Surgery Corrections

Surgery Corrections

Question Answer
47 YOW comes in with a BMI of 67 , chafed skin on inner thighs, under breasts, twice requiring admission for abtx for panniculitis. Also has thick curdy vaginal discharge.Best long term management for this pt? gastric bypass
37 YOw bruising on arms and abdomen x3w. ibuprofen for HA. afebrile. PE:eccymoses over upper extremities and trunk. Lungs CTAB, Labs: norm Hb, 6.8k WBC, 45k plt, Bleeding time is high,PT normal. Bone marrow shows megakayocytes. Explanation for findings? forumulation of antiplatelet antibodies (idiopathic thrombocytopenic purpura)
87 YOM has sudden onset of SOB after emergent colon resection for obstructing Ca. T 100, HR 104, RR 32, BP 88/50. PE: JVD, crackles over midlungfields. NMRG.Liver span is 13. ECG shoews ST elevation. Mostlikely Dx? Cardiogenic schock (MI)
A 13 YOB has increasingly severe left thigh pain and knee pain and limp for 2 days. No Hx of trauma, BMI =20, Passive motion of hip elicits pain, Most likely Dx? slipped capital femoral epiphysis
12 hours after rod stabilization of a femoral fracture, 27 YO homeless ,an has sudden onset of combativeness and disorientation. HR 120, RR 24, BP 140/85. Exam shows petichiae over axila. Most likely cause? fat embolism
A previosuly healthy 47 YOM comes in with 2 weeks of progressive abd swelling. PE shows distention and shifting dullness, bowel sounds are normal. There is no tenderness, masses or organomegaly. Paracentesis: 50ml milky chylous fluid. Most likely cause? Lymphoma
52 YOW has back pain with hx of treatment for breast cancer 5 years ago. Decreases sensitivity below nipples. Hyperreflexive and decr strength with + babinski in legs, arms are normal. Where is the lesion? Thoracic spinal cord: T10 is nipples
Previously healthy *YOB has intermittent pain in the right anterior thigh for the past 3 w.activity level is high.mother notes he limps. 25th percentile ht and wt. Vitals normal. Atalgic gait. Abduction and internal rotation of the feur is limited. Dx? avascular necrosis of the femoral head
ASX 72 YOW comes in with decreased renal fx. Elevation in Cr over last 3 days. got 2nd renal transplant from 65 YO donor 1 m ago. Most likely explanation for decr renal fxx? failure to surpress class II antigen recognition in the host ( rjection)
For 4 hours, a 55 YOM has acute intermittent pain that begins in right flank and radiates to right testicle. Most likely finding on UA? microscopic hematuria (30 /hpf in sediment)
36 hours after admission for evaluation of diffuse abd pain, a 42 YOw is still obstipated. She has a 9yr history of scleroderma. Current temp is 100, P 110, RR22, BP 110/60. Abd is distended with colon dilation and WBC 14k. Next step? laparotomy (toxic megacolon)
The driver of an automobile is brought into ED after head on MVC at 50 mph. He has mid chest tenderness. All diagnostic tests are norma, except an XR of the chest which shows a widened mediatinum. NExt step? aortic arch arteriogram ( I guess they are assuming CT is neg)
A 68 YOM is broguht to the ED because of recurrent vomiting of bright red blood, and near syncope x 3 hours. He is afebrile, pulse 110, respirations are 16, BP 90/60 mm Hg and he has mild epigastric tenderness. Next step? rapid infusion of 0.9% saline. Fluids, then you can figure out the bleeding source
a 62 YOW comes to the physisics with 3 w of progressive SOB, mild pain in right chest, and nonproductive cough. 12 lb wt loss in last 3 m. She had br ca 6 years ago s/p mastectomy. She appears cyanotic and cachectic. friction rub is heard on the right.Dx? malignant pleural effusion (lung mets)
