UWorld Questions & kaplan - surgery review

Linitis plastica

infiltrating cancer that produces a desmoplastic reaction causing the stomach to look fixed and rigid txt with total gastrectomy and + splenctomy

Third space - when will these fluids be found again

into ISF sue to inflmaation or injury mobilized 3-5 days after recovery - requires in IVF rate

CHORIOCARCINOMA

is characterized by *histologically* cytotrophoblastic and synctiotrophablastic cells resembling chronic vili *tumor marker*-- Serum beta human chorionic gonadotropin

Most common location for the tear in boerhaave syndrom

left lateral posterior postion

Head trauma + hypovolemic shock

look for another source of bleeding

Cuases of viral arithtis

HIV, Hepatitis, Mumps rubella, parvovirus

What could cause nephrolithiasis in Crohn's Patients?

Increased absorption of oxalate in the colon.

Flank pain & hematuria in a patient with chrons disease is most likely due to ?

Increased absorption of oxalate, oxalate is normally bound up by calcium in the gut to prevent its absorption

In a uncal herniation, what nerve is most likely to be affected first?

CN III

Reynolds pentad for cholangitits

Jaundice, Fevers, RUQ pain, Mental status changes + elevated cholangitis

Sleep apnea vs. obesity hypoventilation

*Sleep apnea* hypoventilate at night cause *trasient hypoxia and hypercarbia*. *OBESTIY hypoventilation*- NEVER resume normal ventilation - *chronic respiratory failure*

Childs classification 3 labs 3 findings

* 3 labs:* albumine biliruben PT * 3 findings* Ascities nutrition encephalopathy Childs A - 5-6-- 0-5% mortality Childs B 7-9--- 10-15 % mortality childs C 10-15-- > 25% mortality

Finkelstein test

* de qeuvains tenosynovitis* Palapation over the dorsal radial compartment of the hand and finding a bone hard thickening

Risk of CEA surgery

*1-3% of perioperative stoke* nerve injury - hypoglossal, vagus, marginal brnach of the facial nerve -- recurrent carotid narrowing is about 13% in 5 years - recommendation is to take asipirin

Indications for urgent/emergent hemodialysis can be remebered by the acronym AEIOU:

*A*- Acidosis *E*- Electrolytes - hyperkalemia *I*- Itoxication with nephtoxic substances - ethylene gylcol *O*-Overload fluid in renal or congestive heart failure *U*- Uremia - severely symptomatic with mental status changes or pericardial effusions

Inner ear disease

" fullness " = meniere disease Can have *vertigo and hearing loss*

Patient presents with chronic microcytic Anemia, painless GI bleeding, and mumur of aortic stenosis what is the cause of the anemia

*Angiodysplsia* Thin- walled vessels that are lined by endothelium and prone to recurrent and chronic painless bleeding. Diagnosis is dependant on location: Colonoscopy, EGD, Upper endoscopy, small bowel enteroscopy or capsule endoscopy.

Causes of recurrent penumonia - *Involving different regions of the lung*

*Sinopulmonary disease* - CF, imootile cilia non infections vasculitis, broncholitus obliterans *immunodeficency* - HIV, leukemia or immunolgobins

*Paroxysmal vertigo and nystagmus, worse with change of postions*. Hearing loss is not present

*Benign positional vertigo* ___ Do the *dix-hallpike manuver* to diagnosis- patient sits on the table with the legs extended and you tilt there head to a side and then supporting the head have them lean back quickly.-- look for nystagmus patient may experience nausea

Inpatient ICU therapy

*Beta lactam + macrolide (IV) * or Beta lactam + fluroquiinolone

What are the first abnormalities seen after liver transplant

*Biliary and vascular anastomosis*- unique as antigenic reagents are less common in liver then other organs

Causes of recurrent pneumonia in the *same region of the lung*

*Bronchial compresssion* b/c- neoplasm mediastinal adenopathy, vascular anomrlay OR intrinsic bronchial obstruction - bronchiectasis retained foreign body and bronchial stenosis * Aspiration * D/T Seizures, ethanol or drug use, GERD

CRUB-65 - how to determine if the patient should be hospitalized

*C*-Confusion *U*- Uremia BUN > 20 *R*- Respirations tachypenia > 30 *H*- Hypotension BP < 90/60 *A*- Age > 65 *** Score > 2 inpatient Score > 4 then icu patient

What type of fracture always require surgical repair

*Displaced fractures*, are *unstable* and *require surgical repair* but you need to splint the injurgy until some of the swelling decreases

Patient presents with painless genital ulcers - initially they began as *painless papule* that then *ulcerates* over a course of weeks to days. Scrapping of the lesions show many *mononuclear cells containing encapsulated bacilli*

*Donovanosis or granuloma inguinale* - caused by klebsiella granulomatis - more common in tropical regions Papule --> ulcer can occur many times

Fibromatosis disease

*Duputren contracture* - Palmer fascia *Plantar fibromatosis* *Penile fibromatosis* - peyronie disease *Fibromatosis of the dorsal promixal interphalageal DIP joints*

Best next step in managment for cholangitis

*ERCP - both diagnositc and theraputic*

*58 year old post menapausal women* with a history of Parathyroid adenoma wishes to managed medically what is the best therapy

*Estrogen and progestin replacement*, as this patient is post menopausal you need to protect the bone density

Non healing fistula - FRIEND

*F*- Foreign body *R*- Radiation *I*- Infection *E*- Epithelialization *N*- neoplasm *D*-distal obstruction

inpatient Treatment for CAP

*Fluoroquinolone or Beta lactam + macrolide*

What is the treatment for CAP For an OUTpaitent

*Healthy people* - macrolide or doxycycline *Co-morbid conditions* - diabetes malignancy fluoroquinolone or beta lactam + macrolide

middle ear disease sympotoms

*Hearing loss* but no vertigo

ACL tear will have what other symptom to set it apart form other knee injuries

*Hemarthrothosis!* - both MCL and ACL tears can occur from a twisting injury but only ACL tears have significant hemarthorsis

Treatment of Ogilives syndrome

*IV neostigmine* - this is a nonmechanical obstruction D/t necrotics or electrolyte imbalence almost always post surgical *Diagnosis requires you to rule out bostructing carcinoma first *

Causes of pericarditis

*Infection- Viral is most common* Iatrogenic -surgery trauma radiation and drug related Connnective tissue disorders - RA, lupus Cardiac - Dresslers 1-6 weeks post UREMIC - serum BUN Usaully BUN > 60 Maligancy - Lung breas and hodgkins mcc- Treatment like radiation

melanoma that is superfical spreading melanoma on the face,

*Lentigo maligna melanoma * good prognosis oversall tx excision with narrow margins

How to diagnosis avascular necrosis of the femoral head

*MRI - for early onset* is the only study with high specificity and sensitivity

monoclonal gammopathy of undertermined significance VS Multiple myeloma

*Monoclonal gammopathy*-- *NO* ANEMIA, hypercalcemia, lytic lesions and renal insufficency Serum prtein < 3g/Dl < 10% plasma cells in the BM *MULTIPLE myeloma*-- Has anemia hypercalemia, lytic lesions and renal insufficency -serum monocloncal protein > 3 ->10% plasma cells in the bone marrow - elevated B-2 microglobulin

Most common location for diverticula and most common location to bleed.

*Most common location* is the left colon- sigmoid colon the *most common sight to bleed* is the right colon- cecum .

Is rheumatoid factor specific for rheumatoid arthritis

*NO!* also seen in viral arthritis bacerial infection or maligancy

What medications would *prevent* the presecription of sidenifil being orderd

*Nitrates or nitric oxide* SE- headaches flushing dyspepsia nasal congestion abnormal vision diarrhea dizziness and rash

immunological phenomena associated with infective endocarditis

*Oslers nodes*- painful violaceous nodules seen on the fingertips & toes *Roth sopts*- Edematous & hemorrhagic lesions of the retina *Glomerulonephritis* Arthritis or postive rheumatoid factor

First line management for a patient with detrusor hyperactivity - a patient who has urgency when needing to use the bathroom and often dribbles

*Pelvic floor exercises* and bladder training - actively training reduces the symptoms by 80%

Testicule support relieves the pain

*Prehns sign* a sign of epididymitis

What is used for prophalaxis of Toxo in HIV what is used for treatment

*Prophalaxis* -Trimephtoprim and sulfa *treatmentment* - Sulfadiazine and pyrimethamine

Hyponatemia in a patient with heart failure indicates what

*SEVERE HEART FAILURE * - low sodium is associated with high levels of renin, aldosterone vasopressin and norepinephrine SURVIVAL

Symptoms of a gastrojejunocolic fistula

*Severe diarrhea, weight loss and halitosis* b/c of fecal containment of the gastric contents -- Look for history of gastric surgery and s/p complications with ulcers that was never resolved.

Vascular phenomena associated with infective endocarditis

*Systemic arterial emboli*- focal neurological deficits renal or splenic infarcts *septic pulomary infarcts* *mycotic aneurysm* *janeway lesions*- macular erythematous nontender lesions on the palm & soles

Txt for Pneumoyscistist with Low Pao2

*TMP and Sulfa + predenosine*- Watch for allergic reaction with neutropenia hyperkalemia, elevated transaminases

Pronator dift senstive for

*Upper motor neuron disease* - because upper mototr disease causes a *weakness in supination* therefore when you close the eyes the arms pronate up

For an obsese women with a history of pain in her knees what is the best management

*Weight loss* - There is a strong link between obesity and knee OA

Malignant hyperthermia when does it occur

*Within 30 minutes of admistration of general anesthia* and muscle relaxants-->give dantrolene

Reroperitoneal zones

*Zone 1 centeral* - major vessel damage - indication for ex lap *Zone 2 flank hematoma*- no exploration warrented unless penetrating trauma b/c peritoneum with tamponade *Zone 3 pelvic hematoma*- no exploration neeeded because peritoneum will tamponade bleeding

AAA repair and UGI bleed -

*aortoduodenal fistula* - usually small bleed folllowed by 1-2 days by massive bleeding

Most common cause of Lower GI hemorrage in a older adult

*diverticulosis* right side more likely to bleed. rememeber that angiodysplasia is always a less common cause

Acute hemolytic transfusion reaction

*fever & flank pain & hemoglobinuria & renal failure & dic * within *1 hour of transfusion* postive direct coombs test Caused by ABO incompatibly

tender swollen and discoloured wound site with creptitus following a prenetrating injury what is it and what is the treatment

*gas gangrene* TXT : Penicillin G HIGH DOSE Hyperbaric oxygen debridment

Seminoma

*histology*-Large nests of round clear cells with centrally placed nuclei *tumor markers* - placental alkaline phosphatase - pLAP

AAA repair and Delayed fever

*inidcates vascular graft infection* - s. aureus and s. epidermis CT scan - to diagnosis

24 hours after PCI a patient presents with hypotension and *bradycardia* - what complication has developed

*thrid degree heart block*, the only complication that presents with *bradycardia* and hypotension

Yolk sac tumor

*tumor marker*-Increased AFP *histology *-papillary sturctures resembling glomeruli - schiller duval bodies

Clinical presentation of adenocarcinoma of the pancrease

- 85% of people have systemic symptoms like weight loss anorexia fatigue - 80% of people have abdominal pain or back pain - 56% jaundice - migratory superficial thrombophelitis - hepatomegaly and ascites with metastasis

The *HARD signs* of vascular injury that require *immeadate surgical expolration* other symptoms do imaging first

- active hemorrage -expanding hematoma -Pulse deficit -Bruit or thrill -Distal ischmeia - with the 5 p's

inability to comb hair with difficulty holding arms

- add proxmial muscle weakness - polymyositis/dermatomyosititis, endocrine hypo or hyperthryroidism cushing disease and neurmomuclar ( lambert eaton syndrom, myasthenia gravis) and drugs and steroids

Fail chest complications

- can cause pulmonary contusion and aortic transection,

Symptoms of splenic rupture post BAT

- delayed onset hypotension - LUQ pain - pain radiating in the shoulder- kehr sign - left lower rib fracture

Risk factors for pancreatic adenocarcinoma

- smoking - hereditary pancreatitis - nonhereditary chronic pancreatitis - obesity and lack of physical acitivty

Pulmonary embolis signs -EKG -ABG -CT

-*EKG*- S1Q3T3 -*ABG*- hyperventilations - respiratory alkalosis -*CT/ Xray* - wedge shaped infarct

Complications present in APCKD

--Hepatic cysts- most common extra-renal manifestations of adpkd --Valvular heart disease - MVP or aortic regurgitation --Colonic diveritcula --Abdominal wall and inguinal hernia

WARNING SIGNS for etiologies other than IBS

--Rectal bleeding --Nocturnal BM; awkens from or prevents sleep -- worsening abdominal pain --Weight loss --abnomral laboratory findings ( anemia electrolyte disorders)

causes of microscopic hematuria

--Renal : Renal cells cancer, igA nephropathy; --Ureteral - stricture, stone; Bladder; cancer, cystitits, prostate/ urethral - BPh, prostate cancer, urethritiris

Non sexually transmitted epididymitits - occurs in older men and normally gram negative rods

...

