to evaluate for new onset Hepatocellular carcinoma

Question 208

if pt has basal cell carcinoma on their face or ears how do you get rid of it

Answer 208

Mohs micrographic surgery -sequential removal of skin layers with microscopic inspection to confirm margins are clear of malignant tissue (has the highest cure rate)

Question 209

how to determine if cervical spine imaging should be performed NEXUS low-risk criteria

Answer 209

- neurologic deficit - spinal tenderness - altered mental status - intoxication - distracting injury

Question 210

patient has diabetic foot ulcer, when do you test for osteomyelitis (bone biopsy)

Answer 210

1. positive probe-to-bone test 2. ulcer larger tahn 2cm 3. ulcer lasting > 1 week - note that fever, pain, elevated ESR, and sinus tract drainage may be present

Question 211

how to treat a meningioma

Answer 211

complete surgical resection

Question 212

what is the first step after pt has open-book pelvic fracture with disruption of the pelvic ring and anterior widening

Answer 212

they are at risk of life-threatening hemorrhage so the first step is to put on a pelvic binder to decrease pelvic volume and promote tamponade of venous bleeding

Question 213

what are the possible bladder symptoms of diverticulitis

Answer 213

urinary urgency, frequency, sterile pyuria (+ leukocyte esterase with - nitrite/bacteria) due to bladder irritation from adjacent sigmoid colon inflammation

Question 214

what lab valdue has a 95% positive predictive value for diagnosing gallstone pancreatitis and how do you manage these pts

Answer 214

ALT > 150 U/L -early cholecystectomy is indicated in all pts who are medically stable enough to undergo surgery

Question 215

if pt has infected prothetic with coagulase-negative staph (epidermitis) then what do you expect compared to staph aureus

Answer 215

- delayed onset - chronic pain - implant loosening - gait impairment - sinus tract formation

Question 216

how to confirm and treat bronchial rupture

Answer 216

bronchoscopy and treat with operative repair

Question 217

von hippel-lindau is associated with what

Answer 217

excess production of catecholamines due to pheochromocytomas

Question 218

patient with COPD has a secondary spontaneious pneumothorax ... what do you think of

Answer 218

rupture of alveolar bleb (most common cause of acute respiratory symptoms in COPD pts)

Question 219

greatest risk factor for prostate cancer

Answer 219

advanced age | -approximately 30-80% of men older tahn 70 have histologic evidence of prostate cancer

Question 220

general diagnostic workup of solid, firm, nontender testicular mass

Answer 220

testicular cancer until proven otherwise - bilateral scrotal ultrasound - serum tumor markers - radical inguinal orchiectomy

Question 221

what does a fixed teardrop pupil indicate

Answer 221

open globe injury

Question 222

most common cancers causing liver metastases

Answer 222

- GI tract - lung - breast

Question 223

patient with sickle cell and hip pain, what do you think of

Answer 223

avascular necrosis (osteonecrosis)

Question 224

pt presents with hematuria, renovascular congestion (enlarged kidney on imaging), elevated LDH with maybe AKI, and flank pain

Answer 224

renal vein thrombosis | -dx with CT or MR angiography or renal venography

Question 225

first step in diagnosing gastric cancer

Answer 225

EGD | -then you can do test for H pylori stool testing or anything else

Question 226

where should a central venous catheter be placed and why

Answer 226

ideal: lower superior vena cava - if you do it in smaller veins it predisposes to venous perforation or pneumothorax - get portable chest x-ray right after to make sure it was placed correctly if you dont use ultrasound guided CVC placement

Question 227

indications for open reduction and surgical exploration of fractures

Answer 227

- open fractures - neurovascular compromise - significant displacement

Question 228

it you think a pt has wound dehiscence following a surgery what should your next step be

Answer 228

management is determined by extent of tissue involvement --> get imaging of the affected area -usually after chest/sternal surgery soft tissue: only superficial tissues, use local wound care or debridement followed by primary closure sternal: separation of edges of sternum seen by clicking or rocking on palpation, surgical emergency and requires sternal rewiring to prevent cardiac trauma

Question 229

pt with intestine problem (or anything causing fat malabsorption) presents with nephrolithiasis, what do you think of

