Ksurgery 1000-1050

Front 1

Q1000. A 25 year old man presents with a painless, hard testicular mass. Dx?; Diagnostic test? (2)

Back 1

A1000. Dx: Testicular cancer; Diagnostic test:; 1. Pre-op Alpha-fetoprotein and Beta-HCG; 2. Diagnosis is made by performing a radical orchiectomy by the inguinal route. (That irreversible, drastic step is justified because testicular tumors are almost never benign. Beware of the option to do a trans-scrotal biopsy: that is a definitive no-no)

Front 2

Q1001. A 25 year old man is found on a pre-employment chest X- Ray to have what appears to be a pulmonary metastasis from an unknown primary tumor. Subsequent physical examination discloses a hard testicular mass, and the patient indicates that for the past six months he has been losing weight for no obvious reason. Dx?; Diagnostic test?; Tx? (2 steps)

Back 2

A1001. Dx: Testicular Cancer with metastasis. Diagnostic test:; pre-op Blood Test for Alpha-fetoprotein and Beta-HCG levels; Tx:; 1. Removal of testicle; 2. Chemotherapy; (The point of this vignette is that testicular cancer responds so well to chemotherapy, that treatment is undertaken regardless of the extent of the disease when first diagnosed)

Front 3

Q1002. A 60 year old man shows up in the ER because he has not been able to void for the past 12 hours. He wants to, but can not. On physical exam his bladder is palpable half way up between the pubis and the umbilicus, and he has a big, boggy prostate gland without nodules. He gives a history that for several years now, he has been getting up four or five times a night to urinate. Because of a cold, two days ago he began taking anthihystaminics, using “nasal drops”, and drinking plenty of fluids. Dx?; Management?; Tx? (2 possible)

Back 3

A1002. Dx: Acute urinary retention, with underlying BPH; Management: Indwelling bladder catheter, to be left in for at least 3 days; Tx: long-term Alpha-blockers for symptomatic relief, or some form of Prostatic Resection

Front 4

Q1003. On the second post-operative day after surgery for repair of bilateral inguinal hernias, the patient reports that he “can not hold his urine”. Further questioning reveals that every few minutes he urinates a few cc’s of urine. On physical examination there is a large palpable mass arising from the pelvis and reaching almost to the umbilicus. Dx?; Management?

Back 4

A1003. Dx: Acute Urinary Retention with Overflow Incontinence; Management: Indwelling bladder catheter

Front 5

Q1004. A 42 year old lady consults you for urinary incontinence. She is the mother of five children and ever since the birth of the last one, seven years ago, she leaks a small amount of urine whenever she sneezes, laughs, gets out of a chair or lifts any heavy objects. She relates that she can hold her urine all through the night without any leaking whatsoever; Dx?; Tx?

Back 5

A1004. Dx: Stress Incontinence; Tx: Surgical repair of the pelvic floor.

Front 6

Q1005. A 72 year old man who in previous years has passed a total of three urinary stones is now again having symptoms of ureteral colic. He has relatively mild pain that began six hours ago, and does not have much in the way of nausea and vomiting. X-Rays show a 3mm Ureteral stone just proximal to the ureterovesical junction; Management? (3 together)

Back 6

A1005. Management:; 1. Watch him (time); 2. Pain medication; 3. Plenty of Fluids; (there is still a role for watching and waiting. This man is a good example: small stone, almost at the bladder. Give him time, medication for pain, and plenty of fluids, and he will probably pass it)

Front 7

Q1006. A 54 year old lady has a severe ureteral colic. IVP shows a 7mm Ureteral stone at the ureteropelvic junction; Tx?

Back 7

A1006. Tx: Shock-wave Lithotripsy; (whereas a 3mm stone has a 70% chance of passing, a 7mm stone only has a 5% probability of doing so. This one will have to be smashed and retrieved)

Front 8

Q1007. A 33 year old man has urgency, frequency, and burning pain with urination. The urine is cloudy and malodorous. He has mild fever. On physical exam the prostate is not warm, boggy or tender; Dx?; Management? (3 together)

Back 8

A1007. Dx: Urinary Tract Infections; Management:; 1. start Urinary cultures; 2. start Antibiotics; 3. either IVP or Sonogram

Front 9

Q1008. A 72 year old man consults you with a history for that for the past several days he has noticed that bubbles of air come out along with the urine when he urinates. He also gives symptoms suggestive of mild cystitis; Dx? (2 possible); Diagnostic test?; Tx?

