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318 Cards in this Set
- Front
- Back
common post gastrectomy complication associated with rapid emptying of hypertonic gastric contents into the duodenum leading to stimulation of autonomic reflexes
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dumping syndrome
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what is suspected in a pt with blunt trauma to the chest with x-ray findings showing left lower atelectasis with mediastinal deviation to the right
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traumatic rupture of the diaphragm
*more common on the left |
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test of choice to diagnose traumatic rupture of the diaphragm
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barium swallow or CT with contrast
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type of compartment syndrome associated with 4-6 hours of ischemia and soft tissue swelling following surgical fixation
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ischemia-reperfusion syndrome
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what is suspected in a pt presenting with acute onset of back pain and profound hypotension
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rupture of AAA
|
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what can lead to compartment syndrome in a pt with circumferential full-thickness burns involving extremities
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eschar, restricts expansion as edema ensues
*perform escharotomy |
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next step in management in a pt with abdominal injuries that is hypotensive and not responsive to fluid administration
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exploratory laporatomy
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blunt trauma to what part of a full, distended bladder is associated with subdiaphragmatic peritonitis
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bladder dome
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differentiate mild, moderate, and severe TBI
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mild TBI - head injury associated with GCS score of 13-15
moderate - GCS score 9-12 severe - GCS score <8 |
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differentiate the next step in management of a pt with mild-moderate TBI with vomiting, headache, or loss of consciousness
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mild-moderate TBI - if vomiting, headache, or brief loss of consciousness is involved then a head CT should be performed, if normal pt may be discharged
*pt without vomiting, HA, loss of consciousness can be observed for 4-6 hours without neuroimaging |
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pt presents with persistant nausea, vomiting of partially digested food, early satiety and weight loss. he has a hx of peptic ulcer disease
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pyloric stricture
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what type of arm injury is associated with seizures
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posterior dislocation of the shoulder
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what is a complication of appendicitis that is associated with tender, fluctuant mass palpable only with the tip of the examining finger during rectal exam
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pelvic abscess
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next step in management of a pelvic fracture in an elderly person after stabilization of the fracture and DVT prophylaxis
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ECG, CXR, and cardiac enzymes to look for cause of the fall
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pt with hx of afib presents with severe acute-onset midabdominal pain out of proportion to physical examination findings
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acute mesenteric ischemia
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what should be suspected in a pt who remains tachypneic and hypotension after blunt thoracic trauma with CXR revealing multiple rib fractures overlying a lung contusion
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flail chest
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associated with widened mediastinum and left-sided hemothorax
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aortic injury
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blunt trauma to the abdomen associated with hypotension and intraperitoneal fluid
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splenic laceration
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blunt trauma to the upper abdomen associated with negative CT scan
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pancreatic laceration
*stomach perforation would need penetrating trauma (knife) |
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differentiate next step in management of a palpable breast mass in a pt < 30 vs. >30
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<30 years old - ultrasound
>30 years old - mammogram and ultrasound |
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associated with dyspnea, confusion, and petechiae in the upper extremity after multiple fracture of long bones
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fat embolism
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commonly seen in runners that presents with pain between the third and fourth toes reproducible with palpation
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morton neuroma
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next step in management in non-bleeding varices
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medical management with nonselective B-blockers
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CT scan of brain showing numerous minute punctate hemorrhages with blurring of grey-white interface
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diffuse axonal injury
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two most common peripheral artery aneurysms
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femoral and popliteal
*pulsatile masses that can compress adjacent structures |
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intermittent bloody discharge from on nipple
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intraductal papilloma
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epigastric pain associated with right shoulder pain as well as relation to meals
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biliary colic
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next step in manage in a pt presenting with flail chest (pardoxical movement of chest wall)
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positive pressure mechanical ventilation
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next step in management of a pt with blunt abdominal trauma after fluid resuscitation
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FAST examination
*focused assessment with sonography for trauma to assess for intraperitoneal fluid |
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pt with blunt abdominal trauma initially is stable but later develops hypotension, abdominal pain, and left shoulder pain. what is the next best step in management
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abdominal CT with contrast to look for splenic injury
|
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differentiate arterial occlusion with thrombus vs. embolus
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thrombus - slow, progressive narrowing with insidious onset that is usually bilateral
embolus - sudden-onset sever pain and asymmetric pulselessness |
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what does post-op (48 hours) with hypoxemia, respiratory alkalosis, and abnormal CXR signify
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atelectasis
|
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how to prevent post-op pulmonary complications
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incentive spirometry
|
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acute shoulder pain after forceful abduction and external rotation suggests injury to which nerve
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axillary
*anterior dislocation of shoulder |
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next step in management of acute gastrointestinal perforation
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emergent laparotomy
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next step in management of pt needed emergent surgery who's INR is 2.1
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fresh frozen plasma to reverse effects of warfarin
|
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3 bacteria need to prophylax against after removal of spleen
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S. pneumoniae
N. meningitidis H. influenzae |
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next step in management after central venous catheter is placed
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portable CXR to look for pneumothorax, hemothorax, thrombosis, air embolism, myocardial perforation
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elderly pt presents with weakness in upper extremity after motor vehicle accident
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central cord syndrome
*results from hyperextension |
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what should be checked in all patients with clavicular fracture
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neurovascular examination to look for injury to underlying brachial plexus and subclavian artery
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what is the leading cause of death in patients with significant total body surface area burns
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hypovolemic shock
sepsis and septic shock in the setting of adequate fluid resuscitation |
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differentiate next step in management of pts with splenic injury that respond to fluid resuscitation vs. not
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stable after fluid resuscitation - abdominal CT scan
unstable after fluid resuscitation - emergent exploratory laparotomy |
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type of kidney stones associated with Crohn disease and other intestinal diseases that cause fat malabsorption
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calcium oxalate
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next step in manage in pt with RUQ pain associated with ingestion fatty food, fever, and leukocytosis
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cholecystecomy within 72 hours
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pt presents with severe retrosternal and epigastric pain after vomiting for past few hours. on physical exam he has palpable crepitus in the suprasternal notch with CTAB
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esophageal perforation
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first step in management in a pt with suspected PVD
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ABI
|
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next step in manage in pt with suspected PVD and ABI is normal