Answer 229

oxalate crystals in kidney cause gut probs usually increase its absorption

Question 230

how to manage venous air embolism

Answer 230

- left lateral decubitus positioning to trap the VAE on the lateral wall of the right ventricle preventing RVOT obstruction and further embolization into pulmonary circulation - high-flow or hyperbaric oxygen to encourage absorption of air embolus

Question 231

what is a complication of thoracic aortic aneurysm repair and how does it present

Answer 231

anterior spinal cord ischemia | -distal, bilateral flaccid paralysis, loss of pain/temp and crude touch sensation and urinary retention

Question 232

what complication are burn pts at risk for especially if their burns cover > 20% of their surface area - pts present with temp, tachy, hypotension, oliguria, hyperglycemia, thrombocytopenia, and mental status changes - dx with quantitative wound culture and biopsy for histopathology

Answer 232

wound infections and sepsis - soon after injury: gram + sepsis - after 5 days: gram - and fungi * note that a change in burn wound appearance of the loss of skin graft is often the first sign on burn wound infection

Question 233

patient getting laparoscopic surgery gets CO2 insufflation then gets bradycardic, AV block, and sometimes even asystole... why?

Answer 233

increased intra-abdominal pressure stimulates stretch receptors on peritoneum that respond by triggering increase in vagal tone

Question 234

how to treat basal cell carcinoma

Answer 234

excisional biopsy with narrow margin

Question 235

how to diagnose a rotator cuff tear

Answer 235

MRI of area -usually get treated with surgery (preferrably within 6 weeks of injury)

Question 236

how to visualize soft tissues

Answer 236

MRI

Question 237

how to treat tympanic membrane barotrauma

Answer 237

usually heals spontaneously within a few weeks

Question 238

postop hematoma in pt with no personal or family history

Answer 238

insufficient hemostasis

Question 239

variceal hemorrhage bleed algorithm

Answer 239

1. place 2 large-bore IV catheters 2. volume resuscitation, IV octreotide, antibiotics 3. urgent endoscopic therapy of esophageal varices - if that stops the bleeding then give beta-blockers and do endoscopic band ligation 1-2 weeks later - if they continue to bleed do balloon tamponade temporarily then TIPS or shunt surgery - if they have early rebleeding then do endoscopic therapy again then TIPS or shunt surgery if needed

Question 240

if you see intraperitoneal free air on imaging what does this confirm?

Answer 240

bowel perforation which should prompt emergent surgical exploration -presents as bowel contusion then mesenteric ischemia

Question 241

how to manage a peritonsillar abscess

Answer 241

IV abx therapy and urgent drainage of abscess | -pt will have deviation of uvula and unilateral lymphadenopathy

Question 242

most common causes of cirrhosis

Answer 242

- alcohol abuse - chronic viral hepatitis - nonalcoholic fatty liver disease (hx of DM and obesity) *note pts usually dont know they have cirrhosis until they get variceal bleeding or hepatocellular carcinoma

Question 243

what type of fluid resuscitation do you wanna use for burn patients

Answer 243

lactated ringer solution b/c it maintains a normal blood pH whereas normal saline can cause hyperchloremic metabolic acidosis

Question 244

what are the best predictors of postop outcomes following lung resection surgery

Answer 244

FEV1 and DLCO

Question 245

how to manage upper extremity DVT (usually within 7-14 days of PICC insertion)

Answer 245

- dx with duplex ultrasonography | - treat with 3 months of anticoagulation

Question 246

how to help manage pts with AD polycystic kidney disease

Answer 246

- treatment is mainly supportive | - vasopressin-2 receptor antagonist (tolvaptan) may slow progression in some pts

Question 247

benefits of neonatal circumcision

Answer 247

reduced risk of... - uti in first year of life - penile phimosis - cancer - inflammatory disorders in adulthood -decreases risk of acquiring some (not all) stds

Question 248

what are the risk factors for head and neck squamous cell carcinoma and what do you think if a pt has it without these risk factors

Answer 248

- presents as enlarged ulcerated tonsil with ipsilateral cervical adenopathy - risk factors: smoking and alcohol - if pt doesnt have these then look for HPV if pt is younger than expected (HPV-16)

