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46 Cards in this Set

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Q1000. A 25 year old man presents with a painless, hard testicular mass. Dx?; Diagnostic test? (2)
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)
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)
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)
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)
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
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?
A1003. Dx: Acute Urinary Retention with Overflow Incontinence; Management: Indwelling bladder catheter
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?
A1004. Dx: Stress Incontinence; Tx: Surgical repair of the pelvic floor.
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)
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)
Q1006. A 54 year old lady has a severe ureteral colic. IVP shows a 7mm Ureteral stone at the ureteropelvic junction; Tx?
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)
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)
A1007. Dx: Urinary Tract Infections; Management:; 1. start Urinary cultures; 2. start Antibiotics; 3. either IVP or Sonogram
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?
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
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?
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)
Q1010. Even without intake, how much urine must you excrete in waste products?
A1010. 800mL/day
Q1011. Where is Na reabsorbed in the nephron? In exchange for what?
A1011. Distal Tubule. For K and H secretion
Q1012. What patients should receive Colloids instead of Crystalloids? (7)
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
Q1013. What are the equations for calculating Maintenance Fluids/hour?; (3); What else does this work for?
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)
Q1014. Patient is post-surgery and on PE you notice JVD, rales, S3 and slight edema. Dx?
A1014. Hypervolemia
Q1015. What is the acute Tx for Hyperkalemia?; (3)
A1015. Lower Extracellular K:; Calcium Gluconate;; Albuterol;; NaHCO3 with Insulin;
Q1016. What is the chronic Tx for Hyperkalemia?; (2)
A1016. Lower total body K:; Kayexalate;; Dialysis
Q1017. What are the main 3 types of shock?; How can you separate one from the other two by checking the skin temp?
A1017. Check to see if the skin is warm or cold:; Warm: Distributive shock; Cold: Hypovolemic shock; Cardiogenic shock
Q1018. what is the first organ "casualty" of hypovolemic or cardiogenic shock?; Why?
A1018. Kidneys; blood is shunted away from the renal arteries; (always monitor shock patients for renal failure...adequate urine output is essential)
Q1019. what are the 3 types of Distributive shock?
A1019. Septic shock;; Neurogenic shock;; Anaphylactic shock
Q1020. MC bugs that cause Septic shock?
A1020. Gram-Negative
Q1021. what is considered adequate urine output in adult(mL/kg/hr)?; In child > 1 year?; In child < 1 year?
A1021. Adult: 0.5 mL/kg/hr; Child > 1 year: 1.0mL/kg/hr; Child < 1 year: 2.0mL/kg/hr
Q1022. what does the Wedge Pressure represent?; what is normal value?
A1022. Left Ventricular Pressure; normal = 6 - 12 mmHg
Q1023. what is the Wedge Pressure, CO and Systemic Vascular Resistance for:; 1. Cardiogenic shock; 2. Hypovolemic shock; 3. Distributive shock
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
Q1024. Drugs used for Cardiogenic shock; (4)*
A1024. DIMeD:; Dobutamine;; Isoproterenol;; Milrinone;; Dopamine
Q1025. Drugs used for Septic shock; (3)
A1025. Dopamine (High: 10-20ug/kg/min);; Norepinepherine;; Epinenpherine
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?
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
Q1027. which drug is used in Neurogenic shock?; what is the MOA?
A1027. Phenylephrine; MOA: Alpha-1 antagonist (Vasoconstriction)
Q1028. what drug is used for a patient with low CO with high BP?
A1028. Sodium Nitroprusside
Q1029. when is PEEP used?; (2); what is the adverse effect?
A1029. Congestive Heart Failure;; Acute Respiratory Distress Syndrome (ARDS); AE: Hypotension (dec preload)
Q1030. what is the difference in PCWD (wedge) in ARDS vs. CHF?
A1030. ARDS: PCWP < 18; CHF: PCWP > 18
Q1031. Trauma patient has possible cribriform fracture. How do you intubate?
A1031. Orogastric tube; (not Nasogastric)
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?
A1032. Uncal Herniation
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?
A1033. Dx: Concussion
Q1034. (5)* ways to lower ICP in a trauma patient
A1034. HIVED:; Hyperventilation (PCO2 b/t 28 - 32);; Intubation and Sedation;; Ventriculostomy (Burr holes);; Elevate the head of the bed;; Diuretics (Mannitol; Furosemide)
Q1035. which zone in neck injuries must be taken to the OR?
A1035. Zone II
Q1036. Trauma patient enters ED with flaccid paralysis, hypotension, bradycardia, cutaneous vasodilation and a normal to wide pulse pressure. Dx?; what causes this physiologically?
A1036. Neurogenic shock; cause: Impairment of the descending sympathetic path of spinal cord
Q1037. A child comes to the office with painful hands bilaterally and his head "stuck" in rotation. Why is the head like this?; Dx?
A1037. C1 Rotary Subluxation; due to (Dx) Rheumatoid Arthritis
Q1038. Tx for a Tension Pneumothorax; (describe procedure)
A1038. Needle decompression over Second intercostal space, Midclavicular on affected side (followed by a chest tube)
Q1039. Dx:; Absent or decreased upper extremity pulses and BP with increased lower extremity BP
A1039. Injury to Innominate or Subclavian Artery
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?
A1040. Dx: Thoracic Great Vessel Injury; test: Angiography
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.
A1041. Dx:; Pulmonary Contusion
Q1042. at what spinal level of the diaphragm do the structures pass?
A1042. I ate (8) 10 Eggs At 12:; T8 - IVC; T10 - Esophagus (and vagus); T12 - Aorta (and azygos vein)
Q1043. Dx:; a female presents with acute pain of her axilla and a tender cord is identified on PE. Dx? (2 possible); Diagnostic test?
A1043. Dx: Mondor's Dz or Chest Wall infection; Diagnostic test: Ultrasound
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
A1044. Mammary Duct Ectasia
Q1045. When does the Ductus Arteriosus usually close?; What keeps it patent?; What facilitates its closure?
A1045. Closes within the first 24 hours; Patent: Prostaglandin; Closes: Indomethacin