Usmle2 Surgery

Front 1

What are the indications for airway placement in trauma?

Back 1

An airway is needed if the patient is unconscious or has noisy breathing. If an indication for securing an airway exists in a patient with potential cervical spine injury, the airway should be secured before treating the cervical spine injury.

Front 2

How is breathing assessed in trauma?

Back 2

Hearing breath sounds on both sides of the chest and satisfactory pulse oximetry establishes that breathing is adequate.

Front 3

What are the clinical signs of shock?

Back 3

Low blood pressure (BP) (<90 mm Hg systolic), fast weak pulse, and low urinary output (<0.5 ml/kg/h). The patient is pale, cold, shivering, sweating, thirsty, and apprehensive.

Front 4

What are the causes of shock in the trauma setting?

Back 4

Hypovolemic-hemorrhagic shock is the most common cause; pericardial tamponade, tension pneumothorax. Pericardial tamponade and tension pneumothorax are caused by trauma to the chest (blunt or penetrating).

Front 5

What sign indicates that shock is caused by bleeding?

Back 5

In shock caused by bleeding, the central venous pressure is low (empty neck veins). In both pericardial tamponade and tension pneumothorax, CVP is high (distended head and neck veins).

Front 6

What signs differentiate pericardial tamponade from tension pneumothorax?

Back 6

In pericardial tamponade there is no respiratory distress. In tension pneumothorax there is severe respiratory distress, one side of the chest has no breath sounds and is hyperresonant to percussion, and there is tracheal deviation.

Front 7

What is the initial treatment of hypovolemic shock?

Back 7

Volume replacement with 2 L of Ringer lactate (without dextrose), and followed by PRBCs until urinary output 0.5-2 ml/kg/h, while not exceeding CVP of 15 mm Hg.

Front 8

What is the management of pericardial tamponade?

Back 8

Evacuation of the pericardial sac by pericardiocentesis, tube, pericardial window, or open thoracotomy. Fluid and blood administration. The diagnosis is clinical (if diagnosis is unclear sonogram may be used).

Front 9

What is the management of tension pneumothorax?

Back 9

Insert a large gauge needle or large IV catheter into the pleural space. Follow with chest tube connected to underwater seal (both inserted high in the anterior chest wall). Do not wait for x-rays or gases.

Front 10

What are the signs of cardiogenic shock?

Back 10

Hypotension with high CVP (distended veins). Cardiogenic shock is caused by massive myocardial damage (myocardial infarction or myocarditis). Treat with circulatory support.

Front 11

What are the signs of vasomotor shock?

Back 11

Vasomotor shock is seen in anaphylactic reactions and high spinal cord transection or high spinal anesthetic. Circulatory collapse in a flushed, "pink and warm" patient. CVP is low (flat veins). Treatment is fluids, vasoconstrictors.

Front 12

What is the treatment of penetrating head trauma?

Back 12

Penetrating head trauma requires surgical repair.

Front 13

What is the treatment of linear skull fractures?

Back 13

Linear skull fractures are not treated if closed. Open fractures require wound closure. Operative treatment is required if the fracture is comminuted or depressed.

Front 14

What is the treatment of head trauma with unconsciousness?

Back 14

Head trauma with unconsciousness requires a CT for intracranial hematomas. If negative and no neurologic deficits, patients can go home if family will wake them up frequently during next 24 h.

Front 15

What are the signs of a fracture affecting the base of the skull?

Back 15

Raccoon, eyes, rhinorrhea, otorrhea or ecchymosis behind ear. Cervical spine should be assessed with a CT. If the patient was unconscious, a CT of head is ordered to rule out intracranial bleeding.

Front 16

What factors cause neurologic damage from trauma?

Back 16

The initial blow, subsequent development of a hematoma that displaces the midline structures, and development of increased intracranial pressure. Surgery can relieve hematoma, and medical measures can prevent increased ICP.

Front 17

What is the presentation of acute epidural hematoma?

Back 17

Modest trauma to head causes unconsciousness, lucid interval, gradual lapse into coma again, fixed dilated pupil on side of hematoma, then contralateral hemiparesis with decerebrate posture. CT: lens-shaped hematoma. Craniotomy.

Front 18

What is the presentation of acute subdural hematoma?

Back 18

Severe trauma and unconsciousness. The patient is usually not fully awake at any point, and the neurologic damage is severe. CT scan shows a semilunar, crescent-shaped hematoma.

Front 19

What is the treatment of subdural hematoma?

Back 19

If midline structures are deviated, craniotomy is beneficial. If there is no deviation, therapy is ICP monitoring, elevate head, hyperventilate, and give mannitol or furosemide. Avoid over diuresis. Hypothermia will reduce brain oxygen demand.

Front 20

What is diffuse axonal injury?

Back 20

Occurs in more severe trauma. CT shows diffuse blurring of gray- white matter interface and punctate hemorrhages. There is no role for surgery unless there is a hematoma. Therapy is directed at preventing increased intracranial pressure.

Front 21

What is chronic subdural hematoma?

Back 21

Occurs in elderly or in alcoholics. A shrunken brain is injured by minor trauma, tearing the venous sinuses. Mental function deteriorates as a hematoma forms. CT is diagnostic, and treatment is evacuation.

Front 22

What is the management of penetrating trauma to the neck?

Back 22

Requires surgical exploration if there is an expanding hematoma, deteriorating vitals, or esophageal or tracheal injury (coughing, hemoptysis). Severe gunshot wounds of the middle zone of the neck are always explored.

Front 23

What is the treatment of gunshot wounds to the upper neck zone?

Back 23

Arteriographic diagnosis and management is preferred; for gunshot wounds to base of neck, arteriography, esophagogram (water-soluble), esophagoscopy, and bronchoscopy help determine the surgical approach.

Front 24

What are the signs of spinal hemisection (Brown-Sequard syndrome)?

Back 24

Usually caused by a knife blade, causing paralysis and loss of proprioception distal to the injury on the injury side and loss of pain perception distal to the injury on the other side.

Front 25

What is the anterior cord syndrome?

Back 25

Usually caused by burst fractures of the vertebral bodies. There is loss of motor function and loss of pain and temperature sensation on both sides distal to the injury. There is preservation of vibratory and positional sense.

Front 26

What is central cord syndrome?

Back 26

Occurs in the elderly with forced hyperextension of the neck after a rear-end collision. There is paralysis and burning pain in the upper extremities, with preservation of function in the lower extremities.

Front 27

What is the management of spinal cord injuries?

Back 27

Precise diagnosis of cord injury is with magnetic resonance imaging. High-dose corticosteroids immediately after the injury.

Front 28

What is a pneumothorax?

Back 28

Results from penetrating trauma (broken rib or penetrating weapon). Moderate shortness of breath, unilateral absence of breath sounds, hyperresonance to percussion. X-ray, chest tube (upper, anterior), connect to underwater seal.

Front 29

What is the presentation of hemothorax?

Back 29

Results from penetrating trauma. Affected side will be dull to percussion. Diagnosed by chest x-ray.

Front 30

What is the treatment of hemothorax?

Back 30

Chest tube placed low. Bleeding will usually stop spontaneously. Surgery is indicated if 1,500 ml or more is removed when the chest tube is inserted, or if >600 ml of blood drains out over 6 hours.

Front 31

What is the management of severe blunt trauma to the chest?

Back 31

Monitor with blood gases and chest x-rays to detect developing pulmonary contusion; check cardiac enzymes (troponins) and electrocardiogram to detect myocardial contusion. Traumatic transection of the aorta should be sought.

Front 32

What is a sucking chest wound?

Back 32

Characterized by a flap over a wound that sucks air with inspiration and closes during expiration. Tension pneumothorax develops. An occlusive dressing should be applied, which allows air out (tape on three sides) but not in.

Front 33

What is the presentation of flail chest?

Back 33

Multiple rib fractures allow a segment of the chest wall to cave in during inspiration and bulge out during expiration (paradoxic breathing).

Front 34

What is the treatment of flail chest?

Back 34

The underlying pulmonary contusion is sensitive to fluid overload, thus treatment includes fluid restriction, use of colloids (plasma or albumin), and diuretics. If a ventilator is needed, bilateral chest tubes are placed to prevent tension pneumothorax.

Front 35

What is the presentation of pulmonary contusion?

Back 35

Occurs after chest trauma with deteriorating blood gases and "white out" of the lungs on chest x-ray. It can appear up to 48 hours after the injury. Treatment is fluid restriction, colloids, diuretics, and blood gas monitoring.

Front 36

What is the presentation of myocardial contusion?

Back 36

Sternal fractures. ECG shows diffuse ST changes or T wave inversion. Troponins are specific. Treat arrhythmias.

Front 37

What is traumatic rupture of the diaphragm?

Back 37

Bowel enters the chest on the left side. Evaluated with laparoscopy. Surgical repair is done via the abdomen.

Front 38

What is the presentation of traumatic rupture of the aorta?

Back 38

Occurs at junction of arch and descending aorta after deceleration injury. Asymptomatic until hematoma ruptures and causes death. X-ray shows wide mediastinum; transesophageal echocardiography, spiral CT, or MRI angiography.

Front 39

What is the presentation of traumatic rupture of the trachea or major bronchus?

Back 39

Subcutaneous emphysema in upper chest and lower neck, or a large air leak from a chest tube. X-ray shows of air in tissues, and fiberoptic bronchoscopy identifies the lesion and allows intubation beyond the lesion. Surgical repair.

Front 40

What is the differential diagnosis of subcutaneous emphysema?

Back 40

Rupture of the trachea, rupture of the esophagus (after endoscopy), and tension pneumothorax.

Front 41

What is the presentation of air embolism?

Back 41

Occurs when subclavian vein is opened to air (CVP disconnected). Sudden collapse and cardiac arrest. Immediate management includes positioning left side down. Prevented by using Trendelenburg when great veins are to be entered.

Front 42

What is the presentation of fat embolism?

Back 42

Respiratory distress after long bone fractures with petechial rashes in axillae/neck; fever, tachycardia, low platelets; hypoxemia, bilateral patchy infiltrates. Fat droplets in the urine. Treatment: respiratory support.

Front 43

What is the management of gunshot wounds to the abdomen?

Back 43

Exploratory laparotomy for repair of intraabdominal injuries. Low caliber gunshot wounds involving the right upper quadrant are managed with conservative therapy with close followup of clinical signs and serial abdominal CTs.

Front 44

What is the management of stab wounds?

Back 44

If penetration has occurred (protruding viscera) or if hemodynamic instability or signs of peritoneal irritation develop, exploratory laparotomy is mandatory. Otherwise, digital exploration of the wound may be sufficient.

Front 45

What is the management of blunt trauma to the abdomen?

Back 45

Exploratory laparotomy if there are signs of peritoneal irritation or signs of internal bleeding shock, low CVP, with no obvious external source of blood loss.

Front 46

What are the signs of internal bleeding in a patient with blunt trauma?

Back 46

Drop in blood pressure, with tachycardia, low CVP, and low urinary output; a cold, pale, anxious patient who is shivering, thirsty, and perspiring profusely. Signs of shock occur when 25 to 30% of blood volume is acutely lost (1,500 ml in an adult).

Front 47

How is blunt trauma intraabdominal bleeding diagnosed?

Back 47

CT shows blood or injury to liver or spleen. Patients with minor injuries who respond to fluid resuscitation do not need surgery. The patient with major injuries and vital signs that do not improve with fluid resuscitation requires surgery.

Front 48

How is intraabdominal bleeding diagnosed in hemodynamically unstable, blunt trauma patients?

Back 48

Sonogram is done in the ER or operating room to determine if there is blood in the peritoneal cavity. If ultrasound is positive, exploratory laparotomy is indicated.

Front 49

What is the treatment of intraoperative coagulopathy during prolonged abdominal surgery for multiple trauma with multiple transfusions?

Back 49

Empiric treatment with platelet packs and fresh-frozen plasma.

Front 50

What is the presentation of the abdominal compartment syndrome?

Back 50

Occurs when large volume of fluids and blood have been given during prolonged laparotomies; tissues are swollen and abdominal wound cannot be closed without excessive tension. A temporary cover is placed over the abdominal contents.

Front 51

What is the management of pelvic fractures with hematoma bleeding?

Back 51

Diagnosis is based on hypovolemic shock with a pelvic fracture and a large pelvic hematoma. External fixation is the best way to diminish the bleeding. For arterial bleeding, arteriographic embolization is effective.

Front 52

What is the management of urologic injuries?

Back 52

Penetrating urologic injuries are surgically explored and repaired. Blunt injuries may affect the kidney after lower rib fractures, or they may affect the bladder or urethra after a pelvic fracture.

Front 53

What are the signs of urethral injury?

Back 53

Occurs in men with pelvic fracture. Blood in meatus, scrotal hematoma. Sensation of bladder fullness with inability to avoid, and a "high-riding" prostate. Foley should not be inserted, but a retrograde urethrogram should be done.

Front 54

What is the management of bladder injuries?

Back 54

Usually associated with pelvic fracture. Diagnosed by retrograde cystogram. Postvoid contrast films may demonstrate extraperitoneal leaks at the base of the bladder. Management is surgical repair with a suprapubic cystostomy.

Front 55

What is the management of renal injuries secondary to blunt trauma?

Back 55

Usually associated with lower rib fractures. Assessment is by CT scan. Surgical intervention is usually not necessary. Renal artery stenosis caused by trauma may lead to renovascular hypertension.

Front 56

What is the management of scrotal hematomas?

Back 56

Scrotal hematomas can become large, but do not need specific intervention unless a sonogram shows that the testicle is ruptured.

Front 57

What is the management of fracture of the penis?

Back 57

Fracture of corpora cavernosa or fracture of tunica albuginea occurs to erect penis during vigorous intercourse. Pain and a penile hematoma. Emergency surgical repair is required to prevent impotence caused by arteriovenous shunts.

Front 58

What is the management of penetrating injuries of the extremities?

Back 58

When no vessels in vicinity of injury: tetanus prophylaxis, cleaning. If penetration is near a vessel: Doppler or arteriograms are done. If there are absent distal pulses or expanding hematoma: exploration, repair, fasciotomy.

Front 59

What is the management of Crushing injuries to the extremities?

Back 59

May cause hyperkalemia, myoglobinemia, myoglobinuria, renal failure, compartment syndrome. Fluids, osmotic diuretics, alkalinization of the urine, and fasciotomy may be required for crush injuries.

Front 60

What is the presentation of high-voltage electrical burns?

Back 60

Severe muscle damage. Myoglobinemia-myoglobinuric-renal failure (fluids, mannitol; alkalinize urine), posterior dislocation of shoulder, compression fractures of vertebral bodies, cataracts, demyelinization.

Front 61

What is the management of respiratory burns?

Back 61

Burns around mouth or soot in throat. Diagnosis with fiberoptic bronchoscopy; blood gases. Intubation should be done if there is an inadequate airway. If carboxyhemoglobin is elevated, 100% oxygen will aid in removal.

Front 62

What is the management of circumferential burns of the extremities?

Back 62

Impaired blood supply because edema accumulates underneath the eschar. Circumferential burns of the chest may interfere with breathing. Escharotomies (no need for anesthesia) will provide immediate relief.

Front 63

How is the extent of burns in the adult estimated?

Back 63

"Rule of nines." The head and each of the upper extremities are assigned 9% of body surface each. Each lower extremity is assigned two 9% units, and the trunk is given four units of 9% each. Second- and third-degree burns are counted.

Front 64

How are fluid requirements estimated for burns?

Back 64

Parkland formula: kg weight x % burn x 4 ml = RL (without dextrose) required for first 24 h, half should be infused in first 8 h; other half in next 16 h. 2,000 ml of 5% D5W for maintenance. Urinary output should be 1-2 ml/kg/h.

Front 65

How does the estimation of fluid requirements in burned babies differ from the adult?

Back 65

Babies have larger heads and smaller legs; thus "rule of nines" assigns two 9's to head, and both legs share a total of three 9's. Babies need proportionally more fluid than adult; 4 to 6 ml/kg/%. Rate is 20 ml/kg/h if >20%.

Front 66

What is the management of burn injuries?

Back 66

Tetanus, cleaning, silver sulfadiazine. Burns near eyes are covered with triple antibiotic. Pain medication IV. After 1 day of NG suction, intensive nutritional support is provided via gut. After 3 weeks, areas that have not regenerated are grafted.

Front 67

What is the management of dog bites that are provoked?

Back 67

If the dog was petted while eating or teased, no rabies prophylaxis is required, other than observation of the dog for developing signs of rabies. Tetanus prophylaxis.

Front 68

What is the management of unprovoked dog bites or bites from wild animals?

Back 68

The animal can be killed and the brain examined for signs of rabies. If the animal is not available, rabies prophylaxis should consist of immunoglobulin plus vaccine. Tetanus prophylaxis should be given.

Front 69

What are the signs of snake envenomation?

Back 69

30% of snake bitten are not envenomated. Signs of envenomation are severe local pain, swelling, discoloration within 30 min of bite. If present, draw blood for typing/cross, coagulation studies, liver/renal function.

Front 70

What is the management of snakebites?

Back 70

Treatment is antivenom, at least five vials. Surgical excision of the bite site or fasciotomy are rarely needed. Splint the extremity during transportation. Sucking out venom, wrapping with ice, and tourniquets are contraindicated.