Question 249

most sensitive test for medial collateral ligament tear

Answer 249

MRI | -pt will have medial knee and valgus laxity

Question 250

how to treat acute bacterial prostatitis

Answer 250

usually due to e.coli or proteus so treat for 6 weeks with... -fluoroquinolone OR -TMP-SMX

Question 251

patient presents with abdominal pain, diarrhea, nausea, hypotension/tachycardia, dizziness/confusion, fatigue, diaphoresis about 15-30mins after meals -usually after postgastrectomy

Answer 251

Dumping syndrome - rapid emptying of hypertonic gastric contents - caused by loss of normal action of pyloric sphincter due to injury or surgical bypass - manage with small/frequent meals, replace simple sugars with complex carbs, incorporate high-fiber and protein-rich foods

Question 252

patient with thoracic trauma and extensive extrapulmonary air (chest tube with persistent large air leak)

Answer 252

likely tracheobronchial injury | -get bronchoscopy to confirm dx before operative repair

Question 253

upper extremity DVT risk factors and presentation

Answer 253

risk factors: central venous catheters, repeptitive arm motions (baseball pitching), weight lifting, malignancy manifestations: acute arm edema, heaviness, pain, erythema, dilated subq collateral veins in chest/upper extremity, pulmonary embolism

Question 254

if pt has decline in renal function with addition of ACE inhibitors what do you think of

Answer 254

renal artery stenosis | -dx made with renal vascular imaging (renal doppler u/s)

Question 255

recurrent peptic ulcer disease with multiple ulcers and jejunal ulceration suggest what...

Answer 255

zollinger-ellison syndrome (gastrinoma)

Question 256

first step in dx of esophageal cancer based on age...

Answer 256

- younger pts under 50 start with barium swallow | - older pts over 50 OR younger with alarm symptoms have endoscopy right away

Question 257

what abx to give for breast abscess

Answer 257

dicloxacillin or cephalexin

Question 258

diabetic foot infections most likely get the bone how...

Answer 258

polymicrobial (gram + and - and anaerobic bacteria) via contiguous spread from the wound

Question 259

how to treat stress hyperglycemia (usually due to sepsis, burns, or major trauma/hemorrhage) -occurs due to stress triggering cortisol and catecholamines increasing glycogenolysis and gluconeogenesis

Answer 259

- minimization of glucose in IV fluids | - insulin to maintain blood glucose at 140-180 mg/dL

Question 260

classic fat embolism syndrome triad

Answer 260

1. respiratory distress (hypoxemia, dyspnea, tachypnea, tachycardia) 2. neurologic dysfunction (confusion, visual field defects) 3. petechial rash *note: immediate CXR is normal but after 24-48hrs youll see bilateral pulmonary infiltrates

Question 261

what form of imaging is required for pancreatic lesions

Answer 261

CT scan of abdomen has sensitivity > 90%

Question 262

how to confirm a ganglion cyst

Answer 262

transillumination of mass

Question 263

how to manage pts with primary hyperparathyroidism

Answer 263

-parathyroid imaging and parathyroidectomy - hypercalcemia with elevated PTH - parathyroidectomy recommended for symptomatic pts (nephrolithiasis) - younger pts < 50 are likely to have complications during lifetime and should be offered surgery

Question 264

what is a main cause of atelectasis as a postop complication | -pts present with hypoxia (low pO2) which increases respiratory rate causing low pCO2

Answer 264

shallow breathing and weak cough due to pain - usually occurs on postop day.2 or 3 - pts need adequate pain control, deep-breathing exercises, directed coughing, early mobilization, and incentive spirometry to help decrease incidence

Question 265

pathophys of peyronie disease

Answer 265

acquired disorder with fibrosis of tunica albuginea of penis (dorsal nodules/plaques) -restricts expansion and flexibility during erections

Question 266

risk factors for splenic abscess - usually presents with persistent fever, LUQ pain, anorexia, weight loss - dx made with CT scan of abdomen

Answer 266

- immunocompromised - hematologic malignancy - DM -treat with abx plus splenectomy is usually needed cause most pts fail percutaneous aspiration (due to presence of occult microabscesses)

