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1045 Cards in this Set

  • Front
  • Back
Q001. assessing the airway
A001. patient conscious and speaking --> airway present; neck hematoma or emphysema --> patient will loose airway and should be secured; patient unconscious or noisy breathing --> need to secure airway
Q002. airway procedures
A002. in the field --> cricothyroidotomy; in the ER --> orotracheal intubation with pulse oximetry; cervical spine injury --> orotracheal or nasotracheal intubation; maxillofacial injuries --> cricothyroidotomy or percutaneous tracheostomy
Q003. signs of shock
A003. systolic pressure < 90mmHg; fast feeble pulse; low urinary output in patient who is cold, pale, shivering, sweating, thirsty
Q004. traumatic causes of shock
A004. bleeding; pericardial tamponade; tension pneumothorax; hypovolemic shock cannot happen from intracranial bleeding
Q005. hemorrhagic shock Vs. pericardial tamponade Vs. tension pneumothorax
A005. hemorrhage --> CVP is low (empty veins); cardiac tamponade and tension pneumothorax --> CVP high (distended neck veins); pericardial tamponade --> no respiratory distress; tension pneumothorax --> severe respiratory distress, unilateral loss of breath sounds, hyperresonance and mediastinum/tracheal deviation
Q006. hemorrhagic shock in penetrating injuries management
A006. surgical intervention first to stop the bleeding then volume replacement
Q007. non-hemorrhagic shock management
A007. fluid replacement first with 2L of Ringer followed by packed red cells until urine is 0.5-2ml/kg/h and CVP does not exceed 15mmHg
Q008. pericardial tamponade shock management
A008. clinical diagnosis, don’t order x-rays, if unclear order sonogram; prompt evacuation of pericardial sac by pericardiocentesis, tube, pericardial window or open thoracotomy; fluids and red cells while evacuation is being done
Q009. tension pneumothorax shock management
A009. clinical diagnosis, don’t order x-rays or wait blood gases;; big needle or IV catheter into pleural space;; follow with chest tube connected to underwater seal
Q010. preferred route of fluid resuscitation in shock
A010. 2 16-gauge peripheral IV lines; if not --> percutaneous femoral vein catheter or saphenous vein cut-down
Q011. types of head trauma
A011. penetrating; linear skull fracture; base of skull fracture; acute epidural and subdural hematoma; diffuse axonal injury; chronic subdural hematoma
Q012. head trauma + loss of consciousness
A012. CT of head required to rule out hematoma; if negative CT --> send home and wake up frequently in next 24 hours
Q013. base of skull fracture
A013. signs are raccoon eyes, rhinorrhea, otorrhea, ecchymosis behind ear; no antibiotics indicated; cervical spine CT to assess integrity; if has loss consciousness --> head CT; if signs of base fracture --> neck CT also
Q014. neurologic damage from trauma
A014. from initial blow, or later hematoma or increased intracranial pressure; treat hematoma with surgery; treat pressure with drugs (diuretics)
Q015. acute epidural hematoma
A015. sequence of trauma, unconsciousness, lucid interval, gradual coma, fixed dilated pupil, contralateral hemiparesis; CT shows biconvex, lens-shaped hematoma; cure is emergency craniotomy
Q016. acute subdural hematoma
A016. sequence of trauma, unconsciousness, lucid interval, gradual coma mcuh more severe; CT shows semilunar hematoma; if midline deviated --> craniotomy; else --> treat increased intracranial pressure
Q017. diffuse axonal injury from head trauma
A017. CT shows blurring of gray-white matter interface and small punctuate hemorrhages; if no hematoma, no surgery; decrease ICP
Q018. chronic subdural hematoma
A018. in elderly or severe alcoholics; a tear in venous sinuses with hematoma over days or weeks; CT and surgical evacuation is cure
Q019. penetrating neck trauma exploration indications
A019. expanding hematoma; deteriorating vital signs; esophageal or tracheal injury (coughing, hemoptysis); gunshot to middle neck
Q020. neck gunshot wounds
A020. middle zone --> exploration; upper zone --> arteriogram; base of neck --> arteriogram, esophagogram (barium), esophagoscopy, and bronchoscopy before surgery
Q021. neck stab wounds
A021. if upper and middle zones in asymptomatic patients --> observation
Q022. blunt neck trauma
A022. if neurologic deficits or pain to local palpation of cervical spine --> cervical spine CT
Q023. types of chest trauma
A023. rib fracture; pneumothorax; hemothorax; blunt trauma; sucking chest wounds; flail chest; pulmonary contusion; myocardial contusion; traumatic rupture of diaphragm, aorta, trachea or bronchus; air and fat embolism
Q024. rib fracture
A024. can be deadly in elderly; progression of pain --> hypoventilation --> atelectasis --> pneumonia; treat with nerve block
Q025. plain pneumothorax
A025. penetrating trauma due to broken rib or weapon; moderate shortness of breath, unilateral absence of breath sounds and hyperresonance; do chest x-ray, place chest tube, connect to underwater seal
Q026. hemothorax
A026. penetrating trauma due to broken rib or weapon; moderate shortness of breath; unilateral absence of breath sounds and dullness to percussion; do chest x-ray and evacuate blood by chest tube; surgery indicated if --> recover 1.5L of blood with insertion of chest tube or 600ml in tube drainage over 6 hours
Q027. blunt chest trauma
A027. monitor hidden injuries; blood gases,; chest x-ray,; cardiac enzymes,; ECG
Q028. sucking chest wound
A028. flap sucks air in with inspiration and closes in expiration; treat with occlusive dressing to allow air out but not in
Q029. flail chest
A029. multiple rib fracture with paradoxical breathing; treat lung contusion with fluid restriction, colloid solutions and diuretics
Q030. pulmonary contusion
A030. appears immediately or within 48 hours --> deteriorating blood gases and white-out of lungs on x-ray; treat with fluid restriction, colloids and diuretics
Q031. myocardial contusion
A031. suspect it in sternal fractures; do ECG and troponins; treatment is to prevent complications (arrhythmia)
Q032. traumatic rupture of diaphragm
A032. bowel in chest on left side by physical exam and x-ray; evaluate with laparoscopy; surgical repair from abdomen
Q033. traumatic rupture of aorta
A033. hidden injury due to at junction of arch and descending aorta; due to deceleration injury; asymptomatic until rupture occurs; suspect it if first rib, scapula or sternum are fractured; first procedure is x-ray; if normal mediastinum --> transesophageal echo, CT or MRI angio; if wide mediastinum --> aortogram if noninvasive tests are inconclusive; needs prompt surgical repair
Q034. traumatic rupture of trachea or major bronchus
A034. suggested by subcutaneous emphysema or large air leak from chest tube; look for air in x-ray; bronchoscopy de detect lesion and secure airway; then surgical repair
Q035. air embolism
A035. seen as sudden death in intubated trauma patients; also from supraclavicular node biopsy, central venous lines, CVP lines that disconnect; do cardiac massage with left side down; prevent with Trendelenburg position
Q036. fat embolism
A036. multiple trauma patient with long-bone fractures; petechial rash in axilla and neck; fever, tachycardia and respiratory distress; treatment is respiratory support
Q037. types of abdominal trauma
A037. gunshot wounds; stab wounds; blunt trauma; ruptured spleen; complications are intraoperative coagulopathy and abdominal compartment syndrome
Q038. gunshot wound to abdomen
A038. any entry or exit below nipple line is considered to involve abdomen; exploratory laparotomy always to repair
Q039. stab wound to abdomen
A039. if penetration is evident (protruding viscera), hemodynamic instability or peritoneal irritation--> exploratory laparotomy; else --> digital exploration; if equivocal --> CT scan
Q040. signs of internal bleeding after blunt trauma
A040. same as shock; hypotension,; fast pulse,; low CVP and urine,; pale,; cold,; anxious,; shivering,; sweating,; thirsty
Q041. body compartments where internal bleeding can cause shock
A041. needs appriximate 1,500ml loss of blood for shock; potential places --> abdomen, thighs, pelvis; places easily detectable --> lungs, pericardium, neck, arms and legs; not possible --> head
Q042. to determine abdominal internal bleeding after blunt trauma
A042. suspect in multiple trauma patient with normal chest x-ray, no evidence of pelvic or femur fracture who develops signs of shock
Q043. intraabdominal bleeding diagnosis
A043. CT scan determines presence, severity and site of bleeding; if hemodynamically unstable --> do diagnosis while resuscitating with peritoneal lavage or sonogram; if positive --> exploratory laparotomy
Q044. ruptured spleen
A044. most common source of significant intraabdominal bleeding in blunt trauma; hints are ruptured lower left ribs; try to repair, not remove; if removal is needed --> postoperative immunization against encapsulated bugs
Q045. intraoperative coagulopathy after abdominal trauma
A045. treated with platelet packs and fresh-frozen plasma; if there's hypothermia and acidosis --> terminate laparotomy
Q046. abdominal compartment syndrome
A046. abdominal surgical wound cannot be closed in surgery or opens up in postoperative; treat with temporary cover (absorbable mesh or nonabsorbable plastic)
Q047. pelvic fractures
A047. pelvic hematomas are usually left alone if not expanding; have to rule out associated injuries (rectal exam, bladder, pelvic exam and urethra in men); diagnosis is with signs of shock in patient with pelvic fracture who is not bleeding elsewhere; blood transfusions necessary but external fixation Vs. arteriographic embolization Vs. surgery is controversial
Q048. urologic injuries
A048. penetrating trauma; blunt trauma; urethral injury; bladder injury; renal injury; scrotal hematoma; fracture of penis
Q049. hallmark of urologic injuries
A049. hematuria in trauma patient; microscopic hematuria in asymptomatic trauma patient does not need work-up
Q050. urethral traumatic injury
A050. usually result of pelvic fracture; almost exclusively in men with blood at the meatus, scrotal hematoma, not able to void, high-riding prostate on exam; Foley catheter should not be inserted but retrograde urethegram done instead; anterior injuries are repaired immediately, posterior are delayed
Q051. bladder traumatic injury
A051. associated with pelvic fracture, diagnosed by retrograde cystogram which must include postvoid film; surgical repair is done
Q052. renal traumatic injury
A052. usually associated with lower rib fracture; diagnosed by CT scan; mostly managed without surgery; complications are AV fistula with CHF or renal artery stenosis with hypertension
Q053. scrotal hematoma
A053. can attain alarming size but no specific intervention needed unless sonogram shows ruptured testicle
Q054. fracture of the penis
A054. usually due to sex with woman on top; sudden pain, large shaft hematoma and normal glans; emergency surgery required to prevent impotence
Q055. penetrating injury to extremities considerations
A055. determine whether there’s vascular injury or not; if no major vessels in vicinity --> tetanus prophylaxis and debridement; if near major vessels --> Doppler or arteriogram; if obvious vascular injury --> surgery
Q056. combined injuries of arteries, nerves and bone
A056. first do bone,; then vascular repair,; then nerve,; finally a fasciotomy (to prevent compartment syndrome)
Q057. crushing injury of extremities
A057. risks --> hyperkalemia (do fluid correction), myoglobinemia, myoglobinuria, renal failure and compartment syndrome
Q058. chemical burns
A058. massive irrigation to remove offending ageng; don’t try to neutralize
Q059. electrical burns
A059. always deeper than they appear; may involve myoglobinemia, myoglobinuria and renal failure; orthopedic injuries due to massive muscle contraction
Q060. respiratory burns
A060. smoke inhalation in fires; soot or mouth burns are suggestive; diagnose with bronchoscopy; blood gases to determine if intubation is needed; if carboxyhemoglobin is elevated --> 100% O2 reduces half- life
Q061. rule of nines for adults
A061. head and arms --> 9% each; legs --> 18% each; trunk front --> 18%; trunk back --> 18%
Q062. rule of nines for babies
A062. head --> 18%; 2 legs --> 27%
Q063. Parkland formula
A063. kg X % of burn X 4cc RL + 2L D5W; first 1/2 in first 8h, the rest in next 16h; on day 2 --> half of day 1
Q064. burn care
A064. topical silver sulfadiazine is agent of choice; burns around the eyes use triple antibiotic ointment; IV analgesics; enteric nutrition
Q065. tetanus prophylaxis
A065. required for all bites
Q066. dog bites
A066. considered provoked if dog was petted while eating or teased; no rabies prophylaxis needed just observation of the dog; unprovoked dog bites require rabies immunoglobulin + vaccine
Q067. snake bites
A067. severe local pain, swelling and discoloration within 30 minutes; draw blood for typing and cross match, coagulation stdies and liver/renal function; treat with antivenom; don’t make cruciate cuts, suck out venom, wrap with ice or apply tourniquet
Q068. bee stings
A068. wheezing and rash may occur with hypotension; give 0.3-0.5ml epinephrine 1:1,000; remove stingers without squeezing
Q069. black widow spider bite
A069. the spider is black with red hourglass on belly; nausea, vomiting, generalized muscle cramps; treat with IV calcium gluconate
Q070. brown recluse spider bite
A070. skin ulcer with necrotic center surrounded by halo of erythema; dapsone may help
Q071. human bites
A071. bacteriollogically the dirtiest; require extensive irrigation and debridment; may present on fist after punch in mouth
Q072. orthopedic disorders in children
A072. dysplasia of the hip; Legg-Perthes; slipped capital femoral epiphysis; septic hip; acute hematogenous osteomyelitis; genu varum; genu valgus; Osgood-Schlatter; club foot; scoliosis; fractures
Q073. developmental dysplasia of the hip
A073. uneven gluteal folds; hip is easily dislocated with jerck-and-click and returned to normal with snap; if physical is equivocal --> sonogram; treat with abduction splinting with Pavlik harness for 6 months
Q074. Legg-Perthes disease
A074. avascular necrosis of capital femoral epiphysis occurs around age 6; limping, decreased hip motion, hip/knee pain, antalgic gait; diagnose with AP/lateral hip x-rays; treatment is controversial
Q075. slipped capital femoral epiphysis
A075. orthopedic emergency; chubby boy around 13, limping and with groin/knee pain, limited hip motion, flexed hip and thigh is externally rotated; diagnose with x-rays and treat with surgical pinning of femoral head
Q076. septic hip
A076. orthopedic emergency in little toddlers with history of febrile illness and refusal to move the hip; elevated ESR; diagnose by aspiration of hip under general anesthesia; further drainage may be required
Q077. acute hematogenous osteomyelitis in children
A077. history of febrile illness with severe localized bone pain; x-rays don’t show anything for weeks; do bone scan and treat with antibiotics
Q078. genu varum
A078. bow legs normal up to age 3; persistent varus is Blount disease and surgery can be done
Q079. genu valgus
A079. knock knee is normal between 4-8 years; no treatment needed
Q080. Osgood-Schlatter disease
A080. osteochondrosis of tibial tubercle seen in teenagers with persistent pain over tibial tubercle aggravated by contraction of quadriceps; immobilize the knee in extension for 4-6 weeks
Q081. club foot
A081. seen at birth with feet turned inward; plantar flexion of ankle; inversion of foot; adduction of forefoot; internal rotation of tibia; needs serial plaster casts or surgery if uncorrected after 6-8 months
Q082. scoliosis in pediatrics
A082. seen mostly in adolescent girls; look from behind while she bends forward noting hump (mostly over right thorax); bracing to arrest progression; surgery may be needed
Q083. osteogenic sarcoma
A083. ages 10-25; persistent low-grade pain in lower femur or upper tibia; sunburst pattern on x-ray
Q084. Ewing sarcoma
A084. ages 5-15 and grows at diaphysis; onion-skinning seen on x-rays
Q085. metastatic bone tumors
A085. seen min adults from breast (lytic lesions) or prostate (blastic lesions); localized pain and pathologic fractures; bone scan more sensitive but not more specific than x-rays
Q086. multiple myeloma
A086. CRAB --> hypercalcemia, renal failure, anemia, localized bone pain and lytic lesions on x-rays; increased total proteins with normal albumin; Bence-Jones protein; abnormal Igs by serum electrophoresis; infections; treat with chemo
Q087. soft tissue sarcomas
A087. firm, mass fixed to surrounding structures which metastasizes to lungs not lymph nodes; treat with wide local excision, radiotherapy and chemo
Q088. general considerations about fractures
A088. x-rays should include 2 views at 90 degrees to one another and include joints above and below fracture; if not badly displaced or angulated --> closed reduction; else --> open reduction with internal fixation
Q089. clavicular fractures
A089. typically at junction of middle and distal third; treat with figure-of-eight-device 4-6 weeks
Q090. anterior dislocation of the shoulder
A090. most common dislocation; patient holds arm close to body but rotated outward; numbness over deltoid from stretching axillary nerve; AP/lateral x-rays are diagnostic
Q091. posterior shoulder dislocation
A091. occurs after seizures or electrical burns; arm is close to body and internally rotated; needs axillary or scapular lateral view on x-ray
Q092. Colles fracture
A092. fall on outstretched hand results in painful and deformed wrist; fracture is of distal radius which is dorsally displaced and angulated; treat with closed reduction and long arm cast
Q093. Monteggia fracture
A093. diaphyseal fracture of proximal ulna with anterior dislocation of radial head results from direct blow to ulna; broken bone often requires open reduction and internal fixation
Q094. Galeazzi fracture
A094. fracture of distal third of radius from direct blow with dorsal dislocation of distal radioulnar joint; broken bone required open reduction and internal fixation
Q095. scaphoid fracture
A095. fall on outstretched hand; wrist pain with localized tenderness to palpation; usually x-ray is negative until 3 weeks later; undisplaced fractures require spica cast
Q096. metacarpal neck fractures
A096. closed fist hits hard surface; hand is swollen and tender; x-ray is diagnostic; if mild --> closed reduction and ulnar gutter splint; if severe --> Kirschner wire or plate fixation
Q097. hip fractures
A097. typically elderly who sustain fall; hip hurts; affected leg is shortened and externally rotated; diagnose with x-rays
Q098. femoral neck fractures
A098. can compromise vasculature of femoral head; prosthesis achieves faster healing and earlier mobilization
Q099. intratrochanteric fractures
A099. less likely to lead to avascular necrosis; treat with open reduction, pinning and anticoagulation to prevent DVT and pulmonary embolism
Q100. femoral shaft fracture
A100. treat with intramedullary fixation; may lead to shock from blood loss; if open --> orthopedic emergency requiring OR cleaning and closure within 6 hours; if multiple --> may lead to fat embolism
Q101. knee injury
A101. has swelling; if no swelling, unlikely to be serious; MRI is best diagnosis
Q102. collateral ligament injury
A102. lateral blow displaces medial ligaments and vice versa; abduction demonstrates medial injuries and vice versa; treat with hinged cast or surgical repair
Q103. anterior cruciate ligament injury
A103. more common than posterior; knee pain and swelling; with flexed knee at 90 degrees, leg can be pulled anteriorly; treat sedentary patients with immobilization and rehab; treat athletes with arthroscopic reconstruction
Q104. posterior cruciate ligament injury
A104. knee pain and swelling; with flexed knee at 90 degrees, leg can be pulled posteriorly; treat sedentary patients with immobilization and rehab; treat athletes with arthroscopic reconstruction
Q105. meniscal tears
A105. presents with pain, swelling and click when knee is forcefully extended; best diagnosed with MRI; arthroscopic repair is done; complete meniscectomy leads to late development of degenerative arthritis
Q106. tibial stress fractures
A106. seen in young men subjected to forced marches; tenderness on palpation and x-ray is initially normal; repeat x-ray in 2 weeks; treat with cast or crutches
Q107. tibia and fibula fractures
A107. often when pedestrian is hit by car; physical shows angulation; x-rays are diagnostic; casting or intramedullary nailing is treatment; watch out for compartment syndrome after long cast
Q108. rupture of Achilles tendon
A108. seen in out-of-shape middle-aged men subjected to severe strain; loud popping noise is heard and there's loss of balance; there's pain, swelling and limping and palpation reveals a gap; cast in equinus or surgery
Q109. fracture of ankle
A109. falling on inverted foot; AP, lateral and mortise x-rays are diagnostic; if displacement, open reduction and external fixation is needed
Q110. compartment syndrome
A110. orthopedic emergency frequently in forearm or lower leg precipitated by reperfusion after ischemia or crushing injury; there's pain and limited use of extremity, compartment is tight, tender and painful; emergency fasciotomy is treatment
Q111. pain under cast
A111. orthopedic emergency requires removal of cast and examination of limb
Q112. open fracture
A112. orthopedic emergency requires cleaning in OR and suitable reduction within 6 hours from injury
Q113. posterior hip dislocation
A113. hip pain, leg is shortened, adducted and internally rotated; emergency reduction is needed to prevent avascular necrosis
Q114. gas gangrene
A114. penetrating dirty wounds; within 3 days patient looks ill; wound is tender, swollen, discolored and has gas crepitation; treat with IV penicillin, emergency surgical debridement, hyperbaric O2
Q115. radial nerve injury
A115. dorsiflexion is affected; if nerve paralysis remains after reduction of fracture --> surgery
Q116. popliteal artery injury
A116. due to posterior dislocation of knee; check pulses, Doppler and arteriogram; delayed restoration of flow requires prophylactic fasciotomy
Q117. carpal tunnel syndrome
A117. numbness and tingling in distribution of median nerve reproduced by tapping or pressing median nerve over carpal tunnel; clinical diagnosis + wrist x-ray (carpal tunnel view) to rule out other things; initial treatment is splints and antinflammatories; if surgery is needed --> electromyography first
Q118. trigger finger
A118. finger is acutely flexed and patient is unable to extend it; painful snap when extended with other hand; treat with steroid injections or surgery as last resort
Q119. DeQuervain tenosynovitis
A119. due to holding baby's head with wrist flexion and thumb extension; pain over radial distribution can be reproduced by holding thumb inside closed fist then forcing wrist into ulnar deviation; treat with steroid injection; surgery is rarely needed
Q120. felon
A120. abscess in pulp of fingertip due to neglected penetrating injury; presents with throbbing pain and signs of inflammation; can lead to necrosis so surgical drainage is necessary
Q121. gamekeeper thumb
A121. injury of ulnar collateral ligament due to forced hyperextension of thumb; painful and can lead to arthritis; treat with cast
Q122. jersey finger
A122. injury to flexor tendon when finger is forcefully extended; when making a fist, the distal phalanx does not flex; manage with splinting
Q123. mallet finger
A123. extended finger is forcefully flexed and extensor tendon is ruptured; tip of the finger remains flexed when hand is extended; splinting
Q124. traumatically amputated digits
A124. surgically reattached when possible;; clean with sterile saline, wrap in saline moistured gauze and place in sealed plastic bag on bed of ice;; do not put antiseptic solutions, alcohol, dry ice or allow finger to freeze
Q125. lumbar disk herniation presentation
A125. at L4-L5 or L5-S1; months of vague aching discogenic pain (pressure on anterior spinal ligament) followed by neurogenic pain; precipitated by forced movement, coughing, sneezing, defecating; neurogenic pain feels like electric shock down leg
Q126. lumbar disk herniation diagnosis
A126. straight leg raising gives excruciating pain; MRI is confirmatory
Q127. lumbar disk herniation management
A127. initially bed rest for 3 weeks; pain control with nerve blocks; surgery if progressive muscle weakness; emergency surgery if cauda equina syndrome (distended bladder, flaccid rectal sphincter, perineal saddle anesthesia)
Q128. cauda equina syndrome
A128. distended bladder; flaccid rectal sphincter; perineal saddle anesthesia; requires emergency surgical decompression
Q129. ankylosing spondylitis
A129. progressive chronic back pain and morning stiffness worse at rest; bamboo spine on x-ray; antinflammatories and physical therapy; HLA-B27 is also associated with uveitis and inflammatory bowel disease
Q130. metastatic malignancy
A130. progressive back pain worse at night and unrelieved by rest or position; lytic lesions (breast) or blastic lesions (prostate) on x-rays; bone scan for early metastases; MRI is best diagnostic tool
Q131. diabetic ulcers
A131. indolent and located at pressure points; due to neuropathy and microvasculature disease; keep clean or amputate
Q132. arterial insufficiency ulcers
A132. at the tip of the toes usually; they look dirty with a pale base devoid of granulation tissue; associated with absent pulses, trophic changes, claudication, rest pain; initial test is Doppler, then arteriogram; treat with surgical revascularization
Q133. venous stasis ulcers
A133. develops in chronically edematous indurated hyperpigmented skin of legs; painless and associated with varicose veins and cellulitis; use support stockings and surgery may be required
Q134. foot ulcers
A134. need work up for diabetes and arteriosclerotic disease
Q135. Marjolin ulcer
A135. is a squamous cell carcinoma of the skin that develops in chronic leg ulcer from burns or osteomyelitis; biopsy to diagnose; wide local excision and skin graft to cure
Q136. plantar fasciitis
A136. sharp heel pain when stepping, worse in the morning; bony spur on x-ray and tenderness to palpation; resolves in 12-18 months; no surgery, just sumptomatic treatment
Q137. preop assessment: cardiac --> ejection fraction
A137. below 35% poses too much risk
Q138. preop assessment: cardiac --> JVD