What is the management for heart block

...

What size of kidney stone will pass sponstenously with hydration and analgesia

0.6 cm or 6 mm

Crohns disease characteristic

1 most common Location in the GI tract affect is the terminal ileum and colon 2. Rectal sparing - 3. transmural inflammation seen in crohns can result in fissures, fistulas, or strictures 4. Granulomas- NON caseating 5. Skip lesions 6. Sparing of regions of the mucosa between the patchy distributions - coarsely tectured cobblestones appearance 7. Fissures 8.Fistulas 9. Peri-anal disease - like fissures fistulas, abscess and stenosis 10. Hyperplasia of the subserosal and mesenteric adipose tissure can lead to the appearance of creeping fat 11 multiple large lymphoid aggregates in the mucosa and submucosa 12. string sign on barium swallow - dx pyloric stenosis and colon cancer

1. In a patient with suspected peripheral artery disease (claudication, smoker, etc), what is the first thing you do? 2. What is that is normal?

1. Ankle-Brachial Index 2. If it's normal, do after exercise testing.

12 yo boy has blunt chest trauma after an MVA. He is sent home. Two months later, a CXR shows a deviated mediastinum with a mass in the left lower chest. 1.What do you think it is? 2. What should you do?

1. Diaphragmatic Perforation 2. Barium Swallow.

Crohn's symptoms and associations

1. Diarrhea 2. Malabsorption 3. Bile wasting 4. Gallstones 5. Oxalate kidney stones 6. anklylosing spondylitits 7. erythema nodosum 8. uvetitis 9. migratory polyarthitis

How do you initially manage hemoptysis?

1. Establish airway 2. Ensure dynamic stability 3. BRONCHOSCOPY is the procedure of choice to identify bleed and attempt early intervention.

Patient = hemodynamically unstable w/ blunt abdominal trauma. What do you do?

1. Fluid Resuscitation should be started 2. Follow with US exam 3. If there is intraperitoneal blood, then urgent LaparOTOMY. (Not laparoscopy)

There are several interventions for lowering ICP. Name the 4 and the mechanism.

1. Head Elevation -> Increased Venous Outflow from the Head 2. Sedation -> Decreased metabolic demand and control of HTN 3. IV Mannitol -> Extraction of free water our of brain tissue via osmotic diuresis 4. HYPERVENTILATION -> CO2 washout, leading to cerebral vasoconstriction (cause the brain responds to CO2 and pH)

1. In a burn patient with significant total body surface area burns, what is the major cause of morbidity and mortality? 2. What is the second biggest cause?

1. Hypovolemic Shock 2. Assuming good fluid resuscitation, BACTERIAL infection is the next thing.

1. How do you detect intra-abdominal injury in trauma patients who are hemodynamically stable? 2. What about unstable? What do you do if this is inconclusive?

1. If they're stable, use a Abdominal CT. 2. If they're unstable, then you do a FAST ultrasound initially. If this is inconclusive, then you do diagnostic peritoneal lavage BEFORE you proceed to laparotomy.

How do you treat splenic trauma if... 1. The patient is hemodynamically stable? 2. Hemodynamically unstable?

1. If unstable, but responds to fluids, then CT scan. 2. If unstable and unresponsive to fluids, then emergent exploratory laparotomy is needed.

1. What is Ludwig's Angina? 2. Most common Etiology? 3. Cause of death?

1. Infection of Submandibular and Sublingual Glands 2. Infected Tooth (usually 2n3 or 3rd mandibular molar) 3. Asphyxiation

. On POD3, an elderly man complains of pain around his wound. What are the 6 Signs/Symptoms of a Necrotizing Surgical Infection? 2. What do you do?

1. Intense Pain in wound 2. Fever, Hypotension, Tachycardia 3. Decreased sensation at edges of wound 4. CLOUDY-GRAY DISCHARGE 5. Tense edema outside involved skin 6. Subcutaneous Gas with Crepitus 2. URGENT SURGICAL EXPLORATION

Ulcerative colitis conditition

1. Not an autoimmune though related to autoimmune conditions 2. always involves the rectum and then spreads in a step wise fashion 3. HAve broad based ulcers & regions of regenerating mucosa that resemble friable pseudopolyps 4. intestinal crypt abscess and 5. loss of haustra 6. lead pipe appearance 7. Repeative bouts of blood diarrhea

1. What type of a shoulder injury commonly occurs after a tonic-clonic seizure? 2. What is the associated deficit?

1. Posterior Shoulder Dislocation. 2. The patient will hold the arm abbducted and internally rotated.

1. What injury to the GU system is associated with a pelvic fracture? 2. What are the symptoms? (5)

1. Posterior URETHRAL injuries. 2. Blood at urethral meatus, high riding prostate, scrotal hematoma, inability to void, and palpably distended bladder.

A 12 yo boy has right groin pain, knee pain, and limping for 2 weeks. He is obese, and he has restricted hip movements. There is external rotation of the right though on flexion of the hip. 1. What is the diagnosis? 2. How do you fix it?

1. Slipped Capital Femoral Epiphysis (SCFE) 2. Surgical pinning of the femoral head.

A patient has abdominal trauma (car accident) that initially shows no symptoms. However, 8 hours later, he gets epigastric discomfort, left shoulder pain, and mild nausea. His vitals are stable. 1. What is it? 2. What should you do?

1. Splenic Injury 2. Abdominal CT scan with IV contrast.

1. If a wound fails to heal after a prolonged period of time, what should you check for? 2. If this occurs in a burn patient, what is it called?

1. Squamous Cell Carcinoma - Ulcers can degenerate into SCC 2. Marjolin Ulcers.

What is the treatment for Acute Cholecystitis?

1. Treat with observation and supportive care initially, but you ned to do a LAP Chole within 72 hours during the same hospitalization.

MCC of acute pancreatitis

1. biliary gallstones 2. alcohol consumption 3. Hypertrigylceridemia 4. recent ERCP

Associations with Ulcerative colitits

1. damage to the muscularis propia - toxic megacolon 2. colorectal carcinom - risk sharply increasing at 8-10 years which is when colonscopy surveillance is started adn then continued every 1-2 years 3. antierior uveitis - iris cillary body and chorid 4. pyroderma gangrenosum - deep necrotic ulcers typically over the legs 5.priamry scerolsing cholangitits- continous inflmation and scarring of the bile ducts leading to beading pattern on ERCP ( 80% of people with PSC also have UC)

Causes of stertorrhea; 3 classes and multiples causes

1. pancreatic insufficiency 2. Bile salt related - bacterial overgrowth, chrons disease, PSC, *surgical resection of the ileum - 60-100cm* 3.impaired intestinal surface epithelium - Ceilac disease, AIDS enteropathy, Giardiasis

HOw much blood must the chest tube drain to require immeadate OR intervention

1.5L to > 200mL/hr for 3 hours

What is the initial treatment for CO poisoning?

100% O2 with facemask

Amount of blood ( acutely) needed to cause a rise in intrapericardial pressure

100-200ml- acute chronic - 1-2 L of fluid

Spinal cord trauma

1st iv steroids to reduce the swelling and then MRI

HIV screening 15-65

1x

Definition of stage 1 hypertension

2 consective measurments of blood pressure above 140-159 or diastolic 90-99mmhg

How days before should NSAIDS be stopped

2 days

Dietary sodium reduction will reduce the systolic BP by how much

2-8 mmhg

Size of the normal prostate

20-25 g

how much does exercise ( 30 min/day for 5-6 days/week)reduce your approximate systolic BP

4-9 mmHg

Intrinsic kidney disease is defined by how many cc of urine

400cc or less then 6 cc/kg a day

Thrombocytopenia is seen in what % of HIV patients

5-10%, therefore any patient with unexpalined thrombocytopenia should have a HIV test done

What hernia has the highest risk of strangulation

50% of all strangulations is the femoreal hernia below the inguinal ligament - through thte femoral triagnle

What drug reduces the size of the prostate

5a-reductase - finasteride this reduces the dihydrotestosteron and the prostatic volume use in patients with prostates greater then 40 g

HIV + AMS Cortical and subcortical atrophy and secondary ventricular enlagement

AIDS dementia

In general what is the tidal volume needed

6ml/kg - for ideal body weight

What should you do if a suspected scaphoid fracture is negative?

7-10 days in a spica cast and thumb immobilization.

How much decrease systolic occures while on the DASH diet ( high in fruits vegitables and low in saturated fat and total fat )

8-14

Saag of 1.1 or greater

95% accurate in diagnosing a transudative process consistent with portal hypertension

What level of CFU in a urine sample determines a negative result.

< 100,000 CFU/Ml and < 5 WBC

Normal BP vvlabes

< 120 ,,Hg diastolic < 80 ,,HG

palpable breast mass diagnosis different in ages <30 and > 30

< 30 is ultrasonogram - if it is complex cyst or solid mass - image guided core biopsy > 30 - mammogram & ultrasonogram - core biopsy

Stage 2

>systolic 160 and diastolic > 100

what is the best test to identify a colonic bladder fistula

A ct scan - patient will complain of pneumonuria passage of air n the urine or fecaluria - poop in the pee.

Multiple cystic spaces on the lateral side of the neck that vary in sizes

A cystic hygroma - a congential malformation of lymphatic tissue

Why is pretest probability and important factor to consider in Cardiac work up

A postitive stress test in *patients at a low risk* ( Women <50, men < 40, atypical chest pain, no significant risk factors - non smoker no family hisotry of premature CAD) willl likely be *false postive* ----a NEGATIVE test in a high risk patient might be false negative.

Hemisection syndrome

ALWAYS d/t a stab wound in the posterior neck-- Ipsilateral vibration and prop and contralateral pain and temp

Melanoma on pale areas of dark skinned pt's - soles of the feet and palms of the hands

Acral lentignous melanoma worse prognosis because of the depth of these

Risk factors for bladder cancer

CIgerrets smoking, Occupational exposures paintera nd metal workers Chronic cystitis iatrogenic causes ( cyclophosphamide) pelvic radiation exposire

patient with an ulcerated mass that occupies the right breast that extends into the axialla where there are mulitple hard mass what is the next treatment

An ulcerated extensive tumor such as this cannot be operated on therefore Preoperative chemotherapy

A patient has blunt abdominal injury. He complains of diffuse abdominal pain that refers to the left shoulder. Which of the following is most likely injured? 1. Bladder Neck 2. Bladder Dome 3. Anterior Bladder Wall 4. Urethra 5. ANterior Urethra

ANSWER = Bladder DOME. Blunt trauma to the Bladder DOME is the only thing on this list that could cause the peritonitis that the patient has.

What is the first indicator of hypovolemia?

ANSWER = Pulse Rate

location for thymoma

ANTERIOR mediastinum - in a younger patient with an anterior mass or in 20% of those patients with myasthenia gravis.

