USMLE Flashcards
(383 cards)
1
Q
This neurological condition is commonly associated with burst fracture of the vertebra and is characterized by total loss of motor function below the level of lesion with loss of pain and temperature on both sides below the lesion. Diagnosis? Investigative test of choice?
A
Anterior cord syndrome; MRI is the best investigation to study the extent of neurological damage.
2
Q
This neurological syndrome is characterized by burning pain and paralysis in upper extremities with relative sparing of lower extremities; it is commonly see in elderly secondary to forced hyperextension injury to the neck. Diagnosis?
A
Central Cord Syndrome.
3
Q
This neurological syndrome is acute hemisection of the spinal cord and is characterized by ipsilateral motor and proprioception loss and contral lateral pain loss below the level of the lesion. Diagnosis?
A
Brown Sequard syndrome.
4
Q
If a patient has a fracture of a long bone with the fragments being offset, what is the next best step in management?
A
Gentle traction to attempt alignment of the fragments of a fractured long bone is important to prevent further vascular and neurological damage and it should be attempted immediately.
5
Q
This condition results in pain and swelling of the midline sacrococcygeal skin and subcutaneous tissues; this is most common in young men, particularly those with large amounts of body hair. This is believed to develop following chronic activity involving sweating and friction of the skin overlying the coccyx within the superior gluteal cleft. Infection of hair folicles in this region may spread subcutaneously forming an abscess that then ruptures, forming a sinus tract. The chronic sinus tract may then collect hair and debris resulting in recurrent infections and foreign-body reactions. When the sinus become acutely infected, pain swelling, and purulent discharge occur in the midline postsacral intergluteal region. Treatment is by drainage of abscesses and excision of sinus tracts. Diagnosis?
A
PILONDIAL CYST!!!
6
Q
In an anterior shoulder dislocation, which nerve is at most risk of being injured? If this nerve is injured what functions will be decreased?
A
Axillary nerve!!!; axiallary nerve injury can cause paralysis of the deltoid and teres minor muscles as well as loss of sensation over the lateral upper arm.
7
Q
Pancreatic pseudocysts are defined as collections of pancreatic secretion within a fibrous capsule, usually within the pancreas. Pseudocysts may uncommonly become infected resulting in a pancreatic abscess. Pancreatic abscess is typically accompanied by fever and leukocytosis and may result in bacteremia. What is the treatment when a pseudocyst becomes an abscess?
A
Antibiotics and external drainage of the abscess.
8
Q
What imaging study should be ordered in patients with pancreatitis?
A
Abdominal/RUQ ultrasound, as a cause for the pancreatitis should be sought. Choledocolithiasis is the most common cause of pancreatitis, and an ultrasound study early in the disease process may detect the offending stone before it is passed.
9
Q
What investigational study is the best test for identifying retroperitoneal bleeding casued by pelvic fractures?
A
PELVIC ANGIOGRAPHY; not only does pelvic angiography provide the best means for identifying the source of retroperitoneal hemorrhage, but it can also be used to treat it. By embolizing the offending vessel, the bleed can be stopped and the hemodynamics can be stabilized.
10
Q
In hemodynamicall unstable patients who have suffered blunt abdominal trauma and pelvic fracture, both intraperitoneal and retroperitoneal bleeding must be ruled out. What are the appropriate tests for establishing intraperitoneal bleeding? Retroperitoneal bleeding?
A
Focused Assessment with Sonography for Trauma (FAST) and diagnostic peritoneal lavage; if these tests are negative then the next best step in management would be pelvic angiography to search for retroperitoneal bleeding and possibly treating it via embolization of the offending vessel.
11
Q
In a patient who is APNEIC and is also at risk of having a cervical injury, what is the best way to establish and airway in the patient?
A
Orotracheal intubation is the best way to restore the airway. AN orotracheal intubation needs hyperextension of the neck and should be done only after a cervical spine injury is ruled out OR IN THE CASE OF AN APNEIC PATIENT!!! Thus, though a patient may be at risk of having a cervical spine injury, being apneic makes the benefits of orotracheal intubation outweigh the risks, and so orotracheal intubation should be done with care not to move the head. Another option would be to do a surgical cricothyroidectomy.
12
Q
Extremities subjected to at least 4-6 hours of ischemia can suffer from both intracellular and interstitial edema upon reperfusion. When edema causes the pressure within a muscular fascial compartment to rise above 30 mmHg, compartment syndrome occurs leading to further ischemic injury to the confined tissues. What are the five P’s” of compartment syndrome?”
A
1) Pain- the earliest symptom. It is classically increased by passive stretch of the muscles in the affected compartment.
2) Paresthesias- burning or tingling sensations that occur in the distribution of the affected peripheral nerve
3) Pallor- of the overlying skin is the result of tense swelling and compromised perfusion
4) Pulselessness- a late finding, so the presence of a pulse on exam does not rule out compartment syndrome
5) Paresis/paralysis - is also a late finding resulting from nerve and muscle ischemia and necrosis.
13
Q
What is the most sensitive finding on chest x-ray for blunt aortic trauma in a patient who suffers blunt deceleration trauma (MVA or fall from > 10 feet)?
A
Chest X-ray is the initial screening test, and widening of the mediastinum is the most sensitive finding. Where history and chest x-ray findings are equivocal, chest CT and angiography are appropriate.
14
Q
What is the most common cause of frank hematochezia in an elderly patient?
A
Diverticulosis.
15
Q
Persistent pneumothorax and significant air leak following chest tube placement in a patient who has sustained blunt chest trauma suggest what condition? (*other findings include pneumomediastinum and subcutaneous emphysema)
A
Tracheobronchial rupture.
16
Q
What is the first-line modality for diagnosing a urinary stone?
A
NON-CONTRAST SPIRAL CT of the abdomen and pelvis. This test can be obtained relatively quickly and will visualize calcium stones and the majority of non-calcium stones.
17
Q
What are the 4 categories of Eye Opening of the Glasgow coma scale?
A
Spontaneous- 4
To verbal command- 3
To pain- 2
None- 1
18
Q
What are the 5 categories of Verval Response of the Glasgow coma scale?
A
Oriented- 5 Disoriented/Confused- 4 Inappropriate words- 3 Incomprehensible sounds- 2 None- 1
19
Q
What are the 6 categories of the Motor Response of the Glasgow coma scale?
A
Obeys- 6 Localizes- 5 Withdraws- 4 Flexion posturing (Decorticate)- 3 Extension posturing (Decerebrate)- 2 None- 1
20
Q
What is the first step in management of a suspected urethral injury? Why is blind Foley catheterization a bad idea?
A
Retrograde urethrogram is the evaluation of choice, prior to insertion of a Foley catheter. The procedure can be used both to determine whether damage to the urethra has occurred and to determine the location of such damage within the urethra. Blind insertion of a Foley catheter is contraindicated because it can cause infection of a periurethral hematoma and cause abscess formation and could also increase the severity of the urethral tear.
21
Q
This condition is most often seen in patients chronically hospitalized (could occur on say, the 5th day) in the intensive care unit with any of the following conditions: multiorgan failure, sever trauma, surgery, burns, sepsis or prolonged parenteral nutrition. The clinical sins of disease, such as fever and leukocytosis, are vague, and patients most vulnerable to this condition are typically noncommunicative due to their medical condition. The best way to make the diagnosis is to have a high degree of clinical suspicion and to confirm the diagnosis with imaging studies that demonstrate gallbladder distension, thickening of the gallbladder wall and the presence of pericholecystic fluid. Diagnosis? Tx?
A
Acalculous Cholecystitis; the pathogenesis of this condition is unclear, but it is most likely the result of cholestasis and gallbladder ischemia, leading to secondary infection by enteric organisms, edema of the gallbladder serosa and necrosis of the gallbladder. Most patients have no prior history of gallbladder disease. If left undetected, this condition can lead to sepsis and death. The immediate treatment is cholecystostomy, which may be followed by cholecystectomy when the patient’s medical condition improves.
22
Q
Respiration and hemodynamics may be altered after repair of large hernias due to increased pressure within the abdominal cavity that results from replacement of the large hernia contents into the peritoneal cavity. The increased intraabdominal pressure impairs inferior motion of the diaphragm thereby causing hypoventilation. Anesthetics and postoperative pain control measures (narcotics) can also impair ventilation. venous return to the heart is also decreased due to increased intraabdominal pressure; this may result in hypotension is severe. Arterial blood gases seen in the patient will be consistent with hypoventilation i.e. slightly decreased pH (7.35), increased pCO2 (45), hypoxemia (70). What is the best next step in management of this postoperative condition?
A
Early physiotherapy and respiratory exercises (blowing against resistance) are indicated to prevent atelectasis, mucous plugging and pneumonia.
23
Q
Isolated duodenal hematoma most commonly occurs in children following blunt trauma to the abdomen. Patients classically present with epigastric pain and vomiting due to the failure to pass gastric secretions past the obstructing hematoma. Most hematomas resolve spontaneously in 1-2 weeks. What is the conservative management of choice in these patients?
A
Nasogastric suction and parenteral nutrition. Surgery may be considered to evacuate the hematoma if this more conservative method fails.
24
Q
This type of abscess causes perineal pain with a fluctuant mass palpable on the perineum. Pain with ambulation and defecation is common as well as urinary retention. Diagnosis?
A
Anorectal abscess.
25
This type of intraabdominal abscess presents with lower abdominal pain, malaise, low grade fever and the finding of a tender, fluctuant mass palpable only with the tip of the finger on rectal examination, which indicates its location in the rectovesical pouch. Diganosis? What is the most common cause in men vs. women?
Pelvic abscess; the most common cause in men is a ruptured appendicitis, while in women gynecologic issues are more commonly the cause.
26
In a patient with large amounts of hemoptysis the greatest danger is not exsanguination, but rather asphyxiation due to airway flooding with blood. What is the next best step in the management of a patient with this presentation?
Bronchoscopy, to localize and control the source of bleeding is the first step in managing massive hemoptysis. Rigid bronchoscopy has the additional benefit of providing good control of the airway.
27
Duodenal injury may occur during blunt trauma when the duodenum is compressed between the spine and an external solid structure like a steering wheel or seat belt during high-speed decelerating trauma. The second part of the duodenum, being retroperitoneal and therefore the least mobile, is the most commonly injured part of the duodenum in blunt abdominal trauma. Retroperitoneal air on abdominal x-rays is very suggestive. What is the most appropriate test to confim the diagnosis?
CT scan of the abdomen with oral contrast, confirms the diagnosis of duodenal injury and will disclose the presence of a concomitant duodenal hematoma. Noncontrast CT and ultrasound are not sensitive for duodenal injuries.
28
This is a cause of dependent edema that is uncommon. It may result from malignant obstruction, resection of structures, trauma, and filariasis. It classically affects the dorsa of the feet and causes marked thickening and rigidity of the skin. Diagnosis?
Lymphatic obstruction.
29
This is the most common cause of dependent lower extremity edema. It classically worsens throughout the day and resolves overnight when the patient is recumbent. Diagnosis?
Venous valve insufficiency.
30
What is the standard treatment approach for pelvic abscesses?
CT guided percutaneous drainage; surgical drainage may be attempted if percutaneous drainage fails.
31
Any gunshot wound below the 4th intercostal space (the level of the nipple) requires what surgical trauma management?
Exploratory laparotomy; any gunshot wond below the level of the nipple is considered to involve the abdomen because of the blast effect of the bullet. All penetrating traumas to the abdomen require exploratory laparotomy to ensure that there is no life-threatening injury, such as bowel trauma or hemorrhage.
32
This type of dislocation of the glenohumoral joint classically occurs during a tonic-clonic seizure or electrocution. On physical exam the arm is held adducted and internally rotated (fullness is palpable posteriorly, while the anterior shoulder is flat). Diagnosis?
Posterior dislocation of the shoulder joint.
33
Toxicity of this mineral manifests first with diarrhea, nausea, vomiting, and generalized muscle weakness. Deep tendon reflexes will be decreased of absent. Diagnosis?
Magnesium toxicity.
34
In this type of glenohumeral joint dislocation, the arm is held in a slight abduction and external rotation. Diagnosis?
Anterior dislocation of the shoulder joint.
35
When a patient presents with a pulsatile abdominal mass and hypotension, what is the next best step in management?
This is an AAA until proven otherwise, and no further studies are indicated. Thus, the patient should be immediately taken to the operating room for an emergent laporotomy for repair of the aneurysm. Mortality with this condition is approximately 50%; early recognition and operative intervention are essential.
36
A young individual presents with a fleshy immobile mass on the midline of the hard palate. This is a benign bony mass (exostosis), and the growth of bone arises from the midline suture in the hard palate. The patient will usually give a history that the lesion has been present for some time and will deny tenderness. The thin epithelium overlying the bony growth will tend to ulcerate and be slow to heal due to poor vascularity. No medical or surgical therapy is required unless the mass becomes symptomatic. The cause of this mass is unknown and is unrelated to trauma. Diagnosis?
Torus palatinus.
37
Patients with this condition usually have undergone some sort of trauma or surgical intervention to a limb. Classically the patient will complain of severe pain that is worsened on passive range of motion, paresthesias, pallor and paresis of the affected limb (pain not alleviated by narcotics). Diagnosis?
Compartment syndrome; pressure in the compartments can be measured directly using a needle and pressure transducing catheter system. Pressures over 30 mmHg may result in cessation of blood flow through the capillaries and should be treated emergently by fasciotomy.
38
What study is typically done following a neck trauma to rule our carotid artery injury?
Angiogram!!!; this will evaluate the aortic arch and its branches
39
When is ligation of a carotid artery done?
ONLY if there is uncontrolled hemorrhage from the vessel, or if it is occluded. It is not recommended to ligate carotid artery dissection; it may produce acute stroke.
40
When there is an intimal flap of the carotid artery, surgery is recommended to repair the vessel. Intimal flap injury can lead to vessel occlusion and symptoms and signs of ischemia. Today, the availability of what technique may be an alternative option to surgery?
Stenting.
41
Which CN courses directly through the substance of the parotid gland? If a patient required removal of the parotid gland, or just had parotid surgery involving the deep lobe of the parotid gland, what complication would likely result?
