Surgery #2

C. shearing at the proximal femoral epiphysis ~ Symptoms most commonly include chronic (>3 weeks), intermittent, dull pain/ache of the hip, thigh, or knee that is exacerbated by activity, as seen in this patient. The leg is typically externally rotated (foot pointed laterally), and gait may be altered due to pain. On examination, decreased range of motion (particularly internal rotation) and tenderness of the hip may be present. Abduction and external rotation of the thigh during passive flexion of the hip is characteristic. Diagnosis is confirmed by visualization of a posteriorly slipped femoral head on x-ray.

A 12-year-old girl is brought to the clinic by her mother for evaluation of leg pain. The patient first noticed a dull ache in her left thigh a month ago. The pain is intermittent, worse after skipping rope with friends, and typically resolves after rest or ibuprofen. She does not recall any inciting injury to the leg. Prior to last month, the patient had never experienced any similar pain. Medical history is unremarkable. She takes no medications. Family history is notable for sickle cell disease. Temperature is 37.5 C (99.5 F). BMI is at the 97th percentile for age. The abdomen is soft with no hepatosplenomegaly. A few soft, nontender, mobile, 1-cm inguinal lymph nodes are palpable bilaterally. Skin examination reveals a few small, healing abrasions over the bilateral anterior knees. The left hip demonstrates decreased range of motion with internal rotation. There is no increased warmth over the joint. The left foot points laterally during ambulation. Which of the following is the most likely underlying cause of this patient's symptoms? A. bacterial infection of the joint space B. expansion of malignant cells in bone marrow C. shearing at the proximal femoral epiphysis D. transient intraairticular inflammaiton E. vaso-occlusion from intravascular red cell sickling

B. ~ Clavicle fracture is a common sports-related injury & can occur following a blow or fall on the shoulder or outstretched arm. The vast majority r uncomplicated & carry a favorable prognosis. However, the middle third of the clavicle overlies the brachial plexus & the subclavian artery & vein in the thoracic outlet. Therefore, clavicular fractures require a careful neurovas assessment. ~ The presence of "hard signs" (absent distal pulses, bruit at injury site) following a fracture indicate definite arterial injury & require immediate surgical intervention. However, the presence of a stable hematoma, reduced pulse, documented hemorrhage at the time of injury, unexplained hypotension, or an associated neurologic deficit also suggest an arterial injury may have occurred. These "soft signs" require vascular imaging to confirm and localize the site of injury. CT angiography is the diagnostic modality of choice

A 16-year-old boy is brought to the emergency department due to left shoulder and hand pain after he fell on his outstretched hand while playing soccer. He immediately heard a crunching sound and had intense pain in the left shoulder following the injury. Blood pressure is 105/72 mm Hg and pulse is 85/min. On examination, he is holding his left arm with his right hand. There is bruising around the left shoulder and a small hematoma is noted at the base of the neck. Neurologic examination reveals intact sensation in the left upper extremity. The right radial pulse is easily palpable, and the left radial pulse is slightly decreased. X-ray of the left shoulder and chest reveals a displaced fracture of the clavicle with a normal cardiac silhouette. Which of the following is the best next step in management of this patient? A. closed reduction with figure of eight brace B. CT angiogram C. nerve conduction studies D. open reduction of the clavicle E. upper extremity venous duplex scan

E ~ pt w/ poorly localized anterior knee pain has typical features of patellofemoral pain syndrome. one of the most common causes of chronic knee pain in young women. usually related to chronic overuse but can also occur acutely following trauma. ~ dx is primarily based on charac hx & exam findings; however, no indv finding has high clinical utility, & the exam is often normal. In genl, the pain is provoked by maneuvers (squatting, ascending/descending stairs, running or sitting for extended periods) that involve tonic contraction of the quadriceps w/ the knee in flexion. The patellofemoral compression test (reproduction of pain when the patella is compressed into the trochlear groove) is often helpful but may generate significant discomfort for the patient. ~ mgmt: activity modification, NSAIDs, strength & strengthening exercises with emphasis on quads & hip abductors

A 17-year-old girl comes to the office for evaluation of right knee pain. For the past 3 months, the patient has had poorly localized, achy pain at the anterior right knee that is worse when she runs, sits for extended periods, or goes up or down a staircase. She has been taking nonsteroidal anti-inflammatory drugs, which partially relieve the pain but have lost effectiveness over time. The patient also has a sensation that the knee is "giving way" when she is running. Vital signs are normal. BMI is 19 kg/m2. Physical examination shows a normal gait and no visible knee deformities. There is mild pain with flexion of the right knee. With the knee extended, compressing the patella into the trochlear groove reproduces the pain. Which of the following is the best next step in management of this patient? A. hinged knee brace B. intraairticular gluco-corticocid injection C. knee immobilizer D. non weight bearing crutches for 2 weeks E. quadriceps strengthening exercise

A ~ This pt who sustained blunt abdominal trauma during a MVC now has abd pain, LUQ tenderness, & intraperitoneal free fluid on FAST examination. This presentation is concerning for intraabdominal hemorrhage, possibly from splenic injury. ~ Mgmt of suspected intra abdominal hemorrhage depends on the pts hemodynamic status: ✦ unstable (SBP < 90): emergency ex lap ✦ stable: CT abd pelvis

A 19-year-old man is brought to the emergency department by ambulance after a motor vehicle collision. The accident occurred 1 hour ago when his vehicle spun out of control and rolled over. He was wearing his seatbelt and his airbag deployed. The patient is alert and reports abdominal pain. Blood pressure is 110/70 mm Hg, pulse is 106/min, and respirations are 16/min. On examination, lungs are clear to auscultation bilaterally and the chest wall is nontender. Heart sounds are normal. The abdomen is nondistended with tenderness to palpation in the left upper quadrant. There are no gross deformities of the extremities. A Focused Assessment with Sonography for Trauma (FAST) examination reveals free fluid in the leftsubphrenic space. Which of the following is the best next step in management? A. CT scan of abd & pelvis B. DPL C. ex lap D. no additional workup E. serial abdominal exams

A. measure the ABI ~ injury to the popliteal artery is the most feared complication of any knee dislocation bc the resulting lower leg ischemia can cause irreversible injury, requiring ATK amputation ~ Management begins with immediate reduction of the dislocated knee. Given the risk of vascular (popliteal artery) injury, this should be followed by a meticulous vascular examination that includes: ◦ Palpation of the popliteal and distal pulses ◦ Measurement of the ankle-brachial index (ABI) ◦ Duplex ultrasonography (if available) ~ Because pulse examination alone is of limited accuracy in diagnosing vascular injury, obtaining and documenting the ABI are critical.

A 20-year-old collegiate football player is brought to the emergency department due to severe right knee pain following a hard tackle. He cannot bear weight on the right leg. Blood pressure is 142/90 mm Hg, pulse is 108/min, and respirations are 18/min. The right knee is deformed, swollen, and bruised; the lower leg is warm and soft, with a palpable dorsalis pedal pulse. Lateral x-ray of the knee reveals a posterior dislocation, as shown in the exhibit. Immediate reduction is performed under sedation. Which of the following is the best next step in management of this patient? A. measure the ABI B. perform knee arthrocentesis C. perform nerve conduction study D. perform posterior drawer test

E ~ scaphoid fracture can disrupt flow to the proximal segment, leading to avascular necrosis and nonunion. ~ Scaphoid fractures are characterized by tenderness in the anatomic snuffbox, a finding that has high sensitivity for fracture & warrants additional eval w/ imaging. The snuffbox is a shallow depression at the dorsoradial wrist bounded medially by the tendon of the extensor pollicis longus and laterally by the tendons of the abductor pollicis longus and extensor pollicis brevis. ~ X-ray at the time of injury has low sensitivity for scaphoid fracture. Therefore, if initial x-rays r negative, CT scan or MRI of the wrist is recommended to confirm the fracture. As an alternative, the wrist can be immobilized briefly in a thumb spica splint, followed by repeat imaging in 7-10 days.