SAAG is calculate

Abdominal ascities - serum ascitis

Calculation of SAAG

Abdonimal ascities ablumin- serum ascities ablumin Less then 1.3 = transudate Greater then 1.3 = excudate

dysphagia greater for liquids then solids

Achalasia Dx birds beak on barium swallow Tx heller myotomy

An inability to have plantar flexion on squeezing of the gastrocnemius muscles in the prone position

Achillles tendon rupture - this is know as a *thompson test*

Triad of death

Acidosis, coagulapathy and hypothermia - Hypothermia can cuase platelet dysfunction and rewarming indicated acidosis - from lactic acids - give crystalloid

Acute presentation: Abdominal pain, nausea, vomiting diarrhea and sweating. Agitiatio, anexity paraesthesia and confusion. Can be brought on my Drugs

Acute intermittent porphyria and no photosensititvity

Gross of micorscopic hematuia Family history of renal failure hypertension

Acutosomal dominant polycystic kidney disease

Rule of 9's for burns

Adults head - 9% Anterior torso 18% posterior 18% anterior leg 9% posterior leg 9% Anterior arm 4.5 posterior arm 4.5% genitals 1% Baby anterior head 9% posterior 9% Anterior toso 18% posterior 18% anteriro leg 6.75% and posterior 6.75 ANterior arm 4.5% and posterior arm 4.5 genitals 1%

Polymyalgia rhumatic symptoms

Age > 50 *Bilateral pain and morning stiffness* > 1 month Involvement of 2 of the following - neck or torso, shoulders or proximal arms , proximal high or hip + constitutional symptoms

Surgical indications for a neck wound

All GSW and stab wounds in zone 2- expanding hematomas deteriorating vital signs coughing blood, subcutaneousS emphysema

Who should get a pnumococcal polysacrride vaccine

All adults above 65 Or adults under 65 with *chronic disease like:* asthma COPD, emphysema - CAD - Chronic lung disease - Smokers - Alcoholism - cochlear implants - CSF leaks - immunocompromising disease - functional or anatomic asplenia

Melanoma in anus

All mucosal melanomas have BAD prognosis txt with apr ( abdominal peritoneal reseection) + Lymph node resection.

Aortic stenosis - triad of symptoms

Angina, dyspnea, syncope and high possibility of sudden death

In a clavicale fracture, what do you need to do if a bruit is heard under the damaged area?

Angiogram - ensure that the subclavian artery is not damaged.

What is the first test to evaluate suspected peripheral artery disease?

Ankle-Brachial Index using Doppler

Patient presents with her arm held close to the body and the forearm rotated outward. She is in pain and will not move the arm from that positon. the shoulder looks square and there is a lack of sensation over the deltoid

Anterior shoulder dislocation- damage to the axially nerve

what size of breast lump is the cutoff for lumpectomy

Any *mass > 4 cm* also remeber smaller breasts more often require mastectomy

Deceleration injury causes what

Aortic injury

Loud blowing diastolic murmur + bounding pulses

Aortic reguigitation - VALVE REPLACEMENT

Patient presents with severe chest pain radiating to the back with severe hypertension and decrescendo diastolic murmur of aortic regurgitation. - can have weak or absent peripheral pulses and systolic blood pressure variation > 20 mm Hg

Aortic root dissection and use TEE

HARSH systolic murmur + angina + syncope

Aortic stenosis - MCCC congenital bicuspid aortic valve with sytrophic calcification.

Man complains of impotence + thigh and calf pain that is relieved by rest PE - absent femoral and lower extreimty pulse bilaterally

Aortic-iliac stenosis aka *Leriches syndrom* - always inculdes inportence

Complications of penetrating trauma to the groin

Arteriorvenous fistula, then the venous hypertension can develop into lymphaedma

Patient with a prior hisotry of excema and chronic rhinitis with nasal polyps is admitted to the hospital because of possible MI now treated with Asprin and beta blockers presents with wheezing WHY

Asprin induced Asthma or beta blockers can also do it .- Looks for a past history of excema and rhiniris to give Hints that there is atopic past

Riley dray syndrom

Autosomal recessive disease seen in children of ashkenazi jewish have severe orthostatic hypotension

Treatment for PAC - Premature Atrial ventricular contractions

Avoid alcohol, tobacco, caffeine and stress

Best treatment for hypersentitivity pneumonititis

Avoidance of exposure

Medical mangment for Dilated cardiomyopathy

B blockers will improve heart funciton, ---> but heart transplant is indicated

Hypertension 18+

BP every 2 years

hirusprung disease how to diagnosis

Barium enema and 4x more likely in boys definiitive diagnosis is biopsy must inculde all the layers

Raised waxy lesion on the face ( upper lip is classic)- can have teleangectasia or a non healing ulcer what is it and what is the treatment

Basal cell carcinoma Txt with local excision and use 1 mm margins and LN excision.

patient with very tender spot in the third interspace between the third and fourth toes

Benign neuroma -

Sudden onset of vertigo nausea & vomiting - no change in hearing

Benign recurrent vertigo or vestibular neurontitis

What do You give for the management of cocoaine use

Benzodiazepines

Medical managment for Atrial fibrilation

Beta blockers Or Calcium channel blockers (diltiazem)

Treatment of exercise induced asthma

Beta- agonist or mast cell stabilizers like cormolyn

Nausea, vomiting and right sided shoulder or subscapular discomfort

Biliary colic - always related to meals and no fever

What spider bite presnts with muscle cramps, acute abdomen and nausea vomiting what is the treatment

Black widow IV calcium glucoronate and muscle relaxants

Hemorrhage and ab distension

Bleeding into abd cavity - = abd syndrom which can cause decreased renal blood flow -oliguria and dyspnea - elevated diaphragm

How does trimethoprim increase K

Blocking the sodium channel in the collecting tubule similar to the action of the potassium sparing diuretic amiloride

Causes of spontenous rupture of the esophagus

Boerhaave syndrome and pill esophagitits ( from postassium cholride) Barrett esophagus or infectious esophageal ulcer viral or candida in HIV

Mecklers triad

Booerhaave syndrom----Vomiting & chest pain & subcutaneous emphysema

Genu varum - when is it normal and when should surgical correctio be considered

Bow legs- < 3 observe since it is normal , > 3 consider surgical correction.

What is a common complication of aortoiliac vessel repair?

Bowel Ischemia....most commonly afects distal left colon. Colonoscopy shows a discrete segment of cyanotic and ulcerated bowel.

Complication of abdominal aortic aneurysm repeain 1-7%

Bowel ischemia s/t inadequate colonic collateral arterial perfusion to the left and sigmoid colon

After NOMI what do you see on the CT

Bowel thickening and intraluminal gas

Post Surgery for an aneurysm of the infrarenal aorta - 1st postoperative day abdominal pain and bloody diarrhea Full femoral pulses and symmeterical

Bowels ischemia is one known complication of the abdominal aortic aneurysm repair

Tumor arises within the bronchi and causes obstruction- Commonly in people under 30 - present with hemoptysis and atelectasis --

Bronchial adenoma - dx- Ct scan & bronchscopy beware of bleeding

Blunt thoracic trauma --> Pneumothorax that doesnt resolve with chest tube placement, can also see mediastinal air

Bronchial rupture

X ray finidng of *linear atelectasis* normally means what pathology + hx of chronic productive cough with purlent sputum

Bronchiectasiss

middle mediastinum masses

Bronchogenic cyst, tracheal tumors, pericardial cysts, lymphoma, lymph node enlargement, aortic aneurysms of the arch

What spider bit presents with an ulcer that needs to excised and and then skin graft

Brown recluse

plantar fascitis

Burning pain in the plantar area of the foot that is made worse with walking

Trauma - Disability & Comatose -

C spine cannot be cleared so precautions must continue

CHA2DS2- VASc score

C- congestive heart failure -1 H- hypertension - 1 A2- Age > 75 -2 D- Diabetes mellitus - 1 S2- Stroke - Tia - throboembo-2 V- vascular disease -1 A-Age -65-74-1 Sc- Sex women - 1 Max score 9

How do you treat an abscess formed due to Complicated Diverticulitis?

CT guided percutaneous drainage. If you can't get it, then surgery.

Post BAT what identifies splenic injury

CT scan with intravenous contrast

What is tthe best srtdy for bronchitectasis

CT with high resoluation

Mitral stenosis alon what are the pre operative considerations

Can results in cor- pulmonale therfore sondult cardiologist - give prophylactic antibiotics for endocarditis

67 year man has new onset diabetes mellitus, he has increase alkaline phosphatase and increase bilibruben as well as heme + stools WHAT SINGLE LESIONS ACCOUNTS for both of the these findings

Cancer of the ampulla of vader - endoscopic exmaination of the duodenum

"Pain worse at night"- key word for

Cancers

Amount of Kcal in carbs fat protein etoh

Carbs- 4 kcal/gram Fat- 9 kcal/gm protein 4 kcal/gm etoh 7 kcal/gm

Is cauda equina or conus medullaris : Unilateral severe radicular pain *Saddle hypo/anesthiesia* *Asymmetric* motor weakness Hyporeflexia Late onset bowel and bladder dysfunction

Cauda equina syndrom

Direct Blunt abdominal trauma in children

Cause duodenal hematomas

Charactersitics of palcental abruption

Caused by: trauma, hypertension or cocaine There is blood seen on pelvic exam and a *painful pelvic exam* ( previa has no pain)

Can be associated with seizures - CONTRALATERAL homoymous hemianopsia, plegia, paresis, Eyes deviated to the CONTRALATERAL side of damage ( away) C- cerebral and contralateral

Cerebral lobe

Treatment of pancreatitic cancer with metatsis

Chemotherapy - often combination of 5-FU leucovorin oxaliplatin and irinotecan --- *surgery with the whipple procedure only done if the cancer is resectable*

What do you have to do immediatel after placing a central line?

Chest X-ray.

IF hypertrophic osteoarthopathy is found what test do you order

Chest x ray to determine the underlying cause

Lab studies for adenocarcinoma of the pancrease

Cholestatic picture ( increase ALP and direct biliruben) d/t common bile duct obstruction - Elevated CA 19-9 - Ultrasound ( if jaunced ) or CT scan ( if no jaundice ) of abdomen

pathophysiology of brochiectasis

Chronic damage to the the bronchial wallls from infection trauma and tumor - also cystic fibrosis and A 1 antityspin disease

Patient has a postive history for alcoholism and ER admittance for ab pain, now pressents with new onset diabetes constant pain, and steatorrhea

Chronic pancreatitis

What is torus palantinus?

Chronic, hard, bony growth on the midline of the hard palate. It is a congenital anomaly.....don't treat unless symptomatic.

What is the Pringle maneuver

Clamping the portal triad in the *hepaptoduodenal ligament* intermittently with a traumatic clamp - Stops the blood flow into the liver from the *hepatic artery and the portal vein*.

How often should screening for colon cancer be done for a patient with ulcerative colitis

Colonscopy now and then every year after ( or repeat 1 -2 years)

Shoulder paina nd ipsilateral ptosis, and miosis + smoking history

Consider pancoast tumor which can invade the brachial plexus and present with shoulder pain

Duodenal hematoma

Common in children *hitting the handle bars* the sweeling blocks the lumen and casues GI obstruciton *Tx NPO and iv fluids* spontenous resolution in 5-7 days

Pregant lady presents with severe hypotension with abdominal distension.

Complication in pregant women is *visceral aneurysms* - such as splenic, hepatic or other intra abdominal arteries. *MOST common are splenic* - you will a *signet ring sign on x- ray*

Dermoid cyst is found where on the neck

Congential mass ( often present for many years) found in the submental region ( can also be found in other sites of the head and neck inculding orbit, nose and nasopharynx, and oral cavity. ) they are epithelium lined spaces .

Causes of Transudate pleural effusion

Congestive heart failure Cirrhosis Nephrotic syndrome Peritoneal dialysis

Non-bleeding varices are found on Endoscopy. How do you treat them?

Conservative Medical Management - NOn-selective B-Blockers (Propanolol).

How do you treat a non-displaced scaphoid fractures?

Conservatively with wrist immobilization

Any child with joint pain or decreased ROM or pinpoint bone pain following a spetic illness

Consider a septic hip or osteomyelitits

Post op hematuria

Consider bladder overdistention cancer, infection, kidney stones, trauma, postatitis and cylophosphamide

What do you do for a perforated esophagus?

Contrast Esophagography.

Is cauda equina or conus medullaris : Sudden onset severe back pain *Perianal hypo/anesthisia* *Symmetrical* motor weakness Hyperreflexia Early onset bowel and bladder dysfunction

Conus medullaris syndrom

patients that get pellagra

Corn-based diets india, africa, and china and in alcoholics patients with carcinoid syndorm & hartnups disease

patient presents with pain and photophobia of the eyes there is a history of a branch hitting the eye and the slit lamp image is positive

Corneal abrasion

A patient with a known Cranial injugry who is now having hypertension, bradycardia and irregular rspirations

Cushings reflex or triad.- the ischemic brain sends out a sympatheitc nervous system message to the peripherial circulation to vasocontraict BUT the vagus nerve is unaffected, and responds to the increase in BP with=bradycardia

In aptients with traumatic spinal cord injuries (often caused by whiplash), what neurological syndrome commonly occurs years later?

Syringomyelia.