Front 71

What is the management of bee stings?

Back 71

Bees kill many more people than snakes because of anaphylactic reactions. Wheezing, rash, hypotension caused by vasomotor shock ("pink and warm" shock). Epinephrine 0.3 to 0.5 ml of 1:1,000 solution. Stingers removed by scraping.

Front 72

What is the management of black widow spider bites?

Back 72

Black with a red hourglass on the abdomen. The bite causes nausea, vomiting, and severe generalized muscle cramps. The antidote is IV calcium gluconate and a muscle relaxant.

Front 73

What is the management of brown recluse spider bites?

Back 73

A skin ulcer develops the next day, with a necrotic center and a surrounding halo of erythema. Dapsone. Surgical excision and skin grafting may be needed.

Front 74

What is developmental dysplasia of the hip?

Back 74

Familial. Hips can be easily dislocated posteriorly, and returned to normal with a "snap.? Sonogram is diagnostic. X-rays are not useful because hip is not calcified in newborn. Treatment is splinting with Pavlik harness for 6 months.

Front 75

What is the presentation of Legg-Perthes disease?

Back 75

Avascular necrosis of the capital femoral epiphysis occurs age 6, with limping, decreased hip motion, hip/knee pain. Antalgic gait, passive motion of hip is guarded. AP/lateral x-rays. Treatment: containment of femoral head within acetabulum.

Front 76

What is the presentation of slipped capital femoral epiphysis?

Back 76

Overweight boy, age 12-14, with groin pain, limp. Sole of foot on affected side points toward other foot when sitting. Limited hip motion, and as hip is flexed thigh goes into external rotation. X-rays. Treatment is pinning of femoral head.

Front 77

What is the presentation of septic hip infection?

Back 77

Toddlers with a febrile illness who then refuse to move the hip. The hip is flexed, in slight abduction with external rotation. Elevated sedimentation rate. Aspiration of the hip under general anesthesia. Open drainage if pus is obtained.

Front 78

What is the presentation of acute hematogenous osteomyelitis?

Back 78

Seen in children who have had a febrile illness. Severe localized pain in a bone and no history of trauma to that bone. X-rays are negative for the first 2 weeks. Bone scan is diagnostic. Treat with antibiotics.

Front 79

What is genu varum?

Back 79

Bow-legs are normal up to the age of 3. No treatment is necessary. Persistent varus beyond age 3 is most commonly caused by Blount disease (a disturbance of the medial proximal tibial growth plate). Treatment is surgery.

Front 80

What is genu valgus?

Back 80

Knock-knees are normal between ages 4 and 8. No treatment is necessary.

Front 81

What is the presentation of Osgood-Schlatter disease?

Back 81

Osteochondrosis of tibial tubercle in teenagers with persistent pain over tibial tubercle in absence of knee swelling. Aggravated by contraction of quadriceps. Treated with knee extension cast for 4 to 6 weeks.

Front 82

What is the presentation of club foot?

Back 82

Talipes equinovarus is seen at birth. Both feet are turned inward, plantar flexion of ankle, inversion of foot, adduction of forefoot, and internal rotation of tibia. Serial plaster casts. Half require surgery after age 6-8 months.

Front 83

What is the presentation of scoliosis?

Back 83

Adolescent girls, whose thoracic spines are curved toward right with forward bending. A hump over the right thorax. Severe cases cause decreased pulmonary function. Bracing arrests progression; severe cases may need surgery.

Front 84

What is the presentation of supracondylar fractures of the humerus?

Back 84

Occur with hyperextension of the elbow when a child falls on a hand with the arm extended. Vascular or nerve injuries can occur, leading to Volkmann contracture. Treated with casting or traction.

Front 85

What is the treatment of fractures that involve the growth plate?

Back 85

Closed reduction if fracture does not cross the epiphyses or growth plate and does not involve joint. Open reduction is required if growth plate is in two pieces to prevent deformity.

Front 86

What is the presentation of primary malignant bone tumors?

Back 86

Young persons with persistent low- grade bone pain for several months. X-ray shows invasion of the adjacent soft tissues, a "sunburst" pattern, and periosteal "onion skinning.'

Front 87

What is osteogenic sarcoma?

Back 87

The most common primary malignant bone tumor. 25 years old, usually around the knee (lower femur or upper tibia). "Sunburst" pattern on x-rays.

Front 88

What is Ewing sarcoma?

Back 88

Second most common primary malignant bone tumor; it affects younger children (5 to 15), grows in the diaphyses of long bones. A typical "onion skinning" pattern is seen on x-rays.

Front 89

What is the most common malignant bone tumor in adults?

Back 89

Most malignant bone tumors in adults are metastatic from the breast in women or from prostate in men. Bone scan is more sensitive than x-rays (but not specific - if positive, should follow with x-rays). Lytic lesions may cause fractures.

Front 90

What is the presentation of multiple myeloma?

Back 90

Elderly men with fatigue, anemia, pain of bones. X-rays show multiple, punched-out lytic lesions. Bence-Jones protein in urine and abnormal immunoglobulins in blood by immunoelectrophoresis. Treated with chemotherapy.

Front 91

What are soft tissue sarcomas?

Back 91

Soft tissue mass that relentlessly grows over several months anywhere in the body. Firm, fixed to surrounding structures. Metastasize to lungs, but not to lymph nodes. MRI. Incisional biopsy with wide local excision, radiation, chemotherapy.

Front 92

What is the treatment of clavicular fractures?

Back 92

Typically at the junction of middle and distal thirds. Treated with a figure-of-eight device for 4 to 6 weeks.

Front 93

What is the presentation of anterior dislocation of the shoulder?

Back 93

Most common shoulder dislocation. Hold arm close to body but rotated outward as if they were going to shake hands. Numbness in a small area over deltoid from stretching of axillary nerve. AP and lateral x-rays are diagnostic.

Front 94

What is the presentation of posterior shoulder dislocation?

Back 94

Rarely occurs after severe uncoordinated muscle contractions, such as an epileptic seizure or electrical burn. The arm is held close to the body, internally rotated. Axillary x-ray views or scapular lateral views are needed.

Front 95

What is the presentation of Colles fracture?

Back 95

Distal radius fracture from a fall on outstretched hand in elderly osteoporotic women. Deformed and painful wrist looks like a "dinner fork." Dorsally displaced, dorsally angulated fracture of the distal radius. Close reduction and long arm casting.

Front 96

What is the presentation of Monteggia fracture?

Back 96

Results from direct blow to the ulna. Diaphyseal fracture of the proximal ulna with anterior dislocation of the radial head.

Front 97

What is the presentation of Galeazzi fracture?

Back 97

The distal third of the radius receives a direct blow and is fractured; dorsal dislocation of the distal radioulnar joint. Treatment is open reduction and internal fixation of the radius, and closed reduction of the radioulnar joint.

Front 98

What is the presentation of fracture of the scaphoid (carpal navicular)?

Back 98

Young adult who falls on an outstretched hand. Wrist pain. Tender anatomic snuff box. X-rays are negative, but a thumb Spica cast is indicated. If displaced and angulated fracture, open reduction and internal fixation are needed.

Front 99

What is the presentation of metacarpal neck fractures?

Back 99

Typically the fourth or fifth metacarpal. Happen when a closed fist hits a hard surface. The hand is swollen and tender. X-rays are diagnostic. Close reduction and ulnar gutter splint for mild cases; Kirschner wire or fixation for malalignment.

Front 100

What is the presentation of hip fractures?

Back 100

Elderly who sustain a fall and have hip pain. The affected leg is shortened and externally rotated.

Front 101

What is the presentation of femoral neck fractures?

Back 101

Femoral neck fractures compromise the blood supply of the femoral head if displaced. Treatment is a femoral head prosthesis.

Front 102

What is the treatment of intertrochanteric fracture?

Back 102

Open reduction and pinning. Immobilization is high risk for deep venous thrombosis and pulmonary emboli. Post-op anticoagulation is recommended.

Front 103

What is the treatment of femoral shaft fractures?

Back 103

Intramedullary rod fixation. May cause significant internal blood loss. Open fractures require operative cleaning and closure within 6 hours. Multiple fractures may lead to the fat embolism syndrome.

Front 104

What is the presentation of collateral knee ligament injuries?

Back 104

Caused by sideways impact to knee. Lateral impact tears medial ligaments. With the knee flexed, passive abduction or adduction will allow displacement. Isolated injuries are treated with a hinged cast. When several ligaments torn, surgical repair needed.

Front 105

What is the presentation of anterior cruciate ligament tears?

Back 105

Anterior cruciate ligament injuries are more common than posterior. With knee flexed, leg can be pulled anteriorly (anterior drawer test). MRI. Sedentary patients treated with immobilization; athletes require arthroscopic reconstruction.

Front 106

What are meniscal tears?

Back 106

Pain and swelling after a knee injury, and may cause a catching and locking that limits knee motion, and a "click" when knee is extended. MRI. Arthroscopic repair may save the meniscus. Meniscectomy leads to arthritis.

Front 107

What are tibial stress fractures?

Back 107

Seen in young men subjected to forced marches. Tenderness to palpation over a very specific point on the bone, but x-rays are initially normal. Treat with a cast on crutches, and repeat the x-rays in 2 weeks.

Front 108

What is the presentation of rupture of the Achilles tendon?

Back 108

Middle-age men after severe strain. A loud popping noise is heard, followed by falling and clutching of the ankle. Pain, swelling, and limping. Palpation of the tendon reveals a gap. Surgery achieves a rapid cure.

Front 109

What is the presentation of compartment syndrome?

Back 109

Most frequently occurs in the forearm and lower leg. Caused by prolonged ischemia followed by reperfusion; crushing injuries. Tender and tight to palpation. Pulses may be normal. Emergency fasciotomy. Pain under a cast requires removing cast.

Front 110

What is the presentation of posterior dislocation of the hip?

Back 110

Occurs when the femur is driven backward, such as in a head-on car collision. Hip pain and lies with the leg shortened, adducted, and internally rotated (in a broken hip the leg is also shortened, but it is externally rotated). Emergency reduction.

Front 111

What is the presentation of gas gangrene?

Back 111

Occurs with deep, penetrating, contaminated wounds, after 3 days the patient becomes toxic and moribund. The site is tender, swollen, discolored, and gas crepitation. Treatment is penicillin, debridement, and hyperbaric oxygen.

Front 112

What nerve is often injured by fractures of the humerus?

Back 112

Radial nerve injury can be injured in oblique fractures of the middle to distal thirds of the humerus. If nerve paralysis develops, the nerve is entrapped and surgical exploration is required.

Front 113

What artery is often injured by posterior dislocations of the knee?

Back 113

Popliteal artery injuries can occur in posterior dislocations of the knee. Check pulses, Doppler studies, and arteriogram. Prompt reduction will minimize vascular compromise. Prophylactic fasciotomy if significant leg ischemia.

Front 114

What is the presentation of carpal tunnel syndrome?

Back 114

Occurs with repetitive hand work. Numbness and tingling in hands, particularly at night; in distribution of median nerve (thumb, index, middle finger). The symptoms can be reproduced by tapping the median nerve over the carpal tunnel.

Front 115

What is the treatment of carpal tunnel syndrome?

Back 115

Wrist x-rays (including carpal tunnel view) should be done to rule out other causes. Initial treatment is splints and antiinflammatory agents. If surgery is needed, electromyography should be done first.

Front 116

What is the presentation of trigger finger?

Back 116

Occurs in women who wake up at night with an acutely flexed finger, and are unable to extend it unless they pull. Treatment is steroid injection; surgery.

Front 117

What is the presentation of De Quervain tenosynovitis?

Back 117

Occurs in young mothers who force their hand into wrist flexion and thumb extension to hold the baby's head. Pain along the radial side of the wrist and the first dorsal compartment. Treatment is splinting, NSAIDs; steroid injection. Surgery rarely.

Front 118

What is the presentation of Dupuytren contracture?

Back 118

Occurs in older men of Norwegian ancestry with contracture of the palm and palmar fascial nodules. Surgery is the only effective treatment.

Front 119

What is a finger felon?

Back 119

Abscess in the pulp of a fingertip caused by a penetrating injury. Throbbing pain, abscess, fever. Treatment is surgical drainage.

Front 120

What is the presentation of gamekeeper thumb?

Back 120

Injury of the ulnar collateral ligament caused by forced hyperextension of the thumb. Collateral laxity at the thumb-metacarpophalangeal joint causes joint dysfunctional and pain leading to arthritis. Casting is usually done.

Front 121

What is Jersey finger?

Back 121

Injury to the flexor tendon sustained when the flexed finger is forcefully extended. The distal phalanx of the injured finger does not flex with the others.

Front 122

What is Mallet finger?

Back 122

The extended finger is forcefully flexed, and the extensor tendon is ruptured. The tip of the affected finger remains flexed when the hand is extended, resembling a mallet. Treatment is splinting.

Front 123

What is the management of traumatically amputated digits?

Back 123

The amputated digit should be wrapped in a saline-moistened gauze, placed in a sealed plastic bag, and the bag placed on a bed of ice.

Front 124

What is the presentation of lumbar disk herniation?

Back 124

Occurs at L4-L5 or L5-S1. Peak age is 45-46 years. Vague aching pain before sudden severe pain precipitated by a forced movement."Electrical shock that shoots down the leg." Cannot ambulate, affected leg is flexed. Straight leg-raising test. MRI.

Front 125

What is the treatment of lumbar disk herniation?

Back 125

Bedrest. Pain control with nerve blocks. Surgical intervention is needed if progressive weakness and emergency surgery is required if cauda equina syndrome (distended bladder, flaccid rectal sphincter, perineal saddle anesthesia).

Front 126

What is the presentation of cauda equina syndrome?

Back 126

Distended bladder, flaccid rectal sphincter, perineal saddle anesthesia. Surgical emergency requiring immediate decompression.

Front 127

What is the presentation of ankylosing spondylitis?

Back 127

Occurs in young men in thirties or early forties with chronic back pain, morning stiffness. Pain is worse at rest, improves with activity. Symptoms are progressive. X-rays: "bamboo spine." Associated HLA B-27 antigen. Treatment: NSAIDs, physical therapy.

Front 128

What are the signs of metastatic spine malignancy?

Back 128

Elderly with progressive back pain worse at night, unrelieved by rest or position. Weight loss. X-rays lytic breast cancer metastases at pedicles in women; blastic metastases from prostate in men. Bone scan is a more sensitive. MRI.

Front 129

What are diabetic ulcers?

Back 129

Located at pressure points (heel, metatarsal head, tip of toes, necrotic base with some granulation); caused by neuropathy, and microvascular disease. Healing may occur with control of diabetes, cleaning, leg elevation.

Front 130

What are arterial insufficiency ulcers?

Back 130

Affect feet, tip of toes. Pale base without granulation tissue. Absent pulses, trophic changes, claudication, rest pain. Doppler demonstrates pressure gradient. Absence of a pressure gradient indicates microvascular disease.

Front 131

What are venous stasis ulcers?

Back 131

Develop in chronically edematous, indurated, and hyperpigmented skin above the medial malleolus. Painless with granulating bed. Varicose veins. Treatment is support stockings, Ace bandages, Unna boot. Vein stripping, grafting of the ulcer.

Front 132

What is the presentation of Marjolin ulcer?

Back 132

Squamous cell carcinoma of skin, developing in a chronic leg ulcer. A dirty-looking, deeper ulcer develops at the site, with heaped up tissue growth around the edges. Biopsy is diagnostic. Wide local excision and skin grafting.

Front 133

What is the presentation of plantar fasciitis?

Back 133

Common problem of older, overweight patients with sharp heel pain when walking. The pain is worse in the mornings. X-rays show a bony spur. Tenderness to palpation over spur. Spontaneous resolution in 12-18 months. Treatment is symptomatic.

Front 134

What is the presentation of Morton neuroma?

Back 134

Inflammation of common digital nerve at the third interspace, between the third and fourth toes. The neuroma is palpable and very tender. Caused by pointed, high heel shoes that force the toes together. Management: analgesics and wide shoes.

Front 135

What is the presentation of gout?

Back 135

Swelling, redness, pain of sudden onset at first metatarsal-phalangeal joint in a middle-age, obese man with high uric acid. Uric acid crystals in joint fluid.

Front 136

What is the treatment of gout?

Back 136

Treatment for the acute attack is indomethacin and colchicine. Allopurinol and probenecid for chronic control.

Front 137

What cardiac ejection fraction is a contraindication to surgery?

Back 137

Ejection fraction under 35% (normal is 55%) is a prohibitive cardiac risk for noncardiac operations. Mortality would be 55-90%.

Front 138

What is Goldman's index of cardiac risk?

Back 138

11 points for JVD, 10 points for recent MI, 7 points for PVCs or arrhythmia, 5 points for age >70, 4 points emergency surgery, 3 points for aortic stenosis, poor medical condition, or chest/abdomen surgery. Risk is 1% with total of 5.

Front 139

What is the presurgical management of long-term smokers?

Back 139

Smokers have a high PCO2, low forced expiratory volume in 1 second. Cessation of smoking for 8 weeks and intensive respiratory therapy should precede surgery.

Front 140

What are hepatic risk factors for surgery?

Back 140

40% mortality with either bilirubin above 2, albumin below 3, PT >16, or encephalopathy. 85% mortality if three of the above are present, or with either bilirubin>4, albumin <2, or blood ammonia concentration >150 mg/dl.

