Surgery Uworld

presentation of arterial thrombosis (4)?

severe pain in SINGLE extremity. extremity is cool to touch, pallor, pulselessness, paresthesia, paralysis

where does acute epidural hematoma commonly occur and result from laceration to what?

sphenoid bone. laceration of the middle meningeal artery

recurrent, episodic colicky pain in RUQ or epigastric region with corresponding elevation in LFT and alk phos. administration of opioid analgesics (ie morphine) precipitate sxs. dx?

sphincter of oddi dysfunction. opioid makes pain worst by causing sphincter contraction

blunt abdominal trauma (BAT), left sided abdominal pain, anemia.

splenic injury

BAT from MVA, hypotension, tachy, chest and abdominal wall ecchymosis, tender abdomen. what two organs are you most concern for if you see free intraperitoneal fluid?

splenic or liver laceration

65yo male underwent right total knee replacement 6 months ago has 3 weeks of dull pain in right kneed. 99.2F. mild swelling and tenderness over right knee. normal wbc though with 80% neutrophils. most likely etiology?

staph epidermidis subacute, worsening pain in prothestic knee 6 months after knee replacement with neutrophils predominance suggest inflammatory process. removal of infected prothesis usually required

60yo male with right calf pain, swelling and difficulty bearing weight on right leg. u/s suggests DVT in femoral vein. PMH: DMII, HTN and ESRD requiring hemodialysis. tx?

start on unfractionated heparin followed by warfarin. warfarin is preferred LT oral anticoagulant in ESRD pt. it inhibits vitamin K-dependent clotting factors (1972) and anticoagulant proteins C and S. takes several days to become therapeutic and first acts on protein C and S thus causing transient prothrombotic state so can't be start alone. start with IV unfractionated heparin for immediate tx then warfarin bridge

female with low bone density, low caloric intake, hypomenorrhea/amenorrhea with point tenderness over the anterior aspect of the right shin. dx?

stress fracture.

which of the rotator cuff muscles is most commonly injured and why?

supraspinatus is most commonly injured due to degeneration of tendon with age and repeated ischemia induced by impingement between the humerus and acromion during abduction

4 muscles that form the rotator cuff?

supraspinatus, infraspinatus, teres minor, subscapularis

acute knee pain associated with catching of the joint and reduced range of motion. dx? test?

tear of the meniscus. dx via MRI or arthroscopy

how can teratomas be distinguished from other germ cell tumors?

teratomas: presence of fat or calcium (tooth) seen on imaging

what is the psoas sign?

abdominal pain on hip extension

occasional black or tarry stool (ie melena) is suggestive of GI bleed originating where?

above the ligament of treitz

adult pt. blunt chest trauma. persistent JVD, tachy and hypotension despite aggressive fluid resuscitation. chest x-ray shows normal cardiac silhouette without tension pneumothorax.

acute cardiac tamponade. normal chest x-ray because of small amount of pericardial fluid.

45yo female underwent elective hysterectomy. post-op, develops N/V/dizziness, diffuse abdominal pain. PMH: SLE, pernicious anemia, DMII, chronic lower back pain. Meds: vitamin B12 injections, metformin, insulin glargine, prednisone, hydroxychloroquine, acetaminophen. hypotensive that increase with 4L IV fluids. pt has round plethoric face, buffalo hump and central obesity. labs: low sodium, elevated potassium, low glucose. cause of it's acute condition.

adrenal insufficiency trigger from stress due to LT use of glucocorticoids resulting in HPA suppression. pt usually have hyponatremia and hyperkalemia due to concurrent mineralcorticoid insufficiency

pt with fever, jaundice, anorexia, tender hepatomegaly, AST>ALT, macrocytic anemia, mildly elevated INR, thrombocytopenia. dx?

alcoholic hepatitis

pt with mid clavicular fractured that's displaced (x-ray finding). loud bruit heard just beneath the clavicle. next step?

angiogram. careful neurovascular exam should accompany all fractures to the claicle due to its proximity to the subclavian artery and brachial plexus. since a bruit is heard, an angiogram is necessary to rule out injury to the underlying vessel

44yo amel unresponsive and hypotensive after MVA. intubated. large bruises over entire chest wall and collapsed neck veins bilaterally. decrease breath sounds on left side. chest x-ray: large left hemothorax and widened, rightward-deviating mediastinum. dx?

aortic injury suggestive findings: widened mediastinum, large left sided hemothorax, deviation of mediastinum to the right and disruption of normal aortic contour

man with abducted arm suffer from impact where arm was forced backward by another person. presentation, arm held slightly abduction and externally rotated. x-ray shows anterior dislocation of humeral head leading to flattening of deltoid prominence. what nerve is commonly injured with anterior should dislocations. innervation to what muscles?

axillary nerve commonly injured. innervate teres minor and deltoid leading to weakness on shoulder abduction. decrease sensation to skin overlying lateral shoulder

terminal hematuria suggests bleeding from what region (3)? what does presence of terminal hematuria with clots suggest? next step?

bleeding from: - prostate - bladder neck or trigone - posterior urethra - termina hermaturia + clots: urothelial cancer. clots suggests bleeding within bladder ureters. - next: cystoscopy

pt with massive hemoptysis episode, initial management is establishing adequate patent airway. the bleeding lung should be placed in what position and why? what is the initial procedure?

bleeding lung should be placed in dependent position (lateral position) to avoid blood collecting in airways of the opposite lung. bronchoscopy is initial procedure to localize bleeding site

72yo male underwent AAA repair (infrarenal aorta). received perioperative prophylaxis with second gen cephalosporin abx. POD#1, progressive abdominal pain and bloody diarrhea. fever and mild leukkocytosis. tenderness mostly in left lower quadrant without rebound. femoral pulses full and symmetric. dx? path?

bowel ischemia. results from inadequate colonic collateral arterial perfusion to the left and sigmoid colon after loss of IMA during aortic graft placement

what structure is damaged in supra condylar fracture of humerus, especially in children?

brachial artery. presents with signs of ischemia (pain, pallor, pulselessness, paresthesia and pressure)

what 2 things are injured with clavicular fracture and thus warrant careful neurovascular examination?

brachial plexus (exam of hand motor function is sufficient or nerve conduction studies) subclavian artery (angiogram)

chest trauma, pneumothorax that does not resolve with chest tube placement, pneumomediastinum, subcutaneous emphysema. dx?

bronchial rupture

Pt with TB has episode of coughing and SOB. brings up 600mL of blood. BP 105/61. HR 122. intubated and fresh blood fills endotracheal tube. next step in management? next best step if initial step failed?

bronchoscopy greatest danger in pt with massive hemoptysis is no exsanguination but asphyxiation due to airway flooding with blood. initial management is establish adequate patent airway (maintain adequate ventilation and gas exchange). bleeding in dependent position (lateral position) avoid blood collecting in other lung. bronchoscopy to localize bleeding site. - next step it pulmonary ateriography if there's persistent bleeding and initial bronchoscopy can't localize the source

pt suffering from burns now has: hypothermia, tachycardia, oliguria, hyperglycemia, thrombocytopenia, altered mental status. dx?

burn wound sepsis

dilated left ventricle with apical hypokinesis and engorgement of the IVC are characteristics of what type of shock?

cardiogenic shock

pt with weight loss, fatigue, multiple liver lesions on CT scan (suggesting mets). next step?

colonoscopy: colorectal cancer is the most common source of liver metastases.

leg: pain out of proprotion to injury, increase pain on passive stretch (ie extension of the right knee), paresthesia, rapidly increasing and tense swelling. dx?

compartment syndrome

complication of reperfusion of limb following arterio-occlusive ischemia for longer than 4-6 hours that resulted in intercellular and interstitial edema.

compartment syndrome. edema causes pressure within muscular fascial compartment to rise above 30mmhg leading to further ischemia injury

why does eschar the results from circumferential full thickness (third degree) burn lead to acute compartment syndrome?