Best test to diagnosis renal stones

Ct of the abdomen and pelvis without contrast

Clean wounds -

Created in a sterile nontraumatic setting and do not involve the areas ( GI, Respiratory, GU) Risk of infection is 1-1.5%

What test for unexpalined gross hematuria or microscopic hematuria ?

Cystoscopy

Presentation and etiology of a CHF pleural effusion

D/t increase in hydrostatic fluid pressures 61% are bilateral right only 27% Left 12%

TPN and metabolic coma

D/y hyperglucemia and hyperosmolar non ketotic coma and is commonly d/t escessive osmolar diuresis

Osteoporosis women 65 +

DEXA

Complications of AAA repair Day 1/2 Day 3 Day > 3 (x2)

Day 1/2- Third space loss - give more fluids Day 3- Thrid space mobilization adjust fluid Day > 3 - impotence d/t damge of the hypogastric circultation or autonomic nerves around the IMA

Pain in the thyroid + high ESR can have palpiation, diarrhea, sweating

De Quervains = subacute thyroiditis Can have throidtoxicosis becuase of release of hormones by the inflammed gland Normally only lasts for 8 weeks

A young mother complains of radial side of the wrist ad the first doesal compartment- worse when attempting to cary her baby

De quervains tenosynovitis of the abductor or extensor tendons of the thumb

Managent for Dehiscence

Deal with it conservatively--> Tape the wound and bind the abodomen and prevent anything that would increase the abdominal pressure This is will allow some granulation tissue to reform and then the wound can be closed

Physical exam - polymylgia rheumatic

Decrease ROM in shoulders neck and hips

Complications associated with pernicious anemia

Decreased abs of B12 because there is low intrnisic factor, Chronic atrohic gastritis because of attack on the parietal cells of the stomach atrophic gastritis has an increased risk of intestinal type *gastric cancer* and *gastric carcinoid* by 2-3 x

Treatment for syndrome of inapproiate ADH release

Demeclocycline- Occurs in any patietn who might have head trauma or centeral nervous system proceedure or Small cell carcinoma of the lung

Solitary ring enchaning lesion on the MRI, periventricular

Diagnosis is the EBV virus inthe CSF Primary CNS lymphoma second most common cause of mass lesion in HIV infected persons

Cardiac cath shows square root sign

Diagnostic of constictive pericarititis - presents with dyspnea hepatomargaly

abdominal pain, pain referred to the shoulder, shortness of break and vomiting -- X ray shows abdominal viscera above the diaphragm

Diaphragm rupture

Galeazzi fx:

Diaphyseal fracture of the distal radius and ulnar dislocation following direct trauma to the radius

Monteggia fx

Diaphyseal fracture of the promximal ulnar & radial dislocation, results from DIRECT injury to the ULNA

meniscal injury signs and symptoms

Difficulty in extending the knee, mild swelling and pain - with Passive flextion and extention you get a pooping sensation where the examiner places the fingers under the knee

A CT scan of the head shows numerous minute punctate hemorrhages with blurring of the gray-white matter interface after an MVA. What is it?

Diffuse Axonal Injury

Painfulswallowing especially for hot or cold liquids

Diffuse esophageal spasm aka nutcracker esophagus high amplitude contractions inan unco-ordinated fashion tx nifedipine

Hypertrophic osteoarthopathy ( HOA)

Digital clubbing is accompanied by sudden onset arthropathy commonly affecting the wrist and hand joints - pain there * remember your physcial exam* --seeen in lung disease ( Cancer, Tb, bronchititis, or emphysema )

SNake bites

Dont always cause envemonation- signs of venom - pain swelling discoloration

Treatment of an abcess anywhere in the body

Drainage!!

patient presents with transient blindness in the left eye that apppears as if a curtain is being pulled down - what is the diagnosistic test/ work up

Dx fundoscopic exam reveals *Hollenhorst plaque*, a bright shiny spot in a retinal artery physical exam (check carotid bruids, neuro, cardiovascular) + carotid duplex; Tx aspirin or carotid endarterectomy ( if stenosis is 50% ( because it is symptomatic))

hemopericardium diagnostic test

ECG- electrical alterans

What EF is a risk for surgical complications

EF < 35%

polymylgia rheumatic - LAB

ESR >40 sometimes at 100 elecated CRP Normocytic anemia 20% completely normal

What do you do if there is any indication of a thermal inhalation injury in a burn victim?

Early intubation to prevent upper airway obstruction by edema.

Fever that starts 10-15 days post colon surgery and re-anastomosis

Either a anastomosis leak or deep abscess

Most imporant goal folllowing the managment of a rib fracture

Ensure proper pain control - A lack of pain control will result in Hypoventilation and atelectasis and pneumonia

Child with purlent unilateral nasal discharge acute onset

Epiasxis due to foreign body- especially a child around 2 years of age with unilateral signs of blockage + purlent discharge ( ear, nose or lung)

complication of a full thickness burn- 3 days post burn, she complains of pain and paresthesia

Escharotomy - THE ESCHAR IS DEAD TISSUE can compromise lymphatic circulation resulting in a decrease in pulses * pressure of 25-40 mmhg is the threshold to perform escharotomy*

Picks disease

Eupohoira disinhibition apathy compulsive behaviours (eating habits) Hyperorality impaired memory Visual and spatial functions are in tact.

calculation of IV fluid replacement : if sodium is 152

Every *3mEQ/L* that *serum sodium concentration is greater then normal* = *1 L of water deficit* normal = 140 paitent = 152 therefore 152-140=12 12/3 = 4L You dont want to stress the system with 0.9 nacl or pure water therefore use0.45%

Hypernatremic - post surgery means how much fluid deficit

Every 3 Na+ over 140 indicates 1L of water loss

How often should women 21-65 get a pap smear

Every 3 years

Second degree burns

Extend into the dermis - cause pain and blistering and may develop into thrid degree burns

Surgical contraindications when evaluating NSCLS

FEV1 < 800ml, mediastinal LN involvment or distal metastses

TPN and dry scaly skin

FFA def. give FFA

Finding a thyroid nodule next step

FNA- as the results will determine the course of the treatment MAligant or intermediate - surgery Benign then observation

How often should colon cancer be screened for ( 50-75)

FOBT - yearly Colonscopy every 10

third degree burns

FULL thickness and painless

Herbal remedies for weight loss lid lag, palpitations, sweating, weight loss, hyperacitvity and diarrhea what the diagnosiss whats the RAIU Whats the labs

Factitious thyrotoxicosis RAIU is LOW LAbs: tsh low, High t3/ t4 or both depending on the remedy

Diagnosis of the fat emoblism

Fat droplets in the urine or intra-arterial fat globules on fundoscopy.

Post long bone break The patient develops severe dyspnea and confusion. With non-palpable petechiae in the upper part of the body.

Fat embolism is common in patients with polytrauma especaially with multiple fracture of the long bones. ___ key findings_____severe respiratory distress petechial rash, subconjunctival hemorrhage, tachycardia, and fever.

What nerve innervates the anterior compartment of the thigh?

Femoral Nerve

Elderly women has a shortened and extrenally rotated leg what injury do you suspect

Femoral neck fracture with a risk of avascular necrosis

adverse side affects of methimazole

Fetal teratogen in the 1st trimester cholestatic jaundice and agrulocytosis, rash arthralgias and hepatitis

Febrile nonhemolytic transfusion reaction

Fever and chills within *1-6 hours of transfusion * caused by *cytokine* accumulation during blood storage.

treatment of follicular carcinoma

First remove the thyroid then after the tissue is removed you can treat with radioacitve iodine to abalte any remaining tissue

What enema must be avoided in diabetics

Fleet enema becuase iti s a sugar rich hypertonic formula causes dehydration, metabolic acidosis ( loss of bicarb )

Dementia with lewy bodies

Fluctuating cognitive impairment and *bizarre visual hallucinations* - Some *parkinsonism* is seen but there is a poor response to dopaminergic agonist

if there <0.5cc Post op- urine output

Fluid deficit (bleeding out) or acute tenal failure give bolus of 500mL iVF and if they respond then it fluid decifit

things to avoid is acute prostitits

Foley & prostatic massage

A man stabs himself with a nail. The wound is small and clean. What do you do if.... 1. He is unimmunized? 2. He had his last booster > 10 yrs ago? 3. He has his last booster < 10 yrs ago? What is the wound is severe or dirty? 4. Unimmunized? 5. Booster was >10 yrs? 6. Booster was <10 yrs?

For small, clean wounds.... 1. Td Only 2. Td Only 3. Nothing For severe or dirty wounds... 4. Td and TIG 5. Td and TIG 6. Td if lastest booster was given > 5 years ago.

Etiology of diverticula

Form b/c high intraluminal pressure in the colon = herniation of the mucosa and the muscularis mucosa at sights that are penetrated by the vasculature.

Most common fracture in the pediatric population who fall on the outstretched hand --- what ist he most common structure damaged whaat other structures are at risk

Fracture of the of the *supracondyler hummerus* most common structure injurged is the *BRACHIAL ARTERY* followed vby the median nerve, Cubis varus deformity Compartment syndrom- volkmanns ischemic contracture

Suden onset SEVERE psoriasis or recurrent herpes zoster suggests what underlying pathology

HIV infection

Waterbrash taste in the mouth ( sour) Cough, dysphagia, cough Diagnosis and txt

GERD tst: ppi - if it continues after 6 weeks then do EGD and biopsy

Features of alcoholic cerebellar degeneration

Gait dysfunction, truncal ataxia nystagmus intention tremor or dysmeteria impaired rapid alternating movments * muscle hypotonia leading to pendular knee reflex- persistent swing movement of the limb after a DTR is elicited*

Bernard- Soulier syndrom

Giant platletes glucoprotein Ib-IX-V which is a receptor for Von willebrands factor mild thrombocytopenia Giant platetes

After surgery, a patient develps right calf pain and swelling. A clot is shown under Duplex US. What do you do?

Give Heparin acutely. (Not TPA or anything like that).

Patient receives spinal anesthesia and then has diffuse vasodilation - what is the treatment

Give alpha antagonists to prevent vasodilation.

Patient with acute protatitis ( urin is dark and cloudy + burining with urination + fever + high respirations) what do you treat with prostate is tender and can have mylagias and arthralgias

Give ofloxacin for 4 to 6 weeks --- a fluorquinolnes will cover both E coli and chlymydia

heamturia, RBC casts acute renal failure hypertension and edema

Glomerulonephritis

A gradual onset of impotence suggests what kind of mechanism

Gradual suggest organic impotence that pharmological therapy is recommended for the frist step then a vacum erection device

Signs and symptoms of Spianl cord compression

Gradually worsening local back pain Pain *worse lying down* and *worse at night * -- EARLY SIGN - symmetric lower extremity weaknness hypoactive *absent deep tendon reflexes* LATE signs B/l Babinski signs - Decreased spincter tone, parathesthia, paraplegia with *increased DTR*

Contaimined wounds

Gross spillage from one of the systems listed in the first paragraph --infection 10-15%

X ray findings for hypersentiveity penumonitits

Ground glass opacity or haziness of the lower lung feilds

Mitral stenosis + CHF

HIGH risk of mortality - need extensive work up EKG, echo and operative monitoring

Clots with Low platlets

HIT

Infant with a scrotal mass - It is custic and transilluminated by light.

HYDROCELE: fluid in processus or tunica vaginalis will resolve spontaneously by 12 months

What are signs of magnesium toxicity

HYPOREFLEXIA decreased respirations Heart block -> Death flushing and sweating

A kid falls off his bike and hits his head. He briefly lost conciousness, but had no seizures. His vitals are stable, no neuro symptoms, and only a small bruise on PE. What do you do?

He can be discharged if he has a normal CT, with instructions to come back if new symptoms arise.

Ascities leakage through a hernia ulcer

High risk of bacterial peritonitis - evaluate for mental status changes and tap the ascities

An elderly gentleman comes into the ER after being found on the floor at his home. He complains about hip pain primarily, but also complains about SOB, anxiety, and finger numbness. What should you do?

He probably fractured his hip, so get an X-ray. However, you need to find out WHY he fell. In his case, you should work up an MI.