A138. worst factor indicating cardiac risk
Q139. preop assessment: cardiac --> MI
A139. next worst predictor of cardiac complications;; perform surgery after 6 months
Q140. preop assessment: cardiac risk factors
A140. JVD; MI; premature ventricular contractions; rhythm other than sinus; age over 70; emergency surgery; aortic valve stenosis; poor medical condition
Q141. preop assessment: pulmonary risk factors
A141. smoking (high PCO2) --> quit smoking 8 weeks prior to surgery with intensive respiratory therapy; do FEV1 and if abnormal, blood gases
Q142. preop assessment: hepatic risk factors
A142. 40% mortality --> bilirubin > 2, albumin < 3, PT > 16, encephalopathy; 80% mortality --> bilirubin > 4, albumin < 2, ammonia > 150mg/dL
Q143. preop assessment: nutritional risk factors
A143. 20% weight loss in 2 months; albumin < 3; anergy to skin antigens; transferrin < 200; treat with 7-10 days of preoperative nutritional support
Q144. preop assessment: diabetic coma
A144. absolute contraindication to surgery
Q145. postoperative fever causes
A145. high fever --> malignant hypertehermia, bacteremia; usual range fever; atelectasis, day 1; pneumonia, day 3; UTI, day 3; deep venous thrombophlebitis, day 5; wound infection, day 7; deep abscess, 2 weeks
Q146. postop complications
A146. fever; chest pain; aspiration; tension pneumothorax; disorientation/coma; oliguria; abdominal distention; wounds; fluid and electrolyte imbalance
Q147. postop bacteremia
A147. 30-45 minutes of invsive procedures; fever > 104 + chills; do blood cultures x 3; start empiric antibiotics
Q148. postop atelectasis
A148. MCC in first day; rule out malignant hyperthermia and bacteremia; treat with --> deep breathing and coughing, postural drainage, and if needed bronchoscopy; if uncorrected --> pneumonia
Q149. postop deep abscess
A149. fever 2 10-15 days postop; diagnose with CT; percutaneous guided drainage
Q150. periop MI
A150. chest pain only in 30%, the rest present with MI complications; treatment directed at complications; cannot use thrombolytic therapy
Q151. postop PE
A151. ABGs --> hypoxemia, hypocapnia; diagnosis --> MC is CT +- contrast (angio CT); gold standard is angiogram; use heparin
Q152. intraop aspiration
A152. leads to chemical acid injury; prevent with NPO and antacids before induction; treat with bronchoscopy lavage, bronchodilators and respiratory support
Q153. intraop tension pneumothorax
A153. from positive pressure breathing; decreased BP, increased CVP; if abdomen is open --> decompress through diaphragm; else --> needle through anterior chest with chest tube later
Q154. causes of disorientation/coma postop
A154. hypoxia --> first thing to check with ABGs; ARDS --> treat with PEEP, careful of barotrauma; delirium tremens --> in alcoholics, treat with benzos or alcohol; hyponatremia --> from high ADH and free water; may use hypertonic and osmotic diuretics; hypernatremia --> from unreplaced water loss; ammonium --> in cirrhotic patients with bleeding varices who goest for portocaval shunt
Q155. postop oliguria/anuria
A155. urinary retention --> feels need to void but can't; do in-out catheter at 6 hours; after 2nd or 3rd then Foley; oliguria --> from dehydration (responds to 500ml saline bolus) or ARN (high urinary and fractional Na); anuria --> usually mechanical; look for plugged or kinked catheter
Q156. postop paralytic ileus
A156. after abdominal surgery; mild distention, no pain, absent bowel sounds; prolonged by hypokalemia
Q157. early mechanical bowel obstruction
A157. due to postop adhesions; paralytic ileus does not resolve; x-ray --> dilated small bowel loops and air fluid levels; confirm with CT --> proximally distended, distally collapsed bowel; surgical correction
Q158. Ogilvie syndrome
A158. paralytic "ileus" of the colon; follows surgery other than abdominal; large abdominal distention; x-ray --> massively dilated colon; colonoscopy to suck out gas; leave rectal tube in; cecostomy of colostomy may be needed
Q159. postop wound complications
A159. wound dehiscence; evisceration; wound infections; fistulas of GI tract
Q160. wound dehiscence
A160. after open laparotomy; wound is intact but salmon-colored peritoneal fluid leaks out; tape the wound, bound the abdomen and careful mobilization and coughing; eventual re-operation for ventral hernia prevention or correction (not emergency)
Q161. evisceration
A161. complication of wound dehiscence; skin opens and abdominal content rush out; cover with sterile dressings and emergency closure
Q162. GI fistula
A162. bowel content leaks; sepsis if drains to cesspool; fluid/electrolyte loss, nutritional depletion and erosion of belly wall if they drain freely; treat with electrolyte replacement, nutrition beyond the fistula and ostomy bags until nature heals it; nature heals it if FETID not present --> foreign body, epithelialization, tumor, infection, irradiation, IBD or distal obstruction
Q163. postop hypernatremia
A163. if gradual --> rapid volume repletion with slow tonicity --> use D51/2 NS; if rapid --> from osmotic diuresis or DI --> produces CNS symptoms --> correct with D51/3 NS or D5W
Q164. water intoxication
A164. CNS symptoms of hyponatremia; carefully use hypertonic saline
Q165. hypokalemia
A165. from GI loss, loop diuretics, increased aldosterone, correction of DKA; correct at < 10mEq/h
Q166. hyperkalemia
A166. from renal failure, aldosterone antagonists, crush injuries, dead tissue, acidosis; treat with calcium (neutralize effects on membrane, fastest); dextrose/insulin; exchange resins; dialysis
Q167. mechanical intestinal obstruction
A167. caused by adhesions in those with prior laparotomy; colick pain, vomiting, abdominal distention, no passage of gas or feces; x-ray --> distended small bowel loops, air fluid levels; treatment --> NPO, NG suction, IV fluids waiting for spontaneous correction; watch for strangulation --> fever leukocytosis, peritonitis, sepsis
Q168. mechanical intestinal obstruction by hernia
A168. from incarcerated hernia; emergent surgery if strangulation; elective surgery if manual reduction is possible
Q169. appendicitis
A169. anorexia followed by vague paeriumbilical pain; then severe sharp constant pain in right lower quadrant; guarding and rebound tenderness; mild leukoxytosis and fever; emergency appendicectomy; doubtful presentation --> CT
Q170. colonic polyps
A170. most malignant --> familial polyposis, villous adenoma, adenomatous polyp; not premalignant --> juvenile, Peutz-Jeghers, inflammatory and hyperplastic
Q171. indications for surgery in ulcerative colitis
A171. disease > 20 years; nutritional compromise; multiple hospitalizations; need for high-dose steroids or immunosuppresants; toxic megacolon (abdominal pain, fever, leukocytosis, distended colon); also need to remove all rectal mucosa
Q172. hemorrhoids
A172. internal --> painless bleed, rubber band ligation; external --> painful; prolapsed internal --> pain and itching; rule out cancer in all anorectal diseases
Q173. anal fissure
A173. exquisite pain with defecation with blood; constipation from fear of bowel movement; may require physical exam under anesthesia; relax the tight sphincter with stool softener, topical nitroglycerin, botulin toxin or surgery; rule out cancer in all anorectal disease
Q174. ischiorectal perirectal abscess
A174. fever, perirectal pain, no bowel movements; local inflamation signs; surgical drainage; if diabetic --> necrosis --> watch closely; rule out cancer in all anorectal disease
Q175. fistula in ano
A175. draining tract lateral to anus after ischiorectal abscess drainage; rule out necrotic draining tumor; treat with fistulotomy; rule out cancer in all anorectal disease
Q176. GI bleeding stats
A176. 75% upper GI, 25% colon or rectum; if young person with GI bleed --> suspect upper; if elderly --> can be from anywhere
Q177. GI bleed work-up
A177. hematemesis or melena --> start work-up with upper endoscopy; blood per rectum --> NG tube; if blood retrieved --> upper GI bleed --> endoscopy; if no blood retrieved + white fluid --> follow with endoscopy to exclude duodenum bleed; if no blood retrieved + billous fluid --> no upper endoscopy needed; once upper GI bleed is excluded --> exclude hemorrhoids --> if excluded -->; if high volume --> angiography; if low volume --> wait for bleeding to stop then colonoscopy, alternative --> tagged RBC scan; if child --> Meckel --> technetium scan looking for ectopic gastric mucosa
Q178. acute abdominal pain from perforation
A178. sudden onset severe constant generalized abdominal pain; antalgic position; peritoneal irritation signs; free air under diaphragm in upright chest-x-ray
Q179. acute abdominal pain from obstruction
A179. sudden onset colicky pain that is localized; patient moves constantly
Q180. acute abdominal pain from inflammation
A180. gradual onset constant that starts as ill-defined and then localizes; peritoneal irritation signs are localized; systemic signs fever and leukocytosis
Q181. acute abdominal pain from ischemia
A181. severe sudden abdominal pain with blood in the lumen
Q182. primary peritonitis
A182. ascites along with mild generalized acute abdomen and equivocal findings; culture the ascitic fluid and treat with antibiotics
Q183. acute abdomen management
A183. exploratory laparotomy after ruling out:; primary peritonitis --> ascites; myocardial ischemia --> ECG; lower lobe pneumonia --> chest x-ray; PE --> immobilized patient; pancreatitis --> amylase; urinary stones --> x-ray or CT
Q184. mesenteric ischemia
A184. acute abdomen in patient with Afib or recent MI; clot lodges in superior mesenteric; there's pain and blood in lumen
Q185. pyogenic liver abscess
A185. complication of billiary tract disease, acute ascending cholangitis; fever, leukocytosis, tender liver; ultrasound or CT are diagnostic; treat with percutaneous drainage
Q186. amebic abscess of liver
A186. mexico connection; treat with metronidazole; if no improvement --> drainage
Q187. types of jaundice
A187. hemolytic --> unconjugated bilirubin < 6 or 8, no bilirubin in urine; hepatocellular --> both fractions elevated, very high transaminases, modest AP; obstructive --> both fractions elevated, modest transaminases and very high AP --> do ultrasound
Q188. billiary obstruction from stone
A188. ultrasound may not find common duct stone, but stones in a nondistended gallbladder are seen; high alkaline phosphatase; after ultrasound, do ERCP for confirmation and stone removal; after ERCP --> cholecystectomy
Q189. Courvoisier-Terrier sign
A189. large thin-walled distended gallbladder by ultrasound in malignant obstruction
Q190. causes of obstructive jaundice
A190. stone in common duct; malignant obstructive jaundice --> adenocarcinoma of head of pancreas; adenocarcinoma of ampulla of Vater; cholangiocarcinoma of common bile duct
Q191. obstructive jaundice by tumor work-up
A191. first ultrasound --> dilated gallbladder --> CT --> adenocarcinoma of head of pancreas; if positive --> percutaneous biopsy; if negative --> ERCP; ERCP endoscopy shows ampulla of Vater cancers; ERCP cholangiogram show cholangiocarcinoma of common duct or small pancreatic cancers
Q192. ampulla of Vater cancer
A192. malignant obstructive jaundice; anemia; positive occult blood test; endoscopy ERCP is first test
Q193. gallstone disease spectrum
A193. asymptomatic gallstone --> billiary colic --> acute cholecystitis --> acute ascending cholangitis --> obstructive jaundice --> biliary pancreatitis
Q194. biliary colic
A194. stone temporarily obstructs cystic duct; colicky pain in RUQ radiates to right shoulder and back; triggered by fatty food, associated with nausea and vomit; no signs of peritoneal irritation or systemic inflammation; self-limited; diagnose with ultrasound; elective cholecystectomy is indicated
Q195. acute cholecystitis
A195. starts as biliary colic until inflammation of gallbladder occurs; pain becomes constant with fever and leukocytosis and peritoneal signs in RUQ; liver function tests mildly affected; ultrasound --> gallstones, thick gallbladder, pericholecystic fluid; supportive and antibiotics to cool down then elective cholecystectomy; if doesn’t respond --> emergency surgery
Q196. acute ascending cholangitis
A196. stone partially obstructs common bile duct with ascending infection; fever with chills, high WBCs with sepsis; some hyperbilirubinemia and markedly increased AP; treat with ERCP decompression or percutaneous transhepatic cholangiogram; then do cholecystectomy
Q197. biliary pancreatitis
A197. stone obstructs bile and pancreatic ducts at ampulla; stone often pass spontaneously; elevated amylase; ultrasound confirms gallstones in the gallbladder; conservative treatment with elective cholecystectomy; if unresponsive --> ERCP
Q198. acute edematous pancreatitis
A198. due to alcohol or gallstones; high amylase or lipase; key finding is high hematocrit; treat with NPO, rest and fluids
Q199. acute hemorrhagic pancreatitis
A199. alcohol or gallstones; lower hematocrit; high amylase or lipase; Ranson criteria --> leukocytosis, hyperglycemia, hypocalcemia, increased BUN, metabolic acidosis, ARDS; do daily CTs to find abscesses and drain them
Q200. pancreatic abscess
A200. acute suppurative pancreatitis seen in CT after days of persistent fever and leukocytosis; percutaneous drainage required
Q201. pancreatic pseudocyst
A201. late sequela of acute pancreatitis or pancreatic trauma; collection of pancreatic secretions outside the ducts seen in CT or ultrasound; cysts < 6cm or < 6 weeks --> conservative management for resolution; cysts > 6cm or > 6 weeks --> percutaneous, surgical or endoscopic drainage
Q202. glucagonoma
A202. hyperglycemia; anemia; glossitis; stomatitis; migratory necrolytic dermatitis; measure glucagon and do a CT to localize
Q203. esophageal atresia
A203. excessive salivation shortly after birth with choking on first feed; coiled NG tube on x-ray; rule out VACTER; MC is blind upper esophagus and tracheoesophageal fistula; if surgery is delayed --> do gastrostomy
Q204. imperforated anus
A204. may be VACTER presentation; look for fistula to vagina or perineum; if present --> can delay surgery; if absent --> colostomy for high rectal pouches or immediate surgery for low; level of pouch with upside-down x-ray
Q205. congenital diaphragmatic hernia
A205. always on the left; problem is lung hypoplasia with respiratory distress; intubate, ventilate, wait 3-4 days for lung maturation then surgery
Q206. gastroschisis Vs. omphalocele
A206. gastroschisis defect is to the right of the normal cord with loose bowels; requires parenteral nutrition; omphalocele defect has membrane covering with cord going through it; small defects --> immediate correction; large defects --> construct protective Silastic silo and squeeze the contents a little every day
Q207. double bubble sign
A207. air-fluid level in stomach to the left; air-fluid level in first portion of duodenum to the right; nor air in distal bowels; present in duodenal atresia, annular pancreas and malrotation
Q208. intestinal atresia
A208. multiple air-fluid levels throughout abdomen
Q209. necrotizing enterocolitis
A209. premature infant; first feeding causes intolerance, abdominal distention, thrombocytopenia and sepsis; treat with broad-spectrum antibiotics; indications for surgery --> abdominal wall erythema, air in portal vein, pneumatosis, pneumoperitoneum
Q210. meconium ileus
A210. babies with cystic fibrosis; feeding intolerance and bilious vomiting; x-ray --> multiple dilated loops of small bowel; gastrofin enema --> microcolon, meconium pellets; diagnose and treat with gastrografin enema
Q211. hypertrophic pyloric stenosis
A211. nonbilous projectile vomiting after feeding at 3 weeks; visible peristaltic waves and palpable mass in RUQ; if no clinical diagnosis --> sonogram
Q212. biliary atresia
A212. persistent progressive jaundice in 6-8 week baby; do sweat test and serology to rule out CF; diagnosis --> HIDA scan after 1 week of phenobarbital; if no bile reaches duodenum --> laparotomy
Q213. Hirchsprung
A213. chronic constipation; x-ray --> distended proximal good colon with distal normal- looking aganglionic colon; diagnosis --> full-thickness biopsy
Q214. Meckel diverticulum / diverticulitis
A214. lower GI bleed in kid; do radioisotope scan for gastric mucosa in bowel
Q215. vascular rings
A215. pressure on tracheobronchial tree and esophagus; stridor and respiratory distress and dysphagia; barium swallow shows extrinsic compression; bronchoscopy shows segmental tracheal compression
Q216. atrial septal defect
A216. faint pulmonary flow systolic murmur; fixed split of second heart sound; history of frequent colds
Q217. ventricular septal defect
A217. failure to thrive; loud pansystolic murmur at left sternal border; increased pulmonary vasculature
Q218. patent ductus arteriosus
A218. bounding pulses; continuous machinery murmur; if no CHF --> indomethacin; if CHF --> surgery or coil embolization
Q219. tetralogy of Fallot
A219. right to left shunt with cyanosis; bluish hue, clubbing and relieved by squatting; systolic ejection murmur, right ventricular hypertrophy
Q220. transposition of great vessels
A220. kept alive by ASD, VSD or PDA; immediate cyanosis
Q221. coin lesion and lung cancer work-up
A221. check previous x-ray; then do sputum cytology and CT; then bronchoscopy + biopsy for central OR percutaneous biopsy for peripheral
Q222. operability of lung cancer
A222. need aminimum FEV1 of 800; small cell is treated with radio and chemo; hilar metastases can be operated by node metastases not
Q223. subclavian steal syndrome
A223. atherosclerotic stenotic plaque at origin of subclavian; blood reaches the arm in normal activity but not in excursive; in exercise the arm reverses blood from vertebrals and brain; presentation --> arm claudication + posterior neurologic signs (visual and balance); diagnosis --> arteriogram; claudication alone suggests thoracic outlet syndrome
Q224. abdominal aortic aneurysm
A224. pulsatile mass between xiphoid and umbilicus; coincidental finding on x-ray, ultrasound or CT; < 4cm --> observation; > 5-6 cm --> repair; if tender --> will rupture soon --> repair
Q225. arteriosclerotic disease of lower extremities
A225. presentation --> intermittent claudication, shiny atrophic skin, no hair, no peripheral pulses, rest pain, ulceration and gangrene; if doesn't interfere with daily activities --> cessation of smoking, exercise and cilostazol; if severe --> Doppler for pressure gradient; if no gradient --> not amenable to surgery; if gradient --> arteriogram looking for areas of stenosis and good distal vessels; if short stenotic segments --> stents; if large stenotic segments --> bypass graft of sequential stent
Q226. atrial embolization
A226. from atrial fibrillation or recent MI (mural thrombus); pain, pale, poikilothermic, pulseless paresthetic, paralytic lower extremity; do Doppler; if incomplete obstruction --> thrombolytics; if complete --> embolectomy with Fogarty catheter + fasciotomy
Q227. dissecting aortic aneurysm of thoracic aorta
A227. due to hypertension; do CT; if ascending --> surgery; if descending --> control hypertension
Q228. amblyiopia
A228. interference with processing of images in first 6-7 years of life most commonly by strabismus; produces cortical blindness
Q229. strabismus
A229. surgically correct to prevent amblyiopia; if acquired in childhood --> exaggerated convergence --> glasses
Q230. acute angle closure glaucoma
A230. severe eye pain or frontal headache typically in the evening; halos around lights; pupil is dilated and does not respond to light; cloudy cornea; eye is very hard; emergency treatment with acetazolamide, topical betablockers, alpha2 agonists; then emergency laser surgery
Q231. orbital cellulitis
A231. eyelids are inflammed; pupil is dilated and fixed; eye has limited motion; pus in the orbit; emergency CT and drainage
Q232. retinal detachment
A232. flashes of light and floaters in the eye; emergency laser reattachement
Q233. embolic occusion of retinal artery
A233. unilateral sudden loss of vision; have the patient breathe in a paper bag and press/release the eye
Q234. thyroglosal duct cyst
A234. midline; pulling tongue out retracts the mass; surgical removal of cyst, middle segment of hyoid bone and track to base of tongue
Q235. brachial cleft cyst
A235. anterior edge of sternocleidomastoid; may have little opening and blind tract in the skin
Q236. cystic hygroma
A236. at the base of neck; large, mushy, ill-defined mass occupies entire supraclavicular area; often extend into chest and mediastinum; CT before surgery is mandatory
Q237. recently discovered enlarged lymph node
A237. complete history and physical + follow-up 3-4 weeks; if mass persists --> work-up
Q238. persistent enlarged lymph node
A238. could be inflammatory but cancer has to be ruled out; for lymphoma or lymph node metastasis --> removal of node and pathologic exam; could also be squamous cell carcinoma of mucosa of head and neck
Q239. squamous cell carcinoma of mucosa of head and neck
A239. smokers, drinkers, rotten teeth, AIDS; persistent hoarseness; persistent painless ulcer at floor of the mouth; persistent unilateral earache; do triple panendoscopy; FNA may be done but not open biopsy; treatment --> resection, radical neck dissection, radio, chemo
Q240. facial nerve tumor
A240. unilateral facial peripheral paralysis that is insidious; do gadolinium MRI
Q241. parotid tumor
A241. most are adenomas but predispose to malignant; don’t produce facial paralysis; hard painful parotid mass with facial paralysis is carcinoma; FNA may be done but open biopsy is absolutely contraindicated; treat with parotidectomy
Q242. cavernous sinus thrombosis
A242. diplopia in patient with sinusitis; emergency IV antibiotics, CT and drainage is required
Q243. epistaxis
A243. in children, may be from nose picking; treat with phenylephrine and local pressure; in adolescents --> cocaine abuse (posterior packing needed) or nasopharyngeal angiofribroma (surgical excision); in elderly or hypertensives --> can be life-threatening; control BP and posterior packing
Q244. parinaud syndrome
A244. tumor of pineal gland; loss of upper gaze and sunset eyes
Q245. neurogenic claudication
A245. back pain worsened by back extension or standing up, relieved by flexion or sitting down; diagnosis is spinal stenosis; do MRI
Q246. reflex sympathetic dystrophy
A246. causalgia develops after crushing injury; constant burning pain does not respond to analgesics; extremity is cold, cyanotic and moist; diagnosis --> successful sympathetic block; management --> surgical sympathectomy
Q247. testicular torsion
A247. adolescents with testicular pain of sudden onset; no fever, pyuria or history of mumps; testicle is tender but cord is not; clinical diagnosis, don’t do tests; emergency surgery required
Q248. acute epididymitis
A248. severe testicular pain of sudden onset; fever and pyruia is present; cord is tender; do sonogram to rule out testicular torsion; treat with antibiotics
Q249. combined obstruction and infection of urinary tract
A249. urologic emergency because it can lead to kidney destruction in hours; suddenly develops fever, chills and flank pain; treat with IV antibiotics and decompression above the obstruction
Q250. urologic diagnostic procedures
A250. IV pyelogram; looks at kidneys, ureters and some bladder; contraindicated if creatinine >2; CT --> renal tumors and stones; sonogram --> to look for dilation and obstruction; cytoscopy --> to look at bladder mucosa for cancer
Q251. posterior urethral valves
A251. MCC for a newborn not urinating in first day; do catheterization; diagnosis --> voiding cystourethrogram; treatment --> endoscopic fulguration or resection
Q252. hypospadia
A252. urethral opening on ventral side of penis; do not do circumsision because prepuce is needed for correction
Q253. vesicouretheral reflux
A253. signs of peylonephritis in a child; do IVP and voiding cystogram looking for the reflux; if found --> long term antibiotics
Q254. low implantation of urether
A254. normal voiding plus wet with urine all the time in girls but asymptomatic in boys; do IVP then surgery
Q255. ureteropelvic junction obstruction
A255. normal diuresis is ok but large volume cannot handle it (teenage goes drinking); colicky flank pain
Q256. renal cell carcinoma
A256. hematuria, flank pain, flank mass; hypercalcemia, erythocytosis, elevated liver enzymes; work-up --> IVP shows mass; US shows solid, not cystic mass; CT may be first study shows heterogenous solid mass
Q257. cancer of bladder
A257. smoking predisposes; hematuria, irritative voiding symptoms; work-up --> first IVP; best test is cystoscopy
Q258. prostatic cancer
A258. rock hard nodule on rectal exam and high PSA; diagnosis --> transrectal needle biopsy guided by sonogram; CT for extent of involvement; widespread bone metastasis --> androgen ablation, orchiectomy, flutamide
Q259. testicular cancer
A259. painless testicular mass; do AFP and bHCG first for basal levels and follow-up; diagnose and treat with radical orchiectomy; radio and chemo may be given
Q260. urether stone
A260. < 3mm can pass spontaneously with analgesic and fluids; > 7mm needs intervention with shock wave lithotripsy or more invasive such as; basket extraction, sonic probes, laser
Q261. psychogenic impotence
A261. does not interfere with nighttime erections; diagnose with roll of postage stamps
Q262. hyperacute transplant rejection
A262. vascular thrombosis within minutes; caused by preformed antibodies; prevented by ABO matching and lymphocytotoxic crossmatch
Q263. acute transplant rejection
A263. 5 days - 3 months; signs of organ dysfunction even on immunosupressants; confirmed by biopsy; treatment is steroid bolus +- OKT3; liver --> more often due to mechanical problems; do Doppler; heart --> do serial ventricular biopsies
Q264. chronic transplant rejection
A264. years after the transplant with insidious loss of function; irreversible and no treatment available
Q265. what conditions is carpal tunnel syndrome related to
A265. DM; myxedema; hyperthyroid; acromegaly; pregnancy; lipomas; bony abnormalities; hematomas
Q266. what is Charcot's triad associated with
A266. ascending cholangitis
Q267. what is Charcot's triad
A267. fever; jaundice; RUQ pain
Q268. what is ascending cholangitis
A268. infection of bile duct --> sepsis and multiorgan failure
Q269. tx for ascending cholangitis
A269. Antibiotics and supportive care; ERCP decompression of CBD
Q270. what is the best way to dx stones in GB?
