kSurgery: Kaplan Companion to First Aid for USMLE Step 2 CK Flashcards

Terms Definitions
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 pati
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
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?; Nex
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 o
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.
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 pa
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 sam
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 indicat
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 unremarkabl
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 endo
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 pneu
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 m
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
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, confi
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
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 slight
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
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 examinatio
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.
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 h
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 c
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
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
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 dep
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 fee
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,
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
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
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 cyt
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,
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 emergen
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
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 mos
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 bl
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 i
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 flui
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 recover
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 th
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
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
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 bil
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 s
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 mont
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
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 failur
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 t
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 an
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
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?; Diagno
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
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. W
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, barel
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, ba
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
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.
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 irregu
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 th
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 ri
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.
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 ai
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 fract
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 mult
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
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 feelin
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 che
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
A711. Dx: traumatic rupture of the aorta; (King size trauma, fracture of a hard-to-break bone...it 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 subc
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. H
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 moder
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 an
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?; Dia
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
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 rebo
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 “hig
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 T
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
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 fr
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
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
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, anesthe
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?; Diag
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
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?; Diagnos
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 color
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 recentl
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 rem
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 melanoma...it 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 overly
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
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 bec
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
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
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 th
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
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 canc
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
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
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
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 t
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
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 st
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”. Occasional
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?;
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, wrenchi
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
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”)
Q783. A 72 year old recent stroke patient begins to have severe epigastric pain that is exacerbated by eating. Dx?
A783. Dx: Cushing’s Ulcers; (Gastric ulcer related to severe CNS damage)
Q784. A 58 year old woman who is 6 days post-op from a gastrojejunostomy for PUD presents with postprandial RUQ pain and nausea. She reports that vomiting relieves her suffering. Dx?; Diagnostic test?; Tx?
A784. Dx: Afferent Loop syndrome; Diagnostic test: UGI series with contrast; (will show afferent loop without contrast); Tx: Endoscopic Balloon dilatation or Surgical revision
Q785. (5) causes for an Upper GI Hemorrhage
A785. Mallory’s Vices Gave (her) An Ulcer:; Mallory-Weiss Tear;; Varices;; Gastritis;; AV malformation;; Ulcer
Q786. A 54 year old man has had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate abdominal distention, and has not had a bowel movement or passed any gas for five days. He has high pitched, loud bowel
A786. Dx: Mechanical Intestinal Obstruction, due to adhesions; Management: Nasogastric suction, I.V. fluids and careful observation
Q787. A 54 year old man has had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate abdominal distention, and has not had a bowel movement or passed any gas for five days. He has high pitched loud bowel s
A787. Dx: Strangulated Obstruction; (a loop of bowel is dying –or dead- from compression of the mesenteric blood supply); Management: Emergency surgery
Q788. A 54 year old man has had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate abdominal distention, and has not had a bowel movement or passed any gas for five days. He has high-pitched, loud bowel
A788. Dx: Mechanical Intestinal Obstruction, due to an incarcerated (potentially strangulated) Hernia. Management: After suitable fluid replacement needs urgent surgical intervention
Q789. A 55 year old lady is being evaluated for protracted diarrhea. On further questioning she gives a bizarre history of episodes of flushing of the face, with expiratory wheezing. A prominent jugular venous pulse is noted on her neck. Dx?; Diagnostic t
A789. Dx: Carcinoid syndrome. Diagnostic test:; 1. 24 hour Serum determinations of 5-hydroxy-indoleacetic acid (5-HIAA) or 5-HTP;; 2. CT scan of abdomen; Tx: Serotonin antagonists;; then... If Appendiceal < 2cm = Appendectomy. If Appendiceal > 2cm = Right hemicolectomy;; Small intestinal = resect tumor with mesenteric LN
Q790. A 22 year old man develops vague periumbilical pain that several hours later becomes sharp, severe, constant and well localized to the right lower quadrant of the abdomen. On physical examination he has abdominal tenderness, guarding and rebound to
A790. Dx: Acute Appendicitis; Management: Exploratory laparotomy and appendectomy
Q791. A 70 year old male with a history of peripheral vascular disease and hyperlipidemia presents to the ER with diffuse abdominal pain. His BP is 170/100 and his pulse is 90bpm. Supine abdominal radiographs shows air in the wall of the small intestine.
A791. Dx: Small bowel Infarction
Q792. A patient presents with pigmented spots on his lips and a history of recurrent colicky abdominal pain. Dx?
A792. Dx: Peutz-Jeghers syndrome
Q793. A 5 year old child presents with increasing irritability, colicky abdominal pain and rectal bleeding with stools that have a currant jelly appearance. A mass is palpated in the right lower quadrant. Dx?; Diagnostic test? (2)
A793. Dx: Intussusception; Diagnostic test: Abdominal x-ray showing air-fluid levels with a stepladder pattern;; Barium enema (which is also therapeutic)
Q794. A 59 year old is referred for evaluation because he has been fainting at his job where he operates heavy machinery. He is pale and gaunt, but otherwise his physical exam is remarkable only 4+ occult blood in the stool. Lab studies show a hemogoblin
A794. Dx: Cancer of the right colon; Diagnostic test: Colonoscopy and biopsies; Treatment: Blood transfusions and eventually Right Hemicolectomy
Q795. A 56 year old man has bloody bowel movements. The blood coats the outside of the stool, and has been constipated, and his stools have become of narrow caliber. Dx?; Diagnostic test?
A795. Dx: Cancer of the distal, left side of the colon; Diagnostic test: Endoscopy and biopsies; (If given choices start with Flexible Sigmoidoscopy)
Q796. A 42 year old man has suffered from chronic ulcerative colitis for 20 years. He weights 90 pounds and has had at least 40 hospital admissions for exacerbations of the disease. Due to a recent relapse, he has been placed on high dose steroids and imm
A796. Dx: Toxic megacolon; Management: Emergency surgery for the toxic megacolon and removal of the rectum; (but the case illustrates many other indications for surgery: chronic malnutrition, “intractability” and risk of developing cancer)
Q797. A 27 year man is recovering from an appendectomy for gangrenous acute appendicitis with perforation and periappendicular abscess. He has been receiving Clindamycin and tobramycin for seven days. Eight hours ago he developed watery diarrhea, crampy a
A797. Dx: Pseudomembranous colitis from overgrowth of Clostridium Difficile; Diagnostic test: Stool cultures (but proctosigmoidoscopy can show a typical picture before the cultures are back); Management: Stop the clindamycin, give either Vancomycin or Metronidazole, and avoid lomotil
Q798. A 60 year old man known to have hemorrhoids reports bright red blood in the toilet paper after evacuation. Dx?; Management?
A798. Dx: Internal hemorrhoids; Management: Proctosigmoidoscopic Examination; (It is not reassurance and hemorrhoid remedies prescribed by telephone. In all these cases, cancer of the rectum has to be ruled out)
Q799. A 60 year old man known to have hemorrhoids complains of anal itching and discomfort, particularly towards the end of the day. He has perianal pain when sitting down and finds himself sitting sideways to avoid the discomfort. He is afebrile. Dx?; Ma
A799. Dx: External hemorrhoids; Management: Proctosigmoidoscopic Examination; (It is not reassurance and hemorrhoid remedies prescribed by telephone. In all these cases, cancer of the rectum has to be ruled out)
Q800. A 23 year old lady describes exquisite pain with defecation and blood streaks on the outside of the stools. Because of the pain she avoids having bowel movements and when she finally does, the stools are hard and even more painful. Physical examinat
A800. Dx: Anal Fissure; Management: Exam under Anesthesia; (Even though the clinical picture is classical, cancer still has to be ruled out); Tx: Lateral Internal Sphincterotomy
Q801. A 28 year old male is brought to the office by his mother. Beginning four months ago he has had three operations, done elsewhere, for a perianal fistula, but after each one the area has not healed, but actually the surgical wounds have become bigger
A801. Dx: Crohn's Disease; (The perianal area has fantastic blood supply and heals beautifully even though feces bathe the wounds. When it does not, you immediately think of Crohn’s disease); Diagnostic test: Flexible sigmoidoscopy with Biopsy; (You still have to rule out malignancy); Top 3 medical Tx:; 1. Sulfasalazine; 2. Metronidazole; 3. Prednisone
Q802. A 44 year old man shows up in the E.R. at 11 PM with exquisite perianal pain. He can not sit down, reports that bowel movements are very painful, and that he has been having chills and fever. Physical examination shows a hot, tender, red, fluctuant
A802. Dx Ischiorectal abscess; Management: Exam under Anesthesia with Incision and Drainage; (The treatment for all abscesses is drainage. This one is no exception. But as always, cancer has to be ruled out)
Q803. A 62 year old man complains of perianal discomfort, and reports that there are streaks of fecal soiling in his underwear. Four months ago he had a perirectal abscess drained surgically. Physical exam shows a perianal opening in the skin, and a cord-
A803. Dx: Anal Fistula; First:; Rule-out cancer with Proctosigmoidoscopy; Tx: elective Fistulotomy
Q804. A 55-year old, HIV positive man, has a fungating mass growing out of the anus, and rock hard, enlarged lymph nodes on both groins. He has lost a lot of weight, and looks emaciated and ill. Dx?; Diagnostic Test?; Eventual Tx?
A804. Dx: Squamous cell carcinoma of the anus; Diagnostic test: Biopsies of the fungating mass. Eventual treatment: Nigro protocol of pre-operative chemotherapy and radiation
Q805. A 33 year old man vomits a large amount of bright red blood. Where can the bleeding be from?; Diagnostic test?
A805. Bleeding from: Tip of the nose to the ligament of Treitz. Diagnostic test: for all upper G.I. bleeding, start with Endoscopy
Q806. A 33 year old man has had three large bowel movements that he describes as made up entirely of dark red blood. The last one was 20 minutes ago. He is diaphoretic, pale, has a blood pressure of 90 over 70 and a pulse rate of 110. Where is bleeding fr
A806. Bleeding from? Anywhere in GI tract; (The point of the vignette is that something needs to be done to define the area from which he is bleeding. With the available information it could be from anywhere in the G.I. tract); Management: The first diagnostic move here is to place a Nasogastric tube
Q807. A 33 year old man has had three large bowel movements that he describes as made up entirely of dark red blood. The last one was 20 minutes ago. He is diaphoretic, pale, has a blood pressure of 90 over 70 and a pulse rate of 110. A nasogastric tube r
A807. Management: Endoscopy; (Same as if he had been vomiting blood)
Q808. A 72 year old man had three large bowel movements that he describes as made up entirely of dark red blood. The last one was two days ago. He is pale, but has normal vital signs. A nasogastric tube returns clear, green fluid without blood. Diagnostic
A808. Diagnostic test: Upper and Lower Endoscopies; (The clear aspirate is meaningless because he is not bleeding right now. So the guilty territory can be anywhere from the tip of the nose to the anal canal. Across the board, ¾ of all GI bleeding is upper, and virtually all the causes of lower GI bleeding are diseases of the old: diverticulosis, polyps, cancer and angiodysplasias. So, is old, the overall preponderance of upper is balanced by the concentration of lower causes in old people...so it could be anywhere)
Q809. A 7 year old boy passes a large bloody bowel movement. Dx?; Diagnostic test?
A809. Dx: Meckel’s diverticulum; (in this age group); Diagnostic test: Radioactively labeled Technetium scan; (not the one that tags reds cells, but the one that identifies gastric mucosa)
Q810. A 41 year old man has been in the intensive care unit for two weeks, being treated for idiopathic hemorrhagic pancreatitis. He has had several percutaneous drainage procedures for pancreatic abscesses, chest tubes for pleural effusions, and bronchos
A810. Tx: Stress Ulcer; Diagnostic test: Endoscopy; It should have been prevented by keeping the pH of the stomach above 4 with H2 blockers, antiacids or both; Treatment: Angiographic Embolization of the left gastric artery.
Q811. A 59 year old man arrives in the E.R. at 2 AM, accompanied by his wife who is wearing curlers on her hair and a robe over her nightgown. He has abdominal pain that began about one hour ago, and is now generalized, constant and extremely severe. He l
A811. Dx: Acute Peritonitis (Acute Abdomen); Management: Emergency Exploratory Laparotomy
Q812. A 62 year old man with cirrhosis of the liver and ascites, presents with generalized abdominal pain that started 12 hours ago. He now has moderate tenderness over the entire abdomen, with some guarding and equivocal rebound. He has mild fever and le
A812. Dx: Primary Peritonitis; (Peritonitis in the cirrhotic with ascitis, or the child with nephrosis and ascitis, could be primary peritonitis – which does not need surgery!); Diagnostic test: Paracentesis with Cultures of the ascitic fluid will yield a single organism; Treatment: Antibiotics
Q813. A 43 year old man develops excruciating abdominal pain at 8:18 PM. When seen in the E.R. at 8:50 PM, he has a rigid abdomen, lies motionless in the examining table, has no bowel sounds and is obviously in great pain, which he describes as constant.
