1
Q
Most common site of bladder rupture
A
Overall = bladder dome is the weakest part, it’s also the only part that is intraperitoneal => rupture of the bladder dome can cause peritonitis (by leakage of urine into the peritoneum) and therefore shoulder pain (shared dermatome C3-C5 of the phrenic nerve)
Most common site of extraperitoneal bladder rupture = bladder neck
2
Q
45 yo F s/p elective TAH develops N/V/abdominal pain
- Meds: metformin, insulin glargine, prednisone
- round plethoric face, buffalo hump, and central obesity
Cause of acute condition?
A
Acute adrenal insufficiency = adrenal crisis
Pt w/ Cushingoid features (hump, moon face) are especially at high risk
Primary cause = Addison’s
Secondary cause = chronic (even just 3 wks) of steroid use 2/2 HPA suppression
So chronic steroid use suppresses HPA axis so pt’s body cannot appropriately response to stress (ex: surgery)
3
Q
29 yo F 3 days s/p full-thickness burn p/w severe pain and itching of the area
- circumferential eschar formation
- hand is tense and tender
(a) Dx
(b) Mechanism of symptoms
A
(a) Compartment syndrome
- rapidly increasing tense swelling, key is tissue tension
- circumferential eschar can lead to construction of venous/lymphatic drainage
(b) Venous compromise
Don’t confuse this w/ subcutaneous bacterial invasion- cellulitis would have skin worth and gas gangrene (crepitus)
4
Q
Abdominal Xray findings of paralytic ileus
A
Uniformly distended, gas-filled both small and large bowel
5
Q
Organisms responsible for prosthetic joint infections
Early vs. delayed onset infections
A
Early-onset infections (w/in 3 months of arthroplasty): think Staph aureus, GNR, anaerobes
Delayed-onset (over 3 mo): think coagulase-negative staph (staph epidermidis), propionibacterium, enterococci
Tx for both is implant removal/exchange
6
Q
Etiology of mediastinal shift that is not pneumothorax
A
Diaphragmatic hernia- abdominal contents up into thorax causing compression of lungs and mediastinal shift
7
Q
Clinical presentation of Fitz-Hugh-Curtis syndrome
A
Acute onset RUQ pain in F worse w/ inspiration, coughing, or laughing (b/c due to perihepatitis as a complication of PID)
-inflamed liver capsule rubbing against diaphragm
= rare complication of PID
8
Q
Best imaging modality when suspecting perforated peptic ulcer
A
Upright CXR of chest and abdomen
-see penumoperitoneum (free intraperitoneal air under diaphragm)
Would only do upper endoscopy if acute upper GI hemorrhage, not needed for acute perforated PUD
9
Q
22 yo M w/ sudden onset SOB x2hrs while watching tv
- 150 lbs, 6ft2
- sharp r. chest pain worse w/ deep inspiration and cough
- CXR: small right apical pneumothorax
(a) Dx
(b) Tx
A
(a) Dx = primary spontaneous pneumothorax
- rupture of subpleural bleb at rest
- risk factor = tall thin male, cig smoking
(b) Small pneumothorax in stable pt = supplemental O2 to enhance speed of resorption
- if it was large you’d decompress w/ large bore-needle
- if pt was unstable, place chest tube
10
Q
53 yo M after MVA c/o b/l chest pain and left leg pain, left femur fracture, pH 7.56/pO2 81/pCO2 32
- CXR: alveolar opacities over b/l lung bases
- normal PCWP
Dx causing SOB
A
Pulmonary contusion complicates 30-75% of severe blunt chest trauma
- often has delayed onset
- hypoxemia causes hyperventilation => respiratory alkalosis and hypocarbia
11
Q
Xray findings of pulmonary contusion
A
Patchy alveolar infiltrates
12
Q
Ddx for fever on POD5
A
Acute post-op fever (1-7 days after surgery)
- nosocominal infection (pneumonia, catheter associated)
- atelectasis if low grade
- surgical site infection: most commonly group A strep or clostridium perfringens
- noninfections: MI/PE/DVT
13
Q
Ddx of immediate post-op fever
A
Immediate post-op fever (first 2 hrs post-op)
- prior trauma/infection
- blood products
- malignant hyperthermia from anesthesia
14
Q
Ddx for fever on POD14
A
Subacute (1-4 wks) post op fever ddx
- surgical site infection
- C. dif
- drug fever (diagnosis of exclusion, think if abx allopurinol or anticonvulsants started)
- PE/DVT
15
Q
Main clinical feature of acute adrenal insufficiency
A
Severe and often refractory hypotension
- N/V, abdominal pain
- weakness
- fever
16
Q
Abdominal pain following trauma w/ Xray showing air in both small and large bowel
Dx
A
Dx = paralytic (adynamic) ileus
2/2: local release of inflammatory mediators, opioid use, increased splanchnic nerve sympathetic tone following peritoneal irritation
17
Q
Clinical exam finding indicating uncal herniation
A
Ipsilateral pupil dilation 2/2 oculomotor nerve compression
18
Q
50 yo M w/ occasional left calf pain when walking
- occasionally legs cramp at rest
- palpable pulses throughout, NSR on EKG
Next step?