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perform exercise testing with repeat ABI, preexercise and postexercise ABIs
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acute pain and swelling over sacrococcygeal region in younger male is most likely
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pilonidal disease
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next step in management of a child presenting with duodenal hematoma after direct blunt trauma to the upper abdomen
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NGT and parenteral nutrition
*surgery is only indicated if conservative measure fail after a couple of weeks |
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what is volume resuscitation necessary in pt with hypovolemic shock before intubation
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PEEP causes decrease venous return to the heart
sedative medications cause vasodilation |
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next step in manage in newborn caucasian first-born female who was delivered breech. pt has palpable clunk o the hip
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U/S of the hip
*development dysplasia of the hip **X-ray would be done if pt was >4 months old |
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three steps in a pt with massive hemoptysis
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1. intubated to protect the airway
2. stabilize hemodynamically with fluids and placing pt in lateral decubitus position 3. emergent bronchoscopy to visualize and stabilize the bleeding |
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pt rescued from burning building by firefighters has brief tonic-clonic seizure en route, pt also is confused with nausea and dizzines. what is the next step in management
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100% oxygen with facemask
*CO poisoning |
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final sequence of compartment syndrome in which dead muscle has been replaced with fibrous tissue
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volkmann's ischemic contracture
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differentiate meniscal and ligamentous tears of the knee
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meniscal - "popping" sensation with subsequent joint swelling that gradually develops
ligamentous - "popping" sensation with rapid joint swelling due to hemarthrosis |
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treatment of acute mastitis
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analgesics
antibiotics continuation of breast-feeding from affected breast *this reduces progression from mastitis to abscess |
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next step in management of a pt with colicky abd pain with episodic hyperactive BS, N/V, abd distention and diffuse abd tenderness. pt has not had BM for past 3 days
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laparatomy
|
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Pt with epigastric pain that radiates to the back and associated vomiting. Labs show elevated LFTs and Lipase. What is the next step in management
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RUQ U/S
*gallstone pancreatitis |
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next step in management of a newborn infant with a scrotal mass that is cystic and trasilluminates with light
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reassurance and observation
*most hydroceles disappear spontaneously by 12 months |
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younger women with mass suspected of being malignancy on radiography has Bx that shows foamy macrophages and fat globules
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fat necrosis, no further work-up is needed
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edema, dermatitis, and ulcerations found above the medial malleoli are due to what
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venous HTN secondary to valve incompetence
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what vital sign is the first indicator of hypovolemia
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tachycardia
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next step in manage of a pt who fell on outstretched hand now complains of pain their anatomic snuffbox. X-ray do not reveal a fracture
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place thumb in spica cast and repeat radiography in 7-10 days
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which CN can be compromised in pt with head trauma who developed an epidural hematoma
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CN III secondary to transtentorial (uncal) herniation
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cause of ulcer on under sole of foot, not associated with trauma
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peripheral neuropathy
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pt with blunt trauma to the chest presents with tachycardia and tachypnea a few hours after the collision. breath sounds are decreased on the side of the trauma. X-ray will most likely show what
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patchy, irregular alveolar infiltrate due to pulmonary contusion
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pt presents with decreased breath sounds on the left after chest and abd trauma. CXR shows elevated hemidiaphragm on the left as well as a NGT in the pulmonary cavity
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diaphgragmatic injury
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diagnostic study of choice in suspected esophageal performation
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gastrografin-contrast esophagography
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pt presents with severe retrostenal chest pain as well as a CXR showing widened mediastinum with mediastinal emphysema
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esophageal perforation
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trendelenburg sign
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drooping of the contralateral hemipelvis below normal during monopedal stance
**represents paralysis of the gluteus medius and minimus which are innervated by the superior gluteal nervemos |
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most common cause of lower GI hemorrhage in an elderly patient
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diverticulosis
|
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strong association of nasopharyngeal cancer in far eastern or mediterranean pt
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viral infection from EBV
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pt presents with erythematous and edematous cutaneous plaque overlying a mass on the breast with axillary lymphadenopathy
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inflammatory breast cancer
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patients with elevated ALP due to accelerated osteoblast activity are at increased risk for what
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hearing loss
*Paget's disease |
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avascular necrosis of the femoral head associated with children 4-10 years of age. children present with insidious-onset hip or knee pain and antalgic gait
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Legg Calve Perthes disease
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pt presents with blunt chest trauma, hemorrhagic shock and decreased breath sounds on the L
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L sided ipsilateral hemothorax
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differentiate action and sensation of femoral, obturator, and tibeal nerves
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1. femoral - anterior compartment --> extension of the knee, hip flexion; sensation over anterior thigh and medial leg via saphenous branch
2. obturator - medial compartment --> adduction of the thigh; sensation over medial thigh 3. tibial - posterior compartment of thigh and leg--> flexion of the knee and foot; sensation of posterior thigh and leg **tibial and common peroneal are branches from sciatic |
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what does a positive drop arm sign suggest
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rotator cuff tear
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where is an immediate decompression with needle thoracostomy for tension pneumothorax located
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2nd intercostal space in the midclavicular line
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what commonly causes O2 desaturation and shallow breathing in patient post-op day 2/3
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atelectasis
|
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best way to increase FRC in patient
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elevated of head of the bed
*increases the FRC by 20-35% |
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patient complains of pain around the wound on post-op day 3. wound shows cloudy-gray discharge, crepitus, and decreased sensation at the edges of the wound
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necrotizing surgical infection
*surgical exploration is essential |
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main objective in the management of rib fractures
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pain relief
*allows proper ventilation and prevention of atelectasis and pneumonia |
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young boy presents with bone pain. Labs shows elevated ALP. XR shows osteolytic lesion of the metaphysis of the femur. most likely diagnosis
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osteosarcoma
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Pt with blunt chest trauma presents with low BP and elevated PCWP. After rapid infusion of NS, the PCWP increases and BP is minimally increased. what is the most likely diagnosis
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myocardial contusion
|
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pt with history of alcohol use presents with severe epigastric pain and severe diffuse abd pain. what will most likely be seen on CXR
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free air under the diaphragm
*perforated peptic ulcer |
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what is associated with a hypotensive pt with distended neck vein and bilateral breath sounds
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pericardial tamponade
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next step in management of a pt with a perforated peptic ulcer
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emergent exploratory laparatomy
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most common cause for SBO
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adhesions
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Pt with hx of surgically repaired AAA presents with LLQ pain and bloody diarrhea. what will most likely be seen on colonoscopy
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discrete segment of cyanotic and ulcerated bowel 2/2 bowel ischemia during AAA procedure.
