Surgery

describe methanol toxicity

Methanol- found in paint thinner, homemade liquor and windshield washer fluid Alcohol dehydrogenase converts it to formaldehyde (the toxic substance) which leads to dec visual acuity, abd pain, and high anion gap metabolic acidosis Tx- Fomepizole inhibits alcohol dehydrogenase

describe how the kidneys combat metabolic acidosis

1) secrete chloride to reabsorb bicarb 2) secrete H+ in the form on NH4+/ammonium

what type of ab to give in OR to pt undergoing knee replacement ?

1st/2nd gen cephalosporin

pressure above what is concerning for abdominal compartment syndrome?

>25mmHg

Describe the Aa gradient: high (>12) normal

Aa gradient= PA02- Pa02, normal is 10-12 mmHg Note that high Aa gradient assoc w/ V/Q mismatch, diffusion limited or R-> L shunt Normal Aa gradient assoc w/ high altitude, hypoventilation (opioid use)

what preop tests should you get prior to a pneumonectomy?

FEV1 and diffusion capacity of the lung for carbon monoxide to make sure pt can tolerate it

treatment of septic arthritsi?

I&D and abs

tx of auricular hematoma and why?

I&D bc gets diffsuion from perichondrium and lack of bf can cause necrosis easily, can slso get abscess or cauliflower ear from fribocartilage growth

conservative tx of cardiac tamponade?

IV fluids to improve LV preload

what vaccines do you give someone w/ splenectomy

S. pneumo, H influenza, N meningitidis, HAV, HBV and TDAP

most important indicator for breast cancer survival?

TNM

tx of infective endocarditis?

abs and assess for valve replacement

pain control in a heroine addict?

tylenol, ketorolac or short term opioids (morphine)

someone w/ h/o roux en y has petechiae but normal PT, PTT and platelets, dx?

vitamin c deficiency although they are usually deficient in KADE and B12, B1, vitamin C can occur too, copper too get petechiae, coiled hair, gingivitis, impaired wound healing

when do you see 1 alpha hydroxylase decreased?

w/ renal failure

tx of pseudocyst

conservative: serial CT scans for 6-8 wks looking for decreasing size drain if need be

causes of tumors in the mediastinum : Anterior Middle Posterior

4 T's: Teratoma, terrible lymphoma, thyroid goiter, thymic neoplasia BHEM: bronchogenic tumor, hiatal hernia, esophageal cancer, metastasis Neurogenic tumor, multiple myeloma

ICP should be lower than___ and CPP should be greater than____

<20mmHg ; >50mmHg

Describe what these waveforms mean in the jugular vein A X C V Y what does it mean w/ peak V wave?

A= atrial contraction X= atrial relaxation C= bulging of tricuspid vavle w/ ventricular contraction V= passive atrial filling Y= atrial emptying with opening of tricuspid valve

A 74-year-old man comes to urgent care due to persistent back pain at L1 to L4 spinal levels. The patient's symptoms started suddenly while he was having breakfast yesterday. The pain is constant, deep, and dull. He reports no trauma or having had similar pain previously. The symptoms do not change with climbing stairs or lumbar flexion/extension activities. The patient had difficulty falling asleep last night because of increased pain in his lower back. Medical history is significant for hypertension. The patient has a 40 pack-year smoking history, but he does not use alcohol. Medications include amlodipine and enalapril. He is afebrile; blood pressure is 140/90 mm Hg and pulse is 88/min. BMI is 27 kg/m2. Physical examination shows normal range of motion of the spine without point tenderness. Straight leg raise test is normal. The abdomen is soft. Mild tenderness is present with deep palpation from the epigastric to supraumbilical regions. Bowel sounds are normal. Femoral, popliteal, and pedal pulses are symmetric. Erythrocyte sedimentation rate is normal. X-ray of the spine reveals no vertebral abnormalities, but prevertebral calcifications are present. Which of the following is the best next step in management of this patient?

AAA, dx w/ CT scan

A 30-year-old man is brought to the emergency department due to a worsening headache. The patient has had episodic right-sided headaches over the past 6 months. Thirty minutes ago, he began experiencing a right temporal headache while at rest, which gradually worsened to severe pain over the next several minutes. He also had nausea and an episode of vomiting. The patient is now somnolent and difficult to rouse. He has no other medical conditions and had a normal medical evaluation a year ago for military enlistment. Temperature is 37 C (98.6 F), blood pressure is 150/90 mm Hg, pulse is 64/min, and respirations are 14/min. The patient withdraws all extremities to painful stimuli, but left-sided deep tendon reflexes are increased. There is no neck rigidity. Which of the following is the most likely underlying cause of this patient's current condition?

AV malformation

Describe Leriche Syndrome

BL claudication or hip pain, diminished femoral pulses, impotence from atherosclerosis/PAD of the iliac vessels

64-year-old man comes to the office due to urinary urgency, straining to urinate, a sensation of incomplete bladder evacuation, and frequent nocturia over the past several months. He has had no dysuria, fever, chills, abdominal or perineal pain, or penile discharge. The patient had similar symptoms in the past, which had improved after undergoing transurethral resection of the prostate (TURP) 5 years ago. He has no other medical conditions and takes no medications. Vital signs are within normal limits. Physical examination shows a soft and nontender abdomen. There are no external genital lesions, and the perineal sensation is normal. Digital rectal examination shows normal anal sphincter tone and a nontender prostate. Urine dipstick is negative for blood, leukocyte esterase, or nitrites. Which of the following is the most likely cause of this patient's current symptoms?

BPH can still get this after TURP bc androgens will continue to enlarge the prostate

A 68-year-old man is brought to the hospital due to acute fever, malaise, lower abdominal discomfort, and right flank pain. Six months ago, he was hospitalized for similar symptoms and was diagnosed with a urinary tract infection; at that time, his urine culture grew Escherichia coli, and his symptoms completely resolved with antibiotic therapy. Over the past year, the patient has experienced frequent nighttime urination and dribbling but no gross hematuria. There is right costovertebral angle tenderness. Leukocytes16,800/mm3 Creatinine1.2 mg/dL Urinalysis Blood-moderate Bacteria-many White blood cells-50+/hpf Dx?

BPH causing high post-void residual volume and interstitial nephritis

A 74-year-old man is brought to the emergency department due to worsening lethargy and abdominal pain and distension. For the past several days, the patient has had watery diarrhea. However, in the last 24 hours, he has not had a bowel movement, and the abdominal pain and distension have worsened, with the patient becoming progressively more lethargic. Temperature is 38.8 C (101.8 F), blood pressure is 106/60 mm Hg, and pulse is 118/min. On physical examination, the patient is ill appearing and somnolent. The abdomen is distended and diffusely tender. Bowel sounds are decreased. Leukocyte count is 18,000/mm3. Serum potassium is 3.2 mEq/L. Abdominal x-ray is shown in the image below: img shows toxic megacolon

C diff causing toxic megacolon (leukocytosis, low grade fever)

what tumor markers are elevated w/ cholangiocarcinoma? what about hepatocellular carcinoma?

CEA, CA19-9 and AFP AFP

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: Hemoglobin8.1 g/dL Platelets190,000/mm3 Leukocytes3,800/mm3 Serum chemistry Creatinine1.2 mg/dL 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?

CMV infection- get colitis w/ bloody diarrhea, retinitis, esophageal ulcers Dx- biopsy of organ and blood smear shows atypical lymphocytes Tx- ganicyclovir

gold standard diagnostic test for appendicitis? what if children/pregnant?

CT scan US +/-MRI

A 62-year-old man comes to the office due to anorexia, fatigue, and a 9 kg (20 lb) weight loss over the past 6 months. He rarely drinks alcohol and does not use illicit drugs, although he has smoked one pack of cigarettes daily for the past 40 years. The patient has previously been diagnosed with hypertension, diverticulosis, external hemorrhoids, and osteoarthritis. Current medications are atenolol and aspirin, and he has no known drug allergies. Temperature is 37 C (98.6 F), blood pressure is 132/88 mm Hg, pulse is 70/min, and respirations are 12/min. Physical examination reveals a soft abdomen that is mildly tender to deep palpation in the midepigastric region. The sclerae are icteric, and the skin is jaundiced. Laboratory results show: Hemoglobin13.5 g/L Platelets220,000/mm3 Leukocytes5,100/mm3 Albumin3.9 g/dL Total bilirubin6.7 mg/dL Alkaline phosphatase647 U/L Aspartate aminotransferase (SGOT)110 U/L Alanine aminotransferase (SGPT)102 U/L Antimitochondrial antibodies are negative. Abdominal ultrasound demonstrates mild dilation of the common bile duct; there are no stones present in the gallbladder and no evidence of gallbladder wall thickening. Which of the following is the best next step in the management of this patient's

CT scan, likely pancreatic adenocarcinoma

workup of RCC

CT then if likely nephrectomy if unsure then get biopsy

best dx for diverticulitis?

CT w/ IV and oral contrast

Describe DLCO capacity: inc dec normal

DLCO- the diffusing capacity of carbon monoxide inc: polycythemia, asthma, hemorrhage, inc bf like in exercise Dec in: anything that affects the alveoli such as emphysema, pneumoconiosis, fibrosis, sarcoidosis, etc. Normal in: chronic bronchitis, muscular paralysis (guillane barre, polio, myasthenia gravis), scoliosis, obesity

Describe blunt abd traumawhat tells you prognosis of pancreatitis?

