General Surgery Random

Treatment options for Graves disease? What can be injured during surgery?

antithyroid drugs (methimazole or PTU) radioactive iodine surgery (thyroidectomy) recurrent laryngeal nerve

What part of the stomach does H. pylori infect?

antrum and body

Define hemianopsia

blindness in half the visual field

How is Roux-en-Y GB done and what are the complications?

bypassing most of the stomach, entire duodenum, and 100-150 cm of small intestine. Dumping syndrome is a big complication --restrictive and malabsorptive

What are the 3 MC causes of permanent Post-op vision loss?

central retinal artery occlusion ischemic optic neuropathy cerebral vision loss

What are the mechanisms of action of: cocaine amphetamines MDMA

cocaine blocks biogenic amine reuptake (dopamine, norepi, ans serotonin) amphetamines stimulate biogenic amine release and decreases reuptake MDMA: similar to amphetamines: effects 5-HT more than dopamine. May damage serotonergic neurons

What is Plummer-Vinson syndrome?

esophageal webs + dysphagia + iron deficiency anemia

How often do you assess fluid needs on the first day post-op?

every 4-6 hours IV orders should be evaluated every 24 hours or more if special curcumstances

What is Wilson's disease?

excessive accumulation of copper in liver, brain, kidney, cornea; inherited disorder of copper metabolism Cause lead to liver scarring/ cirrhosis,

Tell me about pheochromocytoma How do you diagnose? How do you treat?

it is a catecholamine secreting adrenal tumor which secretes norepinephrine and epinephrine autonomously and intermittently, causing hypertension, palpitations, headaches, excessive sweating 24 hour cetecholamines (urine and serum) CT or MRI to see adrenal tumor Alpha blockers (phenoxybenzamine) BEFORE SURGERY!!!

Which enzyme is more prominently altered with acute pancreatitis?

lipase! Serum lipase is a more sensitive test than serum amylase in patients who present with early acute pancreatitis. Serum lipase rises within four to eight hours, whereas serum amylase rises within six to 12 hours. Serum lipase also remains elevated longer (has a longer half-life), which makes it a better test in patients who present more than 24 hours after symptom onset

Central cord syndrome

loss of pain and temp sensation at the level of hte lesion, where the spinothalamic fibers cross the cord, with other modalities preserved

Anterior cord syndrome

loss of pain and temperature below the level

Biliopancreatic diversion with duodenal switch complications

malnutrition problems

What is the classic triad of chronic pancreatitis?

pancreatic calcification (plain abdominal x-ray), steatorrhea (high fecal fat), and diabetes mellitus

What can cause respiratory acidosis?

pulmonary disease neuromuscular disease hypoventilation -- (opiates barbiturates)

For elective surgery, patients should be free of wheezing and have a peak expiratory flow rate of what?

rate greater than 80% of predicted or of their personal best prior to surgery

first manifestation of unconjugated hyperbilirubinemia?

sceral icterus

Brugada syndrome

structurally normal hearts, electrical pathway incorrect - palpitations, diaphoresis, - autosomal dominant, M > W - Resembles RBBB; ST elevation & RSR' in leads V1, V2, V3. - can cause fast polymorphic V tach (looks like torsades). - Implantable defibrillator required

What can cause metabolic alkalosis?

vomiting/ bulemia OD of antacids addition of bicarbonate

How should perioperative hyperglycemia be treated?

with IV short-acting insulin or SQ sliding scale insulin

What type of hernia in a male pt disappears easily with the patient lying down.

*A direct inguinal hernia is symmetrical, round and disappears easily with the patient lying down. * An indirect inguinal hernia is typically elliptic that does not reduce easily. An obturator hernia is more commonly seen in elderly women and are rarely palpable in the groin. Femoral hernias are rare in males and do not typically reduce with lying down.

Differences between typical findings of adrenal cortical cancer and adenoma

*Adrenal cortical cancer* -Size >4 cm -High attenuation (>10 Hounsfield units on noncontrast phase) -Enhancement on contrast-enhanced phase -Delayed contrast washout (<50% washout at 10 minutes postcontrast) -Calcifications -Irregular shape -Central necrosis *Adenoma* -Low attenuation (<10 Hounsfield units on noncontrast phase) -Rapid washout (>60% washout at 15 minutes postcontrast) -Smooth borders

What are 2 types of dialysis?

*Hemodialysis:* Acquired through an AV fistula (preferred) or prosthetic graft - three times per week + 3-5 hrs per session *Peritoneal dialysis:* Peritoneal membrane is the "dialyzer" while dialysate is instilled into the peritoneal cavity through an indwelling catheter --CAN BE DONE AT HOME

How do you treat claudication?

*Platelet inhibitors:* Cilostazol, Aspirin, Clopidogrel Treat lipids - Statins Revascularization Exercise *βblockers are contraindicated* *treatment for severe PVD?* Surgical graft bypass Angioplasty—balloon dilation Endarterectomy—remove diseased intima and media Surgical patch angioplasty (place patch over stenosis)

What are the 4 MC bariatric surgeries in the US?

*RNYGB* - Roux-en-Y *AGB* -adjustable gastric band *VSG*- vertical band gastroplasty *BPD/ DS* -biliopancreatic diversion/ with/without duodenal switch

Class I indications for CABG from the American College of Cardiology (ACC) and the American Heart Association (AHA) are?? (6)

-Over 50% left main coronary artery stenosis -Over 70% stenosis of the proximal left anterior descending (LAD) and proximal circumflex arteries -Three-vessel disease in asymptomatic patients or those with mild or stable angina -Three-vessel disease with proximal LAD stenosis in patients with poor left ventricular (LV) function -One- or two-Vessel disease and a large area of viable myocardium in high-risk area in patients with stable angina -Over 70% proximal LAD stenosis with either an ejection fraction (EF) below 50% or demonstrable ischemia on noninvasive testing

What are 4 cardiac related things that need to be done before surgery?

-Preoperative EKG on patients 40 years of age and older -If current unstable angina—avoid elective surgeries -If Stage two HTN—control prior to surgery -Patient should take antihypertensive medication on the day of the procedure

Pathophysiology of Jaundice? (9)

-Red blood has a lifespan of 120 days. Splenic macrophages are responsible for the recycling of "aged" RBCs -Hemoglobin is broken down into heme and globin -Globin is further broken down into amino acids and is recycled -Heme is broken down into iron and protoporphyrin -Iron is recycled while protoporphyrin is converted to unconjugated bilirubin (UCB) -Albumin transports UCB to the liver for conjugation by uridine glucuronyl transferase (UGT) in hepatocytes -Conjugated bile is then transferred to the bile canaliculi through the bilirubin canaliculi transport protein for bile formation -Once bile is formed, it is transported to the GB for concentration and storage. Bile is released into the small bowel (duodenum) for fatty food digestion -Normal intestinal microflora will act on the bile and convert it to urobilinogen which is oxidized to stercobilin (which makes stool brown) and urobilin (which makes urine yellow)

What will you find on labs of a pt with chronic kidney disease?

-U/A, spot urine sample for albumin or protein: Cr ratio, SCr level -Broad waxy casts -GFR estimation GFR <60 mL/min -Anemia, hyponatremia, hyperkalemia, hyperphosphatemia, hypocalcemia, hypermagnesemia, hyperuricemia -Metabolic acidosis with high anion gap

5 steps to prevent DVT/ PE in the post op patient?

-Very low risk: early ambulation alone -Low risk: mechanical prophylaxis with intermittent pneumatic compression (IPC) devices -Moderate risk: options of low-molecular-weight heparin (LMWH) or low-dose unfractionated heparin or IPC -High risk: IPC in addition to either LMWH or low-dose heparin -Furthermore, an extended course (4 weeks) of LMWH may be indicated among patients undergoing resections of abdominal or pelvic malignancies

Risk score for post op N/V: (4)

-female gender -nonsmoker -history of motion sickness -expected administration of post-op opioids

Which anesthetic agents are emetogenic? (4)

-nitrous oxide -opioids -physostigmine -propofol (least of the list)

Anti-emetics used after surgery: 3 Rescue antiemetics: 2

-scopolamine patch -dexamethasone -ondansetron 1. prochlorperazine 2. Droperidol

What are 3 medications treatments in someone with a breast tumor?

1. Anti-estrogen Tamoxifen is useful in tumors that are ER-positive - binds and blocks the estrogen receptor in the breast tissue. 2. Aromatase inhibitors: useful in postmenopausal ER positive patients with breast cancer - reduces the production of estrogen 3. Monoclonal AB treatment: useful in patients with HER2 positivity (Human Epidermal Growth Factor Receptor)

6 Risk Factors for Breast Cancer

1. BRCA1 and BRCA2 inherited genetic mutation associated increased risk of both breast and ovarian CA 2. First degree relative with a history of breast cancer 3. Age > 65 4. Onset of menarche < 12 y 5. ↑ Estrogen exposure - postmenopausal HRT 6. Obesity and ETOH

Early complications of bariatric surgery? 5

1. anastomotic leak 2. DVT and PE 3. Bleeding 4. Infection 5. Splenic injury

Indications for Thyroidectomy? (6)

1. in the presence of a very large goiter or a multinodular goiter with relatively low RAI uptake 2. if there is a suspicious or malignant thyroid nodule 3. for patients with ophthalmopathy 4. for the treatment of pregnant patients or children 5. for the treatment of women who wish to become pregnant within 1 year after treatment 6. for patients with amiodarone-induced hyperthyroidism

Late complications of bariatric surgery? 7

1. malnutrition problems 2. marginal ulcer and anastomotic strictures 3. internal hernia 4. cholelithiasis 5. band slippage 6. band erosion 7. esophageal dilation

What are daily maintenance fluid requirements post op for an adult? What is the rule of thumb in what fluid you give?

1500-2500 mL depending on age, gender, weight, surgery, complications..... *2000-2500 mL of 5% dextrose in normal saline or in lactated Ringer solution is delivered daily.* Rough estimate: multiply weight (kg) X 30

What are the 4 levels of cardiac functional status? MET

1: can take care of self, eat, dress, use toilet 3-4: can walk up a flight of steps or a hill or walk on ground at 3-4 mph 4-10: heavy work around teh house, such as scrubbing floors, moving futnirute, can climb two flights of stairs >10: can participate in sports such as swimming, tennis, football, basketball or skiing

Define recurrent UTI

2 uncomplicated UTI in 6 months OR 3+ uncomplicated UTI in 1 year

What flow rate is necessary for sufficient dialysis?

300 cc/min

What is the parkland formula for burns?

4 mg/kg X % BSA First half in 8 hours, remaining half in 16 hours

Colon cancer screening is for what ages?

45-75 Stool test once a year or colonoscopy every 10 unless bad findings

When should you begin mamograms?

50-74 every 2 years, UNLESS 1st degree relative with breast cancer, then you do 10 years before they were diagnosed.

What is the usual length of time to feel fatigue after a surgical procedure? What meds can cause fatigue? What are other things to look into for fatigue?

6-12 weeks sedative-hypnotics, antidepressants, muscle relaxants, opioids, antihypertensives, antihistamines, and many types of antibiotics adrenal, CBC, CMP/ chemistry, anemia, ESR, thyroid,

When should patients stop smoking before surgery?

8 weeks!

Parkinsons treatment? Under 65 Over 65

< 65 Dopamine agonists: bromocriptine, pramipexole, ropinirole. Directly stimulates dopamine receptors. > 65 Sinemet (levodopa/carbidopa)

MC pathogen of epidiymitis in men <35 and >35? Treatment <35 and >35?

<35: GC --- TX: doxycycline PO for 10 days + Ceftriaxone IM once >35: E. coli --- Levofloxacin PO for 10 days

What is the bilirubin level at jaundice?

> 2.5

Difference between a hot and cold thyroid nodule?