CN VII (Facial Nerve); unilateral facial droop
42
What are the four criteria for SIRS (Systemic Inflammatory Response)?
1. Fever or hypothermia
2. Tachypnea
3. Tachycardia
4. Leukocytosis, leukopenia, or bandemia
*Patients meeting at least two of these four criteria are considered to have SIRS. SIRS due to an infection is called sepsis.
43
What is the definition of Sepsis? What is the definition of Septic Shock?
SIRS due to infection; Septic shock is diagnosed in cases of infection-related SIRS where hypotension is unresponsive to fluid resuscitation and vasopressors are required to maintain SBP > 90 mmHg.
44
In the first week following a burn, what bacteria is the most likely cause of wound infection? What about after one week?
S.aureus; Pseudomonas
45
Abdominal CT is used to detect intraabdominal injury in trauma patients who are hemodynamically stable. In hemodynamically unstable patients, what should be the initial test? What should be done next if that exam is inconclusive?
FAST is the first option; the primary tool used in this situation of a hemodynamically unstable patient to determine the need for emergent laparotomy, is a (F)ocused (A)ssessment with (S)onography for (T)rauma. This has 65 to 95% sensitivity for intraperitoneal hemorrhage. A limitation of the FAST exam is that image quality can vary based on operator experience and patient body habitus. Although rarely performed nowadays, a Diagnostic Peritoneal Lavage remains the diagnostic test of choice for detecting intraperitoneal hemorrhage in an unstable patient if the FAST exam is inconclusive.
46
This condition may complicate up to 7% of procedure on the aortoiliac vessels and most commonly affects the distal left colon/rectosigmoid junction. Common causes include loss of colateral circulation, manipulation of vessels with surgical instruments, prolonged aortic clamping and impaired blood flow through the IMA. Patients report dull pain over the ischemic bowel as well as hematochezia. Colonoscopy shows a discrete segment of cyanotic and ulcerated bowel. Diagnosis?
Ischemic Colitis!!!
47
Fever, chills, and deep abdominal pain suggest what condition?
Deep abdominal abscess.
48
What are the most common causes of infective aortic aneurysms?
Staphylococci and Salmonella.
49
Blunt trauma to the upper abdomen can cause a pancreatic contusion, crush injury, laceration or transection. Pancreatic injuries can later be complicated in what way?
By retroperitoneal abscess or pseudocyst.
50
If an unconscious patient is brought in to you with known head trauma, what should be the first step in management?
X-ray of the spine; patients with head trauma can have coexisting cervical spine injury, which should always be assessed before mobilizing the patient. Clinical evaluation of the cervical spine in a patient with blunt trauma is unreliable. Because of grave consequences of missing a cervical spine injury, it is important to rule out a fracture or dislocation of cervical spine vertebrae as the first priority.
51
Patients with Crohn disease, or any other small intestinal disorder resulting in fat malabsorption, are predisposed to what condition that can cause nephrolithiasis?
HYPEROXALURIA!!!; oxalate is obtained from the diet and is a normal product of human metabolism. Symptomatic hyperoxaluria is classically the result of increased oxalate absorption in the gut. Under normal circumstances, calcium binds oxalate in the gut and prevents its absorption. In patients with fat malabsorption, calcium is preferentially bound by fat, leaving oxalate unbound and free to be absorbed into the bloodstream. Failure to adequately absorb bile salts in states of fat malabsorption also cause decreased bile salt reabsorption in the small intestine. Excess bile salts may damage the colonic mucosa and contribute to increased oxalate absorption.
52
What measure is necessary to take in order to reduce the risk of respiratory and cardiac complications after placement of a central line?
Chest x-ray confirmation of catheter tip location after placement.
53
Femoral shaft fractures are generally seen after severe direct trauma. Patients suffering traumatic fractures of the femoral shaft frequently present with signs of shock as a significant amount of blood can be lost into the thigh. On examination, the thigh is often deformed and ecchymotic. What is the preferred management for femoral shaft fracture?
Closed intramedullary fixation of the shaft with medullary reaming and intramedullary nailing. This allows for early mobilization, improved knee and hip function during recovery and decreased hospital cost. In this technique, closed reduction of the fracture segment is followed by intramedullary nail insertion through a small skin insertion over the greater trochanter.
54
This condition is characterized by severe respiratory distress, petechial rash, subconjunctival hemorrhage, tachycardia, tachypnea, and fever. It presents in patients with polytrauma, especially multiple fractures of long bones. Diagnosis? Tx?
FAT EMBOLISM!!!; diagnosis can be confirmed by presence of fat droplets in the urine or presence of intra-arterial fat globules on fundoscopy. It may occur from 12 to 72 hours after the injury. CNS dysfunction initially manifests as confusion and agitation but may progress to stupor, seizures, or coma and frequently is unresponsive to correction of hypoxia. Treatment of Fat Emboli includes prompt respiratory support. Use of heparin, steroids and low molecular weight dextran is controversial.
55
A classic petechial rash occurs with what type of embolism after trauma?
Fat Embolism!
56
The spleen is the most commonly injured organ in cases of blunt trauma. What is the main guide that is the determinant for surgical versus non-surgical management of patients with splenic trauma?
Hemodynamic stability and the ned for blood transfusion are the determinants; patients who present in obvious hemorrhagic shock should undergo immediate laparotomy and splenectomy, but most patients are managed nonoperatively with close ICU monitoring and fluid resuscitation. Some patients who have a hemorrhage but are otherwise hemodynamically stable may be candidates for angiography, which can demonstrate the exact site of hemorrhage and be used to treat the hemorrhage by embolization/
57
This nerve innervates the muscles of the anterior compartment of the thigh (i.e. quadreceps, femoris, sartorius, pectineus), and is therefore responsible for knee extension and hip flexion; it provides sensation to the anterior thigh and medial leg via the saphenous branch. Nerve?
Femoral nerve.
58
This nerve supplies the muscles of the posterior compartment of the thigh, posterior compartment of the leg, and plantar muscles of the foot. These muscles control flexion of the knee and digits, and plantar flexion of the foot. This nerve provides sensation to the leg (except medial side) and plantar foot. Nerve?
Tibial nerve.
59
This nerve innervates the medial compartment of the thigh (i.e. gracilis, adductor longus, adductor brevis, anterior portion of adductor magnus) and controls adduction of the thigh. It provides sensation over the medial thigh. Nerve?
Obturator nerve.
60
This nerve gives rise to two nerves that supply the muscles of the anterior and lateral leg. These nerves provide sensation to the anterolateral leg and dorsum of the foot. Nerve?
Common peroneal, which gives rise to the superficial and deep peroneal.
61
What is another name for the Common peroneal nerve?
Fibular nerve.
62
A patient presents with complaints of daytime fatigue, anorexia, significant weight loss, and visceral-type abdominal pain interfering with sleep; physical exam reveals a tender, full epigastrum. This combination suggests a malignancy affecting what parts of the body?
The upper GI tract or associated solid organs such as the liver, gallbladder or pancreas.
63
Necrotizing surgical infection is characterized by intense pain in the wound, decreased sensitivity at the edges of the wound, cloudy-gray discharge, and sometimes crepitus. What is the next most important step in management once this is recognized?
Early surgical exploration to assess the extent of the process and debride the necrotized tissues.
64
What is the typical age that Legg-Calve-Perthes disease presents in children?
4-10 year old boys.
65
Why is diaphragmatic hernia caused by trauma more common on the left hemidiaphragm?
The right hemidiaphragm is protected by the liver.
66
This is a condition that can be associated with blunt trauma of the abdomen and a sudden increase in intraabdominal pressure. It may cause compression of the lungs and mediastinal deviation. Patients may develop marked respiratory distress. Elevation of the hemidiaphragm on chest x-ray may be the only abnormal finding. The early recognition of this condition is extremely important since the mortality of undiagnosed injury is approx. 30%. Chest X-rays are abnormal in about 85% of cases; however the diagnosis is only made in 27% of cases!!! Diagnosis?
Diphragmatic rupture with leakage of intraabdominal contents into the chest.
67
In a steady resting state the Respiratory Quotient depends upon the proportions of CO2 produced to O2 consumed per unit time. A steady state RQ is close to 1.0 and indicates predominant oxidation of what type of nutrients being used by the body? What about an RQ of 0.8? 0.7?
A steady state RQ close to 1.0 indicates predominant oxidation of carbohydrates and net lipogenesis. The RQ for protein and lipids as sole sources of energy are 0.8 and 0.7, respectively.
68
Why is assessing the Respiratory Quotient (RQ) important when attempting to wean patients from mechanical ventilation?
Because overfeeding, especially with carbohydrates, can cause excessive CO2 production and make weaning more challenging. This factor is especially important in patients with preexisting lung disease.
69
The incidence of this malignancy is highest in the second decade of life; patients typically present complaining of persistent bone pain that may be worse at night; systemic manifestations and pathological fractures are uncommon; the ESR is normal while serum alk phos is elevated. An x-ray film in a 15 year old boy shows an osteolytic lesion of the distal femur along with periosteal inflammation; sun-burst appearance. Diagnosis?
Osteosarcoma.
70
This bone tumor is most common in the second decade of life and it is a small, blue cell (neuroectodermal) malignancy classically associated with systemic manifestations such as fever, malaise and weight loss; it typically affects the diaphyses of long bones as well as the spine and pelvis; x-ray shows an osteolytic lesion with onion-skin appearance. Diagnosis?
Ewing's sarcoma.
71
This is a tumor of adults that often involves the epiphysis of the distal femur or proximal tibia. Radiology characteristically shows a soap-bubble appearance due to the osteolytic quality of the tumor. Diagnosis?
Osteoclastoma.
72
States of magnesium excess are characterized by generalized neuromuscular depression. Clinically, severe hypermagnesemia is rarely seen except in those patients with advanced renal failure treated with magnesium-containing antacids. However, hypermagnesemia is produced intentionally by obstetricians who use parenteral MgSO4 to treat preeclampsia. MgSO4 is administered until the first signs of hypermagnesemia are present. What is the earliest sign?
Loss of deep tendon reflexes (a deficit that occurs with modest hypermagnesemia, 4 mEq/L). Greater elevations of magnesium produce progressive muscle weakness, which culminates in flaccid quadrapelgia and in some cases respiratory arrest due to paralysis of the chest bellows mechanism. Hypotension can occur because of the direct relaxing affect of magnesium. Changes in mental status occur in the late stages of the syndrome and are characterized by somnolence that progresses to coma.
73
What FEna value supports a diagnosis of hypovolemia in the setting of an oliguric patient?
FEna < 1
74
This mineral deficiency is common in malnourished patients and patients with large GI fluid losses. The neuromuscular effects resemble those of calcium deficiency, namely paresthesia, hyperreflexia, muscle spasm, and ultimately, tetany. The cardiac effects are more like those of hypercalcemia. This mineral deficiency causes a functional hypoparathyroidism, which can lower serum calcium and thus result in a combined affect. This deficiency also causes potassium wasting by the kidneys. Diagnosis?
Hypomagnesemia.
75
Whenever bleeding is noted in the early postoperative period, what should the presumption of cause be?
An error in surgical control of blood vessels in the operative field; hematologic disorders that are not apparent during the long operation are most unlikely to surface as problems postoperatively.
76
What serum electrolyte abnormality is of concern when initiating refeeding in a patient who is chronically malnourished?
Hypophosphatemia due to refeeding syndrome", which occurs in malnourished patients who are administered intravenous glucose. During periods of starvation, electrolytes are shifted to the extracellular space to maintain adequate serum concentrations. With refeeding, insulin levels rise and electrolytes are shifted back intracellularly, resulting potentially in hypokalmemia, hypomagnesemia, and hypophosphatemia. Additionally, refeeding results in an increased cellular need for phosphorous for energy production (ATP) and glucose metabolism"
77
A cirrhotic patient with abnormal coagulation studies due to hepatic synthetic dysfunction requiring an urgent operation should undergo transfusion of FFP at what time in relation to the surgery in order to minimize the risk of bleeding?
Transfusions with FFP to replenish Vitamin K-dependent clotting factors should be administered on call to the operating room. The timing of transfusion is dependent on the quantity of each factor delivered and its half life. The half-life of the most stable clotting factor, factor VII, is 4 to 6 hours. Thus transfusion of FFP on call to the operating room ensures that the transfusion is complete prior to the incision, with circulating factors to cover the operative and immediate postoperative period.
78
What is the most common postoperative nosocomial infection? Tx?
Urinary Tract Infection; treatment involves removal of an indwelling catheter as soon as possible and antibiotic therapy for cultures with greater than 100,000 CFU/mL
79
What are the 7 factors that predispose to fistula formation and may prevent closure of a fistula?
Foreign body, radiation, inflammation, epithelialization of the tract, neoplasm distal obstruction, and steroids.
80
What is the agent used to prepare a Hemophilia A patient before surgery? What if the disorder is mild? What if it is severe?
Hemophilia A is a coagulation disorder resulting from a deficiency or abnormality of Factor VIII. Desmopressin (DDAVP) is a synthetic analogue of antidiuretic hormone that increases levels of Factor VII and von Willebrand factor. DDVAP can be used alone for mild Hemophilia A, but is ineffective in severe forms of the disease. For severe Hemophilia A, DDVAP is given in combination with an inhibitor of fibrinolysis such as E-aminocaproic acid (AMICAR). Other agents used in treatment of Hemophilia A include cryopreicpitate and specific Factor VIII concentrates.
81
This is a finding in patients with primary hyperparathyroidism and represents subperiosteal resorption, characteristically on the radial aspect of the middle phalanx.
Osteitis cystica fibrosa.
82
What are the malabsorptive complications that can arise from a Billroth II reconstruction of the stomach?
Patients who have undergone partial gastrectomy (Billroth II) may have impaired calcium absorption, impair fatty acid absorption, B12 deficiency, and Iron deficiency.
83
What ECG change is associated with Hypocalcemia? Hypercalemia?