Front 141

What are the signs of severe nutritional depletion?

Back 141

Loss of 20% of body weight over months, serum albumin below 3, anergy to skin antigens, or serum transferrin level of less than 200 mg/dl. 5-10 days of preoperative nutritional support will reduce surgical risk.

Front 142

What is the presentation of malignant hyperthermia?

Back 142

Develops after onset of anesthetic (halothane or succinylcholine). T >104 F. Metabolic acidosis, hypercalcemia, myoglobinuria.. Family history. Treatment: dantrolene, oxygen, correction of acidosis, and cooling blankets.

Front 143

What are the causes of postoperative fever?

Back 143

Fever in the range 101 -103 F is caused by atelectasis, pneumonia, urinary tract infection, deep venous thrombophlebitis, wound infection, or abscesses.

Front 144

What is atelectasis?

Back 144

Most common cause of post-op fever on the first day. Rule out other causes by auscultating, x-ray, deep breathing and coughing, postural drainage, incentive spirometry. Bronchoscopy for severe cases.

Front 145

When does pneumonia develop after surgery?

Back 145

Pneumonia may develop after 3 days if atelectasis is present. Fever. Chest x-ray shows infiltrates. Sputum cultures. Treat with appropriate antibiotics.

Front 146

When does urinary tract infection cause fever after surgery?

Back 146

Urinary tract infection causes fever starting on post op day 3. Urinalysis, urinary cultures. Treat with antibiotics.

Front 147

When does deep vein thrombophlebitis cause fever after surgery?

Back 147

Produces fever starting on post operative day 5. Doppler study of deep leg and pelvic veins is the best diagnostic modality. Anticoagulate with heparin.

Front 148

When does wound infection cause fever after surgery?

Back 148

Wound infection produces fever on post op day 7. Erythema, warmth, and tenderness. Treat with antibiotics if there is only cellulitis. Open and drain the wound if there is an abscess. A sonogram may be used to evaluate for abscess.

Front 149

When do deep abscesses cause fever after surgery?

Back 149

Subphrenic, pelvic, or subhepatic cause fever around post operative days 10-15. CT scan is diagnostic. Percutaneous radiologically guided drainage is therapeutic.

Front 150

When do pulmonary emboli occur after surgery?

Back 150

Pulmonary emboli occur on post op day 7 in elderly/immobilized. Sudden pleuritic pain, dyspnea, anxiety, diaphoresis, tachycardia, distended neck veins. Hypoxemia, hypocapnia. Spiral CT. After diagnosis, start heparin.

Front 151

What is the presentation of adult respiratory distress syndrome?

Back 151

Seen in patients with a complicated post-op course, often complicated by sepsis. There are bilateral pulmonary infiltrates and hypoxia with no evidence of congestive heart failure.

Front 152

What is the presentation of delirium tremens?

Back 152

Delirium tremens is common in alcoholics. Confusion, hallucinations, combative behavior on second or third postoperative day. IV benzodiazepines are the therapy for delirium tremens.

Front 153

What are the complications of hyponatremia?

Back 153

Induced by excessive hypotonic IV fluids (D5W) in a postoperative patient with high levels of antidiuretic hormone caused by trauma. Confusion, seizures, coma, death. Treatment is hypertonic saline (500 ml of 3%).

Front 154

What are the complications of hypernatremia?

Back 154

Confusion, lethargy, and coma if rapidly induced by unreplaced water loss. May be caused by surgical damage to the posterior pituitary with unrecognized diabetes insipidus. Replacement of fluid deficit with D5 1/2 NS.

Front 155

What is the cause of zero urinary output after surgery?

Back 155

Zero urinary output typically is caused by a mechanical problem, rather than a renal cause. Zero urinary output is often caused by a plugged or kinked Foley catheter.

Front 156

What is the evaluation of low urinary output after surgery?

Back 156

Urinary output <0.5 ml/kg/h represents fluid deficit or RF. Fluid challenge 500 ml IV over 10 min: Dehydrated patients will increase urine. Urinary Na <20 mEq/L in dehydrated. Urine Na >40 mEq/L in RF. Fractional excretion of Na >1 in RF.

Front 157

What is paralytic ileus?

Back 157

Occurs in the first few days after abdominal surgery. Bowel sounds are absent, there is no passage of gas. Mild distension, no pain.

Front 158

What are the x-ray signs of small bowel obstruction?

Back 158

Early mechanical bowel obstruction is caused by adhesions. X-rays will show dilated loops of small bowel and air-fluid levels. CT scan shows a transition point between proximal dilated bowel and distal collapsed bowel at site of obstruction.

Front 159

What is the presentation of Ogilvie syndrome?

Back 159

Paralytic ileus of colon in elderly, sedentary. Abdominal distention. X-rays: dilated colon. Colonoscopy decompress colon, and rules out a mechanical cause of the obstruction, such as cancer of the colon. Long rectal tube.

Front 160

What is the presentation of wound dehiscence?

Back 160

Occurs around fifth post-op day after laparotomy. Wound may appear intact, but "salmon-colored" peritoneal fluid is soaks dressings.Wound should be taped securely, abdomen should be bound. Reoperation at a later date to correct a ventral hernia.

Front 161

What is the presentation of evisceration?

Back 161

A wound dehiscence where the skin opens up and the abdominal contents escape when the patient coughs, strains, or gets out of bed. The bowel should be covered with large sterile dressings soaked with warm saline. Emergency abdominal closure.

Front 162

What is the treatment of hypernatremia?

Back 162

Loss of water (or other hypotonic fluids) and hypertonicity. Every 3 mEq/L that the serum sodium concentration is above 140, represents 1 L of water lost. Therapy requires volume repletion with NS, then 1/2 NS.

Front 163

What is the treatment of hyponatremia?

Back 163

Water has been retained. Rapid hyponatremia requires 3% hypertonic saline. In slowly developing hyponatremia, therapy is water restriction. In hypovolemic, dehydrated losing GI fluids, volume restoration with NS will correct hypovolemia.

Front 164

What are the causes of hypokalemia?

Back 164

Develops when potassium is lost from the GI tract or urine (loop diuretics, or excessive aldosterone). Hypokalemia develops very rapidly when K moves into cells when diabetic ketoacidosis corrected. Therapy is potassium. Max IV K is 10 mEq/h.

Front 165

What are the causes of hyperkalemia?

Back 165

Occurs slowly in renal failure, and occurs rapidly in crushing injuries, acidosis. Therapy is 50% dextrose and insulin, exchange resins, IV calcium, and dialysis.

Front 166

What are the causes of metabolic acidosis?

Back 166

Excessive acids (DKA, lactic acidosis), loss of bicarbonate GI, or inability of kidney to eliminate acids (RF). pH is low (<7.4), bicarbonate is <25. Abnormal acids cause anion gap (Na exceeds sum of Cl and bicarbonate by >10).

Front 167

What is the most common cause of metabolic alkalosis?

Back 167

Occurs from loss of acidic gastric fluid. There is a high blood pH (>7.4), high serum bicarbonate (>25). An increased intake of KCl (between 5 to 10 mEq/h) will usually allow the kidney to correct the problem.

Front 168

What is the most common cause of respiratory acidosis?

Back 168

Impaired ventilation causes acidosis. Abnormal hyperventilation causes alkalosis. Pco2 is low in alkalosis, high in acidosis with abnormal pH of the blood. Therapy: ventilation in acidosis.

Front 169

What are the symptoms of gastroesophageal reflux?

Back 169

Overweight individual with burning retrosternal pain and "heartburn" that is exacerbated by bending over or lying flat in bed, and relieved by the ingestion of antacids or H2 blockers. Barrett esophagus may develop. Endoscopy, biopsies.

Front 170

What are the indications for surgical treatment of hiatal hernia?

Back 170

Laparoscopic Nissen fundoplication for gastroesophageal reflux is indicated for ulceration, stenosis, or dysplastic changes.

Front 171

What is the evaluation of hiatal hernia?

Back 171

pH monitoring, endoscopic biopsies. Lower esophageal sphincter weakness is measured by manometry. Stomach emptying is assessed by emptying study. Esophagogastric junction is determinated by barium swallow.

Front 172

What is the presentation of achalasia?

Back 172

More common in women. Dysphagia is worse for liquids; regurgitation of undigested food. X- rays show megaesophagus. Manometry is diagnostic. Treatment is dilatations or myotomy.

Front 173

What are the signs of cancer of the esophagus?

Back 173

Dysphagia of solids, then soft foods, liquids, and finally saliva. Weight loss. Squamous cell carcinoma occurs in male smokers/drinkers. Adenocarcinoma is seen with gastroesophageal reflux. Most are treated with palliative surgery.

Front 174

What is the presentation of a Mallory Weiss tear?

Back 174

Occurs after prolonged, forceful vomiting. Bright red blood. Endoscopy establishes diagnosis and allows photocoagulation (laser).

Front 175

What is the presentation of Boerhaave syndrome?

Back 175

Prolonged, forceful vomiting leads to esophageal perforation. Epigastric/sternal pain of sudden onset, followed by fever, leukocytosis, and a septic appearance. Contrast (Gastrografin swallow, barium if negative) is diagnostic.

Front 176

What are the signs of instrumental perforation of the esophagus?

Back 176

Epigastric and low sternal pain after completion of endoscopy. Emphysema in the lower neck. Instrumentation is the most common cause of esophageal perforation. Contrast studies and prompt repair are indicated.

Front 177

What is the presentation of gastric adenocarcinoma?

Back 177

More common in the elderly with anorexia, weight loss, vague epigastric pain or early satiety, hematemesis. Endoscopy and biopsies. CT scan assesses operability. Surgery is the best therapy.

Front 178

What is the presentation of gastric lymphoma?

Back 178

Anorexia, weight loss, early satiety. Treatment: chemotherapy or radiotherapy. Surgery is done if perforation. Low-grade lymphomatoid transformation (MALTOMA) can be reversed by eradication of H. pylori.

Front 179

What are the signs of small bowel obstruction?

Back 179

Caused by adhesions from a prior laparotomy. Colicky abdominal pain, vomiting, abdominal distention, and no passage of gas or feces. High-pitched bowel sounds coincide with pain. X-ray: distended loops of small bowel, with air-fluid.

Front 180

What is the treatment of small bowel obstruction?

Back 180

NPO, NG suction, and IV fluids. Spontaneous resolution may occur.

Front 181

What are the signs of strangulated obstruction?

Back 181

Compromised blood supply causes fever, leukocytosis, constant pain, signs of peritoneal irritation, peritonitis and sepsis. Emergency surgery is required.

Front 182

What is the presentation of mechanical intestinal obstruction caused by an incarcerated hernia?

Back 182

Irreducible hernia that previously was reducible. Surgical repair after rehydration if strangulation; elective repair if the hernia was reduced manually and viable bowel.

Front 183

What is the presentation of carcinoid syndrome?

Back 183

Small bowel carcinoid tumor with liver metastases with diarrhea, flushing of the face, wheezing, and right-sided heart valvular damage with prominent jugular venous pulse. Twenty-four-hour urinary collection for 5-hydroxyindolacetic acid is diagnostic.

Front 184

What is the presentation appendicitis?

Back 184

Anorexia, followed by periumbilical pain becomes sharp, severe, constant, localized to right lower quadrant. Tenderness, guarding, rebound on right below umbilicus. Fever, leukocytosis 10000, with neutrophilia, immature forms. CT: inflammed appendix.

Front 185

What is the presentation of cancer of the right colon?

Back 185

Presents with anemia (hypochromic, iron deficiency) in elderly. Stools will be 4+ for occult blood. Colonoscopy and biopsies are diagnostic. Treatment is right hemicolectomy.

Front 186

What is the presentation of cancer of the left colon?

Back 186

Blood-coated, narrow caliber stools, constipation. Proctosigmoidoscopic biopsies. Full colonoscopy to rule out a second primary. CT assesses operability and extent. Pre-op chemotherapy and radiation may be needed for large rectal cancers.

Front 187

Which types of colonic polyps have a high probability of malignant degeneration?

Back 187

Familial polyposis (and variants such as Gardner), villous adenoma, and adenomatous polyp. Polyps that are not premalignant include juvenile, Peutz-Jeghers, inflammatory, and hyperplastic polyps.

Front 188

What are the indications for surgery for chronic ulcerative colitis?

Back 188

Disease for >20 years, severe interference with nutrition, multiple hospitalizations, high-dose steroids or immunosuppressants, or toxic megacolon (pain, fever, leukocytosis, epigastric tenderness, distended colon).

Front 189

What is pseudomembranous enterocolitis?

Back 189

Overgrowth of C difficile caused by antibiotics. Any antibiotic; clindamycin was first antibiotic described; cephalosporins are most common cause. Profuse, watery diarrhea, crampy pain, fever, leukocytosis. Diagnosis by toxin in stool.

Front 190

What is the treatment of pseudomembranous enterocolitis?

Back 190

Antibiotic should be discontinued. Metronidazole is the treatment of choice, with oral vancomycin is an alternate.

Front 191

What are the signs of hemorrhoids?

Back 191

Internal hemorrhoids are associated with bleeding, or external hemorrhoids are painful. Internal hemorrhoids can become painful and produce itching if prolapse occurs.

Front 192

What is the treatment of internal hemorrhoids?

Back 192

Treated with rubber band ligation. External hemorrhoids may need surgery if conservative treatment fails.

Front 193

What are the signs of an anal fissure?

Back 193

Severe pain with defecation; blood streaks on stools. Fissure is usually posterior, in midline. Treatment is stool softeners, topical nitroglycerin, local injection of botulin toxin, dilatation, or lateral internal sphincterotomy.

Front 194

What are the anal manifestations of Crohn disease?

Back 194

Often causes anal fissures, fistula, or small ulceration that fails to heal and gets worse after surgical interventions.

Front 195

What is the presentation of ischiorectal abscess?

Back 195

Fever with exquisite perirectal pain that prevents sitting or bowel movements. Rubor, dolor, calor, and tumor lateral to the anus between the rectum and the ischial tuberosity. Incision and drainage.

Front 196

What is the presentation of fistula in ano?

Back 196

Permanent tract develops after drainage of an ischiorectal abscess. Fecal soiling and perineal discomfort. Opening is lateral to the anus, a cordlike tract may be felt, and discharge may be expressed. Treat with fistulotomy.

Front 197

What is the presentation of squamous cell carcinoma of the anus?

Back 197

More common in HIV and homosexuals who practice anoreceptive sex. Fungating mass grows out of the anus; metastatic to inguinal nodes. Treatment with chemoradiation, followed by surgery.

Front 198

What are the causes of lower gastrointestinal bleeding?

Back 198

Colon angiodysplasia, polyps, diverticulosis, cancer, hemorrhoids. Elderly patients with anal bleeding usually have an upper GI tract source. The upper GI is the most common source of lower GI bleeding.

Front 199

What is the most likely source of bloody emesis?

Back 199

Vomiting blood always indicates a source within the upper GI (tip of the nose to the ligament of Treitz). A NG tube should be placed in a patient with bleeding per rectum. The next diagnostic test is upper GI endoscopy.

Front 200

What is the evaluation of melena?

Back 200

Black, tarry stools indicates digested blood, originating in the upper GI tract. Workup starts with upper GI endoscopy.

Front 201

What is the diagnostic evaluation for red blood per rectum?

Back 201

Red blood per rectum can be caused by upper or lower source. First pass an NG tube and aspirate gastric contents. If blood is retrieved, an upper source has been established (follow with upper endoscopy).

Front 202

What is the diagnostic evaluation of red blood per rectum if the NG tube retrieves nonbilious fluid without blood?

Back 202

If no blood is retrieved and fluid nonbilious, the nose to pylorus has been excluded. Upper endoscopy should follow. If no blood is recovered from NG tube and fluid is green (bile), an upper GI has been excluded.

Front 203

What is the evaluation of active bleeding per rectum, when an upper GI source has been excluded?

Back 203

Anoscopy for bleeding hemorrhoids. If hemorrhoids have been excluded and if bleeding >2 mL/min, an angiogram should be done. If bleeding <0.5 mL/min, then wait until bleeding stops, then colonoscopy. Tagged RBC study if bleeding 0.5-2 mL/min.

Front 204

What is the evaluation of patients with a recent history of blood per rectum who not actively bleeding at the time of presentation?

Back 204

Start workup with upper GI endoscopy if they are young; elderly patients need an upper and a lower GI endoscopy at the same session.

Front 205

What is the evaluation of blood per rectum in a child?

Back 205

Usually caused by Meckel diverticulum. Workup is technetium scan, looking for the ectopic gastric mucosa.

Front 206

What is the most common cause of massive upper GI bleeding in a multiple trauma or complicated post-op patient?

Back 206

Stress ulcers. Endoscopy will confirm. Angiographic embolization is the best treatment.

Front 207

What are the signs of acute abdominal pain caused by perforation?

Back 207

Sudden, constant pain. Avoids movement, guarding. Signs of peritoneal irritation include tenderness, guarding, rebound, silent abdomen. Free air under diaphragm in upright x-rays. Perforated peptic ulcer is most common cause.

Front 208

What are the signs of acute abdominal pain caused by obstruction?

Back 208

Sudden onset of colicky pain. The patient moves constantly, seeking a position of comfort.