Elevated blood urea nitrogen (BUN) (>20 mg/dL), creatinine (>1.8 mg/dL), and/or hematocrit (>44%), which reflect intravascular volume depletion (

A 42-year-old man is brought to the emergency department 35 minutes after being struck by a car while crossing the intersection. The paramedics found him hypotensive and intubated him in the field for respiratory distress. After resuscitation with 2 liters of normal saline, his blood pressure is 110/80 mm Hg and pulse is 90/min. There is diffuse bruising across the chest, and the right lower leg is visibly deformed. CT scan of the head, cervical spine, and abdomen are normal. CT scan of the chest reveals bilateral, mildly displaced rib fractures with underlying pulmonary contusions and a right-sided pneumothorax. A chest tube is placed. The patient undergoes open reduction and internal fixation of right tibial and fibular fractures and is extubated following surgery. One day later his chest tube is draining turbid, green fluid. Repeat chest-x ray shows resolution of the pneumothorax but there is a new right-sided pleural effusion. Which of the following is the most likely diagnosis?

Esophageal perforation

Female is on OCP. Abdominal ultrasound of the right upper quadrant shows a solid liver mass and free fluid in the abdomen. Which of the following is the most likely diagnosis?

Hepatic adenoma that ruptured and bled

A 3-year-old girl is evaluated for hoarseness that has been getting worse over the past 2 months. The patient has had no fever, shortness of breath, or change in activity level. She is eating normally, gaining weight well, and does not seem to be in pain. Vital signs are within normal limits. On physical examination, the ears are normal appearing with no middle ear fluid. The nasal mucosa is clear with no rhinorrhea, and the turbinates are normal in size. There are no oral mucosal lesions. The tonsils are small and nonobstructive. There is no cervical lymphadenopathy. Aside from hoarseness, examination of cranial nerves is normal. Flexible laryngoscopy shows several finger-shaped lesions on both vocal cords. Which of the following is the most likely cause of this patient's current condition?

HPV infection, vertical transmission

what type of fluid to give to a burn pt?

LR

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?

MI due to cardiogenic shock

A 76-year-old man with no past medical history has an operation for a strangulated inguinal hernia, with approximately 40 cm of small bowel resected. On the morning of his third postoperative day, he falls while getting out of bed. Immediately after the fall, the patient is responsive but confused with slurred speech. He cannot explain what happened. His blood pressure is 89/50 mm Hg, pulse is 122/min, and respirations are 24/min. Examination shows decreased bibasilar lung sounds and distended neck veins. Electrocardiogram shows new-onset right bundle branch block with nonspecific ST- and T-wave changes. Immediate resuscitation with wide-open intravenous fluids is attempted but unsuccessful. Shortly thereafter, the patient's pupils start to dilate, his pulse drops to 45/min, and he becomes unresponsive. He eventually dies despite resuscitative efforts. Which of the following is the most likely cause of this patient's death?

Massive PE- get hypotension and/or R sided heart strain. Here he has dilated pupil bc he went into cardiogenic shock and sympathetic NS kicks in which dilates the pupils Dx- can do bedside US for massive PE Tx- fibrinolysis except he recently had sx so CI here

describew what these values are in pulmonary edema (ARDS) hypoxemia corrected with 02? lung compliance (low/high)? A-a gradient (high, low, normal)?

No low inc

best abs for skin flora?

PCNS, cephalosporisn (1st/2nd gen), vancomycin and clindamycin

Temperature is 37.8 C (100 F), blood pressure is 116/72 mm Hg, pulse is 112/min, and respirations are 20/min. Oxygen saturation is 94% on 2 L/min oxygen by nasal cannula. On physical examination, the patient appears slightly uncomfortable and speaks in short sentences. Lung auscultation shows decreased breath sounds over the posterior right base. Cardiac examination reveals a regular rhythm without murmurs or gallops. The abdomen is soft with normal bowel sounds, and there is no erythema, drainage, or dehiscence of the surgical incision. There is mild, bilateral lower extremity pitting edema. ECG shows sinus tachycardia, and chest x-ray reveals right basal atelectasis. Which of the following is the best next step in the management of this patient?

PE so get CTA

how often should someone w/ cirrhosis get an abd US? what other screening test is important?

Q6 months due to risk of hepatocellular carcinoma EGD for varices

describe these signs w/ appendicitis: psoas sign obturator

RLQ pain with extension of right thigh RLQ pain with internal rotation of right thigh

A 53-year-old homeless man comes to the emergency department due to several days of shortness of breath and productive cough. A month ago, the patient was evaluated for dysphagia and was found to have Candida esophagitis. He received nystatin but refused any further workup and left against medical advice. The patient uses cocaine and intravenous heroin. Temperature is 38.8 C (101.8 F), blood pressure is 121/72 mm Hg, pulse is 124/min and regular, and respirations are 22/min. Oxygen saturation is 89% on 2 L/min of oxygen by nasal cannula. He is awake, alert, and in mild respiratory distress. There are extensive white plaques over the oral mucosa. A 2/6 midsystolic murmur is heard at the left upper sternal border. Lung auscultation is remarkable for faint, bilateral crackles. There is no jugular venous distension or lower extremity edema. Which of the following is the most likely underlying mechanism responsible for this patient's hypoxemia?

V/Q mismatch (due to R->L shunting due to pneumonia)

A 45-year-old man comes to the office with a 6-month history of recurrent, burning epigastric pain and diarrhea. His stools are frothy and unusually foul smelling and they float. The patient's clothes fit loosely, and he believes that he may have lost some weight. He has tried several over-the-counter medications, including antacids, H-2 blockers, and proton pump inhibitors, with moderate success. Vital signs are normal. Examination shows no abnormalities except for midepigastric tenderness to deep palpation. Test of the stool for occult blood is positive, and stool fat is also positive. Gastrointestinal endoscopy reveals two duodenal ulcers and a jejunal ulcer. Which of the following is the best explanation for this patient's impaired fat absorption?

ZE sydrome so high acid is inactivating the pancreatic enzymes causing steatorrhea

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. Dx?

abdominal compartment syndrome get dec preload due to venous compression inc CVP

describe VIPoma vs somatostatinoma

achlorhydria, hypokalemia, watery diarrhea achlorhydria, cholelithiasis and steatorrhea, hyperglycemia too

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?

adrenal crisis so give IV hydrocortison primary adrenal insufficiency causes collapse of CV system

A 43-year-old man is found wandering in the street in winter and is brought to the emergency department by a passing motorist. The patient is confused and unable to provide any history. He has no previous hospital records. On examination, there is mild hypothermia (temperature 35 C [95 F]), but vital signs are otherwise normal. The patient appears disheveled and lethargic but follows commands. The oral mucosa is moist, and there are extensive dental caries. The patient has no cervical lymphadenopathy, but there is bilateral, nontender swelling of the cheeks consistent with salivary gland enlargement. Which of the following is the most likely cause of this latter finding?

alcoholism-> sialodenosis due to alcohol, DM or liver dx

what is bp, HR, glucose and temp in someone w/ burn injury?

all elevated due to hypermetabolic state

antibiotic used for anaerobic lung abscess?

ampicillin-sulbactam

what heart condition goes along w/ ankylosing spondylitis?

aortic regurg

A 40-year-old man is brought to the emergency department after a motor vehicle collision. Blood pressure is 130/84 mm Hg and pulse is 102/min. Heart and lung sounds are normal. Abdominal palpation shows fullness and tenderness in the suprapubic region. There is no blood at the urethral meatus, and digital rectal examination reveals a normal prostate. Chest x-ray is normal. Focused Assessment with Sonography for Trauma reveals no intraperitoneal free fluid. Pelvic x-ray reveals fracture of the left pubic ramus. A Foley catheter is placed without resistance, with immediate return of bloody urine. Emergency CT scan of the abdomen and pelvis is performed. Which of the following injuries is most likely to be seen on CT scan in this patient?

anterior bladder wall rupture not dome of bladder bc thats intraperitoneal

tx of idiopathic pulmonary fibrosis?

antifibrotic drugs

describe where these ulcers are: arterial diabetic pressure

at the toes plantar surface under the metatarsals anywhere pressure is like the 1st or 5th MT

A 54-year-old man with a 30-pack-year smoking history undergoes laparoscopic cholecystectomy after an episode of biliary pancreatitis. On the third postoperative day, he is found to be mildly hypoxemic at 90% on room air. His temperature is 36.7° C (98° F), blood pressure is 130/80 mm Hg, heart rate is 90/min, and respirations are 22/min. Lung auscultation shows decreased breath sounds at the bases. Arterial blood gas analysis results are as follows: pH7.44 pO-264 mm Hg pCO234 mm Hg Dx?

atelectasis

describe the causes and symptoms of copper deficiency

bariatric sx or zinc abundance (since it competes w/ copper for absorption) get microcytic anemia and B12 like symptoms (spinocerebellar tract, PC and lateral corticospinal tract)

why is the left spermatic v more common in a varicocele? what risk factors does this person have with a varicocele?

bc it comes off the left renal v and gets compressed b/w the SMA and aorta inc risk of infertility and testicular atrophy

how does crohns dx cause nephrolithiasis? what about too much calcium?

bc it prevents fat absorption and calcium usually binds oxalate in the gut preventing its reabsorption but when the fat isnt absorped, calcium isnt release from fat and it cant bind oxalate so when oxalate is reabsorbed in gut due to low calcium now its taken up in blood stream and secreted as hyperoxaliuria hypercalciuria can cause stones too

describe why lobar pneumonia corrects with 02 when pulmonary edema does not?

because its a smaller poortion of the lung thats involved so 02 actually helps

do these cause osteolytic or osteoblasting lesions? hepatocellular carcinoma and paget's dx multiple myeloma and blastomycosis prostate cancer

both lytic blastic

A 34-year-old man is brought to the emergency department following a high-speed motor vehicle collision. He was found lying outside the car and was intubated by the paramedics. Upon arrival, the patient has absent breath sounds in the right chest, normal breath sounds in the left chest, and hypotension. A right-sided chest tube is placed, resulting in a loud rush of air. Physical examination reveals multiple bruises over the anterior chest wall, with crepitus on palpation. The patient is initially stabilized. Over the next hour, the patient's oxygen saturation progressively declines. Repeat chest x-ray reveals appropriate endotracheal and chest tube placement, reaccumulation of air in the right pleural space, pneumomediastinum, and increased subcutaneous emphysema. Which of the following is the most likely diagnosis? workup and tx?