constriction of venous and lymphatic drainage, fluid accumulation in distally confined space

common causes of scapular winging (long thoracic nerve) (2)?

deep lacerations to the axillary region axillary lymphadenectomy

abdominal pain, pain referred to shoulder, SOB, vomiting. loss of diaphragmatic contour. dx?

diaphragmatic rupture

12yo boy with post-prandial colicky abdominal pain and bilious vomiting. bicycle accident 2 days prior, stpeed and fell on handlebar. US no free intraperitoneal fluid. abdominal x-ray: dilated stomach with scanty distal gas. all labs normal. dx? management?

duodenal hematomas. commonly occur post blunt abdominal trauma. more common in children due to anatomic differences: less abdominal adipose tissue, more pliable ribs (absorb less force). blunt trauma compress duodenum against vertebral column, blood collects btw submucosal and muscular layers of duodenum causing partial or complete obstruction - management: gastric decompression (NG tube) and parenteral nutrition

30yo female in 3rd trimester suddenly develops massive swelling of the lower left extremity. most appropriate workup and treatment?

duplex u/s for DVT and heparin

45yo female to ER with severe abdominal pain, nausea and 2 episodes of bilious vomiting over past 4hrs. last several week, episodic epigastric and RUQ abdominal pain with nausea. PMH: MVP, migraine headaches relieved with NSAIDs. 101F, 140/95. abdomen: tenderness, guarding, rigidity in upper abdomen. rebound tenderness, reduced BS. stool in blood. dx? test?

dx: perforated peptic ulcer test: upright x-ray of the chest and abdomen (free intraperitoneal air under the diaphragm) pt has severe acute-onset abdominal pain, fever, tachy and signs of peritonitis likely has perforated viscus. preceding episodic epigastric pain, nausea, and hx of NSAID and alcohol use, positive guaiac test raise suspicion of PUD as cause of perforated. test will show air under the diaphragm

pt with hypotension and abdominal pain and CT scan shows an enlarged aortic silhouette. dx? tx?

dx: ruptured abdominal aortic aneurysm tx: immediate abdominal surgery

asxs pt, elevated alkaline phosphatase, normal LFT and RUQ U/S, positive antimitochondrial antibody assay. dx?

early primary biliary cholangitis

how is symptomatic patients with epidural hematoma be managed?

emergent neurosurgical hematoma evacuation

right anterior thigh pain that is worse with walking, small pulsatile mass in right groin area. PMH: stable angina, HTN, HLD, COPD with periodic exacerbations. dx?

femoral artery aneurysm findings: pulsatile groin mass below inguinal ligament, anterior thigh pain due to compression of the femoral nerve that runs lateral to the artery. FAA is second most common peripheral artery aneurysm after popliteal aneurysm

pt with mild scleral icterus following appendectomy: elevated inconjugated bilirubin, normal LFT, no evidence of hemolysis (normal hgb). dx

gilbert syndrome (mild jaundice due to decreased activity of UDP-glucuronosyltransferase enzyme). episodes precipitated by stressors.

62yo man suffer burn to >20% body surface area. currently has progressive confusion, lethargy, reduced urine output. 96F. 100/60. 120 pulse. RR 26. sections of second-degree burn progressed to full-thickness necrosis. platelets 80000, wbc 16,000. bg 230. dx?

gram negative sepsis. immediately after severe burns, G+ organisms (s. aureus) from hair follicles and sweat glands dominate. after more than 5 days, most infections are due to G- organisms (pseudomonas) or fungi (candida). burn wound sepsis: hyper or hypothermia, progressive tachy, tachypnea, refractory hypotension.

BAT. hypotension, free intraperitoneal fluid, RUQ pain and brusing, right shoulder pain. fracture of right eight and ninth ribs. dx?

hepatic laceration

complication of jejunoileal bypass or loss of much of ileum due to disease with an intact colon. patho

hyperoxaluria. calcium oxalate stones develop due to excessive absorption of oxalate from the colon. normally, FA absorbed by terminal ileum, calcium and oxalate combine to form insoluble compound that's not absorbed. absence of terminal ileum, unabsorbed FA reach colon where they combine with calcium, leaving free oxalate to be absorbed. excess oxalate excreted by kidneys promoting calcium oxalate stone formation

hypotension, tachycardia, cold extremities, poor organ perfusion, flat neck veins. dx?

hypovolemic shock (usually due to massive internal hemorrphage). loss of intravascular volume -> decrease venous return to right atrium (decreased preload) -> decrease in CO and systemic blood pressure -> in effort to maintain adequate CO and organ perfusion -> sympathetic nervous system activated -> peripheral vasoconstriction (increase SVR) -> increase in HR -> LV (decrease in size due to low filling volume compensates by increasing ejection fraction.

how should acute appendicitis (classic presentationL migratory pain, N/V, fever leukocytosis, McBurney point tenderness, Rovsing sign) be managed and why?

immediate appendectomy to prevent appendiceal rupture.

pt has acute abdomen (rebound tenderness and subdiaphragmatic free air suggesting perforation). emergent laparotomy is required. PMH: HLD, DMII, HTN, chronic atrial fibrillation and CKD. medications: lisinopril, digoxin, warfarin, metoprolol, simvastatin and insulin glarline. HR is 100 and irregular. low Hgb (9), low plt (90), elevated glc, INR 2.1 and digoxin is in theraupeutic level. initial medical treatment? - packed RBC - platelet transfusion - vitamin K - desmopressin - FFP

in addition to pre-operative NG tube, IV fluids and abx, pt's wafarin-induced anticoagulation must be reversed. (although INR is normal for chronic management of atrial fibrillation, if not corrected, pt can have operative bleeding complications. most rapid way of normalizing PPT is restoring vitamin-K dependent clotting factors via infusion of FFP - pt has anemia but does not need to transfuse until under 7 - plt >50 provides adequate hemostasis for most invasive procedures - vitamin can normalize INR but not quick enough in emergent situation - given to pt with mild hemophilia A in order to prevent excessive bleeding during operation

hypertension, bradycardia, respiratory depression (what reflex) is suggestive of what?

increased intracranial pressure - cushing's reflex

most appropriate therapy for pt with gastric outlet obstruction secondary to duodenal ulcer and presents with hypochloremic, hypokalemic metabolic alkalosis

infusion of 0.9% NaCl with supplemental KCL until clinical signs of volume depletion are eliminated

best method of delivering post-op nutrition in 62yo women who underwent whipple procedure for pancreatic head cancer with a jejunostomy in place as she is expected to have prolonged recovery?

institution of enteral feeding via jejunostomy within 24hrs postoperatively

blunt chest trauma, hemorrhagic shock, decreased breath sounds and dullness to percussion over one hemithorax, contralateral tracheal deviation

ipsilateral hemothorax

what test is used to diagnose lactose intolerance and how does it work?

lactose hydrogen breath test. positive hydrogen breath test characterized by rise in measured breath hydrogen level after ingestion of lactose thus indicating bacterial carbohydrate metabolism

earliest clinical indications of hypermagnesemia? usually seen in what population?

loss of deep tendon reflexes. produced intentionally by obstetricians who use parenteral magnesium sulfate to treat preeclampsia

sudden onset odynophagia and retrosternal pain that makes swallowing difficult. endoscopy reveals circumferential deep ulceration with relatively normal surrounding mucosa in middle third of eophagus. dx?

medication induced esophagitis (tetracycline, ASA & NSAIDs, bisphosphonates, iron or potassium chloride (osmotic tissue injury) - common in mid-esophagus due to compression by aortic arch or an enlarged left atrium

head CT: extra-axial well circumscribed dural based mass that is partially calcified on neuroimaging suggests what dx? tx?

meningiomas. benign primary brain tumors. present with headache, seizure, focal neurologic deficits due to mass effect. resection is recommended

periumbilical pain out of proportion to examination findings and hematochezia. dx? test?

mesenteric ischemia mesenteric angiography

subacute, activity-related pain and point tenderness in foot, especially in athletes and military recruit. dx?

