UWORLD

Question 1

Pt complains of popping sound followed by severe pain at the time of injury when his foot was fixed and was twisted. PE reveals localized tenderness on medial side of knee. THis is a meniscal tear. What is the “bucket handle” tears and “McMurray’s sign”?

Answer 1

“bucket handle tears” -locking of the knee joint on extension

McMurray’s sign: palpable or audible snap occurring while slowly extending the leg at the knee from full flexion while simultaneously applying tibial torsion.

Question 2

Pt complains of popping sound followed by severe pain at the time of injury when his foot was fixed and was twisted. PE reveals localized tenderness on medial side of knee. THis is a meniscal tear. What is the “bucket handle” tears and “McMurray’s sign”?

Answer 2

“bucket handle tears” -locking of the knee joint on extension

McMurray’s sign: palpable or audible snap occurring while slowly extending the leg at the knee from full flexion while simultaneously applying tibial torsion.

Question 3

Medial collateral ligament injury is assoc with abduction injury to the knee. What test will help in clinical diagnosis

Answer 3

valgus stress test (when you move the knee laterally)

Question 4

Lateral collateral ligament is rare and would be seen in adduction injury to the knee. What test can clinically diagnose it

Answer 4

varus stress test

Question 5

Respiratory Quotient = CO2 produced/rate of O2 uptake

An RQ close to 1 –>
An RQ at 0.8 –>
An RQ at 0.7 –>

Answer 5

An RQ close to 1 –> carbohydrates major nutrient oxidized
An RQ at 0.8 –> protein
An RQ at 0.7 –> lipid

Question 6

Sepsis is a hypermetabolic, hypercatabolic state wherein both fat and protein are broken down in addition to gluose. Respiratory quotient in a septic patient is? >1, = 1,

Question 7

amt of O2 consumed =

Answer 7

PaO2-PvO2

Question 8

Someone with winged scapula post axillary lymphadenectomy for treatment of breast cancer due to?

Answer 8

injury to long thoracic nerve.

Question 9

Someone with winged scapula post axillary lymphadenectomy for treatment of breast cancer due to?

Answer 9

injury to long thoracic nerve.

Question 10

What is torus palatinus

Answer 10

a congenital condition characterized by chronic growth on hard palate. It is a benign bony growth located on midline suture of hard palate. More common in younger patients, women and Asians. No medical or surgical therapy required unless symptomatic or interferes with speech or eating

Question 11

What’s the most reliable means of monitoring adequacy of circulation in a circumferentially burned limb?

Answer 11

serial exam using doppler US flow meter

Question 12

Respiratory Quotient = CO2 produced/rate of O2 uptake

An RQ close to 1 –>
An RQ at 0.8 –>
An RQ at 0.7 –>

Answer 12

An RQ close to 1 –> carbohydrates major nutrient oxidized
An RQ at 0.8 –> protein
An RQ at 0.7 –> lipid

Question 13

amt of O2 consumed =

Answer 13

PaO2-PvO2

Question 14

Tx rxn: anaphylactic rxn presents with rapid onset of shock, angioedema/urticaria, and resp distress w/in a few secs of transfusion. Caused by?

Answer 14

Caused by recipient anti-IgA abs in someone with IgA def

Question 15

Someone with winged scapula post axillary lymphadenectomy for treatment of breast cancer due to?

Answer 15

injury to long thoracic nerve.

Question 16

Someone with pulsatile groin mass below the inguinal ligament with anterior thigh pain 2/2 to compression of femoral nerve. Suspect.

Answer 16

femoral artery aneurysm

Question 17

What is torus palatinus

Answer 17

a congenital condition characterized by chronic growth on hard palate. It is a benign bony growth located on midline suture of hard palate. More common in younger patients, women and Asians. No medical or surgical therapy required unless symptomatic or interferes with speech or eating

Question 18

A change in which parameter is the FIRST indicator of hypovolemia?

Answer 18

HR goes up and peripheral vasoconstriction occur to maintain BP w/in normal

Question 19

Tx rxn: Febrile nonhemolytic is most common that presents with fever and chills w/in 1-6 hrs of tx. Caused by?

Answer 19

cytokine accumulation during blood storage

Question 20

Tx rxn: acute hemolytic presents with fever, flank pain, hemoglobinuria, renal failure and DIC. Usu occurs w/in 1 hr of tx. What test to order? Caused by?

Answer 20

Test: positive direct Coombs test

Caused by ABO incompatibility

Question 21

Tx rxn: delayed hemolytic rxn presents with mild fever and hemolytic anemia w/in 2-10 days after transfusion. What tests are positive. Caused by?