A270. U/S (98-99% sensitivity); not the best way to dx stones in CBD, only 50% are visualized
Q271. what is ERCP
A271. way to visulaize CBD; can also perform sphincterotomy of duo to clear stones; treats cholelithiasis and choledocolithiasis
Q272. dx of choledocolithiasis
A272. dilated CBD on U/S; >5mm diamter and increased LFTs
Q273. how to manage a patient w gal;stones and pancreatitis
A273. wait for pancreas to resolve itself, then perform cholecystectomy
Q274. causes of LGI bleeds if >40 yo
A274. diverticulosis; angiodysplasia; neoplasm; (all are painless)
Q275. dx of LGI bleed + pain
A275. ischemic bowel; IBD; intussusception; ruptured AAA
Q276. how to localize LGI bleed
A276. colonoscopy; mesenteric angiography; RBC scan
Q277. cause of overt LGI bleed in children
A277. meckel's diverticulum; IBD; polyps
Q278. cause of overt LGI bleed in 20-60 yo
A278. diverticulitis; neoplasm; IBD
Q279. cause of overt LGI bleed in >60 yo
A279. divertic; angiodysplasia; neoplasm
Q280. what is RBC scan
A280. used to dx bleeding if >.1 ml/min; won't always localize bleeding accurately; do 1st then follow with mesenteric angiography
Q281. advantage of mesenteric angiography
A281. 0.5-1.0 ml/min in order to be visualized... can see faster bleeds
Q282. common causes of overt LGI bleeds in children
A282. Meckel's diverticulum; IBD; polyps
Q283. common causes of LGI bleeds in 20-60 yo
A283. IBD; noeplasm; diverticulosis
Q284. common causes of LGI bleeds in >60 yo
A284. neoplasm; diverticulosis; angiodysplasia
Q285. when are maroon colored stools seen?
A285. LGI bleeds without rectum/anus involvment
Q286. features of a rectal bleed
A286. formed stool streaked with blood , or fresh blood at the end of a BM
Q287. what is mortality in head injury with hypoxia and hypotension?
A287. 0.75
Q288. how much is mortality increased in hypoxia?
A288. 2x
Q289. how to tx increased intracranial pressure?; what precautions must be taken?
A289. hyperventilation and mannitol (but must be done cautiously since hyperven --> cerebral vasoconstriction); it is helpful, however, b/c it makes room for expanding lesion, but can lead to cerebral ischemia if prolonged; don't give mannitol unless pts are adequately hydrated
Q290. which type of hematoma (subdural or epidural) is more common
A290. subdural
Q291. what does sluggish pupil dilation indicate
A291. early sign of temporal lobe hernaition; CN III gets compressed against tentorium; herniation 90% of the time is on the same side as the pupil abnormality
Q292. 1st step in managing SBO
A292. fluid resusc; NGT; place Foley to assess fluid response
Q293. complications of SBO
A293. strangulation; bowel necrosis; sepsis; vomiting --> aspiration pneumonitis; intravasc fluid loss --> prerenal azotemia and acute renal insuff
Q294. why is SBO so painful
A294. severe bowel distention --> venous congestion, decreased bowel perf, necrosis; bowel ischemia 2/2 strangulation
Q295. what is an ileus
A295. distention from non-obstructive causes
Q296. gallstone ileus
A296. mechanical obstruction of SB b/c of large gallstone in bowel lumen; intermitt bowel obstruction for several days until stone lodges in distal small bowel --> complete obstruction
Q297. causes of SBO in child
A297. hernia; malrotation; intussusception; meconium ileus; Meckel's divertic; intestinal atresia
Q298. causes of SBO in adult
A298. tumor; hernia; adhesions; crohn's dz; gallstone ileus
Q299. presentation of SBO
A299. passage of intestinal lumenal contents --> cramplike abdominal pain; n/v (bilious); BM occurs with start of obstruction/pain (b/c of incresaed peristalsis); no gas/BM
Q300. association of BM with SBO
A300. usually BM at very start of obstruction, followed by increasdd peristalsis and
Q301. dx if there is stool on DRE of patient with SBO
A301. ileus, NOT mechanical obstruction
Q302. what is early post-op SBO
A302. sx that occur <40d following surgery; results from narrowed lumen, exact cause not known
Q303. w/u for post-op SBO
A303. CT to rule out infection; exact cause not needed
Q304. tx for post-op SBO
A304. supportive care
Q305. cause of chronic mesenteric ischemia
A305. occlussion of 2/3 BV; Dz also seen in 3rd as well
Q306. Dx of chronic mesenteric ischemia
A306. if no ATH, use arteriograpyhy
Q307. tx for chronic mesenteric ischemia
A307. revasc with antegrade aortomesenteric bypass/perivisceral aortic endarterectomy; angioplasty; retrograde bypass from iliac artery
Q308. when to operate on acute mesenteric ischemia
A308. this is a surgical emergency!
Q309. causes of acute mesenteric ischemia
A309. embolism in SMA or celiac artery
Q310. which part of the small intestines is spared in acute mesenteric ischemia? why?
A310. prox jejunum b/c of collaterals
Q311. tx for acute mesenteric ischemia
A311. embolectomy; 2nd-look laparotomy should also be done if bowel doesn't appear viable
Q312. when should a AAA be repaired
A312. 5cm
Q313. #1 cause of morbidity and mortality in AAA repair
A313. cardiac complications
Q314. how should AAA found on physical exam be confirmed
A314. CT scan; don't use arteriography b/c it just shows the lumen of BV, can't dx aneurysm from this, although it will help to plan the operation
Q315. what are the 2 types of AAA repairs; benefits of each
A315. EVAR (endovascular aneurysm repair) - pts with copd, obesity, malig, etc get more protection from rupture with EVAR; open repair - stood the test of time, est as a tx
Q316. disadvantages to EvAR
A316. rquire imaging f/u every 3-6 mos; patient mortality of 2-3%
Q317. presentation of AAA rupture
A317. back pain; pulsaltile mass; hypotension
Q318. management of acute pancreatitis
A318. resuscitative measures/supp O2; monitor cardio-pulm status; CT abdomen
Q319. complications of acute pancreatitis
A319. hemorrhage; necrosis; fluid collection; infection; pleural effusion; -> pulm/renal probs
Q320. process of infected pancreatic necrosis
A320. 2/2 infx by bowel organisms; occurs w/i first few weeks of onset
Q321. pancreatic abscess cause and tx
A321. accumulation of pus and infectious debris; tx with surgical drainage
Q322. tx of infectious pancreatic pseudocyst
A322. percutaneous/operative drainage
Q323. Ranson's criteria seen on admission
A323. WBC >16,000; glucose >200; age > 55yo; AST >250; LDH >350
Q324. Ranson's criteria following 48 hrs
A324. HCt fall by 10%; Ca <8; BUN increase of 5; fluid requirement >6 L; base excess of >4; P02 <60
Q325. value of Ranson's criteria
A325. more criteria have more severe dz and increased risk of comlication and death
Q326. what indicates severe acute pancreatitis
A326. necrosis of pancreas; 50% have inx and increased microvasc permeability; -> increased volume los; decreased perfusion of kidneys, lungs, etc
Q327. when should a contrast-enhanced CT of the pancreas be done?
A327. if pancreatitis dx is in question; if no improvement in 3-5 days; severe pancreatitis based on ranson score (looking for necrosis)
Q328. what, if seen on CT, wouldu indicate severe dz and increased risk of complications
A328. 2+ extrapancreatic fluid collections or necrosis of >50% of pancreas
Q329. management of necrotizing pancreatitis
A329. 50% of time,; complicate by infection, so must adminster proph Antibiotics when necrosis is confirmed on CT
Q330. how should gallstone pancreatitis be treated?
A330. cholecystectomy after pancreatitis has resolved
Q331. which Antibiotics penetrate pancreas
A331. imipenem; cilistatin
Q332. Tx for carotid artery dz
A332. surgery should always be done on sx side 1st, if both are affected
Q333. when should elective CEA be done
A333. if 60% stenosis is seen, unless patient is high risk
Q334. what is complication o fCEA or medical management of carotid artery dz
A334. stroke can occur with either
Q335. how is amt of stenosis determined in carotid artery dz
A335. US; if that is unclear, do MR angiogram, carotid angiogram or CT reconstruction angiogram
Q336. what are risk factors for CEA
A336. prior radiation to the neck; coronary artery stent; recrrent coronary artery stenosis
Q337. what is a short term tx for carotid artery dz
A337. stent
Q338. When should barium enema be used in dx diverticulitis
A338. never- there is sig risk involved with intraeritoneal leakage of barium
Q339. dx of diverticulitis
A339. CT scan will show colonic wall thickening, mesenteric fat stranding; can see diverticulae
Q340. complications of diverticulitis
A340. perforation; abscess; bowel obstruction; fistula (#1 cause of fistulas in adults)
Q341. tx of abscesses from diverticulitis
A341. if small, Antibiotics; if big, CT-guided drainage + Antibiotics; if no imrpovement after 72 hrs, surgery
Q342. if there is an increased risk of recurrence with diverticulitis, management?
A342. elective surgical resection with primary anastamosis even if prior flare-up was treated conservatively
Q343. how should uncomplicated diverticulitis be treated?
A343. monitor hydration, give IV Antibiotics, bowel rest and observation
Q344. how should complicated diverticulitis be treated?
A344. surgical resection; colostommy; closure of the rectal stump; reanastomosis performed at a later date
Q345. what is fascial dehiscence?
A345. disruption of fascial closure within 3 days of operation, with or without operation
Q346. complications of fascial dehiscence
A346. enterocutaneous fistula; evisceration; incisional hernia
Q347. risk factors for fascial dehiscence
A347. failure of surgical technique, anesthetic relaxation; >70 yo; DM; infx; malnutrition; pulm dz
Q348. tx of fascial dehiscence
A348. wound care; elective repair of defect
Q349. time frame that fascial dehiscence is most likely to occur?
A349. up to 3 weeks following surgery, after that, fibrous scar formation has enough strengthh to prevent evisceration
Q350. vitamins involved in wound healing
A350. vitamin c, a, b6; (collagen cross linking)
Q351. tx of ptx
A351. tube thoracostomy/needle aspiration
Q352. difference btwn primary and 2ndary spontaneous ptx
A352. 1ary: from spont rupture of blebs; 2ndary: from bullous emphysematous dz, CF, CA, PCP, necrotizing infx, copd
Q353. sx of tension ptx
A353. dyspnea; jvd; decreased breath sounds; increased resondance; trachea shifts away from affected side
Q354. tx perf of duo ulcers
A354. if no h/o prior ulcers or + HP, omental patch closure and HP tx; if + h/o prior ulcers and - HP, highly selective vagotomy
Q355. tx of perf gastric ulcer
A355. + closure of perf or excise/resect ulcer w 1ary repair or Billroth I/II
Q356. tx of obstructing gastric ulcer
A356. antretomy and Whipple
Q357. are H2 blockers or PPIs more effective in tx ulcers
A357. PPIs
Q358. string sign
A358. seen in hypertrophic pyloric stenosis, showing narrowed pylorus
Q359. stack of coins sign
A359. intestinal obstruction
Q360. tx for intussusception
A360. radiographic reduction; if fails, open surgery
Q361. incision through previous scar- good or bad?
A361. good. promotes wound healing
Q362. featuress of large bowel ischemia
A362. minimal pain; see thumbprinting on barium enema; BVs are usually patent
Q363. when should a colectomy be done on a patient with UC
A363. 10-20 yrs with dz... (after 10 yrs, CA risk increases 4x)
Q364. complication of typhoid fever
A364. Peyer's patches bleed /perf in 2-3rd week following sx
Q365. how to stop intractable bleeding
A365. use laparoscopic towels to pack abdomen
Q366. what is seen on EKG of patient with high Mg?; how can it be reversed
A366. sim to increased K; CaCl2
Q367. what is seen with low Na on EKG
A367. nothing
Q368. what is seen with low K on EKG
A368. flattened T waves and U waves
Q369. when is succussion splash seen in the abdomen
A369. any sort of obstruction
Q370. what are the most common causes of pyloric obstruction
A370. duo ulcer; gastric CA
Q371. how is mild Na deficiency tx?; severe Na defic?
A371. fluid restriction; if CNS sx present, give hypertonic saline
Q372. how is ARDS monitored
A372. ABG
Q373. surgery = physiological stress
A373. surgery = physiological stress
Q374. benefits of enteral feeding
A374. preserves gut mucosal mass and nml gut flora
Q375. benefits of parenteral feedings
A375. good for rapid administration
Q376. what happens if TPN is suddenly DCd?
A376. rebound hypoglycemia,; give D10W when TPN is suddennly DCd
Q377. what does surgery do to fluid levels
A377. following surgery, increased cortisol levels --> increased sugar in serum --> increased urine output
Q378. what TPN additive is good for liver encephalopathy
A378. lactulose
Q379. how is AAA dx?
A379. U/S then CT scan to det true size
Q380. A patient is diagnosed with invasive ductal adenocarcinoma. What is the most important factor in the staging of this patient’s cancer?
A380. Lymph Node Involvement
Q381. Which nerve, if damaged in an axillary dissection, will result in only a sensory deficit?
A381. Intercostobrachial nerve
Q382. What cancer drug can cause pulmonary fibrosis?
A382. Bleomycin
Q383. A 59-yo male presents with complaints of recurrent UTIs. On further questioning, it sounds as if the patient is also experiencing pneumaturia. What is the most likely underlying cause for this patient’s symptoms?
A383. Diverticulitis; (Colorectal fistula is also a cause, but is very rare)
Q384. What is considered the triangle of Calot in GB surgery?
A384. Cystic Duct,; Common Hepatic Duct,; Cystic Artery
Q385. A 73-yo female presents with nausea, vomiting, obstipation and abdominal distention. She is afibrile, with slight tachycardia and a distended abdomen without peritoneal signs. She has no History of surgery. What is the most likely cause of this patient’s bowel obstruction?
A385. Gallstone Ileus; (may also present with pneumobilia)
Q386. A critically ill hemodynamically unstable intubated patient on vasopressors with History of recent MI and long ICU course begins having fevers. Labs are: WBC 19,000, AST 100, ALT 45, ALK Phos 345, total bilirubin 3.0, direct bilirubin 2.8. Abdominal ultrasound shows no stones in the gallbladder. Dx?; What is next step in Tx given patient’s condition?
A386. Dx: Acute Acalculous Cholecystitis; (due to biliary sludge secondary to inactivity of the biliary tree. It is seen in critically ill patients with prolonged periods of fasting or Parenteral nutrition, or in patients with multiple transfusions or trauma patients); Tx: Percutaneous Cholecystostomy; (until patient is stable enough to undergo a cholecystectomy)
Q387. Type of Shock:; An 18-yo male restrained driver with tachycardia, hypotension, and a rigid abdomen
A387. Hypovolemic shock
Q388. Type of Shock:; An 80-yo nursing home resident, febrile, unresponsive, hypotensive, with gram-negative rods cultured in urine.
A388. Distributive shock; (Sepsis or Anaphylaxis)
Q389. Type of Shock:; A 16-yo male victim of a motor vehicle crash with hypotension, bradycardia and the inability to move or feel both lower extremities
A389. Neurogenic shock; (seen in patients with spinal cord injuries; caused by a decrease in sympathetic output; CO, CVP, PCWP and SVR are all decreased)
Q390. Type of Shock:; A 67-yo male in the medical ICU on 15L of oxygen by facemask, hypotension and crackles in the bases of both lungs
A390. Cardiogenic shock; (seen in patients with acute MI and respiratory distress; CO is decreased and everything else is increased)
Q391. What is Duke’s staging for Colon Cancer (A-D)?
A391. A: limited to Mucosa; B1: into the Muscularis Propria; B2: through the Muscularis Propria; C1: into MP with positive LN; C2: through the MP with positive LN; D: Metastasis or Unresectable
Q392. What is the proper medical Tx (post-colectomy) for Duke’s stage C Colon Cancer?; What common cancer Tx is not used in colon cancer?
A392. 5-FU and Leucovorin (Levamisole); Radiation is not used in colon cancer; (only in rectal cancer)
Q393. What is the Diagnostic Test for patients with Rectal Cancer?; What is the adjuvant Tx for T3-T4 Rectal Cancer? (2)
A393. Diagnostic test: Endorectal Ultrasound; Tx: Pre-op Radiation Therapy and 5-FU
Q394. A 52-yo female presents with 5-day history of increasing LLQ pain, N/V and fever. Two previous episodes of the pain were treated with Antibiotics. She is tachycardic, has LLQ pain and diffuse peritoneal signs. A CT shows air in the abdomen. Dx?; Next step?
A394. Dx: Perforated Diverticulum; Next step: Emergency resection of the Sigmoid colon with diverting colostomy
Q395. A 27-yo male presents with severe RLQ and testicular pain that began 5 hours ago. The pain is the worst he has ever experienced and is assoc with nausea. He is writhing in pain and cannot hold still as you talk to him. He is afebrile and has a WBC of 10,300. Diagnostic test?; Dx?
A395. Diagnostic test: Urinalysis; (on every patient with RLQ pain); Dx: Kidney Stone
Q396. An 80-yo female presents with vomiting 5 times that day which was thick and brown in appearance. She also complains of severe abdominal pain that began the previous night and has gotten worse and that she has had no BM or flatus throughout the day. She has no History of previous surgery and underwent a colonoscopy 1 month ago for chronic constipation, which elicited normal results. What is the most likely cause of this bowel obstruction?
A396. Sigmoid Volvulus
Q397. How is Total Body Water calculated in men and women?
A397. Men: 60% of body weight; Women: 50% of body weight
Q398. A patient’s recent blood glucose levels have been high at 500 mg/dL. This morning her sodium was 134 mmol/L. What is the corrected sodium level? (Eqn)
A398. (Na + [glucose – 100] x 0.016) =; (134 + [500 – 100] x 0.016) = 140 mmol/dL
Q399. How is plasma osmolality calculated? (Eqn); An osmolar gap is present if the measured and calculated osmolarity differ by how much?
A399. (2 x Na) + (glucose/18) + (BUN/2.8); Differ by 15 mOsm/kg
Q400. What causes a bluish discoloration of the periumbilical area?; What is another sign of this?
