1
Q
How do you reduce ICP?
A
Raise head Mannitol Sedation Hyperventilation (cerebral vasoconstriction) Removal of CSF
2
Q
How does Hyperventilation reduce ICP?
A
blow off CO2–> cerebral vasoconstriction
3
Q
What regulates ICP?
A
CBF
Pressure in brain parenchyma
Pressure of CSF
4
Q
abrupt onset of bilateral flaccid paralysis and loss of pain/temp below a certain point
A
Anterior spinal cord syndrome
cause: loss of blood flow to anterior spinal artery because of occlusion of the great radicular artery of Adamkiewicz
Upper motor neuron signs develop over days to weeks
5
Q
when do you treat a thoracic aortic aneurysm?
A
> 6cm in diameter
symptoms (chest pain, stridor, hemoptysis)
rapid increase in diameter
rupture
6
Q
how to treat thoracic aortic aneurysm?
A
replace with graft, open or endovascular stent
7
Q
what are the complications of thoracic aortic aneurysm treatment?
A
Paraplegia (up to 20%)
Anterior spinal syndrome
8
Q
Jaundice 2-3 days post surgery that required multiple blood transfusions. Elevated Alk phos and bill; nl AST and ALT
A
Postop cholestasis
after surgery characterized by hypotension (causing decreased liver function), blood loss in the tissues, and massive blood replacement (increased pigment load)
decreased renal bili excretion due to tubular necrosis
9
Q
Most common fracture in children?
A
supracondylar fracture of humerus (FOOSH result)
Complication: entrapment of brachial artery or median nerve
OR
compartment syndrome
10
Q
what is the treatment of duodenal hematoma?
A
observation with NGT and TPN
most resolve spontaneously in 1-2 weeks
11
Q
Bony nontender mass on midline of hard palate of young pt
A
Torus palatinus
congenital
more common in young, women, asians
only surgery if mass is symptomatic, interferes with speech or eating or denture fitting.
12
Q
Blood at urethral meatus, inability to void and high-riding prostate
A
Posterior urethral injury
13
Q
Posterior urethral injury _ perineal or scrotal hematoma
A
pelvic fracture
14
Q
How to assess urethral injury?
A
Retrograde urethrogram (before putting in a Foley)
15
Q
treatment of urethral injury
A
urinary diversion via suprapubic catheter to allow healing
16
Q
Bowen’s disease
A
squamous cell carcinoma in situ of the skin
thin erythematous plaque with well-defined irregular borders and overlaying crust
17
Q
Elevated PCWP in pt with shock. What kind of shock?
A
Cariogenic shock
left ventricular dysfunction
18
Q
Myocardial contusion suggested if…
A
Cariogenic shock
Sternal fracture
treat for arrhythmias
get EKG
19
Q
Signs of hypovolemic shock
A
Decreased preload (right atrial pressure, PCWP), pump function, and venous O2 sat
increased after load (SVR)
20
Q
How assess a broken clavicle
A
Neuromuscular exam because close to subclavian and brachial plexus
angiogram
21
Q
Treatment for a broken clavicle
A
middle third of clavicle–> brace, ice, rest
distal third–> open reduction and internal fixation to avoid nonunion
22
Q
Post embolectomy pain (increased with passive stretch) and paresthesias. Rapid swelling, present pulses
A
Compartment syndrome
Due to tissue swelling after reperfusion
23
Q
Four situations when compartment syndrome is common?
A
- supracondylar elbow fracture in kids
- Proximal/midshaft tibial fracture
- Electrical burns
- Arterial/venous disruption
24
Q
Treatment of compartment syndrome
A
Fasciotomy w/in 4 hrs if possible
25
Fever, chills and deep abdominal pain after blunt abdominal trauma suggests...
Retroperitoneal abscess
must drain!
26
Treatment for scaphoid fracture
X-ray (initially might not show but may show up 7-10 days later)
place in thumb spica cast and then re-xray
27
Prophylaxis of Atelectasis?
quit smoking 8 weeks prior to surgery
incentive spirometry
good pain control
post op--deep breathing exercises
epidural analgesia
positive airway pressure
28
Cause of atelectasis
shallow breathing and weak cough due to pain
29
How to diagnose splenic injury?