Hypocalcemia is associated with Prolonged QT and may be aggravated by both hypomagnesemia and alkalosis; Hypercalcemia is associated with Shortened QT
84
Massive transfusion is associated with hypocalcemia secondary to chelation with citrate in banked blood. Severe, symptomatic hypocalcemia is most commonly encountered following parathyroid or thyroid surgery, or in patients with acute pancreatitis. What is the treatment for these patients?
IV Calcium Gluconate!!!
85
Delivery of this medicine causes a rise in serum pH and shifts K+ intracellularly in exchange for H+ to the serum, in an effort to symptomatically treat hyperkalemia. Medicine?
NaHCO3!!!; sodium bicarbonate.
86
Alopecia, poor wound healing , night blindness or photophobia, anosmia, neuritis, and skin rashes are all characteristic of what mineral deficiency?
Zinc deficiency.
87
The deficiency of this mineral is characterized by cardiomyopathy. Diagnosis?
Selenium deficiency.
88
The deficiency of this trace mineral is characterized by encephalopathy due to toxic accumulation of sulfur-containing amino-acids. Diagnosis?
Molybdenum deficiency.
89
This trace mineral deficiency can occur in patients on long-term TPN and is characterized by difficult-to-control hyperglycemia and peripheral neuropathy and encephalopathy. Diagnosis?
Chromium deficiency.
90
Normal saline and Lactated Ringer solution are examples of isotonic saline solutions. Following administration of large volumes of normal saline, a non-anion-ga metabolic acidosis can result from increased chloride concentrations. These fluids can be used to replace the volume of blood lost in a patient in what ratio?
3:1 (Fluids: blood)
91
The use of colloids in resuscitation of patients in hemorrhagic shock is controversial; in general, however, colloids can be used to replace blood volume lost at what ratio?
1:1 (colloid: blood)
92
What fluid is appropriate to resuscitate a patient with significant nasogastric suction or vomiting losses?
Isotonic saline; this is particularly useful in hyponatremic or hypochloremic states and whenever a tendency to metabolic alkalosis is present. When isotonic solutions are given in large quantities, they overload the kidney's ability to excrete chloride ion, which results in dilutional acidosis. They may also intensify preexisting acidosis by reducing the base bicarbonate-carbonic acid ratio in the body.
93
Administration of what resuscitation fluid is appropriate for replacement of GI losses?
Lactated Ringer solution; this is appropriate for replacing GI losses and correcting extracellular fluid deficits. Lactated Ringer solution contains 130 mEq/L, and thus is hypoosmolar with respect to serum sodium, and provides ~150 mL of free water with every Liter given. Lactated Ringer is sufficiently physiological to enable administration of large amount without significantly affecting the body's acid-base balance. It is worth noting that both isotonic saline and lactated Ringer are acidic with respect tot he plasma NS with 5% Dextrose has a pH of 4.5, while lactated Ringer hase a pH of 6.5.
94
Early sepsis is a physiologically hyperdynamic, hypermetabolic state representing a surge in catecholamines, cortisol, and other stress-related hormones. Changing mental status, tachypnea that leads to respiratory alkalosis and flushed skin are often the earliest manifestations of sepsis. What early hemodynamic change is indicative of occult sepsis?
Intermittent HYPOTENSION!!!; intermittent hypotension requiring fluid resuscitation to maintain adequate urine output is characteristic of occult sepsis. Hyperglycemia and insulin resistance are typical in diabetic as well as non-diabetic patients. This relates to the gluconeogenic state of the stress response. The cardiovascular response to early sepsis is characterized by an increased cardiac output decreased systemic vascular resistance, and decreased peripheral utilization of oxygen, which yields a decreased arteriovenous oxygen difference.
95
Trauma, stress, sepsis, burns and surgery all increase the BMR of the body. The BMR can be multiplied by stress factors to better approximate caloric requirements. What is the stress factor associated with routine operation? Multiple organ failure or severe injury? Less than 50% body surface area burns?
Routine operation = 1.1
Multiple organ failure or severe injury = 1.5
Less than 50% body surface area burns = 2.0
96
When a patient with a tracheostomy tube has a sentinel bleed from inside the tube days later, what is the proper course of action if the bleed has currently stopped? If it is ongoing?
A sentinel bleed such as this occurs from a tracheoinnaminate artery fistula, which carries a greater than 50% mortality rate. If the bleeding has ceased then immediate fiberoptic exploration in the operating room is indicated. If the bleeding is ongoing, stop gap measures such as hyperinflation of the tracheostomy ballon to attempt compression of the artery, reintubation of the patient with an endotracheal tube, and removal of the tracheostomy and placement of a finger through the site with anterior compression of the innominate artery can be attempted, while preparing for median sternotomy.
97
The rapid shallow index is a parameter used to determine the readiness for a patient to be removed from ventilation. Rapid shallow breathing index is the ratio of the respiratory rate to tidal volume. What index ratio has been suggested to predict successful extubation?
Index between 60 and 105.
98
What should the negative inspiratory force of a patient's inspiration be, before they can be successfully extubated from a ventilator?
The negative inspiratory force should be at least greater than -20 cmH2O.
99
What PEEP should a patient be weaned to before they are extubated from a ventilator?
5 cmH2O PEEP.
100
What should the minute ventilation, which is the product of the tidal volume and respiratory rate, should be less than what value before attempting extubation from a ventilator?
< 10 min/L
101
Spontaneous respiratory rate should be below what value in a patient, before attempting to extubate them from the ventilator?
20 breaths/min
102
In a patient with a hemolytic transfusion reaction, what are the steps necessary to protect the kidneys from the damaging effects of hemoglobin precipitation in the renal tubules?
Mannitol and NaHCO3; the precipitation of hemoglobin in the renal tubules is inhibited in an alkaline environment and is promoted in an acidic environment. Stimulating diuresis with mannitol and alkalinizing the urine with sodium bicarbonate intravenously are indicated procedures.
103
This inhalation anesthetic has a low solubility compared with other inhalation anesthetics; it is more soluble in blood than nitrogen and is the only anesthetic gas less dense than air. As a result of these properties, this gas may cause progressive distension or air-filled spaces during prolonged anesthesia. This could be bad for operation on intestinal obstruction. Anesthetic?
Nitrous Oxide.
104
Why does banked blood shift the O2 dissociation curve to the left?!?
Because banked blood is low in 2,3-BPG, thus is shifts the curve to the left and the blood holds on to O2 better and therefore decreases tissue O2 uptake.
105
Dopamine at this level of dosage affects primarily the dopaminergic receptors. Activation of these receptors causes vasodilation of the renal and mesenteric vasculature and mild vasoconstriction of the peripheral bed, which thereby redirects blood flow to the kidneys and bowel. What is the dose level?
Low dose [1-5 mg/(kg x min)]
106
At this level of dopamine dosing B1-receptor activity predominates and the ionotropic effect on the myocardium leads to increased cardiac output and blood pressure. What level dosing is this?
Moderate [2-10 mg/(kg x min)]
107
At this level of dopamine dosing alpha-receptors are activated and cause strong peripheral vasoconstriction, shifting blood from the extremities to the organs, decreased kidney function, and hypoperfusion. What level of dosing is this?
High [>10 mg/(kg x min)]
108
How does Dopamine administration affect the coronary blood flow and any level of dosing?
It INCREASES CORONARY BLOOD FLOW; At all doses, the diastolic pressure can be expected to rise as a result of dopamine administration; since coronary perfusion is largely a result of the head of pressure at the coronary ostia, coronary blood flow can be expected to INCREASE.
109
This is a synthetic catecholamine that is becoming the ionotropic agent of choice in cardiogenic shock. As a B1-adrenergic agonist, it improves cardiac pump performance in pump failure both by positive ionotropy and peripheral vasodilation. With minimal chronotropic effect, this drug only marginally increases myocardial O2 demand. What drug is this?
Dobutamine!!!
110
Thoracic epidural narcotics have become an increasingly popular means of postoperative pain relief in thoracic and upper abdomnial surgery. Local action on gamma opiate receptors ensures pain relief and consequent improvement in respiration without vasodilation or paralysis. The less lipid-soluble opiates are effective for long periods. Their slow absorption into the circulation also ensures a low incidence of centrally mediated side effects, such as respiratory depression, or generalized itching. When these do occur what is the effective antidote?
INTRAVENOUS NALOXONE!!!; not epidural; the locally mediated analgesia is not affected.
111
The development of acute postoperative acalculous cholecystitis is an increasingly recognized complication of the severe illnesses that precipitate admissions to the ICU. The diagnosis is often difficult because the signs and symptoms may be those of occult sepsis. If diagnosis is delayed, mortality and morbidity are very high. What is the treatment for acalculous cholecystitis in the postoperative period?
Percutaneous drainage of the gallbladder!!!; this is usually curative and affords stabilizing palliation if calculous cholecystitis is present. Antibiotics without drainage are too cautious a choice for a patient with this potentially fatal complication. Operative intervention is indicated only if less invasive methods of treatment (percutaneous cholecstostomy tube) have failed.
112
What is the mechanism of action by which PEEP improves oxygenation?
Increasing Functional Residual Capacity; PEEP does this by keeping alveoli open at the end of expiration. Extravascular lung water is shifted from the alveolar to the interstitial space. The overall result is to increase surface area for diffusive exchange of gases.
113
What cardiac condition causes right atrial collapse and equalization of pressures in all four heart chambers?
CARDIAC TAMPONADE!!!; the equalization of pressures occurs because right atrial pressures and central venous pressure are increased and cardiac output is decreased.
114
What is the surgical significance of previous MI within 6 months, functional impairment such as dyspnea on exertion, age over 70 years, mitral regurgitation, more than 5 PVCs in a minute, and a tortuous or calcified aorta?
These are are the main cardiac risk factors associated in noncardiac surgical patients identified by a landmark study by Goldman in 1978.
115
Neurogenic shock is characterized by loss of sympathetic tone peripherally as well as bradycardia owing to loss of the reflexive increase in heart rate in response to hypotension. What is the appropriate first step in management of such a patient?
Initial treatment is with fluid resuscitation followed by initiation of vasoconstrictors such as dopamine or phenylephrine.
116
Accurate measurement of PCWP by a Swan-Ganz catheter may not be possible in the presence of positive air-way pressure with PEEP/CPAP; transmission of the positive airway pressure to the pulmonary microvasculature, via the alveoli, especially in the upper lung zones, results in the measurement of what pressure rather than LAP or LVEDP?
Alveolar pressure.
117
The risk of recurrent stroke appears to be comparable with that for surgical patients who do not have a history of prior stroke the those that do have a stroke history, when undergoing cardiac or peripheral vascular surgery? Most recurrent strokes occur within hours to days following surgery and do not appear to be directly related to operative events. Is mortality after a postoperative stroke high or low?
Mortality is HIGH after a postoperative stroke.
118
What is the initial treatment for someone having an anaphylactoid reaction with laryngeal obstructive signs and possible bronchospasm?
EPINEPHRINE!!!; is the initial treatment, followed by histamine antagonists (H1 and H2 blockers), aminophylline, and hydrocortisone. Conscious patients are usually stabilized with injected or inhaled epinephrine, while unconscious patients and those with refractory hypotension or hypoxia should be intubated. Vasopressors and fluid challenges may be given for shock.
119
Most transfusion reactions are hemolytic and are due to clerical errors that result in administration of blood with major (ABO) and minor antigen incompatibility. Intravascular hemolysis resultis in hemoglobinemia and serum haptoglobin levels are decreased (
A positive Coomb's test.
120
Indirect hyperbilirubenemia and anemia may be seen in what type of transfusion reaction?
Delayed transfusion reaction, which occurs between 2-10 days after trasfusion. Delayed transfusion reactions can occur due to antibodies to Rh antigens and are indicative of extravascular hemolysis.
121
In a ventilated patient what parameters are used to determine ventilation status?
CO2 and PaCO2 levels; due to highly efficient diffusion characteristics these indicators are good measures of adequacy of alveolar ventilation.
122
What effect does hypokalemic metabolic alkalosis have on the urine pH?
It produces paradoxical aciduria, as the kidney excretes hydrogen ion in an effort to conserve potassium ion.
123
A rare but deadly complication of tracheostomy us a tracheoinnominate artery fistula (TIAF); when suspected, the diagnosis should be confirmed or ruled out in the operating room through bronchoscopic evluation. TIAFs can occur as early as 2 days after the tracheostomy or as late as 2 months after the procedure. TIAF formation is often associated with what functional aspect of the tracheostomy procedure?
Low placement of the tracheostomy (i.e. distal to the second and third tracheal rings).
124
What are the appropriate steps to manage a tracheoinnominate artery fistula (TIAF) that forms as a result of low placement of a tracheostomy (i.e. distal to the second and third tracheal rings)?
TIAFs result in a sentinel bleed 50% of the time, followed by very impressive bleeding. If a sentinel bleed is suspected, the patient should be transported immediately to the operating for evaluation. Initial maneuvers for management of TIAF include overinflation of the cuff on the tracheostomy or reintubation from above followed by removal of the tracheostomy and finger compression of the innominate artery against the sternum through the tracheostomy wound.
125
Although Factor VIII is deficient in patients with Von Willebrand disease, what is the only reliable IV solution that should be given to aid coagulation in such patients?
Cryoprecipitate!!!; this is because treatment requires correction of the bleeding time and providing factor VII R: WF (Von Willebrand factor). Only Cryoprecipitate is reliably effective. High purity Factor VIII:C concentrates that are effective in Hemophilia, lack the von Willebrand factor and are consequently undependable.
126
This intraoperative complication may show rigidity instead of anticipated relaxation as its first sign. Treatment should include prompt conclusion of the operative procedure and cessation of anesthesia, hyperventilation with 100% O2, and administration of dantrolene. The urine should be alkalinized to protect the kidneys from myoglobin precipitation. In addition to fever, the syndrome includes tachycardia, increased O2 consumption, increased CO2 production, increased serum K+ and, myoglobinuria, and acidosis. Diagnosis?
Malignant Hyperthermia due to halothane and succinylcholine administration.
127
Cholesterol embolism is a known complication of angiography or aortic manipulation during surgery and can result in lower extremity ischemia, acute myocardial infarction, ischemic bowel, and acute or chronic renal failure. What specific CBC cytologic finding is highly suggestive of cholesterol emboli?