A400. Fox’s sign: Retroperitoneal Hemorrhage; (ex: acute hemorrhagic pancreatitis); another sign: Ecchymosis or discoloration of flank; (Grey Turner’s sign)
Q401. Dx for the triad of HTN, bradycardia and irregular respirations?
A401. Dx: increased ICP
Q402. Dx for calf pain on forced dorsiflexion of the foot in patient (Homan’s sign)
A402. Dx: DVT
Q403. What are the two signs of a basilar skull fracture?
A403. Raccoon Eyes and Battle’s sign (ecchymosis over the mastoid process)
Q404. What is Budd-Chiari syndrome?
A404. Thrombosis of hepatic veins
Q405. MC indication for surgery with Crohn’s Dz?
A405. Small Bowel Obstruction
Q406. MC vessel involved in a bleeding duodenal ulcer?
A406. Gastroduodenal artery
Q407. MC bacteria in stool?
A407. Bacteroides fragilis (“B. frag”)
Q408. MC electrolyte deficiency causing Ileus?
A408. Hypokalemia
Q409. MC cause of Large Bowel Obstruction
A409. Colon Cancer
Q410. MC type of Volvulus?
A410. Sigmoid volvulus
Q411. MC bacteria causing UTI?
A411. E. coli
Q412. MC benign tumor of the liver?
A412. Hemangioma
Q413. A 55-yo man presents with a 20-year History of heartburn. During endoscopy a Biopsy demonstrates a high-grade columnar dysplasia consistent with Barrett’s esophagus. What is the most appropriate Tx?
A413. Esophageal resection
Q414. What is the most important part of the surgical correction of Zenker’s diverticulum?
A414. Myotomy of the Cricopharyngeus muscle; (b/c the diverticulum results from the increased spasticity of this muscle)
Q415. What are two main causes of non-anion gap metabolic acidosis?; How can you tell which is the problem?
A415. Diarrhea and Renal Tubular Acidosis; calculate the Urine Anion Gap (Una – Ucl – Uk)
Q416. What is a common cause of post-op tachyarrhythmia?; What is the Tx?; What is the reason for the initial treatment?
A416. Atrial Fibrillation; Tx: Beta-agonist drip for Rate Control
Q417. What is the next step in a patient presenting with a confirmed Acute MI?; (2 possible); What if the patient is a post-op?
A417. Next:; 1. Thrombolytics; 2. Angioplasty; Post-op:; Angioplasty; (due to possibility of bleeding with thrombolytics; Stenting may be indicated)
Q418. A 60-yo female is post-op on mechanical ventilation. Her blood chemistry shows a Respiratory Acidosis. What initial change in the ventilator is most appropriate?; What (2) vent changes are used to improve the patient’s oxygenation?
A418. First: Increase Tidal Volume; (CO2 is determined by minute ventilation calculated as Ve = RR x Tidal volume [Vt]; CO2 is retained by decreasing the Ve, so to blow off the CO2, either RR or Vt needs to increase); Improve O2: Increase FiO2 or Increase PEEP; (Increasing the amount of O2 the patient receives, the Fraction of Inspired O2, or increasing the surface area and the amount of time O2 can diffuse into the capillaries [PEEP] improves oxygenation)
Q419. What do the thyroid labs look like in Graves Disease?
A419. Decreased TSH; Increased free T-4
Q420. How does Secondary Hyper- and Hypo- thyroidism present in labs of TSH and T-4?
A420. Hyper: Increased TSH; Increased free T-4; Hypo: Decreased TSH; Decreased free T-4
Q421. What is the most serious complication following surgical treatment for a Thyroidectomy?
A421. Recurrent Nerve Damage; (resulting in Abductor Laryngeal paralysis with affected cord assuming the midline. Unilateral results in hoarseness; Bilateral may lead to airway obstruction)
Q422. What is the first step in diagnosing a mass on the thyroid?; What is the difference between a Hot and Cold lesion?; What test can distinguish b/t Hot and Cold lesions?
A422. First test: Fine Needle Aspiration; Hot lesion: Functional; Cold lesion: Non-functional; Hot/Cold test: Radionucleotide thyroid scan
Q423. After performing a VMA for a pheochromocytoma, what imaging exam is most specific in localizing the lesion?
A423. MIBG (a NE analog)
Q424. A 42-yo female was victim of a MVA and has been in the ICU for 2 weeks. She has been stable and on a vent for ARDS. She then suddenly gets acute hypotension (80/42) in addition to WBC of 9,000, HCT = 33%, Na = 130, K = 5.3, Cl = 110. You give the patient 2L of crystalloids but the vitals remain unchanged. A NE drip is started and the BP remains in the 80s/40s. What is the likely cause of this patient’s hypotension?
A424. Acute Adrenal Insufficiency; (Addisonian crisis: considered in any patient with unexplained hypotension that does not respond to fluid or pressors; occurs when the normal response of glutocorticoid release is impaired, most often in patients with long-term steroid use experiencing the stress of illness or surgery)
Q425. What is the disasterous complication of a Supracondylar fracture of the Humerus?
A425. Volkmann’s Contracture; (ischemic injury to the deep tendon flexors of the forearm sustained during a supracondylar humeral fracture; muscle necrosis can begin in 4 – 6 hours after compromised circulation)
Q426. What nerve and artery travel along the mid-Humeral shaft and can be damaged in a fracture to that area?
A426. Radial nerve;; Brachial Profunda (deep brachial) artery
Q427. Where is the MC place for a Mallory-Weiss tear?
A427. In the Stomach near the GE junction
Q428. What is the most proven risk factor of Pancreas cancer?; What is the best initial diagnostic test?
A428. Smoking; Dx test: CT scan with oral and IV contrast
Q429. Why is a posterior hip dislocation an emergency?
A429. To avoid Posterior Avascular Necrosis
Q430. What is the ECG sign with Primary Hyperparathyroidism?
A430. Shortened QT on ECG
Q431. What is the required margin of resection for a melanoma of the following size:; 1. In situ; 2. < 1mm; 3. 1 – 4mm; 4. > 4mm
A431. In situ: 0.5cm; < 1mm: 1 cm; 1 – 4mm: 2cm; > 4mm: 2 – 3cm
Q432. What is used to Dx Achalasia?
A432. Esophageal Manometry
Q433. A 54-yo male presents with angina-like chest pain that is usually assoc with stress and is relieved by nitrates. He is worked-up for an MI, but his troponin and ECG are normal. Dx?
A433. Diffuse Esophageal Spasm; (another chest pain relieved by nitrates)
Q434. What is the MCC of an acute appendicitis?
A434. Lymphoid Hyperplasia; (not fecalith)
Q435. What type of portal system shunt decreases the risk of developing encephalopathy?
A435. Warren distal Splenorectal shunt
Q436. After undergoing a portal shunt procedure one week ago, the patient has become confused and combative. His breathing is unlabored and vitals are normal, but there is a foul smell to his breath and he has asterixis. Dx?; What is seen in the blood sample?
A436. Dx: Hepatic Encephalopathy; In Blood: Increased Ammonia; (blood does not pass liver first to clean it of the ammonia)
Q437. What is the cause of hypotension in Septic shock?
A437. Cytokines from the inflammatory response cause loss of systemic vascular resistance; (as well as fever and leukocytosis)
Q438. Infant presents with excessive salivation and repeated episodes of coughing, choking and cyanosis. Dx?
A438. Dx: Esophageal Atresia; (most common ends in a blind pouch with a distal tracheoesophageal fistula)
Q439. Infant is vomiting and on abdominal films there is a “soap bubble” sign in the ileum. Dx?; Tx?
A439. Dx: Meconium Ileus; Tx: Gastrografin enema; (draws water into the bowel to break-up the meconium plug)
Q440. What bacteria are worrisome after a spenectomy?
A440. Encapsulated bacteria; (Strep pneumonia, H. influnzae, Meningococcus)
Q441. What is a common cause of sudden or unexplained hyperglycemia on a post-op patient on TPN?
A441. Infection
Q442. What complication related to TPN may cause a patient to get a HCO3 of 30 and go into Respiratory Failure?
A442. Increased CO2 production; (due to increasing the daily caloric intake; overfeeding)
Q443. What is an appropriate test if you suspect Clostridium Difficile?
A443. Stool Toxin Assay
Q444. Aside from trauma, what are (2) other causes of Hypovolemic shock?
A444. Small Bowel Obstruction and Pancreatitis; (both due to Third Spacing)
Q445. What neurologic condition may develop if low sodium is corrected too rapidly?; What (2) problems can cause a greater risk of this occurring in the patient?
A445. Central Pontine Myelinolysis; Patient has History of: Malnutrition or Alcoholism
Q446. What can be a devastating outcome of correcting a Hypernatremic patient too rapidly?
A446. Cerebral edema; (by rapidly shifting fluid into cells)
Q447. A 12-yo child presents with pain and inflammation over the ball of his left foot and red streaks extending up the inner aspect of his leg. He removed a wood splinter from his foot the previous day. What is the most likely bug?
A447. Streptococcus; (streaks are lymphatic inflammation)
Q448. A 3-yo presents with a non-tender abdominal mass. What is the MCC of extracranial solid tumors seen in children?; First step?; Tx?
A448. Dx: Neuroblastoma; (from neural crest cells); Diagnostic test: Urine HVA and VMA; (tumor secretes catecholamines); Tx: Surgery, Chemo and Radiation
Q449. A 3-yo child presents with an abdominal mass, HTN and hematuria. Dx?; Diagnostic test?
A449. Dx: Wilm’s Tumor; (originates from kidney and may also present with aniridia); Diagnostic test: CT of abdomen
Q450. A 3-yo presents with abdominal distention and a RUQ mass that moves with respiration. Dx?; Diagnostic test?; Tx?
A450. Dx: Hepatoblastoma;; Diagnostic test: Serum Alpha-Fetoprotein;; Tx: Surgical removal
Q451. A 3-yo presents with a sacrococcygeal mass. Dx?
A451. Dx: Teratoma; (most common site in children, followed by mediastinum)
Q452. What is the leading cause of death following a carotid endarterectomy?
A452. MI
Q453. What drug is most beneficial in closing a Crohn’s fistula?
A453. Infliximab
Q454. A patient with a history of Ulcerative Colitis has fever, tachycardia, a distended abdomen and a dilated transverse colon. Dx?; Tx?
A454. Dx: Toxic Megacolon; Tx: NPO, Nasogastric decompression, IV antibiotic and IV steroids for 48 hours, then Surgery if problem persists; (colonic decompression should not be attempted b/c it can lead to perforation)
Q455. What is the MCC of a mediastinal tumor?; What systemic condition is classically assoc with it?
A455. MCC: Thymoma; Assoc w/: Myasthenia Gravis; (30 – 50% will have it)
Q456. Dx: patient presents with café au lait pigmentation and neurofibromas of the GI tract
A456. Von Recklinghausen Dz
Q457. MC site of sarcoma metastasis?
A457. Lungs
Q458. MCC of Acute Mesenteric Ischemia?; Chronic Mesenteric Ischemia?
A458. Acute: Emboli; Chronic: Atherosclerosis
Q459. A 43-yo male presents with acute onset of chest pain since an episode of vomiting 6 hours ago. He has decreased breath sounds on the left and a mild left pleural effusion. Dx?; Diagnostic test?; Tx?
A459. Dx: Spontaneous Esophageal Rupture; (Boerhaave syndrome); Diagnostic test: Water-soluble or Barium Esophagogram; Tx: Primary Surgical repair
Q460. What is the Chemotherapy treatment for Melanoma in Stage III?; Stage IV?
A460. Stage III: Interferon-2A; Stage IV: Interleukin-2
Q461. A 57-yo asymptomatic male is noted to have a prostate that is normal in shape and size on rectal examination. His PSA is 18 (nml < 2.5). What is the best next step for this patient?
A461. Transrectal US exam with prostate Biopsy
Q462. A 72-yo man has a lower abdominal mass and constantly dribbles urine. Dx?; What is the best next step?
A462. Dx: Overflow Incontinence; Next step: Foley catheter and hospitalization
Q463. What unusual lab value can be elevated with a Small Bowel Obstruction?
A463. Serum Amylase; (also increased with Acute Pancreatitis…both also cause Third Spacing and Hypovolemic shock)
Q464. A 67-yo male presents with N/V 25 days post- appendectomy. He is afebrile, the abdomen is tender and distended. His WBC is 18,00, Na is 140, K is 4.2, Cl is 105 and Bicarb is 14. Dx?; Diagnostic test?; Tx?
A464. Dx: Anion Gap Acidosis secondary to Lactic Acid reflecting Ischemic Bowel; Diagnostic test: CT confirming obstruction; Tx: Surgery
Q465. A 34-yo diabetic woman complains of a 6-month History of numbness and pain in her right hand and thumb that wakes her up at night. Dx?; Tx? (2 together)
A465. Dx: Carpal Tunnel Syndrome; Tx: Nighttime Splint and NSAIDs
Q466. A 42-yo woman presents with persistent epigastric and back pain, Leukocytosis and a serum amylase of 1,300. Dx?; Initial Tx?
A466. Dx: Biliary Pancreatitis; Initial Tx: Rest and IV hydration; (then a Lap Chole)
Q467. Dx: Fever, intermittent RUQ pain and Jaundice
A467. Cholangitis
Q468. Dx: Persistent abdominal pain, RUQ tenderness and leukocytosis
A468. Acute Cholecystitis
Q469. A 52-yo alcoholic with cirrhosis presents with acute hematemesis. Bleeding esophageal varicies are found on UGI endoscopy. Tx?
A469. Tx: Endoscopic Sclerotherapy
Q470. What is the management of a patient presenting with Melena?; (2 steps)
A470. 1. IV fluids and insuring hemodynamic stability; 2. NG tube to rule-out UGI bleed; (melena = tarry stool; is usually a UGI bleed)
Q471. A 75-yo man develops hematochezia and presents with hemodynamic instability. His vital improve slightly with PRBC. What is the next step in Management? (3 together)
A471. 1. NG tube; 2. Proctosigmoidoscopy; 3. Tagged RBC scan with or without Angiography; (these three are most appropriate for a patient that is unstable)
Q472. What is the most common site of occlusion with Claudication?
A472. Superficial Femoral Artery
Q473. A 22-yo hemodynamically stable, intoxicated man presents with stab wounds to the left throacoabdominal region and abdomen. What are the next steps in management? (4 steps)
A473. Initially Observe for 24 – 48 hours:; 1. CXR (to look for pneumothorax, hemothorax and free air in the abdomen); 2. Wound exploration and Peritoneal Lavage; 3. Then repeat the study in 6 hours to make sure no changes are seen; 4. if changes: Diagnostic Laparoscopy to insure bowel is not punctured
Q474. A 24-yo male complains of colicky intermittent umbilical and RLQ abdominal pain of 24 hours, anorexia and nausea. He is afebrile. Dx?
A474. Gastroenteritis; (not appendicitis, b/c appendicitis does not present with intermittent pain)
Q475. A 58-yo woman has acute chest pain and dyspnea post- operatively. The results from cardiopulmonary and abdominal exams are nonspecific. She has a minimally elevated leukocyte count and normal cardiac enzyme levels. Arterial blood gas studies indicate respiratory alkalosis and hypoxemia. CXR and ECG show no pathology. Dx?; Next step?
A475. Dx: Pulmonary Embolism; (sudden onset of chest pain and SOB in patient without pulmonary or cardiac pathology); Next step: Empiric anticoagulation (Heparin or Coumadin) with confirmatory Pulmonary Angiography
Q476. Ten days after undergoing liver transplantation, a patient's levels of gamma-glutamyl transferase (GGT), alkaline phosphatase, and bilirubin begin to rise. What is the most appropriate next step in diagnosis?
A476. Ultrasound of biliary tract and Doppler studies of the anastomosed vessels; (in all other transplants aside from the liver, it would be considered acute rejection and biopsies should be taken)
Q477. What are the (2) rules for Breast cancer in a pregnant woman?
A477. The treatment of breast cancer in a pregnant woman should be the same as that in a nonpregnant woman, except for two restrictions:; 1. no chemotherapy during the first trimester; 2. no radiation therapy during the pregnancy
Q478. A 62-year-old man reports an episode of gross, painless hematuria. There is no history of trauma. The man does not smoke and has had no other symptoms referable to the urinary tract. Physical examination, including rectal examination, is unremarkable. His serum creatinine is 0.8 mg/dL, and, except for the presence of many red cells, his urinalysis is normal and shows no red cell casts. His hematocrit is 46%. What are the most appropriate initial steps in the workup?; (2)
A478. 1. Intravenous pyelogram (IVP); 2. Cystoscopy; (Although most patients with hematuria have benign disease, silent hematuria can be due to renal, ureteral, or bladder cancer, and these malignant processes must be effectively ruled out. IVP will visualize kidney and ureteral tumors, but is not reliable enough to rule out bladder cancer. Direct visualization of the bladder mucosa by cystoscopy is the only way to rule out bladder cancer)
Q479. A 45-year-old man with alcoholic cirrhosis is bleeding from a duodenal ulcer. He has required 6 units of blood over the past 8 hours, and all conservative measures to stop the bleeding, including irrigation with cold saline, IV vasopressin, and endoscopic use of the laser have failed. At the time of admission, when he had received only one unit of blood, showed a bilirubin of 4.5 mg/dL, a prothrombin time of 22 seconds, and a serum albumin of 1.8 g/dL. He was mentally clear when he came in, but has since then developed encephalopathy and is now in a coma. What best describes his operative risk?
A479. Prohibitive regardless of attempts to improve his condition; (The studies show that extremely marginal liver function could be tipped into overt liver failure by an anesthetic and an operation. He is not a surgical candidate)
Q480. A 22-year-old convenience store clerk is shot once with a .38 caliber revolver. The entry wound is in the left midclavicular line, 2 inches below the nipple. There is no exit wound. He is hemodynamically stable. A chest x-ray film shows a small pneumothorax on the left, and demonstrates the bullet to be lodged in the left paraspinal muscles. In addition to the appropriate treatment for the pneumothorax, what will this patient most likely need?
A480. Any gunshot wound below the nipples involves the abdomen, and such is the case here. The management of all gunshot wounds of the abdomen requires Exploratory Laparotomy
Q481. A 68-year-old man is brought to the emergency department with excruciating back pain that began suddenly 45 minutes ago. The pain is constant and is not exacerbated by sneezing or coughing. He is diaphoretic and has a systolic blood pressure of 90 mm Hg. There is an 8-cm pulsatile mass deep in his epigastrium, above the umbilicus. A chest x-ray film is unremarkable. Two years ago, he was diagnosed with prostatic cancer and was treated with orchiectomy and radiation. At that time, his blood pressure was normal, and he had a 6-cm, asymptomatic abdominal aortic aneurysm for which he declined treatment. What is the most likely diagnosis?
A481. Rupturing abdominal aortic aneurysm; (Abdominal aortic aneurysms have a high incidence of rupture once they reach or exceed a size of 6 cm. Often, the first manifestation is excruciating back pain, as the blood leaks into the retroperitoneal space before the aneurysm blows out into the peritoneal cavity. The combination of a big aneurysm and sudden severe back pain should always lead to this presumptive diagnosis)
Q482. A 55-year-old woman has been known for years to have mitral valve prolapse. She has now developed exertional dyspnea, orthopnea, and atrial fibrillation. She has an apical, high-pitched, holosystolic heart murmur that radiates to the axilla and back. Because of her deterioration, surgery has been recommended. What is the most appropriate procedure?
A482. Mitral valve annuloplasty; (Whenever possible, repair of the native mitral valve is preferable to replacement. The way to repair an insufficient valve is to tighten the annulus, bringing the leaflets closer to one another)
Q483. A 23-year-old woman seeks help for exquisite pain with defecation and blood streaks on the outside of her stools, which she has been having for several weeks. She has no fever or leukocytosis. Physical examination done under spinal anesthesia, confirmed the suspected diagnosis, and she is placed on stool softeners and appropriate topical agents, but without success. She is willing to undergo more aggressive treatment. What is the most appropriate next step? (3 possible)
A483. 1. Lateral Internal Sphincterotomy; 2. Forceful Dilation under anesthesia; 3. Botulinum toxin Injections; (The clinical picture is classic for anal fissure, which is perpetuated by the fact that the anal sphincter is "too tight.")
Q484. A 42-year-old woman is thrown from the car which lands on her and crushes her. In the ER it is determined that she has a pelvic fracture, which is confirmed by portable x-rays done as she is being resuscitated. Her initial blood pressure is 50/30 mm Hg, and her pulse is 160/min and barely perceptible. Thirty minutes later, after 2 L Ringer's lactate and 2 U packed cells have been infused, her pressure is only 70/50 mm Hg, and her pulse is 130/min. A sonogram done in the emergency department shows no intra-abdominal bleeding, and a diagnostic peritoneal lavage confirms that there is no blood in the abdomen. Rectal and vaginal exams show no injuries to those organs. There is no blood in her urine. What is the most appropriate next step in management?
A484. External fixation of the pelvis; (Pelvic fractures can bleed massively, and often the source is torn veins that are not easily controlled. Minimizing the motion of the bone fragments by external fixation can be helpful, and it will not make the situation worse)
Q485. Several months after sustaining a crushing injury to his arm, a patient complains bitterly about constant, burning, agonizing pain in that arm, that does not respond to the usual analgesic medications. The pain in his arm is aggravated by the slightest stimulation of the area, such as rubbing from the shirt sleeves. The arm is cold, cyanotic, and moist, but it is not swollen. Pulses at the wrist are normal, and neurologic function of the three major nerves is intact. Dx?; Diagnostic test?; Tx?
A485. Dx: Causalgia; Diagnostic test: Sympathetic block; Tx: Sympathetectomy; (If sympathetic block relieves the symptoms, permanent cure will be obtained with surgical sympathectomy)
Q486. A 71-year-old West Texas farmer of Irish ancestry has a nonhealing, indolent, punched out, clean-looking 2-cm ulcer over the left temple. The ulcer has been slowly growing over the past 3 years. There are no enlarged lymph nodes in the head and neck. Next step?
A486. Full thickness biopsy of the EDGE of the lesion; (The edge of the lesion offers the best information for the pathologist. A biopsy of the center of the lesion deprives the pathologist of all the clues that are found at the interface between the tumor and the normal skin, and in large lesions it runs the risk of sampling necrotic tumor that has outgrown its blood supply)
Q487. A 35-year-old man falls on an outstretched hand and comes in complaining of wrist pain. He relates that he was not able to break the fall, and that the heel of his hand took the brunt of his full weight as it hit the pavement. On physical examination, he is distinctly tender to palpation over the anatomic snuff box. Anteroposterior and lateral x-rays are negative. What is the most likely diagnosis and most appropriate next step in management?