If a patient presents with Any of the following which test do you run-> --Focal neuologic findings --skull fracture, especially signs of basilar skull fracture --Seizure --Prolonged loss of consciousness --persistent altered mental status

Head CT without contrast

Stroke in the basal ganglia

Hemiplegia hemi serensory loss homonymous hemianopsia gaze palsy stupor and coma

A Reversible cause of Restrictive Cardiomyopathy

Hemochromatosis

Heparin induced throbocytopenia ( HIT)

Heparin binds to platelet factor 4 a heparin neutralizing protein released with platelet activation The Hepatin pf4 complex then triggers igG antibodies which bind to the pf4 heparin complex.

Porphyria cuntanea tarda or Cutaneous leuckocytoclastic vasculitis palpable purpura - this is d/t cryoglobulinemia

Hepatitis C

Most common cause of corneal blindness in the US - patient complains of pain, photophobia, blurred vision, tearing and redness.- may be recurrent PE: corneal vesicles and dendritic ulcers are characteristic

Herpes simplex keratitis

A 17 year old boy presents with many years of crampy abdominal pain + diarrheas often with frank blood with dilation and strictures of the inter and intra hepatic ducts. His bilirubin is 3.6--2.9 conjugated ALP is 625 and normal transaminases

High ALkaline phosphatase and dilated extrahapetaic ducts- Primary sclerosisng cholangitis PSC Diarrhea with frank blood is colon cancer the combination is ulcerative colitis

Charcot symptoms for cholangitis

High fevers with right upper quadrant pain and jaundice + elevated alkaline phophatase

Characterisitcs of siADH

High urine osmolality and specific gravity

Choriocarcinoma- hisotlogy and cancer marker

Histologically by *cytotophoblastic and syncytioblastic cells* resembling chorionic villi Serum beta human chorionic gonadotropin

Most important diagnostic feautures of hypersensitivity pnemonitits

History of some antigen exposure ( birds, silos) and then induction of symptoms

pathophysiology of the short bowel syndrome

Hypertonic gastric contents enter the duodenum and small intestine -- there is a fluid shift from intravenous space to the small intestine + release of vasoactive polypepetides

Paricardial effusion physical exam

Hypotension, tackycardia, distended neck veins, pulsus paradoxicus

Most common cause of post surgical AMS

Hypoxia

When ulcers require surgery I.H.O.P

I- intractability H- heminstabily O- obstruction P-perforation

What type of diverticulum is zenkers

pulsion diverticulum - b/c uncoordination of the cricopharygeal muscles txt cricophargengeus myotomy

IF a patient has A lump removed and the lymph nodes and later the biopsy comes back with Positive lymph nodes how does this change the management

IF the cancer is not positive for Her2neu/ER/PR Then do radiation - ( necessary for all lumpectomy) and chemotherapy to control the systemic disease

Sclerosing tenosynovitis

INTENSE PAIN and hisoty of trauma or overuse

The next best step in managment for A spinal cord injugry

IV dose of corticosteroids -- The surgical decompression of a spinal cord injugry depends on the findings of the MRI

patient has a history of a complicated cholecystectomy and ten months later presents with fever chills elevated WBC, ALP Alkaline phosphatase and direct bilirubin. Ct reveals intrahepatic bile duct dilatation with no evidence of stones

Iatrogenic stricture of the common bile duct

When do you need to gve rabies prophylaxis

If bite was unprovoked or dog isnt available for the brain

Stab wound managment to the abdomen

If it penetrates the peritoneum - ( can you see viscera, is there peritonitis or hemodynamic instability) go to OR -- otherwise digital exploration adn observation

What type of imaging do superior sulcus tumors require to stage

Imaging of the head MRI, CT

When do you give endocarditis prophalaxis

In GI prooceedures, GU and HEEENT

When do you screen for chlamydial infections

In all *sexually active women ages 24 and under*.

HEad trauma can cause cerebral salt wasting syndrom what factors are inapprioatly released and what electrolyte is out of balence

Inapproiate secretion of vassopression or ADh, Also inappriopriate secretion of ANP/BNP

Trauma- Circulation + pregnancy -

Increased HR is normal ; decrease hct 31-35% is normal, best to evaluate on the left side

RQ 0.7

Indicates that Fatty acids are being metabolised

Mechanism of action of sidenafil

Inhibits the type V guanosine monophosate phosphodiesterase enzyme

Fever, rash and renal dysfunction and eosinophiluria with WBC casts

Intersitial nephritis

IV line cannot be establishe in a very small child what is the next route of fluid admission

Intraosseous IO canulation - locations are distal tibia or proximal femur - if the growth plate is damged it will affect growth

If c spine injury is suspected what precautions must be take

Intubation with extreme care - lok for c spine tenderness to palpation

A 12 yo male had blunt trauma to the abdomen, and a CT scan finds a duodenal hematoma and no other injuries. What do you do?

Isolated duodenal hematoma is treated conservatively with nasogastric suction and parenteral nutrition.

A postive PPD of grearer then 5mm for a HIV postive person- what is the prescribed managment

Isoniazid and pyrodoxine for 9 months

What does technetium 99m label

It has affinity for the gastric mucosa - to identify meckles diverticulum

A woman has skin/nipple retraction with calcifications on mammography. A 3 cm spiculated masse in the Upper Outer Quadrant of the brest is noted. Histo shows foamy macrophages and fat globules. What is it and what do you do?

It is fat necrosis, and you just do routine follow-up.

Gastric adenocarinoma- where does it spread and what is the treatment

It spreads to the left supraclavicular node, sister mary joseph node and blummershlef nodes --- tx proximal cancer with total gastectomy --- tx distal cancer - wiht distal gastectomy and take out D1 LN at lesser curvatures

electrical burn management

Iv fluids + mannitol + acetazolamide to maintain a high urine out pur

Prepubertal boy presents with profuse bleeding from the nose with an obvious mass

Juvenile nasopharngeal angiofibroma

CRF what electrolyte must be tested before surgery

K must be tested before as it can acculmulate very fast

Paroxysmal supraventicular tachycardia PSVT most common cause

re-entry into the AV node

A well differentiated scc that often grows out of the hair follicle it normally grows rapidly and dies off

Keratoacanthoma

Left lower quandrant flank pain that radiates to the left thigh and scrotum *What is it?* & *what test*

Kidney stone and CT without contrast

Genu valgus

Knock knee observation is ok from 2 - 4 years at 4 the valgus should reach a maxmium and then the normal adult aligment will begin.

Besides tension pneumothorax, what can cause tracheal deviation?

LARGE hemothorax. You'll hear decreased breath sounds and DULLNESS to percussion.

Fluid replacement for burn victums from the parkland formula

LR volume - %BSA x kg x 4ml/kg gie 50% in the first 8 hours and then50% next 16 hours

Cancers that create 1,25 ( OH) 2 vitamin D production

LYMPHOMAS all types

Diagnositc Test for lactose intolerance

Lactose hydrogen breath test - a POSITIVE BREATH TEST = the conculsion that the bacteria are metabolising the lactose

squamous cell cancer of the anus - presentation

Large fungating mass growing out of the anus the mass is Enlarged lymph nodes 2 cm in diameter

Seminoma- histology and cancer marker

Large nests of round clear cells with a centrally placed nuclei and obvious nucleoli- resembling sphereocytes ---present men 20-40 --placental alkaline phophatase PLAP

Poor prognosis factors for breast cancer

Large tumor size Carcinoma with axiallary lymph node involvement high grade carcinom ER / PR negative over expression of HER 2 neu

treatment for chronic venous diseaes

Leg elevation, exercise and compression stockings.

Hyperlipedemia Men 35+

Lipid panel every 5 years

Esophageal leiomyomas- where are they located - anter or posterior mediastnium

Located in the posterior mediastnium and are normally submucosal and asymptomatic. only produce symptoms when >5cm

TSH secreting pituitaryy adenoms have an increase of what acctive subunit

the alpha sub unit.

Common complication of membranous glomerulnephritis

Look for proteinuria, periorbital edema and abdominal distension. *Renal vein thrombosis is a complication of nephrotic syndrome* - d/t antithrombin II -- NOw look for hematuria, abdominal pain and fever

Child presents with a new neck mass, the child has a fever a respiratory infection pain, and elevated white blood cell count .

Lymphadentitis

Placental Abruption classification- Minimal vaginal bleeding and normal fetal heart rate and localized pain and tenderness

MIld abruption

Intraductal papilloma tests

MOST common cuase of the unilateral bloody nipple discharge in women between 20 and 40 You wont see anything on mammaography You need *galactography*

Congential megaureter

MOre common in males then women and presents as a dilated distal ureter in the absences of any pathology. Some remain asympatomatic orther will eventually progress to hydronephrosis

How do you diagnosis the PML virus ( JC virus)

MRI and hx of focal neurological defect

what diagnositic tests are used to diagnosis ligament injury

MRI!

what is magnesium method of action in preventing seizures

Magnesium blocks neuromuscular transmission mediated by acetylcholine at the end plate this stops the seizure signals magnesium also suppresses the centeral nervous system

Patient has green vomting and double bubble sign on x ray

Malrotation d/t ladd bands or duodenal atresia or annular pancrease --- malroation is more likely if there is little normal gas pattern beyond the double bubble. - * ddx- with contrast enema *

Male with the gland penis exposed because the foreskin is pulled back the galnds penis is edematous, dusky and painful what is the managment

Manually Reduce the patient foreskin

RQ 0.8

Means more proteins are being consumed.

What is a Morton Neuroma?

Mechanically induced degenerative neuropathy commonly seen in runners. Presents with PAIN between the 3rd and 4rth toes that is reproducable with palpation, sometimes iwth a clicking sensation. Tx. is conservative with bilateral shoe inserts.

Where do the femoral blood vessels arise from:

Medial femoral circumflex adn the profunda femoris

Alarm symptoms

Melena Perisitent vomitng Hematemesis Weight loss Anemia Dyspahgia/ odynophagia

What Symptoms + GERD would you preform endoscopy

Men age > 50 with symptoms for > 5 years or cancer risk factors OR Alarm symptosm ( dysphagia, odynophagia, weight loss, anmeia, GI bleeding, or recurrent vomiting)

Thessaly Test

Meniscal injury -Pain or locking with interneal and external rotation of the knee while standing on one leg with the knee flexed at 20

Apley test

Meniscal injury- Pain with pressing the heel toward the floor while internally and externally rotating the foot with knee flexed to 90

Bronchogenic cysts - where are they found

Middle mediastinal mass - develop froom foregut remnants tx surgical removal

Bronchogenic cysts

Middle mediastinum masses and are benign

*traction diverticulum* is located where

Middle of the esophagus b/c Lymph node traction it is a sign of cancer

MIld claudication managment vs. severe claudication managment

Mild claudication - Exercise and life style modifications Severe- doppler tracing and arteriogram to localize most common location is the *common femoral -40-45%* aorta/ common iliac artery /popliteal artery - all 15%

systolic murmur _ Dyspnea and fatigue --> progresses to cor pulmonale + afib

Mitral stenosis

Placental Abruption classification- moderate bleeding and pain with fetal tachycardia with decreased variability and or mild late deceleration

Moderate abruption

Posterior mediastinum mass

NEUROGENIC TUMORS - Mengocele, enteric cysts, lymphomas, diaphramatic hernias, esophageal tumors and aortic aneurysms & esophageal leiomyomas

b/L Schwannomas of the eight nerve, meningiomas and gilomas

NF2

A patient developes a whistling noise after rhinoplasty. Why?

Nasal septal perforation - probably caused by a septal hematoma.

Duodenal hematomas treatment

Nasogastric suction with parenteral nutrition, most hematomas will resolve will resolve in 1-2 weeks

Neurofibromas ( schwann cell tumore) + cafe au lait spots, Multiple bengn skin lesions, possible optic giloma and lisch nodules in the iris of the eye

Neurofibromatosis type 1

Diabetic foot ulcers are d/t which processes

Neuropathy, microvascular, insufficiency and relative immunosupression

Prostate nodules + high PSA value

Next is to ultrasound or ultrasound need biopsy

if a patient with GERD develop damage to the lower Esophagus and have had long standing but unsuccessful medical mangement what is the next step

Nissen fundoscoplication - this wraps the fundus around the esophagus to replace the incompetatnt esophageal spincter

A breast-feeding mother has a hard, red, tender, and swollen area on her right breast. If there is no fluctuance, what is the tx? If there is fluctuance, what is the treatment?

No Fluctuance -> just give Antibiotics, analgesics, and continue breast feeding. Flutuance -> Incision and Drainage.