A813. Dx: Acute abdomen plus perforated GI tract; (perforated duodenal ulcer in most cases); Management: Emergency exploratory laparotomy
Q814. A 44 year old alcoholic male presents with severe epigastric pain that began shortly after a heavy bout of alcoholic intake, and reached maximum intensity over a period of two hours. The pain is constant, radiates straight through to the back and is
A814. Dx: Acute pancreatitis; Diagnostic test: Serum and Urinary Amylase and Lipase; If unclear: CT scan (or in a day or two if there is no improvement); Management: NPO, NG suction, IV fluids.
Q815. A 43 year old obese lady, mother of six children, has severe right upper quadrant abdominal pain that began six hours ago. The pain was colicky at first, radiated to the right shoulder and around towards the back, and was accompanied by nausea and v
A815. Dx: Acute cholecystitis; Diagnostic test: Ultrasound (If equivocal, an “HIDA” scan: radionuclide excretion scan); Management: “cool down” the process; Surgery will follow
Q816. A 52 year old man has right flank colicky pain of sudden onset that radiates to the inner thigh and scrotum. There is microscopic hematuria. Dx?; Diagnostic test? (2)
A816. Dx: Ureteral colic; Diagnostic test: Urological evaluation always begins with a Plain Film of the abdomen (a “KUB”); Ultrasound often is the next step; (but traditionally it has been intravenous pyelogram)
Q817. A 59 year old lady has a history of three prior episodes of left lower quadrant abdominal pain for which she was briefly hospitalized and treated with antibiotics. Now she has left lower quadrant pain, tenderness, and a vaguely palpable mass. She ha
A817. Dx: Acute diverticulitis; Diagnostic test: CT scan; (Colonoscopy is not safe in acute setting); Management: Elective Sigmoid resection; (for recurrent attacks, like this case or if she does not respond to medical Tx from initial attack or gets worse); (Treatment is medical for the acute attack: antibiotics, NPO)
Q818. An 82 year old man develops severe abdominal distension, nausea, vomiting and colicky abdominal pain. He has not passed any gas or stool for the past 12 hours. He has a tympanitic abdomen with hyperactive bowel sounds. X-Ray shows distended loops of
A818. Dx: Volvulus of the sigmoid; Management: Proctosigmoidoscopy should relieve the obstruction; (Rectal tube is another option. Eventually surgery to prevent recurrences could be considered)
Q819. A 79 year old man with atrial fibrillation develops and acute abdomen. He has a silent abdomen, with diffuse tenderness and mild rebound. There is a trace of blood in the rectal exam. He has acidosis and looks quite sick. X-Rays show distended small
A819. Dx: Emboli of Mesenteric vessels; (Acute abdomen present in the elderly who has atrial fibrillation, brings to mind embolic occlusion of the mesenteric vessels. Acidosis frequently ensues, and blood in the stool is often seen); Mild Tx: Observe only; Moderate Tx (fever and inc WBC only): IV Antibiotics; Severe Tx (Peritoneal signs): Exploratory Lap with Colostomy
Q820. A 53 year old man with cirrhosis of the liver develops malaise, vague right upper quadrant abdominal discomfort and 20 pound weight loss. Physical exam shows a palpable mass that seems to arise from the left lobe of the liver. Alpha feto protein is
A820. Dx: Liver cell carcinoma; Diagnostic test: CT scan; Tx: If confined to one lobe, Resection.
Q821. A 53 year old man develops vague right upper quadrant abdominal discomfort and a 20 pound weight loss. Physical exam shows a palpable liver with nodularity. Two years ago he had a right hemicolectomy for cancer of the ascending colon. His carcinoemb
A821. Dx: Metastasis to the liver from colon cancer; Diagnostic test: CT scan; Tx: If metastasis are confined to one lobe: Resection. (Otherwise, Chemotherapy if he has not had it)
Q822. A 24 year old lady develops moderate, generalized abdominal pain of sudden onset, and shortly thereafter faints. At the time of evaluation in the ER she is pale, tachycardic, and hypotensive. The abdomen is mildly distended and tender, and she has a
A822. Dx: Bleeding from a ruptured Hepatic Adenoma, secondary to birth control pills. Management:; CAT scan; (will confirm bleeding and probably show the liver adenoma as well); Tx: Surgery
Q823. A 44 year old lady is recovering from an episode of acute ascending cholangitis secondary to choledocholithiasis. She develops fever and leukocytosis and some tenderness in the right upper quadrant. An ultrasound reveals a liver mass. Dx?; Managemen
A823. Dx: Pyogenic abscess; Management: it needs to be drained (the radiologists will do it percutaneously)
Q824. A 29 year old migrant worker from Mexico develops fever and leukocytosis, as well as tenderness over the liver when the area is percussed. He has mild jaundice and an elevated alkaline phosphatase. Ultrasound of the right upper abdominal area shows
A824. Dx: Amebic abscess; (very common in Mexico); Management: Serology for Amebic titers and start on Metronidazole; (This one Abscess that does not have to be drained. Get serology for amebic titers, and start the patient on Metranidazole. Prompt improvement will tell you that you are on the right track...serologies in 3 weeks will confirm. Don’t fall for an option that suggests aspirating the pus and sending it for culture, you can not grow the ameba from the pus)
Q825. A 42 year old lady is jaundiced. She has a total bilirubin of 6 and the laboratory reports that the unconjugated, indirect bilirubin is 6 and the direct, conjugated bilirubin is zero. She has no bile in the urine. Dx?; Management?
A825. Dx: Hemolytic Jaundice; Management: Try to figure out what is chewing her red cells.
Q826. A 19 year old college student returns from a trip to Cancun, and two weeks later develops malaise, weakness and anorexia. A week later he notices jaundice. When he presents for evaluation his total bilirubin is 12, with 7 indirect and 5 direct. His
A826. Dx: Hepatocellular jaundice; Management: Get serologies to confirm diagnosis and type of Hepatitis
Q827. A patient with progressive jaundice which has been present for four weeks is found to have a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated SGOT. The alkaline phosphatase was twice normal value couple of weeks ago, and
A827. Dx: Obstructive jaundice; Diagnostic test: Ultrasound; (looking for dilated intrahepatic ducts, possibly dilated extrahepatic ducts as well, and if we get lucky a finding of gallstones)
Q828. A 40 year old, obese mother of five children presents with progressive jaundice which she first noticed four weeks ago. She has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated SGOT. The alkaline phosphatase is about si
A828. Dx: Obstructive jaundice; Diagnostic test: Ultrasound; (If you need more tests after that, ERCP is the next move, which could also be used to remove the stones from the common duct); Tx: Cholecystectomy
Q829. A 66 year old man presents with progressive jaundice which he first noticed six week ago. He has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated SGOT. The alkaline phosphatase is about six times the upper limit of norm
A829. Dx: Malignant obstructive jaundice. (“Silent” obstructive jaundice is more likely to be due to tumor. A distended gallbladder is an ominous sign: when stones are the source of the problem, the gallbladder is thick- walled, non-pliable); Management: CAT scan and ERCP
Q830. A 66 year old man presents with progressive jaundice which he first noticed six weeks ago. He has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated SGOT. The alkaline phosphatase is about six times the upper limit of nor
A830. Dx: Malignant, but lucky... probably Cholangiocarcinoma at the lower end of the common duct. Next step: get brushings of the common duct for cytological diagnosis. Tx: He could be cured with a pancreatoduodenectomy; (Whipple operation)
Q831. A 64 year old lady presents with progressive jaundice which she first noticed two weeks ago. She has a total bilirubin of 12, with 8 direct and 4 indirect, and minimally elevated SGOT. The alkaline phosphatase is about ten times the upper limit of n
A831. Dx: Malignant Obstructive jaundice; (The coincidence of slowly bleeding into the GI tract at the same time that she develops obstructive jaundice points to an Ampullary carcinoma, another malignancy that can be cured with Radical surgery); Diagnostic test: Endoscopy
Q832. A 56 year old man presents with progressive jaundice which he first noticed six weeks ago. He has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated SGOT. He alkaline phosphatase is about eight times the upper limit of no
A832. Dx: Cancer of the head of the pancreas (Terrible prognosis); Diagnostic test: CAT scan –which may show the mass in the head of the pancreas;; then ERCP –which will probably show obstruction of both common duct and pancreatic duct
Q833. A white, fat, female, aged 40 and mother of five children gives a history of repeated episodes of right upper quadrant abdominal pain brought about by the ingestion of fatty foods, and relieved by the administration of anticholinergic medications. T
A833. Dx: Gallstones, with biliary colic; Diagnostic test: Ultrasound; Tx: Elective cholecystectomy
Q834. A 43 year old obese lady, mother of six children, has severe right upper quadrant abdominal pain that began three days ago. The pain was colicky at first, but has been constant for the past two and a half days. She has tenderness to deep palpation,
A834. Dx: Acute Ascending Cholangitis; Further test: Ultrasound might confirm dilated ducts. Management:; Emergency decompression of the biliary tract... ERCP is the first choice, but PTC (percutaneous transhepatic cholangiogram) is another option
Q835. A white, fat, female, aged 40 and mother of five children gives a history of repeated episodes of right upper quadrant abdominal pain brought about by the ingestions of fatty foods, and relieved by the administration of anticholinergic medications.
A835. Dx: She passed a common duct stone and had a transient episode of Cholangitis (the shaking chill, the high phosphatase) and a bit of Biliary Pancreatitis (the high amylase). Diagnostic test: Ultrasound (It will confirm the diagnosis of gallstones); Management: If she continues to get well, elective Cholecystectomy. If she deteriorates, she may have the stone still impacted at the Ampulla of Vater, and may need ERCP and sphincterotomy to extract it
Q836. A 33 year old, alcoholic male, shows up in the E.R. with epigastric and mid-abdominal pain that began 12 hours ago shortly after the ingestion of a large meal. The pain is constant, very severe, and it radiates straight through to the back. He vomit
A836. Dx: Acute edematous pancreatitis. Management: put the pancreas at rest...NPO, NG suction, IV fluids
Q837. A 56 year old alcoholic male is admitted with a clinical picture of acute upper abdominal pain. The pain is constant, radiates straight through to the back, and is extremely severe. He has a serum amylase of 800, WBC of 18,000 blood glucose of 150,
A837. Dx: Hemorrhagic Pancreatitis (In fact, he is in deep trouble, with at least eight of Ranson’s criteria predicting 80 to 100% mortality); Management/test: Very intensive support will be needed, but the common pathway to death from complication of hemorrhagic pancreatitis frequently is by way of pancreatic abscesses that need to be drained as soon as they appear. Thus serial CT scans will be required.
Q838. A 57 year old alcoholic male is being treated for acute hemorrhagic pancreatis. He was in the intensive care unit for one week, required chest tubes for pleural effusion, and was on a respirator for several days, but eventually improved enough to be
A838. Dx: Pancreatic abscess; Diagnostic test: CT scan; Tx: Drainage
Q839. A 49 year old alcoholic male presents with ill-defined upper abdominal discomfort and early satiety. On physical exam he has a large epigastric mass that is deep within the abdomen, and actually hard to define. He was discharged from the hospital 5
A839. Dx: Pancreatic pseudocyst; Diagnostic test: You could diagnose it on the cheap with an ultrasound, but CT scan is probably the best choice. Tx: It will need to be drained, and the radiologist will do it with CT guidance
Q840. A 55 year old lady presents with vague upper abdominal discomfort, early satiety and a large but ill-defined epigastric mass. Five weeks ago she was involved in an automobile accident where she hit the upper abdomen against the steering wheel. Dx?;
A840. Dx: Pancreatic pseudocyst, secondary to trauma; Diagnostic test: CT scan
Q841. A disheveled, malnourished individual shows up in the emergency room requesting medication for pain. He smells of alcohol and complains bitterly of constant epigastric pain, radiating straight through to the back that he says he has had for several
A841. Dx: Chronic pancreatitis; Diagnostic test: AXR visualizing calcifications; Management: Stop alcohol, replacement of pancreatic enzymes and control of the diabetes; ERCP
Q842. On the first post-operative day after an open cholecystectomy, a patient has a temperature of 101. Dx?; Diagnostic test?; Management? (2 together)
A842. Dx: Atelectasis; Diagnostic test: Chest X-ray; Management:; 1. Incentive Spirometry; 2. Encourage deep breathing and coughing
Q843. On the third post-operative day after an open cholecystectomy, a patient develops a temperature of 101. Dx?; Diagnostic test?; Tx?