A487. Dx: Carpal Navicular fracture; Tx: Thumb Spica Cast; (Nondisplaced fractures of the carpal navicular are notorious for not showing up on x-ray films at the time of injury. The mechanism of injury plus the physical findings described in this vignette are sufficient to make a presumptive diagnosis and to indicate the use of a cast)
Q488. A 56-year-old man develops slow, progressive paralysis of the facial nerve on one side. It took several weeks for the full- blown paralysis to become obvious, and it has been present now for 3 months. It affects both the forehead and the lower face. He has no pain anywhere, and no palpable masses by physical examination. What is the most likely diagnosis?
A488. Facial nerve tumor; (Slowly developing paralysis on one side is suggestive of a tumor. Since there are no physical findings, such as pain or a mass, to place the tumor in the parotid gland, it must be impinging on the nerve itself at a more proximal location)
Q489. A young mother complains of pain along the radial side of the wrist and the first dorsal compartment. She relates that the pain is often caused by the position of wrist flexion and simultaneous thumb extension that she assumes to carry the head of her baby. On physical examination, the pain is reproduced by asking her to hold her thumb inside her closed fist, and then forcing the wrist into ulnar deviation. What is the most likely diagnosis?
A489. Tenosynovitis of the abductor or extensor tendons of the thumb; (De Quervain's tenosynovitis); (The clinical presentation is classic for De Quervain's tenosynovitis, including the positive Finkelstein sign: the pain reproduced by ulnar deviation to stretch the affected tendons)
Q490. A 44-year-old homeless woman presents to the emergency department because she is "bleeding from the breast." Physical examination shows a huge, fungating, ulcerated mass that occupies the entire right breast and is firmly attached to the chest wall. The right axilla is full of hard masses that are not movable either. Core biopsies of the breast are read as highly undifferentiated infiltrating ductal carcinoma, and assay for estrogen and progesterone receptors are negative. What is the most appropriate next step in management?
A490. Radiation and chemotherapy; (Although this is an impressive, very advanced cancer with a poor prognosis, it can be expected to shrink significantly with local radiation plus systemic chemotherapy. It may do so to the point at which a palliative mastectomy becomes technically feasible, something that cannot be done at this time)
Q491. A 54-year-old African American man, with a history of smoking and drinking, describes progressive dysphagia that began 3 months ago. He first noticed difficulty swallowing meat; it then progressed to other solid foods, then to soft foods, and now to liquids as well. He locates the place where the food "sticks" at the lower end of the sternum. He has lost 30 pounds. What is the most appropriate first step in diagnosis?
A491. Barium swallow; (The clinical picture is that of a cancer of the esophagus, and given his race and history of smoking and drinking, it is probably a squamous cell carcinoma. The description of where the dysphagia is felt suggests a low location, but such subjective feelings lack precision. The tumor will eventually be seen and biopsied by endoscopy, but the endoscopist will first want to know the exact location of the tumor and the degree to which the lumen is occluded. Otherwise, there is a high risk of instrumental perforation of the esophagus. The best way to obtain that information is to do a barium swallow)
Q492. A 45-year-old woman, who wears high-heeled, pointed shoes, complains of pain in the forefoot after prolonged standing or walking. Occasionally, she also experiences numbness, a burning sensation, and tingling in the area. Physical examination shows no obvious deformities and a very tender spot in the third interspace, between the third and fourth toes. There is no redness, limitation of motion, or signs of inflammation. What is the most likely diagnosis?
A492. Morton's Neuroma; (The location and circumstances are classic for Morton's neuroma, a benign neuroma of the third plantar interdigital nerve)
Q493. A 66-year-old woman picks up a bag of groceries out of the supermarket cart to place it in the trunk of her car. As she does so, she feels sharp, sudden pain in the middle of her arm, and her humerus suddenly breaks. She arrives at the emergency department cradling her arm; the deformity leaves no doubt that the bone is broken. What is the most likely reason for the fracture?
A493. Bony metastasis to the humerus from breast cancer; (A fracture from such trivial strain signifies a very weakened bone. In this age and gender, the most likely cause would be a lytic lesion from metastatic breast cancer. In a man, we would have suspected metastatic lung cancer - not prostate, because prostatic metastases are blastic rather than lytic)
Q494. A 62-year-old man has had gastroesophageal reflux disease diagnosed by pH monitoring, and present for several years. He has been less than totally compliant with medical management, which he follows when the pain is bad, but discontinues when he feels better. Endoscopy and biopsies show severe peptic esophagitis, with Barrett's esophagus and early dysplastic changes, but no overt carcinoma. Additional tests show good esophageal motility, with low pressure in the lower esophageal sphincter and normal gastric emptying. What is the most appropriate treatment at this time?
A494. Laparoscopic Nissen fundoplication; (Transthoracic resection of the lower esophagus would be the procedure if a very early cancer were to develop at the esophagogastric junction)
Q495. A pedestrian is hit by a car. The paramedics report that he was unconscious at the site, and he arrives at the emergency department in coma, strapped to a head board with sandbags on either side of his head. Initial survey shows stable vital signs, and his pupils are of equal size and reactive to light. He is rapidly intubated by the nasotracheal route over a flexible bronchoscope and then sent for CT scans of the head. As he is being positioned on the table, it is noted that there is a sizable hematoma behind his right ear and that clear fluid is dripping from the ear canal. What is most advisable, considering this new finding?
A495. Extend the CT scan to include his neck; (The clinical findings are indicative of a fracture of the base of the skull, and thus he has sustained very significant trauma to the head. The integrity of the cervical spine has to be ascertained, and the CT that he is already going to have can be extended to include that area)
Q496. During the performance of a supraclavicular node biopsy under local anesthesia, a hissing sound is suddenly heard, and the patient suddenly dies. At the time of the catastrophic event, the target node was under traction, and the final cut was being made blindly behind it to free it up completely. The patient, an otherwise healthy 24-year-old man, was inhaling at that moment. What has most likely caused this patient's death?
A496. Major Vein injury with Air Embolism; (Major veins at the base of the neck have negative pressure during inspiration and, if injured at that moment, will suck air rather than bleed. The air embolism then leads to sudden death)
Q497. A man who weighs 65 kg sustains second and third degree burns over both of his lower extremities when his pants catch on fire. When examined shortly thereafter, it is ascertained that virtually all of the skin from both groins to the tip of the toes, front and back, has been burned. According to the modified Parkland formula, what is the approximate total amount of IV fluid that he can be expected to require during the first 24 hours post-burn?
A497. 11,360 mL; (4 mL of Ringer's lactate per kilogram of body weight, times the percentage of the body surface that has been burned; plus an additional 2000 mL of dextrose 5% in water to cover MAINTENANCE fluid needs. In the "rule of nines," each lower extremity represents 18% of the body surface. Thus, this patient has sustained a 36% body burn: 4 × 65 × 36 = 9360, plus 2000 = 11,360)
Q498. A 49-year-old woman has a firm, 2-cm mass in the right breast that has been present for 3 months. Mammogram has been read as "cannot rule out cancer," but it cannot diagnose cancer either. A fine-needle aspiration of the mass (FNA) and cytology do not identify any malignant cells. What is the most appropriate next step in management?
A498. Core or Incisional Biopsies; (Negative findings do not have the same diagnostic value that positive findings have. If this had been a 19-year-old woman suspected of having a fibroadenoma, one would have been satisfied with negative imaging studies (in that age, a sonogram) or the negative FNA. But, at age 49, the risk of cancer is much higher. Given negative findings in the least invasive studies, one would feel compelled to move to more aggressive ways to obtain better tissue sampling)
Q499. A 44-year-old woman has a palpable nodule in the right lobe of her thyroid gland. The nodule measures 2 cm and is firm. The rest of the thyroid gland cannot be felt and is not tender. She also describes losing weight in spite of a ravenous appetite, palpitations, and heat intolerance. She is thin, fidgety, and constantly moving, with moist skin and a pulse of 105/min. She has no exophthalmos or pretibial edema. Her TSH is reported as much lower than normal, and she has elevated levels of free T4. What is the most appropriate next step in diagnosis?
A499. Radionuclide Thyroid Scan; (the patient is hyperthyroid. She has no clinical signs of acute thyroiditis, and none of the other findings seen in Graves disease; however, she has a thyroid nodule, which raises the possibility of a hyperfunctioning adenoma (a "hot" adenoma). If indeed she does, the scan will show that the nodule traps all the iodine, with suppression of the rest of the gland)
Q500. Patient hurts his knee, causing him the ability to bend his leg inward to a greater extent then normally possible. What structure is damaged?
A500. Lateral Collateral Ligament; (Varus test)
Q501. Patient hurts his knee, causing him the ability to bend his leg outward to a greater extent then normally possible. What structure is damaged?
A501. Medial Collateral Ligament; (Valgus test)
Q502. Patient hurts his knee, causing him to feel loose intra- articular bodies and a locking of the knee. What structure is damaged?
A502. Medial Meniscus
Q503. What is the first step in the evaluation of a palpable thyroid nodule?
A503. Ultrasound
Q504. A front-seat passenger in a car involved in a head-on collision relates that he hit the dashboard with his knees, however, he is specifically complaining of severe pain in his right hip, rather than knee pain. He lies in the stretcher in the emergency department with the right lower extremity shortened, adducted, and internally rotated. What is the most likely injury?
A504. Posterior dislocation of the hip; (not fracture of the femoral neck)
Q505. A 25-year-old man is shot with a .22 caliber revolver. The entrance wound is in the anteromedial aspect of his upper thigh, and the exit wound is about 3 inches lower, in the posterolateral aspect of the thigh. He has a large, expanding hematoma in the upper inner thigh. There are no palpable pulses in the foot. The bone is intact by physical examination and x-ray films. What is the most appropriate next step in management?
A505. Surgical Exploration; (Arteriograms are very often used in vascular trauma, but are not needed here. We would use an arteriogram if the anatomic location of the injury suggested vascular involvement, but the clinical signs did not confirm such suspicion. Arteriograms are also used when the specific surgical approach is dictated by precise knowledge of the site of extravasation, a situation that does not apply here)
Q506. A 7-year-old boy passes a large, bloody bowel movement. He is hemodynamically stable, and he has a hemoglobin of 14 g/dL. Nasogastric aspiration yields clear, greenish fluid. Physical examination, including anoscopy, is unremarkable. What is the most appropriate next diagnostic test?
A506. Radioactively labeled Technetium Scan; (In this age group, with no obvious anal pathology and negative gastric aspirate, the leading cause of gastrointestinal bleeding is Meckel's diverticulum. The specific source is ulceration of the normal ileal mucosa by acid produced by gastric mucosa in the diverticulum. The technetium scan identifies that ectopic gastric mucosa. Upper gastrointestinal endoscopy would have been appropriate if the gastric aspirate had produced blood)
Q507. An 81-year-old man with Alzheimer disease who lives in a nursing home undergoes surgery for a fractured femoral neck. On the 5th postoperative day, it is noted that his abdomen is grossly distended and tense, but not tender; no evidence of occult blood. X-ray films show a few distended loops of small bowel and the gas pattern of distention extends throughout the entire large bowel, including the sigmoid and rectum. No stool is seen in the films. Otherwise he does not appear to be ill. Vital signs are normal for his age. What is the most likely diagnosis?; Diagnostic test?; Tx?
A507. Dx: Ogilvie Syndrome; (a type of colonic dysfunction often seen in elderly patients who are not too active to begin with and are then further immobilized by extra-abdominal surgery); Diagnostic test: Colonoscopy; (rules out obstructing cancer, which is always a consideration in this age group, and allows the gas to be sucked out as the instrument advances); Tx: A long tube is then left in place
Q508. A 42-year-old, right-handed man has had a history of progressive speech difficulties and right hemiparesis for 5 months. He has had progressively severe headaches for the past 2 months, which are worse in the mornings. At the time of admission, he is confused and vomiting, and has blurred vision, papilledema, and diplopia. Shortly thereafter, his blood pressure increases to 190/110 mm Hg, and he develops bradycardia. What is most likely the significance of the hypertension and the bradycardia?
A508. There is a near-terminal increase in intracranial pressure; (the development of hypertension and bradycardia (Cushing's reflex) signifies that the brain has run out of compensatory mechanisms to minimize the intracranial pressure elevation generated by increased intracranial volume. When that point is reached, brain perfusion suffers and death is imminent)
Q509. On the 5th postoperative day, it is noticed that large amounts of clear, pink, salmon-colored fluid are soaking the wound dressings. The incision appears intact and not particularly red or inflamed, but there are indeed traces of the clear pink fluid on his skin. He has no specific complaints. He is still NPO and on IV fluids, but has already been passing gas per rectum, and plans had been made to feed him today. The abdomen is not distended, and he has normal bowel sounds. He is afebrile. What is the most appropriate next step in management?
A509. Tape the wound securely, bind the abdomen, and avoid events that would suddenly increase his intra-abdominal pressure; (The situation described is that of a wound dehiscence that has not yet progressed to a wound evisceration. The former can be dealt with at leisure, if the latter is avoided. He will eventually require re-closure, but it can be done whenever it is most convenient. Remember: Pink fluid on an abdominal surgical wound is a leak of intra-abdominal fluid)
Q510. A 24-year-old woman sustains multiple injuries in a car accident, including a pelvic fracture. She is hemodynamically stable. Initial assessment shows no vaginal or rectal injuries; however, when a Foley catheter is inserted, bloody urine is recovered. What would be the best way to evaluate her urologic injury?
A510. Retrograde cystogram including post-void films; (it is important to include post-void films because extravasation at the bladder neck can be obscured by the dye that is filling the bladder)
Q511. A 62-year-old woman has a 4-cm, hard mass under the nipple and areola of her rather small left breast. The mass occupies most of the breast, but the breast is freely movable from the chest wall. There is no dimpling or ulceration of the skin over the mass, and careful palpation of the axilla is completely negative. A core biopsy of the breast mass has established a diagnosis of infiltrating ductal carcinoma, and the mammogram showed no other lesions in that breast or the other one. A chest x-ray film and liver function tests are normal. She has no symptoms suggestive of brain or bone metastasis. What Tx should be offered to this woman?
A511. Modified Radical Mastectomy including axillary sampling; (Lumpectomy, axillary sampling, and post-op radiation would have been the correct answer for a smaller tumor in a larger breast)
Q512. A 49-yo obese man presents with a serum calcium of 14. He has uncontrolled DM and bipolar disorder (for which he takes lithium). What is the most likely cause of the calcium elevation?
A512. Parathyroid Hyperplasia secondary to Renal Failure from the uncontrolled DM; (when the kidney loses its ability to reabsorb calcium and Vit D, hypocalcemia triggers the parathyroid gland to increase their production of parathyroid hormone)
Q513. A 5-yo boy is brought to the ER after ingesting a half-bottle of liquid drain cleaner. What is the next step?
A513. Tracheostomy; (even though the step doesn’t state a breathing problem, airway edema, stridor and difficulty breathing is likely)
Q514. A 46-yo woman presents to the ER with RUQ pain and fever. She has scleral icterus. There are no peritoneal signs; bowel sounds are present. Dx?; What is the best initial Tx?; If that doesn’t work?
A514. Dx: Acute Cholangitis; First: Antibiotics and fluid resuscitation; Next: Percutaneous Transhepatic Drainage
Q515. What is the best Diagnostic test for a Breast mass in a younger woman?
A515. Ultrasound
Q516. What is the treatment post-operative for a premenopausal woman who had a modified radical mastectomy for a 3cm mass with negative LN?
A516. Chemotherapy
Q517. A 63-yo man is disease-free after BCG therapy for CIS bladder cancer. In addition to a physical exam, cystoscopy and urinary cytology, what should be done?
A517. IVP (to rule-out upper tract tumors)
Q518. A 78-yo man presents with RUQ pain, N/V and a 30lb weight loss over the past 3 months. He has scleral icterus and asymmetric thickening of the gallbladder. Dx?
A518. Adenocarcinoma of the GB
Q519. A 10-yo boy presents with persistent hoarseness that worsens with singing. There are multiple lesions on his true vocal cords. Dx?
A519. Laryngeal Papilloma; (benign and located on the true vocal cords. In kids they present as multiple lesions and are caused by HPV)
Q520. What is the best Diagnostic test to define an enlarged Parathyroid gland?
A520. Ultrasound
Q521. A 52-yo female has melanotic pigmentation of her buccal mucosa and hamartomas throughout her GI tract. What other cancer is assoc with this condition?
A521. Ovarian CA
Q522. What is the medical treatment for Carcinoid syndrome? (2) What is the drug class of these drugs?
A522. Octreotide, a Somatostatin analogue;; Cyproheptadine, a Serotonin antagonist
Q523. A 53-yo woman presents with 12 mo History of neck pain, 15lb weight gain and malaise. Dx?
A523. Hashimoto Thyroiditis
Q524. A 41-yo woman complains of tenderness in her right knee for the past 3 weeks. A synovial aspiration reveals no evidence of bacteria or crystals. Dx?
A524. Bursitis
Q525. What nerve is affected in a mid humeral fracture?
A525. Radial; (wrist extension and sensory to back of hand)
Q526. What nerve is affected in an elbow dislocation?
A526. Ulnar; (finger abduction and sensory to last 2 digits)
Q527. What type of orthopedic problem is assoc with a patient who has DM or syphilis (causing peripheral neuropathy to the extreme of not feeling a fracture) leads to gradual arthritis and joint deformity?
A527. Charcot Joint
Q528. MCC of bacterial osteomyelitis?
A528. Staph Aureus
Q529. What diagnostic test do you order in a patient who has a posterior knee dislocation?
A529. Angiogram
Q530. What are the MC Hip problems in the following ages:; 1. Newborn; 2. Toddler; (also diagnostic test); 3. 6 - 9 yo; 4. 9 - 14 yo
A530. Newborn = Congenital Hip Dysplasia; Toddler = Septic Hip; (Tx: Aspiration under anesthesia); 6 - 9 yo = Avascular Necrosis; 9 - 14 yo = Slipped Capital Femoral Epiphysis
Q531. MC place of an Intracerebral hemorrhage? Cause?
A531. Basal Ganglia (due to HTN)
Q532. A patient is found on the side of the road with bruising of the head, increased BP, bradycardia and respiratory irregularities. Dx?
A532. Increased Intracranial Pressure; (do not treat HTN initially…it is body’s way of trying to increase cerebral perfusion)
Q533. What is the usual cause of sudden deafness?
A533. Viral; (mumps, measles, chickenpox, influenza, or adenovirus)
Q534. MCC of acquired hearing loss in children?
A534. Bacterial Meningitis
Q535. A child has a fever and has a lateral neck mass. Dx?
A535. Branchial Cleft cyst
Q536. A child has a midline neck mass and it elevates with tongue protrusion. Dx?
A536. Thyroglossal Duct cyst
Q537. (3) MCC of Otitis Media. Tx?
A537. Strep Pneumonia, H. Influenza, Moraxella;; Tx: Amoxicillin
Q538. A child has inflammation of the tympanic membrane which has vesicles on its surface. Dx?; Tx?
A538. Dx: Infectious Myringitis (inflammation of TM); Tx: Erythromycin or Clarithromycin
Q539. A patient presents with hearing loss on the right side. A Weber test for hearing loss is performed and a tuning fork is placed on the head. What would signal a Conductive problem?; Sensorineural problem?
A539. Conductive: Sound is heard louder in affected ear (right); Sensorineural: Sound is hear louder in unaffected ear (left)
Q540. A patient presents with hearing loss on the right side. A Rinne test for hearing loss is performed and a tuning fork is placed on the mastoid process. It stays there until the patient can’t hear it anymore, then it is placed by the same ear. What would signal a Conductive problem?; Sensorineural problem?
A540. Conductive: Cannot hear the continuing sound of the fork when placed next to the ear;; Sensorineural: Can hear the continuing sound of the fork when placed next to the ear.
Q541. A male patient complains of transient pain in the buttocks, buttock atrophy and impotence. What is the problem?; Tx?
A541. Aortoiliac Occlusive Dz; (Leriche’s syndrome); Tx: Aortoiliac bypass graft
Q542. A patient presents with sudden onset of unilateral blindness like “a shade is pulled over his eye”; Dx?; Diagnostic test?; Tx? (2 possible)
A542. Dx: TIA secondary to Carotid Stenosis; Diagnostic test: Ultrasound of Carotid; Tx:; if >70% stenosis: Carotidendarterectomy;; If <70% stenosis: daily Aspirin
Q543. A patient presents with abdominal tenderness, bloody diarrhea and “thumbprinting” on abdominal x-ray. Dx?
A543. Acute Bowel Infarction
Q544. A patient presents with a history of varicose veins and has localized leg pain with cord-like induration, reddish discoloration and mild fever. Dx?; Tx?
A544. Dx: Thrombophlebitis; Tx: NSAIDs and warm compresses
Q545. A patient presents with syncope, vertigo, confusion and upper extremity claudication during exercise. Dx?
A545. Subclavian Steal Syndrome; (left subclavian artery obstruction proximal to vertebral artery)
Q546. A patient presents with upper extremity paresthesias, weakness, cold temperature, edema and venous distention. Dx?
A546. Cervical rib; (compromising subclavian vessel blood flow; no neuro problems help distinguish it from SSS)
Q547. What (2) Dx cause Uric Acid kidney stones?
A547. Gout or Leukemia
Q548. What causes a Struvite renal stone?
A548. UTI
Q549. What are the (2) biggest concerns with electrical burns?
A549. Cardiac Arrhythmias;; Renal Failure; (from muscle necroisis leading to myoglobinuria and acidosis; maintaining high urine output with fluids helps prevent this)
Q550. What is the classic cardiac sign with Hypothermia?
A550. J-wave; (a small positive deflection following QRS complex)
Q551. If a patient with hyperthermia begins to have convulsions, what do you do?
A551. Give Diazepam
Q552. Where are the MEN-1 tumors located?
A552. All start with “P”:; Pituitary,; Pancreas,; Parathyroid
Q553. What are the tumors in MEN-2 vs MEN-3?
A553. MEN-2 (MPP):; Medullary Thyroid CA,; Pheochromocytoma,; Parathyroid;; MEN-3 (MPM):; Medullary Thyroid CA,; Pheochromocytoma,; Mucosal Neuromas
Q554. What is the difference b/t Mallory-Weiss syndrome and Boerhaave syndrome on exam?
A554. Boerhaave syndrome presents with mediastinal emphysema
Q555. What is the type of esophageal divertivcula most commonly requiring surgery?; Where is it located?
A555. Zenker’s diverticulum; location: Pharyngoesophageal area
Q556. A 52-yo woman presents due to 3 months of early satiety, weight loss and non-bilious vomiting. Dx?
A556. Gastric Outlet Obstruction
Q557. A 25-yo develops weight loss, night sweats and a fistula draining from his RLQ s/p appendectomy. Dx?; Tx?
A557. Dx: Post-op Actinomycosis infection; Tx: Penicillin (or Tetracycline)
Q558. A 70-yo man with a History of HTN develops cramping lower abdominal pain 2 days s/p AAA repair. A few hours later he develops bloody diarrhea. Dx?
A558. Ischemic Colitis; (suspected and time patient develops acute abdominal pain followed by rectal bleeding and is common post AAA)
Q559. Which is massive lower GI bleeding more common with: Diverticulosis or Diverticulitis?; Tx for each?