Answer 21

Test: positive direct Coombs test, positive new antibody screen
Caused by anamnestic antibody response

Question 22

Hemorrhagic shock can be divded into 4 categories depending on amt of blood loss.
Class IV

Answer 22

> 40% (>2000 ml)
HR > 140
BP markedly decreased

Question 23

Tx rxn: urticarial/allergic presents with urticaria, flushing, angioedema and pruitis within 2-3 hrs of tx. Caused by

Answer 23

Caused by recipient IgE antibodies and mast cell activation

Question 24

Tx rxn: Transfusion-related acute lung injury presents with resp distress and signs of noncardiogenic pulmonary edema w/in 6 hrs of tx. Caused by?

Answer 24

Caused by donor anti-leukocyte abs

Question 25

Hypoxemia can be caused by reduced inspired O2 tension, hypoventilation, diffusion limitation, shunt, and V/Q mismatch. What is characteristic of alveolar hypoventilation?

Answer 25

respiratory acidosis | normal A-a gradient

Question 26

Nerve damage from wearing crutches

Answer 26

radial nerve

Question 27

Hemorrhagic shock can be divded into 4 categories depending on amt of blood loss. Class I

Answer 27

72 | BP normal

Question 28

After MVC, someone develops dyspnea, tacypnea, chest pain, hypoxemia that worsened by fluids and patchy irregular alveolar infiltrates on chest x-ray. Suspect?

Answer 28

pulmonary contusion

Question 29

Whistling noise during respiration after rhinoplasty? Suspect?

Answer 29

nasal septal perforation likely from septal hematoma

Question 30

Hemorrhagic shock can be divded into 4 categories depending on amt of blood loss. Class IV

Answer 30

>40% (>2000 ml) HR > 140 BP markedly decreased

Question 31

Cricothyroidectomy should be converted to formal tracheostomy if MV is needed past 5-7 days. Why?

Answer 31

high incidence of tracheal stenosis

Question 32

A-a gradient is normal when it's

Answer 32

Pulmonary Embolism Atelectasis Pleural effusion Pulmonary edema There is a decrease in PCO2 (respiratory alkalosis) due to compensatory hyperventilation

Question 33

Persistent pneumothorax and significant air leak following chest tube placement in a pt who has sustained blunt chest trauma suggests?

Answer 33

tracheobronchial rupture. (normally right main bronchus)

Question 34

Trismus (inability to open the mouth normally), limited cervical extension, neck pain, fever... suspect

Answer 34

retropharyngeal abscess -usual source is from local penetrating trauma. In order to fully evaluate the extent of the infection, do a CT of the neck and/or lateral radiographs of the neck which may show lordosis of cervical spine with gas and swelling in retropharygneal area. Treatment is IV abx and urgent drainage of abscess

Question 35

4 T's for ddx for anterior mediasinum mass.

Answer 35

- thymoma - teratoma - thyroid neoplasm - terrible lymphoma

Question 36

After MVC, someone develops dyspnea, tacypnea, chest pain, hypoxemia that worsened by fluids and patchy irregular alveolar infiltrates on chest x-ray. Suspect?

Answer 36

pulmonary contusion

Question 37

Whistling noise during respiration after rhinoplasty? Suspect?

Answer 37

nasal septal perforation likely from septal hematoma

Question 38

What fixes paradoxical movement in flail chest?

Answer 38

positive pressure mech ventilation by replacing the normal negative intrapleural pressure during spon vent with positive intrapleural press

Question 39

Cricothyroidectomy should be converted to formal tracheostomy if MV is needed past 5-7 days. Why?

Answer 39

high incidence of tracheal stenosis

Question 40

What are some common causes of gastric outlet obstruction?

Answer 40

- malignancy - PUD - chrohn - strictures 2/2 to ingestion of caustic agents - gastric bezoars

Question 41

Persistent pneumothorax and significant air leak following chest tube placement in a pt who has sustained blunt chest trauma suggests?

Answer 41

tracheobronchial rupture. (normally right main bronchus)

Question 42

Trismus (inability to open the mouth normally), limited cervical extension, neck pain, fever... suspect

Answer 42

retropharyngeal abscess -usual source is from local penetrating trauma. In order to fully evaluate the extent of the infection, do a CT of the neck and/or lateral radiographs of the neck which may show lordosis of cervical spine with gas and swelling in retropharygneal area. Treatment is IV abx and urgent drainage of abscess

Question 43

Blunt abd trauma --> delayed onset hypotension, LUQ abd pain, left shoulder pain (kehr sign). If hemo stable, do what? If not hemo stable, do what?