A
Thinking PAD (peripheral artery disease) => next step is ABI
NOT arterial duplex ultrasound- much less sepcific and sensitive for PAD
19
Q
25 yo in MVA, unable to void despite urge
- blood at urethral meatus and scrotal hematoma
- high-riding prostate, distended bladder on exam
Dx
A
Dx = posterior urethral injury
-prostate high0riding b/c displaced by pelvic hematoma
20
Q
Etiology of tic douloureux
A
Tic douloureux = trigeminal neuralgia
Etiology = external compression of the trigeminal nerve
21
Q
Clinical presentation after injury to
(a) Radial nerve
(b) Ulnar nerve
(c) Median nerve
A
(a) Radial nerve injury => wrist drop due to limitation of wrist extension
(b) Ulnar nerve injury => claw hand
(c) Median nerve => loss of sensation to skin over lateral 3 1/2 fingers
22
Q
Mechanism by which the following lower ICP
(a) Head elevation
(b) Sedation
(c) IV mannitol
(d) Hyperventilation
A
Interventions to lower ICP
(a) Elevate head of the bed to increase venous outflow from the brain
(b) Sedate the pt to decrease metabolic demand
(c) IV mannitol works as an osmotic diuretic to extract free water from brain tissue
(d) Hyperventilation increases pCO2 which causes cerebral vasoconstriction
23
Q
65 yo M p/w suden onset severe r. leg pain
- h/o recent anterior wall MI, HTN, DM, HLD
- below the knee r. leg is cool to touch and pale
- DP pulse not palpable, popliteal full
- numbness over dorsum of r. leg and foot
Mechanism of symptoms
A
Symptoms most likely caused by arterial embolism to the popliteal artery
- you know it’s arterial b/c cool and pale (venous would be swollen and warm from pooled venous blood)
- it’s acute, so you’re thinking embolism over a more chronic process like thrombosis
- embolism from cardiac origin consistent w/ h/o acute MI
- nerve damage alone wouldn’t account for missing pulse or cold/pale
24
Q
Normal value of mixed venous oxygen saturation
A
60-80%
25
21 yo M w/ progressive SOB and cough x6 wks
- CT w/ mediastinal mass compressing trachea
- elevated serum levels of serum AFP and beta-hCG
Dx?
Dx = mixed germ cell tumor
-give away is the elevated AFP
beta-hCG elevations are also seen in seminomas, but to also explain the elevated AFP = nonseminomatous germ cell tumor
26
ABG values seen in atelectasis
Atelectasis causes areas of VQ mismatch => hypoxia => increased work of breathing (dyspnea, tachypnea)
Tachypnea => low pCO2 (blowing off tons of CO2)
-expect respiratory alkalosis
27
Mgmt of flail chest
1. Analgesia to allow pt to take full breaths
- 2/2 pain pts take shallow breaths => decrease bibasilar breath sounds
2. Mechanical positive pressure ventilation can be used to correct the paradoxical chest wall movement by replacing the normal negative intrapleural pressure
- forces segment to move outward w/ the rest of the rib cage during inspiration
28
62 yo M w/ 20% BSA burn and mild inhalation injury 5 days ago assessed for progressive confusion, lethargy, and oliguria
- 96F, BP 110/60, HR 120, RR 26
- some areas of partial thickness injury have progressed to full-thickness necrosis
- Plts 80k, WBC 16k, glucose 230
Dx
Dx = gram-negative sepsis
Pts w/ 20% or more BSA burned are at high risk for infection 2/2 disruption of skin barrier
Day 5 => highest risk for gram negative (pseudomonas) or fungal infection (candida)
29
Pt w/ hemoptysis, intubated and fresh blood fills the endotracheal tube
Next step?