A843. Urinary tract infection; Diagnostic Test: Urinalysis and Urinary culture; Tx: appropriate Antibiotics
Q844. On the fourth post-operative day after an open cholecystectomy, a patient develops a temperature of 101. There is tenderness to deep palpation in the calf, particularly when the foot is dorsiflexed. Dx?; Diagnostic test?; Tx?
A844. Dx: Deep Venous Thrombosis; Diagnostic test: Duplex ultrasound; (Doppler flow plus real time B-mode); Tx: Anticoagulation to prevent thrombus propagation
Q845. Seven days after an inguinal hernia repair, a patient returns to the clinic because of fever. The wound is red, hot and tender. Dx?; Management? (3 steps)
A845. Wound infection; Management:; 1. Open the wound; 2. Drain the pus; 3. Pack it and leave it open
Q846. Two weeks after an open cholecystectomy a patient develops fever and leukocytosis. The wound is healing well and does not appear to be infected. Dx?; Where is greatest possibility? (2); Diagnostic test?; Tx?
A846. Dx: Deep Abscess; Places: Subphrenic or Subhepatic; (Had the operation been an appendectomy, pelvic abscess would be the first pick); Diagnostic test: CT scan to find the abscess and to guide the radiologist for the (Tx) Percutaneous Drainage.
Q847. On the fifth post-operative day after a right hemicolectomy for cancer, the dressings covering the midline abdominal incision are found to be soaked with a clear, pinkish, salmon- colored fluid. Dx?; Management? (3 steps)
A847. Dx: Wound dehiscence Management:; 1. Keep the patient in bed; 2. Tape his belly together; 3. Schedule surgery for re-closure of the wound if the patient can take the re-operation. (If too sick, the development of a ventral incisional hernia may have to be accepted now and repaired later)
Q848. Following the discovery of the copious, salmon colored, pinkish clear fluid along the post-op abdominal incision, the patient gets out of bed, or sneezes forcefully, and you are confronted with a bucket-full of small bowel; Dx?; Management? (2 steps
A848. Dx: Evisceration; Management:; 1. keep the bowel covered and moist with sterile dressings; 2. Rush the patient to the OR for re-closure
Q849. A 62 year old lady was drinking her morning cup of coffee at the same time she was applying her makeup, and she noticed in the mirror that there was a lump in the lower part of her neck, visible when she swallowed. She consult you for this and on ph
A849. Diagnostic test: FNA
Q850. A 21 year old college student is found on a routine physical examination to have a single, 2cm nodule in the thyroid gland. The young man had radiation to his head and neck when he was thirteen years old because of persistent acne. His thyroid funct
A850. Diagnostic test: FNA; Tx: Surgical removal (due to radiation leading to cancer)
Q851. A 44 year old lady has a palpable mass in her thyroid gland. She also describes losing weight in spite of a ravenous appetite, palpitations and heat intolerance. She is a thin lady, fidgety and constantly moving, with moist skin and a pulse rate of
A851. Dx: A “hot” Adenoma; Management/test:; 1. confirm hyperthyroidism by measuring Free T4; 2. Confirm source of the excessive hormone with Radioactive Iodine Scan; 3. give Beta-blocker; Tx: Surgery (after Beta blocking)
Q852. A 22 year old male has a 2 cm round firm mass in the lateral aspect of his neck, which has been present for four months. Clinically this is assumed to be an enlarged jugular lymph node and it is eventually removed surgically. The pathologist reports
A852. Dx: Follicular Carcinoma of the Thyroid (metastitic); (There is no such thing as “lateral aberrant thyroid”); Diagnostic test: Look for the primary with a Thyroid Scan. Tx: Eventually Surgery
Q853. An automated blood chemistry panel done during the course of a routine medical examination indicates that an asymptomatic patient has a serum calcium of 12.1 in a lab where the upper limit of normal is 9.5. Repeated determinations are consistently b
A853. Dx: Parathyroid Adenoma; Diagnostic test: PTH determination and Sistimibi scan to localize the adenoma; Tx: Surgical excision
Q854. A 32 year old woman is admitted to the psychiatry unit because of wild mood swings. She is found to be hypertensive and diabetic and to have osteoporosis. (she had not been aware of such diagnosis beforehand). It is also ascertained that she has bee
A854. Dx: Cushings Dz; (The appearance is so typical, that you will probably be given a photograph on the test, with an accompanying brief vignette); Diagnostic test:; 1. AM and PM cortisol determinations; 2. Dexamethasone suppression tests; 3. MRI of the head looking for the pituitary microadenoma; Tx: removed by the trans-nasal, trans-sphenoidal route
Q855. A 28 year old lady has virulent peptic ulcer disease. Extensive medical management including eradication of H.Pylori fails to heal her ulcers. She has several duodenal ulcers in the first and second portions of the duodenum. She has watery diarrhea.
A855. Dx: Gastrinoma (Zollinger-Ellison); Diagnostic test:; 1. Serum gastrin; 2. CT scans (or MRI) of the pancreas looking for the tumor; Tx: Surgical excision
Q856. A second year medical student is hospitalized for a neurological work-up for a seizure disorder of recent onset. During one of his convulsions it is determined that his blood sugar is extremely low. Further work-up shows that he has high levels of i
A856. Dx: Exogenous administration of insulin; (If the C-peptide had been high along with the insulin level, the diagnosis would have been insulinoma); Management: Psychiatric evaluation and counseling; (He is faking the disease. If it had been insulinoma, CT scan or MRI looking for the tumor in the pancreas, to be subsequently removed surgically)
Q857. A 48 year old lady has had severe, migratory necrolytic dermatitis for several years, unresponsive to all kinds of “ herbs and unguents”. She is thin, has mild stomatitis and mild diabetes mellitus. Dx?; Diagnostic test? (2); Tx?; If this Tx is
A857. Dx: Glucagonoma; Diagnostic test:; 1. Determine Glucagon levels; 2. CT scan or MRI looking for the tumor in the pancreas. Tx: Surgery will follow If inoperable:; 1. Somatostatin can help symptomatically; 2. Streptozocin is the indicated chemotherapeutic agent
Q858. A 45 year old lady comes to your office for a “regular checkup”. On repeated determinations you confirm the fact that she is hypertensive. When she was in your office three years ago, her blood pressure was normal. Laboratory studies at this tim
A858. Dx: Hyperaldosteronism or Adrenal Adenoma; Diagnostic test:; 1. Aldosterone and renin levels. 2. If confirmatory (aldo high, renin low) proceed with determinations lying down and sitting up, to differentiate Hyperplasia (not surgical) from Adenoma (surgical). Hyperplasia Tx: Aldactone; Adenoma Tx: Imaging studies (CT scan or MRI) and Surgery
Q859. A thin, hyperactive 38 year old lady is frustrated by the inability of her physicians to help her. She has episodes of severe pounding headache, with palpitations, profuse perspiration and pallor, but by the time she gets to her doctor ’s office s
A859. Dx: Pheochromocytoma; Diagnostic test:; 1. 24hr urinary determination of metanephrine and VMA (Vanillylmandelic acid); 2. CT scan of adrenal glands; Meds before surgery: Alpha-blockers
Q860. A 17 year old man is found to have a blood pressure of 190/115. This is checked repeatedly in both arms and it is always found to be elevated, but when checked in the legs it is found to be normal. Dx?; Diagnostic test? (2 steps); Tx?
A860. Dx: Coarctation of the Aorta; Diagnostic test:; 1. Chest X-Ray, looking for scalloping of the ribs; 2. Aortogram; Tx: Surgery
Q861. A 23 year old lady has had severe hypertension for two years, and she does not respond well to the usual medical treatment for that condition. A bruit can be faintly heard over her upper abdomen. Dx?; Diagnostic test?; Tx? (2 possible)
A861. Dx: Renovascular Hypertension due to Fibromuscular Dysplasia; Diagnostic test: Arteriogram will precede (Tx) Surgical correction or Balloon dilatation
Q862. A 72 year old man with multiple manifestations of arteriosclerotic occlusive disease has hypertension of relatively recent onset, and is refractory to the usual medical therapy. He has a faint bruit over the upper abdomen. Dx?
A862. Dx: Renovascular Hypertension due to arteriosclerotic plaque at the origin of the Renal Artery…or arteries; (this is usually bilateral)
Q863. Within eight hours after birth, it is noted that a baby has excessive salivation. A small, soft nasogastric tube is inserted and the baby is taken to X-Ray to have a “babygram” done. The film shows the tube coiled back upon itself in the upper c
A863. Dx: Tracheo-esophageal fistula; (the most common type with proximal blind esophageal pouch and distal TE fistula); Management:; 1. Rule-out the associated anomalies (“VACTER”: vertebral, anal, cardiac, TE and renal/radial). The vertebral and radial will be seen in the same X-ray you already took, you need Echo for the heart, Sonogram for the kidneys and Physical Exam for the anus. Tx: Surgical repair
Q864. A newborn baby is found on physical exam to have an imperforate anus. Management? (2 steps)
A864. Management:; 1. This is part of the “VACTER” (vertebral, anal, cardiac, TE and renal/radial) group, so look for the others as mentioned. 2. For the imperforate anus, look for a fistula nearby (to the vagina in little girls, to the perineum in little boys), which will help determine the level of the blind pouch and the timing and type of surgery (primary repair versus colostomy and repair later).
Q865. A newborn baby is noted to be tachypneic, cyanotic and grunting. The abdomen is scaphoid and there are bowel sounds heard over the left chest. An X-Ray confirms that there is bowel in the left thorax. Shortly thereafter, the baby develops significan
A865. Dx: Congenital Diaphragmatic Hernia; Management:; 1. keep the kid alive with endotracheal intubation; 2. Hyperventilation (careful not to blow up the other lung); 3. Sedation; 4. NG suction; (Tx: The main problem is the hypoplastic lung. It is better to wait 36 to 48 hours to do Surgery to allow transition from fetal circulation to newborn circulation)
Q866. At the time of birth it is noted that a child has a large abdominal wall defect to the right of the umbilicus. There is a normal cord, but protruding from the defect there is a matted mass of angry looking, edematous bowel loops. Dx?; Tx?
A866. Dx: Gastroschisis; Tx: Pediatric Surgeon must get the bowel back into the belly; they may need to use a silicon “silo” to gradually close the abdominal wall defect.
Q867. A newborn baby is noted to have a shiny, thin, membranous sac at the base of the umbilical cord. Inside the sac one can see part of the liver, and loops of normal looking bowel. Dx?; Management?; Tx?
A867. Dx: Omphalocele; Management: Look for other congenital defects. These kids can have a host of other congenital defects; Tx: Repair is performed by a Pediatric surgeon
Q868. A newborn is noted to have a moist medallion of mucosae occupying the lower abdominal wall, above the pubis and below the umbilicus. It is clear that urine is constantly bathing this congential anomaly. Dx?; what is important regarding this repair?
A868. Dx: Exstrophy of the urinary bladder; Important: Repair must be done within the first 48 hours, or it will not have a good chance to succeed. It takes time to arrange for transfer of a newborn baby to a distant city that specializes in this repair. If a day or two are wasted before arrangements are made, it will be too late
Q869. Half an hour after the first feed, a baby vomits greenish fluid. The mother had polyhydramnios and the baby has Down’s syndrome. X-Ray shows a “double bubble sign”: a large air fluid level in the stomach, and smaller one in the first portion o
A869. Dx: Duodenal Atresia or Annular Pancreas; (innocent vomit is clear-whitish. Green vomiting in the newborn is bad news. It means something serious); Management: Look for other congenital anomalies first; Tx: Emergency Surgery
Q870. Half an hour after the first feed, a baby vomits greenish fluid. X-Ray shows a "double bubble sign”: a large air fluid level in the stomach, and a smaller one in the first portion of the duodenum. There is air in the distal bowel, beyond the
A870. Dx:; 1. Incomplete obstruction from duodenal stenosis,; 2. Annular Pancreas,; 3. Malrotation of bowel; Diagnostic test: Contrast enema; (and if not diagnostic order a water-soluble gastrographin Upper GI study)
Q871. A newborn baby has repeated green vomiting during the first day of life, and does not pass any meconium. Except for abdominal distention, the baby is otherwise normal. X-Ray shows multiple air fluid levels and distended loops of bowel. Dx?; Cause?
