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310 Cards in this Set

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  • Back
  • 3rd side (hint)
A patient is diagnosed with invasive ductal adenocarcinoma. What is the most important factor in the staging of this patient’s cancer?
Lymph Node Involvement
Which nerve, if damaged in an axillary dissection, will result in only a sensory deficit?
Intercostobrachial nerve
What cancer drug can cause pulmonary fibrosis?
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?

(Colorectal fistula is also a cause, but is very rare)
What is considered the triangle of Calot in GB surgery?
Cystic Duct,

Common Hepatic Duct,

Cystic Artery
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?
Gallstone Ileus

(may also present with pneumobilia)
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.
What is next step in Tx given patient’s condition?
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)
Type of Shock:
An 18-yo male restrained driver w/ tachycardia, hypotension, and a rigid abdomen
Hypovolemic shock
Type of Shock:
An 80-yo nursing home resident, febrile, unresponsive, hypotensive, w/ gram-negative rods cultured in urine.
Distributive shock

(Sepsis or Anaphylaxis)
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
Neurogenic shock

(seen in patients w/ spinal cord injuries; caused by a decrease in sympathetic output; CO, CVP, PCWP and SVR are all decreased)
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
Cardiogenic shock
(seen in patients w/ acute MI and respiratory distress; CO is decreased and everything else is increased)
What is Duke’s staging for Colon Cancer (A-D)?
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
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?
5-FU and Leucovorin (Levamisole)

Radiation is not used in colon cancer
(only in rectal cancer)
What is the Diagnostic Test for patients w/ Rectal Cancer?
What is the adjuvant Tx for T3-T4 Rectal Cancer? (2)
Diagnostic test: Endorectal Ultrasound

Tx: Pre-op Radiation Therapy and 5-FU
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.
Next step?
Dx: Perforated Diverticulum

Next step: Emergency resection of the Sigmoid colon w/ diverting colostomy
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?
Diagnostic test: Urinalysis
(on every patient w/ RLQ pain)

Dx: Kidney Stone
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?
Sigmoid Volvulus
How is Total Body Water calculated in men and women?
Men: 60% of body weight

Women: 50% of body weight
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)
(Na + [glucose – 100] x 0.016) =

(134 + [500 – 100] x 0.016) = 140 mmol/dL
How is plasma osmolality calculated? (Eqn)

An osmolar gap is present if the measured and calculated osmolarity differ by how much?
(2 x Na) + (glucose/18) + (BUN/2.8)

Differ by 15 mOsm/kg
What causes a bluish discoloration of the periumbilical area?
What is another sign of this?
Fox’s sign: Retroperitoneal Hemorrhage
(ex: acute hemorrhagic pancreatitis)

another sign: Ecchymosis or discoloration of flank
(Grey Turner’s sign)
Dx for the triad of HTN, bradycardia and irregular respirations?
Dx: increased ICP
Dx for calf pain on forced dorsiflexion of the foot in patient (Homan’s sign)
What are the two signs of a basilar skull fracture?
Raccoon Eyes and Battle’s sign (ecchymosis over the mastoid process)
What is Budd-Chiari syndrome?
Thrombosis of hepatic veins
MC indication for surgery w/ Crohn’s Dz?
Small Bowel Obstruction
MC vessel involved in a bleeding duodenal ulcer?
Gastroduodenal artery
MC bacteria in stool?
Bacteroides fragilis (“B. frag”)
MC electrolyte deficiency causing Ileus?
MC cause of Large Bowel Obstruction
Colon Cancer
MC type of Volvulus?
Sigmoid volvulus
MC bacteria causing UTI?
E. coli
MC benign tumor of the liver?
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?
Esophageal resection
What is the most important part of the surgical correction of Zenker’s diverticulum?
Myotomy of the Cricopharyngeus muscle
(b/c the diverticulum results from the increased spasticity of this muscle)
What are two main causes of non-anion gap metabolic acidosis?
How can you tell which is the problem?
Diarrhea and Renal Tubular Acidosis

calculate the Urine Anion Gap (Una – Ucl – Uk)
What is a common cause of post-op tachyarrhythmia?
What is the Tx?
What is the reason for the initial treatment?
Atrial Fibrillation

Tx: Beta-agonist drip for Rate Control
What is the next step in a patient presenting w/ a confirmed Acute MI?
(2 possible)