Massive hemoptysis that doesn't stop w/ intubation: first step is bronchoscopy to localize the bleeding site (suction to improve visualization), and therapy (balloon tamponade, electrocautery)
If doesn't improve w/ initial bronc and/or pulmonary artery embolization, then would do urgent thoractomy (cut into pleural space)
30
How to calculate ABI
(a) Value diagnostic for occlusive PAD
Ankle brachial index = (highest systolic BP on ankle) / (highest systolic BP on arm)
(a) PAD under .9 is diagnostic for occlusive PAD
31
40 yo M p/w right lower abdominal pain that radiates to the r. groin x7 days, +fever/anorexia
- 2 weeks ago treated for right thigh furunculosis
- no rebound/guarding
- extension of right hip increases pain
- WBC 13.5
(a) Next step
(b) Dx
(a) Next step = CT abdomen pelvis
(b) Psoas abscess- typically w/ abdominal/flank pain radiating to groin
- fits w/ history of skin infection (furunculosis is a skin boil)
- positive psoas sign
32
16 yo M FOOSH p/w clavicular fracture and loud bruit heard just beneath the clavicle
Next step?
First step for any clavicular fracture is neurovascular exam to assess underlying brachial plexus and subclavian artery
=> next step in this case in an angiogram
Wouldn't do open reduction of the clavicle at all b/c middle clavicular fractures can be managed non-op w/ brace, rest, ice
33
31 yo M p/w pain and swelling over coccyx
-no PMH, no other problems
Dx?
Pilonidal disease = dermal sinus tract originating over the coccyx causing pain and swelling of midline sacrococcygeal skin and subQ tissue
- from chronic sweating/friction over superior gluteal cleft hair follicle
- infection of hair follicle in the region that spread subcutaneously, forming abscess that ruptures forming a pilonidal sinus tract
34
How to decrease bowel ischemia as a complication of AAA repair
Checking sigmoid colon perfusion following placement of aortic graft
35
31 yo M s/p MVA, given 3L NS and 5 L/min O2
- BP 85/55, HR 120
- flat neck veins, trachea shifted slightly right, absent breath sounds over left hemithorax w/ dullness to percussion
Dx
Dx = hemothorax
- hypotensive despite appropriate fluids = hypotensive shock
- no external bleeding => suspect internal bleeding, hemithoraces are able to hold enough blood to cause hypovolemic shock
36
72 yo M on POD1 from AAA repair develops progressive abdominal pain and bloddy diarrhea
-T 101F, mildly distended abdomen TTP, WBC 12k
Dx
Dx = ischemic bowel
-bowel ischemia is a known complication (1-7%) of abdominal aortic aneurysm repair 2/2 inadequate colonic collateral arterial perfusion after loss of IMA during aortic graft placement
37
76 yo F w/ lower abdominal pain x2 days
- first CT: sigmoid diverticula and perisigmoid stranding
- 5 days later CT: 5cm rim-enhancing perisigmoid fluid collection
(a) Dx
(b) Tx
(a) Dx = acute diverticulitis (complicated b/c pt is elderly) w/ abscess
(b) Fluid collection over 3cm gets CT-guided percutaneous drainage
- if under 3cm: can do IV abx w/ observation
38
Surgery that puts one at risk for:
Unilateral facial droop
Unilateral facial droop 2/2 injury to facial nerve, which courses straight thru the two lobes of the parotid gland => parotid neoplasm resection could result in unilateral facial droop
39
Clinical features of fat embolism
Severe respitaory distress, petechial rash, subconjunctival hemorrhage, tachycardia/tachypnea/fever
-typical in pt w/ polytrauma (ex: multiple long bone fractures, burns)
40
Differentiate clinical picture of medial cruciate ligament tear vs. meniscal tear
Meniscal tear: pt hears a pop, pain/clicking/catching upon extension
MCL: laxity when stabilize lateral leg, hand placed on medial leg and outward pressure applied
41
75 yo M s/p AAA repair p/w LLQ abdominal pain and bloody diarrhea
- h/o prostate cancer and radiation therapy
- CT shows thickening of colon at rectosigmoid jxn
- ulcerations seen on colonoscopy
Dx
Dx = ischemic colitis
- higher risk after vascular procedure (manipulated of vessels, possibly prolonged clamping/loss of collaterals)
- CT shows thickened bowel w/ air in it
- typically see pain, hematochezia, diarrhea, lactic acidosis clinically
42
25 yo M falls out of tree, no LOC, p/w sharp left chest pain w/ inspiration
- equal breath sounds, normal CXR
- TTP at left costal margin, TTP at LUQ w/ guarding, bruising on left chest wall
- Hb 11.8
- negative FAST
Next step
Next step = abdominal CT w/ contrast
-high suspicion for splenic injury
HDS and negative FAST, still get CT b/c of risk factors: anemic, guarding in LUQ, bruising indicative of internal bleeding
43
34 yo M s/p laparotomy for GSW develops 101.7 on POD6
- clear lungs, soft abdomen, wound w/o discharge
- right IJ catheter and foley in place
- no swelling/erythema of extremities
- BCx grow coagulase-negative staph in 4/4 bottles
Cause of fever
Dx = catheter (central line)-associated infection
-staph epidermidis
= Acute post-op infxn (1-7 days): nosocomial infection, surgical site infection (often group A strep or clostridium perfringens), noninfectious MI/PE/DVT
44
Which toes do you cast?