bronchial rupture causing quick reaccumulation of air dx- bronchoscopy tx- sx

A 35-year-old man is evaluated in the hospital burn unit due to abdominal distension and intolerance of enteral feedings. The patient was admitted 6 days ago after an electrical flash injury that caused burns to 40% of his total body surface area. He has undergone 2 of 3 planned surgeries for burn excision and grafting and remains intubated and on mechanical ventilation. He was doing well with enteral feedings until the past 24 hours, when he developed high gastric residual volumes and progressive abdominal distension. Temperature is 39.1 C (102.4 F). Blood pressure is 112/60 mm Hg and pulse is 110/min. Oxygen saturation is 97% on minimal ventilator settings, including a fraction of inspired oxygen (FiO2) of 35%. On examination, all surgical dressings are clean and dry. Heart and lung sounds are normal. The abdomen is distended, soft, and tympanitic to percussion. Bowel sounds are decreased. Which of the following is the best next step in management of this patient?

burn wound sepsis which differs from SIRS criteria, pt aslo likely has ileus give abs and get blood cultures

Dx a thoracic dissection/aneurysm in someone stable vs unstable? Back

cTA vs TEE

causes of atraumatic splenic rupture?

cancer, SLE, EBV etc

most sources of candida are from...

central venous lines in the hospitla

pt with this posterior knee dislocation gets a reduction, next step?

check pulses or ABI

53 yr old make RUQ pain and 20 lb weight loss, abd US shows dilated liver ducts but GB is normal size. ALP elevated, dx?

cholangiocarcinoma

A 56-year-old man comes to the office due to 3 weeks of right upper quadrant abdominal pain and 6.6 kg (14.5 lb) of weight loss. Over the last week, he has noticed jaundice and dark urine. The patient has a history of ulcerative colitis in remission and hypertension. He does not use tobacco, alcohol, or illicit drugs. Temperature is 37 C (98.6 F), blood pressure is 110/74 mm Hg, and pulse is 80/min. BMI is 21 kg/m2. The patient appears cachectic. Hepatomegaly is present, but there is no ascites. Laboratory results are as follows: Aspartate aminotransferase170 U/L Alanine aminotransferase202 U/L Alkaline phosphatase470 U/L Total bilirubin4.1 mg/dL CT scan of the abdomen reveals dilated intrahepatic ducts and a normal-sized common bile duct. Carcinoembryonic antigen and CA 19-9 levels are elevated, and serum alpha-fetoprotein level is normal. What is the most likely diagnosis?

cholangiocarcinoma from acute sclerosing cholangitis

A 30-year-old man comes to the office due to 3 days of dysuria and urinary frequency. He had similar symptoms twice over the past 4 months; both times, he was told he had a urinary tract infection and had complete resolution of symptoms following short courses of antibiotic therapy. He is sexually active and has pain with ejaculation but no urethral discharge or fever. The patient smokes a pack of cigarettes daily and does not use alcohol or illicit drugs. He has no other chronic medical issues. Temperature is 37.2 C (99 F), blood pressure is 120/80 mm Hg, and pulse is 78/min. Abdomen is soft and nontender. There is no costovertebral angle tenderness. External genitalia are normal without any focal tenderness, rashes, or ulcerations. Rectal examination reveals a smooth, nontender prostate. Urinalysis is as follows: pH5.4 Proteinnone Bloodnegative Glucosenegative Leukocyte esterasepositive Nitritespositive Bacteriamany White blood cells20-30/hpf Red blood cells1-2/hpf Which of the following is the most likely cause of this patient's current symptoms

chronic prostatitis - get sterile pyruia w/ nontender prostate and back pain acute prostatitis on the other hand due to N gonorrhea or chlamydia in young or E coli and pseudomonas in old, get tender prostate w/ oainful ejaculation

whats the difference b/w an early scar and late scar (after years)

collagen type III-> type I

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?

colon cancer

A 52-year-old woman undergoes laparoscopic cholecystectomy due to recurrent episodes of biliary colic. After a period of observation in the postanesthesia care unit, the patient is discharged home. Three days later, the patient returns due to persistent abdominal pain and nausea. She takes acetaminophen and hydrocodone every 6 hours. Temperature is 38 C (100.4 F), blood pressure is 120/68 mm Hg, and pulse is 104/min. Physical examination shows intact port incisions with no erythema or discharge. There is mild generalized tenderness of the abdomen with some guarding. Bowel sounds are diminished. The remainder of the examination is normal. Laboratory testing shows leukocytes at 16,000/mm3; serum electrolytes and bilirubin are normal. Abdominal x-ray reveals generalized distension of the small and large bowel, stool in the distal colon, and intraperitoneal free air. Dx?

colon injury, get CT w/ oral contrast

differentiating DVT from compartment syndrome

compartment has paresthesia and DVT does not

A 34-year-old woman comes to the office due to difficulty hearing, especially in the left ear. The hearing loss has worsened over the past year, and she is now having trouble hearing people at work; however, when the environment is noisy, she can understand speech better than when she is in a quiet room. The patient also hears ringing in the left ear. She has no dizziness, vertigo, or ear pain. She has had no significant noise exposure. The patient has no other medical conditions and takes no medications. Her mother had surgery for hearing loss when she was in her 40s. On examination, the tympanic membranes are clear with a good light reflex, good landmarks, and no middle ear effusion. There is a slight reddish hue behind the left tympanic membrane. Which of the following is the most likely mechanism of this patient's condition?

conductive HL due to bony overgrowth

with an AV fistula what happens to these? Afterload Preload CO

dec afterload because you introduced a low resistance system inc the preload bc high pressure means more return to heart if you inc return to heart you inc CO

what is Sp02 and Pa02 in methemoglobinemia?

dec, inc bc Pa02 is based on alveolar oxygen concentration not Hb bound concentration

what does selenium do?

deficiency can lead to cardiomyoapthy and thyroid issues

causes of priapsim tx?

drugs (cocaine, trazodone), sickle cell or blood dyscrasia (CML, MM) aspiration of blood then phenylephrine

A 40-year-old man comes to the office for evaluation of hoarseness. The patient first noticed the symptoms 4 months ago. Since then, his voice has gotten progressively more "raspy." He has no fever, throat pain, shortness of breath, or trouble swallowing. Medical history includes asthma and gastroesophageal reflux disease. Medications include inhaled budesonide, albuterol, and omeprazole. The patient smokes 3 or 4 cigarettes per day. Vital signs are within normal limits. Flexible laryngoscopy shows irregular, exophytic growths in clusters on the surfaces of the vocal cords. Pathology shows no malignant features. Dx?

due to HPV

describe uric acid kidney stones

due to gout get urine pH <5.5 tx w/ alkalinization of urine w/ K citrate

how do you dx infection in someone w/ recent burns?

due to hypermetabolic state cant use typical SIRS criteria so look for tachycardia, fever, leukocytosis and new onset enteral feeding intolerance (from splanchnic hypoperfusion)

describe ecthyma gangrenosum vs pyoderma gangrenosum

due to pseudomonas infection while IC; get macules and pustules and febrile neutrophillic process when you have IBD or RA; afebrile ; Tx steroids

describe carotid a dissections

due to trauma/objects in mouth with fall or neck manipulation get hemiplaegia, aphasia, and thunderclap headache with ptosis and miosis dx- CT or MRA Tx- anticoagulant, statin and antihypertensive

A 59-year-old man comes to the office for postoperative follow-up. He underwent a partial (distal) gastrectomy for a perforated peptic ulcer 3 weeks ago. The patient also received an extended course of antibiotics, with the last dose taken 2 weeks ago. For the past 10 days, he has had intermittent abdominal cramps and diarrhea. Symptoms begin 20-30 minutes after the patient eats and are associated with nausea, weakness, palpitations, light-headedness, and diaphoresis. He has no symptoms overnight, and there is no associated fever or weight loss. Tempis 36.7 C (98 F), blood pressure is 130/65 mm Hg, pulse is 80/min, and respirations are 18/min. On examination, the abdomen is soft and nontender with normal bowel sounds. The surgical wound is healing well and has no erythema or discharge. Cardiopulmonary examination is normal. Complete blood count is normal. Dx?:

dumping syndrome- nausea, cramping etc due to hypertonic gastric contents dumping into duodenum then get fluid shift into duodenum causing hypotension noctural symptoms are NOT common tx- smaller meals

dx and tx of hepatic adenoma

dx- US then biopsy tx- sx excision

side effects of nissen fundoplicaton

dysphagia, gas bloat syndrome (bloating and cant belch and dx clinically) also, gastric paresis due to CN X damage- get bloating, early satiety, vomitting; dx- rule out bowel obstruction w/ EGD and XRAY then do synctigraphy can also get anastomotic leak which is more likely to be close to the time of surgery; order CT w/ oral contrast and fix immediately, even if testing is nondiagnostic but clinical suspicion is high

what dec risk of infection w/ burn pt?

early grafting

differentiate eccrine vs apocrine sweat glands-

eccrine functional at birth and not assoc w/ hair follicle appocrine functional at puberty and assoc w/ hair follicle

Front A 16-year-old boy is brought to the emergency department by his mother due to a possible hand injury. She noticed that the patient's right hand was swollen and that he was not using it despite being right-handed. He has a history of oppositional defiant disorder and refuses to say how his hand was injured. Temperature is 38 C (100.4 F), blood pressure is 110/72 mm Hg, and pulse is 80/min. The dorsum of the right hand is swollen. There is erythema centered over the long finger metacarpophalangeal (MCP) joint, where there is a small, linear scab; the area is fluctuant on palpation, and passive movement of the joint elicits severe pain. Right hand x-ray reveals soft tissue swelling, no retained foreign body, and no underlying fractures or dislocations. Which of the following is the best next step in management of this patient?

