USMLE Step 2 CK Surgery (Kaplan) I

Retroperitoneal air in the abdomen. DX?
Duodenal injury (2nd portion)
Evaluation of retroperitoneal air. DX WU?
CT scan with contrast or UGI w gastograffin (if neg. do barium study)

Describe how retroperitoneal air might occur?
blunt trauma > duodenal compression between external solid object & spine (ie. steering wheel) > perforation of duodenum
M/C injured portion of duodenum during trauma? Why?
2nd portion of duodenum b/c it is the most immobile
Duodenal injury is a common oversite b/c
of its retroperitoneal location
Indications that a duodendal injury has occured ?
retroperitoneal air and/or obliteration of the psoas margin
DPL / CT / USG are used in the dx of duodenal injuriees b/c
they are not sensitive enough to detect duodenal injury
How long should the 3 dose tetanus vaccine provide coverage?
10 years
Best study for revealing esophageal perforation?
?
Definitive management for esophageal perforation?
Primary closure & drainage of mediastinum w/n 6 hours
complication of esophageal perforation if not managed w/n 6 hours?
mediastinitis (may result)
In esophageal injury avoid
endoscopy (to prevent further rupture)
Obese boy w c/o rt knee pain, rt knee exam nl, restricted hip motion, external rotation of thigh with flexing of hip. DX?
slipped femoral capitis
Slipped femoral capitis. Management?
emergent external screws
Slipped femoral capitis is m/c in?
obese male adolescents
First step w high suspicion of posterior urethral injury. Management?
retrograde urethrogram, suprapubic catheter, delayed repair
Anterior / Posterior urethral injuries. Contrast Tx.
Anterior – stat surgical repair Posterior – retrograde urethrogram delayed repair
In setting of urethral injury. DO NOT
do not insert foley cather, do not use diuretics (may worsen problem)
Retrograde cystogram is used when there is high suspicion of?
bladder injury
Unonscious pt receives OT intubation. Reasoning?
establish airway, protection from aspiration
erythema & edema of non lactating breast. High on DDX?
locally advanced inflammatory cancer
High suspicion of locally advanced cancer merits DX W/U?
biopsy
erythema & edema of non-lactating breast. DDX?
inflammatory CA, cellulitis, mastitis
breast w fluctuating mass. M/L?
an abscess
breast w fluctuating mass. Management?
drainage & antibiotics
Atelectasis. Tx?
bronchoscopy c repeat CXRS
Weakness in upper extremities greater than lower extremeities. Syndrome?
Central cord syndrome
central cord syndrome is associated w?
hyperextension injury
syndrome associated w unilateral paralysis
?
Complete motor paralysis & loss of sensation distal to lesion.
Anterior cord syndrome
anterior cord syndrome is typically a result of what type of injury?
compression injury causes ant. cord syndrome
type of cerebral contusion that selectively causes Upper limb sparing & lower limb
None?
What is false about this statement: All penetrating wounds in middle zone of neck should be surgically explored.
Stab wounds to middle zone pt may be safely observed?
Zone 1 of neck. Boundaries?
lower zone: clavicle to cricoid cartilage
Zone 2 of neck. Boundaries?
middle zone: cricoid to angle of mandible
Zone 3 of neck. Boundaries?
upper zone: angle of mandible to base of the skull
general structures of concern in zone 2.
major vasculature, larygotracheal apparatus, pharyngoesophageal structures
complete: All ___ wounds should be surgically explored in zone 2.
gunshot
General division of the neck can be done to improve management by dividing into anatomic components
digestive, respiratory, cardiovascular
selective management may be considered in zones?
zone 1 and zone 3
Indications for surgery according to digestive component of neck.
dysphagia, crepitation, hematemisis, dysphonia, hemoptysis, palpable laryngeal injury
Indications for surgery according to respiratory component of neck.
subcutaneous emphysema, stridor, tracheal tear,
Indications for surgery according to cardiovascular component of neck.
persistent hemorrhage, expanding hematoma, coma, stroke
gunshot wound to zone 1 is an indication for
esophogram w bronchoscopy
gunshot wound to zone 3 is an indication for
esophogram w bronchoscopy
expanding neck hematoma. Management Zone 1
surgical intervention
stab wound in asymptomatic patient
observation zone 1 zone 2
a popping sound of the knee m/l indicates?
medial meniscal tear
contrast shapes of the menisci
medial meniscus – C shaped, lateral meniscus – O shaped
meniscal injury is commonly due to what type of injury?
twisting injuries w a fixed footing
Minimum database consists of what?
History, Physical Exam Findings, and Diagnostic Test R7esults
What 5 things make up the signalment?
breed, age, species, sex and reproductive status
What drug can cats tolerate given alone but will cause seizure-like activity in dogs?
Ketamine
Boxers and Giant breeds are sensitive to what drug?
Acepromazine
Sighthounds are sensitive to what class of drugs? Examples of this drug class include?
Barbiturates
Exs- Thiopental Sodium, Methohexital, Thiamylal, Pentobarbital, Secanol, and Phenobarbital
What 2 conditions are very young animals prone to?
Hypothermia and hypoxia
When is a patient considered geriatric?
when they have reached 75% of the normal lifespan of that spp/breed