A 23-year-old man comes to the office due to right wrist pain. Earlier today, while running to home plate during a baseball game, he landed forcefully on his outstretched right hand with the palm facing down. Since then, the patient has had right wrist pain and swelling. He has had partial relief with acetaminophen and local application of ice packs, but the pain still limits his activities. The patient's medical history is unremarkable. Vital signs are normal. Physical examination shows mild swelling at the dorsum of the right wrist. There is maximal tenderness proximal to the base of the first metacarpal, and the pain worsens with radial deviation of the wrist. Radiographs of the wrist in multiple views reveal no fracture or dislocation. Which of the following is the most appropriate next step in management of this patient? A. analgesics & PT B. local anesthetic & corticosteroid injection C. surgical exploration & tendon repair D. synovial fluid aspiration & analysis E. thumb spica splint & repeat radiography in 10 days

E. radiologic imaging of the foot - pt likely has a calcaneal stress fracture, which is caused by repetitive micro trauma in high impact activities (running). most common occur in young men & obese indvs, often following an abrupt increase or a transition of activities to hard surfaces ~ heel pain worse with ambulation, especially during the first step of the morning or after rest ~ calcaneal squeeze test: tenderness with medial-lateral squeezing of the calcaneus ~ dx can be confirmed with imaging: xray frequently negative in early stages ~ plantar fasciitis: pain is worse with toe dorsiflexion

A 24-year-old man comes to the clinic due to foot pain. For the past 2 weeks, the patient has had gradually increasing pain in his left heel. The symptoms are worse when he walks, and it has become difficult to ambulate. The patient is a recreational runner and started training for a marathon 1 month ago. Vital signs are normal. BMI is 29 kg/m2. Pedal pulses are full and symmetric bilaterally. The ankle has normal range of motion in all directions. Squeezing the heel laterally and medially reproduces the pain. Examination of the forefoot is normal, with no pain on dorsiflexion or plantar flexion of the toes. In addition to activity modification, which of the following is the most appropriate next step in management of this patient? A. 25-hydroxyvitamin D level B. ankle & foot stabilization with an air-stirrup brace C. corticosteroid injection at tender points D. plantar fascia release surgery E. radiologic imaging of the foot

C ~ In this pt, there is no evidence of cardiac tamponade (no pericardial effusion) or hemothorax (equal breath sounds, no pleural effusion), & the irregular opacities revealed on CXR likely represent a pulmonary contusion that does not require immediate intervention. Given the absence of an intrathoracic source of shock, intraabdominal organ (spleen) injury due to penetrating abdominal trauma should be suspected. For patients with PAT, immediate ex lap is indicated for: ✦ hemodynamic instability (SBP < 90 mm Hg). ✦ peritonitis (rigidity, rebound tenderness). ✦ evisceration (externally exposed intestines). Bc this pt already has an indication for laparotomy, the abdominal portion of the FAST exam is not necessary as it does not change mgmt. However, it is sometimes performed in practice (immediately following the cardiac portion) because a + result (intraperitoneal free fluid) further confirms the need

A 24-year-old man is brought to the emergency department after being shot during a street fight. On the way to the hospital, the patient became obtunded and required intubation. He also received 2 L of normal saline. On arrival, blood pressure is 86/40 mm Hg and pulse is 130/min. The trachea is midline, and breath sounds are equal bilaterally. Heart sounds are normal. Two gunshot wounds are present: one in the leftsixth intercostal space just lateral to the midclavicular line and another in the left seventh intercostal space posteriorly. Portable chest x-ray shows irregular opacities at the left lung base. Focused Assessment with Sonography for Trauma reveals no pericardial effusion and is equivocal for intraperitoneal free fluid. Transfusion of uncrossmatched blood is pending. Which of the following is the best next step in management of this patient? A. CT scan of the abdomen B. diagnostic peritoneal lavage C. ex lap D. local wound exploration E. plain radiograph of the abdomen

B. impaired generation of negative inspiratory pressure Flail chest (fracture of >/3 contiguous ribs in >/ 2 locations creates an isolated chest wall segment that moves paradoxically to the rest of the rib cage during respiration) negatively impacts respiration and oxygenation in multiple ways, including the following: ◦ Impaired generation of negative intrathoracic pressure during inspiration and increased dead space during expiration cause ineffective ventilation. ◦ Pulmonary contusion in the underlying lung impedes oxygen diffusion, diminished breath sounds here ◦ Fracture-related pain causes respiratory splinting (ie, decreased inspiratory effort) and bibasilar atelectasis.

A 25-year-old man is brought to the emergency department after a high-speed motor vehicle collision. The patient was restrained, but there was prolonged extrication due to extensive vehicular damage. Supplemental oxygen and intravenous fluids were administered on the way to the hospital. On arrival, the patient is alert and can speak but appears to have increased work of breathing. Blood pressure is 110/66 mm Hg, pulse is 120/min, and respirations are 34/min. Pulse oximetry is 88% on 10 L oxygen via nonrebreather mask. The trachea is midline and the neck veins are flat. There are several chest wall and abdominal bruises. A portion of the anterior left chest moves inward during inspiration. Breath sounds are diminished in the anterior left lung but normal elsewhere. The abdomen is nondistended, soft, and nontender to palpation. The left thigh is deformed, but compartments are soft and distal pulses are intact. There are no focal neurologic deficits. Which of the following is the most likely cause of this patient's hypoxia? A. extensive air leakage from the tracheobronchial tree B. impaired generation of negative inspiratory pressure C. lung compression from increased intrapleural pressure D. occlusion of pulmonary vasculature by fat emboli E. pulmonary congestion from contused myocardium

E. XRAY of the ankle The Ottawa ankle rules were developed to determine which pts require imaging to r/o an ankle fracture. These rules have high sensitivity (up to 99%) for detecting fracture and can help reduce the number of unnecessary radiographs. ◦ Plain radiographs of the ankle are indicated in patients with pain in the area of the malleolus in association with either: ✦ Point tenderness over the posterior margin or tip of the malleolus OR ✦ Inability to bear weight after the injury and for 4 steps during medical evaluation (inability to walk to the examination room)

A 26-year-old man comes to the emergency department for evaluation of right ankle pain. The patient was playing basketball just prior to arrival when he jumped in the air and landed on his friend's foot, rolling his right ankle. He immediately fell to the ground. The patient was unable to walk off the basketball court by himself and is unable to walk to the examination room unaided. Blood pressure is 110/80 mm Hg and pulse is 76/min. BMI is 20 kg/m2. The lateral aspect of the right ankle has significant swelling and tenderness to palpation over the lateral malleolus. There is no bruising and no tenderness to palpation over the anterior aspect of the foot. The patient can plantar flex and dorsiflex the ankle. Sensation is normal. Which of the following is the best next step in management of this patient? A. ankle splinting & NSAIDs B. immediate surgical fixation C. intra-articular aspiration D. MRI of the ankle & foot E. XRAY of the ankle

E. medical meniscus tear ~ Examination typically shows joint line tenderness of the involved side (medial joint line tenderness with medial meniscus injury). Patients may also have clicking, locking, or catching and reproduction of pain during provocative maneuvers such as the Thessaly test (performed in this patient) or McMurray test. ~ X-ray may reveal osteoarthritis in older patients with tears caused by chronic degeneration of the cartilage, but plain film is usually normal in young patients with traumatic tears. Diagnosis is confirmed with MRI or arthroscopy.

A 30-year-old woman comes to the office for evaluation of left knee pain. She was participating in a recreational hockey tournament a week ago when she collided with another player, and they both hit the wall. The patient was able to skate off the ice but noted some pain in the left knee. She had partial pain relief with ice and elevation of the left leg, but, the next morning, she noticed that her knee was swollen. On examination, the patient has a small left knee effusion without erythema or palpable warmth. There is tenderness at the medial aspect of the knee at the joint line, but gait is normal. With the patient standing on the left leg and the knee bent slightly, internal and external knee rotation elicits a click and significant, sharp pain. X-ray of the knee joint is normal. Which of the following is the most likely diagnosis in this patient? A. anserine bursitis B. ACL tear C. iliotibial band syndrome D. MCL tear E. medical meniscus tear F. patellar dislocation G. patellar tendon rupture H. patellofemoral pain syndrome

A. bone loss ~ Prolactin suppresses production of GnRH in the hypothalamus, leading to decreased release of FSH and LH, manifesting as central hypogonadism. In premenopausal women, this typically presents with anovulation, oligo/amenorrhea, and infertility. ~ The resultant estrogen deficiency can cause vasomotor symptoms (eg, hot flashes), vaginal dryness and atrophy, and dyspareunia. Because estrogen maintains bone mass in premenopausal women, prolonged estrogen deficiency can lead to osteoporosis and an increased risk for fragility fractures. ~ Therefore, all patients with hyperprolactinemia and hypogonadal symptoms warrant treatment (eg, dopamine agonists).