EOSINOPHILIA!!!; this is strongly suggestive of cholesterol atheroembolization, and other laboratory findings include microscopic hematuria or proteinuria and elevated inflammatory mediators such as erythrocyte sedimentation rate.
128
What treatment should be considered in patients with neurological symptoms and carbon monoxide poisoning, as this treatment reduces the half-life of carboxyhemoglobin?
Hyperbaric O2.
129
What inhalation agent is most likely to cause a patient with a bowel obstruction to develop increasingly distended loops of bowel after induction?
Nitrous Oxide (N2O)!!!; this is becasue nitrous oxide is 30 times more soluble than nitrogen in the blood and enters a collection of trapped air at a rate faster than at which nitrogen leaves the collection. Thus, this leads to an increase in volume of trapped air such as loops of bowel leading to bowel distension.
130
Succinylcholine is a depolarizing neuromuscular blocking agent that causes what effect on serum electrolytes? What patients do you not want to use this in?
Increase in serum K+; it causes a rise in serum potassium of up to 1.0 mEq/L within a few minutes after administration. This is caused by efflux of potassium from the skeletal muscle at the neuromuscular junction. Patients with burns, trauma, severe infections or neuromuscular disorders have a greater than normal potassium efflux that occasionally causes severe hyperkalemia.
131
What neuromuscular blocking agent do you not want to use in patients with burns, trauma, severe infections or neuromuscular disorders, because these patients with have a greater than normal potassium efflux from their cells that occasionally causes severe hyperkalemia?
Succinycholine.
132
Rapid intravenous injections of Morphine may cause what effect on blood pressure?
Hypotension.
133
Pancuronium is a neuromuscular blocking agent that is associated with what effect on heart rate?
Tachycardia!!!
134
In a patient with CHF and low volume status who requires immediate surgery, what technique will allow physicians to assess his volume status ad need for ongoing ionotropic support, and help dictate further treatment (volume, afterload reduction, etc.)
Pulmonary Artery Catheterization!!!
135
PT is used for the extrinsic or intrinsic pathway?
EXTRINSIC!!!
136
PT detects deficiencies in what which coagulation factors?
Factors II, VII, IX, X and Fibrinogen, and is used to monitor patients receiving Warfarin.
137
What coagulation factor deficiencies does thrombin time assess?
Thrombin time assess the qualitative abnormalities in fibrinogen and the presence of inhibitors to fibrin polymerization. A standard amount of fibrin is added to a fixed volume of plasma and clotting time is measured.
138
The appropriate margin for wide excision of melanomas is dependent on the depth of the lesion. For thin lesions, less than or qual to 1mm in depth what is the minimal requirement for margins? For intermediate (1-4mm)? For thick (>4mm) lesions?
Thin melanomas (4mm) = 2cm margin
139
Inflammation, proliferation and remodeling are the sequence of events for what process?
WOUND HEALING!!!
140
What are the primary cells that enter a wound during the inflammatory phase of woud healing?
Neutrophils and Monocytes.
141
What are the biochemical mediators that are released during day 2 of wound healing when monocytes migrate into the wound site?
Monocytes secrete numerous growth factors such as TNF, TGF, PDGF and FBGF, all of which are essential to wound healing.
142
At what phase do angiogenesis and collagen formation take place during wound healing?
The proliferative phase.
143
When is the first point at which collagen deposition is maximal in a wound, during the process of wound healing?
2-3 weeks, at which time the remodeling phase begins.
144
Pyoderma gangrenosum is a rare cause of cutaneous ulcerations that can be associated with inflammatory bowel disease (Crohn's and Ulcerative colitis) as well as other immune disorders. What is the mainstay of treatment for such wounds?
Systemic steroids and immunosuppressants.
145
What is the most effective method of rewarming in a patient with frostbite?
Water Immersion; rapid rewarming by immersion in water slightly above normal body temperature (40-44C; or 104-112F) is the most effective method, however, because the frostbitten region is numb and especially vulnerable, it should be protected from trauma or excessive heat during treatment. Further treatment may include elevation to minimize edema, administration of antibiotics and tetanus toxoid, and debridement of necrotic skin as needed.
146
The superficial flexor digitalis tendons inserts on what part of the fingers?
The middle phalanx.
147
The deep flexor digitalis tendons insert on what part of the finger?
The distal phalanx.
148
Does the superficial or deep flexor digitalis muscle have tendons that share a common muscle belly?
The deep flexor digitalis muscle; since the tendons of the deep flexors share a common muscle belly, only the superficial flexors can move a finger when the adjacent fingers are immobilized.
149
What is a tenoma and what type of anatomical structure is it involved in the healing of?
A tenoma is a tendinous inflammation that is formed in the process of healing tendon injury. A difficult balance has to be struck between the desire to prevent adhesions by early mobilization and the risk of rupturing an unhealed tendon.
150
This type of wound is a wound in which no part of the respiratory, gastrointestinal, or GU tract is entered (e.g. herniorrhaphy and breast surgery). What class of wound is this?
Clean wound; Class I
151
In this class of wound, the respiratory, GI, or GU tracts may be entered, but there is no evidence of active infection or gross spillage (e.g. cholecystectomy or elective colon resection, with adequate bowel preparation. What class of wound is this?
Clean-contaminated; Class II
152
These type of wounds include open accidental wounds encountered early after injury, those with extensive introduction of bacteria into a normally steile area of the body, or gross spillage of viscus contents such as from the intestine (e.g. include penetrating abdominal trauma, large tissue injury, and enterotomy during bowel obstruction. What class of wound is this?
Contaminated; Class III
153
This type of wound includes traumatic wounds in which a significant delay in treatment has occurred and in which necrotic tissue is present, those wounds created in the presence of purulent material, and those involving a perforated viscus accompanied by a high degree of contamination (e.g. perforated diverticulitis and necrotizing soft tissue infections). What class of wound is this?
Dirty; Class IV
154
Mohs surgery describes a technique for resecting either basal or squamous cell carcinoma on the face or near the nose or eye in order to achieve optimal cosmetic results. Resection of the tumor is performed in small increments with immediate frozen section analysis in order to ensure negative margins. The disadvantage of the Mohs technique is the longer time required. What is the difference in cure rate between Mohs surgery and wide local excision of a basal cell carcinoma?
There is NO DIFFERENCE.
155
Early wound management is characterized by early excision of areas of devitalized tissue, with exception of deep wounds of the palms, soles, genitals and face. Early excision leads to decreased hospital stay and lower cost. This is especially true of burns covering more than 30-40% of the total body surface area. In conjunction with early excision, topical antimicrobials such as silver sulfadiazine are extremely important in delaying colonization of newly excised or fresh burn wounds. What time points constitute early excision?
Between 3 and 7 days after the injury. Staged excision of deep partial-thickness or full-thickness burns occurs in this time period.
156
What are the three main topical agents used to treat burns in burn victims?
Silver nitrate, silver sulfadiazine, and mafenide acetate.
157
Hyponatremia, hypokalemia, hypocalcemia, hypochloremia, methemoglobinemia; these are all complications associated with what treatment used for treating the wounds of burn victims?
Silver nitrate.
158
Neutropenia is the main complication of this topical compound used to treat the wounds in burn patients.
Silver sulfadiazine
159
The main side effects of this topical compound used to treat wounds in burn victims is metabolic acidosis secondary to the inhibition of carbonic anhydrase.
Mafenide acetate.
160
While epithelialization is responsible for the healing of a closed incision, what is the primary method of closure of open wounds?
WOUND CONTRACTURE!!!; during this process, the skin surrounding the wound is pulled over the wound surface and may account for up to a 90% reduction in the size of an open wound. In areas of greater adherence to the underlying tissue, the ability of contraction to close the wound is hindered due to the decreased mobility of the skin
161
In a child with a cleft lip and/or palate, what is the recommended timeline for repair of the cleft lip? The cleft palate?
Repair of the lip in the first 3 months of life; repair of the palate at 12-18 months (palate repair after 2 years of age is associated with a high incidence of speech impairment.
162
Should wounds that are dirty or contaminated, that are traumatically induced by a puncture, gunshot, or crush injury, or that are older than 6 hours be closed or left open? Should prophylactic antibiotics be given in any of these cases, if so which ones?
OPEN!!!; prophylactic antibiotics have not been demonstrated to prevent wound infections in any of these cases.
163
What is the optimal time that antibiotics should be administered IV prior to an operation?
1 hour prior to incision.
164
Continuation of antibiotics postoperatively for more than 24 hours is indicated only inpatients with what preexisting condition?
INFECTION!!!; eg. secondary to a perforated viscera, but not after routine elective operations without signs of infection.
165
The most common organism in patients with nosocomial bacteremia is what bug?
Coagulase-NEGATIVE-staphylococcus.
166
The Parkland formula recommends 4 mL LR/kg for each percent of TBSA burned in a burn victim for what time period after injury? Over what amount of time should the first half of this calculated fluid be administered? The remaining half?
First 24 hours; 1st half to be administered over first 8 hrs; remaining half over the next 16 hrs.
4mL LR/kg x 80 (kg) x 50% TBSA = 16,000
16,000/2 = 8000 in the first 8 hrs
8,000 (mL)/ 8 hours = 1000 mL/h rate for the first 8 hrs
167
This skin ulceration is associated with underlying inflammatory disorders such as IBD, rheumatic heart disease, and malignancy. Diagnosis?
Pyoderma gangrenosum; these lesions are painful ulcerations surrounded by erythema.
168
This is an ulcer that is a squamous cell carcinoma that arises in a chronic wound and is treated with surgical excision. What is the name of this type of ulcer?
Marjolin ulcer.
169
In a patient who has an acute diaphragmatic rupture (which occurs in about 4% of patients who sustain either blunt abdominal or chest trauma) what is the first course of action?
Immediate laparotomy, which allows for both examination of the intra-abdominal solid and hollow viscera for associated injuries and for adequate exposure of the diaphragm to allow secure repair. Because of the risk of vascular compromise of the contents of the hernia, exacerbated by the negative thoracic pressure, acute diaphragmatic rupture should be repaired immediately.
170
In a trauma patient, Diagnostic peritoneal lavage findings of a WBC greater than 500/uL, an elevated amylase value, or detection of bile, bacteria, or food fibers should prompt what immediate action to rule out a bowel injury?
Exploratory Laparotomy.
171
Patients with lower rib fractures may have associated abdominal injuries and should undergo appropriate evaluation (i.e. ultrasound examination, CT scanning, or peritoneal lavage). Patients who are elderly, have multiple rib fractures, demonstrate ventilatory compromise, or have underlying respiratory compromise are at increased risk for pulmonary complications such as atelectasis, pneumonia, and respiratory failure and should be hospitalized for observation. What is the most effective method at ensuring pain control in hospitalized patients with rib fractures?
Epidural catheters, continuous narcotic infusions, and patient-controlled analgesia.
172
What is the treatment of choice in patients with venous injuries hemodynamic instability?
Ligation of the injured vein; and the role of venous repair in patients hemodynamically stable patients with combined arterial and venous extremity injuries is controversial. Proximal veins should be repaired to avoid the sequelae of chronic venous insufficiency.
173
Diaphragmatic or abdominal injuries should be suspected in patients with a penetrating injury below the nipples. What is the next best step in the management of a stable patient with such injuries?
Diagnostic laparoscopy; this is appropriate to evaluate for an abdominal injury in penetrating trauma to the thoracoabdominal transition area. CT scan has low sensitivity in diagnosing abdominal injuries in the setting of penetrating trauma and local wound exploration is contraindicated in penetrating trauma to the chest, given the risk of creating a pneumothorax.
174
Are insulin levels increased or decreased when humans get injured?
Increased; though the intermediate release of catecholamines causes a transient drop in insulin levels, shortly there after there is a significant rise in plasma insulin levels. Because of increased peripheral insulin resistance and increased insulin production, the overall net effect after severe injury is that of HYPERGLYCEMIA.
175
Are patients usually hypo- or hyperglycemic after a traumatic injury?
HYPERGLYCEMIA; There is increased insulin production and increased peripheral insulin resistance when there is trauma to the body, thus the net effect is HYPERGLYCEMIA.
176
Are levels of thyroid hormone increased or normal after a patient sustains a trauma?
Decreased; since injured patients are highly hypermetabolic, it might be expected that the activity of the thyroid hormones would be increased. This is not the case however, and there is no increase in thyroid levels seen.
177
what is the initial management of choice for closed radial nerve palsies associated with a fractured humerus?
Fracture reduction and observation, since prognosis is excellent- the incidence of recovery is close to 90%. Operative intervention may be indicated after several months if function does not appear to be returning; either primary repair or reconstruction with sural nerve graft can be employed at that time.
178
What is the most common initial manifestation of increased intracranial pressure?
Change in level of consciousness.
179
Hypertension, bradycardia, and irregular respirations make up what triad, and signify what injury?
Cushing's triad; they are a sign of increased intracranial pressure
180
What is the recommended treatment for a patient with a flail chest injury?
Adequate analgesia, chest physiotherapy, and mechanical ventilation if respiratory compromise develops. At least two fractures in each of three adjacent rib or costal cartilages are required to produce this condition. The complications of flail chest are no longer believed to arise from the paradoxical movement, but rather the underlying pulmonary parenchymal injury with resultant hypoventilation leading to atelectasis, pneumonia, and respiratory failure.
181
What musculoskeletal site and injury is associated with the highest rate of vascular injury when a facture/dislocation occurs?
Knee dislocation; due to the extreme force required to dislocate the joint. Angiograms and vascular compromise is suspected, owing to clinical examination or Doppler confirmation of flow abnormalities.
182
Most parenchymal lung injuries will stop bleeding and heal spontaneously with tube thoracostomy alone. How many milileters of blood are an automatic indication for thoracic exploration?
1500 mL of blood on initial chest tube placement or persistent bleeding at a rate of 200 mL/hr for 4hrs or 100 mL/hr for 8 hrs.
183
Crepitus in a soft tissue infection implies anaerobic metabolism. Since human tissue cannot survive in an anaerobic environment, gas associated with an infection implies dead tissue and therefore what type of intervention is indicated?