Question 267

how to manage AAA 3-5.5cm large

Answer 267

lifestyle modification (smoking cessation is best)

Question 268

patient presents with murmur after permanent pacemaker placement

Answer 268

tricuspid regurgitation - adverse effect of pacemaker - can cause cor pulmonale

Question 269

what is a characteristic image finding in pts with entamoeba histolytica

Answer 269

single, subcapsular, low-density lesion in the right lobe of the liver cause it has more blood supply than the left -dx made with serology (needle aspiration not needed)

Question 270

when to think about scurvy (vitamin C deficiency)

Answer 270

- common in alcoholism - usually within 3 months of vitamin C deficient diet - presents with the following 1. cutaneous manifestations: follicular hyperkeratosis, perifollicular hemorrhage, ecchymosis, petechiae, coiled hairs 2. gingivitis: receded gums that bleed easily and dental caries 3. impaired wound healing 4. systemic symptoms: arthralgias, malaise, weakness

Question 271

what is a size of lung nodule that independently correlates with > 50% malignant probability

Answer 271

2cm or larger | -always biopsy and

Question 272

when to manage a stress fracture why referring to ortho

Answer 272

for fracture at high risk of malunion | -ex: anterior tibial cortex, 5th metatarsal

Question 273

what is fournier gangrene (presents as rapid onset skin infection of lower abdomen, scrotum, and perineum with crepitus and significant systemic manifestations like hypotension, high fever and leukocytosis) -DO SURGERY RIGHT AWAY

Answer 273

life-threatening necrotizing fasciitis - quickly progresses to sepsis and death without intervention - occur in the setting of cutaneous breakdowns in perianal/genital region that allow portal entry of polymicrobial colonic or urogenital organisms - spreads along subQ fat via fascial planes

Question 274

how to empirically treat human bite wounds

Answer 274

aerobic and anaerobic oral organsims so give amox-clav

Question 275

if a patient is on long term total parenteral nutrition what should you look out for

Answer 275

TPN can cause gallbladder stasis and predisposes to gallstone formation and bile sludging, both of which may lead to cholecystitis

Question 276

patient with any enlarging ballotable neck swelling near an incision should be dealt with how

Answer 276

its likely a hematoma and is life threatening cause it can become a lethal upper airway obstruction -immediately drain the hematoma and explore the wound in the OR to control the source of bleeding and see if a endotracheal tube is needed or not

Question 277

how to describe hypoventilation based on lab values

Answer 277

normal A-a gradient and respiratory acidosis

Question 278

what is a surgical cricothyrotomy

Answer 278

when you trach their neck to make sure you have airway access if endotracheal intubation doesnt work

Question 279

patient get a bite then develops a small ulcer, what do you think of

Answer 279

brown recluse spider bite -over the course of a few days a deep skin ulcer develops with erythematous halo and a necrotic center, which can progress to an eschar

Question 280

at what platelet count should you be okay to put someone on warfarin

Answer 280

> 150,000 | -if its below dont put them on it yet

Question 281

how to diagnostically evaluate heparin-induced thrombocytopenia

Answer 281

- serotonin release assay is the gold standard confirmatory test - start treatment in suspected cases prior to confirmatory tests

Question 282

greater trochanteric pain syndrome

Answer 282

overuse syndrome involving tendons of gluteus medius and minimus at greater trochanter - chronic lateral hip pain - treat with exercise, pt, nsaids, and steroid injections

Question 283

indications for bariatric surgery

Answer 283

BMI > 40 BMI > 35 with serious comorbidity (T2DM, hypertension, OSA) BMI > 30 with resistant T2DM or metabolic syndrome

Question 284

what is radiation proctitis (acute vs chronic) | -colonoscopy demonstrates mucosal pallor, friability, and telangiectasias confined to the rectum

Answer 284

- caused my mucosal damage associated with pelvic radiation therapy - acute RP presents < 8weeks post-radiation with diarrhea, tenesmus, and mucus discharge - chronic RP occurs months to years after radiation, resulting in hematochezia, anemia, and possibly strictures

Question 285

tender, nonpurpuric, erythematous, or violaceous nodules measuring 2-3 cm and usually located on shins

