UWorld Questions & kaplan - surgery review
Linitis plastica
infiltrating cancer that produces a desmoplastic reaction causing the stomach to look fixed and rigid txt with total gastrectomy and + splenctomy
Third space - when will these fluids be found again
into ISF sue to inflmaation or injury mobilized 3-5 days after recovery - requires in IVF rate
CHORIOCARCINOMA
is characterized by *histologically* cytotrophoblastic and synctiotrophablastic cells resembling chronic vili *tumor marker*-- Serum beta human chorionic gonadotropin
Most common location for the tear in boerhaave syndrom
left lateral posterior postion
Head trauma + hypovolemic shock
look for another source of bleeding
Cuases of viral arithtis
HIV, Hepatitis, Mumps rubella, parvovirus
What could cause nephrolithiasis in Crohn's Patients?
Increased absorption of oxalate in the colon.
Flank pain & hematuria in a patient with chrons disease is most likely due to ?
Increased absorption of oxalate, oxalate is normally bound up by calcium in the gut to prevent its absorption
In a uncal herniation, what nerve is most likely to be affected first?
CN III
Reynolds pentad for cholangitits
Jaundice, Fevers, RUQ pain, Mental status changes + elevated cholangitis
Sleep apnea vs. obesity hypoventilation
*Sleep apnea* hypoventilate at night cause *trasient hypoxia and hypercarbia*. *OBESTIY hypoventilation*- NEVER resume normal ventilation - *chronic respiratory failure*
Childs classification 3 labs 3 findings
* 3 labs:* albumine biliruben PT * 3 findings* Ascities nutrition encephalopathy Childs A - 5-6-- 0-5% mortality Childs B 7-9--- 10-15 % mortality childs C 10-15-- > 25% mortality
Finkelstein test
* de qeuvains tenosynovitis* Palapation over the dorsal radial compartment of the hand and finding a bone hard thickening
Risk of CEA surgery
*1-3% of perioperative stoke* nerve injury - hypoglossal, vagus, marginal brnach of the facial nerve -- recurrent carotid narrowing is about 13% in 5 years - recommendation is to take asipirin
Indications for urgent/emergent hemodialysis can be remebered by the acronym AEIOU:
*A*- Acidosis *E*- Electrolytes - hyperkalemia *I*- Itoxication with nephtoxic substances - ethylene gylcol *O*-Overload fluid in renal or congestive heart failure *U*- Uremia - severely symptomatic with mental status changes or pericardial effusions
Inner ear disease
" fullness " = meniere disease Can have *vertigo and hearing loss*
Patient presents with chronic microcytic Anemia, painless GI bleeding, and mumur of aortic stenosis what is the cause of the anemia
*Angiodysplsia* Thin- walled vessels that are lined by endothelium and prone to recurrent and chronic painless bleeding. Diagnosis is dependant on location: Colonoscopy, EGD, Upper endoscopy, small bowel enteroscopy or capsule endoscopy.
Causes of recurrent penumonia - *Involving different regions of the lung*
*Sinopulmonary disease* - CF, imootile cilia non infections vasculitis, broncholitus obliterans *immunodeficency* - HIV, leukemia or immunolgobins
*Paroxysmal vertigo and nystagmus, worse with change of postions*. Hearing loss is not present
*Benign positional vertigo* ___ Do the *dix-hallpike manuver* to diagnosis- patient sits on the table with the legs extended and you tilt there head to a side and then supporting the head have them lean back quickly.-- look for nystagmus patient may experience nausea
Inpatient ICU therapy
*Beta lactam + macrolide (IV) * or Beta lactam + fluroquiinolone
What are the first abnormalities seen after liver transplant
*Biliary and vascular anastomosis*- unique as antigenic reagents are less common in liver then other organs
Causes of recurrent pneumonia in the *same region of the lung*
*Bronchial compresssion* b/c- neoplasm mediastinal adenopathy, vascular anomrlay OR intrinsic bronchial obstruction - bronchiectasis retained foreign body and bronchial stenosis * Aspiration * D/T Seizures, ethanol or drug use, GERD
CRUB-65 - how to determine if the patient should be hospitalized
*C*-Confusion *U*- Uremia BUN > 20 *R*- Respirations tachypenia > 30 *H*- Hypotension BP < 90/60 *A*- Age > 65 *** Score > 2 inpatient Score > 4 then icu patient
What type of fracture always require surgical repair
*Displaced fractures*, are *unstable* and *require surgical repair* but you need to splint the injurgy until some of the swelling decreases
Patient presents with painless genital ulcers - initially they began as *painless papule* that then *ulcerates* over a course of weeks to days. Scrapping of the lesions show many *mononuclear cells containing encapsulated bacilli*
*Donovanosis or granuloma inguinale* - caused by klebsiella granulomatis - more common in tropical regions Papule --> ulcer can occur many times
Fibromatosis disease
*Duputren contracture* - Palmer fascia *Plantar fibromatosis* *Penile fibromatosis* - peyronie disease *Fibromatosis of the dorsal promixal interphalageal DIP joints*
Best next step in managment for cholangitis
*ERCP - both diagnositc and theraputic*
*58 year old post menapausal women* with a history of Parathyroid adenoma wishes to managed medically what is the best therapy
*Estrogen and progestin replacement*, as this patient is post menopausal you need to protect the bone density
Non healing fistula - FRIEND
*F*- Foreign body *R*- Radiation *I*- Infection *E*- Epithelialization *N*- neoplasm *D*-distal obstruction
inpatient Treatment for CAP
*Fluoroquinolone or Beta lactam + macrolide*
What is the treatment for CAP For an OUTpaitent
*Healthy people* - macrolide or doxycycline *Co-morbid conditions* - diabetes malignancy fluoroquinolone or beta lactam + macrolide
middle ear disease sympotoms
*Hearing loss* but no vertigo
ACL tear will have what other symptom to set it apart form other knee injuries
*Hemarthrothosis!* - both MCL and ACL tears can occur from a twisting injury but only ACL tears have significant hemarthorsis
Treatment of Ogilives syndrome
*IV neostigmine* - this is a nonmechanical obstruction D/t necrotics or electrolyte imbalence almost always post surgical *Diagnosis requires you to rule out bostructing carcinoma first *
Causes of pericarditis
*Infection- Viral is most common* Iatrogenic -surgery trauma radiation and drug related Connnective tissue disorders - RA, lupus Cardiac - Dresslers 1-6 weeks post UREMIC - serum BUN Usaully BUN > 60 Maligancy - Lung breas and hodgkins mcc- Treatment like radiation
melanoma that is superfical spreading melanoma on the face,
*Lentigo maligna melanoma * good prognosis oversall tx excision with narrow margins
How to diagnosis avascular necrosis of the femoral head
*MRI - for early onset* is the only study with high specificity and sensitivity
monoclonal gammopathy of undertermined significance VS Multiple myeloma
*Monoclonal gammopathy*-- *NO* ANEMIA, hypercalcemia, lytic lesions and renal insufficency Serum prtein < 3g/Dl < 10% plasma cells in the BM *MULTIPLE myeloma*-- Has anemia hypercalemia, lytic lesions and renal insufficency -serum monocloncal protein > 3 ->10% plasma cells in the bone marrow - elevated B-2 microglobulin
Most common location for diverticula and most common location to bleed.
*Most common location* is the left colon- sigmoid colon the *most common sight to bleed* is the right colon- cecum .
Is rheumatoid factor specific for rheumatoid arthritis
*NO!* also seen in viral arthritis bacerial infection or maligancy
What medications would *prevent* the presecription of sidenifil being orderd
*Nitrates or nitric oxide* SE- headaches flushing dyspepsia nasal congestion abnormal vision diarrhea dizziness and rash
immunological phenomena associated with infective endocarditis
*Oslers nodes*- painful violaceous nodules seen on the fingertips & toes *Roth sopts*- Edematous & hemorrhagic lesions of the retina *Glomerulonephritis* Arthritis or postive rheumatoid factor
First line management for a patient with detrusor hyperactivity - a patient who has urgency when needing to use the bathroom and often dribbles
*Pelvic floor exercises* and bladder training - actively training reduces the symptoms by 80%
Testicule support relieves the pain
*Prehns sign* a sign of epididymitis
What is used for prophalaxis of Toxo in HIV what is used for treatment
*Prophalaxis* -Trimephtoprim and sulfa *treatmentment* - Sulfadiazine and pyrimethamine
Hyponatemia in a patient with heart failure indicates what
*SEVERE HEART FAILURE * - low sodium is associated with high levels of renin, aldosterone vasopressin and norepinephrine SURVIVAL
Symptoms of a gastrojejunocolic fistula
*Severe diarrhea, weight loss and halitosis* b/c of fecal containment of the gastric contents -- Look for history of gastric surgery and s/p complications with ulcers that was never resolved.
Vascular phenomena associated with infective endocarditis
*Systemic arterial emboli*- focal neurological deficits renal or splenic infarcts *septic pulomary infarcts* *mycotic aneurysm* *janeway lesions*- macular erythematous nontender lesions on the palm & soles
Txt for Pneumoyscistist with Low Pao2
*TMP and Sulfa + predenosine*- Watch for allergic reaction with neutropenia hyperkalemia, elevated transaminases
Pronator dift senstive for
*Upper motor neuron disease* - because upper mototr disease causes a *weakness in supination* therefore when you close the eyes the arms pronate up
For an obsese women with a history of pain in her knees what is the best management
*Weight loss* - There is a strong link between obesity and knee OA
Malignant hyperthermia when does it occur
*Within 30 minutes of admistration of general anesthia* and muscle relaxants-->give dantrolene
Reroperitoneal zones
*Zone 1 centeral* - major vessel damage - indication for ex lap *Zone 2 flank hematoma*- no exploration warrented unless penetrating trauma b/c peritoneum with tamponade *Zone 3 pelvic hematoma*- no exploration neeeded because peritoneum will tamponade bleeding
AAA repair and UGI bleed -
*aortoduodenal fistula* - usually small bleed folllowed by 1-2 days by massive bleeding
Most common cause of Lower GI hemorrage in a older adult
*diverticulosis* right side more likely to bleed. rememeber that angiodysplasia is always a less common cause
Acute hemolytic transfusion reaction
*fever & flank pain & hemoglobinuria & renal failure & dic * within *1 hour of transfusion* postive direct coombs test Caused by ABO incompatibly
tender swollen and discoloured wound site with creptitus following a prenetrating injury what is it and what is the treatment
*gas gangrene* TXT : Penicillin G HIGH DOSE Hyperbaric oxygen debridment
Seminoma
*histology*-Large nests of round clear cells with centrally placed nuclei *tumor markers* - placental alkaline phosphatase - pLAP
AAA repair and Delayed fever
*inidcates vascular graft infection* - s. aureus and s. epidermis CT scan - to diagnosis
24 hours after PCI a patient presents with hypotension and *bradycardia* - what complication has developed
*thrid degree heart block*, the only complication that presents with *bradycardia* and hypotension
Yolk sac tumor
*tumor marker*-Increased AFP *histology *-papillary sturctures resembling glomeruli - schiller duval bodies
Clinical presentation of adenocarcinoma of the pancrease
- 85% of people have systemic symptoms like weight loss anorexia fatigue - 80% of people have abdominal pain or back pain - 56% jaundice - migratory superficial thrombophelitis - hepatomegaly and ascites with metastasis
The *HARD signs* of vascular injury that require *immeadate surgical expolration* other symptoms do imaging first
- active hemorrage -expanding hematoma -Pulse deficit -Bruit or thrill -Distal ischmeia - with the 5 p's
inability to comb hair with difficulty holding arms
- add proxmial muscle weakness - polymyositis/dermatomyosititis, endocrine hypo or hyperthryroidism cushing disease and neurmomuclar ( lambert eaton syndrom, myasthenia gravis) and drugs and steroids
Fail chest complications
- can cause pulmonary contusion and aortic transection,
Symptoms of splenic rupture post BAT
- delayed onset hypotension - LUQ pain - pain radiating in the shoulder- kehr sign - left lower rib fracture
Risk factors for pancreatic adenocarcinoma
- smoking - hereditary pancreatitis - nonhereditary chronic pancreatitis - obesity and lack of physical acitivty
Pulmonary embolis signs -EKG -ABG -CT
-*EKG*- S1Q3T3 -*ABG*- hyperventilations - respiratory alkalosis -*CT/ Xray* - wedge shaped infarct
Complications present in APCKD
--Hepatic cysts- most common extra-renal manifestations of adpkd --Valvular heart disease - MVP or aortic regurgitation --Colonic diveritcula --Abdominal wall and inguinal hernia
WARNING SIGNS for etiologies other than IBS
--Rectal bleeding --Nocturnal BM; awkens from or prevents sleep -- worsening abdominal pain --Weight loss --abnomral laboratory findings ( anemia electrolyte disorders)
causes of microscopic hematuria
--Renal : Renal cells cancer, igA nephropathy; --Ureteral - stricture, stone; Bladder; cancer, cystitits, prostate/ urethral - BPh, prostate cancer, urethritiris
Non sexually transmitted epididymitits - occurs in older men and normally gram negative rods
...