Stable vs. unstable
stable--> CT
Unstable--> DLP or FAST exam
30
treatment of splenic injury
Hemodynamically stable--> depends on grade of injury--> high grade then surgery but try to fix not remove
Unstable--> emergent exploratory laparotomy
31
How to treat hemoptysis
Protect non bleeding lung by positioning pt bleeding side down
Establish airway
Reverse any coagulopathies
stop bleeding
32
How to control bleeding in pts with hemoptysis
```
Bronchoscopy
-balloon occlusion
-iced saline lavage
-diluted epi/vasopressin/thrombin
-laser therapy
Arteriography and selective bronchial artery embolization
```
33
Most common bug causing hospital acquired pneumonia
MSSA
34
Orthotropic
Donor organ placed in normal anatomic position (liver, heart)
35
Heterotropic
donor organ placed in different site than normal (kidney, pancreas)
36
what HLA are most important to match in a renal allograft?
HLA-B and HLA-DR
37
Unilateral hip pain in a middle aged adult
```
Infection
trauma
arthritis
bursitis (superficial pain with pressure)
radiculopathy
```
38
tetanus prophylaxis
If had >3 toxoid doses then just get vaccine if last booster >10 yrs (clean wound) or >5 yrs (dirty wound)
If no vaccine or
39
first step in managing burn injury
secure airway
can get airway edema if injury to upper airway present
40
abdominal pain out of proportion to exam
Rule out mesenteric ischemia
test: mesenteric A gram
41
What is the primary cause of acute arterial occlusion?
Embolization
| acute thrombosis of an atheromatous lesion and vascular trauma
42
What are the 6 Ps of acute arterial occlusion?
```
Pain
Paralysis
Pallor
Paresthesia
Polar (Poikilothermic)
Pulselessness
```
43
Most common cause of acute arterial occlusion?
A fib
44
How to treat an acute arterial occlusion?
Surgical embolectomy via cutdown and Fogarty balloon
45
What skin lesion tends to be found in chronic wounds?
Squamous cell carcinoma
associated with chronically wounded, scarred or inflamed skin.
46
What are the six etiologies of acute mediastinitis
```
Esophageal perforation
posted wound infection
head and neck infection
Lung or pleural infection
Rib or vertebral osteomyelitis
distant infection
```
47
Treatment for acute mediastinitis
Wide drainage
treat primary cause
antibiotics
48
How do you increase FRC?
Incentive spirometry, coughing, and frequent repositioning/ early ambulation
also sitting upright-->reduces intraabdominal pressure acting on the undersurface of the diaphragm
49
abdominal pain, cramping, nausea, abdominal distention, emesis, hight-pitched bowel sounds
small bowel obstruction
pain can come in waves due to peristaltic rush
can also get fever, tachycardia, leukocytosis and metabolic acidosis if more severe
see dilated bowel with air-fluid levels on AXR
50
What is the initial management of SBO?
NPO
NGT
IVF
foley
51
causes of SBO
ABCs:
Adhesions--#1 in adults in US
Bulge (hernia)--#1 in world and kids
Cancer and tumors
52
what are signs of strangulated bowel with SBO?
Fever, severe/continuous pain, hematemesis, Shock, peritoneal signs, acidosis (increased lactic acid), abdominal free air, gas in bowel wall or portal vein.
53
What is the differential diagnosis for paralytic ileus?
```
postoperative (resolves 3-5 days)
Electrolyte abnormalities (hypokalemia)
Medications (anticholinergic, narcotics)
Inflammatory intra-abdominal process
Sepsis/shock
Spine injury
Retroperitoneal hemorrhage
```
54
palpable locking or catching when the knee joint is extended while under load
medial meniscus tear
confirm diagnosis with MRI or arthroscopy
55
NG tube in the chest after blunt trauma to the abdomen
Ruptured diaphragm
On left side
nausea, vomiting, respiratory distress, shifted mediastinum
tx: surgical exploration
56
pulsatile groin mass below the inguinal ligament with anterior thigh pain
Femoral artery aneurysm
can result in thrombosis and ischemia
second most common after popliteal aneurysm
associated with AAA
57
signs of a retroperitoneal hematoma
sudden hemodynamic instability and ipsilateral flank or back pain.
flat neck veins, tachycardia, back pain, recent cardiac cath
confirm with non-contrast CT scan
58
Complications after AAA repair?
