Surgery Cards 2

Front 1

A patient is diagnosed with invasive ductal adenocarcinoma. What is the most important factor in the staging of this patient’s cancer?

Back 1

Lymph Node Involvement

Front 2

Which nerve, if damaged in an axillary dissection, will result in only a sensory deficit?

Back 2

Intercostobrachial nerve

Front 3

What cancer drug can cause pulmonary fibrosis?

Back 3

Bleomycin

Front 4

A 59-yo male presents with complaints of recurrent UTIs. On further questioning, it sounds as if the patient is also experiencing pneumaturia.
What is the most likely underlying cause for this patient’s symptoms?

Back 4

Diverticulitis

(Colorectal fistula is also a cause, but is very rare)

Hint 4

None

Front 5

What is considered the triangle of Calot in GB surgery?

Back 5

Cystic Duct,

Common Hepatic Duct,

Cystic Artery

Hint 5

None

Front 6

A 73-yo female presents with nausea, vomiting, obstipation and abdominal distention. She is afibrile, with slight tachycardia and a distended abdomen without peritoneal signs. She has no Hx of surgery.
What is the most likely cause of this patient’s bowel obstruction?

Back 6

Gallstone Ileus

(may also present with pneumobilia)

Hint 6

None

Front 7

A critically ill hemodynamically unstable intubated patient on vasopressors w/ Hx of recent MI and long ICU course begins having fevers. Labs are: WBC 19,000, AST 100, ALT 45, ALK Phos 345, total bilirubin 3.0, direct bilirubin 2.8. Abdominal ultrasound shows no stones in the gallbladder.
Dx?
What is next step in Tx given patient’s condition?

Back 7

Dx: Acute Acalculous Cholecystitis
(due to biliary sludge secondary to inactivity of the biliary tree. It is seen in critically ill patients w/ prolonged periods of fasting or Parenteral nutrition, or in patients w/ multiple transfusions or trauma patients)

Tx: Percutaneous Cholecystostomy
(until patient is stable enough to undergo a cholecystectomy)

Hint 7

None

Front 8

Type of Shock:
An 18-yo male restrained driver w/ tachycardia, hypotension, and a rigid abdomen

Back 8

Hypovolemic shock

Hint 8

None

Front 9

Type of Shock:
An 80-yo nursing home resident, febrile, unresponsive, hypotensive, w/ gram-negative rods cultured in urine.

Back 9

Distributive shock

(Sepsis or Anaphylaxis)

Hint 9

None

Front 10

Type of Shock:
A 16-yo male victim of a motor vehicle crash w/ hypotension, bradycardia and the inability to move or feel both lower extremities

Back 10

Neurogenic shock

(seen in patients w/ spinal cord injuries; caused by a decrease in sympathetic output; CO, CVP, PCWP and SVR are all decreased)

Hint 10

None

Front 11

Type of Shock:
A 67-yo male in the medical ICU on 15L of oxygen by facemask, hypotension and crackles in the bases of both lungs

Back 11

Cardiogenic shock
(seen in patients w/ acute MI and respiratory distress; CO is decreased and everything else is increased)

Hint 11

None

Front 12

What is Duke’s staging for Colon Cancer (A-D)?

Back 12

A: limited to Mucosa
B1: into the Muscularis Propria
B2: through the Muscularis Propria
C1: into MP w/ positive LN
C2: through the MP w/ positive LN
D: Metastasis or Unresectable

Hint 12

None

Front 13

What is the proper medical Tx (post-colectomy) for Duke’s stage C Colon Cancer?

What common cancer Tx is not used in colon cancer?

Back 13

5-FU and Leucovorin (Levamisole)

Radiation is not used in colon cancer
(only in rectal cancer)

Hint 13

None

Front 14

What is the Diagnostic Test for patients w/ Rectal Cancer?
What is the adjuvant Tx for T3-T4 Rectal Cancer? (2)

Back 14

Diagnostic test: Endorectal Ultrasound

Tx: Pre-op Radiation Therapy and 5-FU

Hint 14

None

Front 15

A 52-yo female presents w/ 5-day history of increasing LLQ pain, N/V and fever. Two previous episodes of the pain were treated w/ Abx. She is tachycardic, has LLQ pain and diffuse peritoneal signs. A CT shows air in the abdomen.
Dx?
Next step?

Back 15

Dx: Perforated Diverticulum

Next step: Emergency resection of the Sigmoid colon w/ diverting colostomy

Hint 15

None

Front 16

A 27-yo male presents with severe RLQ and testicular pain that began 5 hours ago. The pain is the worst he has ever experienced and is assoc w/ nausea. He is writhing in pain and cannot hold still as you talk to him. He is afebrile and has a WBC of 10,300.
Diagnostic test?
Dx?

Back 16

Diagnostic test: Urinalysis
(on every patient w/ RLQ pain)

Dx: Kidney Stone

Hint 16

None

Front 17

An 80-yo female presents w/ vomiting 5 times that day which was thick and brown in appearance. She also complains of severe abdominal pain that began the previous night and has gotten worse and that she has had no BM or flatus throughout the day. She has no Hx of previous surgery and underwent a colonoscopy 1 month ago for chronic constipation, which elicited normal results. What is the most likely cause of this bowel obstruction?

Back 17

Sigmoid Volvulus

Front 18

How is Total Body Water calculated in men and women?

Back 18

Men: 60% of body weight

Women: 50% of body weight

Hint 18

None

Front 19

A patient’s recent blood glucose levels have been high at 500 mg/dL. This morning her sodium was 134 mmol/L.
What is the corrected sodium level? (Eqn)

Back 19

(Na + [glucose – 100] x 0.016) =

(134 + [500 – 100] x 0.016) = 140 mmol/dL

Hint 19

None

Front 20

How is plasma osmolality calculated? (Eqn)

An osmolar gap is present if the measured and calculated osmolarity differ by how much?

Back 20

(2 x Na) + (glucose/18) + (BUN/2.8)

Differ by 15 mOsm/kg

Hint 20

None

Front 21

What causes a bluish discoloration of the periumbilical area?
What is another sign of this?

Back 21

Fox’s sign: Retroperitoneal Hemorrhage
(ex: acute hemorrhagic pancreatitis)

another sign: Ecchymosis or discoloration of flank
(Grey Turner’s sign)

Hint 21

None

Front 22

Dx for the triad of HTN, bradycardia and irregular respirations?

Back 22

Dx: increased ICP

Front 23

Dx for calf pain on forced dorsiflexion of the foot in patient (Homan’s sign)

Back 23

Dx: DVT

Front 24

What are the two signs of a basilar skull fracture?

Back 24

Raccoon Eyes and Battle’s sign (ecchymosis over the mastoid process)

Front 25

What is Budd-Chiari syndrome?

Back 25

Thrombosis of hepatic veins

Front 26

MC indication for surgery w/ Crohn’s Dz?

Back 26

Small Bowel Obstruction

Front 27

MC vessel involved in a bleeding duodenal ulcer?

Back 27

Gastroduodenal artery

Front 28

MC bacteria in stool?

Back 28

Bacteroides fragilis (“B. frag”)

Front 29

MC electrolyte deficiency causing Ileus?

Back 29

Hypokalemia

Front 30

MC cause of Large Bowel Obstruction

Back 30

Colon Cancer

Front 31

MC type of Volvulus?

Back 31

Sigmoid volvulus

Front 32

MC bacteria causing UTI?

Back 32

E. coli

Front 33

MC benign tumor of the liver?

Back 33

Hemangioma

Front 34

A 55-yo man presents with a 20-year Hx of heartburn. During endoscopy a Bx demonstrates a high-grade columnar dysplasia consistant w/ Barrett’s esophagus. What is the most appropriate Tx?

Back 34

Esophageal resection

Front 35

What is the most important part of the surgical correction of Zenker’s diverticulum?

Back 35

Myotomy of the Cricopharyngeus muscle
(b/c the diverticulum results from the increased spasticity of this muscle)

Hint 35

None

Front 36

What are two main causes of non-anion gap metabolic acidosis?
How can you tell which is the problem?

Back 36

Diarrhea and Renal Tubular Acidosis

calculate the Urine Anion Gap (Una – Ucl – Uk)

Hint 36

None

Front 37

What is a common cause of post-op tachyarrhythmia?
What is the Tx?
What is the reason for the initial treatment?

Back 37

Atrial Fibrillation

Tx: Beta-agonist drip for Rate Control

Hint 37

None

Front 38

What is the next step in a patient presenting w/ a confirmed Acute MI?
(2 possible)

What if the patient is a post-op?

Back 38

Next:
1. Thrombolytics
2. Angioplasty

Post-op:
Angioplasty

(due to possibility of bleeding w/ thrombolytics; Stenting may be indicated)

Hint 38

None

Front 39

A 60-yo female is post-op on mechanical ventilation. Her blood chemistry shows a Respiratory Acidosis.
What initial change in the ventilator is most appropriate?
What (2) vent changes are used to improve the patient’s oxygenation?

Back 39

First: Increase Tidal Volume
(CO2 is determined by minute ventilation calculated as Ve = RR x Tidal volume [Vt]; CO2 is retained by decreasing the Ve, so to blow off the CO2, either RR or Vt needs to increase)

Improve O2: Increase FiO2 or Increase PEEP
(Increasing the amount of O2 the patient receives, the Fraction of Inspired O2, or increasing the surface area and the amount of time O2 can diffuse into the capillaries [PEEP] improves oxygenation)

Hint 39

None

Front 40

What do the thyroid labs look like in Graves Disease?

Back 40

Decreased TSH; Increased free T-4

Front 41

How does Secondary Hyper- and Hypo- thyroidism present in labs of TSH and T-4?

Back 41

Hyper: Increased TSH; Increased free T-4

Hypo: Decreased TSH; Decreased free T-4

Hint 41

None

Front 42

What is the most serious complication following surgical treatment for a Thyroidectomy?

Back 42

Recurrent Nerve Damage

(resulting in Abductor Laryngeal paralysis w/ affected cord assuming the midline. Unilateral results in hoarseness; Bilateral may lead to airway obstruction)

Hint 42

None

Front 43

What is the first step in diagnosing a mass on the thyroid?
What is the difference between a Hot and Cold lesion?
What test can distinguish b/t Hot and Cold lesions?

Back 43

First test: Fine Needle Aspiration

Hot lesion: Functional
Cold lesion: Non-functional

Hot/Cold test: Radionucleotide thyroid scan

Hint 43

None

Front 44

After performing a VMA for a pheochromocytoma, what imaging exam is most specific in localizing the lesion?