Will Healthy colonic mucosa bleed in responce to anticoagulaiton

No healthy mucosa wont bleed, normally only large masses or polyps so a patient with BRBPR should be given a colonscopy

WOuld you remove the lymph nodes from a sarcoma ?

No, because they spread hematogenously

OCP effect on blood pressure

Normally increase *3-6mmHg of systolic* and *2-5 of diastolic* but in *5% can cause overt hypertension* mechanism is unclear but possibly d/t an increase of angiotensiongen in the liver

physical signs of cor pulmonole

P2 loud- this is the pulmonic component of the 2nd heart sound and a right ventricular 3 rd heart sound - tricuspid regurgitation murmur

How do you get a false elevation of ABI

Occurs in vessel calcification - like in paitents with diabetes

Slipped capital head fracture

Occurs most often in overweight children, can occur bilaterally look for pain in the distribution of the the obturator nerve limited internal rotation.

Location of the diabetic foot ulcer

Occurs on the sole of the foot or high weight bearing sites

High pitched holosystolic murmur + dyspnea + fatigue

Often MVP - ( association - women, marfans ect.) - Tx annuloplasty or valve replacment

Oliguria definition ( w/o preexisting kidney disease)

Oliguria is defined as urine less then 400cc or less then 6cc/kg of urine output per day

Symptomatic difference between cholithiasis and cholangitis

Only *cholangitits* will present with *FEVER and JAUNDICE*

If suturing a child what is the agent to *achieve conscious sedation*

Oral or rectal midazolam or diazepam

Low grade knee pain, in 10-25 y/o. xray shouws codmans triganle with sunburst appearance

Osteosarcoma

What is dangerous about intubating a Trauma patient who is in hypovolemic shock?

PEEP can further decrease venous return to the heart, exacerbating the shock.

A patient has persistent nausea and vomiting of partially digested food. He has a history of attempted suicide with acid ingestion. What is the likely cause?

PYLORIC stricture (NOT esophageal stricture)

Symptoms of avascular necrosis

Pain - worse on e*xternal rotation decreased range of motion* and sometimes CLICKING on ambulation.

Symptoms that suggest maligancy of the spinal cord and not degenerative process

Pain i s worse lying down because the epidural venous plexus is disteneded

What is the prime objective in managing a rib fracture?

Pain relief....if they're in too much pain, they get atelectasis and pneumonia

McMurry test

Painful click with passive flexion and extension of the knee with the examiner thumb and index finger placed on the medial and lateral joint

Post PCI 12-24hours - patients presents with hypotension tackycardia and a new *pansystolic murmur*, there are also *rales* present on auscultation

Papillary muscle rupture - look for the new onset murmur + pulmonary congestion

A man has a wedge fracture of L2 after a bike accident. Abdominal CT shows a small retroperitoneal bleed and splenic laceration. He is treated with analgesics and supportive measures. On Day 3, he complains of abdominal pain and nausea. His abdomen is distended, tympani, and mildly tender, without rebound or guarding. Bowel Sounds are absent. X-ray of the abdomen shows gaseous distension of the LARGE and SMALL bowel. What is the cause?

Paralytic Ileus. Classically if follows abdominal surgery, but it can also occur in cases or retroperitoneal hemorrhage associated with vertebral fracture.

What type of pleural effusions cause a glucose of less then 60

Parapneumonic effusion, maligancy, tuberculosis or rheumatoid arthritis

Phlegmasia cerulea dolens

Patient present with acute onset leg edema and pain and cyanosis - high risk nerve damage and venous gangrene

Constant watery Diarrhea, Dermatitis and dementia

Pellagra a deficiency in niacin

In acute ruptured appendicitis, where is common place to find an abscess?

Pelvic Abscess.

A patient with an MI 2 weeks ago and a serious case of acalceous cholecystitis what is the managment

Percutaneous drainage via a cholecystectomy tube with interval 6 to 8 weeks

ECG with the sign of electracal alternas is a sign of what ? what treatment ?

Pericardial effusion Pericardiocentesis

Patient presentation with hypotension - ( wont respond to IV bolus ) tackycardia, and elevated jugular venous pressure

Pericardial tamponade

Sucking chest wound management

Place a 3 sided occlusive bandage on top to allow air out but not in and then place chest tube else where

A patient shows signs of a traumatic spinal cord injury. After they are hemo stable and airway is secure, what should you do?

Place a Foley...they could have urinary retentiona nd could have bladder distension and damage.

Pain every time the foot strikes the ground - *worse in the morning* preventing him from putting any weight on the heel

Plantar fasciitis

Light criteria

Pleural fluid *protein*/serum protein > *0.5 * Pleural fluid *LDH*/serum LDH >*0.6* Pleural fluid LDH >2/3 of the upper limit of normal serum LDH

A patient with a history of COPD and smoking suddenly develoops Shortness of breath what is the most likely etiologies

Pneumothorax- d/t *Apical blebs* d/t the chronic destruction of the elastic parts of the aveoli

Causes of restrictive cardiomyopathy

Sarcoidosiss, amyloidosis, hemochromatosis, endomyocardial fibrosis, *Left ventricular VOLUME is normal*, wall thickness may be normal or increased

Cough lasting greater then 8 weeks : what is the differential diagnosis

Post nasal drip asthma and GERD

Centeral cord syndrom

Post whiplash in the elderly with preexisitng degenerative conditions- Upper extremities more affected with pain and paralysis

type 3 hiatal hernia

Presence of BOTH types txt surgical repair

insicional hernia

Presents as bulging at wound site with increased abd pressure ( e.g. coughing) needs to be repaired surgically

Air emboli

Presents as sudden death in an intubated respirator pt. managment is immediate !!!! TRENDELENBURG POSTION and caridac masssage

Most common cause Of osteomyelitus from a nail puncture

Pseudomonas aeruginosa !!!

Patient has well circumscribed raised papules and plaques covered with a thick silvery scales - The lesions are found on the scalp trunk and extensor areas of the extremities

Psoriasis

Post trauma patient has deteriorating ABG and white out lung on CXR what is the txt

Pulmomary contusion give colloid + diuretics + fluid restriction

Complications of obestity hypoventilation syndrom

Pulmonary hypertension cor pulomnale, decondary erythocytosis hypoxia and chronic hypercapnia

Obesity hypoventilation syndrom

Pulmonary hypertension with cor -pulmoale secondary ethryocytosis hypoxia chronic hypercapnia - d/t hypoventilation Respiratory acidosis

Treatment polymyalgia rheumatica

RESPONS TO GLUCOCORITCOIDS

Hypertension and possible renal failure

REnal artery stenosis

What is Central Cord Syndrome?

REsults from hyperextension injuries, particularly in elderly patients with spondylosis. It is characterized by more weaknesses in the upper extremities than the lower extremities.

Patient has a rosy hue with telangiectasia over the cheeks nose and chin. - flushing can be precipitated by hot drinks heat emotion and other causes of rapid body temp changes

ROSACEA

What is the RQ for a mechanically ventilated patient

RQ 1.05 This is CO2 to O2 At steady statte this ratio depends mainly upon the major feul being oxidized for ATP production.

How will the RQ value of a patient receiving purely carbohydrate diet be? What about Protein? Fat?

RQ value = CO2 produced to O2 consumed Carb = 1.0 or higher Protein = 0.8 Fat = 0.7

What is a simple way to increase a patient's function residual lung capactiy?

Raise the head of the bed.

Anticoagulation + skin necrosis

Rare side effects of warfarin start heparin with it to prevent it

After a subarachnoid haemorrhage at what day will rebleeding occur and what day will vasospasm occur

Rebleeding occurs in the first 24 hours Vasospasm after 3 days .

Rome diagnostic criteeria for irritable bowel syndrome

Recurrent abdominal pain/discomfort > days/month for the past 3 months & > 2 of the following - Symptom improvement with bowel movement -Change in frequency of the stool - Chnage in stool form

NEck blunt trauma

Risk of carotid dissection ( txt with anticoagulation) or largenal edema ( tx intubation)

Renal complications of sickle cell trait

Renal medullary carcinoma and UTI , and hematuria - this is d/t *renal papillary necrosis* that presents with *hematuria* with intact RBC- these situations normally occur and resolve spontaneously. *** sickle cell trait patients also cant concentrate their urine very well

Managment for a 72 year old with a displaced femoral neck fracture

Replacement of the femoral head with a metal prosthesis ---Because the femoral head has tenuous blood supply the chances of surviving a neck fracture with out developing a vascular necrosis are slim.

Shoulder pain that resolves with lidocaine Vs. Shoulder pain that doesnt

Resolves with lidocain- tendinitis Fails to resolve with lidocaine - Rotator cuff tear

Treatment for fat emoblism

Respiratory support low molecular weight Heparin & steroids

How do you treat a stres fracture?

Rest and Analgesics.

Treatment for osgood schlatter disease

Rest and ice after physical activity - physical activity doesnt need to be stopped

When can you see false negative DPL/FAST

Retroperitoneal injuries

symptoms of resistrictive cardiomyopathy

Right sided heart failure signs can predominate - prominant jugular venous distension, bilateral ankle edema and tender hepatomegaly ALSO symptoms of left sided failure

what fluid to use in hypovlemia or isotonic fluid loss

Ringers lactate

Continous air leak into the chest tube. + subcutenous emphysema

Ruptures tracheal/bronchi - go to the OR

Chest pain, epigastric pain and abnomral chest x-ray findings of mediastinal air with a widened mediastinum: what diagnositc test

Ruputured esophagus: With contrast esophagography - rememeber you need water soluable contrast *most common location is left posterior lateral*

Placental Abruption classification- Continous knife like uterine pain with fetal bradycardia, severe late declerations or fetal death. DIC is possible

SEVERE abruption

Increased Platlet Destruction

SLE Hparin Idiopathic thrombocytopenic purpura DIC Thrombocytopenic-purpura hemolytic uremic syndrom antiphophalipid syndrom HIT - post surgery d/t heparin

A women falls on a hyperextened wrist, 3 days later she comes to see you with swelling at the dorsum of the thumb. X ray is normal. what is the diagnosis what is the managment

Scaphoid fracture -the proximal fracture is vulnerable to avascular necrosis Pain is found while palpating the anatomic snuffbox Xray: Wrist needS to be pronated and ulnar deviation to expose the schapoid and only shows up 10 days post injury - management place in spica thumb cast for 10 days then RTC for xray

pathophsiology of migraine

Serotonergic control of blood vessels is dysegulated and therefore there is cerebral vasodilation

Because treatment for chemotherapy-induced nausea and vomiting

Serotonin antagonists that target 5HT3 receptor are considered first line

A young patient with Confusion rapid breathing and abdominal pain - she had a recent history of infection what is her underlying pathology and what electrolyte is most likley Abnormal

She has *diabetes* and the infection induced a diabetic crisis the electrolyte that is abnormal would be her *total body K*- Note her serum potassium would be elevated but the total body is decreased

Postprandial (20-30 min after eating) abdominal cramps weakness light headiness and disphoresis

Short bowel syndrome- symptoms. common post gastrectomy ( not for those who got proximal vagotomy)

Pancoast tumor Clincial Symptoms

Shoulder pain horners syndrom ( from sympathetic chain and inferior cervical ganglion) C8-T2 neurological involvement - weakness and atrophy of the intrinsic hand muslcces pain and paresthesias of the 4th and 5th digits medial arm and forarme Supraclavicular lymph nodes enlargements Weight loss

Small PTX management

Simple observation is okay if no symptoms - no free fluid -not expanding

GIST

Soft tissue tumor of stomach tx wedge resection w/ 1 cm negative margin no affect on LN

NSCLS treatment Stage 1 / Stage 2 Stage 3 / Stage 4

Stage 1 / Stage 2- 1st get spirometery to see if the patient can have a lobectomy Stage 3 / Stage 4 - chemotherapy and radiation

NSCLS Stage 1 Stage 2 Stage 3 Stage 4

Stage 1- local Stage 2- hilar lymph nodes involved Stage 3- distal lymph nodes Stage 4- metastatic cancer

Complication post rhinoplasty that presents with a whistling noise heard

Spetum perforation it is not one of the most common but definately one of the most serious The septum is cartilage therefore getting its nutrition from the over lying mucosa damage to that results in death of the underlying cartilage

Complication of Chronic pancreatitis - pain located int he upper left quandrant may be referred to the left shoulder. ON EGD you will see gastric varies without esophageal varices

Splenic vein thrombosis As the splenic vein runs along the back of the pancreas chronic irritation may cause and occlusion

Nasopharynegeal carcinoma

Sqamous cell of origin seen more in people of mediterranean or far eastern descent * asymptomatic until diagnosis which is at a late stage* Symptoms- recurrent ottitis media, recurrent epistaxis or nasal obstuction **associated with the EBV virus**also smoking and chronic nitrosamine consumption

Cancers that produce PTHrp

Squamous cell cancers ( eg. lung, head, neck esophagus) renal and Bladder cancer Ovarian and endometrial cancer Breast Cancer ( made ONLY by the cells that invade the bone marrow therefore systemic levels arent raised)

Renal lacerations stable unstable

Stable - angiograph and planned operative repair unstable - iv pyelo to detect if 2 kidneys are present then OR for nephrectomy

Steatorrhea effects on Calcium phosphate and parathyroid hormone

Steatorrhea basically means there is a decrease in the absorption of fat soluble viatmines in the bowel in the form of micelles. Therefore Decrease vit D = decrease Calcium and decrease Phosphate levels because of the elevated PTH levels

What cancer screening test do you preform on those with pernicious anemia

Stool occult blood looking for gastric gancer ( or carcinoid)

Patient has an episode of LOC when working out his biceps at the gym

Subclavian steal syndrom - no symptoms at rest but decrease brain blood flow with increase demand to the arms

A darkening of pigment under the finger nail

Subungual melanoma - Txt with DIP amputations

Stab to the neck and hemiparesis

Suggests injury to the carotid get angiogram and wither vascular or neurosurg consult.