Cast pink toe, but don't need to cast the middle 2/3/4th toes b/c the surrounding metatarsals act as splints and nonunion is uncommon
45
Coagulase-negative staphylocci in a pt w/ indwelling catheter
Staph epidermidis infection of the indwelling catheter
46
63 yo M p/w r. knee pain/swelling x3 days
- no trauma
- PMH: DM2, HTN, CLD, mild COPD
- PSH: smoker and drinks
- mild swelling anterior to patella, faint erythema and sharp tenderness
- passive range of motion is normal
Cause of acute symptoms?
Prepatellar bursitis = synovial sac inflammation
- often 2/2 staph aureus, but can be noninfectious
- active mov't is more painful than passive ROM b/c less tension on the bursa
No hx of gout and gout is less common
47
59 yo F w/ RUQ pain, N/V/F x1 day
- PMH: poorly controlled diabetes
- 102F, HR 101
- TTP in RUQ
- WBC 18.3, Alk phos 93, AST 42 ALT 40
- Imaging: distended GB w/ gas in GB wall and lumen, no gas in biliary tree
(a) Dx
(b) Tx
(a) Emphysematous cholecystitis = life-threatening form of acute cholecystitis from infection in GB wall from gas-forming bacteria
- higher risk in immunocompromised (ex: diabetes)
- see air-fluid levels and gas in GB wall, occasionally pneumobilia
(b) Emergent cholecystectomy and broad spectrum abx (amp-sulbactam = Unasyn) to cover clostridium
48
55 yo F s/p fall down stairs
- rapid, shallow breaths, r. chest wall tenderness
- CXR: right 6th rib fracture w/ no pneumonthorax and r. bsailar atelectasis
Mgmt
Mgmt = adequate analgesia w/ mix of NSAIDs and analgesia
-very important to manage pain b/c rib fractures are very painful => associated w/ hypoventilation which increases risk for atelectasis and pneumonia
49
Most common peripheral artery aneurysms
(a) How do they present?