Back 44

MIBG (a NE analog)

Front 45

A 42-yo female was victim of a MVA and has been in the ICU for 2 weeks. She has been stable and on a vent for ARDS. She then suddenly gets acute hypotension (80/42) in addition to WBC of 9,000, HCT = 33%, Na = 130, K = 5.3, Cl = 110. You give the patient 2L of crystalloids but the vitals remain unchanged. A NE drip is started and the BP remains in the 80s/40s. What is the likely cause of this patient’s hypotension?

Back 45

Acute Adrenal Insufficiency

(Addisonian crisis: considered in any patient w/ unexplained hypotension that does not respond to fluid or pressors; occurs when the normal response of glutocorticoid release is impaired, most often in patients w/ long-term steroid use experiencing the stress of illness or surgery)

Hint 45

None

Front 46

What is the disasterous complication of a Supracondylar fracture of the Humerus?

Back 46

Volkmann’s Contracture

(ischemic injury to the deep tendon flexors of the forearm sustained during a supracondylar humeral fracture; muscle necrosis can begin in 4 – 6 hours after compromised circulation)

Hint 46

None

Front 47

What nerve and artery travel along the mid-Humeral shaft and can be damaged in a fracture to that area?

Back 47

Radial nerve;

Brachial Profunda (deep brachial) artery

Hint 47

None

Front 48

Where is the MC place for a Mallory-Weiss tear?

Back 48

In the Stomach near the GE junction

Front 49

What is the most proven risk factor of Pancreas cancer?

What is the best initial diagnostic test?

Back 49

Smoking

Dx test: CT scan w/ oral and IV contrast

Hint 49

None

Front 50

Why is a posterior hip dislocation an emergency?

Back 50

To avoid Posterior Avascular Necrosis

Front 51

What is the ECG sign w/ Primary Hyperparathyroidism?

Back 51

Shortened QT on ECG

Front 52

What is the required margin of resection for a melanoma of the following size:
1. In situ
2. < 1mm
3. 1 – 4mm
4. > 4mm

Back 52

In situ: 0.5cm

< 1mm: 1 cm

1 – 4mm: 2cm

> 4mm: 2 – 3cm

Hint 52

None

Front 53

What is used to Dx Achalasia?

Back 53

Espohageal Manometry

Front 54

A 54-yo male presents w/ angina-like chest pain that is usually assoc w/ stress and is relieved by nitrates. He is worked-up for an MI, but his troponin and ECG are normal. Dx?

Back 54

Diffuse Esophageal Spasm

(another chest pain relieved by nitrates)

Hint 54

None

Front 55

What is the MCC of an acute appendicitis?

Back 55

Lymphoid Hyperplasia

(not fecalith)

Hint 55

None

Front 56

What type of portal system shunt decreases the risk of developing encephalopathy?

Back 56

Warren distal Splenorectal shunt

Front 57

After undergoing a portal shunt procedure one week ago, the patient has become confused and combative. His breathing is unlabored and vitals are normal, but there is a foul smell to his breath and he has asterixis.
Dx?
What is seen in the blood sample?

Back 57

Dx: Hepatic Encephalopathy

In Blood: Increased Ammonia

(blood does not pass liver first to clean it of the ammonia)

Hint 57

None

Front 58

What is the cause of hypotension in Septic shock?

Back 58

Cytokines from the inflammatory response cause loss of systemic vascular resistance
(as well as fever and leukocytosis)

Hint 58

None

Front 59

Infant presents with excessive salivation and repeated episodes of coughing, choking and cyanosis. Dx?

Back 59

Dx: Esophageal Atresia

(most common ends in a blind pouch with a distal tracheoesophageal fistula)

Hint 59

None

Front 60

Infant is vomiting and on abdominal films there is a “soap bubble” sign in the ileum.
Dx?
Tx?

Back 60

Dx: Meconium Ileus

Tx: Gastrografin enema

(draws water into the bowel to break-up the meconium plug)

Hint 60

None

Front 61

What bacteria are worrisome after a spenectomy?

Back 61

Encapsulated bacteria

(Strep pneumonia, H. influnzae, Meningococcus)

Hint 61

None

Front 62

What is a common cause of sudden or unexplained hyperglycemia on a post-op patient on TPN?

Back 62

Infection

Front 63

What complication related to TPN may cause a patient to get a HCO3 of 30 and go into Respiratory Failure?

Back 63

Increased CO2 production

(due to increasing the daily caloric intake; overfeeding)

Hint 63

None

Front 64

What is an appropriate test if you suspect Clostridium Difficile?

Back 64

Stool Toxin Assay

Front 65

Aside from trauma, what are (2) other causes of Hypovolemic shock?

Back 65

Small Bowel Obstruction and Pancreatitis

(both due to Third Spacing)

Hint 65

None

Front 66

What neurologic condition may develop if low sodium is corrected too rapidly?
What (2) problems can cause a greater risk of this occurring in the patient?

Back 66

Central Pontine Myelinolysis

Patient has Hx of: Malnutrition or Alcoholism

Hint 66

None

Front 67

What can be a devastating outcome of correcting a Hypernatremic patient too rapidly?

Back 67

Cerebral edema

(by rapidly shifting fluid into cells)

Hint 67

None

Front 68

A 12-yo child presents w/ pain and inflammation over the ball of his left foot and red streaks extending up the inner aspect of his leg. He removed a wood splinter from his foot the previous day.
What is the most likely bug?

Back 68

Streptococcus

(streaks are lymphatic inflammation)

Hint 68

None

Front 69

A 3-yo presents with a non-tender abdominal mass. What is the MCC of extracranial solid tumors seen in children?
First step?
Tx?

Back 69

Dx: Neuroblastoma
(from neural crest cells)

Diagnostic test: Urine HVA and VMA
(tumor secretes catecholamines)

Tx: Surgery, Chemo and Radiation

Hint 69

None

Front 70

A 3-yo child presents w/ an abdominal mass, HTN and hematuria.
Dx?
Diagnostic test?

Back 70

Dx: Wilm’s Tumor
(originates from kidney and may also present w/ aniridia)

Diagnostic test: CT of abdomen

Hint 70

None

Front 71

A 3-yo presents w/ abdominal distention and a RUQ mass that moves with respiration.
Dx?
Diagnostic test?
Tx?

Back 71

Dx: Hepatoblastoma;

Diagnostic test: Serum Alpha-Fetoprotein;

Tx: Surgical removal

Hint 71

None

Front 72

A 3-yo presents with a sacrococcygeal mass.
Dx?

Back 72

Dx: Teratoma

(most common site in children, followed by mediastinum)

Hint 72

None

Front 73

What is the leading cause of death following a carotid endarterectomy?

Back 73

MI

Front 74

What drug is most beneficial in closing a Crohn’s fistula?

Back 74

Infliximab

Front 75

A patient with a history of Ulcerative Colitis has fever, tachycardia, a distended abdomen and a dilated transverse colon.
Dx?
Tx?

Back 75

Dx: Toxic Megacolon

Tx: NPO, Nasogastric decompression, IV antibiotic and IV steroids for 48 hours, then Surgery if problem persists
(colonic decompression should not be attempted b/c it can lead to perforation)

Hint 75

None

Front 76

What is the MCC of a mediastinal tumor?
What systemic condition is classically assoc w/ it?

Back 76

MCC: Thymoma

Assoc w/: Myasthenia Gravis
(30 – 50% will have it)

Hint 76

None

Front 77

Dx: patient presents w/ café au lait pigmentation and neurofibromas of the GI tract

Back 77

Von Recklinghausen Dz

Front 78

MC site of sarcoma metastasis?

Back 78

Lungs

Front 79

MCC of Acute Mesenteric Ischemia?

Chronic Mesenteric Ischemia?

Back 79

Acute: Emboli

Chronic: Atherosclerosis

Hint 79

None

Front 80

A 43-yo male presents w/ acute onset of chest pain since an episode of vomiting 6 hours ago. He has decreased breath sounds on the left and a mild left pleural effusion.
Dx?
Diagnostic test?
Tx?

Back 80

Dx: Spontaneous Esophageal Rupture
(Boerhaave syndrome)

Diagnostic test: Water-soluble or Barium Esophagogram

Tx: Primary Surgical repair

Hint 80

None

Front 81

What is the Chemotherapy treatment for Melanoma in Stage III?
Stage IV?

Back 81

Stage III: Interferon-2A

Stage IV: Interleukin-2

Hint 81

None

Front 82

A 57-yo asymptomatic male is noted to have a prostate that is normal in shape and size on rectal examination. His PSA is 18 (nml < 2.5). What is the best next step for this patient?

Back 82

Transrectal US exam w/ prostate Bx

Front 83

A 72-yo man has a lower abdominal mass and constantly dribbles urine.
Dx?
What is the best next step?

Back 83

Dx: Overflow Incontinence

Next step: Foley catheter and hospitalization

Hint 83

None

Front 84

What unusual lab value can be elevated w/ a Small Bowel Obstruction?

Back 84

Serum Amylase

(also increased w/ Acute Pancreatitis…both also cause Third Spacing and Hypovolemic shock)

Hint 84

None

Front 85

A 67-yo male presents w/ N/V 25 days post-appendectomy. He is afebrile, the abdomen is tender and distended. His WBC is 18,00, Na is 140, K is 4.2, Cl is 105 and Bicarb is 14.
Dx?
Diagnostic test?
Tx?

Back 85

Dx: Anion Gap Acidosis secondary to Lactic Acid reflecting Ischemic Bowel

Diagnostic test: CT confirming obstruction

Tx: Surgery

Hint 85

None

Front 86

A 34-yo diabetic woman complains of a 6-month Hx of numbness and pain in her right hand and thumb that wakes her up at night.
Dx?
Tx? (2 together)

Back 86

Dx: Carpal Tunnel Syndrome

Tx: Nighttime Splint and NSAIDs

Hint 86

None

Front 87

A 42-yo woman presents w/ persistent epigastric and back pain, Leukocytosis and a serum amylase of 1,300.
Dx?
Initial Tx?

Back 87

Dx: Biliary Pancreatitis

Initial Tx: Rest and IV hydration
(then a Lap Chole)

Hint 87

None

Front 88

Dx: Fever, intermittent RUQ pain and Jaundice

Back 88

Cholangitis

Front 89

Dx: Persistent abdominal pain, RUQ tenderness and leukocytosis

Back 89

Acute Cholecystitis

Front 90

A 52-yo alcoholic w/ cirrhosis presents w/ acute hematemesis. Bleeding esophageal varicies are found on UGI endoscopy. Tx?