4 t's for anterior mediastinal mass

T- thyoma T- teratoma T- terrible lymphoma T- thyroid

Teens with persisitent pain over the tibial tubercle it is aggrevated by quad contraction - what is it and what is the mangment

THis is osgood schlatter disease Txt with pain control and gental stretching of the quads - this condition resolves once the growth plate ossifys

When Do you give both Tetanus vaccine and TIG to a patient with a dirt wound

TIG is only given if the patient has never received any tetanus vaccine ** if the wound is clean the vaccine is only administered if it has been greater then 10 years if the wound is dirty the vaccine is only administered if it has been greater then 5 years

Renal failure in a patient undergoing chemotherapy

TUmor lysis syndrom renal failure from a large scale release of uric acid

Symptoms of myocardial contusion

Tackycardia and new bundle branch or arrthymia- sternal fracture is a commonly associated finding

Non reactive pupils Syses deviated toward the hemiparesis !!! -- T- in thalmus for toward Thalamus --Hemiparesis hemi sensory defect

Thalamus

After a gastric lymphoma has been diagnosised what is next step before tereatment with chemo and radiation begins

The *depth of the tumor invasion* needs to be determined as the chemotherapy and radiation will melt the tumor away and might result in a *perforation* therefore if the tumor extends the full thickness surgery is indicated to resect the tumor

What determines the txt for a gastric lymphoma

The depth of invasion - Ct scan LN biopsy , bone marrow biopsy partial thickness - radiation Full thickness - surgical resection

Which par tof hte brain does the PML ( papiloma virus ) infect

The white matter

How do you detect uric acid stones?

They are radiolucent, so you use CT or IVP.

A patient present with *peripheral neuropathy* of the foot, of the fingers and *palable purpura*

This is *monoeuritits multiplex* a painful asymmertical asynchronous sensory & motor neuropathy -damaging greater then 2 nerves. Often seen in vasculitites - *like cryoglobinemia*

pregnant Patient *week 33 present* with *blood pressure > 150 systolic*, *proteinuria*, No headaches or visual disturbances oliguria, increased serum creatine and thrombocytopenia

This is MILD preeclampsia and all that is done is to Wait until week 37 for delivery therefore the best management is to admit to the hospital

If a new infant - has symeterical gluteal folds but the physician cannot completely abduct the infants thights when her hips and knees are flex ed

This is an inconculsive finding for developmental dysplasia od the hip. Do an ultrasound to be sure

Several months after sustaining a crushing injury to his arm - patient now has constant agonizing pain that no medication can help and is aggrevated by even the lightest touch.

This is known as *causalgia or reflex sympathetic dystrophy or sudeks*. - the cure is the surgical *sympathectomy*

Steatorrhea + Bone pain/ tenderness with muscle weakness or cramps with gait abnormalities

This is the classical picture of vit D def.

List of anterior mediastinum masses

Thymoma, retro-sternal thyroid, teratoma, lymphoma. ** if the mass is large the patient may complain of chest heaviness, if it invades when horners syndrome, and facial and upper extremity edema when the tumors invade locally**

Most severe complication of a 26 year old man with IBD who presents with A fever increase HR, Increase WBC and anemia ? what is the test

Toxic megacolon. requires a X ray to demonstrate the dilation -- Patient would present with the signs of SIRS + anemia and altered sensorium electrolyte disturbances Hypotension

Most comon inherited bleeding disorder

Von Willevrand with def or imparied action of the von willibrand factor Prolonged aPtt and Bleeding time the platelet counts are normal

If a patient is profoundly hypothryoid - post surgery--what what is the managment

Treament is steroids - because if you just increase thyroid homrone the body might go into overdrive.

Doppler findings : what does this mean triphasic wave Biphasic wave Monophasic wave

Triphasic is the nomrla wave form with a rapid systolic flow and brief phase of reverse flow secondary to elastic recoil. Biphasic is moderate stenosis Monophasic is severe stenosis

Melanoma that is < 0.75mm in depth

Tx excsiion w/ 1cm margins

Surgical txt for sarcoma

Txt with 1 cm negative margins - check CT of the chest for METS ( hematogenously)

Melanoma depth >4 mm

Txt with 2 cm margins and remove palpable lymph nodes but patient will most likely die from mets

Lateral blow to a stationary knee results in

Unhappy triad- acl, mcl and medial meniscus

Blood on th emeatus, scrotal hematoma, high riding prostate,

Uretheral injury DX retrograde urethrogram, TXTsuprapubic catheter *NO FOLEY *

If a patient has a CR > 1.5 but still requires a CT what can be done to reduce the risk of Nephrotoxicity

Use non ionic contrast

IN ARDS with low oxygenation despite fio2 of 70% what value can you increase to help the oxygenation

increase the PEEP this will push more oxygen across the membrate

Inability to maintain to an errection

Vacuum device if he has cardiovascular co-morbidities Yohimbine - alpha blocker sildenafil - phosphodiesterase inhibitors

Treatment for paroxysmal supraventricular tachycardia

Valsalva manuevers carotid sinus massage and immersion in cold water increase *via increase in vagal tone* and *decrease in conduction through the AV Node*

Adverse effects of PTU

Vasculitis, Rash, arthalgias, hepatitis, and agranulocytosis

Next strep in managment for venous disease after leg elevation, exercise and compression has fail]ed

Venous duplex ultrasound to identify venous reflux or isufficency *Persistent symptoms need endovenous ablation*

General features of genral anesthia

increased physiological control increase pulmonary complicatitons Decrease HR/BP

Bilateral extremity edema and stasis dermatitis. hemosiderin, xerosis and statis dermatitis is the most classsically involes the emdial leg.

Venous hypertension d/t venous valvular incompetence resulting in pooling of the venous blood and increased postcapillary venues. the colour is causes by hemosiderin deposition. Xerosis is most common early finding

What heart condition is lidocaine to treat, what is a complication and how does it affect someones prognosis

Ventricular arrhythmias Can cause asystole Doesnt affect the prognosis

Anterior cord syndrome

Veretbral burst fractures - presents as bilateral loss of everything BUT fine touch and propreception

How does acute blood loss affect the CBC levels of RBC, WBC hct, hgb

Very common trick question Acute blood loss doesnt afftect the CBC in any way

TPN and elevated LFT

Very common up to 30% TPN can cause fatty liver structureal liver damage and chirrhosis

Causes of a decrease in platlet production

Viral infections - EBC, Hep C and HIV Chemotherapy myelodysplasia age>60 Congential FANCONI Syndrom Vit b12 or folate Deficeny

A patient presents with Biliary Colic. What actually causes the pain?

Viscous Distension of the Gallbladder mucosa.

Low hemoglobin post surgery

Volume depletion secondary to intra-operative blood loss

Hemangioblastoma ( cerebellum) + angiomatous lesion of the retina + Cysts in the pancrease, kidney and genital tract, + clear cell renal carcinoma+ neuroendocrine pancrease tumor+ phenochromocytoma --> mutation on chromosome 3

Von hippal Lindau syndrom

Most effective non pharmalogic measure to decrease blood pressure

WEight loss Reduce BMI < 25 - 5-20 mmHg per 10 kg

How does alcohol use affect your surgical mangment

Wait for the patient to go through withdrawl before preforming any surgical treatments

How do you confirm the diagnosis of Esophageal Perforation?

Water-Soluble Contrast Esophagram

Signs of malnuitrition

Weight loss greater then 20% Albumin < 3 give 7-10 days of pre-op nutritional support

When would you suspect a mesentery injury

When there is bowel injury as the mesentery is stronger then bowel

How does this effect your post op management:Bloody sputum:

indicates active infection or lung cancer; requires a full work-up including CXR, CT scan, and bronchoscopy

Classic symptoms of AVN

Worse on external rotation decreased range of motions and sometimes clicking with ambulation

Side effects of Eryhtropeoiten therapy

Worsening of hypertension - can have a 10mmhg rise in diastolic pressure. Headachs Flu - like syndorm red cell aplasia

In the case of an amputation injury (like cutting off your finger), how do you transport it?

Wrap it in saline-moistened gauze, sealed in a plastic bag, and THEN placed on ice.

Treatment Post Scaphoid fracture

Wrist immobilization for 6-10 weeks in a spica cast

pneumothorx and hemothorax diagnostic test

X ray

RQ close to 1 menas what about the major nuitrietn being metabolised

indicates that carbohydrates are the major nutrients being metabolised.

A pregnant women with asymptomatic bacteruria ( <100, 000 cfu) Do you treat? or not

You do treat as the association between *preterm delivery/low birth weight has been demonstrated*. treat with *nitrofurantoin*

elderly patient who begins to have diffuse abdominal pain after an episode of hypoperfusion. what do you find on angiogram?

You see alternating narrowing and dilation of the arterial branches - this is *non occulsive mesenteric ischemia*

When do you start screening for ulcerative colitis

You should start at 8 years post diagnosis of the disease

De Quervain tenosynovitis

Young women who complain of pain on the radial side of the wrist - no evident deofrmity

Patellofemoral pain

Young women with chronic overuse of the knee ___ Test is to reproduce the pain on extension while compressing the patella

What is the most common hernia

indirect hernia -goes through the internal ring lateral to the epigastric vessels

When someone is bleeding and there is bright red blood in colon what test

a Tagged red blood cell study - check the bleeding is in the small intestine or colon

Supprative phelbitis

infected thrombus at site of venipunture, Tx remove catheter and surgical excision of infected vein to the first non-infected branch

Acid or base injestion what is the managment

acid- milk alkali - orange juice

Cellulitis

active infections are asociated with a higher risk of post op complications - DELAY until wound is resolved

Function of -osins

an *alpha 1 blocker* that relaxs the trigone and sphincter facilitating urine flow

Causes of exudative pleural effusions

infections maligancy connective tissue disease inflammatory disorders movement of fluid FROM the abdomen to the pleural space coronary artery bypass surgery * pulmonary embolism usually*

Thymic cysts

are rare benign congenital cysts that occur laterally in the neck along the embyonic path of descent of the thymus gland

Most common ethnic group to get lactose intolerance

asian americans

lung coin lesion seen with an AIr-cresent sign

aspergilloma

Bladder injury - what situation is it associated with

associated with *seatbelt trauma* get a retrograde cystogram and post void films then surgical repair

Gonococcal spetic arthritihis

asympetical poly arthritis associated with tenosinovitis and skin rash, isolated purullent mono and oligoarthritis - 75% of poeple have silent preceeding infections

normal urine output

at least 0.5-1 mL/kg/hr

What do you give in oragnophosphate poisioning - salvation lacrimation, urination and defecations

atropine

IMmune thromcovytopenia

autoimmune disroder due igG autoantibodies agaisnt the platelet membrane glycoproteins. DIAGNOSIS Of exculsion Txt glucocortidocoids

Tx for esophagel cancer in the upper 1/3

chemo and radiation only

tx for esophageal cancer in the middle third

chemo and radiation to shrink the tumor and then esphagectomy

Sexually transmitted epididymitis causes

chlamydia trachomatis and neisseria gonorrhea occurs in younger and sexually acitve men __ this form often presents with discharge from the urethra, *pain* will normally be *less then ,12 hours in duration* which may localize to the *top of the testicles* many paitents have nasea and vomiting

Burns and methmeoglobinemia Symptoms and treatment

chocolate brown blood, centeral cyanosis of the trunk arrthymias seizures coma Iv methylene blue

MOST important risk factor for bladder cancer

cigerette smoking Stopping will only reduce the risk 20 yeears post.

