Step 2 Surgery

Front 1

common post gastrectomy complication associated with rapid emptying of hypertonic gastric contents into the duodenum leading to stimulation of autonomic reflexes

Back 1

dumping syndrome

Front 2

what is suspected in a pt with blunt trauma to the chest with x-ray findings showing left lower atelectasis with mediastinal deviation to the right

Back 2

traumatic rupture of the diaphragm
*more common on the left

Front 3

test of choice to diagnose traumatic rupture of the diaphragm

Back 3

barium swallow or CT with contrast

Front 4

type of compartment syndrome associated with 4-6 hours of ischemia and soft tissue swelling following surgical fixation

Back 4

ischemia-reperfusion syndrome

Front 5

what is suspected in a pt presenting with acute onset of back pain and profound hypotension

Back 5

rupture of AAA

Front 6

what can lead to compartment syndrome in a pt with circumferential full-thickness burns involving extremities

Back 6

eschar, restricts expansion as edema ensues
*perform escharotomy

Front 7

next step in management in a pt with abdominal injuries that is hypotensive and not responsive to fluid administration

Back 7

exploratory laporatomy

Front 8

blunt trauma to what part of a full, distended bladder is associated with subdiaphragmatic peritonitis

Back 8

bladder dome

Front 9

differentiate mild, moderate, and severe TBI

Back 9

mild TBI - head injury associated with GCS score of 13-15
moderate - GCS score 9-12
severe - GCS score <8

Front 10

differentiate the next step in management of a pt with mild-moderate TBI with vomiting, headache, or loss of consciousness

Back 10

mild-moderate TBI - if vomiting, headache, or brief loss of consciousness is involved then a head CT should be performed, if normal pt may be discharged

*pt without vomiting, HA, loss of consciousness can be observed for 4-6 hours without neuroimaging

Front 11

pt presents with persistant nausea, vomiting of partially digested food, early satiety and weight loss. he has a hx of peptic ulcer disease

Back 11

pyloric stricture

Front 12

what type of arm injury is associated with seizures

Back 12

posterior dislocation of the shoulder

Front 13

what is a complication of appendicitis that is associated with tender, fluctuant mass palpable only with the tip of the examining finger during rectal exam

Back 13

pelvic abscess

Front 14

next step in management of a pelvic fracture in an elderly person after stabilization of the fracture and DVT prophylaxis

Back 14

ECG, CXR, and cardiac enzymes to look for cause of the fall

Front 15

pt with hx of afib presents with severe acute-onset midabdominal pain out of proportion to physical examination findings

Back 15

acute mesenteric ischemia

Front 16

what should be suspected in a pt who remains tachypneic and hypotension after blunt thoracic trauma with CXR revealing multiple rib fractures overlying a lung contusion

Back 16

flail chest

Front 17

associated with widened mediastinum and left-sided hemothorax

Back 17

aortic injury

Front 18

blunt trauma to the abdomen associated with hypotension and intraperitoneal fluid

Back 18

splenic laceration

Front 19

blunt trauma to the upper abdomen associated with negative CT scan

Back 19

pancreatic laceration
*stomach perforation would need penetrating trauma (knife)

Front 20

differentiate next step in management of a palpable breast mass in a pt < 30 vs. >30

Back 20

<30 years old - ultrasound
>30 years old - mammogram and ultrasound

Front 21

associated with dyspnea, confusion, and petechiae in the upper extremity after multiple fracture of long bones

Back 21

fat embolism

Front 22

commonly seen in runners that presents with pain between the third and fourth toes reproducible with palpation

Back 22

morton neuroma

Front 23

next step in management in non-bleeding varices

Back 23

medical management with nonselective B-blockers

Front 24

CT scan of brain showing numerous minute punctate hemorrhages with blurring of grey-white interface

Back 24

diffuse axonal injury

Front 25

two most common peripheral artery aneurysms

Back 25

femoral and popliteal
*pulsatile masses that can compress adjacent structures

Front 26

intermittent bloody discharge from on nipple

Back 26

intraductal papilloma

Front 27

epigastric pain associated with right shoulder pain as well as relation to meals

Back 27

biliary colic

Front 28

next step in manage in a pt presenting with flail chest (pardoxical movement of chest wall)

Back 28

positive pressure mechanical ventilation

Front 29

next step in management of a pt with blunt abdominal trauma after fluid resuscitation

Back 29

FAST examination
*focused assessment with sonography for trauma to assess for intraperitoneal fluid

Front 30

pt with blunt abdominal trauma initially is stable but later develops hypotension, abdominal pain, and left shoulder pain. what is the next best step in management

Back 30

abdominal CT with contrast to look for splenic injury

Front 31

differentiate arterial occlusion with thrombus vs. embolus

Back 31

thrombus - slow, progressive narrowing with insidious onset that is usually bilateral
embolus - sudden-onset sever pain and asymmetric pulselessness

Front 32

what does post-op (48 hours) with hypoxemia, respiratory alkalosis, and abnormal CXR signify

Back 32

atelectasis

Front 33

how to prevent post-op pulmonary complications

Back 33

incentive spirometry

Front 34

acute shoulder pain after forceful abduction and external rotation suggests injury to which nerve

Back 34

axillary
*anterior dislocation of shoulder

Front 35

next step in management of acute gastrointestinal perforation

Back 35

emergent laparotomy

Front 36

next step in management of pt needed emergent surgery who's INR is 2.1

Back 36

fresh frozen plasma to reverse effects of warfarin

Front 37

3 bacteria need to prophylax against after removal of spleen

Back 37

S. pneumoniae
N. meningitidis
H. influenzae

Front 38

next step in management after central venous catheter is placed

Back 38

portable CXR to look for pneumothorax, hemothorax, thrombosis, air embolism, myocardial perforation

Front 39

elderly pt presents with weakness in upper extremity after motor vehicle accident

Back 39

central cord syndrome
*results from hyperextension

Front 40

what should be checked in all patients with clavicular fracture

Back 40

neurovascular examination to look for injury to underlying brachial plexus and subclavian artery

Front 41

what is the leading cause of death in patients with significant total body surface area burns

Back 41

hypovolemic shock
sepsis and septic shock in the setting of adequate fluid resuscitation

Front 42

differentiate next step in management of pts with splenic injury that respond to fluid resuscitation vs. not