What is the management for heart block
...
What size of kidney stone will pass sponstenously with hydration and analgesia
0.6 cm or 6 mm
Crohns disease characteristic
1 most common Location in the GI tract affect is the terminal ileum and colon 2. Rectal sparing - 3. transmural inflammation seen in crohns can result in fissures, fistulas, or strictures 4. Granulomas- NON caseating 5. Skip lesions 6. Sparing of regions of the mucosa between the patchy distributions - coarsely tectured cobblestones appearance 7. Fissures 8.Fistulas 9. Peri-anal disease - like fissures fistulas, abscess and stenosis 10. Hyperplasia of the subserosal and mesenteric adipose tissure can lead to the appearance of creeping fat 11 multiple large lymphoid aggregates in the mucosa and submucosa 12. string sign on barium swallow - dx pyloric stenosis and colon cancer
1. In a patient with suspected peripheral artery disease (claudication, smoker, etc), what is the first thing you do? 2. What is that is normal?
1. Ankle-Brachial Index 2. If it's normal, do after exercise testing.
12 yo boy has blunt chest trauma after an MVA. He is sent home. Two months later, a CXR shows a deviated mediastinum with a mass in the left lower chest. 1.What do you think it is? 2. What should you do?
1. Diaphragmatic Perforation 2. Barium Swallow.
Crohn's symptoms and associations
1. Diarrhea 2. Malabsorption 3. Bile wasting 4. Gallstones 5. Oxalate kidney stones 6. anklylosing spondylitits 7. erythema nodosum 8. uvetitis 9. migratory polyarthitis
How do you initially manage hemoptysis?
1. Establish airway 2. Ensure dynamic stability 3. BRONCHOSCOPY is the procedure of choice to identify bleed and attempt early intervention.
Patient = hemodynamically unstable w/ blunt abdominal trauma. What do you do?
1. Fluid Resuscitation should be started 2. Follow with US exam 3. If there is intraperitoneal blood, then urgent LaparOTOMY. (Not laparoscopy)
There are several interventions for lowering ICP. Name the 4 and the mechanism.
1. Head Elevation -> Increased Venous Outflow from the Head 2. Sedation -> Decreased metabolic demand and control of HTN 3. IV Mannitol -> Extraction of free water our of brain tissue via osmotic diuresis 4. HYPERVENTILATION -> CO2 washout, leading to cerebral vasoconstriction (cause the brain responds to CO2 and pH)
1. In a burn patient with significant total body surface area burns, what is the major cause of morbidity and mortality? 2. What is the second biggest cause?
1. Hypovolemic Shock 2. Assuming good fluid resuscitation, BACTERIAL infection is the next thing.
1. How do you detect intra-abdominal injury in trauma patients who are hemodynamically stable? 2. What about unstable? What do you do if this is inconclusive?
1. If they're stable, use a Abdominal CT. 2. If they're unstable, then you do a FAST ultrasound initially. If this is inconclusive, then you do diagnostic peritoneal lavage BEFORE you proceed to laparotomy.
How do you treat splenic trauma if... 1. The patient is hemodynamically stable? 2. Hemodynamically unstable?
1. If unstable, but responds to fluids, then CT scan. 2. If unstable and unresponsive to fluids, then emergent exploratory laparotomy is needed.
1. What is Ludwig's Angina? 2. Most common Etiology? 3. Cause of death?
1. Infection of Submandibular and Sublingual Glands 2. Infected Tooth (usually 2n3 or 3rd mandibular molar) 3. Asphyxiation
. On POD3, an elderly man complains of pain around his wound. What are the 6 Signs/Symptoms of a Necrotizing Surgical Infection? 2. What do you do?
1. Intense Pain in wound 2. Fever, Hypotension, Tachycardia 3. Decreased sensation at edges of wound 4. CLOUDY-GRAY DISCHARGE 5. Tense edema outside involved skin 6. Subcutaneous Gas with Crepitus 2. URGENT SURGICAL EXPLORATION
Ulcerative colitis conditition
1. Not an autoimmune though related to autoimmune conditions 2. always involves the rectum and then spreads in a step wise fashion 3. HAve broad based ulcers & regions of regenerating mucosa that resemble friable pseudopolyps 4. intestinal crypt abscess and 5. loss of haustra 6. lead pipe appearance 7. Repeative bouts of blood diarrhea
1. What type of a shoulder injury commonly occurs after a tonic-clonic seizure? 2. What is the associated deficit?
1. Posterior Shoulder Dislocation. 2. The patient will hold the arm abbducted and internally rotated.
1. What injury to the GU system is associated with a pelvic fracture? 2. What are the symptoms? (5)
1. Posterior URETHRAL injuries. 2. Blood at urethral meatus, high riding prostate, scrotal hematoma, inability to void, and palpably distended bladder.
A 12 yo boy has right groin pain, knee pain, and limping for 2 weeks. He is obese, and he has restricted hip movements. There is external rotation of the right though on flexion of the hip. 1. What is the diagnosis? 2. How do you fix it?
1. Slipped Capital Femoral Epiphysis (SCFE) 2. Surgical pinning of the femoral head.
A patient has abdominal trauma (car accident) that initially shows no symptoms. However, 8 hours later, he gets epigastric discomfort, left shoulder pain, and mild nausea. His vitals are stable. 1. What is it? 2. What should you do?
1. Splenic Injury 2. Abdominal CT scan with IV contrast.
1. If a wound fails to heal after a prolonged period of time, what should you check for? 2. If this occurs in a burn patient, what is it called?
1. Squamous Cell Carcinoma - Ulcers can degenerate into SCC 2. Marjolin Ulcers.
What is the treatment for Acute Cholecystitis?
1. Treat with observation and supportive care initially, but you ned to do a LAP Chole within 72 hours during the same hospitalization.
MCC of acute pancreatitis
1. biliary gallstones 2. alcohol consumption 3. Hypertrigylceridemia 4. recent ERCP
Associations with Ulcerative colitits
1. damage to the muscularis propia - toxic megacolon 2. colorectal carcinom - risk sharply increasing at 8-10 years which is when colonscopy surveillance is started adn then continued every 1-2 years 3. antierior uveitis - iris cillary body and chorid 4. pyroderma gangrenosum - deep necrotic ulcers typically over the legs 5.priamry scerolsing cholangitits- continous inflmation and scarring of the bile ducts leading to beading pattern on ERCP ( 80% of people with PSC also have UC)
Causes of stertorrhea; 3 classes and multiples causes
1. pancreatic insufficiency 2. Bile salt related - bacterial overgrowth, chrons disease, PSC, *surgical resection of the ileum - 60-100cm* 3.impaired intestinal surface epithelium - Ceilac disease, AIDS enteropathy, Giardiasis
HOw much blood must the chest tube drain to require immeadate OR intervention
1.5L to > 200mL/hr for 3 hours
What is the initial treatment for CO poisoning?
100% O2 with facemask
Amount of blood ( acutely) needed to cause a rise in intrapericardial pressure
100-200ml- acute chronic - 1-2 L of fluid
Spinal cord trauma
1st iv steroids to reduce the swelling and then MRI
HIV screening 15-65
1x
Definition of stage 1 hypertension
2 consective measurments of blood pressure above 140-159 or diastolic 90-99mmhg
How days before should NSAIDS be stopped
2 days
Dietary sodium reduction will reduce the systolic BP by how much
2-8 mmhg
Size of the normal prostate
20-25 g
how much does exercise ( 30 min/day for 5-6 days/week)reduce your approximate systolic BP
4-9 mmHg
Intrinsic kidney disease is defined by how many cc of urine
400cc or less then 6 cc/kg a day
Thrombocytopenia is seen in what % of HIV patients
5-10%, therefore any patient with unexpalined thrombocytopenia should have a HIV test done
What hernia has the highest risk of strangulation
50% of all strangulations is the femoreal hernia below the inguinal ligament - through thte femoral triagnle
What drug reduces the size of the prostate
5a-reductase - finasteride this reduces the dihydrotestosteron and the prostatic volume use in patients with prostates greater then 40 g
HIV + AMS Cortical and subcortical atrophy and secondary ventricular enlagement
AIDS dementia
In general what is the tidal volume needed
6ml/kg - for ideal body weight
What should you do if a suspected scaphoid fracture is negative?
7-10 days in a spica cast and thumb immobilization.
How much decrease systolic occures while on the DASH diet ( high in fruits vegitables and low in saturated fat and total fat )
8-14
Saag of 1.1 or greater
95% accurate in diagnosing a transudative process consistent with portal hypertension
What level of CFU in a urine sample determines a negative result.
< 100,000 CFU/Ml and < 5 WBC
Normal BP vvlabes
< 120 ,,Hg diastolic < 80 ,,HG
palpable breast mass diagnosis different in ages <30 and > 30
< 30 is ultrasonogram - if it is complex cyst or solid mass - image guided core biopsy > 30 - mammogram & ultrasonogram - core biopsy
Stage 2
>systolic 160 and diastolic > 100
what is the best test to identify a colonic bladder fistula
A ct scan - patient will complain of pneumonuria passage of air n the urine or fecaluria - poop in the pee.
Multiple cystic spaces on the lateral side of the neck that vary in sizes
A cystic hygroma - a congential malformation of lymphatic tissue
Why is pretest probability and important factor to consider in Cardiac work up
A postitive stress test in *patients at a low risk* ( Women <50, men < 40, atypical chest pain, no significant risk factors - non smoker no family hisotry of premature CAD) willl likely be *false postive* ----a NEGATIVE test in a high risk patient might be false negative.
Hemisection syndrome
ALWAYS d/t a stab wound in the posterior neck-- Ipsilateral vibration and prop and contralateral pain and temp
Melanoma on pale areas of dark skinned pt's - soles of the feet and palms of the hands
Acral lentignous melanoma worse prognosis because of the depth of these
Risk factors for bladder cancer
CIgerrets smoking, Occupational exposures paintera nd metal workers Chronic cystitis iatrogenic causes ( cyclophosphamide) pelvic radiation exposire
patient with an ulcerated mass that occupies the right breast that extends into the axialla where there are mulitple hard mass what is the next treatment
An ulcerated extensive tumor such as this cannot be operated on therefore Preoperative chemotherapy
A patient has blunt abdominal injury. He complains of diffuse abdominal pain that refers to the left shoulder. Which of the following is most likely injured? 1. Bladder Neck 2. Bladder Dome 3. Anterior Bladder Wall 4. Urethra 5. ANterior Urethra
ANSWER = Bladder DOME. Blunt trauma to the Bladder DOME is the only thing on this list that could cause the peritonitis that the patient has.
What is the first indicator of hypovolemia?
ANSWER = Pulse Rate
location for thymoma
ANTERIOR mediastinum - in a younger patient with an anterior mass or in 20% of those patients with myasthenia gravis.