What if the patient is a post-op?
1. Thrombolytics
2. Angioplasty


(due to possibility of bleeding w/ thrombolytics; Stenting may be indicated)
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?
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)
What do the thyroid labs look like in Graves Disease?
Decreased TSH; Increased free T-4
How does Secondary Hyper- and Hypo- thyroidism present in labs of TSH and T-4?
Hyper: Increased TSH; Increased free T-4

Hypo: Decreased TSH; Decreased free T-4
What is the most serious complication following surgical treatment for a Thyroidectomy?
Recurrent Nerve Damage

(resulting in Abductor Laryngeal paralysis w/ affected cord assuming the midline. Unilateral results in hoarseness; Bilateral may lead to airway obstruction)
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?
First test: Fine Needle Aspiration

Hot lesion: Functional
Cold lesion: Non-functional

Hot/Cold test: Radionucleotide thyroid scan
After performing a VMA for a pheochromocytoma, what imaging exam is most specific in localizing the lesion?
MIBG (a NE analog)
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?
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)
What is the disasterous complication of a Supracondylar fracture of the Humerus?
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)
What nerve and artery travel along the mid-Humeral shaft and can be damaged in a fracture to that area?
Radial nerve;

Brachial Profunda (deep brachial) artery
Where is the MC place for a Mallory-Weiss tear?
In the Stomach near the GE junction
What is the most proven risk factor of Pancreas cancer?

What is the best initial diagnostic test?

Dx test: CT scan w/ oral and IV contrast
Why is a posterior hip dislocation an emergency?
To avoid Posterior Avascular Necrosis
What is the ECG sign w/ Primary Hyperparathyroidism?
Shortened QT on ECG
What is the required margin of resection for a melanoma of the following size:
1. In situ
2. < 1mm
3. 1 – 4mm
4. > 4mm
In situ: 0.5cm

< 1mm: 1 cm

1 – 4mm: 2cm

> 4mm: 2 – 3cm
What is used to Dx Achalasia?
Espohageal Manometry
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?
Diffuse Esophageal Spasm

(another chest pain relieved by nitrates)
What is the MCC of an acute appendicitis?
Lymphoid Hyperplasia

(not fecalith)
What type of portal system shunt decreases the risk of developing encephalopathy?
Warren distal Splenorectal shunt
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.
What is seen in the blood sample?
Dx: Hepatic Encephalopathy

In Blood: Increased Ammonia

(blood does not pass liver first to clean it of the ammonia)
What is the cause of hypotension in Septic shock?
Cytokines from the inflammatory response cause loss of systemic vascular resistance
(as well as fever and leukocytosis)
Infant presents with excessive salivation and repeated episodes of coughing, choking and cyanosis. Dx?
Dx: Esophageal Atresia

(most common ends in a blind pouch with a distal tracheoesophageal fistula)
Infant is vomiting and on abdominal films there is a “soap bubble” sign in the ileum.
Dx: Meconium Ileus

Tx: Gastrografin enema

(draws water into the bowel to break-up the meconium plug)
What bacteria are worrisome after a spenectomy?
Encapsulated bacteria

(Strep pneumonia, H. influnzae, Meningococcus)
What is a common cause of sudden or unexplained hyperglycemia on a post-op patient on TPN?
What complication related to TPN may cause a patient to get a HCO3 of 30 and go into Respiratory Failure?
Increased CO2 production

(due to increasing the daily caloric intake; overfeeding)
What is an appropriate test if you suspect Clostridium Difficile?
Stool Toxin Assay
Aside from trauma, what are (2) other causes of Hypovolemic shock?
Small Bowel Obstruction and Pancreatitis

(both due to Third Spacing)
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?
Central Pontine Myelinolysis

Patient has Hx of: Malnutrition or Alcoholism
What can be a devastating outcome of correcting a Hypernatremic patient too rapidly?
Cerebral edema

(by rapidly shifting fluid into cells)
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?