A871. Dx: Intestinal atresia; Cause: Vascular accident in utero; (thus there are no other congenital anomalies to look for, but there may be multiple points of atresia)
Q872. A very premature baby develops feeding intolerance, abdominal distention and a rapidly dropping platelet count. The baby is four days old, and was treated with indomethacin for a patent ductus. Dx?; Management? (3 together); Reasons for surgical Tx?
A872. Dx: Necrotizing Enterocolitis; Management:; 1. Stop all feedings; 2. Broad spectrum antibiotics; 3. IV fluids/nutrition; Tx: Surgical intervention if they develop abdominal wall erythema, air in the biliary tree or pneumoperitoneum
Q873. A three day old, full term baby is brought in because of feeding intolerance and bilious vomiting. X-Ray shows multiple dilated loops of small bowel and a “ground glass” appearance in the lower abdomen. The mother has cystic fibrosis. Dx?; Manag
A873. Dx: Meconium Ileus; Management:; 1. Gastrografin enema may be both diagnostic and therapeutic, so it is the obvious first choice. 2. If unsuccessful, surgery may be needed. 3. The kid has cystic fibrosis, and management of the other manifestations of the disease will also be needed
Q874. A three week old baby has had “trouble feeding” and it is not quite growing well. He now has bilious vomiting and is brought in for evaluation. X-Ray shows a classical “double bubble”, along with normal looking gas pattern in the rest of the
A874. Dx: Malrotation of the bowel (not all will show up on day one); Diagnostic test: Contrast enema to verify the malrotation; Tx: Emergency surgery
Q875. A 3 week old first-born, full term baby boy began to vomit three days ago. The vomiting is projectile, has no bile in it, follows each feeding and the baby is hungry and eager to eat again after he vomits. He looks somewhat dehydrated and has visibl
A875. Dx: Hypertrophic Pyloric Stenosis; Management:; 1. Check electrolytes: hypokalemic, hypochloremic metabolic alkalosis may have developed (correct it). 2. Rehydrate; Tx: Ramsted Pyloromyotomy
Q876. An 8 week old baby is brought in because of persistent, progressively increasing jaundice. The bilirubin is significantly elevated and about two thirds of it is conjugated, direct bilirubin. Ultrasound rules out extrahepatic masses, serology is nega
A876. Dx: Biliary Atresia; Diagnostic test:; 1. HIDA scan; 2. Percutaneous Liver Biopsy; Tx: Exploratory laparotomy
Q877. A two month old baby boy is brought in because of chronic constipation. The kid has abdominal distention, and plain X- Rays show gas in dilated loops of bowel throughout the abdomen. Rectal exam is followed by expulsion of stool and flatus, with rem
A877. Dx: Hirschsprungs’ disease (aganglionic megacolon); Diagnostic test:; 1. Barium enema will define the normal-looking aganglionic distal colon and the abnormal-looking thickness; 2. Biopsy of the rectal mucosa; Tx: Surgical excision of aganglionic segment
Q878. A 9 month old, chubby, healthy looking little boy has episodes of colicky abdominal pain that make him double up and squat. The pain lasts for about one minute, and the kid looks perfectly happy and normal until he gets another colick. Physical exam
A878. Dx: Intussusception; Management: Barium enema is both diagnostic and therapeutic in most cases. Tx: If reduction is not achieved radiologically, exploratory laparotomy and manual reduction will be needed
Q879. A one year old baby is referred to the University Hospital for treatment of a subdural hematoma. In the admission examination it is noted that the baby has retinal hemorrhages. Dx?
A879. Child Abuse
Q880. A one year old child is brought in with second degree burns of both buttocks. The stepfather relates that the child fell into a hot tub. Dx?
A880. Child Abuse
Q881. A three year old girl is brought in for treatment of a fractured humerus. The mother relates that the girl fell from her crib. X-Rays show evidence of other older fractures at various stages of healing in different bones. Dx?
A881. Child Abuse
Q882. A 4 year old boy passes a large bloody bowel movement. Dx?; Diagnostic test?; Tx?
A882. Dx: Meckel’s diverticulum; Diagnostic test: Radioisotope scan looking for gastric mucosa in the lower abdomen; Tx: Surgical excision
Q883. A 15 year old girl has a round, 1cm cystic mass in the midline of her neck at the level of the hyoid bone. When the mass is palpated at the same time that the tongue is pulled, there seems to be a connection between the two. The mass has been presen
A883. Dx: Thyroglossal Duct Cyst; Tx: Sistrunk operation; (removal of the mass and the track to the base of the tongue, along with the medial segment of the hyoid bone).
Q884. An 18 year old woman has a 4cm fluctuant round mass on the side of her neck, just beneath and in front of the sternomastoid. She reports that is has been there at least 10 years, although she thinks that it has become somewhat larger in the last yea
A884. Dx: Branchial Cleft Cyst; Tx: Elective surgical removal
Q885. A 6 year old child has a mushy, fluid filled mass at the base of the neck, that has been noted for several years. The mass is about 6 cm. in diameter, occupies most of the supraclavicular area and seems by physical exam to go deeper into the neck an
A885. Dx: Cystic hygroma; Diagnostic test: CT scan to see how deep this thing goes. (They can extend down into the chest and mediastinum); Tx: Surgical removal will eventually be done
Q886. A 22 year old lady notices an enlarged lymph node in her neck. The node is in the jugular chain, measures about 1.5cm, is not tender, and was discovered by the patient yesterday. The rest of the history and physical exam are unremarkable. Management
A886. Management: Reschedule an appointment for 3 weeks to see its progress; (If the node has gone away by then, it was inflammatory and nothing further is needed. If it’s still there, it could be neoplastic and something needs to be done)
Q887. A 22 year old lady seeks help regarding an enlarged lymph node in her neck. The node is in the jugular chain, measures about 2cm, is firm, not tender, and was discovered by the patient six weeks ago. There is a history of low grade fever and night s
A887. Dx: Lymphoma (most likely); Disgnostic test: Tissue diagnosis will be needed. You can start with FNA of the available nodes, but eventual node biopsy will be needed to establish not only the diagnosis but also the type of lymphoma
Q888. A 72 year old man has 4cm hard mass in the left supraclavicular area. The mass is movable, non tender and has been present for three months. The patient has had a 20 pound weight loss in the past two months, but is otherwise asymptomatic. Dx?; Manag
A888. Dx: Malignant metastasis to a supraclavicular node from a primary tumor below the neck. Management:; 1. Look for the obvious primary tumors: lung, stomach, colon, pancreas, and kidney; 2. The node itself will eventually be Biopsied
Q889. A 69 year old man who smokes and drinks and has rotten teeth has a hard, fixed, 4cm mass in his neck. The mass is just medial and in front of the sternomastoid muscle, at the level of the upper notch of the Thyroid cartilage. It has been there for a
A889. Dx: Metastatic squamous cell carcinoma to a jugular chain node, from a primary in the mucosa of the head and neck (oro-pharyngeal-laryngeal territory); Diagnostic test: Triple Endoscopy; (examination under anesthesia of the mouth, pharynx, larynx, esophagus and tracheobronchial tree); (Don’t biopsy the node! FNA is OK if Triple endoscopy not available)
Q890. A 69 year old man who smokes and drinks and has rotten teeth has hoarseness that has persisted for six weeks in spite of antibiotic therapy; Dx?; Diagnostic test?
A890. Dx: Squamous cell carcinoma of the mucosa of the head and neck; Diagnostic test: Triple endoscopy to find and biopsy the primary tumor
Q891. A 69 year old man who smokes and drinks and has rotten teeth has a painless ulcer in the floor of the mouth that has been present for 6 weeks and has not healed. Dx?; Diagnostic test?
A891. Squamous cell carcinoma of the mucosa of the head and neck; Diagnostic test: Triple endoscopy to find and biopsy the primary tumor
Q892. A 69 year old man who smokes and drinks and has rotten teeth has unilateral ear ache that has not gone away in 6 weeks. Physical examination shows serious otitis media on that side, but not on the other. Dx?; Diagnostic test?
A892. Dx: Squamous cell carcinoma of the mucosa of the head and neck; Diagnostic test: Triple endoscopy to find and biopsy the primary tumor
Q893. A 52 year old man complains of hearing loss. When tested he is found to have unilateral sensory hearing loss on one side only. He hoes not engage in any activity (such as sport shooting) that would subject that ear to noise that spares the other sid
A893. Dx: Acoustic Nerve Neuroma; (Unilateral versions of common ENT problems in the adult suggest malignancy. Note that if the hearing loss had been conductive, a Cerumen Plug would be the obvious first diagnosis); Diagnostic test: MRI looking for the tumor
Q894. 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 three months. It affects both the forehead as well as the l
A894. Dx: Gradual, unilateral nerve paralysis suggests a neoplastic process; Diagnostic test: Gadolinium enhanced MRI
Q895. A 45 year old man presents with a 2cm firm mass in front of the left ear, which has been present for four months. The mass is deep to the skin and it is painless. The patient has normal function of the facial nerve. Dx?; Management?
A895. Dx: Pleomorphic adenoma (mixed tumor) of the parotid gland; Management: Referral to a head and neck surgeon for formal superficial parotidectomy; (FNA is appropriate, but the point of the question will be to bring out the fact that parotid masses are never biopsied in the office or under local anesthesia)
Q896. A 65 year old man present with a 4cm hard mass in front of the left ear, which has been present for six months. The mass is deep to the skin and it is fixed. He has constant pain in the area, and for the past two months has had gradual progression o
A896. Dx: Cancer of the parotid gland; Management: Referral to a head and neck surgeon for formal superficial parotidectomy; (Amateurs should not mess with parotid)
Q897. A two year old boy has unilateral ear ache. Dx?
A897. Dx: Unilateral versions of common bilateral ENT conditions in toddlers suggest Foreign Body
Q898. A two year old has unilateral foul smelling purulent rhinorrhea. Dx?
A898. Dx: Unilateral versions of common bilateral ENT conditions in toddlers suggest foreign body
Q899. A two year old has unilateral wheezing and the lung on that side looks darker on X-Rays (more air) than the other side. Dx?
A899. Dx: Unilateral versions of common bilateral ENT conditions in toddlers suggest foreign body
Q900. A 4 year old child is brought by his mother to the emergency room because “she is sure that he must have swallowed a marble”. The kid was indeed playing with marbles and apparently completely healthy when he was put to bed, but four hours later
A900. Dx: Acute Epiglotitis; Diagnostic test: Lateral X-ray of the neck; Management: A real emergency where expert help is needed!; 1. Ready to use bag and mask if needed. 2. OR for Nasotracheal Intubation. 3. Start IV antibiotics along the way for H.Pylori; Bradychardia develops: Atropine will help, but hypoxia is the problem.
Q901. A 45 year old lady with a history of a recent tooth infection shows up with a huge, hot, red, tender, fluctuant mass occupying the left lower side of her face and upper neck, including the underside of the mouth. The mass pushes up the floor of the
A901. Dx: Ludwigs’ Angina (An abscess of the floor of the mouth); Tx:; 1. Tracheostomy; 2. Incision & Drainage of the abscess
Q902. A 29 year old lady calls your office at 10 AM with the history that she woke up that morning with one side of her face paralyzed. Dx?; Management?
A902. Dx: Bell’s palsy; Management: Immediate anti-viral medication; (the process is idiopathic and will resolve spontaneously in most cases)
Q903. A patient with multiple trauma from a car accident is being attended to in the emergency room. As multiple invasive things are done to him, he repeatedly grimaces with pain. The next day it is noted that he has a facial nerve paralysis on one side.
A903. Dx: Paralysis from Edema; (Trauma to the temporal bone can certainly transect the facial nerve, but when that happens the nerve is paralyzed right there and then. Nothing needs to be done...it will correct itself)
Q904. Your office receives a phone call from Mrs. Rodriguez. You know this middle aged lady very well because you have repeatedly treated her in the past for episodes of sinusitis. In fact, six days ago you started her on decongestants and oral antibiotic
A904. Dx: Cavernous Sinus Thrombosis or Orbital Cellulitis; Management: This is a real emergency (fact that is most likely questioned). 1. Immediate Hospitalization,; 2. high dose IV Antibiotic treatment; 3. Surgical Drainage of the paranasal sinuses or the orbit. Dx Test: CT scan (which will also be needed to guide the surgery)
Q905. A 10 year old girl has epistaxis. Her mother says that she picks her nose all the time. Dx?; Tx?