Popliteal and femoral artery aneurysms
(a) Present as pulsatile mass in either groin or popliteal fossa
50
Most common injury 2/2
(a) fracture of midshaft of the humerus
(b) supracondylar fracture of humerus
Most common injury 2/2
(a) Fracture of midshaft of the humerus = radial nerve
- b/c radial groove is on the posterior surface of the humerus
(b) Supracondylar fracture of humerus (kid falls on outstretched arm) = injury to brachial artery
51
3 components of GCS
GCS = glasgow coma scale, used to predict prognosis of coma and other severe conditions
3 components
1. eye opening
2. verbal response
3. motor response
52
Give 4 Ddx for anterior mediastinal mass
1. thymoma
2. teratoma- look for elevations in random hormones (AFP, beta-hCG)
3. thyroid neoplasm
4. terrible lymphoma
53
45 yo M s/p MVA unable to void
- blood at urethral meatus and scrotal hematoma
- exam shows high riding prostate
(a) Dx
(b) Next step
(a) Dx = posterior urethral injury, typically associated w/ pelvic fracture
(b) Next step is to assess urethra w/ retrograde urethrogram to assess urethral patentcy
- must be done before foley catheter inserted b/c it can cause infection of periurethral hematoma
54
Differentiate hypovolemic shock, cardiogenic shock, and septic
(a) Preload
(b) Cardiac index
(c) Systemic vascular resistance
(d) Mixed venous oxygen saturation
Parameteres in shock
Hypovolemic shock
(a) Decreased preload
(b) Decreased pump function (cardiac index)
(c) Increased SVR (afterload)
(d) Decrease mixed venous O2 sat
Cardiogenic shock
- increased preload and increased afterload
- obv super decreased pump fxn
- decreased O2 sat
Septic shock
- preload nromal or a bit reduced
- cardiac index increased, afterload decreased, and mixed venous O2 sat increased
55
44 yo M s/p MVA
- large bruises on chest wall w/ b/l collapsed neck veins
- CXR: large left hemothorax w/ widened, rightward-deviating mediastinum
Dx
Dx = aortic injury
- no specific clinical findings, but key is widened mediastinum w/ left hemothroax causing right mediastinal shift
- you know it's a blood vessel (and not esophageal/diaphragmatic/bronchial) rupture b/c hemothorax (not pneumothorax)
56
Tx of appendiceal abscess
If pt is unstable- immediate removal
If pt is stable- they can be tx w/ IV abx, bowel rest, possibly percutaneous abscess drainage
-return in 6-8 wks for elective appendectomy = interval appendectomy
57
35 yo M fell on rusty fence, wound bleeding and contminated w/ dirt but w/o purulent drainage
-completed childhood vaccines, last tetanus vaccine at age 23
Next step?
Only tetanus vaccine (no TIG = tetanus immunoglobulin)
-only give TIG for dirty/severe wounds in immunocompromised (ex: HIV), unimmunized, or incomplete (fever than 3 shots) or unknown vaccination status
-so this person had full vaccine set (full childhood vaccines) and booster at 23 => doesn't matter that wound is dirty, don't need TIG
58
55 yo p/w chronic pain in buttock, hip, and thigh muscles associated w/ walking
-exam: decreased femoral, popliteal, and dorsalis pedis pulses
(a) Dx
(b) Most likely additional compliant
```
(a) Aortoiliac occlusion = leriche syndrome
Triad of
1. b/l hip, thigh, buttocks claudication
2. ED
3. b/l LE atrophy 2/2 chronic ischemia
```
(b) Impotence
59
34 yo M s/p MVA intubated
- decreased r. breath sounds => r. chest tube placed
- bruises over chest wall and subcutaneous emphysema
- CXR at 3 hrs: accumulation of air in pleural space, pneumomediastinum
Dx
Dx = bronchial rupture
= tracheobronchial perfortion
-persistent pneumothorax and palpable crepitus below the skin
- Need to think of something that would cause air (not blood like aortic injury, or bowel content like diaphragm rupture) into the mediastinum
- esophageal rupture would produce similar picture but VERY unlikely to be caused by trauma
60
Explain left sided shoulder pain in pt w/ splenic trauma
Referred pain to left shoulder due to phrenic nerve irritation from splenic hemorrhage
61
63 yo M p/w severe abd pain x4hr
- non-bloody vom x1
- Meds: digoxin, warfarin, simvastatin
- BP 130/70, HR 100
- abdomen diffusely TTP w/ positive rebound tenderness
Hgb 9.5, WBC 7.5, plt 90
INR 2.1
Xray: free air under the diaphragm
Best initial tx?