(streaks are lymphatic inflammation)
A 3-yo presents with a non-tender abdominal mass. What is the MCC of extracranial solid tumors seen in children?
First step?
Dx: Neuroblastoma
(from neural crest cells)

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

Tx: Surgery, Chemo and Radiation
A 3-yo child presents w/ an abdominal mass, HTN and hematuria.
Diagnostic test?
Dx: Wilm’s Tumor
(originates from kidney and may also present w/ aniridia)

Diagnostic test: CT of abdomen
A 3-yo presents w/ abdominal distention and a RUQ mass that moves with respiration.
Diagnostic test?
Dx: Hepatoblastoma;

Diagnostic test: Serum Alpha-Fetoprotein;

Tx: Surgical removal
A 3-yo presents with a sacrococcygeal mass.
Dx: Teratoma

(most common site in children, followed by mediastinum)
What is the leading cause of death following a carotid endarterectomy?
What drug is most beneficial in closing a Crohn’s fistula?
A patient with a history of Ulcerative Colitis has fever, tachycardia, a distended abdomen and a dilated transverse colon.
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)
What is the MCC of a mediastinal tumor?
What systemic condition is classically assoc w/ it?
MCC: Thymoma

Assoc w/: Myasthenia Gravis
(30 – 50% will have it)
Dx: patient presents w/ café au lait pigmentation and neurofibromas of the GI tract
Von Recklinghausen Dz
MC site of sarcoma metastasis?
MCC of Acute Mesenteric Ischemia?

Chronic Mesenteric Ischemia?
Acute: Emboli

Chronic: Atherosclerosis
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.
Diagnostic test?
Dx: Spontaneous Esophageal Rupture
(Boerhaave syndrome)

Diagnostic test: Water-soluble or Barium Esophagogram

Tx: Primary Surgical repair
What is the Chemotherapy treatment for Melanoma in Stage III?
Stage IV?
Stage III: Interferon-2A

Stage IV: Interleukin-2
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?
Transrectal US exam w/ prostate Bx
A 72-yo man has a lower abdominal mass and constantly dribbles urine.
What is the best next step?
Dx: Overflow Incontinence

Next step: Foley catheter and hospitalization
What unusual lab value can be elevated w/ a Small Bowel Obstruction?
Serum Amylase

(also increased w/ Acute Pancreatitis…both also cause Third Spacing and Hypovolemic shock)
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.
Diagnostic test?
Dx: Anion Gap Acidosis secondary to Lactic Acid reflecting Ischemic Bowel

Diagnostic test: CT confirming obstruction

Tx: Surgery
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.
Tx? (2 together)
Dx: Carpal Tunnel Syndrome

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

Initial Tx: Rest and IV hydration
(then a Lap Chole)
Dx: Fever, intermittent RUQ pain and Jaundice
Dx: Persistent abdominal pain, RUQ tenderness and leukocytosis
Acute Cholecystitis
A 52-yo alcoholic w/ cirrhosis presents w/ acute hematemesis. Bleeding esophageal varicies are found on UGI endoscopy. Tx?
Tx: Endoscopic Sclerotherapy
What is the management of a patient presenting w/ Melena?
(2 steps)
1. IV fluids and insuring hemodynamic stability

2. NG tube to rule-out UGI bleed

(melena = tarry stool; is usually a UGI bleed)
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)
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)
What is the most common site of occlusion w/ Claudication?
Superficial Femoral Artery
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)
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
A 24-yo male complains of colicky intermittent umbilical and RLQ abdominal pain of 24 hours, anorexia and nausea. He is afebrile.

(not appendicitis, b/c appendicitis does not present w/ intermittent pain)
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.
Next step?
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
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?
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)
What are the (2) rules for Breast cancer in a pregnant woman?
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
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?
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)
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?
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)
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?
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
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?
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)
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?
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)
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)
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.")
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?
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)
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.
Diagnostic test?
Dx: Causalgia

Diagnostic test: Sympathetic block

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

(The location and circumstances are classic for Morton's neuroma, a benign neuroma of the third plantar interdigital nerve)
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?
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)
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?
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)
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?
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)
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?
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)
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?
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)
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?
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)
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?
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)
Patient hurts his knee, causing him the ability to bend his leg inward to a greater extent then normally possible. What structure is damaged?
Lateral Collateral Ligament
(Varus test)
Patient hurts his knee, causing him the ability to bend his leg outward to a greater extent then normally possible. What structure is damaged?
Medial Collateral Ligament
(Valgus test)
Patient hurts his knee, causing him to feel loose intra-articular bodies and a locking of the knee. What structure is damaged?
Medial Meniscus
What is the first step in the evaluation of a palpable thyroid nodule?
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?
Posterior dislocation of the hip
(not fracture of the femoral neck)
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?
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)
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?
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)
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?
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
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?
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)
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?
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)
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?
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)
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?
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)
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?
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)
A 5-yo boy is brought to the ER after ingesting a half-bottle of liquid drain cleaner. What is the next step?
(even though the step doesn’t state a breathing problem, airway edema, stridor and difficulty breathing is likely)
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.
What is the best initial Tx?
If that doesn’t work?
Dx: Acute Cholangitis