*most commonly affects the distal left colon |
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when is technetium-99 labeled erythrocyte scintigraphy used in cases of lower GI bleeding
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when the source cannot be identified by colonoscopy
|
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What does an RQ (ratio of CO2 produced to O2 uptake) close to 1.0 signify
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carbohydrates is the major nutrient being oxidized
*0.8 = protein **0.7 = lipids |
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what is the next step in management of a hemodynamically unstable patient who has an inconclusive FAST scan
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diagnostic peritoneal lavage
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next step in management of a penile fracture
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retrograde urethrogram followed by surgical exploration
|
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what two indications require administration of tetanus-diphereria toxoid
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1. minor clean wounds who received a booster > 10 years ago
2. severe or dirty wounds who received a booster > 5 years ago |
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Pt presents with RUQ pain a few days post-operatively, U/S shows thickened gallbladder but no gallstones
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acalculous cholecystitis
|
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what two neurological deficits are associated with burst fracture of the vertebra
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loss of motor function
loss of pain and temperature proprioception remains intact *Anterior cord syndrome |
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anterior cord syndrome is associated with what injury
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burst fracture of the vertebra
|
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what test should be administered in any pt with suspected urethral injury
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retrograde urethrogram
|
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what is the next step in management of a pt post-op from cardiac surgery presenting with fever, chest pain, leukocytosis, and mediastinal widening on CXR
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surgery debridement and antibiotic therapy
*acute mediastinitis |
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next step in management of a pt with the classic presentation of RLQ pain, N/V, fever, and leukocytosis
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immediate surgery
*No need for CT, only used when appendicitis is suspected with atypical presentation |
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what should you watch out for post operatively in patients who take corticosteroids daily
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acute adrenal insufficiency
*N/V, abd pain, hypoglycemia, hypotension |
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Following an MVA, pt had chest tube placed for pneumothorax. Hours later the CXR revealed pneumomediastinum and on physical exam there is subcutaneous emphysema.
|
bronchial rupture
|
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when is administration of tetanus immune globulin indicated
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in those with with more sever or dirty sounds and an unclear or incomplete immune history
*these individuals will received both the toxoid and globulin |
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most indication for intubation in the trauma patient
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altered mental status
|
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next step in management in pt with multiple gun shots that is in hypovolemic shock
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control the bleeding site --> exploratory laparatomy
*DO NOT fluid resuscitate first |
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next step in management of a gunshot victim who is hypotensive with distended neck veins and clear breath sounds
|
pericardiocentesis
*followed by thoracotomy and then exploratory laparatomy |
|
next step in management of a stabbing victim to the chest who presents with hypotension, distended neck veins, and clear breath sounds
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median sternotomy for open repair
*Do not bother with pericardiocentesis |
|
next step in management of a gunshot victim who presents with hypotension, distended neck veins, and respiratory distress with deviated trachea
|
immediate big-bore needle to 2nd intercostal space
*followed by chest tube |
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what should you look for in a pt with fixed, dilated pupils with multiple injuries in both upper and lower extremities who is hypotensive
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look for the source of bleeding outside of the cranium
*bleeding in the head does NOT cause hypotension |
|
what type of skull fracture must go to the OR
|
comminuted or depressed skull fractures
*Not linear |
|
what is associated with basal skull fractures
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raccoon eyes
rhino/otorrhea ecchymosis behind the ear |
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pt in a high-speed MVA was unconscious at the site, he regains consciousness briefly during the ambulance ride, but arrives at the ED in deep coma with a fixed, dilated right pupil and contralateral hemiparesis
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acute subdural hematoma is a better bet than acute epidural (bigger trauma, sicker patient)
|
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pt presents with small crescent-shaped hematoma on CT after MVA, but no deviation of medline structures. what is the next step in management
|
control the ICP with: head elevation, mannitol, furosemide, hyperventilation, hypothermia