A 32-year-old woman comes to the office due to 7 months of irregular periods and 3 months of amenorrhea. Her only preexisting medical condition is hypothyroidism treated with levothyroxine. The patient lives with her husband and 4-year-old son. Her husband uses condoms for contraception. Family history is significant for breast cancer in her mother. Examination shows mild vaginal dryness. The remainder of the physical examination, including visual fields, is normal. Laboratory results are as follows: Cr 1.1, Prolactin 100 (<20), TSH 1.2 A pregnancy test is negative. MRI reveals a 7 mm pituitary microadenoma. The most important reason for treating this patient now is to prevent which of the following? A. bone loss B. breast cancer C. endometrial cancer D. permanent infertility E. rapid increase in adenoma size

E. place the patient in respiratory isolation ~ Although there are several possible etiologies for the presence of hemoptysis, this patient's presentation (coming from an endemic area, symptoms, and upper-lobe involvement) is suggestive of pulmonary tuberculosis. Tuberculosis typically has radiographic abnormalities (eg, patchy or nodular opacity, multiple nodules, cavity) involving the apical-posterior segments of the upper lobes of the lungs. This patient is now stable, and the next step is to place him in complete respiratory isolation to avoid further exposure to healthcare professionals and other individuals. Respiratory isolation should be continued until the diagnosis of tuberculosis can be confirmed or refuted by additional testing (eg, acid-fast bacilli smear and culture).

A 34-year-old male immigrant from Mexico is brought to the emergency department after coughing up foamy sputum with a "significant" amount of bright-red blood. His clothes are stained red, but he is not currently having any coughing spells. He has no recent trauma and no other medical problems. He takes no medications. His blood pressure is 112/63 mm Hg, pulse is 97/min, and respirations are 16/min. Pulse oximetry shows 95% on room air. The patient is mildly agitated. Breath sounds are audible bilaterally with some expiratory wheezing on the right side. Intravenous fluids are initiated, and the patient is placed on supplemental oxygen. Portable chest x-ray shows a dense opacity in the right upper lobe. Which of the following is the best initial step in management of this patient? A. administer broad spectrum abx B. obtain bronchoscopic eval C. order CT scan of the chest with contrast D. perform endotracheal intubation E. place the patient in respiratory isolation

A. cerebral vasoconstriction ~ the brain parenchyma, the CSF, & cerebral blood flow (CBF) determine the overall intracranial pressure ~ the partial pressures of O2 & CO2 also play an important role in regulating CBF. In conditions such as stroke or trauma, these systems are disrupted and interventions may be required to lower ICP. ~ CBF is an important target for therapy, & paCO2 is a potent regulator of CBF (much greater than paO2). As levels of cerebral paCO2 rise, so does blood flow. Lowering cerebral arterial paCO2 through hyperventilation results in rapid vasoconstriction and a consequent decrease in ICP. Other interventions to lower ICP do so by lowering systemic pressures and reducing metabolic demand (sedation), or increasing venous outflow (head elevation), reducing brain parenchyma water content/volume (mannitol), or reducing the volume of CSF (therapeutic lumbar punctures).

A 34-year-old man is treated in the intensive care unit after being involved in a motorcycle accident. He has multiple injuries, including severe traumatic brain injury. Head CT scan shows areas of contusion and swelling without subdural or epidural hematoma. On the second day of hospitalization, a ventriculostomy is placed for invasive intracranial pressure monitoring. On the third day, his pressure is high despite adequate sedation, elevation of the head of the bed, and removal of cerebrospinal fluid. Hyperventilation would decrease this patient's intracranial pressure by which of the following mechanisms? A. cerebral vasoconstriction B. decreased capillary leak C. decreased sympathetic output D. increased pO2 E. increased venous outflow from the head

A ~ retropharyngeal abscess w/ neck pain, odynophagia, & fever following penet. trauma to the pos. pharynx. neck stiffness & bulging of the pharyngeal wall. Such deep space infections of the neck can progress rapidly to surrounding structures. Behind the pos. pharyngeal wall lies the retropharyngeal space, a deep compartment of the neck defined anteriorly by the buccopharyngeal fascia and constrictor muscles of the pharynx and posteriorly by the alar fascia; it communicates laterally with the parapharyngeal space ~ Infection w/n the retropharyngeal space can extend pos. thru the alar fascia into the "danger" space (b/w the alar & prevertebral fasciae), which can rapidly transmit infection into the posterior mediastinum. Acute necrotizing mediastinitis, a life-threatening comp ~ all pts diagnosed w/ retropharyngeal abscess need CXR (AP & lateral views) to look for widened mediastinum.

A 36-year-old woman comes to the emergency department with worsening fever and sore throat. Four days ago, the patient accidentally swallowed a fish bone that scratched her throat and caused some discomfort. She felt better after some time and did not seek medical attention, but for the past 2 days, she has had severe sore throat and difficulty swallowing. The patient also reports neck pain and stiffness. Temperature is 39 C (102.2 F), blood pressure is 126/80 mm Hg, and pulse is 106/min. Examination shows pooling of saliva in the hypopharynx. The posterior pharyngeal wall is red and bulging. The neck is stiff with reduced passive range of motion. Lung auscultation is normal. Lateral radiographs of the neck reveal increased thickness of the prevertebral soft tissues with an air-fluid level. Because of potential contiguous spread of the disease, this patient is at greatest risk for developing which of the following? A. acute necrotizing mediastinitis B. cranial subdural empyema C. Ludwig angina D. septic cavernous sinus thrombosis E. spinal epidural abscess

E. mesenteric ischemia ~ AMI typically presents with sudden-onset, severe, poorly localized (visceral) midabdominal pain accompanied by nausea and vomiting. Early in the course of illness, physical examination is typically unremarkable (eg, minimal, diffuse tenderness) despite the presence of severe pain; this finding is classically referred to as "pain out of proportionto the examination findings" (eg, intense pain out of proportion to minimal tenderness on examination, in this patient). Local ischemia can lead to an urge to defecate, as seen in this patient. ~ If bowel infarction occurs, more focal abdominal tenderness (due to local inflammation/infarction), peritoneal signs (eg, guarding, rebound tenderness), rectal bleeding, and sepsis can develop. Most patients have leukocytosis, elevated hemoglobin (hemoconcentration), elevated amylase, and metabolic acidosis (lactic acidosis).

A 37-year-old hospitalized man is evaluated for acute onset of intense, periumbilical abdominal pain associated with nausea and vomiting. He has an urge to defecate and has had 2 bowel movements since the pain began. The patient has a history of alcohol and intravenous heroin use. He was admitted 4 days ago for fever, chills, and shortness of breath and was diagnosed with acute bacterial endocarditis. Blood cultures grew Staphylococcus aureus, and an echocardiogram showed vegetations on the mitral valve. He is currently being treated with intravenous vancomycin. On examination, the patient appears in significant distress and is restless. Temperature is 37.5 C (99.5 F), blood pressure is 150/90 mm Hg, pulse is 110/min and regular, and respirations are 18/min. The pupils are equal, round, and 3 mm in size. The lungs are clear to auscultation. A 3/6 holosystolic murmur is present over the apex. There is no S3. On abdominal palpation, minimal diffuse tenderness is present. There is no rigidity or rebound. Bowel sounds are decreased. There is no tremor. Which of the following is the most likely cause of this patient's abdominal pain? A. acalculous cholecystitis B. acute pancreatitis C. alcohol withdrawal D. intra-abdominal abscess E. mesenteric ischemia F. opioid withdrawal G. papillary muscle rupture

E ~ This pts presentation is most consistent with a frontal lobe tumor. Brain tumors can be asymptomatic or minimally symptomatic until increased ICP causes HA (classically worse with recumbency), papilledema. Other common manifestations: unprovoked first seizure, focal deficits, & cognitive dysfunction (impaired memory). ~ Specific deficits, which are sometimes subtle & present for weeks to months, help with tumor localization. Frontal lobe involvement can affect personality, language, motor, or executive functions (planning, inhibition, attention). This patient's personality changes (acting strangely) over the past few months likely reflect a frontal lobe mass. Although frontal lobe damage classically causes disinhibition & impulsiveness, it may also lead to depressive symptoms, including decreased motivation and/or lack of concern regarding the diagnosis (abulia) and loss of interest (anhedonia)

A 38-year-old, right-handed woman is brought to the emergency department after a brief seizure witnessed by her husband. The patient has never before had a seizure but has had headaches for several weeks. Her husband says that she has acted strangely for several months. The patient used to be quite social, but lately, she is not motivated to participate in any social activities and has lost interest in everyday activities. She will not talk unless directly spoken to and has impaired memory. The patient has no significant medical or psychiatric history. There is no family history of neurologic disorders. Temperature is 36 C (96.8 F), blood pressure is 130/78 mm Hg, and pulse is 86/min. On examination, the patient is somnolent but wakes to voice and follows commands. The pupils are equal and reactive. Funduscopy reveals bilateral papilledema. Bilateral upper and lower extremity muscle strength is normal. Neuroimaging is most likely to reveal which of the following findings in this patient? A. frontotemporal lobe atrophy B. ischemic infarction to the brainstem C. right parietal lobe lesion D. sclerosis of the medial temporal lobe E. solitary mass in the frontal lobe