SAAG is calculate
Abdominal ascities - serum ascitis
Calculation of SAAG
Abdonimal ascities ablumin- serum ascities ablumin Less then 1.3 = transudate Greater then 1.3 = excudate
dysphagia greater for liquids then solids
Achalasia Dx birds beak on barium swallow Tx heller myotomy
An inability to have plantar flexion on squeezing of the gastrocnemius muscles in the prone position
Achillles tendon rupture - this is know as a *thompson test*
Triad of death
Acidosis, coagulapathy and hypothermia - Hypothermia can cuase platelet dysfunction and rewarming indicated acidosis - from lactic acids - give crystalloid
Acute presentation: Abdominal pain, nausea, vomiting diarrhea and sweating. Agitiatio, anexity paraesthesia and confusion. Can be brought on my Drugs
Acute intermittent porphyria and no photosensititvity
Gross of micorscopic hematuia Family history of renal failure hypertension
Acutosomal dominant polycystic kidney disease
Rule of 9's for burns
Adults head - 9% Anterior torso 18% posterior 18% anterior leg 9% posterior leg 9% Anterior arm 4.5 posterior arm 4.5% genitals 1% Baby anterior head 9% posterior 9% Anterior toso 18% posterior 18% anteriro leg 6.75% and posterior 6.75 ANterior arm 4.5% and posterior arm 4.5 genitals 1%
Polymyalgia rhumatic symptoms
Age > 50 *Bilateral pain and morning stiffness* > 1 month Involvement of 2 of the following - neck or torso, shoulders or proximal arms , proximal high or hip + constitutional symptoms
Surgical indications for a neck wound
All GSW and stab wounds in zone 2- expanding hematomas deteriorating vital signs coughing blood, subcutaneousS emphysema
Who should get a pnumococcal polysacrride vaccine
All adults above 65 Or adults under 65 with *chronic disease like:* asthma COPD, emphysema - CAD - Chronic lung disease - Smokers - Alcoholism - cochlear implants - CSF leaks - immunocompromising disease - functional or anatomic asplenia
Melanoma in anus
All mucosal melanomas have BAD prognosis txt with apr ( abdominal peritoneal reseection) + Lymph node resection.
Aortic stenosis - triad of symptoms
Angina, dyspnea, syncope and high possibility of sudden death
In a clavicale fracture, what do you need to do if a bruit is heard under the damaged area?
Angiogram - ensure that the subclavian artery is not damaged.
What is the first test to evaluate suspected peripheral artery disease?
Ankle-Brachial Index using Doppler
Patient presents with her arm held close to the body and the forearm rotated outward. She is in pain and will not move the arm from that positon. the shoulder looks square and there is a lack of sensation over the deltoid
Anterior shoulder dislocation- damage to the axially nerve
what size of breast lump is the cutoff for lumpectomy
Any *mass > 4 cm* also remeber smaller breasts more often require mastectomy
Deceleration injury causes what
Aortic injury
Loud blowing diastolic murmur + bounding pulses
Aortic reguigitation - VALVE REPLACEMENT
Patient presents with severe chest pain radiating to the back with severe hypertension and decrescendo diastolic murmur of aortic regurgitation. - can have weak or absent peripheral pulses and systolic blood pressure variation > 20 mm Hg
Aortic root dissection and use TEE
HARSH systolic murmur + angina + syncope
Aortic stenosis - MCCC congenital bicuspid aortic valve with sytrophic calcification.
Man complains of impotence + thigh and calf pain that is relieved by rest PE - absent femoral and lower extreimty pulse bilaterally
Aortic-iliac stenosis aka *Leriches syndrom* - always inculdes inportence
Complications of penetrating trauma to the groin
Arteriorvenous fistula, then the venous hypertension can develop into lymphaedma
Patient with a prior hisotry of excema and chronic rhinitis with nasal polyps is admitted to the hospital because of possible MI now treated with Asprin and beta blockers presents with wheezing WHY
Asprin induced Asthma or beta blockers can also do it .- Looks for a past history of excema and rhiniris to give Hints that there is atopic past
Riley dray syndrom
Autosomal recessive disease seen in children of ashkenazi jewish have severe orthostatic hypotension
Treatment for PAC - Premature Atrial ventricular contractions
Avoid alcohol, tobacco, caffeine and stress
Best treatment for hypersentitivity pneumonititis
Avoidance of exposure
Medical mangment for Dilated cardiomyopathy
B blockers will improve heart funciton, ---> but heart transplant is indicated
Hypertension 18+
BP every 2 years
hirusprung disease how to diagnosis
Barium enema and 4x more likely in boys definiitive diagnosis is biopsy must inculde all the layers
Raised waxy lesion on the face ( upper lip is classic)- can have teleangectasia or a non healing ulcer what is it and what is the treatment
Basal cell carcinoma Txt with local excision and use 1 mm margins and LN excision.
patient with very tender spot in the third interspace between the third and fourth toes
Benign neuroma -
Sudden onset of vertigo nausea & vomiting - no change in hearing
Benign recurrent vertigo or vestibular neurontitis
What do You give for the management of cocoaine use
Benzodiazepines
Medical managment for Atrial fibrilation
Beta blockers Or Calcium channel blockers (diltiazem)
Treatment of exercise induced asthma
Beta- agonist or mast cell stabilizers like cormolyn
Nausea, vomiting and right sided shoulder or subscapular discomfort
Biliary colic - always related to meals and no fever
What spider bite presnts with muscle cramps, acute abdomen and nausea vomiting what is the treatment
Black widow IV calcium glucoronate and muscle relaxants
Hemorrhage and ab distension
Bleeding into abd cavity - = abd syndrom which can cause decreased renal blood flow -oliguria and dyspnea - elevated diaphragm
How does trimethoprim increase K
Blocking the sodium channel in the collecting tubule similar to the action of the potassium sparing diuretic amiloride
Causes of spontenous rupture of the esophagus
Boerhaave syndrome and pill esophagitits ( from postassium cholride) Barrett esophagus or infectious esophageal ulcer viral or candida in HIV
Mecklers triad
Booerhaave syndrom----Vomiting & chest pain & subcutaneous emphysema
Genu varum - when is it normal and when should surgical correctio be considered
Bow legs- < 3 observe since it is normal , > 3 consider surgical correction.
What is a common complication of aortoiliac vessel repair?
Bowel Ischemia....most commonly afects distal left colon. Colonoscopy shows a discrete segment of cyanotic and ulcerated bowel.
Complication of abdominal aortic aneurysm repeain 1-7%
Bowel ischemia s/t inadequate colonic collateral arterial perfusion to the left and sigmoid colon
After NOMI what do you see on the CT
Bowel thickening and intraluminal gas
Post Surgery for an aneurysm of the infrarenal aorta - 1st postoperative day abdominal pain and bloody diarrhea Full femoral pulses and symmeterical
Bowels ischemia is one known complication of the abdominal aortic aneurysm repair
Tumor arises within the bronchi and causes obstruction- Commonly in people under 30 - present with hemoptysis and atelectasis --
Bronchial adenoma - dx- Ct scan & bronchscopy beware of bleeding
Blunt thoracic trauma --> Pneumothorax that doesnt resolve with chest tube placement, can also see mediastinal air
Bronchial rupture
X ray finidng of *linear atelectasis* normally means what pathology + hx of chronic productive cough with purlent sputum
Bronchiectasiss
middle mediastinum masses
Bronchogenic cyst, tracheal tumors, pericardial cysts, lymphoma, lymph node enlargement, aortic aneurysms of the arch
What spider bit presents with an ulcer that needs to excised and and then skin graft
Brown recluse
plantar fascitis
Burning pain in the plantar area of the foot that is made worse with walking
Trauma - Disability & Comatose -
C spine cannot be cleared so precautions must continue
CHA2DS2- VASc score
C- congestive heart failure -1 H- hypertension - 1 A2- Age > 75 -2 D- Diabetes mellitus - 1 S2- Stroke - Tia - throboembo-2 V- vascular disease -1 A-Age -65-74-1 Sc- Sex women - 1 Max score 9
How do you treat an abscess formed due to Complicated Diverticulitis?
CT guided percutaneous drainage. If you can't get it, then surgery.
Post BAT what identifies splenic injury
CT scan with intravenous contrast
What is tthe best srtdy for bronchitectasis
CT with high resoluation
Mitral stenosis alon what are the pre operative considerations
Can results in cor- pulmonale therfore sondult cardiologist - give prophylactic antibiotics for endocarditis
67 year man has new onset diabetes mellitus, he has increase alkaline phosphatase and increase bilibruben as well as heme + stools WHAT SINGLE LESIONS ACCOUNTS for both of the these findings
Cancer of the ampulla of vader - endoscopic exmaination of the duodenum
"Pain worse at night"- key word for
Cancers
Amount of Kcal in carbs fat protein etoh
Carbs- 4 kcal/gram Fat- 9 kcal/gm protein 4 kcal/gm etoh 7 kcal/gm
Is cauda equina or conus medullaris : Unilateral severe radicular pain *Saddle hypo/anesthiesia* *Asymmetric* motor weakness Hyporeflexia Late onset bowel and bladder dysfunction
Cauda equina syndrom
Direct Blunt abdominal trauma in children
Cause duodenal hematomas
Charactersitics of palcental abruption
Caused by: trauma, hypertension or cocaine There is blood seen on pelvic exam and a *painful pelvic exam* ( previa has no pain)
Can be associated with seizures - CONTRALATERAL homoymous hemianopsia, plegia, paresis, Eyes deviated to the CONTRALATERAL side of damage ( away) C- cerebral and contralateral
Cerebral lobe
Treatment of pancreatitic cancer with metatsis
Chemotherapy - often combination of 5-FU leucovorin oxaliplatin and irinotecan --- *surgery with the whipple procedure only done if the cancer is resectable*
What do you have to do immediatel after placing a central line?
Chest X-ray.
IF hypertrophic osteoarthopathy is found what test do you order
Chest x ray to determine the underlying cause
Lab studies for adenocarcinoma of the pancrease
Cholestatic picture ( increase ALP and direct biliruben) d/t common bile duct obstruction - Elevated CA 19-9 - Ultrasound ( if jaunced ) or CT scan ( if no jaundice ) of abdomen
pathophysiology of brochiectasis
Chronic damage to the the bronchial wallls from infection trauma and tumor - also cystic fibrosis and A 1 antityspin disease
Patient has a postive history for alcoholism and ER admittance for ab pain, now pressents with new onset diabetes constant pain, and steatorrhea
Chronic pancreatitis
What is torus palantinus?
Chronic, hard, bony growth on the midline of the hard palate. It is a congenital anomaly.....don't treat unless symptomatic.
What is the Pringle maneuver
Clamping the portal triad in the *hepaptoduodenal ligament* intermittently with a traumatic clamp - Stops the blood flow into the liver from the *hepatic artery and the portal vein*.
How often should screening for colon cancer be done for a patient with ulcerative colitis
Colonscopy now and then every year after ( or repeat 1 -2 years)
Shoulder paina nd ipsilateral ptosis, and miosis + smoking history
Consider pancoast tumor which can invade the brachial plexus and present with shoulder pain
Duodenal hematoma
Common in children *hitting the handle bars* the sweeling blocks the lumen and casues GI obstruciton *Tx NPO and iv fluids* spontenous resolution in 5-7 days
Pregant lady presents with severe hypotension with abdominal distension.
Complication in pregant women is *visceral aneurysms* - such as splenic, hepatic or other intra abdominal arteries. *MOST common are splenic* - you will a *signet ring sign on x- ray*
Dermoid cyst is found where on the neck
Congential mass ( often present for many years) found in the submental region ( can also be found in other sites of the head and neck inculding orbit, nose and nasopharynx, and oral cavity. ) they are epithelium lined spaces .
Causes of Transudate pleural effusion
Congestive heart failure Cirrhosis Nephrotic syndrome Peritoneal dialysis
Non-bleeding varices are found on Endoscopy. How do you treat them?
Conservative Medical Management - NOn-selective B-Blockers (Propanolol).
How do you treat a non-displaced scaphoid fractures?
Conservatively with wrist immobilization
Any child with joint pain or decreased ROM or pinpoint bone pain following a spetic illness
Consider a septic hip or osteomyelitits
Post op hematuria
Consider bladder overdistention cancer, infection, kidney stones, trauma, postatitis and cylophosphamide
What do you do for a perforated esophagus?
Contrast Esophagography.
Is cauda equina or conus medullaris : Sudden onset severe back pain *Perianal hypo/anesthisia* *Symmetrical* motor weakness Hyperreflexia Early onset bowel and bladder dysfunction
Conus medullaris syndrom
patients that get pellagra
Corn-based diets india, africa, and china and in alcoholics patients with carcinoid syndorm & hartnups disease
patient presents with pain and photophobia of the eyes there is a history of a branch hitting the eye and the slit lamp image is positive
Corneal abrasion
A patient with a known Cranial injugry who is now having hypertension, bradycardia and irregular rspirations
Cushings reflex or triad.- the ischemic brain sends out a sympatheitc nervous system message to the peripherial circulation to vasocontraict BUT the vagus nerve is unaffected, and responds to the increase in BP with=bradycardia
In aptients with traumatic spinal cord injuries (often caused by whiplash), what neurological syndrome commonly occurs years later?
Syringomyelia.