eikinella infection due to human bite surgical irrigation and abs

when do you start feeding someone w/ a burn injury?

enteral feeding very soon after (<12 hrs) to offset the hypermetabolic state

In preparation for cardioversion, a pt undergoes transesophageal echocardiography, which rules out a mural thrombus. That evening, the patient develops severe chest and interscapular back pain. Temperature is 38.9 C (102 F), blood pressure is 100/70 mm Hg, and pulse is 108/min. The patient is in distress and restless. Heart and lung sounds are normal. ECG shows sinus tachycardia without ST segment changes. Chest x-ray reveals a widened mediastinum. Stool testing for occult blood is negative. Which of the following is the best next step to diagnose this patient's condition

esophageal perforation so get CXRAY then water soluble esophagography

alcohol related osteonecrosis likely due to...

fat embolism

A 35-year-old woman is being evaluated for a breast mass first noticed during a routine physical examination last week. The patient had bilateral reduction mammoplasty for mammary hyperplasia 2 years ago. She takes no medications and has no allergies; her paternal grandmother died at age 65 of breast cancer. Breast examination shows a fixed mass palpated in the upper outer quadrant of the right breast. Mammography shows a 3 x 3-cm spiculated mass with coarse calcifications in the upper outer quadrant of the right breast. Ultrasonography of the breast shows a hyperechoic mass. Core biopsy shows foamy macrophages and fat globules, and the mass is excised with concordant pathologic findings. Which of the following is the most appropriate course of action in management of this patient?

fat necrosis, watch closely

describe ascariasis

fecal oral route round worm that can cause obstruction of IC valve and pulmonary sypmtoms w/ eosinophilia Tx- bendazole

tx of osteoarthritis

first line - acetaminophen second line- NSAIDs and strength exercises

what's the triad of wilm's tumor?

flank mass, HTN and hematuria

what movement worsens a herniated disk? spondylolysis or spinal stenosis?

flexion extension (walking downhill )

Patient on OCPs. Subsequent abdominal CT scan reveals a well-circumscribed, 5-cm mass with a central scar that appears hypodense on noncontrast imaging. Imaging with contrast indicates the lesion is hyperdense

focal nodular hyperplasia (looks like orange) hepatic adenoma- centripetal enhancement with no scar (looks very dark)

describe what happens w/ zinc deficiency

food taste different, anosmia, papulopustular rash, delayed wound healing, alopecia

A 66-year-old man comes to the emergency department due to worsening abdominal pain. Over the past week, he has had vague lower abdominal discomfort, nausea, anorexia, and constipation. This morning, the patient had sudden, severe lower abdominal pain accompanied by lightheadedness and an episode of vomiting. The pain initially improved but then gradually intensified to involve the entire abdomen. Temperature is 38.3 C (100.9 F), blood pressure is 110/54 mm Hg, pulse is 108/min, and respirations are 20/min. On physical examination, the patient is alert and cooperative but appears uncomfortable. Heart and lung sounds are normal. Bowel sounds are diminished. The abdomen is diffusely tender with guarding and rebound tenderness. Dx?

free air due to diverticulitis perforation

A 65-year-old man comes to the office due to 4 months of abdominal pain, nausea, and occasional emesis. The pain is deep, mid-epigastric, persistent, and non-radiating. There is no consistent relationship between the pain and food intake. He has no difficulty swallowing, hematemesis, black stools, blood in the stool, or diarrhea. The patient thinks he may have lost weight recently. He emigrated to the United States from China 20 years ago but frequently travels to China to visit family. He has no significant medical or surgical history. The patient does not use tobacco, alcohol, or illicit drugs. Temperature is 36.9 C (98.4 F), blood pressure is 110/78 mm Hg, pulse is 78/min, and respirations are 16/min. BMI is 20 kg/m2. Heart and lung sounds are normal. The upper abdomen is mildly tender to palpation but nondistended. Hepatomegaly is present. Bowel sounds are normoactive. Laboratory results are as follows: Hemoglobin7.8 g/dL Mean corpuscular volume72 µm3 Platelets380,000/mm3 Leukocytes8,100/mm3 Neutrophils60% Eosinophils1% Lymphocytes29% Total bilirubin0.6 g/dL Albumin2.8 g/dL Alkaline phosphatase182 U/L Aspartate aminotransferase (SGOT)74 U/L Alanine aminotransferase (SGPT)64 U/L Lipase55 U/L (normal: 5-70 U/L) Laboratory testing last year was normal. Which of the following is most likely causing this patient's symptoms?

gastric cancer perform EGD

A 72-year-old man comes to the emergency department due to a weeklong history of malaise, fever, dry cough, shortness of breath, and pain in the right upper abdomen. Two months ago, the patient was diagnosed with unresectable adenocarcinoma of the head of the pancreas. He refused chemotherapy, and a palliative biliary stent was placed. Temperature is 38.4 C (101.1 F), blood pressure is 110/64 mm Hg, pulse is 108/min, and respirations are 20/min. Physical examination reveals decreased breath sounds at the right lung base and guarding and tenderness in the right upper quadrant. Laboratory results are as follows: Hemoglobin10.4 g/dL Platelets400,000/mm3 Leukocytes15,000/mm3 Sodium134 mEq/L Potassium3.8 mEq/L Creatinine0.8 mg/dL Total bilirubin1.2 mg/dL Direct bilirubin0.4 mg/dL Alkaline phosphatase270 U/L Aspartate aminotransferase (SGOT)48 U/L Alanine aminotransferase (SGPT)52 U/L Chest x-ray reveals a pleural effusion on the right side. In addition to intravenous fluids and empiric antibiotics, which of the following is the best next step in management of this patient?

get CT bc its a liver abscess

A 76-year-old man is admitted to the coronary care unit after an episode of substernal chest pain. His other medical problems include hypertension, hyperlipidemia, and type 2 diabetes mellitus. He has a history of a diverticular bleed 2 years ago. After initial workup, cardiac catheterization is performed and shows 70% left main coronary artery stenosis, 90% proximal left anterior descending artery stenosis, and 80% right coronary artery stenosis. Antiplatelet agents are stopped, and the patient is continued on a heparin drip in preparation for coronary artery bypass surgery the next day. Five hours after the catheterization, his blood pressure is 75/60 mm Hg and pulse is 120/min and regular. He complains of some generalized weakness and back pain but denies chest pain, shortness of breath, nausea, and abdominal discomfort. On physical examination, he appears diaphoretic and clammy. Neck veins are flat. Heart sounds are normal, and the chest is clear to auscultation. The right groin arterial puncture site is mildly tender, without any swelling or bruits. He receives 1000 mL of normal saline with symptomatic improvement. His blood pressure is 96/60 mm Hg and pulse is 85/min. His repeat ECG is unchanged from the initial ECG at presentation. Which of the following is the most appropriate next step in managing this patient?

get CT of abdomen and pelvis to look for a retroperitoneal hematoma retroperitoneal hematomas occur <12 hrs post catheterization

A 78-year-old man is brought to the emergency department due to an episode of syncope while working in his garden. He is now alert and oriented. He has chest and neck pain that developed just prior to the syncopal episode. Over the past week, he has had a cough, chest tightness, and whitish sputum production. Medical history is significant for long-standing hypertension, hyperlipidemia, and type 2 diabetes mellitus. The patient is a lifetime nonsmoker. Temperature is 37.3 C (99.2 F), blood pressure is 144/92 mm Hg on the right arm and 142/90 mm Hg on the left arm, and pulse is 109/min. ECG shows sinus tachycardia, voltage criteria for left ventricular hypertrophy, and no ST-segment or T-wave changes. Chest x-ray is shown in the exhibit. A bedside transthoracic echocardiogram shows a small pericardial effusion. Which of the following is the best next step in management of this patient?

get CTA, this is a thoracic dissection

patient w/ roux en y has epigastric pain and nausea, workup? what else can happen in these pts?

get ERCP first because anastomotic stenosis can occur can also tell you if its an ulcer can also get anastomotic leak which is more likely to be close to the time of surgery; order CT w/ oral contrast and fix immediately, even if testing is nondiagnostic but clinical suspicion is high can also get cholelithiasis (put on urosdeoxycholic acid for 6 months post sx)

A 55-year-old man comes to the emergency department due to right lower quadrant pain and is diagnosed with acute appendicitis. The patient is admitted to the hospital after undergoing an emergency appendectomy. He has a history of Graves disease treated with methimazole but has not been taking his medications regularly. One day after the procedure, the patient becomes restless, tremulous, agitated, and short of breath. Temperature is 38.9 C (102 F), blood pressure is 210/110 mm Hg, and pulse is 140/min. Lung examination is notable for fine bibasilar crackles. ECG shows sinus tachycardia. =Describe what happens to CI, SVR and PCWP (up or down=)

get HOHF from thyroid storm so get inc, dec, inc

describe tertiary hyperparathyroidism secondary?

get high PTH, high Ca, high P due to end stage renal disease that causes parathyroid hyperplasia high PTH, low Ca, high P