A cancerous lesion does not make hormone and will not take up iodine from a radioactive thyroid scan. (COLD NODULE) A non-cancerous lesion does make hormone and will take up iodine at either a normal rate or a quicker rate. (HOT NODULE)

A 35-year-old man presents to the office with acute onset right flank pain radiating to the groin with intermittent nausea and vomiting. A urinalysis and computed tomography of the abdomen and pelvis without contrast were ordered. An urgent referral for outpatient urologist evaluation would be most appropriate for which of the following findings? A. A 10.5 mm mid-ureteral stone B. A 3 mm stone in the distal ureter C. Hydronephrosis with urinary tract infection D. Ureteral obstruction from a stone in a transplanted kidney

A. A 10.5 mm mid-ureteral stone referral for OUTPATIENT urologist eval

A 60-year-old woman presents to the clinic reporting left lower quadrant abdominal pain, constipation, and bloating. She denies nausea, vomiting, fever, or consumption of undercooked foods. On physical exam, there is moderate tenderness to palpation of the left lower quadrant but no rigidity or guarding. Bowel sounds are hypoactive throughout. All vital signs are within normal parameters for age. Which of the following is most likely to confirm the diagnosis? A. Abdominal CT with contrast B. Abdominal X-ray C. Colonoscopy D. Pelvic ultrasound

A. Abdominal CT with contrast most likely to confirm the presence of diverticulitis.

A 16-year-old girl is being evaluated for an appendectomy by general surgery. The patient reports having very heavy menstrual periods with frequent bleeding through pads and tampons onto her clothing. She uses 12-16 pads or tampons per day but states this is normal for all the women in her family. She reports no spontaneous joint pain or other bleeding problems. Which of the following diagnostic studies may be increased in this patient? A. Activated partial prothrombin time B. Platelet count C. Platelet function analysis D. Prothrombin time

A. Activated partial prothrombin time Von Willebrand disease -normal platelet count -normal Pt/INR -normal aPTT (prolonged if very low factor VIII)

A 37-year-old man is brought to the postanesthesia care unit following a laparoscopic cholecystectomy. Which of the following findings indicates need for emergent fluid resuscitation? A. Agitation B. Decreased skin turgor C. Dry mucous membranes D. Increased capillary refill time

A. Agitation WRONG: Dry mucous membranes (C) and increased capillary refill time (D) are also indications of mild or moderate hypovolemia but do not indicate hypovolemic shock and the need for emergent fluid resuscitation.

A 22-year-old woman on her first postoperative night in the hospital complains of constant chest tightness and shortness of breath for the past hour. She has well-controlled asthma and is a lifelong nonsmoker. Vitals include a temperature of 98.8°F, heart rate 64 beats per minute, blood pressure 116/78 mm Hg, and oxygen saturation 99%. Physical exam reveals bilateral expiratory wheezing. Bedside chest radiograph and chest computed tomography are unremarkable. Which of the following is the best therapy for the most likely diagnosis? A. Albuterol B. Apixaban C. Levofloxacin D. Oxygen

A. Albuterol Pt is having bronchospasms

A 19-year-old woman who is G1P0 at 14 weeks gestation presents with lower abdominal pressure and urinary frequency. Workup is negative except for a urinalysis, which demonstrates positive leukocyte esterase, nitrites, and 15-20 WBC/hpf. What management is indicated? A. Amoxicillin B. Ciprofloxacin C. Levofloxacin D. Send urine culture and hold treatment

A. Amoxicillin The patient presents with a UTI in pregnancy, which should be treated with an antibiotic that is safe in pregnancy like amoxicillin.

A 63-year-old right-handed man presents to the emergency department with a sudden onset of numbness on the right side of his face, arm, and leg, as well as right arm and leg weakness. His symptoms started fifteen minutes prior to presentation. On exam, the patient has mild aphasia, mild dysarthria, a pronator drift of his right arm, diminished strength of his right arm and leg, and diminished sensation on the right side. Computed tomography of the brain and computed tomography angiography of his brain and neck were performed and by the time the scans were finished the patient had complete resolution of his symptoms. The computed tomography angiography of the neck revealed a 90% stenotic atherosclerotic lesion of the left internal carotid artery. Carotid endarterectomy was scheduled. The most appropriate next step is administration of which of the following? A. Aspirin B. Clopidogrel C. Dual antiplatelet therapy D. Warfarin sodium

A. Aspirin For patients undergoing CEA, low-dose aspirin treatment should be started prior to the procedure and is continued for at least three months after CEA is done. Carotid revascularization is not recommended for patients with chronic total occlusion of the carotid artery.

A 15-year-old boy presents to the ER with after he fell off his bike 30 minutes ago and hit his head on the concrete. He lost consciousness for 1 minute. He has vomited twice since his fall. VS are BP 134/82 mm Hg, HR 89 bpm, RR 16 breaths/minute, T 98.2°F, and oxygen saturation 99% on room air. The patient has a GCS of 14. On PE, you note a 4 cm by 5 cm hematoma over his left temporal bone. You also notice that he has been slow to respond to questions, and his parents report that he seems "sleepier" than usual. What is the most appropriate next step in management of this patient's condition? A. CT head without contrast B. Discharge home with follow-up instructions C. Observe for 4-6 hours and discharge home D. Urgent neurosurgical consult E. X-ray of the skull

A. CT head without contrast

A 65-year-old man with a history of diabetes, atrial fibrillation, peripheral vascular disease, chronic obstructive pulmonary disease, and hyperlipidemia presents to the emergency department for evaluation of gradually worsening left leg pain that began eight hours ago. The pain is constant and exacerbated by minimal walking. Both dorsalis pedis pulses are thready, however, the left femoral pulse is weaker than the right. There is equal movement and intact sensation in both lower extremities. Which of the following is the best test to confirm the diagnosis and facilitate timely treatment? A. CTA of the pelvis with runoff B. D-dimer C. Doppler ultrasound D. Magnetic resonance angiography of the pelvis with runoff What is this disease and what are the 6 Ps??

A. CTA of the pelvis with runoff in the assessment of acute arterial embolism that is not immediately limb-threatening. Classically, the six Ps outline the presentation of arterial occlusion: paresthesia, pain, pallor, poikilothermia, reduced pulses, and paralysis. Treatment depends on etiology, location, severity, and health of the patient, but may include thrombolysis, stenting, thrombectomy, or surgery (bypass).

If someone has arthritic pain but also has a history of GERD, what medication can they use? A. Celecoxib B. Diclofenac C. Indomethacin D. Meloxicam

A. Celecoxib Celecoxib is a selective cyclooxygenase-2 inhibitor that has decreased gastrointestinal toxicity compared to nonselective agents and may be substituted in patients with risk factors for the development of peptic ulcers Can't use diclofenac due to their presence of peptic ulcers/ GERD

A 56-year-old woman is brought to the ER by her coworker with reports of sudden-onset dizziness. The patient describes the dizziness as "feeling off balance." She reports that she was walking to a meeting approximately 1 hour ago when she suddenly became nauseous and was unable to walk without falling. She reports a coworker wheeled her to a car in a desk chair to bring her to the hospital. She has vomited twice in the emergency department since arrival. She reports a headache that is predominantly located over the back of her head. She reports no head injury or recent illness. She has a history of HTN for which she is prescribed losartan, but she says she has been out of her medication for the past 3 months. She smokes two to five cigarettes on weekends socially with friends. Vital signs reveal blood pressure 184/108 mm Hg, heart rate 96 bpm, respiratory rate 22/min, and oxygen saturation 98%. She is afebrile. Neurologic examination reveals bidirectional nystagmus, skew deviation of the eyes, and a positive Romberg test result. What is the most likely diagnosis? A. Cerebellar hemorrhage B. Heat stroke C. Posterior cerebral artery occlusion D. Posterior fossa tumor E. Vestibular neuritis

A. Cerebellar hemorrhage Commonly due to hypertension, cigarette use, old age, anticoagulant use, bleeding disorders, and stimulant use

A 58-year-old man presents to the ED reporting a moderate amount of hemoptysis that began earlier that day. He has no history of cigarette smoking or chronic lung disease. He has felt ill for the past week and has had an ongoing dry cough. After further clarification, he estimates he has expectorated < 30 mL of blood. Which of the following is the best next step in evaluating this patient? A. Chest radiograph B. High-resolution computed tomography C. Lung biopsy D. Magnetic resonance imaging

A. Chest radiograph

A 64-year-old woman presents to the ER complaining of a yellow tint to her eyes and skin. This began approximately one month prior and has become progressively worse. She also has constant gnawing upper abdominal pain, which is worse at night. She reports a 15-pound weight loss over the past few months, generalized weakness, dark urine, and pruritus. PE confirms the presence of diffuse jaundice, scleral icterus, and pain on palpation of the epigastrium and right upper quadrant. Laboratory tests reveal elevated serum bilirubin and alkaline phosphatase levels. Bedside transabdominal ultrasound is performed and reveals a pancreatic mass. Which of the following is the most appropriate next step to assess disease extent and resectability? A. Contrast-enhanced abdominal computed tomography B. Echoendoscope-guided fine needle aspiration biopsy C. Endoscopic retrograde cholangiopancreatogram D. Magnetic resonance cholangiopancreatography

A. Contrast-enhanced abdominal computed tomography BC it is pancreatic cancer

A 28-year-old man with hemophilia A presents to the clinic for presurgical consultation for an epidermal inclusion cyst removal. His hematology records reveal a mild severity of his hemophilia for which he is not taking any daily prophylactic therapy. Which of the following therapies should be employed prior to his surgery? A. Desmopressin B. Fresh frozen plasma C. Protamine sulfate D. Vitamin K

A. Desmopressin Desmopressin (DDAVP) is an analog of vasopressin (antidiuretic hormone) which promotes factor VIII and VWF release from storage pools.

Which of the following is a risk factor for developing small bowel carcinoma? A. Diet high in salt-cured foods B. History of irritable bowel syndrome C. Obesity D. Tobacco use

A. Diet high in salt-cured foods also red meat and alcohol

A 76-year-old man with a history of diabetes mellitus and hyperlipidemia presents to the emergency room with a sudden onset of epigastric pain 48 hours ago. Now he is experiencing intractable nausea, vomiting, and fever beginning 12 hours prior to arrival. Physical examination reveals marked tenderness and guarding in the epigastrium, poor turgor, hypotension, tachycardia, and a temperature of 101.3°F. Laboratory results show amylase of 301 U/L and lipase of 1186 U/L. CT scan of the abdomen is pending. Based on the patient's expected diagnosis, which of the following findings would be consistent with his most likely diagnosis? A. Ecchymosis of the flanks B. Improvement in pain when lying supine C. Melena D. Pain radiating to the left scapula

A. Ecchymosis of the flanks Sign of retroperitoneal bleeding- from acute pancreatitis

A 34-year-old man with a recent herpes simplex infection reactivation presents with lesions on his hands and feet for three days. He denies fever, chills, malaise, and arthralgia. He has tried cetirizine without resolution. On physical exam, erythematous, papular target lesions measuring less than 3 cm with three concentric zones of color change are noted. The three concentric zones involve a dusky central area, a dark red inflammatory zone surrounded by a pale ring, and an erythematous halo at the periphery of the lesion. Koebner phenomenon is also noted. Biopsy reveals scattered necrotic keratinocytes and lymphocytic exocytosis. Which of the following is the most likely diagnosis? A. Erythema multiforme B. Stevens-Johnson syndrome C. Sweet syndromeYour Answer D. Urticaria

A. Erythema multiforme target like lesions

A 69-year-old woman presents to the clinic complaining of neck and bone pain, dyspnea, and hoarseness that began three weeks ago. She also reports unintended weight loss, fatigue, and intermittent fevers. Observation reveals a bilaterally enlarged, asymmetric goiter. Multiple firm thyroid nodules are identified on palpation with a dominant nodule in the upper left lobe and anterior cervical lymphadenopathy. Core needle biopsy with cytopathology confirms the suspected diagnosis while imaging indicates pulmonary involvement. Which of the following initial interventions is appropriate? A. External beam radiation therapy B. Levothyroxine administration C. Primary tumor resection D. Radioiodine therapy

A. External beam radiation therapy Because they have distant metastasis, surgical resection is not going to get it all

A 30-year-old man is following up to receive results from his recent endoscopy for suspected peptic ulcer disease. Biopsy urease testing is positive, and he is started on the appropriate therapy. When should repeat testing be performed? A. Four weeks after completing therapy B. Immediately after completing therapy C. One week after completing therapy D. Two weeks after completing therapy

A. Four weeks after completing therapy Testing earlier than this could cause a false-negative result

A 78-year-old man with a history of hypertension presents to the emergency department with worsening neurologic deficits. His wife reports he became confused shortly after completing yard work this morning. His vital signs show a blood pressure of 224/116 mm Hg, pulse of 110 beats per minute, and temperature of 98.3°F. He is alert and oriented but is having trouble finding appropriate words. He reports a severe headache and feels nauseous. Physical exam reveals right hemisensory loss and left gaze preference. Throughout the exam, the patient becomes aphasic. Suddenly, he has a myoclonic seizure lasting 3 minutes. He is taken for computed tomography, which reveals the image above. Which of the following is the most likely diagnosis? A. Hemorrhagic stroke B. Ischemic stroke C. Postictal paralysis D. Transient ischemic attack

A. Hemorrhagic stroke The clinical presentation of hemorrhagic stroke typically includes headache, vomiting, altered mental status, and a decreased level of consciousness. Seizures may occur in hemorrhagic stroke within the first 24 hours and can occur up to 30 days after the stroke.