metatarsal stress fractures

femoral nerve provides innervation to what muscles (motor and sensory)?

motor: muscles of anterior compartment of thigh allowing for knee extension and hip flexion sensory: anterior thigh and medial leg via saphenous branch

how does brain metastasis typically appear on head CT?

multiple ring enhancing lesions at the grey-white junction (intra-axial)

tachycardia, new bundle branch blocks, arrhythmia, associated sternal fracture. dx

myocardial contusion

pt suffer MVA has an elevated pulmonary capillary wedge pressure at baseline should raise suspicion for what? path? next step?

myocardial dysfunction due to cardiac contusion and warrants echocardiogram usually will see slightly elevated PCWP as baseline that increase significantly after infusion of saline without an appreciable change in systemic blood pressure. suggestive of elevated intracardiac filling pressures due to left ventricular dysfunction from myocardial contusion

EBV infection. mediterranean and far eastern descent. recurrent OM, epistaxis. nasal obstruction. dx?

nasopharyngeal carcinoma (NPC)

wound site: intense pain around wound, decrease sensitivity at the edges of wound, cloudy-gray discharge, sometimes crepitus. dx? next step in management?

necrotizing surgical infection (common in ppt with diabetes, usually polymicrobial) parenteral antibiotics and urgent surgical debridement

can you use lower molecular weight heparin (ie enoxaparin) and rivaroxaban for DVT in pt with ESRD?

no. LMWH and rivaroxaban are contraindicated in pt with end stage renal disease. IV unfractionated heparin is recommended.

ABI values and meaning?

* <0.90: abnormal. diagnostic of occlusive PAD with 90% sensitivity and 95% specificity in sxs pt * 0.91-1.30: normal * >1.30: calcified and uncompressible vessels, additional vascular studies should be considered

what is Leriche syndrome and 3 associated characteristics?

* arterial occlusion at the bifurcation of the aorta into the common iliac arteries aka aortoiliac occlusion. triad: - bilateral hip, thigh, and buttock claudication - impotence (common in mne) - symmetric atrophy of the bilateral lower extremities due to chronic ischemia (soft or absent pulses from groin distally)

CT scan findings: ARDS vs pulmonary contusion?

- ARDS: bilateral patchy alveolar infitrates - pulmonary contusion: patchy, irregular (nonlobar) alveolar infiltrate, unilateral

pt with UC have an increased risk of colorectal cancer. when should pt get CRC screening and how often?

- CRC screening with colonoscopy and mucosal sampling beginning 8 years after the initial diagnosis. Repeat every 1-2 years thereafter.

what lab value is positive in vaccination against HepB

only Anti-HBs is positive. in order for pt to be anti-HBc positive: pt have to had been infected and resolved

what airway assess is preferred in apneic pt with cervical spine injury?

orotracheal intubation

46yo male suffer fall during bike rate. LOC and report severe back and abdominal pain. no intracranial bleed. CT shows small retroperitoneal bleed and splenic laceration. pt treated with conservative management with analgesics. day 3, diffuse abdominal pain and nausea. distended, tympanic and mildly tender without rebound or guarding. dx?

paralytic ileus. ileus commonly due to abdominal surgery but can also occur in retroperitoneal/abdominal hemorrhage, inflammation, intestinal ischemia or electrolyte abnormalities.

episodic pain and tenderness at inferior patella and patellar tendon, usually seen in athletes in jumping sports or in occupations with repetitive forceful knee extension

patellar tendinitis

chronic anterior knee pain, common in female. presents with peripatellar pain worsened by activity or prolonged SITTING.

patellofemoral pain syndrome

stat transthoracic echocardiogram is helpful in diagnosis of what (2)?

pericardial effusion and cardiac tamponade

75-year-old man with a history of myocardial infarction 2 years ago, peripheral vascular disease with symptoms of claudication after walking half a block, hypertension, and diabetes presents with a large ventral hernia. He wishes to have the hernia repaired. what is the most appropriate next step in his preoperative workup (2)?

persantine thallium stress test and EKG - assess the need for coronary angiogram with possible need for angioplasty, stenting or surgical revascularization prior to repair. exercise stress test can evaluate pt's cardiac function, pt's functional status is limited by peripheral vascular disease and so pharmacologic stress test is preferred.

pt with spinal cord injuries especially involving whiplash in MVA are at risk for what complication later in the future? presentation?

post traumatic syringomyelia. sxs develop years to months later. cape-like distribution. enlargement of central canal of the spina cord due to CSF retention resulting in impaired strength and pain/temp sensation

anterior knee pain, tenderness, erythema, localized swelling, common in occupations requiring repetitive kneeling. dx? common etiology?

prepatellar bursitis. often due to s. aureus which infect the bursa via penetrating trauma, repetitive friction or extension from local cellulitis

what biliary condition is associated with ulcerative colitis? patho?

primary sclerosing cholangitis: chronic, progressive disorder of unknown etiology characterized by inflammation, fibrosis and stricturing of intra- and extra-hepatic bile ducts. usually asxs but can present with fatigue and pruritus - continued bile duct obstruction --> fat-soluble vitamin deficiencies, end-stage liver disease and portal hyptertension

34yo female: several months of chronic abdominal pain (RLQ and mid-abdomen), non-bloody diarrhea, weight loss, mouth ulcers, elevated ESR. dx? what's the name for the ulcers? how do you know it's not celiac disease?

- Crohn disease - aphthous ulcers - celiac disease: chronic diarrhea, abdominal pain, weight loss and anemia of malabsorption * elevated inflammatory markers like ESR are uncommon, no oral manifestations

what is the most common cause of iron deficiency anemia in the elderly? what is the next step in management after occult blood test? does the results of occult blood test matter/

- GI bleed - colonoscopy and endoscopy - single negative occult blood test does not exclude the possibility of GI bleed

critically ill patients. imaging shows gallbladder wall thickening, distension and pericholecystic fluid. dx? tx? patho?

- acalculous cholecystitis - abx and percutaneous cholecystostomy -> cholecystectomy - path: cholestasis and gallbladder ischemia leading to secondary infection by enteric organisms and resultant edema and necrosis of the gallbladder. FYI: most pt affected have no prior history of GB disease

presentation of achalasia vs esophageal stricture?

- achalasia (esophageal dysmotility): dysphagia (both solids and liquids) + regurgitation of undigested food or saliva - esophageal stricture: progressive dysphasia (solid to liquid). interesting that disease progress, it can lead to improvement of heartburn symptoms by blocking the reflux

elderly and dehydrated post-operative patients are prone to what post-op complication in the oral region? prevention?

- acute bacterial parotitis with a. aureus. - prevention: adequate fluid hydration and oral hygiene

33yo male with 2 episodes of vomiting containing small amount of blood. pt drank alcohol and used cocaine with friend last night. work up with terrible headache and took several ASA. pt smokes pack of cigarettes daily and drinks 1-2 cans of beer daily. dx? cause of hematemesis?

- acute erosive gastropathy characterize by hemorrhagic lesions after ischemia or exposure of gastric mucosa to various injurious agents (alcohol, asa, cocaine) - cause: gastric mucosal erosion: asa (decrease protective PG production), cocaine (cause vasoconstriction and reduce gastric blood flow), asa and alcohol (direct mucosal injury via destroy secreted mucins and bicarbonate -> allow acid, bile acids and proteases to leak into lamina propria)

68yo male. post MI infarction course marked by CHF and intermittent hypoT. 4th day, severe miabdominal pain. PE: 90/60, HR 110, abdomen soft with generalized tenderness and distension. hypoactive BS, positive hematest. dx? next step?

- acute mesenteric ischemia - angiography due to absence of peritoneal signs. if positive peritoneal signs then pt should undergo emergent laparotomy

oliguria, azotemia, elevated BUN:Cr in post-operative state indicate what renal problem? etiology? what should be ruled out first? next step in management if first etiology is ruled out?