~ This pt has been receiving aggressive fluid resuscitation in the setting of acute pancreatitis, an inflammatory condition that can cause abdominal swelling from visceral edema, intraabdominal third spacing of fluids, and ileus (evidenced by decreased bowel sounds). Now, he has a tensely distended abdomen & clinical signs concerning for abdominal compartment syndrome, including difficulty breathing & basilar atelectasis (from diaphragmatic elevation causing lung compression) & decreased UOP (from increased intraabdominal pressure reducing renal perfusion) ~ bc elevated IAP is transmitted to the thoracic cavity thru the diaphragm, ACS also has significant CV consequences: ✦ Altho reduced cardiac preload is typ reflected in a low CVP, the two are uncoupled in ACS, where CVP is increased (despite reduced preload) due to external compression ✦ decreased cardiac preload -> decreased CO

A 40-year-old man is evaluated in the hospital after being admitted for acute alcohol-induced pancreatitis 24 hours ago. He has been receiving aggressive intravenous hydration and pain control. Over the past 2 hours, the patient has become increasingly restless and now reports difficulty breathing and abdominal distension. Blood pressure is 80/60 mm Hg, pulse is 122/min, and respirations are 28/min. Heart and lung sounds are normal. The abdomen is significantly distended and tense. Bowel sounds are decreased. Bilateral lower extremity and flank edema are present. Chest x-ray reveals basilar atelectasis but no other infiltrates. His urine output has markedly decreased over the past 2 hours. Which of the following pathophysiologic changes are most likely present in this patient at this time compared to a few hours earlier? A. decreased cardiac preload B. decreased CVP C. decreased LE venous pressure D. increased abdominal wall compliance E. increased CO

C ~ This pres is concerning for acute calculous cholecystitis, an inflammatory condition of the gallbladder that can occur when a gallstone obstructs the cystic duct which causes bile stasis w/n the proximal biliary tree, which dramatically increases the risk for secondary bacterial infection. Therefore, affected patients typically receive empiric antibiotic therapy while awaiting definitive treatment with cholecystectomy. Coverage is provided for common enteric pathogens, including gram-negative bacteria from the Enterobacteriaceae family (eg, Escherichia coli, Klebsiella, Enterobacter), gram-positive cocci (eg, Enterococcus), and anaerobes (eg, Clostridium). A common first-line agent is piperacillin-tazobactam, which has excellent coverage against aerobic and anaerobic gram-negative pathogens, as well as many gram-positive pathogens.

A 45-year-old woman comes to the emergency department due to 18 hours of abdominal pain and fever. The pain began suddenly after she ate dinner and drank 2 glasses of wine. It has been constant and radiates to the right shoulder blade. The patient has had similar episodes in the past, but the pain has never lasted longer than 45 minutes or been so severe. Temperature is 38.8 C (101.8 F), blood pressure is 110/70 mm Hg, pulse is 105/min, and respirations are 19/min. Heart and lung sounds are normal. Abdominal examination shows mild distension and tenderness in the right upper quadrant and epigastrium with voluntary guarding but no rebound tenderness. Bowel sounds are decreased. Laboratory results are significant for leukocytosis with a left shift. Which of the following antibiotics is most appropriate for this patient? A. azithromycin B. clindamycin C. pip-tazo D. vancomycin

D. MRI of the head ~ bells palsy does not usually cause hearing loss ~ facial twitching not so representative of bells palsy either ~ Patients with facial weakness (from any cause) often have incomplete eye closure, which can lead to exposure keratitis (as seen in this patient with a red, irritated eye). Therefore, eyelid closure should be evaluated and eye-protection strategies (eg, lubrication drops, taping the eye closed at night) should be performed in patients unable to fully close the eye.

A 45-year-old woman comes to the office to discuss her facial asymmetry. For the past 6 weeks, the right side of her face has been progressively weakening. The patient notices there are fewer wrinkles on the right side of her forehead than on the left, and the fold in front of her cheek seems less deep. Sometimes she has "spasms" of the right side of her face, and her right eye feels "gritty, like there is sand in it." The patient has no chronic medical conditions and takes no medications. Vital signs are within normal limits. On examination, the ears are clear with no lesions. She is unable to hear a finger rub on the right side. Extraocular movements are intact; there is edema and erythema of the conjunctiva on the right, and normal conjunctiva on the left. Pupils are equal and reactive to light. There is asymmetry between the left and right sides of the face at rest. When asked to move her face, there is a little movement of right-sided parts of the face, including the forehead. There is incomplete eye closure of the right eye; the left eye closes fully. Which of the following is the most appropriate next step in diagnosis? A. CT angiography of the head B. HIV testing C. LP D. MRI of the head E. no additional testing

E ~ Several aspects of this pts pres suggest that her refractory, acute-onset hypotension following surgery is due to adrenal crisis. Adrenal crisis can develop in the setting of an acute stressor (illness, surgery) in pts w/ adrenal insufficiency (chronic primary AI, secondary AI). This pts hx of SLE (which often requires prednisone therapy for flares) & evidence of hypercortisolism (central obesity, purple striae, glucocorticoid-induced hyperglycemia) suggest chronic glucocorticoid therapy. Pts on chronic glucocorticoid therapy can develop H-P-adrenal axis suppression & secondary AI. Bc their pituitary gland is unable to increase ACTH secretion when needed (acute stressor), these patients are at high risk of acute AI (adrenal crisis) ~ primarily presents with hypoglycemia, hypotension & shock which is often refractory to initial volume resus & tx requires IV steroids in addition

A 45-year-old woman is brought to the emergency department due to left groin and abdominal pain accompanied by nausea and vomiting. The patient has a history of systemic lupus erythematosus, hypertension, and glucocorticoid-induced hyperglycemia. Abdominal examination shows central obesity;skin striae; and a nonreducible, tender mass in the left groin. CT scan of the abdomen reveals a left femoral hernia containing a bowel segment and dilated small bowel loops. The patient undergoes urgent exploratory laparotomy for resection of the obstructed bowel loop and repair of the hernia. There are no intraoperative complications, but she abruptly develops hypotension in the postoperative recovery unit. Blood pressure remains <90/60 mm Hg despite intravenous fluid boluses. Which of the following is the best immediate step in management of this patient? A. CT scan of the abdomen B. dobutamine infusion C. IM epinephrine D. IV colloid solutions E. IV hydrocortisone

C. ex lap ~ for patients with penetrating abdominal trauma, any of the following is an indication for immediate ex lap: ✦ evidence of ongoing hemorrhage: hemodynamic instability (systolic bp < 90) or frank blood from the NG tube or rectum ✦ peritonitis (rigidity, rebound tenderness) ✦ evisceration ✦ impalement (penetrating object still in situ) ~ pts w/o above indication: undergo further eval to determine whether peritoneal penetration has occurred (CT scan, local wound exploration) &/or whether intra-abdominal injuries are present (FAST)

A 48-year-old man is brought to the emergency department after being stabbed once in the abdomen during a robbery. The patient sustained no other injuries. Blood pressure is 114/68 mm Hg and pulse is 118/min. Bilateral breath sounds are clear and equal. Heart sounds are normal without murmur. Abdominal examination shows a nonbleeding puncture wound to the left upper quadrant measuring approximately 2.5×1 cm. The abdomen is rigid and diffusely tender. Rectal examination reveals no blood. Resuscitation with intravenous crystalloid is ongoing. Which of the following is the best next step in management of this patient? A. CT scan of the abdomen with IV contrast B. diagnostic peritoneal lavage C. ex lap D. local wound exploration E. observation with serial abdominal examinations

A. CMV infection ~ One of the most common opportunistic infections following renal transplantation is cytomegalovirus (CMV) ~ CMV reactivation results in viremia &/or tissue-invasive disease. The gastrointestinal tract is the most common organ system affected, and patients usually manifest symptoms of colitis or enteritis, including fever, malaise, vomiting, bloody diarrhea, and abdominal pain. Laboratory studies often show cytopenias due to bone marrow involvement, and peripheral blood smear typically reveals atypical lymphocytes. ~ Patients with symptoms of CMV colitis typically have multiple, large, shallow erosions or ulcers on colonoscopy. Treatment with antivirals (eg, ganciclovir) and a reduction of immunosuppressant medication is usually required.