Back 90

Tx: Endoscopic Sclerotherapy

Front 91

What is the management of a patient presenting w/ Melena?
(2 steps)

Back 91

1. IV fluids and insuring hemodynamic stability

2. NG tube to rule-out UGI bleed

(melena = tarry stool; is usually a UGI bleed)

Hint 91

None

Front 92

A 75-yo man develops hematochezia and presents w/ hemodynamic instability. His vital improve slightly w/ PRBC.
What is the next step in Management? (3 together)

Back 92

1. NG tube

2. Proctosigmoidoscopy

3. Tagged RBC scan w/ or w/o Angiography

(these three are most appropriate for a patient that is unstable)

Hint 92

None

Front 93

What is the most common site of occlusion w/ Claudication?

Back 93

Superficial Femoral Artery

Front 94

A 22-yo hemodynamically stable, intoxicated man presents w/ stab wounds to the left throacoabdominal region and abdomen. What are the next steps in management? (4 steps)

Back 94

Initially Observe for 24 – 48 hours:
1. CXR (to look for pneumothorax, hemothorax and free air in the abdomen)
2. Wound exploration and Peritoneal Lavage
3. Then repeat the study in 6 hours to make sure no changes are seen
4. if changes: Diagnostic Laparoscopy to insure bowel is not punctured

Hint 94

None

Front 95

A 24-yo male complains of colicky intermittent umbilical and RLQ abdominal pain of 24 hours, anorexia and nausea. He is afebrile.
Dx?

Back 95

Gastroenteritis

(not appendicitis, b/c appendicitis does not present w/ intermittent pain)

Hint 95

None

Front 96

A 58-yo woman has acute chest pain and dyspnea post-operatively. The results from cardiopulmonary and abdominal exams are nonspecific. She has a minimally elevated leukocyte count and normal cardiac enzyme levels. Arterial blood gas studies indicate respiratory alkalosis and hypoxemia. CXR and ECG show no pathology.
Dx?
Next step?

Back 96

Dx: Pulmonary Embolism
(sudden onset of chest pain and SOB in patient w/o pulmonary or cardiac pathology)

Next step: Empiric anticoagulation (Heparin or Coumadin) w/ confirmatory Pulmonary Angiography

Hint 96

None

Front 97

Ten days after undergoing liver transplantation, a patient's levels of gamma-glutamyl transferase (GGT), alkaline phosphatase, and bilirubin begin to rise.
What is the most appropriate next step in diagnosis?

Back 97

Ultrasound of biliary tract and Doppler studies of the anastomosed vessels

(in all other transplants aside from the liver, it would be considered acute rejection and biopsies should be taken)

Hint 97

None

Front 98

What are the (2) rules for Breast cancer in a pregnant woman?

Back 98

The treatment of breast cancer in a pregnant woman should be the same as that in a nonpregnant woman, except for two restrictions:
1. no chemotherapy during the first trimester
2. no radiation therapy during the pregnancy

Hint 98

None

Front 99

A 62-year-old man reports an episode of gross, painless hematuria. There is no history of trauma. The man does not smoke and has had no other symptoms referable to the urinary tract. Physical examination, including rectal examination, is unremarkable. His serum creatinine is 0.8 mg/dL, and, except for the presence of many red cells, his urinalysis is normal and shows no red cell casts. His hematocrit is 46%. What are the most appropriate initial steps in the workup?
(2)

Back 99

1. Intravenous pyelogram (IVP)

2. Cystoscopy

(Although most patients with hematuria have benign disease, silent hematuria can be due to renal, ureteral, or bladder cancer, and these malignant processes must be effectively ruled out. IVP will visualize kidney and ureteral tumors, but is not reliable enough to rule out bladder cancer. Direct visualization of the bladder mucosa by cystoscopy is the only way to rule out bladder cancer)

Hint 99

None

Front 100

A 45-year-old man with alcoholic cirrhosis is bleeding from a duodenal ulcer. He has required 6 units of blood over the past 8 hours, and all conservative measures to stop the bleeding, including irrigation with cold saline, IV vasopressin, and endoscopic use of the laser have failed. At the time of admission, when he had received only one unit of blood, showed a bilirubin of 4.5 mg/dL, a prothrombin time of 22 seconds, and a serum albumin of 1.8 g/dL. He was mentally clear when he came in, but has since then developed encephalopathy and is now in a coma.
What best describes his operative risk?

Back 100

Prohibitive regardless of attempts to improve his condition
(The studies show that extremely marginal liver function could be tipped into overt liver failure by an anesthetic and an operation. He is not a surgical candidate)

Hint 100

None

Front 101

A 22-year-old convenience store clerk is shot once with a .38 caliber revolver. The entry wound is in the left midclavicular line, 2 inches below the nipple. There is no exit wound. He is hemodynamically stable. A chest x-ray film shows a small pneumothorax on the left, and demonstrates the bullet to be lodged in the left paraspinal muscles. In addition to the appropriate treatment for the pneumothorax, what will this patient most likely need?

Back 101

Any gunshot wound below the nipples involves the abdomen, and such is the case here. The management of all gunshot wounds of the abdomen requires Exploratory Laparotomy

Front 102

A 68-year-old man is brought to the emergency department with excruciating back pain that began suddenly 45 minutes ago. The pain is constant and is not exacerbated by sneezing or coughing. He is diaphoretic and has a systolic blood pressure of 90 mm Hg. There is an 8-cm pulsatile mass deep in his epigastrium, above the umbilicus. A chest x-ray film is unremarkable. Two years ago, he was diagnosed with prostatic cancer and was treated with orchiectomy and radiation. At that time, his blood pressure was normal, and he had a 6-cm, asymptomatic abdominal aortic aneurysm for which he declined treatment.
What is the most likely diagnosis?

Back 102

Rupturing abdominal aortic aneurysm

(Abdominal aortic aneurysms have a high incidence of rupture once they reach or exceed a size of 6 cm. Often, the first manifestation is excruciating back pain, as the blood leaks into the retroperitoneal space before the aneurysm blows out into the peritoneal cavity. The combination of a big aneurysm and sudden severe back pain should always lead to this presumptive diagnosis)

Hint 102

None

Front 103

A 55-year-old woman has been known for years to have mitral valve prolapse. She has now developed exertional dyspnea, orthopnea, and atrial fibrillation. She has an apical, high-pitched, holosystolic heart murmur that radiates to the axilla and back. Because of her deterioration, surgery has been recommended.
What is the most appropriate procedure?

Back 103

Mitral valve annuloplasty

(Whenever possible, repair of the native mitral valve is preferable to replacement. The way to repair an insufficient valve is to tighten the annulus, bringing the leaflets closer to one another)

Hint 103

None

Front 104

A 23-year-old woman seeks help for exquisite pain with defecation and blood streaks on the outside of her stools, which she has been having for several weeks. She has no fever or leukocytosis. Physical examination done under spinal anesthesia, confirmed the suspected diagnosis, and she is placed on stool softeners and appropriate topical agents, but without success. She is willing to undergo more aggressive treatment. What is the most appropriate next step? (3 possible)

Back 104

1. Lateral Internal Sphincterotomy

2. Forceful Dilation under anesthesia

3. Botulinum toxin Injections

(The clinical picture is classic for anal fissure, which is perpetuated by the fact that the anal sphincter is "too tight.")

Hint 104

None

Front 105

A 42-year-old woman is thrown from the car which lands on her and crushes her. In the ER it is determined that she has a pelvic fracture, which is confirmed by portable x-rays done as she is being resuscitated. Her initial blood pressure is 50/30 mm Hg, and her pulse is 160/min and barely perceptible. Thirty minutes later, after 2 L Ringer's lactate and 2 U packed cells have been infused, her pressure is only 70/50 mm Hg, and her pulse is 130/min. A sonogram done in the emergency department shows no intra-abdominal bleeding, and a diagnostic peritoneal lavage confirms that there is no blood in the abdomen. Rectal and vaginal exams show no injuries to those organs. There is no blood in her urine. What is the most appropriate next step in management?

Back 105

External fixation of the pelvis

(Pelvic fractures can bleed massively, and often the source is torn veins that are not easily controlled. Minimizing the motion of the bone fragments by external fixation can be helpful, and it will not make the situation worse)

Hint 105

None

Front 106

Several months after sustaining a crushing injury to his arm, a patient complains bitterly about constant, burning, agonizing pain in that arm, that does not respond to the usual analgesic medications. The pain in his arm is aggravated by the slightest stimulation of the area, such as rubbing from the shirt sleeves. The arm is cold, cyanotic, and moist, but it is not swollen. Pulses at the wrist are normal, and neurologic function of the three major nerves is intact.
Dx?
Diagnostic test?
Tx?

Back 106

Dx: Causalgia

Diagnostic test: Sympathetic block

Tx: Sympathetectomy
(If sympathetic block relieves the symptoms, permanent cure will be obtained with surgical sympathectomy)

Hint 106

None

Front 107

A 71-year-old West Texas farmer of Irish ancestry has a nonhealing, indolent, punched out, clean-looking 2-cm ulcer over the left temple. The ulcer has been slowly growing over the past 3 years. There are no enlarged lymph nodes in the head and neck. Next step?

Back 107

Full thickness biopsy of the EDGE of the lesion
(The edge of the lesion offers the best information for the pathologist. A biopsy of the center of the lesion deprives the pathologist of all the clues that are found at the interface between the tumor and the normal skin, and in large lesions it runs the risk of sampling necrotic tumor that has outgrown its blood supply)

Hint 107

None

Front 108

A 35-year-old man falls on an outstretched hand and comes in complaining of wrist pain. He relates that he was not able to break the fall, and that the heel of his hand took the brunt of his full weight as it hit the pavement. On physical examination, he is distinctly tender to palpation over the anatomic snuff box. Anteroposterior and lateral x-rays are negative. What is the most likely diagnosis and most appropriate next step in management?

Back 108

Dx: Carpal Navicular fracture

Tx: Thumb Spica Cast

(Nondisplaced fractures of the carpal navicular are notorious for not showing up on x-ray films at the time of injury. The mechanism of injury plus the physical findings described in this vignette are sufficient to make a presumptive diagnosis and to indicate the use of a cast)

Hint 108

None

Front 109

A 56-year-old man develops slow, progressive paralysis of the facial nerve on one side. It took several weeks for the full-blown paralysis to become obvious, and it has been present now for 3 months. It affects both the forehead and the lower face. He has no pain anywhere, and no palpable masses by physical examination. What is the most likely diagnosis?