Best test to diagnosis renal stones
Ct of the abdomen and pelvis without contrast
Clean wounds -
Created in a sterile nontraumatic setting and do not involve the areas ( GI, Respiratory, GU) Risk of infection is 1-1.5%
What test for unexpalined gross hematuria or microscopic hematuria ?
Cystoscopy
Presentation and etiology of a CHF pleural effusion
D/t increase in hydrostatic fluid pressures 61% are bilateral right only 27% Left 12%
TPN and metabolic coma
D/y hyperglucemia and hyperosmolar non ketotic coma and is commonly d/t escessive osmolar diuresis
Osteoporosis women 65 +
DEXA
Complications of AAA repair Day 1/2 Day 3 Day > 3 (x2)
Day 1/2- Third space loss - give more fluids Day 3- Thrid space mobilization adjust fluid Day > 3 - impotence d/t damge of the hypogastric circultation or autonomic nerves around the IMA
Pain in the thyroid + high ESR can have palpiation, diarrhea, sweating
De Quervains = subacute thyroiditis Can have throidtoxicosis becuase of release of hormones by the inflammed gland Normally only lasts for 8 weeks
A young mother complains of radial side of the wrist ad the first doesal compartment- worse when attempting to cary her baby
De quervains tenosynovitis of the abductor or extensor tendons of the thumb
Managent for Dehiscence
Deal with it conservatively--> Tape the wound and bind the abodomen and prevent anything that would increase the abdominal pressure This is will allow some granulation tissue to reform and then the wound can be closed
Physical exam - polymylgia rheumatic
Decrease ROM in shoulders neck and hips
Complications associated with pernicious anemia
Decreased abs of B12 because there is low intrnisic factor, Chronic atrohic gastritis because of attack on the parietal cells of the stomach atrophic gastritis has an increased risk of intestinal type *gastric cancer* and *gastric carcinoid* by 2-3 x
Treatment for syndrome of inapproiate ADH release
Demeclocycline- Occurs in any patietn who might have head trauma or centeral nervous system proceedure or Small cell carcinoma of the lung
Solitary ring enchaning lesion on the MRI, periventricular
Diagnosis is the EBV virus inthe CSF Primary CNS lymphoma second most common cause of mass lesion in HIV infected persons
Cardiac cath shows square root sign
Diagnostic of constictive pericarititis - presents with dyspnea hepatomargaly
abdominal pain, pain referred to the shoulder, shortness of break and vomiting -- X ray shows abdominal viscera above the diaphragm
Diaphragm rupture
Galeazzi fx:
Diaphyseal fracture of the distal radius and ulnar dislocation following direct trauma to the radius
Monteggia fx
Diaphyseal fracture of the promximal ulnar & radial dislocation, results from DIRECT injury to the ULNA
meniscal injury signs and symptoms
Difficulty in extending the knee, mild swelling and pain - with Passive flextion and extention you get a pooping sensation where the examiner places the fingers under the knee
A CT scan of the head shows numerous minute punctate hemorrhages with blurring of the gray-white matter interface after an MVA. What is it?
Diffuse Axonal Injury
Painfulswallowing especially for hot or cold liquids
Diffuse esophageal spasm aka nutcracker esophagus high amplitude contractions inan unco-ordinated fashion tx nifedipine
Hypertrophic osteoarthopathy ( HOA)
Digital clubbing is accompanied by sudden onset arthropathy commonly affecting the wrist and hand joints - pain there * remember your physcial exam* --seeen in lung disease ( Cancer, Tb, bronchititis, or emphysema )
SNake bites
Dont always cause envemonation- signs of venom - pain swelling discoloration
Treatment of an abcess anywhere in the body
Drainage!!
patient presents with transient blindness in the left eye that apppears as if a curtain is being pulled down - what is the diagnosistic test/ work up
Dx fundoscopic exam reveals *Hollenhorst plaque*, a bright shiny spot in a retinal artery physical exam (check carotid bruids, neuro, cardiovascular) + carotid duplex; Tx aspirin or carotid endarterectomy ( if stenosis is 50% ( because it is symptomatic))
hemopericardium diagnostic test
ECG- electrical alterans
What EF is a risk for surgical complications
EF < 35%
polymylgia rheumatic - LAB
ESR >40 sometimes at 100 elecated CRP Normocytic anemia 20% completely normal
What do you do if there is any indication of a thermal inhalation injury in a burn victim?
Early intubation to prevent upper airway obstruction by edema.
Fever that starts 10-15 days post colon surgery and re-anastomosis
Either a anastomosis leak or deep abscess
Most imporant goal folllowing the managment of a rib fracture
Ensure proper pain control - A lack of pain control will result in Hypoventilation and atelectasis and pneumonia
Child with purlent unilateral nasal discharge acute onset
Epiasxis due to foreign body- especially a child around 2 years of age with unilateral signs of blockage + purlent discharge ( ear, nose or lung)
complication of a full thickness burn- 3 days post burn, she complains of pain and paresthesia
Escharotomy - THE ESCHAR IS DEAD TISSUE can compromise lymphatic circulation resulting in a decrease in pulses * pressure of 25-40 mmhg is the threshold to perform escharotomy*
Picks disease
Eupohoira disinhibition apathy compulsive behaviours (eating habits) Hyperorality impaired memory Visual and spatial functions are in tact.
calculation of IV fluid replacement : if sodium is 152
Every *3mEQ/L* that *serum sodium concentration is greater then normal* = *1 L of water deficit* normal = 140 paitent = 152 therefore 152-140=12 12/3 = 4L You dont want to stress the system with 0.9 nacl or pure water therefore use0.45%
Hypernatremic - post surgery means how much fluid deficit
Every 3 Na+ over 140 indicates 1L of water loss
How often should women 21-65 get a pap smear
Every 3 years
Second degree burns
Extend into the dermis - cause pain and blistering and may develop into thrid degree burns
Surgical contraindications when evaluating NSCLS
FEV1 < 800ml, mediastinal LN involvment or distal metastses
TPN and dry scaly skin
FFA def. give FFA
Finding a thyroid nodule next step
FNA- as the results will determine the course of the treatment MAligant or intermediate - surgery Benign then observation
How often should colon cancer be screened for ( 50-75)
FOBT - yearly Colonscopy every 10
third degree burns
FULL thickness and painless
Herbal remedies for weight loss lid lag, palpitations, sweating, weight loss, hyperacitvity and diarrhea what the diagnosiss whats the RAIU Whats the labs
Factitious thyrotoxicosis RAIU is LOW LAbs: tsh low, High t3/ t4 or both depending on the remedy
Diagnosis of the fat emoblism
Fat droplets in the urine or intra-arterial fat globules on fundoscopy.
Post long bone break The patient develops severe dyspnea and confusion. With non-palpable petechiae in the upper part of the body.
Fat embolism is common in patients with polytrauma especaially with multiple fracture of the long bones. ___ key findings_____severe respiratory distress petechial rash, subconjunctival hemorrhage, tachycardia, and fever.
What nerve innervates the anterior compartment of the thigh?
Femoral Nerve
Elderly women has a shortened and extrenally rotated leg what injury do you suspect
Femoral neck fracture with a risk of avascular necrosis
adverse side affects of methimazole
Fetal teratogen in the 1st trimester cholestatic jaundice and agrulocytosis, rash arthralgias and hepatitis
Febrile nonhemolytic transfusion reaction
Fever and chills within *1-6 hours of transfusion * caused by *cytokine* accumulation during blood storage.
treatment of follicular carcinoma
First remove the thyroid then after the tissue is removed you can treat with radioacitve iodine to abalte any remaining tissue
What enema must be avoided in diabetics
Fleet enema becuase iti s a sugar rich hypertonic formula causes dehydration, metabolic acidosis ( loss of bicarb )
Dementia with lewy bodies
Fluctuating cognitive impairment and *bizarre visual hallucinations* - Some *parkinsonism* is seen but there is a poor response to dopaminergic agonist
if there <0.5cc Post op- urine output
Fluid deficit (bleeding out) or acute tenal failure give bolus of 500mL iVF and if they respond then it fluid decifit
things to avoid is acute prostitits
Foley & prostatic massage
A man stabs himself with a nail. The wound is small and clean. What do you do if.... 1. He is unimmunized? 2. He had his last booster > 10 yrs ago? 3. He has his last booster < 10 yrs ago? What is the wound is severe or dirty? 4. Unimmunized? 5. Booster was >10 yrs? 6. Booster was <10 yrs?
For small, clean wounds.... 1. Td Only 2. Td Only 3. Nothing For severe or dirty wounds... 4. Td and TIG 5. Td and TIG 6. Td if lastest booster was given > 5 years ago.
Etiology of diverticula
Form b/c high intraluminal pressure in the colon = herniation of the mucosa and the muscularis mucosa at sights that are penetrated by the vasculature.
Most common fracture in the pediatric population who fall on the outstretched hand --- what ist he most common structure damaged whaat other structures are at risk
Fracture of the of the *supracondyler hummerus* most common structure injurged is the *BRACHIAL ARTERY* followed vby the median nerve, Cubis varus deformity Compartment syndrom- volkmanns ischemic contracture
Suden onset SEVERE psoriasis or recurrent herpes zoster suggests what underlying pathology
HIV infection
Waterbrash taste in the mouth ( sour) Cough, dysphagia, cough Diagnosis and txt
GERD tst: ppi - if it continues after 6 weeks then do EGD and biopsy
Features of alcoholic cerebellar degeneration
Gait dysfunction, truncal ataxia nystagmus intention tremor or dysmeteria impaired rapid alternating movments * muscle hypotonia leading to pendular knee reflex- persistent swing movement of the limb after a DTR is elicited*
Bernard- Soulier syndrom
Giant platletes glucoprotein Ib-IX-V which is a receptor for Von willebrands factor mild thrombocytopenia Giant platetes
After surgery, a patient develps right calf pain and swelling. A clot is shown under Duplex US. What do you do?
Give Heparin acutely. (Not TPA or anything like that).
Patient receives spinal anesthesia and then has diffuse vasodilation - what is the treatment
Give alpha antagonists to prevent vasodilation.
Patient with acute protatitis ( urin is dark and cloudy + burining with urination + fever + high respirations) what do you treat with prostate is tender and can have mylagias and arthralgias
Give ofloxacin for 4 to 6 weeks --- a fluorquinolnes will cover both E coli and chlymydia
heamturia, RBC casts acute renal failure hypertension and edema
Glomerulonephritis
A gradual onset of impotence suggests what kind of mechanism
Gradual suggest organic impotence that pharmological therapy is recommended for the frist step then a vacum erection device
Signs and symptoms of Spianl cord compression
Gradually worsening local back pain Pain *worse lying down* and *worse at night * -- EARLY SIGN - symmetric lower extremity weaknness hypoactive *absent deep tendon reflexes* LATE signs B/l Babinski signs - Decreased spincter tone, parathesthia, paraplegia with *increased DTR*
Contaimined wounds
Gross spillage from one of the systems listed in the first paragraph --infection 10-15%
X ray findings for hypersentiveity penumonitits
Ground glass opacity or haziness of the lower lung feilds
Mitral stenosis + CHF
HIGH risk of mortality - need extensive work up EKG, echo and operative monitoring
Clots with Low platlets
HIT
Infant with a scrotal mass - It is custic and transilluminated by light.
HYDROCELE: fluid in processus or tunica vaginalis will resolve spontaneously by 12 months
What are signs of magnesium toxicity
HYPOREFLEXIA decreased respirations Heart block -> Death flushing and sweating
A kid falls off his bike and hits his head. He briefly lost conciousness, but had no seizures. His vitals are stable, no neuro symptoms, and only a small bruise on PE. What do you do?
He can be discharged if he has a normal CT, with instructions to come back if new symptoms arise.
Ascities leakage through a hernia ulcer
High risk of bacterial peritonitis - evaluate for mental status changes and tap the ascities
An elderly gentleman comes into the ER after being found on the floor at his home. He complains about hip pain primarily, but also complains about SOB, anxiety, and finger numbness. What should you do?
He probably fractured his hip, so get an X-ray. However, you need to find out WHY he fell. In his case, you should work up an MI.