A 50-year-old man comes to the emergency department due to 2 days of malaise, decreased appetite, abdominal discomfort, and bloody stools. The patient had end-stage renal disease and underwent kidney transplantation 4 months ago. He had no major postoperative issues and currently takes mycophenolate, tacrolimus, and prednisone. The patient has a 15 pack-year smoking history but quit several years ago. Temperature is 37 C (98.6 F), blood pressure is 110/70 mm Hg, pulse is 104/min, and respirations are 22/min. Physical examination shows mild abdominal tenderness in the left lower quadrant. Rectal examination is normal. Stool is guaiac positive. Laboratory results are as follows: Hb 8.1, Plts 190K, Leukocytes 3,800 Cr 1.2 Atypical lymphocytes are seen on peripheral blood smear. A colonoscopy reveals multiple ulcerations throughout the colon. Which of the following is the most likely diagnosis for this patient? A. CMV infection B. EBV infection C. GVHD D. HSV1 infection E. ischemic colitis

B. ankle-brachial index ~ This pt has multiple risk factors for atherosclerosis (diabetes, hypertension, and smoking) & symptoms consistent with intermittent claudication. The next step in mgmt should be to obtain physiologic testing with ankle-brachial index (ABI) to confirm the presence of peripheral arterial disease (PAD) as a cause of his symptoms. ABI is an inexpensive and noninvasive vascular test used to confirm the diagnosis of PAD in such patients. It is defined as the ratio of resting systolic blood pressure at the ankle to the systolic brachial blood pressure. An ABI of <0.90 is considered diagnostic of occlusive PAD with a 90% sensitivity and 95% specificity in symptomatic patients.

A 50-year-old man comes to the physician for a preventive visit. He has no chest pain or shortness of breath but does complain of occasional left posterior calf pain. The pain occurs most often with walking in the course of his job as a postal carrier, but he occasionally has leg cramps at rest. His other medical problems include diet-controlled diabetes mellitus and hypertension, but he does not take any medication regularly. The patient was hospitalized for chest pain 2 years ago. Cardiac stress test at that time was negative and he has had no recurrence. The patient has a 30-pack-year smoking history but does not use alcohol or illicit drugs. His father died suddenly at age 60, and his mother had a stroke in her 70s. His blood pressure is 138/92 mm Hg, pulse is 88/min, and body mass index is 28 kg/m2. Heart and lung examinations show no abnormalities. Popliteal, dorsalis pedis, and posterior tibial pulses are palpable bilaterally. An electrocardiogram shows normal sinus rhythm. His hemoglobin A1c level is 7.2%. Which of the following is the most appropriate next step in management of this patient? A. abdominal aortic US B. ankle-brachial index C. arterial US of the LE D. exercise stress test E. nerve conduction studies

B. greater trochanteric pain syndrome - overuse syndrome involving the tendons of the gluteus medius & minimus, where they run over the greater trochanter ~ presents with chronic lateral hip pain that is worsened with repetitive hip flexion (climbing stairs, walking uphill, getting out of a car) or lying on the affected side ~ PE: localized tenderness over the greater trochanter during flexion. hip ROM is normal, although abduction may aggravate the pain ~ tx: local heat, activity modification, and NSAIDs. PT,. local corticosteroid injection ~ Hip osteoarthritis usually causes pain in the deep, medial aspect of the joint. Radiation to the groin or thigh is more typical than radiation to the lateral hip. this patient's tenderness over the trochanter is more consistent with GTPS

A 53-year-old man comes to the office due to right-sided lateral hip pain that makes it difficult for him to lie on that side while sleeping. He describes the pain as burning and localizes it to the outer surface of his thigh. Because the patient has not been able to sleep well due to the pain, he now feels fatigued. The pain has recently occurred during the day and is worse with activity and prolonged standing. The patient has no other medical conditions and takes no medications. Vital signs are within normal limits. BMI is 37 kg/m2. Physical examination shows tenderness over the lateral aspect of the right hip and buttock with deep palpation. Neurologic examination shows no abnormalities. Which of the following is the most likely cause of this patient's pain? A. femoral neck stress fracture B. greater trochanteric pain syndrome C. hip OA D. iliotibial band syndrome E. meralgia paresthetica F. osteoid osteoma

D. immediate wound exploration ~ This patient with an enlarging fluid collection (ballotable neck swelling) developing after thyroidectomy likely has an expanding neck hematoma. An expanding neck hematoma is life-threatening due to the potential for airway obstruction, either from direct airway compression or from vascular compression causing venous congestion leading to laryngeal edema. Stridor, dysphagia, voice changes, and "tripod positioning" are all signs of increasing upper airway obstruction; however, patients can initially have few or no symptoms (as in this patient with only mild neck tightness). Notably, patients often maintain their peripheral blood oxygenation concentration until rapid (<1 min) decompensation. The most important step in management is to decompress the airway by immediately evacuating the hematoma (including at the bedside if necessary).

A 53-year-old woman is evaluated in the postanesthesia care unit following thyroid surgery. She underwent a total thyroidectomy for a retrosternal goiter that was causing dysphagia from esophageal compression. The patient states her neck feels a little "tight" but has no significant pain or difficulty breathing. Medical history is otherwise unremarkable. Temperature is 37 C (98.6 F), blood pressure is 126/86 mm Hg, and pulse is 100/min. Oxygen saturation is 99% on room air. On physical examination, the patient appears comfortable, with no distress. Pupils are equal, round, and reactive. Voice is normal. Neck incision is well-approximated, and there is a 4-cm ballotable swelling under the incision. The lungs are clear to auscultation. Heart sounds are normal. The neck swelling increases in size during the examination. Which of the following is the best next step in management? A. compressive dressing application B. CT scan of the neck with contrast C. fluoroscopic swallowing study D. immediate wound exploration E. urgent cricothyrotomy

B. IV lactated ringer <- septic shock ~ After securing an airway, if needed, the goals in managing septic shock include restoring adequate tissue perfusion & identifying the underlying infection & treating it appropriately. Crystalloid solution (NS, LR) is the fluid of choice to restore volume quickly ~ IV boluses to improve systolic bp > 90 at which perfusion is considered adequate. If the patient fails to respond or develops evidence of volume overload w/o improvement in bp, then vasopressors (NE) should be started to improve perfusion ~ This pts arterial blood gas is suggestive of a compensated metabolic acidosis (likely lactic acidosis due to organ hypoperfusion); therefore, it would be reasonable to administer isotonic saline without concern about worsening the acidosis ~ The use of bicarbonate is not clearly indicated unless there is a severe acute acidosis (pH <7.2).

A 55-year-old man is brought to the emergency department due to a gunshot wound to the left abdomen. He undergoes an exploratory laparotomy involving a partial small bowel resection and a left nephrectomy. His postoperative hemoglobin is 10.4 mg/dL. The patient has no other medical history and takes no medications. Recovery is uneventful until postoperative day 4 when he develops fever, tachypnea, and shortness of breath. The patient is lethargic but responsive. Temperature is 38.9 C (102 F), blood pressure is 75/50 mm Hg, pulse is 110/min and regular, and respirations are 22/min. There is no jugular venous distention. Lung auscultation reveals crackles at the right lung base. There are no cardiac murmurs. Abdominal examination shows a well-healing abdominal wound and a soft, nondistended abdomen. His urine output over the last 12 hours is 100 mL. Laboratory results are as follows: Hb 9.6, Leukocytes 17K HCO3 15, BUN 24, Cr 1.2, albumin 2.8 pH 7.28, PaO2 64, PaCO2 32 Broad-spectrum antibiotics are started. Which of the following additional treatments is the most appropriate next step in management of this patient? A. HD B. IV lactated ringer C. IV albumin infusion D. IV dopamine E. IV hydrocortisone F. IV NaHCO3 G. RBC transfusion

D. laparoscopic cholecystectomy ~ acute pancreatitis: most likely due to alcohol or gallstones ~ gallstones are the most likely etiology in this pt (lack of alcohol use, gallstones on US, ALT > 150) ~ Initial mgmt of gallstone pancreatitis requires determining whether urgent intervention w/ ERCP is indicated. Urgent ERCP (for stone removal and/or sphincterotomy) is indicated if either of the following is present: ✦ CBD obstruction (dilated CBD containing a stone on US) ✦ Evidence of acute cholangitis (fever, RUQ pain, jaundice, hypotension, confusion) ~ In the absence of these indications, pts w/ gallstone pancreatitis r treated using supportive care (eg, IV fluids, analgesics). Following the resolution of pancreatitis (improved symptoms, normalization of laboratory values), early elective cholecystectomy is recommended because it significantly reduces the incidence of recurrent attacks.