- acute pre-renal failure - etiology: hypovolemia - urinary catheter obstruction should first be ruled out via foley catheter change to ensure it's not clogged - next step: IV fluid challenge

what is a potential spinal injury complication associated with thoracic aortic aneurysm surgery? patho? presentation?

- anterior spinal cord infarction - spinal artery receive blood from radicular arteries that originate from the thoracic aorta such as artery of Adamkiewicz - present with spinal shock (abrupt onset of bilateral flaccid paralysis and loss of pain and temp below the level of spinal injury. UMN sxs develop over days to weeks. vibration and proprioception are usually intact.

54yo man with 30-pack-year smoking history underwent laparoscopic cholecystectomy. POD3, mildly hypoxemic at 90% on room air. lung auscultation shows decreased breath sounds at lung base. ABG shows pH 7.44, p02 64, pCO2 34. dx? reason for observed findings?

- atelectasis due to impaired cough and shallow breathing. following abdominal and thoracocabdominal surgery, change in lung compliance -> impaired cough and shallow breathing -> limit recruitment of alveoli in lung bases and weak cough predispose to small-airway mucus plugging -> hypoxia -> stimulate RR causing low pCO2.

stress fracture: - demographics - cause - RF - presentation? - findings on x-ray

- athletes (runners, dancers) or individuals who suddenly increase their activity level - caused by repeated tension or compression without adequate rest - female athlete triad: low caloric intake, hypomenorrhea/amenorrhea - activity related pain, swelling, point tenderness on palpation - x-ray: normal in first few weeks but may reveal periosteal reaction at the site of fracture

chronic GERD predisposes pt to what 2 conditions?

- barrett's esophagus (intestinal metaplasia of the lower esophagus) - esophageal stricture -> progressive dysphagia to solid foods without anorexia or weight loss. symmetric, circumferential narrowing on barium swallow.

physicians should have a high suspicion for what in pts with MVA or falls from >10feet (anxiety, tachy, hypertension)? mechanism of injury? what is a sensitive finding on chest x-ray?

- blunt aortic injury due to blunt deceleration trauma - mediastinal widening

pt vomiting multiple times. now chest x-ray shows unilateral pleural effusion (with or without pneumothorax), subcutaneous or mediastinal emphysema and widened mediastinum. pleural fluid (exudative, low pH and very high amylase). dx? why is pleural fluid low in pH and high in amylase?

- boerhaave syndrome - high amylase due to saliva in the esophageal contents

common complication of AAA repair? presentation? reason?

- bowel ischemia - inadequate colonic collateral arterial perfusion to left and sigmoid colon after loss of IMA during graft placement - abdominal pain, bloody diarrhea, fever, mild leukocytosis

pt suffer rapid deceleration chest trauma from MVA (forceful impact of car's steering wheel). chest x-ray shows persistent pneumothorax despite chest tube placement and pneumomediastinum, subcutaneous emphysema. dx? most common structure involved?

- bronchial rupture - right main bronchus is most commonly injured.

52yo man has decreased libido and impotence for past several months. fatigue, anorexia and weight loss. drinks alcohol but not tabacco or drugs. vitals normal. bilateral gynecomastia, firm and small testes. labs show decreased total T3 and T4 but normal TSH. most likely dx? reason for the finginds?

- chronic liver disease - hypogonadism (erectile dysfunction and testicular atrophy) due to primary gonadal injury, cirrhosis asstd with elevated circulating estradiol due to increased conversion from androgens. euthyroid status (decreased total T3 and T4 but free T3 and T4 unchanged, TSH normal) due to decreased liver synthesis of thyroid hormones like TBG and other proteins.

53yo male. 2day hx of right calf pain and swelling (worse with knee flexion). Hx of IV drug use, bacterial endocarditis and embolic stroke (result in left-sided hemiparesis, wheel chair bound). 140/90. HR 100. no JVD or hepatojugular reflex. abdomen is distended with shifting dullness and fluid wave. hepatosplenomegaly present. right calf is swollen and tender to palpable. cause of ascites? cause of calf swelling and pain?

- chronic liver disease (hx of IV drug use, increased risk of hep C infection) - unilateral calf pain: DVT from immobility to stroke

patho of primary biliary cholangitis? presentation? demographics? tx?

- chronic liver disease characterized by autoimmune destruction of intrahepatic bile ducts - common in middle-aged women - insidious onset, pruritus and fatigue - tx: ursodeoxycholic acid (UDCA): decrease biliary secretion and anti-inflammatory effects

unexplained chronic abdominal pain (postprandial, epigastric), food aversion and weight loss. dx? what do you see int he patient's PMH?

- chronic mesenteric ichemia - atherosclerosis

what are the 3 neoplasms associated with FAP?

- colorectal - desmoids and osteomas - brain tumors

management of SBO: conservative vs non-conservative?

- conservative (bowel rest, NG tube suction, correction of metabolic derangements). no signs of complicated SBO - emergency abdominal exploration: complicated SBO with risk of impending ischemia, strangulation, necrosis. Findings: fever, hemodynamic instability (hypoT, tachy), guarding, leukocytosis, significant metabolic acidosis

what 4 structures are compressed during uncal (transtentorial) herniation and their respective presentation?

- contralateral crus cerebri against tentorial edge: ipsilateral hemiparesis - ipsilateral CNIII: loss parasympathetic (mydriasis), loss motor (ptosis and down and out gaze of ipsilateral pupil from unopposed trochlear nerve) - ipsilateral posterior cerebral artery (contralateral homonymous hemianopsia from ischemia of visual cortex) - reticular formation: altered level of consciousness, coma

what is extraperitoneal bladder injury (EPBI)? sxs (3)? signs of what should be present?

- contusion or rupture of the neck, anterior wall or anterolateral wall of the bladder - sxs: localized pain, gross hematuria, associated pelvic fracture - signs of peritonitis (diffuse abdominal tenderness, guarding, rebound) should not be present

pt with ileal crohn disease or ileal resection are predispose to cholesterol stone formation. why?

- decreased enterohepatic recycling of bile acids: increased concentration of bilirubin conjugates and total calcium in the gallbladder

definition of varicocele? presentation?

- definition: tortuous dilation of the pampiniform plexus of veins - soft scrotal mass (bag of worms) that increase with standing/valsalva maneuvers and decrease in supine position

59yo male post-op partial (distal) gastrectomy for perforated ulcer 3 weeks ago. last 10 days, has intermittent abdominal cramps and diarrhea. sxs begins 30 minutes after eating: nausea, weakness, palpitations, light-headedness and diaphoresis. no other sxs overnight. vitals normal. dx? next step in management?

- dumping syndrome - dietary modification dumping syndrome involved GI (N, diarrhea, diaphoresis) and vasomotor (palpitations and diaphoresis) sxs. common postgastrectomy. caused by loss of normal action of pyloric sphincter (injury or gastric bypass) that leads to rapid emptying of hypertonic gastric contents into duodenum and small intestine. this causes fluid shifts from intravascular space to small intestine leading to hypotension, stimulation of autonomic reflexes and release of intestinal vasoactive polypeptides

patho of dumping syndrome and presentation?

- dumping syndrome involved GI (N, diarrhea, diaphoresis) and vasomotor (palpitations and diaphoresis) sxs. common postgastrectomy. - caused by loss of normal action of pyloric sphincter (injury or gastric bypass) that leads to rapid emptying of hypertonic gastric contents into duodenum and small intestine. this causes fluid shifts from intravascular space to small intestine leading to hypotension, stimulation of autonomic reflexes and release of intestinal vasoactive polypeptides

73yo male, nursing home resident underwent laparotomy for SBO. has advanced dementia. POD #8: pain and swelling on left angle of jaw. fever. swelling, erythema and tenderness of region of left parotid gland. elevated WBC. dx? preventative measures?

- dx: acute bacterial parotitis - prevention: adequate fluid intake and oral hygiene.

pt develops whistling noise during respiration following rhinoplasty. dx? patho?

- dx: nasal septal perforation - patho: septa hematoma. septum is made up of cartilage and has poor blood supply contrast to the rich anatomosing blood supply of the nasal sidewall. cartilage relies completely on the overlying mucosa for nourishment by diffusion.

