Surgery Questions USMLE 2 Set 2 Flashcards

diagnostic test
Terms Definitions
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 remarkable
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
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 shows
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
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?
Child Abuse
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?
Child Abuse
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?
Child Abuse
A 4 year old boy passes a large bloody bowel movement.
Dx?
Diagnostic test?
Tx?
Dx: Meckel’s diverticulum

Diagnostic test: Radioisotope scan looking for gastric mucosa in the lower abdomen

Tx: Surgical excision
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 present for
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).
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 year or t
Dx: Branchial Cleft Cyst

Tx: Elective surgical removal
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 and ches
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
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?
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)
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 sweats
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
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?
Management?
Dx: Malignant mets 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
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 at leas
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)
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?
Dx: Squamous cell carcinoma of the mucosa of the head and neck

Diagnostic test: Triple endoscopy to find and biopsy the primary tumor
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?
Squamous cell carcinoma of the mucosa of the head and neck

Diagnostic test: Triple endoscopy to find and biopsy the primary tumor
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?
Dx: Squamous cell carcinoma of the mucosa of the head and neck

Diagnostic test: Triple endoscopy to find and biopsy the primary tumor
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 side.
Dx?
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
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 lower f
Dx: Gradual, unilateral nerve paralysis suggests a neoplastic process

Diagnostic test: Gadolinium enhanced MRI
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?
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)
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 of left
Dx: Cancer of the parotid gland

Management: Referral to a head and neck surgeon for formal superficial parotidectomy
(Amateurs should not mess with parotid)
A two year old boy has unilateral ear ache.
Dx?
Dx: Unilateral versions of common bilateral ENT conditions in toddlers suggest Foreign Body
A two year old has unilateral foul smelling purulent rhinorrhea.
Dx?
Dx: Unilateral versions of common bilateral ENT conditions in toddlers suggest foreign body
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?
Dx: Unilateral versions of common bilateral ENT conditions in toddlers suggest foreign body
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 he had
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.
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 mouth
Dx: Ludwigs’ Angina
(An abscess of the floor of the mouth)

Tx:
1. Tracheostomy
2. Incision & Drainage of the abscess
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?
Dx: Bell’s palsy

Management: Immediate anti-viral medication
(the process is idiopathic and will resolve spontaneously in most cases)
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.
Dx?
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)
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 antibiotics for
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)
A 10 year old girl has epistaxis. Her mother says that she picks her nose all the time.
Dx?
Tx?
Dx: Bleeding from the Anterior part of the septum

Tx: Phenylephrine spray and local pressure
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)
Dx:
1. Septal perforation from cocaine abuse
2. Posterior juvenile Nasopharyngeal Angiofibroma
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)
Dx: Epistaxis secondary to hypertension

Management:
1. Lower BP with Medication
2. Involve ENT

(These are serious problems that can end up with death)
A 57 year old man seeks help for “dizziness”. On further questioning he explains that the room spins around him
Dx?
Management?
Dx: Vestibular Apparatus

Management: Symptomatic treatment (meclizine, phenergan, diazepam), or an ENT workup
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 fixed
Dx: Atrial septal defect

Diagnostic test: Echocardiography

Tx: Surgical closure of the defect
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?
Dx: Ventricular septal defect

Diagnostic test: Echocardiography

Tx: surgical correction
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)
Patent Ductus Arteriosus

Diagnostic test: Echocardiography

Tx:
1. Surgical closure
2. Indomethacin
A patient known to have a congenital heart defect requires extensive dental work.
Management?
Management: antibiotic prophylaxis for subacute bacterial endocarditis
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 squattin
Dx: Tetralogy of Fallot

Diagnostic test: Echocardiogram
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 indicated? (2)
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
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 has had
Dx: Chronic Aortic Insufficiency

Diagnostic test: Echocardiogram

Next step: Aortic valve replacement
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 detoxif
Dx: Acute Aortic Insufficiency due to Endocarditis

Management:
1. Emergency valve replacement
2. Antibiotics for a long time
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 diastoli
Dx: Mitral stenosis

Diagnostic test: Echocardiogram

Tx: Eventually surgical mitral valve repair
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.
Dx?
Di
Dx: Mitral Regurgitation

Diagnostic test: Echocardiogram

Tx: eventually surgical repair of the valve (Annuloplasty) or possibly valve replacement
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 sedentary li
It’s a heart attack waiting to happen...

