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Flashcards in USMLE Deck (383)
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1

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?

Anterior cord syndrome; MRI is the best investigation to study the extent of neurological damage.

2

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?

Central Cord Syndrome.

3

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?

Brown Sequard syndrome.

4

If a patient has a fracture of a long bone with the fragments being offset, what is the next best step in management?

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

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?

PILONDIAL CYST!!!

6

In an anterior shoulder dislocation, which nerve is at most risk of being injured? If this nerve is injured what functions will be decreased?

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

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?

Antibiotics and external drainage of the abscess.

8

What imaging study should be ordered in patients with pancreatitis?

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

What investigational study is the best test for identifying retroperitoneal bleeding casued by pelvic fractures?

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

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?

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

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?

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

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?"

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

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)?

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

What is the most common cause of frank hematochezia in an elderly patient?

Diverticulosis.

15

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)

Tracheobronchial rupture.

16

What is the first-line modality for diagnosing a urinary stone?

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

What are the 4 categories of Eye Opening of the Glasgow coma scale?

Spontaneous- 4
To verbal command- 3
To pain- 2
None- 1

18

What are the 5 categories of Verval Response of the Glasgow coma scale?

Oriented- 5
Disoriented/Confused- 4
Inappropriate words- 3
Incomprehensible sounds- 2
None- 1

19

What are the 6 categories of the Motor Response of the Glasgow coma scale?

Obeys- 6
Localizes- 5
Withdraws- 4
Flexion posturing (Decorticate)- 3
Extension posturing (Decerebrate)- 2
None- 1

20

What is the first step in management of a suspected urethral injury? Why is blind Foley catheterization a bad idea?

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

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?

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

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?

Early physiotherapy and respiratory exercises (blowing against resistance) are indicated to prevent atelectasis, mucous plugging and pneumonia.

23

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?

Nasogastric suction and parenteral nutrition. Surgery may be considered to evacuate the hematoma if this more conservative method fails.

24

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?

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.