Prompt surgical exploration and debridement, and intravenous antibiotics.
184
Most infections causing gas gangrene are polymicrobial, but when they are monomicrobial what is the most common pathogen associated with this type of necrotizing fasciitis?
Group A strep (GAS), although Clostridium is often the first bug that comes to mind.
185
What is the best next step in the workup of a patient with suspected rectal perforation or rectovesicular fistula?
CT scan.
186
A patient presents with a gunshot wound to the thigh, and a pale, cool, hypesthetic foot with palpable pulses. What is the next best step in management?
Surgical exploration!!!; the presence of ischemic changes following vascular trauma is an indication for emergency exploration and repair. The presence of palpable pulses does not reliably exclude significant arterial injury. Nonsurgical management of arterial trauma when distal pulses are palpable may lead to delayed sequelae of embolization, occlusion, secondary hemorrhage, false aneurysm, and traumatic arteriovenous fistula.
187
During shock, the sympathetic nervous system and adrenal medulla are stimulated to release catecholamines. Renin, angiotensin, antidiuretic hormone, adrenocorticotropin, and cortisol levels are increased. Resultant changes include sodium and water retention and increase in potassium excretion, protein catabolism and gluconeogenesis. Potassium levels rise as a result of increased tissue release, anaerobic metabolism and decreased renal perfusion. What will occur depending on the level of renal function?
If renal function is maintained, potassium excretion is high and normal plasma potassium levels are restored. If renal function is low HYPERKALEMIA may result.
188
This resuscitative fluid is metabolized to bicarbonate in the liver; along with the hemodynamic improvement that follows volume restitution, liver function improves, lactate metabolism improves, excess lactate levels drop, and metabolic acidosis improves. Which fluid is this?
Ringer's lactate!!!
189
Urethral injuries can be associated with pelvic fractures, and suspicion of a urethral injury should be increased if any of the following signs are present: blood at the urethral meatus, a scrotal hematoma, or a free floating (high-riding) prostate is present on rectal exam. If patient has a pelvic trauma that is believed to involve the urethra, what is the next best step in management in order to evaluate the injury?
RETROGRADE URETHROGRAM!!!
190
What is the mechanism of action of the pneumatic antishock garment (PASG)?
Increases peripheral vascular resistance.
191
Although indications for thoracotomy in the ER are controversial, when does the procedure appear to be the most beneficial?
1) To release cardiac tamponade in patients with penetrating thoracic trauma who are deteriorating too rapidly for a subxiphoid pericardial window to be created
2) To allow cross-clamping of the descending aorta in patients with intra-abdominal bleeding for whom other measures are not effective in maintaining blood pressure
3) To allow effective internal cardiac massage in patients who arrive in the ER with faint or absent pulses and distant heart sounds, and for whom other resuscitative efforts are unsuccessful
*it is not helpful for patients with no vital signs, or those with blunt trauma to multiple organ systems and absent vital signs on arrival to the ER.
192
In the absence of sepsis, what is the initial treatment of choice for patients with an enterocutaneous fistula?
Non-operative treatment with bowel rest, TPN, and correction of electrolyte abnormalities.
193
Traumatic arterial injuries can be handled with several techniques. Primary end-to-end anastamosis is preferable if this can be accomplished without tension. When 5cm of artery has been destroyed, it is imposible to perform a tension-free anastomosis. In this case what is the next best step in management?
Reversed saphenous vein graft is the repair of choice; the use of prosthetic material (Gore-Tex) in a potentially infected field is also avoided, as infection at the suture line often leads to delayed hemorrhage.
194
What blood/RBC/WBC findings on peritoneal lavage constitue a positive diagnostic peritoneal lavage? When in the presence of a positive DPL is exploratory laparotomy necessary?
RBC > 100,000/uL; > 10cc gross blood initially; WBC > 500/uL, or elevated amylase, bilirubin, or alkaline phosphatase; exploratory laparotomy is necessary in patients who are hemodynamically unstable or who demonstrate clinical deterioration
195
In patients with cervical or thoracic injuries, loss of sympathetic regulation results in loss of vasomotor tone and hypotension. Patients with neurogenic shock are warm and pink, as opposed to those who are hypovolemic and who are cold and clammy. Because of loss of the reflexive tachycardic response to hypotension, these people are usually also bradycardic. What is the initial treatment for the patient with neurogenic shock?
Fluid resuscitation initially, and vasoconstrictors after the intravascular volume has been restored.
196
A trauma patient is intubated in the field for unresponsiveness and on presentation to the ER, her hear rate is 160 beats per minute and her blood pressure is 60/35 mm Hg. What is the most appropriate recommendation for her fluid resuscitation?
Initial fluid bolus, second fluid bolus is there is only a transient response to the first; blood transfusion if there is a transient response to the second fluid bolus.
197
A patient has a hemothorax with greater than or equal to 1500 mL of immediate drainage of blood through the thoracostomy tube after placement and greater than 200 mL/hr of continuous drainage of blood for several hours after the original evacuation. What is indicated for the next step in the management of this patient?
Thoracotomy in the operating room.
198
Tracheobronchial injuries are uncommon and can occur with blunt or penetrating trauma. Blunt injuries to the tracheobronchial tree occur after direct compression of the airway with a closed glottis or after decelerating injuries causing partial or complete avulsion of the right mainstem bronchus from the carina or tracheal lacerations. Patients may present with pneumothorax, subcutaneous emphysema, pneumomediastinum, hemoptysis, and respiratory distress. What is the next best step for a smal injury?
Small injuries usually heal spontaneously with supportive care, but are associated with late complications such as stricture formation at the site of injury and recurrent pulmonary infection.
199
Free fluid in the abdomen or pelvis in the absence of solid organ injury warrants what type of intervention?
Exploratory laparotomy; to evaluate for small bowel or mesenteric injury.
200
The purpose in cross-matching before transplantation surgery is to determine whether the recipient has circulating antibodies against donor HLA antigens. Such antibiodies do not occur naturally, but rather are the result of prior sensitization during pregnancy, blood transfusions or previous transplantation. A complement-dependent lymphocytic cross-match is performed by adding what recipient blood components with what donor blood components?
Recipient serum (where antibodies of interest would be present) and complement, to donor cells (T cells, B-cells, or monocytes). If specific antidonor antibodies are present, antibody binding results in cell lysis. This is considered a positive cross-match; if a positive cross-match is detected to donor T cells (HLA class I), transplantation will result in hyperacute rejection.
201
In tumor lysis syndrome hyperkalemia and hyperphosphatemia are the result of tumor cell lysis; hypocalcemia is the result of precipitation of phosphate and calcium. Which immunologic cells are responsible for mediating tumor lysis syndrome?
Cytotoxic T cells (especially in lymphomas, which are most commonly associated with tumor lysis syndrome); This is because T lymphocytes involved in T cell lymphoma express the T cell receptor, which is recognized by Cytotoxic T cells; in turn CT T cells kill cell that express specific antigens, including viral, tumor, and nonbiologic antigens.
202
The effectiveness in cyclosporine in preventing allograft rejection seen in organ transplantation comes from it ability to inhibit PRODUCTION of which Interleukin?
IL-2!!!; without IL-2 from helper T cells there is no clonal expansion of alloantigen-directed cytotoxic T cell and no stimulation of antibody production by B cells.
203
Can a patient proceed with an organ transplant if they have a positive cross-match with donor cell HLA-antigen?
NO!!! a positive cross-match means that the recipient has circulating antibodies that are cytotoxic to donor-strain lymphocytes. This incompatibility, which almost always leads to acute humoral rejection of the graft, precludes transplantation.
204
If signs of hyperacute rejection takes place during an organ transplant operation, what is the next best step in management?
Intraoperative biopsy of the transplanted tissue; this is performed to evaluate for signs of hyperacute rejection such as extensive intravascular deposits of fibrin, platelets, PMNs, and RBCs.
205
What are the leading causes of death in patients surviving more than 1 year after cardiac transplantation?
Infection and rejection.
206
What are the main biological matching criteria for cardiac transplantation?
Heart size and ABO blood type; donor hearts protected by simple hypothermia are ideally transplanted within four hours. In contrast kidneys, for example, which can be preserved for up to 48 hours. Increased ischemic time is a significant predictor of poor outcomes in heart transplant patients. Thus usual tissue typing procedures such as those seen in kidney transplantation, are impractical in cardiac transplantation, and in pairing donor and recipient for heart transplants there must be at least ABO blood compatibility.
207
What are the main medical therapies indicated for treatment of acute rejection (1 week-3 months) of organ transplantation?
High dose steroid and an anti-T-cell antibiody (e.g. OKT3, which is a murine monoclonal antibody to CD3 complex)
208
The MELD (model for end-stage liver disease) score is a statistical model employed for adult patients that has been shown to have high predictive capacity in identifying patients with end-stage liver disease at greatest risk of mortality within 3 months. The MELD score enables liver allocation to be based on 3 objective variables. What are these variables?
1) Total bilirubin
2) INR
3) Serum Creatinine
209
What is the only therapy for Type I insulin-dependent diabetes that maintains normal serum glucose levels and normal glucose tolerance tests?
Whole-organ pancreas transplantation.
210
The presence of extrahepatic malignancy should defer liver transplantation for how many years after curative therapy for malignancy?
2 years.
211
Recent substance abuse, presence of active sepsis, current extrahepatic malignancy, poor cardiac or pulmonary function, and patients with hepatocellular carcinoma with metastatic disease with obvious vascular invasion or significant tumor burden are all contraindications for what type of hepatic therapy in someone with end-stage liver disease?
LIVER TRANSPLANTATION!!!
212
OKT3 is a monoclonal antibody against the CD3 antigen complex on mature T cells. In addition to minor side effects such as fevers and headaches that result from cytokine release that can occur with infusion of any therapeutic antibody, what are the specific, severe complications that can arise when administering patient OKT3 in with regard to the pulmonary system, renal system, and CNS?
Non-cardiogenic pulmonary edema, encephalopathy, aseptic meningitis, and nephrotoxicity.
213
Are elevated serum levels of the B-subunit of human chorionic gonadotropin (hCG), alpha fetoprotein, and lactate dehydrogenase useful indicators of tumor activity or recurrence in patients with seminomatous or non-seminomatous testicular tumors?
Non-seminomatous!!!
214
Does grading have a large effect on prognosis of soft tissue sarcoma, transitional cell cancers of the bladder, astrocytoma, and chondrosarcoma?
Yes!!!; There seems to be significant prognostic value in the grading of these malignancies.
215
What is the most common abdominal malignancy of childhood?
Wilm's tumor (nephroblastoma).
216
Benign soft tissue tumors far outnumber their malignant counterparts. Because of this prolonged delays are common before definitive treatment of soft tissue sarcomas is instituted. Risk for malignancy is increased for tumors greater than 5 cm in largest diameter, as well as for those lesions that are symptomatic or that have enlarged rapidly over a short period of time. Properly performed biopsy is critical in the initial treatment of any soft tissue mass. Improperly performed biopsies can complicate the care of the sarcoma patient and in rare circumstances even eliminate surgical options. Thus what is the most appropriate next step in diagnosis of a of tissue mass once it is discovered?
INCISIONAL BIOPSY!!!; excisional biopsies should be reserved for small masses for which complete excision would not jeopardize subsequent treatment should a sarcoma be found. For all other masses, incisional biopsy should be performed. The incision should be placed directly over the mass and should be oriented along the axis of the extremity.
217
Kidney transplant is the treatment of choice for patients with end-stage renal disease. It offers the patients a chance to lead healthy, normal lives. Compared with dialysis, it is associated with better patient survival, improved quality of life, and decreased longterm costs. Dialysis is less expensive than renal transplantation, however, if the graft function lasts for less than how many years?
2 years; if the graft lasts longer than 2 years, then the renal transplantation becomes the more cost effective treatment.
218
In terms of radiation oncology, only about 30% of the biologic damage from x-rays is due to the direct effects on the target molecule. The remainder is due to an indirect action mediated by free radical scavengers such as sulfydryl. The percentage of cells killed by a given dose of X-rays or gamma rays is greatly increased by molecular O2; thus what tissue condition related to O2 would decrease the therapeutic effects of radiation?
TISSUE HYPOXIA!!!; cells deficient in O2 are resistant to radiation.
219
Among the basic principles of radiation biology is the observation that the sensitivity of mammalian cells to radiation varies with their position in the cell cycle. In what phase of the cell cycle are cells most radio-sensitive?
M-PHASE!!!; mitotic phase.
220
How do the overall and disease-free survival rates for breast lumpectomy and radiation, compare for mastectomy, in patients with Stage I and II breast cancers.
They are equal.
221
Excessive amounts of dietary fat and deficiency of fiber have been clearly associated with what type of cancer?
Colon Cancer; animal fats have also been associated with cancer of the exocrine pancreas, the prostate and with the endometrium.
222
How are cardiac donors matched to recipients?
Size and ABO blood type.
223
BRCA 1 is associated with an increase in what malignancies in men?
Colon cancer and prostate cancer.
224
Is BRCA1 or BRCA2 mutation associated with increased risk of gallbladder, bile duct, and pancreatic cancers, as well as gastric cancer, malignant melanoma, and in men, prostate cancer?
BRCA2 mutation.
225
Which mutation, BRCA1 or BRCA2, is more likely to lead to a estrogen receptor-positive breast cancer?
BRCA2.
226
What is the antineoplastic alkylating agent associated with hemorrhagic cystitis?
Cyclophosphamide
227
This is a vinca alkaloid that can cause peripheral and central neuropathies.
Vincristine.
228
This is a platinum alkylating agent associated with ototoxicity, neurotoxicity, and nephrotoxicity.
Cisplatin
229
This antimetabolite is used to treat colon cancer and is associated with mucositis, dermatitis, and cerebellar dysfunction.
5-Fluorouracil.
230
Post transplant lymphoproliferative disorders (PTLD) (i.e. lymphomas) are associated with what virus? What is the treatment?
EBV!!!; treatment can include multiple modalities including withdrawal of immunosuppression, antiviral therapy with ganciclovir, chemotherapy, or immunotherapy with monoclonal antibodies.