A 58-year-old man comes to the office due to an ulcer on the sole of the right foot. The patient noticed the wound 4 weeks ago. He has no history of trauma to the area. The ulcer has failed to heal despite wound care with moisture-retentive dressings and pressure offloading with orthotic devices. The patient has had no right foot pain, redness, swelling, fever, or chills. He has a 10-year history of diabetes mellitus complicated by diabetic neuropathy and nephropathy. He also has hypertension and hyperlipidemia. The patient does not use tobacco, alcohol, or illicit drugs. Vital signs are within normal limits. Physical examination shows a 3-cm ulcer under the first metatarsal head of the right foot; the wound has a clean base and no significant discharge. There is no surrounding erythema or areas of fluctuance or tenderness. Which of the following is the best next step in management of this patient's foot ulcer

get imaging to rule out osteomyelitis always consider osteo in a nonhealing DM foot ulcer; get imaging if ulcer is: -deep -lasting >1wk -large >2cm -inc inflammatory markers

symptoms of pancoast tumor

get shoulder pain, horners syndrome, arm pain/weakness

A 63-year-old man comes to the emergency department due to left leg pain. The patient typically has pain in both legs after walking a couple of blocks, but several hours ago, severe left leg pain suddenly developed while he was resting. He reports numbness in the left leg, and he is also experiencing intermittent palpitations. Medical history includes hypertension and hyperlipidemia. The patient has smoked a pack of cigarettes daily for 45 years. Blood pressure is 130/80 mm Hg, and pulse is 116/min and irregular. On examination, hair is sparse on both legs. Distal pulses are absent on the left and diminished on the right. Sensation to light touch is decreased on the dorsum of the left foot and leg, and ankle dorsiflexion is weaker on the left. Which of the following is the best first step in management of this patient?

give heparin then do CT angio

describe gastric outlet obstruction

hear succussion splash on ausculation bowel sounds usually normal

A 45-year-old man comes to the emergency department for colicky, right upper quadrant pain; vomiting; and melena for 24 hours. He has no hematemesis. Medical history is significant for nonalcoholic steatohepatitis, which was diagnosed by percutaneous liver biopsy 5 days ago. The biopsy also showed mild fibrosis around portal tracts without bridging fibrosis or regenerative hepatocyte nodules. Temperature is 37.4 C (99.3 F), blood pressure is 95/60 mm Hg, pulse is 110/min, and respirations are 15/min. Scleral icterus is present. Cardiopulmonary examination is unremarkable. The abdomen is tender to palpation in the right upper quadrant. Laboratory results are as follows: Hemoglobin8.7 g/dL Platelets545,000/mm3 Leukocytes12,000/mm3 Albumin3.8 g/dL Total bilirubin4.1 mg/dL Which of the following is the likely diagnosis?

hemobilia - complication of biopsies/ERCP, etc. due to damage of biliary tree

what indicates testicular necrosis on US after a torsion?

heterogenous echotexture

What have a normal A-a gradient? which diseases/processes do not correct iwth supplemental 02?

high altitude, hypoventilation pulmonary edema, massive PE, right-> left cardiac shunt

what do you want LVEDV and LVESV to be in HOCM? high or low?

high and high bc you want plenty of fluid there but also high LVESV either due to low SV or high afterload to allow for more effective ejection

what do you see in neurogenic shock?

hypoTN, bradycardia, distention of bladder, flaccid muscle tone, dec DTRs

too much fluids over blood products in a trauma pt can result in what triad?

hypothermia, acidosis and coagulopathy (dilute the coagulation factors)

tx of abdominal abscess?

if <3cm then use abs if >3cm then do percutaneous drainage and if that doesnt work then do sx

treatment for mitral regurgitation?

if LVEF is b/w 30-60% then repair the valve

if cervical CT shows cervical fracture, what is next step?

image the thoracic and lumbar spine too

management of cervical radiculopathy?

imaging not usually required NSAIDs and avoid action provoking mechanisms

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?

immediate surgery to repair the hematoma

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?

impaired generation of negative intrathoracic pressure during inhalation

neer's test looks for

impingement of the rotator cuff tendons

what can cause bradycardia during laparoscopy?

inc C02 into the stomach which causes peritoneal stretching and vagal stimulation

what post operative thing helps reduce post op pneumonia the most?

incentive spirometer

treatment of a septal hematoma?

incision and drainage bc can lead to necrosis if not

what do you want to rule out prior to giving steroids for acute transplant rejection?

infection

A 26-year-old man comes to the emergency department due to 6 weeks of intermittent lower abdominal pain and cramps accompanied by rectal urgency, bloody diarrhea, nausea, and decreased appetite. His symptoms have become more severe over the past 2 days. The patient has never traveled outside the country and has not been prescribed antibiotics recently. Temperature is 38.5 C (101.3 F), blood pressure is 90/50 mm Hg, pulse is 130/min, and respirations are 15/min. The patient is ill appearing and lethargic. Bowel sounds are decreased. The abdomen is distended, tympanic to percussion, and diffusely tender to palpation; rebound tenderness and muscle rigidity are absent. Rectal examination shows marked tenderness and mucus mixed with blood in the vault. Laboratory results are as follows: Hemoglobin10.2 g/dL Leukocytes31,600/mm3 Platelets398,000/mm3 Intravenous fluids are started, with improvement of blood pressure to 104/58 mm Hg and pulse to 108/min. Dx and Tx

inflammatory bowel disease causing toxic megacolon (fever, tachycardia and hypotension) Dx- CT scan of abdomen Tx- steroids

An 18-year-old man is brought to the emergency department after falling and striking his chest. He had been playing an interactive video game when he lost his balance and hit his left chest against the coffee table. The patient now has moderate left-sided chest pain, worse with deep inspiration. He also feels lightheaded. On examination, the patient appears uncomfortable and is taking shallow breaths. Blood pressure is 88/50 mm Hg, pulse is 122/min, and respirations are 28/min. Jugular veins are flat. The trachea is midline. The left chest wall has intact, bruised skin and is exquisitely tender to palpation. Breath sounds are present on the right but diminished in the left lung base, which is dull to percussion. Heart sounds are normal without murmurs. The abdomen is soft, nondistended, and nontender. Which of the following is the most likely cause of this patient's condition?

intercostal injury causing hemothorax

A 54-year-old woman comes to the emergency department due to 2 days of abdominal pain. She has also had anorexia, nausea, hiccups, and shortness of breath. The patient was diagnosed with acute appendicitis and underwent a laparoscopic appendectomy 10 days ago. She had been recovering well until the abdominal pain returned. Temperature is 39.3 C (102.8 F), blood pressure is 120/70 mm Hg, pulse is 94/min, and respirations are 24/min. BMI is 30 kg/m2. No scleral icterus or skin rash is present. Breath sounds are decreased at the right base. The abdomen is mildly distended, and palpation of the right upper quadrant elicits pain. The abdominal surgical incisions are mildly tender without surrounding erythema or discharge. Bowel sounds are decreased. Leukocyte count is 24,000/mm3, and chest x-ray reveals a right pleural effusion. Dx?

intrabd abscess

describe: Gilbert syndrome Crigler Najjar Dubin Johnson Rotor syndrome Biliary atresia

lack of UGT causing inc UCB w/ stress lack of UGT causing high UCB and kernicterus which damages the basal ganglia deficiency of bile canalicular system causing CB inc and dark liver same as Dubin Johnson but liver not dark lack of extrahepatic bile ducts, get high CB ; need liver transplant

pancreatitis

lipase levels initially since they rise first then CT since it shows up after 48 hours

A 44-year-old-woman comes to the emergency department due to worsening abdominal pain. Two weeks ago, the patient underwent a laparoscopic hysterectomy and bilateral salpingo-oophorectomy for adenomyosis. She was eating normally until 2 days ago, when she began experiencing increasing nausea and abdominal cramping after meals. Now, the patient has abdominal cramping every few minutes and has vomited her pain medication. Her last bowel movement was 3 days ago, and she has not passed flatus today. Vital signs are within normal limits. The abdomen is distended and tympanic on percussion. There is abdominal tenderness to palpation, but no rebound or guarding. The skin is intact over all the abdominal incisions, but the right-sided incision has an underlying tender, palpable mass. Bowel sounds are hyperactive. Abdominal x-ray reveals multiple air-fluid levels within the small bowel and no air in the rectum. A nasogastric tube is placed. next step?

laparotomy bc this is a complete obstruction

first line tx for open angle glaucoma?

latanoprost (a prostaglandin)

A 52-year-old woman is brought to the emergency department due to severe dizziness, unsteadiness, and nausea. The spinning sensation began suddenly when the patient's head was tilted back and to the left while getting her hair washed at a salon. When she tried to get out of the chair, she tilted to the left and was unable to sit upright without assistance. She reports no similar symptoms in the past but recently had an upper respiratory illness. Medical history includes hypertension and hyperlipidemia. The patient is an active smoker with a 20-pack-year history and drinks alcohol occasionally. Temperature is 37 C (98.6 F), blood pressure is 144/90 mm Hg, and pulse is 92/min and regular. On physical examination, the patient appears uncomfortable and keeps her eyes closed. The pupils are equal and reactive, and nystagmus is present. Impaired pinprick sensation is present on the left side of the face and right upper and lower extremities. Deep tendon reflexes are normal throughout. Which of the following is the most likely cause of this patient's current condition?

lateral medullary/wallenberg syndrome where PICA is affected/vertebral artery causing dysphagia, dec gag reflex, nystagumus, vertigo, IL pain/temp loss to face and CL to body.