Why do anesthetic drugs pose a risk to geriatric patients?
They are more likely to have difficulty metabolizing drugs because of liver or kidney dz/failure
Describe a lethargic patient
They have a mild decrease in loss of consciousness and can be aroused with minimal difficulty
Describe a obtunded patient
This patient more depressed than lethargic patients and cannot be fully aroused
Describe a stuporous patient
This patient is in a sleep-like state; can only be aroused with painful stimuli
Describe a comatose patient
This patient cannot be aroused and is unresponsive to all stimuli including pain
Describe the c/s a patient who is <5% dehydrated
not detectable
Describe the c/s a patient who is 5-6% dehydrated
mild loss of skin elasticity
Describe the c/s a patient who is 6-8% dehydrated
mild loss of skin elasticity
+ dry mucous membranes and depressed globes within orbits
Describe the c/s a patient who is 8-10% dehydrated
mild loss of skin elasticity,dry mucous membranes, depressed globes within orbits
+more persistent skin tent, and increased PCV/TP
Describe the c/s a patient who is 10-12% dehydrated
mild loss of skin elasticity,dry mucous membranes, depressed globes within orbits,more persistent skin tent, and increased PCV/TP
+ dry, pale MM and CRT >2 seconds
Describe the c/s a patient who is 12-15% dehydrated
all of those and signs of shock and death
Dehydration increases the risk of what 3 things? things done to body b/c of
Hypotension, poor tissue perfusion and kidney damage
What is the formula to figure out how much fluid is needed to get your dehydrated patient back to hydrated?
(Wt in kg) x (1000 mL/kg) x (% dehydrated) = how much to give
Fluid maintenance rate for dogs?
60 mls ****check
Where are some other places to check if gums are pigmented?
conjunctiva, inner vulva, or prepuce
Normal rest heart rate for dogs and cats?
Dogs= 60-180 bpm
Cats= 110-220 bpm
Normal respiration rate for dogs and cats?
Dogs= 10-30/min
Cats= 25-40/min
What are 4 problems associated with obese animals?
They can experience dyspnea, difficult to draw blood from, it is harder to assess the hydration status of them, and difficult to auscultate
What risk are associated with thin animals? What else should you be wondering?
Hypothermia. Does this animal have an underlying condition making them then that could put them in additional risk under anesthesia?
What is the 1st thing you should do after weighing your animal?
Compare the animals current weight to previous weights
Normal body temp for dogs and cats?
100-102.5
How long should you fast a adult dog for a normal procedure?
Food 8-12 hours before surgery
Water 2-4 hours
How long should a patient having a GI surgery be fasted?
Food- 24 hours
Water 8-12 hours
How long should a neonate/ pediatric patient be fasted? Why?
4-6 hours for both food and water because you risk causing dehydration and hypoglycemia
Why do we fast patients?
To avoid vomiting/regurgitation during surgery or recovery which can cause esophagitis causing strictures, respiratory pneumonia or aspiration pneumonia
What does Famotidine do and why would we give it before surgery?
Famotidine stops production of HCL acid in the stomach and it is given before surgery to prevent damage caused to the esophagus if the patient were to vomit or regurgitate
What can prolonged fasting lead to?
Longer recovery period, delays in healing, and other assoc. risks such as hepatic lipidosis
If the animal will not eat what are your options?
hand/syringe feeding, inserting feeding tubes, or total parenteral nutrition (in jugular vein)
What should you always do once your patient enters the facility and is taken from the owner?
Properly ID the animal with a cage card, ID collar or both
Name 6 diagnostic tests that are performed presurgery.
CBC, ECG, Urinalysis, chemistry panel, radiographs and clotting times
Why do we check PCV and RBC? What does an increase indicate? A decrease?
To determine the blood’s ability to deliver oxygen to tissues. Increase indicates usually dehydration (leads to inc. viscocity of blood, poor perfusion and decreased cardiac output) Decreased levels usually mean anemia
If your PCV/RBC is lower that __ in a dog &
__ in a cat you should report it immediately.
dog lower that 25%
cat lower than 20%
Why do we check Total plasma protein? What does an increase indicate? A decrease?
Decreased levels can lead to drug potency. Increased values indicate dehydration. Decreased values indicate possible decreased production by liver or a loss through the renal, hepatic or GI systems.
TP values lower than ___ should be reported immediately.
less than 4.0
Why do we do blood smears? What do you report?
To evaluate RBC and WBC morphology and plt estimation. also can perform coagulation test with blood in red top tube. Report all decreases in plt count or abnormal coagulation test results
What are the things we are most concened about in the urinalysis? What do they show?
Specific gravity(detect dehydration- high or renal insufficiency/failure- low, not concentrating), Glucose and ketones (used to detect diabetes), and WBC & RBC (can indicate crystalluria or UTI) can be normal in sml amounts
Do a urinalysis within how many minutes?
