Firecracker quizzes

What is the TMT for diverticulitis?

-IV Cipro & Metro -IV fluids -NPO

What is the TMT strategy for acute pancreatitis?

1-NPO 2-IV fluids (Isotonic then Hartmanns [Lactated ringer solution] 3-IV pain med

A 55-year-old gentleman has an abnormal abdominal x-ray which demonstrates free air outlining the left kidney and psoas muscle. A thorough history reveals that the patient had an upper endoscopy and colonoscopy performed three days prior. Which segment of the gastrointestinal tract was likely perforated during this procedure? (Transverse colon OR 2nd part of duodenum)

2nd part of duodenum -The kidneys lie in retroperitoneal space, therefore the presence of free air surrounding the kidneys indicates damage to a structure that is located retroperitoneally (2nd part of duodenum) Transverse colon -Located intraperitoneal (Ascending & Descending are retroperitoneal)

**PICTURE** Angiodysplasia -Characterized by tortuous, deformed mucosal & submucosal blood vessels seen in the GI tract -Most commonly presents as HEMATOCHEZIA in the elderly -Most often found in terminal ileum, cecum, & ascending colon Angiosarcoma -Rare, aggressive blood vessel malignancy that typically occurs in the head, neck, & breast areas -It is associated w/ radiation therapy -Rare in the Large intestine making it unlikely in this pt

A 76-year-old man is hospitalized after presenting to the emergency department (ED) with a 2-month history of generalized weakness and pallor. Laboratory studies done in the ED are significant for a hemoglobin of 6.0 g/dL. Upon further questioning, the patient reports occasional passage of fresh blood with his stools. He denies any other changes in his bowel habits. The gastroenterologist is consulted and performs a colonoscopy. The colonoscopy reveals findings demonstrated in the image below: Which of the following is the most likely diagnosis? (Angiodysplasia OR Angiosarcoma)

A 42-year-old man with a 3-day history of cough, sore throat and increased nasal drainage now presents with worsening fatigue and fever. He has no significant past medical history and previously underwent an unknown abdominal surgery in Mexico after a motor vehicle accident. One hour after initial presentation, the patient begins to develop a pinpoint, diffuse rash with a worsening headache and mental status changes. The patient's temperature is 39.2°C (102.5°F), blood pressure is 83/61 mmHg, pulse is 126/min, respirations are 25/min and oxygen saturation is 91% on room air. Laboratory studies show a leukocyte count of 18,000/mm3, creatinine of 1.8 mg/dL, platelet count of 77,000/mm3 and basophilic spots within erythrocytes on peripheral smear. Following administration of intravenous fluids, what is the most appropriate next step in management? (Administration of Vanco + Ceftriaxone OR Vasopressors)

Administration of Vanco + Ceftriaxone -Pt likely develops postsplenectomy sepsis (Howell-Jolly bodies describe on PBS) -Pts need prophylaxis against S.pneumo, H.influenzae, Nesseria Vasopressors -TMT for this pt should follow this algorithm: 1-IV Fluids 2-AB's 3-If pt continues to to be hypotensive despite fluid resuscitation >> Vasopressors

A 58-year-old man presents to the emergency department with abdominal pain for the last six hours. He describes the pain as constant, achy, and radiates to the left shoulder and back. He appears disheveled and smells of alcohol. He is short of breath on conversation. His temperature is 37.9°C (100.3°F), pulse is 115/min, respirations are 20/min, and blood pressure is 80/60 mmHg. Physical examination is significant for abdominal distention with epigastric tenderness. Bowel sounds are decreased. Rectal examination shows no abnormalities. Test of the stool for occult blood is negative. Laboratory studies show the following: Hb 10.5 Leuko. 15,5K Serum Ca++. 7.0mg/dL Amylase. 950U/L Lipase 800U/L Glucose. 190mg/dL What of the following characteristics of this pt has the worst prognostic implication? (Hemoglobin OR AGE)

Age -Use RANSON'S criteria PANCREAS 1-Po2 (<60mmHg) 2-Age (>55) 3-Neutro's (WBC's >16K) 4-Calcium (<8mg/dL) 5-Renal (BUN >5) 6-Elevated enzymes (LDH >2x's N, ALT >6X's N) 7-Albumin 8-Sugar (Glucose >200mg/dL) 9-Fluids Sequestration >600mL 10-Base deficit >4mEq/L Hemoglobin -Not on Ranson's list

***PICTURE*** Narcotic administration -XR shows RT side colonic distention, causes include: >Narcotic administration >Mechanical obstruction (severe constipation, adhesions, mass) >Infectious colitis (transmural inflammation) >Sepsis (Ileus) Prior Abd surgery

An elderly patient who underwent orthopedic repair of a hip fracture developed abdominal distention and dull diffuse abdominal pain. He denies fever or diarrhea. WBC count was 4.8. An abdominal plain film was obtained (shown here). Colonoscopy revealed no obstruction or other abnormalities. Which is the likely inciting factor in the development of this condition? (Prior abd surgery OR Narcotic administration)

A 76 year-old woman with a past medical history of hypertension, hyperlipidemia and ulcerative colitis presents to the emergency department with abdominal pain and yellowing skin. She states that she has had right upper quadrant pain for the past two months as well as decreased appetite. As a result, she has lost 20 pounds during that time span. She denies fever, nausea, vomiting, diarrhea or increased pain with eating; however, she has noticed clay-colored stools . Her medications include lisinopril, mesalamine, and simvastatin.The patient's temperature is 37.4°C, blood pressure is 108/66 mmHg, pulse is 68/min, respirations are 18/min, and weight is70 kg (155 lb). On physical examination, she is jaundiced, with mild tenderness to palpation in the right upper quadrant and a palpable mass below the liver. Laboratory Values: ALT 170 U/L AST 150 U/L Alkaline phosphatase 390 U/L Bilirubin 15.1 mg/dL Amylase 20 Lipase 40 Which of the following is the best next step in the diagnosis of this patient? (Abdominal US OR CT of abdomen)

