Surgery+medicine Flashcards
(51 cards)
A pt with htn, DM, hypercholesterolemia comes with difficulty walking n mild pain in his left foot for the past several months. Significantly deformed left ankle and mildly deformed left foot r observed. X-ray shows bone loss, large osteophytes, several extraarticular bone fragments. The most likely cause of this patient’s foot pain is?
Nerve damage-> Charcot joint
A 51 yr old comes due to 2 months of pain and numbness of her rt index n middle fingers, which turn white when subjected to cold. She has no problems with her left fingers or toes. There are 2 small ulcers on the tip of her rt index finger. The best next step in the mx is?
Check for autoantibodies ( ANA, RF) n inflammatory markers
- if ANA is positive, specific antibodies such as antitopoisomerase-1 for systemic sclerosis may b obtained.
- the pt is having Raynaud phenomenon which can b primary( young females, symmetric attacks without tissue injury) or secondary( usu >40, males, asymmetric, clinical features of tissue ischemia eg. Ulcers; associated with systemic diseases like SLE, RA, scleroderma)
Supracondylar fracture, when it occurs following a fall onto an outstretched hand, the distal fragment of the humerus is posteriorly displaced
- which neurovascular structures r at high risk of injury?
- if one falls with a flexed elbow?
- the anteriorly displaced proximal fragment can entrap the MEDIAN NERVE & BRACHIAL ARTERY.
- flexed…- ulnar nerve damage which is located at the posterior aspect of the medial epicondyle.
Mx of radial shaft fracture if neurovascular compromise occurs?
Open reduction and surgical exploration.
- if no NV damage, closed fracture, no significant displacement- closed reduction and immobilization.
A 13 yr old girl is noticed to have a rt sided lumbar prominence during forward test. No tenderness or other abnormalities. The best next step in the mx is?
🚩X-ray of the spine- to c severity of the disease, directs mx.
- Dx is adolescent idiopathic scoliosis( AIS)- lateral curvature of the spine without a specified etiology.
🚩forward bend test shows asymmetric thoracic or lumbar prominence.
A 44 yr old woman comes with signs n sxs of carpal tunnel syndrome. She has stiffness in the wrist n fingers in the morning n feels better by the midday. Which of the ff is the best next step?
A)hbA1c B)RF. C)MRI of the cervical spine
RF-
Common risk factors for CTS include DM, pregnancy, obesity, hypothyroidism
- but this pt has morning stiffness suggesting RA as the cause of CTS.
60yr old man comes with 6months of progressive back pain, thigh pain n headache. He uses hearing aid for recently acquired left sided hearing loss. Lower extremities show mild anterolateral femoral bowing. No other abdominal findings. Dx? Cause?
Rx?
Lab?
Paget disease of the bone Osteoclast dysfunction. Rx- bisphosphonates - serum calcium n phosphate r normal - ALP n urine hydroxyproline r high
A pt who required below knee amputation following trauma now has pain in the absent portion of the limb.
Dx
Mx
Phantom limb pain
- mx- MULTIMODAL PAIN REGIMEN-pharmacotherapy- antidepressants, gabapentin, ketamine, analgesics
- adjuvant therapies- CBT, mirror therapy…
A sudden forceful contraction of quadriceps especially in those with tendinous fragility(eg. A 62 yr old known CKD patient who missed a step n fell on her knee), resulting in a popping sound, rapid swelling, inability to support wt, palpable defect below or above the patella
Most likely Dx?
Imaging
Mx
Rupture of the quadriceps-patellar tendon complex
🚩patellar tendon tear- occurs distal to the patella, patella rides high, palpable defect below the patella
🚩quadriceps tendon tear- proximal to the patella, patella rides low, palpable defect above the patella
- complete tear is surgically managed
A pt comes with impaired shoulder abduction following a fall. He is asked to lower his arm slowly after passive abduction of the arm above the head, as he is lowering it below horizontal, the arm suddenly drops
Dx
Rotator cuff tear
Dry eyes, dry mouth with mild dental caries in a 73 yr old hypothyroid pt is most likely due to?
Age related exocrine gland atrophy( age related sicca syndrome).- commonly in females, thyroid disorders, DM
- SS occurs in middle aged adults n onset >65 is very unlikely
Clavicular fracture- hard sign Vs soft signs, mx?