Management: Cardiac Catheterization
(to see if he is a suitable candidate for coronary revascularization)
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 sedentary li
Management: Angioplasty

(He is lucky. He has good distal vessels...smokers and diabetics often do not...and enough cardiac function left. He clearly needs coronary bypass, and with 3-vessel disease there should be no argument for angioplasty instead of surgery)
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?
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.
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 calcifications in
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)
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 60% of
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
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% of h
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)
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.
Managem
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)
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, blurr
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
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?
Dx: Abdominal Aortic Aneurysm

Tx: Elective surgical repair
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?
Management
Dx: Abdominal Aortic Aneurysm that is beginning to leak.

Management: Get a consultation with the vascular surgeons today
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 the umbi
Dx: Abdominal Aortic Aneurysm, rupturing right now.

Tx: Emergency surgery
A retired businessman has claudication when walking more than 15 blocks.

Management?
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”)
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 qualify yet
Diagnostic test:
1. Start with Doppler studies
2. If he has significant gradient, Arteriogram comes next

Tx: Bypass surgery or stenting
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 wife
Dx: Claudication

Dx test:
1. Start with Doppler studies
2. If he has significant gradient, Arteriogram comes next

Tx: Bypass surgery or stenting
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 per m
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
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 mediastinum
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.
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 spontaneously.
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
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?
Diagnostic test?
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
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?
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)
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?
Diagno
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.
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, but
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
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. Thinking that
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).
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 vision
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 w/ Mannitol, Hyperventilation and Steroids

Tx: Surgery
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?
Dx: Craniopharyngioma

Diagnostic test: MRI

Tx: Pituitary surgery
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 Tx is not
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
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 questioning h
Dx: Acromegaly

Diagnostic test:
1. Growth hormone levels
2. MRI for surgery

Tx: Pituitary surgery
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 areas are
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
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 she had
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
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 nerve
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
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 known a
Dx: Tumor is in the pineal gland (Parinaud’s syndrome)

Diagnostic test: MRI

Tx: Neurosurgery
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 demonstrates
Dx: Tumor of the Posterior Fossa.
(Most brain tumors in children are located there, and cerebellar function is affected)

Diagnostic test: MRI

Tx: Neurosurgery
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?
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
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?
Management
Dx: Spinal cord Hemisection
(Brown-Sequard’s syndrome)

Management: high dose corticosteroids soon after a spinal cord injury may help minimize the permanent damage.
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 and pos
Dx: Anterior cord syndrome

Management: high dose corticosteroids soon after a spinal cord injury may help minimize the permanent damage.
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?
Dx: Central Cord syndrome

Management: high dose corticosteroids soon after a spinal cord injury may help minimize the permanent damage.
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 the br
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
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 when he
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
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 exercise for
Dx: Neurogenic Claudication

Diagnostic test: MRI

Tx: Eventually surgical decompression of this cauda equina
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 that p
Dx: Tic Doloreaux (Trigeminal neuralgia)

Diagnostic test: Rule out organic lesions with MRI

Tx: Anticonvulsants
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 area. T
Dx: Causalgia (reflex sympathetic distrophy)

Management:
1. Sympathetic block is diagnostic
2. Surgical sympathectomy will be curative
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”.
Dx?
Man
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)
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?
Management?
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
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, but sho
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
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 rotation and
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
A child with a febrile illness but no history of trauma has persistent, severe localized pain in a bone.
Dx?
Diagnostic test?
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)
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 menstruate.
M
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)
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 periosteal “on
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
A 66 year old lady picks up a bag of groceries and her arm snaps broken
Dx?
Diagnostic test? (3 steps)
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 mets,
3. start looking for the primary cancer site
(In women, breast. In men, prostate. In heavy smokers, lung...and so on)
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?
Dx: Soft tissue sarcoma is the concern