Front 209

What disorder is uniquely characterized by severe abdominal pain with blood in the lumen of the gut?

Back 209

Ischemic colitis.

Front 210

What is the presentation of primary peritonitis?

Back 210

Child with nephrosis and ascites, or an adult with cirrhotic ascites with a diffuse acute abdominal pain with equivocal physical findings, and fever and leukocytosis. Cultures of the ascitic fluid will yield a single organism. Treat with antibiotics.

Front 211

What are the signs of acute pancreatitis?

Back 211

Alcoholic with an upper, acute abdomen. Rapid onset over 2-3 h, with constant, epigastric pain, radiating straight through to back, with nausea, vomiting, retching. Increased amylase or lipase. CT shows pancreatic enlargement and inflammation.

Front 212

What is the treatment of pancreatitis?

Back 212

Nothing per oral, nasogastric suction, IV fluids.

Front 213

What is the presentation of biliary tract disease?

Back 213

Obese woman in her forties with multiple children and right upper quadrant abdominal pain.

Front 214

What are the signs of ureteral stones?

Back 214

Sudden onset of colicky flank pain radiating to inner thigh and scrotum/labia, urgency and frequency; microhematuria on urinalysis. Plain x-rays usually show the stone; CT scan is best diagnostic test.

Front 215

What is the presentation of acute diverticulitis?

Back 215

Inflammatory processes giving acute abdominal pain in the left lower quadrant. Elderly with fever, leukocytosis, peritoneal signs in left lower quadrant; tender mass. CT. Treatment: NPO, IV fluids, antibiotics. Surgery if no response to antibiotics; elec

Front 216

What is the presentation of volvulus of the sigmoid?

Back 216

Elderly with severe abdominal distention. X-rays: air-fluid levels small bowel, distended colon, air-filled loop in RUQ that tapers down toward LLQ (parrot's beak).

Front 217

What is the treatment of volvulus of the sigmoid?

Back 217

Rigid proctosigmoidoscope resolves problem. Rectal tube is left in place. Recurrences are treated with elective resection.

Front 218

What are the signs of mesenteric ischemia?

Back 218

Occurs in elderly with atrial fibrillation or a MI (thrombus in superior mesenteric artery) with an acute abdomen. Blood in the bowel lumen (the only condition of pain with GI bleeding), acidosis and sepsis. Treatment is supportive.

Front 219

What is the presentation of hepatocellular carcinoma?

Back 219

Hepatocellular carcinoma is seen only with cirrhosis. Vague right upper quadrant discomfort and weight loss. Blood marker is alpha-fetoprotein. CT scan will show location and extent. Treatment is resection.

Front 220

What is the most common liver malignancy?

Back 220

Metastatic cancer to the liver is more common than primary cancer of the liver by 20:1. If the primary malignancy is slow growing and the metastases are confined to one lobe, resection can be done. Radioablation.

Front 221

What is the cause of hepatic adenomas?

Back 221

Arise as a complication of birth control pills. Rupture and bleed massively inside the abdomen. CT scan is diagnostic.

Front 222

What is the cause of pyogenic liver abscess?

Back 222

Most often a complication of biliary tract disease, particularly acute, ascending cholangitis. Fever, leukocytosis, and a tender liver. Sonogram or CT scan is diagnostic. Percutaneous drainage is required.

Front 223

What is the presentation of amebic abscess of the liver?

Back 223

Recent immigrants; men from Mexico. Definitive diagnosis is by serology. Treated with metronidazole. Seldom requiring drainage.

Front 224

What are the causes of jaundice in adults?

Back 224

Jaundice may be hemolytic, hepatocellular, or obstructive.

Front 225

What is the presentation of hemolytic jaundice?

Back 225

Usually hyperbilirubinemia of 6 or 8, and all the elevated bilirubin is unconjugated (indirect), with no elevation of the direct, conjugated fraction. No bile in the urine. Workup should determine the cause of hemolysis.

Front 226

What is the presentation of hepatocellular jaundice?

Back 226

Elevation of direct and indirect bilirubin, and very high levels of transaminases, with modest elevation of the alkaline phosphatase. Hepatitis is the most common cause.

Front 227

What is the presentation of obstructive jaundice?

Back 227

Elevations of direct and indirect bilirubin, modest elevation of transaminases, very high alkaline phosphatase. Sonogram for dilatation of ducts, stones. In malignant obstruction, a large, gallbladder is identified (Courvoisier sign).

Front 228

What is the presentation of obstructive jaundice caused by stones?

Back 228

Obese, fecund woman in forties, high alkaline phosphatase, dilated ducts, gallbladder with stones. Endoscopic retrograde cholangiopancreatography confirms.

Front 229

What is the treatment of obstructive jaundice caused by a gallstone?

Back 229

Sphincterotomy to remove common duct stone followed by cholecystectomy.

Front 230

What are the causes of obstructive jaundice caused by tumor?

Back 230

Adenocarcinoma of the head of the pancreas, adenocarcinoma of the ampulla of Vater, or cholangiocarcinoma arising in the common duct.

Front 231

What is the evaluation of obstructive jaundice?

Back 231

Sonogram: dilated gallbladder. CT may reveal pancreatic cancer. If CT is negative, ERCP is next step. Ampullary cancers or cancers of common duct produce obstruction. Cholangiogram will show intrinsic tumors of duct or small pancreatic cancers.

Front 232

What is biliary colic?

Back 232

Stone occludes cystic duct. Colicky pain in RUQ, radiating to right shoulder/back, precipitated by fatty food. Nausea, vomiting. No peritoneal irritation or fever. Lasts 10-30 min. Sonogram gallstones. Elective cholecystectomy.

Front 233

What is the presentation of acute cholecystitis?

Back 233

Starts as a biliary colic, but the stone in the cystic duct causes an inflammatory process in the obstructed gallbladder. Pain constant; fever and leukocytosis; and peritoneal irritation in the right upper quadrant. Liver function tests are normal.

Front 234

What are the ultrasound findings in choledococystis?

Back 234

Sonogram shows gallstones, thick-walled gallbladder, and pericholecystic fluid. Rarely, a radionuclide scan (HIDA) is needed (shows uptake in the liver, common duct, and duodenum, but not in the occluded gallbladder).

Front 235

What is the treatment of cholangitis?

Back 235

NG suction, NPO, fluids, antibiotics. Elective cholecystectomy. If no response, emergency cholecystectomy is needed. Emergency percutaneous transhepatic cholecystostomy may be best temporizing option if surgical risk.

Front 236

What is the presentation of acute ascending cholangitis?

Back 236

Stones in common duct cause ascending infection. Patients are older and sicker. Temperature 104-105 F, with chills, very high WBC, sepsis. Hyperbilirubinemia, high alkaline phosphatase.

Front 237

What is the treatment of acute cholangitis?

Back 237

IV antibiotics and emergency decompression of the common duct by ERCP or by percutaneous transhepatic cholecystectomy. Cholecystectomy.

Front 238

What is the presentation of biliary pancreatitis?

Back 238

Stones impacted in ampulla obstruct pancreatic and biliary ducts. Sonogram confirms gallstones in gallbladder.

Front 239

What is the treatment of biliary pancreatitis?

Back 239

Conservative treatment (NPO, NG suction, fluids) usually leads to improvement, elective cholecystectomy is done later. If stone does not pass, ERCP and sphincterotomy may be required.

Front 240

What are the causes of acute pancreatitis?

Back 240

Complication of gallstones, or in alcoholics. Acute pancreatitis may be edematous, hemorrhagic, or suppurative (pancreatic abscess). Late complications include pancreatic pseudocyst and chronic pancreatitis.

Front 241

What is the presentation of acute pancreatitis?

Back 241

Alcoholic or patient with gallstones with epigastric and midabdominal pain after a heavy meal or alcohol. Pain is constant, radiates to back, vomiting, and retching. Tenderness and mild rebound in the upper abdomen.

Front 242

What are the laboratory abnormalities of pancreatitis?

Back 242

Elevated serum amylase or lipase (early on) or urinary amylase or lipase (after 2 days) are diagnostic. The hematocrit is not decreased. Resolution usually follows a few days of pancreatic rest (NPO, NG suction, IV fluids).

Front 243

What is acute hemorrhagic pancreatitis?

Back 243

Pancreatitis with drop in hematocrit. Ranson's criteria at time of presentation are an elevated WBC, elevated glucose, low calcium. Blood urea nitrogen goes up, metabolic acidosis and low arterial PO2. Abscesses should be drained.

Front 244

What is the presentation of pancreatic abscess?

Back 244

Persistent fever and leukocytosis develop about 10 days after the onset of pancreatitis. CT will reveal the collection of pus, and percutaneous drainage is indicated.

Front 245

What is the presentation of pancreatic pseudocyst?

Back 245

Late sequela of acute pancreatitis or of pancreatic trauma. 5 weeks after the onset of pancreatitis. Collection of pancreatic fluid outside the pancreatic ducts. Pressure symptoms are early satiety, vague discomfort, a deep palpable mass.

Front 246

What is the management of pancreatic pseudocyst?

Back 246

Cysts <6 cm, or present for <6 weeks are not likely to have complications and can be observed for spontaneous resolution. >6 cm or cysts>6 weeks are treated with drainage percutaneously or surgically into GI, or endoscopically into stomach.

Front 247

What is the presentation of chronic pancreatitis?

Back 247

Repeated episodes of pancreatitis (usually alcoholic), eventually developing calcified pancreas, steatorrhea, diabetes, and constant epigastric pain.

Front 248

What is the treatment of chronic pancreatitis?

Back 248

Diabetes,steatorrhea controlled with insulin and pancreatic enzymes, but the pain is resistant to most modalities of therapy. If ERCP shows obstruction and dilatation, operations that drain the pancreatic duct may be effective.

Front 249

What is the management of abdominal hernias?

Back 249

Abdominal hernias should be electively repaired to prevent obstruction and strangulation. Exceptions include umbilical hernias (close spontaneously) and esophageal sliding hiatal hernias.

Front 250

At what age should mammogram screening begin?

Back 250

Mammography should be started at age 40 (earlier if family history). Mammograms are not done before age 20 or during lactation, but mammograms can be done during pregnancy. Mammographically guided multiple core biopsies are the best method of biopsy.

Front 251

What are fibroadenomas?

Back 251

Occur in young women (late teens, early twenties) as a firm, rubbery mass that moves with palpation. Either fine-needle aspirate or sonogram establishs diagnosis. Removal is optional, although most women desire removal.

Front 252

What are giant juvenile fibroadenomas?

Back 252

Occur in very young adolescents; very rapid growth. Removal is needed to avoid deformity of the breast.

Front 253

What is the presentation of cystosarcoma phyllodes?

Back 253

Occurs in the late 20s and grow over many years, becoming very large, replacing and distorting the entire breast. No invasion. Most are benign, but may become malignant sarcomas. Core or incisional biopsy is needed and removal is mandatory.

Front 254

What is the presentation of fibrocystic changes?

Back 254

Cystic mastitis occurs in the thirties and forties (resolves with menopause), with bilateral tenderness related to menstrual cycle (worse in the last 2 weeks). If there is no "dominant" or persistent mass, mammogram is all that is needed.

Front 255

What is the management of persistent cysts?

Back 255

Aspiration is done. If clear fluid is obtained and the mass disappears, no further treatment is indicated. If the mass persists or recurs after aspiration, biopsy is required. If bloody fluid is aspirated, it should be sent for cytology.

Front 256

What is the presentation of intraductal papilloma?

Back 256

Occurs in young women (twenties to forties) with bloody nipple discharge. Mammogram is needed to identify potential lesions, but small papilloma are not visible. Galactogram may be diagnostic and guide surgical resection.

Front 257

What is a breast abscess?

Back 257

Occurs in lactating women. Incision and drainage is needed with biopsy of the abscess wall.

Front 258

What are the signs of breast cancer?

Back 258

Palpable breast mass. Elderly patient, ill-defined, fixed mass, retraction of overlying skin, retraction of the nipple, eczematoid lesions, reddish orange peel skin over the mass (inflammatory cancer), and palpable axillary nodes.

Front 259

What is the diagnostic approach to breast cancer during pregnancy?

Back 259

Diagnosed exactly as in non-pregnant women. Treated the same except for no radiotherapy during the pregnancy, and no chemotherapy during the first trimester.

Front 260

What is the radiologic appearance of breast cancer on mammograms?

Back 260

Irregular area of increased density with fine microcalcifications not present in previous study.

Front 261

What is the treatment of resectable breast cancer?

Back 261

Lumpectomy plus axillary sampling plus post-op radiation; or modified radical mastectomy. Lumpectomy can be offered only when the tumor is small, in a relatively large breast, away from nipple and areola.

Front 262

What is the most common type of breast cancer?

Back 262

Infiltrating ductal carcinoma is most common form of breast cancer. Inflammatory cancer is the only variant with much worse prognosis. Variants (lobular, medullary, mucinous) are treated same as infiltrating ductal cancer.

Front 263

What is ductal carcinoma in situ?

Back 263

Metastases are not possible thus no axillary sampling is needed. Total simple mastectomy is recommended for multicentric lesions throughout the breast, and lumpectomy followed by radiation is done the lesion is confined to one quarter of breast.

Front 264

What are the indications for adjuvant chemotherapy for breast cancer?

Back 264

Adjuvant systemic therapy should follow surgery. Chemotherapy in most cases; hormonal therapy is added if tumor is receptor positive. Premenopausal women receive tamoxifen, postmenopausal receive anastrozole.

Front 265

What are the signs of breast cancer metastasis?

Back 265

Persistent headache or back pain (with localized tenderness) in women who recently had breast cancer suggests metastasis. CT of brain for metastases and bone scan for bone metastases in the pedicles are indicated.

Front 266

What is the evaluation of thyroid nodules?

Back 266

Thyroid nodules in euthyroid patients are indicate cancer. If FNA is benign, observe for growth. If malignant or indeterminate results, follow with a thyroid lobectomy. Thyroidectomy for follicular cancers.

Front 267

What is the likelihood ov cancer in a nodule in a patient who has symptoms of hyperthyroidism?

Back 267

Thyroid nodules in hyperthyroid patients are never caused by cancer. Signs of hyperthyroidism: weight loss, ravenous appetite, palpitations, heat intolerance, moist skin, hyperactivity, tachycardia, atrial fibrillation. TSH is low.

Front 268

What is the presentation of hyperparathyroidism?

Back 268

Most commonly high serum calcium. Repeat calcium determinations, look for low phosphorus, and rule out bone metastases. If findings persist, do parathyroid hormone determination. 90% have single adenoma.

Front 269

What are the signs of Cushing syndrome?

Back 269

Round, ruddy, hairy face, buffalo hump, supraclavicular fat pads, obese trunk with abdominal stria, thin weak extremities. Osteoporosis, diabetes, hypertension, mental instability.

Front 270

How is Cushing syndrome diagnosed?

Back 270

Suppression with low dosage dexamethasone test rules out Cushing. If there is no suppression, 24-h urine cortisol is measured. If elevated, perform high-dose suppression test. Suppression of cortisol at a higher dose identifies pituitary microadenoma.

Front 271

What diagnosis is suggested by a high-dose dexamethasone suppression test that shows no suppression?

Back 271

No suppression identifies adrenal adenoma.

Front 272

What is the presentation of gastrinoma?

Back 272

Aggressive peptic ulcer disease, resistant to therapy (including eradication of pylori) and with multiple ulcers, ulcers extending beyond first portion of the duodenum; watery diarrhea.

Front 273

What is the evaluation of gastrinomas?

Back 273

Measure gastrin, locate the tumor with CT with contrast of pancreas. Remove the gastrinoma. Omeprazole helps with metastatic disease.

Front 274

What is the presentation of insulinoma?

Back 274

CNS symptoms because of hypoglycemia when the patient is fasting. Differentiated from reactive hypoglycemia (attacks occur after eating), and with self-administration of insulin (low C-peptide). CT (with contrast) of pancreas is done to locate tumor.

Front 275

What is nesidioblastosis?

Back 275

Hypersecretion of insulin in the newborn, requiring 95% pancreatectomy.

Front 276

What is the presentation of glucagonoma?

Back 276

Severe migratory necrolytic dermatitis, mild diabetes, anemia, glossitis, and stomatitis. Glucagon assay is diagnostic, CT scan is used to locate the tumor, resection is curative. Somatostatin and streptozocin can help metastatic, disease.

Front 277

What are the causes of primary hyperaldosteronism?

Back 277

Adenoma or hyperplasia of adrenal. Hypokalemia in a hypertensive female who is not on diuretics. Modest hypernatremia and metabolic alkalosis. Aldosterone levels are high, renin levels low. Adrenal CT localizes adenoma.

Front 278

What is the presentation of pheochromocytoma?

Back 278

Thin, hyperactive women with attacks of pounding headache, perspiration, palpitations, and pallor; extremely high blood pressure. The pressure may be normal when measured.

Front 279

What is the laboratory evaluation of pheochromocytoma?

Back 279

24-h urinary vanillylmandelic acid (false positives) or metanephrine (specific). CT of adrenals or radionuclide studies if looking for extraadrenal sites. Tumors are usually large. Surgery after control of hypertension with alpha-blockers.

Front 280

What is the presentation of coarctation of the aorta?

