Winter Icmd Midterm Adjunct

Front 1

Tx Hemorrhoids

Back 1

Sigmoid/Colonoscopy (hemorrhoids can mask CA)
↑ water, dietary fiber & stool softeners
poop as soon as you feel an urge, but let the bowel do the pushing
continued problems → surgery; rubber band hemorrhoiectomy; do not pack the anal canal [it will try to clamp down, you end up with a spastic anal sphincter]

Front 2

Pilonidal Cyst

Back 2

painful, infected cystic abscess near upper gluteal cleft containing hair and skin
hairy 20 yo men who sit a lot

maybe ingrown hair from sitting

Tx: incise and drain wait for infection to subside; once infection has subsided you must completely incise all of the epithelial lining; don't close the wound, let it stay open and granulate.

Front 3

Mecke's Diverticulum

Back 3

Rules of 2's

2% of the population
2 inches long, 2 feet from the ileocecal jnx
2% symptomatic,
2 ectopic tissue possibilities
present at 2 yo
males 2x as likely as females

absent on imaging? try technetium 99m scan for gastric mucosa.

"If you find one, take the darn thing out."

Front 4

Stents

Back 4

Devices used to maintain lumenal patency when constricted by pathology

"You're not curing anybody with a stent, you're making their life more livable."

~every specialty places stints

Front 5

Shunt

Back 5

moving liquid to a different destination than its usual one

eg gastric bypass

Front 6

Feeding Tubes

Back 6

GI tract tolerates food, oral route not available

Many types: from soft small diameter nasogastric to PEG tubes

Front 7

Baseline caloric needs

Back 7

Young Adult Males 2700 ± 100 C/d
Young Adult Females 2100 ± 100 C/d

at least 50ml H20/h

Front 8

Best indicator or blood volume

Back 8

urine output

Front 9

3 Things which can heighten your metabolic rate

Back 9

any acute inflammatory state
sepsis
major injury

Front 10

Caloric Content of Nutrition Types

Back 10

Protein & CHO 4Cal/gm
Fat 9 Cal/gm
EtOH 7 Cal/gm

Front 11

Nutritional requirements for critically ill pts

Back 11

considerable muscle breakdown

will need lots of protein, specifically Glutamine
+ A & C
Zinc helps wound healing

Front 12

TPN

Back 12

hypertonic solution into central venous access

expensive, a great culture medium, will require insulin even in non-diabetics

complications: infxn, small bowel atrophy, choliary stasis (et al), hepatic fatty metamophosis

Front 13

hernia

Back 13

protrusion of an organ through the wall of its normal anatomic location

you can have a henia of anything anywhere: eg. vastus lateralis thorugh fascia lata

Front 14

most common hernia in women

Back 14

inguinal

its a trick question, femoral are more common in women then men but inguinal are more common than femoral in both

Front 15

most common cause of hernia

Back 15

valsalva maneover

Front 16

hesselbach's triangle

Back 16

fascia bordered by:

inguinal ligament
rectus sheith
inferior epigastric artery & vein

site of direct hernia

Front 17

tension on the wall of a hollow strx

Back 17

pressure on the wall * diameter of the wall

Front 18

toddler with an umbilical hernias

Back 18

majority resolve by age 4

Front 19

Richter's Hernia

Back 19

dangerous: no vomit, no air fluid level

fascial defect, one side of a piece of bowel has stuck into it but not all

bowel contents can't go by; you don't think its a hernia until they infarct and perf and die

Front 20

Hernia progression, tx

Back 20

majoirty of umbilical hernias resolve spontaneously

the rest get bigger, must tx

extrinsic: support
anatomic repair
tension free repair is the big deal now
open/laproscopic

Front 21

Most common volvulus

Back 21

Infants: midgut associated with congenital malrotation

Adults: Cecum or Sigmoid; usually a man with a redundant, very mobile colon;

Front 22

beak on barium enema

Back 22

volvulus

Front 23

tx volvlulus

Back 23

sigmoid: be may do it
colonoscopy may work

otherwise → operate

save as much small bowel as you can
resect as much redundant colon as you can

Front 24

who decides whether a pt needs surgery

Back 24

the surgeon

"medical clearance" is not an indication for surgery

if you as a surgeon don't think surgery is indicated, you send the pt to a specialist to give a great explanation

Front 25

Surgery and Social History

Back 25

Tob

If you can get a pre-op pt to quit for 2 weeks you will markedly ↓ post-op pulmonary problems

(one week not as good but better than nothing)

Front 26

Operative Consent

Back 26

should be a fully informed one, including risks, benefits and alternatives

Front 27

surgery under anesthesia w/in 3 mo of MI

Back 27

30% risk for reinfarction

Front 28

pre op Hgb

Back 28

8gm enough for healthy person

need more if CV problems\

other peoples blood is NOT GOOD FOR YOU. Do not transfuse up to optimal Hg if you don't need to → serious complications