Answer 43

if stable --> abdominal CT scan wtih IV contrast to look for splenic injury if unstable --> urgent laparatomy

Question 44

Gastrochisis is a protrusion of bright red intestines to the ___ side of a normal umbilicus without a membrane. What to do

Answer 44

RIGHT | surgical emergency

Question 45

FOr any pt who suffers blunt deceleration trauma (MVA or fall from > 10 feet), what must be ruled out? What's the initial screening test? and the most sensitive finding?

Answer 45

blunt aortic trauma must be ruled out and CXR is the initial screening test and widening of the mediastinum is the most sensitive finding.

Question 46

Plain films of the foot show a hairline fracture of the shaft of the second metatarsal in someone who has had painin that foot that started wks again with activity and now with rest. Dx? What to do?

Answer 46

Stress aka hairline fracture | Treatment: rest, analgesia, and a hard-soled shoe

Question 47

When do you actually give someone tetanus abs

Answer 47

any individual with a severe or dirty wound WITH really immunocompromised state or an unclear or incomplete immunization history

Question 48

HOw does positive pressure MV worsen someone in hypovolemic shock that has not been adequately resuscitated?

Answer 48

-positive pressure MV increases intrathoracic pressure which decreases venous return to heart and thereby decreases ventricular preload. In someone who is already in hypovolemic shock, this can cause circulatory collapse unless volume adequately resuscitated