Back 109

Facial nerve tumor

(Slowly developing paralysis on one side is suggestive of a tumor. Since there are no physical findings, such as pain or a mass, to place the tumor in the parotid gland, it must be impinging on the nerve itself at a more proximal location)

Hint 109

None

Front 110

A young mother complains of pain along the radial side of the wrist and the first dorsal compartment. She relates that the pain is often caused by the position of wrist flexion and simultaneous thumb extension that she assumes to carry the head of her baby. On physical examination, the pain is reproduced by asking her to hold her thumb inside her closed fist, and then forcing the wrist into ulnar deviation. What is the most likely diagnosis?

Back 110

Tenosynovitis of the abductor or extensor tendons of the thumb
(De Quervain's tenosynovitis)

(The clinical presentation is classic for De Quervain's tenosynovitis, including the positive Finkelstein sign: the pain reproduced by ulnar deviation to stretch the affected tendons)

Hint 110

None

Front 111

A 44-year-old homeless woman presents to the emergency department because she is "bleeding from the breast." Physical examination shows a huge, fungating, ulcerated mass that occupies the entire right breast and is firmly attached to the chest wall. The right axilla is full of hard masses that are not movable either. Core biopsies of the breast are read as highly undifferentiated infiltrating ductal carcinoma, and assay for estrogen and progesterone receptors are negative. What is the most appropriate next step in management?

Back 111

Radiation and chemotherapy

(Although this is an impressive, very advanced cancer with a poor prognosis, it can be expected to shrink significantly with local radiation plus systemic chemotherapy. It may do so to the point at which a palliative mastectomy becomes technically feasible, something that cannot be done at this time)

Hint 111

None

Front 112

A 54-year-old African American man, with a history of smoking and drinking, describes progressive dysphagia that began 3 months ago. He first noticed difficulty swallowing meat; it then progressed to other solid foods, then to soft foods, and now to liquids as well. He locates the place where the food "sticks" at the lower end of the sternum. He has lost 30 pounds. What is the most appropriate first step in diagnosis?

Back 112

Barium swallow
(The clinical picture is that of a cancer of the esophagus, and given his race and history of smoking and drinking, it is probably a squamous cell carcinoma. The description of where the dysphagia is felt suggests a low location, but such subjective feelings lack precision. The tumor will eventually be seen and biopsied by endoscopy, but the endoscopist will first want to know the exact location of the tumor and the degree to which the lumen is occluded. Otherwise, there is a high risk of instrumental perforation of the esophagus. The best way to obtain that information is to do a barium swallow)

Hint 112

None

Front 113

A 45-year-old woman, who wears high-heeled, pointed shoes, complains of pain in the forefoot after prolonged standing or walking. Occasionally, she also experiences numbness, a burning sensation, and tingling in the area. Physical examination shows no obvious deformities and a very tender spot in the third interspace, between the third and fourth toes. There is no redness, limitation of motion, or signs of inflammation. What is the most likely diagnosis?

Back 113

Morton's Neuroma

(The location and circumstances are classic for Morton's neuroma, a benign neuroma of the third plantar interdigital nerve)

Hint 113

None

Front 114

A 66-year-old woman picks up a bag of groceries out of the supermarket cart to place it in the trunk of her car. As she does so, she feels sharp, sudden pain in the middle of her arm, and her humerus suddenly breaks. She arrives at the emergency department cradling her arm; the deformity leaves no doubt that the bone is broken. What is the most likely reason for the fracture?

Back 114

Bony metastasis to the humerus from breast cancer

(A fracture from such trivial strain signifies a very weakened bone. In this age and gender, the most likely cause would be a lytic lesion from metastatic breast cancer. In a man, we would have suspected metastatic lung cancer - not prostate, because prostatic metastases are blastic rather than lytic)

Hint 114

None

Front 115

A 62-year-old man has had gastroesophageal reflux disease diagnosed by pH monitoring, and present for several years. He has been less than totally compliant with medical management, which he follows when the pain is bad, but discontinues when he feels better. Endoscopy and biopsies show severe peptic esophagitis, with Barrett's esophagus and early dysplastic changes, but no overt carcinoma. Additional tests show good esophageal motility, with low pressure in the lower esophageal sphincter and normal gastric emptying. What is the most appropriate treatment at this time?

Back 115

Laparoscopic Nissen fundoplication

(Transthoracic resection of the lower esophagus would be the procedure if a very early cancer were to develop at the esophagogastric junction)

Hint 115

None

Front 116

A pedestrian is hit by a car. The paramedics report that he was unconscious at the site, and he arrives at the emergency department in coma, strapped to a head board with sandbags on either side of his head. Initial survey shows stable vital signs, and his pupils are of equal size and reactive to light. He is rapidly intubated by the nasotracheal route over a flexible bronchoscope and then sent for CT scans of the head. As he is being positioned on the table, it is noted that there is a sizable hematoma behind his right ear and that clear fluid is dripping from the ear canal. What is most advisable, considering this new finding?

Back 116

Extend the CT scan to include his neck

(The clinical findings are indicative of a fracture of the base of the skull, and thus he has sustained very significant trauma to the head. The integrity of the cervical spine has to be ascertained, and the CT that he is already going to have can be extended to include that area)

Hint 116

None

Front 117

During the performance of a supraclavicular node biopsy under local anesthesia, a hissing sound is suddenly heard, and the patient suddenly dies. At the time of the catastrophic event, the target node was under traction, and the final cut was being made blindly behind it to free it up completely. The patient, an otherwise healthy 24-year-old man, was inhaling at that moment. What has most likely caused this patient's death?

Back 117

Major Vein injury with Air Embolism

(Major veins at the base of the neck have negative pressure during inspiration and, if injured at that moment, will suck air rather than bleed. The air embolism then leads to sudden death)

Hint 117

None

Front 118

A man who weighs 65 kg sustains second and third degree burns over both of his lower extremities when his pants catch on fire. When examined shortly thereafter, it is ascertained that virtually all of the skin from both groins to the tip of the toes, front and back, has been burned. According to the modified Parkland formula, what is the approximate total amount of IV fluid that he can be expected to require during the first 24 hours post-burn?

Back 118

11,360 mL
(4 mL of Ringer's lactate per kilogram of body weight, times the percentage of the body surface that has been burned; plus an additional 2000 mL of dextrose 5% in water to cover MAINTENANCE fluid needs. In the "rule of nines," each lower extremity represents 18% of the body surface. Thus, this patient has sustained a 36% body burn: 4 × 65 × 36 = 9360, plus 2000 = 11,360)

Hint 118

None

Front 119

A 49-year-old woman has a firm, 2-cm mass in the right breast that has been present for 3 months. Mammogram has been read as "cannot rule out cancer," but it cannot diagnose cancer either. A fine-needle aspiration of the mass (FNA) and cytology do not identify any malignant cells. What is the most appropriate next step in management?

Back 119

Core or Incisional Biopsies

(Negative findings do not have the same diagnostic value that positive findings have. If this had been a 19-year-old woman suspected of having a fibroadenoma, one would have been satisfied with negative imaging studies (in that age, a sonogram) or the negative FNA. But, at age 49, the risk of cancer is much higher. Given negative findings in the least invasive studies, one would feel compelled to move to more aggressive ways to obtain better tissue sampling)

Hint 119

None

Front 120

A 44-year-old woman has a palpable nodule in the right lobe of her thyroid gland. The nodule measures 2 cm and is firm. The rest of the thyroid gland cannot be felt and is not tender. She also describes losing weight in spite of a ravenous appetite, palpitations, and heat intolerance. She is thin, fidgety, and constantly moving, with moist skin and a pulse of 105/min. She has no exophthalmos or pretibial edema. Her TSH is reported as much lower than normal, and she has elevated levels of free T4. What is the most appropriate next step in diagnosis?

Back 120

Radionuclide Thyroid Scan

(the patient is hyperthyroid. She has no clinical signs of acute thyroiditis, and none of the other findings seen in Graves disease; however, she has a thyroid nodule, which raises the possibility of a hyperfunctioning adenoma (a "hot" adenoma). If indeed she does, the scan will show that the nodule traps all the iodine, with suppression of the rest of the gland)

Hint 120

None

Front 121

Patient hurts his knee, causing him the ability to bend his leg inward to a greater extent then normally possible. What structure is damaged?

Back 121

Lateral Collateral Ligament
(Varus test)

Hint 121

None

Front 122

Patient hurts his knee, causing him the ability to bend his leg outward to a greater extent then normally possible. What structure is damaged?

Back 122

Medial Collateral Ligament
(Valgus test)

Hint 122

None

Front 123

Patient hurts his knee, causing him to feel loose intra-articular bodies and a locking of the knee. What structure is damaged?

Back 123

Medial Meniscus

Front 124

What is the first step in the evaluation of a palpable thyroid nodule?

Back 124

Ultrasound

Front 125

A front-seat passenger in a car involved in a head-on collision relates that he hit the dashboard with his knees, however, he is specifically complaining of severe pain in his right hip, rather than knee pain. He lies in the stretcher in the emergency department with the right lower extremity shortened, adducted, and internally rotated. What is the most likely injury?

Back 125

Posterior dislocation of the hip
(not fracture of the femoral neck)

Hint 125

None

Front 126

A 25-year-old man is shot with a .22 caliber revolver. The entrance wound is in the anteromedial aspect of his upper thigh, and the exit wound is about 3 inches lower, in the posterolateral aspect of the thigh. He has a large, expanding hematoma in the upper inner thigh. There are no palpable pulses in the foot. The bone is intact by physical examination and x-ray films. What is the most appropriate next step in management?

Back 126

Surgical Exploration

(Arteriograms are very often used in vascular trauma, but are not needed here. We would use an arteriogram if the anatomic location of the injury suggested vascular involvement, but the clinical signs did not confirm such suspicion. Arteriograms are also used when the specific surgical approach is dictated by precise knowledge of the site of extravasation, a situation that does not apply here)

Hint 126

None

Front 127

A 7-year-old boy passes a large, bloody bowel movement. He is hemodynamically stable, and he has a hemoglobin of 14 g/dL. Nasogastric aspiration yields clear, greenish fluid. Physical examination, including anoscopy, is unremarkable. What is the most appropriate next diagnostic test?