Front 29

Swan-Ganz catheters

Back 29

tells you the RA pressure

BAD FOR PEOPLE

Do not insert one if you don't need to

Front 30

Pre-op malnutrition

Back 30

bad for healing
↑ risks infection/death

>10% body weight rdxn pre op, give TPN and try to get it back

Front 31

Irradiated Tissue

Back 31

Looks and acts like very old tissue

old tissue doesn't heal well

Front 32

Spacial location of healing

Back 32

healing progresses more slowly as you move distally. Face heals very well, feet not so much. plan accordingly for suture removal.

Front 33

Birth Control and Surgery

Back 33

increased disk for Throboses

Front 34

Lenovox

Back 34

low molecular weight heparin

decreases thromboembolic problems when given just before surgery

Front 35

post-op ambulation

Back 35

minimizes complications

pt needs to know about it pre-op

Front 36

Newhoff's Law

Back 36

if you don't get out of bed
you don't get any pain meds

Front 37

PCA pump

Back 37

self administered pain meds,best

Front 38

Epideural Catheters with local anesthetics

Back 38

greatly reduce post-op narcotic use, helps Gi motility

best if thoracic

Front 39

Incentive spirometers

Back 39

helpful post-op if used properly, but 10 little breaths aren't worth one deep breath

Front 40

Post-Op Ileus

Back 40

can be fatal, fixed quickly with an NG tube


BUT in general start oral intake ASAP. hiccups means they're not ready.

Front 41

Dressing the surgical area

Back 41

make it neat and small → faster psychological recovery for pt if they think it was a minor procedure

Front 42

NG/drain outputs

Back 42

abnormal losses, should be replaced with appropriate fluids

gastric juice = chloride
pancreatic jucie= alkaline

Front 43

Daily labs

Back 43

don't order them; wasting blood and money; order what you need.

Front 44

Febrile post-op after clean surgery

Back 44

First 48 hours think atelectasis
days 3-5 foley infx if there is one
after that: superficial or deep wound infx

Front 45

Post-op shock w/in 24 hours after abdominal/thoracic surgery

Back 45

bleeding until proven otherwise

Front 46

Bleeding with good Hgb & Hct

Back 46

you bleed whole blood: you don't know how much you've lost until you've expanded their volume

Front 47

acute abdomen

Back 47

severe pain w/ rapid onset

(SSx)

pt too sick not to have surgery

Front 48

acalculous cholecystitis

Back 48

sludge from no duodenal CCK

usually people who've already beeni n the ICU for a while

Front 49

gallstone ileus, how did it get there

Back 49

erosion through the wall
could not possibly pass through sphincter of Oddi & be big enough to obstruct bowel

Front 50

Antibiotics & Surgery

Back 50

Don't start utnil 30 minutes before: all that would do would make sure that anything in the gut is resistant

repeate q4h intra-op

Do not continue post op for clean cases → c dif

Front 51

insulinomas

Back 51

abdominal pain, fat, sweaty and shakey

insulinomas: eating something makes their blood sugar better

Front 52

pseudocyst of pancreas

Back 52

from chronic pancreatitis

Front 53

cancer of the pancreas

Back 53

first sign of tail pancreatic CA is infiltration into nerveous strx behind wall

head may be caught earlier

Front 54

Laproscopic Surgery

Back 54

significant advantages

consult MUST say possible open on operative consent

Front 55

steri-strips

Back 55

nice because you don'thave to take them out

Front 56

gas gangrene

Back 56

rapid advancement: cut all all tissue

Front 57

Major e⁻lyte balances

Back 57

correct slowly

take as long to fix them as it takes to dvlp

Front 58

Fat as an endocrine organ

Back 58

converts adrenal androgens to estrogens → anovulatory women, gynecomastia in men

Front 59

Thyroid pills

Back 59

you'll lose weight: sweat like crazy, hair falls out

Front 60

Malabsorption Surgical Procedures

Back 60

Jejunocolic & Jejunoileal bypass

malabsorption surgical procedure

lots of problems: so much of your absorption in the terminal ileum

Front 61

Restrictive Procedures

Back 61

subtotal gastrectomy
gastric bypass
gastroplasties
gastric banding
sleeve gastrectomy

Front 62

Combined Weight Loss Surgical Procedures

Back 62

Roux-Y "short limb" gastric Bypass is the gold standard

Biliopancreatic diversion (Scopinaro)
"Long-limb" gastric bypass
Duodenal switch

Front 63

Dumping Syndrome

Back 63

good in distal bowel releases PYY and GLP-1 from L cells, geos to hypothalamus and induce satiety

Front 64

What is the crescent sign?