A 67 YOW, 8m bilateral calf pain with walking. initially only after long walk, now only after 300 ft. pain is relieved with rest. She has hypertension and hypercholesterol. She is on atherscler drugs and smokes. pulses decr bil.elevated BUN. Next step? ABI is first before duplex. arteriogram is a preop test
Following diganosis of ectopic pregnancy in a 25 YOW, an abdominal operation is performed. Exam of the abdomen shows a normal uterine pregnancy but an inflamed appendix. An appy is performed despite the fact the consented only ectopic removal. Is that ok? inappropriate because the patient had not been previously infomred of the risks of an appendectomy
A 67 YOW with ESRD, aterosclerodic CAD, T2DM undergoes formation of an AVF in left forearm under ax block. 24 hours later. SHe has SOB, , tacycardia, RR 38 with JVD. S3 and S4 are present. Most likely Dx? high output congestive heart failure ( atelectasis just doesnt cover enoguh)
4 days after CABG, a hospitalized 47 YOM has the sudden onset of severe pain in his left great toe. He was admitted to the hospital 10 days ago for chest pain with exertion, and has been getting aspirin and heparin. CBC: 12.2/27%/8. PT and PTT normal. Dx? heparin induced thrombocytopenia
a 27 YOw, HIV +, 6 m of nonbloody diarrhea now with bloody diarrhea. She has a high fever, and a rigid abdomen. She ends up with an ileostomy for a perforated cecum and the path report shows nuclear inclusion bodeis in colon. Most likely organism? CMV
12 hours after pancreatic abscess drainage, a 52 YOM with alcoholism becomes bradycardic and hypoxic and requires intubation. His FiO2 is 100, with a tidal volume of 1000 and PEEP of 2.5. He still has acidosis with O2 = 48 and CO2 of 40. Next step? Increase PEEP
a 60 YOW has a sigmoid resection and colostomy for diverticulitis with rupture. That night she becomes confused, oliguric and febrile. the area around the colostomy is indurated and crepitant. Most likely causal organism? Clostridium perfringens ( gas gangrene)
A 45 YOm has daily temps to 100.9 and 15 lb wt loss over 3 m. he has pallor, normal vitals and normal CV and P exams except a low pitched disatolic rumble at the apex that dissappears when he lies on his R side. Hb is 10. Most liekly dx? Atrial myxoma ( cancer picture with diastolic rumble)
52 YOW, 2m R foot swelling w/o fever or pain. No trauma history, 25 y histroy of T1 DM. Peswelling on dorsal foot and med and lat ankles. The is small effusion over ankle. Decr sensation below ankles. XR shows osteopenia and disorganized foot. Cause? lack of normal joint sensation (Charcot foot)
62 YOM w hemoptysis for 1w.5 y hx of daily productive cough, 20 y of hypertension, 88 yr pack history. Ca concentration is 11 (high) with coin lesion in lung. Most likely dx? PTH secreting tumor is squamous cell Ca
Previously healthy 37 YOW has left groin and thigh pain for 3 d. Exam shows a non reducible mass in the groin. Operative exploration shows a hernia sac medial to the femoral vein. Dx? femoral hernia
A 62 YOW has difficulty swallowing liquidsand solid over the past month. 10 yr hx of dyspepsia, substernal burning and occasional n/v. EG shows GE junction stricture and baretts esophagus. Dx? sliding hiatal hernia (much more common than paraesophageal)
24 hr after romoval of parathyroid adenoma for primary hyperparathyroidism, a 42 YOW has perioral numbness and tingling. He serum Ca is 6.8 (low). Normal albumin levels. Next step? oral vitamin D (make sure she can absorb Ca)
A 30 YOM has painless, progressive enlargement of the left testicle for 8m. There is no nodule and the scrotum cant be transluminated, Most likely dx? testicular tumor
A 37 YOW comes w 3m of headaches. The headaches now occur daily and are relieved by aspirin. Her pulse is 76, RR 12, BP 158/95. Surum Na: 140. Cl 100. K 2.6 (low) Ibcarb 34, BUN 9. Dx? aldosteronoma