231
In familial hypercalciuric hypercalcemia, are 24 hour calcium excretion levels increased or decreased?
Decreased!!!
232
If a patient has tertiary hyperparathyroidism, manifested by persistent hypercalcemia secondary to autonomous parathyroid function after renal transplantation?
Total parathyroidectomy with autotransplantation, or subtotal parathyroidectomy.
233
In renal transplantation Cyclophosphamide is an immunosuppressant that is used, but normally held in the immediate post-op period due to its nephrotoxicity, until what renal lab value returns to normal?
Creatinine.
234
If a renal transplant patient's WBC count fall secondary to Azathiaprine administration (a medication the patient needs for immunosuppression) what is the next best step to manage the patient?
Decrease the does of Azathiaprine.
235
An elevation in creatinine in a renal transplant patient at 3-month follow-up can be secondary to rejection, anastomotic problems, urologic complications, infection, or nephrotoxicity of various medications. With a normal ultrasound, no fever, and nor graft tenderness, what is the most likely cause? Tx?
Nephrotoxicity of medication; adjust medical regimen.
236
At 6 months post kidney transplantation, with graft tenderness, fever, and an edematous kidney on ultrasound, and negative bacterial cultures, rejection must be suspected. What is the next best step in management in the treatment of first rejection?
Steroid boost; addition of monoclonal antibodies to CD3 or pooled antibodies against lymphocytes (ALGs) is also appropriate in the treatment of first rejection.
237
Does current treatment of inflammatory breast cancer consist of multimodality therapy with chemotherapy, surgery, radiation, or all three?
All three; the results are a 50% 5-year survival rate.
238
Though there are many causes of hypercalcemia, hyperparathyroidism is by far the most prevalent. The majority of patients with hyperparathyroidism have a single parathyroid adenoma, which can be localized in 75-80% of patients with what type of scanning?
Sestamibi scanning.
239
Glucagonomas are usually solitary and large, and as such are easily identifiable on CT-scanning of the abdomen. Usually located in the body or tail of the pancreas, resection requires distal pancreatectomy. Metastases are common and should be resected whenever feasible. What medication used to treated esophageal varicies, carcinoid tumor, and acromegaly can be used to treat the hyperglycemia of a glucagonoma in the case of unresectable disease?
OCTREOTIDE!!!
240
After adrenalectomy for a functioning adenoma, even with a normally functioning contralateral adrenal gland, how long after the procedure might a patient need steroid therapy?
6 to 12 months
241
Cysts are common lesions in the breasts of women in their thirties and forties; malignancies are relatively rare. All such lesions justify attention, however, thus what is the next best step in management in a patient who presents with a cystic lesion of the breast?
Aspration of the mass and cytology; if the lesion does not completely disappear after aspiration, excision is advised.
242
At what age should women start getting breast examinations and how often? What about mammograms?
The National Cancer Center Network recommends a breast examination every 3 years for women of 20 years of age or older, and a yearly mammogram and breast examination for women over the age of 40.
243
Radiation induced thyroid cancer is usually of what histologic type?
Papillary Thyroid Carcinoma.
244
The treatment of this type of thyroid cancer consists of a near-total (or total) thyroidectomy for multiple reasons: (1) a high incidence of bilaterality (2) a greater incidence of complications if a second operation is necessary (3) better detection of recurrent or persistent disease (using thyroglobulin levels), and (4) more effective use of radioactive iodine therapy postoperatively. The latency period of these tumors can be 20 to 30 year after radiation exposure. Diagnosis?
Papillary Thyroid Cancer.
245
Lobular carcinoma in situ is considered to be a risk factor for invasive breast cancer. Which is the most common type it is associated with?
Ductal Carcinoma.
246
What is the most common type of breast tumor between puberty and the early thirties?
Fibroadenomas.
247
Patients with pheochromocytomas should be treated preoperatively with alpha-blockade using phenoxybenzamine at what time interval prior to surgical resection?
1-3 weeks; beta-blockade may be necessary in addition to alpha-blockade for optimal blood pressure control, but should not be started in the absence of alpha-blockade because of the risk of cardiovascular collapse and extreme unopposed vasoconstriction. With, alpha-blockade, however, patients also require volume expansion.
248
Chemotherapy can be administered to a pregnant patient, but should be delayed until what time period in the pregnancy, in order to avoid increased risk of fetal abnormalities?
Any time AFTER THE 1ST TRIMESTER!!!; aka in the 2nd and 3rd trimesters.
249
If Paget's disease presents with a mass, what type of cancer is that mass most likely to be?
Infiltrating Ductal Carcinoma.
250
What medication should be prescribed 10 days prior to a thyroidectomy for a patient with Graves disease, in order to prevent possible thyroid storm developing in the operating room?
Lugol iodide solution; propylthiouracil and methimazole can also be used preoperatively, but are contraindicated in pregnant women, or women who are trying to get pregnant.
251
What is the appropriate treatment for a patient who has developed thyrotoxicosis?
Beta-adrenergic blockade, for example, with propranolol.
252
Osteitis fibrosa cystica is a condition characterized by severe demineralization with subperiosteal bone resorption (most prominent in the middle phalanx of the second and third fingers), bone cysts, and tufting of the distal phalanges on bone films. Osteitis fibrosa cystica is associated with what endocrine disease?
HYPERPARATHYROIDISM!!!;
253
What is the more common cause of hyperparathyroidism: adenoma or hyperplasia?
Single parathyroid adenoma is found in about 85% of cases; hyperplasia of all four glands occurs in about 10-15% of cases.
254
What potent antibiotic selectively destroys islet cells of the pancreas and may be useful in controlling symptoms from unresectable malignant tumors of the islet cells, but has little to offer in the definitive managment of the typical benign islet cell insulinoma?
Streptozocin.
255
The most common risk factor in this cancer is age. Another important risk factor is positive family history in a first degree relative or presence of a genetic mutation such as BRCA1 or 2, which can be inherited through either the maternal or paternal side of the family. Other risk factors include excessive estrogen exposure, obesity, alcohol use, hormone replacement, ionizing radiation, and a history of this cancer, or previous abnormal tissue biopsy. Diet has no correlation. Diagnosis?
Breast Cancer.
256
What is the appropriate management for a patient diagnosed with ITP who is asymptomatic and has a platelet count greater than 30,000/uL?
This patient can be treated expectantly with follow-up.
257
What is the initial treatment in a symptomatic patient diagnosed with ITP, or a patient with a platelet count of less than 30,000/uL?
Prednisone (1mg/kg); this is the initial medical treatment, and IVIg is used in patients with severe bleeding or preoperatively prior to splenectomy. Platelet transfusions are reserved for patients with severe acute bleeding. Splenectomy is indicated in patients who have severe symptomatic thrombocytopenia, patients in whom remission is only achieved with toxic doses of steroids, patients with relapse after initial steroid therapy, patients with persistent thrombocytopenia for longer than 3 months and a platelet count of <10,000/uL after 6 weeks of therapy.
258
Patients with appendiceal adenocarcinoma, a rare neoplasm accounting for less than 0.5% of GI tumors, should undergo what formal treatment as the definitive treatment for their cancer?
Right Hemicolectomy, especially is there has been lymphatic invasion of the tumor, because these lymphatics drain together.
259
The initial management of this esophageal disorder includes medications (calcium channel blockers, long-acting nitrates), and other management options include endoscopic dilation or injection of botulinum toxin into the LES. Surgery results in improvement in more than 90% of patients, compared with only 70% of patients treated with forceful dilatation. Surgical treatment is an esophagomyotomy. Diagnosis?
Achalasia.
260
Does total proctolectomy in a patient with Ulcerative Colitis prevent peripheral arthritis and ankylosing spondylitis, or Primary Sclerosing Colangitis?
Peripheral arthritis and ankylosing spondylitis; surgery is NOT preventative or curative for Primary Sclerosing Colangitis.
261
Is it Crohn's disease or Ulcerative Colitis (UC) that ALWAYS involves the rect(UM)?
Ulcerative Colitis (UC)!!!
262
Internal drainage of a pancreatic pseudocyst via cyst gastrostomy is the definitive treatment for a mature, symptomatic cyst. When is this treatment contraindicated?
When infection is present in the cyst!!!; and malignancy should be excluded if there is no preceding history of pancreatitis.
263
What is the treatment of choice for an INFECTED pancreatic pseudocyst?
Percutaneous catheter drainage with antibiotics; thus, an infected cyst is treated in much the same way that an infected pancreatic abscess is treated. Additionally, malignancy should be excluded if there is no preceding history of pancreatitis.
264
What is the most frequent complication of end colostomies?
Parastomal herniation; this commonly occurs when the stoma is placed lateral to, rather than through, the rectus muscle. Symptomatic herniation requires operative relocation of the stoma, or mesh hernioraphy.
265
What is the main contraindication to performing a Whipple procedure in a patient with pancreatic tumor?
Involvement of the superior mesenteric artery by a pancreatic tumor precludes resection for cure and therefore is a contraindication to proceeding with a Whipple procedure; involvement of the superior mesenteric vein does not necessarily preclude resection for cure as 2 to 3 cm of the portal vein/superior mesenteric vein can be resected and an end-to-end anastomosis or venous bypass graft can be performed.
266
What type of antiarrhythmic drug can be used with or without long-acting nitrates to prevent recurrence of variceal bleeding, but is not indicated in the acutely bleeding patients who are hemodynamically unstable?
B-blockers!!!
267
Octreotide or Vasopressin with nitroglycerin, and B-blockers with or without a long-acting nitrate make up the medical therapy that is. indicated for what GI condition?
Acute esophageal variceal bleeding and prevention of re-bleeding, respectively.
268
Hemorrhage, perforation, disease refractory to medical therapy, and inability to rule our a malignancy are all indications for surgery in what GI disease? Tx?
Persistent Gastric Ulcer disease; surgical resection via either a distal gastrectomy with gastroduodenostomy (Billroth I reconstruction) or with gastrojejunostomy (Billroth II reconstruction) to definitively rule out malignancy. Only ulcers associated with acid hypersecretion require a vagatomy as well (type II- body of stomach, with concomitant duodenal ulcer, or type III- prepyloric). Type I (in the body and along the lesser curvature) and type IV (near the gastroesophageal junction) do not require vagotomy.
269
Do type I (body with concomitant duodenal ulcer) and type II (prepyloric) gastric ulcers, or type III (in the body and along the lesser curvature) and type IV (near the gastroesophageal junction) require vagotomy?
Only type I and II, because they are associated with acid hypersecretion.
270
Hemorrhage secondary to diverticulosis, recurrent episodes of diverticulitis, , intractability to medical therapy, and complicated diverticulitis are what indications to what sort of diverticular treatment? Next best step?
Surgical management!!!
271
What is the definitive treatment for for biliary dyskinesia?
Cholecystecomy; this results in an improvement in symptoms in 85% to 94% of the time.
272
How is the diagnosis of biliary dyskinesia made?
CCK-HIDA scan; technetium labeled HIDA is injected intravenously, which is subsequently excreted into the biliary tract. After filling the gallbladder, CCK is given IV to stimulate gallbladder contraction. A gallbladder ejection fraction of less than 35% at 20 min is diagnostic of biliary dyskinesia
273
Gallbladder polyps may be observed with no action taken, and only serial ultrasounds if they are less than what size?
<1 cm in size.
274
Patients with evidence of gallbladder carcinoma should undergo what operation in order to surgically remove their carcinoma?
Radical Cholecystectomy (portal lymphadenectomy and either wedge or formal resection of the liver surrounding the gallbladder fossa in addition to the cholecystectomy).
275
This condition is more common in the elderly; history of trauma, sudden muscular exertion, or anticoagulation can usually be elicited; the pain is of sudden onset and sharp in nature; it typically presents as an abdominal mass and does not change with the contracture of the rectus muscle; the diagnosis can be established preoperatively with an U/S or CT scan showing a mass within the rectus sheath; management is conservative unless symptoms are severe and bleeding persists, in which case surgical evacuation and ligation of bleeding vessels may be required. Diagnosis?
Hematoma of the Rectus Sheath!!!
276
What is the initial therapy for an amebic liver abscess as opposed to a pyogenic liver abscess?
Metronidazole monotherapy for amebic liver abscess; percutaneous drainage and antibiotics against Gram (-) and anaerobic bacteria (E.coli, Klebsiella, bacteroides, enterococcus, and anaerobic streptococci) is the initial therapy attempted for Pyogenic Abscesses. If improvement of the amoebic abscess fails to improve, then more antimicrobial agents can be added. Abscesses that are refractory to medical therapy may require laparotomy.
277
The overwhelming majority of sliding hiatal hernias are totally asymptomatic, even many of those with demonstrable reflux. Even in the presence of reflux, esophageal inflammation rarely develops because the esophagus is so efficient at clearing the refluxed acid. Symptomatic hernias should be treated vigorously by the variety of medical measures that have been found helpful. Patients who do have symptoms of episodic reflux and remain untreated can expect their disease to progress to intolerable esophagitis or fibrosis and stenosis. Neither the presence of the hernia nor its size is important in deciding on surgical therapy. What is?
Once esophagitis has been documented to to persist under adequate medical therapy, manometric or pH studies may help determine the optimum surgical treatment.
278
Ischemic colitis presents as hematochezia, fever, and abdominal pain. How does the management of acute mesenteric ischemia differ from ischemic colitis?
Ischemic colitis rarely requires surgical intervention unless full-thickness necrosis, perforation, or refractory bleeding are present. Mesenteric ischemia affects the small bowel and requires immediate surgical intervention. Expectant management with IV fluids, bowel rest, and supportive care is the treatment of choice for Ischemic Colitis.
279
Are all patients who undergo bowel resection guaranteed to experience permanent changes in bowel habits?
No; patients may undergo resection of a large fraction of the colon and suffer little long-term change in bowel habits because the reserve capacity of the colon for water absorption greatly exceeds the normal requirements for maintaining bowel function.
280
Can the colon absorb short-chain, or long-chain fatty acids?
Short chain.
281
How do Na, K, Cl, and HCO3 get transported in the colon?