55yo male asian immigrant. recent onset neck swelling. several episodes of epistaxis. no trauma to neck or nose. PMH: syphilis and recurrent bacterial sinusitis. drinks 2 beers daily, 30-pack year smoking. PE: mass in posterior nasal cavity. biopsy shows undifferentiated carcinoma. dx? RF? - alcohol use - spirochete infection - viral infection - bacterial infection?

- dx: nasopharyngeal carcinoma - RF: viral infection, especially w EBV pt has NPC, undifferentiated carcinoma of squamous cell origin. usually seen in pt of mediterranean or far eastern descent. usually asxs until met. present with recurrent OM (result from eustachian tube obstruction by tumor), recurrent epistaxis, nasal obstruction Association: EBV, smoking, chronic nitrosamine consumption (diets rich in salted fish)

34yo man presents to ER with sudden onset, severe pain in penis. during sexual intercourse, heard a crackling sound followed by pain and rapid loss of penile erection. pain aggravate when he tries to urinate and has not been able to pass urine. PE shows swollen and ecchymotic penis. dx? next step in management?

- dx: penile fracture - dx: clinical - tx: urological emergency. retrograde urethrogram (indication: blood in meatus, hematuria, dysuria, urinary retention)

subacute presentation of fever and lower abdominal pain radiating to the groin. abdominal pain with hip extension (what sign) detected on exam. test to confirm diagnosis? dx? tx?

- dx: psoas abscess - psoas sign - CT scan of abdomen and pelvis - drainage with abx

24hr after blunt trauma to chest (ie MVA), pt has tachypnea, tachycardia and HYPOXIA (PaO2 = 60mmHg). PE: chest wall bruising and decreased breath sounds. CT: PATCHY IRREGULAR (NONLOBAR) ALVEOLAR INFILTRATE. dx? tx?

- dx: pulmonary contusion - tx: supportive: pain control, pulmonary hygiene (nebulizer treatment, chest physiotherapy), supplemental oxygen

neck pain, odynophagia, and fever following penetrating trauma to posterior pharynx (ie fish bone). dx? complication and path?

- dx: retropharyngeal abscess - cx: acute necrotizing mediastinitis. infection of retropharyngeal space drain into the superior mediastinum. extension through alar fascia into "danger space" (btw alar and prevertebral fascia) can transmit infection into posterior mediastinum (at level of diaphragm) and cause acute necrotizing mediastinitis

patient with history of chronic cirrhosis and ascites presents with low-grade fever, abdominal discomfort and altered mental status. dx? patho?

- dx: spontaneous bacterial peritonitis - patho: intestinal bacterial translocation directly into the ascitic fluid or hematogenous spread to liver and ascitic fluid (due to other bacterial infections)

hematuria at the end of voiding and small clots. dx? RF (3)?

- dx: urothelial cancer - RF: age (>40), M>F, smoking

edema, statsis dermatitis, venous ulcerations in lower extremity. dx? location of presentation?

- dx: venous insufficiency due to valve incompetence - location: medial leg superior to medial malleolus

28yo man involved in high-speed MVA. pain in right pelvis and lower abdomen. palpate fullness and mild tenderness in suprapubic region without rigidity or rebound tenderness. no blood in urethral meatus, DRE normal. right pubic ramus fracture on x-ray. foley placed without resistance with immediate return of frank blood. dx? explain the sxs?

- extraperitoneal bladder injury (contusion or rupture of neck, anterior wall, anterolateral wall of bladder. rupture cause extravasation of urine into adjacent tissue cause localized pain in lower abdomen and pelvic. pelvic fracture may be present. gross hematuria usually present. urinary retention (suprapubic fullness( may occur especially with injury to bladder neck.

parotid surgery involving the deep lobe of the parotid gland carries significant risk for what complication? presentation?

- facial nerve palsy. two lobe of parotid gland separated by facial nerve which courses through the gland. - unilateral facial droop

mechanism of supracondylar fracture of the humerus (most common fractures in pediatric population). reason? most common complications (2) and respective presentation? tx?

- fall on outstretched hand - entrapment of brachial artery (loss of brachial and radial pulses) or median nerve (inability to flex index and thumb) - supracondylar area is thin and weak due to physiologic remodeling in childhood. - tx: analgesia and immobilization. consult ortho if displaced fracture

How does adrenal insufficiency present differently between female and male? common presentation: fatigue, weakness, anorexia, weight loss

- female: hypogonadism (loss of libido, decreased pubic hair) due to decreased androgen production - male: NO sxs of hypogonadism because androgens are primarily produced in the testes

path of sphincter of oddi dysfunction? what do you see on labs? abdominal u/s?

- functional biliary disorder due to dyskinesia or stenosis of the sphincter of oddi - labs: mildly elevated LFT, elevated alk phos - u/s: dilated common bile duct in absence of stones

cause of stone formation in pt on total parenteral nutrition or prolonged fasting? patho?

- gallbladder stasis: absent normal stimulus of CCK release and CCK contraction -> biliary stasis -> formation of biliary sludge and gallstones. normal: presence of proteins and FA in duodenum acts as stimulus for release of CCK which in turn stimulates the contraction of the gallbladder

describe the mechanism of actions of interventions in decreasing ICP: - head elevation - sedation - IV mannitol - removal of CSF - hyperventilation

- head elevation: increase venous outflow from brain - sedation: decrease metabolic demand - IV mannitol: osmotic diuresis - removal of CSF: reduce CSF volume and pressure - hyperventilation: cerebral vasoconstriction. lowering cerebral arterial paCO2 through hyperventilation results in rapid vasoconstriction and consequent decrease in ICP

what are 5 interventions and their respective mechanism for lowering intracranial pressure?

- head elevation: increase venous outflow from the brain - sedation: decrease metabolic demand and control of HTN - IV mannitol: osmotic diuresis -> extract free water from brain tissue - hyperventilation: CO2 washout via cerebral vasoconstriction - removal of CSF: reduction of CSF volume and pressrue

4 indications for urgent exploratory laparotomy in penetrating abdominal trauma? next step for pt who are more stable and without indication for urgent laparotomy?

- hemodynamic instability - PERITONITIS (rebound tenderness, guarding) - evisceration (ie externally exposed intestines) - blood from NG tube or on rectal examination - next step in stable pt: CT imaging of abdomen

young female with large, painful hepatic mass. Elevated alk phos and GGT, normal liver markers. minimal alcohol consumption and LT use of oral contraceptives. Most like dx of mass? what does elevated GGT suggests? tx? findings on U/S?

- hepatic adenoma - elevated GGT: biliary compression or obstruction - tx: avoid needle biopsy due to risk of bleeding. surgical excision is preferred method - US: well-demarcated, hyperechoic lesion

pt with end stage liver disease presents with: decreased glomerular infiltration (increased creatinine) in absence of shock and proteinuria. failure to respond to normal saline bolus. dx? path? tx?

- hepatorenal syndrome - renal vasoconstriction in response to decreased total renal blood flow and vasodilatory substance synthesis - tx: liver transplant

most common complication of thyroidectomy? presentation? findings on EKG?

- hypocalcemia due to hypoparathyroidism - nonspecific sxs: fatigue, anxiety and depression. involuntary contractions (tetany involving lips, face, extremities), seizures - prolonged QT interval

what two conditions can exacerbate hepatic encephalopathy in pt with bad cirrhosis and why?

- hypokalemia leads to intracellar acidosis (excreted potassium replaced by hydrogen ions intracellularly) -> more hydrogen send to kidney -> increase NH3 production in renal tubular cells - metabolic alkalosis (elevated bicarbonate): promotes conversion of ammonium (NH4+) which can't enter the CNS into NH3 which can cross the CNS

MVA. types of shock? - decreased PCWP at baseline that improves towards normal with saline infusion - slightly elevated PCWP that increased after saline infusion while no/minimal changes in systemic blood pressure

- hypovolemic shock - cardiogenic shock

what are the 2 most common causes of esophageal rupture? manifestations (2)?