A 55-year-old woman comes to the emergency department due to acute-onset midepigastric pain that radiates to her back. She also has nausea and vomiting. Medical history is significant for plantar fasciitis and hypertension, for which she takes amlodipine. The patient does not use tobacco, alcohol, or recreational drugs. Temperature is 37.1 C (98.8 F), blood pressure is 117/76 mm Hg, pulse is 102/min, and respirations are 16/min. Examination shows tenderness to deep palpation in the epigastrium. The remainder of the examination is within normal limits. Laboratory test results are as follows: Albumin 4.2, ALP 148, AST 111, ALT 160 amylase 940, Lipase 2,155 Hb 12.8, Plts 220K, Leukocytes 13,200 Abdominal ultrasonography is notable for revealing several stones within the gallbladder without gallbladder wall thickening. The patient is admitted to the hospital and given supportive care with pain control, intravenous fluids, and nothing by mouth. She recovers rapidly and can eat within 2 days. Her enzyme levels begin to trend down, and the patient says she feels normal. Which of the following is the best next step in management of this patient? A. amlodipine discontinuation & close f/u B. ERCP C. HIDA scan D. laparoscopic cholecystectomy E. repeat US in 4 weeks

C. pyoderma gangrenosum ~ form of neutrophilic dermatosis that starts as an inflammatory papule, pustule, or nodule and progresses to form a painful expanding ulcer with a purulent or fibrinous base and an irregular, violaceous border. PG can present as a single or as multiple lesions, usually on the trunk or lower extremities. Nearly 30% are triggered by local trauma (ie, pathergy) ~ risk is increased in patients who have an underlying systemic inflammatory disorder: IBD, autoimmune arthropathies (RA), & hematologic conditions (ALL) ~ diagnosed clinically after excluding other diagnoses (infection, cutaneous cancers). Biopsy of the ulcer margin is recommended and typically shows a mixed cellular infiltrate with dermal and epidermal necrosis. Surgical debridement is usually avoided due to the potential of inducing pathergy; most lesions respond to treatment with local or systemic glucocorticoids.

A 56-year-old woman comes to the office for evaluation of a leg ulcer. The patient bumped her left leg on a chair 2 weeks ago and noticed painful papules at the injury site several days later. The lesions rapidly enlarged and opened, causing worsening pain and drainage. The ulcer progressively enlarged despite the use of topical antiseptics. The patient has a history of rheumatoid arthritis and does not use tobacco, alcohol, or illicit drugs. Temperature is 37.2 C (99 F), blood pressure is 130/78 mm Hg, and pulse is 86/min. Physical examination shows a tender ulcer on the lower left extremity, as shown in the exhibit. There are no other lesions. Which of the following is the most likely cause of this patient's skin condition? A. cutaneous small vessel vasculitis B. pseudomonas aeruginosa infection C. pyoderma gangrenosum D. thromboangitis obliterans E. venous valvular insufficiency

A. arterial embolism the sudden development of ALI in this previously asymptomatic patient without PAD (eg, normal pulses in unaffected extremities) or vascular trauma is most consistent with embolic occlusion.

A 58-year-old man comes to the emergency department due to sudden onset of severe right leg pain several hours ago; the leg has since become numb. He has never had similar symptoms and has no history of trauma, fever, or chills. The patient recently had an acute anterior wall myocardial infarction that resulted in cardiogenic shock; he is undergoing cardiac rehabilitation. Temperature is 36.7 C (98.1 F), blood pressure is 120/70 mm Hg, pulse is 90/min and regular, and respirations are 16/min. Cardiopulmonary examination is unremarkable. Compared with the left leg, the right leg appears pale and is cool to the touch. In the right lower extremity, the popliteal pulse is normal, but more distal pulses are not palpable. Pulses in the other extremities are normal. Neurologic examination shows loss of sensation over the dorsum of the right foot and mild weakness with dorsiflexion. Which of the following is the most likely cause of this patient's symptoms? A. arterial embolism B. arterial thrombosis C. arterial vasculitis D. cerebral ischemia E. nerve compression F. venous thrombosis

A. abduction of thumb against resistance ~ distal radius (colles) fracture, FOOSH in athletes (high impact falls) or elderly pts with osteoporosis (low impact falls). pain, swelling, dinner fork deformity of the wrist ~ dorsal displacement of the wrist can result in compression of the median nerve

A 58-year-old previously healthy woman comes to the emergency department due to wrist pain after a fall. The patient was walking her dog when it suddenly ran toward a squirrel, pulling her to the ground. She tried to brace herself with her outstretched hand and injured the wrist. Physical examination shows a gross deformity of the wrist with extensive swelling and bruising. Distal pulses and testing for capillary refill are normal. The patient had no sensory symptoms initially but developed paresthesia in the affected hand while in the emergency department. X-ray results are shown below: Which of the following is most likely to be abnormal due to associated nerve injury in this patient? A. abduction of thumb against resistance B. adduction of the index & 4th digit C. extension of the fingers against resistance D. sensation on dorsum of thumb-index web space E. two point discrimination over little finger

G. SCC ~ Malignancy is extremely likely in a pt w/ a persistent (>2 weeks), palpable (>1.5 cm), firm neck mass; a smoking history; & no preceding infection. ~ By far the most common malignancy in an upper cervical node is mucosal head and neck SCC. Indeed, the first (& only) apparent manifestation may be a palpable cervical lymph node, representing regional nodal metastasis. Referred otalgia is another common presenting symptom, facilitated by either the glossopharyngeal nerve (CN IX) (innervates both the base of tongue and the EAC) or the vagus nerve (CN X; innervates parts of the larynx/hypopharynx and the EAC). Identification of the primary source of head and neck SCC is essential to direct tx. Thorough exam includes endoscopic visualization using laryngopharyngoscopy as well as neck imaging (CT with contrast) to evaluate the primary site & characterize the cervical nodal disease.

A 62-year-old man comes to the office for evaluation of a lump in his neck. The patient first noticed the lump under the right side of his jaw about 4 months ago when he cut himself while shaving. The lump is slowly getting larger. He has also had occasional deep-seated right ear pain. The patient has had no fevers, chills, cough, or shortness of breath. He has had no change in his diet and no weight loss. Medical history is significant for hypertension and type 2 diabetes mellitus. The patient smokes 2 packs of cigarettes daily and uses alcohol occasionally. Physical examination shows a firm, nontender, right-sided submandibular mass that is 3 cm in diameter. Ear examination is normal. There are no abnormal skin lesions. Oral cavity examination shows poor dentition and no mucosal lesions. The tonsils are small and soft with no lesions. Chest examination is unremarkable. The abdomen is soft and nontender with no hepatosplenomegaly. There is no other lymphadenopathy. Complete blood count is within normal limits. Which of the following is the most likely cause of this patient's condition? A. CLL B. granulomatous polyangitis C. hodgkin lymphoma D. infectious mono E. medullary thyroid carcinoma F. mycobacterial lymphadenitis G. SCC

C ~ This pt is most likely in cardiogenic shock due to an acute MI. Perioperative MI is common in patients undergoing noncardiac surgery; intraop hemorrhage requiring blood transfusion increases the risk (likely due to reduced O2 delivery to the myocardium). they often lack chest pain, possibly due to receipt of postoperative pain control. ~ Significant infarction of the LV leads to impaired contractility & a decrease in LV stroke volume. Cardiac index is low as tachycardia cannot make up for the decrease in SV. The increased pressure in the LV is transmitted back to the LA & the lungs; therefore, PCWP, which estimates left atrial pressure, is elevated. pts experience dyspnea & hypoxemia due to pulmonary edema, & lung exam reveals bilateral crackles.

A 62-year-old man undergoes a partial pancreatectomy for exocrine pancreatic cancer. The surgery is complicated by excessive peripancreatic bleeding requiring careful surgical hemostasis. The patient receives packed red blood cell transfusion during the surgery as well as intravenous normal saline. He is transferred to the surgical intensive care unit for close monitoring and is successfully extubated. Twelve hours later, the nurse reports decreased oxygen saturation. The patient has received multiple doses of morphine for pain control since the surgery. Temperature is 37.5 C (99.5 F), blood pressure is 80/40 mm Hg, pulse is 112/min, and respirations are 28/min. The patient's pulse oximetry shows 87% on 4 L nasal cannula oxygen. Examination reveals bilateral basal crackles. The abdomen is mildly distended and tender, and bowel sounds are decreased. There is no rebound tenderness or rigidity. Pulmonary artery catheter readings show a cardiac index of 2 L/min/m2 (normal, 2.8-4.2) and a pulmonary capillary wedge pressure of 20 mm Hg (normal, 6-15). Which of the following is the most likely etiology of this patient's current condition? A. acute pancreatitis B. adrenal crisis C. MI D. PE E. retroperitoneal hemorrhage F. TRALI

B. A popliteal cyst is due to extrusion of synovial fluid from the knee joint into the gastrocnemius or semimembranosus bursa thru a communication b/w the joint & the bursa. Excessive synovial fluid formation (OA or RA & + pressure in the knee during extension can cause passage of fluid into the bursa & gradual enlargement of the cyst. Popliteal cysts are often asymptomatic & present as a chronic, painless bulge behind the knee. The diagnosis is usually apparent on exam, with a soft mass in the medial popliteal space that is most noticeable with knee extension & less prominent with flexion. ~ Rupture (following strenuous exercise) can cause posterior knee and calf pain, with tenderness and swelling of the calf resembling deep venous thrombosis (DVT). An arc of ecchymosis is often visible distal to the medial malleolus ("crescent sign"). Ultrasound can rule out DVT and confirm the popliteal cyst.