Abdominal US -In pts w/ RUQ pain, jaundice, & elevated ALP & bilirubin >> abdominal US is FIRST LINE -US would show suspected OBSTRUCTION and resulting ductal dilation CT of abdomen -Used if US cannot rule out a benign cause >> to look for malignancy

A 66-year-old man presents for a routine follow-up appointment. His past medical history is significant for type 2 diabetes mellitus, gout, hypertension, and peripheral artery disease. His current medications include metformin, allopurinol, and lisinopril. His last PSA was 11 months ago, his last hemoglobin A1c was 6.9, and his blood pressure today is 122/84. He has a 50 pack-year smoking history. Which of the following is the best next step in management? (Repeat PSA OR Abdominal US for Aneurysm screening)

Abdominal US for Aneurysm screening -Pt is >65ys and has smoking Hx qualifying him for a USPSTF recommendation of screening for AAA PSA -Screening is no sooner than 1 year (This pt had a screening <1yr ago) and usually it is recommended for every 2-4ys

A 12-year-old Caucasian boy with epistaxis is evaluated in the emergency room. He reports a two-week history of feeling "stopped up" on the right side of his nose and has had frequent nosebleeds from the right nare for the past few months. He also thinks that the hearing in his right ear is diminished. He denies any rashes, easy bruising, or blood in his stool. He has no significant medical history and is up-to-date on his vaccinations. On physical exam, the boy is sitting comfortably with his parents. Vital signs include a heart rate of 60/min, blood pressure of 110/70 mmHg, and a temperature of 37°C (98.6°F). There is no lymphadenopathy. There is some dried blood noted around his right nare; his left nare is clear. On anterior nasal exam, no scabbing is seen. Otolaryngology was consulted for a more comprehensive exam, which is pending. Notable lab findings include the following: Lymphocytes 30% What is the most likely diagnosis? (Angiofibroma OR Nasal polyp)

Angiofibroma -Benign vascular tumor found in adolescent males >> Presents w/: >Recurrent nosebleeds & unilateral nasal obstruction >Tumors can erode into adjacent structures such as cranial cavity & cause diplopia from involvement of optic chasm >In this pt, the the tumor has obstructed the eustachian canal Nasal polyps >Allergic nasal polyps are the most common >> would show elevated IgE & eosinophilia >> this pt has normal CBC

A 29-year-old man presents to clinic due to red spotting on his toilet paper after wiping when passing stool. He denies pain, pruritus, or other symptoms. Physical examination of the anorectal region is unremarkable. Which of the following is the next best step in diagnosis? (Anoscopy OR Capsule endoscopy)

Anoscopy -Pt likely has internal hemorrhoids >> Anoscopy is used to confirm the Dx

A 75-year-old man with a past medical history of hypertension, diabetes, and a sixty pack-year history of smoking presents to the emergency room with severe posterior chest pain. The patient reports that the pain came on suddenly while at home, and he describes the pain as a sharp "tearing" sensation between his shoulder blades. On arrival to the emergency department, his temperature is 36.6°C (97.8°F), heart rate is 128/min, and blood pressure is 190/65 mmHg in the left arm and 215/75 mmHg in the right arm. A chest x-ray demonstrates mediastinal widening. What is the most likely cause of this patient's widened pulse pressure? (Aortic Regurg OR Right carotid artery dissection)

Aortic Regurg -Acute aortic dissection can lead into the aortic root >> leading to aortic regurg Right carotid artery dissection -Would present as acute neck pain, & is a common cause of ischemic stroke -Would not be expected to cause chest pain -Would not cause widened pulse pressure

A 51-year-old obese woman comes to the emergency department with severe abdominal pain. She localizes the pain in the epigastrium, and says the pain is constant and radiates to her flanks. She gets a small amount of relief when leaning forward with her knees tucked to ther chest. Blood pressure is 102/76 mmHg, pulse is 104/min, temperature is 38.7°C (101.8°F). On physical exam her eyes appear jaundiced, and she is markedly tender in her epigastrium. Laboratory results show leukocytosis, elevated liver enzymes and markedly elevated amylase. Urinalysis is positive for bilirubin. Abdominal ultrasound shows gallstones within the gallbladder, but the common bile duct is not visualized. Which of the following is the most appropriate next step in management? (ERCP OR Laparoscopic Cholecystectomy)

ERCP -Pt is persenting with acute pancreatitis SECONDARY to retained gallstone in the CBD at ampulla of Vater >> she is also showing early signs of ASCENDING CHOLANGITIS shown by: >Jaundice >Tachycardia >Fever -A gallstone at this location obstructs both the pancreatic duct and biliary system >> ERCP is the next best step b/c it is both diagnostic and therapeutic Laparoscopic Cholecystectomy -IS INDICATED for pt >> but NOT NOW >> after removal of retained gallstone by ERCP

A 49-year-old woman is in the burn ICU after a natural gas explosion at her home. She sustained greater than 50% total body surface area of partial- to full-thickness burns. Which of the following is recommended to decrease overall mortality in this patient? (Early enteral feeding OR Initiation of systemic AB's upon admission)

Early enteral feeding -Only option that has been shown to decrease mortality in burn victims Systemic AB's upon admission -should be given in TOPICAL form