Back 42

stable after fluid resuscitation - abdominal CT scan
unstable after fluid resuscitation - emergent exploratory laparotomy

Front 43

type of kidney stones associated with Crohn disease and other intestinal diseases that cause fat malabsorption

Back 43

calcium oxalate

Front 44

next step in manage in pt with RUQ pain associated with ingestion fatty food, fever, and leukocytosis

Back 44

cholecystecomy within 72 hours

Front 45

pt presents with severe retrosternal and epigastric pain after vomiting for past few hours. on physical exam he has palpable crepitus in the suprasternal notch with CTAB

Back 45

esophageal perforation

Front 46

first step in management in a pt with suspected PVD

Back 46

ABI

Front 47

next step in manage in pt with suspected PVD and ABI is normal

Back 47

perform exercise testing with repeat ABI, preexercise and postexercise ABIs

Front 48

acute pain and swelling over sacrococcygeal region in younger male is most likely

Back 48

pilonidal disease

Front 49

next step in management of a child presenting with duodenal hematoma after direct blunt trauma to the upper abdomen

Back 49

NGT and parenteral nutrition
*surgery is only indicated if conservative measure fail after a couple of weeks

Front 50

what is volume resuscitation necessary in pt with hypovolemic shock before intubation

Back 50

PEEP causes decrease venous return to the heart
sedative medications cause vasodilation

Front 51

next step in manage in newborn caucasian first-born female who was delivered breech. pt has palpable clunk o the hip

Back 51

U/S of the hip
*development dysplasia of the hip
**X-ray would be done if pt was >4 months old

Front 52

three steps in a pt with massive hemoptysis

Back 52

1. intubated to protect the airway
2. stabilize hemodynamically with fluids and placing pt in lateral decubitus position
3. emergent bronchoscopy to visualize and stabilize the bleeding

Front 53

pt rescued from burning building by firefighters has brief tonic-clonic seizure en route, pt also is confused with nausea and dizzines. what is the next step in management

Back 53

100% oxygen with facemask
*CO poisoning

Front 54

final sequence of compartment syndrome in which dead muscle has been replaced with fibrous tissue

Back 54

volkmann's ischemic contracture

Front 55

differentiate meniscal and ligamentous tears of the knee

Back 55

meniscal - "popping" sensation with subsequent joint swelling that gradually develops
ligamentous - "popping" sensation with rapid joint swelling due to hemarthrosis

Front 56

treatment of acute mastitis

Back 56

analgesics
antibiotics
continuation of breast-feeding from affected breast
*this reduces progression from mastitis to abscess

Front 57

next step in management of a pt with colicky abd pain with episodic hyperactive BS, N/V, abd distention and diffuse abd tenderness. pt has not had BM for past 3 days

Back 57

laparatomy

Front 58

Pt with epigastric pain that radiates to the back and associated vomiting. Labs show elevated LFTs and Lipase. What is the next step in management

Back 58

RUQ U/S
*gallstone pancreatitis

Front 59

next step in management of a newborn infant with a scrotal mass that is cystic and trasilluminates with light

Back 59

reassurance and observation
*most hydroceles disappear spontaneously by 12 months

Front 60

younger women with mass suspected of being malignancy on radiography has Bx that shows foamy macrophages and fat globules

Back 60

fat necrosis, no further work-up is needed

Front 61

edema, dermatitis, and ulcerations found above the medial malleoli are due to what

Back 61

venous HTN secondary to valve incompetence

Front 62

what vital sign is the first indicator of hypovolemia

Back 62

tachycardia

Front 63

next step in manage of a pt who fell on outstretched hand now complains of pain their anatomic snuffbox. X-ray do not reveal a fracture

Back 63

place thumb in spica cast and repeat radiography in 7-10 days

Front 64

which CN can be compromised in pt with head trauma who developed an epidural hematoma

Back 64

CN III secondary to transtentorial (uncal) herniation

Front 65

cause of ulcer on under sole of foot, not associated with trauma

Back 65

peripheral neuropathy

Front 66

pt with blunt trauma to the chest presents with tachycardia and tachypnea a few hours after the collision. breath sounds are decreased on the side of the trauma. X-ray will most likely show what

Back 66

patchy, irregular alveolar infiltrate due to pulmonary contusion

Front 67

pt presents with decreased breath sounds on the left after chest and abd trauma. CXR shows elevated hemidiaphragm on the left as well as a NGT in the pulmonary cavity

Back 67

diaphgragmatic injury

Front 68

diagnostic study of choice in suspected esophageal performation

Back 68

gastrografin-contrast esophagography

Front 69

pt presents with severe retrostenal chest pain as well as a CXR showing widened mediastinum with mediastinal emphysema

Back 69

esophageal perforation

Front 70

trendelenburg sign

Back 70

drooping of the contralateral hemipelvis below normal during monopedal stance
**represents paralysis of the gluteus medius and minimus which are innervated by the superior gluteal nervemos

Front 71

most common cause of lower GI hemorrhage in an elderly patient

Back 71

diverticulosis

Front 72

strong association of nasopharyngeal cancer in far eastern or mediterranean pt

Back 72

viral infection from EBV

Front 73

pt presents with erythematous and edematous cutaneous plaque overlying a mass on the breast with axillary lymphadenopathy

Back 73

inflammatory breast cancer

Front 74

patients with elevated ALP due to accelerated osteoblast activity are at increased risk for what

Back 74

hearing loss
*Paget's disease

Front 75

avascular necrosis of the femoral head associated with children 4-10 years of age. children present with insidious-onset hip or knee pain and antalgic gait

Back 75

Legg Calve Perthes disease

Front 76

pt presents with blunt chest trauma, hemorrhagic shock and decreased breath sounds on the L

Back 76

L sided ipsilateral hemothorax

Front 77

differentiate action and sensation of femoral, obturator, and tibeal nerves

Back 77

1. femoral - anterior compartment --> extension of the knee, hip flexion; sensation over anterior thigh and medial leg via saphenous branch
2. obturator - medial compartment --> adduction of the thigh; sensation over medial thigh
3. tibial - posterior compartment of thigh and leg--> flexion of the knee and foot; sensation of posterior thigh and leg
**tibial and common peroneal are branches from sciatic

Front 78

what does a positive drop arm sign suggest

Back 78

rotator cuff tear

Front 79

where is an immediate decompression with needle thoracostomy for tension pneumothorax located