Answer 285

erythema nodosum | -associated with IBD (especially crohn disease)

Question 286

how to confirm a posterior urethral injury

Answer 286

retrograde urethrography | -pt will present with blood at the urethral meatus and a high-riding prostate

Question 287

CT with gall bladder that looks calcified on the outside

Answer 287

porcelain gallbaladder | -associated with increased risk for gallbladder adenocarcinoma and usually requires cholecystectomy

Question 288

what to give a patient on warfarin who emergently needs surgery

Answer 288

prothrombin complex concentrate and IV vitamin K | -if PCC is unavailable you can give fresh frozen plasma

Question 289

if an old fracture or break hasnt come back together yet what might they have

Answer 289

chronic osteomyelitis - pt presents with: intermittent pain/swelling and sinus tract formation - open bone biopsy for assessment and treat with surgical debridement of infected and necrotic bone

Question 290

what type of tumor produces EPO

Answer 290

renal cell carcinoma

Question 291

patient presents with oropharyngeal infection (pharyngitis or tonsillitis) -leads to local invasion of lateral pharyngeal wall and infection of neurovascular bundle (especially internal jugular vein)

Answer 291

Lemierre syndrome - caused by Fusobacterium necrophorum - thrombosis of the vein allows dissemination of septic emboli to distal sites

Question 292

trousseau syndrome

Answer 292

- hypercoagulability disorder - recurrent and migratory superficial thrombophlebitis at unusual sites (arm, chest) - usually associated with occult visceral malignancy: pancreatic is most common, stomach, lung, or prostate carcinoma

Question 293

when preoperatively should pts getting a pheochromocytoma removed take alpha blockers

Answer 293

7-14 days prior to surgery followed by beta blockers 2-3 days prior to surgery *never give beta without alpha blockers first cause otherwise you can cause a hypertensive crisis

Question 294

how to manage atrial flutter

Answer 294

- results from large reentrant circuit involving cavotricuspid isthmus of right atrium - risk for arterial thromboembolism so pts should be on chronic anticoagulation

Question 295

triad of aortoiliac occlusion (Leriche syndrome) | -men with atherosclerosis who smoke are at high risk for this

Answer 295

- bilateral hip, thigh, and buttock claudication - impotence - absent or diminished femoral pulses (often with symmetric atrophy of bilateral lower extremities due to chronic ischemia)

Question 296

what is pituitary apoplexy

Answer 296

sudden hemorrhage into enlarged pituitary adenoma - pts present with sudden onset headache and visual disturbances - severe hypotension and distributive shock

Question 297

most common cause of a lung abscess

Answer 297

aspiration of oropharyngeal anaerobic bacteria - symptoms may look like TB with subacute fever, night sweats, weight loss, and cough with putrid sputum - x-ray reveals cavitary infiltrates often with air-fluid levels

Question 298

patient presents after cardiac surgery with what looks like an infection with chest pain... what do you think

Answer 298

acute mediastinitis - fever - chest pain - leukocytosis - mediastinal widening on x-ray -requires drainage, surgical debridement, and prolonged antibiotic therapy

Question 299

pt presents with episodic headache, hypertension, hyperglycemia

Answer 299

pheochromocytoma | -measurement of urine or plasma metanephrines is initial step in diagnostic evaluation

Question 300

irregular scrotal mass that increases in size with valsalva and doesnt transilluminate

Answer 300

varicocele

Question 301

patient with lower and upper motor neuron signs... what do you do you think if its def not lou-gerigs

Answer 301

cervical myelopathy | -gait dysfunction is usually the first sign

Question 302

acute tonsillitis presentation

Answer 302

- tonsillar erythema and exudates - tender anterior cervical nodes and palatal petechiae *if pt has pooling of saliva (trismus) and uvular deviation then its more likely peritonsillar abscess

Question 303

how does a nonanion gap metabolic acidosis present

Answer 303

- loss of bicarb | - can happen with pancreatic or small bowel leaks

Question 304

3 essential elements of informed consent

Answer 304

- diagnosis - risks and benefits of both proposed treatment and alternatives - risk of refusing treatment