A 22 YOM is brought to the ED after a GSW to the right calf. Swelling and much pain with passive range of motion. Next step? surgical decompression ( compartment syndrome)
5 d after emergent sigmoid colectomy for perforated diverticulum , a 57 YOM has a temp of 104. Lots of oxygen therpay and now has decr breath sounds at a lung base. Sputum shows many leukocytes with G – rods. Most likely organism? Psudomonas ( hospital acquied pneumonia)
Before elective cholecystectomy, a 68 YOM with chronic renal failure has multiple electrolyte disturbances on Chemistry studies. Next step? initiate dialysis before surgery
A 77 YOM has a sever nosebleed not stopped by anterior packing and he spits clots out side his mouth. Most likely source of the bleed? sphenopalatine artery (MCC posterior nosebleeds
67 YO postal worker with a 5 min episode of weakness and numbness in his hand. Ni sequelae and has smoked 1ppd x 45 years. Carotid bruits are heard bilaterally. ECG shows normal sinus rhythym with mulitple premature atrial contraction.s Next step? carotid duplex ultrasound
A 42 YO is admitted to the hospital with a piece of meat lodged in the lower esophagus. With difficulty is it removed with an endoscope. That evening the pt has a temp of 101. Most apporopriate dx study? water soluble contrast upper GI study( concern for esophageal rupture after endoscopy)
A 25 YOW has 2m of a pigmented lesion under her ring finger. A photo of the lesion is shown (ugly, raised, black, irrrgular). Most likely Dx? melanoma
An 18 YOW comes to the physican for advice about screenin with a fam hx of colon ca. She has the APC gene.2 polyps are seen on colonoscopy. Best long term treatment? prctocolectomy with ileoanal reservoir. Almost certainly will get Ca at some point
Routine mammorgraphy on a 52 YOw shows six stippled microcalcification in a cluster in the upper outer quadrant of the left creast, not presen t 1 y ago. No lump. Next step? needle localized open biopsy (not FNa)
A 1 yr old boy has persistent cough, loose stools and facial rash for 2 m. 4lb wt loss. 50th percentile for ht and 20th for wt. Temp is 37, pulse is 100 resp is 18. Ct shows tumor in panceas. Most likely Dx? VIPoma. especially with flushing. arises from non beta islet cells of pancreas
A hospitalized 72 YOM has not voided since catheter removal 8h ago. He had a sigmoid colectomy for recurrent diverticulitis 2 d ago. He is currently receiving 5% dextrose and 0.45% saline. His temp is 100.8. Most likely cause of inability to void? bladder outflow obstruction
A 6YOB comes to ED 30 mins after MVC. On arrival he is awake and alert. There is an obvious scalp laceration over the left frontoparietal area. There are no neurologic deficits. A CT scan of the head shows a liner temporal skull fracture. Most likely CT? epidural hematoma
52 YOW with well controlled T2DM has 34 hr of abdominal pain. Vomited 3 times in ED. BMI is 38, Temp is 103.1, Pulse is 120, RR 28. Exam shows scleral icterus. She has high slk phos and mild LFTs. Dx? ascending cholangitis
52 YO nulligravid woman comes to physician due to 2 m of progressive abdominal swelling and decr appetitie. She has astma treated with steroidsand T2DM. Exam shows a fluid wave. An Ct shows mulple levic masses and omental thickening. Most likely dx? ovarian adenocarcinoma
18 YOM has pain in the R hip and flank after an autoaccident. He is stable. Exam shows eccymosis over the iliac crest, and right flank abraisions. urinalysis shows gross blood. Ct cervical spine is normal. next step? Ct abdomen (but is might be slective renal angiography)
A 42 YOW comes in with sever ranghe hypertension and a bruit with hyperplasia of the right renal artery. What is the mech of the patient HTN? increased serum aldosterone ( not renin as that acts locally)