First: Antibiotics and fluid resuscitation

Next: Percutaneous Transhepatic Drainage
What is the best Diagnostic test for a Breast mass in a younger woman?
What is the treatment post-operative for a premenopausal woman who had a modified radical mastectomy for a 3cm mass w/ negative LN?
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?
IVP (to rule-out upper tract tumors)
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?
Adenocarcinoma of the GB
A 10-yo boy presents w/ persistent hoarseness that worsens with singing. There are multiple lesions on his true vocal cords. Dx?
Laryngeal Papilloma

(benign and located on the true vocal cords. In kids they present as multiple lesions and are caused by HPV)
What is the best Diagnostic test to define an enlarged Parathyroid gland?
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?
Ovarian CA
What is the medical treatment for Carcinoid syndrome? (2) What is the drug class of these drugs?
Octreotide, a Somatostatin analogue;

Cyproheptadine, a Serotonin antagonist
A 53-yo woman presents w/ 12 mo Hx of neck pain, 15lb weight gain and malaise. Dx?
Hashimoto Thyroiditis
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?
What nerve is affected in a mid humeral fracture?

(wrist extension and sensory to back of hand)
What nerve is affected in an elbow dislocation?

(finger abduction and sensory to last 2 digits)
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?
Charcot Joint
MCC of bacterial osteomyelitis?
Staph Aureus
What diagnostic test do you order in a patient who has a posterior knee dislocation?
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
Newborn = Congenital Hip Dysplasia

Toddler = Septic Hip
(Tx: Aspiration under anesthesia)

6 - 9 yo = Avascular Necrosis

9 - 14 yo = Slipped Capital Femoral Epiphysis
MC place of an Intracerebral hemorrhage? Cause?
Basal Ganglia (due to HTN)
A patient is found on the side of the road w/ bruising of the head, increased BP, bradycardia and respiratory irregularities. Dx?
Increased Intracranial Pressure
(do not treat HTN initially…it is body’s way of trying to increase cerebral perfusion)
What is the usual cause of sudden deafness?

(mumps, measles, chickenpox, influenza, or adenovirus)
MCC of acquired hearing loss in children?
Bacterial Meningitis
A child has a fever and has a lateral neck mass. Dx?
Branchial Cleft cyst
A child has a midline neck mass and it elevates with tongue protrusion. Dx?
Thyroglossal Duct cyst
(3) MCC of Otitis Media.

Strep Pneumonia, H. Influenza, Moraxella;

Tx: Amoxicillin
A child has inflammation of the tympanic membrane which has vesicles on its surface.
Dx: Infectious Myringitis (inflammation of TM)

Tx: Erythromycin or Clarithromycin
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?
Conductive: Sound is heard louder in affected ear (right)

Sensorineural: Sound is hear louder in unaffected ear (left)
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?
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.
A male patient complains of transient pain in the buttocks, buttock atrophy and impotence.
What is the problem?
Aortoiliac Occlusive Dz
(Leriche’s syndrome)

Tx: Aortoiliac bypass graft
A patient presents with sudden onset of unilateral blindness like “a shade is pulled over his eye”
Diagnostic test?
Tx? (2 possible)
Dx: TIA secondary to Carotid Stenosis

Diagnostic test: Ultrasound of Carotid

if >70% stenosis: Carotidendarterectomy;
If <70% stenosis: daily Aspirin
A patient presents with abdominal tenderness, bloody diarrhea and “thumbprinting” on abdominal x-ray. Dx?
Acute Bowel Infarction
A patient presents w/ a history of varicose veins and has localized leg pain w/ cord-like induration, reddish discoloration and mild fever.
Dx: Thrombophlebitis

Tx: NSAIDs and warm compresses
A patient presents w/ syncope, vertigo, confusion and upper extremity claudication during exercise. Dx?
Subclavian Steal Syndrome
(left subclavian artery obstruction proximal to vertebral artery)
A patient presents with upper extremity paresthesias, weakness, cold temperature, edema and venous distention. Dx?
Cervical rib