MI!
atheroembolism, decamping hypotension, acute renal failure, ureteral injury, hemorrhage
colonic ischemia (IMA sacrificed during surgery--usually seen in first week )
59
Abdominal pain, tenderness and peritoneal signs, abdominal wall ecchymosis, abdominal distention, hypoactive bowel sounds
blunt abdominal trauma
first give fluids, FAST exam, then exploratory laparotomy
60
SIRS criteria
two of the four criteria
1. Temp >38.5 or 90
3. RR >20
4. WBC >12,000, 10% bands
sepsis= SIRS with known infection and associated end organ dysfunction
61
Another name for Wilson's disease
Hepatolenticular degeneration
62
Treatment for osteoarthritis
Acetaminophen
63
bone findings in osteoarthritis
narrowing of the joint space and osteophyte formation
bony enlargement
effects hands and weight-bearing joints
64
gradual onset of shoulder stiffness, Decreased ROM of shoulder, +/- pain, reduced passive and active ROM
Adhesive capsulitis
glenohumeral joint loses its normal distensibility due to chronic inflammation, fibrosis and contracture of joint capsule
65
Rotator cuff tendinopathy vs. adhesive capsulitis
can coexist
RC tendinopathy have more pain than stiffness
guarding with active ROM b/c of pain but normal ROM
66
Use of transthroacic echocardiogram
initial evaluation of infective endocarditis
67
Assessment of Raynaud phenomenon
test for autoantibodies and inflammatory marker in suspected secondary RP (older females with asymmetric raynauds)
Also CBC and metabolic panel
Urinalysis
RF
ESR and complement levels (C3 and C4)
68
systemic disorders associated with secondary raynaud phenomenon
SLE
Scleroderma
thromboangiitis obliterans (Buerger's disease--test with ateriogram)
69
Imaging used for acute pancreatitis
US
70
Dry eyes, dry mouth, cough and dyspareunia
Sick syndrome-- generalized dryness of mucous membranes
Autoimmune sialadenitis in Sjogren syndrome
71
extra glandular features of Sjogren syndrome
arthritis, lymphadenopathy, Raynaud phenomenon or vasculitis
autoantibodies (ANA, RF, Anti-SSA and Anti-SSB)
72
acute monoarticular arthritis with chondrocalcinosis
calcium pyrophosphate dehydrate crystal deposition disease (Pseudogout)
73
secondary causes of pseudogout
hyperPTH, hypothyroid, hemochromatosis
74
Recently diagnosed DM2 and hepatomegaly with arthritis
hereditary hemochromatosis
also get bronzed skin
restrictive or dilated cardiomyopathy
75
New iron deficiency anemia in elderly patients
think GI bleed (polyps, cancer, angiodysplasia)
76
Use of radioisotope scans
identify source of active bleeding
77
patient with liver disease and ascites with temp >37.8, diffuse abdominal pain and/or mental status change
spontaneous bacterial peritonitis
due to intestinal bacteria translocation into the ascitic fluid or via blood to liver and fluid
test mental status with Reitan trail test (timed connect the numbers test)
PMN count in ascites >250 + positive culture of peritoneal fluid confirm diagnosis
78
Treatment for non bleeding esophageal varices
Nonselective beta blocker (propranolol and nadolol)
Or endoscopic variceal ligation
79
Treatment for actively bleeding esophageal varices
Octreotide
80
Progressive proximal muscle weakness with difficulty ascending and descending stairs
Polymyositis
81
Ddx for proximal muscle weakness
```
muscular dystrophy
Polymyositis and dermatomyositis
Hypothyroid
Corticosteroids
HIV myopathy
```
82
Antimitochrondrial antibody
Primary biliary cholangitis
83
First symptoms of PBC
Pruritus and fatigue
then jaundice, steatorrhea, hepatomegaly, portal HTN and Osteopenia
84
Treatment for PBC
Ursodeoxychlic acid
85
Dubin-Johnson syndrome
Pts have high conjugated bilirubin
icterus with otherwise normal exam
mainly asymptomatic
usually icterus is triggered by illness, pregnancy or OCP
black liver; high levels of coproporphyrin I
86
Young middle aged woman on long term oral contraceptives with a large painful hepatic mass. Diagnosis? labs?