30 or less
Chemistry panels look at what 6 things?
ALT (liver), ALP/ALKP (liver), BUN (kidneys), Creatinine (kidneys), Glucose (diabetes screen), Electrolytes (Na, K, Ca)
ALT. increases caused by?
Associated with liver. increases indicate any injury to hepatocytes or from any illness like GI disease (like chronic diarrhea and vomiting) or inflammation and administration of steroids or anticonvulsants,
ALP (ALKP) increases caused by?
Associated with liver, or bone or GI tract. Increases caused by isoenzymes which come from many different places such as Osteoblasts- immature bone cells
Chondroblasts- immature cartilage cells
Liver
Placenta
Renal epithelium
Intestinal epithelium
BUN increased by? decreased by?
BUN is associated with the kidneys. increased from dehydration, kidney disease or blockages like blocked toms. BUN is decreased by liver failure because liver is not synthesizing it, also by not eating
What 3 tests can be done to determine a clotting abnormality and what are the results of these tests?
Buccal Mucosal Bleeding Time (BMBT), Short nail trim to the quick, or placing blood sample into a red top tube and waiting for a clot to form. In all cases clot formation should occur within 4 minutes.
Name 2 Diagnostic test to check the heart. When/ why will your decide to perform these?
ECK- to evaluate the electrical activity of the heart, pattern, rhythm. Ultrasound of heart. These are performed when heart dz is suspected, heartworm positive, history of trauma, electrolyte abnormalities, or if the animal is geriatric.
How many different Physical Status Classifications are there?
5
PI list the amount of risk, physical condition and examples
Minimal risk. Physical condition- normal, healthy animal w/o underlying disease. Examples- spay, neuter, declaw, hip radiographs for hip dysplasia
PII list the amount of risk, physical condition and examples
Slight risk, minor disease. Physical Condition- slight to mild systemic disturbances; animal compensates. Examples- neonates, geriatric, obese, unknown skin tumors, uncomplicated hernia, local infection.
PIII list the amount of risk, physical condition and examples
Moderate risk, obvious disease. Physical condition- moderate systemic, disease mild clinical signs. Examples- anemia, moderate dehydration, fever, low-grade murmur, or heart disease.
PIV list the amount of risk, physical condition and examples
High risk, significant disease. Physical condition- Preexisting systemic disease. Examples- severe dehydration, shock, uremia, high fever, severe heart or lung disease, diabetes, emaciation
PV list the amount of risk, physical condition and examples
Extreme risk, moribund- risky whether they have surgery or not. Physical condition- life threatening disease that may not be corrected by surgery, animal may not survive 24 hours. Examples- advanced heart, liver, kidney, lung or terminal disease, severe shock, head injury, severe trauma.
Why do we give the animal IV fluids during surgery?
Fluids are constantly being lost while operating, also to keep drugs circulating through and eliminate them as well and to increase blood pressure
What are some signs of overhydration?
Eye/nose discharge, swelling of conjunctiva, SQ edema, increased lung sounds and respiration rate (will sound wet), dyspnea, coughing, restlessness, and hemodilution (diluting RBCs).
What are the rates dogs and cats with excessive hemorrhage or low blood pressure be increased to?
Dogs- up to 40 ml/kg/hr max of 1 hr
Cats- up to 20 ml/kg/hr max of 1 hr
What are the rates dogs and cats in shock be increased to?
Dogs- up to 50-90 ml/kg/hr max of 1 hr
Cats- up to 40-60 ml/kg/hr max of 1 hr
1/4 of max dose given in 15 minute increments then patient is evaluated
Animals that are in shock may show what signs?
Pale MM, low BP with increased heart rate, slow heart rate (when the body is giving up)
How many mLs of blood can a 3×3 gauze hold? a 4×4?
3×3 can hole 5-6 mLs and a 4×4 can hold 10 mLs of blood
What type of drip set to patients less than 10 Kg receive?
60 gtt/mL
What type of drip set to patients greater than 10 Kg receive?
VTI uses 15 gtt/ mL so use this
Body fluids are made up of how much % water, other solutes and the % of water is located where? What % is blood volume in dogs and cats?
Water is 60% of body weight. Intracellular fluid (inside cells) is 40%, extracellular fluid (outside cells) is 20% it consists of 2 categories interstitial fluid (between cells) 15% or intravascular fluid (inside a blood vessel) 5%. The other 40% is solutes.
Blood volume is 8-9% in dogs and 6-7% in cats.
How much of the IV fluids administered will stay in the intravascular space (is a fraction)? How much and where will the rest of the fluid go?
1/3 will stay in the intravascular space. 2/3 will diffuse into the interstitial space.
Which kind of fluids cannot move readily out of the intravascular space?
Colloids
Osmolarity is what? Normal Osmolarity equals?
Osmolarity is the solute concentration maintained in all body fluids. Normal concentration is 300 mOsm/L
What is the most common fluid type?
Crystalloids
What are the 3 general categories for crystalloids?
Balanced electrolyte solutions, Saline solutions, and Dextrose solutions
posterior urethral injury