If a patient presents with Any of the following which test do you run-> --Focal neuologic findings --skull fracture, especially signs of basilar skull fracture --Seizure --Prolonged loss of consciousness --persistent altered mental status
Head CT without contrast
Stroke in the basal ganglia
Hemiplegia hemi serensory loss homonymous hemianopsia gaze palsy stupor and coma
A Reversible cause of Restrictive Cardiomyopathy
Hemochromatosis
Heparin induced throbocytopenia ( HIT)
Heparin binds to platelet factor 4 a heparin neutralizing protein released with platelet activation The Hepatin pf4 complex then triggers igG antibodies which bind to the pf4 heparin complex.
Porphyria cuntanea tarda or Cutaneous leuckocytoclastic vasculitis palpable purpura - this is d/t cryoglobulinemia
Hepatitis C
Most common cause of corneal blindness in the US - patient complains of pain, photophobia, blurred vision, tearing and redness.- may be recurrent PE: corneal vesicles and dendritic ulcers are characteristic
Herpes simplex keratitis
A 17 year old boy presents with many years of crampy abdominal pain + diarrheas often with frank blood with dilation and strictures of the inter and intra hepatic ducts. His bilirubin is 3.6--2.9 conjugated ALP is 625 and normal transaminases
High ALkaline phosphatase and dilated extrahapetaic ducts- Primary sclerosisng cholangitis PSC Diarrhea with frank blood is colon cancer the combination is ulcerative colitis
Charcot symptoms for cholangitis
High fevers with right upper quadrant pain and jaundice + elevated alkaline phophatase
Characterisitcs of siADH
High urine osmolality and specific gravity
Choriocarcinoma- hisotlogy and cancer marker
Histologically by *cytotophoblastic and syncytioblastic cells* resembling chorionic villi Serum beta human chorionic gonadotropin
Most important diagnostic feautures of hypersensitivity pnemonitits
History of some antigen exposure ( birds, silos) and then induction of symptoms
pathophysiology of the short bowel syndrome
Hypertonic gastric contents enter the duodenum and small intestine -- there is a fluid shift from intravenous space to the small intestine + release of vasoactive polypepetides
Paricardial effusion physical exam
Hypotension, tackycardia, distended neck veins, pulsus paradoxicus
Most common cause of post surgical AMS
Hypoxia
When ulcers require surgery I.H.O.P
I- intractability H- heminstabily O- obstruction P-perforation
What type of diverticulum is zenkers
pulsion diverticulum - b/c uncoordination of the cricopharygeal muscles txt cricophargengeus myotomy
IF a patient has A lump removed and the lymph nodes and later the biopsy comes back with Positive lymph nodes how does this change the management
IF the cancer is not positive for Her2neu/ER/PR Then do radiation - ( necessary for all lumpectomy) and chemotherapy to control the systemic disease
Sclerosing tenosynovitis
INTENSE PAIN and hisoty of trauma or overuse
The next best step in managment for A spinal cord injugry
IV dose of corticosteroids -- The surgical decompression of a spinal cord injugry depends on the findings of the MRI
patient has a history of a complicated cholecystectomy and ten months later presents with fever chills elevated WBC, ALP Alkaline phosphatase and direct bilirubin. Ct reveals intrahepatic bile duct dilatation with no evidence of stones
Iatrogenic stricture of the common bile duct
When do you need to gve rabies prophylaxis
If bite was unprovoked or dog isnt available for the brain
Stab wound managment to the abdomen
If it penetrates the peritoneum - ( can you see viscera, is there peritonitis or hemodynamic instability) go to OR -- otherwise digital exploration adn observation
What type of imaging do superior sulcus tumors require to stage
Imaging of the head MRI, CT
When do you give endocarditis prophalaxis
In GI prooceedures, GU and HEEENT
When do you screen for chlamydial infections
In all *sexually active women ages 24 and under*.
HEad trauma can cause cerebral salt wasting syndrom what factors are inapprioatly released and what electrolyte is out of balence
Inapproiate secretion of vassopression or ADh, Also inappriopriate secretion of ANP/BNP
Trauma- Circulation + pregnancy -
Increased HR is normal ; decrease hct 31-35% is normal, best to evaluate on the left side
RQ 0.7
Indicates that Fatty acids are being metabolised
Mechanism of action of sidenafil
Inhibits the type V guanosine monophosate phosphodiesterase enzyme
Fever, rash and renal dysfunction and eosinophiluria with WBC casts
Intersitial nephritis
IV line cannot be establishe in a very small child what is the next route of fluid admission
Intraosseous IO canulation - locations are distal tibia or proximal femur - if the growth plate is damged it will affect growth
If c spine injury is suspected what precautions must be take
Intubation with extreme care - lok for c spine tenderness to palpation
A 12 yo male had blunt trauma to the abdomen, and a CT scan finds a duodenal hematoma and no other injuries. What do you do?
Isolated duodenal hematoma is treated conservatively with nasogastric suction and parenteral nutrition.
A postive PPD of grearer then 5mm for a HIV postive person- what is the prescribed managment
Isoniazid and pyrodoxine for 9 months
What does technetium 99m label
It has affinity for the gastric mucosa - to identify meckles diverticulum
A woman has skin/nipple retraction with calcifications on mammography. A 3 cm spiculated masse in the Upper Outer Quadrant of the brest is noted. Histo shows foamy macrophages and fat globules. What is it and what do you do?
It is fat necrosis, and you just do routine follow-up.
Gastric adenocarinoma- where does it spread and what is the treatment
It spreads to the left supraclavicular node, sister mary joseph node and blummershlef nodes --- tx proximal cancer with total gastectomy --- tx distal cancer - wiht distal gastectomy and take out D1 LN at lesser curvatures
electrical burn management
Iv fluids + mannitol + acetazolamide to maintain a high urine out pur
Prepubertal boy presents with profuse bleeding from the nose with an obvious mass
Juvenile nasopharngeal angiofibroma
CRF what electrolyte must be tested before surgery
K must be tested before as it can acculmulate very fast
Paroxysmal supraventicular tachycardia PSVT most common cause
re-entry into the AV node
A well differentiated scc that often grows out of the hair follicle it normally grows rapidly and dies off
Keratoacanthoma
Left lower quandrant flank pain that radiates to the left thigh and scrotum *What is it?* & *what test*
Kidney stone and CT without contrast
Genu valgus
Knock knee observation is ok from 2 - 4 years at 4 the valgus should reach a maxmium and then the normal adult aligment will begin.
Besides tension pneumothorax, what can cause tracheal deviation?
LARGE hemothorax. You'll hear decreased breath sounds and DULLNESS to percussion.
Fluid replacement for burn victums from the parkland formula
LR volume - %BSA x kg x 4ml/kg gie 50% in the first 8 hours and then50% next 16 hours
Cancers that create 1,25 ( OH) 2 vitamin D production
LYMPHOMAS all types
Diagnositc Test for lactose intolerance
Lactose hydrogen breath test - a POSITIVE BREATH TEST = the conculsion that the bacteria are metabolising the lactose
squamous cell cancer of the anus - presentation
Large fungating mass growing out of the anus the mass is Enlarged lymph nodes 2 cm in diameter
Seminoma- histology and cancer marker
Large nests of round clear cells with a centrally placed nuclei and obvious nucleoli- resembling sphereocytes ---present men 20-40 --placental alkaline phophatase PLAP
Poor prognosis factors for breast cancer
Large tumor size Carcinoma with axiallary lymph node involvement high grade carcinom ER / PR negative over expression of HER 2 neu
treatment for chronic venous diseaes
Leg elevation, exercise and compression stockings.
Hyperlipedemia Men 35+
Lipid panel every 5 years
Esophageal leiomyomas- where are they located - anter or posterior mediastnium
Located in the posterior mediastnium and are normally submucosal and asymptomatic. only produce symptoms when >5cm
TSH secreting pituitaryy adenoms have an increase of what acctive subunit
the alpha sub unit.
Common complication of membranous glomerulnephritis
Look for proteinuria, periorbital edema and abdominal distension. *Renal vein thrombosis is a complication of nephrotic syndrome* - d/t antithrombin II -- NOw look for hematuria, abdominal pain and fever
Child presents with a new neck mass, the child has a fever a respiratory infection pain, and elevated white blood cell count .
Lymphadentitis
Placental Abruption classification- Minimal vaginal bleeding and normal fetal heart rate and localized pain and tenderness
MIld abruption
Intraductal papilloma tests
MOST common cuase of the unilateral bloody nipple discharge in women between 20 and 40 You wont see anything on mammaography You need *galactography*
Congential megaureter
MOre common in males then women and presents as a dilated distal ureter in the absences of any pathology. Some remain asympatomatic orther will eventually progress to hydronephrosis
How do you diagnosis the PML virus ( JC virus)
MRI and hx of focal neurological defect
what diagnositic tests are used to diagnosis ligament injury
MRI!
what is magnesium method of action in preventing seizures
Magnesium blocks neuromuscular transmission mediated by acetylcholine at the end plate this stops the seizure signals magnesium also suppresses the centeral nervous system
Patient has green vomting and double bubble sign on x ray
Malrotation d/t ladd bands or duodenal atresia or annular pancrease --- malroation is more likely if there is little normal gas pattern beyond the double bubble. - * ddx- with contrast enema *
Male with the gland penis exposed because the foreskin is pulled back the galnds penis is edematous, dusky and painful what is the managment
Manually Reduce the patient foreskin
RQ 0.8
Means more proteins are being consumed.
What is a Morton Neuroma?
Mechanically induced degenerative neuropathy commonly seen in runners. Presents with PAIN between the 3rd and 4rth toes that is reproducable with palpation, sometimes iwth a clicking sensation. Tx. is conservative with bilateral shoe inserts.
Where do the femoral blood vessels arise from:
Medial femoral circumflex adn the profunda femoris
Alarm symptoms
Melena Perisitent vomitng Hematemesis Weight loss Anemia Dyspahgia/ odynophagia
What Symptoms + GERD would you preform endoscopy
Men age > 50 with symptoms for > 5 years or cancer risk factors OR Alarm symptosm ( dysphagia, odynophagia, weight loss, anmeia, GI bleeding, or recurrent vomiting)
Thessaly Test
Meniscal injury -Pain or locking with interneal and external rotation of the knee while standing on one leg with the knee flexed at 20
Apley test
Meniscal injury- Pain with pressing the heel toward the floor while internally and externally rotating the foot with knee flexed to 90
Bronchogenic cysts - where are they found
Middle mediastinal mass - develop froom foregut remnants tx surgical removal
Bronchogenic cysts
Middle mediastinum masses and are benign
*traction diverticulum* is located where
Middle of the esophagus b/c Lymph node traction it is a sign of cancer
MIld claudication managment vs. severe claudication managment
Mild claudication - Exercise and life style modifications Severe- doppler tracing and arteriogram to localize most common location is the *common femoral -40-45%* aorta/ common iliac artery /popliteal artery - all 15%
systolic murmur _ Dyspnea and fatigue --> progresses to cor pulmonale + afib
Mitral stenosis
Placental Abruption classification- moderate bleeding and pain with fetal tachycardia with decreased variability and or mild late deceleration
Moderate abruption
Posterior mediastinum mass
NEUROGENIC TUMORS - Mengocele, enteric cysts, lymphomas, diaphramatic hernias, esophageal tumors and aortic aneurysms & esophageal leiomyomas
b/L Schwannomas of the eight nerve, meningiomas and gilomas
NF2
A patient developes a whistling noise after rhinoplasty. Why?
Nasal septal perforation - probably caused by a septal hematoma.
Duodenal hematomas treatment
Nasogastric suction with parenteral nutrition, most hematomas will resolve will resolve in 1-2 weeks
Neurofibromas ( schwann cell tumore) + cafe au lait spots, Multiple bengn skin lesions, possible optic giloma and lisch nodules in the iris of the eye
Neurofibromatosis type 1
Diabetic foot ulcers are d/t which processes
Neuropathy, microvascular, insufficiency and relative immunosupression
Prostate nodules + high PSA value
Next is to ultrasound or ultrasound need biopsy
if a patient with GERD develop damage to the lower Esophagus and have had long standing but unsuccessful medical mangement what is the next step
Nissen fundoscoplication - this wraps the fundus around the esophagus to replace the incompetatnt esophageal spincter
A breast-feeding mother has a hard, red, tender, and swollen area on her right breast. If there is no fluctuance, what is the tx? If there is fluctuance, what is the treatment?
No Fluctuance -> just give Antibiotics, analgesics, and continue breast feeding. Flutuance -> Incision and Drainage.