A 46 YOM with chronic alcoholism comes to the ED w/ 12 hr of n/v and mid abdominal pain radiating toback.pulse is 120 , respirations are 20 and BP is 110/60. Abdominal exam shows tenderness to palpation upper quadrants. Most important thing to give? Lactated ringers ( not any of the med choices, needs fluids)
A 24 YOM is brought to ED with burns on 50% of body, He weighs 75 kg. clearly needs fluids. How much in next 24 hours? 15 L of lactated ringers ( 4ml/kg/% burn)
A 47 YOM comes with 2 d of fever and severe rectal pain. Has type 2 DM treated w metformin. Temp is 102.4 Exam shows mass at anal verge on left. Hb is 9.6. WBC is 18 k. Next step? I and D this is a perirectal abscess
A 47 yOM comes to physician for eval prior to an abdominal perineal resection fro rectal Ca. In last 6 y he has had left ankle swelling. Duplex shows chrinic occlusion of left iliac and femoal veins. Most apporpiatemanagemnt for venus disease? low does heparin rpophylaxis ( these are stable DVTs), just need to prevent new ones
A 23 YOW has left shoulder pain for 12 h after falling down stair. She has diffuse abd tenderss, an Hb f 10, and WBC of 11k. Most likely Dx? ruptured spleen
37 YOM is brought to ED 30 min after MVC. Abd pain on arrival. Pulse 84, , RR 18, BP 110/82. Abd exam shows diffuse tenderness.Bowel sounds decreased. supine CXR shows bowel loops in the thorax and no left costophrenic angle. Dx? ruptured diaphragm
68 YOM has recurrent stridor x 2 hours. 2 y/a he underwent radiation for laryngeal cancer. Exam shows a bulky tumor involving the upper and middle neck bilaterally. ABGs on 100% O2 shows: low pH, CO2 52, O2 55, HCO3 17. Neck step? tracheostomy ( retention of CO2 is impendings respiratory collapse)
87 YOM has 3 episodes of pneumonia over last 6m, 1 requiring admission. Increasingly bad breath over this time period. CBC, electrolytes, LFTs all normal. CXR shows scarring of right lung base. dx? Pharyngoesophageal diverticulum (Zenker's)
57 YOM comes with 2 m of difficulty swallowing. Food stukc when swallows and he has drank more water to deal with this. Moderate dysphagia. Extensive smoking and drinking hx. CXR normal. next step? EGD ( suspect SCCa)
8 YOG has sensation that something is in her left eye for 1d with photophobia and decreased vision for 6h. Parents notice child frequently rubs eye. Exam shows tearing with erythema. Small vesicle with erythematous base on conjunctiva. Dx? herpes simplex conjunctivitis
66 YOW has acute vision loss in R eye x 1 h. No pain or previous hx. T2DM, HTN. Pupil does not react to direct light but is consensual with conlat light. Movement is intact. PE: pallor of disc, macular edema, thin arterioles, thickening of retinal v. Dx? central retinal artery occlusion
While recieving radiation for optic glioma in right paratemporal area , 62 YOM has sudden onset of severe abd pain. Steroids for edema, tenderness in all 4 quadrants. XR shows free air under diaphragm. Next step? laparotomy for ruptured viscus
37 YOM comes with inability to conceive for 3 y. Wife had kids no problems in previous marrige. Pt is healthy and well developed. irregular, ropy mass in upper left hemiscrotum. Results of semen analysis are normal. Most likely cause of infertility? varicocele
An 80 YOW with atherosclerosis and chronic Afib has severe abd pain x 4h. Exam shows mild abd pain with absent bowel sounds. Occult blood test is +.WBC: 28 k. ABG: ph 7.18, CO2 35, Po2 62. AXR shows non specific gas pattern. Next step? exploratory celiotomy (likely mesenteric ischemia)