Back 127

Radioactively labeled Technetium Scan
(In this age group, with no obvious anal pathology and negative gastric aspirate, the leading cause of gastrointestinal bleeding is Meckel's diverticulum. The specific source is ulceration of the normal ileal mucosa by acid produced by gastric mucosa in the diverticulum. The technetium scan identifies that ectopic gastric mucosa. Upper gastrointestinal endoscopy would have been appropriate if the gastric aspirate had produced blood)

Hint 127

None

Front 128

An 81-year-old man with Alzheimer disease who lives in a nursing home undergoes surgery for a fractured femoral neck. On the 5th postoperative day, it is noted that his abdomen is grossly distended and tense, but not tender; no evidence of occult blood. X-ray films show a few distended loops of small bowel and the gas pattern of distention extends throughout the entire large bowel, including the sigmoid and rectum. No stool is seen in the films. Otherwise he does not appear to be ill. Vital signs are normal for his age.
What is the most likely diagnosis?
Diagnostic test?
Tx?

Back 128

Dx: Ogilvie Syndrome
(a type of colonic dysfunction often seen in elderly patients who are not too active to begin with and are then further immobilized by extra-abdominal surgery)

Diagnostic test: Colonoscopy
(rules out obstructing cancer, which is always a consideration in this age group, and allows the gas to be sucked out as the instrument advances)

Tx: A long tube is then left in place

Hint 128

None

Front 129

A 42-year-old, right-handed man has had a history of progressive speech difficulties and right hemiparesis for 5 months. He has had progressively severe headaches for the past 2 months, which are worse in the mornings. At the time of admission, he is confused and vomiting, and has blurred vision, papilledema, and diplopia. Shortly thereafter, his blood pressure increases to 190/110 mm Hg, and he develops bradycardia. What is most likely the significance of the hypertension and the bradycardia?

Back 129

There is a near-terminal increase in intracranial pressure
(the development of hypertension and bradycardia (Cushing's reflex) signifies that the brain has run out of compensatory mechanisms to minimize the intracranial pressure elevation generated by increased intracranial volume. When that point is reached, brain perfusion suffers and death is imminent)

Hint 129

None

Front 130

On the 5th postoperative day, it is noticed that large amounts of clear, pink, salmon-colored fluid are soaking the wound dressings. The incision appears intact and not particularly red or inflamed, but there are indeed traces of the clear pink fluid on his skin. He has no specific complaints. He is still NPO and on IV fluids, but has already been passing gas per rectum, and plans had been made to feed him today. The abdomen is not distended, and he has normal bowel sounds. He is afebrile. What is the most appropriate next step in management?

Back 130

Tape the wound securely, bind the abdomen, and avoid events that would suddenly increase his intra-abdominal pressure
(The situation described is that of a wound dehiscence that has not yet progressed to a wound evisceration. The former can be dealt with at leisure, if the latter is avoided. He will eventually require re-closure, but it can be done whenever it is most convenient. Remember: Pink fluid on an abdominal surgical wound is a leak of intra-abdominal fluid)

Hint 130

None

Front 131

A 24-year-old woman sustains multiple injuries in a car accident, including a pelvic fracture. She is hemodynamically stable. Initial assessment shows no vaginal or rectal injuries; however, when a Foley catheter is inserted, bloody urine is recovered. What would be the best way to evaluate her urologic injury?

Back 131

Retrograde cystogram including post-void films

(it is important to include post-void films because extravasation at the bladder neck can be obscured by the dye that is filling the bladder)

Hint 131

None

Front 132

A 62-year-old woman has a 4-cm, hard mass under the nipple and areola of her rather small left breast. The mass occupies most of the breast, but the breast is freely movable from the chest wall. There is no dimpling or ulceration of the skin over the mass, and careful palpation of the axilla is completely negative. A core biopsy of the breast mass has established a diagnosis of infiltrating ductal carcinoma, and the mammogram showed no other lesions in that breast or the other one. A chest x-ray film and liver function tests are normal. She has no symptoms suggestive of brain or bone metastasis. What Tx should be offered to this woman?

Back 132

Modified Radical Mastectomy including axillary sampling

(Lumpectomy, axillary sampling, and post-op radiation would have been the correct answer for a smaller tumor in a larger breast)

Hint 132

None

Front 133

A 49-yo obese man presents w/ a serum calcium of 14. He has uncontrolled DM and bipolar disorder (for which he takes lithium).
What is the most likely cause of the calcium elevation?

Back 133

Parathyroid Hyperplasia secondary to Renal Failure from the uncontrolled DM

(when the kidney loses its ability to reabsorb calcium and Vit D, hypocalcemia triggers the parathyroid gland to increase their production of parathyroid hormone)

Hint 133

None

Front 134

A 5-yo boy is brought to the ER after ingesting a half-bottle of liquid drain cleaner. What is the next step?

Back 134

Tracheostomy
(even though the step doesn’t state a breathing problem, airway edema, stridor and difficulty breathing is likely)

Hint 134

None

Front 135

A 46-yo woman presents to the ER w/ RUQ pain and fever. She has scleral icterus. There are no peritoneal signs; bowel sounds are present.
Dx?
What is the best initial Tx?
If that doesn’t work?

Back 135

Dx: Acute Cholangitis

First: Antibiotics and fluid resuscitation

Next: Percutaneous Transhepatic Drainage

Hint 135

None

Front 136

What is the best Diagnostic test for a Breast mass in a younger woman?

Back 136

Ultrasound

Front 137

What is the treatment post-operative for a premenopausal woman who had a modified radical mastectomy for a 3cm mass w/ negative LN?

Back 137

Chemotherapy

Front 138

A 63-yo man is disease-free after BCG therapy for CIS bladder cancer. In addition to a physical exam, cystoscopy and urinary cytology, what should be done?

Back 138

IVP (to rule-out upper tract tumors)

Front 139

A 78-yo man presents w/ RUQ pain, N/V and a 30lb weight loss over the past 3 months. He has scleral icterus and asymmetric thickening of the gallbladder. Dx?

Back 139

Adenocarcinoma of the GB

Front 140

A 10-yo boy presents w/ persistent hoarseness that worsens with singing. There are multiple lesions on his true vocal cords. Dx?

Back 140

Laryngeal Papilloma

(benign and located on the true vocal cords. In kids they present as multiple lesions and are caused by HPV)

Hint 140

None

Front 141

What is the best Diagnostic test to define an enlarged Parathyroid gland?

Back 141

Ultrasound

Front 142

A 52-yo female has melanotic pigmentation of her buccal mucosa and hamartomas throughout her GI tract. What other cancer is assoc w/ this condition?

Back 142

Ovarian CA

Front 143

What is the medical treatment for Carcinoid syndrome? (2) What is the drug class of these drugs?

Back 143

Octreotide, a Somatostatin analogue;

Cyproheptadine, a Serotonin antagonist

Hint 143

None

Front 144

A 53-yo woman presents w/ 12 mo Hx of neck pain, 15lb weight gain and malaise. Dx?

Back 144

Hashimoto Thyroiditis

Front 145

A 41-yo woman complains of tenderness in her right knee for the past 3 weeks. A synovial aspiration reveals no evidence of bacteria or crystals. Dx?

Back 145

Bursitis

Front 146

What nerve is affected in a mid humeral fracture?

Back 146

Radial

(wrist extension and sensory to back of hand)

Hint 146

None

Front 147

What nerve is affected in an elbow dislocation?

Back 147

Ulnar

(finger abduction and sensory to last 2 digits)

Hint 147

None

Front 148

What type of orthopedic problem is assoc w/ a patient who has DM or syphilis (causing peripheral neuropathy to the extreme of not feeling a fracture) leads to gradual arthritis and joint deformity?

Back 148

Charcot Joint

Front 149

MCC of bacterial osteomyelitis?

Back 149

Staph Aureus

Front 150

What diagnostic test do you order in a patient who has a posterior knee dislocation?

Back 150

Angiogram

Front 151

What are the MC Hip problems in the following ages:
1. Newborn
2. Toddler
(also diagnostic test)
3. 6 - 9 yo
4. 9 - 14 yo

Back 151

Newborn = Congenital Hip Dysplasia

Toddler = Septic Hip
(Tx: Aspiration under anesthesia)

6 - 9 yo = Avascular Necrosis

9 - 14 yo = Slipped Capital Femoral Epiphysis

Hint 151

None

Front 152

MC place of an Intracerebral hemorrhage? Cause?

Back 152

Basal Ganglia (due to HTN)

Front 153

A patient is found on the side of the road w/ bruising of the head, increased BP, bradycardia and respiratory irregularities. Dx?

Back 153

Increased Intracranial Pressure
(do not treat HTN initially…it is body’s way of trying to increase cerebral perfusion)

Hint 153

None

Front 154

What is the usual cause of sudden deafness?

Back 154

Viral

(mumps, measles, chickenpox, influenza, or adenovirus)

Hint 154

None

Front 155

MCC of acquired hearing loss in children?

Back 155

Bacterial Meningitis

Front 156

A child has a fever and has a lateral neck mass. Dx?

Back 156

Branchial Cleft cyst

Front 157

A child has a midline neck mass and it elevates with tongue protrusion. Dx?

Back 157

Thyroglossal Duct cyst

Front 158

(3) MCC of Otitis Media.

Tx?

Back 158

Strep Pneumonia, H. Influenza, Moraxella;

Tx: Amoxicillin

Hint 158

None

Front 159

A child has inflammation of the tympanic membrane which has vesicles on its surface.
Dx?
Tx?

Back 159

Dx: Infectious Myringitis (inflammation of TM)

Tx: Erythromycin or Clarithromycin

Hint 159

None

Front 160

A patient presents with hearing loss on the right side. A Weber test for hearing loss is performed and a tuning fork is placed on the head.
What would signal a Conductive problem?
Sensorineural problem?

Back 160

Conductive: Sound is heard louder in affected ear (right)

Sensorineural: Sound is hear louder in unaffected ear (left)

Hint 160

None

Front 161

A patient presents with hearing loss on the right side. A Rinne test for hearing loss is performed and a tuning fork is placed on the mastoid process. It stays there until the patient can’t hear it anymore, then it is placed by the same ear.
What would signal a Conductive problem?
Sensorineural problem?

Back 161

Conductive: Cannot hear the continuing sound of the fork when placed next to the ear;

Sensorineural: Can hear the continuing sound of the fork when placed next to the ear.

Hint 161

None

Front 162

A male patient complains of transient pain in the buttocks, buttock atrophy and impotence.
What is the problem?
Tx?

Back 162

Aortoiliac Occlusive Dz
(Leriche’s syndrome)

Tx: Aortoiliac bypass graft

Hint 162

None

Front 163

A patient presents with sudden onset of unilateral blindness like “a shade is pulled over his eye”
Dx?
Diagnostic test?
Tx? (2 possible)

Back 163

Dx: TIA secondary to Carotid Stenosis

Diagnostic test: Ultrasound of Carotid

Tx:
if >70% stenosis: Carotidendarterectomy;
If <70% stenosis: daily Aspirin

Hint 163

None

Front 164

A patient presents with abdominal tenderness, bloody diarrhea and “thumbprinting” on abdominal x-ray. Dx?