A559. Diverticulosis; Tx: high fiber diet, stool softeners; (Diverticulitis Tx is Antibiotics, analgesics and clear liquid diet if mild; resection if severe)
Q560. What is Jaundice without scelral icterus or increased bilirubin?; Cause?
A560. Pseudojaundice; Caused by increased ingestion of foods rich in beta- carotene
Q561. What liver tumor is treated by cessation of OCPs?; What is this patient at risk for if she wants a large family?
A561. Hepatocellular Adenomas;; Risk: if treated by cessation of OCP rather then tumor resection, she is at risk for rupture and hemorrhage during future pregnancies
Q562. MC clinical finding in Portal HTN
A562. Splenomegaly
Q563. MCC of Portal HTN inside the USA?; Outside the USA?
A563. In USA: Alcoholism; Outside USA: Schistosomiasis
Q564. Aside from US, what is the diagnostic test of Acute Cholecystitis?
A564. HIDA scan; (if the GB is not seen within 1 hour post Technetium injection, it is diagnostic for acute cholecystitis)
Q565. What is the Dx of an ERCP that shows “beads on a string” in the bile ducts? Tx? (2 depending on severity and place)
A565. Dx: Sclerosing Cholangitis;; Tx:; 1. Pallitive Tx: Balloon dilation with stent placement;; 2. Extrahepatic stricture: Removal of ducts with T-tube placement;; Intrahepatic stricture: Liver Transplant
Q566. Dx: Anti-mitochondrial Ab
A566. Primary Biliary Cirrhosis
Q567. Dx: Anti-Neutrophil Cytoplasmic Ab
A567. Primary Sclerosing Cholangitis
Q568. A 32-yo male who underwent a laparotomy for a GSW to the abdomen 2 days ago is found to have a tender belly without rebound and is leaning forward on his stretcher breathing at a rate of 28/min. Dx?
A568. Pancreatitis; (Tachypnea is one of the presenting signs)
Q569. When is the only time a Direct inguinal hernia is more common?
A569. In patients > 50yo
Q570. What are the boundaries of Hesselbach’s Triangle?
A570. Inferior border: Inguinal Ligament; Medial border: Rectus Abdominis; Lateral border: Inferior Epigastric vessels
Q571. How is each type of Hiatal Hernia corrected?
A571. Sliding: usu Antacids and head elevation; (15% require a Nissen Fundoplication); Paraexophageal: Surgery
Q572. After an URI a child presents with a painless, soft mobile mass in the neck that transilluminates. Dx?; Diagnostic test?; Tx?
A572. Dx: Cystic Hygroma; Diagnostic test: CT scan; Tx: Surgical excision
Q573. MC congenital lung lesion
A573. Lobar Emphysema; (presents with mediastinal shift)
Q574. How can you tell the difference b/t Congenital Diaphragmatic Hernia or Congenital Cystic Adenomatoid Malformation?
A574. Placement of the NG tip:; In Thorax: CDH; In Abdomen: CCAM
Q575. A premature infant born at 33 weeks gestation now at 1 week of age has developed feeding intolerance, is febrile, and has hematochezia and a distended belly. Dx?
A575. Necrotizing Enterocolitis; (presents in premature births and is similar to sepsis with feeding intolerance, apneic spells, bloody diarrhea and abdominal pain)
Q576. What is the order of structures transversed with the spinal anesthesia after the Sub-Q layer? (6)
A576. SILEDS:; Supraspinous ligament,; Interspinous ligament,; Ligamentum flavum,; Epidural space,; Dura mater,; Subarachnoid space
Q577. What (2) serological markers are monitored for Pineal tumors?
A577. AFP and beta-HCG
Q578. A kidney transplant recipient is seen in the ER for nausea and abdominal pain, fever and elevated creatinine. Dx?; Diagnostic test?; Tx?
A578. Dx: Acute Rejection; Diagnostic test: Ultrasound-guided Biopsy; Tx: Pulse Steroid treatment (or OKT3) is 90% effective
Q579. MC infection after Pancreas transplant
A579. UTI
Q580. MC post-transplant problem in a Pancreas transplant?; Tx?
A580. Post-op Metabolic Acidosis; (due to excessive loss of bicarb in urine); Tx: Oral replacement
Q581. A 53-yo woman who is s/p liver transplant calls you asking what she can take for some musculoskeletal pain. Dx?; What can you give her?
A581. Dx: AE of Tacrolimus meds; (can ultimately lead to renal failure); Give her Acetaminophen; (new liver will be able to tolerate it)
Q582. MC infection post heart transplant?; Tx?
A582. CMV (a trigger for graft-related atherosclerosis); Tx: Ganciclovir
Q583. How will a flexor tendon injury of the hand present?
A583. With a Straight finger; (due to unapposed Extensors)
Q584. A patient is in the hospital with pneumonia and a lung abscess. His morning labs show low sodium, chloride and serum osmolarity with an increased urine osmolarity. Dx?; Tx?
A584. Dx: SIADH; Tx: Water Restriction (and treat primary cause)
Q585. what is a decrease in the release of ADH called?; Tx?
A585. Diabetes Insipidus (Decreased = Diabetes); Tx: Vasopressin
Q586. `What test should be performed before inserting an Arterial Line or obtaining a blood gas?; Describe
A586. Allen Test; (measures adequate collateral blood flow to hand via the ulnar artery. Patient makes fist, then both ulnar and radial artery are occluded; patient then opens blanched hand. The ulnar artery is released and if the patient has a strong blush to the hand, the ulnar artery is adequate)
Q587. A post-operative patient has a new onset of CHF, dyspnea and a dysrhythmia. Dx?; Tx?
A587. Myocardial Infarct; (often post-op they don't present with chest pain); Tx: Be MONA (no heparin): Beta blocker; Morphine; Oxygen; Nitrates; Aspirin
Q588. What is FENa? Equation?
A588. Fractional Excretion of Na (sodium); Equation: YOU NEED PEE; (Una x Pcr)/(Pna x Ucr) x 100
Q589. What is the value for a Pre-Renal FENA vs a Renal FENA?
A589. Pre-Renal: < 1; Renal: > 1
Q590. What is a common anesthesia used for children and burn victims?
A590. Ketamine
Q591. What are the contraindications for the depolarizing agent Succinylcholine? (4); Why?
A591. Patients with:; Burns,; Increased ICP,; Neuromuscular Dz,; Eye trauma; Reason: causes Hyperkalemia (and increased intraocular pressure)
Q592. What is the Tx of life-threatening respiratory depression with morphine or Demerol?
A592. Narcan (Naloxone)
Q593. Main side effect of epidural anesthesia?
A593. Orthostatic Hypotension
Q594. Main side effect of Spinal anesthesia?
A594. Urinary retention
Q595. Which hernia type involves only one side wall of the bowel?
A595. Richter hernia
Q596. Which hernia sac exists as both a direct and indirect hernia?
A596. Pantaloon hernia (like pant legs)
Q597. in a trauma patient if oral and nasal endotrachial intubation is contraindicated, what is the best way to get an airway?
A597. Cricothyroidotomy; (not tracheostomy...that is only in OR)
Q598. What is the Glascow Coma Score for Eye opening?
A598. Eye opening ("four eyes"):; 4: Opens spontaneously; 3: Opens to Voice; 2: Opens to Pain; 1: Does Not open
Q599. What is the Glascow Coma Score for Motor response?
A599. Motor response ("6-cylinder motor"):; 6: Obeys Commands; 5: Localizes Pain stimulus; 4: Withdrawls from pain; 3: Decorticate Posture; 2: Decerebrate posture; 1: No movement
Q600. What is the Glascow Coma Score for Verbal response?
A600. Verbal response ("Jackson 5"):; 5: Appropriate and oriented; 4: Confused; 3: Inappropriate words; 2: Incomprehensible sounds; 1: No sounds
Q601. What is the GCS of a man in a Coma?; Of a Dead man?
A601. Coma: 8 or less; Dead: 3
Q602. what are the most emergent orthopedic surgeries? (2)
A602. 1. Hip Dislocation (must be reduced immediately); 2. Exsanguinating Pelvic fracture (external fixator)
Q603. When is a surgical cricothyroidotomy not recommended?; What is done instead/
A603. in patient younger then 12-yo; (Perform Needle Cricothyroidectomy)
Q604. If you only have one vial of blood from a trauma victim to send to the lab, what test should be ordered?
A604. Type and Cross
Q605. what is the Tx for human or dog bites? (3 together)
A605. Leave wound open, Irrigation and Antibiotics
Q606. What test may help identify the site of a massive UGI bleed when endoscopy fails to Dx the cause and blood continues per NGT?
A606. Mesenteric Angiography
Q607. What are the (3) possible Tx regimens for H. Pylori PUD?
A607. MOC, MOA or COA; M: Metronidazole;; O: Omeprazole (PPI);; C: Clarithromycin;; A: Ampicillin
Q608. What are the classic Sx of Carcinoid syndrome? (4)*
A608. B-FDR (Be FDR in a cool CAR):; Bronchospasm;; Flushing;; Diarrhea;; Right-sided heart failure
Q609. what tumors are assoc with carcinoid syndrome? (3)*
A609. BLT:; Bronchus CA;; Liver Metastasis;; Testicular CA or Ovary CA; (occurs when venous draining from the tumor gains access to the systemic circulation by avoiding heatic degradation via the portal system)
Q610. MCC of colonic Fistulas
A610. Diverticulitis
Q611. MC fistula type
A611. Colovesical fistula
Q612. Dx: large air/fluid level in the RLQ forming a "coffee bean" sign
A612. Cecal Volvulus
Q613. What procedure is used if kindey stones are too large or too hard to remove via lithotripsy?
A613. Percutaneous Nephrolithotomy
Q614. Crohn's dz or Ulcerative Colitis:; Full-thickness wall involvement
A614. Crohn's Dz
Q615. Crohn's dz or Ulcerative Colitis:; Crypt Abscess
A615. Ulcerative Colitis
Q616. Crohn's dz or Ulcerative Colitis:; Pseudopolyps
A616. Ulcerative Colitis
Q617. Crohn's dz or Ulcerative Colitis:; Bloody Diarrhea
A617. Ulcerative Colitis
Q618. Crohn's dz or Ulcerative Colitis:; Granulomas
A618. Crohn's Dz
Q619. MCC of painful Hepatomegaly
A619. Hepatocellular CA
Q620. Dx: Thrombosis of Hepatic veins
A620. Budd-Chiari
Q621. Dx:; jaundice, pruritus, palpable nontender distended gallbladder; Tx?
A621. Adenocarcinoma of the head of the Pancreas; Tx: Whipple
Q622. A patient presents with HTN, HA, polyuria, weakness and Hypokalemia. Dx?; First Diagnostic test?; Tx? (2 depending on type)
A622. Dx: Conn's syndrome; Diagnostic test: Plasma Aldosterone and Renin levels; Tx:; 1. Adrenal Adenoma or Unilateral hyperplasia: Laparoscopic Unilateral Adrenalectomy; 2. Bilateral hyperplasia: Spironolactone
Q623. A patient presents with a psoriatic-appearing rash over the trunk and limbs, glossitis, stomatitis and new-onset diabetes. His labs show anemia, low amino acid levels and hyperglycemia. Dx?; Diagnostic test?; Tx? (2 together)
A623. Dx: Glucagonoma; Diagnostic test: Tolbutamide stimulation test; Tx:; 1. Surgical resection of tumor; 2. Somatostatin for Necrotizing Migratory Erythema rash
Q624. what is the Tx for hyperparathyroidism in the MEN-1 and MEN-2 patients?
A624. Removal of all parathyroid tissue with autotransplant of some of the parathyroid into the forearm
Q625. A patient presents with a palpable neck mass, hypercalcemia and elevated PTH. Dx?; Tx?
A625. Parathyroid CA (the key is the neck mass: primary hyperparathyroidism have nonpalpable thyroids); Tx: Remove CA, Ipsilateral Thyroid lobe and all enlarged LN
Q626. A patient complains of abdominal pain. On AXR there are "eggshell" calcifications near the RUQ. Dx?
A626. Splenic Artery Aneurysm
Q627. How are maintenance fluids calculated in children?
A627. 4, 2, 1 per hour:; 4cc/kg for the first 10kg; 2cc/kg for the second 10kg; 1cc/kg for every kg over the first 20; ex: 25kg patient is (4 x 10) + (2 x 10) + (1 x 5) = 65cc/hour
Q628. Tx for Trachial or Esophageal Foreign Body?
A628. RIGID boronchoscope or espohpagoscope
Q629. Infant has Bilious vomiting. What is the presumed Dx until proven otherwise?
A629. Malrotation of the gut
Q630. Malignant tumor of the liver that presents in the first 3 years of life
A630. Hepatoblastoma
Q631. Define:; Contracture of the forearm flexors secondary to forearm compartment syndrome; MC Cause?
A631. Volkmann's contracture; Cause:; Supracondylar humerus fracture
Q632. You suspect a newborn has developmental dysplasia. What is the Diagnostic test?
A632. Ultrasound; (the bones are too new to see on x-ray)
Q633. what is the cause of a fever of 104-105:; 1. Shortly after anesthesia; 2. after instrumentation procedure (like cystoscopy)
A633. 1. Malignant Hyperthermia; 2. Bacteremia
Q634. What are the (2) MCC of post-operative chest pain? How many days after the operation does each occur?
A634. Day 1 - 2: MI; Day 5 - 7: PE
Q635. What is the new gold standard as a diagnostic test for a pulmonary embolism?
A635. V/Q scan; (previously it was a pulmonary angiogram, but they are costly and time-consuming)
Q636. What is the normal urine output?; What is the Dx if the urine output is zero?
A636. Normal: about 1/kg/hr; Zero: Mechanical error; (not from kidneys; more likely from a kinked catheter)
Q637. Several hours after completion of surgery for multiple gunshot wounds to the abdomen, a 70 Kg., 52-year-old man is reported to have hourly urinary outputs of 17cc, 13cc, and 21cc, in three consecutive hours. His blood pressure has hovered around 95 to 125 systolic during that time. Dx? (2 possible); What is the next step to differentiate b/t the two and results for each?; Tx?
A637. Dx: Dehydration or Renal Failure (Oliguria can be from shock, but in the presence of an adequate perfusing pressure, it is one of these two); Next step: Test Urine Sodium; Dehydration: Low (20 - 30Meq); Tx: Give more Fluids; Renal Failure: High (>40Meq); Tx: Stop Fluids
Q638. 12 days after surgery for multiple gunshot wounds, a 27- year-old man becomes progressively disoriented and unresponsive. He’s had multiple complications, including several intraabdominal abscesses that have been percutaneously drained. He has bilateral pulmonary infiltrates, and a PO2 of 65 while breathing 40% oxygen. Meticulous attention has been paid to his fluid balance, and there is no evidence that he is in congestive heart failure. Dx?; Next step?
A638. Dx: ARDS; Next step: PEEP; (then check for underlying reason, like sepsis from abscess)
Q639. An alcoholic patient presents with Acute Pancreatitis with a septic abdomen. On post-operative day 2 he begins to get disoriented. Why?
A639. Delerium Tremens; (seen in post-op day 2 in alcoholics)
Q640. If a patient presents with post-operative disorientation, what are the 6 possible reasons?; What schold be checked with each?
A640. 1. ARDS - check blood gases; 2. DT - if alcoholic; 3. HypoN/HyperN - check serum sodium; 4. DM/TPN - Hypoglycemia - check blood sugar; 5. Hepatic Enceph in Cirrhotic patient - check Ammonia level; 6. Check Medications
Q641. What "type" of esophageal problem:; 1. Inability to swallow solids then liquids; 2. Inability to swallow liquids then solids; give one example of each
A641. solids to liquids: Mechanical (cancer); liquids to solids: Mobility (DES)
Q642. A patient presents 2 days after a hernia repair with signs of a bowel obstruction. Dx?; Diagnostic test/Tx?
A642. Dx: Paralytic Ileus; Diagnostic test/Tx: Barium Tag; (a little bit of barium at a time over a few hours)
Q643. What does an acute appendicitis usually begin with?
A643. Anorexia; (then periumbilical pain to RLQ pain; if the paient looks like appendicitis, but can eat well, its probably not an appendicitis)
Q644. What is the main presentation of Right-sided Colon cancer?; Left-sided?
A644. Right-sided: Anemia; Left-sided: Blood in stool
Q645. A 32-yo male presents with excessive bleeding from the rectum. First Diagnostic test?; Depending on the results, what is the next test?
A645. First Dx Test: NG tube; If blood in stomach: Endoscopy; If no blood in stomach: Angiography; (not a colonoscopy--that much blood makes it hard to visualize)
Q646. Aside from an increased conjugated bilirubin, what is the signature lab result for obstructive jaundice?; in what "benign" Dx will you see this value at an extreme high?; First Dx test?
A646. Increased Alk Phos; Extreme Alk Phos: Acute Ascending Cholangitis; Dx Test: ERCP
Q647. what does TSH and T-4 look like if a patient has a thyroid cancer?
A647. Normal
Q648. A patient presents with HTN, HypoK and is not on diuretics. Dx?; Diagnostic test?
A648. Dx: Hyperaldosteronism (Conn's Syndrome); Diagnostic test:; Increased Aldosterone with a Decreased Renin
Q649. In a patient with a congenital diaphragmatic hernia, what is the first step to Tx?
A649. Tx the Hypoplastic lung
Q650. What does a decreasing platelet count signify in a child with Necrotizing Enterocolitis?
A650. Sepsis
Q651. How do you differentiate intermittent claudication form a neurogenic source versus a vascular source?
A651. Neurogenic source: Positional and does not stop with rest
Q652. What is the Tx if claudication does not interfere with daily life?; If it does, what is the first Dx test?; Tx?; when is it not a surgical possibility to Tx?
A652. Not interfering with life: do Nothing; If it is:; First: Dopler studies (then Arteriogram); Tx: Angioplasty with stent or saph vein bypass; Not surgical: if no Pressure Gradient seen on Doppler (means Dz is in the small vessels)
Q653. A child presents with a mass at the base of the neck, in the supraclavicular area. Dx?
A653. Cystic Hygroma
Q654. A child presents with a mass up and down the anterior edge of the sternomastoid. Dx?
A654. Branchial cleft cysts
Q655. What is removed in a Thyroglossal cyst repair?; (3)
A655. 1. the Mass,; 2. the Middle segment of the Hyoid bone; 3. a core of muscle from the Tongue all the way back to the Foramen Cecum
Q656. 3 months ago, an 18-year-old woman noticed the presence of a 2 cm., firm, non-tender node located in the left jugular chain, at the level of the hyoid bone. She thinks it is larger now than when it first came to her attention. For the past 3 weeks she has had low grade fever and night sweats. Physical exam confirms the presence of the node, and also shows 2 other smaller nodes on that side of the neck, as well as enlarged nodes in both axillas. Dx?; First Diagnostic test?
A656. Dx: possible Lymphoma (The timetable of inflammatory neck nodes is measure in weeks, while that of neoplastic nodes is typically of months); First Dx test: FNA (an excisional Biopsy will be needed to establish tumor type)
Q657. A 72-year-old man seeks help for a 4 cm., fixed, hard mass in the left jugular chain, at the level of the upper edge of the thyroid cartilage. Patient says that he found it a week ago, but his wife claims that it has been present for at least 6 months. The patient has a long-standing history of alcohol and tobacco abuse, and he has terrible oral hygiene. Dx?; Diagnostic test?
A657. Dx: Metastatic Squamous Cell CA; from a primary in the head or neck mucosa; Diagnostic test: FNA (do NOT BIOPSY the tumor)
Q658. Aside from palpable mass in the neck, what are (3) other potential presentations for a metastatic SCC of the head or neck mucosa?
A658. 1. Persistent unilateral ear ache with serous otitis media; 2. Persistent hoarseness; 3. Unhealing ulcer in the mouth
Q659. what (2) times do you Never do a tissue Biopsy to diagnose cancer in the face/neck?
A659. 1. mass in neck when suspecting Metastasis SCC from head or neck mucosa; 2. PAROTID gland (too close to facial nerve)
Q660. Neurological problems of vascular nature have sudden onset. By HPI, how can you tell if it is occlusive versus hemorrhagic?
A660. without Headache = Occlusive; with very severe headache = Hemorrhagic
Q661. Location of brain tumor in patient with:; Anosmia
A661. base of Frontal Lobe
Q662. Location of brain tumor in patient with:; Loss of upper gaze
A662. Pineal area
Q663. Location of brain tumor in patient with:; Ataxia, unstable gait
A663. Posterior Fossa
Q664. What is the best imaging method for a brain tumor?
A664. MRI
Q665. What (2) classes of people are UTIs not expected?; What is the work-up for in this case?; (2 together)
A665. Not in:; 1. Children; 2. Men; Work-up: as if it were an Obstruction:; 1. massive Antibiotics; 2. Decompression of urinary tract above the "obstruction"
Q666. A 74-year-old man has a 3mm. ureteral stone lodged just above the ureterovesical junction. He is receiving IV fluids and analgesics, with the expectation that the stone will pass. He suddenly develops chills, his temperature shoots up to 104, and he complains of severe flank pain. Dx?; Tx? (2 together)
A666. Dx: Obstruction plus Infection; Tx:; 1. massive Antibiotics; 2. Decompression of urinary tract above the obstruction; (In the presence of infection, manipulating and attempting to extract the stone would be hazardous)
Q667. A 59-year-old man reports an episode of gross, painless hematuria, without any history of trauma. He has normal renal function. Diagnostic test? (2); why are these tests done?; If he had "poor renal flow" or "a history or renal failure", what is the Dx test? (2)
A667. Dx Test:; 1. IVP; 2. Cystoscopy; (Performed to rule out Cancer of the Kidney, ureter or bladder); Poor kidney function (creatinine > 2):; 1. CT scan; 2. Cystoscopy
Q668. A man presents with a painless enlargement of the right testis. He began feeling heaviness in that part of the scrotum 6 months ago. There is diffuse enlargement but it is difficult to determine if it is intratesticular or extratesticular. What is the next step?
A668. Ultrasound; (best way to discriminate b/t intra- or extra- testicular mass)
Q669. A patient presents with an acute subdural hematoma without a midline shift or anisocoria (unequal pupils). What is the next step?
A669. Hyperventilation, Diuresis and fluid restriction
Q670. What is the first step when suspecting a pulmonary embolism?
A670. Arterial Blood Gas; (an increased alveolar-arterial oxygen difference supports the Dx; a Duplex Doppler and V/Q scan are important for confirming the Dx, but a blood gas should be done first)
Q671. What can occur with massive blood loss with multiple transfusions during an abdominal procedure?; Tx?
A671. Coagulopathy; Tx: FFP and Platelets
Q672. What is the first step in Tx of a rib fracture in an elderly patient?
A672. Intercostal nerve block; (eliminating pain without interfering with ventilation)
Q673. A patient is shot in the lateral thigh. What is the next step in management?