A 68-year-old previously healthy woman underwent surgery for a left hemicolectomy for suspected malignancy. Approximately 36 hours after surgery she noted the onset of chest pain and difficulty breathing. On physical examination, she appears anxious and has a temperature of 37oC, blood pressure of 130/80 mm Hg, heart rate of 100 beats per minute, and respiratory rate of 30 breaths per minute. Her oxygen saturation is 88% on room air. Breath sounds are normal and cardiac exam reveals tachycardia with a normal rhythm. Examination of her extremities reveals moderate swelling and tenderness of the left lower leg. Chest X-ray is normal, and an electrocardiogram shows sinus tachycardia and nonspecific ST changes. Ultrasound examination of the left leg shows a large thrombus in the femoral vein. In addition to administering supplemental oxygen and intravenous fluids, which of the following is the most appropriate next step? A. Low-molecular-weight heparin subcutaneously B. Tissue plasminogen activator intravenously C. Unfractionated heparin intravenously D. Warfarin given orally

A. Low-molecular-weight heparin subcutaneously

A 28-year-old man presents to the clinic complaining of "gnawing" abdominal pain 30 minutes after each meal. He is currently taking valsartan, atorvastatin, and ibuprofen. In addition to cessation of offending agents, which of the following is the best treatment? A. Omeprazole for eight weeks B. Omeprazole for four weeks C. Ranitidine for eight weeks D. Ranitidine for four weeks

A. Omeprazole for eight weeks proton pump inhibitor that is continued for four to eight weeks in patients with duodenal ulcers and eight to twelve weeks in patients with gastric ulcers. Any ulcer that is caused by nonsteroidal anti-inflammatory drugs requires a minimum of eight weeks of therapy.

A 57-year-old woman with a history of recurrent nephrolithiasis presents to the clinic for evaluation of ongoing nausea, constipation, loss of appetite, generalized bone pain, and depressed mood. Laboratory results include elevated serum calcium, elevated parathyroid hormone levels, and decreased phosphate levels. A sestamibi scan performed was suspicious for a right inferior parathyroid gland adenoma. During the surgical excision of the parathyroid adenoma, which of the following should be measured intraoperatively to confirm the cause of the primary hyperparathyroidism has been removed? A. Parathyroid hormone level B. Serum calcium level C. Serum phosphate level D. Urine calcium excretion level

A. Parathyroid hormone level

A 48-year-old woman presents to the clinic complaining of a painful varicosity in her right lower extremity, despite one year of conservative therapy. On exam, there is a tortuous vein in the midcalf with several surrounding telangiectasias and reticular veins. Duplex ultrasound reveals saphenous vein reflux. Which of the following treatment options represents the best clinical intervention for this patient? A. Saphenous radiofrequency ablation B. Saphenous venous stenting C. Surface laser therapy D. Surface venous phlebectomy

A. Saphenous radiofrequency ablation conservative management is generally preferred as initial treatment and includes lower extremity elevation and compression stockings. Symptomatic patients with venous reflux who have failed to gain improvement with conservative measures should have ablation of the refluxing vein.

While awaiting operative removal of pheochromocytoma, which of the following classes of medications are used for control of hypertension? A. alpha-adrenergic blocker B. beta-adrenergic blocker C. ACE inhibitor D. diuretic

A. alpha-adrenergic blocker are used preoperatively to control hypertension in a patient with pheochromocytoma that occurs from unopposed alpha stimulation when the tumor is manipulated.

What is the CHADSVASc score used for?

A. fib and Stroke Risk!!! Age: <65 y/o -0 65-74. +1 ≥75 +2 Female. +1. Male- 0 CHF history No- 0 Yes +1 Hypertension history No- 0 Yes +1 Stroke/TIA/thromboembolism history No- 0 Yes +2 Vascular disease history (prior MI, peripheral artery disease, or aortic plaque) No- 0 Yes +1 Diabetes history No-0. Yes +1

Which of the following is the pathophysiologic process of a transudative pleural effusion? A. increased fluid production due to increased hydrostatic pressure B. decreased lymphatic clearance of fluid from the pleural space C. infection in the pleural space D. bleeding into the pleural space

A. increased fluid production due to increased hydrostatic pressure Chronic heart failure accounts for 90% of transudates. Hypoalbuminemia, cirrhosis, and acute atelectasis are also causes of a transudate.

Lab results for a post-operative oliguric patient reveals an increased BUN to creatinine ratio. The patient has a low fractional excretion of sodium (less than 1%). Which of the following is the most likely diagnosis? A. prerenal azotemia B. acute tubular necrosis C. acute glomerulonephritis D. obstructive uropathy

A. prerenal azotemia Patients who have prerenal azotemia with otherwise normal kidneys will have severe sodium retention in order to help to save fluid. The amount of sodium in the urine is therefore very low.

What antihypertensive medication is contraindicated in patients with renal artery stenosis? What is the treatment of renal artery stenosis?

ACE inhibitors (lead to renal insufficiency) Stenting of the renal arteries ( percutaneous transluminal angioplasty plus stent placement)

Patient with chronic rheumatoid arthritis on maintenance prednisone and methotrexate undergoes surgery. She develops hyponatremia, hypoglycemia, and hypotension. In addition to IV fluid therapy, which of the following is the best initial therapy? and what does she have? A. Epinephrine B. Fludrocortisone (Florinef) C. Hydrocortisone D. Glucagon

Acute phase of adrenal crisis C. Hydrocortisone and IVF

How do you diagnose urinary retention?

Acute: bladder US/ PVR: 500mL of urine or GREATER, Urine culture, CBC if possible infection Chronic: PVR bladder volume by catherization or US Detrusor sphincter dyssynergia: PVR > 150 mL

A patient diagnosed with Barrett's esophagus is at an increased risk for the development of what type of cancer?

Adenocarcinoma (squamous cell is not typical for esophageal cancer) (transitional cell is a cancer of the bladder)

Medications that can exacerbate orthostatic hypotension? (13)

Alcohol Alpha blockers (Zosins) Antidepressants: SSRI, MAOI, TCA... Antihypertensive drygs Antiparkinsonism drugs: Levodopa., prmipexole Antipsychotic drugs: olanzapine, risperidone Beta blockers Diuretic drugs: furosemide, hydrochlorothiazide Muscle relaxants Narcotic as: morphine PDEinhibitors: sildenafil, tadalafil Sedatives/ hypnotics: pam/ lam Vasodilators: hydralazine, nitroglycerin, CCB...

After the diagnosis of SAH is made, what additional study is essential?

Angiography, to look for a ruptured Berry aneurysm (the most common source of SAH)

What can cause metabolic acidosis? Anion gap formula?

Anion gap= Na - (Cl + HCO3-) = 10-16 Increaswed ion gap (>16) -lactic acidosis (metforming) -DKA -Aspirin overdose Low anion gap (<16) -diarrhea -pancreatic/ biliary drainage -renal tubular acidosis

What antibodies are found in Graves disease?

Anti-thyrotropin antibodies

At what PFT level are patients considered at increased risk for complications?

At increased risk if FEv1 is less than 50% of normal or PaCO2 > 45 mm.

A 68-year-old woman presents after recovering from a total abdominal hysterectomy two days prior. There were no intraoperative complications. She is able to void urine on her own, however, she reports feeling like she cannot completely empty her bladder. You decide to perform a spontaneous voiding trial. What postvoid residual volume indicates postoperative urinary retention? A. 100 mL B. 120 mL C. 80 mL D. 90 mL

B. 120 mL

A 38-year-old man with type 2 diabetes mellitus is brought to the recovery area following a gastric sleeve procedure. His daily medication regimen includes insulin glargine, acarbose, and metformin. He is alert and oriented to time, person, place, and situation. After 15 minutes, he begins to complain of palpitations, anxiety, and peripheral paresthesias. Serum glucose concentration is 63 mg/dL using a bedside glucometer. Which of the following is the best initial treatment? A. 0.5 cups of sweetened fruit juice B. 4 glucose tablets C. 50% dextrose 25 g IV D. Glucagon 1 mg IM

B. 4 glucose tablets Can't drink juice because he is on acarbose (DM med) which slows down metabolism so it wouldn't work fast enough

A 47-year-old woman with a history of hypertension presents to the ED with a severe headache that began suddenly three hours prior to arrival. She has a history of recurrent frontal headaches for the last month and is currently being treated for migraine. Today, she also complains of blurry vision, diplopia, nausea, vomiting, and confusion. Her vital signs are BP 95/45 mm Hg, HR 118 bpm, RR 23/min, T 36.7°C, and pulse oximetry of 98% on room air. Neurologic exam reveals a dilated and minimally reactive left pupil, a globe deviated inferiorly, and bitemporal hemianopsia. Lab results reveal only hyponatremia of 129 mEq/L. Normal saline is administered. A CT scan reveals an intrasellar mass. Which of the following is an appropriate step in the management of this patient? A. Administer intravenous 3% saline B. Administer intravenous hydrocortisone C. Administer intravenous mannitol D. Arrange for rapid radiation therapy

B. Administer intravenous hydrocortisone The patient has a pituitary tumor. Hydrocortisone is the preferred steroid to administer because it provides both glucocorticoid and mineralocorticoid effects. Clinical improvement is usually seen within a few hours of steroid administration.

A 75-year-old woman presents to your office with a wound on her left lower leg that has not healed after three months. She is otherwise healthy and does not have diabetes. On physical examination, she is mildly overweight (body mass index 28). She has a 4 cm wound over the anterior medial left leg. It is shallow, with granulation tissue and eschar, and without surrounding erythema or purulent drainage. Her lower extremities are moderately edematous with skin hyperpigmentation and dry skin. Her feet are warm, dorsalis pedis pulses are palpable, and she has intact sensation to light touch over her toes. Which of the following is the most appropriate treatment for her leg wound? A. Application of bacitracin ointment B. Compression stockings and adherent dressings C. Skin grafting of the wound D. Treatment with a diuretic and local wound care

B. Compression stockings and adherent dressings chronic venous insufficiency

A 72-year-old woman presents to the emergency department with left lower quadrant abdominal pain and mild diarrhea. On abdominal exam, there is left lower quadrant tenderness. Which of the following is the best study to confirm the most likely diagnosis? A. Colonoscopy B. Computed tomography of the abdomen with oral and intravenous contrast C. Stool studies D. White blood cell count

B. Computed tomography of the abdomen with oral and intravenous contrast Colonoscopy causes a risk of perforation in acute diverticulitis

How do you treat chronic pancreatitis? A. Acetaminophen B. Dietary modifications C. Meperidine D. Pancreatic enzyme replacement

B. Dietary modifications First-line treatment of chronic pancreatitis involves dietary modification with small, low fat meals and cessation of smoking and alcohol use. If chronic pain persists despite compliance with these lifestyle modifications, pancreatic enzyme supplements can be added to suppress pancreatic exocrine secretion and thereby reduce stimulation-associated pain.