The medial third of the clavicle overlies the brachial plexus n subclavian aa n vein.
- hard signs- absent distal pulses, bruit at the injury site- indicate definite arterial injury- immediate surgical intervention
- soft signs- stable hematoma, reduced pulse, unexplained hypotension, … CT ANGIOGRPHY is done
- uncomplicated fractures r treated conservatively- rest, ice, sling or figure of eight bandage
68yr old comes with 2 days of rt foot pain and swelling. X-ray reveals soft tissue swelling, small tibiotalar joint effusion, chronic calcification of the articulation cartilage
Dx?
Pseudogout- calcium pyrophosphate dihydrate crystals
Chondrocalcinosis is suggestive .
A 42 yr old woman comes with a mass on her rt wrist she has hyperlipidemia n rheumatoid arthritis 2 cm mass on the extensor surface of the rt wrist, firm mobile nontender, it transilluminates on penlight examination
Dx?
Ganglion cyst- harmless, common in those with underlying joint disorder
A 55 yr old man comes with worsening of joint pain, morning stiffness lasting for hours , weight loss, fatigue. P/E MCP n PIP Joints of both hands show mild boggy swelling and tenderness on gentle squeezing. RF is negative
The best next step is?
Anti-cyclic citrulinated peptide antibody assay
A 56 yr old woman is brought to the hospital for confusion n a wk hx of intermittent headache, vision changes. T 36.6, BP- 220/115 PR-90, her hands r shiny, thickened with multiple telangiectasia. Pitting LE edema
Cr-3.4, BUN-20 normal CT
Dx? The best next step in the mx is?
Scleroderma renal crisis( SRC)
Thickened skin n telangiectasia r indicative of systemic sclerosis.
- SRC is a complication of SS- collagen deposition-> renal vascular injury-> renal ischemia-> RAAS -> hypertensive emergency( this pts headache, confusion, visual changes)
- mx is ACE inhibitors typically captopril.
A 62 yr old is diagnosed to have septic arthritis culture of the synovial fluid is sent n abx r started. An appropriate additional intervention will b?
Serial joint aspiration
A pt with multiple risk factors for osteoporosis including age>65 smoking, hx of salpingoopherectomy… should b screened by?
Dual-energy X-ray absorptiometery( DEXA)
- x Ray of pelvis… is not the answer
A 58 yr old had a fall in an outstretched hand with accompanying radial fracture
- which nerve is at greatest risk of involvement? Which of the ff is going to b impaired?
A) abduction of the thumb against resistance
B) adduction of the index n 4th digit
C) extension of fingers against resistance
D) sensation on the dorsum of the thumb-index web space
- colles fracture- median nerve is affected - sensation of the lateral 3 n half digits n motor to the at mms=> ABDUCTION of thumb against resistance is lost
- carpal tunnel syndrome can also result
In a pt with clinical suspension of ankylosing spondylitis, Dx is confirmed by?
X-ray of the sacroiliac joint.
- NOT HLA-B27! Has strong association, but is nonspecific n not necessary for Dx.
A pt on disease modifying agents for RA has mild megaloblastic anemia, other cell counts r normal; no mucositis. What additional ADR is expected in this pt?
Hepatotoxicity
- MTX- cytopenias, stomatitis, hepatotoxicity
Common side effect of hydroxychloroquine, a disease modifying agent, is?
Retinopathy - baseline n periodic eye examination is necessary.
A 35 yr old female who twisted her left ankle a month ago presents with worsening of pain in the ankle n lower calf. The pain is severe constant burning stinging n is worsened by movement. Decreased range of motion, light touch elicits severe pain. X-ray shows patchy areas of osteopenia. Other tests r normal.
Dx?
Complex regional pain syndrome - possibly due to inflammatory cytokines…
- follows trauma, surgery
- edema erythema intense pain with light touch …
- imaging may show patchy demineralization
A 38yr old comes with progressive hip pain localized at the groin. He takes steroids for sarcoidosis. Forced abduction n internal rotation aggravate the pain. X-ray is normal.
Dx?
Avascular necrosis (disruption of bone vasculature)-MRI is more sensitive - osteoarthritis - uncommon in age<40, X-ray findings would have been there