A 59-year-old male inpatient with a history of hypertension is status post open reduction and internal fixation of his right tibia following a motor vehicle accident. On postoperative day 10, his surgical site appears erythematous, with edema extending from the right knee to the right ankle. On palpation, he experiences extreme tenderness, and crepitus is present. His temperature is 39.1°C (102.4°F), blood pressure is 94/52 mmHg, pulse is 102/min, and respiratory rate is 27/min. Skin aspirate and blood cultures are obtained. What is the organism most likely responsible for his condition? (C.diff OR GAS)

GAS There are two type of gangrene Type I Polymicrobial >> Involves at least one anaerobic species (Bacteroids, C.perfringens or, Peptostreptococcus) + Facultative anaerobic Strep & enterobacter (E.coli, Enterobacter, Klebsiella) Type II GAS alone OR GAS + S.aureus

An 85-year-old man is evaluated in the emergency department for sudden-onset chest pain. The pain started while he was sitting in his chair, watching television early in the morning, and felt like a "tearing" sensation that went through to his back. He has a past medical history of type 2 diabetes, hyperlipidemia, and hypertension, which has been managed with three medications. On physical examination, his temperature is 36.8°C (98.24°F), and heart rate is 123/min. His blood pressure is 200/105 mmHg in the right arm and 160/95 mmHg in the left arm. An electrocardiogram is obtained and shows sinus tachycardia with non-specific ST changes. A chest x-ray is remarkable for increased mediastinal width with clear lung fields. CT angiogram confirms the presence of a dissecting lesion distal to the subclavian artery. The patient is started in labetalol. What is the next best step in management? (Emergent Aortic surgery repair OR IV nitroprusside)

IV nitroprusside -Pt presents w/ a DESCENDING aortic dissection 'lesion distal to the subclavian artery" >> TMT is to control BP Emergent aortic surgery repair -Type B aortic dissections do not require surgery

A 60-year-old man with a history of benign prostatic hyperplasia presents to the emergency department for worsening abdominal pain for the past day. He has been unable to urinate during this time. He states that he has had frequent episodes of hesitancy in the past, but symptoms usually resolve on their own. Vitals include a temperature of 37.1°C (98.8°F), blood pressure of 140/88 mmHg, heart rate of 95/min, and respiratory rate of 14/min. Physical examination reveals a distended abdomen, and a smooth, enlarged, nontender, prostate. A bedside bladder scan is performed and reveals 700 cc of urine, and a straight catheterization is performed. Preliminary laboratory testing is shown in the table below. BUN. 20mg/dL Creatinine. 1.4mg/dL Which of the following diagnostic studies would be important to obtain next in the workup for this patient? (PSA OR Kidney US)

Kidney US -Pt likely has hydronephrosis 2ndary to BPH >> next step is to Dx hydronephrosis with US PSA -Checking would not change mgmt, as we already know it would be elevated

A 58-year-old obese female is being evaluated for a total knee arthroplasty. The osteoarthritis of her left knee failed pharmacologic and lifestyle changes. Her past medical history includes gastroesophageal reflux disease, hypertension, and type 2 diabetes. Her current medications include omeprazole, lisinopril, amlodipine, metformin, and glipizide. Which of the following drugs (or combination of drugs) should be withheld on the morning of surgery?

Metformin & Glipizide -It is recommended that all HYPOGLYCEMIC & non-insulin injectables be withheld the morning before surgery

A 34-year-old woman presents to the emergency department with acute lower abdominal pain. Her pain started last night in the epigastrium and by today has moved to her lower right quadrant. A computed tomography (CT) scan was obtained to confirm the diagnosis of appendicitis. However, the scan revealed a 3 cm well-demarcated non-enhancing lesion in the right lobe of the liver. What is the best management for her liver lesion? (No TMT OR Elective surgical resection at a later date)

No TMT -PT likely has a simple cyst that contains clear fluid that does not communicate w/ the intrahepatic biliary tree -Simple cyst >> appears as well-demarcated non-enhancing lesion -Most do not require TMT >Cysts larger >4cm is recommended periodic monitoring w/ US >For Symptomatic larger cysts -Needle aspiration -Internal drainage -Wide unroofing -Liver resection Elective surgical resection -Not required d/t to size of cyst

A 64-year old woman with hypertension and coronary artery disease presents for a preoperative evaluation before she is scheduled to have a total hip replacement. She has had several years of increasing hip pain that has failed conservative management. She is able to still climb one flight of stairs, but cannot climb two flights because of her hip pain. She denies any chest pain at rest or with activity. Her medications include atorvastatin and hydrochlorothiazide. On cardiovascular exam, she has a normal S1 and S2 without murmurs, rubs or gallops. She had a twelve-lead electrocardiogram performed three months ago during her annual physical, which demonstrated no Q waves, ST-segment changes, left ventricular hypertrophy, bundle-branch-blocks or arrhythmias. What further cardiac testing should be obtained prior to surgery? (Pharmacological stress test OR No further cardiac testing required)

No further cardiac testing required -Pt's scheduled surgery (hip replacement is considered an INTERMEDIATE risk surgery) >> b/c she has no other RF, she has a 0.4% risk of having a cardiac complication >> so she needs no other testing -Criteria uses 6 risk factors 1-High risk surgery 2-Ischemic heart disease 3-Heart failure 4-Cerebrovascular disease 5-Insulin dependent DM 6-CKD Pharmacological testing -Indicated for pts with unknown or poor functional capacity defined as inability to preform less than 4 metabolic equivalents (such as brisk walking on level ground, walking up a hill or Climbing a flight of stairs) >> This pt can climb a flight of stairs