A 63-year-old man with a medical history significant for type 2 diabetes mellitus, hypertension, and chronic kidney disease presents with fatigue and dyspnea on exertion for the past month. A physical examination is unremarkable except for conjunctival pallor. His vital signs are within normal limits except for a HR of 106 bpm. A fecal occult blood test is negative. Laboratory tests are ordered and the results show a creatinine of 2.1 mg/dL, a potassium of 3.8 mmol/L, a hemoglobin of 9.8 gm/dL, and a mean corpuscular volume of 82 fL. Which of the following is the best next step in management of this patient's condition? A. Begin erythropoietin therapy B. Evaluate iron stores C. Order a hemoglobin electrophoresis D. Refer for emergent dialysi E. Supplement folate and vitamin B12

B. Evaluate iron stores In patients with chronic kidney disease that does not require dialysis, anemia is common. The severity of the anemia typically correlates with the severity of the kidney disease. The anemia is primarily secondary to low levels of erythropoietin produced by the kidneys. The red cells are morphologically normal and normochromic although their life span is decreased. Reticulocyte counts will be decreased.

Which of the following pathogens is most likely to cause infection in a patient postsplenectomy? A. Campylobacter jejuni B. Haemophilus influenzae C. Mycoplasma pneumoniae D. Staphylococcus aureus

B. Haemophilus influenzae Patients are at an increased risk of infection postsplenectomy, particularly by encapsulated organisms such as Streptococcus pneumoniae, Haemophilus influenzae, and meningococci.

A 52-year-old man with alcoholic cirrhosis is admitted following a transjugular intrahepatic portosystemic shunt placement. After 12 hours, he exhibits signs of confusion with day-night reversal and disorientation. Physical examination reveals asterixis, increased deep tendon reflexes, and a bilateral positive Babinski sign. Cranial nerves III through X are intact with normal function. Which of the following is the most likely diagnosis? A. Alcohol withdrawal B. Hepatic encephalopathy C. Korsakoff syndrome D. Wernicke encephalopathy

B. Hepatic encephalopathy These are wrong: Korsakoff syndrome (C) is a chronic manifestation secondary to thiamine deficiency in patients with alcoholism. It is preceded by Wernicke encephalopathy (D) with the addition of anterograde and retrograde amnesia and confabulation. Wernicke encephalopathy presents with the classic triad of confusion, ataxia, and nystagmus that progresses to ophthalmoplegia with lateral rectus palsy and conjugate gaze palsies.

A 35-year-old woman presents to the office with multiple complaints that have been worsening over the last several weeks. She is complaining of anxiety, intermittent palpitations, unintentional weight loss, and heat intolerance. Physical exam reveals a tremor. Which of the following best describes the tremor associated with the most likely diagnosis? A. Dampens with activity B. High frequency and low amplitude C. Occurs exclusively with standing position D. Present at rest

B. High frequency and low amplitude

Perforation is a complication that occurs in 10% of patients with acute cholecystitis and is characterized by which of the following? A. Coarse cough B. Hypoactive bowel sounds C. Jaundice D. Nausea and vomiting

B. Hypoactive bowel sounds

A 58-year-old woman presents to the clinic with a pruritic rash on her right breast. She states this rash has spread over the past 4 weeks, and her breast has become tender. Physical examination reveals a tender, warm right breast with thickened, purplish skin overlying half of the breast and an erythematous, flattened nipple. Axillary lymph nodes are enlarged, mobile, and nontender. Which of the following is the most likely diagnosis? A. Eczema of the breast B. Inflammatory breast cancer C. Mastitis D. Paget disease of the breast

B. Inflammatory breast cancer -picture shows peau de orange but there would be more erythema and a flattened nipple

An 89-year-old man with a history of atherosclerosis and peripheral artery disease presents with a sudden onset of severe abdominal pain for the last two hours. He has associated nausea and vomiting. Abdominal exam reveals mild diffuse tenderness without any focal areas of tenderness, distention, or organomegaly. Hemoccult is negative. Considering the most likely diagnosis, which of the following laboratory tests would you expect to be elevated? A. Gamma-glutamyl transferase B. Lactate C. Lipase D. Total bilirubin

B. Lactate Acute mesenteric ischemia

A 78-year-old man undergoes laparoscopic surgery for a small bowel obstruction. Which metabolic disturbance is he most at risk for postoperatively? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

B. Metabolic alkalosis

A 78-year-old man undergoes laparoscopic surgery for a small bowel obstruction. Which metabolic disturbance is he most at risk for postoperatively? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

B. Metabolic alkalosis Metabolic alkalosis would be the most likely acid-base disturbance to develop postoperatively in this patient presentation. Volume contraction combined with gastric fluid loss is the most common cause. During this type of surgery, aggressive third-spacing of fluid into the peritoneal cavity, as well as the intestinal lumen, is the cause of volume contraction. Postoperatively, nasogastric decompression of the stomach causes acid loss. As the stomach works to replenish hydrochloric acid, bicarbonate (HCO3-) is released into the serum. The patient also loses potassium from the gastric fluid during nasogastric suctioning. The combination of the volume contraction and the postoperative measures causes a hypochloremic, hypokalemic metabolic alkalosis.

A 42-year-old woman presents to the clinic complaining of early satiety, increased belching, abdominal bloating, and postprandial nausea. She has a medical history of hypertension, diabetes mellitus, and major depressive disorder. Her current medications include amlodipine, metformin, repaglinide, and amitriptyline. A scintigraphic gastric emptying study reveals reduced gastric motility, and she is started on conservative therapy. Which of the following medications should be added with refractory symptoms? A. Clarithromycin B. Metoclopramide C. Metronidazole D. Paliperidone

B. Metoclopramide Bc this is gastroparesis - metoclopramide will incresae motility!

A 31-year-old man is admitted following a laparoscopic cholecystectomy. After two days, he reports obstipation, nausea, and vomiting with mild, diffuse abdominal pain. Physical examination reveals abdominal distention with tympany and mild abdominal tenderness to palpation without rebound tenderness or guarding. Which of the following makes ileus a more likely diagnosis than small bowel obstruction? A. Abdominal distention B. Mild, diffuse abdominal pain C. Obstipation D. Vomiting

B. Mild, diffuse abdominal pain ileus- neurogenic failure of loss of peristalsis WRONG: Abdominal distention (A), obstipation (C), and vomiting (D) may be found in both ileus and small bowel obstruction.

A 32-year-old woman presents six hours after ingesting 40 tablets of regular-strength (325 mg) aspirin in a suicide attempt. She is lethargic with a heart rate of 106 beats/minute, blood pressure of 142/84 mm Hg, respiratory rate of 30 breaths/minute, and a temperature 38.5°C. What abnormality would be expected on her arterial blood gas? A. Mixed respiratory acidosis with a metabolic alkalosis B. Mixed respiratory alkalosis with a metabolic acidosis C. Pure metabolic acidosis D. Pure respiratory alkalosis

B. Mixed respiratory alkalosis with a metabolic acidosis from salicylate toxicity

A 25-year-old man presents to the clinic for a painless testicular mass that has slowly grown over the past 5 months. Vital signs include HR of 90 bpm, BP of 120/80 mm Hg, RR of 20/minute, oxygen saturation of 98% on room air, and T of 98.6°F. Physical examination reveals a nontender ovoid-shaped mass in the right testicle. Ultrasound of the bilateral scrotum reveals an inhomogeneous right testicular mass with calcifications, cystic areas, and indistinct margins. Laboratory studies include an alpha-fetoprotein of 1,000 ng/mL, lactate dehydrogenase of 1,200 IU/L, and beta-human chorionic gonadotropin of 10,000 mIU/mL. Which of the following is the suspected histological diagnosis? A. Leydig cell tumor B. Nonseminoma germ cell tumor C. Seminoma germ cell tumor D. Sertoli cell tumor E. Transitional cell tumor

B. Nonseminoma germ cell tumor Most testicular cancers are germ cell tumors, which are subclassified as seminoma tumors or nonseminoma tumors

What is the most appropriate treatment for a hyperfunctioning nodule without thyrotoxicosis? A. Fine-needle aspiration B. Observation with routine assessment C. Radioactive iodine D. Thyroidectomy

B. Observation with routine assessment

A 58-year-old man presents to the emergency department complaining of two hours of right leg weakness and pain of sudden onset. On exam, his right leg is pale and cool to the touch. Sensation and muscle strength are diminished on the right from thigh to toes, and no pedal, popliteal, or femoral pulses are palpable on the right. Sensation and pulses are normal on the left. Which of the following is an appropriate clinical intervention for this patient? A. Intra-arterial thrombolysis B. Open embolectomy C. Pharmacomechanical thrombolysis D. Transcatheter embolectomy

B. Open embolectomy because they are in need of revascularization and they have a LARGE emboli

A patient is scheduled for a unilateral adrenal tumor resection for suspected adrenocortical carcinoma. Which of the following surgical approaches would be best for this adrenalectomy? A. Laparoscopic transabdominal B. Open transabdominal C. Posterior retroperitoneoscopic D. Retroperitoneal open

B. Open transabdominal for greater visualization

A 26-year-old woman at 31 weeks gestation reports to the clinic complaining of progressive difficulty urinating, severe pain that radiates from her low back to her labia, and burning with urination. Vitals indicate HR 103 bpm, RR 18/min, BP 131/92 mm Hg, T 100.6°F, and SpO2 99% on room air. Laboratory studies reveal hematuria, pyuria, and increased serum creatinine. Diagnostic imaging results are shown above. Which of the following is the first-line clinical intervention for this patient? A. Dialysis B. Percutaneous nephrostomy C. Pyeloplasty D. Retrograde ureteral stenting

B. Percutaneous nephrostomy Less amount of radiation for a pregnant patient

A 38-year-old man presents to the primary care clinic for a 6-week follow-up. He was recently diagnosed with Helicobacter pylori-associated peptic ulcer disease (PUD) after an upper endoscopy. At his last visit, he was placed on omeprazole 40 mg BID and bismuth subcitrate potassium 140 mg/metronidazole 145 mg/tetracycline 125 mg four times daily for 14 days. Today, he states his dyspepsia has significantly improved, and he is no longer having any other gastrointestinal symptoms. Vital signs are BP 118/78 mm Hg, pulse 77 bpm, RR 13 breaths/minute, and temperature 99°F. Physical exam reveals a nontender abdomen with no rigidity or guarding. What is the best next step in the treatment of this patient? A. Perform serologic testing for Helicobacter pylori B. Perform urea breath test for Helicobacter pylori C. Prescribe an H2-receptor antagonist to take with meals D. Provide reassurance and follow-up in 6 months E. Repeat upper endoscopy in 6 weeks

B. Perform urea breath test for Helicobacter pylori (less invasive)

A patient's arterial blood gas is noted to have a pH of 7.32, pCO2 of 32 mm Hg, and bicarbonate of 16 mmol/L. Which of the following is the correct interpretation of this arterial blood gas? A. Metabolic acidosis with respiratory alkalosis B. Pure metabolic acidosis C. Pure respiratory acidosis D. Respiratory acidosis with metabolic alkalosis

B. Pure metabolic acidosis -compensation for a metabolic acidosis involves stimulation of the respiratory center, thereby increasing minute ventilation in an attempt to decrease the pCO2 and bring the pH back near 7.4. With normal respiratory compensation, for every 1 mmol/L decrease in HCO3, there should be a 1 mm Hg decrease in pCO2. If the measured value of pCO2 in higher than expected, there is a concomitant respiratory acidosis. Likewise, if the measured value of pCO2 is lower than expected, there is a concomitant respiratory alkalosis. The anticipated pCO2 can also be calculated using the formula pCO2 = (1.5 * [HCO3] + 8) +/- 2. In this case, with a HCO3 16 mmol/L, the expected pCO2 is 32 mm Hg (1.5 * 16 + 8). Because the calculated pCO2 and the measured pCO2 are the same, this patient has a pure metabolic acidosis.