A 6-year-old boy is brought to the office for follow-up for a limp. His symptoms began 2 months ago as a dull ache in the left knee with an intermittent limp. The parents brought him to an urgent care center at that time and were reassured that the laboratory evaluation and x-rays of the knees and hips were normal. The pain has not worsened, but the patient now has a persistent limp with no other joint or muscle pain. He has been well except for a brief upper respiratory infection with low-grade fever about 2 weeks ago. He has a history of recurrent ear infections and had tympanostomy tubes placed 2 years ago. The patient takes no daily medications, and immunizations are up to date. Temperature is 37.1 C (98.8 F), blood pressure is 95/65 mm Hg, pulse is 80/min, and respirations are 16/min. BMI is at the 60th percentile. Examination shows a well-appearing and alert child. Range of motion, particularly internal rotation and abduction, of the left hip is markedly limited. The remainder of the examination is normal. Which of the following is the most likely diagnosis in this patient?

legg calve perths dx bc transient synovitis only lasts 1 month tops may see + trendelenburg sign for LCP's dx

A 34-year-old woman comes to the physician with a several-month history of chest pain. The pain is left-sided, does not change with deep inspiration, and typically lasts several hours. She currently has the pain; it is unrelated to physical activity but worsens with emotional stress. The patient has no cough, syncope, or shortness of breath. She has no significant family history and does not use tobacco, alcohol, or illicit drugs. She takes no medications and has no drug allergies. Her blood pressure is 110/70 mm Hg and pulse is 78/min. Heart sounds are normal. Lungs are clear to auscultation. ECG shows normal sinus rhythm with no significant abnormalities. Which of the following is the best next step in the management of this patient?

likely anxiety due to normal EKG and no risk factors if something more was suspected you would do an exercise or pharmacologic EKG

A 65-year-old man comes to the office due to 3 days of progressive right flank pain. He also notes 4 weeks of dysuria and urinary frequency. The patient has a history of coronary artery disease and hypertension. His father died from prostate cancer. Temperature is 37.1 C (98.8 F), blood pressure is 130/86 mm Hg, pulse is 82/min, and respirations are 16/min. The abdomen is soft and nontender. No suprapubic tenderness is present, but there is mild right-sided costovertebral angle tenderness. The external genitalia are normal in appearance, and there is no penile discharge. Rectal examination shows mildly enlarged prostate without nodules or tenderness. Urinalysis results are as follows: Creatinine1.5 mg/dL Blood-moderate Bacteria-none Red blood cells30-40/hpf Casts- none Dysmorphic cells-none Urine gram stain is negative, and urine culture does not grow any organisms. Abdominal ultrasound reveals right-sided hydronephrosis and a normal left-sided kidney and ureter. Which of the following is the most appropriate next step?

likely bladder cancer get cystoscopy

pt had injury to thigh w/ firm nodule that is inc in pain and wont go away, dx ?

likely sarcoma so get core needle biopsy then if it positive get CT of chest and abdomen to look for mets to lungs

describe if you get a bruit or mass on palpation in these situations after cardiac catheterization: hematoma pseudoaneruysm AV fistula

mass with no bruit bulging pulsatile mass and systolic bruit no mass and continuous bruit

A 76-year-old man comes for outpatient follow-up after recent coronary artery bypass grafting surgery. He has abundant, yellowish wound discharge from the lower part of the surgical midsternal wound. The patient has no chest pain, dyspnea, fevers, or abdominal swelling. He underwent uncomplicated coronary artery bypass grafting surgery for severe coronary artery disease 9 days ago, which included internal thoracic artery harvesting. Medical history also includes hypertension and type 2 diabetes mellitus. The patient is afebrile, and vital signs are within normal limits. On examination, the sternum appears stable to palpation. There is swelling and soft tissue separation at the lower part of the wound with copious discharge. Which of the following is the next best step in managing this patient?

mediastinitis get CT scan tx- IV abs and sx

A 72-year-old man undergoes coronary artery bypass graft (CABG) for severe coronary artery disease.On the third postoperative day, he complains of dyspnea and worsening retrosternal pain despite continuous analgesia with morphine. His temperature is 38.6° C (101.5° F), blood pressure is 112/52 mm Hg, pulse is 125/min and irregularly irregular, and respirations are 28/min. His ECG shows atrial fibrillation with rapid ventricular response. An x-ray film of the chest shows widening of the mediastinum. Echocardiography reveals a small amount of pericardial fluid. Laboratory studies show: Hemoglobin8.9 mg/dL WBC count16,300/mm3 Platelet count512,000/mm3 Creatinine1.7 mg/dL CPK430 U/L Which of the following will this patient most likely require?

mediastinitis so surgical debridement and abs

tx of phantom limb pain

multimodal pain management

workup of VAP?

must get sample of lower respiratory tract to confirm

complicatoin of retropharyngeal abscess?

necrotizing mediastinitis in the danger space

for a pneumothorax what is the first two steps?

needle thoracostomy then intubate

A 64-year-old man comes to the office for evaluation of leg pain. The patient underwent a below-the-knee amputation 3 months ago due to a nonhealing plantar ulcer associated with osteomyelitis. He has been trying to be fitted for a walking prosthesis but bearing weight on the stump has caused significant pain. The patient describes the pain as an intermittent burning sensation that has not improved with pain medication. Medical history is notable for type 2 diabetes mellitus, hypertension, and peripheral vascular disease. The patient smokes a pack of cigarettes a day and has 1-2 drinks every night. On physical examination, the amputation incision is well healed, and the distal flap has no areas of blanching. There is slight bogginess over the end of the skin flap. Gentle pressure over the flap reproduces the pain, which radiates up the leg. Which of the following is the most likely cause of this patient's leg pain

neuroma- occurs weeks to months after amputation ; get pain w/ palpation due to nonpainful stimuli dx- gold standard is resolution of pain w/ analgesia injection tx- sx, TCAs

do you get peritonitis w/ a bladder rupture? dx?

no bc urine is sterile retrograde cystography

what type of NMJB agent should be used in crush injuries?

nondepolarizing- rocuronium bc of risk of hyperkalemia w/ succinylcholine

what types of shock have high CVP? low?

obstructive and cardiogenic vs hypovolemic and distributive

describe bile acid diarrhea

occurs in 10% of post-op cholecystectomy where bile acid dumps into duodenum and bile acids irritate the colon bc ileum cant keep up w/ reabsorption tx- cholestyramine will dec bile acids

describe transient synovitis

occurs in kids 3-8 yrs old; get pain following URI

C diff and stable vs unstable

oral fidaxomicin or vancomycin oral vanco and IV metronidazole

when do you give sodium bicarb to someone w/ acidosis?

pH <7.2

A 65-year-old man comes to the office due to 4 weeks of persistent epigastric pain and nausea. The patient lost approximately 4.5 kg (9.9 lb) over this period. He was diagnosed with type 2 diabetes mellitus 6 months ago, which is controlled with a low-carbohydrate diet. He has a 45-pack-year history of smoking. He does not use alcohol or illicit drugs. Bowel sounds are present, and the abdomen is soft with mild epigastric tenderness to deep palpation. No hepatosplenomegaly or shifting dullness is present. The remainder of the examination is normal. Dx?

pancreatic cancer - due to weight loss and type 2 DM recently dx

A previously healthy 19-year-old man comes to the emergency department (ED) due to persistent abdominal discomfort. The patient previously came to the ED 3 days ago after he fell while mountain biking. He did not lose consciousness and recalls hitting the handlebars prior to flipping and landing on his back. His trauma workup—which included CT scan of the chest, abdomen, and pelvis—was negative, and he was discharged. Since then, the patient has had persistent upper abdominal discomfort and nausea, along with an episode of nonbilious emesis. Temperature is 38.1 C (100.6 F), blood pressure is 104/62 mm Hg, and pulse is 108/min. The lungs are clear to auscultation, and heart sounds are normal. Ecchymosis is present across the upper abdomen, which is tender to palpation with voluntary guarding. Bowel sounds are decreased. Bedside ultrasonography reveals a large amount of free fluid in the upper abdomen. Which of the following is the most likely cause of this patient's condition?

pancreatic duct injury bc can be missed on CT

Tx of SBO

partial SOB and stable -NPO -IV fluids -foley cath -NGT -mointer for hypoK and acidosis complete/ worsening or fever inc WBC then laparotomy -tx depends on the underlying issue

A 65-year-old woman is brought to the hospital due to bilateral leg weakness and tingling for 6 hours. She has also had new low back pain for 2 days. Medical conditions include obesity and degenerative disc disease. The patient also underwent a hysterectomy for uterine cancer 15 years ago. Vital signs are within normal limits. Spinal tenderness is present at the T6 level. Lower extremity strength is 3/5 bilaterally, and upper extremity strength is 5/5 bilaterally. Deep tendon reflexes are brisk in the lower extremities. MRI of the back reveals multilevel degenerative disc disease and a fluid collection spanning T6-T8. What is the most appropriate next step in management of this patient?

perform laminectomy w/ decompression

tx of acute pericardial effusion? chronic?

pericardiocentesis pericardial window

A 34-year-old man comes to the office due to intermittent dizziness over the past 3 months. The patient has had episodes of a sudden spinning sensation, accompanied by nausea, that resolve spontaneously after approximately a minute. Symptoms occur when he is lifting heavy weights, riding on an elevator, or after sneezing. He has had no headache or ear pain but has trouble hearing out of the right ear. The patient had a concussion after a bicycle collision 4 months ago but has no other medical conditions and has had no recent upper respiratory illness. Vital signs are within normal limits. Physical examination shows normal ears, including tympanic membranes. There is no extremity weakness or sensory loss. No nystagmus is present at rest but performing a Valsalva maneuver provokes nystagmus and the other reported symptoms. Which of the following is the most likely diagnosis?

periphymphatic fistula-> get similar symptosm to menieres but get changes w/ pressure (elevator, valsalva, etc)

what can cause vitamin K deficiency?

poor diet, malabsorption and hepatocellular disease

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?

popliteal cyst- resembles DVT but get crescent sign (eccymosis distal to medial malleolus)

what are these levels in various testicular cancers: B-hcg and AFP seminoma non-seminoma leydig sertoli

positive, negative positive, positive neg, neg w/ high estrogen neg, neg w/ high testosterone

A 74-year-old man comes to the office due to difficulty swallowing food. The symptoms began 4 months ago when the patient was eating steak and felt like a bite got stuck in the middle of his chest, which resolved after drinking a glass of water. Since then, he has had several similar episodes when eating bread or meat and has modified his diet to soft foods. He has no difficulty drinking liquids and has had no chest or abdominal pain, vomiting, melena, or weight loss. The patient has occasional nighttime heartburn, especially after eating spicy food, and takes antacids as needed. His other medical conditions include hypertension, for which he takes lisinopril. He does not use tobacco, alcohol, or illicit drugs. Family history is unremarkable. Vital signs are within normal limits. Physical examination shows normal dentition and oropharyngeal mucosa. Tonsils are normal. The lungs are clear on auscultation, and heart sounds are normal. The abdomen is soft and nontender with no organomegaly. The remainder of the physical examination shows no abnormalities. Which of the following is the best next step in management of this patient?