Back 164

Acute Bowel Infarction

Front 165

A patient presents w/ a history of varicose veins and has localized leg pain w/ cord-like induration, reddish discoloration and mild fever.
Dx?
Tx?

Back 165

Dx: Thrombophlebitis

Tx: NSAIDs and warm compresses

Hint 165

None

Front 166

A patient presents w/ syncope, vertigo, confusion and upper extremity claudication during exercise. Dx?

Back 166

Subclavian Steal Syndrome
(left subclavian artery obstruction proximal to vertebral artery)

Hint 166

None

Front 167

A patient presents with upper extremity paresthesias, weakness, cold temperature, edema and venous distention. Dx?

Back 167

Cervical rib

(compromising subclavian vessel blood flow; no neuro problems help distinguish it from SSS)

Hint 167

None

Front 168

What (2) Dx cause Uric Acid kidney stones?

Back 168

Gout or Leukemia

Front 169

What causes a Struvite renal stone?

Back 169

UTI

Front 170

What are the (2) biggest concerns w/ electrical burns?

Back 170

Cardiac Arrhythmias;

Renal Failure
(from muscle necroisis leading to myoglobinuria and acidosis; maintaining high urine output w/ fluids helps prevent this)

Hint 170

None

Front 171

What is the classic cardiac sign with Hypothermia?

Back 171

J-wave
(a small positive deflection following QRS complex)

Hint 171

None

Front 172

If a patient with hyperthermia begins to have convulsions, what do you do?

Back 172

Give Diazepam

Front 173

Where are the MEN-1 tumors located?

Back 173

All start with “P”:

Pituitary,
Pancreas,
Parathyroid

Hint 173

None

Front 174

What are the tumors in MEN-2 vs MEN-3?

Back 174

MEN-2 (MPP):
Medullary Thyroid CA,
Pheochromocytoma,
Parathyroid;

MEN-3 (MPM):
Medullary Thyroid CA,
Pheochromocytoma,
Mucosal Neuromas

Hint 174

None

Front 175

What is the difference b/t Mallory-Weiss syndrome and Boerhaave syndrome on exam?

Back 175

Boerhaave syndrome presents with mediastinal emphysema

Front 176

What is the type of esophageal divertivcula most commonly requiring surgery?
Where is it located?

Back 176

Zenker’s diverticulum

location: Pharyngoesophageal area

Hint 176

None

Front 177

A 52-yo woman presents due to 3 months of early satiety, weight loss and non-bilious vomiting. Dx?

Back 177

Gastric Outlet Obstruction

Front 178

A 25-yo develops weight loss, night sweats and a fistula draining from his RLQ s/p appendectomy.
Dx?
Tx?

Back 178

Dx: Post-op Actinomycosis infection

Tx: Penicillin (or Tetracycline)

Hint 178

None

Front 179

A 70-yo man w/ a Hx of HTN develops cramping lower abdominal pain 2 days s/p AAA repair. A few hours later he develops bloody diarrhea.
Dx?

Back 179

Ischemic Colitis

(suspected and time patient develops acute abdominal pain followed by rectal bleeding and is common post AAA)

Hint 179

None

Front 180

Which is massive lower GI bleeding more common with: Diverticulosis or Diverticulitis?
Tx for each?

Back 180

Diverticulosis

Tx: high fiber diet, stool softeners

(Diverticulitis Tx is Abx, analgesics and clear liquid diet if mild; resection if severe)

Hint 180

None

Front 181

What is Jaundice without scelral icterus or increased bilirubin?
Cause?

Back 181

Pseudojaundice

Caused by increased ingestion of foods rich in beta-carotene

Hint 181

None

Front 182

What liver tumor is treated by cessation of OCPs?
What is this patient at risk for if she wants a large family?

Back 182

Hepatocellular Adenomas;

Risk: if treated by cessation of OCP rather then tumor resection, she is at risk for rupture and hemorrhage during future pregnancies

Hint 182

None

Front 183

MC clinical finding in Portal HTN

Back 183

Splenomegaly

Front 184

MCC of Portal HTN inside the USA?

Outside the USA?

Back 184

In USA: Alcoholism

Outside USA: Schistosomiasis

Hint 184

None

Front 185

Aside from US, what is the diagnostic test of Acute Cholecystitis?

Back 185

HIDA scan

(if the GB is not seen within 1 hour post Technetium injection, it is diagnostic for acute cholecystitis)

Hint 185

None

Front 186

What is the Dx of an ERCP that shows “beads on a string” in the bile ducts? Tx? (2 depending on severity and place)

Back 186

Dx: Sclerosing Cholangitis;

Tx:
1. Pallitive Tx: Balloon dilation w/ stent placement;

2. Extrahepatic stricture: Removal of ducts w/ T-tube placement;
Intrahepatic stricture: Liver Transplant

Hint 186

None

Front 187

Dx: Anti-mitochondrial Ab

Back 187

Primary Biliary Cirrhosis

Front 188

Dx: Anti-Neutrophil Cytoplasmic Ab

Back 188

Primary Sclerosing Cholangitis

Front 189

A 32-yo male who underwent a laparotomy for a GSW to the abdomen 2 days ago is found to have a tender belly without rebound and is leaning forward on his stretcher breathing at a rate of 28/min. Dx?

Back 189

Pancreatitis

(Tachypnea is one of the presenting signs)

Hint 189

None

Front 190

When is the only time a Direct inguinal hernia is more common?

Back 190

In patients > 50yo

Front 191

What are the boundaries of Hesselbach’s Triangle?

Back 191

Inferior border: Inguinal Ligament

Medial border: Rectus Abdominis

Lateral border: Inferior Epigastric vessels

Hint 191

None

Front 192

How is each type of Hiatal Hernia corrected?

Back 192

Sliding: usu Antacids and head elevation
(15% require a Nissen Fundoplication)

Paraexophageal: Surgery

Hint 192

None

Front 193

After an URI a child presents w/ a painless, soft mobile mass in the neck that transilluminates.
Dx?
Diagnostic test?
Tx?

Back 193

Dx: Cystic Hygroma

Diagnostic test: CT scan

Tx: Surgical excision

Hint 193

None

Front 194

MC congenital lung lesion

Back 194

Lobar Emphysema

(presents w/ mediastinal shift)

Hint 194

None

Front 195

How can you tell the difference b/t Congenital Diaphragmatic Hernia or Congenital Cystic Adenomatoid Malformation?

Back 195

Placement of the NG tip:

In Thorax: CDH

In Abdomen: CCAM

Hint 195

None

Front 196

A premature infant born at 33 weeks gestation now at 1 week of age has developed feeding intolerance, is febrile, and has hematochezia and a distended belly. Dx?

Back 196

Necrotizing Enterocolitis

(presents in premature births and is similar to sepsis with feeding intolerance, apneic spells, bloody diarrhea and abdominal pain)

Hint 196

None

Front 197

What is the order of structures transversed with the spinal anesthesia after the Sub-Q layer? (6)

Back 197

SILEDS:
Supraspinous ligament,
Interspinous ligament,
Ligamentum flavum,
Epidural space,
Dura mater,
Subarachnoid space

Hint 197

None

Front 198

What (2) serological markers are monitored for Pineal tumors?

Back 198

AFP and beta-HCG

Front 199

A kidney transplant recipient is seen in the ER for nausea and abdominal pain, fever and elevated creatinine.
Dx?
Diagnostic test?
Tx?

Back 199

Dx: Acute Rejection

Diagnostic test: Ultrasound-guided Bx

Tx: Pulse Steroid treatment (or OKT3) is 90% effective

Hint 199

None

Front 200

MC infection after Pancreas transplant

Back 200

UTI

Front 201

MC post-transplant problem in a Pancreas transplant?

Tx?

Back 201

Post-op Metabolic Acidosis
(due to excessive loss of bicarb in urine)

Tx: Oral replacement

Hint 201

None

Front 202

A 53-yo woman who is s/p liver transplant calls you asking what she can take for some musculoskeletal pain.
Dx?
What can you give her?

Back 202

Dx: AE of Tacrolimus meds
(can ultimately lead to renal failure)

Give her Acetaminophen
(new liver will be able to tolerate it)

Hint 202

None

Front 203

MC infection post heart transplant?
Tx?

Back 203

CMV
(a trigger for graft-related atherosclerosis)

Tx: Ganciclovir

Hint 203

None

Front 204

How will a flexor tendon injury of the hand present?

Back 204

With a Straight finger

(due to unapposed Extensors)

Hint 204

None

Front 205

A patient is in the hospital with pneumonia and a lung abscess. His morning labs show low sodium, chloride and serum osmolarity with an increased urine osmolarity.
Dx?
Tx?

Back 205

Dx: SIADH

Tx: Water Restriction (and treat primary cause)

Front 206

what is a decrease in the release of ADH called?
Tx?

Back 206

Diabetes Insipidus
(Decreased = Diabetes)

Tx: Vasopressin

Front 207

`What test should be performed before inserting an Arterial Line or obtaining a blood gas?
Describe

Back 207

Allen Test

(measures adequate collateral blood flow to hand via the ulnar artery. Patient makes fist, then both ulnar and radial artery are occluded; patient then opens blanched hand. The ulnar artery is released and if the patient has a strong blush to the hand, the ulnar artery is adequate)

Front 208

A post-operative patient has a new onset of CHF, dyspnea and a dysrhythmia.
Dx?
Tx?

Back 208

Myocardial Infarct

(often post-op they don't present w/ chest pain)

Tx: Be MONA (no heparin):
Beta blocker; Morphine; Oxygen; Nitrates; Aspirin

Front 209

What is FENa? Equation?

Back 209

Fractional Excretion of Na (sodium)

Equation: YOU NEED PEE
(Una x Pcr)/(Pna x Ucr) x 100

Front 210

What is the value for a Pre-Renal FENA vs a Renal FENA?

Back 210

Pre-Renal: < 1

Renal: > 1

Front 211

What is a common anesthesia used for children and burn victims?

Back 211

Ketamine

Front 212

What are the contraindications for the depolarizing agent Succinylcholine? (4)
Why?

Back 212

Patients with:
Burns,
Increased ICP,
Neuromuscular Dz,
Eye trauma

Reason: causes Hyperkalemia
(and increased intraocular pressure)

Front 213

What is the Tx of life-threatening respiratory depression w/ morphine or Demerol?