A 62-year-old woman comes to the emergency department due to acute leg pain. The patient, who recently started an exercise program for weight loss, felt pain at the right knee and posterior calf while walking on a treadmill. She subsequently developed swelling at the calf and right ankle. Medical history is notable for type 2 diabetes mellitus, hypertension, and hypercholesterolemia. The patient does not use tobacco or alcohol. Temperature is 36.5 C (97.7 F), blood pressure is 166/88 mm Hg, and pulse is 90/min. BMI is 41 kg/m2. Examination shows tenderness and induration at the medial head of the gastrocnemius. There is moderate pitting edema at the ankle and a crescent-shaped patch of ecchymosis at the medial malleolus. Which of the following is the most likely cause of this patient's symptoms? A. anserine bursitis B. ruptured popliteal cyst C. stress fracture of tibia D. tear of MCL E. tear of medial meniscus F. venous thrombosis

◦ In a pt w/ multiple pigmented lesions, a lesion that is substantially different from the others (shape, color) may represent melanoma "ugly duckling sign": sensitivity of up to 90% for melanoma. ◦ Palpable nodularity often corresponds with vertical growth of a melanoma & increases metastatic risk. The Breslow depth is the most important prognostic indicator in malignant melanoma. ◦ Benign pigmented lesions are usually asymptomatic; biopsy should be considered for moles that itch, bleed, or are associated with local sensory symptoms (tingling). ~ Altho this pts lesion does not have any of the ABCDE (Asymmetry, Border irregularity, Color variation w/ lesion or compared to others, >/ 6 mm, evolving over time) characteristics, she has a pruritic, nodular lesion that is sign diff from her other pigmented lesions: full-thickness excisional biopsy with initial margins of 1-3 mm of normal tissue

A 62-year-old woman comes to the office for evaluation of a pigmented lesion on her left forearm. She first noticed the lesion 4 months ago and says it occasionally itches but is otherwise asymptomatic. The patient also has numerous "freckles" that she attributes to playing golf during the summer. Medical history includes psoriasis, hypertension, and mild chronic obstructive pulmonary disease. She quit smoking 5 years ago and drinks 2 or 3 glasses of wine a week after golfing. On examination, there is a 5-mm, dark brown lesion at the dorsal surface of her distal left forearm; it has a smooth border and a small, eccentric nodule. In addition, multiple scattered, flat, light brown lesions are present on the nose, cheeks, and dorsal surface of the hands. Which of the following is the most appropriate next step in management of this patient's forearm lesion? A. LN B. excisional biopsy C. re-exam in 3-6 mo D. shave biopsy E. topical 5-FU

D. IV acetazolamide ~ angle-closure glaucoma is characterized by narrowing or closure of the anterior chamber angle, leading to decreased aqueous outflow and elevated intraocular pressure. Exam findings include conjunctival injection; corneal edema; palpable firmness of the eyeball; and a fixed, mid-dilated pupil. The diagnosis is confirmed by gonioscopy to visualize the corneal angle and/or tonometry to measure IOP ~ Initial mgmt is directed at rapidly lowering IOP. Combination therapy with multiple topical agents is recommended; a typical regimen includes timolol, apraclonidine, and pilocarpine eye drops. In addition, oral or intravenous acetazolamide is recommended to rapidly reduce further production of aqueous humor. Subsequently, laser iridotomy can facilitate aqueous outflow and provide definitive management.

A 62-year-old woman is brought to the emergency department due to an acute right-sided headache, ocular pain, and nausea. She was watching television in the evening after dinner when the symptoms began; initial treatment with cold compresses and acetaminophen was ineffective. The patient then developed decreased vision in the right eye and called for an ambulance. On examination, she appears uncomfortable and has episodic retching. The right eye has red conjunctival flushing; the right pupil is mid-dilated and nonreactive to light. Which of the following is the most appropriate next step in management of this patient? A. dilated fundus examination B. fluorescein eye examination C. high dose IV methylprednisolone D. IV acetazolamide E. oral valacyclovir

E ~ Rotator cuff impingement or tendinopathy: ✦ pain with abduction, external rotaiton ✦ subacromial tenderness ✦ normal ROM w/ + impingement tests (neer, hawkins) ~ Rotator cuff tear: ✦ similar to above ✦ weakness with abduction & external rotation ✦ > 40 ~ supraspinatus is most commonly injured due to degeneration of the tendon with age & repeated ischemia by impingement b/w the humerus & acromion during abduction. dx of complete tear: drop arm test: abduct arm above head, pt will unable to lower the arm smoothly & it will drop rapidly around mid-descent.

A 63-year-old man comes to the office due to right shoulder pain and weakness for the past 3 days. The patient was moving boxes at his home when he tripped, fell, and landed on his right shoulder. He has had partial relief of his pain from over-the-counter analgesics and stretching exercises, but the weakness has persisted. Vital signs are normal. The right shoulder has no visible deformity or bony tenderness. There is full passive motion of the right shoulder, but active motion is limited. There is significant weakness with resisted abduction of the right shoulder compared to the left side. After passive abduction of the right arm above the head, the patient is asked to slowly lower his arm; as he is lowering it below horizontal, the arm suddenly drops rapidly, in association with moderate, sharp pain. Sensation is intact. Which of the following is the most likely diagnosis in this patient? A. biceps tendon tear B. humeral neck fracture C. long thoracic nerve injury D. lower brachial trunk injury E. rotator cuff tear

C ~ This pt has a large (>1 cm) BCC in the periorbital region, a cosmetically sensitive area that has a high risk for cancer recurrence after tx. The mgmt of BCC is determined largely by the risk of lesion recurrence, which is based primarily on the location and size of the cancer: ✦ Low-risk BCC includes most lesions < 2 cm in size on the trunk or extremities, excluding the hands and feet. ✦ High-risk BCC includes lesions on the face, neck, hands, feet, or genitalia, especially those ≥ 1 cm; lesions ≥2 cm in any location; & lesions with an aggressive histology or poorly defined borders ~ First-line tx for high-risk BCC is Mohs micrographic surgery. This procedure allows for the highest cure rate and maximal preservation of normal tissue, an ideal choice for treating nonmelanoma skin cancers of the face, where the recurrence risk is high and cosmesis is a concern.

A 67-year-old man comes to the office due to a "sore" on the right side of his face. The sore has been growing slowly over the past year, and it bleeds and oozes at times. The patient recently retired from his job as a mail carrier and spent his entire career delivering mail outdoors. He is otherwise healthy and has a 30-pack-year history. Skin examination reveals a 1.5-cm lesion, as shown in the exhibit. Biopsy shows basal cell carcinoma. Which of the following is the best next step in management of this patient? A. CT scan of the head & neck B. curettage & ED C. mohs micrographic surgery D. standard surgical excision with 4 mm margins E. topical chemo with 5-FU

D. EGD ~ This patient's weight loss, epigastric fullness, and abdominal pain relieved with antacids raise suspicion for gastric cancer. Incidence is particularly high in Eastern Asia (eg, South Korea), Eastern Europe, and the Andean part of South America where diets are rich in salt-preserved foods (damages stomach mucosa) and nitroso compounds (carcinogenic). Other risk factors include Helicobacter pylori infection, smoking, alcohol use, and atrophic gastritis. ~ pts with gastric cancer usually develop persistent epigastric pain that often worsens with eating (due to the irritant effects of gastric acid on the tumor) and weight loss (due to insufficient caloric intake). Proximal stomach tumors may also cause dysphagia and postprandial nausea and vomiting. The diagnosis is generally established using esophagogastroduodenoscopy (EGD) to visualize the stomach and obtain biopsy samples of suspicious lesions.