Which of the following is the therapy of choice for long-term management of esophageal varices in a patient who cannot tolerate beta blocker therapy? A. Octreotide (Sandostatin) B. Sclerotherapy C. Transjugular intrahepatic portosystemic shunt D. Sengstaken-Blakemore tube

B. Sclerotherapy Octreotide is only for acute variceal bleeding

Which of the following preoperative laboratory test results indicates an increased risk for wound complications after surgery? A. Hemoglobin below 28g/dL B. Serum albumin below 3.5g/dL C. Serum glucose above 150mg/dL D. Total blood lymphocyte count above 3,000 cells/mm3

B. Serum albumin below 3.5g/dL indicates malnutrition glucose alone isn't a good marker of long term sugar control- a high A1C would be a better marker

A 40 year-old patient with a history of recurrent kidney stones presents with acute onset of right flank pain and hematuria. The patient is afebrile and pain is poorly controlled on oral medications. On CT scan a 1 cm stone is noted in the renal pelvis. Which of the following is the most appropriate intervention for this patient? A. Antibiotics B. Shock wave lithotripsy C. Ureterolithotomy D. Fluid hydration

B. Shock wave lithotripsy lithotripsy is indicated in patients with stones greater than 6 mm in size or intractable pain

Which of the following statements is true regarding the local anesthetic lidocaine? A. It is a member of the class of ester anesthetics B. Symptoms of overdose include seizures and cardiac dysrhythmia C. The maximum dose is 3-5 mg/kg when prepared with epinephrine D. The mechanism of action is via calcium channel blockade

B. Symptoms of overdose include seizures and cardiac dysrhythmia

Why must the preoperative preparation for surgical resection of a patient with a diagnosed pheochromocytoma involve propranolol initiation after a 10-14 day course of phenoxybenzamine? A. To allow for an initial decrease in the contracted blood volume B. To avoid unopposed alpha-adrenergic receptor stimulation C. To avoid unopposed beta-adrenergic receptor stimulation D. To normalize the blood pressure elevation exacerbated by phenoxybenzamine

B. To avoid unopposed alpha-adrenergic receptor stimulation The beta-adrenergic blockade is initiated after the alpha-adrenergic blockade during medical preparation for a pheochromocytoma resection to avoid unopposed alpha-adrenergic receptor stimulation. Following effective alpha-adrenergic blockade with phenoxybenzamine, beta-adrenergic blockade is initiated with a medication such as propranolol, to allow for blocking of the vasodilatory peripheral beta-adrenergic receptors. If the beta-adrenergic blockade is initiated first, the unopposed alpha-adrenergic receptor stimulation can cause worsening hypertension.

A 21-year-old woman presents to the clinic complaining of fatigue, headaches, weakness, abdominal pain, and nausea. Review of her past visits indicates an unintentional weight loss. Vitals are HR 87, RR 16, BP 104/67, T 98.6°F, and SpO2 100% on room air. Physical examination reveals hyperpigmentation of the gingival mucosa. Which of the following tissues is responsible for producing the deficient hormone that is causing her symptoms? A. Adrenal medulla B. Zona fasciculata C. Zona glomerulosa D. Zona reticularis

B. Zona fasciculata

Postmenopausal patient is diagnosed with grade I breast cancer. The tumor is 0.7 cm in size, estrogen-receptor positive, and axillary nodes are negative. After undergoing a lumpectomy, which of the following adjuvant therapy is indicated for this patient? A. chemotherapy B. tamoxifen C. ovarian ablation D. bisphosphonate therapy

B. tamoxifen (Chemotherapy is indicated in breast cancer with tumors larger than 1 cm in site.)

What layer of the brain does a subarachnoid hemorrhage occur?

Between the arachnoid and pia mater

What is worse than a Mallory Weiss tear?

Boerhaave syndrome! The esophagus completely ruptures

What vessel is more commonly injured in an acute subdural hematomas?

Bridging veins

Which of the following, based upon current literature, best defines a transient ischemic attack? A. A focal neurologic deficit lasting for less than 30 minutes, caused by reversible cerebral ischemia B. A focal neurologic sign or symptom lasting for at least 30 minutes, but less than 24 hours, caused by reversible central nervous system ischemia C. An episode of neurologic dysfunction caused by cerebral, spinal, or retinal ischemia, without acute tissue infarction D. An episode of neurologic dysfunction that resolves without residual functional deficit, but with evidence of acute tissue infarction on diffusion-weighted MRI studies

C. An episode of neurologic dysfunction caused by cerebral, spinal, or retinal ischemia, without acute tissue infarction

A 32-year-old man presents with complaints of bleeding with defecation and anal pruritus. Exam reveals a hemorrhoid prolapsed out of the anal canal requiring manual reduction. How would you classify this patient's hemorrhoids? A. Grade I B. Grade II C. Grade III D. Grade IV

C. Grade III Grade III hemorrhoids prolapse out of the anal canal with defecation or straining and require manual reduction. Hemorrhoids arise from a plexus or cushion of dilated arteriovenous channels and connective tissue. Patients with hemorrhoids present with complaints of bleeding, anal pruritus, prolapse, and pain due to thrombosis. Treatment is typically conservative, though surgical options are available for thrombosed hemorrhoids. Grade I (A) hemorrhoids are visualized on anoscopy and may bulge into the lumen but do not prolapse below the dentate line. Grade II (B) hemorrhoids prolapse out of the anal canal with defecation or with straining but reduce spontaneously. Grade IV (D) hemorrhoids are irreducible and may strangulate.

A man presents to the emergency department with amaurosis fugax, dysarthria, and aphasia that have persisted but not worsened for the past two hours. Physical examination reveals an audible bruit in the neck. Which of the following indicates a need for carotid artery stenting? A. Age ≥ 70 years B. Carotid artery stenosis of 65% C. History of chronic obstructive pulmonary disease D. Prior contralateral endarterectomy

C. History of chronic obstructive pulmonary disease Patients with recently symptomatic carotid artery stenosis of 70 to 99% should undergo carotid endarterectomy as long as, the patient has not had prior ipsilateral endarterectomy, and the patient does not have clinically significant cardiac, pulmonary, or chronic disease that increases the risk of anesthesia and surgery

A 62-year-old man is having routine lab work drawn as part of a complete yearly physical. His complete blood count demonstrates a decreased hemoglobin and hematocrit with an elevated mean corpuscular volume. Which of the following in his patient's history could explain these findings? A. Beta-thalassemia trait B. Chronic kidney disease C. History of partial gastrectomy D. Ulcerative colitis

C. History of partial gastrectomy leading to vitamin B12 or folate deficiency

A septic patient is noted to have respiratory alkalosis. What electrolyte disturbance is commonly associated with this patient presentation? A. Hypercalcemia B. Hypermagnesemia C. Hypokalemia D. Hyponatremia

C. Hypokalemia Alkalosis can result in hypokalemia and an intracellular acidosis from the shift of potassium from the serum into the intracellular space.

A 50-year-old man presents to the emergency department with diffuse abdominal pain and obstipation. Imaging reveals high-grade small bowel obstruction. The patient is admitted to the hospital, however, fails to improve with medical management. He is taken to the operating room for exploratory laparotomy with lysis of adhesions with minimal blood loss. Postoperatively, the patient is tachycardic and hypotensive with low urine output. Hemoglobin is 17 g/dL. Lactic acid is 4 mmol/L. Which of the following is the most likely diagnosis? A. Cardiogenic shock B. Distributive shock C. Hypovolemic shock D. Obstructive shock

C. Hypovolemic shock

A 49-year-old man presents to the emergency department complaining of sudden-onset, severe, colicky right lower quadrant abdominal pain. His pain was initially intermittent but has become constant in the past 30 minutes. He reports nausea and vomiting, and physical examination reveals diffuse abdominal distention and tympany to percussion without rebound tenderness or guarding. Abdominal X-ray results are shown above. Which of the following is the most appropriate definitive intervention? A. Cecopexy B. Endoscopic decompression C. Ileocecectomy D. Surgical detorsion

C. Ileocecectomy Preoperative antibiotics (e.g., cefotetan, ampicillin-sulbactam) should be administered for patients with suspected perforation, ischemia, or necrosis. Ileocecectomy is the preferred surgical treatment for cecal volvulus, and an ileocolic anastomosis is indicated in patients who are not hemodynamically unstable. Cecopexy with or without placement of a cecostomy tube can be implemented in unstable patients without signs of bowel ischemia, perforation, or necrosis.

An 18-year-old man is admitted to the hospital with reports of nonbloody diarrhea and right lower quadrant abdominal pain. Physical examination reveals nonulcerated, tender nodules on the anterior shins and a tender, palpable mass in the lower abdomen. Lab studies show an elevated C-reactive protein and erythrocyte sedimentation rate, while colonoscopy identifies deep skip lesions present from the ileocecal valve to the splenic flexure. Which of the following is the best treatment? A. Azathioprine with mercaptopurine B. Enteric-coated budesonide C. Infliximab with mercaptopurine D. Mesalamine

C. Infliximab with mercaptopurine Induction of remission is achieved using biologic agents (infliximab) in combination with azathioprine or mercaptopurine. Once remission is achieved, patients will remain on biologic agents indefinitely and taper thiopurine medications over 1 to 2 years. While 5-aminosalicylate agents (sulfasalazine, mesalamine) have traditionally been used as first-line treatment of Crohn disease, their efficacy is controversial and use is recommended only in mild cases.

A 55-year-old man presents to the clinic with left calf pain. The pain typically begins after walking for a few minutes and resolves with rest. He currently smokes and has a medical history of hypertension and dyslipidemia. A lesion is identified on the left anterior shin. Which of the following lesion findings is most likely present? A. Calloused border B. Exudate C. Intense pain D. Necrotic eschar

C. Intense pain periphral arterial disease resuls from atherosclerosis

In which of the following locations is a palpable mass expected to be found during physical examination of a patient with a spigelian hernia? A. At the site of prior incision B. Just inferior to the inguinal ligament C. Just lateral to the rectus abdominis D. Medial to the inferior epigastric vessels

C. Just lateral to the rectus abdominis Spigelian hernias are a form of ventral hernia resulting from a defect in the spigelian aponeurosis, which is bordered by the rectus abdominis muscle medially and the linea semilunaris laterally. Risk factors for developing a spigelian hernia include increased intra-abdominal pressure (e.g., obesity, chronic cough, multiparity), trauma, and factors that weaken the tissue layers of the aponeurosis (e.g., smoking, collagen disorders).

Which of the following factors indicates a need for esophagogastroduodenoscopy in a patient with dyspepsia? A. Inadequate response to calcium carbonate therapy B. Male sex C. Melena D. Worsened symptoms at night

C. Melena alarm features of gastroesophageal malignancy, such as unintentional weight loss, progressive dysphagia, odynophagia, persistent vomiting, gross gastrointestinal bleeding, palpable mass or lymphadenopathy, family history of upper gastrointestinal malignancy, and unexplained iron-deficiency anemia.

Chronically untreated dyspepsia can lead to which of the following pathologic changes in the esophagus? A. Atrophic squamous epithelium B. Increased intraepithelial lymphocytes C. Metaplastic columnar epithelium D. Stratified squamous epithelium

C. Metaplastic columnar epithelium Dyspepsia or heartburn can be functional or a symptom of gastroesophageal reflux disease (GERD). Chronically uncontrolled or inadequately treated GERD leads to mucosal damage in the stratified squamous epithelium of the distal esophagus. The damaged mucosa is usually replaced by new squamous cells, but in some patients, the damage can lead to pathologic columnar metaplasia, which is diagnostic of Barrett esophagus. The reason for the pathologic metaplasia is unknown. The columnar epithelium is more resistant to reflux-induced damage, but it predisposes the patient to adenocarcinoma of the esophagus. First-line therapy for functional dyspepsia, GERD, and Barrett esophagus is a proton-pump inhibitor (PPI) and lifestyle changes, including weight loss, consuming smaller portions, and consuming less of the foods that induce symptoms. Some observational and in-vitro data suggest that aggressive anti-reflux therapy decreases the risk of malignant transformation.