Back 9

A1008. Dx: Pneumaturia due to a Fistula between the bowel and the bladder. (Most commonly from sigmoid colon to dome of the bladder, due to diverticulitis); or Sigmoid Cancer; Diagnostic test: CT scan; (Intuitively you would think that either cystoscopy, sigmoidoscopy or contrast studies would verify the diagnosis, but they seldom show anything in this case); Tx: Surgery will be needed

Front 10

Q1009. A 32 year old man has sudden onset of impotence. One month ago he was unexpectedly unable to perform with his wife after an evening of heavy eating and heavier drinking. Ever since then he has not been able to achieve an erection when attempting to have intercourse with his wife, but he still gets nocturnal erections and can masturbate normally; Dx?; Management?

Back 10

A1009. Dx: Classical Psychogenic Impotence; (young man, sudden onset, partner-specific. Organic impotence is typically older, of gradual onset and universal); Management: Curable with psychotherapy if promptly done; (It will become irreversible after two years)

Front 11

Q1010. Even without intake, how much urine must you excrete in waste products?

Back 11

A1010. 800mL/day

Front 12

Q1011. Where is Na reabsorbed in the nephron? In exchange for what?

Back 12

A1011. Distal Tubule. For K and H secretion

Front 13

Q1012. What patients should receive Colloids instead of Crystalloids? (7)

Back 13

A1012. Patients with excess Na and water, but still hypovolemic (Ascites, CHF, post-cardiac bypass patients);; Patients unable to make Albumin (Liver disease, transplant recipients);; Severe Hemorrhage or Coagulopathy;; ER patient with Flail chest due to rib fractures that progresses to Respiratory contusions

Front 14

Q1013. What are the equations for calculating Maintenance Fluids/hour?; (3); What else does this work for?

Back 14

A1013. Up to 10kg: 100mL/kg/day (4mL/kg/hr); 11 - 20kg: 1,000mL + 50mL/kg/day for each kg above 10 (40mL/hr + 2mL/kg/hr for each kg above 10); >20kg: 1,500mL + 20mL/kg/hr for each kg above 20 (60mL/hr + 1mL/kg/hr for each kg above 20); Same for estimating daily Caloric expenditure (except replace mL by kcal)

Front 15

Q1014. Patient is post-surgery and on PE you notice JVD, rales, S3 and slight edema. Dx?

Back 15

A1014. Hypervolemia

Front 16

Q1015. What is the acute Tx for Hyperkalemia?; (3)

Back 16

A1015. Lower Extracellular K:; Calcium Gluconate;; Albuterol;; NaHCO3 with Insulin;

Front 17

Q1016. What is the chronic Tx for Hyperkalemia?; (2)

Back 17

A1016. Lower total body K:; Kayexalate;; Dialysis

Front 18

Q1017. What are the main 3 types of shock?; How can you separate one from the other two by checking the skin temp?

Back 18

A1017. Check to see if the skin is warm or cold:; Warm: Distributive shock; Cold: Hypovolemic shock; Cardiogenic shock

Front 19

Q1018. what is the first organ "casualty" of hypovolemic or cardiogenic shock?; Why?

Back 19

A1018. Kidneys; blood is shunted away from the renal arteries; (always monitor shock patients for renal failure...adequate urine output is essential)

Front 20

Q1019. what are the 3 types of Distributive shock?

Back 20

A1019. Septic shock;; Neurogenic shock;; Anaphylactic shock

Front 21

Q1020. MC bugs that cause Septic shock?

Back 21

A1020. Gram-Negative

Front 22

Q1021. what is considered adequate urine output in adult(mL/kg/hr)?; In child > 1 year?; In child < 1 year?

Back 22

A1021. Adult: 0.5 mL/kg/hr; Child > 1 year: 1.0mL/kg/hr; Child < 1 year: 2.0mL/kg/hr

Front 23

Q1022. what does the Wedge Pressure represent?; what is normal value?

Back 23

A1022. Left Ventricular Pressure; normal = 6 - 12 mmHg

Front 24

Q1023. what is the Wedge Pressure, CO and Systemic Vascular Resistance for:; 1. Cardiogenic shock; 2. Hypovolemic shock; 3. Distributive shock

Back 24

A1023. Cardiogenic shock:; Wedge = UP; CO = DOWN; SVR = UP; Hypovolemic shock:; Wedge = DOWN; CO = DOWN; SVR = UP; Distributive shock:; Wedge = DOWN or NML; CO = UP; SVR = DOWN

Front 25

Q1024. Drugs used for Cardiogenic shock; (4)*

Back 25

A1024. DIMeD:; Dobutamine;; Isoproterenol;; Milrinone;; Dopamine

Front 26

Q1025. Drugs used for Septic shock; (3)

Back 26

A1025. Dopamine (High: 10-20ug/kg/min);; Norepinepherine;; Epinenpherine

Front 27

Q1026. which Cardiogenic Shock drug can increase both CO and SVR based on the dosage?; (List dosage and effects); What do the other Cardiogenic shock drugs do?