Na is absorbed through active transport; K is excreted into the colonic lumen passively
Cl and HCO3 are exchanged across the epithelium; Cl is absorbed and HCO3 is excreted
282
Hepatic adenomas are associated with oral contraceptive use; cessation of OCPs may be adequate to allow regression of the lesion, if the lesion is smaller than what size?
<4 cm; if a hepatic adenoma is smaller than 4 cm, then ceasing OCP use alone may be enough to cause regression.
283
For hepatic adenomas >4 cm, what is the treatment that is advocated?
Surgical resection; other indications for surgical resection include failure to regress with cessation of OCPs or inability to stop taking OCPs, and desire to become pregnant. Lesions >4 cm in size have an increased risk of rupture with hemorrhage, which may in fact be the initial clinical presentation.
284
Focal nodular hyperplasia (FNH) is rarely symptomatic and unlike hepatic adenoma does not carry an associated risk of malignant degeneration or hemorrhage. If FNH cannot be distinguished from a hepatic adenoma on CT scan, a nuclear medicine scan can be obtained that may demonstrate a hot" lesion in the setting of FNH, and a "cold" lesion in the setting of hepatic adenoma. Given the decreased associated risks of FNH, what is the next best step in management once it is discovered?"
No treatment; surgical resection of an FNH lesion is only indicated if the lesion becomes symptomatic.
285
This disease has a chronic and slowly progressive course with intermittent symptom free periods. The symptoms are anorexia, abdominal pain, diarrhea, fever, and weight loss. Extra-intestinal syndromes that may be seen include ankylosing spondylitis, polyarthritis, erythema nodosum, pyoderma gangrenosum, gallstones, hepatic fatty infiltration, and fibrosis of the biliary tract, pancreas and retroperitoneum. About 10% of the patients, especially those who are young, show onset of the disease as an abrupt event that may be mistaken for acute appendicitis. Diagnosis? Treatment when surgical appendectomy is mistakenly undertaken?
Regional Enteritis; appendectom is indicated in such patients as long as the cecum at the base of the appendix is not involved; otherwise, the risk of fecal fistula must be considered. Interestingly, 90% of patients who present with the acute-appendicitis form of Regional Enteritis, will not progress to development of the full-blown chronic disease.
286
What is the best treatment for patients suffering from iatrogenic injury of the common bile duct due to previous surgery?
End-to-side choledocojejunostomy (Roux-en-Y) performed over a stent; the injuries commonly occur in the proximal portion of the extrahepatic biliary system. Choledocoduodenostomy generally cannot be performed because of the proximal location of the stricture. Primary repair of the common bile duct may result in recurrent stricture. Thus the best approach is the Choledocojejunostomy (Roux-en-Y).
287
A rise in serum gastrin levels of what magnitude, after administration of secretin, is diagnostic of Zollinger-Ellison syndrome?
A rise in Gastrin greater than 200 pg/mL
288
What is the most likely location of tumor in a patient who has a gastrinoma and MEN I?
90% of gastrinomas are located within the gastrinoma triangle- the three corners of the triangle are defined by the junction of the second and third portions of the duodenum, the junction of the neck and body of the pancreas, and the junction of the cystic and common bile duct.
289
Epidermoid cancers of the anal canal metastasize to the inguinal nodes as well as to the perirectal and mesenteric nodes. The results of local radial surgery have been disappointing. What is the treatment and protocol that is used to treat epidermoid carcinoma of the anus?
Nigro protocol; combining external radiation with synchronous chemotherapy (flurouracil and mitomycin) has been used as the standard of treatment for the disease, whereas radical surgical approaches are now reseved for treatment failures and recurrences.
290
ethnocentrism
a belief that ones country is superior, based on ethnicity and race
291
A cecal volvulus involves axial rotation of the terminal ileum, cecum, and ascending colon with concomitant twisting of the associated mesentery. Colonoscopic decompression is usually unsuccessful and does not prevent recurrence of the cecal volvulus. If an elderly patient presents with a cecal volvulus, what is the treatment of choice?
Right Hemicolectomy; immediate surgery is required to correct the volvulus and prevent ischemia.
292
What is the most prevalent extrauterine indication for laparotomy during pregnancy?
Appendicitis; the duration of gestation does not influence the severity of disease, but the diagnosis does become more difficult as the pregnancy progresses. Pregnancy should not delay surgery if appendicitis is suspected; appendiceal perforation greatly increases the chances of premature labor and fetal mortality (~20% for each). In contrast, negative laparotomy under general anesthesia and nonperforated appendicitis are associted with very low risk to both the fetus and the mother (less than 1% and 5% respectively).
293
Which type of diaphragmatic hernia puts the patient at the greatest risk for both strangulation and obstruction of the GI tract?
Paraesophageal hernia.
294
Where are the vast majority of pancreatic carcinomas located?
The head of the pancreas; it carries a 1-2% 5 year survival rate; 10-15% after pancreatoduodenectomy
295
The most common cause for small intestinal bleed in a patient under the age of 30 is Meckle diverticula. Because Meckle diverticula can contain ectopic gastric mucosa, acid secretion can cause small-bowel ulcerations. What is the diagnostic test for Meckle diverticula?
99-Technitium pertechnetate scan.
296
This condition results from a congenital dilation of the extrahepatic biliary ducts. Intrahepatic dilation can coexist (Caroli disease) but this represents a distinct problem and is handled differently. Patients may present with symptoms at any age, but the classic triad of epigastric pain, abdominal mass, and jaundice is not frequently seen. Rather, most patients present with other conditions such as cholecystitis, cholangitis, or pancreatitis. Non-surgical treatment of this condition results in high morbidity and mortality and therefore surgery is recommended in all cases. Diagnosis? Tx?
Choledochal cyst; tre present recommendation is for complete resection of the cyst and Roux-en-Y choledochojejunostomy. Since malignant changes in choledochal cysts have been frequently described, complete resection rather than the performance of an internal drainage procedure is preferred whenever the resection can be done safely.
297
Are stress ulcers that occur in the setting of shock, sepsis, major surgery, trauma, and burns more likely due to an increase in gastric acid secretion or ischemia? What part of the stomach are stress ulcers usually found in?
Ischemia; McClelland et. al. showed that patients subjected to trauma and subsequent hemorrhagic shock do not have increased gastric acid secretion, but rather show decreased splanchnic blood flow. Ischemic damage to the mucosa may therefore play a role. Unlike chronic benign gastric ulcers, which are generally found along the lesser curvature and in the antrum, acute erosive lesions usually involve the body and fundus and spare the antrum.
298
What disease is described by the triad of fever, jaundice, and pain in the RUQ? What is the name of this triad?
This describes Cholangitis; this is Charcot's triad.
299
Does cholangitis usually occur in the young or the elderly?
Elderly.
300
What is the main therapy targeted at in Acute Cholangitis?
Decompression of the common bile duct.
301
Recently, this lesion has been identified more frequently as a source of GI bleeding. It is characteristically located within 6 cm distal to the gastroesophageal junction. This lesion typically consists of an abnormally large submucosal artery that protrudes through a small, solitary mucosal defect. For unclear reasons, the lesions may bleed spontaneously and massively, in which case they require emergency intervention. Upper endoscopy is usually successful in localizing the lesion, and permanent hemostasis can be obtained endoscopically in most cases with injection sclerotherapy, electrocoagulation, or heater probe. If surgery is required, a gastrotomy and simple ligation or wedge resection of the lesion may be adequate. Diagnosis?
Dieulafoy lesion.
302
Carcinoid tumors arise from enterochromaffin cells in the crypts of Liberkuhn. When they are encountered in the appendix and are less than 2cm in size, simple appendectomy is the procedure of choice. When tumors are larger than 2cm, what is the next best step in management?
Right Hemicolectomy.
303
In a patient with total pancreatectomy, why do iron deficiency and pernicious anemia result?
This is because like pancreatico-duodenectomy, total pancreatectomy results in resection of the duodenum distal to the common bile duct, and gallbladder. Because iron absorption occurs primarily in the duodenum these patients will have iron deficiency anemia. Pernicious anemia results due to lack of pancreatic enzymes required for B12 vitamin absorption.
304
The mean presentation of this liver tumor in adults is ~45 years; it has become an increasingly common incidental finding on imaging. The vast majority of these lesions are asymptomatic and there is no evidence that they undergo malignant transformation. The risk of rupture and severe hemorrhage into or from hemangiomas is extremely low; when it does occur it is usually iatrogenic (following attempted biopsy). Given the benign and static nature of these lesions, management by angiographic embolization or resection should be reserved only for the rare patient with symptomatic or complicated lesions. *This is the most common tumor of the liver. Diagnosis?
Hepatic Hemangioma
305
Why is it important to obtain a CEA antigen level in patients with newly diagnosed colon cancer?
To get a baseline CEA serum value; patients in whom the levels fall to below 2 to 3 ng/mL after resection have an excellent prognosis for disease control.
306
What do very high elevations of CEA antigen in a patient diagnose with a primary colonic malignancy suggest in terms of metastasis?
Extensive liver disease or peritoneal spread.
307
What is the DEFINITIVE operation of choice for patients with Ulcerative Colitis? (*Indications for operation in UC include high-grade dysplasia or carcinoma, toxic megacolon, and intractability to medical therapy)
TOTAL PROCTOLECTOMY with either end ileostomy or ileoanal J-pouch anastomosis.
308
Patients with either UC or Crohn disease can develop toxic megacolon, which is manifest by fever, abdominal pain, and marked dilation of the large bowel. What is the surgical treatment indicated for this specific complication?
Subtotal colectomy with end ileostomy.
309
What therapy is the mainstay of treatment for patients with squamous cell carcinoma of the anus?
Chemoradiation with the Nigro Protocol.
310
What is the treatment of choice for patients with recurrent squamous cell carcinoma of the anus, after the use of chemoradiation and the Nigro Protocol?
Abdominal Perineal resection involving removing the rectum and anus with formation of a permanent end colostomy.
311
What is the surgical procedure of choice for distal rectal cancers that involve the sphincters or that are too close to obtain an adequate margin (2 cm), and in patients for whom sphincter-sparing surgery is contraindicated because of fecal incontinence?
The same as that for recurrent squamous cell carcinoma of the anus; Abdominal Perineal resection involving removing the rectum and anus with formation of a permanent end colostomy.
312
What is the surgical procedure of choice for proximal and midrectal cancers?
Low-Anterior Resection; LAR involves the removal of the rectum to below the peritoneal reflection through an abdominal approach.
313
What percentage of patients with Aortic Stenosis will have congestive heart failure as their first presenting symptom?
ONE THIRD of patients with aortic stenosis will have CHF as their presenting symptom!!!; patients with aortic stenosis and congestive heart failure have a worse prognosis.
314
At what valve size do patients with aortic stenosis begin to start showing signs and symptoms?
1 cm^2; patients with aortic stenosis may not develop symptoms until the aortic valve area is about 1 cm^2.
315
What is the most commonly used predictor of postoperative pulmonary reserve?
The predicted postoperative forced expiratory volume in 1 second is the most commonly used predictor of postoperative pulmonary reserve. Most patients will tolerate a lobectomy with an FEV1 greater than 60% of predicted.
316
What is the initial treatment of a lung abscess, once the diagnosis has been made?
Systemic antibiotics directed against the causative agent; the duration of the therapy is dependent on the severity of the underlying pneumonia that resulted in the abscess and can last up to 12 weeks; often the abscess drains spontaneously via the tracheobronchial tree, but if it fails to resolve with medical therapy, intervention may be required, ranging from percutaneous drainage to surgical drainage of the abscess or resectional therapy.
317
What is the recommended surgical treatment for Diffuse Esophageal Spasm?
Myotomy along the length of the manometric abnormality.
318
What is the first step in management of a patient who has ingested a caustic, alkali, chemical substance?
Esophagogram with water-soluble contrast (Gastrograffin); corrosive injuries of the esophagus most frequently occur in young children due to accidental ingestion of strong alkali cleaning substances; esophagogram is performed if perforation is suspected or for localization of a perforation prior to surgical intervention.
319
What is the initial test of choice in a patient who is suspected of having Boerhaave syndrome?
Contrast Esophagogram; this is the initial test of choice and is indicated with barium for a suspected thoracic perforation and water-soluble contrast (Gastrograffin) for an abdominal perforation. Barium is inert in the chest, but it causes peritonitis in the abdomen, whereas aspirated Gastrograffin can cause severe pneumonitits.
320
What is one of the major life-threatening complications that can occur post-CABG surgery, that would require taking the patient back to the OR and exploring the mediastinum?
Cardiac Tamponade; in this case a patient should be taken back to the OR for exploration and drainage of the mediastinal hematoma.
321
Equalization of pressures across all four heart chambers on Swan-Ganz catheter monitoring or collapse of the right atrium on Echocardiography are diagnostic of what cardiac condition?
Cardiac Tamponade.
322
Chylothorax may occur after a thoracic surgery, or it may follow malignant invasion or compression of the thoracic duct. Intraoperative recognition of thoacic duct injury is managed by ligation of the duct. Direct repair of the duct is impractical owing to the extreme firability of the thoracic duct. Injuries not recognized until several days after intrathoracic surgery frequently heal following what management strategy?
Institution of a low-fat diet (a medium-chain, low-fat diet often reduces the flow of chyle), and either repeated thoracentesis or tube thoracostomy drainage.
323
In adults, do mediastinal masses occur most commonly in the anterior superior, middle, or posterior superior mediastinum?
Anterior Superior.
324
Cysts (pericardial, bronchogenic, or enteric) are the most common tumors of what region of the mediastinum?
Middle Region.
325
Neurogenic tumors are the most common of the primary tumors in what region of the mediastinum?
Posterior Region.
326
Thymomas, Lymphomas, and Germ cell tumors (in order of descending frequency), are the most common primary neoplasms of what region of the mediastinum?
Anteriorsuperior Region.
327
Operative intervention is usually recommended for thoracic aortic aneurysms of what size and qualification?
Those that are greater than 5 to 6 cm in diameter, or those that are increasing in size.