*surgery has little to offer |
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elderly man becomes "senile" over a period of 3-4 weeks after a fall down the stairs a week before the mental changes began
|
chronic subdural hematoma
*craniotomy will have spectacular improvement |
|
which part of the neck needs immediate surgical exploration even if the pt is a stable gunshot victim
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middle zone (II)
*extends from cricoid to angle of mandible **zones I and III should have angiography before surgery if pt is stable |
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what can hyperextension of the neck during an MVA lead to
|
central cord syndrome
*paralysis + burning pain on both upper extremities with good motor function in both legs |
|
next step in management in a plain rib fracture
|
pain management, NOT strapping or binding
|
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how much blood recovered from a hemothorax chest tube indicates thoractomy
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>1500 mL or 600 over 6 hours
|
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management of a pt with flail chest due to multiple broken ribs bilaterally
|
1. use of colloids rather than crystalloids due to need for fluid restriction
2. monitor for signs of pulmonary or myocardial contusion 3. CXR/ CT scan to look for transection of the aorta |
|
Pt with multiple broken ribs presents with hypotension, distended neck veins, and no breaths sounds on one side of the chest. what is the next step in management
|
needle thoracostomy, do NOT get a CXR first
*tension pneumothorax from fractured ribs |
|
what should be done if CXR shows widened mediastinum but CT scan is inconclusvie in a pt suspected of having ruptured aorta
|
aortagram
|
|
three things that can give thoracic subcutaneous emphysema
|
1. rupture of the esophagus (after endoscopy)
2. tension pneumothorax 3. traumatic rupture of the trachea or major bronchus |
|
Pt who has received a chest tube for a traumatic pneumothorax is putting out a very large amount of air through the tube
|
look for major bronchial injury from trauma
|
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pt with chest tube suddenly goes into cardiac arrest
|
air embolism
|
|
next step in mangemetn of a peenetrating gunshot to the abdomen
|
exploratory laparotomy every time
*anything below the nipple line is abdomen **knife wounds only need surgery if peritoneal penetration took place |
|
where in the body can internal bleeding lead to hypovolemic shock
|
1. abdomen
2. pelvis 3. upper leg |
|
next step in management of a pt who had splenectomy after abdominal trauma
|
vaccinations against encapsulated organisms
*S. pneumo, H. Influenza B, N. Meningococcus |
|
next step in management of an unstable vs. stable pt with a pelvic fracture
|
stable - left alone
unstable - external fixation |
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man with pelvic fracture from trauma has blood at the meatus, what is the next step in management
|
retrograde urethrogram
|
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woman involved in MVA has pelvic fracture, foley catheter reveals gross hematuria. what is the next step in management
|
retrograde cystogram
|
|
differentiate hematuria in adults vs. children
|
adults - gross hematuria is always investigated, traumatic microhematuria does NOT
children - gross or microhematuria is ALWAYS investigated. *start with sonogram |
|
next step in management of a pt with a gunshot wound to the anteriomedial vs. anteriolateral aspect of the thigh
|
anteriomedial - arteriogram if vascular injury isn't obvious, if obvious (hematoma present) then surgical exploration is indicated
anteriolateral - only needs wound cleaning and tetanus prophylaxis |
|
what future problems can electrical burns lead to sings they are always much bigger than they appear
|
myoglobinuria leading to renal failure
*Pt needs lots of IV fluids, diuretics, and alkalinization of the urine |
|
parkland formula
|
4 mL of Ringer Lactate x Kg x %burned (up to 50%)
+ 2L of D5W for maintenance *give 1/2 in first 8 hours and 1/2 in next 16 hours |
|
how much urinary output should burn patients have
|
1 to 2 mL/kg per hour
|
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Rule of 9's for body surface area in burn victims Adults vs. Children
|
Adult - Head 9%, Trunk 36%, Legs 36%, Arms 18%
Children - Head 18%, Trunk 36%, Legs 27%, Arms 18% |
|
another name for avascular necrosis of the capital femoral epiphysis in a child
|
Legg-Perthes disease
|
|
next step in management of an obese adolescent with pain in the groin with a flexed hip and leg that is externally rotated
|
orthopaedic surgery with pinning of the femoral head
*slipped capital femoral epiphysis |
|
best option to view acute osteomyelitis
|
bone scan
x-ray will not show anything for 2 weeks |
|
what bone tumor is associated with periosteal onion skinning and involving the diaphysis of long bones
|
Ewing sarcoma
|
|
next step in management of a pathologic fracture in an adult
|
whole body bone scan to look for other metastases
*start looking for the primary tumor |
|
which bone is injured when a young adult falls on an outstretched hand and comes in with tenderness in the anatomic snuff box
|
scaphoid bone fracture
|
|
famous fracture an elderly woman with osteoporosis gets when she falls on an outstretched hand
|
Colles fracture
dorsally displaced distal radius |
|
differentiate next step in management of an elderly man with displaced femoral neck fracture vs. intertrochanteric fracture
|
displaced femoral neck - metal prothesis due to risk of avascular necrosis
intertrochanteric - open reduction and pinning |
|
next step in management of a stress fracture of the tibia
|
cast and repeat x-ray in 2 weeks, fracture will usually show up by then
|
|
do normal pulses rule OUT the diagnosis of compartment syndrome
|
NO
|
|
what can be injured during posterior dislocation of the knee
|
popliteal artery
|
|
pt had one finger that is acutely flexed, he can only extend it by pulling on it at which he feels a painful "snap"