Involves prostatic or membranous urethra;superior to the urogenital diaphragm.

sx: blood in meatus, inability to void, high-riding prostate. Perineal/scrotal hematoma. Pelvic fracture can cause.

Dx- retrograde urethrogram.
Tx- suprapubic catheter until it heals

anterior urethral injury

Involves the bulbar or penile urethra, inferior to the urogenital diaphragm.

sx: Perineal tenderness or hematoma & bleeding from urethra but normal prostate. Usually 2/2 blunt trauma to perineum or instrumentation.

intraperitoneal bladder rupture
Blunt trauma to full bladder –> burst at bladder dome –> GROSS HEMATURIA in 98%. suprapubic pain and difficulty voiding. more likely in kids.
dx: cystogram shows leak.
Tx: operation and repair of defect followed by Foley drainage.,
traumatic renal injuries
hematuria, abd distension, flank pain, ecchymosis. May be palpable mass
PAD work up
ABI using doppler in high risk or asympto pts
gold standard – contrast arteriography
tx: aspiring and cilostazol (PDEi)
esophageal rupture
mc follows UE, less commonly with alcoholic vomiting
Signs: Pneumomediastinum (palpable crepitus –> homanns sign), fever, + pleural effusion, does not cause circulatory collapse
Dx: water-soluble contrast esophagography
Tx: Primary closure of esophagus and drainage of mediastinum within 6hrs to prevent mediastinitis,
broad spec Abx, +/- parenteral nutrition
mallory weiss tear
a longitudinal tear in mucosal membrane of the GEJ. Occur from a sudden powerful or prolonged force due to coughing, vomiting, seizures, prolapse of the stomach into the esophagus or CPR.
, Tx: usually heals on it’s own (stop NSAIDs, alcohol, reduce vomiting/coughing)
-fluids/blood transfusions
-endoscopic treatment > epi injection, cautery, compression (endoclip/band)
-surgery is rare
bowel ischemia
Always consider it as an early complication of operation on the abdominal aorta . Pt presents with bloody diarrhea and abdominal pain. Its due to infarction of Inferior Mesenteric artery, 1-2 daya post surgery.
CT – thickening of bowel wall
colonoscopy – cyanotic mucosa with hemorrhagic ulcerations
radiation proctitis