328
This condition results due to an outpouching of mucosa between the lower pharyngeal constrictor and the cricopharyngeus muscles. It is though to result from an incoordination of cricopharyngeal relaxation with swallowing. This condition occurs in elderly patients more often and more common on the left. The typical patient present with symptoms of dysphagia, weight loss, and choking. Diagnosis?
Pharyngoesophageal (Zenker) diverticulum.
329
What is the surgical treatment for a Zenker diverticulum?
Excision of the diverticulum, and division of the cricopharyngeus muscle (cricopharyngeal myotomy), which can be done under local anesthesia in the cooperative patient.
330
Thoracic outlet syndrome designates a symptom complex whose precise cause is unknown. It is felt to result from compression of the brachial plexus or subclavian vessels, or both, in the anatomic space bounded by the first rib, the clavicle, and the scalene muscles. What does the initial conservative management consist of for a patient diagnosed with Thoracic Outlet syndrome? If conservative management does not work, what surgical options are there?
Conservative management consists of an exercise program to strengthen the shoulder girdle muscles and decrease shoulder droop; operative treatments include division of the scalenus anticus and medus muscles, first rib resection, cervical rib resection, combination of all three, and thus decompression of the brachial plexus.
331
What type of tumor generally is the cause of a pancoast tumor?
Bronchogenic Carcinoma.
332
At low infusion rates the B-adrenergic effects of Epinephrine predominate causing increased heart rate, stroke volume and contractility. At higher infusion rates, Alpha-adrenergic receptor are stimulated resulting in an increase in blood pressure and systemic vascular resistance. Prolonged use of high-dose epinephrine is limited by renal and splanchnic vasoconstriction, cardiac dysrhythmias, and increased myocardial oxygen demand. Epinephrine is typically used as a short-term agent given in intravenous boluses during what cardiac event?
Cardiac Arrest!!!
333
Norepinehprine is acts through release at nerve synapses, and acts on Alpha- and Beta-adrenergic receptors resulting in an increase in afterload and glomerular perfusion pressure with preservation of cardiac output. Norepinephrine is associated with increase in urine output in what type of patients?
Hypotensive, septic patients.
334
What medication is a synthetic catecholamine that enhances MYOCARDIAL CONTRACTILITY with minimal changes in HEART RATE, and is often used in treatment of shock following myocardial infarction to support myocardial contractility while reducing peripheral vascular resistance? Why wouldn't you use Dopamine in this setting?
DOBUTAMINE!!!!; you would not use dopamine because this would increase heart rate and peripheral vascular resistance as well, depending on the dose, and this would lead to further decreased cardiac output in the setting of shock.
335
In a patient who has developed oliguria after an extended surgical procedure, in whom you suspect the most likely cause of oliguria to be hypovolemia, what would be the most accurate means of diagnosing this hemodynamic state?
Swan-Ganz catheter; pulmonary artery catheter is the best means to assess volume status, and it does so through measuring preload pressures in the left atrium (by inference from the pulmonary capillary wedge pressure). Patients who undergo long, difficult operations in large surgical fields collect third-space fluids and become intravascularly depleted despite large volumes of intravenous fluid and blood replacement. The proper management usually involves titrating the cardiac output by providing as much fluid as necessary to keep the wedge pressure near 15 mmHg.
336
Two cardiovascular conditions of the lower extremity that could be potential causes of compartment syndrome in the extremities are acute arterial occlusion without collateral inflow and rapid reperfusion of ischemic muscle. Another common cause of compartment syndrome is orthopedic trauma to the leg. The need for fasciotomy is based on clinical judgement. If fasciotomy is indicated, which fascial compartments must be opened?
ALL 4 FASCIAL COMPARTMENTS SHOULD ALWAYS BE OPENED!!!
337
Atherosclerotic occlusion of the Subclavian artery proximal to the Vertebral artery is the anatomic situation that results in what syndrome?
Subclavian steal syndrome; on being subjected to exercise, the involved extremity (usually the left, which is more prone to atherosclerosis because of anatomical differences) develops relative ischemia, which gives rise to reversal of flow through the the vertebral artery with consequent diminished flow to the brain. The upper extremity symptom is intermittent claudication.
338
Gated blood pool scans (e.g. MUGA or multiple gated acquisition scan) that demonstrate ejection fractions of 35% or less and reversible perfusion defects on dipyridamole-thallium imaging are used in what predictive context?
They are used to predict perioperative ischemic cardiac events among patients undergoing peripheral vascular reconstruction.
339
Why is Urokinase a preferred thrombolyitc reagent to streptokinase?
Because it is associated with fewer allergic reactions.
340
What is the most common peripheral artery aneurysm?
Popliteal artery aneurysm.
341
A mycotic aortic aneurysm is a sequelae of infection, most commonly with Staph aureus or Salmonella. What is the treatment for an infrarenal mycotic aortic aneurysm?
Traditionally it has been that an axillofemoral bypass is performed and then the involved intraabdominal aorta is excised. If the aorta is debrided and replaced, autogenous graft material is used (e.g. superficial femoral vein). Antibiotic therapy is also administered for 3 to 6 months.
342
What are the four types of urinary incontinence?
Stress, Urge, Overflow, and Total.
343
This type of urinary incontinence is associated with women with previous birth trauma, with aging, and with neurologic injuries. Diagnosis?
Stress incontinence.
344
What are non-operative treatments for stress incontinence? Surgical treatment in women?
Estrogen therapy, pelvic floor exercises, and timed voiding are non-operative treatments; surgery involves a urethral sling procedure.
345
Anticholinergic medications, biofeedback, and timed voiding are all strategies used to treat what form of urinary incontinence?
Urge incontinence.
346
A spinal cord injury above the level of the sacrum results in a hyperreflexic bladder and what type of incontinence?
Urge incontinence.
347
Overflow incontinence results from what preceding condition?
Bladder outlet obstruction.
348
Total incontinence, or continuous leakage of urine suggests the presence of what condition?
FISTULA!!!; (commonly vesicovaginal or vesicocutaneous) this typically requires surgical intervention.
349
Hypospadias in the scrotal area is associated with what condition of the testicles?
Bilateral undescended testes, and infertility; this must be differentiated from pseudohermaphroditism and adrenogenital syndrome.
350
90% of bladder cancers are of transitional cell origin. It is most prevalent among men with a history of heavy smoking and is usually superficial and multifocal, even when recurrent. When the disease is still superficial, what is the treatment of choice?
Transurethral resection of visible lesions and intravesicular chemotherapy (topical); more radical surgical resection is reserved for advanced stages of the disease.
351
What is the size cut-off of kidney stones that are likely to pass spontaneously?
1 cm; stones that are >1 cm are unlikely to pass spontaneously, though stones <0.5 cm usually do pass spontaneously.
352
Surgical intervention consisting of inguinal orchiopexy should be performed before what age in an infant boy who presents with undescended testicles?
Before 1 year; by the 2nd year, a testicle not in the cooler environment of the scrotal sac will begin to undergo histologic changes characterized by reduced spermatogonia.
353
Close follow-up by a physician is indicated until what age, for all patients who have had an undescended testicle?
Until the teenage years because they may be at an increased risk for malignancy throughout life.
354
What is the therapy of choice in a patient found to have a seminoma of the testicle?
Therapy generally consists of removing the affected testis and sampling the lymphnodes (usually external iliac) for evidence of metastasis. If metastases are present, radiation therapy is given locally to areas of known involvement. Radiation therapy is highly effective in seminoma, and metastatic disease may be palliated for extended periods.
355
If a patient presents with testicular torsion, what consideration should be payed to the unaffected testicle?
The unaffected testicle should undergo orchiopexy as well, regardless of whether the affected testicle is viable or not.
356
Testicular torsion usually occurs in what age group?
12 to 18 years of age.
357
For renal cell cancers less than a certain size, a partial nephrectomy can be performed, but for larger lesions, a radical nephrectomy (which includes the kidney, ipsilateral adrenal gland, and perirenal fat) is indicated. What is the size delineation that determines which procedure will be performed?
4 cm; renal cell cancers 4 cm will be treated with radical nephrectomy.
358
Simple renal cysts found on imaging DO NOT require further follow-up normally, because they are benign lesions. What qualities found on imaging, however, will raise suspicion for possibility of malignancy?
Multiple septations and calcifications.
359
What is the initial treatment of priapism in non-sickle cell patients?
Intracorporal Alpha-adrenergic injection are given while monitoring blood pressure and pulse.
360
If a patient is too unstable for primary repair of a ureteral injury during surgery, what is the next best step in management?
Placement of a catheter in the proximal ureter, which will allow reconstruction at a later date is permissible.
361
If a male patient suffers trauma to the urethra that is diagnosed to have caused complete disruption what is the next best step in management?
A suprapubic catheter should be placed temporarily and definitive repair delayed 4 to 6 months, at which time the hematoma will have resolved and the prostate will have descended into the proximity of the urogenital diaphragm.
362
The treatment for this prostatic condition involves broad-spectrum antibiotics until the patient is afebrile and hemodynamically stable; treatment is then continued for a total of three weeks with oral antibiotics. Diagnosis?
Bacterial Prostatitis.
363
What is the pathological mechanism for the production of most meniscal tears?
Flexion with rapid rotation; a classic example (football knee) involves a player who is hit while running. The medial meniscus is the portion that is most commonly injured.
364
What is the current treatment of choice for a patient with a meniscal tear of the knee joint?
Early surgical removal of the displaced menisci is usually recommended to prevent further damage to the cartilage or ligaments.
365
Would injury to the radial nerve at the wrist cause motor abnormalities, sensory abnormalities, or both?
Primarily Sensory abnormalities; the dorsum of the hand from the radial aspect of the fourth digit over the thumb, including the thenar pad and thumb web, becomes insensate after severance of the radial nerve at the wrist. Radial nerve injuries more proximal would impair extension of the wrist and digits as well as forearm supination.
366
Compartment syndrome is most commonly associated with what type of fractures?
Supracondylar fractures of the humerus and tibial shaft.
367
Open reduction of a fracture involves the restoration of normal bone alignment under direct observation ar surgery. In effect, open reduction converts a simple fracture into a compound (or open) fracture and thereby increases the risk of infection. Operative manipulation also increases trauma at the fracture site and may consequently add to the probability of infection. Hematomas at the site of fracture may be important for early healing; open reduction, which usually involves removing the clots in the field, could contribute to a delay in bone healing and non-union. So, in what way is open reduction advantageous???
Shorter period of immobilization; the major advantage of open reduction is the shorter period of immobilization it allows, an advantage that often outweighs all the disadvantages previously mentioned, as in open reductions of femoral neck fractures in the elderly. This allows these patients to get out of bed much sooner, than if they were treated with several weeks of traction.
368
Osteitis fibrosa cystica is found with hemorrhagic cystic lesions (brown tumors) usually ocuring in the long bones. What endocrine abnormality is this often associated with? Tx?
Hyperparathyroidism; treatment is parathyroidectomy.
369
Osteomalacia is defined as a defect in mineralization of adult bone that results from what metabolic abnormalities? Tx?
Vitamin D metabolism abnormalities. Treatment involves vitamin D supplementation.
370
What is the treatment of choice for Osteogenic Sarcoma: chemo or radiation?
Chemo; the tumor is NOT sensitive to radiation, but responds well to combination chemotherapy, followed by surgical resection or amputation.
371
This type of bone tumor typically presents with severe pain that is characteristically relieved by ASA; on radiograph the lesion appears as a small radiolucency (usually
Osteoid osteoma; Lesions gradually regress over 5 to 10 years, but most are excised to relieve symptoms. Surgical extirpation is usually curative.
372
This pediatric bone tumor is a round-cell type tumor; it is highly malignant and effects children in the age range of 5-15 years and tends to be in the diaphyses of long-bones. The spine and pelvis can also be primary sites. Fever and weight loss are common. Periosteal onion skinning is common. Dx? Treatment?
Ewing sarcoma; treatment usually involves a combination of radiation and systemic chemotherapy, with 5 year survivals around 50%. Adjuvant surgery in combination with radiation and chemotherapy improves the 5-year survival rate to about 75%.
373
The Glasgow Coma scale was developed to enable initial assessment of the severity of head trauma; it is also now used to standardize serial neurologic examinations in the early post-injury period. What prognosticating power does the GCS hold for what intervention?
The GCS can be used to prognosticate outcome and likelihood of neurosurgical intervention.
374
What are optimal Cerebral Perfusion Pressure and Intracranial Pressure in a patient post head trauma?
CPP >70 mmHg and ICP <20 mmHg
375
Most fractures of the skull do not require surgical correction, unless they are two specific conditions?
Depressed and/or Compound fractures.
376
Depressed and/or Compound skull fractures require what form of treatment?
Surgical replacement.
377
Persistent cerebrospinal fluid drainage from the nose or ear for what length of time requires surgical repair of the torn dura?
14 days.
378
In a patient with Xanthochromia (the yellow appearance of CSF caused by the degradation of heme to bilirubin in the RBCs in the CSF during bleeding) and suspected subarachnoid hemorrhage, what is the next best step in the management of a patient after spinal tap?
Four-vessel cerebral angiogram to assess for cerebral aneurysm; given that only about 85% of aneurysms are identified on the initial study, a second angiogram should be performed within 7 to 10 days after the first study to completely rule out aneurysm.
379
Initial management of this neurovascular condition consists of medical therapy to counter-act cerebral vasospasm, blood pressure control, and anticonvulsant therapy. Diagnosis?
Subarachnoid hemorrhage.
380
The onset of irregular respirations, bradycardia, and finally, increased blood pressure is what triad? What acute condition does this represent?
This is Cushing's triad that represents an acute increased in Intracranial Pressure in a patient. Irregular respiration are due to hypoperfusion of the brainstem; hypertension and bradycardia are due to decreased cerebral perfusion pressure and the compensatory response.
381
What layer of the meninges do meningiomas form from? What is the main mode of treatment for them?
Arachnoid layer; main mode of treatment is excision.
382
What is the best test for diagnosis of a brain abscess?
Contrast CT.
383
What therapy is the initial treatment of choice for nasoppharyngeal carcinoma?
Radiation is the initial treatment of choice for primary nasopharyngeal carcinoma; a strong association exists with EBV infections, such that EBV titers may be used to follow a patient's response to treatment.