So pt has an acute abdomen (rebound tenderness, intraperitoneal air) => needs immediate reversal of warfain-induced anticoagulation, best achieved w/ FFP
-FFP will immediately replace vitamin-K dependent clotting factors
Would be too slow to give actual vit K for reversal bc would have to wait for liver to regenerate clotting factors
=> emergently pre-op reversal of warfarin anticoagulation done w/ FFP transfusion
62
Sphincter of Oddi dysfunciton
(a) Clinical manifestations
(b) Lab values
(c) Diagnostic test
(d) Tx
Sphincter of Oddi = where bile ducts dumps into duodenum
(a) Intermittent RUQ pain, similar to biliary colic
- so similar that can be the actual reason for biliary colid, evidenced by persistence of pain after cholecystectomy
(b) Elevated liver enzymes (esp alk phos) during pain attack, resolves when attacks subside
(c) Diagnostic test = sphincter of Oddi manometry
(d) Tx = ERCP sphincterotomy
63
6o yo M presents w/ DVT
PMH: DM2, HTN, ESRD on HD
Tx
Tx = unfractionated heparin followed by warfarin
- can't give warfarin alone b/c it can cause transient pro-coagulation b/c it inhibits proteinC/S first
- can't give LMWH (enoxaparin) or rivaroxaban (XA inhibitor) b/c contraindicated in ESRD
64
35 yo c/o muscle weakness and sensory loss in upper extremities
- PMH: MVA 7 yr ago: whiplash cervical spine injury
- moderate wasting of small hand muscles
- intact light touch, vibration, and position senses
Dx
Dx = syringomyelia = fluid filled cavity that compresses surrounding tissue, causing diminished strength/pain/temp in cape-like distribution
-complicates 3-4% of spinal cord injuries, especially after whiplash/cervical spine injuries
Dx made w/ MRI
65
Specific surgery that you see ischemic colitis after
AAA repair- pts have high risk (diffuse atherosclerotic disease) and there may have been loss of collateral circulation, manipulation of vessels during surgery, prolonged aortic clamping, impaired blood flow thru IMA
66
12 yo boy 2 hrs s/p MVA develops tachypnea and tachycardia
- afebrile, normotensive
- bruises on right chest, decreased right breath sounds
- hypoxemic on ABG
- CXR: patchy irregular alveolar infiltrate in right middle and lower lobes
Dx
Dx = pulmonary contusion
- tachypnea, tachycardia, and hypoxia, usually develops w/in the first 24 hrs (can be immediate or delayed)
- chest wall bruising and decreased breath sounds on the side of the contusion
- CXR w/ patchy irregular alveolar infiltrates
67
Describe the mechanism of paralytic ileus s/p abdominal surgery
- local release of inflammatory mediators
- opioids for analgesic use
- increased splanchnic nerve sympathetic tone following peritoneal irrtation
68
Ppl w/ blunt abdominal trauma- who gets CT?
Get CT if:
- abnormal mental status
- normal mental status w/ positive FAST
- normal mental status, negative FAST, w/ RF (anemia, guarding)
69
Explain why aortoiliac occlusion is often a missed diagnosis
Aortoiliac occlusion (Leriche syndrome) has a triad of findings:
1. b/l hip, thigh, and buttocks claudication
2. impotency
3. LE b/l atrophy 2/2 chronic ischemia
But a lot of older men have claudication (2/2 osteoarthritis) and impotency (2/2 other vascular disease), so can easily be missed
70
2 possible complications of untreated pancreatic injury
1. retroperitoneal abscess
| 2. pancreatic pseudocyst
71
Appearance of venous hypertension
LE edema medial leg superior to medial malleolus
-erythrocyte extravasation from increased pressure causes classic red discoloration from hemosiderin deposition
Appearance = red, swollen, skin changes/ulcerations
72
Differentiate infections expected immediately vs. later in burn victims
Immediately (first 5 days): expect infections from hair follicles and sweat glands = gram positive (ex: staph aureus)
While after 5 days- most common are gram negative (pseudomonas) or fungi (candida)
73
30 yo p/w left knee pain after being struck from the side in a hockey game
- felt popping sensation in knee, has small l. knee effusion w/o erythema/warmth
- while standing knee is slightly bent, knee locks w/ sharp pain upon internal rotation
- normal Xray
Dx
Dx = medial meniscus tear
- pain, clicking, or catching upon extension indicates meniscal tear
- pt often reports popping sound
- b/c meniscus is not directly perfused, effusion typically not apparent until a few hrs after injury
74
How to best preserve an amputated finger?