Diagnositic test: MRI
(Leave biopsy and further management to the experts)
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. There
Dx: Compartment syndrome

Tx: Emergency Fasciotomy
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?
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)
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?
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)
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. There i
Dx: Anterior Dislocation of the Shoulder, with Axillary nerve damage

Diagnostic test: Get AP and lateral X-Rays

Tx: Reduce
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 day she
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
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 rotated.
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
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?
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)
A football player is hit straight on his right leg and he suffers a posterior dislocation of his knee.
Management? (3 steps)
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)
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)
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
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)
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)
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, 1 surg
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
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)
Dx: Gout

Diagnostic test: Serum Uric Acid

Tx: Colchicine, Allopurinol or Probenicid
A 67 year old diabetic has an indolent, unhealing ulcer at the heel of the foot
Management? (3 steps)
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
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?
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
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?
Dx: Venous Stasis Ulcer

Management: Unna boot and Support stockings

Tx: Varicose vein surgery
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 “horizontal lie
Dx: Testicular Torsion
(urological emergency)

Tx: Emergency surgery to save the testicle
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 cord is
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)
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)
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)
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 fever, nau
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)
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)
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
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 instructe
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)
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?
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
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?
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
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?
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)
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)
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
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 interv
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
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?
Dx: (classic) Ureteropelvic Junction Obstruction

Diagnostic test: Ultrasound

Tx: Surgical Repair will follow
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?
If test
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
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)
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)
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?
Dx: Renal cell carcinoma
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 cultures
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)
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?
Dx: Cancer of the Prostate

Diagnostic test: Trans-rectal needle biopsy

Tx: Surgical resection after the extent of the disease has been established
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 for so
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)
A 25 year old man presents with a painless, hard testicular mass.
Dx?
Diagnostic test? (2)
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)
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 past six m
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)
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 gland wit
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
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 examinatio
Dx: Acute Urinary Retention with Overflow Incontinence

Management: Indwelling bladder catheter
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 heavy
Dx: Stress Incontinence

Tx: Surgical repair of the pelvic floor.
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-Rays show
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)
A 54 year old lady has a severe ureteral colic. IVP shows a 7mm Ureteral stone at the ureteropelvic junction
Tx?
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)
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)
Dx: Urinary Tract Infections

Management:
1. start Urinary cultures
2. start Antibiotics
3. either IVP or Sonogram
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 test?
Tx?
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
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 have i
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)
Even without intake, how much urine must you excrete in waste products?
800mL/day
Where is Na reabsorbed in the nephron? In exchange for what?
Distal Tubule. For K and H secretion
What patients should receive Colloids instead of Crystalloids? (7)
Patients w/ 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 w/ Flail chest due to rib fractures that progresses to Respiratory contusions
What are the equations for calculating Maintenance Fluids/hour?
(3)

What else does this work for?
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)
Patient is post-surgery and on PE you notice JVD, rales, S3 and slight edema.
Dx?
Hypervolemia
What is the acute Tx for Hyperkalemia?
(3)
Lower Extracellular K:

Calcium Gluconate;
Albuterol;
NaHCO3 w/ Insulin;
What is the chronic Tx for Hyperkalemia?
(2)
Lower total body K:

Kayexalate;
Dialysis
What are the main 3 types of shock?
How can you separate one from the other two by checking the skin temp?
Check to see if the skin is warm or cold:

Warm:
Distributive shock

Cold:
Hypovolemic shock;
Cardiogenic shock
what is the first organ "casualty" of hypovolemic or cardiogenic shock?
Why?
Kidneys

blood is shunted away from the renal arteries

(always monitor shock patients for renal failure...adequate urine output is essential)
what are the 3 types of Distributive shock?
Septic shock;

Neurogenic shock;

Anaphylactic shock
MC bugs that cause Septic shock?
Gram-Negative
what is considered adequate urine output in adult(mL/kg/hr)?