Back 280

Infants with HTN in arms, with normal pressure in the lower extremities. Chest x-ray shows scalloping of the ribs (erosion from large collateral intercostals). Spiral CT scan or MRI angiogram, arteriogram. Surgical correction is curative.

Front 281

What is the presentation of renovascular hypertension?

Back 281

In young women with fibromuscular dysplasia, or old men with arteriosclerotic occlusive disease. Hypertension is resistant to medications, and there is faint bruit over the flank or upper abdomen.

Front 282

What is the evaluation of renovascular hypertension?

Back 282

Doppler of the renal vessels. Arteriographic visualization is often needed. Therapy is balloon dilatation and stenting.

Front 283

What is the presentation of esophageal atresia?

Back 283

Excessive salivation after birth, or choking with first feed. NG tube coiled in upper chest. Normal gas pattern in bowel indicates the most common form in which there is a blind pouch upper esophagus and a fistula between lower esophagus and trachea.

Front 284

What congenital disorder is associated with esophageal atresia?

Back 284

Vertebral, anal, cardiac, tracheal, esophageal, renal, and radial [VACTER] constellation. The anus may be imperforate. Check x-ray for vertebral and radial anomalies, echocardiogram for cardiac anomalies, sonogram for renal anomalies.

Front 285

What is the treatment of imperforated anus?

Back 285

Colostomy is indicated for high rectal pouches, followed later by a repair; or a primary repair can be done if the blind pouch is almost at anus. Level of pouch is determined with x-rays taken upside down, with a metal marker taped to anus.

Front 286

What is the presentation of congenital diaphragmatic hernia?

Back 286

Always on left. Bowel will be up in chest. The hypoplastic lung retains fetal-type circulation. Repair must be delayed 3-4 days to allow maturation. Low-pressure ventilation, sedation, NG suction. Extracorporeal membrane oxygenation.

Front 287

What is the presentation of gastroschisis?

Back 287

Abdominal wall defect in middle of abdomen. In gastroschisis the cord is normal, the defect is to the right of the cord, there is no protective membrane.

Front 288

What is an omphalocele?

Back 288

Cord goes to the defect, which has a thin membrane under which normal bowel is visible with a slice of liver.

Front 289

What is the treatment of gastroschisis?

Back 289

Small defects can be closed primarily, but large defects require construction of a Silastic "silo" to protect the bowel. The contents of the silo are then pressed into the belly. Complete closure can be done in about a week.

Front 290

What is the presentation of exstrophy of the urinary bladder?

Back 290

Abdominal wall defect over the pubis (which is not fused), with a medallion of red bladder mucosa. Repair can be done within the first 1 or 2 days of life.

Front 291

What disorders cause green vomiting in the newborn?

Back 291

Green vomiting and a "double-bubble" are found in duodenal atresia, annular pancreas, or malrotation. Malrotation is diagnosed with contrast enema or upper GI. The first signs of malrotation can appear at any time within the first few weeks of life.

Front 292

What is the presentation of intestinal atresia?

Back 292

Green vomiting, but instead of a double bubble there are multiple air-fluid levels throughout the abdomen.

Front 293

What is necrotizing enterocolitis?

Back 293

Occurs in premature infants at the first feeding. There is feeding intolerance, abdominal distention, and a rapidly dropping platelet count (in babies, a sign of sepsis). Treatment: stop all feedings, broad-spectrum antibiotics, fluids, nutrition.

Front 294

What are the indications for surgery in necrotizing enterocolitis?

Back 294

Surgical intervention is required if they develop abdominal wall erythema, air in the portal vein, intestinal pneumatosis, or pneumoperitoneum (intestinal necrosis and perforation).

Front 295

What is the presentation of meconium ileus?

Back 295

Baby with cystic fibrosis, bilious vomiting. Multiple dilated loops of small bowel and a ground-glass appearance. Gastrografin enema is diagnostic (pellets of meconium in terminal ileum) and therapeutically dissolves the meconium pellets.

Front 296

What is the presentation of hypertrophic pyloric stenosis?

Back 296

Age 3 weeks in first-born boys with nonbilious projectile vomiting after feedings. The infant is hungry, dehydrated, with visible gastric peristaltic waves and a palpable olive-size mass in right upper quadrant. Sonogram is diagnostic.

Front 297

What is the treatment of hypertrophic pyloric stenosis?

Back 297

Therapy begins with rehydration and correction of the hypochloremic, hypokalemic metabolic alkalosis, followed by Ramstedt pyloromyotomy.

Front 298

What is the presentation of biliary atresia?

Back 298

Suspected in 6- to 8-week-old babies with persistent, increasing jaundice. Serologies, sweat test, HIDA scan after 1 week of phenobarbital. If no bile reaches the duodenum with phenobarbital stimulation, surgical exploration is needed.

Front 299

What is the presentation of Hirschsprung disease?

Back 299

Aganglionic megacolon may go undiagnosed. Failure to pass meconium, and constipation. X-rays: distended proximal colon,"normal-looking" distal colon, which is aganglionic. Full-thickness biopsy of rectal mucosa.

Front 300

What is the presentation of intussusception?

Back 300

6- to 12-month-old overweight, child with episodes of colicky abdominal pain. The pain lasts for about 1 minute. Vague mass on the right side of the abdomen and "currant jelly" stools. Barium or air enema is both diagnostic and therapeutic.

Front 301

What is the presentation of congenital vascular rings?

Back 301

Stridor, respiratory distress with hyperextended position for breathing. Difficulty swallowing. Barium swallow: extrinsic compression from abnormal vessel. Bronchoscopy: segmental tracheal compression. Surgery divides aortic arch.

Front 302

What is the presentation of aortic stenosis?

Back 302

Angina and exertional syncope. Harsh midsystolic heart murmur at the right second intercostal space. Echocardiogram. Valvular replacement if there is a gradient > 50 mm Hg, or at first indication of failure, angina, syncope.

Front 303

What is the presentation of chronic aortic insufficiency?

Back 303

Wide pulse pressure, blowing, high-pitched, diastolic heart murmur at second intercostal space and along the left lower sternal border. Valvular replacement at the first evidence on echocardiogram of LV dilatation.

Front 304

What is the presentation of acute aortic insufficiency?

Back 304

Endocarditis in young drug addicts may cause acute congestive heart failure and a new, loud diastolic murmur at the right second intercostal space. Treatment is valve replacement and long-term antibiotics.

Front 305

What is the presentation of mitral stenosis?

Back 305

Caused by rheumatic fever years before. Dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, cough, hemoptysis. Low-pitched, rumbling, diastolic, apical murmur. Cachectic; atrial fibrillation. Echocardiogram.

Front 306

What is the treatment of mitral stenosis?

Back 306

If symptoms: mitral commissurotomy or balloon valvuloplasty.

Front 307

What is the presentation of mitral regurgitation?

Back 307

Exertional dyspnea, orthopnea, and atrial fibrillation. Apical, high-pitched, holosystolic murmur that radiates to the axilla and back. If symptoms become disabling, annuloplasty is preferred over prosthetic replacement.

Front 308

What is the presentation of coronary disease?

Back 308

Middle- age sedentary man, with a family history, a history of smoking, type II diabetes, and hypercholesterolemia. Progressive, unstable, angina is an indicaton for cardiac catheterization and evaluation for revascularization.

Front 309

What are the indications for intervention in coronary disease?

Back 309

Intervention if >70% stenosis, good distal vessel, and adequate ventricular function. Single vessel disease is treated with angioplasty/stent. Triple vessel disease is treated with coronary bypass using internal mammary.

Front 310

What are the hemodynamic signs of left ventricular failure?

Back 310

Cardiac output <5 liters/min, or a cardiac index <3). Pulmonary wedge pressure (or left atrial pressure, or left end-diastolic pressure) <20 suggest the need for more IV fluids. >20 suggests ventricular failure.

Front 311

What is the presentation of chronic constrictive pericarditis?

Back 311

Dyspnea on exertion, hepatomegaly, ascites. Catheterization shows "square root sign," equalization of pressures. Treatment is pericardectomy.

Front 312

What is the treatment of small cell cancer of the lung?

Back 312

Chemotherapy and radiation.

Front 313

What is the most important factor in determining the operability of lung cancer?

Back 313

Operability of lung cancer is predicated on residual function after resection. Central lesions require pneumonectomy. Peripheral lesions can be removed with lobectomy. A minimum FEV1 of 800 ml is needed after surgery.

Front 314

What is subclavian steal syndrome?

Back 314

Stenosis at origin of subclavian before takeoff of vertebral artery allows blood to reach arm. Exercise causes the arm to draw blood away from brain via vertebral artery, causing arm claudication, visual symptoms, disequilibrium.

Front 315

What is the indication for repair of aortic aneurysms?

Back 315

If the aneurysm <4 cm, it can be observed. If >5-6 cm, the patient should have elective repair because chance of rupture is very high. A tender abdominal aortic aneurysm will rupture within a day, and immediate repair is indicated.

Front 316

What is the presentation of ruptured aortic aneurysm?

Back 316

Excruciating back pain with a large abdominal aortic aneurysm indicates that the aneurysm is leaking. Retroperitoneal hematoma is forming, and rupture into the peritoneal cavity will occur in minutes. Emergency surgery is required.

Front 317

What are the signs of arteriosclerotic occlusive disease of the lower extremities?

Back 317

First manifestation is pain brought about by walking and relieved by rest (intermittent claudication). If claudication does not interfere with patient's lifestyle, no evaluation is indicated. Cessation of smoking, exercise, cilostazol are beneficial.

Front 318

What is the evaluation of atherosclerotic occlusive disease?

Back 318

Disabling intermittent claudication is evaluated with Doppler. Arteriogram to identify stenosis. Short stenotic segments can be treated with angioplasty/stenting. Extensive disease requires saphenous vein grafts, sequential stents.

Front 319

What is rest pain?

Back 319

Pain in the calf that prevents sleep. Sitting up and dangling the leg over the edge of the bed relieves the pain. Shiny atrophic skin without hair, and no peripheral pulses.

Front 320

What is the presentation of arterial embolic occlusion?

Back 320

Occurs in atrial fibrillation or a MI (embolus from mural thrombus). Sudden painful, pale, poikilothermic, pulseless, paresthetic, paralytic extremity.

Front 321

What is the treatment of arterial embolic occlusion?

Back 321

Heparin should be initiated. Doppler will locate obstruction. Early occlusion may be treated with thrombolytics. Embolectomy with Fogarty catheter for complete obstructions. Fasciotomy should be added if muscle ischemia has occurred.

Front 322

What is the presentation of dissecting aneurysm of the thoracic aorta?

Back 322

Occurs in the poorly controlled hypertensive. Sudden, severe, tearing chest pain that radiates to back and migrates down. Unequal pulses in upper extremities. X-ray: wide mediastinum. Normal ECG and cardiac enzymes rule out MI. Spiral CT.

Front 323

What is the treatment of dissecting aneurysms of the thoracic aorta?

Back 323

Dissections of the ascending aorta are treated surgically, whereas those in the descending are managed medically with control of the hypertension.

Front 324

What is the presentation of basal cell carcinoma?

Back 324

Raised waxy lesion, or a nonhealing ulcer with a preference for the upper part of the face (above the lips). It does not metastasize, but can cause local invasion. Local excision with 1 mm margins is curative.

Front 325

What is the presentation of squamous cell carcinoma of the skin?

Back 325

Nonhealing ulcer with a preference for the lower lip (and below the lips); can metastasize to lymph nodes. Excision with 0.5 to 2 cm margin, and node dissection. Radiation treatment is another option.

Front 326

What is the presentation of melanoma?

Back 326

Originates in a pigmented lesion. Melanomas are asymmetric (A), have irregular borders (B), have different colors (C) within the lesion, and have a diameter (D) that exceeds 0.5 cm.

Front 327

What is the treatment of melanoma?

Back 327

Lesions <1 mm deep have a good prognosis and require local excision. Deeper lesions require excision with 2-3 cm margin. Lesions >4 mm have a poor prognosis. Lesions between 1 and 4 mm benefit from chemotherapy, node dissection.

Front 328

What is amblyopia?

Back 328

Vision impairment from interference with processing of images during first 6 years. If strabismus is not corrected, there will be permanent cortical blindness. If vision is impeded by congenital cataract, amblyopia will develop.

Front 329

What is the presentation of strabismus?

Back 329

The reflection from a light comes from different areas of cornea in each eye. Strabismus should be surgically corrected when diagnosed to prevent the development of amblyopia.

Front 330

What causes of a white pupil in a baby?

Back 330

Retinoblastoma.

Front 331

What is the presentation of acute angle closure glaucoma?

Back 331

Severe eye pain or frontal headache, starting when pupils were dilated for several hours (watching TV in dark). Halos around lights. Pupil is mid-dilated and does not react to light, cornea is cloudy with a greenish hue, eye feels hard.

Front 332

What is the treatment of angle closure glaucoma?

Back 332

Iridoplasty in which a hole is made in iris to drain anterior chamber. Administer carbonic anhydrase inhibitor (Diamox), apply topical beta-blockers, alpha-2-selective adrenergic agonists. Mannitol and pilocarpine may also be used.

Front 333

What is the presentation of orbital cellulitis?

Back 333

Eyelids are warm, tender, red, and swollen; fever. The pupil is dilated and fixed, and the eye has limited motion. There is pus in the orbit. Emergency CT scan. Treatment is drainage.

Front 334

What is the presentation of retinal detachment?

Back 334

The patient sees flashes of light and"floaters," or "a snow storm" within the eye, or a big dark cloud at top of his visual field. Emergency laser "spot welding" will protect the remaining retina.

Front 335

What is the presentation of embolic occlusion of the retinal artery?

Back 335

Elderly patient with sudden loss of vision from one eye. Treatment is having the patient breathe into a paper bag and apply repeatedly pressure to vasodilate and shake the clot into a more distal location.

Front 336

What is a thyroglossal duct cyst?

Back 336

Located on the midline, at the level of the hyoid bone, and is connected to the tongue; 1 or 2 cm in diameter. Treatment is removal of cyst, middle segment of hyoid bone, and track that leads to base of tongue.

Front 337

What are branchial cleft cysts?

Back 337

Located along the anterior edge of the sternomastoid muscle, several centimeters in diameter, and sometimes have a small opening in the skin overlying them.

Front 338

What is the presentation of cystic hygroma?

Back 338

Located at the base of the neck as a large, soft, ill-defined mass that occupies the entire supraclavicular area and extends deeper into the chest. Often extend into the mediastinum. CT scan is necessary before surgical removal.

Front 339

What is the presentation of lymphoma?

Back 339

Typically seen in young adults with multiple enlarged nodes, low fever, night sweats. Usually a node is excised for pathologic study to determine specific type of lymphoma.Treatment is chemotherapy.

Front 340

What is the presentation of squamous cell carcinoma of the head and neck?

Back 340

Elderly men who smoke, drink, and have dental decay; and patients with AIDS. First sign is metastatic node in neck. Panendoscopy for primary tumor. Treatment is resection, radical neck dissection, radiotherapy, and chemotherapy.

Front 341

What is the presentation of acoustic nerve neuroma?

Back 341

Suspected in an adult who has sensory hearing loss in one ear, but not the other. MRI is the best diagnostic modality.

Front 342

What is the presentation of facial nerve tumors?

Back 342

Gradual unilateral facial nerve paralysis affecting the forehead and the lower face. (sudden onset of facial paralysis suggests Bell palsy.) Gadolinium-enhanced MRI is the best diagnostic study.

Front 343

What is the presentation of pleomorphic, parotid adenomas?

Back 343

Painless, palpable, soft mass around angle of mandible. Benign but have potential for malignant degeneration.

Front 344

What is the presentation of parotid gland cancer?

Back 344

A hard, painful parotid mass or a mass with paralysis is most likely a parotid cancer.

Front 345

What is the presentation of Ludwig angina?

Back 345

Abscess of the floor of the mouth caused by a dental infection. Incision and drainage are done, but intubation and tracheostomy may also be needed.

Front 346

What is the presentation of Bell palsy?

Back 346

Sudden paralysis of the facial nerve. Treatment is acyclovir, famciclovir, or valacyclovir.

Front 347

What is the presentation of cavernous sinus thrombosis?

Back 347

Diplopia (from paralysis of extrinsic eye muscles) in a patient with frontal or ethmoid sinusitis. Requires hospitalization, IV antibiotics, CT scans, and drainage of the affected sinuses.

Front 348

What are the causes of epistaxis?

Back 348

Digital trauma causes bleeding from anterior septum. Cocaine abuse (septal perforation) or juvenile nasopharyngeal angiofibroma. Elderly and hypertensive nosebleeds can be life-threatening.

Front 349

What is the treatment of epistaxis?

Back 349

Phenylephrine spray and pressure controls bleeding. BP should be controlled; posterior packing. Surgical ligation of vessels may be necessary.

Front 350

What are the causes of dizziness?

Back 350

Dizziness may be caused by inner ear disease or cerebral disease. When the inner ear is the cause, the room spins. When the problem is in the brain, the patient is unsteady but the room is stable.

Front 351

What is the treatment of peripheral vertigo?

Back 351

Peripheral vertigo is treated with meclizine, Phenergan, or diazepam.

Front 352

What is the presentation of ischemic stroke?

Back 352

Sudden onset of neurologic deficits occurs without headache when the deficits are caused by an arterial occlusion.