Place amputated finger in saline moistened gauze on a bed of ice
- don't want to fully submerge in water, may make vessel repair harder
- not directly on ice (don't let it freeze)
- not in antiseptic or alcohol solution b/c can cause chemical injury
75
23 yo M p/w hurting knee during basketball game
- mild soft-tissue swelling of left knee w/o effusion
- tenderness at medial joint line
- normal ROM w/o crepitus
- abduction (valgus) stress test shows some laxity
Dx
Dx = MCL injury (medial collateral ligament)
Valgus stress test = laxity when lateral leg is stabilized, laxity upon pressure to medial leg
76
Explain physiology:
Pt in MVA presents w/ flat neck veins and bruises over abdomen, immediately after intubation and mechanical ventilation => cardiac arrest
Mechanical ventilation acutely increases intrathoracic pressure, which decreases systemic venous return and therefore would put someone in hypovolemic shock (flat neck veins, probably hemorrhagic shock) into immediate cardiac arrest
Explains why you must replace intravascular volume before attempting ventilation to prevent circulatory collapse
77
When is sigmoid resection indicated in a pt w/ complicated diveritculitis
Sigmoid resection generally reserved for pts w/ fistulas, perforation w/ peritonitis, obstruction, or recurrent attacks of diverticulitis
78
76 yo p/w substernal CP 5 hrs s/p cardiac catch
- BP 75/60, HR 120
- Flat neck veins
- Groin puncture site normal
- VS improve to 96/60 w/ 1L NS
Next step?
Next step = CT abdomen/pelvis w/o contrast for retroperitoneal hematoma
-common complications of cardiac cath: bleeding/hematoma at site (localized or w/ retroperitoneal extension), arterial dissection, acute thrombosis, pseudoaneurysm, AV fistula
79
72 yo s/p CABG c/o dyspnea, retrosternal pain, fever, tachy, smal cloudy fluid in sternal wound drain
- CXR: mediastinal widening
- Echo: small pericardial fluid
- WBC 16.3
(a) Dx
(b) Next step
(a) Mediastinitis 2/2 intraop wound contamination
- anyone who presents w/ fever, CP, leukocytosis, and mediastinal widening after cardiac surgery = mediastinitis
(b) Next step = surgical debridement and abx
80
Risk factor for undifferentiated carcinoma of the posterior nasal cavity
Undifferentiated carcinoma of the posterior nasal cavity = nasopharyngeal carcinoma, very strong association w/ ebstein-barr virus
81
(a) When does drug fever occur?
(b) How to diagnose?
(c) Common drugs
(a) Occurs 1-2 after initiation of therapy
(b) Drug fever is a diagnosis of exclusion
(c) Anticonvulsants, abx, allopurinol
82
23 yo M s/p MVA found unresponsive
- intubated, given 2L, BP now 80/40 HR 120
- neck veins distended, multiple bruises over anterior chest and upper abdomen
- CXR: small, left pleural effusion and normal cardiac contours
Dx
Dx = pericardial tamponade
Recall: Beck's triad: hypotension (despite resuscitation), distended neck veins, muffled heart sounds
-such acute accumulation of fluid so pericardiac sac is so tense, doesn't take much fluid (so not even a visible amount of fluid) to accumulate to get pericardial tamponade
Would see blood in pleural space if lung contusion
83
First clinical sign of wound infection in burn victim
Change in appearance of the wound (ex: partial thickness injury turns into a full-thickness injury) or loss of viable skin graft
84
Dreaded complication of untreated epidural hematoma
Uncal herniation due to the increase in ICP
| -uncus of the temporal lobe is the most inferior part of the brain, herniates thru the foramen magnum
85
88 yo M c/o severe r. calf pain/burning s/p femoral artery embolectomy
- pain worse w/ passive extension of knee
- pulses are palpable
(a) Dx
(b) Mechanism
(a) Dx = compartment syndrome
(b) Caused by soft-tissue swelling
- reperfusion of limb after 4-6 hrs of ischemia can cause intracellular and interstitial edema, if this edema causes pressure w/in fascial compartment to exceed 30mmHg = compartment syndrome
Not DVT- which is asymptomatic or simply vague aching pain (not severe)
86
Marker of nasopharyngeal carcinoma progression/malignant
Association btwn nasopharyngeal carcinoma is so strongly associated w/ EBV than EBV titers can be used to track progress for malignancy
87
Surgery that puts one at risk for:
Winged scapula
Winged scapula 2/2 injury to long thoracic nerve, located in the axilla and at risk during axillary lymphadenectomy for tx of breast cancer
88
Describe two physical exam tests indicative of ACL injury
Anterior drawer test: pt supine w/ knee flexed, laxity of proximal tibia when pulled anteriorly
Lachman test: knee at 30 degrees flexion, stabilize distal femur and pull proximal tibia anteriorly w/ the other
89
54 yo F w/ suspected scaphoid fracture
(a) Next step
(b) Most common complication of scaphoid fracture
(a) Scaphoid fractures may not show up on initial imaging, so can do repeat Xray in 7-10 days
(b) Scaphoid fractures carry a significant risk of osteonecrosis 2/2 anatomy of the blood supply being susceptible to injury by fracture
=> immobilize pt w/ case, then monitor w/ serial Xrays to r/o osteonecrosis and nonunion of the fracture
90
Describe patellofemoral pain syndrome
Chronic anterior knee pain
- most common in women
- worsened by activity or prolonged sitting
91
84 yo M w/ acute onset back pain and hypotension
Rupture AAA until proven otherwise
Immediately take to OR
92
What part of the bladder is most susceptible to rupture?