Will Healthy colonic mucosa bleed in responce to anticoagulaiton
No healthy mucosa wont bleed, normally only large masses or polyps so a patient with BRBPR should be given a colonscopy
WOuld you remove the lymph nodes from a sarcoma ?
No, because they spread hematogenously
OCP effect on blood pressure
Normally increase *3-6mmHg of systolic* and *2-5 of diastolic* but in *5% can cause overt hypertension* mechanism is unclear but possibly d/t an increase of angiotensiongen in the liver
physical signs of cor pulmonole
P2 loud- this is the pulmonic component of the 2nd heart sound and a right ventricular 3 rd heart sound - tricuspid regurgitation murmur
How do you get a false elevation of ABI
Occurs in vessel calcification - like in paitents with diabetes
Slipped capital head fracture
Occurs most often in overweight children, can occur bilaterally look for pain in the distribution of the the obturator nerve limited internal rotation.
Location of the diabetic foot ulcer
Occurs on the sole of the foot or high weight bearing sites
High pitched holosystolic murmur + dyspnea + fatigue
Often MVP - ( association - women, marfans ect.) - Tx annuloplasty or valve replacment
Oliguria definition ( w/o preexisting kidney disease)
Oliguria is defined as urine less then 400cc or less then 6cc/kg of urine output per day
Symptomatic difference between cholithiasis and cholangitis
Only *cholangitits* will present with *FEVER and JAUNDICE*
If suturing a child what is the agent to *achieve conscious sedation*
Oral or rectal midazolam or diazepam
Low grade knee pain, in 10-25 y/o. xray shouws codmans triganle with sunburst appearance
Osteosarcoma
What is dangerous about intubating a Trauma patient who is in hypovolemic shock?
PEEP can further decrease venous return to the heart, exacerbating the shock.
A patient has persistent nausea and vomiting of partially digested food. He has a history of attempted suicide with acid ingestion. What is the likely cause?
PYLORIC stricture (NOT esophageal stricture)
Symptoms of avascular necrosis
Pain - worse on e*xternal rotation decreased range of motion* and sometimes CLICKING on ambulation.
Symptoms that suggest maligancy of the spinal cord and not degenerative process
Pain i s worse lying down because the epidural venous plexus is disteneded
What is the prime objective in managing a rib fracture?
Pain relief....if they're in too much pain, they get atelectasis and pneumonia
McMurry test
Painful click with passive flexion and extension of the knee with the examiner thumb and index finger placed on the medial and lateral joint
Post PCI 12-24hours - patients presents with hypotension tackycardia and a new *pansystolic murmur*, there are also *rales* present on auscultation
Papillary muscle rupture - look for the new onset murmur + pulmonary congestion
A man has a wedge fracture of L2 after a bike accident. Abdominal CT shows a small retroperitoneal bleed and splenic laceration. He is treated with analgesics and supportive measures. On Day 3, he complains of abdominal pain and nausea. His abdomen is distended, tympani, and mildly tender, without rebound or guarding. Bowel Sounds are absent. X-ray of the abdomen shows gaseous distension of the LARGE and SMALL bowel. What is the cause?
Paralytic Ileus. Classically if follows abdominal surgery, but it can also occur in cases or retroperitoneal hemorrhage associated with vertebral fracture.
What type of pleural effusions cause a glucose of less then 60
Parapneumonic effusion, maligancy, tuberculosis or rheumatoid arthritis
Phlegmasia cerulea dolens
Patient present with acute onset leg edema and pain and cyanosis - high risk nerve damage and venous gangrene
Constant watery Diarrhea, Dermatitis and dementia
Pellagra a deficiency in niacin
In acute ruptured appendicitis, where is common place to find an abscess?
Pelvic Abscess.
A patient with an MI 2 weeks ago and a serious case of acalceous cholecystitis what is the managment
Percutaneous drainage via a cholecystectomy tube with interval 6 to 8 weeks
ECG with the sign of electracal alternas is a sign of what ? what treatment ?
Pericardial effusion Pericardiocentesis
Patient presentation with hypotension - ( wont respond to IV bolus ) tackycardia, and elevated jugular venous pressure
Pericardial tamponade
Sucking chest wound management
Place a 3 sided occlusive bandage on top to allow air out but not in and then place chest tube else where
A patient shows signs of a traumatic spinal cord injury. After they are hemo stable and airway is secure, what should you do?
Place a Foley...they could have urinary retentiona nd could have bladder distension and damage.
Pain every time the foot strikes the ground - *worse in the morning* preventing him from putting any weight on the heel
Plantar fasciitis
Light criteria
Pleural fluid *protein*/serum protein > *0.5 * Pleural fluid *LDH*/serum LDH >*0.6* Pleural fluid LDH >2/3 of the upper limit of normal serum LDH
A patient with a history of COPD and smoking suddenly develoops Shortness of breath what is the most likely etiologies
Pneumothorax- d/t *Apical blebs* d/t the chronic destruction of the elastic parts of the aveoli
Causes of restrictive cardiomyopathy
Sarcoidosiss, amyloidosis, hemochromatosis, endomyocardial fibrosis, *Left ventricular VOLUME is normal*, wall thickness may be normal or increased
Cough lasting greater then 8 weeks : what is the differential diagnosis
Post nasal drip asthma and GERD
Centeral cord syndrom
Post whiplash in the elderly with preexisitng degenerative conditions- Upper extremities more affected with pain and paralysis
type 3 hiatal hernia
Presence of BOTH types txt surgical repair
insicional hernia
Presents as bulging at wound site with increased abd pressure ( e.g. coughing) needs to be repaired surgically
Air emboli
Presents as sudden death in an intubated respirator pt. managment is immediate !!!! TRENDELENBURG POSTION and caridac masssage
Most common cause Of osteomyelitus from a nail puncture
Pseudomonas aeruginosa !!!
Patient has well circumscribed raised papules and plaques covered with a thick silvery scales - The lesions are found on the scalp trunk and extensor areas of the extremities
Psoriasis
Post trauma patient has deteriorating ABG and white out lung on CXR what is the txt
Pulmomary contusion give colloid + diuretics + fluid restriction
Complications of obestity hypoventilation syndrom
Pulmonary hypertension cor pulomnale, decondary erythocytosis hypoxia and chronic hypercapnia
Obesity hypoventilation syndrom
Pulmonary hypertension with cor -pulmoale secondary ethryocytosis hypoxia chronic hypercapnia - d/t hypoventilation Respiratory acidosis
Treatment polymyalgia rheumatica
RESPONS TO GLUCOCORITCOIDS
Hypertension and possible renal failure
REnal artery stenosis
What is Central Cord Syndrome?
REsults from hyperextension injuries, particularly in elderly patients with spondylosis. It is characterized by more weaknesses in the upper extremities than the lower extremities.
Patient has a rosy hue with telangiectasia over the cheeks nose and chin. - flushing can be precipitated by hot drinks heat emotion and other causes of rapid body temp changes
ROSACEA
What is the RQ for a mechanically ventilated patient
RQ 1.05 This is CO2 to O2 At steady statte this ratio depends mainly upon the major feul being oxidized for ATP production.
How will the RQ value of a patient receiving purely carbohydrate diet be? What about Protein? Fat?
RQ value = CO2 produced to O2 consumed Carb = 1.0 or higher Protein = 0.8 Fat = 0.7
What is a simple way to increase a patient's function residual lung capactiy?
Raise the head of the bed.
Anticoagulation + skin necrosis
Rare side effects of warfarin start heparin with it to prevent it
After a subarachnoid haemorrhage at what day will rebleeding occur and what day will vasospasm occur
Rebleeding occurs in the first 24 hours Vasospasm after 3 days .
Rome diagnostic criteeria for irritable bowel syndrome
Recurrent abdominal pain/discomfort > days/month for the past 3 months & > 2 of the following - Symptom improvement with bowel movement -Change in frequency of the stool - Chnage in stool form
NEck blunt trauma
Risk of carotid dissection ( txt with anticoagulation) or largenal edema ( tx intubation)
Renal complications of sickle cell trait
Renal medullary carcinoma and UTI , and hematuria - this is d/t *renal papillary necrosis* that presents with *hematuria* with intact RBC- these situations normally occur and resolve spontaneously. *** sickle cell trait patients also cant concentrate their urine very well
Managment for a 72 year old with a displaced femoral neck fracture
Replacement of the femoral head with a metal prosthesis ---Because the femoral head has tenuous blood supply the chances of surviving a neck fracture with out developing a vascular necrosis are slim.
Shoulder pain that resolves with lidocaine Vs. Shoulder pain that doesnt
Resolves with lidocain- tendinitis Fails to resolve with lidocaine - Rotator cuff tear
Treatment for fat emoblism
Respiratory support low molecular weight Heparin & steroids
How do you treat a stres fracture?
Rest and Analgesics.
Treatment for osgood schlatter disease
Rest and ice after physical activity - physical activity doesnt need to be stopped
When can you see false negative DPL/FAST
Retroperitoneal injuries
symptoms of resistrictive cardiomyopathy
Right sided heart failure signs can predominate - prominant jugular venous distension, bilateral ankle edema and tender hepatomegaly ALSO symptoms of left sided failure
what fluid to use in hypovlemia or isotonic fluid loss
Ringers lactate
Continous air leak into the chest tube. + subcutenous emphysema
Ruptures tracheal/bronchi - go to the OR
Chest pain, epigastric pain and abnomral chest x-ray findings of mediastinal air with a widened mediastinum: what diagnositc test
Ruputured esophagus: With contrast esophagography - rememeber you need water soluable contrast *most common location is left posterior lateral*
Placental Abruption classification- Continous knife like uterine pain with fetal bradycardia, severe late declerations or fetal death. DIC is possible
SEVERE abruption
Increased Platlet Destruction
SLE Hparin Idiopathic thrombocytopenic purpura DIC Thrombocytopenic-purpura hemolytic uremic syndrom antiphophalipid syndrom HIT - post surgery d/t heparin
A women falls on a hyperextened wrist, 3 days later she comes to see you with swelling at the dorsum of the thumb. X ray is normal. what is the diagnosis what is the managment
Scaphoid fracture -the proximal fracture is vulnerable to avascular necrosis Pain is found while palpating the anatomic snuffbox Xray: Wrist needS to be pronated and ulnar deviation to expose the schapoid and only shows up 10 days post injury - management place in spica thumb cast for 10 days then RTC for xray
pathophsiology of migraine
Serotonergic control of blood vessels is dysegulated and therefore there is cerebral vasodilation
Because treatment for chemotherapy-induced nausea and vomiting
Serotonin antagonists that target 5HT3 receptor are considered first line
A young patient with Confusion rapid breathing and abdominal pain - she had a recent history of infection what is her underlying pathology and what electrolyte is most likley Abnormal
She has *diabetes* and the infection induced a diabetic crisis the electrolyte that is abnormal would be her *total body K*- Note her serum potassium would be elevated but the total body is decreased
Postprandial (20-30 min after eating) abdominal cramps weakness light headiness and disphoresis
Short bowel syndrome- symptoms. common post gastrectomy ( not for those who got proximal vagotomy)
Pancoast tumor Clincial Symptoms
Shoulder pain horners syndrom ( from sympathetic chain and inferior cervical ganglion) C8-T2 neurological involvement - weakness and atrophy of the intrinsic hand muslcces pain and paresthesias of the 4th and 5th digits medial arm and forarme Supraclavicular lymph nodes enlargements Weight loss
Small PTX management
Simple observation is okay if no symptoms - no free fluid -not expanding
GIST
Soft tissue tumor of stomach tx wedge resection w/ 1 cm negative margin no affect on LN
NSCLS treatment Stage 1 / Stage 2 Stage 3 / Stage 4
Stage 1 / Stage 2- 1st get spirometery to see if the patient can have a lobectomy Stage 3 / Stage 4 - chemotherapy and radiation
NSCLS Stage 1 Stage 2 Stage 3 Stage 4
Stage 1- local Stage 2- hilar lymph nodes involved Stage 3- distal lymph nodes Stage 4- metastatic cancer
Complication post rhinoplasty that presents with a whistling noise heard
Spetum perforation it is not one of the most common but definately one of the most serious The septum is cartilage therefore getting its nutrition from the over lying mucosa damage to that results in death of the underlying cartilage
Complication of Chronic pancreatitis - pain located int he upper left quandrant may be referred to the left shoulder. ON EGD you will see gastric varies without esophageal varices
Splenic vein thrombosis As the splenic vein runs along the back of the pancreas chronic irritation may cause and occlusion
Nasopharynegeal carcinoma
Sqamous cell of origin seen more in people of mediterranean or far eastern descent * asymptomatic until diagnosis which is at a late stage* Symptoms- recurrent ottitis media, recurrent epistaxis or nasal obstuction **associated with the EBV virus**also smoking and chronic nitrosamine consumption
Cancers that produce PTHrp
Squamous cell cancers ( eg. lung, head, neck esophagus) renal and Bladder cancer Ovarian and endometrial cancer Breast Cancer ( made ONLY by the cells that invade the bone marrow therefore systemic levels arent raised)
Renal lacerations stable unstable
Stable - angiograph and planned operative repair unstable - iv pyelo to detect if 2 kidneys are present then OR for nephrectomy
Steatorrhea effects on Calcium phosphate and parathyroid hormone
Steatorrhea basically means there is a decrease in the absorption of fat soluble viatmines in the bowel in the form of micelles. Therefore Decrease vit D = decrease Calcium and decrease Phosphate levels because of the elevated PTH levels
What cancer screening test do you preform on those with pernicious anemia
Stool occult blood looking for gastric gancer ( or carcinoid)
Patient has an episode of LOC when working out his biceps at the gym
Subclavian steal syndrom - no symptoms at rest but decrease brain blood flow with increase demand to the arms
A darkening of pigment under the finger nail
Subungual melanoma - Txt with DIP amputations
Stab to the neck and hemiparesis
Suggests injury to the carotid get angiogram and wither vascular or neurosurg consult.