- iatrogenic (with endoscopy) and esophagitis-related etiologies are most common. esophageal rupture from blunt trauma is rare - manifestations: pneumomediastinum and pleural effusions

where is the ideal placement of the central venous catheter? what is the next best step after placement of CVC? how about in setting of ultrasound-guided CVC placement?

- ideal placement: CVC tip is in the lower superior vena cava - portable chest-x-ray to confirm placement - confirmatory chest x-ray can be omitted in setting of uncomplicated ULTRASOUND-guided CVC placement

what is trochanteric bursitis? patho? presentation?

- inflammation of bursa around the insertion of gluteus medium into femur's greater trochanter - due to excessive frictional forces 2/2 to overuse, trauma, joint crystals - presentation: superficial unilateral hip pain, worsen by external pressure to upper lateral thigh (lying on affected side)

Pt in hemorrhagic shock. best resuscitative measure (2)?

- infusion of packed RBC - early administration of FFP and platelets as indicated by PT and platelet count on lab especially in severely injured trauma pt. when transfused with RBC, recipient develops dilutional thrombocytopenia and deficiencies in Factors V and VIII. so admin of FFP and platelet can decrease mortality

what does initial hematuria suggests? terminal? total? clots not associated with what?

- initial: urethral damage - terminal: bladder or prostatic damage - total: kidney or ureters damage - clots usually not seen with renal causes of hematuria (ie. glomerular disease)

frequent, watery, nocturnal diarrhea (10-12 nonbloddy water BM perday with asstd abdominal cramping) in health care worker (usually female). colonoscopy shows dark brown mucosal pigmentation in proximal colon. dx? name of pigmentation?

- laxative abuse - melanosis coli (dark brown discoloration of colon with pale patches of lymph follicles)

venous hypertension: - patho - presentation

- lower extremity venous valvular incompetence resulting in pooling of venous blood and increased pressure in postcapillary venules. increased pressure damage capillaries leading to loss of fluid, plasma proteins and RBC into tissue. RBC extravasation causes hemosiderin deposition -> classic coloration of stasis dermatitis. inflammation of venules/capillaries, fibrin deposition, platelet aggregation -> microvascular disease -> ulcerations - bilateral lower extremity edema and stasis dermatitis (medial leg below knee and above medial malleolus), ulcers

pt with recurrent vomiting and abdominal discomfort. pt places stethoscope over the upper abdomen and rocks the pt back and forth at the hips. what is this maneuver and it is most helpful in diagnosing what disease?

- maneuver: abdominal succussion splash - gastric outlet obstruction (GOO) * retained gastric material >3 hours after a meal will generate a splash sound, indicating the presence of hollow viscus filled with fluid and gas

acute knee pain associated with catching or reduced range of motion suggests that dx? path? next step if symptoms persist? tx in younger pt?

- meniscal injury/tears: rotational force on planted foot (younger pt), degeneration of meniscal cartilage (older pt) - MRI if sxs persist - surgery in younger pt to relieve pain or reduce risk of further joint injury

most common metatarsal to be injured in metatarsal stress fractures. what is the initial treatment. which metatarsal is at increased risk for nonunion and warrant more aggressive treatment like what?

- most common injured: second metatarsal. middle metatarsals (2rd, 3rd, 4th) managed conservatively because surrounding metatarsals at as splints and nonunion is uncommon. rest and simple analgesics. - 5th metatarsals increased risk of nonunion so managed with casting or internal fixation

do most pt with aortic rupture make it to the hospital? location of injury?presentation?

- most pt with aortic rupture die in the field - injury to aorta just distal to the left subclavian artery and may be contained as hematoma within the mediastinum. - hypertension (due to visceral afferent reflexed and pseudocoarctation syndrome). JVD not present

skin erythema and swelling, severe pain out of proportion to PE, tissues becoming necrotic (crepitus, purulent drainage. CT scan shows gas in deep tissue. dx? etiology?

- necrotizing fasciitis with Group A strep

avascular necrosis and nonunion are complications of scaphoid fracture. next step in management if radiographs of wrist in multiple views reveal no fracture or dislocation? should you use corticosteroids injections? how about just analgesics, rest and wrist splint?

- next: MRI of wrist and forearm. - corticosteroid injections appropriate for short-term tx of joint inflammation and bursitis but no appropriate for fractures as they can impede healing - analgesics and rest and wrist splint appropriate for soft tissue injuries like wrist sprain

what are the 3 associated neoplasms of Lynch Syndrome (3)?

- ovarian cancer - colorectal cancer - endometrial cancer

labs in hypoparathyroidism? insufficient calcium intake?

- parathyroid hormone deficiency: hypocalcemia, hyperphosphatemia in presence of normal renal function - insufficient calcium intake: hypocalcemia. induce PTH secretion causing secondary secondary parathyroidism -> high PTH increase bone resorption, convert 25-Vita D to 1,25-vita D in kidneys and stimulate gut absorb calcium and increase renal phosphate loss resulting in HYPOPHOSPHATEMIA

2 mechanisms for GI perforation? what part of the GI tract is most frequently involved?

- penetrating abdominal trauma - BAT: damage to mesenteric bloody supply, subsequent GI necrosis and eventual perforation - most frequently involve: jejunum

older adolescents and young adult: fever, pharyngeal pain, earache, uvula deviation, spasm of jaw muscles (trismus, unable to follow open mouth). dx? patho? tx?

- peritonsillar abscess (PTA) - acute bacterial infection of region between tonsil and pharyngeal muscles. persistent tonsillitis/pharyngitis that process to cellulitis/phlegmon -> pus collection into abscess. - needle aspiration or I&D + abx (GAS and respiratory anaerobes)

characteristic of lactose intolerance: -hydrogen breath test -reducing substance -stool pH -stool osmotic gap

- positive hydrogen breath test - positive stoll test for reducing substance - low stool pH - increasing stool osmotic gap

men with pelvic fracture are at significant risks for what complication? patho? presentation? diagnostic test?

- posterior urethral injury (PUI). - abrupt upward shifting of bladder and prostate can lead to urethral tearing which commonly affects the membranous urethra at the bulbomembranous junction (dividing point between anterior and posterior urethra) - BLOOD IN URETHRAL MEATUS, inability to void, perineal or scrotal hematoma, HIGH-RIDING PROSTATE on DRE - test: retrograde urethrogram

45yo male. POD#2 for upper abdominal ventral hernia repair. chronic cough with some early morning sputum productions. vitals normal except for RR 28. decreased breath sounds at right lung bases without wheezes or prolonged expiration. abdominal distention and diffuse tenderness without rebound. chest x-ray shows dense opacity at right lung base. dx? what's the arterial blood gas at room air?

- postoperative atelectasis - alkalosis, pO2 70 (hypoxemia), pCO2 27 (hypocapnia) atelectasis due to airway obstruction from retained airway secretions, decreased lung compliance, post-op pain and medications that interfere with deep breathing

34yo immigrant from mexico. cough up foamy sputum with significant amount of bright red blood. chest x-ray shows dense opacity in right upper lobe. dx? next step?

- probably primary tuberculosis. first step is to place pt in respiratory isolation to avoid further exposure to healthcare professionals

pt with labs: - HBsAg (negative) - Anti-HBsAg antibodies (positive) - Anti-HAV antibodies (negative) - Anti-HCV antibodies (positive) her splenomegaly is from what? what vaccine should she get?

- pt infected with Hep C - presence of Anti-HBsAg antibodies indicate immunity against hepB - not immune against Hep A so should receive vaccine

what is the appropriate dosing and timing of abx ppx to prevent surgical site infections in elective procedures? elective colon resections? continuation of abx for more than 24hr after elective procedure is complete?

- recommendation: single dose, no greater than 1 hours prior to incision. oral, nonabsorbable abx regiment vs aerobes and anaerobes in combo with mechanical bowel prep before election colon resections. - don't continue abx for more than 24hr post operation to prevent increasing microbial drug resistance

first line therapy in treatment of septic shock after securing airway. second line?