A 28-year-old woman is admitted after open colonic resection for ulcerative colitis. Vitals include HR 96 bpm, RR 18 breaths/min, BP 105/67 mm Hg, T 97.7°F, and SpO2 99% on room air. Physical exam reveals decreased skin turgor, increased capillary refill time, and dry mucous membranes. Laboratory findings include serum potassium 5.3 mEq/L, serum sodium 136 mEq/L, and serum chloride 89 mmol/L. Which of the following therapies is indicated? A. Hypertonic saline B. Lactated Ringer solution C. Normal saline D. Plasma-Lyte solution

C. Normal saline

Which of the following medications helps obese patients lose weight by altering fat digestion due to pancreatic lipase inhibition? A. Liraglutide B. Lorcaserin C. Orlistat D. Phentermine-topiramate

C. Orlistat First-line treatment of obesity includes lifestyle modification (food diaries, exercise, low-calorie diet, new eating patterns, behavioral modification therapy, and group therapy). Underlying depression may be treated with selective serotonin reuptake inhibitors. Sympathomimetics may be used as appetite suppressants. Orlistat, liraglutide, lorcaserin, and phentermine-topiramate may be used for weight loss. Orlistat alters fat digestion by inhibiting pancreatic lipases.

A 45-year-old man with a past medical history significant for obesity, status post partial gastrectomy, returns to the clinic following a recent barium swallow study for complaints of abdominal pressure and fullness. Results from the study show displacement of the gastroesophageal junction and herniation of a portion of the gastric fundus into the thoracic cavity. Which of the following is the most likely diagnosis? A. Esophageal motility disorder B. Esophagitis C. Paraesophageal hiatus hernia D. Sliding hiatus hernia

C. Paraesophageal hiatus hernia

A 66-year-old man with a medical history significant for hypertension and chronic kidney disease presents for a routine examination. Laboratory tests are available and include an estimated glomerular filtration rate of 31 mL/min/1.73 m2, potassium of 4.1 mmol/L, magnesium of 2 mEq/L, calcium of 10 mg/dL, and parathyroid hormone level of 160 pg/mL. A physical exam is completed and is unremarkable. Vital signs are a BP of 132/82 mm Hg, HR of 87 bpm, SpO2 of 97% on room air, and T of 98.4°F. Decreasing the intestinal absorption of which of the following will benefit the patient the most? A. Calcium B. Magnesium C. Phosphate D. Potassium E. Sodium

C. Phosphate

Which of the following is a cause of prerenal azotemia? A. Infection B. Renal toxins C. Poor renal perfusion D. Urinary tract obstruction

C. Poor renal perfusion

A 72-year-old man has been recently diagnosed with an esophageal stricture. Which of the following findings in the patient's past medical history would be most consistent with this diagnosis? A. Iron deficiency anemia B. Peptic ulcer disease C. Radiation therapy to the neck D. Tobacco abuse

C. Radiation therapy to the neck PUD is NOT but GERD is associated with esophageal narrowing

A 30-year-old man who weighs 75 kg presents to the emergency department for burns to his left arm and left leg after a large container of boiling water spilled on him just prior to arrival. There is white, peeling skin on the entirety of both his left arm and left leg. He has severe pain along the borders of the burn, but no sensation to the burned areas. Distal pulses are intact. After ensuring there is no airway or breathing compromise and removal of overlying materials and clothes, what is the next step in treatment? A. Escharotomy B. Prophylactic antibiotic infusion C. Ringer's lactate solution 4 L infusion over eight hours D. Transfer to a burn center

C. Ringer's lactate solution 4 L infusion over eight hours BC of Parklands formula

Which of the following upper endoscopy findings is consistent with a benign peptic ulcer? A. Clubbed folds surrounding the ulcer crater B. Irregular, thickened ulcer margins C. Smooth ulcer base filled with exudate D. Ulcerated mass protruding into the lumen

C. Smooth ulcer base filled with exudate Endoscopic findings indicating clubbed folds surrounding the ulcer crater (A), irregular, thickened ulcer margins (B), or an ulcerated mass protruding into the lumen (D) are suggestive of *malignancy.*

A 40 year-old-man presents to the emergency department reporting continuous, severe pain in the left groin for four hours. He has vomited three times since the onset of pain. On exam, he has a tender left inguinal hernia with slight erythema of the overlying skin, as well as abdominal tenderness and guarding. His temperature is 101.1°F. What is the best treatment? A. Analgesia and antibiotics B. Manual reduction C. Surgical repair D. Truss application

C. Surgical repair Required to treat a strangulated hernia with hernia

Which of the following is an absolute indication for the initiation of dialysis in a patient with chronic kidney disease? A. Estimated glomerular filtration rate under 10 mL/min/1.73 m2 B. Persistent hyperkalemia C. Uremic pericarditis D. Volume overload

C. Uremic pericarditis Signs and symptoms of uremia include anorexia, nausea, vomiting, pericarditis, peripheral neuropathy, confusion, lethargy, coma, or death. Any patient with uremic pericarditis, pleuritis, or encephalopathy has an absolute indication for the initiation of dialysis.

Which of the following reduces the risk of post-lumbar puncture headache? A. Inserting the needle bevel perpendicular to the spine B. Lying supine for one hour after the lumbar puncture is completed C. Using a higher gauge needle D. Using a Quincke needle

C. Using a higher gauge needle

A 32-year-old woman presents to the office with a concerning skin lesion on her arm. The lesion is biopsied and she is diagnosed with melanoma that is less than 1 mm in thickness. Which of the following is the next best step in caring for this patient? A. Application of imiquimod for 90 days B. Mohs microsurgical approach C. Wide excision with a 1 cm margin of normal tissue D. Wide excision with a 2 cm margin of normal tissue

C. Wide excision with a 1 cm margin of normal tissue treatment of choice when the lesion is less than 1 mm in thickness

A 25 year-old female presents with right lower quadrant pain, right flank pain, nausea, and vomiting. Her temperature is 39.6 degrees C. There is right CVA tenderness and RLQ tenderness. Pelvic exam is unremarkable. Urinalysis reveals pH 7.0, trace protein, negative glucose, negative ketones, positive blood, and positive nitrates. Specific gravity is 1.022. Microscopic shows 102 RBCs/HPF, 50-75 WBCs/HPF, rare epithelial cells, and WBC casts. The most likely diagnosis is: A. acute salpingitis B. nephrolithiasis. C. acute pyelonephritis D. appendicitis

C. acute pyelonephritis Due to the fever and symptoms (with pyuria with leukocyte casts)

In suspected subarachnoid hemorrhage with a negative head CT, which of the following studies should be used to help establish the diagnosis of subarachnoid hemorrhage? A. complete blood count B. lipid profile C. lumbar puncture D. electrocardiogram

C. lumbar puncture

A patient with a bowel perforation secondary to a gunshot wound is being prepped for surgery. Appropriate antibiotic prophylaxis and treatment includes which of the following? A. cefoxitin and gentamicin B. vancomycin and penicillin G C. nafcillin, gentamicin, and metronidazole D. metronidazole, clindamycin, and cefoxitin

C. nafcillin, gentamicin, and metronidazole

How do you diagnose AAA? What is treatment?

CT or transesophageal echocardiogram -Immediate surgical repair (even if asymptomatic) if >5.5 cm or expands >0.6 cm per year -Monitor annually if >3 cm. Monitor every 6 months if >4 cm -Beta-blocker

How do you diagnose diverticular disease?

CT scan with contrast

What is the most common type of kidney stone? and what juice makes these worse? Where is it most likely to get stuck?

Calcium oxylate --grapefruit juice makes them worse Ureterovesicular junction

Pruritis is common in pregnant women, what is the medication of choice?

Chlorpheniramine has been recommended as the first generation antihistamine of choice for use during pregnancy

What disease is associated with the 5 Fs? what are they?

Cholelithiasis 1. Fat 2. Forty 3. Fertile 4. Female 5. Flatulant

How do you treat pyelonephritis outpatient? Inpatient? Pregnant?

Ciprofloxacin, levofloxacin, or cephalexin IV ceftriaxone if inpatient Pregnant: IV/ IM ceftriaxone- requiring inpatient stay

If a patient takes methadone regularly what do you do with that for surgery? What about buprenorphine (suboxone)? --for opioid addiction

Continue the usual dose through the perioperative period at HALF THE USUAL DOSE continue buprenorphine and maximize the use of non-opioid analgesics

What does a palpable non-tender gallbladder suggest?

Courvoisiers sign!! Suggests pancreatic cancer obstructing the gall bladder

Sickle Cell Treatment?

Crisis: Symptomatic Repeated crisis: hydroxyurea

A 46-year-old man presents to the clinic complaining of calf pain while walking. He has a past medical history of hypertension, dyslipidemia, and diabetes mellitus. Which of the following ankle-brachial index results is most likely? A. 0.95 B. 1.01 C. 1.25 D. 1.4

D. 1.4 Due to calcification and sclerosis of arteries, the ankle-brachial index value may be falsely elevated, therefore, values > 1.4 require further studies, including Doppler ankle waveforms and toe pressures. ~all the other answers are within normal limits (less than 0.9 is worrisome)

A 70-year-old man presents to the clinic one month after coronary artery bypass grafting. He complains of frequent palpitations and an episode of syncope the previous day. Electrocardiogram in the office reveals one run of nonsustained ventricular tachycardia. Which of the following diagnostic studies would be most helpful to obtain next? A. 24-hour Holter monitor B. Chest X-ray C. Echocardiogram D. Electrophysiologic study

D. Electrophysiologic study If nonsustained ventricular dysrhythmias are noted on electrocardiogram, an electrophysiologic study can be performed to identify mechanisms of induction of dysrhythmias and to localize their source. Electrophysiologic studies are also helpful when a patient with cardiomyopathy or ischemic heart disease presents with syncope and an electrocardiogram is negative for dysrhythmia, because the electrophysiologic study can be used to induce a ventricular dysrhythmia.

A 48-year-old man presents with epigastric pain which radiates to his back. He has a history of alcohol misuse disorder. Which of the following serum blood analysis abnormalities most specifically indicates the suspected diagnosis? A. Elevated alanine aminotransferase (ALT) B. Elevated amylase C. Elevated aspartate aminotransferase (AST) D. Elevated lipase

D. Elevated lipase acute pancreatitis is MC from gallstones and chronic excessive alcohol consumption

A 60-year-old woman with a history of diabetes mellitus presents to the emergency department with rapidly progressive erythema and edema of the right lower extremity over the last five hours. On physical exam, the patient has severe pain, a large area of erythema, and is febrile. What is the most appropriate intervention? A. Admission to internal medicine team and intravenous clindamycin B. Computed tomography imaging prior to clinical disposition C. Discharge with oral cephalexin D. Emergent surgical consultation and empiric vancomycin and piperacillin-tazobactam

D. Emergent surgical consultation and empiric vancomycin and piperacillin-tazobactam Necrotizing fascitis

A 31-year-old man presents to the emergency department after an episode of syncope following sexual intercourse. Upon regaining consciousness at home, patient began complaining of a severe headache and started to vomit. Physical examination reveals an uncomfortable man with positive meningeal signs. Blood pressure is 162/94 mm Hg. CT scan of the head without contrast reveals no acute pathology. Based on the most likely diagnosis, what would you expect on the patient's lumbar puncture? A. Decreased opening pressure B. Decreased protein C. Elevated glucose D. Hemoglobin degradation products

D. Hemoglobin degradation products Hemoglobin degradation products (xanthochromia) are found in the cerebrospinal fluid of a patient with a subarachnoid hemorrhage. A subarachnoid hemorrhage is most commonly caused by a ruptured saccular aneurysm.

A 55-year-old man with a medical history of hypertension presents to the emergency department with worsening diffuse muscle cramps and weakness for the past 2 days. The weakness started bilaterally in his legs but now involves his arms. He reports that exercising is more difficult because of the weakness. The patient reports taking hydrochlorothiazide, which he started 2 weeks earlier for hypertension. Vital signs include a HR of 103 bpm, BP of 142/80 mm Hg, RR of 20/min, oxygen saturation of 98% on room air, and T of 98.6°F. Physical examination reveals a distressed man with 3 out of 5 strength in each extremity. The patient has no ptosis, intact cranial nerves, and intact sensation with light touch. Which of the following is the most likely cause of the patient's symptoms? A. Hypermagnesemia B. Hyperuricemia C. Hypocalcemia D. Hypokalemia E. Hyponatremia

D. Hypokalemia

The main complication with the use of transjugular intrahepatic portosystemic shunt (TIPS) procedure is which of the following? A. increased portal pressures resulting in further esophageal varices B. increased portal pressures resulting in a worsening of cirrhosis C. Budd-Chiari syndrome D. Increased risk of encephalopathy

D. Increased risk of encephalopathy TIPS procedures involve the placement of a stent in the liver in order to shunt blood away from the portal vein into the hepatic vein which bypasses the cirrhotic liver parenchyma. Its main complication is encephalopathy from the accumulation of toxic substances in the brain since the liver no longer acts as a filter.