A905. Dx: Bleeding from the Anterior part of the septum; Tx: Phenylephrine spray and local pressure
Q906. An 18 year old boy has epistaxis. The patient denies picking his nose. No source of anterior bleeding can be seen by physical examination. Dx? (2 possible)
A906. Dx:; 1. Septal perforation from cocaine abuse; 2. Posterior juvenile Nasopharyngeal Angiofibroma
Q907. A 72, hypertensive male, on aspirin for arthritis, has a copious nosebleed. His blood pressure is 220/105 when seen in the E.R. He says he began swallowing blood before it began to come out through the front of his nose. Dx?; Management? (2)
A907. Dx: Epistaxis secondary to hypertension; Management:; 1. Lower BP with Medication; 2. Involve ENT (These are serious problems that can end up with death)
Q908. A 57 year old man seeks help for “dizziness”. On further Questioning he explains that the room spins around him; Dx?; Management?
A908. Dx: Vestibular Apparatus; Management: Symptomatic treatment (meclizine, phenergan, diazepam), or an ENT workup
Q909. During a school physical exam, a 12 year old girl is found to have a heart murmur. She is referred for further evaluation. An alert cardiology fellow recognized that she indeed has a pulmonary flow systolic murmur, but he also notices that she has a
A909. Dx: Atrial septal defect; Diagnostic test: Echocardiography; Tx: Surgical closure of the defect
Q910. A three month old boy is hospitalized for ‘failure to thrive”. He has a loud, pansystolic heart murmur best heard at the left sternal border. Chest X-Ray shows increased pulmonary vascular markings. Dx?; Diagnostic test?; Tx?
A910. Dx: Ventricular septal defect; Diagnostic test: Echocardiography; Tx: surgical correction
Q911. A three day old premature baby has trouble feeding and pulmonary congestion. Physical exam shows bounding peripheral pulses and a continuous, machinery-like heart murmur. Dx?; Diagnostic test?; Tx? (2 possible)
A911. Patent Ductus Arteriosus; Diagnostic test: Echocardiography; Tx:; 1. Surgical closure; 2. Indomethacin
Q912. A patient known to have a congenital heart defect requires extensive dental work. Management?
A912. Management: antibiotic prophylaxis for subacute bacterial endocarditis
Q913. A 6 year old boy is brought to the U.S. by his new adoptive parents, from an orphanage in Eastern Europe. The kid is small for his age, and has a bluish hue in the lips and tips of his fingers. He has clubbing and spells of cyanosis relieved with sq
A913. Dx: Tetralogy of Fallot; Diagnostic test: Echocardiogram
Q914. A 72 year old man has a history of angina and exertional syncopal episodes. He has a harsh midsystolic heart murmur best heard at the second intercostal space and along the left sternal border. Dx?; Diagnostic test?; Definitive Tx?; When is it indic
A914. Dx: Aortic Stenosis; Diagnostic test: Echocardiogram; Tx: Surgical Valvular replacement; Surgery indications:; 1. gradient of more than 50 mm.Hg. 2. indication of CHF, angina or syncope
Q915. A 72 year old man has been known for years to have a wide pulse pressure and a blowing, high-pitched, diastolic heart murmur best heard at the second intercostal space and along the left lower sternal border with the patient in full expiration. He h
A915. Dx: Chronic Aortic Insufficiency; Diagnostic test: Echocardiogram; Next step: Aortic valve replacement
Q916. A 26 year old drug-addicted man develops congestive heart failure over a short period of a few days. He has a loud, diastolic murmur at the right, second intercostal space. A physical exam done a few weeks ago, when he had attempted to enroll in a d
A916. Dx: Acute Aortic Insufficiency due to Endocarditis; Management:; 1. Emergency valve replacement; 2. Antibiotics for a long time
Q917. A 35 year old lady has dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, cough and hemoptysis. She has had these progressive symptoms for about 5 years. She looks thin and cachectic, has atrial fibrillation and a low- pitched, rumbling d
A917. Dx: Mitral stenosis; Diagnostic test: Echocardiogram; Tx: Eventually surgical mitral valve repair
Q918. A 55 year old lady has been known for years to have mitral valve prolapse. She now has developed exertional dyspnea, orthopnea and atrial fibrillation. She has an apical, high pitched, holosystolic heart murmur that radiates to the axilla and back.
A918. Dx: Mitral Regurgitation; Diagnostic test: Echocardiogram; Tx: eventually surgical repair of the valve (Annuloplasty) or possibly valve replacement
Q919. A 55 year old man has progressive, unstable, disabling angina that does not respond to medical management. His father and two older brothers died of heart attacks before the age of 50. The patient stopped smoking 20 years ago, but still has a sedent
A919. It’s a heart attack waiting to happen... Management: Cardiac Catheterization; (to see if he is a suitable candidate for coronary revascularization)
Q920. On a routine pre-employment physical examination, a chest X-Ray is done on a 45 year old chronic smoker. A “coin lesion” is found in the upper lobe of the right lung. Dx?; Next step?
A920. Dx: Cancer of the lung; Next step: Find and older chest X-Ray if one is available (from one or more years ago). If an older X-Ray has the same unchanged lesion, it is not likely cancer. No further work up is needed now, but the lesion should be followed with periodic X-Rays.
Q921. A 54 year old man with a 40 pack/year history of smoking gets a chest X-Ray because of persistent cough. A peripheral, 2cm “coin lesion” is found in the right lung. A chest X-Ray taken two years ago had been normal. CT scan shows no calcificatio
A921. Dx: Cancer of the lung; Diagnostic test:; 1. Start with Bronchoscopy and washings,; 2. if unrewarding go to Percutaneous Needle Biopsy; 3. if still unsuccessful go to Open Biopsy (Thoracotomy and Wedge Resection)
Q922. A 72 year old chronic smoker with severe COPD is found to have a central, hilar mass on chest X-Ray. Bronchoscopy and biopsy establish a diagnosis of squamous cell carcinoma of the lung. His FEV1 is 1100, and a ventilation/perfusion scan shows that
A922. Management: It takes an FEV1 of at least 800 to survive surgery and not be a pulmonary cripple afterwards. If this fellow got a pneumonectomy (which he would need for a central tumor) he would be left with an FEV1 of 440. No way... Don’t do any more tests. He is not a surgical candidate. Tx: pursue Chemotherapy and Radiation
Q923. A 62 year old chronic smoker has an episode of hemoptysis. Chest X-ray shows a central hilar mass. Bronchoscopy and biopsy establish a diagnosis of squamous cell carcinoma of the lung. His FEV1 is 2200, and a ventilation/perfusion scan shows that 30
A923. Diagnostic test: CT scan and Mediastinoscopy; (to ascertain if surgery has a decent chance to cure him); Tx: Pneumonectomy (can tolerate it due to high FEV1)
Q924. A 33 year old lady is undergoing a diagnostic work-up because she appears to have Cushing’s syndrome. Chest X- Ray shows a central, 3cm round mass on the right lung. Bronchoscopy and biopsy confirm a diagnosis of small cell carcinoma of the lung.
A924. Management: Radiation and chemotherapy. (Small cell lung cancer is not treated with surgery, and thus we have no need to determine FEV1 or nodal status)
Q925. A 54 year old right handed laborer notices coldness and tingling in his left hand as well as pain in the forearm when he does strenuous work. What really concerned him, though, is that in the last few episodes he also experienced transitory vertigo,
A925. Dx: Subclavian Steal syndrome; (A combination of “claudication of the arm” with posterior brain neurological symptoms is classical for this); Management: Angiographic study (If you had been given the vignette without it), then Vascular surgery
Q926. A 62 year old man is found on physical exam to have a 6cm pulsatile mass deep in the abdomen, between the xiphoid and the umbilicus; Dx?; Tx?
A926. Dx: Abdominal Aortic Aneurysm; Tx: Elective surgical repair
Q927. A 62 year old man has vague, poorly described epigastric and upper back discomfort. He has been found on physical exam to have a 6cm pulsatile mass deep in the abdomen, between the xiphoid and the umbilicus. The mass is tender to palpation. Dx?; Man
A927. Dx: Abdominal Aortic Aneurysm that is beginning to leak. Management: Get a consultation with the vascular surgeons today
Q928. A 68 year old man is brought to the ER with excruciating back pain that began suddenly 45 minutes ago. He is diaphoretic and has a systolic blood pressure of 90. There is an 8cm pulsatile mass palpable deep in his abdomen, between the xiphoid and th
A928. Dx: Abdominal Aortic Aneurysm, rupturing right now. Tx: Emergency surgery
Q929. A retired businessman has claudication when walking more than 15 blocks. Management?
A929. Management: If he is smoking he should quit; otherwise he needs nothing; (Vascular surgery, or angioplasty and stenting are palliative procedures. They do not cure arteriosclerotic occlusive disease. Claudication has an unpredictable course, thus there is no advantage to an “early operation”)
Q930. A 56 year old postman describes severe pain in his right calf when he walks two or three blocks. The pain is relieved by resting 10 or 15 minutes, but recurs if he walks again the same distance. He can not do his job this way, and he does not qualif
A930. Diagnostic test:; 1. Start with Doppler studies; 2. If he has significant gradient, Arteriogram comes next; Tx: Bypass surgery or stenting
Q931. A patient consults you because he “can not sleep”. On Questioning it turns out that he has pain in the right calf, which keeps him from falling asleep. He relates that the pain goes away if he sits by the side of the bed and dangles the leg. His
A931. Dx: Claudication; Dx test:; 1. Start with Doppler studies; 2. If he has significant gradient, Arteriogram comes next; Tx: Bypass surgery or stenting
Q932. A 45 year old man shows up in the ER with a pale, cold, pulseless, paresthetic, painful and paralytic lower extremity. The process began suddenly two hours ago. Physical exam shows no pulses anywhere in that lower extremity. Pulse at the wrist is 95
A932. Dx: Embolization by the broken-off tail of a clot from the left atrium; Tx: Emergency surgery with use of Fogarty catheters to retrieve the clot
Q933. A 74 year old man has sudden onset of extremely severe, tearing chest pain that radiates to the back and migrates down shortly after it’s onset. His blood pressure is 220/100, he has unequal pulses in the upper extremities and he has a wide medias
A933. Dx: Dissecting aneurysm of the thoracic Aorta; Management:; 1. if high BP, beta-blockers or IV nitrates to lower BP (b/c forces that dissected the vessel plus the force of the dye injection could further shear the aorta); 2. Arteriogram (first if BP is normal); Tx:; Ascending Aorta = emergency surgery; Descending Aorta = intensive therapy (in the ICU) for the hypertension will be the preferable option.
Q934. A 62 year old right handed man has transient episodes of weakness in the right hand, blurred vision, and difficulty expressing himself. There is not associated headache, the episodes last about 5 or 10 minutes at the most, and they resolve spontaneo
A934. Dx: Transient Ischemic Attacks; in the territory of the left carotid artery (probably an ulcerated plaque at the left carotid bifurcation); Diagnostic test: Angiogram; Treatment: Carotid endarterectomy
Q935. A 61 year old man presents with a one year history of episodes of vertigo, diplopia, blurred vision, dysarthria and instability of gait. The episodes last several minutes, have no associated headache and leave no neurological sequela. Dx?; Diagnosti
A935. Dx: Transient Ischemic Attacks (but now the vertebrals may be involved); Diagnostic test: Arteriogram that examines all the arteries going to the brain (i.e. an aortic arch study); Tx: Vascular surgery will follow
Q936. A 60 year old diabetic male presents with abrupt onset of right third nerve paralysis and contralateral hemiparesis. There was no associated headache. The patient is alert, but has the neurological deficits mentioned. Dx?; Diagnostic test?
A936. Dx: Stroke; (Neurological catastrophes that begin suddenly and have no associated headache are vascular occlusive); Diagnostic test: CT scan (Vascular surgery in the neck is designed to prevent strokes, not to treat them once they happen)
Q937. A 64 year old black man complains of a very severe headache of sudden onset and then lapses into a coma. Past medical history reveals untreated hypertension and examination reveals a stuporous man with profound weakness in the left extremities. Dx?;
A937. Dx: Vascular Hemorrhagic stroke; (Neurological catastrophes of sudden onset with severe headache); Diagnostic test: CT scan; Tx: Supportive with eventual rehabilitation efforts if he survives.