(compromising subclavian vessel blood flow; no neuro problems help distinguish it from SSS)
What (2) Dx cause Uric Acid kidney stones?
Gout or Leukemia
What causes a Struvite renal stone?
What are the (2) biggest concerns w/ electrical burns?
Cardiac Arrhythmias;

Renal Failure
(from muscle necroisis leading to myoglobinuria and acidosis; maintaining high urine output w/ fluids helps prevent this)
What is the classic cardiac sign with Hypothermia?
(a small positive deflection following QRS complex)
If a patient with hyperthermia begins to have convulsions, what do you do?
Give Diazepam
Where are the MEN-1 tumors located?
All start with “P”:

What are the tumors in MEN-2 vs MEN-3?
MEN-2 (MPP):
Medullary Thyroid CA,

MEN-3 (MPM):
Medullary Thyroid CA,
Mucosal Neuromas
What is the difference b/t Mallory-Weiss syndrome and Boerhaave syndrome on exam?
Boerhaave syndrome presents with mediastinal emphysema
What is the type of esophageal divertivcula most commonly requiring surgery?
Where is it located?
Zenker’s diverticulum

location: Pharyngoesophageal area
A 52-yo woman presents due to 3 months of early satiety, weight loss and non-bilious vomiting. Dx?
Gastric Outlet Obstruction
A 25-yo develops weight loss, night sweats and a fistula draining from his RLQ s/p appendectomy.
Dx: Post-op Actinomycosis infection

Tx: Penicillin (or Tetracycline)
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.
Ischemic Colitis

(suspected and time patient develops acute abdominal pain followed by rectal bleeding and is common post AAA)
Which is massive lower GI bleeding more common with: Diverticulosis or Diverticulitis?
Tx for each?

Tx: high fiber diet, stool softeners

(Diverticulitis Tx is Abx, analgesics and clear liquid diet if mild; resection if severe)
What is Jaundice without scelral icterus or increased bilirubin?

Caused by increased ingestion of foods rich in beta-carotene
What liver tumor is treated by cessation of OCPs?
What is this patient at risk for if she wants a large family?
Hepatocellular Adenomas;

Risk: if treated by cessation of OCP rather then tumor resection, she is at risk for rupture and hemorrhage during future pregnancies
MC clinical finding in Portal HTN
MCC of Portal HTN inside the USA?

Outside the USA?
In USA: Alcoholism

Outside USA: Schistosomiasis
Aside from US, what is the diagnostic test of Acute Cholecystitis?
HIDA scan

(if the GB is not seen within 1 hour post Technetium injection, it is diagnostic for acute cholecystitis)
What is the Dx of an ERCP that shows “beads on a string” in the bile ducts? Tx? (2 depending on severity and place)
Dx: Sclerosing Cholangitis;

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

2. Extrahepatic stricture: Removal of ducts w/ T-tube placement;
Intrahepatic stricture: Liver Transplant
Dx: Anti-mitochondrial Ab
Primary Biliary Cirrhosis
Dx: Anti-Neutrophil Cytoplasmic Ab
Primary Sclerosing Cholangitis
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?

(Tachypnea is one of the presenting signs)
When is the only time a Direct inguinal hernia is more common?
In patients > 50yo
What are the boundaries of Hesselbach’s Triangle?
Inferior border: Inguinal Ligament

Medial border: Rectus Abdominis

Lateral border: Inferior Epigastric vessels
How is each type of Hiatal Hernia corrected?
Sliding: usu Antacids and head elevation
(15% require a Nissen Fundoplication)

Paraexophageal: Surgery
After an URI a child presents w/ a painless, soft mobile mass in the neck that transilluminates.
Diagnostic test?
Dx: Cystic Hygroma

Diagnostic test: CT scan

Tx: Surgical excision
MC congenital lung lesion
Lobar Emphysema

(presents w/ mediastinal shift)
How can you tell the difference b/t Congenital Diaphragmatic Hernia or Congenital Cystic Adenomatoid Malformation?
Placement of the NG tip:

In Thorax: CDH

In Abdomen: CCAM
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?
Necrotizing Enterocolitis

(presents in premature births and is similar to sepsis with feeding intolerance, apneic spells, bloody diarrhea and abdominal pain)
What is the order of structures transversed with the spinal anesthesia after the Sub-Q layer? (6)
Supraspinous ligament,
Interspinous ligament,
Ligamentum flavum,
Epidural space,
Dura mater,
Subarachnoid space
What (2) serological markers are monitored for Pineal tumors?
AFP and beta-HCG
A kidney transplant recipient is seen in the ER for nausea and abdominal pain, fever and elevated creatinine.
Diagnostic test?
Dx: Acute Rejection

Diagnostic test: Ultrasound-guided Bx

Tx: Pulse Steroid treatment (or OKT3) is 90% effective
MC infection after Pancreas transplant
MC post-transplant problem in a Pancreas transplant?