Bladder dome- only part of the bladder that is covered by peritoneum => only part of the bladder where injury would permit leakage into the peritoneum
93
55 yo Asian M p/w neck swelling and multiple episodes of epistaxis
- h/o syphilis and recurrent bacterial sinusitis
- mass in posterior nasal cavity, biopsy showed undifferentiated carcinoma
Dx
Undifferentiated carcinoma of squamous cell origin = nasopharyngeal carcinoma
-higher frequency in mediterranean or Far E. descent
94
18 yo F at 8 wks gestation p/w open fracture of tibia and fibula, 6hr later develops severe dyspnea and confusion
-HR 110 RR 20
(a) Dx
(b) Other physical exam findings
(a) Classic fat embolism: fat from marrow blocks blood flow
| (b) Often accompanied by petechiae
95
When is sigmoid resection indicated in a pt w/ complicated diveritculitis
Sigmoid resection generally reserved for pts w/ fistulas, perforation w/ peritonitis, obstruction, or recurrent attacks of diverticulitis
96
84 yo M p/w severe back pain x1 hr
- syncope for under 1 minute, gross hematuria
- c/o SOB
- BP 72/55, HR 112, O2 92%
- EKG: prominent horizontal ST-seg depression in anterior chest leads
Dx
Dx = ruptured AAA
-tempting to think acute MI b/c of the localizing EKG findings, but that wouldn't explain hypotension and back pain
AAA ruptured in retroperitoneum
-creates aortocaval fistula w/ IVC, causing venous congestion in retroperitoneal structures (the bladder), distended bladder veins rupture => gross hematuria
97
Risk factor for pilonidal disease
Pilonidal cyst = pilonidal sinus tract causing pain/swelling of the midline sacrococcygeal skin
-young males w/ larger amounts of body hair
98
Pt develops whistling noise during respiration following rhinoplasty
Dx
Suspect nasal septal perforation, likely resulting from septal hematoma
99
Formula explaining SBP to ICP
CPP (cerebral perfusion pressure) = MAP - ICP
-hence why you want to keep MAP high and ICP low to maintain adequate perfusion to the brain
100
Most common location of stress fracture
Tibia
-initial Xray often normal
101
Typical cause of bacterial tenosynovitis
Penetrating injury to the hand (ex: cat bite) OR from hematogenous spread of distant Neisseria gonorrhoeae
102
Surgery that puts one at risk for:
Tongue palsy
Tongue palsy 2/2 hypoglossal nerve injury 2/2 surgery below the mandible
ex: surgery for submandibular gland
103
Explain why intraabdominal pathology can cause pain in the shoulder
2/2 subdiaphragmatic peritonitis and irritation of the diaphragm (Kehr sign)
- phrenic nerve originates from C3-C5 which also mediate sensation for the shoulder region (so they share a dermatome)
- so if something (air, fluid, bowel contents) intraperitoneally and irritates the diaphragm, this can classically cause shoulder pain
104
CNS pathology associated w/ lucid interval
Lucid interval = LOC, then lucid interval before deterioration (2/2 hematoma expansion)
Cause = epidural hematoma (middle meningeal artery tear)
105
Management of pneumothorax
(a) Small vs. large
(b) Stable vs. unstable
Managing pneumonthorax
Unstable- place chest tube (tube thoracostomy)
Stable- depends on size. Small = give supplemental O2 to enhance resorption, large = large-bore needle decompression
106
39 yo F p/w perioral numbness
-chronic muscle cramps
Pertinent lab values: BUN 10, Cr 0.8, Ca2+ 6.5, Phos 5.8
Dx
Dx = autoimmune primary hypoparathyroidism
Low Ca2+ w/ high phosphorus- explained by insufficient PTH hormone production
Surgery
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