Back 27

A1026. Dopamine; Med dose [Inc CO]: 5-10ug/kg/min; High dose [Big Inc SVR]: 10-20ug/kg/min; Other drugs: Inc CO and Dec SVR

Front 28

Q1027. which drug is used in Neurogenic shock?; what is the MOA?

Back 28

A1027. Phenylephrine; MOA: Alpha-1 antagonist (Vasoconstriction)

Front 29

Q1028. what drug is used for a patient with low CO with high BP?

Back 29

A1028. Sodium Nitroprusside

Front 30

Q1029. when is PEEP used?; (2); what is the adverse effect?

Back 30

A1029. Congestive Heart Failure;; Acute Respiratory Distress Syndrome (ARDS); AE: Hypotension (dec preload)

Front 31

Q1030. what is the difference in PCWD (wedge) in ARDS vs. CHF?

Back 31

A1030. ARDS: PCWP < 18; CHF: PCWP > 18

Front 32

Q1031. Trauma patient has possible cribriform fracture. How do you intubate?

Back 32

A1031. Orogastric tube; (not Nasogastric)

Front 33

Q1032. patient in a MVA arrives with an enlarging pupil and a decrease in the level of consciousness since he arrived in the ED. It is obvious he has an increase in ICP. What is specifically causing the symptoms?

Back 33

A1032. Uncal Herniation

Front 34

Q1033. A 20yo female has brief loss of consciousness following head injury. She presents to the ED awake but is amnestic to the event and keeps asking the same questions over and over again. Dx?

Back 34

A1033. Dx: Concussion

Front 35

Q1034. (5)* ways to lower ICP in a trauma patient

Back 35

A1034. HIVED:; Hyperventilation (PCO2 b/t 28 - 32);; Intubation and Sedation;; Ventriculostomy (Burr holes);; Elevate the head of the bed;; Diuretics (Mannitol; Furosemide)

Front 36

Q1035. which zone in neck injuries must be taken to the OR?

Back 36

A1035. Zone II

Front 37

Q1036. Trauma patient enters ED with flaccid paralysis, hypotension, bradycardia, cutaneous vasodilation and a normal to wide pulse pressure. Dx?; what causes this physiologically?

Back 37

A1036. Neurogenic shock; cause: Impairment of the descending sympathetic path of spinal cord

Front 38

Q1037. A child comes to the office with painful hands bilaterally and his head "stuck" in rotation. Why is the head like this?; Dx?

Back 38

A1037. C1 Rotary Subluxation; due to (Dx) Rheumatoid Arthritis

Front 39

Q1038. Tx for a Tension Pneumothorax; (describe procedure)

Back 39

A1038. Needle decompression over Second intercostal space, Midclavicular on affected side (followed by a chest tube)

Front 40

Q1039. Dx:; Absent or decreased upper extremity pulses and BP with increased lower extremity BP

Back 40

A1039. Injury to Innominate or Subclavian Artery

Front 41

Q1040. Dx:; patient in a MVA enters ER with chest trauma, new systolic murmur, dyspnea, unequal BP or pulse in extremities. CXR shows widened mediastinum, aortic knob, area b/t pulmonary artery and aorta. After stabalizing patient, what is the diagnostic test?

Back 41

A1040. Dx: Thoracic Great Vessel Injury; test: Angiography

Front 42

Q1041. Dx:; a 25-yo female presents after MVA with dyspnea, tachycardia and local bruising over right side of chest. CXR shows a right upper lobe consolidation.

Back 42

A1041. Dx:; Pulmonary Contusion

Front 43

Q1042. at what spinal level of the diaphragm do the structures pass?

Back 43

A1042. I ate (8) 10 Eggs At 12:; T8 - IVC; T10 - Esophagus (and vagus); T12 - Aorta (and azygos vein)

Front 44

Q1043. Dx:; a female presents with acute pain of her axilla and a tender cord is identified on PE. Dx? (2 possible); Diagnostic test?

Back 44

A1043. Dx: Mondor's Dz or Chest Wall infection; Diagnostic test: Ultrasound

Front 45

Q1044. Dx:; a 45-yo woman presents with breast pain that does not vary with her menstrural cycle with lumps in her nipple/areolar complex and a History of a non-bloody nipple discharge

Back 45

A1044. Mammary Duct Ectasia

Front 46

Q1045. When does the Ductus Arteriosus usually close?; What keeps it patent?; What facilitates its closure?

Back 46

A1045. Closes within the first 24 hours; Patent: Prostaglandin; Closes: Indomethacin