Front 353

What is the presentation of hemorrhagic stroke?

Back 353

Neurologic deficit associated with very severe headache.

Front 354

What is the presentation of brain tumors?

Back 354

Constant, progressive, severe headache with neurologic deficits, worse in the mornings, developing over months. As ICP increases, blurred vision, projectile vomiting, and focal deficits develop.

Front 355

What is the presentation of infectious neurologic problems, such as meningitis?

Back 355

Infectious neurologic problems develop over days and there is an identifiable source of infection. Metabolic problems develop over hours to days and affect the entire CNS. Degenerative diseases develop over years.

Front 356

What are transient ischemic attacks?

Back 356

Sudden, transitory loss of neurologic function without headache which resolves without sequela. Most common origin is stenosis of internal carotid, or ulcerated plaque at carotid bifurcation. TIAs are predictors of stroke.

Front 357

What is the evaluation of transient ischemic attack?

Back 357

Duplex studies (sonogram plus Doppler) followed by arteriogram. Carotid endarterectomy is indicated if the lesions are found in the location that explains the neurologic symptoms.

Front 358

What is the presentation of ischemic stroke?

Back 358

Sudden onset with the neurologic deficits that last for more than 24 hours, leaving permanent sequela without headache. Ischemic strokes are not amenable to carotid endarterectomy

Front 359

What is the evaluation of cerebrovascular accidents?

Back 359

CT scan to rule out extensive infarcts or the presence of hemorrhage. Intravenous infusion of tissue-type plasminogen activator (t-PA) is best if started within 90 minutes up to 4 hours after the onset of symptoms.

Front 360

What is the presentation of intracranial bleeding?

Back 360

Hemorrhagic stroke occurs in uncontrolled hypertension with a sudden, severe headache, followed by neurologic deficits. CT is used to evaluate location and extent of hemorrhage, and therapy is directed at control of hypertension.

Front 361

What is the presentation of subarachnoid bleeding from intracranial aneurysms?

Back 361

Extremely severe headache of sudden onset ("thunderclap"). Because the blood is in the subarachnoid space, there may be no neurologic findings. Meningeal irritation and nuchal rigidity is present.

Front 362

What is the treatment of subarachnoid hemorrhage?

Back 362

CT should be done, looking for blood in subarachnoid space (spinal tap can identify blood that is not visible on CT), and follow with arteriogram to locate the aneurysm of the circle of Willis. Therapy is clipping of aneurysm.

Front 363

What are the symptoms of brain tumors?

Back 363

Progressively increasing headache for several months, worse in mornings, and signs of increased ICP: blurred vision, papilledema, projectile vomiting, bradycardia, hypertension (Cushing reflex). MRI has better detail for tumors.

Front 364

What is the acute management of increased intracranial pressure caused by brain tumors?

Back 364

Increased ICP is treated with high-dose dexamethasone, while awaiting surgical removal.

Front 365

What are the signs of a tumor at the base of the frontal lobe?

Back 365

Inappropriate behavior, optic nerve atrophy on the side of the tumor, contralateral papilledema, and anosmia (Foster-Kennedy syndrome).

Front 366

What is the presentation of craniopharyngioma?

Back 366

Occurs in children who are short for their age with bitemporal hemianopsia and a calcified lesion above the sella turcica.

Front 367

What is the presentation of prolactinomas?

Back 367

Amenorrhea and galactorrhea in young women. Diagnostic evaluation includes pregnancy test, thyroid function tests for hypothyroidism, prolactin level, and MRI of the sella.

Front 368

What is the treatment of prolactinomas?

Back 368

Therapy with bromocriptine is used in most cases. Transnasal, trans-sphenoidal surgical removal is reserved for patients who desire pregnancy, or who fail to respond to bromocriptine.

Front 369

What is the presentation of acromegaly?

Back 369

Large hands, feet, tongue, and jaws. Hypertension, diabetes, headache, and hats that no longer fit.

Front 370

How is acromegaly diagnosed?

Back 370

Somatomedin C and pituitary MRI. Surgical removal is preferred, but radiation is an option.

Front 371

What is the presentation of pituitary apoplexy?

Back 371

Bleeding into a pituitary tumor. Headache, visual loss, headache, followed by signs of compression of nearby structures by hematoma (deterioration of vision, bilateral optic nerve pallor), and pituitary destruction (stupor, hypotension).

Front 372

What is the treatment of pituitary apoplexy?

Back 372

Immediate steroid replacement and replacement of other pituitary hormones. MRI scan.

Front 373

What are the signs of pineal gland tumors?

Back 373

Loss of upper gaze and "sunset eyes" (Parinaud syndrome).

Front 374

What is the most common location of brain tumors in children?

Back 374

Tumors in children are most commonly located in the posterior fossa. Cerebellar symptoms (stumbling, truncal ataxia); children often assume the knee-chest position to relieve headache.

Front 375

What is the presentation of brain abscesses?

Back 375

Headache, signs of increased ICP: blurred vision, papilledema developing over 1-2 weeks. Fever and a source of the infection, such as otitis media or mastoiditis. CT is diagnostic. Drainage is required.

Front 376

What is the presentation of spinal cord tumors?

Back 376

Most tumors affecting the spinal cord are metastatic and extradural. Metastases may compress the cord directly, or may cause a vertebral fracture which compresses the cord. MRI is the best diagnostic modality for the spinal cord.

Front 377

What is neurogenic claudication?

Back 377

Occurs in elderly with pain caused by walking and relieved by rest. The patient can walk without pain when hunched over. Pain is not relieved by rest. Pain is relieved by bending over. The cause is spinal stenosis.

Front 378

What is the presentation of trigeminal neuralgia?

Back 378

Tic douloureux is severe, sharp, shooting, pain in face, triggered by touching cheek. Lasts 60 sec. Patients are in sixties, and have a normal neurologic exam. MRI rules out organic lesions. Anticonvulsants, radiofrequency ablation.

Front 379

What is the presentation of reflex sympathetic dystrophy?

Back 379

Several months after a crushing injury. Severe, constant, burning pain that does not respond to analgesics. Pain is aggravated by slight stimulation of area. Extremity is cold, cyanotic, moist. Sympathetic block is diagnostic. Treatment is sympathectomy.

Front 380

What is the presentation of testicular torsion?

Back 380

Young adolescents with severe testicular pain of sudden onset, but no fever, pyuria, or recent mumps. Testis is swollen, tender, ?high riding? with horizontal lie. The cord is not tender. Immediate surgical detorsion and bilateral orchiopexy.

Front 381

What is the presentation of acute epididymitis?

Back 381

Seen in sexually active young men with severe testicular pain of sudden onset. Fever, pyuria, swollen and tender testis in normal position. Spermatic cord is very tender. Ultrasound is done to exclude torsion.

Front 382

What is the presentation of obstruction and infection of the urinary tract?

Back 382

Destruction of the kidney may occur in a few hours with death from sepsis. A patient with a ureteral stone suddenly develops chills, fever spike (104 F), and flank pain.

Front 383

What is the treatment of septic obstruction of the urinary tract?

Back 383

IV antibiotics, immediate decompression of the urinary tract above the obstruction. Ureteral stent or percutaneous nephrostomy.

Front 384

What is the presentation of acute bacterial prostatitis

Back 384

Seen in older men who have chills, fever, dysuria, urinary frequency, diffuse low back pain, and a tender prostate. Antibiotics are indicated. Continued prostatic massage could lead to septic shock.

Front 385

What is the presentation of posterior urethral valves?

Back 385

Posterior urethral valves are most common reason a newborn boy can not urinate on first day. Catheterization is done. Voiding cystourethrogram is diagnostic, and endoscopic fulguration or resection will remove the valves.

Front 386

What is the presentation of hypospadias?

Back 386

The urethral opening is on the ventral side of the penis. Circumcision should never be done because the skin of the prepuce will be needed for the plastic reconstruction that will eventually be done.

Front 387

What is the presentation of vesicoureteral reflux and infection?

Back 387

Dysuria, frequency, low abdominal and perineal pain, flank pain, fever, chills in a child. Obtain a voiding cystogram looking for reflux. If reflux is found, long-term antibiotics are used for prevention.

Front 388

What is the presentation of low implantation of a ureter?

Back 388

Patient voids normally, but is constantly wet with urine (urine drips from low implanted ureter). If physical examination does not find the abnormal ureteral opening, IVP will demonstrate opening.

Front 389

What is the presentation of ureteropelvic junction obstruction?

Back 389

An anomaly at UPJ allows normal urinary output to flow without difficulty, but if a large diuresis occurs, the narrow area impairs flow, causing colicky flank pain.

Front 390

What is the most common presentation of cancers of the kidney, ureter, and bladder?

Back 390

Hematuria is the most common presentation for cancers of the kidney, ureter, or bladder. Most cases of hematuria are caused by benign disease.

Front 391

What is the evaluation of hematuria?

Back 391

Evaluation begins with a CT scan, looking for renal or ureteral tumors, and continues with cystoscopy, which rules out cancer of the bladder.

Front 392

What is the presentation of renal cell carcinoma?

Back 392

Hematuria, flank pain, and a flank mass. Hypercalcemia, erythrocytosis, and elevated liver enzymes. CT gives the best detail, showing the mass to be heterogenic solid tumor. Treatment is surgery.

Front 393

What is the presentation of transitional cell cancer?

Back 393

Hematuria, irritative voiding symptoms. Correlation with smoking. Diagnosis is by cystoscopy. Treatment is surgery and intravesical Bacillus Calmette-Guerin vaccine. High rate of recurrence requires follow-up.

Front 394

What is the presentation of prostatic cancer?

Back 394

Increases with age. Most asymptomatic. Detected by rectal exam (rock-hard nodule) and prostatic specific antigen. Surveillance stops at age 75. Transrectal needle biopsy. CT assess extent of disease.

Front 395

What is the treatment of prostatic cancer?

Back 395

Surgery and/or radiation. Widespread bone metastases respond for a few years to androgen ablation, surgical (orchiectomy) or luteinizing hormone-releasing hormone agonists, or antiandrogens (flutamide).

Front 396

What is the presentation of testicular cancer?

Back 396

Affects young men, in whom it presents as a painless testicular mass. Testicular tumors are almost always malignant.

Front 397

What is the treatment of testicular cancer?

Back 397

Radical orchiectomy. Blood samples for alpha-fetoprotein and beta- human chorionic gonadotropin. Lymph node dissection in some cases. Most testicular cancers are radiosensitive and chemosensitive.

Front 398

What is the presentation of acute urinary retention?

Back 398

Common in benign prostatic hypertrophy. Precipitated by antihistamines, nasal drops, high fluids. Bladder is palpable. Indwelling catheter should be placed. Therapy is alpha-blockers. 5-Alpha-reductase inhibitors for large prostates.

Front 399

What is the surgical treatment of benign prostatic hyperplasia?

Back 399

Minimally invasive laser heat to destroy prostatic tissue. Microwaves, radiofrequency energy, high-intensity ultrasound waves, high-voltage electrical energy. Transurethral resection of prostate (TURP) is rarely done.

Front 400

What is the presentation of postoperative urinary retention?

Back 400

Very common. The patient may not feel the need to void because of pain medication. Involuntary release of urine every few minutes. Distended bladder will be palpable. An indwelling bladder catheter is needed.

Front 401

What is the presentation of stress urinary incontinence?

Back 401

Common in middle-age multiparas. Leakage of small amounts of urine with intraabdominal pressure caused by sneezing, laughing, lifting. Incontinence does not occur at night. Weak pelvic floor with prolapsed bladder neck.

Front 402

What is the presentation of nephrolithiasis?

Back 402

Passage of ureteral stones produces colicky flank pain with radiation to inner thigh, labia/scrotum. Most are visible on x-rays or CT. Stones <3 mm at ureterovesical junction have a 70% chance of passing spontaneously. 7-mm stone has a 5% probability.

Front 403

What liver condition is associated with an elevated alpha-fetoprotein?

Back 403

Hepatocellular carcinoma

Front 404

What is the presentation of perforated peptic ulcer?

Back 404

Sudden, severe abdominal pain radiating to back and shoulders, nausea, vomiting, rebound tenderness, guarding

Front 405

What is the management of perforated peptic ulcer when free air is present under the diaphragm?

Back 405

Surgery

Front 406

How is severe upper gastrointestinal bleeding managed?

Back 406

ABC's, IV fluids, nasogastric suction, gastric lavage with normal saline, blood transfusion

Front 407

What is the treatment of gastrointestinal bleeding that does not respond to endoscopic treatment?

Back 407

Surgery

Front 408

What are the causes of upper GI bleeding?

Back 408

Duodenal ulcer (40%), gastric ulcer (20%), gastritis (20%), varices (10%), Mallory-Weiss tear (10%)

Front 409

What percentage of gastric tumors are malignant?

Back 409

95% are carcinomas

Front 410

What are the symptoms of gastric cancer?

Back 410

Pain, anorexia, weight loss

Front 411

What are the risk factors for gastric cancer?

Back 411

Age >60, nitrites in diet, chronic gastritis

Front 412

What is a Krukenberg tumor?

Back 412

Metastases to the ovary of a gastrointestinal malignancy

Front 413

What is a Virchow's node?

Back 413

Metastases to the left supraclavicular fossa

Front 414

List the risk factors for cholelithiasis

Back 414

Fertile, fat, forty, female

Front 415

What are the types of gallstones?

Back 415

Cholesterol 75%, pigment stones 25%

Front 416

What is the initial diagnostic test for cholelithiasis?

Back 416

RUQ ultrasound

Front 417

What are the complications of cholelithiasis?

Back 417

Acute cholecystitis, choledocholithiasis, gallstone pancreatitis, gallstone ileus, cholangitis

Front 418

What is acute cholecystitis?

Back 418

Blockage of the cystic duct by an impacted stone, resulting in inflammation, infection, gangrene of gallbladder

Front 419

What is Murphy's sign?

Back 419

Inspiratory arrest upon deep palpation of RUQ in cholecystitis

Front 420

What is the presentation of cholecystitis?

Back 420

Fever, nausea, tender gallbladder, leukocytosis, referred right side subscapular pain

Front 421

What test is indicated when acute cholecystitis is suspected, but the ultrasound is equivocal?

Back 421

Hepatobiliary iminodiacetic acid (HIDA) scan. Failure to visualize the gallbladder is diagnostic of acute cholecystitis

Front 422

How is acute cholecystitis treated?

Back 422

IV fluids, antibiotics, cholecystectomy

Front 423

How is choledocholithiasis treated?

Back 423

Endoscopic retrograde cholangiopancreatography (ERCP) with papillotomy and stone removal

Front 424

What are the complications of choledocholithiasis?

Back 424

Cholangitis, pancreatitis

Front 425

What are the signs and symptoms of obstructive jaundice?

Back 425

Jaundice, pruritus, dark urine, clay-colored stool, weight loss

Front 426

RUQ pain, jaundice, fever/chills are part of what triad?

Back 426

Charcot's triad of cholangitis

Front 427

What is Courvoisier's sign?

Back 427

Painless enlargement of the gallbladder, jaundice caused by cancer of the head of the pancreas

Front 428

What are the common lab abnormalities in cholangitis?

Back 428

Leukocytosis, elevated direct bilirubin, increased alkaline phosphatase (bile duct obstruction from inflammation)

Front 429

What organism is the cause of cholangitis?

Back 429

E coli

Front 430

How is cholangitis treated?

Back 430

IV fluids, antibiotics, endoscopic retrograde cholangiopancreatography with papillotomy

Front 431

What disorder commonly occurs with sclerosing cholangitis?

Back 431

Inflammatory bowel disease

Front 432

What is the surgical procedure for distal cholangiocarcinoma?

Back 432

Whipple procedure, consisting of pancreaticoduodenectomy

Front 433

What are the causes of acute pancreatitis?

Back 433

Gallstones, ethanol, ERCP, trauma, steroids, mumps and other viruses, autoimmune disorders, scorpion stings, hypertriglyceridemia, didanosine

Front 434

What is Cullen's sign?

Back 434

Periumbilical ecchymosis in hemorrhagic pancreatitis

Front 435

What is Grey-Turner sign?

Back 435

Flank ecchymoses in hemorrhagic pancreatitis

Front 436

pancreatitis

Back 436

Systemic inflammatory response syndrome, necrosis, pseudocyst, pancreatic ascites, fistula, cystic duct obstruction, intestinal obstruction

Front 437

Name two signs of acute pancreatitis on abdominal x-ray

Back 437

Sentinel loop of dilated bowel in LUQ next to inflamed pancreas. Colon cutoff sign: Distended transverse colon and absence of colonic gas distal to splenic flexure.

Front 438

Severe pancreatitis should be evaluated by what radiologic study?

Back 438

Abdominal CT

Front 439

How should suspected gallstone pancreatitis be evaluated?

Back 439

Ultrasound of RUQ for gallstones

Front 440

Prognosis in acute pancreatitis is estimated by what criteria?

Back 440

Ranson's criteria: 1-2 (<5% mortality rate), 3-4 (15%), 5-6 (40%), 7-8 (100%)

Front 441

What are Ranson's criteria for acute pancreatitis at presentation?

Back 441

Age >55, WBC >16,000, glucose >200, AST > 250, LDH >350

Front 442

What are Ranson's criteria for acute pancreatitis at 48 hours?