Back 64

small microfractures around the head of the femoral epiphysis, early after avasculature in Legg Calve Perthes disease

Front 65

What is a Herndon hump?

Back 65

"pistol grip" appearance of femoral neck as it widens and dvlps a protuberance while remodelling in chronic stage of SCFE

Front 66

What is the Klein’s line used for?

Back 66

SCFE

drawn along superior aspect of femoral neck

in normal hip epiphysis overlaps kline line

Front 67

When examining the hip, what range of motion tests are the most important?

Back 67

internal rotation
abduction
extension

Front 68

What views are obtained when doing plain film x-rays of the hip to rule out LCPD?

Back 68

anteroposterior and lateral views with comparison of the opposite side

frong-lateral if hip involved

Front 69

Describe the presentation of a toddler’s fracture

Back 69

Accidental spiral tibial fractures in toddlers 2° to trivial mechanism, tripping

toddler refuses o bear weight, PE and imaging subtle,

pain when knee and ankle passively twisted in oppostie directions

tx: long leg cast

Front 70

toddler refuses to bear weight on one leg

pain when knee and ankle passively twisted in oppostie directions

Back 70

toddler's fracture

Accidental spiral tibial fractures in toddlers 2° to trivial mechanism, tripping

tx: long leg cast

Front 71

child w/ limp hx sexually active

Back 71

GC or reactive arthritis

Front 72

child w/ limp hx bleeding disorder

Back 72

hemarthrosis

Front 73

child w/ limp hx insect bite

Back 73

lyme

Front 74

child w/ limp hx pharyngitis

Back 74

rheumatic fever

Front 75

child w/ limp hx trauma

Back 75

fx, soft tissue injury

Front 76

child w/ limp hx back pain

Back 76

diskitis, vertebral osteomyelitis

Front 77

child w/ limp hx abd pain

Back 77

psoas abscess, accute abdomen

Front 78

child w/ limp hx intermittent pain at rest

Back 78

CA

Front 79

child w/ limp hx improves with activity

Back 79

Rehumatological

Front 80

child w/ limp hx worses with activity

Back 80

overuse injury, stress fracture

Front 81

child w/ limp hx diarrhea

Back 81

reactive arthritis

Front 82

child w/ limp hx recent

Back 82

infectious or traumatic

Front 83

child w/ limp hx insidious

Back 83

LCPD or SCFE

Front 84

child w/ limp hx worse in morning

Back 84

transient synovitis or JIA

Front 85

child w/ limp hx pain that awakens child at night

Back 85

CA

Front 86

child w/ limp hx fever & malaise

Back 86

CA or rheumatologic

Front 87

child w/ limp hx weight loss

Back 87

CA

Front 88

child w/ limp hx recent URI

Back 88

transient synovitis

Front 89

Child w/ limp
PE: T>100.4

Back 89

infectious or neoplastic

Front 90

Child w/ limp
PE: abdominal mass

Back 90

neuroblastoma, psoas abscess

Front 91

Child w/ limp
PE:abdominal tenderness

Back 91

appy

Front 92

Child w/ limp
PE:conjunctivitiy, enthesitis, urethritis

Back 92

reactive arthritis

Front 93

Child w/ limp
PE:erythema chronicum migrans

Back 93

lyme

Front 94

Child w/ limp
PE: external rotation w/ hip flexion

Back 94

SCFE

Front 95

Child w/ limp
PE: galeazzi sign

Back 95

leg lenth discrepency

Front 96

Child w/ limp
PE: lymadenopathy, splenomegaly

Back 96

CA

Front 97

Child w/ limp
PE: loss of internal rotation

Back 97

SCP or SCFE

Front 98

Child w/ limp
PE: Obesity

Back 98

SCFE

Front 99

Child w/ limp
PE: overlying warmth, redness

Back 99

inflammatory arthritis, osteomyelitis, septic arthritis

Front 100

Child w/ limp
PE: painless, no-pruritic vesiculopustular skin lesions

Back 100

GC

Front 101

Child w/ limp
PE: psoas sign

Back 101

appy or psoas abscess

Front 102

Child w/ limp
PE: metaphyseal rib, or vertebral fractures or finger fracture in non-ambulatory children

Back 102

child abuse

Front 103

Septic Arthritis

Back 103

EMERGENCY: usually hematogenous dissemiation of staph aureus;

child appears systemically ill w/ rapidly progressive joint pain, limited ROM & fever.

M=F 3-6; hip will be flexed, abducted and externally rotated

Tx: prompt surgical drainage & antibiotics following US, arthrocentesis w/ fluid & blood cultures

Front 104

Transient Synovitis

Back 104

sterile effusion resolves without tx or sequelae

child awakens with limp in morning and refuses to walk; after loosening up limp may improve.