healthy 19 YOF brought to ED with 4 h severe abd pain . Sx began 3w ago as intermittent colicky pain. Exam 1 w ago showed 5 cm cyst. Abd exam shows tenderness with rebound and guarding in RLQ, Palpable 10 cm that is complex, cystic on u/s. Next step? exploratory laparoscopy or lapartomy ( point is this is ovarian torsion and IT IS NOT CT DRAINGAGE)
35 YOW with chronic renal failure sustain compression fracture of T12. Ca 7, Ph 11, Cr 6, Alk Phos 600. Most likely cause of fracture? secondary hyperparathyroidism ( renal failure)
57 YOW in ED w 1 day of fever, chills weakness. Had spleen out for ITP 10 y ago. Got blood and appropriate Immunizations at that time. Temp 102.8. P 100, RR 20, BP 80/50. crackles at right lung base. CXr shows signs of pneumonia. Best abtx? vancomycin and ceftriaxone
52 YOW comes to physician because of 3 episodes of bright red blood per rectum in pat 2 w. 10 y hypercholesterolemai,. Stable vitals. CV is normal. Abdomen is soft and nontender, no masses are palpated. rectal exam shows internal hemmorids. Next step? colonoscopy ( must r/o cancer)
Previously healthy 42 YOM comes to physician because of 2 days of right knee pain. The symptoms began when he was getting up from a low chair. His temp is. Exam of knee shows tenderness to palpation along medial joint line and joint effusion. Dx? torn meniscus
76 YOM sustained a midshaft femur fracture during MVC. In ED circumference of right thigh is 2x left thigh. Pulse is 120, RR 16, BP 80/60.Large boe IV catherter is inserted. What finding best indicates adequate resuscitation in this pt? urine output 30-40mL
72 YOW brought in 48h after Son found her down . On arrival she has severe pain of hip and thigh. Pulse 126, RR 30, BP 80/40. There is marked external roation and shortening of the RLE. CV exam normal. Most likely cause for hemodynaic instability? hypovolemia
72 YOM is extubated and taken to recovery after a 4 hr operation for a bleeding duodenal . ABGs show: pH 7.24, PCO2 85, PO2 60. Next step in management? reintubation and mechanical ventilation
A 75 YOM is scheduled to undergo elective repair of AAA. Hx of HTN. PE: 6cm palpable AAA. A ECG is normal. What study is most accurate to predict his risk for a perioperative MI? radionucleotide scan with thalium and dipyramidole
82 YOW comes to physician with 4m of right sided HA, joint pain, malaise. Exam shows tenderness over right temporal a. Both temporal aa are palpable. ESR 87 (H). Next step? predisone and temporal artery biopsy immediately (Giant cell arteritis, shoot first, ask questions later)
42 YOW comes with 10 y of intermittent palpitation. Sx last a few mins and have no CP, SOB, or dizziness. Worse with stress and caffeine. No problems with exercise. CV largely normal. There is a midsystolic click heard best at the apex. Most likely dx? hyperthyroidism
42 YOW comes with 2 d of rust colored discharge in her bra. She has no hx of serious illness and takes no meds. No fhx of br ca. Stable vitals. Exam of breast shows no abnormalities, no fluid can be expressed from nipples. Most likely dx? intraductal papilloma
27 YOM comes to ED 40min after MVC. wearing a helmet. On arrival he is a and o x3. Stable vitals. Abd exam shows mild distention. Pelvis is unstable. Blood at urethral meatus. On DRE the prostate is not palpable. Next step to eval the urethral bleed? retrograde urethrography
An othersie healthy 30 YOM has an acneform infection of left axila for 2w. Previous infection of same region and groin area. Exam shows acute inflammatory changes woth purulent drainage from small sinus openings.Infection involves what skin structures? apocrine glands (axilla and groin, this is hidradenitis suprativa), eccrine are the sweat glands that are everywhere