Back 442

Base deficit >4, increase in BUN >5, fluid sequestration >6 L, Ca2+ <8.5, decrease in Hct > 10%, PaO2 <60

Front 443

List the four common laboratory abnormalities in acute pancreatitis

Back 443

Hyperamylasemia within 24 h, hyperlipasemia within 72-96 h, hypocalcemia, glycosuria

Front 444

What are the indications for drainage of a pancreatic pseudocyst?

Back 444

Cyst >6 cm for 6 weeks, or infection of the pseudocyst

Front 445

What are five common causes of chronic pancreatitis?

Back 445

Alcoholism, biliary tract disease, cystic fibrosis, hypercalcemia, pancreas divisum

Front 446

How does a mass of the pancreatic head usually present?

Back 446

Obstructive, painless jaundice, malabsorption, Courvoisier's gallbladder (enlarged, palpable gallbladder)

Front 447

Name the serologic markers for pancreatic cancer

Back 447

Carcinoembryonic antigen, CA 19-9

Front 448

A tumor of the head of the pancreas should be treated with what surgical procedure?

Back 448

Whipple procedure (pancreaticoduodenectomy)

Front 449

What is the most common benign liver tumor?

Back 449

Hemangioma

Front 450

What is the most common primary liver cancer?

Back 450

Hepatocellular carcinoma (hepatoma)

Front 451

What is the most common type of liver cancer?

Back 451

Metastatic cancer

Front 452

Name the liver tumor that is associated with oral contraceptives and anabolic steroids.

Back 452

Hepatic adenoma

Front 453

How is hepatic adenoma treated?

Back 453

Discontinuation of birth control pills and observation

Front 454

What is the most common cause of parasitic liver abscesses?

Back 454

Entamoeba histolytica

Front 455

What is the sign of Pseudomonas aeruginosa infection of wounds and burns?

Back 455

Fruity odor

Front 456

What are the major risk factors for hepatocellular carcinoma?

Back 456

Wilson's disease, alpha-1-antitrypsin deficiency, carcinogens, hemochromatosis, alcoholic cirrhosis, hepatitis B, hepatitis C

Front 457

What are two factors that contribute to the formation of hernias?

Back 457

Increased intraabdominal pressure (lifting, straining, cough, pregnancy, ascites, obesity) and congenital defects

Front 458

What is an indirect inguinal hernia?

Back 458

Inguinal hernia that protrudes from the peritoneal cavity lateral to the epigastric vessels

Front 459

What is a direct inguinal hernia?

Back 459

Inguinal hernia that protrudes from the peritoneal cavity medial to the epigastric vessels

Front 460

What is a femoral hernia?

Back 460

Hernia that protrudes through the femoral sheath in the femoral canal medial to the femoral vein

Front 461

What is the name of the hernia that protrudes through esophageal hiatus?

Back 461

Hiatal hernia

Front 462

What type of hernia is incarcerated and only involves one side of th bowel wall?

Back 462

Richter's hernia

Front 463

What is the most common hernia in both males and females?

Back 463

Indirect inguinal hernia; the hernia that protrudes from the peritoneal cavity lateral to the epigastric vessels

Front 464

What type of hernia is more common in females than males?

Back 464

Femoral hernia

Front 465

What are the symptoms and signs of small bowel obstruction?

Back 465

Abdominal discomfort or pain, nausea, vomiting, distension, cramping, high-pitched bowel sounds

Front 466

Name the two most common causes of small bowel obstruction

Back 466

Adhesions, hernias

Front 467

How should adhesive small bowel obstruction be treated initially?

Back 467

NPO, IV fluids, nasogastric suction

Front 468

Name the signs of small bowel obstruction on abdominal x-ray

Back 468

Distended bowel loops, air-fluid levels, paucity of gas in colon

Front 469

What is the typical acid-base disturbance caused by small bowel obstruction?

Back 469

Hypovolemic hypochloremic hypokalemic alkalosis caused by vomiting

Front 470

What is the presentation of large bowel obstruction?

Back 470

Cramping, abdominal pain, distention, nausea, feculent vomitus

Front 471

List the three most common causes of large bowel obstruction

Back 471

Colon cancer, diverticulitis, volvulus

Front 472

Name the two most common causes of lower GI bleeding

Back 472

Diverticulosis, angiodysplasia

Front 473

Rectal cancer usually presents with what findings?

Back 473

Hematochezia, tenesmus, incomplete evacuation of stool

Front 474

After treatment of colon cancer, what marker should be followed?

Back 474

Carcinoembryonic antigen

Front 475

How does appendicitis classically present?

Back 475

Periumbilical pain, followed by nausea and vomiting, anorexia; followed later by right lower quadrant pain

Front 476

In patients with appendicitis, what is the chronological order in which pain, nausea, and vomiting occur?

Back 476

Pain usually occurs before nausea and vomiting in appendicitis; however, in gastroenteritis, nausea and vomiting occur before pain.

Front 477

What laboratory tests should be ordered for suspected appendicitis?

Back 477

CBC, urinalysis, beta-hCG, radiographs of abdomen, chest x-ray, abdominal ultrasound

Front 478

Ovarian causes of abdominal pain should be evaluated with what test?

Back 478

Ultrasound

Front 479

Where on the abdomen is McBurney's point?

Back 479

Point of maximal tenderness located one-third of the distance from the anterior iliac spine to the umbilicus associated with appendicitis

Front 480

When palpation of the left lower quadrant causes pain in the right lower quadrant, what sign is present?

Back 480

Rovsing's sign associated with appendicitis

Front 481

What is the obturator sign?

Back 481

Pain on internal rotation of the leg with the hip and knee flexed, suggesting appendicitis

Front 482

What is the management of abscess caused by appendicitis?

Back 482

Percutaneous drainage, antibiotics, appendectomy in 6-8 weeks

Front 483

What is the most common tumor of the appendix?

Back 483

Carcinoid tumor

Front 484

What substances do carcinoid tumors secrete?

Back 484

Serotonin, histamine, prostaglandins

Front 485

What is the second most common cause of cancer death in women?

Back 485

Breast cancer

Front 486

What area of the breast is the most common site of breast cancer?

Back 486

Upper outer quadrant

Front 487

List the classic symptoms and signs of breast cancer?

Back 487

Mass, dimple, nipple retraction, nipple discharge, rash, edema, enlarged axillary lymph node

Front 488

How should a nonpalpable, suspicious lesion on mammography be evaluated?

Back 488

Stereotactic or needle localized excisional biopsy

Front 489

What is the most common cause of bloody nipple discharge?

Back 489

Intraductal papilloma

Front 490

What is Paget's disease of the breast?

Back 490

Invasion of epidermal layers of the skin near the nipple by tumor cells

Front 491

What is mastitis?

Back 491

Infection of the breast, usually caused by Staphylococcus aureus, associated with breast feeding

Front 492

What is the treatment of breast fibroadenoma?

Back 492

Observation or excisional biopsy

Front 493

What is the treatment of breast mastitis?

Back 493

Cephalexin (Keflex) or dicloxacillin and continued breast feeding

Front 494

What is the treatment for breast ductal carcinoma in situ?

Back 494

Lumpectomy plus radiotherapy or total simple mastectomy

Front 495

What is the treatment for lobular carcinoma in situ?

Back 495

Close follow-up or bilateral simple mastectomy in high-risk patients

Front 496

What is the best treatment for invasive breast carcinoma?

Back 496

Lumpectomy plus radiotherapy or modified radical mastectomy (chemotherapy optional for both); sentinel lymph node biopsy and axillary lymph node dissection.

Front 497

What are the recommendations for breast cancer screening?

Back 497

Monthly self-breast examinations, annual breast examinations by physician after 40 years old, annual mammograms after 40 years old.

Front 498

List the major risk factors for peripheral vascular disease?

Back 498

Smoking, diabetes

Front 499

What are two common symptoms of peripheral vascular disease?

Back 499

Intermittent claudication, ischemic rest pain

Front 500

List the signs of peripheral vascular disease?

Back 500

Absent pulses, atrophic skin changes (shiny skin, hair loss, thick toenails), dependent rubor, muscle atrophy, gangrene of skin

Front 501

What is claudication?

Back 501

Reproducible lower extremity pain, usually calves, exacerbated by walking and relieved by rest

Front 502

What percentage of patients with leg claudication will lose a limb in 5 years?

Back 502

5%. Claudication is not a limb-threatening condition

Front 503

What is ischemic rest pain of the foot?

Back 503

Severe foot pain at rest caused by peripheral vascular disease

Front 504

How do patients with ischemic rest pain obtain partial pain relief?

Back 504

Hanging the foot over the side of the bed in a dependent position

Front 505

What is the prognosis for ischemic rest pain of the lower extremity?

Back 505

Ischemic rest pain is limb-threatening because 85% of patients will lose the limb in 5 years

Front 506

What test is the gold standard for diagnosis of peripheral vascular disease?

Back 506

Arteriogram

Front 507

Initial management of peripheral vascular disease consists of what conservative measures?

Back 507

Smoking cessation, exercise, aspirin, clopidogrel (Plavix)

Front 508

List the interventional options for peripheral vascular disease

Back 508

Percutaneous transluminal angioplasty, surgical revascularization, amputation

Front 509

When is surgery indicated for peripheral vascular disease?

Back 509

Rest pain, loss of tissue, incapacitating claudication

Front 510

Name the ?six P's? that indicate acute arterial occlusion

Back 510

Pain, Pallor, Pulselessness, Paralysis, Poikilothermia (cold), Paresthesias

Front 511

Acute arterial occlusion is most commonly cause by what cause?

Back 511

Embolization, usually from the heart thrombi in 85%

Front 512

What is the medical treatment for acute arterial occlusion?

Back 512

Heparin

Front 513

What is the treatment for compartment syndrome of an extremity?

Back 513

Emergent fasciotomy

Front 514

What are the five risk factors for abdominal aortic aneurysm?

Back 514

Atherosclerosis, smoking, hypertension, age >60 years, male gender

Front 515

Abdominal aortic aneurysm occurs most frequently at what location?

Back 515

Below the renal arteries

Front 516

When is surgery indicated for an abdominal aortic aneurysm?

Back 516

More than 5 cm in size or growth >4 mm/year or if symptomatic

Front 517

What is the classic triad of ruptured abdominal aortic aneurysm

Back 517

Abdominal pain, hypotension, pulsatile abdominal mass

Front 518

What is the name and treatment of the fracture of the fifth metacarpal that occurs after striking an object with a fist?

Back 518

Boxer fracture; treat with closed reduction and ulnar splint. If skin broken, débride and give amoxicillin/clavulanate (Augmentin), cefuroxime (Ceftin) or doxycycline for human oral pathogens

Front 519

What is the name and treatment of the fracture of the carpal bone that causes tenderness in the anatomical snuffbox?

Back 519

Scaphoid fracture. Treatment is thumb Spica cast.

Front 520

What is the most common fracture of the wrist that results from a fall on an outstretched hand and causes fracture of the distal radius with dorsal displacement of the distal fragment?

Back 520

Colles' fracture. Treat with closed reduction and cast.

Front 521

What is the name and treatment of ulnar diaphyseal fracture and dislocation of the radial head?

Back 521

Monteggia fracture (?nightstick fracture?). Treatment is closed reduction of the radial head and open reduction, internal fixation of ulna.

Front 522

What is the name and treatment of radial head subluxation caused by forceful pulling by the hand?

Back 522

Nursemaid elbow. Treatment is manual reduction by supination at 90 elbow flexion.

Front 523

What is the name and treatment of the most common shoulder dislocation (95%)?

Back 523

Anterior shoulder dislocation. Treatment is closed reduction, sling, rehabilitation.

Front 524

What is the name and treatment of the most common fracture in school-aged children, which may also threaten the brachial artery?

Back 524

Supracondylar fracture of the humerus. Treatment is closed reduction and pinning.

Front 525

What is the differential diagnosis of abdominal pain in the right lower quadrant?

Back 525

Appendicitis, ovarian cyst, pelvic inflammatory disease, ectopic pregnancy, inflammatory bowel disease, Meckel's diverticulitis, intussusception

Front 526

What is the most common cause of abdominal pain in the left lower quadrant?

Back 526

Diverticulitis, ovarian cyst, pelvic inflammatory disease, ectopic pregnancy, inflammatory bowel disease, Meckel's diverticulitis, intussusception

Front 527

What is the most common cause of left lower quadrant abdominal pain?

Back 527

Diverticulitis, pelvic inflammatory disease, ectopic pregnancy, ovarian cyst, mass obstructing the colon, constipation, sigmoid volvulus

Front 528

What is the most common cause of right upper quadrant pain?

Back 528

Cholecystitis, choledocholithiasis, cholangitis, hepatitis, hepatoma, pneumonia

Front 529

What are the common causes of epigastric pain?

Back 529

Peptic ulcer, gastritis, gastroenteritis, pancreatitis, myocardial infarction

Front 530

25 year old with vomiting of blood after taking naproxen and 5 glasses of vodka, diaphoretic, epigastric tenderness. What is the diagnosis?

Back 530

Acute gastritis

Front 531

34 year old with peptic ulcer disease, melena, tachycardia, diaphoretic, epigastric tenderness; nasogastric aspirate is bloody. What is the diagnosis?

Back 531

Bleeding duodenal ulcer

Front 532

52 y/o prior abdominal surgeries, abdominal pain, nausea, vomiting, obstipation; hyperactive bowel sounds, distended abdomen; dilated loops of small bowel, paucity of colon gas, air-fluid levels. Diagnosis?

Back 532

Small bowel obstruction

Front 533

80 year old smoker with atrial fibrillation, diabetes, sudden onset of pain and numbness in right leg; leg is poikilothermic, pulseless. Angiogram demonstrates occlusion of common femoral artery. What is the diagnosis?

Back 533

Acute arterial occlusion

Front 534

8 year old boy with involuntary tics, such as eye blinking, coughing, throat clearing, sniffing, and facial movements; coprolalia. What is the diagnosis?

Back 534

Tourette's syndrome

Front 535

What are the signs of basilar skull fracture?

Back 535

Hemotympanum, clear otorrhea/rhinorrhea, raccoon eyes, Battle sign (mastoid ecchymosis)

Front 536

Ecchymosis of the lower abdomen from a seatbelt is a sign of what injury?

Back 536

Small bowel perforation

Front 537

What is Beck's triad, which is seen in cardiac tamponade and tension pneumothorax?

Back 537

Hypotension, jugular venous distension, decreased heart sounds

Front 538

What are the signs of tension pneumothorax?

Back 538

Unilateral absence of breath sounds, jugular venous distension, mediastinal shift

Front 539

Difficulty swallowing liquids which is greater than difficulty with solids suggests what type of disorder?

Back 539

Oropharyngeal dysphagia

Front 540

Difficulty swallowing both liquids and solids occurs in what disorder?

Back 540

Esophageal dysphagia

Front 541

How does mechanical obstruction affect the ability to swallow solids and liquids?

Back 541

Difficulty swallowing solids is greater than difficulty swallowing liquids when mechanical obstruction is the cause

Front 542

How is Zenker's diverticulum treated?

Back 542

Myomectomy and excision of diverticulum

Front 543

What are the causes of esophageal dysphagia?

Back 543

Achalasia, esophageal stricture, esophageal web, scleroderma, esophageal cancer

Front 544

What is achalasia?

Back 544

Ganglionic loss causing inability of the lower esophageal sphincter to relax and loss of peristalsis; ?bird beak? appearance on barium swallow and increased pressure of lower esophageal sphincter.

Front 545

What is Plummer-Vinson syndrome?

Back 545

Iron-deficiency anemia, dysphagia, esophageal web, atrophic glossitis

Front 546

What is Barrett's esophagus?

Back 546

Columnar metaplasia of squamous epithelium of distal esophagus, occurring because of acid injury from gastroesophageal reflux disease

Front 547

What is the complication of Barrett's esophagus?

Back 547

Esophageal cancer

Front 548

Which esophageal cancer is associated with alcohol and tobacco use?

Back 548

Squamous cell cancer

Front 549

What is the surgical term for esophageal perforation caused by severe vomiting?

Back 549

Boerhaave's syndrome

Front 550

What are the signs of gastroesophageal reflux disease?

Back 550

Substernal chest pain, heartburn, regurgitation, which are worse after meals and in the supine position

Front 551

How is Barrett's esophagus treated?

Back 551

Antacids, H2 blockers or proton pump inhibitors; surveillance EGD and biopsies

Front 552

List the complications of gastroesophageal reflux disease

Back 552

Ulceration, strictures, Barrett's esophagus, bleeding, aspiration

Front 553

What are the common causes of epigastric pain?

Back 553

Peptic ulcer disease, gastritis, pancreatitis, cholecystitis, coronary ischemia, gastroesophageal reflux disease

Front 554

What is priapism?

Back 554

Intractable, painful erection; caused by venous thrombosis, trazodone, sickle cell disease

Front 555

What is balanitis?

Back 555

Inflammation of the glans caused by poor hygiene

Front 556

What is testicular torsion?

Back 556

Twisting of the vasculature of the testicle; spontaneous or caused by trauma; usually rotates medial; therefore, detorsion is usually accomplished by twisting the testicle laterally.

Front 557

What is a hydrocele testes?

Back 557

Collection of fluid in the tunica vaginalis

Front 558

What is a varicocele?