Back 79

2nd intercostal space in the midclavicular line

Front 80

what commonly causes O2 desaturation and shallow breathing in patient post-op day 2/3

Back 80

atelectasis

Front 81

best way to increase FRC in patient

Back 81

elevated of head of the bed
*increases the FRC by 20-35%

Front 82

patient complains of pain around the wound on post-op day 3. wound shows cloudy-gray discharge, crepitus, and decreased sensation at the edges of the wound

Back 82

necrotizing surgical infection
*surgical exploration is essential

Front 83

main objective in the management of rib fractures

Back 83

pain relief
*allows proper ventilation and prevention of atelectasis and pneumonia

Front 84

young boy presents with bone pain. Labs shows elevated ALP. XR shows osteolytic lesion of the metaphysis of the femur. most likely diagnosis

Back 84

osteosarcoma

Front 85

Pt with blunt chest trauma presents with low BP and elevated PCWP. After rapid infusion of NS, the PCWP increases and BP is minimally increased. what is the most likely diagnosis

Back 85

myocardial contusion

Front 86

pt with history of alcohol use presents with severe epigastric pain and severe diffuse abd pain. what will most likely be seen on CXR

Back 86

free air under the diaphragm
*perforated peptic ulcer

Front 87

what is associated with a hypotensive pt with distended neck vein and bilateral breath sounds

Back 87

pericardial tamponade

Front 88

next step in management of a pt with a perforated peptic ulcer

Back 88

emergent exploratory laparatomy

Front 89

most common cause for SBO

Back 89

adhesions

Front 90

Pt with hx of surgically repaired AAA presents with LLQ pain and bloody diarrhea. what will most likely be seen on colonoscopy

Back 90

discrete segment of cyanotic and ulcerated bowel 2/2 bowel ischemia during AAA procedure.
*most commonly affects the distal left colon

Front 91

when is technetium-99 labeled erythrocyte scintigraphy used in cases of lower GI bleeding

Back 91

when the source cannot be identified by colonoscopy

Front 92

What does an RQ (ratio of CO2 produced to O2 uptake) close to 1.0 signify

Back 92

carbohydrates is the major nutrient being oxidized
*0.8 = protein
**0.7 = lipids

Front 93

what is the next step in management of a hemodynamically unstable patient who has an inconclusive FAST scan

Back 93

diagnostic peritoneal lavage

Front 94

next step in management of a penile fracture

Back 94

retrograde urethrogram followed by surgical exploration

Front 95

what two indications require administration of tetanus-diphereria toxoid

Back 95

1. minor clean wounds who received a booster > 10 years ago
2. severe or dirty wounds who received a booster > 5 years ago

Front 96

Pt presents with RUQ pain a few days post-operatively, U/S shows thickened gallbladder but no gallstones

Back 96

acalculous cholecystitis

Front 97

what two neurological deficits are associated with burst fracture of the vertebra

Back 97

loss of motor function
loss of pain and temperature
proprioception remains intact
*Anterior cord syndrome

Front 98

anterior cord syndrome is associated with what injury

Back 98

burst fracture of the vertebra

Front 99

what test should be administered in any pt with suspected urethral injury

Back 99

retrograde urethrogram

Front 100

what is the next step in management of a pt post-op from cardiac surgery presenting with fever, chest pain, leukocytosis, and mediastinal widening on CXR

Back 100

surgery debridement and antibiotic therapy
*acute mediastinitis

Front 101

next step in management of a pt with the classic presentation of RLQ pain, N/V, fever, and leukocytosis

Back 101

immediate surgery
*No need for CT, only used when appendicitis is suspected with atypical presentation

Front 102

what should you watch out for post operatively in patients who take corticosteroids daily

Back 102

acute adrenal insufficiency
*N/V, abd pain, hypoglycemia, hypotension

Front 103

Following an MVA, pt had chest tube placed for pneumothorax. Hours later the CXR revealed pneumomediastinum and on physical exam there is subcutaneous emphysema.

Back 103

bronchial rupture

Front 104

when is administration of tetanus immune globulin indicated

Back 104

in those with with more sever or dirty sounds and an unclear or incomplete immune history
*these individuals will received both the toxoid and globulin

Front 105

most indication for intubation in the trauma patient

Back 105

altered mental status

Front 106

next step in management in pt with multiple gun shots that is in hypovolemic shock

Back 106

control the bleeding site --> exploratory laparatomy
*DO NOT fluid resuscitate first

Front 107

next step in management of a gunshot victim who is hypotensive with distended neck veins and clear breath sounds

Back 107

pericardiocentesis
*followed by thoracotomy and then exploratory laparatomy

Front 108

next step in management of a stabbing victim to the chest who presents with hypotension, distended neck veins, and clear breath sounds

Back 108

median sternotomy for open repair
*Do not bother with pericardiocentesis

Front 109

next step in management of a gunshot victim who presents with hypotension, distended neck veins, and respiratory distress with deviated trachea

Back 109

immediate big-bore needle to 2nd intercostal space
*followed by chest tube

Front 110

what should you look for in a pt with fixed, dilated pupils with multiple injuries in both upper and lower extremities who is hypotensive

Back 110

look for the source of bleeding outside of the cranium
*bleeding in the head does NOT cause hypotension

Front 111

what type of skull fracture must go to the OR

Back 111

comminuted or depressed skull fractures
*Not linear

Front 112

what is associated with basal skull fractures

Back 112

raccoon eyes
rhino/otorrhea
ecchymosis behind the ear

Front 113

pt in a high-speed MVA was unconscious at the site, he regains consciousness briefly during the ambulance ride, but arrives at the ED in deep coma with a fixed, dilated right pupil and contralateral hemiparesis

Back 113

acute subdural hematoma is a better bet than acute epidural (bigger trauma, sicker patient)

Front 114

pt presents with small crescent-shaped hematoma on CT after MVA, but no deviation of medline structures. what is the next step in management

Back 114

control the ICP with: head elevation, mannitol, furosemide, hyperventilation, hypothermia
*surgery has little to offer

Front 115

elderly man becomes "senile" over a period of 3-4 weeks after a fall down the stairs a week before the mental changes began

Back 115

chronic subdural hematoma
*craniotomy will have spectacular improvement

Front 116

which part of the neck needs immediate surgical exploration even if the pt is a stable gunshot victim