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

Tx: Oral replacement
A 53-yo woman who is s/p liver transplant calls you asking what she can take for some musculoskeletal pain.
What can you give her?
Dx: AE of Tacrolimus meds
(can ultimately lead to renal failure)

Give her Acetaminophen
(new liver will be able to tolerate it)
MC infection post heart transplant?
(a trigger for graft-related atherosclerosis)

Tx: Ganciclovir
How will a flexor tendon injury of the hand present?
With a Straight finger

(due to unapposed Extensors)
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.

Tx: Water Restriction (and treat primary cause)
what is a decrease in the release of ADH called?
Diabetes Insipidus
(Decreased = Diabetes)

Tx: Vasopressin
`What test should be performed before inserting an Arterial Line or obtaining a blood gas?
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)
A post-operative patient has a new onset of CHF, dyspnea and a dysrhythmia.
Myocardial Infarct

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

Tx: Be MONA (no heparin):
Beta blocker; Morphine; Oxygen; Nitrates; Aspirin
What is FENa? Equation?
Fractional Excretion of Na (sodium)

Equation: YOU NEED PEE
(Una x Pcr)/(Pna x Ucr) x 100
What is the value for a Pre-Renal FENA vs a Renal FENA?
Pre-Renal: < 1

Renal: > 1
What is a common anesthesia used for children and burn victims?
What are the contraindications for the depolarizing agent Succinylcholine? (4)
Patients with:
Increased ICP,
Neuromuscular Dz,
Eye trauma

Reason: causes Hyperkalemia
(and increased intraocular pressure)
What is the Tx of life-threatening respiratory depression w/ morphine or Demerol?
Narcan (Naloxone)
Main side effect of epidural anesthesia?
Orthostatic Hypotension
Main side effect of Spinal anesthesia?
Urinary retention
Which hernia type involves only one side wall of the bowel?
Richter hernia
Which hernia sac exists as both a direct and indirect hernia?
Pantaloon hernia (like pant legs)
in a trauma patient if oral and nasal endotrachial intubation is contraindicated, what is the best way to get an airway?

(not tracheostomy...that is only in OR)
What is the Glascow Coma Score for Eye opening?
Eye opening ("four eyes"):

4: Opens spontaneously
3: Opens to Voice
2: Opens to Pain
1: Does Not open
What is the Glascow Coma Score for Motor response?
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
What is the Glascow Coma Score for Verbal response?
Verbal response ("Jackson 5"):
5: Appropriate and oriented
4: Confused
3: Inappropriate words
2: Incomprehensible sounds
1: No sounds
What is the GCS of a man in a Coma?
Of a Dead man?
Coma: 8 or less

Dead: 3
what are the most emergent orthopedic surgeries? (2)
1. Hip Dislocation
(must be reduced immediately)

2. Exsanguinating Pelvic fracture
(external fixator)
When is a surgical cricothyroidotomy not recommended?
What is done instead/
in patient younger then 12-yo

(Perform Needle Cricothyroidectomy)
If you only have one vial of blood from a trauma victim to send to the lab, what test should be ordered?
Type and Cross
what is the Tx for human or dog bites? (3 together)
Leave wound open, Irrigation and Abx
What test may help identify the site of a massive UGI bleed when endoscopy fails to Dx the cause and blood continues per NGT?
Mesenteric Angiography
What are the (3) possible Tx regimens for H. Pylori PUD?