-damage to lower parts of colon after exposure to X-rays or other ioinizing radiation as part of radiation therapy

sx: diarrhea, rectal bleeding, urgency, tenesmus. Later strictures and fistulas may form

dx: lower endoscopy, colonoscopy or flexible sigmoidoscopy

tx: chronic: sucralfate enemas, endoscopic cauterization of bleeding vessels (APC: argon plasma coagulation or topical formaldehyde)

how do you monitor a circumferentially burned limb?
doppler US flow meter
acute mesenteric thrombosis
abdominal pain out of proportion to physical findings, N/V and bloody diarrhea d/t mucosal sloughing.
– numerous atherosclerotic RG
colonic angiodysplasia
Dilated malformed submucosal and mucosal blood vessels common in right colon. patients > 60. common cause of GI bleed in elderly.
proximal vs distal small bowel obstruction
proximal: v, abd pain, abnL air filling on x-ray
distal: colicky abd pain, vomiting, abd distension, constipation/obstination, dilated loops of bowel on abd x-raysimple: luminal occlusion
strangulation: loss of blood supply to bowel wall

humeral neck fracture
-acute onset, after elderly fall on outstreched arm. swelling, ecchymosis, and crepitus over fx
– axillary n damage may be present
-determine degree of displacement and neuro compromise- xray (axillary view r/o dislocation) 2 views, CT scan- surgical planning
-tx: ice, pain meds, sling, ortho referral for ORIF
adrenal insufficiency
n/v, abdominal pain, hypoglycemia, HOTN after stressful event (surgical event) in person who is steroid dependent
– suspect if PMH suggests exogenous steroid use (SLE)
myocardial contusion
-may cause hemorrhage, edema, cell necrosis
– tachycardia
CXR – may show rib fx, which is a common cause
-EKG will show PVCs, Twaves changes, ST elevation
-CPK & Troponin enzyme levels elevated
-overall mortality is 10%
post-op atelectasis signs
hypoxemia with borderline low pCO2, VSS
dec lung compliance,ph=7.44, PO2 = 64, PCO2 = 34

torus palatinus
congenital, benign bony growth (exostosis) on midline hard palate. fleshy, immobile
no medical or surgical tx unless growth becomes sympto or interferes with speech or eating
mc in young pts, womens and asians.
urinary calculi
flank or abd pain radiating to groin. n/v
dx: non-contrast spiral CT of abdomen and pelvis
stress fracture
a series of microscopic fissures in bone that forms without any evidence of injury to other tissues, and results from repeated, strenuous activities such as running or jumping
– sharp, localized pain over bony surface that is worse with palpation
morton neuroma
mc cause of pain in forefoot in women 25-50 usually b/c shoes
– a/w pain bw 3rd and 4th toes on plantar surface
– mulder sign: clicking sensation when simultaneously palpating this space and squeezing metatarsal joints
– tx injections, strength into flexion with nerve gliding and surgery last case scenario
which types of arm fractures cause these nerve damages
midshaft humerus fx: radial nerve
supra condular fx of humerous: brachial a
humeral fx: ulnar n (claw hand)
ways to reduce ICP
1. head elevation: Inc venous outflow from head
2. sedation: decrease metabolic demand and control HTN
3. IV manitol: extraction of free water out of the brain tissue –> osmotic diuresis
4. hyperventilation: CO2 washout, leading to cerebral VC
scaphoid fracture
– mc carpal bone fracture, typically seen in young adults.
– fall on an outstretched hand.
sx: tender in the anatomic snuffbox or with resisted supination, and has limited range of motion of the wrist and thumb.dx: X-ray is often negative. May require special scaphoid views or repeat x-ray 10 to 14 days after treatment.

