________ presents with mid-systolic, crescendo-decrescrendo right 2nd intercostal+ left sternal border
Aortic stenosis radiates to _________
______ increases the murmur of aortic stenosis
_______ decreases the murmur of aortic stenosis
when is the valve replaced in aortic stenosis
if symptomatic, gradient > 50 or CHF
________ presents with Holosystolic murmur with click at the apex radiating to axilla
Most common cause of mirtal regurgitation
Early peaking systolic ejection murmur increased by Valsalva,
decreased by squatting/handgrip
if pt with HOCM present with syncope, arrhythmia or FH of HOCM
place an Implantable Cardioverter Defibrillator
Acute: young person with endocarditis & sudden CHF with
loud diastolic murmur at right 2nd intercostal space
Acute Aortic Regurgitation/Insufficiency
blowing high-pitched diastolic at 2nd intercostal space
+ left lower sternal border assoc’d with wide pulse pressure.
Chronic Aortic Regurgitation/Insufficiency
what is the first line treatment of chronic aortic regurgitation
medical therapy with vasodilators
Low pitched rumbling diastolic at apex with opening snap
complication of mitral stenosis
extreme drop in platelets + clots in post-op patient who has received
heparin within 5-14 days
Heparin Induced Thrombocytopenia
treatment of heparin Induced Thrmbocytopenia includes _________
STOP HEPARIN, give lepirudin or argatroban
Lidocaine + epinephrine should not be given in the following places: ______, _______, _______ and _____
fingers, nose, penis and toes
A patient takes amlodipine for hypertension. When should
this patient discontinue this medication prior to surgery?
Hold morning dose
For how long should an active smoker be told to quit before surgery?
why are patients with nephrotic syndrome at increased risk of clotting?
loss of antithrombin III in urine
symptoms of malignant hyperthermia
high fever (>104 degrees celcius), muscle rigidity, metabolic acidosis, hyperkalemia
treatment of malignant hyperthermia
IV dantrolene, 100% oxygen, Cooling blankets, correct acidosis
patient presents with fever less than 24hrs of surgical operation. most likely cause?
patient presents with fever within 24hrs of surgical operation. most likely causes?
atelectasis, necrotizing fasciitis
management of atelectasis
incentive spirometry, mobilization
symptoms of atelectasis
low-grade fever, non productive cough
CXR findings for atelectasis
bilateral fluffy lower lobe infiltrates without consolidation
management of necrotizing fasciitis
surgical debridement, antibiotics
symptoms of necrotizing fasciitis post operatively
high fever, ill, rash
findings for necrotizing fasciitis
gas in tissue
post operative fever Day 2-5. Most likely causes?
post operative fever Day 7. Most likely causes?
central line infection cellulitis wound infection dehiscence pulmonary embolus
post operative fever Day 10-15. Most likely cause?
prevention of decubitus (pressure) ulcers
change position every two hours
LDH effusion/LDH serum > 0.6
Protein effusion/protein serum >0.5
what stage of pressure ulcer- intact skin, red, blanches with pressure
what stage of pressure ulcer- break in dermis, blister
what stage of pressure ulcer -into subcutaneous tissue and muscle?
what stage of pressure ulcer- involvement of bone?
what makes an exudative effusion complicated?
flank pus, +gram/culture, pH <7.2
diagnostic criteria of ARDS
- PaCO2/ FiO2 < 200 (< 300=acute lung injury)
- Bilateral alveolar infiltrates
- PCWP < 18 (Rules out cardiogenic cause of pulmonary edema)
when should 3% Normal saline be used
severe hyponatremia (<110), seizures
rapid correction of hyponatremia could lead to ____
central pontine myelinosis
rapid correction of hypernatremia could lead to _____
Pain/dysphagia worse with liquids, chest pain, no regurgitation. Suspect?
Diffuse esophageal spasm
Confirmatory diagnosis of diffuse esophageal spasm
Management of diffuse esophageal spasm
CCB or nitrates
Barium swallow done at the time of pain showing “corkscrew esophagus” is suspicious of
Diffuse esophageal spasm
Usually idiopathic, can be associated with Chagas’ disease and patient presents with dysphagia to liquids and solids. Suspect?
Barium swallow for achalasia shows?
Management of achalasia
CCB; Nitrates; Botox; Dilation; heller myotomy
Terrible breath, regurgitation of dinner in the morning. Suspect?
False diverticulum, only contains mucosa
Progressive dysphagia, weight loos with h/o smoking or alcoholism . Suspect?
Squamous cell esophageal carcinoma
Progressive dysphagia, weight loos with h/o GERD/ Barrett’s. Suspect?
Adenocarcinoma of the esophagus
Management of early stage esophageal carcinoma
Management of advanced esophageal carcinoma
Chemo + RT and then surgery
Management of metastatic esophageal carcinoma
Epigastric pain worse after eating or laying down with h/o hiatal hernia. Suspect?