A 60-year-old man presents to the emergency department for a fall from a ladder. He has a past medical history of hypertension and hyperlipidemia. He is sexually active, and denies any illicit drug use. He has a 20 pack-year history of smoking but quit 20 years ago. The physician orders a chest radiograph to rule out any fracture, which reveals a right-sided solitary pulmonary nodule measuring approximately 0.7 cm. He has no previous chest radiograph or other imaging. What is the next best step in management for the solitary pulmonary nodule? (Follow-up w/ CT in 6 months OR Perform CT now)

Perform CT -Once a nodule is identified the best initial step: >Compare previous imaging -If no previous imaging (or if nodule is suspicious) >CT imaging Follow up CT in 6 months -B/c there is no imaging available now, a CT is indicated at this time

A 25-year-old man is admitted after undergoing emergent appendectomy. The patient is placed on maintenance intravenous fluids with nothing by mouth for the first 24 hours. After this period, he attempts to drink a small amount of water, and subsequently has one episode of nausea and vomiting. Oral liquids are discontinued for 24 hours. He attempted to drink water again and has another episode of vomiting. Since the operation 48 hours ago, he has had no bowel movements. He is alert and in no acute distress. Vital signs are temperature 37.2°C (98.9°F), heart rate 75/min, respiratory rate 12/min, and blood pressure 115/65 mmHg. Serial abdominal exams have been stable since the operation. Exam is notable for decreased bowel sounds and mild abdominal distension. In addition, he exhibits mild diffuse abdominal tenderness to palpation. In addition to continuing maintenance fluids, what is the most appropriate next step in evaluation? (Perform gastrograffin contrast CT OR Perform bedside plain abdominal XR)

Perform bedside plain abdominal XR -Pt most likely has post-op paralytic ileus >> refers to the constipation & intestinal atony >> Pts present w/: >Abd distention >Nausea >Vomiting >Intolerance to oral foods/drinks >Delayed flatulence or passage of stool >Abd pain -Next best step is to perform a PLAIN ABD XR (KUB) Perform Gastrograffin contrast CT -Used in pts that present w/ ileus lasting longer than 4-7 days

A 23-year-old man is brought to the emergency department by ambulance after being struck by a moving vehicle in a parking lot. He is complaining of intense pain in the left leg. He has been conscious, alert and oriented since the accident. The patient is able to speak in full sentences and answer questions appropriately. His pulse is 110 beats/minutes, blood pressure is 152/82 mm Hg, oxygen saturation is 99% on room air, and respirations are 26/min. He has regular cardiac rhythm and equal bilateral breath sounds. Radial and dorsalis pedis pulses are easily palpable bilaterally. An area of ecchymosis on the superolateral aspect of his left leg is tender to palpation. Which of the following is the most appropriate next step in management? (perform secondary survey OR CT angio of LE)

Perform secondary survey -Follows the ABCDE >> secondary survey rule CT angio of Lower extremities -Completion of the secondary survey is more important than further eval of the leg >> the pt has a palpable pulse in the leg so this sig reduces the chance of sig vascular injury

What is the most significant risk factor for a patient's pancreatic pseudocyst?

Previous Hx of pancreatitis

A 43-year-old intoxicated man is transferred to the burn unit after falling into an open campfire. He has flame burns to his entire right upper extremity circumferentially, the palmar aspect of his hands bilaterally, and his entire right lower extremity. What is the approximate total body surface area which has been burned?

Rule of nines -The head and each arm =9% -Anterior/posterior torso, each leg = 18% -Perineum/genital area = 1% This pt -Entire RUE = 9% -Palmar aspect of BOTH hands = 3% -Entire right LE = 18% Approximately 30%

A 45-year-old woman presents to an orthopedic surgeon for left hand weakness. She reports that for the last six months, her left hand and wrist have progressively become weaker, while also noticing a "deformity" in her left wrist. She suffered a supracondylar fracture to her left upper extremity one year ago. Past medical history is significant for hypertension, type II diabetes mellitus, obesity, and hyperlipidemia. Her vital signs are within normal limits. On examination, her left wrist is flexed and the metacarpophalangeal joints of her left digits are extended at rest. Passive extension of the digits of her left hand is met with significant resistance and pain. What is the most likely diagnosis? (Volkmann ischemic contracture OR Dupuyen contracture)

Volkmann ischemic contracture -May be complication of previous supracondylar fracture -Caused by obstruction of the brachial artery >> leads to decreased perfusion of the flexor muscles of the forearm >>> leads to ischemia & necrosis of muscle fibers -On PE, Presents as fixed joint extension of the MCP joints, Flexion of Wrist, pronation of forearm, and flexion of elbow Dupuyen contracture -Common in men ages 40-60 >> presents w/: >Inability to extend the affected digits >> even if pressing down on the digit >Most commonly affects the 4th digit >Fibrous nodules in hand

How long should a fistula be allowed to close before using it for dialysis?

6 weeks

A 67-year-old man complains of a 4 month history of increasing inability to swallow solid foods, but no problem swallowing liquids as of yet. He has had a 25 lb weight loss during this time, which is unintentional and unrelated to his diet. Which of the following is the best next step in management? (Endoscopy OR Barium Swallow)

Barium Swallow -In general the best initial step in evaluating dysphagia is barium swallow Endoscopy -Would do this after barium swallow

A 32-year-old previously healthy woman presents to the emergency department with abdominal pain. She reports her pain began about a week ago in her right upper quadrant, is episodic in nature, and has progressively worsened. She has no past medical conditions, and her only medication is an oral contraceptive pill, which she has been taking for 10 years. She is sexually active and does not smoke or drink alcohol. Her physical examination is significant for tenderness in the right upper quadrant and mild hepatomegaly. Urine pregnancy test is negative. What is the next best step in diagnosis? (CT of liver OR Abd XR)