Q938. A 39 year old lady presents to the ER with a history of a severe headache of sudden onset that she says is different and worse than any headache she has ever had before. She is given pain medication and sent home. She improves over the next few days
A938. Dx: Subarachnoid bleeding from an intracranial aneurysm. (the nuchal rigidity betrays the presence of blood in the subarachnoid space); Diagnostic test:; 1. CT scan to find bleeder; 2. Angiograms will eventually follow, in preparation for (Tx) Surgery to clip the aneurysm
Q939. A 31 year old nursing student developed persistent headaches that began approximately 4 months ago, have been gradually increasing in intensity and are worse in the mornings. For the past three weeks, she has been having projectile vomiting. Thinkin
A939. Dx: Brain Tumor; (Neurological processes that develop over a period of a few months and lead to increased intracranial pressure, spell out tumor); Diagnostic test: MRI (If not offered, settle for CT scan); Management: Measures to decrease intracranial pressure include Mannitol, Hyperventilation, and high dose Steroids (decadron).
Q940. A 42 year old right handed man has a history of progressive speech difficulties and right hemiparesis for five months. He has had progressively severe headaches for the last two months. At the time of admission he is confused, vomiting, has blurred
A940. Dx: Brain tumor; (but now with two added features...there are localizing signs: left hemisphere, parietal and temporal area...and he manifests the Cushing’s reflex of extremely high intracranial pressure); Management: Emergent Decrease ICP with Mannitol, Hyperventilation and Steroids; Tx: Surgery
Q941. A 12 year old boy is short for his age, has bitemporal hemianopsia and has a calcified lesion above the sella in X- Rays of the head. Dx?; Diagnostic test?; Tx?
A941. Dx: Craniopharyngioma; Diagnostic test: MRI; Tx: Pituitary surgery
Q942. A 23 year old nun presents with a history of amenorrhea and galactorrhea of six months duration. She is very concerned that other may think that she is pregnant, and she vehemently denies such a possibility. Dx?; Diagnostic test? (2 steps); Tx?; If
A942. Dx: Prolactinoma; Diagnostic test:; 1. Measure Prolactin level (Every time you suspect a functioning tumor of an endocrine gland, you measure the appropriate hormone); 2. MRI to see tumor for surgery; Tx: Trans-nasal, trans-sphenoidal; If inoperable: Bromocriptine
Q943. A 44 year old man is referred for treatment of hypertension. His physical appearance is impressive: he has big, fat, sweaty hands; large jaw and thick lips, large tongue and huge feet. He is also found to have a touch of diabetes. In further Questio
A943. Dx: Acromegaly; Diagnostic test:; 1. Growth hormone levels; 2. MRI for surgery; Tx: Pituitary surgery
Q944. A 15 year old girl has gained weight and become “ugly”. She shows a picture of herself a year ago, where she was a lovely young lady. Now she has a hairy, red, round face full of pimples; her neck has a posterior hump and her supraclavicular are
A944. Dx: Cushing’s syndrome; Diagnostic test:; 1. AM and PM cortisol levels; 2. Dexamethasone suppression test; 3. MRI of the sella; Tx:; 1. Cushings Dz: Trans-sphenoidal pituitary surgery; 2. Adrenal CA: Adrenalectomy; 3. Ectopic ACTH: remove Primary tumor
Q945. A 55 year old lady is involved in a minor traffic accident where her car was hit sideways by another car that she “did not see” at an intersection. When she is tested further it is recognized that she has bitemporal hemianopsia. Ten years ago sh
A945. Dx: Nelson’s syndrome; (Years ago, before imaging studies could identify pituitary microadenomas, patients with Cushing’s were treated with bilateral adrenalectomy instead of pituitary surgery. In some of those patients the pituitary microadenoma kept on growing and eventually gave pressure symptoms); Diagnostic test: MRI will show the tumor; Tx: Trans-nasal, trans-sphenoidal surgery will remove it
Q946. A 42 year old man has been fired from his job because of inappropriate behavior. For the past two months he has gradually developed very severe, “explosive” headaches that are located on the right side, above the eye. Neurologic exam shows optic
A946. Dx: Brain tumor in the right frontal lobe; (Foster-Kennedy syndrome); (A little knowledge of neuroanatomy can help localize tumors. The frontal lobe has to do with behavior and social graces, and is near the optic nerve and the olfactory nerve); Diagnostic test: MRI; Tx: Neurosurgery
Q947. A 32 year old man complains of progressive, severe generalized headaches that began three months ago are worse in the mornings and lately have been accompanied by projectile vomiting. He has lost his upper gaze and he exhibits the physical finding k
A947. Dx: Tumor is in the pineal gland (Parinaud’s syndrome); Diagnostic test: MRI; Tx: Neurosurgery
Q948. A six year old boy has been stumbling around the house and complaining of severe morning headaches for the past several months. While waiting in the office to be seen, he assumes the knee-chest position as he holds his head. Neurological exam demons
A948. Dx: Tumor of the Posterior Fossa. (Most brain tumors in children are located there, and cerebellar function is affected); Diagnostic test: MRI; Tx: Neurosurgery
Q949. A 23 year old man develops severe headache, seizures and projectile vomiting over a period of two weeks. He has low grade fever, and was recently treated for acute otitis media and mastoiditis. Dx?; Diagnostic test?; Tx?
A949. Dx: Brain abscess; (Signs and symptoms suggestive of brain tumor that develop in a couple of weeks with fever and an obvious source on infection, spell out abscess); Diagnostic test: These are seen in CT as well as they would on MRI, and the CT is cheaper and easier to get...so pick CT if offered. Tx: Resected by the neurosurgeons
Q950. An 18 year old street fighter gets stabbed in the back, just to the right of the midline. He has paralysis and loss of proprioception distal to the injury on the right side, and loss of pain perception distal to the injury on the left side. Dx?; Man
A950. Dx: Spinal cord Hemisection; (Brown-Sequard’s syndrome); Management: high dose corticosteroids soon after a spinal cord injury may help minimize the permanent damage.
Q951. A patient involved in a car accident sustains a burst fracture of the vertebral bodies. He develops loss of motor function and loss of pain and temperature sensation on both sides distal to the injury, while showing preservation of vibratory sense a
A951. Dx: Anterior cord syndrome; Management: high dose corticosteroids soon after a spinal cord injury may help minimize the permanent damage.
Q952. An elderly man is involved in a rear end automobile collision where he hyperextends his neck. He develops paralysis and burning pain of both upper extremities while maintaining good motor function in his legs. Dx?; Management?
A952. Dx: Central Cord syndrome; Management: high dose corticosteroids soon after a spinal cord injury may help minimize the permanent damage.
Q953. A 52 year old lady has constant, severe back pain for two weeks. While working on her yard, she suddenly falls and can not get up again. When brought to the hospital she is paralyzed below the waist. Two years ago she had a mastectomy for cancer of
A953. Dx: Canacer metastasis causing Spinal fracture; (Most tumors affecting the spinal cord are metastatic, extradural; the sudden onset of the paralysis suggests a fracture with cord compression or transection); Diagnostic test: MRI is the best imaging modality for the spinal cord. Tx: Neurosurgeons may be able to help if the cord is compressed rather than transected
Q954. A 45 year old male gives a history of aching back pain for several months. He has been told that he had muscle spasms, and was given analgesics and muscle relaxants. He comes in now because of the sudden onset of very severe back pain that came on w
A954. Dx: Lumbar disk Herniation; (The peak age incidence is 45, and virtually all of these are either L4-L5 or L5-S1); Diagnostic test: MRI; Management:; 1. Bed rest will take care of most of these; 2. Neurosurgical intervention only if there is progressive weakness or sphincteric deficits
Q955. A 79 year old man complains of leg pain brought about by walking and relieved by rest. On further questioning it is ascertained that he has to sit down or bend over for the pain to go away. Standing at rest will not do it. Furthermore, he can exerci
A955. Dx: Neurogenic Claudication; Diagnostic test: MRI; Tx: Eventually surgical decompression of this cauda equina
Q956. A 60 year old man complains of extremely severe, sharp, shooting, “like a bolt of lighting”, pain in his face which is brought about by touching a specific area, and which lasts about 60 seconds. His neurological exam is normal, but it is noted
A956. Dx: Tic Doloreaux (Trigeminal neuralgia); Diagnostic test: Rule out organic lesions with MRI; Tx: Anticonvulsants
Q957. Several months after sustaining a crushing injury of his arm, a patient complains bitterly about constant, burning, agonizing pain that does not respond to the usual analgesic medications. The pain is aggravated by the slightest stimulation of the a
A957. Dx: Causalgia (reflex sympathetic distrophy); Management:; 1. Sympathetic block is diagnostic; 2. Surgical sympathectomy will be curative
Q958. In the newborn nursery it is noted that a child has uneven gluteal folds. Physical exam of the hips reveals that one of them can be easily dislocated posteriorly with a jerk and a “ click”, and returned to normal position with a “snapping”.
A958. Dx: Developmental Dysplasia of the hip; Management: Abduction splinting; (Don’t order X-Rays in a newborn. Calcification is still incomplete and you will not see anything)
Q959. A 6 year old boy has insidious development of limping with decreased hip motion. He complains occasionally of knee pain on that side. He walks into the office with an antalgic gait. Passive motion of the hip is guarded. Dx?; Diagnostic test?; Manage
A959. Dx: Legg-Perthes disease; (avascular necrosis of the capital femoral epiphysis); [Remember that hip pathology can show up with knee pain]; Diagnostic test: AP and lateral X-Rays for diagnosis; Management: Contain the femoral head within the acetabulum by casting and crutches
Q960. A 13 year old boy complains of pain in the groin (it could be the knee) and is noted by the family to be limping. He sits in the office with the foot on the affected side rotated towards the other foot. Physical examination is normal for the knee, b
A960. Dx: Slipped Capital Femoral Epiphysis; (Forget the details: a bad hip in this age group is slipped capital femoral epiphysis, an orthopedic emergency); Diagnostic test: AP and lateral X-Rays; Tx: The orthopedic surgeons will pin the femoral head in place
Q961. A little toddler has had the flu for several days, but he was walking around fine until about two days ago. He now absolutely refuses to move one of his legs. He is in pain, holds the leg with the hip flexed, in slight abduction and external rotatio
A961. Dx: Septic Hip (orthopedic emergency); Management:; 1. Under general anesthesia the hip is aspirated to confirm the diagnosis, and; 2. Open arthrotomy is done for drainage
Q962. A child with a febrile illness but no history of trauma has persistent, severe localized pain in a bone. Dx?; Diagnostic test?
A962. Dx: Acute Hematogenous Osteomyelitis; Diagnostic test: Bone Scan; (don’t fall for the X-Ray option. X-Ray will not show anything for two weeks)
Q963. A 12 year old girl is referred by the school nurse because of potential scoliosis. The thoracic spine is curved toward the right, and when the girl bends forward a “hump” is noted over her right thorax. The patient has not yet started to menstru
A963. Management:; 1. Baseline x-rays to monitor progression; 2. Bracing may be needed to arrest progression; 3. Pulmonary function could be limited if there is large deformity; (The point is that scoliosis may progress until skeletal maturity is reached. At the onset of menses skeletal maturity is about 80%, so this patient still has a way to go)
Q964. A 16 year old boy complains of low grade but constant pain in his distal femur present for several months. He has local tenderness in the area, but is otherwise asymptomatic. X- Rays show a large bone tumor, with “sunburst” pattern and periostea
A964. Dx: Osteogenic Sarcoma or Ewing’s Sarcoma; Management: The point of the vignette is that you do not mess with these. Do not attempt biopsy. Referral is needed, not just to an orthopedic surgeon (they see one of these every three years), but to a specialist on bone tumors
Q965. A 66 year old lady picks up a bag of groceries and her arm snaps broken; Dx?; Diagnostic test? (3 steps)
A965. Dx: A pathologic fracture (i.e: for trivial reasons) means bone tumor, which in the vast majority of cases will be metastatic. Diagnostic test:; 1. Get X-Rays to diagnose this particular broken bone,; 2. whole body Bone Scans to identify other metastasis,; 3. start looking for the primary cancer site; (In women, breast. In men, prostate. In heavy smokers, lung...and so on)
Q966. A 58 year old lady has a soft tissue tumor in her thigh. It has been growing steadily for six months, it is located deep into the thigh, is firm, fixed to surrounding structures and measures about 8cm in diameter; Dx?; Diagnostic test?
A966. Dx: Soft tissue sarcoma is the concern; Diagnositic test: MRI; (Leave biopsy and further management to the experts)
Q967. A middle aged homeless man is brought to the ER because of very severe pain in his forearm. The history is that he passes out after drinking a bottle of cheap wine and he slept on a park bench for an indeterminate time, probably more than 12 hours.
A967. Dx: Compartment syndrome; Tx: Emergency Fasciotomy
Q968. A patient presents to the ER complaining of moderate but persistent pain in his leg under a long leg plaster cast that was applied six hours earlier for an ankle fracture; Management?