M: Metronidazole;
O: Omeprazole (PPI);
C: Clarithromycin;
A: Ampicillin
What are the classic Sx of Carcinoid syndrome? (4)*
B-FDR (Be FDR in a cool CAR):

Right-sided heart failure
what tumors are assoc w/ carcinoid syndrome? (3)*

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)
MCC of colonic Fistulas
MC fistula type
Colovesical fistula
Dx: large air/fluid level in the RLQ forming a "coffee bean" sign
Cecal Volvulus
What procedure is used if kindey stones are too large or too hard to remove via lithotripsy?
Percutaneous Nephrolithotomy
Crohn's dz or Ulcerative Colitis:

Full-thickness wall involvement
Crohn's Dz
Crohn's dz or Ulcerative Colitis:

Crypt Abscess
Ulcerative Colitis
Crohn's dz or Ulcerative Colitis:

Ulcerative Colitis
Crohn's dz or Ulcerative Colitis:

Bloody Diarrhea
Ulcerative Colitis
Crohn's dz or Ulcerative Colitis:

Crohn's Dz
MCC of painful Hepatomegaly
Hepatocellular CA
Dx: Thrombosis of Hepatic veins
jaundice, pruritus, palpable nontender distended gallbladder
Adenocarcinoma of the head of the Pancreas

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

Diagnostic test: Plasma Aldosterone and Renin levels

1. Adrenal Adenoma or Unilateral hyperplasia: Laparoscopic Unilateral Adrenalectomy
2. Bilateral hyperplasia: Spironolactone
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.
Diagnostic test?
Tx? (2 together)
Dx: Glucagonoma

Diagnostic test: Tolbutamide stimulation test

1. Surgical resection of tumor
2. Somatostatin for Necrotizing Migratory Erythema rash
what is the Tx for hyperparathyroidism in the MEN-1 and MEN-2 patients?
Removal of all parathyroid tissue w/ autotransplant of some of the parathyroid into the forearm
A patient presents with a palpable neck mass, hypercalcemia and elevated PTH.
Parathyroid CA

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

Tx: Remove CA, Ipsilateral Thyroid lobe and all enlarged LN
A patient complains of abdominal pain. On AXR there are "eggshell" calcifications near the RUQ.
Splenic Artery Aneurysm
How are maintenance fluids calculated in children?
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
Tx for Trachial or Esophageal Foreign Body?
RIGID boronchoscope or espohpagoscope
Infant has Bilious vomiting. What is the presumed Dx until proven otherwise?
Malrotation of the gut
Malignant tumor of the liver that presents in the first 3 years of life
Contracture of the forearm flexors secondary to forearm compartment syndrome

MC Cause?
Volkmann's contracture

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

(the bones are too new to see on x-ray)
what is the cause of a fever of 104-105:
1. Shortly after anesthesia
2. after instrumentation procedure (like cystoscopy)
1. Malignant Hyperthermia

2. Bacteremia
What are the (2) MCC of post-operative chest pain? How many days after the operation does each occur?
Day 1 - 2: MI

Day 5 - 7: PE
What is the new gold standard as a diagnostic test for a pulmonary embolism?
V/Q scan

(previously it was a pulmonary angiogram, but they are costly and time-consuming)
What is the normal urine output?
What is the Dx if the urine output is zero?
Normal: about 1/kg/hr

Zero: Mechanical error
(not from kidneys; more likely from a kinked catheter)
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?
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
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.
Next step?

Next step: PEEP
(then check for underlying reason, like sepsis from abscess)
An alcoholic patient presents with Acute Pancreatitis w/ a septic abdomen. On post-operative day 2 he begins to get disoriented. Why?
Delerium Tremens

(seen in post-op day 2 in alcoholics)
If a patient presents with post-operative disorientation, what are the 6 possible reasons?
What schold be checked with each?
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
What "type" of esophageal problem:
1. Inability to swallow solids then liquids
2. Inability to swallow liquids then solids

give one example of each
solids to liquids: Mechanical (cancer)

liquids to solids: Mobility (DES)
A patient presents 2 days after a hernia repair with signs of a bowel obstruction.
Diagnostic test/Tx?
Dx: Paralytic Ileus

Diagnostic test/Tx: Barium Tag
(a little bit of barium at a time over a few hours)
What does an acute appendicitis usually begin with?
(then periumbilical pain to RLQ pain; if the paient looks like appendicitis, but can eat well, its probably not an appendicitis)
What is the main presentation of Right-sided Colon cancer?