Question 49

``` widened mediastinum large left-sided hemothorax deviation of mediastinum to the right disruption of aortic contour on cxr ``` -all signs of possible

Answer 49

aortic injury can be confirmed with CT

Question 50

Prosthetic joint infection: early vs delayed-onset infection

Answer 50

early-onset: w/in 3 months of primary arthroplasty; most common org is staph aureus; treat with implant removal/exchange delayed-onset: > 3 mo after primary arthroplasty; most common org is staph epid; treat with implant removal/exchange

Question 51

what characterizes post-operative cholestasis?

Answer 51

benign condition that often develops after a major surgery characterized by hypotension, extensive blood loss into tissues, and massive blood repalcement. Jaundice develops due to increased pigment load from tx, decreased liver function due to hypotension and decreased renal bilirubin excretion from tubular necrosis. Jaundice is evident by 2nd or 3rd day with bilirubin peaking by POD10

Question 52

How to manage someone with duodenal hematoma (most commonly due to direct blunt abd trauma in children)

Answer 52

Usually self-resolving so manage with NG suction and parenteral nutrition. If fails, then surgery

Question 53

How soon after surgery can you start anticoagulation in a patient who needs it

Answer 53

48-72 hrs post-surgery in hemodynamically stable pts

Question 54

how does thoracic artery aneurysm repair lead to anterior spinal cord syndrome (loss of spinothalamic and corticospinal)

Answer 54

the artery that supplies the anterior spinal cord is the anterior spinal artery which is a branch of the artery of Adamkiewicz from the thoracic arota. Therefore, thoracic aortic surgery can result in reduced blood flow during aortic cross clamping or hypotension and lead to anterior spinal cord infarction

Question 55

Bacterial infection usu bronchopneumonia or burn wound infection leading to sepsis is the leading complication of burn victims after adequate fluid resusc. which are the 2 most likely organisms involved

Answer 55

staph aureus | pseudomonas

Question 56

How can one confirm fat embolism

Answer 56

presence of fat droplets in urine | presence of intra-arterial fat globules on fundoscopy

Question 57

How do these interventions help with lowering ICP: 1) head elevation 2) sedation 3) IV mannitol 4) hyperventilation 5) removal of CSF

Answer 57

1) head elevation: increased venous outflow from the brain 2) sedation: decreased metabolic demand & control of HTN 3) IV mannitol: extraction of free water from brain tissue --> osmotic diuresis 4) hyperventilation: CO2 washout --> cerebral vasoconstriction 5) removal of CSF --> reduction of CSF volume/pressure

Question 58

What's the most common bone in the body to be affected by stress fractures

Answer 58

tibia ("shint splints" or medial tibial stress syndrome")

Question 59

Acute bacterial parotitis can occur in older pts post-surgery presenting as fever, leukocytosis and parotid inflammation. How to prevent? What's the most common causative agent?

Answer 59

- adequate fluid hydration and oral hygiene can prevent | - Staph aureus

Question 60

Leriche syndrome -triad of symptoms?

Answer 60

arterial occlusion at the bifurcation of aorta into common iliac arteries aka aortoiliac occlusion. Triad: bilateral hip/thigh/buttock claudication, impotence, and symmetric atrophy of b/l LE due to chronic ischemia

Question 61

Who is at greatest risk of Leriche syndrome/aortoiliac occlusion

Answer 61

men at high risk for atherosclerosis (e.g. smokers)

Question 62

Congenital adhesions are called

Answer 62

Ladd's bands

Question 63

What are the most impt steps in management of lactic acidosis from septic shock?

Answer 63

IV normal saline with or without vasopressure therapy to maintain the intravascular pressure and abx to correct the underlying infection

Question 64

Femoral nerve: motor and sensory functions?

Answer 64

motor: muscles of anterior compartment so impt for knee extension and hip flexion. Sensation: anterior thigh and medial leg via the saphenous branch

Question 65

Obturator nerve: motor and sensory functions?

Answer 65

motor: muscles of medial compartment so impt in adduction of thighs sensation: medial thigh

Question 66

What's impt about moving pt from supine to sitting post-op

Answer 66

supine to sitting can increase the functional residual capacity by 20-35%.

Question 67

What to do if someone needs urgent surgery and is on warfarin?

Answer 67

will need to reverse INR to lessen chances of bleeding excessively during surgery by giving infusion of FFP to restore vit K-dependent clotting factors.

Question 68

define massive hemoptysis

Answer 68

> 600 ml of expectorated blood over a 24 hr period or a bleeding rate > 100 mL/hr

Question 69

WHat's initial management of someone with massive hemoptysis

Answer 69

- adequate airway - aqequate ventilation and gas exchnage - make sure hemo stable - placed with bleeding lung in dependent postion to avoid blood collection of opposite lung - bronchoscopy is initial procedure of choice as it can localize bleed, and can intervene therapeutically

Question 70

positive drop arm sign when you passively abduct pt's arm and then release and ask pt to lower it. instead of lowering it, it just drops down, signfying

Answer 70

rotator cuff tear

Question 71

after gynecologic surgeries, a woman develops unexplained fever and you suspect thromboplebitis. How to treat?

Answer 71

- heparin | - abx

Question 72

Pressure ulcers are caused by impaired blood flow leading to ischemia. Check CBC and blood cx as culturing will just get skin flora. Can do tissue biopsy to r/o marjolins ulcer. Best prevention is turning pt q2h. What are the 4 stages of pressure ulcers

Answer 72

stage 1 = skin intact but red and still blanches with pressure stage 2 = blister or break in the dermis stage 3 = subcutaneous destruction into the muscle stage 4= involvement of joint or bone

Question 73

adenocarcinoma of the lungs can cause pleural effusions characterized by

Answer 73

exudative with high hyaluronidase

Question 74

Lung cancer assoc with hypercalcemia

Answer 74

squamous cell -PTHrp

Question 75