Question 305

what does the coffee bean sign mean on x-ray

Answer 305

volvulus - dilated, inverted, u-shaped loop of colon - patients without perforation or peritonitis can undergo flexible sigmoidoscopy to reduce twisted segment and avoid emergency surgery

Question 306

how does sigmoid volvulus present risk factors: sigmoid colon redundancy (dilation/elongation from chronic constipation) and colonic dysmotility (underlying neurologic disorders)

Answer 306

presentation - slowly progressive abdominal discomfort/distension possibly with obstructive symptoms - abdomen distension and tympanic to percussion imaging - x-ray: dilated, inverted u-shaped loop of colon (coffee bean sign) - CT scan: dilated sigmoid colon, mesenteric twisting (whirl sign) management - endoscopic detorsion (flexible sigmoidoscopy) and elective sigmoid colectomy - emergency sigmoid colectomy if perforation/peritonitis present

Question 307

how to treat small bowel obstruction

Answer 307

- NG tube for gastric decompression | - emergency laparotomy due to high risk of life-threatening complications (bowel ischemia, perforation)

Question 308

key finding in pts with otosclerosis (conductive hearing loss)

Answer 308

improvement of speech understanding in noisy environment

Question 309

what is the most common neuropathy in hemodialysis patients

Answer 309

carpal tunnel syndrome - 1/3 of pts get it - symptoms usually get worse during hemodialysis treatments

Question 310

how is hemodialysis access obtained

Answer 310

surgically creating AV fistula -forms enlarged vein serving as access point and facilitates adequate blood flow to and from hemodialysis machine note: if the AV fistula gets too big that can lead to high-output heart failure

Question 311

symptoms of primary adrenal insufficiency

Answer 311

main clinical features: hypotension and shock fatigue, weight loss, abdominal pain, anorexia, and GI disturbance

Question 312

clinical indicators of thermal and smoke inhalation injuries note: treat all these pts with high flow oxygen via non-rebreather mask with a low threshold for intubation (key reason to intubate is progressive airway edema)

Answer 312

- burns of face - singeing of eyebrows - oropharyngeal inflammation - blistering or carbon deposits - carbonaceous sputum - stridor - carboxyhemoglobin level > 10% - history of confinement in burning building

Question 313

woman > 40yo with multiparity, vaginal delivery, and chronic constipation/straining

Answer 313

rectal prolapse - protruding rectal mass that occurs with valsalva - treatment is surgical

Question 314

how to treat cataracts (loss of acuity, glare, halos around lights, lens opacification, loss of red reflex)

Answer 314

surgical removal of lens with implantation of prosthetic lens

Question 315

patient presents with obliterative endarteritis and submucosal fibrosis (which stiffens the rectum and impairs its compliance) --> resulting in urgency and fecal incontinence

Answer 315

chronic radiation proctitis --> chronic tissue hypoxia results in neovascularization and telangiectasia formation (which are prone to hemorrhage)

Question 316

what should be considered in post-menopausal women with new-onset abdominal pain and/or concerning gastrointestinal symptoms

Answer 316

epithelial ovarian cancer

Question 317

HPV can cause what to the anus

Answer 317

anal squamous intraepithelial lesion which is a precursor to anal squamous cell carcinoma - small lesions can be treated topically with trichloroacetic acid - larger lesions managed with radiofrequency ablation

Question 318

sudden development of limb ischemia in pts with no previous problems

Answer 318

embolic arterial occlusion | -most arterial emboli are cardiac in origin

Question 319

constricting apple core mass on x-ray

Answer 319

most frequently associated with constriction of lumen of colon by stenosing ANNULAR COLORECTAL CARCINOMA -most appropriate next step is proctocolectomy

Question 320

younger woman with hypertension and carotid stenosis

Answer 320

fibromuscular dysplasia of renal artery

Question 321

how to treat transitional cell carcinoma

Answer 321

endoscopic resection

Question 322

breast mass with clear brown fluid on aspiration

Answer 322

fibrocystic disease -if its clear milky then its a galactocele

Question 323

what to look out for after radiation to bone

Answer 323

hypercalcemia and hypercalcemic crisis

Question 324

patient on steroid stops taking them then has severe hypotension unresponsive to LR or saline... what do you do