4 t's for anterior mediastinal mass
T- thyoma T- teratoma T- terrible lymphoma T- thyroid
Teens with persisitent pain over the tibial tubercle it is aggrevated by quad contraction - what is it and what is the mangment
THis is osgood schlatter disease Txt with pain control and gental stretching of the quads - this condition resolves once the growth plate ossifys
When Do you give both Tetanus vaccine and TIG to a patient with a dirt wound
TIG is only given if the patient has never received any tetanus vaccine ** if the wound is clean the vaccine is only administered if it has been greater then 10 years if the wound is dirty the vaccine is only administered if it has been greater then 5 years
Renal failure in a patient undergoing chemotherapy
TUmor lysis syndrom renal failure from a large scale release of uric acid
Symptoms of myocardial contusion
Tackycardia and new bundle branch or arrthymia- sternal fracture is a commonly associated finding
Non reactive pupils Syses deviated toward the hemiparesis !!! -- T- in thalmus for toward Thalamus --Hemiparesis hemi sensory defect
Thalamus
After a gastric lymphoma has been diagnosised what is next step before tereatment with chemo and radiation begins
The *depth of the tumor invasion* needs to be determined as the chemotherapy and radiation will melt the tumor away and might result in a *perforation* therefore if the tumor extends the full thickness surgery is indicated to resect the tumor
What determines the txt for a gastric lymphoma
The depth of invasion - Ct scan LN biopsy , bone marrow biopsy partial thickness - radiation Full thickness - surgical resection
Which par tof hte brain does the PML ( papiloma virus ) infect
The white matter
How do you detect uric acid stones?
They are radiolucent, so you use CT or IVP.
A patient present with *peripheral neuropathy* of the foot, of the fingers and *palable purpura*
This is *monoeuritits multiplex* a painful asymmertical asynchronous sensory & motor neuropathy -damaging greater then 2 nerves. Often seen in vasculitites - *like cryoglobinemia*
pregnant Patient *week 33 present* with *blood pressure > 150 systolic*, *proteinuria*, No headaches or visual disturbances oliguria, increased serum creatine and thrombocytopenia
This is MILD preeclampsia and all that is done is to Wait until week 37 for delivery therefore the best management is to admit to the hospital
If a new infant - has symeterical gluteal folds but the physician cannot completely abduct the infants thights when her hips and knees are flex ed
This is an inconculsive finding for developmental dysplasia od the hip. Do an ultrasound to be sure
Several months after sustaining a crushing injury to his arm - patient now has constant agonizing pain that no medication can help and is aggrevated by even the lightest touch.
This is known as *causalgia or reflex sympathetic dystrophy or sudeks*. - the cure is the surgical *sympathectomy*
Steatorrhea + Bone pain/ tenderness with muscle weakness or cramps with gait abnormalities
This is the classical picture of vit D def.
List of anterior mediastinum masses
Thymoma, retro-sternal thyroid, teratoma, lymphoma. ** if the mass is large the patient may complain of chest heaviness, if it invades when horners syndrome, and facial and upper extremity edema when the tumors invade locally**
Most severe complication of a 26 year old man with IBD who presents with A fever increase HR, Increase WBC and anemia ? what is the test
Toxic megacolon. requires a X ray to demonstrate the dilation -- Patient would present with the signs of SIRS + anemia and altered sensorium electrolyte disturbances Hypotension
Most comon inherited bleeding disorder
Von Willevrand with def or imparied action of the von willibrand factor Prolonged aPtt and Bleeding time the platelet counts are normal
If a patient is profoundly hypothryoid - post surgery--what what is the managment
Treament is steroids - because if you just increase thyroid homrone the body might go into overdrive.
Doppler findings : what does this mean triphasic wave Biphasic wave Monophasic wave
Triphasic is the nomrla wave form with a rapid systolic flow and brief phase of reverse flow secondary to elastic recoil. Biphasic is moderate stenosis Monophasic is severe stenosis
Melanoma that is < 0.75mm in depth
Tx excsiion w/ 1cm margins
Surgical txt for sarcoma
Txt with 1 cm negative margins - check CT of the chest for METS ( hematogenously)
Melanoma depth >4 mm
Txt with 2 cm margins and remove palpable lymph nodes but patient will most likely die from mets
Lateral blow to a stationary knee results in
Unhappy triad- acl, mcl and medial meniscus
Blood on th emeatus, scrotal hematoma, high riding prostate,
Uretheral injury DX retrograde urethrogram, TXTsuprapubic catheter *NO FOLEY *
If a patient has a CR > 1.5 but still requires a CT what can be done to reduce the risk of Nephrotoxicity
Use non ionic contrast
IN ARDS with low oxygenation despite fio2 of 70% what value can you increase to help the oxygenation
increase the PEEP this will push more oxygen across the membrate
Inability to maintain to an errection
Vacuum device if he has cardiovascular co-morbidities Yohimbine - alpha blocker sildenafil - phosphodiesterase inhibitors
Treatment for paroxysmal supraventricular tachycardia
Valsalva manuevers carotid sinus massage and immersion in cold water increase *via increase in vagal tone* and *decrease in conduction through the AV Node*
Adverse effects of PTU
Vasculitis, Rash, arthalgias, hepatitis, and agranulocytosis
Next strep in managment for venous disease after leg elevation, exercise and compression has fail]ed
Venous duplex ultrasound to identify venous reflux or isufficency *Persistent symptoms need endovenous ablation*
General features of genral anesthia
increased physiological control increase pulmonary complicatitons Decrease HR/BP
Bilateral extremity edema and stasis dermatitis. hemosiderin, xerosis and statis dermatitis is the most classsically involes the emdial leg.
Venous hypertension d/t venous valvular incompetence resulting in pooling of the venous blood and increased postcapillary venues. the colour is causes by hemosiderin deposition. Xerosis is most common early finding
What heart condition is lidocaine to treat, what is a complication and how does it affect someones prognosis
Ventricular arrhythmias Can cause asystole Doesnt affect the prognosis
Anterior cord syndrome
Veretbral burst fractures - presents as bilateral loss of everything BUT fine touch and propreception
How does acute blood loss affect the CBC levels of RBC, WBC hct, hgb
Very common trick question Acute blood loss doesnt afftect the CBC in any way
TPN and elevated LFT
Very common up to 30% TPN can cause fatty liver structureal liver damage and chirrhosis
Causes of a decrease in platlet production
Viral infections - EBC, Hep C and HIV Chemotherapy myelodysplasia age>60 Congential FANCONI Syndrom Vit b12 or folate Deficeny
A patient presents with Biliary Colic. What actually causes the pain?
Viscous Distension of the Gallbladder mucosa.
Low hemoglobin post surgery
Volume depletion secondary to intra-operative blood loss
Hemangioblastoma ( cerebellum) + angiomatous lesion of the retina + Cysts in the pancrease, kidney and genital tract, + clear cell renal carcinoma+ neuroendocrine pancrease tumor+ phenochromocytoma --> mutation on chromosome 3
Von hippal Lindau syndrom
Most effective non pharmalogic measure to decrease blood pressure
WEight loss Reduce BMI < 25 - 5-20 mmHg per 10 kg
How does alcohol use affect your surgical mangment
Wait for the patient to go through withdrawl before preforming any surgical treatments
How do you confirm the diagnosis of Esophageal Perforation?
Water-Soluble Contrast Esophagram
Signs of malnuitrition
Weight loss greater then 20% Albumin < 3 give 7-10 days of pre-op nutritional support
When would you suspect a mesentery injury
When there is bowel injury as the mesentery is stronger then bowel
How does this effect your post op management:Bloody sputum:
indicates active infection or lung cancer; requires a full work-up including CXR, CT scan, and bronchoscopy
Classic symptoms of AVN
Worse on external rotation decreased range of motions and sometimes clicking with ambulation
Side effects of Eryhtropeoiten therapy
Worsening of hypertension - can have a 10mmhg rise in diastolic pressure. Headachs Flu - like syndorm red cell aplasia
In the case of an amputation injury (like cutting off your finger), how do you transport it?
Wrap it in saline-moistened gauze, sealed in a plastic bag, and THEN placed on ice.
Treatment Post Scaphoid fracture
Wrist immobilization for 6-10 weeks in a spica cast
pneumothorx and hemothorax diagnostic test
X ray
RQ close to 1 menas what about the major nuitrietn being metabolised
indicates that carbohydrates are the major nutrients being metabolised.
A pregnant women with asymptomatic bacteruria ( <100, 000 cfu) Do you treat? or not
You do treat as the association between *preterm delivery/low birth weight has been demonstrated*. treat with *nitrofurantoin*
elderly patient who begins to have diffuse abdominal pain after an episode of hypoperfusion. what do you find on angiogram?
You see alternating narrowing and dilation of the arterial branches - this is *non occulsive mesenteric ischemia*
When do you start screening for ulcerative colitis
You should start at 8 years post diagnosis of the disease
De Quervain tenosynovitis
Young women who complain of pain on the radial side of the wrist - no evident deofrmity
Patellofemoral pain
Young women with chronic overuse of the knee ___ Test is to reproduce the pain on extension while compressing the patella
What is the most common hernia
indirect hernia -goes through the internal ring lateral to the epigastric vessels
When someone is bleeding and there is bright red blood in colon what test
a Tagged red blood cell study - check the bleeding is in the small intestine or colon
Supprative phelbitis
infected thrombus at site of venipunture, Tx remove catheter and surgical excision of infected vein to the first non-infected branch
Acid or base injestion what is the managment
acid- milk alkali - orange juice
Cellulitis
active infections are asociated with a higher risk of post op complications - DELAY until wound is resolved
Function of -osins
an *alpha 1 blocker* that relaxs the trigone and sphincter facilitating urine flow
Causes of exudative pleural effusions
infections maligancy connective tissue disease inflammatory disorders movement of fluid FROM the abdomen to the pleural space coronary artery bypass surgery * pulmonary embolism usually*
Thymic cysts
are rare benign congenital cysts that occur laterally in the neck along the embyonic path of descent of the thymus gland
Most common ethnic group to get lactose intolerance
asian americans
lung coin lesion seen with an AIr-cresent sign
aspergilloma
Bladder injury - what situation is it associated with
associated with *seatbelt trauma* get a retrograde cystogram and post void films then surgical repair
Gonococcal spetic arthritihis
asympetical poly arthritis associated with tenosinovitis and skin rash, isolated purullent mono and oligoarthritis - 75% of poeple have silent preceeding infections
normal urine output
at least 0.5-1 mL/kg/hr
What do you give in oragnophosphate poisioning - salvation lacrimation, urination and defecations
atropine
IMmune thromcovytopenia
autoimmune disroder due igG autoantibodies agaisnt the platelet membrane glycoproteins. DIAGNOSIS Of exculsion Txt glucocortidocoids
Tx for esophagel cancer in the upper 1/3
chemo and radiation only
tx for esophageal cancer in the middle third
chemo and radiation to shrink the tumor and then esphagectomy
Sexually transmitted epididymitis causes
chlamydia trachomatis and neisseria gonorrhea occurs in younger and sexually acitve men __ this form often presents with discharge from the urethra, *pain* will normally be *less then ,12 hours in duration* which may localize to the *top of the testicles* many paitents have nasea and vomiting
Burns and methmeoglobinemia Symptoms and treatment
chocolate brown blood, centeral cyanosis of the trunk arrthymias seizures coma Iv methylene blue
MOST important risk factor for bladder cancer
cigerette smoking Stopping will only reduce the risk 20 yeears post.