possibly esophageal carcinoma->adenocarcinoma from barretts esophagus get EGD w/ biopsies

52-year-old woman comes to the office due to intermittent right upper-quadrant pain and nausea. The patient has a history of obesity and gallstones, for which she underwent elective cholecystectomy a year ago. The pain is located in the right subcostal area and generally lasts 30-60 minutes. The patient recalls that she had similar pain episodes before the surgery. Laboratory results after one of the episodes are as follows: Total bilirubin2.1 mg/dL Direct bilirubin1.2 mg/dL Alkaline phosphatase185 U/L Aspartate aminotransferase (AST, SGOT)84 U/L Alanine aminotransferase (ALT, SGPT)72 U/L An ultrasound of the abdomen reveals mild dilation of the common bile duct. The pancreas is visualized and appears normal. Dx?

post-cholecystectomy syndrome, where you miss a CBD stone or cystic duct stone and get inflammation and dilation of the CBD perform ERCP

A 4-year-old boy is brought to the clinic for evaluation of scrotal swelling. His mother first noticed swelling near his right testicle after giving him a bath 2 days ago. It has not been painful, and the patient has had no difficulty urinating. Neither the mother nor the patient recalls specific trauma to the area. The patient is otherwise healthy and takes no medications. Temperature is 37.1 C (98.8 F). Initial blood pressure is 160/96 mm Hg; a repeat assessment is 158/92 mm Hg. Physical examination shows an alert child who is active and cooperative. The abdomen is nontender, and bowel sounds are present. Genitourinary examination reveals Tanner stage 1 development with bilateral testicles within the scrotum. There is a palpable, nontender, soft, coiled mass superior to the right testicle. When a light is placed at the base of the scrotum, the mass does not transilluminate. In addition, the mass does not decrease in size when the patient is supine. Urinalysis reveals no blood, nitrites, or leukocyte esterase. Which of the following is the best next step in management of this patient?

prepubertal male, R sided varicocele, does not reduce w/ supination-> think IVC compression due to Wilm's tumor and get US of abdomen and pelvis

how do you start the workup for someone w/ acute trauma and you have no idea what happened?

primary survey (ABCD's) then get chest, pelvic XRAY, cervical CT and FAST exam

A 43-year-old woman on the surgical floor is being evaluated for increasing shortness of breath. She was brought to the emergency department 8 hours ago following a high-speed motor vehicle collision. The patient had been drinking alcohol prior to driving. She was restrained and air bags were deployed, but her right knee smashed against the front console. Trauma workup revealed a right femur fracture as well as bruising of the face and chest without underlying fractures. The patient received 3 L of isotonic fluids and was admitted for observation and pain management prior to anticipated fracture fixation. She now has increased work of breathing. Blood pressure is 138/82 mm Hg, pulse is 102/min, and respirations are 24/min. Pulse oximetry shows an oxygen saturation of 90% on 4 L of oxygen. The patient is alert with no focal neurological deficits. Diffuse rales are heard in the anterior lung fields bilaterally. Heart sounds are normal. There are no other changes to the clinical examination. CT scan of the chest reveals peripheral, anterior ground-glass opacities in both lungs. Which of the following is the most likely diagnosis in this patient?

pulmonary contusion

A 64-year-old man comes to the emergency department due to 2 days of fevers, chills, and positional chest pain. Temperature is 39.2 C (102.6 F), blood pressure is 100/60 mm Hg, pulse is 130/min and irregular, andrespirations are 20/min. The patient appears unwell and uncomfortable. Examination shows clear lungs, distant heart sounds, no heart murmurs, and minimal lower extremity edema. Blood leukocytes are 25,000/mm3 with 80% neutrophils. ECG shows atrial fibrillation with rapid ventricular response and low-amplitude QRS complexes. Chest x-ray reveals normal lung fields. Bedside echocardiography reveals normal left and right ventricular function, no significant valvular disease, and a moderate pericardial effusion with no evidence of tamponade. Blood cultures are obtained, and broad-spectrum antibiotics are administered. Dx?

purrulent pericarditis due to neutrophil predominence tx- pericardiocentesis

anaphylaxis transfusion reaction has..

rash and wheezing

58 yr old man w/ gastric adenocarcinoma presents w/ this after tube feeds are started, dx? sodium inc, potassium drop, phosphorus plummets

refeeding sydnrome- due to hypokalemia but mostly hypophosphatemia get muscle weakness and arrythmias

A 59-year-old man comes to the office with a 3-month history of persistent right ear pain. He has tried to control the pain with acetaminophen and ibuprofen but with no improvement. He has no other medical issues. He works as a welder and has smoked a pack of cigarettes daily for 40 years and drinks a case of beer each weekend. Vital signs are within normal limits. Right ear examination shows a normal external ear, normal external auditory canal, and a clear tympanic membrane with no middle ear fluid. Palpation of the temporomandibular joint elicits no tenderness or crepitus. His left ear examination shows no abnormalities. Oral cavity examination shows poor dentition, but there are no ulcers. The tonsils are not enlarged, and posterior pharyngeal wall is nonerythematous. There is a nontender 2-cm lymph node on the right side of his neck. Which of the following is the best next step in management of this patient?

referred otalgia is almost always due to head and neck SCC in smokers dx- flexible laryngopharngoscopy

most cases of chemical pneumonitis (aspiration w/out pneumonia)...

resolve spontaneously

pH7.53 PO290 mm Hg PCO225 mm Hg Bicarbonate20 mEq/L SP02 98% cause?

respiratory alkalosis, could be from poor pain control not from PE bc would have dec Sp02

what do you want to order on pts w/ a penile fracture?

retrograde urethorgraphy bc urethra damaged in approximately 20% of cases

tx of sigmoid volvulus

rigid proctosigmoidoscopy with decompression & untwisting of the volvulus (rotation of the large intestine on its mesenteric axis; twisting can promote ischemic bowel, gangrene, perforation). if peritonitis then lap w/ colectomy

A 44-year-old man comes to the office for follow-up after being evaluated in the emergency department for a shoulder injury. Two weeks ago, the patient fell on an outstretched hand at work; x-ray in the hospital showed a posterior glenohumeral dislocation without fracture. The dislocation was reduced successfully under procedural sedation, and the arm was placed in a sling. The patient was advised to follow up with the outpatient provider in 2 weeks. Since the injury, he has been unable to abduct the arm without severe pain and difficulty. He has no medical history and takes no medications regularly. On examination, the patient has no shoulder numbness but has limited abduction due to pain. Distal pulses and sensation are intact. There is no shoulder asymmetry. Which of the following is the most likely cause of this patient's current symptoms?

rotator cuff injury not axillary n bc would have paresthesia along the deltoid

A 55-year-old man comes to the office for follow-up due to recurrent episodes of jaw pain. The patient's most recent episode was a week ago. He had pain that worsened with eating, accompanied by a tender mass under the left jaw and fever. All symptoms resolved within a few days with oral antibiotic treatment. This was the third episode in the past year. Which of the following is the most likely underlying reason for this patient's recurrent episodes of jaw pain?

sialolithiasis

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?

sigmoid cancer bc left sided cancers show up as bright red blood and right sided are more melena

A 7-year-old girl is brought to the emergency department due to a right arm injury. While jumping on a trampoline, she slipped and fell onto her outstretched right hand. The patient had immediate pain and would not move her arm. She did not hit her head or lose consciousness. On examination, the patient is crying in pain, with significant ecchymosis and swelling just above the elbow. She is holding the right arm in flexion and winces when it is moved. X-ray reveals a supracondylar fracture with posterior displacement of the distal humerus fragment, as shown in the image below. what could be injured?

since the distal humerus went posteriorly the proximal humerus went anterior and could damage the brachial artery

describe what you see in hypovolemic shock

small LV cavity volume with EF of 75%

A 38-year-old woman comes to the office due to abdominal bloating, excessive flatulence, and diarrhea over the past 3 months. She has 4 or 5 nonbloody, loose stools a day, including at night. The patient has a history of obesity and lost 30 kg (66 lb) after undergoing Roux-en-Y gastric bypass surgery 3 years ago. She takes multiple vitamin supplements daily but has not taken antibiotics recently. The patient has not traveled recently or been exposed to anyone with diarrheal illness. Temperature is 37 C (98.6 F), blood pressure is 130/84 mm Hg, and pulse is 78/min. BMI is 28 kg/m2. Abdominal examination shows no abnormalities. Which of the following is the most likely cause of this patient's symptoms?

small intestinal bacterial overgrowth- get with previoux roux en y procedure that allows for bacteria to grow in the portion of small bowel that is now hooked up to stomach; due to dec acid production get inc bacteria here. Get malabsorption with bloating and diarrhea. Also may see B12 deficiency and inc folate due to bacterial production CAN get nighttime symptoms unlike dumping syndrome Dx- endoscopy or breath test tx- rifamixin

define phlegmon

soft tissue inflammation thats not walled off like an abscess is

describe dysphagia with solids vs solids and liquids tx of eosinophilllic esophagitis?

solids only = mechanical obstruction solids and liquids = motility issue (spasms or achalasia) topical GCs