Pt with shoulder pain, ptosis, constricted pupil and facial edema?

Answer 75

pancoast tumor/superior sulcus syndrome usu from small cell

Question 76

pt with lung cancer with ptosis that is better after 1 min of upward gaze

Answer 76

lambert eaton assoc with small cell carcinoma from ab to presynaptic calcium channels

Question 77

what is krukenberg cancer?

Answer 77

gastric cancer that has metasized to ovaries

Question 78

What is virchow's node

Answer 78

gastric cancer with swollen supraclavicular LNs

Question 79

What is gastric lymphoma assoc with

Answer 79

HIV

Question 80

What is MALT lymphoma assoc with

Answer 80

H. pylori and can be treated with triple therapy

Question 81

What is blummer's shelf

Answer 81

gastric cancer metastasis that can be felt on digital rectal exam.

Question 82

What is sister mary joseph

Answer 82

gastric cancer with umbilical LNs

Question 83

What is mentriers'

Answer 83

protein losing enteropathy on EGD can see enlarged rugae

Question 84

Pt has bilious vomiting, post-prandial pain and recently lost 200 lbs.

Answer 84

SMA syndrome happens when 3rd part of duodenum is compressed by aorta and SMA. Treatment is nutrition.

Question 85

Choledochal cysts can present as persistent jaundice in a newborn. What's the diff btw type 1 and type 4

Answer 85

type 1 = fusiform dilatation of CBD -> treat with excision | type 4 = caroli's disease when cysts are in intrahepatic ducts that will necessitate liver tx

Question 86

TIPS can improve portal HTN but can worsen

Answer 86

hepatic encephalopathy by interrupting clearance of ammonia.

Question 87

Post-op splenectomy can lead to thrombocytosis when plts are above 1,000,000. How to treat.

Answer 87

Give aspirin (anti-plt)

Question 88

Post-splenectomy vaccines

Answer 88

s. pneumo h influenzae n meningitides (also post-op penicillin -impt in immune function)

Question 89

+ Casoni skin test and liver cysts and eosinophilia

Answer 89

echinococcus | will do surgery to remove cysts but be careful of anaphy rxn and give albendazole

Question 90

which deficiency is assoc with carcinoid tumor

Answer 90

niacin deficiency bc tryptophan is used to make niacin and is used to make all the excess serotonin instead niacin is assoc with the Ds: diarrhea, dermatitis, death, dementia

Question 91

List the 3 Light's criteria to determine if an effusion is exudative or not.

Answer 91

Pleural fluid protein/Serum protein > 0.5 Pleural fluid LDH/Serum LDH > 0.6 Pleural fluid LDH > 2/3 upper limit of normal

Question 92

How to calculate basal energy expenditure in males and females

Answer 92

males: 25 kcal/kg/day females: 22 kcal/kg/day

Question 93

Pt with recent h/o of skin infection presenting with fever and abdominal pain radiating to the groin and pain with hip extension points to what dx? How to dx and treat?

Answer 93

psoas abscess which can occur either hematologic seeding from a distant infection or from direct extension of an intraabdominal infection (diverticulitis, osteomyeltis) Risk factors: HIV, IV drug use, diabetes, Chrohns Dx: CT scan of abdomen & pelvis; blood and abscess cxs Treatment: Drainage and broad spectrum abxs

Question 94

In supracondylar fracture, one should worry about brachial artery or median nerve injury. Compartment syndrome is concerning as well although rare. What can compartment syndrome lead to/?

Answer 94

Volkman contracture which is permanent flexion contracture of the hand at the wrist, resulting in a claw-like deformity of the hand and fingers. Passive extension of fingers is restricted and painful. Volkmann's Ischemic Contracture is the direct result of undiagnosed Compartment Syndrome. It is excruciatingly painful and disabling

Question 95

What to suspect when a pt presents with recent cardiac cath, anticoagulation with heparin, sudden onset of hypotension, tachycardia, flat neck veins and back pain? How to diagnose and treat?

Answer 95

retroperitoneal hematoma due to bleeding from arterial access site that usu occurs w/n 12 hrs of catheterization. Dx is confirmed with NON-contrast CT or ultrasound Treatment is bed rest, IV fluids or blood tx

Question 96

Which part of the bladder is the only region covered by peritoneum and can cause referred pain to left shoulder (kehr sign)?

Answer 96

dome of the bladder

Question 97

How to treat penile fracture?

Answer 97

emergent urethrogram to assess for urethral injury and emergent surgery to evacuate the hematoma to mend the torn tunica albuginea

Question 98

Pts who take daily prednisone >/- 20 mg for > 3 wks are at high risk of adrenal insufficiency when in stressful conditions like surgery. Impt to give stress dose of steroids during the acute stressful condition. What are some clinical clues that may suggest perioperative adrenal insufficiency?

Answer 98

- unexplained nausea/vomiting, abd pain - hyponatremia, hyperkalemia - hypoglycemia - hypotension

Question 99

Acute mediastinitis is a possible complication of cardiac surgery that is usually due to intraop wound contamination. What is typical presentation? What can you see on xray? How to dx and treat?

Answer 99

presentation: usu w/in 14d with fever, tachycardia, chest pain, leukocytosis, sternal wound drainage or purulent discharge CXR: may show widened mediastinum Dx is clinically made Treatment is drainage, surgical debridement wtih immediate closure and abx therapy.

Question 100

AF can occur after CABG but is usually self-limiting with resolution

Answer 100

rate control best with beta blockers or amiodarone > 24 hrs of AF, can consider anticoagulation and/or cardioversion

Question 101

Post-thyroidectomy is the most common cause of hypoparathyroidism. What is the second most common case of primary hypoparathyroidism?

Answer 101

autoimmune

Question 102

nasopharyngeal carcinoma is an undifferentiated carcinma of squamous cell origin that is usu asymp until too late. They often present with recurrent otitis media (due to tumor obstructing eustacian tube), recurrent epistaxis, and/or nasal obstruction. This is strongly assoc with what virus and what social risk factors

Answer 102

strongly assoc with EBV | assoc with smoking and chronic nitrosamine consumption (salted fish)