An 18 year-old male is involved in a motor vehicle accident with a question of cervical spine fracture. What is the imaging test of choice to initially evaluate this patient and clear his cervical c-spine? A. Positron emission tomography B. Magnetic resonance imaging C. Computed tomography D. Lateral radiograph

D. Lateral radiograph X-rays are MC used as the initial screen for cervical spine injury

Which of the following is better visualized with transesophageal echocardiogram (TEE) than transthoracic echocardiogram? A. Ventricular wall motion B. Pulmonary arteries C. Right ventricle D. Left atrial appendage

D. Left atrial appendage TEE allows 2-D and Doppler imaging of the heart through the esophagus. Given the close proximity of the esophagus to the heart, high-resolution images can be obtained, especially of the left atrium, mitral valve apparatus, and aorta

While assessing a patient's functional capacity as part of the preoperative cardiac risk, the patient states that she can walk independently, but slowly, and can complete light chores around her home, but she cannot do her own yard work or go up and down stairs without assistance. Which of the following options is the correct way to document her functional capacity? A. 4-7 METs B. 7-10 METs C. Greater than 10 METs D. Less than 4 METs

D. Less than 4 METs Functional capacity, or cardiac functional status, is an important indicator of postoperative cardiac complication risk, and it should be assessed at the initial preoperative evaluation. Poor functional capacity is associated with increased cardiac complications in noncardiac surgery. A patient's functional capacity is expressed in metabolic equivalents (1 MET equals 3.5 mL O2 uptake/kg per minute, which is the resting oxygen uptake in the seated position). Self-care, the ability to complete activities of daily living (ADLs), vacuuming, walking 2 mph, and writing are examples of poor functional capacity (less than 4 METs). The ability to walk up a flight of stairs, walk 4 mph, walking a golf course, doing yard work, and cycling are examples of moderate functional capacity (4-10 METs). Jogging, playing singles tennis, swimming, and skiing are examples of excellent functional capacity (greater than 10 METs). One specific indicator of increased risk of postoperative cardiopulmonary complications is the inability to climb two flights of stairs or walk four blocks.

A 58-year-old man presents to the clinic complaining of new-onset melena. He has no past medical history and is not currently taking medications. Neither upper endoscopy nor colonoscopy identify the source of hemorrhage. Contrast angiography reveals a long, nonbranching anomalous arterial branch originating from the superior mesenteric artery that traverses the mesentery toward the right lower quadrant. Which of the following is the most likely diagnosis? A. Angiodysplasia B. Colorectal carcinoma C. Dieulafoy lesion D. Meckel diverticulum

D. Meckel diverticulum

A 34-year-old woman presents to the clinic for a wound check one week after breast reconstructive surgery with insertion of silicone implants. The patient had a complete bilateral mastectomy following removal of a malignant left breast mass the previous year. There were no regional or distant metastases at that time. Which of the following represents appropriate health maintenance counseling for this patient? A. Begin annual chest X-rays B. Begin bilateral breast ultrasounds every 6 months for 10 years C. Continue yearly mammograms D. Obtain magnetic resonance imaging as needed for implant-related concerns

D. Obtain magnetic resonance imaging as needed for implant-related concerns If they took all the origial breast tissue they no longer need mammograms-- MRIs are good for implant related concerns

A 37-year-old woman presents to the clinic after being sent by her primary care provider for further evaluation of a thyroid nodule, discovered on her most recent annual physical exam. Thyroid-stimulating hormone was found to be 3.4 mU/L. Ultrasound of the thyroid revealed a solid hypoechoic mass with irregular margins. Fine needle aspiration revealed calcified psammoma bodies. Based on the patient's ultrasound and histology results, which of the following would be the most likely diagnosis? A. Anaplastic thyroid cance B. Benign thyroid nodule C. Follicular thyroid cancer D. Papillary thyroid cancer

D. Papillary thyroid cancer Papillary thyroid cancer is the most common type of thyroid cancer and typically the least aggressive. It is associated with psammoma bodies on fine needle aspiration.

Which of the following cell types are involved in medullary thyroid carcinoma? A. Chief cells B. Follicular cells C. Oxyphil cells D. Parafollicular cells

D. Parafollicular cells

Which is typically impaired in Guillain-Barre syndrome? A. Dorsal spinal columns B. Motor cortex C. Neuromuscular junctions D. Peripheral nerve fibers E. Ventral spinal columns

D. Peripheral nerve fibers

A 36-year-old woman presents with complaints of a new neck mass. Physical exam reveals a 1.0 cm smooth, discrete, and fixed nodule on her lower anterior neck. She reports no other symptoms. Thyroid-stimulating hormone levels are subnormal. Which of the following is the most appropriate diagnostic test? A. Excisional biopsy B. Fine needle aspiration C. Measurement of serum antithyroid peroxidase D. Radionuclide thyroid scan

D. Radionuclide thyroid scan WRONG ANSWERS A fine needle aspiration (B) is indicated in patients with a nonfunctioning nodule on radionuclide scan or if thyroid-stimulating levels are normal or elevated and thyroid ultrasound is abnormal.

A 79-year-old man presents with cramping, periumbilical abdominal pain that began yesterday and gradually has worsened. He has associated anorexia, nausea, and vomiting. A CT scan of the abdomen is ordered and shows dilated proximal loops of bowel and collapsed distal segments of bowel with nonspecific bowel wall thickening noted. Which of the following is the most likely diagnosis based on the CT findings? A. Adynamic ileus B. Cecal volvulus C. Pseudo-obstruction D. Small bowel obstruction

D. Small bowel obstruction

A 63-year-old woman undergoes resection of non-small cell lung cancer tumors and is placed on mechanical ventilation during her recovery in the intensive care unit. Following extubation, she complains of epigastric pain with nausea and later produces coffee-ground emesis. Upper endoscopy reveals multiple petechial hemorrhages with small red and black erosions. Which of the following is the most likely diagnosis? A. Gastric carcinoma B. Gastric sarcoidosis C. Peptic ulcer disease D. Stress gastritis

D. Stress gastritis Erosive gastritis is most commonly caused by nonsteroidal anti-inflammatory drugs, alcohol, stress, and portal hypertension. Stress gastritis, a subtype of erosive gastritis, is more likely to occur in patients with mechanical ventilation, coagulopathy, trauma, burns, shock, sepsis, central nervous system injury, liver failure, kidney disease, or multiorgan failure.

An 18-year-old man presents to the clinic with a bulge in his groin. Which of the following anatomic locations would be consistent with an indirect inguinal hernia? A. Location within the Hesselbach triangle B. Medial to the inferior epigastric vessels C. Protrusion through the femoral ring D. Superior to the inguinal ligament

D. Superior to the inguinal ligament

A 20-year-old office worker presents with nine months of gradually worsening pain and swelling at his intergluteal cleft. Physical exam demonstrates a slightly tender mass near his natal cleft accompanied by purulent drainage with a hair protruding near the sinus opening. He is afebrile and there is no evidence of abscess. Which of the following interventions is likely to have the best long-term outcome for him? A. Daily gentle washing with an antibacterial cleanser B. Incision and drainage C. Initiate broad spectrum antibiotics D. Surgical excision of all sinus tracts

D. Surgical excision of all sinus tracts

A 43-year-old woman presents to the clinic with three days of severe right upper quadrant pain with radiation toward the right inferior scapula that usually occurs for an hour or two after consuming a meal. She has experienced nausea and vomiting with the pain but no fever, diarrhea, or constipation. She is not in pain at the time of visit. On physical examination, the woman has no significant tenderness over the right upper quadrant. Based on the history and physical examination, which of the following is the most likely diagnosis? A. Acute mesenteric ischemia B. Acute pancreatitis C. Small bowel obstruction D. Symptomatic cholelithiasis

D. Symptomatic cholelithiasis

A 64-year-old woman presents to the clinic complaining of early satiety and food-provoked epigastric pain. Her past medical history includes hypertension, osteoarthritis, and dyslipidemia for which she takes amlodipine, hydrochlorothiazide, meloxicam, and atorvastatin. She also recently completed outpatient therapy for community-acquired pneumonia. Upper endoscopy reveals a shallow ulcer with a smooth base and minimal bleeding. Tissue samples are positive for urease. Which of the following agents is a component of the appropriate therapy regimen? A. Amoxicillin B. Clarithromycin C. Ranitidine D. Tetracycline

D. Tetracycline she needs quad therapy because she was recently treated for CAP which would be with a macrolide

A 66-year-old man with type II diabetes mellitus presents to the clinic one week after undergoing a lower leg mole biopsy to discuss pathology results. He complains of redness, tenderness, and pus at the biopsy site. Physical exam reveals erythema and edema surrounding the biopsy site and purulent drainage, but no fluctuance is appreciated. Which of the following therapies would be best for the most likely diagnosis? A. Cephalexin B. Ciprofloxacin C. Piperacillin/tazobactam D. Trimethoprim/sulfamethoxazole

D. Trimethoprim/ sulfamethoxazole Culture and susceptibility testing should be obtained of the purulent material. The most common cause of purulent cellulitis is Staphylococcus aureus. Empiric therapy (pending culture results) should be: Appropriate therapeutic options include clindamycin, trimethoprim/sulfamethoxazole, or tetracyclines (doxycycline or minocycline).

Which of the following is the most common type of incontinence in the elderly population? A. Mixed incontinence B. Overflow incontinence C. Stress incontinence D. Urge incontinence

D. Urge incontinence

Renal cell carcinoma most commonly presents with which of the following symptoms or signs? A. hypocalcemia B. inguinal pain C. anemia D. hematuria

D. hematuria

A 40-year-old male is hit in the face with a baseball. There is nasal deformity with bleeding. The most appropriate initial management is to: A. treat the hematoma with I&D and antibiotics. B. consult with an ENT for immediate reconstructive nasal surgery. C. reduce septal defect using open technique. D. maintain nasal patency and nasal cosmesis.

D. maintain nasal patency and nasal cosmesis. --until closed reduction can be attempted in 1 week

What is Ranson's Criteria?

Determines severity of acute pancreatitis AT ADMIT: (at the GALLA) Glucose > 200 Age > 55 Leukocyte > 16,000 LDH > 350 AST > 250 AT 48 HRS: (CHF BHA) Calcium < 8 Hematocrit: decreased by > 10% Fluid sequestration > 6 L Arterial PO2 < 60 BUN: increase by 1.8+ HCO3 < 20

A 24-year-old male is initially found to have a single nodule in the right lobe of his thyroid gland. He is clinically and chemically euthyroid. The next step is to: A. Reassure the patient and reassess yearly. B. Recheck in 1-3 months. D. Do a fine needle aspiration. D. Obtain a CT scan of the neck. E. Obtain an ultrasound

E. Obtain an ultrasound

What is glasgow coma scale?

EYES - 4 VERBS - 5 MOTORS - 6

Difference between epidural and subdural hematomas?

Epidural: much more acute LOC/ symptoms after injury -- middle meningeal artery Subdural: can be chronic, pt presents 2 weeks after fall with neuro symptoms -- bridging veins so slow growing bleed

Explain Lights Criteria

Establishing cause of pleural effusion Basically ↑ Protein and ↑ LDH = Exudative Pleural fluid -protein/serum protein ratio > 0.5 -Pleural fluid LDH/serum LDH -ratio greater than 0.6 -Pleural fluid LDH > two-thirds the upper limits of the laboratory normal serum LDH

Treatment options for fibroadenoma of the breast?

Fibroadenomas less than 5 cm without concerning features can be observed at one to two-month intervals for growth or regression If there is a growth of the lesion, the lesion is greater than 5 cm, or (in adolescents) if the lesion persists to adulthood, excisional biopsy is warranted

What is the most common cause of green, straw- colored, or brown nipple discharge?