A 59-year-old man comes to the emergency department due to a sore throat. He says that he was assaulted during an altercation in a bar 7 days ago. The following day, the patient noticed some neck pain and stiffness, followed by a sore throat. Today, he has severe throat pain, which has spread to his left shoulder and radiates down his left arm. The patient drinks 6-12 beers daily and has a 50-pack-year smoking history. Medical history includes type 2 diabetes mellitus and hypertension. Temperature is 38.6 C (101.5 F), blood pressure is 108/70 mm Hg, pulse is 106/min, and respirations are 16/min. On examination, the patient is awake and alert. Abrasions are present on the head, neck, and face. Mild swelling and ecchymosis are noted on the forehead and around the right eye. The posterior pharynx is normal; there is no trismus or drooling. Right upper extremity strength is 5/5, and left upper extremity strength is 4/5. Cervical spine tenderness is present at the C5 and C6 level. Laboratory results are as follows: Hemoglobin11 g/dL Platelets260,000/mm3 Leukocytes16,300/mm3 What is the best next step in management of this patient?

spinal epidural abscess get MRI w/ contrast

most common areas of ischemic colitis?

splenic flexure and rectosigmoid junction

An 18-year-old football player is brought to the emergency department due to persistent pain following a hard tackle. The patient had just caught a pass when he was tackled from the front, with the opponent landing all his weight on the patient's abdomen. Immediately afterward, he began to experience abdominal discomfort and nausea. Blood pressure is 92/64 mm Hg, pulse is 118/min, and respirations are 24/min. The patient is alert but appears anxious. Bilateral breath sounds are clear and equal. Heart sounds are normal without murmur. The abdomen is mildly distended and tender to palpation diffusely. Chest x-ray and pelvic x-ray are normal. Focused Assessment with Sonography for Trauma reveals intraperitoneal free fluid. Dx?

splenic rupture

most common cause of osteomyelitis in children, teenagers, sickle cell?

staph aureus, N gonorrhea, salmonella

bugs that cause osteomyelitis w/ puncture wounds?

staph aurues and pseudomonas

A 55-year-old man is brought to the emergency department due to sudden onset of palpitations and chest tightness. His other medical problems include hypertension, gout, and type 2 diabetes mellitus. Cardiac monitoring shows atrial fibrillation at a rate of 120-140/min. His initial blood pressure is 112/70 mm Hg and oxygen saturation is 92% on room air. As the nurse is attempting to establish intravenous access, the patient becomes unresponsive. There is no palpable pulse over the carotids or femoral arteries, and he has agonal breathing. The cardiac monitor still shows atrial fibrillation at the same rate. Which of the following is the best next step in management of this patient?

start chest compressions -> only rhythms that you can use defib are pulseless V fib and V tachy

Pt undergoes cardiac sx. On palpation the sternum appears to be rocking and clicking with patient coughing. Dx?

sternal dehiscence, take to OR and fix

A 21-year-old military recruit comes to the medical clinic due to right forefoot pain. She is in her second month of basic training and has had worsening pain for the past 3 weeks. The patient has no history of acute trauma. The pain initially occurred only with activity but is now present at rest. Medical history is unremarkable, and she takes no medications. Vital signs are normal. Examination shows swelling in the foot and point tenderness over the second metatarsal. Plain x-rays of the foot show a faint lucency over the shaft of the second metatarsal. In addition to appropriate analgesia, which of the following is the most appropriate next step in management?

stress fracture stay off of it and analgesia

Tx of minor pneumothoax? major?

supplemental 02 thoracostomy tube or needle decompression if no tube available

A 22-year-old man comes to the emergency department due to sudden-onset dyspnea 2 hours ago while watching television. The patient's dyspnea is gradually improving but he still has sharp right-sided chest pain that is worse with deep inspiration or cough. His medical history is unremarkable. The patient smokes 4-5 cigarettes daily and occasionally drinks alcohol. Temperature is 36.7 C (98 F), blood pressure is 140/80 mm Hg, pulse is 86/min, and respirations are 18/min. Pulse oximetry shows 98% on room air. He weighs 68 kg (150 lb), is 188 cm (6 ft 2 in) tall, and has a BMI of 19.3 kg/m2. Physical examination is unremarkable. Chest x-ray reveals a small right apical pneumothorax. Which of the following is the most appropriate management of this patient?

supplemental 02 wich enhances the resorption speed if emergent then place chest tueb

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?

suppurative parotitis ; adequate oral intake and oral hygiene would have prevented this

A 42-year-old man comes to the office due to increasing anal pain. Three days ago, he noticed mild anal discomfort when wiping after a bowel movement; since then, the pain has steadily increased and is now constant and severe. The patient has had no anal drainage, hematochezia, or melena. Medical history includes hypertension and type 2 diabetes mellitus. There is no family history of colon cancer. Temperature is 38.3 C (100.9 F), blood pressure is 122/74 mm Hg, and pulse is 90/min. Examination shows an erythematous, tender, 2-cm mass external to the anal verge on the right. Digital rectal examination is normal, and stool guaiac testing is negative. Incision and drainage are performed under local anesthesia, yielding approximately 5 mL of purulent fluid. Which of the following is the best next step in management of this patient?

systemic abs, not c-scope bc no symptoms of IBD

pulmonary embolism symptoms

tachypnea, dyspnea, and/or hypoxemia.

34-year-old man comes to the emergency department due to acute-onset central chest and epigastric pain radiating to the mid-lower back. His last use of cocaine was a day ago. On examination, the patient is in severe distress due to pain. Skin is cool and clammy. Blood pressure is 210/120 mm Hg and equal in both arms. Pulse is 110/min and regular, and respirations are 22/min. Pulse oximetry shows 95% on room air. BMI is 34 kg/m2. There is no pulse asymmetry. Jugular venous pressure is normal. Breath sounds are decreased at the left lower base, and percussion is dull in the same area. Heart sounds are normal with no murmurs or extra sounds. ECG reveals sinus tachycardia with nonspecific T-wave changes. Serum troponin is normal. D-dimer is elevated. Serum lipase is normal. Chest x-ray shows a moderate-sized left pleural effusion. Which of the following is the most likely cause of the patient's current condition?

tear in aorta causing pleural effusion

what do you monitor for in all thyroid cancer except medullary? medullary

thyroglobulin bc that will be inc w/ cancer reoccurance if they had a thyroiectomy -> can check for reoccurrence by withdrawing their synthroid and if they have inc in TG then cancer back for medullary check the calcitonin

causes of post op fever <24 hrs vs >24 hrs

tissue trauma vs infections

describe pseudohypercalcemia

total serum calcium inc due to high albumin with normal ionized calcium level

A 21-year-old woman comes to the office for evaluation of progressively increasing dyspnea and nonproductive cough for the past 2 weeks. Four months ago, the patient underwent bilateral lung transplantation for bronchiectasis due to underlying cystic fibrosis. Other medical conditions include pancreatic insufficiency and osteoporosis. Current medications are pancreatic enzymes, multivitamins, tacrolimus, mycophenolate mofetil, and prednisone. Temperature is 38 C (100.4 F), blood pressure is 110/78 mm Hg, pulse is 96/min, and respirations are 18/min. Pulse oximetry shows 98% with the patient using 2 liters/min of supplemental oxygen. Examination shows bilateral lung crackles. Chest x-ray reveals perihilar opacities, interstitial edema, and small bilateral pleural effusions. What is the most appropriate next step in management?

transplant rejection that can look like an infection, get BAL

A 25-year-old man comes to the office due to decreased force of the urinary stream and incomplete emptying of the bladder. He has no urgency, frequency, nocturia, dysuria, or fever. Bowel movements are regular. The patient has no chronic medical conditions and takes no medications. Vital signs are within normal limits. The abdomen is soft and nontender. External genitalia are normal; no penile discharge is noted. No inguinal lymphadenopathy is present. Neurologic examination shows no abnormalities. Urinalysis is normal. Postvoid residual volume is high. What is the most likely cause of this patient's current condition?

urethral stricture

when do you tx thyroid cancer w/ radioactive iodine?

when LNs are involved or very large tumor

describe sphincter of oddi dysfunction, causes, dx, tx?

when the sphincter stenoses due to opioids, etc. dx- sphincter manometry Tx- sphincterotomy

when do you use wet-to-dry dressings w/ ulcers? what about moisture retained dresssings?

when the wound is infected or devitalized bc when that dressing dries and you pull it off you are debriding the tissue this helps promote wound healing and repitheliaziation

when dont you give someone thrombolytics with an endocarditis?

with endocarditis bc inc risk of hemorrhage (bc bacteria erode the walls of heart)

A 65-year-old woman comes to the office due to 4 weeks of progressive abdominal pain that is constant and worse with eating. It has caused her to eat less often, and she has noticed some weight loss. The patient has had several years of heartburn, which is relieved by over-the-counter medications. She has taken omeprazole for the last 4 weeks, but it has not improved the pain. The patient has a 10-pack-year smoking history but quit several years ago. She does not use alcohol. Vital signs are within normal limits. BMI is 34 kg/m2. Abdominal examination shows epigastric tenderness. Stool occult blood testing is negative. Complete blood count, liver studies, and serum chemistry are normal. Upper gastrointestinal endoscopy is performed and reveals mild esophagitis but no gastritis. Abdominal ultrasound shows 2 large gallstones with no gallbladder wall thickening or pericholecystic fluid, and there is no ductal dilatation. The pancreas is poorly visualized due to overlying gas. Which of the following is the most appropriate next step in management of this patient?

you havent visualized the pancreas so need to do CT to rule out pancreatic tumor HIDA scan performed when cholecystitis suggestive but US is normal

A 42-year-old man with a history of Crohn disease comes to the office for follow-up. He had a partial ileal resection due to a stricture and also had multiple surgeries to treat an enterocutaneous fistula. The patient has received parenteral nutrition for the past several weeks and recently restarted oral feeding. He reports nonbloody diarrhea but no fever or abdominal pain. The patient says that food does not taste the same as before. On examination, he has patchy alopecia and a pustular, crusting skin rash with scaling and erythema around the mouth and on the extremities. No abdominal tenderness is present and bowel sounds are normal. The jugular venous pulse is normal and there is no lower extremity edema. Which of the following is most likely to improve this patient's current condition?

zinc deficiency