tx: thumb spica and referral. Improper treatment may lead to avascular necrosis.

drug fever in postop pt
typically seen 1-2 post op.
mc a/w anticonvulsants and bactrim
neck trauma

all unstable, penetrating wounds – immediate surgery (regardless zone)

if stable
zone 1 – angiography with possible embolization
zone 2 – immediate surgery
zone 3 – angiography, soluble-contrast esophagram, esophagoscopy, bronchogram. even if asympto

if stabbled in upper and middle zones, and azympto, can observe for 12 hours

pulmonary contusion

severe blunt chest trauma (MVA). Dyspnea, chest pain, hypoxemia worse with IVF, patchy alveolar infiltrates.

-may not develop until 1-2 post-trauma

– give colloids, not crystalline. check ABGs, CXR. intubate with PEEP if needed

traumatic diaphragm rupture
MVA. moderately resp distress
PE: no breath sounds over entire left chest
xray: multiple air fluid levels on chest
tx: lap
3 things that cause subemphysema
1. ruptured esophagus
2. Tension PNX
3. rupture of trachea or major bronchus
traumatic rupture of trachea
subq air
dx: CXR shows presence of air in tissues
txL fiberoptic bronchoscopy to confirm dx and level of injury. surgery- t/c if putting out very lg amt of air through chest tube and collapsed lung not expanding

obstructive surgical janudice

– obese, fecund women in 40s has recurrent episodes of abd pain, high AP, dilated ducts on sonogram, non-dilated GB full of stones

dx u/s, confirm with ERCP
tx: sphicterotomy and remove common duct stone. follow with cholecystectomy

emphysematous cholecystitis
– males, 50-75 yo; RF: db, gallstones,
– acute cholecystitis that arises 2/2 infection with gas forming bacteria;
-sx: RUQ pain, n/v, low-grade fever, crepitus in abodominal wall near gallbladder;-dx: abdominal U/S w air fluid levels in GB, curvilinear gas shadowing in GB; mild unconjugated hyperbilirubinemia; mild inc LFT;
-comps: gangrene, perforation;

tx: fluid/electrolyte rescucitation, early CCK, parenteral abx effective against G+ anaerobic clostridium (Unasyn, Zosyn, AG/FQ + clinda/metro)

pre-op hepatic RF
BR>2
albumin<3 PT>16
encephalitis-if 3 RF, 85% mortality
if 4 RF, 100% mortality

cardiac pre-op rF
1. EF <35 – prohibits non-cardiac surgery
2. JVD – optimize meds
3. recent MI – defere 6 months
4. severe angina – perfect cath
pulmonary pre-op rf
smoking
high PCP2
FEV1 <1.5
nutritional pre-op risk
loss of 20% body mass
serum albumin <3
anergy to sking allergy
serum transferrin<200
db coma
hip fx and treatment

external rotation and shortened leg

femoral neck fx: femoral head replacement, high risk of avascular necrosis
intertrochanteric fx: open reduction and pinning
femoral shagt fxL intramedullary rod fixation

direct blow to ulnar (monteggia fx) or radius (Galeazzi fx)

a diaphyseal fx and displaced dislocation of nearby joint

tx: open reduction and internal fixation of diaphysial fx
closed reduction of dislocated joint

posterior dislocation of hip

internally rotated and shorted

emergency reduction

subclavian steal s/d
-arteriosclerotic stenotic plaque at origin of sublcavian allows enought blood to reach the arm in normal, but not vigorous activities. blood is then “stolen” from vertebral artery
-psterior neuro problems: visual sx, equilibrium problems
– claudification in the arm during exercisesdx: angiography
tx: bypass surgery