Back 116

middle zone (II)
*extends from cricoid to angle of mandible
**zones I and III should have angiography before surgery if pt is stable

Front 117

what can hyperextension of the neck during an MVA lead to

Back 117

central cord syndrome
*paralysis + burning pain on both upper extremities with good motor function in both legs

Front 118

next step in management in a plain rib fracture

Back 118

pain management, NOT strapping or binding

Front 119

how much blood recovered from a hemothorax chest tube indicates thoractomy

Back 119

>1500 mL or 600 over 6 hours

Front 120

management of a pt with flail chest due to multiple broken ribs bilaterally

Back 120

1. use of colloids rather than crystalloids due to need for fluid restriction
2. monitor for signs of pulmonary or myocardial contusion
3. CXR/ CT scan to look for transection of the aorta

Front 121

Pt with multiple broken ribs presents with hypotension, distended neck veins, and no breaths sounds on one side of the chest. what is the next step in management

Back 121

needle thoracostomy, do NOT get a CXR first
*tension pneumothorax from fractured ribs

Front 122

what should be done if CXR shows widened mediastinum but CT scan is inconclusvie in a pt suspected of having ruptured aorta

Back 122

aortagram

Front 123

three things that can give thoracic subcutaneous emphysema

Back 123

1. rupture of the esophagus (after endoscopy)
2. tension pneumothorax
3. traumatic rupture of the trachea or major bronchus

Front 124

Pt who has received a chest tube for a traumatic pneumothorax is putting out a very large amount of air through the tube

Back 124

look for major bronchial injury from trauma

Front 125

pt with chest tube suddenly goes into cardiac arrest

Back 125

air embolism

Front 126

next step in mangemetn of a peenetrating gunshot to the abdomen

Back 126

exploratory laparotomy every time
*anything below the nipple line is abdomen
**knife wounds only need surgery if peritoneal penetration took place

Front 127

where in the body can internal bleeding lead to hypovolemic shock

Back 127

1. abdomen
2. pelvis
3. upper leg

Front 128

next step in management of a pt who had splenectomy after abdominal trauma

Back 128

vaccinations against encapsulated organisms
*S. pneumo, H. Influenza B, N. Meningococcus

Front 129

next step in management of an unstable vs. stable pt with a pelvic fracture

Back 129

stable - left alone
unstable - external fixation

Front 130

man with pelvic fracture from trauma has blood at the meatus, what is the next step in management

Back 130

retrograde urethrogram

Front 131

woman involved in MVA has pelvic fracture, foley catheter reveals gross hematuria. what is the next step in management

Back 131

retrograde cystogram

Front 132

differentiate hematuria in adults vs. children

Back 132

adults - gross hematuria is always investigated, traumatic microhematuria does NOT
children - gross or microhematuria is ALWAYS investigated.
*start with sonogram

Front 133

next step in management of a pt with a gunshot wound to the anteriomedial vs. anteriolateral aspect of the thigh

Back 133

anteriomedial - arteriogram if vascular injury isn't obvious, if obvious (hematoma present) then surgical exploration is indicated
anteriolateral - only needs wound cleaning and tetanus prophylaxis

Front 134

what future problems can electrical burns lead to sings they are always much bigger than they appear

Back 134

myoglobinuria leading to renal failure
*Pt needs lots of IV fluids, diuretics, and alkalinization of the urine

Front 135

parkland formula

Back 135

4 mL of Ringer Lactate x Kg x %burned (up to 50%)
+ 2L of D5W for maintenance
*give 1/2 in first 8 hours and 1/2 in next 16 hours

Front 136

how much urinary output should burn patients have

Back 136

1 to 2 mL/kg per hour

Front 137

Rule of 9's for body surface area in burn victims Adults vs. Children

Back 137

Adult - Head 9%, Trunk 36%, Legs 36%, Arms 18%
Children - Head 18%, Trunk 36%, Legs 27%, Arms 18%

Front 138

another name for avascular necrosis of the capital femoral epiphysis in a child

Back 138

Legg-Perthes disease

Front 139

next step in management of an obese adolescent with pain in the groin with a flexed hip and leg that is externally rotated

Back 139

orthopaedic surgery with pinning of the femoral head
*slipped capital femoral epiphysis

Front 140

best option to view acute osteomyelitis

Back 140

bone scan
x-ray will not show anything for 2 weeks

Front 141

what bone tumor is associated with periosteal onion skinning and involving the diaphysis of long bones

Back 141

Ewing sarcoma

Front 142

next step in management of a pathologic fracture in an adult

Back 142

whole body bone scan to look for other metastases
*start looking for the primary tumor

Front 143

which bone is injured when a young adult falls on an outstretched hand and comes in with tenderness in the anatomic snuff box

Back 143

scaphoid bone fracture

Front 144

famous fracture an elderly woman with osteoporosis gets when she falls on an outstretched hand

Back 144

Colles fracture
dorsally displaced distal radius

Front 145

differentiate next step in management of an elderly man with displaced femoral neck fracture vs. intertrochanteric fracture

Back 145

displaced femoral neck - metal prothesis due to risk of avascular necrosis
intertrochanteric - open reduction and pinning

Front 146

next step in management of a stress fracture of the tibia

Back 146

cast and repeat x-ray in 2 weeks, fracture will usually show up by then

Front 147

do normal pulses rule OUT the diagnosis of compartment syndrome

Back 147

NO

Front 148

what can be injured during posterior dislocation of the knee

Back 148

popliteal artery

Front 149

pt had one finger that is acutely flexed, he can only extend it by pulling on it at which he feels a painful "snap"

Back 149

trigger finger

Front 150

how to maintain an amputated digit on the way to the ED

Back 150

clean it with sterile saline
wrap it in a saline-moistened gauze
place it in a bag and the bag on ice

Front 151

middle aged man comes in with sudden onset back pain that is like an electrical shock that shoots down the leg. he keeps the affected leg flexed. straight-leg raising gives excruciating pain

Back 151

lumbar disk herniation

Front 152

middle aged man comes in with severe back pain, distended bladder, flaccid rectal sphincter, and perineal saddle area anesthesia

Back 152

cauda equina syndrome

Front 153

first pre-operative test to determine pulmonary function in a pt with a smoking history