CT of liver -Pt is likely presenting w/ a hepatic adenoma -Predominantly occurs in young women 20-40y/o -Have long association w/: >long term contraceptive use >Anabolic steroids >Glycogen storage disease -Classic presentation >Pain in RUQ >Pt can present w/ abdominal mass or Hepatosplenomegaly Abd XR -Not used to Dx hepatic adenoma (Question asks for best method to Dx)

An 80-year-old man is brought to the emergency room by his daughter. She explains to the physician that she and her father were climbing stairs when her father suddenly lost vision in his left eye. The patient describes "a curtain dropping in front of my left eye", with no pain or preceding symptoms. Visual acuity exam reveals impaired finger counting vision in the left eye, and 20/30 vision in the right eye. Funduscopic examination reveals retinal whitening with a cherry red spot in the macula. What is the best step to establish the etiology of this patient's vision loss? (Carotid US OR Fundoscopy)

Carotid US -Most cases of CRAO are caused by Carotid atherosclerosis and US would help to visual this Fundoscopy -Only used to help Dx CRAO >> the question asks about identifying the etiology of it

A 52-year-old man is involved in a high-speed motor vehicle collision. He has obvious external signs of head trauma. He arrives to the emergency department comatose and with agonal respirations. He is intubated immediately. His blood pressure remains low, and he requires vasopressor support to maintain a mean arterial pressure of 65-70 mmHg. A CT scan of the head demonstrates large, bifrontal contusions. A ventriculostomy is inserted and his intracranial pressure (ICP) is measured to be 40 mmHg. What is the next step in the management of the patient? (Administer mannitol OR Cerebrospinal fluid CSF drainage)

Cerebrospinal fluid CSF drainage -Pt presents w/intracranial HTN >> the most appropriate TMT is CSF drainage Administer Mannitol -May cause hypotension >> This pt was in a MVC so it may be difficult to maintain his BP >> Would not use mannitol for this pt

A 51-year-old obese man presents with a one-day history of abdominal pain. His symptoms started about an hour after eating a large dinner consisting of fried fish. While the pain was diffuse at first, it is now localized to the upper right quadrant of his abdomen. He called his wife to come home from work so that she could take him into the emergency department. He experienced an episode similar to this six months ago, but it was self-limited. On exam, his vital signs are normal. He has tenderness in the right upper quadrant but has no peritoneal signs. His serum WBC is 16,000/mm3. Serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyl transpeptidase (GGT), alkaline phosphatase, and bilirubin levels are within normal limits. A serum lipase is also obtained which is normal. Ultrasound reveals cholelithiasis and a thickened gallbladder wall. What is the most likely diagnosis? (Cholecystitis OR Cholangitis)

Cholecystitis -Acute inflammation of the gallbladder most commonly caused by gallstone obstruction of the cystic duct Cholangitis -Infection of the Common Bile Duct >> Most often d/t a complication of choledocholithiasis >> usually presents w/ CHARCOT's triad of: 1-RUQ pain 2-Jaundice 3-Fever

A 16-year-old boy presents to the emergency department with pain in his left wrist after a fall during soccer practice two hours ago. A teammate accidentally ran into him and knocked him down, causing him to land on his left hand. On examination, his left wrist is edematous but without deformities. There is tenderness to palpation along the carpal bones as well as the distal radius and ulna. Sensation is equal and grip strength is 5/5 bilaterally. Radial and ulnar pulses are 2+ bilaterally. Wrist range of motion is limited by pain. Plain films of the patient's left wrist show: What is the most likely diagnosis? (Scaphoid fracture OR Colles fracture)

Colles fracture -Most common in youths involved in high-impact sports & seniors w/ osteoporosis >> mechanism involves falling on outstretched hand (FOOSH) with the wrist in extension -Pts would present w/wrist swelling, pain, and/or visible deformity (Dinner-fork deformity) -Wrist pain and distal radius fracture Scaphoid fracture -Can also occur from FOOSH injuries but classic symptoms is pain in the anatomical snuff box

A 55-year-old man presents to his physician for six month history of fatigue. He also describes feeling depressed and has had a loss of appetite during this time. He denies any nausea, vomiting, abdominal pain, or diarrhea. He has noticed that his stools have become more pale in color. He denies any sexual activity. He has a 30 pack-year smoking history. He has lost 30 pounds since his last visit one year ago. Vitals are within normal limits. On physical examination, he has notable icterus of his skin and sclera. Abdominal exam reveals a painless, enlarged gallbladder. Initial laboratory tests are obtained and shown below. What is the most likely finding on abdominal US? (Gallbladder wall thickening and intraluminal non-obstructing stones OR Dilation of the CBD & pancreatic duct)

Dilation of the CBD and pancreatic duct -Pt presents w/ painless jaundice, & wt loss concerning for pancreatic cancer -PT has RF of smoking -PE may reveal painless, enlarged gallbladder (Courvoisier's sign) -Classic finding on AXR is dilation of the CBD and pancreatic duct (aka DOUBLE DUCT sign) Gallbladder well thickening & intraluminal non-obstructing stones -This describes Chronic cholecystitis >> pt would present w/ RUQ pain

A 32-year-old man presents with nausea, vomiting, and decreased mentation following head trauma. Vitals show bradycardia, hypertension, and decreased respirations. What is the most appropriate next step in management? (Craniotomy OR Hyperventilation)

Hyperventilation -Hyperventilation, Mannitol, Hypothermia, Decompressive craniectomy, Glucocorticoids (specific instances) >> are all tmts for lowering ICP >> In this case lowering ICP via hyperventilation is most appropriate Craniotomy -Craniectomy (not craniotomy, but is similar) is used to decrease intracranial HTN >> however this is used to acutely lower ICP