Back 558

Palpable, ?bag of worms? dilation of veins of the spermatic cord

Front 559

What are the complications of cryptorchidism?

Back 559

5-10 times increased risk of germ cell tumors; atrophy, sterility, and inguinal hernias

Front 560

What is the treatment for cryptorchidism?

Back 560

Orchiopexy; will decrease the risk of sterility, but not decrease the risk of malignancy

Front 561

What is the most common cause of orchitis?

Back 561

Mumps virus; orchitis occurs 1 week after parotiditis

Front 562

What organisms are the most likely cause of epididymitis in children?

Back 562

Gram-negative rods

Front 563

What is the cause of squamous cell carcinoma of the penis?

Back 563

Human papilloma virus types 16, 18, 31, and 33

Front 564

What category of testicular tumors accounts for 95% of all cases?

Back 564

Germ cell tumors; peak incidence of 15-34 years of age

Front 565

What is a seminoma of the testes?

Back 565

Malignant, painless enlargement of testis; most common germ cell tumor, radiosensitive

Front 566

What grading system is used to stage prostatic carcinoma?

Back 566

Gleason system

Front 567

Which prostate disorder commonly affects the peripheral zone?

Back 567

Prostatic carcinoma

Front 568

Which prostate disorder commonly affects the central zone?

Back 568

Nodular hyperplasia

Front 569

Which prostate disorder causes an increase in total prostate-specific antigen, with a decreased fraction fo free prostate specific antigen?

Back 569

Prostatic carcinoma

Front 570

Which prostate disorder causes an increase in total prostate-specific antigen, with a proportionate increase in the fraction of free prostate specific antigen?

Back 570

Nodular hyperplasia

Front 571

A patient with prostate cancer and an increased prostatic acid phosphatase is likely to have what complication?

Back 571

Penetration of the prostate capsule by the prostate cancer

Front 572

A patient with prostate cancer and an increased alkaline phosphatase is likely to have what complication?

Back 572

Osteoblastic lesions from bony metastasis of the prostate cancer

Front 573

What is the primary arterial supply to the gonads?

Back 573

The testicular or ovarian arteries supply the gonads, which branch from the abdominal aorta

Front 574

What is the primary venous drainage of the gonads?

Back 574

The gonads on the left drain to the left testicular/ovarian vein, which drains to the left renal vein. The gonads on the right drain to the right testicular/ovarian vein, which drains into inferior vena cava

Front 575

What is the lymph drainage of the gonads?

Back 575

Deep lumbar nodes

Front 576

What are the contents of the spermatic cord?

Back 576

Genitofemoral nerve, ductus deferens, ductus deferens artery, pampiniform venous plexus, autonomic nerves (sympathetic and parasympathetic), cremasteric muscle and vessels, testicular artery, lymphatics.

Front 577

What structures are found in the transverse cervical (cardinal) ligament of the uterus?

Back 577

Uterine vessels

Front 578

What structures are found in the suspensory ligament of the ovaries?

Back 578

Ovarian vessels, lymphatics, autonomic nerves

Front 579

What structures are found in the broad ligament?

Back 579

Round ligaments of the uterus, ovarian ligament, ureters, uterine tubes, and uterine vessels

Front 580

What is the anatomic relationship of the ureter and the uterine artery?

Back 580

Ureter lies posterior and inferior to uterine artery. ?Water under the bridge?

Front 581

What is an intestinal intussusception?

Back 581

Telescoping of the intestines, resulting in intestinal obstruction

Front 582

What is the most common location for volvulus?

Back 582

Sigmoid colon; occurs most frequently in middle-aged and elderly men

Front 583

What section of the colon is most frequently affected by diverticulosis?

Back 583

Sigmoid colon

Front 584

What type of neoplastic colonic polyp is the most common?

Back 584

Tubular adenoma (75%); benign and pedunculated

Front 585

What type of neoplastic colonic polyp is highly malignant?

Back 585

Villous adenoma; sessile tumor >4 cm with finger-like projections

Front 586

What are the signs of a mass in the head of the pancreas?

Back 586

Courvoisier sign: Painless jaundice, malabsorption and an enlarged, palpable gallbladder

Front 587

What type of hyperbilirubinemia results from cholestasis?

Back 587

Conjugated hyperbilirubinemia

Front 588

How does hepatic failure affect the brain?

Back 588

Coma, hepatic encephalopathy, characterized by asterixis, hyperreflexia, behavioral changes

Front 589

The portal vein is formed by the confluence of what two vessels?

Back 589

Splenic vein and superior mesenteric veins

Front 590

What nerve must be avoided during parotid gland surgery because it traverses the parotid gland?

Back 590

Facial nerve (CN VII)

Front 591

Posterior perforation of an ulcer in the first part of the duodenum can rupture what blood vessel?

Back 591

Gastroduodenal artery; rupture can cause massive hemorrhage.

Front 592

What two structures merge to form the hepatopancreatic ampulla of Vater?

Back 592

The common bile duct and pancreatic duct drain into the duodenum through the ampulla of Vater

Front 593

The hepatic artery, portal vein, and common bile duct comprise what structure?

Back 593

The porta hepatis

Front 594

What is the suspensory ligament of Treitz?

Back 594

Supports the duodenum at the duodenojejunal flexure

Front 595

What is the function of the puborectalis muscle?

Back 595

Maintains the rectum in a 90º flexure

Front 596

What is the venous drainage of internal hemorrhoids?

Back 596

Superior rectal vein, which drains to portal circulation

Front 597

What is the innervation of internal hemorrhoids?

Back 597

Visceral innervation; ligation is not painful

Front 598

What is the venous drainage of external hemorrhoids?

Back 598

Inferior rectal vein, which drains to systemic circulation and IVC

Front 599

What is the innervation of external hemorrhoids?

Back 599

Somatic innervation; ligation of external hemorrhoids is painful

Front 600

The external anal sphincter consists of what type of muscle?

Back 600

The external anal sphincter consists of striated muscle under voluntary control by the pudendal nerve. The internal anal sphincter consists of smooth muscle under involuntary control.

Front 601

What are the boundaries of Hesselbach's triangle?

Back 601

Hesselbach's triangle is bounded by the inferior epigastric artery, inguinal ligament, lateral border of rectus abdominus muscle

Front 602

What factors regulate the secretion of gastric acid?

Back 602

Secretion is stimulated by histamine, acetylcholine, gastrin; secretion is inhibited by prostaglandin, somatostatin, gastric inhibitory peptide

Front 603

What factors regulate the secretion of somatostatin?

Back 603

Secretion is stimulated by acid; secretion is inhibited by vagal stimulation.

Front 604

What is the purpose of intrinsic factor?

Back 604

Binds vitamin B12 for uptake in terminal ileum

Front 605

What is the purpose of somatostatin?

Back 605

Inhibits the secretion of acid and pepsinogen; inhibits the production of pancreatic and small intestine secretions. Inhibits gallbladder contraction; decreases release of insulin and glucagon.

Front 606

Which chemical potentiates the actions of acetylcholine and gastrin in stimulating parietal cell H+ secretion?

Back 606

Histamine; H2 blockers block the actions of histamine.

Front 607

Which drug blocks the effects of histamine on parietal cells?

Back 607

Cimetidine (H2 receptor blocker)

Front 608

Parasympathetic innervation of the gastrointestinal tract occurs via which nerves?

Back 608

Vagus nerve and pelvic nerve. Parasympathetic innervation is usually stimulatory.

Front 609

Which pancreatic enzymes are responsible for fat digestion?

Back 609

Lipase, phospholipase A, and colipase

Front 610

What is the cause of steatorrhea after ileal resection?

Back 610

Ileal resection prevents bile acid reabsorption and recirculation, resulting in depletion of the bile acid pool, resulting in fat malabsorption

Front 611

What is the dumping syndrome?

Back 611

Rapid delivery of large amounts hypertonic food to the small intestine after vagotomy, resulting in distention and diarrhea.

Front 612

What is the most common salivary gland tumor?

Back 612

Pleomorphic adenoma, consisting of epithelial and mesenchymal elements.

Front 613

What is oral hairy leukoplakia?

Back 613

Irregular white mucosal patches in the mouth, associated with AIDS; caused by Epstein-Barr virus.

Front 614

What type of cancer accounts for 95% of oral cancers?

Back 614

Squamous cell carcinoma

Front 615

What is the most common esophageal cancer?

Back 615

Squamous cell carcinoma; proximal two-thirds of esophagus.

Front 616

What are the risk factors for esophageal cancer?

Back 616

Alcohol and tobacco use

Front 617

What part of the esophagus is the most common location for adenocarcinoma?

Back 617

Distal one-third of the esophagus; adenocarcinoma is a mucin-producing glandular tumor.

Front 618

What are the risk factors for gastric carcinoma?

Back 618

Chronic gastritis, Helicobacter pylori infection, blood type A, nitrosamines; men > 50 years old; low-fiber diet.

Front 619

What are the risk factors for esophageal carcinoma?

Back 619

Achalasia, Barrett esophagus, corrosive esophagitis, diverticula, esophageal webs, family history

Front 620

What are the risk factors for nephrolithiasis?

Back 620

Low fluid intake, hypercalcemia, gout, enzyme deficiency, renal tubular acidosis, allopurinol, chemotherapy, loop diuretics, inflammatory bowel disease, family history

Front 621

What tests are used to evaluate for nephrolithiasis?

Back 621

Urinalysis (hematuria, pH, crystals), x-ray (90% of stones are radiopaque); helical CT scan without contrast is the best test for nephrolithiasis

Front 622

What is the initial treatment of kidney stones?

Back 622

Hydration and analgesia

Front 623

What is the most common urinary tract malignancy?

Back 623

Bladder (transitional cell) cancer

Front 624

What is the strongest risk factor for bladder cancer?

Back 624

Smoking

Front 625

How does bladder cancer usually present?

Back 625

Painless hematuria

Front 626

What is the best diagnostic test for bladder cancer?

Back 626

Cystoscopy

Front 627

What is the most common cancer in men?

Back 627

Prostate cancer. Lung cancer causes more deaths than prostate cancer.

Front 628

Prostate cancer presents with metastatic disease in what percentage of patients?

Back 628

40% of patients with prostate cancer have metastatic disease at presentation

Front 629

What are the most common complications of prostatectomy?

Back 629

Impotence and incontinence

Front 630

What are the recommendations for screening for prostate cancer?

Back 630

Digital rectal examination and prostate specific antigen every year >50 years old (or >40 years old if African American or a positive family history of prostate cancer)

Front 631

Injury to the upper trunk of the brachial plexus will result in what finding?

Back 631

Erb-Duchenne palsy or Waiter's tip (C5, C6)

Front 632

The lower trunk of the brachial plexus can be damage by what type of injury?

Back 632

Klumpke injury due to sudden upward jerk of the arm (C8, T1); associated with Horner's syndrome

Front 633

Injury to the ulnar nerve will result in what finding?

Back 633

Claw hand (impaired wrist flexion and adduction)

Front 634

Injury to the radial nerve will result in what finding?

Back 634

Wrist drop

Front 635

Pain with wrist flexion caused by repetitive motion injury is indicative of injury to what nerve?

Back 635

Median nerve (carpal tunnel syndrome)

Front 636

Injury to the axillary nerve will result in paralysis of what muscle?

Back 636

Deltoid paralysis

Front 637

Injury to the long thoracic nerve during a mastectomy will result in what finding?

Back 637

Winged scapula

Front 638

Injury to the musculocutaneous nerve will result in what findings?

Back 638

Decreased elbow flexion and loss of biceps reflex

Front 639

A patient with foot drop has an injury to which nerve?

Back 639

Common peroneal nerve

Front 640

Loss of ability to plantarflex is a sign of what lesion?

Back 640

Injury to the tibial nerve

Front 641

Loss of ability to make a fist is a sign of what lesion?

Back 641

Injury to the median nerve at elbow

Front 642

Injury to the median nerve at wrist will result in what sign?

Back 642

Inability to form an ?O? with the thumb and index finger because of damage to the anterior interosseous nerve branch

Front 643

Anterior shoulder dislocation may injure which nerve?

Back 643

Axillary nerve; resulting in impaired abduction of the shoulder and loss of sensation over lateral upper arm.

Front 644

What maneuvers are useful for evaluating the median nerve at the wrist?

Back 644

Tinel's sign: tapping over the median nerve to elicit tingling. Phalen's test: Patient pushes the hands together - tingling or numbness over the thumb, index, middle and ring fingers confirms carpal tunnel syndrome.

Front 645

Loss of knee jerk reflex (quadriceps) and loss of sensation over anterior thigh suggests injury to what nerve?

Back 645

Femoral nerve

Front 646

What are the signs of obturator nerve injury?

Back 646

Numbness and pain radiating to the inner thigh; loss of thigh adduction

Front 647

Inability to rise from a seated position or climb stairs due to loss of gluteus maximus function is a sign of injury to which nerve?

Back 647

Inferior gluteal nerve

Front 648

Injury to the superior gluteal nerve will result in what sign?

Back 648

Positive Trendelenburg sign; when standing on one leg, the pelvis drops on the side opposite to the stance leg. The weakness is present on the side of the stance leg because of paralysis of the gluteus medius and minimus muscles.

Front 649

Posterior hip dislocation in a motor vehicle accident may injure what nerve?

Back 649

Sciatic nerve

Front 650

Fracture of fibular neck may cause injury to what nerve?

Back 650

Common peroneal nerve, causing foot drop

Front 651

After a motor vehicle accident, a patient presents with leg in external rotation, appearing shorter than the contralateral leg. What fracture is likely?

Back 651

Fracture of the femoral neck

Front 652

Landing on a foot after a large drop may cause fracture of what bone in the foot?

Back 652

Calcaneus

Front 653

Hyperextension of the neck may cause what type of fracture?

Back 653

Hangman fracture, characterized by anterior subluxation of C2, bilateral fracture of C2 pars interarticularis

Front 654

Hyperflexion of the neck may cause what fracture?

Back 654

Teardrop fracture caused by subluxation of vertebrae; spinal cord injury

Front 655

What artery passes through the anatomic snuffbox?

Back 655

Radial artery

Front 656

Radial or ulnar artery patency is evaluated by what test?

Back 656

Allen test is used before arterial blood sampling from the wrist.

Front 657

What are the steps in the Allen test?

Back 657

1) The patient clenches fist. 2) Pressure is applied over the ulnar and the radial arteries. 3) Ulnar pressure is released and the color should return in 7 seconds.

Front 658

Lateral impact to the knee damages what structures?

Back 658

Anterior cruciate ligament, medial collateral ligament, and medial meniscus

Front 659

A torn anterior cruciate ligament is indicated by what sign?

Back 659

Positive anterior drawer sign

Front 660

What sign suggests a torn medial collateral ligament?

Back 660

Abnormal passive abduction of the leg

Front 661

What is the most common site for a clavicular fracture?

Back 661

Middle one-third

Front 662

What is the term for increased pressure within a fascial compartment that causes damage to muscles and neurovascular structures?

Back 662

Compartment syndrome

Front 663

What ligament can be stretched or torn by inversion of the ankle?

Back 663

Anterior talofibular ligament (ankle sprain)

Front 664

What common carpal bone fracture can lead to avascular necrosis?

Back 664

Scaphoid fracture

Front 665

What are the muscles of the rotator cuff?

Back 665

Supraspinatus, infraspinatus, teres minor, subscapularis muscles

Front 666

What is tennis elbow (lateral epicondylitis)?

Back 666

Syndrome of pain on extension of the wrist and supination on of the forearm. Overuse injury; microscopic tearing in extensor carpi radialis brevis muscle.

Front 667

What are the signs of thoracic outlet syndrome?

Back 667

Sensory loss of the medial forearm and hand, disappearance of radial pulse on turning head away from affected side, atrophy of thenar, hypothenar, and interosseous muscles; cervical accessory rib is often present.

Front 668

What traumatic injury is suggested by an internally rotated and adducted leg appearing shorter than the contralateral leg?

Back 668

Posterior dislocation of the hip

Front 669

What traumatic injury presents with an externally rotated and abducted leg?

Back 669

Anterior dislocation of the hip

Front 670

What is bone avascular necrosis?

Back 670

Infarction of osteocytes, leading to joint pain, osteoarthritis

Front 671

What is Legg-Calve-Perthes disease?

Back 671

Idiopathic avascular necrosis of the head of the femur

Front 672

What is Osgood-Schlatter disease?

Back 672

Traction phenomenon resulting from repetitive quadriceps contraction upon the immature tibial tubercle. Most frequent cause of self-limiting knee pain in children aged 10-15 years.

Front 673

What conditions delay wound healing?

Back 673

Poor circulation, infection, necrotic tissue debris, foreign bodies, nutritional deficiencies, diabetes

Front 674

What is the most common thyroid carcinoma?

Back 674

Papillary carcinoma

Front 675

What is the best diagnostic test to evaluate a thyroid nodule?

Back 675

Fine needle aspiration

Front 676

What parathyroid disorder is caused by chronic renal failure or deficiency of vitamin D?

Back 676

Secondary hyperparathyroidism

Front 677

What is the normal flora of the colon?

Back 677

Bacteroides fragilis, E. coli

Front 678

Which bacteria is associated with nosocomial wound infections?

Back 678

Staphylococcus aureus