A673. Tetanus prophylaxis; (since there is no damage to vessels, no Doppler, surgical exploration or arteriogram is indicated)
Q674. MCC of Transitional cell tumors of the bladder
A674. Smoking; (66% compared to 15% from Aniline dyes)
Q675. When there is a trauma patient that has a hematocrit of < 30, what should be transfused?
A675. Packed RBC
Q676. What nerve can be affected if an anesthesiologist wants to perform an axillary block for local pain control and the posterior wall of the axillary artery is pierced during the procedure?
A676. Ulna nerve
Q677. How do you treat a patient with a big, palpable pseudocyst of the pancreas?
A677. Endoscopic Cystogastrostomy; (an endoscopic anastomosis b/t the cyst and the stomach)
Q678. A man is shot in the upper zone of the neck yet is conscious, hemodynamically stable and neurologically intact. What is the next step?
A678. Arteriogram
Q679. What is the best drug for a estrogen/progesterone receptor positive breast tumor in postmenopausal patients?
A679. Anastrozole; (suppresses production of estrogens)
Q680. What nerve during a carotid endarterectomy is prone to damage producing a difficulty in swallowing?
A680. Glossopharyngeal
Q681. Lack of what procedure can predispose a man to penile cancer?
A681. Circumcision
Q682. What electrolyte is extremely increased with a crush injury?
A682. Potassium (causing Hyperkalemia)
Q683. An asymptomatic patient form Mexico has a CT scan done of the abdomen which shows four thin-walled structures 1cm in diameter throughout his liver. Dx?
A683. Simple Liver Cysts; (Amebic abscesses present with fever, leukocytosis, a tender liver and elevated Alk Phos)
Q684. A 27-yo woman from Asia moved to the US and presents with gross hematuria. She reports a low-grade fever and weight loss for over one year. Urinalysis shows pyuria, but cultures are negative for bacteria. IVP reveals diminished contrast excretion and cavitary lesions in the right kidney. Dx?
A684. Tuberculosis; (Secondary TB commonly affects the kidneys and can spread to the epididymis and prostate in men; this is a classic presentation with hematuria, weight loss, low fever, negative cultures and increased leukocytes, and cavitary lesions)
Q685. If a patient presents with a TIA consisting of no bleeding and no signs of extensive infarction within the first 3 hours of onset, what is the next step?
A685. IV infusion of Tissue-type Plasminogen Activator; (tPA can be used as a “clot buster” in patients w/in first 3 hours, though better if started in first 90 minutes of Sx)
Q686. What is the next step in the fracture of a clavicle?
A686. Figure-eight Cast; (not arteriogram)
Q687. A 45-yo man presents with a pale, pulseless, paresthetic, painful and paralytic right lower extremity. On exam, no pulses are apparent in the RLE. Dx?; Tx?
A687. Dx: Emboli in Rt Common Iliac; Tx: Fogarty Balloon-tipped Catheter
Q688. Before performing a Pneumonectomy for SCC of the lung, what should be done?
A688. CT scan of the Chest and upper Abdomen; (to rule-out metastasis)
Q689. What is the next step to confirm a Dx of PE in a patient that has atelectasis and patchy pneumonic infiltrates?
A689. Spiral CT scan of the Chest; (a V/Q scan is not reliable for a patient with atelectasis and infiltrates)
Q690. A 14-year-old boy is hit over the right side of the head with a baseball bat. He loses consciousness for a few minutes, but recovers promptly and continues to play. One hour later he is found unconscious in the locker room. His right pupil is fixed and dilated. Dx?; How is it diagnosed?; Tx?
A690. Dx: Acute epidural hematoma (probably right side); Diagnostic Test: CT scan; Treatment: Emergency surgical decompression (craniotomy); Good prognosis if treated, fatal within hours if it is not.
Q691. A 32-year-old male is involved in a head-on, high-speed automobile collision. He is unconscious at the site, regains consciousness briefly during the ambulance ride and arrives at the E.R. in deep coma, with a fixed, dilated right pupil. Dx?; Diagnostic Test?; Tx?
A691. Dx: Acute Subdural hematoma; Diagnostic Test: CT scan; (Also need to check cervical spine!); Treatment: Emergency craniotomy; poor prognosis because of brain injury
Q692. A 77-year-old man becomes “senile” over a period of three or four weeks. He used to be active and managed all of his financial affairs. Now he stares at the wall, barely talks and sleeps most of the day. His daughter recalls that he fell from a horse about a week before the mental changes began. Dx?; Diagnostic Test?; Tx?
A692. Dx: Chronic subdural hematoma. Diagnostic Test: CT scan; Treatment: Surgical decompression (craniotomy); Spectacular improvement expected
Q693. A car hits a pedestrian. He arrives in the ER in coma. He has …(raccoon eyes… or clear fluid dripping from the nose…or clear fluid dripping from the ear…or ecchymosis behind the ear)…; Dx?; Diagnostic Test?; Tx?
A693. Dx: Base of the skull fracture. Diagnostic Test: CT scan and cervical spine X-Rays. Tx: needs neurosurgical consult and antibiotics
Q694. A 45-year-old man is involved in a high-speed automobile collision. He arrives at the ER in coma, with fixed dilated pupils. He has multiple other injuries (extremities, etc). His blood pressure is 70 over 50, with a feeble pulse at a rate of 130. What is the reason for the low BP and high pulse rate?
A694. significant blood loss to the outside (could be scalp laceration), or inside (abdomen, pelvic fractures)…not from neurological injury
Q695. A 22-year-old gang member arrives in the E.R. with multiple guns shot wounds to the abdomen. He is diaphoretic, pale, cold, shivering, anxious, asking for a blanket and a drink of water. His blood pressure is 60 over 40. His pulse rate is 150, barely perceptible. Dx?; Management? (3); Tx?
A695. Dx: Hypovolemic shock; Management: Big bore IV lines, Foley catheter and I.V. antibiotics. Tx: Ideally Exploratory Lap immediately for control of bleeding, and then fluid and blood administration.
Q696. A 22-year-old gang member arrives in the E.R. with multiple guns shot wounds to the chest and abdomen. He is diaphoretic, cold, shivering, anxious, asking for a blanket and a drink of water. His blood pressure is 60 over 40. His pule rate is 150, barely perceptible. He has big distended veins in his neck and forehead. He is breathing OK, has bilateral breath sounds and no tracheal deviation. Dx?; Diagnostic test?; Tx?
A696. Dx: Pericardial tamponade; Diagnostic test: No X-Rays needed, this is a clinical diagnosis!; Do Pericardial window. Tx: If positive, follow with Thoracotomy, and then Exploratory Lap.
Q697. A 22-year-old gang member arrives in the E.R. with a single gunshot wound to the precordial area. He is diaphoretic, cold, shivering, anxious, asking for a blanket and a drink of water. His blood pressure is 60 over 40. His pule rate is 150, barely perceptible. He has big distended veins in his neck and forehead. He is breathing OK, has bilateral breath sounds and no tracheal deviation. Dx?; Management?
A697. Dx: Pericardial Tamponade; Management: Exploratory Lap; (when the location of the wound strongly suggests pericardial tamponade, emergency thoracotomy might be done right away without prior pericardial window)
Q698. A 22-year-old gang member arrives in the E.R. with multiple gun shot wounds to the chest and abdomen. He has labored breathing is cyanotic, diaphoretic, cold and shivering. His blood pressure is 60 over 40. His pulse rate is 150, barely perceptible. He is in respiratory distress, has big distended veins in his neck and forehead, his trachea is deviated to the left, and the right side of his chest is tympantic, with no breath sounds. Dx?; Management? (2 steps); Tx?
A698. Dx: Tension pneumothorax; Management:; 1. Immediate big bore IV catheter placed into the right pleural space (2nd intercostal midclavicular); 2. followed by Chest Tube to the right side, Immediately!; (Watch out for trap that offers chest X-Ray as an option. This is a clinical diagnosis, and patient needs that chest tube now. He will die if sent to X-Ray.); Tx: Exploratory lap will follow
Q699. A 72 year old man who lives alone calls 911 saying that he has severe chest pain. He cannot give a coherent history when picked up by the EMT, and on arrival at the ER he is cold and diaphoretic and his blood pressure is 80 over 65. He has an irregular, feeble pulse at a rate of 130. His neck and forehead veins are distended and he is short of breath. Dx?; Management?
A699. Dx: Cardiogenic shock, from massive MI; Management: verify high CVP. EKG, enzymes, coronary care unit etc. Do not drown him with enthusiastic fluid “ resuscitation”, but use thrombolytic therapy if offered
Q700. A 17 year old girl is stung by a swarm of bees…or a man of whatever age breaks out with hives after a penicillin infection …or a patient undergoing surgery under spinal anesthetic… eventually develop BP of 75 over 25, pulse rate of 150, but they look warm and flushed rather than pale and cold. CVP is low. Dx?; Management? (2)
A700. Dx: Vasomotor shock; (massive vasodilation, loss of vascular tone); Management: Vasoconstrictors and Volume replacement as needed
Q701. A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stable vital signs. No breath sounds on the right. Resonant to percussion. Dx?; Diagnostic Test?; Tx (specific)?
A701. Dx: Plain pneumothorax; Diagnostic Test: There is time to get a chest X-Ray if the option if offered; Treatment: Chest tube to underwater seal and suction, high in the pleural cavity
Q702. A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stale vital signs. No breath sounds on at the base on the right chest, faint distant breath sounds at the apex. Dull to percussion. Dx?; Diagnostic Test?; Tx?
A702. Dx: Hemothorax; Diagnostic Test: Chest X-Ray; Treatment: Chest tube on the right, at the base of the pleural cavity
Q703. A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stable vital signs. No breath sounds on at the base on the right chest, faint distant breath sounds at the apex. Dull to percussion. A chest tube placed at the right pleural base recovers 120 cc of blood, drains another 20 c in the next hour. Dx?; Further Tx?
A703. Dx: Hemothorax; Further treatment: The point of this one is that most hemothoraxes do not need exploratory surgery. Bleeding is from lung parenchyma (low pressure), stops by itself. Chest tube is all that is needed. Key clue: little blood retrieved, even less afterwards
Q704. A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has blood pressure is 95 over 70, pulse rate of 100. No breath sounds on at the base on the right chest, faint distant breath sounds at the apex. Dull to percussion. A chest tube placed at the right pleural base recovers 1250 cc of blood…(or it could be only 450 cc at the outset, but followed by another 420 cc in the next hour and so on). Dx?; Further Tx?
A704. Dx: Hemothorax; Further treatment: The rare exception who is bleeding from a systemic vessel (almost invariably intercostal) will need Thoracotomy to ligate the vessel
Q705. A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stable vital signs. No breath sounds on the right. Resonant to percussion at the apex of the right chest, dull at the base. Chest X-Ray shows one single, large air-fluid level. Dx?; Tx?
A705. Dx: Hemo-pneumothorax; Tx: Chest tube, surgery only if bleeding a lot
Q706. A 33-year-old lady is involved in a high-speed automobile collision. She arrives at the E.R. gasping for breath, cyanotic at the lips, with flaring nostrils. There are bruises over both sides of the chest, and tenderness suggestive of multiple fractured ribs. Blood pressure is 60 over 45. Pulse rate 160, feeble. She has distended neck and forehead veins, is diaphoretic. Left hemithorax has no breath sounds, is tympanic to percussion. Dx?; Where is the trauma?; Management?
A706. Dx: Tension Pneumothorax; Where is the penetrating trauma? The fractured ribs can act as a penetrating weapon. Management: Chest Tube to the left immediately!
Q707. A 54-year-old lady crashes her car against a telephone pole at high speed. On arrival at the E.R. she is in moderate respiratory distress. She has multiple bruises over the chest, and multiple site of point tenderness over the ribs. X-Rays show multiple rib fractures on both sides. On closer observation it is noted that a segment of the chest wall on the left side caves in when she inhales, and bulges out when she exhales. Dx?; Next step if she is going to OR?; Next step if not doing well?
A707. Dx: Flail Chest; (paradoxical breathing); to OR:; prophylactic Bilateral Chest Tubes; (because she is at high risk to develop tension pneumothorax when under the positive pressure breathing of the anesthetic); not well:; Intubate and give Positive Pressure ventilation; (Flail chest is usually assoc with pulmonary contusion, leading to inadequate respiration from pain)
Q708. A 54-year-old lady crashes her car against a telephone pole at high speed. On arrival at the E.R. she is breathing well. She has multiple bruises over the chest and multiple sites of point tenderness over the ribs. X-Rays show multiple rib fractures on both sides, but the lung parenchyma is clear and both lungs are expanded. Two days later her lungs “white out ” on X-Rays and she is in respiratory distress. Dx?; Management? (2 together)
A708. Dx: Pulmonary contusion. It does not always show up right away, may become evident one or two days after the trauma. Management:; 1. Fluid restriction (using colloids) and diuretics,; 2. Respiratory support:; (intubation, mechanical ventilation and PEEP if needed)
Q709. A 54-year-old lady crashes her car against a telephone pole at high speed. On arrival at the E.R. she is breathing well. She has multiple bruises over the chest, and is exquisitely tender over the sternum at a point where there is a crunching feeling of crepitation elicited by palpation. Dx?; Further Tests?
A709. Dx: Sternal fracture; (but the point is that she is at high risk for myocardial contusion and for traumatic rupture of the aorta); Further tests:; Most important:; 1. CT scan; 2. Transesophageal echo; (or arteriogram looking for aortic rupture); Also work-up for MI:; 1. EKG; 2. Cardiac enzymes
Q710. A 53-year-old man is involved in a high-speed automobile collision. He has moderate respiratory distress. Physical exam shows no breath sounds over the entire left chest. Percussion is unremarkable. Chest X-Ray shows air fluid levels in the left chest. Dx?; Management?
A710. Dx: Diaphragmatic rupture; (It is always on the left); Management: Surgical repair
Q711. A motorcycle daredevil attempts to jump over the 12 fountains in front of Caesar’s Palace Hotel in Las Vegas. As he leaves the ramp at very high speed his motorcycle turns sideways and he hits the retaining wall at the other end, literally like a rag doll. At the ER he is found to be remarkably stable, although he has multiple extremity fractures. A chest X-Ray shows fracture of the left first rib and widened mediastinum. Dx?; Diagnostic Test?; Tx?
A711. Dx: traumatic rupture of the aorta; (King size trauma, fracture of a hard-to-break could be first rib, scapula or sternum...and the tell-tale hint of widened mediastinum); Diagnostic Test: Arteriogram (aortogram); Treatment: Emergency surgical repair
Q712. A 34-year-old lady suffers severe blunt trauma in a car accident. She has multiple injuries to her extremities, has head trauma and has a pneumothorax on the left. Shortly after initial examination it is noted that she is developing progressive subcutaneous emphysema all over her upper chest and lower neck. Dx?; Test for additional findings?; Diagnostic test?; Tx?
A712. Dx: Traumatic rupture of the trachea or major bronchus; Additional findings: Chest X-Ray would confirm the presence of air in the tissues; Diagnostic test: Fiberoptic bronchoscopy; (to confirm diagnosis and level of injury and to secure an airway); Tx: Surgical repair
Q713. A 26-year-old lady has been involved in a car wreck. She has fractures in upper extremities, facial lacerations and no other obvious injuries. Chest X-Ray is normal. Shortly thereafter she develops hypotension, tachycardia and dropping hematocrit. Her CVP is low. Dx?; Diagnostic Test if stable?; Unstable? (2 possible); Tx?
A713. Dx: Abdominal bleed; Diagnostic test:; Patient is stable: CT scan; Unstable:; 1. Diagnostic Peritoneal Lavage; or; 2. Ultrasound in ER; Tx: Exploratory Lap
Q714. A 19 year old gang member is shot in the abdomen with a 38 caliber revolver. The entry wound is in the epigastrium, to the left of the midline. The bullet is lodged in the psoas muscle on the right. He is hemodynamically stable, the abdomen is moderately tender. Management (specific)?
A714. Management:; A penetrating wound of the abdomen gets exploratory laparotomy every time. preparations prior to surgery:; an indwelling bladder catheter, a big bore venous line for fluid administration and a dose of broad spectrum antibiotics.
Q715. A 19 year old gang member is shot once with a 38 caliber revolver. The entry wound is in the left mid-clavicular line, two inches below the nipple. The bullet is lodged in the left paraspinal muscles. He is hemodynamically stable, but he is drunk and combative and physical exam is difficult to do. Management?
A715. Management:; The point here is to remind you of the boundaries of the abdomen. Although this sounds like a chest wound, it is also abdominal. The belly begins at the nipple line. The chest does not end at the nipple line, though. Belly and chest are not stacked up like pancakes, they are separated by a dome. This fellow needs all the stuff for a penetrating chest wound (chest X-Ray, chest tube if needed), plus the exploratory lap
Q716. A 27 year old intoxicated man smashes his car against a tree. He is tender over the left lower chest wall. Chest X-Ray shows fractures of the 8th, 9th and 10th ribs on the left. He has a blood pressure of 85 over 68 and a pulse rate of 128. Dx?; Diagnostic test if stable?; Diagnostic test if crashing? (2); Tx?
A716. Dx: Ruptured spleen; Management if Stable: CT Scan; (if he responds promptly to fluid administration, and does not require blood; further management in that case may well be continued observation with serial CT scans); Management if “crashing”: Peritoneal Lavage or Sonogram followed by (Tx)Exploratory Laparotomy
Q717. A 27 year old intoxicated man smashes his car against a tree. He is tender over the left lower chest wall. Chest X-Ray shows fractures of the 8th, 9th and 10th ribs on the left. He has a blood pressure of 85 over 68 and a pulse rate of 128, which do not respond satisfactorily to fluid and blood administration. He has a positive peritoneal lavage and an exploratory laparotomy where a ruptured spleen is found and it is not salvagable. Further Management?
A717. Further Management:; administration of Pneumovax and some would also Immunize for Hemophilus Influenza B and Meningococcus
Q718. A 31 year old lady smashes her car against a wall. She has multiple injuries including upper and lower extremity fractures. Her blood pressure is 75 over 55, with a pulse rate of 110. On physical exam she has a tender abdomen, with guarding and rebound on all quadrants. Dx?; Management?
A718. Dx: Blood (and possible feces) in the belly; Management: Exploratory lap
Q719. A 31 year old lady smashes her car against a wall. Her abdomen is tender with guarding and rebound tenderness present in all quadrants; Dx?; Management?
A719. Dx: Ruptured bowel; Management: Exploratory lap, and repair of the injuries
Q720. A patient involved in a high speed automobile collision has multiple injuries, including a pelvic fracture. On physical exam there is blood in the meatus. Dx? (2 possible); Diagnostic test?
A720. Dx: Bladder or Urethral injury; (pelvic fracture plus blood in the meatus); Diagnostic test: Retrograde Urethrogram; (because urethral injury would be compounded by insertion of a Foley catheter)
Q721. A 19 year old male is involved in a severe automobile accident. Among many other injuries he has a pelvic fracture. He has blood in the meatus, scrotal hematoma and the sensation that he wants to urinate but can not do it. Rectal exam shows a “high riding prostate”. Dx?; Diagnostic Test?; Management?
A721. Dx: Posterior Urethral injury. Diagnostic test: Retrograde Urethrogram; Management:; Suprapubic catheter; (and the repair is delayed 6 months)
Q722. A 19 year old male is involved in a motorcycle accident. Among many other injuries he has a pelvic fracture. He has blood in the meatus and scrotal hematoma. Retrograde urethrogram shows an anterior urethral injury. Management?
A722. Management: Anterior urethral injuries are repaired right away
Q723. A patient involved in a high speed automobile collision has multiple injuries, including a pelvic fracture. Insertion of a Foley catheter shows that there is gross hematuria. Dx?; Diagnostic test?
A723. Dx: Bladder injury; (Presumably there was no blood in the meatus to warn against the insertion of an indwelling catheter, and since the latter was accomplished without problem, the urethra must be intact); Diagnostic test: Retrograde Cystogram
Q724. A patient involved in a high speed automobile collision has multiple injuries, including rib fractures and abdominal contusions. Insertion of a Foley catheter shows that there is gross hematuria, and retrograde cystogram is normal. Dx?; Diagnostic Test?
A724. Dx: Kidney injury; (Lower injuries have been ruled out); Diagnostic test: CT scan; (They will not ask you for fine-judgment surgical decisions, but the rule is that traumatic hematuria does not need surgery even if the kidney is smashed. They operate only if the renal pedicle is avulsed or the patient is exsanguinating)
Q725. A 35 year old male is about to be discharged from the hospital where he was under observation for multiple blunt trauma sustained in a car wreck. It is then discovered that he has microscopic hematuria. Management?
A725. Management: Gross traumatic hematuria in the adult always has to be investigated
Q726. A 4 year old falls from his tricycle. In the ensuing evaluation he is found to have microscopic hematuria. Management?
A726. Management: Microhematuria in kids needs to be investigated, as it often signifies congenital anomalies… particularly if the magnitude of the trauma does not justify the bleeding. Start with a Sonogram
Q727. A 14 year old boy slides down a banister, not realizing that there is a big knob at the end of it. He smashes the scrotum and comes in to the E.R. with a scrotal hematoma the size of a grapefruit. What should be the physician's concern?; Diagnostic test?; Management?
A727. Concern: The issue in scrotal hematomas is whether the testicle is ruptured or not. Diagnostic test: Sonogram; Management: If ruptured, surgery will be needed. If intact, only symptomatic treatment
Q728. A 41 year old male presents to the E.R. reporting that he slipped in the shower and injured his penis. Exam reveals a large penile shaft hematoma with normal appearing glans. Dx?; Tx?
A728. Dx: Fracture of the tunica albuginea; (including the usual cover story given by the patient. These always happen during sexual intercourse with woman on top); Tx: this is one of the few urological emergencies. Surgical repair is needed
Q729. You get a phone call from a frantic mother. Her 7 year old girl spilled Drano all over her arms and legs. You can hear the girl screaming in pain in the background. Management?
A729. Management:; The point of this question is that chemical injuries – particularly alkalis-need copious, immediate, profuse irrigation. Instruct the mother to do so right at home with tap water, for at least 30 minutes before rushing the girl to the E.R
Q730. While trying to hook up illegally to cable TV, an unfortunate man comes in contact with a high tension electrical power line. He has an entrance burn wound in the upper outer thigh and an exit burn lower down on the same side. Tx?; What can occur from this event?; Management of this? (3)
A730. Management: Extensive surgical Debridement; (there is deep tissue destruction); What can occur? Myoglobinemia; (leading to myoglobinuria and to Renal Failure); Management:; 1. lots of IV fluids,; 2. Osmotic Diuretics (Mannitol),; 3. Alkalinization of the urine
Q731. A man is rescued by firemen from a burning building. On admission it is noted that he has burns around the mouth and nose, and the inside of his mouth and throat look like the inside of a chimney. Dx?; Diagnostic Test?; Management?