|
trigger finger
|
|
how to maintain an amputated digit on the way to the ED
|
clean it with sterile saline
wrap it in a saline-moistened gauze place it in a bag and the bag on ice |
|
middle aged man comes in with sudden onset back pain that is like an electrical shock that shoots down the leg. he keeps the affected leg flexed. straight-leg raising gives excruciating pain
|
lumbar disk herniation
|
|
middle aged man comes in with severe back pain, distended bladder, flaccid rectal sphincter, and perineal saddle area anesthesia
|
cauda equina syndrome
|
|
first pre-operative test to determine pulmonary function in a pt with a smoking history
|
FEV1
|
|
hepatic risk factors for surgery
Tbili, Alb, PT |
bilirubin >2
albumin <3 PT > 16 |
|
what should you watch out for in a pt with malignant hypethermia
|
myoglobinuria
|
|
post-op fever W's
|
wind
water walking wound |
|
antidote for ARDS
|
PEEP
|
|
post-op massive colonic dilation
|
ogilvie syndrome
|
|
every 3 mEq of Na above normal (140) represent 1 L lost of water
|
*
|
|
resuscitation fluid of choice in a pt with metabolic acidosis secondary to shock wit lactic acid production
|
ringer's lactate
|
|
next step in management of a pt with what sounds like GERD, but the symptoms certain
|
esophageal pH monitoring
|
|
next step in management of a pt in which GERD is certain
|
endoscopy and biopsy to assess the extent and potential complications
|
|
pt states they have difficulty with swallowing, liquids are more difficult than solids
|
achalasia
|
|
steps needed to assess esophageal cancer
|
barium swallow
endoscopy with biopsy CT scan |
|
study of choice if perforation is suspected
|
gastrograffin swallow
|
|
pt presents with colicky abd pain, high-pithced bowel sounds, and air-fluid levels on KUB
|
bowel obstruction
|
|
pt with bowel obstruction in the hospital now presents with fever, leukocytosis, abd tenderness, and rebound tenderness
|
strangulated obstruction
*emergency surgery |
|
differentiate R-sided and L-sided colon CA
|
R - bleed, anemia with occult blood in the stool
L - obstruct, constipated with narrow caliber stools |
|
next step in management of a pt with UC that has suspected toxic megacolon
|
emergency resection of involved colon, including rectal mucosa
|
|
treatment for a pt with C. diff colitis
|
stop the current antibiotics
start metronidazole or oral vancomycin |
|
what is ALWAYS the next step in management in a pt with anorectal bleeding/pain/abscess/fistula
|
rule out CA first
|
|
Best treatment for a pt with anorectal cancer
|
Nigro protocol
*preoperative chemotherapy (5-FU and mitomycin) and radiation if CA is < 5cm |
|
first diagnostic move in a pt that is actively bleeding from the GI tract
|
NG tube and aspirate
|
|
diagnostic study of choice in a pt that is actively bleeding and upper GI and hemorrhoids have been ruled out
|
tagged red-cell study
|
|
study of choice in a pt that is NOT actively bleeding and NG tube aspirate is negative
|
endoscopy both ends
|
|
study of choice in a child that passes a large bloody bowel movement
|
radioactively labeled technetium scan to look for gastric mucosa
|
|
what type of patient does peritonitis not need exploratory surgery
|
cirrhotic with ascites
|
|
pt presents with abd distension, N/V, and colicky abd pain. He has a tympanitic abd with hyperactive BS. X-ray shows distended loops of small and large bowel with a very large gas shadow located in the RUQ and tapers to the LLQ with the shape of a parrot's beak
|
sigmoid volvulus
|
|
next step in management in a pt with sigmoid volvulus
|
proctosigmoidoscopy and rectal tube
|
|
young adult woman presents in a hypovolemic state with a Hgb of 7. she denies being pregnant because she has been on birth control pills for the past 10 years
|
bleeding from ruptured hepatic adenoma 2/2 birth control pills
|
|
differentiate next step in management of a liver abscess secondary to amebic vs. ascending cholangitis
|
amebic - metronidazole
ascending cholangitis - percutaneous drainage |
|
differentiate the type of juandice causing elevated transaminases vs. elevated alkaline phosphatase
|
elevated AST/ALT - hepatocellular jaundice (serology)
elevated ALP - obstructive jaundice (RUQ U/S) |
|
differentiate the cause of a gallbladder being thickened and nonpliable vs. thin-walled and distended
|
thickened - stone
thin and palpable - malignancy (pancreas, bile ducts, ampulla) |
|
Pt presents with progressive jaundice is found to have highly elevated ALP. she is also anemic and as positive occult blood in the stool. A RUQ U/S shows thin-walled distended gallbladder
|
ampullary carcinoma
*obstructive jaundice + bleeding into the GI tract |
|
next step in management of a pt with a few day history of RUQ pain. Now she presents with temp of 104, WBC of 22, bilirubin of 5 and ALP of 2000
|
ERCP + IV antibiotics
*acute ascending cholangitis |
|
what should you think of in a pt with epigastric pain radiating through the back with low serum calcium, high BUN, and metabolic acidosis
|
hemorrhagic pancreatitis
|
|
what are the criteria to drain pancreatic pseudocysts
|
>6cm
>6 weeks after pancreatitis |
|
next step in management of a newborn with an umbilical hernia
|
observation for up to 2 years
|
|
what is the next step in management of a young woman (18) with a firm, rubbery breast mass
|
sonogram
*Do not do mammogram on young patients, breast is too dense **Reassurance alone is never the option |
|
next step in management of a younger pt with cystosarcoma phyllodes (large fibroadenoma)
|
margin-free resection
*can turn into a malignant sarcoma |
|
how would you work up 35 year old pt with bilateral tender breasts and multiple lumps that come and go with the menstrual cycle
|
*fibrocystic disease
1. mammogram 2. aspiration of the cyst - if mass goes away and fluid is clear --> do nothing - if fluid is bloody --> cytology - if mass does NOT go away --> biopsy |
|
next step in management of a middle-aged woman with a 2cm breast mass
|
mammographically guided multiple core biopsies
|
|
next step in management of a middle-aged woman who develops a breast mass after recent trauma