Back 153

FEV1

Front 154

hepatic risk factors for surgery
Tbili, Alb, PT

Back 154

bilirubin >2
albumin <3
PT > 16

Front 155

what should you watch out for in a pt with malignant hypethermia

Back 155

myoglobinuria

Front 156

post-op fever W's

Back 156

wind
water
walking
wound

Front 157

antidote for ARDS

Back 157

PEEP

Front 158

post-op massive colonic dilation

Back 158

ogilvie syndrome

Front 159

every 3 mEq of Na above normal (140) represent 1 L lost of water

Back 159

*

Front 160

resuscitation fluid of choice in a pt with metabolic acidosis secondary to shock wit lactic acid production

Back 160

ringer's lactate

Front 161

next step in management of a pt with what sounds like GERD, but the symptoms certain

Back 161

esophageal pH monitoring

Front 162

next step in management of a pt in which GERD is certain

Back 162

endoscopy and biopsy to assess the extent and potential complications

Front 163

pt states they have difficulty with swallowing, liquids are more difficult than solids

Back 163

achalasia

Front 164

steps needed to assess esophageal cancer

Back 164

barium swallow
endoscopy with biopsy
CT scan

Front 165

study of choice if perforation is suspected

Back 165

gastrograffin swallow

Front 166

pt presents with colicky abd pain, high-pithced bowel sounds, and air-fluid levels on KUB

Back 166

bowel obstruction

Front 167

pt with bowel obstruction in the hospital now presents with fever, leukocytosis, abd tenderness, and rebound tenderness

Back 167

strangulated obstruction
*emergency surgery

Front 168

differentiate R-sided and L-sided colon CA

Back 168

R - bleed, anemia with occult blood in the stool
L - obstruct, constipated with narrow caliber stools

Front 169

next step in management of a pt with UC that has suspected toxic megacolon

Back 169

emergency resection of involved colon, including rectal mucosa

Front 170

treatment for a pt with C. diff colitis

Back 170

stop the current antibiotics
start metronidazole or oral vancomycin

Front 171

what is ALWAYS the next step in management in a pt with anorectal bleeding/pain/abscess/fistula

Back 171

rule out CA first

Front 172

Best treatment for a pt with anorectal cancer

Back 172

Nigro protocol
*preoperative chemotherapy (5-FU and mitomycin) and radiation if CA is < 5cm

Front 173

first diagnostic move in a pt that is actively bleeding from the GI tract

Back 173

NG tube and aspirate

Front 174

diagnostic study of choice in a pt that is actively bleeding and upper GI and hemorrhoids have been ruled out

Back 174

tagged red-cell study

Front 175

study of choice in a pt that is NOT actively bleeding and NG tube aspirate is negative

Back 175

endoscopy both ends

Front 176

study of choice in a child that passes a large bloody bowel movement

Back 176

radioactively labeled technetium scan to look for gastric mucosa

Front 177

what type of patient does peritonitis not need exploratory surgery

Back 177

cirrhotic with ascites

Front 178

pt presents with abd distension, N/V, and colicky abd pain. He has a tympanitic abd with hyperactive BS. X-ray shows distended loops of small and large bowel with a very large gas shadow located in the RUQ and tapers to the LLQ with the shape of a parrot's beak

Back 178

sigmoid volvulus

Front 179

next step in management in a pt with sigmoid volvulus

Back 179

proctosigmoidoscopy and rectal tube

Front 180

young adult woman presents in a hypovolemic state with a Hgb of 7. she denies being pregnant because she has been on birth control pills for the past 10 years

Back 180

bleeding from ruptured hepatic adenoma 2/2 birth control pills

Front 181

differentiate next step in management of a liver abscess secondary to amebic vs. ascending cholangitis

Back 181

amebic - metronidazole
ascending cholangitis - percutaneous drainage

Front 182

differentiate the type of juandice causing elevated transaminases vs. elevated alkaline phosphatase

Back 182

elevated AST/ALT - hepatocellular jaundice (serology)
elevated ALP - obstructive jaundice (RUQ U/S)

Front 183

differentiate the cause of a gallbladder being thickened and nonpliable vs. thin-walled and distended

Back 183

thickened - stone
thin and palpable - malignancy (pancreas, bile ducts, ampulla)

Front 184

Pt presents with progressive jaundice is found to have highly elevated ALP. she is also anemic and as positive occult blood in the stool. A RUQ U/S shows thin-walled distended gallbladder

Back 184

ampullary carcinoma
*obstructive jaundice + bleeding into the GI tract

Front 185

next step in management of a pt with a few day history of RUQ pain. Now she presents with temp of 104, WBC of 22, bilirubin of 5 and ALP of 2000

Back 185

ERCP + IV antibiotics
*acute ascending cholangitis

Front 186

what should you think of in a pt with epigastric pain radiating through the back with low serum calcium, high BUN, and metabolic acidosis

Back 186

hemorrhagic pancreatitis

Front 187

what are the criteria to drain pancreatic pseudocysts

Back 187

>6cm
>6 weeks after pancreatitis

Front 188

next step in management of a newborn with an umbilical hernia

Back 188

observation for up to 2 years

Front 189

what is the next step in management of a young woman (18) with a firm, rubbery breast mass

Back 189

sonogram
*Do not do mammogram on young patients, breast is too dense
**Reassurance alone is never the option

Front 190

next step in management of a younger pt with cystosarcoma phyllodes (large fibroadenoma)

Back 190

margin-free resection
*can turn into a malignant sarcoma

Front 191

how would you work up 35 year old pt with bilateral tender breasts and multiple lumps that come and go with the menstrual cycle

Back 191

*fibrocystic disease
1. mammogram
2. aspiration of the cyst
- if mass goes away and fluid is clear --> do nothing
- if fluid is bloody --> cytology
- if mass does NOT go away --> biopsy

Front 192

next step in management of a middle-aged woman with a 2cm breast mass

Back 192

mammographically guided multiple core biopsies

Front 193

next step in management of a middle-aged woman who develops a breast mass after recent trauma

Back 193

Cancer until proven otherwise
mammogram and biopsy

Front 194

management of a pt with infiltrating ductal carcinoma

Back 194

1. lumpectomy vs. modified radical mastectomy
-close to nipple, size of tumor, size of breast
2. axillary node sampling
-chemotherapy needed if present
3. radiation therapy if lumpectomy is performed