Coin lesions are seen in the lung + red nodules on the skin and the patient has been visiting arizona during the dry season
coccidiocodomycosis
morton neuroma
commonly occurs in runners and is not a true neuroma. symptomss of numbness and burning of the toes aching and burning in the distal forefoot that radiates from the metatarsals to the 3rd & 4th toes
Secondary intention
contaminated wounds left open to prevent abscess formation - granulation tissue forms first then contraction via myofibroblasts
Pseudodementia or reversible cognition abnormalities
d/t *Severe depresssion* especially in older adults with symptoms simlar to dementia
High amylase in the pleural fluid
d/t esophageal rupture
hypersplenism
dequestration in the spleen, platelet cout remains > 30, 0000 & the mass and function is normal. Clinical bleeding doesnt occur
Hypokalemia post surgery
diarrhea or vomiting fix K at rate of < 10 mEq/hr
Any patient that suffers a *pelvic fracture* and has the urge to urinate but doesnt
do a *retrograde urethrogram* to ensure no damage to region before you place a foley.
If patient has a dysuria before surgery
do urine culture and delay surgery until resolved.
Primary intention - epithelization by POD , Max collagen - avoid weight lifting Complete healing by
epithelization by POD - 2 days Max collagen -5-7 days avoid weight lifting- 4-6 weeks Complete healing by - 6 months
tx for esophageal cancer in the lower 1/3
esophagectomy and proximal gastrectomy
how often should women 50-75 get momogram
every 2 years
Treatment for mesothelioma
extrapleural pneumonectomy is currative but high risk of morbidity/mortality
Stroke in the cerebellum
facial weakness and neck stiffness Gaze palsy OR NYSTAGMUS Gait atxia NO HMIPARESIS Stupor or coma - b/c brain stem effected
Inhalation of burn managment - how to manage it
fibroscopic bronchoscopy -intubate
thrombotic microangiography
fomartion of platelet rich thrombi in the microcirculation seen in - HUS, thrombotic thrombocytopenic purpura, hemolytic uremic syndrome and disseminated intravascular coagulation. Labs - thrombocytopenia and schistocytes with anemai
Priapism in trauma
fresh spinal cord injury check for anal spincter tone brady cardia and possibly neurogenic shock
How does this effect your post op management: Green sputum:
give oral antibiotics, and schedule surgery after Tx is complete
Groserelin
gonadotropin releasing hormone *GnRH agonist* incdicated for the treatment of androgen recpetor positive prostate cancer and advance breast cancer and for reduction of endometriotic lesions
Reversible cause of restrictive cardiomyopathy
hemochromoataiss
What is the Trigger in excersise induced asthma
high minute ventilation of sry cold air which stimulates mast cell degranulation and airway constriciton.
juvenile angiofibroma
highly *vascular fibrous tumor* that classically affect adolescent males and appears to be relaed to androgenic stimulation- puberty . Manifests as unilateral epistaxis
Symptoms of multiple myeloma CRAB
hyperCALCEMIA, Renal failure, ANemia and BONE pain - X ray shows punched out lesions
Factors that contribute to the formation of acalculous cholecystitis
hypovolemia, absence of alimentary nutrition multiple blood transfusions narcotic use and prolonged ventilator dependance.
CRF and operative hypotension
if the patient has taken steroids consider aldosterone
GSW below the nipple line
immmeadatly exploratory laportomy
Electrical burns - appear benign on the surface
makes a large amount of interior damage to muscle nerves and vessels and muscle injury
scrotal hematoma what test and what are you looking for
manage non-op unless testicle is ruptured and you can tell this on US
pericaridal cysts - where are they found
middle mediastinal masses - typicall water bottle appearance - tx surgical removal Clincial presentation: most patients are asymptomatic - may present with dyspnea Often congnetial but might be a complication from pericarditis - look for a single layer of mesothelium cells Xray seen at the cardio-phrenic angle
Embryonal carcinoma
most commonly occurs in young men and typically presents as a solitary painless testicular mass. *tumor marker*-increase alpha fetal protein. *Histology* - small cells with indistinct borders and scant cytoplasm- sheets of crowded nuclei and high mitotic rate with necrosis
If there is 0cc Post op-urine output
most likely a kinked or plugged foley
Posterior mediastinal mass
neurogenic tumors aka neuilemoma
Loss of the proprioceptive sensation from the legs ataxia and paresthesisa
neurosyphilis
minor head trauma ( GCS= 15 with non severe mechanism & no vomiting, headaches, loss of consciousness
no head ct
Female military recruit presents with pain in her right foot lasted for at least 1 week, there is swelling and tenderness on the foot. pinpoint tnederness
non displaced hairline stress fracture- txt is analgesics and rest
If a patient presents with any of the following which test do you run -> - vomiting - headache - questionable or breif loss of consciousness -Injury caused by high rsik mechanism of injury -severe mechanism of injury
observation for 4-6 hr or head Ct without contrast
FLank pain, low volume coids with or without occasional high volume voids
obstructive uropathy
What Enema agent can not be given to thoses in renal failure
osmotic agent - risk are dehydration and hypermagnesium
Atelectasis what does the blood gas look like
pH 7.49 Po2 70mmhg Pco2 27mmHg Patient is hypoxemia and then the patient hyperventilates to overcome this
Mulder sign
pain between the third and fourth toes on the plantar surface and a clicking sensation when simultaneously palpating this space and squeezing metatarsal joints
Symptoms of Osgood schlatter disease
pain on the *tibial tubercule and patella mostly after repetitive exercise*. occurs between children ages 10 to 15 years the problem is in the distal tibial insertion because this insertion is yet to ossify
Type 2 hiatal hernia
paraesophageal hernia - risk of incarceration and strangulation tst Surgical repain
Painless vaginal bleeding
placenta previa
Esophageal rupture
pneumonediastinum and pleural effusion, diagnosed is confirmed by water soluable contrast
Difference in complications from a posterior ulcer to an anterior ulcer
posterior ulcers bleed - gastrodeodenal artery Anterioir ulcers- perforate
Wound infection:
red and tender area on incision site; Tx drainage and BID wet-to-dry dressing changes, no antibiotics unless cellulitis is spreading
Blunt trauma to the back or Lower rib fracture
renal injuyy check with CT scanand amange non-op if Possible
Fistula + abscess managment
requires percuteneous drainage
Fistula + peritonitis managment
requires surgical exploration
Neurilemoma
schwann cell nerve sheath tumors Dumbell shapped tumor found adjacent to vertebral bodies, develops from nerves and nerve sheathes
scaly erthymatous rash on the face chest back and groions
seborrheic dermatitis
type 1 hiatal hernia
sliding hernia- risk of reflux esophagitits tx PPI
Embryonal carcinoma- histoolgy and cancer marker.
small cells with indistinct boarders and scant cytoplasm - with sheets of crowded nuclei - high mitotic rate and necrosis can have *alpha fetoprotein AFP *
therapy for umbilical hernias in children under 2
small umbilical hernias close spontaneously in children before 2 years
Causes of spinal cord compresssion
spinal injurgy maligancy infection
Staging of esophageal cancer - stage 1 stage 2 stage 3 stage 4
stage 1- submucosa only stage 2 - invades muscularis stage 3- invades adventitia stage 4- metastatic
what must be given perioperatively in a paitent that has a kidney transplant
steroids
Stab to the neck + hoarseness
suggests injury to the airway, larynx ( voicebox) or recurrent laryngeal nerve DX: laryngoscopy or exploration
Stab wound to the neck + dysphagia
suggests injury to the esophagus- dx esophagocopy or barium swallow
impaired upward gaze is compression on what part of the brain
supra-pineal recess, remember parinaud syndrom, with eyes that deviate downward known as the sun setting effect.
Post op fluid managment
surgical blood loss replace in a 3:1 ration with IVF- replace 500ml blood loss with 1.5: NS or LR
Stab wound to the nipple line
suspect damage to the diaphragm or to the abdominal organs
Infraclavicale stab wound
suspect injury to the artery or vein dx angiogram if stable urgent exploration if unable
Weakness in the upper extremities and loss of pain and temperature sensation in a cap like distribution over the neck-
syringomyelia- causes are congential in arnold chiari or Post whip-lash injurgy
Prehypertension
systolic 120-139mmhg; diastolic 90-99mmhg
Stage 1
systolic 140-159 mm Hg or diastolic 90-99 mmHg
Low grade epiphyseal pain in a child. X rays shows an onion skinnig pattern what is it and what is the mutation
t(11:22) - ewing sarcoma
Subclavian venous catheter complication
tension pneumothorax is life threatening condition
when should adults get TD vaccine vs. Tdap
the TD vaccine should be given every 10 years after 18 and the tdap booster should be give to an adult once.
who should not get a LAP Nissen funoplication
the morbiditly obese instead just give gastric biopsy
What symptoms define a case of diverticulitis as complicated
the presence of *abscess or fistula* or perforation
What would you do for a pressure ulcer on a hernia
there is a high risk of rupture and this requires urgent repair
CRF and intra operative bleeding
this is d/t platelet dysfunction secondary to uremia * give desmopression or FFP* but not platlets
Child with history of nose bleeds and a dried crust on the *anterior portion*
this is epistaxis from picking the nose and intermittent trauma to nasal mucosa
Post op- bypass patient presents with a cyanotic toe
this is trah foot this is a post op embolization and tx with LMW- heparin + long term aspirn
Radioacitve iodine uptake
this requires a thyroglobin measurment - *LOW thyroglobulin indicates exogenous thyroid hormone* elvated thyroglobulin - indicates a glandular source thyroiditis iodine expsure extraglandular production
Symetrical polyarticular arthritis is a young patient, that is an acute onset and short duration. + fever + RF and weakly postiive ANA
ths is viral arthritis the *short duration and acute onset* should be the biggest hint, as RF or SLE would NOT resolve in this time
ANterior mediastnium masses
thyomas, lyphomas, teratomas + germ cell neoplasms
multiple Ring enhancing lesiosnin the HIV infected patients, MRI reveals multiple spherical and located in the basal ganglia
toxoplasmosis give TMP-SMX
Club foot - b/l inverted foot
tx is serial plaster casts on adducted forefoot
WRIST INJURY: management administer analgesics and rest
txt for a sprain
Melanoma depth 0.76-3.99 +/- palpable lymph nodes
txt with excision of 2cm margins + palpable lymph nodes - Removal - non palpable LN - sentinel LN biopsey
Which gastric stomach ulcer types are d/t increase in acid production
type 2- duodenum and stomach type 3- pylorus txt is total vagectomy and pylorectomy
How does this effect your post op management: Smoking:
up to 6× risk for post-op complications due to compromised ventilation, must quit smoking for 2 months before surgery
Cardioplegia solution
used to stop the heart in MID-Diastole - to protect it from ischemia and provide a motionless feild- often used with hypothermia to prolong time of safe ischemia- 2.5 hours
How does this effect your post op management: Severe COPD
very high risk for acute pulmonary failure with surgery; teach patient about incentive spirometry, give bronchodilators, and mobilize post-op to prevent atelectasis
Who should get a Digital rectal examination and PSA antigen levels
who are at risk of dying from prostate cancer. ONLY people with signs of metastatic disease need treatment - Bone pain, voiding obstructions.
Define clean contaminated wound and the risk of infection post surgery
wound that is created in a sterile environment but involves *entry* into *respiratory, GI, Or GU systems* with no or limited spillage POst surgery Risk of infection 3-5%
a 4cm mass in left neck- present for 6 months HARD History of smoking + rotten teeth what do suspect and how do you test
you suspect mouth cancer most likely squamous cell cancer that has metasisized to the neck lymph node. Confrim with pan-endocscopy triple endoscopy and mucosal biopsies
if there are duodenal ulcers in th 2nd - and 4th part of duodenum what does this indicate
zollinger ellision syndrom - gastrinoma