|
Cancer until proven otherwise
mammogram and biopsy |
|
management of a pt with infiltrating ductal carcinoma
|
1. lumpectomy vs. modified radical mastectomy
-close to nipple, size of tumor, size of breast 2. axillary node sampling -chemotherapy needed if present 3. radiation therapy if lumpectomy is performed |
|
first line treatment of advanced, neglected breast cancer that is a bleeding, fungating, ulcerated mass
|
chemotherapy
|
|
differentiate hormonal therapy option for post vs. pre-menopausal women if estrogen and progesterone receptor positive after chemotherapy
|
pre-menopausal - tamoxifen
post-menopausal - anastrazole |
|
what are worrisome features for a thyroid nodule
|
young, male, single nodule, hx of radiation to neck, solid mass on sonogram, cold nodule on scan
|
|
what two forms of thyroid cancer is a total thyroidectomy always indicated
|
medullary
follicular *only papillary (<1cm in size) may a hemithryoidectomy with isthmusectomy be performed |
|
workup of a pt suspected of having cushing's disease (hypercortisolism)
|
1. overnight (low-dose) suppression test
2. 24 hour urine cortisol 3. high-dose suppression test |
|
pt presents with virulent PUD, medical therapy fails to eradicate the ulcers including H. pylori. pt also has water diarrhea
|
gastrinoma
|
|
how would you differentiate hyperaldosteronism from an adenoma vs. hyperplasia
|
postural changes of serum aldosterone levels
appropriate response - adenoma no response or inappropriate - hyperplasia *both have elevated aldosterone with low renin |
|
what other associations might be seen in a baby with a TE fistula
|
V - vertebral
A - anal C - cardiac TE - fistula R - renal |
|
how do you differentiate duodenal atresia/anular pancreas, malrotation, and intestinal atresia in a newborn with bilious vomiting
|
Duodenal atresia/anular pancreas - double bublble + no air in distal bowel beyond the duodenum
malrotation - double bubble + normal gas pattern in distal bowel intestinal atresia - No double bubble, multiple air-fluid levels and distended loops of bowel |
|
very premature baby develops feeding intolerance, abd distension, and rapidly dropping platelet count
|
necrotizing enterocolitis
|
|
newborn baby presents with progressively increasing jaundice, the bilirubinemia is mostly conjugated
|
biliary atresia
|
|
next step in management of a newborn with biliary atresia
|
1. phenobarbital
2. HIDA scan |
|
9 month baby presents with episodes of colicky abd pain. on physical exam the RLQ feels "empty" and has currant jelly stools
|
intussusception
|
|
what two issues are looked at in a pt with lung cancer
|
1. pulmonary function, FEV1 of at least 800mL is needed to survive after surgery
2. can surgery cure him (look for metastases using CT, PET, and mediastinoscopy if necessary) |
|
treatment for small cell lung cancer
|
radiation and chemotherapy
*not treated with surgery |
|
A laborer notices coldness and tingling in his left hand as well as pain when he does strenuous work. he also experiences vertigo, blurred vision, and difficulty articulating his speech
|
subclavian steal syndrome
|
|
when would you do further workup in a pt with claudication
|
if it affects their lifestyle
*Do NOT work up retired people that hardly move anyways |
|
what type of skin cancer is associated with the upper part of the face
|
basal cell carcinoma
*waxy raised lesion or punched out ulcer |
|
where is the classic location of squamous cell carcinoma
|
lower lip
|
|
at what depth is wide local excision (2 cm) recommended over margin free excision for a melanoma
|
>1mm in depth
|
|
next step in management of a pt with acute angle glaucoma
|
systemic carbonic anhydrase inhibitors, topical B-blockers, alpha-2 agonists
|
|
next step in management of a pt with orbital cellulitis
|
CT scan + surgical drainage
|
|
next step in management of an elderly pt with sudden monocular blindness
|
1. aspirin
2. breath into paper bag (increase CO2) 3. have someone press hard on the eye and release it repeatedly |
|
differentiate location of thyroglossal duct cyst vs. branchial cleft cyst
|
thyroglossal duct cyst - midline
branchial cleft cyst - side of neck, in front of SCM |
|
6 year child with mushy, fluid-filled mass at the base of the neck
|
cystic hygroma
|
|
what is your best ally to determine if an enlarged lymph node is inflammatory vs. neoplastic
|
time
|
|
next step in management of an elderly pt who smokes, drinkes, has rotten teeth and has a hard, fixed 4-cm mass in his neck in front of the SCM
|
1. panendoscopy to look for primary site of SCC
2. CT scan will follow to determine extent and operability 3. platinum-based chemotherapy and radiation |
|
what does unilateral version of common ENT problems in the adult suggest
|
malignancy
|
|
unilateral ENT problems in children suggest
|
foreign body
|
|
ludwig angina
|
abscess of the floor of the mouth
|
|
next step in management of a patient with Bell's palsy (unilateral facial paralysis)
|
antiviral medication
steroids |
|
next step in management of a pt with repeated episodes of sinusitis, not presents with seeing double
|
cavernous sinus thrombosis
orbital cellulitis *either way they are hospitalized, given high-dose IV abx, and surgical drainage with CT guidance |
|
next step in management of a younger pt with testicular pain, fever, exquisitely tender testes, and testis in normal position
|
sonogram to rule out torsion
|
|
next step in management of a pt with hx of multiple ureteral stones presents with fever and flank pain
|
IV abx + ureteral stent or percutaneous nephrostomy
|
|
next step in management of a pt suspected of having pyelonephritis
|
IV abx + sonogram to rule out obstruction
|
|
newborn baby has not urinated
|
posterior urethral valve
*drain bladder with catheter, voiding cystourethrogram |
|
6 year old girl voids normally but is also wet with urine all the time between voiding normally
|
low implantation of one ureter
*this ureter empties into the vagina |
|
16 year old boy goes on beer-drinking binge for the first time and shortly develops colicky flank pain
|
ureteropelvic junction obstruction
|
|
next step in management of a nodule felt during DRE