A731. Dx: Inhalation burns; Diagnostic test: Bronchoscopy; Management: Respiratory support
Q732. A patient has suffered third degree burns to both of his arms when his shirt caught on fire while lighting the back yard barbecue. The burned areas are dry, white, leatherly anesthetic, and circumferential all around arms and forearms. What is main problem?; Management? (2)
A732. Problem: Circumferential burns; (The leatherly eschar will not expand, while the are under the burn will develop massive edema, thus circulation will be cut off or in the case of circumferential burns of the chest, breathing will be compromised); Management: Compulsive monitoring of peripheral pulses and capillary filling. Escharotomies at the bedside at the first sign of compromised circulation
Q733. A toddler is brought to the E.R. with burns on both of his buttocks. The areas are moist, have blisters and are exquisitely painful to touch. The story is that the kid accidentally pulled a pot of boiling water over himself. what type of burn?; What should the physician question?; Management? (2)
A733. Dx: Second degree burn; (Note that in kids third degree is deep bright red, rather than white leatherly as in the adult); Question: How did it really happen? Burns in kids always bring up the possibility of child abuse, particularly if they have the distribution that you would expect if you grabbed the kid by arms and legs and dunked him in a pot of boiling water. Management: Silvadene cream. Possibly reporting to authorities for child abuse
Q734. An adult male who weight “X” Kgs. Sustains second and third degree burns over ---whatever--- The burns will be depicted in a drawing, indicating what is second degree (moist, blisters, painful) and what is third degree (white, leatherly, anesthetic). What is the equation for proper fluid resuscitation management?; What fluid and how much in first 8 hours?
A734. Management:; 4cc per Kg. of body weight per percentage of burned area; (up to 50%); (if patient is 70kg and 18% burned, then 70x4x18); Fluid: Ringers Lactate; (half of the calculated dose goes in during first 8 hours)
Q735. A 42 year old lady drops her hot iron on her lap while doing the laundry. She comes in with the shape of the iron clearly delineated on her upper thigh. The area is white, dry, leatherly, anesthetic. Tx?
A735. Tx: Early excision and skin grafting; (in very small third degree burns)
Q736. A 22 year old gang leader comes to the E.R. with a small, 1 cm. deep sharp cut over the knuckle of the right middle finger. He says he cut himself with a screwdriver while fixing his car. Dx?; Management?
A736. Dx: The description is classical for a human bite. No, nobody actually bit him, he did it by punching someone in the mouth...and getting cut with the teeth that were smashed by his fist. The imaginative cover story usually comes with this kind of lesion. Management: human bites are bacteriological the dirtiest that one can get. Rabies shots will not be needed, but surgical exploration by an orthopedic surgeon will be required.
Q737. A 65 year old West Texas farmer of Swedish ancestry has an indolent, raised, waxy, 1.2 cm skin mass over the bridge of the nose that has been slowly growing over the past three years. There are no enlarged lymph nodes in the head and neck. Dx?; Diagnostic Test?; Tx?
A737. Dx: Basal cell carcinoma; Diagnostic test: Full thickness biopsy at the edge of the lesion (punch or knife); Treatment: Surgical excision with clear margins, but conservative width
Q738. A 71 year old West Texas farmer of Irish ancestry has a non- healing, indolent, punched out, clean looking 2 cm ulcer over the left temple, that has been slowly becoming larger over the past three years. There are no enlarged lymph nodes in the head and neck. Dx?; Diagnostic Test?; Tx?
A738. Dx: Basal cell carcinoma; Diagnostic Test: Full thickness biopsy at the edge of the lesion (punch or knife); Tx: Surgical excision with clear margins, but conservative width
Q739. A blond, blue eyed, 69 year old sailor has a non-healing, indolent 1.5 cm. ulcer on the lower lip, that has been present, and slowly enlarging for the past 8 months. He is a pipe smoker, and he has no other lesions or physical findings. Dx?; Diagnostic Test?; Tx? (2 possible)
A739. Dx: Squamous cell carcinoma; Diagnostic test: Biopsy; Treatment: Surgical resection with wider (about 1 cm) clear margins. Local radiation therapy is another option
Q740. A red headed 23 year old lady who worships the sun, and who happens to be full of freckles, consults you for a skin lesion on her shoulder that concerns her. She has a pigmented lesion that is asymmetrical, with irregular borders, of different colors within the lesion, and measuring 1.8 cms; Dx?; Diagnostic Test?
A740. Dx: Melanoma or Dysplastic Nevus; Diagnostic test: full thickness biopsy at the edge of the lesion; margin free local excision if superficial melanoma; (Clarks’ levels one or two, or under 0.75 mm); wide local excision with 2 or 3 cm margin if deep melanoma
Q741. A 35 year old blond, blue eyed man left his native Minnesota at age 18, and has been living the life as a crew member for a sailing yacht charter operation in the Caribbean. He has multiple nevi all over his body, but one of them has changed recently. Dx?; Management?
A741. Dx: Melanoma; (Change in a pigmented lesion is the other tip off to melanoma...It may be growth, or bleeding, or ulceration, or change in color); Management: Full-thickness biopsy at the edge of the lesion; margin free local excision if superficial melanoma; (Clarks’ levels one or two, or under 0.75 mm); wide local excision with 2 or 3 cm margin if deep
Q742. A 44 year old man has unequivocal signs of multiple liver metastasis, but no primary tumor has been identified by multiple diagnostic studies of the abdomen and chest. The only abnormality in the physical exam is a missing toe, which he says was removed at the age of 18 for a black tumor under the toenail. Dx?; Diagnostic Test for initial problem?
A742. Dx: Malignant Melanoma; (the alternate version has a glass eye, and history of enucleation for a tumor. No self-respecting malignant tumor would have this time interval, but melanoma will); Diagnostic Test: full thickness biopsy at the edge of the lesion; margin free local excision if superficial melanoma; (Clarks’ levels one or two, or under 0.75 mm); wide local excision with 2 or 3 cm. margin if deep melanoma
Q743. A 32 year old gentleman had a Clark’s level 5, 3.4 mm. Deep, melanoma removed from the middle of his back three years ago. He now has…(a tumor in a weird place, like his left ventricle, his duodenum, his ischiorectal area...anywhere!); Dx?
A743. Dx: Melanoma; (The point of this vignette is that invasive has to be deep...metastasizes to all the usual places [lymph nodes plus liver-lung-brain-bone] but it is also the all-time- champion in going to weird places where few other tumors dare to go)
Q744. An 18 year old lady has a firm, rubbery mass in the left breast that moves easily with palpation. Dx?; Diagnostic Test?; Imaging technique for young patient?
A744. Dx: Fibroadenoma; Diagnostic Test: Tissue diagnosis...(choices in order); 1. FNA; 2. Core Biopsy; 3. Excisional Biopsy; (The only safe answer, even if the presentation favors benign disease, is to get tissue diagnosis); Sonogram is the only imaging technique suitable for the very young breast
Q745. A 27 year old immigrant from Mexico has a 12 x 10 x 7 cm. mass in her left breast. It has been present for seven years, and slowly growing to its present size. The mass is firm, rubbery, completely movable, is not attached to chest wall or to overlying skin. There are no palpable axillary nodes. Dx?; Diagnostic Test?
A745. Dx: Cystosarcoma Phyllodes; (basically same presentation as Fibroadenoma, but >25yo); Diagnostic test: given the size best done with core or incisional biopsy; (no need for axillary node dissection with phyllodes...metastasis is rare)
Q746. A 35 year old lady has a ten year history of tenderness in both breasts, related to menstrual cycle, with multiple lumps on both breasts that seem to “come and go” at different times in the menstrual cycle. Now has a firm, round, 2 cm. mass that has not gone away for 6 weeks. Dx?; Diagnostic Test?
A746. Dx: Fibrocystic disease; Diagnostic test: Aspiration of the Cyst; (tissue diagnosis [i.e: biopsy] becomes impractical when there are lumps every month); If the mass goes away and the fluid aspirated is clear, that’s all. If the fluid is bloody it goes to cytology. If the mass does not go away, or recurs she needs biopsy. (Answers that offer mammogram or sonogram in addition to the aspiration would be OK, but not as the only choice)
Q747. A 34 year old lady has been having bloody discharge from the right nipple, on and off for several months. There are no palpable masses. Dx?; Diagnostic Test?; if test is inconclusive?
A747. Dx: Intraductal papilloma; Diagnostic test: Mammogram; (the way to detect breast cancer that is not palpable); (If negative, one may still wish to find an resect the intraductal papilloma to provide symptomatic relief. Resection can be guided by galactogram, or done as a retroareolar exploration)
Q748. A 26 year old lactating mother has cracks in the nipple and develops a fluctuating, red, hot, tender mass in the breast, along with fever and leukocytosis. Dx?; Management?
A748. Dx: Abscess; (However, only lactating breasts are “entitled” to develop abscesses. On anybody else, a breast abscess is a cancer until proven otherwise.); Management: Incision and Drainage; (if an option includes drainage with biopsy of the abscess wall, go for that one)
Q749. A 49 year old has a firm 2cm mass in the right breast that has been present for 3 months. Dx?; Management?
A749. Dx: This could be anything. (Age is the best determinant for Cancer of the breast. If she had been 72, you go for cancer. At 22, you favor benign. But they will not ask you what this is, they will ask what do you do.); Management: You have to have tissue. Core biopsy is OK, but if negative you don’t stop there. Only excisional biopsy will rule out cancer
Q750. A 69 year old lady has a 4 cm hard mass in the right breast, with ill defined borders, movable from the chest wall but not movable within the breast. The skin overlying the mass is retracted an has an “orange peel” appearance…or the nipple became retracted six months ago. Dx?; Diagnostic Test?
A750. Dx: Cancer of the Breast; Diagnostic test: Core or Excisional Biopsy
Q751. A 62 year old lady has an eczematoid lesion in the areola. It has been present for 3 months and it looks to her like “some kind of skin condition” that has not improved or gone away with a variety of lotions and ointments; Dx?; Diagnostic Test?
A751. Dx: Paget’s disease of the breast; (which is a cancer under the areola); Management: Full thickness punch biopsy of the skin would be OK, but core biopsy or incisional biopsy of the tissue underneath would be OK also
Q752. A 42 year old lady hits her breast with a broom handle while doing her housework. She noticed a lump in that area at the time, and one week later the lump is still there. She has a 3 cm hard mass deep inside the affected breast, and some superficial ecchymosis over the area; Dx?
A752. Dx: Cancer, until proven otherwise; (A classical trap for the unwary. Trauma often brings the area to the attention of the patient...but is not cause of the lump.)
Q753. A 58 year old lady discovers a mass in her right axilla. She has a discreet, hard, movable, 2cm mass. Examination of her breast is negative, and she has not enlarged lymph nodes elsewhere; Dx?; Diagnostic Test? (2)
A753. Dx: Cancer, until proven otherwise; (A tough one, but another potential presentation for cancer of the breast. In a younger patient you would think lymphoma. It could still be lymphoma on her.); Diagnostic test:; 1. Mammogram; (we are now looking for an occult primary); 2. Biopsy Node
Q754. A 60 year old lady has a routine, screening mammogram. The radiologist reports an irregular area of increased density, with fine microcalcifications, that was not present two year ago on a previous mammogram; Dx?; Further Management?
A754. Dx: Cancer of the Breast; Further management: Stereotactic Radiologically guided Core Biopsy; (If unsatisfactory, the next move would be needle localized excisional biopsy)
Q755. A 44 year old lady has a 2cm palpable mass in the upper outer quadrant of her right breast. A core biopsy shows infiltrating ductal carcinoma. The mass is freely movable and her breast is of normal, rather generous size. She has no palpable axillary nodes; Tx? (2 steps)
A755. Tx:; 1. Segmental Resection (Lumpectomy) and axillary node dissection; 2. followed by Radiation Therapy to the remaining breast; Axillary node dissection is to help determine the need for adjuvant systemic therapy
Q756. A 62 year old lady has a 4 cm hard mass under the nipple and areola of her rather smallish left breast. A core biopsy has established a diagnosis of infiltrating ductal carcinoma. There are no palpable axillary nodes. Management?
A756. Management: Modified Radical Mastectomy; (A Lumpectomy is an option only when the tumor is small [in absolute terms and in relation to the breast] and located where most of the breast can be spared.) A modified radical mastectomy is the choice here. Why go after the axillary nodes when they are not palpable?: Because palpation is notoriously inaccurate in determining the presence or absence of axillary metastasis.
Q757. A 44 year old lady shows up in the Emergency Room because she is “bleeding from the breast”. Physical exam shows a huge, fungating, ulcerated mass occupying the entire right breast, and firmly attached to the chest wall. The patient maintains that the mass has been present for only “a few weeks”, but a relative indicates that it has been there at least two years, maybe longer. Dx?; Diagnostic Test?; Management?
A757. Dx: Advanced Cancer of the Breast; Diagnostic Test: Core or an Incisional biopsy; Management: currently inoperable, and incurable as well...but palliation can be offered. Chemotherapy is the first line of treatment. (In many cases the tumor will shrink enough to become operable)
Q758. A 37 year old lady has a lumpectomy and axillary dissection for a 3cm infiltrating ductal carcinoma. The pathologist reports clear surgical margins and metastatic cancer in 4 out of 17 axillary nodes. Management?
A758. Management: Chemotherapy; (Only very small tumors with negative nodes and very favorable histological pattern are “cured” with surgery alone. More extensive tumors need adjuvant systemic therapy, and the rule is that premenopausal women get chemotherapy and postmenopausal women get hormonal therapy.)
Q759. A 66 year old lady has a modified radical mastectomy for infiltrating ductal carcinoma of the breast. The pathologist reports that tumor measures 4 cm. in diameter and that 7 out of 22 axillary node are positive for metastasis. The tumor is estrogen and progesterone receptor positive. Management?
A759. Management: Hormonal therapy; (The agent used is Tamoxifen)
Q760. A 44 year old lady complains bitterly of severe headaches that have been present for several weeks and have not responded to the usual over-the-counter headache remedies. She is two years post-op. from modified radical mastectomy for T3, N2, M0 cancer of the breast, and she had several courses of post-op chemotherapy which she eventually discontinued because of the side effects. Dx?; Diagnostic Test?
A760. Dx: Brain metastasis (until proven otherwise); (Don’t get hung up on the TNM classification, if the numbers are not 1 for the tumor and zero for the nodes and metastasis, the tumor is bad.); Diagnostic Test: CT scan of the brain
Q761. A 39 year old lady completed her last course of postoperative adjuvant chemotherapy for breast cancer six months ago. She comes to the clinic complaining of constant back pain for about 3 weeks. She is tender to palpation over two well circumscribed areas in the thoracic and lumbar spine. Dx?; Diagnostic Test?
A761. Dx: Bone metastasis until proven otherwise; Diagnostic test: Bone Scan; (the most sensitive test for bone metastasis); If positive, X-Rays are needed to rule out benign reasons for the scan to “light up”.
Q762. A young mother is visiting your office for routine medical care. She happens to have her 18 month old baby with her, and you happen to notice that one of the pupils of the baby is white, while the other one is black. Dx Differential? (2)
A762. Dx Diff: Retinoblastoma or Cataracts; (An ophthalmological and potentially life-and-death emergency. A white pupil (leukocoria) at this age can be retinoblastoma. This kid needs to see the ophthalmologist not next week, but today or tomorrow. If it turns out to be something more innocent, like a cataract, the kid still needs it corrected to avoid amblyopia.)
Q763. Your distant cousins that you have not seen for years visit you and brag about their beautiful baby with “huge, shiny eyes”. They show you a picture that indeed proves their assertion (or the exam booklet will have such a picture). Dx?
A763. Dx: Huge eyes in babies can be Congenital Glaucoma. (Tearing will indeed make them shine all the time. If undiagnosed, blindness will ensue.)
Q764. A 53 year old lady is in the ER complaining of extremely severe frontal headache. The pain started about one hour ago, shortly after she left the movies where she watched a double feature. On further questioning, she reports seeing halos around the lights in the parking lot when leaving the theater. On physical exam the pupils are mid-dilated, do not react to light, the corneas are cloudy and with a greenish hue, and the eyes feel “hard as a rock”. Dx?; Management?; Medicine Tx? (3 possible)
A764. Dx: Acute glaucoma; (most are asymptomatic); Management: An ophthalmologist is needed stat; Tx:; 1. Diamox; 2. Pilocarpine drops; 3. Mannitol
Q765. A 32 year old lady presents in the E.R. with swollen, red, hot, tender eyelids on the left eye. She has fever and leukocytosis. When prying the eyelids open, you can ascertain that her pupil is dilated and fixed and that she has very limited motion of that left eye. Dx?; Management?; Tx?
A765. Dx: Orbital Cellulitis; Management: CT scan; (Ophthalmological emergency that requires immediate consultation); Tx: Surgical drainage
Q766. A frantic mother reaches you on the phone, reporting that her 10 year old boy accidentally splashed Drano on his face and is screaming in pain complaining that his right eye hurts terribly. Management?
A766. Management: The key is immediate irrigation. Instruct the mother to pry the eye open under the cold water tap at home, and irrigate for about ½ hour before she brings the kid to the hospital.
Q767. A 59 year old, myopic gentleman reports “seeing flashes of light” at night, when his eyes are closed. Further questioning reveals that he also sees “floaters” during the day, that they number ten or twenty, and that he also sees a cloud at the top of his visual field. Dx?; Management and Tx?
A767. Dx: Retinal Detachment; (that “cloud” at the top of the visual field is hemorrhage settling at the bottom of the eye); Management: Another Ophthalmological emergency. The retina specialist will use Laser treatment to “spot weld” the retina back in place
Q768. A 77 year old man suddenly loses sight from the right eye. He calls you on the phone 10 minutes after the onset of the problem. He reports no other neurological symptoms. Dx?; Management?
A768. Dx: Embolic occlusion of the retinal artery; Management: Another ophthalmological emergency...although little can be done for the problem. He has to get the ER instantly and it might help for him to breathe into a paper bag on route, and have someone press hard on his eye and release repeatedly
Q769. A 55 year old man is diagnosed with type two diabetes mellitus. On questioning about eye symptoms he reports that sometimes after a heavy dinner the television becomes blurry and he has to squint to see it clearly. Dx?; Management?
A769. Dx: Simply DM-related changes in eye; (no big deal: the lens swells and shrinks in response to swings in blood sugar); Management: regular ophthalmological follow up for retinal complications
Q770. A 54 year old obese man gives a history of burning retrosternal pain and “heartburn” that is brought about by bending over, wearing tight clothing or lying flat in bed at night. He gets symptomatic relief from antiacids, but the disease process seems to be progressing since it started several years ago. Dx?; Management?
A770. Dx: Gastroesophageal reflux; Management: Endoscopy and biopsies; (to assess the extent of esophagitis and potential complications before medication)
Q771. A 62 year old man describes severe epigastric and substernal pain that he can not characterize well. There is a history suggestive of gastroesophageal reflux, and EKG and cardiac enzymes have been repeatedly negative. Diagnostic test?
A771. Diagnostic test: Acid Perfusion (Bernstein) test; (it reproduces the pain when the lower esophagus is irrigated with an acid solution to tell if it is only GERD)
Q772. A 44 year old black man describes progressive dysphagia that began 3 months ago with difficulty swallowing meat, progressed to soft foods and is now evident for liquids as well. He locates the place where food “sticks” at the lower end of the sternum. He has lost 30 pounds of weight. Dx?; Diagnostic tests? (3 in order)
A772. Dx: Carcinoma of the Esophagus; Diagnostic test:; 1. Barium swallow; 2. Endoscopy with biopsies; 3. CT scan
Q773. A 47 year old lady describes difficulty swallowing which she has had for many years. She says that liquids are more difficult to swallow than solids, and she has learned to sit up straight and wait for the fluids to “make it through”. Occasionally she regurgitates large amounts of undigested food. Dx?; Diagnostic test? (3); Tx? (3 possible)
A773. Dx: Achalasia; Diagnostic test:; 1. Manometry studies (gold standard); 2. CXR with barium swallow; 3. Endoscopy; Tx:; 1. Pneumatic dilation; 2. Surgical Myotomy; 3. Botox injection (if patient >50 yo is first Tx)
Q774. A 24 year old man spends the night cruising bars and drinking heavily. In the wee hours of the morning he is quite drunk and he starts vomiting repeatedly. He initially brings up gastric contents only, but eventually he vomits bright red blood. Dx?; Diagnostic test?
A774. Dx: Mallory Weiss tear; Diagnostic test: Endoscopy; (Photocoagulation may be used if needed)
Q775. A 24 year old man spends the night cruising bars and drinking heavily. In the wee hours of the morning he is quite drunk and starts vomiting repeatedly. Eventually he has a particularly violent episode of vomiting and he feels a very severe, wrenching epigastric and low sternal pain of sudden onset. On arrival at the E.R. one hour later he still has the pain, he is diaphoretic, has fever and leukocytosis and looks Quite ill. Dx?; Diagnostic test?; Tx?
A775. Dx: Boerhave’s syndrome; Diagnostic test: Gastrographin swallow; Treatment: Emergency surgical repair; (Prognosis depends on time elapsed between perforation and treatment)
Q776. A 55 year old man has an upper G.I. endoscopy done as an outpatient to check on the progress of medical therapy for gastric ulcer. Six hours after the procedure, he returns complaining of severe, constant, retrosternal pain that began shortly after he went home. He looks prostrate, very ill, is diaphoretic, has a temperature of 104 and respiratory rate of 30. Dx?; Diagnostic test?
A776. Dx: Instrumental perforation of the esophagus; Diagnostic test: Gastrographin swallow
Q777. A 72 year old man has lost 40 pounds of weight over a two or three month period. He gives a history of anorexia for several months, and of vague epigastric discomfort for the past 3 weeks. Dx?; Diagnostic test?
A777. Dx: Cancer of the stomach; Diagnostic test: Endoscopy and biopsies
Q778. A 55 year old patient with known PUD presents with sudden onset of severe epigastric pain. Physical exam reveals guarding and rebound tenderness. Dx?; Diagnostic test?
A778. Dx: Anterior Perforated ulcer; Diagnostic test: Chest or Abdominal x-ray to show free air under diaphragm
Q779. A 52 year old woman presents due to 3 months of early satiety, weight loss and non-bilious vomiting. Dx?
A779. Dx: Gastric Outlet Obstruction
Q780. A 55 year old patient with known PUD presents with sudden onset of severe epigastric pain that radiates to the back. Physical exam reveals guarding and rebound tenderness. An Abdominal x-ray does not show free air under diaphragm. Dx?
A780. Dx: Posterior Perforated ulcer; (An Abdominal x-ray will not show free air under diaphragm if it is a posterior perforation)
Q781. A 45 year old Japanese male smoker presents with weight loss and epigastric pain exacerbated by eating. Dx?; Diagnostic test?
A781. Dx: Gastric Ulcer; Diagnostic test: Endoscopy with Biopsy
Q782. A 24 year old patient who was recently a burn victim over 36% of his body presents with epigastric pain exacerbated by eating. Dx?
A782. Dx: Curling’s Ulcers; (Gastric stress ulcers with severe burns. “Burnt paper CURLS”)