Right-sided: Anemia

Left-sided: Blood in stool
A 32-yo male presents with excessive bleeding from the rectum.
First Diagnostic test?
Depending on the results, what is the next test?
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)
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?
Increased Alk Phos

Extreme Alk Phos: Acute Ascending Cholangitis

Dx Test: ERCP
what does TSH and T-4 look like if a patient has a thyroid cancer?
A patient presents with HTN, HypoK and is not on diuretics.
Diagnostic test?
Dx: Hyperaldosteronism (Conn's Syndrome)

Diagnostic test:
Increased Aldosterone with a Decreased Renin
In a patient with a congenital diaphragmatic hernia, what is the first step to Tx?
Tx the Hypoplastic lung
What does a decreasing platelet count signify in a child with Necrotizing Enterocolitis?
How do you differentiate intermittent claudication form a neurogenic source versus a vascular source?
Neurogenic source: Positional and does not stop w/ rest
What is the Tx if claudication does not interfere with daily life?

If it does, what is the first Dx test?

when is it not a surgical possibility to Tx?
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)
A child presents with a mass at the base of the neck, in the supraclavicular area.
Cystic Hygroma
A child presents with a mass up and down the anterior edge of the sternomastoid.
Branchial cleft cysts
What is removed in a Thyroglossal cyst repair?
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
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.
First Diagnostic test?
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)
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.
Diagnostic test?
Dx: Metastatic Squamous Cell CA
from a primary in the head or neck mucosa

Diagnostic test: FNA
(do NOT BX the tumor)
Aside from palpable mass in the neck, what are (3) other potential presentations for a metastatic SCC of the head or neck mucosa?
1. Persistent unilateral ear ache with serous otitis media

2. Persistent hoarseness

3. Unhealing ulcer in the mouth
what (2) times do you Never do a tissue Bx to diagnose cancer in the face/neck?
1. mass in neck when suspecting Mets SCC from head or neck mucosa

2. PAROTID gland
(too close to facial nerve)
Neurological problems of vascular nature have sudden onset. By HPI, how can you tell if it is occlusive versus hemorrhagic?
without Headache = Occlusive

with very severe headache = Hemorrhagic
Location of brain tumor in patient with:

base of Frontal Lobe
Location of brain tumor in patient with:

Loss of upper gaze
Pineal area
Location of brain tumor in patient with:

Ataxia, unstable gait
Posterior Fossa
What is the best imaging method for a brain tumor?
What (2) classes of people are UTIs not expected?

What is the work-up for in this case?
(2 together)
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"
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.
Tx? (2 together)
Dx: Obstruction plus Infection

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)
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)
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
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?

(best way to discriminate b/t intra- or extra- testicular mass)
A patient presents with an acute subdural hematoma without a midline shift or anisocoria (unequal pupils). What is the next step?
Hyperventilation, Diuresis and fluid restriction
What is the first step when suspecting a pulmonary embolism?
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)
What can occur with massive blood loss with multiple transfusions during an abdominal procedure?

Tx: FFP and Platelets
What is the first step in Tx of a rib fracture in an elderly patient?
Intercostal nerve block

(eliminating pain w/o interfering w/ ventilation)
A patient is shot in the lateral thigh. What is the next step in management?
Tetanus prophylaxis

(since there is no damage to vessels, no Doppler, surgical exploration or arteriogram is indicated)
MCC of Transitional cell tumors of the bladder

(66% compared to 15% from Aniline dyes)
When there is a trauma patient that has a hematocrit of < 30, what should be transfused?
Packed RBC
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?
Ulna nerve
How do you treat a patient with a big, palpable pseudocyst of the pancreas?
Endoscopic Cystogastrostomy

(an endoscopic anastomosis b/t the cyst and the stomach)
A man is shot in the upper zone of the neck yet is conscious, hemodynamically stable and neurologically intact. What is the next step?
What is the best drug for a estrogen/progesterone receptor positive breast tumor in postmenopausal patients?

(suppresses production of estrogens)
What nerve during a carotid endarterectomy is prone to damage producing a difficulty in swallowing?
Lack of what procedure can predispose a man to penile cancer?
What electrolyte is extremely increased with a crush injury?
Potassium (causing Hyperkalemia)
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.
Simple Liver Cysts

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

(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)
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?
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)
What is the next step in the fracture of a clavicle?
Figure-eight Cast

(not arteriogram)
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: Emboli in Rt Common Iliac

Tx: Fogarty Balloon-tipped Catheter
Before performing a Pneumonectomy for SCC of the lung, what should be done?
CT scan of the Chest and upper Abdomen
(to rule-out metastasis)
What is the next step to confirm a Dx of PE in a patient that has atelectasis and patchy pneumonic infiltrates?
Spiral CT scan of the Chest

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