A 46-year-old movie actor with a history of hypertension presents to the emergency department with severe chest pain. He is in so much pain that he is barely able to speak. The pain is described as a "tearing" and "ripping" sensation that radiates to his back. An EKG and portable chest X-ray are obtained immediately. The EKG is without signs of ischemia, but the chest X-ray demonstrates a widened mediastinum. Esmolol is used to control his blood pressure, lowering his systolic pressure from 166 mmHg to 120 mmHg. He has no abdominal pain and his urinalysis is normal. A CT angiogram is obtained once he is stabilized that demonstrates an aortic intimal flap corresponding to a dissection of the descending aorta. What is the best immediate treatment for this condition? (Urgent Ex-LAP OR ICU admission + BP control)

ICU admission + BP control -TMT is based on if AAA rupture is Stanford Type A to type B Type A (Ascending aortic dissection) -Urgent repair Type B (Descending Aortic dissections) W/out signs of leakage -MGM w/ BP control (Esmolol)

Describe the criteria for establishing the risk of malignancy associated w/ lung cancer

Low risk -nodule size less than 0.8 cm -age <40 years -no tobacco history or greater than 15 years since smoking cessation -smooth nodule on imaging. Intermediate -nodule size 0.8 to 2 cm -age 40-60 years, -current smoker or 5 to 15 years since smoking cessation -scalloped characteristics on imaging High risk -nodule size greater than 2 cm -age over 60 years -current smoker OR less than 5 years since smoking cessation -spiculation or radiations on imaging

A 56-year-old woman presents to her internist with a chief complaint of swelling and pain in her right arm and hand in addition to recent unintentional weight loss. The past 40 years she has smoked a pack of cigarettes daily, and she drinks alcohol socially on weekends. Physical exam is significant for atrophy of the intrinsic hand muscles of the right hand and a palpable mass in the supraclavicular fossa. CT scan of the chest reveals a right-sided apical chest wall tumor. Which part of the brachial plexus is most likely lesioned in this patient? (Lower trunk OR Upper trunk)

Lower trunk -Pt presents w/ thoracic outlet syndrome, which include: >Edema of the affected upper extremity >Atrophy of the intrinsic muscles of the hand Upper trunk -Pt would present w/ Erb palsy > pts present w/: >Waiter's tip sign >> arm adducted, medially rotated, extended, and pronated

A 62-year-old female is evaluated in the emergency department for sudden onset of severe abdominal cramping, bloody diarrhea, nausea and vomiting shortly following a meal. She denies any recent weight loss or early satiety. She has a history of hyperlipidemia and hypertension for which she takes simvastatin, hydrochlorothiazide, and lisinopril. Her family history is notable for coronary artery disease, and her father passed away from a myocardial infarction at age 60. On examination, she is in acute distress and is clutching her abdomen. There is tenderness to palpation of the abdomen, most prominently in the left lower quadrant with voluntary guarding and absence of rebound pain. A complete blood count is remarkable for a white blood cell count of 13,000 cells/mL. Stool culture is negative. Colonoscopy shows dusky mucosa with edema and hemorrhage throughout the proximal colon. Biopsy shows intraepithelial lymphocytes, pseudomembrane formation, and coagulation. What is the most likely etiology of her symptoms? (Occlusion of a branch of the SMA OR Viral invasion of intestinal mucosa)

Occlusion of a branch of the SMA -Pt is presenting with Acute ischemic colitis as a result of atherosclerotic occlusion of a brach of the SMA -PMH of HTN & hyperlipidemia + Age predispose her to condition -Symptoms include: >Abd cramping >Bloody diarrhea >Nausea >Vomiting >Urgency to move bowels >Low-grade fever >Labs that show leukocytosis d/t inflammation Results of colonoscopy >Pseudomembrane >Dusky mucosa >Hemorrhage C.Diff >Stool sample is negative >> so cannot be C.diff

A 13-year-old boy presents to the emergency department with a nosebleed after he awoke and found his pillow soaked with blood. This is his fifth visit to the emergency department this year for epistaxis. He denies head trauma or upper respiratory infection symptoms. He is otherwise healthy and does not take any medications. Of note, his father also has a history of severe, recurrent nosebleeds for which he has required blood transfusions. Vital signs include temperature of 36.9°C (98.4°F), pulse of 114/min, blood pressure of 98/56 mmHg, respiratory rate of 12/min, and oxygen saturation of 99% on room air. On physical exam, he has blood in the nares bilaterally. He has several telangiectasias on his face and lips but no bruising or rashes. The rest of his physical exam is unremarkable. What is the most likely diagnosis? (VWF deficiency OR Osler-Weber-Rendu syndrome)

Osler-Weber-Rendu -AKA hereditary hemorrhagic telangiectasia >> AD disorder characterized by: >Telangiectasis >Recurrent epistaxis >GI bleeding >Hematuria >Iron deficiency anemia >Many pts have AV malformations in the pulm, hepatic, & cerebral circulations VWF deficiency -Typically presents w/ easy bruising (Pt does not have) -Prolonged bleeding from mucosal surfaces (GI, uterine) -Typically NO TELANGIECTASIAS

A 78-year-old man with a history of diabetes and hypertension presents to an outpatient clinic with complaints of urinary dribbling. The patient denies urgency and nocturia, but states he is unable to completely empty his bladder when he tries. The patient currently takes hydrochlorothiazide for his hypertension and metformin for his diabetes. The patient's blood work reveal an HbA1c of 6.5%. His temperature is 37.0°C (98.6°F), heart rate is 70/min, blood pressure 140/90 mmHg, and his respirations are 18/min. The patient's digital rectal exam reveals a smooth, enlarged prostate without nodules. Which of the following most accurately describes this patient's presentation? (Functional incontinence OR Overflow incontinence)