A968. Management: Remove the cast; (The point of this vignette is that you never give pain medication and do nothing else for pain under a cast. The cast has to come off right away. It may be too tight, it may be compromising blood supply, it may have rubbed off a piece of skin)
Q969. A young man involved in a motorcycle accident has an obvious open fracture of his right thigh. The femur is sticking out through a jagged skin laceration; Management?
A969. Management: Reduction in the OR within 6 hours; (The point of this one is that open fractures are orthopedic emergencies. This fellow may need to have other problems treated first...abdominal bleeding, intracranial hematomas, chest tubes, etc, but the open fracture should be in the OR getting cleaned and reduced within six hours of the injury)
Q970. A 55 year old lady falls in the shower and hurts her right shoulder. She shows up in the ER with her arm held close to her body, but rotated outwards as if she were going to shake hands. She is in pain and will not move the arm from that position. T
A970. Dx: Anterior Dislocation of the Shoulder, with Axillary nerve damage; Diagnostic test: Get AP and lateral X-Rays; Tx: Reduce
Q971. After a grand mal seizure, a 32 year old epileptic notices pain in her right shoulder and she can not move it. She goes to the near-by “Doc in a Box”, where she has X-Rays and is diagnosed as having a sprain and given pain medication. The next d
A971. Dx: Posterior Dislocation of the Shoulder; (Very easy to miss on regular X-Rays); Diagnostic test: Get X-Rays again but order Axillary view or Scapular Lateral
Q972. A front seat passenger in a car that had a head-on collision relates that he hit the dashboard with his knees, and complains of pain in the right hip. He lies in the stretcher in the ER with the right extremity shortened, adducted, and internally ro
A972. Dx: Posterior Dislocation of the Hip. (Emergency: The blood supply of the femoral head is tenuous, and delay in reduction could lead to avascular necrosis); Diagnostic test: X-Rays; Tx: Emergency reduction
Q973. A 77 year old man falls in the nursing home and hurts his hip. X-Rays show that he has a displaced femoral neck fracture; Dx?; Tx?
A973. Dx: Hip fracture; Tx: Metal prosthetic surgery; (The point of this vignette is that blood supply to the femoral head is compromised in this setting and the patient is better off with a metal prosthesis put in, rather than an attempt at fixing the bone. With intertrochanteric fractures on the other hand, the broken bones can be pinned together and expected to heal)
Q974. A football player is hit straight on his right leg and he suffers a posterior dislocation of his knee. Management? (3 steps)
A974. Management:; 1. Check pulses; 2. Arteriogram; 3. Reduction; (The point here is that posterior dislocation of the knee can nail the popliteal artery. Attention to integrity of pulses, arteriogram and prompt reduction are the key issues)
Q975. A young recruit complains of localized pain in his tibia after a forced march at boot camp. He is tender to palpation over a very specific point on the bone, but X-Rays are normal; Dx?; Management? (2 steps)
A975. Dx: Stress Fracture; (The lesson here is that stress fractures will not show up radiologically until 2 weeks later); Management:; 1. Treat the guy as if he had a fracture (cast); 2. Repeat the X-Ray in 2 weeks
Q976. A man who fell from a second floor window has clinical evidence of fracture of his femur. The vignette gives you a choice of X-Rays to order. What are the rules for ordering x-rays? (3)
A976. Here are the rules:; 1. Always get X-Rays at 90 degrees to each other (for instance, AP and lateral); 2. Always include the joints above and below; 3. if appropriate (this case is) check the other bones that might be in the same line of force (here the lumbar spine)
Q977. A healthy 24 year old man steps on a rusty nail at the stables where he works as a horse breeder. Three days later he is brought to the ER moribund, with a swollen, dusky foot, in which one can feel gas crepitation. Dx?; Management? (3 steps: 1 med,
A977. Dx: Gas gangrene; Management:; 1. Tons of IV penicillin; 2. Immediate surgical debridement of dead tissue; 3. followed by a trip to the nearest hyperbaric chamber for hyperbaric O2 treatment
Q978. A 55 year old, obese man suddenly develops swelling, redness and exquisite pain at the first metatarsal-phalangeal joint; Dx?; Diagnostic test?; Tx? (3 possible)
A978. Dx: Gout; Diagnostic test: Serum Uric Acid; Tx: Colchicine, Allopurinol or Probenicid
Q979. A 67 year old diabetic has an indolent, unhealing ulcer at the heel of the foot; Management? (3 steps)
A979. Management:; 1. control the diabetes; 2. keep the ulcer clean; 3. keep the leg elevated...and be resigned to the thought that you may end up amputating the foot
Q980. A 67 year old smoker with high cholesterol and coronary disease has an indolent, unhealing ulcer at the tip of his toe. The toe is blue, and he has no peripheral pulses in that extremity. Dx?; Diagnostic test? (2 steps); Tx?
A980. Dx: Ischemic Ulcers; (usually are at the farthest away pint from where the blood comes); Diagnostic test:; 1. Doppler studies looking for pressure gradient; 2. Arteriogram. Tx: Revascularization may be possible, and then the ulcer may heal
Q981. A 44 year old, obese woman has an indolent, unhealing ulcer above her right malleolus. The skin around it is thick and hyperpigmented. She has frequent episodes of cellulitis, and has varicose veins; Dx?; Management?; Tx?
A981. Dx: Venous Stasis Ulcer; Management: Unna boot and Support stockings; Tx: Varicose vein surgery
Q982. A 14 year old boy presents in the Emergency Room with very severe pain of sudden onset in his right testicle. There is no fever, pyuria or history of recent mumps. The testis is swollen, exquisitely painful, “high riding”, and with a “ horizon
A982. Dx: Testicular Torsion (urological emergency); Tx: Emergency surgery to save the testicle
Q983. A 24 year old man presents in the emergency room with very severe pain of recent onset in his right scrotal contents. There is fever of 103 and pyuria. The testis is in the normal position, and it appears to be swollen and exquisitely painful. The c
A983. Dx: Acute Epididimitis; Diagnostic test: Ultrasound (to rule-out torsion); Tx: Antibiotics; (The differential diagnosis is with testicular torsion. Torsion is a surgical emergency. Epididimitis is not. Don’t rush this guy to the OR. If the vignette is not clear-cut, i.e: and adolescent that looks like epidimitis, but could be torsion, pick a sonogram to rule out torsion before you choose the non-surgical option)
Q984. A 72 year old man is being observed with a ureteral stone that is expected to pass spontaneously. He develops chills, a temperature spike to 104 and flank pain. What should be given to him?; What is initial Tx? (2)
A984. Give: Massive IV Antibiotics; Tx:; Decompression by:; 1. Ureteral stent, or; 2. Percutaneous Nephrostomy; (Obstruction and Infection of the urinary tract: a true urological emergency. In a septic patient stone extraction would be hazardous)
Q985. An adult female relates that five days ago she began to notice frequent, painful urination, with small volumes of cloudy and malodorous urine. For the first three days she had no fever, but for the past two days she has been having chills, high feve
A985. Dx: Pyelonephritis; Management:; 1. Hospitalization; 2. IV antibiotics; 3. Sonogram to make sure that there is no concomitant obstruction; (UTI should not happen in men or in children, and thus they should trigger looking for a cause. Women of reproductive age on the other hand, get cystitis all the time and they are treated with appropriate antibiotics without great fuss)
Q986. A 62 year old male presents with chills, fever, dysuria, urinary frequency, diffuse low back pain and an exquisitely tender prostate on rectal exam; Dx?; Management? (2 steps)
A986. Dx; Acute Bacterial Prostatitis; Management:; 1. I.V. antibiotics; 2. what should not be done is any more rectal exams or any vigorous prostatic massage...doing so could lead to septic shock
Q987. You receive a call from a patient at 3:00 AM. His regular urologist retired five years ago, and he has not sought a replacement. At about 11:00 PM last night, the patient injected himself with papaverine directly into the corpora, as he had been ins
A987. Dx: Priapism (urological emergency); Management:; 1. Emergency Alpha Agonist (phenylephrine, epinephrine or terbutaline) into the corpora; 2. Once the crisis is over, the patient has to be switched from papaverine to Prostaglandin E1, which in now the agent of choice to achieve erection because it is less likely to produce priapism; (Continued erection beyond four hours begins to damage the corpora)
Q988. You are called to the nursery to see an otherwise healthy looking newborn boy because he has not urinated in the first 24 hours of life. Physical exam shows a big distended urinary bladder. Dx? (2 possible); First step?; Diagnostic test?; Tx?
A988. Dx: Urinary Obstruction secondary to; 1. Meatal Stenosis; 2. Posterior Urethral valves; First step: Drain the bladder with a catheter; (it will pass through the valves); Diagnostic test: Voiding cystourethrogram; Tx: Endoscopic Fulguration or Resection
Q989. A bunch of newborn boys are lined up in the nursery for you to do circumcisions. You notice that one of them has the urethral opening in the ventral side of his penis, about mid- way down the shaft. Dx?; Next step?
A989. Dx: Hypospadias; Next step: The point of the vignette is that you don’t do the circumcision. The foreskin may be needed later for reconstruction when the hypospadias is surgically corrected
Q990. A 7 year old child falls off a jungle gym and has minor abrasions and contusions. When checked by his pediatrician, a urinalysis shows microhematuria; Dx?; Diagnostic test?
A990. Dx: Congenital Anomaly; (Hematuria from the trivial trauma in kids means congenital anomaly of some sort); Diagnostic test: start with Sonogram (IVP may be needed later)
Q991. A 9 year old boy gives a history of three days of burning on urination, with frequency, low abdominal and perineal pain, left flank pain and fever and chills for the past two days; Dx?; Management? (2 steps)
A991. Dx: UTI; (Little boys are not supposed to get urinary tact infections. There is more than meets the eye here. A congenital anomaly has to be ruled out); Management:; 1. treat the infection; 2. Sonogram right away to begin the work up
Q992. A mother brings her 6-year-old girl to you because “ she has failed miserably to get proper toilet training”. On questioning you find out that the little girl perceives normally the sensation of having to void, voids normally and at appropriate
A992. Dx: (classic vignette) Low implantation of one ureter; (In little boys there would be no symptoms, because low implantation in boys is still above the sphincter, but in little girls the low ureter empties into the vagina and has no sphincter. The other ureter is normally implanted and accounts for her normal voiding pattern); Management:; 1. PE might show the abnormal ureteral opening; 2. IVP; Tx: Surgical repair
Q993. A 16 year old boy sneaks out with his older brother’s friends, and goes on a beer-drinking binge for the first time in his life. He shortly thereafter develops colicky flank pain; Dx?; Diagnostic test?; Tx?
A993. Dx: (classic) Ureteropelvic Junction Obstruction; Diagnostic test: Ultrasound; Tx: Surgical Repair will follow
Q994. A 62 year old male known to have normal renal function reports an episode of gross, painless hematuria. Further Questioning determines that the patient has total hematuria rather than initial or terminal hematuria; Dx? (2 possible); Diagnostic test?
A994. Dx: Either Infection or Tumor can produce hematuria. (The blood is coming anywhere from the kidneys to the bladder, rather than the prostate or the urethra. In older patients without signs of infection cancer is the main concern); Diagnostic test: IVP (“gold standard-first study” in urology, except in postential obstruction, then Ultrasound); If normal the next step: Cystoscopy
Q995. A 70 year old man is referred for evaluation because of a triad hematuria, flank pain and a flank mass. He also has hypercalcemia, erythrocytosis and elevated liver enzymes; Dx?; Diagnostic test? (2 steps)
A995. Dx: Renal cell carcinoma (also known as clear cell carcinoma, or hypernephroma); Diagnostic test:; 1. IVP first; 2. CT scan next would be the standard sequence. (In real life, if a urologist saw a patient with a palpable flank mass, he or she might go straight for the CT scan)
Q996. A 61 year old man presents with a history of hematuria. Intravenous pyelogram shows a renal mass, and sonogram shows it to be solid rather than cystic. CT scan shows a heterogenic, solid tumor. Dx?
A996. Dx: Renal cell carcinoma
Q997. A 55 year old, chronic smoker, reports three instances in the past two weeks when he has had painless, gross, total hematuria. In the past two months he has been treated twice for irritative voiding symptoms, but has not been febrile and urinary cul
A997. Dx: Bladder Cancer; Diagnostic test:; 1. IVP; 2. Cystogram; (With this very complete presentation some urologist would go for the cystoscopy first, but the standard sequence of IVP first and cystoscopy next is the only correct answer for an exam. An option both IVP and cystoscopy would be OK)
Q998. A 59 year old black man has a rock-hard, discrete, 1.5cm nodule felt in his prostate during a routine physical examination; Dx?; Diagnostic test?; Tx?