Diagnosis: hepatic adenomas
U/S shows well-demarcated hyperechoic lesions
Labs: elevated alk phase and GGT but otherwise normal liver markers
87
Long term risks of hepatic adenoma
growth, rupture, malignant transformation
88
Risk factors for gout
medications (diuretics, low dose aspirin)
Surgery, trauma, recent hospitalization
volume depletion
alcohol
89
Gout onset
12-24 hrs
90
Septic arthritis onset
days
fever and chills plus acute monoarticular arthritis
91
Etiology of small intestinal bacterial overgrowth
```
anatomical abnormalities (strictures, surgery)
Motility disorders (DM, scleroderma)
Other (ESRD, AIDS, Cirrhosis, advanced age)
```
Diagnose with jejunal aspirate
92
Esophageal stricture vs. adenocarcinoma on barium swallow
Stricture--> symmetric narrowing
Adenocarcinoma--> asymmetric narrowing
93
Where is zinc absorbed?
Jejunum
94
alopecia, abnormal taste, bollus, pustulous lesions around body orifices and or extremities, impaired wound healing
zinc deficiency
can result from chronic TPN
95
Selenium deficiency
cardiomyopathy
96
Risk factors for pancreatic cancer
```
first degree relative
hereditary pancreatitis
gremlin mutations
cigarette smoking
obesity
non hereditary chronic pancreatitis
```
97
most common causes of cirrhosis
alcohol abuse
| viral hepatitis
98
morning stiffness in DIP joints, dactylics (sausage digits) and nail involvement plus red plaques with silvery scaling
Psoriatic arthritis
99
pain in the plantar surface of heel
| worse when start running or first steps of the day
Plantar fasciitis
100
Numbness or pain between the 3rd and 4th toes and clicking sensation when squeezing joints
morton neuroma
101
gnawing epigastric pain and intermittent melena
duodenal ulcer
worse on empty stomach
Causes: H. pylori and NSAIDs
102
characteristics of ascites
color (bloody, milky, turbid, straw)
Neutrophils
Total protein
Serum to ascites albumin gradient (SAAG)
103
SAAG indications
>1.1= portal HTN (increased hydrostatic pressure)
104
What is the most specific marker for androgen producing adrenal tumors?
DHEA-S (only produced in the adrenals
| DEAH and T are also produced in ovaries and testes
105
Treatment for Actinomyces
penicillin
associated with Dental trauma
106
Anterior MI
LAD blocked
changes in V1-V6
107
ST elevation in leads II, III and aVF
inferior MI
LCX or RCA
108
Right ventricle MI
RCA
ST elevation in leads V4-V6R
109
ST elevation in I and aVL
| With ST depression in leads V1-V3
LCX Posterior MI
110
ST depression in I and aVL
RCA Posterior MI
111
Rash on the trunk that extends to the palms and soles with generalized lymphadenopathy
secondary syphilis
112
Next step in acne treatment after topical retinoids
topical antibiotics
| erythromycin, clindamycin
113
Causes of exudate plural effusions
infection, autoimmune dz, neoplasm
114
What are the dietary recommendations for people with renal calculi?
Increase fluid intake
Decreased sodium intake
Normal dietary calcium intake
115
Signs of hypokalemia
muscle weakness, arrhythmias and EKG changes
116
Multiple system atrophy
Degenerative dz charaterized by:
Parkinsonism
Autonomic dysfunction (orthostatic hypotension, loss of bladder control, impotence, stridor)
Widespread neurologic signs
117
Who should get the 13 valent pneumococcal conjugate vaccine
All adults >65 yo
then get the 23 talent after 6-12 mo
118
Who should just get the 23 valent pneumococcal vaccine?