Front 195

first line treatment of advanced, neglected breast cancer that is a bleeding, fungating, ulcerated mass

Back 195

chemotherapy

Front 196

differentiate hormonal therapy option for post vs. pre-menopausal women if estrogen and progesterone receptor positive after chemotherapy

Back 196

pre-menopausal - tamoxifen
post-menopausal - anastrazole

Front 197

what are worrisome features for a thyroid nodule

Back 197

young, male, single nodule, hx of radiation to neck, solid mass on sonogram, cold nodule on scan

Front 198

what two forms of thyroid cancer is a total thyroidectomy always indicated

Back 198

medullary
follicular
*only papillary (<1cm in size) may a hemithryoidectomy with isthmusectomy be performed

Front 199

workup of a pt suspected of having cushing's disease (hypercortisolism)

Back 199

1. overnight (low-dose) suppression test
2. 24 hour urine cortisol
3. high-dose suppression test

Front 200

pt presents with virulent PUD, medical therapy fails to eradicate the ulcers including H. pylori. pt also has water diarrhea

Back 200

gastrinoma

Front 201

how would you differentiate hyperaldosteronism from an adenoma vs. hyperplasia

Back 201

postural changes of serum aldosterone levels
appropriate response - adenoma
no response or inappropriate - hyperplasia
*both have elevated aldosterone with low renin

Front 202

what other associations might be seen in a baby with a TE fistula

Back 202

V - vertebral
A - anal
C - cardiac
TE - fistula
R - renal

Front 203

how do you differentiate duodenal atresia/anular pancreas, malrotation, and intestinal atresia in a newborn with bilious vomiting

Back 203

Duodenal atresia/anular pancreas - double bublble + no air in distal bowel beyond the duodenum
malrotation - double bubble + normal gas pattern in distal bowel
intestinal atresia - No double bubble, multiple air-fluid levels and distended loops of bowel

Front 204

very premature baby develops feeding intolerance, abd distension, and rapidly dropping platelet count

Back 204

necrotizing enterocolitis

Front 205

newborn baby presents with progressively increasing jaundice, the bilirubinemia is mostly conjugated

Back 205

biliary atresia

Front 206

next step in management of a newborn with biliary atresia

Back 206

1. phenobarbital
2. HIDA scan

Front 207

9 month baby presents with episodes of colicky abd pain. on physical exam the RLQ feels "empty" and has currant jelly stools

Back 207

intussusception

Front 208

what two issues are looked at in a pt with lung cancer

Back 208

1. pulmonary function, FEV1 of at least 800mL is needed to survive after surgery
2. can surgery cure him (look for metastases using CT, PET, and mediastinoscopy if necessary)

Front 209

treatment for small cell lung cancer

Back 209

radiation and chemotherapy
*not treated with surgery

Front 210

A laborer notices coldness and tingling in his left hand as well as pain when he does strenuous work. he also experiences vertigo, blurred vision, and difficulty articulating his speech

Back 210

subclavian steal syndrome

Front 211

when would you do further workup in a pt with claudication

Back 211

if it affects their lifestyle
*Do NOT work up retired people that hardly move anyways

Front 212

what type of skin cancer is associated with the upper part of the face

Back 212

basal cell carcinoma
*waxy raised lesion or punched out ulcer

Front 213

where is the classic location of squamous cell carcinoma

Back 213

lower lip

Front 214

at what depth is wide local excision (2 cm) recommended over margin free excision for a melanoma

Back 214

>1mm in depth

Front 215

next step in management of a pt with acute angle glaucoma

Back 215

systemic carbonic anhydrase inhibitors, topical B-blockers, alpha-2 agonists

Front 216

next step in management of a pt with orbital cellulitis

Back 216

CT scan + surgical drainage

Front 217

next step in management of an elderly pt with sudden monocular blindness

Back 217

1. aspirin
2. breath into paper bag (increase CO2)
3. have someone press hard on the eye and release it repeatedly

Front 218

differentiate location of thyroglossal duct cyst vs. branchial cleft cyst

Back 218

thyroglossal duct cyst - midline
branchial cleft cyst - side of neck, in front of SCM

Front 219

6 year child with mushy, fluid-filled mass at the base of the neck

Back 219

cystic hygroma

Front 220

what is your best ally to determine if an enlarged lymph node is inflammatory vs. neoplastic

Back 220

time

Front 221

next step in management of an elderly pt who smokes, drinkes, has rotten teeth and has a hard, fixed 4-cm mass in his neck in front of the SCM

Back 221

1. panendoscopy to look for primary site of SCC
2. CT scan will follow to determine extent and operability
3. platinum-based chemotherapy and radiation

Front 222

what does unilateral version of common ENT problems in the adult suggest

Back 222

malignancy

Front 223

unilateral ENT problems in children suggest

Back 223

foreign body

Front 224

ludwig angina

Back 224

abscess of the floor of the mouth

Front 225

next step in management of a patient with Bell's palsy (unilateral facial paralysis)

Back 225

antiviral medication
steroids

Front 226

next step in management of a pt with repeated episodes of sinusitis, not presents with seeing double

Back 226

cavernous sinus thrombosis
orbital cellulitis
*either way they are hospitalized, given high-dose IV abx, and surgical drainage with CT guidance

Front 227

next step in management of a younger pt with testicular pain, fever, exquisitely tender testes, and testis in normal position

Back 227

sonogram to rule out torsion

Front 228

next step in management of a pt with hx of multiple ureteral stones presents with fever and flank pain

Back 228

IV abx + ureteral stent or percutaneous nephrostomy

Front 229

next step in management of a pt suspected of having pyelonephritis

Back 229

IV abx + sonogram to rule out obstruction

Front 230

newborn baby has not urinated

Back 230

posterior urethral valve
*drain bladder with catheter, voiding cystourethrogram

Front 231

6 year old girl voids normally but is also wet with urine all the time between voiding normally

Back 231

low implantation of one ureter
*this ureter empties into the vagina

Front 232

16 year old boy goes on beer-drinking binge for the first time and shortly develops colicky flank pain

Back 232

ureteropelvic junction obstruction

Front 233

next step in management of a nodule felt during DRE

Back 233

transrectal needle biopsy

Front 234

management of a pt with bony metastases from prostate cancer

Back 234

orchiectomy
LHRH agonists
anti-androgens (flutamide)