Answer 324

give IV steroids

Question 325

possible side effect of diphenhydramine

Answer 325

urine retention

Question 326

3cm cavity in upper lobe of lung with round 2cm mass in lumen in pt with hemoptysis, what do you think of

Answer 326

aspergilloma

Question 327

first step to examine for AAA in stable pt

Answer 327

bedside transabdominal ultrasound

Question 328

patient with rapidly progressive painful ulcer with purulent base and violaceous border following small local trauma like a bump or something -they will also have some sort of underlying systemic inflammatory disorder

Answer 328

pyoderma gangrenosum | -usually get skin biopsy and treat with steroids

Question 329

patient presents with GI bleeding that cant be seen on endoscopy or colonoscopy and hes pretty old > 60

Answer 329

angiodysplasia | -associated with aortic stenosis which is associated with low levels of vWF multimers

Question 330

patients who undergo splenectomy should be given what drugs to take if they get a fever before theyve had their vaccinations

Answer 330

amox-clav

Question 331

what is the post burn injury hypermetabolic response

Answer 331

- hachycardia, hypertension - increased gluconeogenesis and insulin resistance = hyperglycemia - increased basal metabolic rate = febrile - increased protein and lipid catabolism = increased lean muscle wasting -treat: early excision and grafting, propranolol, insulin, nutrition, and anabolic steroids

Question 332

what can be an early sign of sepsis in burn pts

Answer 332

acute enteral feeding intolerance which can indicate end-organ hypoperfusion and dysfunction

Question 333

how to treat a calcaneal spur

Answer 333

incidental finding and do not require treatment | -they usually dont cause pain on their own

Question 334

what are you concerned about in a patient with a lung transplant

Answer 334

look for bronchiolitis obliterans - gradually progressive dyspnea, non-productive cough and an obstructive pattern (FEV1/FVC < 70%) - chronic lung transplant rejection - get bronchoalveolar lavage to rule out infection - biopsy will show submucosal lymphocytic infiltrate

Question 335

if someone has rhabdo, what are you nervous about

Answer 335

pts with rhabdo are likely to have hyperkalemia so avoid K-containing fluids

Question 336

patient with cholecystectomy then has unremitting diarrhea WITHOUT fever or leukocytosis

Answer 336

bile acid diarrhea - unresorbed bile acids spill into the colon, irritating the mucosa - secretory diarrhea (fasting diarrhea with nocturnal episodes) - unremarkable serum and stool studies - treat with bile acid binding resins (cholestyramine and colestipol)

Question 337

budesonide

Answer 337

used to treat microscopic colitis

Question 338

myositis ossificans

Answer 338

formation of lamellar bone in extraskeletal tissues - can be traumatic or neurogenic - pt presents with intramuscular mass, pain, swelling, induration days to weeks following the injury - increased Alk Phos, ESR, CRP - x-ray shows periosteal bone reaction and calcification with radiolucent center - treat with ROM exercise/NSAIDs or surgical excision

Question 339

what type of injury should make you think of an acute rotator cuff injury

Answer 339

acute glenohumeral dislocation - decreased abduction due to pain BUT in tact sensation - positive drop arm test- arm held in 90 degree abduction and released, inability to hold arm steady suggests a tear

Question 340

what is tertiary hyperparathyroidism

Answer 340

- look for this in pts with CKD - chronic hypocalcemia and hyperphosphatemia - due to parathyroid hyperplasia and loss of feedback inhibition of PTH by calcium - VERY HIGH PTH - mild hypercalcemia and hyperphosphatemia - usually refractory to medical therapy - parathyroidectomy often needed

Question 341

how to treat a lung abscess

Answer 341

first-line: ampicillin-sulbactam, imipenem, or meropenem alternate: clindamycin

Question 342

what is the landmark for distinguishing surgical levels of axillary lymph does during dissections

Answer 342

pectoralis minor muscle

Question 343

pt presents with general body pain and random vessels with signs of narrowing, thrombosis, and/or ischemia

Answer 343

polyarteritis nodosa - segmental, transmural inflammation of medium-sized arteries - usually kidney and gi tract are affected