Back 213

Narcan (Naloxone)

Front 214

Main side effect of epidural anesthesia?

Back 214

Orthostatic Hypotension

Front 215

Main side effect of Spinal anesthesia?

Back 215

Urinary retention

Front 216

Which hernia type involves only one side wall of the bowel?

Back 216

Richter hernia

Front 217

Which hernia sac exists as both a direct and indirect hernia?

Back 217

Pantaloon hernia (like pant legs)

Front 218

in a trauma patient if oral and nasal endotrachial intubation is contraindicated, what is the best way to get an airway?

Back 218

Cricothyroidotomy

(not tracheostomy...that is only in OR)

Front 219

What is the Glascow Coma Score for Eye opening?

Back 219

Eye opening ("four eyes"):

4: Opens spontaneously
3: Opens to Voice
2: Opens to Pain
1: Does Not open

Front 220

What is the Glascow Coma Score for Motor response?

Back 220

Motor response ("6-cylinder motor"):
6: Obeys Commands
5: Localizes Pain stimulus
4: Withdrawls from pain
3: Decorticate Posture
2: Decerebrate posture
1: No movement

Front 221

What is the Glascow Coma Score for Verbal response?

Back 221

Verbal response ("Jackson 5"):
5: Appropriate and oriented
4: Confused
3: Inappropriate words
2: Incomprehensible sounds
1: No sounds

Front 222

What is the GCS of a man in a Coma?
Of a Dead man?

Back 222

Coma: 8 or less

Dead: 3

Front 223

what are the most emergent orthopedic surgeries? (2)

Back 223

1. Hip Dislocation
(must be reduced immediately)

2. Exsanguinating Pelvic fracture
(external fixator)

Front 224

When is a surgical cricothyroidotomy not recommended?
What is done instead/

Back 224

in patient younger then 12-yo

(Perform Needle Cricothyroidectomy)

Front 225

If you only have one vial of blood from a trauma victim to send to the lab, what test should be ordered?

Back 225

Type and Cross

Front 226

what is the Tx for human or dog bites? (3 together)

Back 226

Leave wound open, Irrigation and Abx

Front 227

What test may help identify the site of a massive UGI bleed when endoscopy fails to Dx the cause and blood continues per NGT?

Back 227

Mesenteric Angiography

Front 228

What are the (3) possible Tx regimens for H. Pylori PUD?

Back 228

MOC, MOA or COA

M: Metronidazole;
O: Omeprazole (PPI);
C: Clarithromycin;
A: Ampicillin

Front 229

What are the classic Sx of Carcinoid syndrome? (4)*

Back 229

B-FDR (Be FDR in a cool CAR):

Bronchospasm;
Flushing;
Diarrhea;
Right-sided heart failure

Front 230

what tumors are assoc w/ carcinoid syndrome? (3)*

Back 230

BLT:

Bronchus CA;

Liver Mets;

Testicular CA or Ovary CA

(occurs when venous draining from the tumor gains access to the systemic circulation by avoiding heatic degradation via the portal system)

Front 231

MCC of colonic Fistulas

Back 231

Diverticulitis

Front 232

MC fistula type

Back 232

Colovesical fistula

Front 233

Dx: large air/fluid level in the RLQ forming a "coffee bean" sign

Back 233

Cecal Volvulus

Front 234

What procedure is used if kindey stones are too large or too hard to remove via lithotripsy?

Back 234

Percutaneous Nephrolithotomy

Front 235

Crohn's dz or Ulcerative Colitis:

Full-thickness wall involvement

Back 235

Crohn's Dz

Front 236

Crohn's dz or Ulcerative Colitis:

Crypt Abscess

Back 236

Ulcerative Colitis

Front 237

Crohn's dz or Ulcerative Colitis:

Pseudopolyps

Back 237

Ulcerative Colitis

Front 238

Crohn's dz or Ulcerative Colitis:

Bloody Diarrhea

Back 238

Ulcerative Colitis

Front 239

Crohn's dz or Ulcerative Colitis:

Granulomas

Back 239

Crohn's Dz

Front 240

MCC of painful Hepatomegaly

Back 240

Hepatocellular CA

Front 241

Dx: Thrombosis of Hepatic veins

Back 241

Budd-Chiari

Front 242

Dx:
jaundice, pruritus, palpable nontender distended gallbladder
Tx?

Back 242

Adenocarcinoma of the head of the Pancreas

Tx: Whipple

Front 243

A patient presents w/ HTN, HA, polyuria, weakness and Hypokalemia.
Dx?
First Diagnostic test?
Tx? (2 depending on type)

Back 243

Dx: Conn's syndrome

Diagnostic test: Plasma Aldosterone and Renin levels

Tx:
1. Adrenal Adenoma or Unilateral hyperplasia: Laparoscopic Unilateral Adrenalectomy
2. Bilateral hyperplasia: Spironolactone

Front 244

A patient presents with a psoriatic-appearing rash over the trunk and limbs, glossitis, stomatitis and new-onset diabetes. His labs show anemia, low amino acid levels and hyperglycemia.
Dx?
Diagnostic test?
Tx? (2 together)

Back 244

Dx: Glucagonoma

Diagnostic test: Tolbutamide stimulation test

Tx:
1. Surgical resection of tumor
2. Somatostatin for Necrotizing Migratory Erythema rash

Front 245

what is the Tx for hyperparathyroidism in the MEN-1 and MEN-2 patients?

Back 245

Removal of all parathyroid tissue w/ autotransplant of some of the parathyroid into the forearm

Front 246

A patient presents with a palpable neck mass, hypercalcemia and elevated PTH.
Dx?
Tx?

Back 246

Parathyroid CA

(the key is the neck mass: primary hyperparathyroidism have nonpalpable thyroids)

Tx: Remove CA, Ipsilateral Thyroid lobe and all enlarged LN

Front 247

A patient complains of abdominal pain. On AXR there are "eggshell" calcifications near the RUQ.
Dx?

Back 247

Splenic Artery Aneurysm

Front 248

How are maintenance fluids calculated in children?

Back 248

4, 2, 1 per hour:

4cc/kg for the first 10kg
2cc/kg for the second 10kg
1cc/kg for every kg over the first 20

ex: 25kg patient is
(4 x 10) + (2 x 10) + (1 x 5) = 65cc/hour

Front 249

Tx for Trachial or Esophageal Foreign Body?

Back 249

RIGID boronchoscope or espohpagoscope

Front 250

Infant has Bilious vomiting. What is the presumed Dx until proven otherwise?

Back 250

Malrotation of the gut

Front 251

Malignant tumor of the liver that presents in the first 3 years of life

Back 251

Hepatoblastoma

Front 252

Define:
Contracture of the forearm flexors secondary to forearm compartment syndrome

MC Cause?

Back 252

Volkmann's contracture

Cause:
Supracondylar humerus fracture

Front 253

You suspect a newborn has developmental dysplasia. What is the Diagnostic test?

Back 253

Ultrasound

(the bones are too new to see on x-ray)

Front 254

what is the cause of a fever of 104-105:
1. Shortly after anesthesia
2. after instrumentation procedure (like cystoscopy)

Back 254

1. Malignant Hyperthermia

2. Bacteremia

Front 255

What are the (2) MCC of post-operative chest pain? How many days after the operation does each occur?

Back 255

Day 1 - 2: MI

Day 5 - 7: PE

Front 256

What is the new gold standard as a diagnostic test for a pulmonary embolism?

Back 256

V/Q scan

(previously it was a pulmonary angiogram, but they are costly and time-consuming)

Front 257

What is the normal urine output?
What is the Dx if the urine output is zero?

Back 257

Normal: about 1/kg/hr

Zero: Mechanical error
(not from kidneys; more likely from a kinked catheter)

Front 258

Several hours after completion of surgery for multiple gunshot wounds to the abdomen, a 70 Kg., 52-year-old man is reported to have hourly urinary outputs of 17cc, 13cc, and 21cc, in three consecutive hours. His blood pressure has hovered around 95 to 125 systolic during that time.
Dx? (2 possible)
What is the next step to differentiate b/t the two and results for each?
Tx?

Back 258

Dx: Dehydration or Renal Failure
(Oliguria can be from shock, but in the presence of an adequate perfusing pressure, it is one of these two)

Next step: Test Urine Sodium

Dehydration: Low (20 - 30Meq)
Tx: Give more Fluids

Renal Failure: High (>40Meq)
Tx: Stop Fluids

Front 259

12 days after surgery for multiple gunshot wounds, a 27-year-old man becomes progressively disoriented and unresponsive. He’s had multiple complications, including several intraabdominal abscesses that have been percutaneously drained. He has bilateral pulmonary infiltrates, and a PO2 of 65 while breathing 40% oxygen. Meticulous attention has been paid to his fluid balance, and there is no evidence that he is in congestive heart failure.
Dx?
Next step?

Back 259

Dx: ARDS

Next step: PEEP
(then check for underlying reason, like sepsis from abscess)

Front 260

An alcoholic patient presents with Acute Pancreatitis w/ a septic abdomen. On post-operative day 2 he begins to get disoriented. Why?

Back 260

Delerium Tremens

(seen in post-op day 2 in alcoholics)

Front 261

If a patient presents with post-operative disorientation, what are the 6 possible reasons?
What schold be checked with each?

Back 261

1. ARDS - check blood gases
2. DT - if alcoholic
3. HypoN/HyperN - check serum sodium
4. DM/TPN - Hypoglycemia - check blood sugar
5. Hepatic Enceph in Cirrhotic patient - check Ammonia level
6. Check Medications

Front 262

What "type" of esophageal problem:
1. Inability to swallow solids then liquids
2. Inability to swallow liquids then solids

give one example of each

Back 262

solids to liquids: Mechanical (cancer)

liquids to solids: Mobility (DES)

Front 263

A patient presents 2 days after a hernia repair with signs of a bowel obstruction.
Dx?
Diagnostic test/Tx?

Back 263

Dx: Paralytic Ileus

Diagnostic test/Tx: Barium Tag
(a little bit of barium at a time over a few hours)

Front 264

What does an acute appendicitis usually begin with?

Back 264

Anorexia
(then periumbilical pain to RLQ pain; if the paient looks like appendicitis, but can eat well, its probably not an appendicitis)

Front 265

What is the main presentation of Right-sided Colon cancer?

Left-sided?

Back 265

Right-sided: Anemia

Left-sided: Blood in stool

Front 266

A 32-yo male presents with excessive bleeding from the rectum.
First Diagnostic test?
Depending on the results, what is the next test?