A998. Dx: Cancer of the Prostate; Diagnostic test: Trans-rectal needle biopsy; Tx: Surgical resection after the extent of the disease has been established
Q999. An 82 year old gentleman who has congestive heart failure and chronic obstructive pulmonary disease is told by his primary care physician that his level of prostatic specific antigen (PSA) is abnormally high. The gentleman has seen ads in the paper
A999. Tx: As a rule, asymptomatic prostatic cancer is not treated after age 75; (An example of technology running amock. This man should have never had the PSA in the first place, much less the sonogram and biopsy. After a certain age, most men get prostatic cancer...but die of something else)
Q1000. A 25 year old man presents with a painless, hard testicular mass. Dx?; Diagnostic test? (2)
A1000. Dx: Testicular cancer; Diagnostic test:; 1. Pre-op Alpha-fetoprotein and Beta-HCG; 2. Diagnosis is made by performing a radical orchiectomy by the inguinal route. (That irreversible, drastic step is justified because testicular tumors are almost never benign. Beware of the option to do a trans-scrotal biopsy: that is a definitive no-no)
Q1001. A 25 year old man is found on a pre-employment chest X- Ray to have what appears to be a pulmonary metastasis from an unknown primary tumor. Subsequent physical examination discloses a hard testicular mass, and the patient indicates that for the pa
A1001. Dx: Testicular Cancer with metastasis. Diagnostic test:; pre-op Blood Test for Alpha-fetoprotein and Beta-HCG levels; Tx:; 1. Removal of testicle; 2. Chemotherapy; (The point of this vignette is that testicular cancer responds so well to chemotherapy, that treatment is undertaken regardless of the extent of the disease when first diagnosed)
Q1002. A 60 year old man shows up in the ER because he has not been able to void for the past 12 hours. He wants to, but can not. On physical exam his bladder is palpable half way up between the pubis and the umbilicus, and he has a big, boggy prostate gl
A1002. Dx: Acute urinary retention, with underlying BPH; Management: Indwelling bladder catheter, to be left in for at least 3 days; Tx: long-term Alpha-blockers for symptomatic relief, or some form of Prostatic Resection
Q1003. On the second post-operative day after surgery for repair of bilateral inguinal hernias, the patient reports that he “can not hold his urine”. Further questioning reveals that every few minutes he urinates a few cc’s of urine. On physical exa
A1003. Dx: Acute Urinary Retention with Overflow Incontinence; Management: Indwelling bladder catheter
Q1004. A 42 year old lady consults you for urinary incontinence. She is the mother of five children and ever since the birth of the last one, seven years ago, she leaks a small amount of urine whenever she sneezes, laughs, gets out of a chair or lifts any
A1004. Dx: Stress Incontinence; Tx: Surgical repair of the pelvic floor.
Q1005. A 72 year old man who in previous years has passed a total of three urinary stones is now again having symptoms of ureteral colic. He has relatively mild pain that began six hours ago, and does not have much in the way of nausea and vomiting. X-Ray
A1005. Management:; 1. Watch him (time); 2. Pain medication; 3. Plenty of Fluids; (there is still a role for watching and waiting. This man is a good example: small stone, almost at the bladder. Give him time, medication for pain, and plenty of fluids, and he will probably pass it)
Q1006. A 54 year old lady has a severe ureteral colic. IVP shows a 7mm Ureteral stone at the ureteropelvic junction; Tx?
A1006. Tx: Shock-wave Lithotripsy; (whereas a 3mm stone has a 70% chance of passing, a 7mm stone only has a 5% probability of doing so. This one will have to be smashed and retrieved)
Q1007. A 33 year old man has urgency, frequency, and burning pain with urination. The urine is cloudy and malodorous. He has mild fever. On physical exam the prostate is not warm, boggy or tender; Dx?; Management? (3 together)
A1007. Dx: Urinary Tract Infections; Management:; 1. start Urinary cultures; 2. start Antibiotics; 3. either IVP or Sonogram
Q1008. A 72 year old man consults you with a history for that for the past several days he has noticed that bubbles of air come out along with the urine when he urinates. He also gives symptoms suggestive of mild cystitis; Dx? (2 possible); Diagnostic tes
A1008. Dx: Pneumaturia due to a Fistula between the bowel and the bladder. (Most commonly from sigmoid colon to dome of the bladder, due to diverticulitis); or Sigmoid Cancer; Diagnostic test: CT scan; (Intuitively you would think that either cystoscopy, sigmoidoscopy or contrast studies would verify the diagnosis, but they seldom show anything in this case); Tx: Surgery will be needed
Q1009. A 32 year old man has sudden onset of impotence. One month ago he was unexpectedly unable to perform with his wife after an evening of heavy eating and heavier drinking. Ever since then he has not been able to achieve an erection when attempting to
A1009. Dx: Classical Psychogenic Impotence; (young man, sudden onset, partner-specific. Organic impotence is typically older, of gradual onset and universal); Management: Curable with psychotherapy if promptly done; (It will become irreversible after two years)
Q1010. Even without intake, how much urine must you excrete in waste products?
A1010. 800mL/day
Q1011. Where is Na reabsorbed in the nephron? In exchange for what?
A1011. Distal Tubule. For K and H secretion
Q1012. What patients should receive Colloids instead of Crystalloids? (7)
A1012. Patients with excess Na and water, but still hypovolemic (Ascites, CHF, post-cardiac bypass patients);; Patients unable to make Albumin (Liver disease, transplant recipients);; Severe Hemorrhage or Coagulopathy;; ER patient with Flail chest due to rib fractures that progresses to Respiratory contusions
Q1013. What are the equations for calculating Maintenance Fluids/hour?; (3); What else does this work for?
A1013. Up to 10kg: 100mL/kg/day (4mL/kg/hr); 11 - 20kg: 1,000mL + 50mL/kg/day for each kg above 10 (40mL/hr + 2mL/kg/hr for each kg above 10); >20kg: 1,500mL + 20mL/kg/hr for each kg above 20 (60mL/hr + 1mL/kg/hr for each kg above 20); Same for estimating daily Caloric expenditure (except replace mL by kcal)
Q1014. Patient is post-surgery and on PE you notice JVD, rales, S3 and slight edema. Dx?
A1014. Hypervolemia
Q1015. What is the acute Tx for Hyperkalemia?; (3)
A1015. Lower Extracellular K:; Calcium Gluconate;; Albuterol;; NaHCO3 with Insulin;
Q1016. What is the chronic Tx for Hyperkalemia?; (2)
A1016. Lower total body K:; Kayexalate;; Dialysis
Q1017. What are the main 3 types of shock?; How can you separate one from the other two by checking the skin temp?
A1017. Check to see if the skin is warm or cold:; Warm: Distributive shock; Cold: Hypovolemic shock; Cardiogenic shock
Q1018. what is the first organ "casualty" of hypovolemic or cardiogenic shock?; Why?
A1018. Kidneys; blood is shunted away from the renal arteries; (always monitor shock patients for renal failure...adequate urine output is essential)
Q1019. what are the 3 types of Distributive shock?
A1019. Septic shock;; Neurogenic shock;; Anaphylactic shock
Q1020. MC bugs that cause Septic shock?
A1020. Gram-Negative
Q1021. what is considered adequate urine output in adult(mL/kg/hr)?; In child > 1 year?; In child < 1 year?
A1021. Adult: 0.5 mL/kg/hr; Child > 1 year: 1.0mL/kg/hr; Child < 1 year: 2.0mL/kg/hr
Q1022. what does the Wedge Pressure represent?; what is normal value?
A1022. Left Ventricular Pressure; normal = 6 - 12 mmHg
Q1023. what is the Wedge Pressure, CO and Systemic Vascular Resistance for:; 1. Cardiogenic shock; 2. Hypovolemic shock; 3. Distributive shock
A1023. Cardiogenic shock:; Wedge = UP; CO = DOWN; SVR = UP; Hypovolemic shock:; Wedge = DOWN; CO = DOWN; SVR = UP; Distributive shock:; Wedge = DOWN or NML; CO = UP; SVR = DOWN
Q1024. Drugs used for Cardiogenic shock; (4)*
A1024. DIMeD:; Dobutamine;; Isoproterenol;; Milrinone;; Dopamine
Q1025. Drugs used for Septic shock; (3)
A1025. Dopamine (High: 10-20ug/kg/min);; Norepinepherine;; Epinenpherine
Q1026. which Cardiogenic Shock drug can increase both CO and SVR based on the dosage?; (List dosage and effects); What do the other Cardiogenic shock drugs do?
A1026. Dopamine; Med dose [Inc CO]: 5-10ug/kg/min; High dose [Big Inc SVR]: 10-20ug/kg/min; Other drugs: Inc CO and Dec SVR
Q1027. which drug is used in Neurogenic shock?; what is the MOA?
A1027. Phenylephrine; MOA: Alpha-1 antagonist (Vasoconstriction)
Q1028. what drug is used for a patient with low CO with high BP?
A1028. Sodium Nitroprusside
Q1029. when is PEEP used?; (2); what is the adverse effect?
A1029. Congestive Heart Failure;; Acute Respiratory Distress Syndrome (ARDS); AE: Hypotension (dec preload)
Q1030. what is the difference in PCWD (wedge) in ARDS vs. CHF?
A1030. ARDS: PCWP < 18; CHF: PCWP > 18
Q1031. Trauma patient has possible cribriform fracture. How do you intubate?
A1031. Orogastric tube; (not Nasogastric)
Q1032. patient in a MVA arrives with an enlarging pupil and a decrease in the level of consciousness since he arrived in the ED. It is obvious he has an increase in ICP. What is specifically causing the symptoms?
A1032. Uncal Herniation
Q1033. A 20yo female has brief loss of consciousness following head injury. She presents to the ED awake but is amnestic to the event and keeps asking the same questions over and over again. Dx?
A1033. Dx: Concussion
Q1034. (5)* ways to lower ICP in a trauma patient
A1034. HIVED:; Hyperventilation (PCO2 b/t 28 - 32);; Intubation and Sedation;; Ventriculostomy (Burr holes);; Elevate the head of the bed;; Diuretics (Mannitol; Furosemide)
Q1035. which zone in neck injuries must be taken to the OR?
A1035. Zone II
Q1036. Trauma patient enters ED with flaccid paralysis, hypotension, bradycardia, cutaneous vasodilation and a normal to wide pulse pressure. Dx?; what causes this physiologically?
A1036. Neurogenic shock; cause: Impairment of the descending sympathetic path of spinal cord
Q1037. A child comes to the office with painful hands bilaterally and his head "stuck" in rotation. Why is the head like this?; Dx?
A1037. C1 Rotary Subluxation; due to (Dx) Rheumatoid Arthritis
Q1038. Tx for a Tension Pneumothorax; (describe procedure)
A1038. Needle decompression over Second intercostal space, Midclavicular on affected side (followed by a chest tube)
Q1039. Dx:; Absent or decreased upper extremity pulses and BP with increased lower extremity BP
A1039. Injury to Innominate or Subclavian Artery
Q1040. Dx:; patient in a MVA enters ER with chest trauma, new systolic murmur, dyspnea, unequal BP or pulse in extremities. CXR shows widened mediastinum, aortic knob, area b/t pulmonary artery and aorta. After stabalizing patient, what is the diagnostic
A1040. Dx: Thoracic Great Vessel Injury; test: Angiography
Q1041. Dx:; a 25-yo female presents after MVA with dyspnea, tachycardia and local bruising over right side of chest. CXR shows a right upper lobe consolidation.
A1041. Dx:; Pulmonary Contusion
Q1042. at what spinal level of the diaphragm do the structures pass?
A1042. I ate (8) 10 Eggs At 12:; T8 - IVC; T10 - Esophagus (and vagus); T12 - Aorta (and azygos vein)
Q1043. Dx:; a female presents with acute pain of her axilla and a tender cord is identified on PE. Dx? (2 possible); Diagnostic test?
A1043. Dx: Mondor's Dz or Chest Wall infection; Diagnostic test: Ultrasound
Q1044. Dx:; a 45-yo woman presents with breast pain that does not vary with her menstrural cycle with lumps in her nipple/areolar complex and a History of a non-bloody nipple discharge
A1044. Mammary Duct Ectasia
Q1045. When does the Ductus Arteriosus usually close?; What keeps it patent?; What facilitates its closure?
A1045. Closes within the first 24 hours; Patent: Prostaglandin; Closes: Indomethacin
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