After MVC, 23 YOM is brought to ED. He was unrestrained driver. BP is 150/90.He has retrosternal and interscap CP, dyspnea, hoarseness. XR shows fracture of sternum and left first rib, widening of superior mediatiunum, caudal displacement of bronch. Dx? rupture of thoracic aorta
Over past 6w, 30 YOW has increasing nervousness, sweating, insomnia. 10 lb wt loss .lump on right side of thyroid. Pulse 110, BP 130/50, 4×4 cm mass on the R side of the thyroid gland, no other thyroid tissue. Thyroid uptake only in area of nodule. Dx? toxic thyroid adenoma
42 YOW comes with 1w yellow eyes, nausea, R sided abdominal cramps. Had a lap choley 2m ago. Intraop cholangiogram not performed. no meds. Vitals normal. CVP exam normal. Abd exam shows RUQ tenderness w/ no distention or peroneal signs. Cause of jaundice? choledocholithiasis (cystic duct stone not detected w/o cholangiogram)
2 d S/P carotid endarterectomy, 62 YOM with slurred speech, weakness in R arm,leg for 1 h. He had no neuro findings at d/c. BP 170/95. Incision is clean dry and intact. No abnormalities on carotid duplex. CT head shows intraparenchymal hemorrhage. Cause? hypertension
56 YOW 3m of excessive sweating nervousness, tremors, tachycardia, hunger. Sx worsenby fasting. Selective angiography shows 1 cm tumor in tail of pancreas. Dx? insulinoma
presentaation of glucagonoma? necrotizing migratory erythema, esp on abdomen, buttocks, perineum
presentation of vipoma? watery diarrhea, hypokalemia, dehydration, weakness
presentation of somatostainoma? mild DM, steatorrhea, galstones
presentation of insulinoma? neuroglycopenic sx: headache, lethargy, diplopia, and blurred vision, particularly with exercise or fasting. Severe hypoglycemia
sx of carcinoid? FlushingDiarrheaWheezingAbdominal crampingPeripheral edema
During exlap, a 4×7 cm cystic lesion in the tail of the pancreas is found in a 46 YOW. Biopsy of the wall cyst shows a cystadenoma. Managemnt? distal pancreatectomy
27 YOW brought to ED 30 mins after deep laceration on her back. What anaesthetic would provide the longest anaesthesia? bupivacaine
42 YOF 2 days of right upper abd pain and itching. 3 episodes of in last few months. No fever or vomiting. Exam shows scleral icterus. Mass is palpated in RUW. U/s shows no gallstones. CT shows 5cm cystic structure medial to gallbladder. Next step? RUQ palpable mass, jaundic = choledochal cyst. tx is ruen en Y cystojejunostomy
18 YOM c omes to ED 10 mins after stab wound to right chest. He is SOB. P 120, BP 70/40, Breath sounds absenmt on right. Trachea is midline, neck veins are flat. most likely dx? massive hemothorax
42 YOM had 4×4 cm painless ulcer over right medial malleolus x 6m. He has a histroy of DVT that occured during a femur fracture 30 years ago. Pedal pulses are plapable. 2+ edema of RLE. LLE is normal. Most liekly cause of ulcer? venous valvular insudffioceicny
67 YOM admitted for 6w of n/v.decreased appetitie resulting in 16 kg wt loss. has distal gastrectomv for peptic ulcer 35y/a. He is cachectic with severe temporal wasting. Biopsy of a stomach mass is adenoca. What is the cause of metabolic abnormalities? increased serum tumor necrosis factor concentration ( causes cachexia)
15 YOG has progressive SOB for 2 hours. she had an appendectomy yesterday, not out of bed since. @ L saline over last 24 hours. T 99.8, P 90, RR 22. BP 105/63. No jvd, decr br sounds. dullness in left lund field. 3/6 holosystolic murmur. Mech of SOB? collapse of right middle lobe of lung from decreased inspiratory effort. POD1= atelectasis
Previously healthy 27 YOM comes t with 3m of intermittent abd pain and diarrhea.. 10lb wt loss. T 100.4, P72, BP 114/82. Abd exam shows RLQ tenderness. Hct 31, WBC 12k, Barium enema shows massive colonic dilation. Dx? crohns disease