Dx of exclusion following WBC, Sed Rate &CRP to distinguish from septic arthritis

Front 105

Growing Pains

Back 105

Dx of exclusions

moderate severe, typically symmetrical pain noticeable in evening while resting after day of activity during which there was no limp;

simple analgesics, thermal tx relieves;

Front 106

child appears systemically ill w/ rapidly progressive joint pain, limited hip ROM & fever.

Back 106

Septic Arthritis: EMERGENCY

usually hematogenous dissemiation of staph aureus;

child appears systemically ill w/ rapidly progressive joint pain, limited ROM & fever.

M=F 3-6; hip will be flexed, abducted and externally rotated

Tx: prompt surgical drainage & antibiotics following US, arthrocentesis w/ fluid & blood cultures

Front 107

moderate symmetrical pain noticeable in evening while resting after day of activity during which there was no limp;

Back 107

Growing Pains, Dx of exclusion

simple analgesics, thermal tx relieves;

Front 108

child awakens with limp in morning and refuses to walk; limp improves after lostening up

Back 108

Transient synovitis: sterile effusion resolves without tx or sequelae

Dx of exclusion following WBC, Sed Rate &CRP to distinguish from septic arthritis

Front 109

Describe a positive Trendelenburg sign, the muscle & nerve involved, and the “Trendelenburg gait”

Back 109

See OMM

Front 110

Describe a “short-leg” gait.

Back 110

longer leg will stay in flection when standing or child will walk on toes of shorter leg.

pelvis will move up and down more than normal walking; not antalgic;

anatomical or fnx: addxn contraction will cause affected LE to seem shorter, abdxn makes it seem longer

Front 111

Describe a “steppage” gait.

Back 111

inability to dorsiflex the foot, so instead flex hip and knee so toes can clear ground

Front 112

Describe a “equinus” gait.

Back 112

toe walking, a variety of causess: cerebral palsey, tight achilles tendon, calcaneal fracture, foreing body in foot

Front 113

Which type of gait is a “painful” gait?

Back 113

antalgic gaints

Front 114

Fist Percussion over CVA

Back 114

pain = pyelonephirits or obstructive uropathy

Front 115

Obturator sign

Back 115

is psoas sign

flecion and internal rotation vs resistance

Front 116

severe abdominal pain out of propoortion

Back 116

mesenteric ischemia until proven otherwise

Front 117

Potantial life threatening conditions of acute abdomen

Back 117

ruptured leaking abdominal aortic aneurism
perforated viscus
acute pancreatitis
intestinal obstrx
mesenteric ischemia

Front 118

onset of page

Back 118

rapid: vascular problem like ischemia, passage of stone rupture of viscous cyst or ectopic pregnancy

slow: inflmmation, like appendicitis or cholecystitis

Front 119

duration of abdominal pain in history

Back 119

<24 hours and and increasing intensity likely to be a surgical problem

Front 120

character of abdominal pain

Back 120

dull, achy, burning = visceral
sharp/stabbing = peritoneal
crapming = osbstruction
tearing = dissecting aneurism

Front 121

severe, out of proportion abdominal pain

Back 121

mesenteric ischemia or pancreatitis

Front 122

abdominal pain aggregated by omovement

Back 122

parietal paritoneal pain

Front 123

abominal pain releived iwth eating

Back 123

ulcer pain

Front 124

abdominal pain releaved by change in position:

Back 124

pancreatitis and other peritonitises releived by fetal position

Front 125

What are the risk factors that identify the patients at greater risk for having a significant disease process, who present with abdominal pain?

Back 125

extremes of age: vitals do not accurately reflect degree of illness.
any abnormal vital sign
severe pain w/ rapid onset
dehydration
pallor & diarphoresis

Front 126

What is the importance of discussion of “number of times the diaper is wet” in a pediatric patient?

Back 126

decreasing frequency ≈ dehydration

Front 127

Discuss importance of General Appearance on physical exam of patient presenting with abdominal pain.

Back 127

pale, sweaty and still are more acutely ill w/ peritonitis

pts who are writinghave visceral pain

Front 128

Discuss the importance of vital signs in the physical exam of a patient with abdominal pain.

Back 128

appendicitis or cholecysitis generally >100
101+ raises suspicion of salpingitis, pyelonephritis, bacteiral enteritis, ruptured viscus

Front 129

abdominal pain with nausea and vomiting

Back 129

almost any pathology

excessive ≈ pancreatitis or obstrx
lack ≈ ovarian/uterine

vomitting AFTER onset of pain ≈ surgical
vomiting BEFORE onset of pain ≈ gastroenteritis
diarrhea plus vomiting almost always ≈ gastroenteritis