Overflow incontinence -Pts will have perpetually full bladders, leading to urine dribbling, resulting from the inability of the bladder to hold anymore urine & low urine output -Pt has BPH which is obstructing the bladder outlet leading to his overflow incontinence Functional incontinence Functional incontinence results from impaired health or environmental conditions that lead to an inability to reach the toilet in time. Medical causes of functional incontinence are weakness, arthritis, poor vision, confusion, and dementia. Environmental conditions are unfamiliar setting, distant bathroom facilities, bed rails, and physical restraints. This patient did not exhibit any of those characteristics

A 56-year-old man presents to his primary care doctor because of pain and "stiffness" of his right hand. He enjoys painting, and has recently noticed that his hand is painful, stiff and doesn't work like it used to. He has also felt lumpiness in the palm of his right hand. On exam, the patient's 4th finger is in a flexed position. When laying his hand flat on the table and pushing down, the 4th finger will not straighten. Fibrosis of which of the following is most likely causing this patient's current condition? (Palmar aponeurosis OR Flexor digitorum profundus)

Palmar aponeurosis -Pt has dupuyen contracture >> caused by fibrosis of the palmar aponeurosis -Common in men ages 40-60 >> presents w/: >Inability to extend the affected digits >> even if pressing down on the digit >Most commonly affects the 4th digit >Fibrous nodules in hand

A 43-year-old woman with a history of chronic alcohol abuse arrives at the emergency department with abdominal pain. She was admitted to the hospital two months prior with hematemesis. At that time she was found to have ruptured esophageal varices and a transjugular intrahepatic portosystemic shunt was placed. At this visit, she is not complaining of coughing nor is she throwing up blood. On physical exam, her liver is palpated 4 cm below her costal margin and distended veins radiating from the umbilicus are observed. Which of the following anastomoses underlies the physical exam finding of distended veins around the umbilicus? (Paraumbilical & superficial epigastric veins OR Paraumbilical & inferior epigastric veins

Paraumbilical & superficial epigastric veins

A previously healthy 22-year-old man presents to the emergency department with a chief complaint of severe abdominal pain. Just prior to arrival he had a red, gelatinous bowel movement. Vital signs are within normal limits. Physical exam is notable for numerous mucocutaneous hyperpigmented macules, most prominently on the patient's lips, perioral region, buccal mucosa, palms of his hands, and soles of his feet. Rectal exam is positive for frank blood. A computed tomography scan reveals bowel that has "telescoped" within itself, seen as concentric rings on CT. The patient is rushed into surgery to correct the intussusception. During the laparotomy, the surgeon resects the intussuscepted small intestine and notes that the bowel is filled with numerous sessile, pedunculated, and lobulated polyps. Tissue samples of the polyps are sent to pathology and and the diagnosis is confirmed. What gene is most likely mutated in this patient? (STK or APC)

STK -Pt presents w/ Peutz-Jeghers >> it is AD disorder w/ a mutation in STK11 detected in 50-80% of families APC -Associated w/ Colon cancer (FAP, Turcot's, Gardners)

A 55-year-old man presents to his primary care physician for productive cough and fever. He has a past medical history of hypertension and hyperlipidemia. He is sexually active, and denies any illicit drug use. He is a current 1-pack-per-day smoker, and has been smoking for 15 years. A chest radiograph reveals a lower left lobe consolidation, and a right-sided solitary pulmonary nodule measuring approximately 1.5 cm. He has no previous chest imaging. The physician schedules a computed tomography of the chest following resolution of the pneumonia, which reveals a persistent right-sided pulmonary nodule of similar size with scalloped margins. What is the next best step in management? (Schedule a PET scan OR Schedule a transthoracic needle biopsy)

Schedule a PET scan -Must determine risk of malignancy >> this pt has an INTERMEDIATE risk of malignancy: >Age (40-60) >Nodule size (1.5cm which is <3cm) >Scalloped margins on imaging -Next best step is PET Schedule a transthoracic needle biopsy -Would be inicated for a pt with HIGH RISK of malignancy

A 36-year-old man with a past medical history of intravenous drug use and endocarditis presents with left-sided abdominal pain for the past four days. Occasionally, he also has sharp chest pain that is worse with inspiration, fatigue and chills. The patient's temperature is 39.2°C (102.6°F), blood pressure is 118/76 mmHg, pulse is 102/min, respirations are 22/min and oxygen saturation is 94% on room air. Physical exam demonstrates dullness to percussion about the left lung base and tenderness to palpation about the left upper abdomen with a splenic length of approximately 20 cm. Laboratory studies show a leukocyte count of 14,000/mm3. After initiating broad-spectrum antibiotics and intravenous fluids, the patient continues to spike fevers up to 39.8°C (103.6°F). What is the most appropriate next step in management? (Splenectomy OR CT-guided percutaneous aspiration)

Splenectomy (+IV AB's is GOLD STRD for TMT) -Pt has developed a splenic abscess >> should be suspected in pts w/history of IV drug abuse, endocarditis or an infection at another site -Presentation may include: >Fever (recurrent & resistant to AB's) >leukocytosis >left-sided pleural effusion >Left-sided pleuritic chest pain >splenomegaly best visualized w/ CT CT-guided percutaneous aspiration -This in combo w/ IV antibiotics can sometimes be used to treat splenic abscess but the GOLD STRD is splenectomy + IV AB's