Immediate after birth of a 30 w infant, a harsh to and fro murmur consistent with PDA is heard. Indomethacin is given, and murmur stops. Explanation of effect? cyclooxygenase inhibition with increased norepinephrine release
28 YOW recently gained 80 lbs, which she atributes to stress. BMI is 40. BP 130/85. He obesity puts her at greatest risk for developing? cholycystitis
9 days after a pylorus sparing pancreatoduodenectomy for adenocarcinoma of the pancreas, a 62 YOM has tons of drainage from NG tube.high amalse in fluid. Serum electrolyes show low bicarb, and ABG shows met acidosis. What is the mech of these findings? nasogastric suction ( metabolic acidosis)
62 YOM comes 5m after noticing a mass in right side of neck. Hx of enlarged thymus treated with radiation duroing infancy. Exam shows 4 cm mass that moves with swallowing. TSH is normal. FNA shows follicular neoplasm. Next step? thyridectomy ( high suspicion for cancer in this gentleman)
47 YOM has pearly surface papule on upper lip for 18m. Exam shows some telangiectasias. Pic shown on upper lip. Dx? basal cell carcinoma
42 YOM in ED after MVC where he briefly lost consciousness nd has brusing over abdomen in seatbelt pattern. 3 days later he vomits billious fluid positive for blood. He is afebrile, Abdomen is tympanic CBC lfts are normal. gastric bubble on XR. Dx? duodenal hematoma
67 YOW of dyspnea, myalgias anf flank pain during transfusionof RBCs immediately after colon resection for colon ca. Intraopperative blood loss 1200. Blood in surgical drain, urine is dark. Post op hct is 21. Next step to make dx? repeat type and cross match of blood
Previously healthy 15 YOB sudden onset of anterior right sided CP. temp is 36.9, pulse is 90, respirations are 18, BP 110/70, XR shows no problems. XR shows samll right pneumothorax. Next step? observation
24 YOW laparoscopy for eval of chronic pelvic pain shceduled. before operation she gets narcotics, freaks out and doesnt want operation. what do you do? cancel operation
67 YOM 1w of increasingly severe abd pain, fever, vomiting decr appetite.2 y/a he was admitted for similar porblme. Intermitten LLQ abd pain for 5 y. T 103, pulse 105, respirations 22, BP 150/90. WBC 21k. XRA non specific. Next step? CT abdomen pelvis
37 YOW woman with carpal tunnel. What study best helps confirm dx? nerve conduction studies
77 resident of SNF with 2d fever and vomting for 2 d. Alert but unable to give a history. Aks for drink of water. T101.5, BP 110/60, Exam shows distened abdomen with high pitched bowel sounds. Supine XRA shows multipl dilated lops of small bowel. Dx? emphesematous cholycystitis i think
Person comes in from trauma with GCS 5, next step? intubate and ventilate
52YOW w/ GBM does not want surgery. She understand an op is the only effective treatment of her tumor, and that without an operation she will die. She is afraid of the adverse effect. she lapses into a coma, husband wants surgery. important consideration? her previous expressed wishes trump his new ones
. Ten years ago, a 60YOW s/p aortic valve replacement with a pig valve. now has dysnea on exertion. Examination and x-ray of the chest show evidence of congestive heart failure. Which of the following is the most likely explanation for these findings? degeneration of valve
42 YOW in ED with 2 d of intermittent lower abd pain, n/v. No stoll or flatus in this time. High pitched bowel sounds. Had hysterectomy 2 y ago for leiomyota uteri. Most likely mech of sx? adhesions= proliferation of fibroblasts forming scar tissue in area of operation
4YOBis 4-month history of frequent falls. his calves increasing in size. PE: enlarged muscles of the calves and lumbar lordosis. Sensation is intact. He has difficulty arising from a supine position. Dx? Duchenne muscular dstrophy