- restoring adequate tissue perfusion through IV fluids (crystalloid) - vasopressors like dopamine to control blood pressure if pt fails to respond to fluid therapy or develops evidence of volume overload

54yo suffer fall to wrist (landed forcefully on palm). PE shows left wrist tenderness at dorsoradial wrist lateral to the tendon of the extensor pollicus longus. fracture? tx? potential complications?

- scaphoid fracture - tx: displaced fracture tx surgically. nondisplaced fracture tx with wrist immobilization - cx: osteonecrosis because blood supply enters at the distal pole and flows proximally can be disrupted

shin splints (medial tibial stress syndrome) vs tibial stress fractures: - demographics - presentation

- shin splints and stress fracture cause anterior leg pain - shin splints more common in overweight rather than underweight pt (stress fracture) - regional tenderness (shin splints) focal tenderness (stress fracture)

pt with chronic HepC infection has intermittent elevation of transaminases and skin findings consistent with what? strong correlation with what immunological conditions?

- skin findings consisten with porphyria cutanea tarda (PCT) - fragile skin, photosensitivity, vesicles and erosions on dorsum of hands - essential mixed cryoglobulinemia: circulating immune complexes deposit in small-medium vessels + associated low serum complement levels -> palpable purpura, arthralgias and renal complications

pt with cirrhosis and ascites accompanied by fever and lethargy. sxs of hepatic encephalopathy may be present. what are you concern for? what are you two MC symptoms? test to make the diagnosis?

- spontaneous bacterial peritonitis - fever and subtle changes in mental status - test: paracentesis (positive ascites fluid culture and neutrophil count >250/mm3)

65yo man. suffer burn injury to left leg 4 years ago that required extensive local care and skin grafting resulting in residual scar tissue. during tx, pt develop chronic draining wound that never completely closed. last 6 wks, has enlarging nodule at lesion site with persistent pain and increasing drainage. topical therapy didn't help. biopsy of nodule most like show what? dx?

- squamous cell carcinoma - marjolin ulcer

management of primary spontaneous pneumothorax: - small pneumothoraces - large pneumothoraces - stable vs unstable pt

- stable, small pneumothoraces: observation and supplemental oxygen - stable, large pneumothoraces: needle decompression, insertion at the 2nd or 3rd intercostal space in the midclavicular line or at the fifth intercostal space in the mid or anterior axillary - hemodynamically unstable: emergent chest tube placement

blunt genitourinary trauma: management in hemodynamically stable pt (2)? unstable pt?

- stable: urinalysis and contrast-enhanced CT scan of abdomen and pelvis in stable pt with evidence of hematuria - hemodynamically unstable with evidence of renal trauma: IV pyelography prior to surgical evaluation

what two symptoms are seen in pt with esophageal perforation (aka boerhaave syndrome) and patho?

- suprasternal crepitus: subcutaneous emphysema - pneumomediastinum: retrosternal pain from air and contamination of the mediastinum with gastric contents

sxs of acute adrenal insufficiency (adrenal crisis)? what triggers it? occurs in what patient population (2)?

- sxs: refractory HYPOTENSION, vomiting, abdominal pain, fever - triggers: acute illness or major stressors (ie surgery) - primary adrenal insufficiency (addison disease) or suppression of the HPA axis due to chronic glucocorticoid use.

blow to side leading to twisting knee injury with foot fixed. dx? sxs? what to see on physical exam?

- tear of the medial meniscus - sxs: reduced extension, sensation of instability, effusion - pt have palpable locking or catching when the joint is rotated or extended while under load (pt stand on one leg with kneed slightly bent, internal rotation on knee elicits locking sensation and significant, sharp pain.

rapid onset dyspnea, tachycardia, hypotension, distension of neck veins. dx? tx?

- tension pneumothorax - immediate needle thoracostomy

65yo man in ED with COPD exacerbation. elevated temp and high RR, low O2sat. trachea intubated and placed on mechanical vent. central venous catheter placed in subclavian vein (fluids, steroids and abx given). pt continue to desat over next 20 minutes with pulseOx at 83%. elevated inspiratory pressures. BP 80/50, HR 120. trachea deviated to left. absent breath sounds on right. wheezes on left side. neck veins distended. dx? cause? next step in management?

- tension pneumothorax (complication of central venous catheter placement) -> displace mediastinal structures and compromises cardiopulmonary function. positive ventilation can worsen the condition. - tx with needle thoracostomy in hemodynamically unstable pt followed by emergency tube thoracostomy

initial treatment for anal fissure: - dietary modification (high fiber diet, increase fluid intake) - stool softeners - sitz baths: increase blood flow to injured mucosa - ? - ?

- topical anesthetics (lidocaine) to enhance comfort - topical vasodilators: nifedipine, nitroglycerin to reduce pressure in and increase blood flow to anal sphincter and facilitate healing

- what causes varicocele? - common in what demographics? - common on what side and why? - presentation (worsen, better)? - transilluminate? test of choice?

- tortuous dilation of pampiniform plexus of veins surrounding spermatic cord and testis in scrotum - post-pubertal males - left sided. left spermatic (gonadal) veins enters left renal vein at right angle. aorta and SMA compress left renal and gonadal veins lead to increase venous pressure causing incompentence of valves -> retrograde blood flow toward testes -> left spermatic venous dilation. right gonadal veins empties directly into IVC. - soft mass (bags of wormns) worsens on standing and valsalva maneuvers. decreases when supine - does NOT transilluminate. - U/S show retrograde venous flow

middle aged adult, superficial unilateral hip pain that is exacerbated by external pressure to the upper lateral thigh (when lying on the affect side in bed). dx? patho?

- trochanteric bursitis (inflammation of bursa surrounding insertion of gluteus medius into femur's greater trochanter - excessive frictional forces secondary to overuse, trauma, joint crystals or infection

hematemesis, melena, anemia, BUN:Cr>20. dx? tx for stable pt?

- upper GI bleed (UGIB) - PRBC transfusion for hemoglobin <7g/dL

pt with abdominal pain, hematemesis and melena. "burning and fullness" abdominal discomfort that's relieved by food. dx? BUN/Cr ratio and reason?

- upper GI bleed from peptic ulcer - usually tachycardic suggests at least mild volume depletion - UGIB usually have ELEVATED BUN:Cr due to increased urea production from intestinal breakdown of hemoglobin and increased urea reabsorption in proximal tubule due to associated hypovolemia

differential diagnosis for initial hematuria (2)?

- urethritis - trauma (catherization)

what causes medial collateral ligament tear (2)? findings (2)

- valgus stress or severe twisting injury - findings: tenderness of medial knee, valgus laxity

3 requirements to make the diagnosis of acute liver failure?

1. severe acute livery injury: elevated aminotransferases (>1000U/L) 2. signs of hepatic encephalopathy 3. impaired hepatic synthetic function (INR > 1.5)

differential diagnosis for anterior mediastinal mass (4)?

4 T's: thymoma teratoma and other germ cell tumors thyroid neoplasm terrible lymphoma

pt presents with severe back pain, syncope, hypotension

AAA rupture

pt has sxs suggestive of intermittent claudication with multiple RF for atherosclerosis (DMII, HTN, smoking). what should be the next step in management?