Front 235

next step in management of young patient with a testicular mass

Back 235

1. sonogram
2. radical orchiectomy
3. platinum-baed chemotherapy

Front 236

what is the cause of pneumaturia in an elderly adult
*fistula between bowel and bladder

Back 236

diverticulitis or cancer

Front 237

the only absolute contraindication to organ transplant

Back 237

HIV positive

Front 238

list some situations in which an airway must be secured

Back 238

1. unconscious
2. breathing is noisy or gurly
3. expanding hematoma in the neck
4. emphysema in the neck

Front 239

differentiate treatment of hemorrhagic shock if you're near by a trauma city or further away

Back 239

near by - surgical intervention
further - volume replacement

Front 240

next step in management of a patient with head trauma and a negative CT scan

Back 240

they can go home only if the family will wake them up frequently during the next 24 hours

Front 241

differentiate what a patient looks like with acute subdural hematoma

Back 241

sick patient with severe neurologic damage
-need to lower ICP with hyperventilation, mannitol, and elevation of head

Front 242

what type of patient does a chronic subdural hematoma happen in

Back 242

elderly patient
severe alcoholic

Front 243

what part of the neck needs immediate surgical exploration for patient with a gunshot wound

Back 243

middle zone

Front 244

what type of fluid resuscitation should be used in a patient with pulmonary contusion

Back 244

colloid instead of crystalloid
diuretics
*lung is very sensitive to fluid overload

Front 245

what else should be looked for in a patient with flail chest

Back 245

traumatic transection of the aorta
*big trauma required to get flail chest

Front 246

what tests should be ordered in a patient with massive trauma to the chest

Back 246

CXR - pulmonary contusion and diaphragm rupture
ECG and tropinin - myocardial contusion
CT - aortic rupture

Front 247

problems that can arise in a patient with a newly placed Central line

Back 247

1. air embolism
2. pneumothorax

Front 248

most common cause of coagulopathy in a trauma patient

Back 248

multiple transfusions causing dilution thrombocytopenia

Front 249

cause of abdominal compartment syndrome in a trauma patient

Back 249

lots of fluids and blood products have been given during the course of a prolonged laparatomy

Front 250

best way to deal with a pelvic fracture

Back 250

external fixation and allow time for the tamponade effect

Front 251

clues for a man with posterior urethral injury due to a pelvic fracture

Back 251

high-riding prostate on DRE
sensatin of wanting to void but cannot

Front 252

what should be assessed in penetrating trauma to the extremities

Back 252

whether vascular injury has occured
*anatomic location
**doppler studies or arteriogram if needed

Front 253

what can be a sequelae in high-voltage electric burns

Back 253

myobloinemia-myoglobinura-renal failure

Front 254

differentiate treatment of black widow and brown recluse spider bites

Back 254

black widow - IV calcium gluconate
brown recluse - surgical excision

Front 255

a child what what type of fracture could lead to volkmann contracture and development of a compartment syndrome

Back 255

supracondylar fracture of the humerus

Front 256

best physical exam maneuver to elicit collateral ligament tear

Back 256

knee flexed at 20-30 degrees and do passive abduction or adduction will produce pain

Front 257

most reliable physical finding for compartment syndrome

Back 257

excruciating pain with passive extension

Front 258

fracture of what should be looked for in a fall from height

Back 258

lumbar or thoracic spine

Front 259

when is surgical intervention necessary in a person with a lumbar disk herniation

Back 259

when there is progressive muscle weakness

Front 260

next step in management of a patient with cauda equina syndrome

Back 260

emergent surgical decompression

Front 261

what is the worst single finding predict high cardiac risk in a pre-op patient

Back 261

congestive heart failure
*look for JVD
**next worse is recent MI (within 6 months)

Front 262

next step in management of a patient with fevers and chills 30-45 minutes post-op

Back 262

start empiric antibiotics
*do not culture blood 3 times before starting abx

Front 263

what should be done to a patient that develops a PE while anti-coagulated therapeutically

Back 263

inferior vena cava filter

Front 264

most reliable test to determine peri-operative MI

Back 264

troponins

Front 265

what should be suspected if a post-op patient gets confused and disoriented

Back 265

hypoxia
*check bloos gases

Front 266

bilateral pulmonary infiltrates and hypoxia with no evidence of CHF

Back 266

ARDS

Front 267

what type of electrolyte deficit can prolong ileus

Back 267

hypokalemia

Front 268

next step in management of a patient with ogilvie syndrome

Back 268

colonoscopy to decompress the colon and rule out mechanical cause for the problem, a long rectal tube is left in

Front 269

differentiate next step in management of a patient with wound dehiscence vs. evisceration

Back 269

dehiscence - eventual re-operation to avoid or treat ventral hernia
evisceration - emergent abdominal closure

Front 270

differentiate how to treat hyponatremia from inappropriate ADH vs. losing large amounts of isotonic fluids

Back 270

inappropriate ADH - water restriction
isotonic fluid loss - volume replacement with isotonic fluids

Front 271

next step in management of a patient with hyperkalemia

Back 271

50% dextrose and insulin
IV calcium gluconate
*hemodialysis is ultimate therapy

Front 272

best test to establish the presence of reflux

Back 272

pH monitoring

Front 273

next step in management of a patient with GERD refractive to medication

Back 273

pH monitoring, endoscopy and biopsy, manometry, gastric emptying study, and barium swallow to determine if Nissen fundoplication is valid
*if dysplastic changes are seen than resection is needed

Front 274

patient has difficulty with swallowing liquids > solids

Back 274

achalasia
*barium swallow shows bird's beak
**manometry for definitive diagnosis

Front 275

usual work up for patient with dysphagia

Back 275

1. barium swallow
2. endoscopy, biopsy if necessary
3. manometry if necessary

Front 276

next step in management of a patient suspected of having boerhaave syndrome

Back 276

gastrografin swallow
emergent surgical repair

Front 277

most common reason for patient presenting with emphysema in the lower neck

Back 277

instrumental perforation of the esophagus

Front 278

Cause of gastric MALTOMA

Back 278

H. pylori

Front 279

next step in management of a patient with a mechanical SBO develops fever, leukocytosis, and signs of peritoneal irritation