Retroperitoneal air in the abdomen. DX?
Duodenal injury (2nd portion)
Evaluation of retroperitoneal air. DX WU?
CT scan with contrast or UGI w gastograffin (if neg. do barium study)
Describe how retroperitoneal air might occur?
blunt trauma > duodenal compression between external solid object & spine (ie. steering wheel) > perforation of duodenum
M/C injured portion of duodenum during trauma? Why?
2nd portion of duodenum b/c it is the most immobile
Duodenal injury is a common oversite b/c
of its retroperitoneal location
Indications that a duodendal injury has occured ?
retroperitoneal air and/or obliteration of the psoas margin
DPL / CT / USG are used in the dx of duodenal injuriees b/c
they are not sensitive enough to detect duodenal injury
How long should the 3 dose tetanus vaccine provide coverage?
10 years
Best study for revealing esophageal perforation?
?
Definitive management for esophageal perforation?
Primary closure & drainage of mediastinum w/n 6 hours
complication of esophageal perforation if not managed w/n 6 hours?
mediastinitis (may result)
In esophageal injury avoid
endoscopy (to prevent further rupture)
Obese boy w c/o rt knee pain, rt knee exam nl, restricted hip motion, external rotation of thigh with flexing of hip. DX?
slipped femoral capitis
Slipped femoral capitis. Management?
emergent external screws
Slipped femoral capitis is m/c in?
obese male adolescents
First step w high suspicion of posterior urethral injury. Management?
retrograde urethrogram, suprapubic catheter, delayed repair
Anterior / Posterior urethral injuries. Contrast Tx.
Anterior – stat surgical repair Posterior – retrograde urethrogram delayed repair
In setting of urethral injury. DO NOT
do not insert foley cather, do not use diuretics (may worsen problem)
Retrograde cystogram is used when there is high suspicion of?
bladder injury
Unonscious pt receives OT intubation. Reasoning?
establish airway, protection from aspiration
erythema & edema of non lactating breast. High on DDX?
locally advanced inflammatory cancer
High suspicion of locally advanced cancer merits DX W/U?
biopsy
erythema & edema of non-lactating breast. DDX?
inflammatory CA, cellulitis, mastitis
breast w fluctuating mass. M/L?
an abscess
breast w fluctuating mass. Management?
drainage & antibiotics
Atelectasis. Tx?
bronchoscopy c repeat CXRS
Weakness in upper extremities greater than lower extremeities. Syndrome?
Central cord syndrome
central cord syndrome is associated w?
hyperextension injury
syndrome associated w unilateral paralysis
?
Complete motor paralysis & loss of sensation distal to lesion.
Anterior cord syndrome
anterior cord syndrome is typically a result of what type of injury?
compression injury causes ant. cord syndrome
type of cerebral contusion that selectively causes Upper limb sparing & lower limb
None?
What is false about this statement: All penetrating wounds in middle zone of neck should be surgically explored.
Stab wounds to middle zone pt may be safely observed?
Zone 1 of neck. Boundaries?
lower zone: clavicle to cricoid cartilage
Zone 2 of neck. Boundaries?
middle zone: cricoid to angle of mandible
Zone 3 of neck. Boundaries?
upper zone: angle of mandible to base of the skull
general structures of concern in zone 2.
major vasculature, larygotracheal apparatus, pharyngoesophageal structures
complete: All ___ wounds should be surgically explored in zone 2.
gunshot
General division of the neck can be done to improve management by dividing into anatomic components
digestive, respiratory, cardiovascular
selective management may be considered in zones?
zone 1 and zone 3
Indications for surgery according to digestive component of neck.
dysphagia, crepitation, hematemisis, dysphonia, hemoptysis, palpable laryngeal injury
Indications for surgery according to respiratory component of neck.
subcutaneous emphysema, stridor, tracheal tear,
Indications for surgery according to cardiovascular component of neck.
persistent hemorrhage, expanding hematoma, coma, stroke
gunshot wound to zone 1 is an indication for
esophogram w bronchoscopy
gunshot wound to zone 3 is an indication for
esophogram w bronchoscopy
expanding neck hematoma. Management Zone 1
surgical intervention
stab wound in asymptomatic patient
observation zone 1 zone 2
a popping sound of the knee m/l indicates?
medial meniscal tear
contrast shapes of the menisci
medial meniscus – C shaped, lateral meniscus – O shaped
meniscal injury is commonly due to what type of injury?
twisting injuries w a fixed footing

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