adults under 65yo when have chronic medical conditions
119
Risks of iron deficiency anemia in kids
prematurity
lead exposure
infants consuming: low iron formula, cows milk before 1yo, exclusively breast milk after 6mo
Toddlers who consume a lot of milk or very little iron
120
How to calculate PAO2
PAO2= 150-PaCO2/0.8
121
Causes of normal A-a gradient hypoxia
high altitude
| CNS depression
122
Recurrent painful oral aphthous ulcers
Genital ulcers
uveitis
Behcet disease
| also can have erythema nodosum and high risk of vasculitis with thrombosis
123
Criterial for long-term oxygen therapy in COPD pts
1. all pts w/ PaO2 60mmHg with SaO2 >90%
124
Signs of hypercalcemia
```
Constipation
anorexia
weakness
polyuria
neurologic abel
```
(stones, bones, groans, psychiatric overtones)
125
back pain, anemia, renal dysfunction, elevated ESR, hypercalcemia
Multiple myeloma
| x-ray shows multiple punched out lytic lesions
126
Treatment for mild persistent asthma
albuterol inhaler plus inhaled corticosteroids
127
colon condition associated with Down syndrome
Hirschsprung disease
failure of neural crest cells to migrate
involves rectosigmoid colon
128
Signs of hirschsprung disease
poor feeding, abdominal distention, failure to pass meconium and even biliary emesis
Squirt sign--explosive gas and stool on rectal exam
129
How diagnose complete bowel obstruction w/o perf
contrast enema
130
How to diagnose Hirschsprung
rectal suction biopsy
absence of ganglion cells
131
Risk factors for celiac disease
```
Type 1 DM
first degree relative
autoimmune thyroiditis
Down syndrome
selective IgA deficiency
```
132
Extra intestinal manifestation of celiac
short stature and weight loss
iron deficiency anemia
dermatitis herpetiformis
133
Diagnosis of celiac
Anti-tissue transglutaminase antibody IgA
duodenal biopsy (increased intraepithelial lymphocytes and flattened villi)
134
How to approach a solitary pulmonary nodule
determine probability of malignancy
if high chance-->excise
135
When excise a solitary pulmonary nodule
High chance of malignancy
lesion growth on imaging
positive FDG-PET scan
suspected malignancy on path
136
Cough, large volume sputum, recurrent fever, hemoptysis
Bronchiectasis
137
Chest X-ray for bronchiectasis shows
linear atelectasis
dilated and thickened airways
irregular peripheral opacities
138
Diagnosis of bronchiectasis
CT first
| then sputum analysis, branch if focal disease
139
fetal macrosomia, rapid growth initially
omphalocele or umbilical hernia
macroglossia
hemihyperplasia
Beckwith-Wiedemann syndrome
| 11q15 gene
140
Beckwith-Wiedmann complications
Wilms tumor
Hepatoblastoma
hypoglycemia
141
urinary homovanillic and vanilmandelic acid assay is for...
Neuroblastoma
142
thrombocytopenia, hemolytic anemia, renal failure + altered mental status, low-grade fever
Thrombotic thrombocytopenic Purpura (TTP)
143
Diagnosis of TTP
Clinical
| peripheral blood smear (increased number of schistocytes)
144
Primary source for PE clots
Proximal deep veins in lower extremity (above knee--iliofemoral vein clot)
other less common: calf, renal, pelvic, upper extremity veins, right heart
145
Exquisitely tender skin post chemo
Herpes zoster
146
Complications of PEEP
alveolar damage, tension pneumothorax, hypotension
147
Colon cancer screening recommendation for IBD
8 years after diagnosis
| colonoscopy with biopsy every 1-2 years
148
Colon cancer screening in family history of adenomatous polyps or CRC
colonoscopy age 40 or 10 years before age of diagnosis of family member
repeat every 3-5 years
149
migratory superficial thrombophlebitis
Trousseau's syndrome
hyper coagulation with unexplained superficial venous thrombosis at unusual sites (arm and chest)
150
Cancer associated with Trousseau's syndrome
Pancreas
lung, prostate, stomach, colon
151
Fluid for resuscitation of children
Isotonic crystalloid
| --> NS
152
Most common cause of bile ductopenia
Primary biliary cirrhosis
| failed liver txp, hodgkin's, GVH, sarcoid, CMV, HIV, meds
Surgery Shelf exam
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