|
transrectal needle biopsy
|
|
management of a pt with bony metastases from prostate cancer
|
orchiectomy
LHRH agonists anti-androgens (flutamide) |
|
next step in management of young patient with a testicular mass
|
1. sonogram
2. radical orchiectomy 3. platinum-baed chemotherapy |
|
what is the cause of pneumaturia in an elderly adult
*fistula between bowel and bladder |
diverticulitis or cancer
|
|
the only absolute contraindication to organ transplant
|
HIV positive
|
|
list some situations in which an airway must be secured
|
1. unconscious
2. breathing is noisy or gurly 3. expanding hematoma in the neck 4. emphysema in the neck |
|
differentiate treatment of hemorrhagic shock if you're near by a trauma city or further away
|
near by - surgical intervention
further - volume replacement |
|
next step in management of a patient with head trauma and a negative CT scan
|
they can go home only if the family will wake them up frequently during the next 24 hours
|
|
differentiate what a patient looks like with acute subdural hematoma
|
sick patient with severe neurologic damage
-need to lower ICP with hyperventilation, mannitol, and elevation of head |
|
what type of patient does a chronic subdural hematoma happen in
|
elderly patient
severe alcoholic |
|
what part of the neck needs immediate surgical exploration for patient with a gunshot wound
|
middle zone
|
|
what type of fluid resuscitation should be used in a patient with pulmonary contusion
|
colloid instead of crystalloid
diuretics *lung is very sensitive to fluid overload |
|
what else should be looked for in a patient with flail chest
|
traumatic transection of the aorta
*big trauma required to get flail chest |
|
what tests should be ordered in a patient with massive trauma to the chest
|
CXR - pulmonary contusion and diaphragm rupture
ECG and tropinin - myocardial contusion CT - aortic rupture |
|
problems that can arise in a patient with a newly placed Central line
|
1. air embolism
2. pneumothorax |
|
most common cause of coagulopathy in a trauma patient
|
multiple transfusions causing dilution thrombocytopenia
|
|
cause of abdominal compartment syndrome in a trauma patient
|
lots of fluids and blood products have been given during the course of a prolonged laparatomy
|
|
best way to deal with a pelvic fracture
|
external fixation and allow time for the tamponade effect
|
|
clues for a man with posterior urethral injury due to a pelvic fracture
|
high-riding prostate on DRE
sensatin of wanting to void but cannot |
|
what should be assessed in penetrating trauma to the extremities
|
whether vascular injury has occured
*anatomic location **doppler studies or arteriogram if needed |
|
what can be a sequelae in high-voltage electric burns
|
myobloinemia-myoglobinura-renal failure
|
|
differentiate treatment of black widow and brown recluse spider bites
|
black widow - IV calcium gluconate
brown recluse - surgical excision |
|
a child what what type of fracture could lead to volkmann contracture and development of a compartment syndrome
|
supracondylar fracture of the humerus
|
|
best physical exam maneuver to elicit collateral ligament tear
|
knee flexed at 20-30 degrees and do passive abduction or adduction will produce pain
|
|
most reliable physical finding for compartment syndrome
|
excruciating pain with passive extension
|
|
fracture of what should be looked for in a fall from height
|
lumbar or thoracic spine
|
|
when is surgical intervention necessary in a person with a lumbar disk herniation
|
when there is progressive muscle weakness
|
|
next step in management of a patient with cauda equina syndrome
|
emergent surgical decompression
|
|
what is the worst single finding predict high cardiac risk in a pre-op patient
|
congestive heart failure
*look for JVD **next worse is recent MI (within 6 months) |
|
next step in management of a patient with fevers and chills 30-45 minutes post-op
|
start empiric antibiotics
*do not culture blood 3 times before starting abx |
|
what should be done to a patient that develops a PE while anti-coagulated therapeutically
|
inferior vena cava filter
|
|
most reliable test to determine peri-operative MI
|
troponins
|
|
what should be suspected if a post-op patient gets confused and disoriented
|
hypoxia
*check bloos gases |
|
bilateral pulmonary infiltrates and hypoxia with no evidence of CHF
|
ARDS
|
|
what type of electrolyte deficit can prolong ileus
|
hypokalemia
|
|
next step in management of a patient with ogilvie syndrome
|
colonoscopy to decompress the colon and rule out mechanical cause for the problem, a long rectal tube is left in
|
|
differentiate next step in management of a patient with wound dehiscence vs. evisceration
|
dehiscence - eventual re-operation to avoid or treat ventral hernia
evisceration - emergent abdominal closure |
|
differentiate how to treat hyponatremia from inappropriate ADH vs. losing large amounts of isotonic fluids
|
inappropriate ADH - water restriction
isotonic fluid loss - volume replacement with isotonic fluids |
|
next step in management of a patient with hyperkalemia
|
50% dextrose and insulin
IV calcium gluconate *hemodialysis is ultimate therapy |
|
best test to establish the presence of reflux
|
pH monitoring
|
|
next step in management of a patient with GERD refractive to medication
|
pH monitoring, endoscopy and biopsy, manometry, gastric emptying study, and barium swallow to determine if Nissen fundoplication is valid
*if dysplastic changes are seen than resection is needed |
|
patient has difficulty with swallowing liquids > solids
|
achalasia
*barium swallow shows bird's beak **manometry for definitive diagnosis |
|
usual work up for patient with dysphagia
|
1. barium swallow
2. endoscopy, biopsy if necessary 3. manometry if necessary |
|
next step in management of a patient suspected of having boerhaave syndrome
|
gastrografin swallow
emergent surgical repair |
|
most common reason for patient presenting with emphysema in the lower neck
|
instrumental perforation of the esophagus
|
|
Cause of gastric MALTOMA
|
H. pylori
|
|
next step in management of a patient with a mechanical SBO develops fever, leukocytosis, and signs of peritoneal irritation