Coin lesions are seen in the lung + red nodules on the skin and the patient has been visiting arizona during the dry season

coccidiocodomycosis

morton neuroma

commonly occurs in runners and is not a true neuroma. symptomss of numbness and burning of the toes aching and burning in the distal forefoot that radiates from the metatarsals to the 3rd & 4th toes

Secondary intention

contaminated wounds left open to prevent abscess formation - granulation tissue forms first then contraction via myofibroblasts

Pseudodementia or reversible cognition abnormalities

d/t *Severe depresssion* especially in older adults with symptoms simlar to dementia

High amylase in the pleural fluid

d/t esophageal rupture

hypersplenism

dequestration in the spleen, platelet cout remains > 30, 0000 & the mass and function is normal. Clinical bleeding doesnt occur

Hypokalemia post surgery

diarrhea or vomiting fix K at rate of < 10 mEq/hr

Any patient that suffers a *pelvic fracture* and has the urge to urinate but doesnt

do a *retrograde urethrogram* to ensure no damage to region before you place a foley.

If patient has a dysuria before surgery

do urine culture and delay surgery until resolved.

Primary intention - epithelization by POD , Max collagen - avoid weight lifting Complete healing by

epithelization by POD - 2 days Max collagen -5-7 days avoid weight lifting- 4-6 weeks Complete healing by - 6 months

tx for esophageal cancer in the lower 1/3

esophagectomy and proximal gastrectomy

how often should women 50-75 get momogram

every 2 years

Treatment for mesothelioma

extrapleural pneumonectomy is currative but high risk of morbidity/mortality

Stroke in the cerebellum

facial weakness and neck stiffness Gaze palsy OR NYSTAGMUS Gait atxia NO HMIPARESIS Stupor or coma - b/c brain stem effected

Inhalation of burn managment - how to manage it

fibroscopic bronchoscopy -intubate

thrombotic microangiography

fomartion of platelet rich thrombi in the microcirculation seen in - HUS, thrombotic thrombocytopenic purpura, hemolytic uremic syndrome and disseminated intravascular coagulation. Labs - thrombocytopenia and schistocytes with anemai

Priapism in trauma

fresh spinal cord injury check for anal spincter tone brady cardia and possibly neurogenic shock

How does this effect your post op management: Green sputum:

give oral antibiotics, and schedule surgery after Tx is complete

Groserelin

gonadotropin releasing hormone *GnRH agonist* incdicated for the treatment of androgen recpetor positive prostate cancer and advance breast cancer and for reduction of endometriotic lesions

Reversible cause of restrictive cardiomyopathy

hemochromoataiss

What is the Trigger in excersise induced asthma

high minute ventilation of sry cold air which stimulates mast cell degranulation and airway constriciton.

juvenile angiofibroma

highly *vascular fibrous tumor* that classically affect adolescent males and appears to be relaed to androgenic stimulation- puberty . Manifests as unilateral epistaxis

Symptoms of multiple myeloma CRAB

hyperCALCEMIA, Renal failure, ANemia and BONE pain - X ray shows punched out lesions

Factors that contribute to the formation of acalculous cholecystitis

hypovolemia, absence of alimentary nutrition multiple blood transfusions narcotic use and prolonged ventilator dependance.

CRF and operative hypotension

if the patient has taken steroids consider aldosterone

GSW below the nipple line

immmeadatly exploratory laportomy

Electrical burns - appear benign on the surface

makes a large amount of interior damage to muscle nerves and vessels and muscle injury

scrotal hematoma what test and what are you looking for

manage non-op unless testicle is ruptured and you can tell this on US

pericaridal cysts - where are they found

middle mediastinal masses - typicall water bottle appearance - tx surgical removal Clincial presentation: most patients are asymptomatic - may present with dyspnea Often congnetial but might be a complication from pericarditis - look for a single layer of mesothelium cells Xray seen at the cardio-phrenic angle

Embryonal carcinoma

most commonly occurs in young men and typically presents as a solitary painless testicular mass. *tumor marker*-increase alpha fetal protein. *Histology* - small cells with indistinct borders and scant cytoplasm- sheets of crowded nuclei and high mitotic rate with necrosis

If there is 0cc Post op-urine output

most likely a kinked or plugged foley

Posterior mediastinal mass

neurogenic tumors aka neuilemoma

Loss of the proprioceptive sensation from the legs ataxia and paresthesisa

neurosyphilis

minor head trauma ( GCS= 15 with non severe mechanism & no vomiting, headaches, loss of consciousness

no head ct

Female military recruit presents with pain in her right foot lasted for at least 1 week, there is swelling and tenderness on the foot. pinpoint tnederness

non displaced hairline stress fracture- txt is analgesics and rest

If a patient presents with any of the following which test do you run -> - vomiting - headache - questionable or breif loss of consciousness -Injury caused by high rsik mechanism of injury -severe mechanism of injury

observation for 4-6 hr or head Ct without contrast

FLank pain, low volume coids with or without occasional high volume voids

obstructive uropathy

What Enema agent can not be given to thoses in renal failure

osmotic agent - risk are dehydration and hypermagnesium

Atelectasis what does the blood gas look like

pH 7.49 Po2 70mmhg Pco2 27mmHg Patient is hypoxemia and then the patient hyperventilates to overcome this

Mulder sign

pain between the third and fourth toes on the plantar surface and a clicking sensation when simultaneously palpating this space and squeezing metatarsal joints

Symptoms of Osgood schlatter disease

pain on the *tibial tubercule and patella mostly after repetitive exercise*. occurs between children ages 10 to 15 years the problem is in the distal tibial insertion because this insertion is yet to ossify

Type 2 hiatal hernia

paraesophageal hernia - risk of incarceration and strangulation tst Surgical repain

Painless vaginal bleeding

placenta previa

Esophageal rupture

pneumonediastinum and pleural effusion, diagnosed is confirmed by water soluable contrast

Difference in complications from a posterior ulcer to an anterior ulcer

posterior ulcers bleed - gastrodeodenal artery Anterioir ulcers- perforate

Wound infection:

red and tender area on incision site; Tx drainage and BID wet-to-dry dressing changes, no antibiotics unless cellulitis is spreading

Blunt trauma to the back or Lower rib fracture

renal injuyy check with CT scanand amange non-op if Possible

Fistula + abscess managment

requires percuteneous drainage

Fistula + peritonitis managment

requires surgical exploration

Neurilemoma

schwann cell nerve sheath tumors Dumbell shapped tumor found adjacent to vertebral bodies, develops from nerves and nerve sheathes

scaly erthymatous rash on the face chest back and groions

seborrheic dermatitis

type 1 hiatal hernia

sliding hernia- risk of reflux esophagitits tx PPI

Embryonal carcinoma- histoolgy and cancer marker.

small cells with indistinct boarders and scant cytoplasm - with sheets of crowded nuclei - high mitotic rate and necrosis can have *alpha fetoprotein AFP *

therapy for umbilical hernias in children under 2

small umbilical hernias close spontaneously in children before 2 years

Causes of spinal cord compresssion

spinal injurgy maligancy infection

Staging of esophageal cancer - stage 1 stage 2 stage 3 stage 4

stage 1- submucosa only stage 2 - invades muscularis stage 3- invades adventitia stage 4- metastatic

what must be given perioperatively in a paitent that has a kidney transplant

steroids

Stab to the neck + hoarseness

suggests injury to the airway, larynx ( voicebox) or recurrent laryngeal nerve DX: laryngoscopy or exploration

Stab wound to the neck + dysphagia

suggests injury to the esophagus- dx esophagocopy or barium swallow

impaired upward gaze is compression on what part of the brain

supra-pineal recess, remember parinaud syndrom, with eyes that deviate downward known as the sun setting effect.

Post op fluid managment

surgical blood loss replace in a 3:1 ration with IVF- replace 500ml blood loss with 1.5: NS or LR

Stab wound to the nipple line

suspect damage to the diaphragm or to the abdominal organs

Infraclavicale stab wound

suspect injury to the artery or vein dx angiogram if stable urgent exploration if unable

Weakness in the upper extremities and loss of pain and temperature sensation in a cap like distribution over the neck-

syringomyelia- causes are congential in arnold chiari or Post whip-lash injurgy

Prehypertension

systolic 120-139mmhg; diastolic 90-99mmhg

Stage 1

systolic 140-159 mm Hg or diastolic 90-99 mmHg

Low grade epiphyseal pain in a child. X rays shows an onion skinnig pattern what is it and what is the mutation

t(11:22) - ewing sarcoma

Subclavian venous catheter complication

tension pneumothorax is life threatening condition

when should adults get TD vaccine vs. Tdap

the TD vaccine should be given every 10 years after 18 and the tdap booster should be give to an adult once.

who should not get a LAP Nissen funoplication

the morbiditly obese instead just give gastric biopsy

What symptoms define a case of diverticulitis as complicated

the presence of *abscess or fistula* or perforation

What would you do for a pressure ulcer on a hernia

there is a high risk of rupture and this requires urgent repair

CRF and intra operative bleeding

this is d/t platelet dysfunction secondary to uremia * give desmopression or FFP* but not platlets

Child with history of nose bleeds and a dried crust on the *anterior portion*

this is epistaxis from picking the nose and intermittent trauma to nasal mucosa

Post op- bypass patient presents with a cyanotic toe

this is trah foot this is a post op embolization and tx with LMW- heparin + long term aspirn

Radioacitve iodine uptake

this requires a thyroglobin measurment - *LOW thyroglobulin indicates exogenous thyroid hormone* elvated thyroglobulin - indicates a glandular source thyroiditis iodine expsure extraglandular production

Symetrical polyarticular arthritis is a young patient, that is an acute onset and short duration. + fever + RF and weakly postiive ANA

ths is viral arthritis the *short duration and acute onset* should be the biggest hint, as RF or SLE would NOT resolve in this time

ANterior mediastnium masses

thyomas, lyphomas, teratomas + germ cell neoplasms

multiple Ring enhancing lesiosnin the HIV infected patients, MRI reveals multiple spherical and located in the basal ganglia

toxoplasmosis give TMP-SMX

Club foot - b/l inverted foot

tx is serial plaster casts on adducted forefoot

WRIST INJURY: management administer analgesics and rest

txt for a sprain

Melanoma depth 0.76-3.99 +/- palpable lymph nodes

txt with excision of 2cm margins + palpable lymph nodes - Removal - non palpable LN - sentinel LN biopsey

Which gastric stomach ulcer types are d/t increase in acid production

type 2- duodenum and stomach type 3- pylorus txt is total vagectomy and pylorectomy

How does this effect your post op management: Smoking:

up to 6× risk for post-op complications due to compromised ventilation, must quit smoking for 2 months before surgery

Cardioplegia solution

used to stop the heart in MID-Diastole - to protect it from ischemia and provide a motionless feild- often used with hypothermia to prolong time of safe ischemia- 2.5 hours

How does this effect your post op management: Severe COPD

very high risk for acute pulmonary failure with surgery; teach patient about incentive spirometry, give bronchodilators, and mobilize post-op to prevent atelectasis

Who should get a Digital rectal examination and PSA antigen levels

who are at risk of dying from prostate cancer. ONLY people with signs of metastatic disease need treatment - Bone pain, voiding obstructions.

Define clean contaminated wound and the risk of infection post surgery

wound that is created in a sterile environment but involves *entry* into *respiratory, GI, Or GU systems* with no or limited spillage POst surgery Risk of infection 3-5%

a 4cm mass in left neck- present for 6 months HARD History of smoking + rotten teeth what do suspect and how do you test

you suspect mouth cancer most likely squamous cell cancer that has metasisized to the neck lymph node. Confrim with pan-endocscopy triple endoscopy and mucosal biopsies

if there are duodenal ulcers in th 2nd - and 4th part of duodenum what does this indicate

zollinger ellision syndrom - gastrinoma