A 72-year-old man comes to the office due to upper abdominal pain and weight loss. The abdominal pain is worse when eating food and is sometimes relieved with over-the-counter antacids. He has not had dysphagia, melena, or rectal bleeding. The patient has a history of hypertension, which is well controlled with chlorthalidone. He does not take other prescription or over-the-counter medications and does not use tobacco, alcohol, or illicit drugs. The patient emigrated from South Korea 20 years ago. Temperature is 36.8 C (98.2 F), blood pressure is 110/70 mm Hg, pulse is 84/min, and respirations are 14/min. BMI is 17.2 kg/m2. Mucous membranes are dry. Cardiopulmonary examination shows no abnormalities. Epigastric fullness and tenderness are present, but there is no hepatosplenomegaly. Peripheral pulses are full and capillary refill is normal. Which of the following is the best next step in management? A. CEA testing B. CT angiogram of the mesenteric vessels C. CT scan of the abdomen D. EGD E. H pylori stool antigen testing

A. adequate fluid intake & oral hygiene ~ Suppurative parotitis often occurs in elderly postop pts, particularly those with dementia who are at risk of inadequate fluid hydration & poor oral hygiene. In these patients, salivary stasis (due to NPO status, poor oral hygiene, & dehydration) leads to retrograde seeding of bacteria from the oral cavity (Staph aureus, oral flora) through Stensen duct to the parotid gland. pts then have rapid-onset & excruciatingly painful swelling of the involved parotid gland that is aggravated by chewing. Examination shows an exquisitely tender, swollen, & erythematous gland. Purulent fluid can often be expressed from the parotid duct. ~ Altho the dx is typically evident after clinical eval, imaging (CT scan or US) should be obtained to assess for salivary stones or neoplasms obstructing the duct, as well as to differentiate between suppurative parotitis and an abscess.

A 73-year-old man is seen in the hospital due to severe left facial pain and inability to fully open his mouth. These symptoms began earlier today. Eight days ago, the patient underwent a laparotomy for intestinal obstruction. The procedure went well, and he has had several bowel movements since the operation. Medical history is significant for dementia and colon cancer, which was diagnosed 5 years ago and is currently in remission. The patient resides in a nursing home. Temperature is 38.9 C (102 F), blood pressure is 150/80 mm Hg, pulse is 90/min, and respirations are 16/min. Examination shows swelling, erythema, and severe tenderness in the left preauricular area. Laboratory studies reveal a white blood cell count of 15,600/mm3. Which of the following would most likely have prevented this complication? A. adequate fluid intake & oral hygiene B. administration of polysaccharide vaccine C. administration of tetanus toxoid D. avoidance of extreme jaw opening during intubation E. avoidance of volatile anesthetic agents during surgery F. encouragement of incentive spirometry G. initiation of early ambulation

B. dilation of the tricuspid valve annulus - pt with prolonged uncontrolled HTN & progressive dyspnea, LE edema, & JVD = decompensated left sided HF due to hypertensive heart disease. holosystolic murmur at LLSB = TR ~ RV enlargement causes tricuspid annular dilation + tethering (increased tension) of the chordae tendineae, both of which restrict adequate closure of the normal TV leaflets ~ prominent V waves on JVP waveform is highly specific for TR (absent x descent during ventricular systole - there is no decrease in RA pressure during systole bc of the regurg)

A 78-year-old man comes to the office due to lower extremity swelling. He has had progressive exertional dyspnea over the past 2 years. Over the past 2 months, the patient has noticed lower extremity swelling, decreased appetite, and increased abdominal girth. He has a history of poorly controlled hypertension but no known coronary artery disease. The patient is a lifetime nonsmoker. He has no history of prior surgeries. Blood pressure is 165/88 mm Hg and pulse is 72/min and regular. He is afebrile. On physical examination, the jugular veins are distended and there are prominent V waves. A holosystolic murmur is heard at the lower sternal border, and there is 3+ pitting edema of the lower extremities bilaterally. Which of the following best explains the physical examination findings in this patient? A. dilation of the pulmonary arteries B. dilation of the tricuspid valve annulus C. flailing of a tricuspid valve leaflet D. fusion of the tricuspid valve commissures E. increased intrapericardial pressure

D. spinal cord compression ~ This elderly patient has weakness in her upper and lower extremities accompanied by atrophy in her hands and stiffness with hyperreflexia in her legs. In combination with Lhermitte sign (electric shock-like pain with neck flexion), these symptoms are most consistent with cervical spinal cord compression ~ often has an insidious onset that results from degenerative changes in the vertebral bodies, discs, and joints that causes the following: ◦ Compression of the spinal cord, specifically the spinal cord descending tracts, leads to myelopathic symptoms with upper motor neuron (UMN) signs (eg, hyperreflexia, spastic gait, stiffness/weakness) below the lesion. ◦ Compression of the cervical spinal nerve roots at the same level leads to radiculopathy with lower motor neuron (LMN) findings (eg, atrophy, hyporeflexia) and pain that follow a radicular pattern in the upper extremities.

A 78-year-old woman comes to the office due to worsening clumsiness and weakness of her hands for the past several months. The patient has had difficulty performing daily activities such as buttoning shirts or tightly holding garden tools. She also reports stiffness in her legs and neck. Medical history is significant for hypertension and osteoarthritis. Physical examination shows bony outgrowth at distal and proximal interphalangeal joints. There is wasting of the intrinsic hand muscles, and grip strength is decreased bilaterally. Neck flexion elicits an electric shock-like sensation down the patient's back. Ankle reflexes are 3+ bilaterally. Which of the following is the most likely diagnosis? A. ALS B. inflammatory myopathy C. MS D. spinal cord compression E. ulnar neuropathy

E. sigmoid colon adenocarcinoma ~ left sided colon tumors (descending & sigmoid): obstruct the flow of stool, leading to crampy or colicky pain &/or a change in bowel habits. hematochezia is common. ~ rectal tumors : bleeding is typically visible as hemataochezia or frank red blood. narrowed stools, tenesmus, and a sensation of a mass in the rectum ~ right sided colon tumors (cecal): occult bleeding & IDA.

An 84-year-old woman comes to the office due to 2 months of bright red bleeding from the rectum. The patient also has intermittent crampy abdominal pain and a 6-kg (13.2-lb) unintentional weight loss. She reports no fevers, tenesmus, chest pain, palpitations, or vomiting. Medical history is significant for obesity and chronic kidney disease. Temperature is 37.6 C (99.7 F), blood pressure is 130/80 mm Hg, and pulse is 70/min. The patient appears cachectic. There is no palpable lymphadenopathy. Cardiac auscultation reveals normal rate and rhythm and no heart murmurs. Lung sounds are normal. The abdomen is nontender and nondistended. Which of the following is the most likely diagnosis? A. angiodysplasia B. cecal adenocarcinoma C. diverticular bleeding D. internal hemorrhoids E. sigmoid colon adenocarcinoma

~ bulging of the bony cortex

Buckle fractures are common in children & typically occur at the distal radius &/or ulna due to a fall onto an outstretched hand. Xray is diagnostic & shows __________.

~ flattened y descent due to restriction of passive RV filling ~ *y descent represents the filling of the RA during early diastole* ~ pulsus paradoxus - no kussmaul's sign constrictive pericarditis: - x & y present with prominent descents - no pulsus paradoxus - present kussmaul's sign ~ pericardial calcification on cxr

Increased intrapericardial pressure occurs in cardiac tamponade: What does the JVP demonstrate?

A ~ This pt has an episode of massive hemoptysis (> 600 mL of expectorated blood over a 24hrs or a bleeding rate >100 mL/hr) The greatest danger in massive hemoptysis is not exsanguination but asphyxiation due to the airway flooding w/ blood. Initial mgmt involves establishing an adequate patent airway, maintaining adequate ventilation & gas exchange, & ensuring hemodynamic stability. The patient should be placed with the bleeding lung in the dependent position (lateral position) to avoid blood collection in the airways of the opposite lung. ~ Bronchoscopy is the initial procedure of choice in such pts as it can localize the bleeding site, provide suctioning ability to improve visualization, & include other therapeutic interventions (balloon tamponade, electrocautery) ~ urgent thoracotomy: reserved for pts w/ unilateral bleeding who continue to bleed despite initial bronchoscopy &/or pulmonary artery embolization

Item 2 of 2 The patient's initial laboratory results are as follows: Leukocytes 12,500 Hb 10.5 Plts 225K Creatinine 1.2 INR 1.1 While in the emergency department, the patient has an episode of coughing and shortness of breath. He brings up approximately 600 mL of blood. His blood pressure is 105/61 mm Hg and pulse is 122/min. He is intubated, and fresh blood fills the endotracheal tube. Which of the following is the most appropriate next step in management of this patient? A. bronchoscopy B. CT scan of the chest with contrast C. FFP infusion D. pulmonary arteriography E. urgent thoracotomy

~ prominent V waves ~ the v wave represents filling of the right atrium during ventricular systole *blood return into the heart* ~ it is prominent bc it is getting blood returned + blood from TR

What is highly specific for TR on JVP waveform?