A 76-year-old man presents to the physician complaining of heart palpitations that started one week ago. He reports feeling fatigued and short of breath during this time period. He has a history of hypertension and paroxysmal atrial fibrillation. Current medications include lisinopril and diltiazem. He has alcoholism but has been abstinent for the past 2 years. Electrocardiogram (ECG) reveals atrial fibrillation and the patient is admitted to the hospital for treatment. He is started on heparin and warfarin. On day 3, he begins feeling nauseous and reports pain in the left upper quadrant of his abdomen with radiation to the left shoulder. Examination elicits tenderness in the left upper quadrant without peritoneal signs. Repeat ECG reveals normal sinus rhythm. His pulse is 84/min and blood pressure is 130/84 mmHg. Further studies reveal an INR of 2.1 and troponin I levels are undetectable. Chest x-ray reveals a small left-sided pleural effusion. Which of the following is the most likely diagnosis? (Splenic infarction OR Acute cholecystitis) What is the next best step in MGMT? (CT scan of the abdomen OR Splenectomy)

Splenic infarction -Splenic infarction often occurs in the setting of embolic disease >> PTs typically present: >Left-sided abdominal pain >Tenderness >Nausea >+/- Splenomegaly >Pt will ofter get referred pain to the shoulder Acute cholecystitis -Pt would have RUQ pain TMT CT scan of abdomen -> GOLD STRD for suspected splenic infarct TMT includes: 1-CT scan > to assess the degree of infarction & rule out abscess 2-Hydration 3-Analgesics 4-Observation Splenectomy -Only used in pts w/ severe injury, splenic abscess, or any splenic insult that leads to hemodynamic instability

A 35-year-old right hand dominant man presents with acute onset right shoulder pain after a fall. He denies any associated numbness or tingling. On physical exam, he has mild swelling with diffuse tenderness to palpation about the shoulder. He has 5/5 biceps strength, 5/5 triceps strength, 4/5 shoulder abduction strength, 3/5 shoulder internal rotation strength and 4/5 shoulder external rotation strength at 0 and 90 degrees abduction. He is able to abduct his shoulder past 90 degrees. When his hand is placed behind his back, he is unable to lift his hand off of his back. Shoulder radiographs demonstrate no acute fractures or dislocations. Which muscle is most likely torn in this patient? (teres minor OR Subscapularis)

Subscapularis -Pt will present w/ decreased ability to internally rotate the shoulder against resistance & increased passive external rotation compared to contralateral side -Provocative test include the lift off test & belly press test >Bell press test >> positive if the pts elbow drops back when pressing their palm against their abdomen (internally rotating the shoulder) Teres minor -Helps with external rotation specifically at 90degrees of abduction -Tear is evident if pt is unable to hold their arm in 90degrees abduction/external rotation >> the arm instead falls into internal rotation >> (This pt has intact external rotation)

A 52-year-old man presents to clinic with abdominal pain. He began experiencing intermittent abdominal pain 3 months ago, accompanied by bloody stools and a decrease in the caliber of his stools. He also noticed increasing fatigue. Abdominal examination is significant for tenderness to palpation in the left lower quadrant. Colonoscopy reveals an exophytic mass in the sigmoid colon. Further imaging of the abdomen reveals three masses in the right lobe of the liver. Which treatment option will provide the greatest likelihood of cure for the hepatic lesions? (Surgical resection OR Radiofrequency ablation)

Surgical resection -Pt presenting w/ left-sided colon cancer that has metastasized to his liver -Hepatic mets can be treated with both options but surgical resection provides the greatest chance of CURING IT Radiofrequency ablation -Answer above

A 56-year-old woman presents to her primary care physician due to two months of progressive fatigue and recent onset of diffuse itchiness. She has a past medical history of mild intermittent asthma for which she takes uses an albuterol inhaler. Review of systems is positive for occasional right upper abdominal discomfort during the past week, unrelated to mealtimes. The patient's temperature is 36.6°C (98°F), blood pressure is 129/77 mmHg, pulse is 65/min, and respirations are 10/min. On exam, her liver span is 15 cm. Abdomen is non-distended and mildly tender to palpation in the upper right quadrant. Laboratory findings are: ALP 150U/L Total Bili. 4.8mg.dL Direct Bili. 4.2mg/dL Hb. 8.9mg/dL -Antimitochondrial antibodies -Antinuclear antibodies Empiric iron tablets, Vitamin A, calcium, and Vitamin D are started. At this time, what is the most appropriate additional step in management?

TMT w/ ursodeoxycholic acid (+Methotrexate and/or colchicine) -1st-line TMT for Primary Biliary Cholangitis >> adds to survival

A 26-year-old man presents to the emergency department following a motor vehicle accident in which he was a restrained driver in a head-on collision. According to paramedics, his vitals at the scene included a blood pressure of 85/64 mmHg, heart rate of 115/min, and respiratory rate of 10/min. Glasgow Coma Score was 5. Paramedics in the field performed an endotracheal intubation, and initiated a 2L normal saline bolus through two peripheral intravenous lines. In the emergency department, vitals include a blood pressure of 105/75 mmHg, heart rate of 104/min, and respiratory rate of 13/min. Mechanical breath sounds are present bilaterally, and the abdomen is distended with diminished bowel sounds. What is the next step in management in the primary survey of this patient? (Undress the pt and look for other injuries OR Ex-LAP)

Undress the pt and look for other injuries -Part of primary survey >>After ABCD + neurological has been assessed, next step is E (Examine for Exposure) Examine the body to look for injuries >>After primary survey is assessed a secondary head-to-toe survey may be given Ex-LAP -If pt was hemodynamically unstable w/ peritoneal signs or had evisceration status post-trauma then would do emergent surgery