18 YOM comes with stab wound unresponsive. Pulse is 130, RR 8, and shallow, BP 60/40/ Intubated and given fluids, pulse is now 130, BP 70/40. Exam shows 2cm wound at left 6th ICS in midclavicular line. + JVD. trachea midline. Inaudible heart sounds. Dx? pericardual tamponade
70 YOM in hospital for elective CABG. On day of operation carotid bruit is heard. Next step in Dx? Duplex of neck
Ten days after admission to the hospital because of acute pancreatitis, a 56-year-old man with alcoholism develops chills and temperatures to 39.4°C (103°F). Examination shows a tender abdomen with hypoactive bowel sounds. most likely Dx? pancreatic abscess
24 YOW nulligravid, has syncopal episode. sever cramps in lower abdomen over 6h. vaginal bleeding for 2d. She is diaphoretic. Her temp is 37 , P 130, RR 26, BP 80/60. PE: blood in vagina, diffuse abd tenderness, pain with cervical motion. next step? Give Fluids
A 52 YOM, 5m pain in left knee exacerbated by long distance walking. Has HTN controlled. Exam of knee shows mild crepitus with flexion and extension, no effusion or warmth. XR of knee shows narrowing L joint space. BMI is 29. What step might imrpove Sx? weight loss program
A previously healthy 32 YOM with 3d of pain and swelling of right knee. 2 w ago he injured his right knee during touch FB. HIV test negative. homosexual. T 101.5, p 100, BP 120/60. Exam shows warmth erythema, joint effusion. XR confirms. Next step? arthrocentesis
A 57 YOW with inoperable SmCCa of lung has lethargy, loss of appetite and nausea. Radiation 2.5 y ago. Stable angina pectoris. P is 68, RR 16, BP 118/72. No JVD, skin turgor normal. Labs show low Na, low urine Osm. Most likely explanation? SIADH from tumor
A 8lb 6 oz female newborn has a plapable clunk of her hip when it is abducted, flexed, and lifted forward. Posterior pressure on flexed hip elicits a similar clunk. Most likely Dx? congenital hip displasia
A previously helath 72 YOM comes to physician with decreased urinary output for 2d. No output in 8h. Exam shows suprapubic fullness and enlarged prostate. Serum urea concentration is 88, serum CR is 3.5. Next step? bladder catherization
3 YOB 2w of persistent cough and wheezing. Sx occur when he laughs . 3 w ago he had an episode of chocking. T 99.7, p 90, RR 20, BP 70/45. Expiratory wheezes are heard on right with normal airflow. Sx dont improves with albuterol. Dx? foreign body aspiration
2 h after undergoing a right hepatic lobectomy, a 59 YOW has a distended abdomen. Her pulse is 120, BP 100/60. Most likely cause of these findings? poor mechanical hemostasis
3 d after a lap choly, 42 YOW has hematomas at all surgical siters. She was treated for DVTs 3 y/a but not taking any meds. Prior to op labs were normal. she got heparin and ACDs for operation. Now has isolated low platelets. Dx? heparin induced thrombocytopenia
2 days after surgical repiar of AAA, 67 YOM requires increasing vent/intubated and is being mech vented at FiO2 0.6 and PEEP 7.5 . He is diaphoretic. BP 90/60, +JVD. No breath sounds on left, trachea shifted to right. Pulse ox 82. Next step? needle aspiration of left side of chest
A previously healthy 62 YOM comes with 2m of cough. He has smoked 2 ;acks of cigarettes for 40 y. Exam WNL. CXR shows 2.5 cm non calcified pulm nodule. CT scan confirms. XR 1 y/a has nothing. Next step? bronchoscopy iwth transbronchial biopsy
What is the mech of diabetes type 2? abnormal insulin secretion with insulin resistance
3 YOG with left leg pain after a fall. Hx of fractures after minor trauma. Has blue sclerae. Obvious deformity in left thigh. XR shows new fracture of left femur and evidence of previous fracture. Most likely cause of findings? defective type 1 collagen

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