In child > 1 year?
In child < 1 year?
Adult: 0.5 mL/kg/hr

Child > 1 year: 1.0mL/kg/hr

Child < 1 year: 2.0mL/kg/hr
what does the Wedge Pressure represent?
what is normal value?
Left Ventricular Pressure

normal = 6 - 12 mmHg
what is the Wedge Pressure, CO and Systemic Vascular Resistance for:
1. Cardiogenic shock
2. Hypovolemic shock
3. Distributive shock
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
Drugs used for Cardiogenic shock
(4)*
DIMeD:

Dobutamine;
Isoproterenol;
Milrinone;
Dopamine
Drugs used for Cardiogenic shock
(4)*
DIMeD
Drugs used for Septic shock
(3)
Dopamine (High: 10-20ug/kg/min);

Norepinepherine;

Epinenpherine
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?
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
which drug is used in Neurogenic shock?

what is the MOA?
Phenylephrine

MOA: Alpha-1 antagonist (Vasoconstriction)
what drug is used for a patient with low CO with high BP?
Sodium Nitroprusside
when is PEEP used?
(2)

what is the adverse effect?
Congestive Heart Failure;
Acute Respiratory Distress Syndrome (ARDS)

AE: Hypotension (dec preload)
what is the difference in PCWD (wedge) in ARDS vs. CHF?
ARDS: PCWP < 18

CHF: PCWP > 18
Trauma patient has possible cribriform fracture. How do you intubate?
Orogastric tube

(not Nasogastric)
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?
Uncal Herniation
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?
Dx: Concussion
(5)* ways to lower ICP in a trauma patient
HIVED:

Hyperventilation (PCO2 b/t 28 - 32);
Intubation and Sedation;
Ventriculostomy (Burr holes);
Elevate the head of the bed;
Diuretics (Mannitol; Furosemide)
(5)* ways to lower ICP in a trauma patient
HIVED
which zone in neck injuries must be taken to the OR?
Zone II
Trauma patient enters ED with flaccid paralysis, hypotension, bradycardia, cutaneous vasodilation and a normal to wide pulse pressure.
Dx?
what causes this physiologically?
Neurogenic shock

cause:
Impairment of the descending sympathetic path of spinal cord
A child comes to the office with painful hands bilaterally and his head "stuck" in rotation.

Why is the head like this?
Dx?
C1 Rotary Subluxation

due to (Dx) Rheumatoid Arthritis
Tx for a Tension Pneumothorax
(describe procedure)
Needle decompression over Second intercostal space, Midclavicular on affected side (followed by a chest tube)
Dx:
Absent or decreased upper extremity pulses and BP w/ increased lower extremity BP
Injury to Innominate or Subclavian Artery
Dx:
patient in a MVA enters ER w/ 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 test?
Dx: Thoracic Great Vessel Injury

test: Angiography
Dx:
a 25-yo female presents after MVA w/ dyspnea, tachycardia and local bruising over right side of chest. CXR shows a right upper lobe consolidation.
Dx:
Pulmonary Contusion
at what spinal level of the diaphragm do the structures pass?
I ate (8) 10 Eggs At 12:

T8 - IVC

T10 - Esophagus (and vagus)

T12 - Aorta (and azygos vein)
Dx:
a female presents w/ acute pain of her axilla and a tender cord is identified on PE.

Dx? (2 possible)

Diagnostic test?
Dx: Mondor's Dz or Chest Wall infection

Diagnostic test: Ultrasound
Dx:
a 45-yo woman presents with breast pain that does not vary w/ her menstrural cycle w/ lumps in her nipple/areolar complex and a Hx of a non-bloody nipple discharge
Mammary Duct Ectasia
When does the Ductus Arteriosus usually close?

What keeps it patent?

What facilitates its closure?
Closes w/i the first 24 hours

Patent: Prostaglandin

Closes: Indomethacin
/ 172
Term:
Definition:
Definition:

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