ABI to confirm presence of peripheral arterial disease

29yo. persistent vomiting and abdominal pain for last 24hrs. pain is crampy, diffuse and getting worse. normal BM 3 days ago and has no diarrhea. green emesis with no blood. normal vitals. BP 119/76 (sitting) 94/65 (standing). abdomen is distended and hyperactive BS. percussion shows tympany, diffusely tender to palpation. no rebound or guarding. labs are all normal. what historic findings most likely? - appendectomy 6 months ago - fatty food intolerance - high alcohol consumption - occasional black or tarry stool

pt has SBO. adhesions from previous surgery

what does the GCS assess (3)?

pt's ability to open his/her eyes, motor responses, verbal responses

45yo male with persistent nausea and vomiting of partially digested food. sxs for 1 month. good appetite but has early satiety. denies hematemesis, black stool, difficulty swallowing, chest pain. PMH: DMII, suicide attempt 3 months prior where he ingested acid. hx of peptic ulcer disease and takes antiacids for heartburn. smokes 1 pack daily. normal vitals except elevated HR. dry mucous membrane. abdominal exam shows succussion splash on epigastrium. dx?

pyloric stricture. - gastric outlet obstruction due to mechanical obstruction: postprandial pain, vomiting, early satiety. PE shows succussion splash elicit by placing stethoscope over upper abdomen and rocking pt back and forth at hips, retained material >3hr after meal will generate splash sound and indicate presence of hallow viscus filled with fluid and gas. RF: acid ingestion cause fibrosis post acute injury. ** esophageal stricture and dysmotility (achalasia) tend to present with dysphagia. abdominal succussion splash is not common

what is damaged in fracture of midshaft of humerus. presentation?

radial nerve is most commonly damaged. radial nerve passes through radial groove (posterior surface of humerus). damage during fracture due to traction of nerve by fracture end or after the reduction of fracture due to impingement of the radial nerve during closed reduction. presentation is wrist drop due to marked limitation of extension at wrist joint

common cause of radial nerve injury (2) and presentation?

radial nerve. humeral mid-shaft fracture and use of improperly fitted crutches. weakness on wrist and fingers extension

Labs for pt with resolved hepB infection? immunized with HepB vaccine

resolved infxn: - positive: anti-HBs, anti-HBc - negative: HBsAg vaccinated - positive: anti-HBs - negative: anti-HBc, HBsAg

first step in management of post-op patient, asxs, who is found to have a serum sodium level of 125mEq/L? complication of rapid correction?

restriction of free water then search for underlying etiology. complication of rapid correction is central pontine myelinolysis

after cardiac catherization, pt presents with sudden hemodynamic instability (hypotension, tachy, flat neck veins, improvement post fluids infusion) and ipsilateral flank or back pain. dx? diagnostic test? tx?

retroperitoneal hematoma. dx confirmed with non-contrast CT scan of abdomen and pelvis or abdominal ultrasound tx: supportive, bed rest, intensive monitoring, IV fluids and/or blood transfusion

pt on wafarin has to undergo emergent surgical procedure, what must be done before pt is in operating room?

reversal of anticoagulant achieved pre-operatively by infusion of FFP

what is the D-xylose test and it's usage?

D-xylose is a monosaccharide that is absorbed in the proximal small intestine without degradation by pancreatic or brush border enzyme. it is subsequently excreted in urine. pt with proximal small intestine mucosal disease (ie celiac) can't absorb d-xylose in intestine and thus concentration in venous and urine will be low. in contrast, pt with malabsorption due to enzyme deficiencies (ie chronic pancreatitis) will have normal d-xylose level

pt with impaired abduction of the shoulder following fall n outstretched hands. dx?

rotator cuff tear - weakness on abduction which can be appreciated with the drop arm test. with completely tear pt unable to lower the arm smoothly and will drop rapidly around mid-abduction

subacute shoulder pain on abduction from repetitive activity above shoulder height (ie painting ceilings). dx?

rotator cuff tendinopathy (RCT). chronic tensile loading and compression by surrounding structures can lead to microtears in rotator cuff tendons esp supraspinatus, fibrosis and inflammatory calcification

path of penila fracture?

rupture of corpus cavernosum due to traumatic shear in tunica albuginea (which envelops the corpus cavernosum). usually occur when penis is in erect state

female pt with sudden onset of right lower abdominal pain that is not diffuse (diffuse abdominal rigidity with rebound and guarding). hemodynamic instability? dx?

ruptured ovarian cyst. lower quadrant tenderness with hemoperitoneum. decrease hematocrit due to intra-abdominal blood loss.

pt with subacute presentation of delayed-onset prosthetic joint infection. what bug?

s. epidermidis

treatment of adrenal crisis?

IV hydrocortison or dexamethasone with aggressive fluid support

80yo female with osteoarthritis takes ASA and NSAIDs is being evaluated for fatigue and pallor conjunctiva. cause of her anemia?

NSAID common cause of iron deficiency anemia due to chronic blood loss from GI due to gastritis and/or gastric ulcers

what is the metabolic abnormality in pt with primary adrenal insufficiency?

PAI: hyponatremia and hyperkalemia due to concurrent mineralocorticoid insufficiency.

what serum hormone levels are helpful in differentiating seminomatous germ cell tumors from nonseminomatous variants?

seminoma: 1/3 pt has elevated b-HCG, normal AFP nonseminomatous (yolk sac, choriocarcinoma, embryonal, mixed): elevated AFP and B-HCG

fever, tachycardia, hypotension, poor urine output. dx?

septic shock

25yo man with mass in mouth. lump for many years. no weight loss, asxs. negative TED. PE: 2x2cm mass on hard palate that is immobile and has bony hard consistency. dx?

torus palatinus (TP), benign bony growth on midline suture of hard palate. genetic and environmental factors. more common in younger pt, female and asians. thin epithelium overlying bony growth tends to ulcerate with normal trauma of oral cavity and heal slowly due to poor blood supply. surgery indicated if sxs

persisten pneumothorax and significant air leak following chest tube placement in pt who sustained blunt chest trauma. dx?

tracheobronchial rupture. findings including subcutaneous emphysema and pneumomediastinum

23yo male pt suffered MVC and lower extremity fracture, abdominal bruising and scalp lacerations. has pain and SOB. BP 95/60 HR 120. given 1L IV fluids. becomes progressively drowsy, weakness on right side of body. BP 160 HR 50. dx? which nerve is compromised during exam? - abducens - accessory - facial - oculomotor

transtentorial (uncal) herniation. oculomotor never compromised. pt has uncal herniation 2/2 right sided epidural hematoma (rupture of middle meningeal artery due to high pressure from MVA). high arterial pressure system can expand and compress temporal lobe (made worse with fluid resuscitation). elevated ICP (HTN, bradycardia, respiratory depression). uncus is most innermost part of temporal lobe and herniates through tentorium to cause pressure on ipsilateral oculomotor nerve, ipsilateral posterior cerebral artery, contralateral cerebral peduncle.

MVA and significant head trauma. ipsilateral hemiparesis, ipsilateral mydriasis and strabismus, contralateral hemianopsia, altered mentation. dx?

transtentorial uncal herniation

claw hand is result of injury to what nerve? common cause (2)?

ulnar nerve fracture of medial epicondyle of humerus, deep laceration of anterior wrist

african american infant with bulge in periumbilical area, covered by skin, more pronounced during crying. born to 18yo mother without prenatal care, does not take prenatal vitamins. dx? next step?

umbilical hernia. observe for spontaneous resolution. usually resolve by 5yo. surgery is currently no indicated

MVA pt suffering BAT. hemodynamically unstable. FAST reveals free intraperitoneal fluid in abdomen. what is the next step? what organs are we worried about being damaged?

urgent laparotomy. spleen and liver are the 2 most commonly injured organs that can lead to intraabdominal hemorrhage

soft left scrotal mass that worsen on standing and valsalva maneuver but decreases in supine position

varicocele

bilateral lower extremity edema and stasis dermatitis. dx?

venous hypertension resulting from lower extremity venous valvular incompetence leading to pooling of venous blood and increased pressures in postcapillary venules

to confirm correct CVC placement, what do you see on portable chest-xray?

visualizatoin of catheter tip just proximal to the angle between the trachea and right mainstem bronchus (confirms appropriate placement)

pt <30yo w unexplained chronic hepatitis, likely dx? what 3 features confirm the diagnosis?

wilson's disease - low serum ceruloplasmin - increase urinary excretion of copper - kayser fleischer rings

hypogonadism, impaired taste, impaired wound healing, alopecia, skin rash with PERIORAL involvement. what mineral is deficient?

zinc