Fibrocystic disease

At what level of hyperglycemia is surgical site infection common?

Glucose above 140

Describe the 4 grades of hemorrhoids?

Grade 1: Do not protrude through the anus Grade 2: Prolapses through anus but reduces spontaneously Grade 3: Prolapses through anus and needs manual reduction Grade 4: Cannot be reduced and may strangulate

Short QT on ekg shows which electrolyte disorder?

Hypercalcemia

What is the electrolyte disorder of malignancy?

Hypercalcemia Stones, bones, abdominal groans, and psychiatric moans

Prolonged PR interval widened QRS shows which electrolyte disorder?

Hypermagnesemia

What can cause respiratory alkalosis?

Hyperventilation PE fever hyperthyroid anxiety salicylate intoxication septicemia

Long QT on ekg shows which electrolyte disorder?

Hypocalcemia

Tall T waves on ekg (not peaked) shows which electrolyte disorder?

Hypomagnesemia

How do you diagnose orthostatic hypotension?

Hypotension without a compensatory increase in HR (<10) suggests autonomic impairment Marked increase (> 100 bpm, or by >30 bpm) suggests hypovolemia, OR if symptoms develop without hypotension = POTS

What are the treatment options for acute cholecystitis?

IV fluids Antibiotics Pain control Surgery (lap choley is choice)

What anticoagulant do you use for a DVT post op?

IV heparin then switch to Warfarin

Ileus after surgery?

Ileus that persists for more than 3 d following surgery is termed postoperative adynamic ileus or paralytic ileus

What is the most common cause of bloody nipple discharge in a young woman?

Intraductal papilloma

Adjustable gastric banding (lap-band)

Less operative risk but less average weight loss with more complications --band slippage, prolapse, dilation

Brown-Sequard syndrome (hemisection of the cord)

Loss of joint position sense and vibration sense on the same side as lesion and pain and temperature on the opposite side a few levels below the lesion Lesion of half-ipsilateral cervical cord lesion Contralateral sensory findings: pain and temperature loss

Types of Breast Tumors (4)

MC: *Infiltrating Intraductal Carcinoma* (IIC) 80% - classic painless stony hard unilateral mass. Begins as ductal carcinoma in situ (DCIS) *Infiltrating lobular* (10%) frequently bilateral *Paget's disease of the nipple* (1%) chronic eczematous itchy, scaling rash on the nipples and areola *Inflammatory breast cancer* (2%) red swollen, warm and itchy breast often with nipple retraction and peau d'orange (NO LUMP)

How do you treat pseudomembranous colitits?

MCC by c. diff Tx: IV metronidazole or PO vancomycin

imaging study of choice for the evaluation and follow-up of peripheral arteriovenous malformations:

MRI!!! then CTA

What does MUDPILES stand for and when do you use it?

Methanol Uremia Diabetic Ketoacidosis Paraldehyde Infection Lactic Acidosis Ethylene Glycol Salicylates Use it to remember causes for metabolic acidosis (increased ion gap)

What artery is associated with epidural hematomas?

Middle meningeal artery

What vessel is most commonly innjured in epidural hematomas?

Middle meningeal artery

Define the difference between seminomatous and Non-seminomatous germ cell testicular tumor markers:

NONseminomatous common - 90% have a positive AFP and/or B-HCG --tend to grow more quickly and are made up of more than one type of cell Seminomatous rare - only 10% are AFP positive --very sensitive to radiation therapy Most testicular cancers are germ cell tumors, which are subclassified as seminoma tumors or nonseminoma tumors

Medications to treat UTI? What about if pregnant?

Nitrofurantoin (macrobid), bactrim, fosfomycin, ciprofloxacin Nitrofurantoin or cephalexin if pregnant

Can serum sodium be corrected quickly?

No! needs to be done slowly to avoid OSMOTIC DEMYELINATION SYNDROME -< 10 mEq/L over 24 hours

A 42 year-old patient who is being treated for colon cancer with chemotherapy develops nausea and vomiting. Which of the following drugs would be the most effective in controlling the nausea and vomiting?

Ondansetron NOT scopolamine (bc it works against motion sickness not medication induced N/V)

What are the 6 Ps of arterial embolism?

Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia

MC type of thyroid cancer? what is the biggest risk factor?

Papillary carcinoma (PAPILLARY IS POPULAR) radiation to the head and neck

When should someone be transfered to a burn center?

Partial thickness burn covering greater than 10% BSA. Burns in pts with pre-existing medical conditions like diabetes.

How do you treat toxic megacolon?

Patients with IBD should initially receive IV glucocorticoids (methylprednisolone, hydrocortisone). Infliximab or cyclosporine should be administered in cases of primary treatment failure. Subtotal colectomy with end ileostomy is the procedure of choice for surgery in patients refractory to second-line therapy after three days.

50 year-old male with history of alcohol abuse presents with acute, severe epigastric pain radiating to the back. The patient admits to an episode of coffee ground emesis. On examination he is ill-appearing with a rigid, quiet abdomen and rebound tenderness. What is the most likely diagnosis?

Perforated duodenal ulcer

How does Zinc deficiency present in dermatology?

Perioral pustular rash

Tell me about Pheochromocytoma + treatment

Pheochromocytomas are catecholamine-secreting tumors that arise from chromaffin cells of the adrenal medulla. The classic triad of symptoms consists of episodic headache, sweating, and tachycardia. forceful palpitations, tremor, pallor, dyspnea, generalized weakness, and panic attack-type symptoms. Diagnosis is typically made by measurements of urinary and plasma fractionated metanephrines and catecholamines Treatment with an alpha-adrenergic blocker, such as phenoxybenzamine, is started first to control blood pressure and expand the contracted blood volume.

What electrolyte is increased naturally during surgery/ times of stress?

Potassium (so don't give potassium in the 24 hour window after surgery)

What electrolytes need to be monitored post op?

Potassium will increase, so do not give supplemental potassium!!! (during the first 24 hours) Post-op thyroid or parathyroid surgery you need to monitor CALCIUM!!!!

Difference between primary and secondary hyperparathyroidism?

Primary = ↑ PTH usually caused by a PTH secreting parathyroid ADENOMA Secondary =↑ PTH by a physiologic response to hypocalcemia or vitamin D deficiency. Chronic kidney disease is the MC cause

What labs could you order for nipple discharge?

Prolactin and TSH (among others)

What does Romberg test for?

Proprioception

MC pathogen in post op pneumonia?

Pseudomonas aeruginosa -hospital acquired or ventilator associated TX: piperacillin/ tazobactam cefepime levofloxacin imipenem meropenem if MRSA: vanc or linezolid should be added

How is Vertical sleeve gastrectomy done?

Reduces stomach to < 25% of original by resection of a large portion along greater curvature including the entire fundus

Breast cancer prevention in high risk patients?

SERM: Tamoxifen or Raloxifene can be used in postmenopausal or women > 35 with high risk - treat for 5 years.

What is Paget's disease of the breast?

Scaling rash/dermatitis of the nipple caused by invasion of skin by cells from a ductal carcinoma (CANCEROUS)

Sentinel loop on Xray

Seen in pancreatitis

What are 3 tumor markers for diagnosing testicular cancer? What are the steps in workup? What is the most common type of testicular cancer?

Serum HCG, alpha-fetoprotein (AFP), and lactate dehydrogenase (LDH) PE, scrotal US, tumor markers, CXR, CT Seminoma : (sensitive to radiation)

Describe Goodell sign?

Softening of the cervix during gestation. Normally the cervix feels like the tip of the nose, during pregnancy and feels like the lips of your mouth

4 Stages of pressure ulcers

Stage 1: erythema of localized area, usually non-blanching over the bony surface Stage 2: partial loss of dermal layer, resulting in pink ulceration Stage 3: full dermal loss often exposing subcutaneous tissue and fat Stage 4: full thickness ulceration exposing bone, tendon, or muscle. Osteomyelitis may be present

What is Virchows triad (for DVT)?

Stasis Hypercoagulable state (smoker/ pregnant...) Trauma (surgery, cellulitis)

What is the MC bacteria that causes meningitis?

Strep pneumonia

What type of renal stone is highly associated with chronic infectino?

Struvite

What is prophylactic medication for DVT and PE?

Subcutaneous heparin and low-molecular-weight heparin are equivalent in reducing both deep venous thrombosis and pulmonary embolism

What is bleeding from bridging veins called?

Subdural Hematoma (banana on subway)

If a patient has colicky pain in the lower abd and passed out when trying to have a BM. LMP was 6 weeks ago and has vaginal spotting. Temp is 37, BP 96/60, 110 PR, 98% O2, pelvic exam shows cervical motion adnexal tenderness: how do you differentiate between ectopic pregnancy and PID?

Suspicious for ectopic pregnancy because period is late, with vaginal bleeding and abd pain. PID usually has temp above 389 and pelvic pain after cessation of menses.

first manifestation of conjugated hyperbilirubinemia?

Tea colored urine

Patient with adrenal insufficiency is taking hydrocortisone 25 mg daily. What should the patient do with the hydrocortisone dose when they develop a minor illness such as a cold?

To better mimic the normal physiologic response the baseline dose should be doubled for the duration of the illness. Doses should be increased 5-10 fold with major events such as surgery.

What pulmonary diseases are absolute contraindications to elective surgeries?

Trachitis, bronchitis, pneumonia

What do you do for a patient with uncontrolled asthma who needs surgery? For elective surgery what should someones peak expiratory flow rate % be?

Treat them with the step above in asthma therapy greater than 80% of predicted or 80% of their personal best

What disease is characterized by sharp shooting pain in one side of the face? How do you treat it?

Trigeminal Neuralgia Carbamazepine

What are 4 choices of medications for MRSA skin infection?

Trimethoprim-sulfamethoxazole (TMP-SMZ) (bactrum) Clindamycin PO Doxycycline PO BID IV Vanc or linezolid

Lead poisoing

Type of microcytic anemia -basophilic stippling -lead lines on XR -TX = EDTA (chelating therapy)

How do you diagnose cholecystitis?

US is initial test of choice HIDA is gold standard will see gallbladder wall thickening >3 mm, fluid, gallstones

What is the definition of oliguria?

Urinary output less than 400 mL per day -an early sign of impaired renal function

Wells criteria What is it for?

Used to rule out DVT/ PE: Symptoms of DVT (3 points) ---(swelling, tenderness, superficial veins, edema) No alternative diagnosis better explains the illness (3 points) Tachycardia with pulse > 100 (1.5 points) Immobilization (>= 3 days) or surgery in the previous four weeks (1.5 points) Prior history of DVT or pulmonary embolism (1.5 points) Presence of hemoptysis (1 point) Presence of malignancy (1 point)

How do you calculate maintenance fluids to give over 24 hours?

Weight (kg) X 30 = amount to give over 24 hours

What does WEAPON mnemonic stand for with Gastric cancer?

Weight loss Emesis Anorexia Pain of epigastrum Obstruction Nausea

When is lithotripsy indicated?

When stones are > 1 cm

What are associated conditions to Wilms tumor? WAGR syndrome

Wilms Tumor Aniridia (no iris) Genitourinary anomalies (hypospadias/ cryptorchidism) Retardation

What are the 5 Ws that can cause fever post op?

Wind Water Wound Walking Wonder drug/ Whopper (abcess)

Zinc deficiency is characterized by

a perioral pustular rash

What can over replacement hyperthyroidism cause?

a. fib and decreased bone mineral density

What imaging do you use for ongoing evaluation of a AAA?

abdominal US

What causes Volkmann's contracture and what is it?

acute / untreated compartment syndrome. or an arterial injury Volkmann's contracture is a permanent flexion contracture of the hand at the wrist, resulting in a claw-like deformity of the hand and fingers. Passive extension of fingers is restricted and painful.

Aplastic anemia labs show:

all three cell lines are decreased (pancytopenia) decreased WBC, RBC, and platelets --normal MCV

Patients with congestive heart failure are at increased risk for sudden cardiac death and should receive

an implantable cardioverter-defibrillator