Back 279

emergency surgery
*strangulated obstruction has taken place

Front 280

massive upper GI bleed in the stressed, multiple trauma patient

Back 280

stress ulcers
*angiographic embolization

Front 281

next step in management of a patient that is actively bleeding and the upper GI tract has been ruled out

Back 281

1. anoscopy to r/o hemorrhoids
2. angiogram or tagged red-cell study
*colonoscopy is useless during active bleeding

Front 282

how do you confirm the diagnosis of acute abdomen caused by perforation

Back 282

free air under the diaphragm in upright x-ray

Front 283

associated with a huge air-fluid loop in the RUQ that tapers down toward the LLQ

Back 283

sigmoid volvulus

Front 284

what can lead to pyogenic liver abscess

Back 284

acute ascending cholangitis

Front 285

next step in management of a patient with suspected cancer causing obstructive jaundice

Back 285

1. CT scan - adenocarcinoma of pancreas
2. ERCP if negative - cholagiocarcinoma of common duct or adenocarcinoma of ampulla

Front 286

next step in management of a patient with acute cholecystitis who is not a surgical candidate that is not improving

Back 286

percutaneous transhepatic cholecystotomy

Front 287

two things that are associated with acute pancreatitis

Back 287

gallstones
alcoholics

Front 288

what can develop after about 10 days in a patient with acute hemorrhagic (necrotizing) pancreatitis

Back 288

pancreatic abscess
*need daily CT scan to look for development of abscess

Front 289

which form of thyroid cancer is associated with psammoma bodies

Back 289

papillary thyroid cancer
*this one doesn't require total thyroidectomy if <1cm

Front 290

this endocrine tumor is associated with migratory necrolytic dermatitis

Back 290

glucagonoma

Front 291

how do you treat hyperaldosteronism from hyperplasia vs. adenoma
*remember both have high aldosterone with low renin and there are postural changes to distinguish

Back 291

hyperplasia - medically
adenoma - surgery

Front 292

VACTER constellation

Back 292

vertebral
anal
cardiac
tracheal
esophageal
renal

Front 293

next step in management of a patient with congenital diaphragmatic hernia

Back 293

Repair in 3 or 4 days to allow maturation
give low-pressure ventilation so lung is not blown out

Front 294

next step in management of a patient with meconium ileus

Back 294

gastrografin enema
*both diagnostic and therapeutic

Front 295

next step in management of a 7 week old baby with persistent, progressive jaundice

Back 295

HIDA scan with phenobartibal

Front 296

what is suspected in a 12 months old child that has abdominal pain that has currant jelly stools and an "empty" RLQ

Back 296

intussusception

Front 297

next step in management of a patient with coin lesion found on CXR

Back 297

1. sputum cytology
2. CT scan chest/abd
3. bronchoscopy w/ biopsy or percutaneous biopsy if not established by previous two

Front 298

how would one differentiate subclavian steal syndrome from thoracic outlet syndrome

Back 298

subclavian steal syndrome has both vascular and neurologic symptoms due to the reversal of blood flow from vertebral artery

Front 299

differentiate excision margin in basal cell carcinoma vs. squamous cell carcinoma

Back 299

BCC - 1mm is enough and curative
SCC - 0.5 - 2cm and node dissection

Front 300

next step in management of a patient with orbital cellulitis

Back 300

emergency CT scan and drainage

Front 301

next step in management of a patient with a known kidney stones that suddenly develops fevers (104 - 105) and exquisite flank pain

Back 301

1. IV abx
2. immediate decompression with ureteral stent or percutaneous nephrostomy

Front 302

most common reason for a newborn boy not to urinate during the first day of life

Back 302

posterior urethral valve
*voiding cystourethrogram

Front 303

next step in management of a young child with flank pain, fevers, and chills

Back 303

1. Start abx
2. IVP
3. voiding cystogram
*look for reflux

Front 304

differentiate clean vs. clean contaminated vs. contaminated vs. dirty

Back 304

clean - operative field does not enter into a colonized part of the body
clean contaminated - operative field enters into a colonized viscus or lumen but under controlled circumstances
contaminated - gross contamination is presence with absence of infection
dirty - active infection is already present

Front 305

hydradenitis suppurativa

Back 305

infection involving the apocrine sweat glands in the axillary, inguinal, and perineal regions - results in a chronic abscess

Front 306

differentiate closure technique for contaminated op-field vs. dirty op-field

Back 306

contaminated (ruptured appendix) - delayed primary closure
dirty (abscess) - packed open and heal by secondary intention

Front 307

diabetic patient presents with signs of diffuse peritonitis, what should be the next step in management

Back 307

volume resuscitation and correction of serum electrolytes, glucose, and pH if needed
*must be done before emergent surgery

Front 308

what criteria is needed for emergent preoperative dialysis

Back 308

1. life-threatening hyperkalemia
2. severe metabolic acidosis 2/2 retained organic acids
3. uremic pericarditis
4. volume overload
*AEIOU

Front 309

when is surgical treatment of spontaneous pneumothorax indicated

Back 309

recurrence (ipsilateral or contralateral)

Front 310

differentiate treatment in patient with suspected pneumothorax vs. tension pneumothorax

Back 310

pneumo - CXR and chest tube
tension - immediate insertion of needle following by chest tube

Front 311

first step in management of a pt suspected of having an PE

Back 311

ABG

Front 312

what should be done in a patient in a MVA that is alert and oriented with only a forehead laceration

Back 312

cervical spine x-ray to rule out cervical spine injury

Front 313

what electrolyte abnormality is seen in a patient with a massive crush injury

Back 313

hyperkalemia
*massive tissue damage

Front 314

asymptomatic patient with multiple liver simple, thin walled cystic structures

Back 314

simple liver cysts
*amebic liver cysts present with fever, leukocytosis, tender liver, and elevated ALP

Front 315

best way to intubate a patient with multiple facial fracture, brisk bleeding into his nose, mouth, and throat

Back 315

cricothyroidotomy

Front 316

even if the patient has a resectable lung cancer with enough FEV1 left over, what you do before you perform a lobectomy

Back 316

CT scan to look for metastasis

Front 317

young person with persistent headache that is usually worse in the mornings

Back 317

brain tumor

Front 318

next step in management of a patient with a localized full thickness burn (white, dry, leathery, and anesthetic)

Back 318

immediate excision and grafting