|
emergency surgery
*strangulated obstruction has taken place |
|
massive upper GI bleed in the stressed, multiple trauma patient
|
stress ulcers
*angiographic embolization |
|
next step in management of a patient that is actively bleeding and the upper GI tract has been ruled out
|
1. anoscopy to r/o hemorrhoids
2. angiogram or tagged red-cell study *colonoscopy is useless during active bleeding |
|
how do you confirm the diagnosis of acute abdomen caused by perforation
|
free air under the diaphragm in upright x-ray
|
|
associated with a huge air-fluid loop in the RUQ that tapers down toward the LLQ
|
sigmoid volvulus
|
|
what can lead to pyogenic liver abscess
|
acute ascending cholangitis
|
|
next step in management of a patient with suspected cancer causing obstructive jaundice
|
1. CT scan - adenocarcinoma of pancreas
2. ERCP if negative - cholagiocarcinoma of common duct or adenocarcinoma of ampulla |
|
next step in management of a patient with acute cholecystitis who is not a surgical candidate that is not improving
|
percutaneous transhepatic cholecystotomy
|
|
two things that are associated with acute pancreatitis
|
gallstones
alcoholics |
|
what can develop after about 10 days in a patient with acute hemorrhagic (necrotizing) pancreatitis
|
pancreatic abscess
*need daily CT scan to look for development of abscess |
|
which form of thyroid cancer is associated with psammoma bodies
|
papillary thyroid cancer
*this one doesn't require total thyroidectomy if <1cm |
|
this endocrine tumor is associated with migratory necrolytic dermatitis
|
glucagonoma
|
|
how do you treat hyperaldosteronism from hyperplasia vs. adenoma
*remember both have high aldosterone with low renin and there are postural changes to distinguish |
hyperplasia - medically
adenoma - surgery |
|
VACTER constellation
|
vertebral
anal cardiac tracheal esophageal renal |
|
next step in management of a patient with congenital diaphragmatic hernia
|
Repair in 3 or 4 days to allow maturation
give low-pressure ventilation so lung is not blown out |
|
next step in management of a patient with meconium ileus
|
gastrografin enema
*both diagnostic and therapeutic |
|
next step in management of a 7 week old baby with persistent, progressive jaundice
|
HIDA scan with phenobartibal
|
|
what is suspected in a 12 months old child that has abdominal pain that has currant jelly stools and an "empty" RLQ
|
intussusception
|
|
next step in management of a patient with coin lesion found on CXR
|
1. sputum cytology
2. CT scan chest/abd 3. bronchoscopy w/ biopsy or percutaneous biopsy if not established by previous two |
|
how would one differentiate subclavian steal syndrome from thoracic outlet syndrome
|
subclavian steal syndrome has both vascular and neurologic symptoms due to the reversal of blood flow from vertebral artery
|
|
differentiate excision margin in basal cell carcinoma vs. squamous cell carcinoma
|
BCC - 1mm is enough and curative
SCC - 0.5 - 2cm and node dissection |
|
next step in management of a patient with orbital cellulitis
|
emergency CT scan and drainage
|
|
next step in management of a patient with a known kidney stones that suddenly develops fevers (104 - 105) and exquisite flank pain
|
1. IV abx
2. immediate decompression with ureteral stent or percutaneous nephrostomy |
|
most common reason for a newborn boy not to urinate during the first day of life
|
posterior urethral valve
*voiding cystourethrogram |
|
next step in management of a young child with flank pain, fevers, and chills
|
1. Start abx
2. IVP 3. voiding cystogram *look for reflux |
|
differentiate clean vs. clean contaminated vs. contaminated vs. dirty
|
clean - operative field does not enter into a colonized part of the body
clean contaminated - operative field enters into a colonized viscus or lumen but under controlled circumstances contaminated - gross contamination is presence with absence of infection dirty - active infection is already present |
|
hydradenitis suppurativa
|
infection involving the apocrine sweat glands in the axillary, inguinal, and perineal regions - results in a chronic abscess
|
|
differentiate closure technique for contaminated op-field vs. dirty op-field
|
contaminated (ruptured appendix) - delayed primary closure
dirty (abscess) - packed open and heal by secondary intention |
|
diabetic patient presents with signs of diffuse peritonitis, what should be the next step in management
|
volume resuscitation and correction of serum electrolytes, glucose, and pH if needed
*must be done before emergent surgery |
|
what criteria is needed for emergent preoperative dialysis
|
1. life-threatening hyperkalemia
2. severe metabolic acidosis 2/2 retained organic acids 3. uremic pericarditis 4. volume overload *AEIOU |
|
when is surgical treatment of spontaneous pneumothorax indicated
|
recurrence (ipsilateral or contralateral)
|
|
differentiate treatment in patient with suspected pneumothorax vs. tension pneumothorax
|
pneumo - CXR and chest tube
tension - immediate insertion of needle following by chest tube |
|
first step in management of a pt suspected of having an PE
|
ABG
|
|
what should be done in a patient in a MVA that is alert and oriented with only a forehead laceration
|
cervical spine x-ray to rule out cervical spine injury
|
|
what electrolyte abnormality is seen in a patient with a massive crush injury
|
hyperkalemia
*massive tissue damage |
|
asymptomatic patient with multiple liver simple, thin walled cystic structures
|
simple liver cysts
*amebic liver cysts present with fever, leukocytosis, tender liver, and elevated ALP |
|
best way to intubate a patient with multiple facial fracture, brisk bleeding into his nose, mouth, and throat
|
cricothyroidotomy
|
|
even if the patient has a resectable lung cancer with enough FEV1 left over, what you do before you perform a lobectomy
|
CT scan to look for metastasis
|
|
young person with persistent headache that is usually worse in the mornings
|
brain tumor
|
|
next step in management of a patient with a localized full thickness burn (white, dry, leathery, and anesthetic)
|
immediate excision and grafting
|