Back 266

First Dx Test: NG tube

If blood in stomach: Endoscopy

If no blood in stomach: Angiography

(not a colonoscopy--that much blood makes it hard to visualize)

Front 267

Aside from an increased conjugated bilirubin, what is the signature lab result for obstructive jaundice?

in what "benign" Dx will you see this value at an extreme high?
First Dx test?

Back 267

Increased Alk Phos

Extreme Alk Phos: Acute Ascending Cholangitis

Dx Test: ERCP

Front 268

what does TSH and T-4 look like if a patient has a thyroid cancer?

Back 268

Normal

Front 269

A patient presents with HTN, HypoK and is not on diuretics.
Dx?
Diagnostic test?

Back 269

Dx: Hyperaldosteronism (Conn's Syndrome)

Diagnostic test:
Increased Aldosterone with a Decreased Renin

Front 270

In a patient with a congenital diaphragmatic hernia, what is the first step to Tx?

Back 270

Tx the Hypoplastic lung

Front 271

What does a decreasing platelet count signify in a child with Necrotizing Enterocolitis?

Back 271

Sepsis

Front 272

How do you differentiate intermittent claudication form a neurogenic source versus a vascular source?

Back 272

Neurogenic source: Positional and does not stop w/ rest

Front 273

What is the Tx if claudication does not interfere with daily life?

If it does, what is the first Dx test?
Tx?

when is it not a surgical possibility to Tx?

Back 273

Not interfering w/ life: do Nothing

If it is:
First: Dopler studies
(then Arteriogram)
Tx: Angioplasty w/ stent or saph vein bypass

Not surgical: if no Pressure Gradient seen on Doppler
(means Dz is in the small vessels)

Front 274

A child presents with a mass at the base of the neck, in the supraclavicular area.
Dx?

Back 274

Cystic Hygroma

Front 275

A child presents with a mass up and down the anterior edge of the sternomastoid.
Dx?

Back 275

Branchial cleft cysts

Front 276

What is removed in a Thyroglossal cyst repair?
(3)

Back 276

1. the Mass,
2. the Middle segment of the Hyoid bone
3. a core of muscle from the Tongue all the way back to the Foramen Cecum

Front 277

3 months ago, an 18-year-old woman noticed the presence of a 2 cm., firm, non-tender node located in the left jugular chain, at the level of the hyoid bone. She thinks it is larger now than when it first came to her attention. For the past 3 weeks she has had low grade fever and night sweats. Physical exam confirms the presence of the node, and also shows 2 other smaller nodes on that side of the neck, as well as enlarged nodes in both axillas.
Dx?
First Diagnostic test?

Back 277

Dx: possible Lymphoma
(The timetable of inflammatory neck nodes is measure in weeks, while that of neoplastic nodes is typically of months)

First Dx test: FNA
(an excisional Bx will be needed to establish tumor type)

Front 278

A 72-year-old man seeks help for a 4 cm., fixed, hard mass in the left jugular chain, at the level of the upper edge of the thyroid cartilage. Patient says that he found it a week ago, but his wife claims that it has been present for at least 6 months. The patient has a long-standing history of alcohol and tobacco abuse, and he has terrible oral hygiene.
Dx?
Diagnostic test?

Back 278

Dx: Metastatic Squamous Cell CA
from a primary in the head or neck mucosa

Diagnostic test: FNA
(do NOT BX the tumor)

Front 279

Aside from palpable mass in the neck, what are (3) other potential presentations for a metastatic SCC of the head or neck mucosa?

Back 279

1. Persistent unilateral ear ache with serous otitis media

2. Persistent hoarseness

3. Unhealing ulcer in the mouth

Front 280

what (2) times do you Never do a tissue Bx to diagnose cancer in the face/neck?

Back 280

1. mass in neck when suspecting Mets SCC from head or neck mucosa

2. PAROTID gland
(too close to facial nerve)

Front 281

Neurological problems of vascular nature have sudden onset. By HPI, how can you tell if it is occlusive versus hemorrhagic?

Back 281

without Headache = Occlusive

with very severe headache = Hemorrhagic

Front 282

Location of brain tumor in patient with:

Anosmia

Back 282

base of Frontal Lobe

Front 283

Location of brain tumor in patient with:

Loss of upper gaze

Back 283

Pineal area

Front 284

Location of brain tumor in patient with:

Ataxia, unstable gait

Back 284

Posterior Fossa

Front 285

What is the best imaging method for a brain tumor?

Back 285

MRI

Front 286

What (2) classes of people are UTIs not expected?

What is the work-up for in this case?
(2 together)

Back 286

Not in:
1. Children
2. Men

Work-up: as if it were an Obstruction:
1. massive Abx
2. Decompression of urinary tract above the "obstruction"

Front 287

A 74-year-old man has a 3mm. ureteral stone lodged just above the ureterovesical junction. He is receiving IV fluids and analgesics, with the expectation that the stone will pass. He suddenly develops chills, his temperature shoots up to 104, and he complains of severe flank pain.
Dx?
Tx? (2 together)

Back 287

Dx: Obstruction plus Infection

Tx:
1. massive Abx
2. Decompression of urinary tract above the obstruction
(In the presence of infection, manipulating and attempting to extract the stone would be hazardous)

Front 288

A 59-year-old man reports an episode of gross, painless hematuria, without any history of trauma. He has normal renal function.
Diagnostic test? (2)
why are these tests done?
If he had "poor renal flow" or "a history or renal failure", what is the Dx test? (2)

Back 288

Dx Test:
1. IVP
2. Cystoscopy

(Performed to r/o Cancer of the Kidney, ureter or bladder)

Poor kidney function (creatinine > 2):
1. CT scan
2. Cystoscopy

Front 289

A man presents with a painless enlargement of the right testis. He began feeling heaviness in that part of the scrotum 6 months ago. There is diffuse enlargement but it is difficult to determine if it is intratesticular or extratesticular.
What is the next step?

Back 289

Ultrasound

(best way to discriminate b/t intra- or extra- testicular mass)

Hint 289

None

Front 290

A patient presents with an acute subdural hematoma without a midline shift or anisocoria (unequal pupils). What is the next step?

Back 290

Hyperventilation, Diuresis and fluid restriction

Front 291

What is the first step when suspecting a pulmonary embolism?

Back 291

Arterial Blood Gas

(an increased alveolar-arterial oxygen difference supports the Dx; a Duplex Doppler and V/Q scan are important for confirming the Dx, but a blood gas should be done first)

Hint 291

None

Front 292

What can occur with massive blood loss with multiple transfusions during an abdominal procedure?
Tx?

Back 292

Coagulopathy

Tx: FFP and Platelets

Hint 292

None

Front 293

What is the first step in Tx of a rib fracture in an elderly patient?

Back 293

Intercostal nerve block

(eliminating pain w/o interfering w/ ventilation)

Hint 293

None

Front 294

A patient is shot in the lateral thigh. What is the next step in management?

Back 294

Tetanus prophylaxis

(since there is no damage to vessels, no Doppler, surgical exploration or arteriogram is indicated)

Hint 294

None

Front 295

MCC of Transitional cell tumors of the bladder

Back 295

Smoking

(66% compared to 15% from Aniline dyes)

Hint 295

None

Front 296

When there is a trauma patient that has a hematocrit of < 30, what should be transfused?

Back 296

Packed RBC

Front 297

What nerve can be affected if an anesthesiologist wants to perform an axillary block for local pain control and the posterior wall of the axillary artery is pierced during the procedure?

Back 297

Ulna nerve

Front 298

How do you treat a patient with a big, palpable pseudocyst of the pancreas?

Back 298

Endoscopic Cystogastrostomy

(an endoscopic anastomosis b/t the cyst and the stomach)

Hint 298

None

Front 299

A man is shot in the upper zone of the neck yet is conscious, hemodynamically stable and neurologically intact. What is the next step?

Back 299

Arteriogram

Front 300

What is the best drug for a estrogen/progesterone receptor positive breast tumor in postmenopausal patients?

Back 300

Anastrozole

(suppresses production of estrogens)

Hint 300

None

Front 301

What nerve during a carotid endarterectomy is prone to damage producing a difficulty in swallowing?

Back 301

Glossopharyngeal

Front 302

Lack of what procedure can predispose a man to penile cancer?

Back 302

Circumcision

Front 303

What electrolyte is extremely increased with a crush injury?

Back 303

Potassium (causing Hyperkalemia)

Front 304

An asymptomatic patient form Mexico has a CT scan done of the abdomen which shows four thin-walled structures 1cm in diameter throughout his liver.
Dx?

Back 304

Simple Liver Cysts

(Amebic abscesses present with fever, leukocytosis, a tender liver and elevated Alk Phos)

Hint 304

None

Front 305

A 27-yo woman from Asia moved to the US and presents w/ gross hematuria. She reports a low-grade fever and weight loss for over one year. Urinalysis shows pyuria, but cultures are negative for bacteria. IVP reveals diminished contrast excretion and cavitary lesions in the right kidney.
Dx?

Back 305

Tuberculosis

(Secondary TB commonly affects the kidneys and can spread to the epididymis and prostate in men; this is a classic presentation with hematuria, weight loss, low fever, negative cultures and increased leukocytes, and cavitary lesions)

Hint 305

None

Front 306

If a patient presents with a TIA consisting of no bleeding and no signs of extensive infarction within the first 3 hours of onset, what is the next step?

Back 306

IV infusion of Tissue-type Plasminogen Activator

(tPA can be used as a “clot buster” in patients w/in first 3 hours, though better if started in first 90 minutes of Sx)

Hint 306

None

Front 307

What is the next step in the fracture of a clavicle?

Back 307

Figure-eight Cast

(not arteriogram)

Hint 307

None

Front 308

A 45-yo man presents with a pale, pulseless, paresthetic, painful and paralytic right lower extremity. On exam, no pulses are apparent in the RLE.
Dx?
Tx?

Back 308

Dx: Emboli in Rt Common Iliac

Tx: Fogarty Balloon-tipped Catheter

Hint 308

None

Front 309

Before performing a Pneumonectomy for SCC of the lung, what should be done?

Back 309

CT scan of the Chest and upper Abdomen
(to rule-out metastasis)

Hint 309

None

Front 310

What is the next step to confirm a Dx of PE in a patient that has atelectasis and patchy pneumonic infiltrates?

Back 310

Spiral CT scan of the Chest

(a V/Q scan is not reliable for a patient w/ atelectasis and infiltrates)

Hint 310

None