Risk factors for GERD
Hiatal hernia Obesity Pregnancy EtOH/ smoking Acidic, spicy foods/caffeine Certain meds
Best diagnostic test for GERD
24-hr pH monitoring
What can be used to treat GERD if incompetent LES or symptoms persists after maximum dose of PPI
A Nissen fundoplication
Alcoholic presents with bright red blood in emesis after severe vomiting. Suspect?
To confirm diagnosis of Mallory-Weiss tear do?
Hematemesis after vomiting, subcutaneous emphysema, severe pain, fever leukocytosis and ill appearing. Suspect?
Full thickness esophageal rupture
Diagnostic test when you suspect full thickness esophageal rupture
Management of boerhaave syndrome
Management of varices
Octreotide/SST Balloon tamponade Endoscopic sclerotherapy Banding Beta blocker if asymptomatic
Risk factors of gastric ulcers
When is the pain from gastric ulcer worse
Worse with eating
Treatment of H.pylori cause of gastric ulcer
Complications of partial/total gastrectomy
Management of H.pylori gastric lymphoma
Treat H.pylori with triple therapy
Epigastric pain of duodenal ulcer improves with
Management of Duodenal ulcer
Triple therapy for 14 days then test for eradication
Unremitting peptic ulcers + watery diarrhea. Suspect?
Diagnostic test for Zollinger-Ellison Syndrome
Secretin stimulation test (inappropriately high gastrin)
Management of Zollinger-Ellison Syndrome
Check for MEN syndrome
Omeprazole for metastases
Epigastric pain, nausea, vomiting with increased amylase + lipase. Diagnosis?
Complications of acute pancreatitis
Pseudo cyst Hemorrhage Abscess Sepsis ARDS
Complication of chronic pancreatitis
Splenic vein thrombosis which leads to gastric varices
Large, non-tender gallbladder, itching, jaundice - what sign?
Courvoiser’s sign of pancreatic cancer
Migratory thrombophlebitis- what sign
Trousseau’s sign of pancreatic cancer
Which endocrine pancreatic tumor presents with malabsorption and steatorrhea
Complications of gallbladder
RUQ pain, elevated bilirubin + alkaline phosphatase
RUQ pain, fever, jaundice, hypotension, AMS
Which hematoma does not cross the suture lines
Which hematoma shows biconvex lens on non-contrast CT scan
What vessel is responsible for epidural hematoma?
Middle meningeal artery
Semilunar, crescent shaped on CT. What hematoma?
What vessel is responsible for subdural hematoma?
Raccoon eyes, CSF rhinorrhea/otorrhea, ecchymosis behind the ear is suggestive of?
Basilar skull fracture
Management of ICP
Elevation of head of bed
Hyperventilating to PCO2 35
Mannitol/ furosemide & avoid excess IVF
Maintain adequate CPP (MAP- ICP)
What zone of penetrating neck injury warrants surgical exploration?
Forced neck hyperextension (whiplash); paralysis & burning pain in the upper extremities. Suspect?
Central cord syndrome
Vertebral body burst fractures; loss of motor, pain and temperature distal to injury on both sides. Suspect?
Anterior cord syndrome
Gun shot wounds or stab cutting the cord at one level; paralysis & loss of proprioception distal to injury on the same side; loss of pain & temperature sensation on opposite side. Diagnosis?
Flail chest symptom to watch out for
Inward movement of chest with inspiration
Complication to watch out for with flail chest
Management of rib fracture
Pain control w/ aggressive respiratory therapy
What do you see on CXR 48 hours after for the diagnosis of pulmonary contusion
White out of lungs on CXR
Difference between pneumothorax and hemothorax
Dullness to percussion for hemothorax
Difference between tension pneumothorax and hemothorax
Trachea deviates toward the side of injury
What injuries increases the suspicion of aortic rupture
- 1st rib
- Sternal fracture
How do you intubate a patient with tracheal rupture?
Fiber optic bronchoscopy
The four spaces FAST exam checks
Next step in a stable patient who had an abdominal trauma
Lower rib + abdominal bleed
Splenic/ liver laceration
Lower rib fracture + hematuria
Kher sign + viscera in the left thorax on XR
Retro peritoneal fluid + epigastric pain
Seizure/electric burn; arm is internally rotated and addicted on exam. ?
Posterior shoulder dislocation
Fall on outstretched hand; arm externally rotated and abducted arm
Anterior shoulder dislocation
Direct blow to proximal ulna, anterior dislocation of radial head
Direct blow to distal radius, dorsal dislocation of radioulnar joint
Shortened and externally rotated leg
kg x BSA% x 4
Management of circumferential burns