Surgery NBME Form 1 - Questions and Answers 42 yo - hospital w/ piece of meat lodged in lower esophagus meat removed by esophagoscopy w/ difficulty evening - 101 F most app dx study? water-soluble contrast upper gastrointestinal study don't repeat what procedure damaged her esophagus water-solubl...
Surgery NBME Form 1 42 yo - hospital w/ piece of meat lodged in lower esophagus meat removed by esophagoscopy w/ difficulty evening - 101 F most app dx study? water -soluble contrast upper gastrointestinal study don't repeat what procedure damaged her esophagus water -soluble aka gastrograffin - dx esophageal rupture neck x -ray - if food/thing stuck in oropharynx upper GI study - if want to look at thorax if this procedure is non -dx > Ba study if perforation confirmed > primary closure of esophagus and d rainage of mediastinum PE: Hamman sign - crunching sound on chest ausc 52 yo - ED due to 4 days of progressive back pain and weakness/numbness in legs hasn't urinated in 12 days PMHx: L.mastectomy (for breast cancer) 5 yrs ago PE: CNs intact; muscle stre ngth 3 -4/5 in lower ext; DTRs 3+ in knees/ankles; Babinski sign BL; sens to pinprick dec below nipples; sens to vibration absent in lower ext unable to walk MSE: gucci insertion of catheter - 400 mL of urine most likely location of abnormality? thoracic sp inal cord breast cancer loves to met to the bone mass compressing on spinal cord dec pinprick sens below T4 = thoracic location *LMN signs at level of lesion UMN signs below level of lesion* early signs: symmetric lower -ext weakness, hypoactive/abs DTRs late signs: BL Babinski reflex, dec rectal sphincter tone, paraparesis/paraplegia w/ inc DTRs, sens loss mgnt: emergency MRI; IV glucocorticoids; rad -onc and neurosurg consultations 37 yo - bruising on arms/abd for 3 wks meds: Ibuprofen (occ HAs) PE: ecchy moses over upper ext/trunk; lungs clear; cardiac/abd - gucci CBC: Hgb, WBC - WNL; dec plt (45,000); inc PT (15), bleeding time (11) bone marrow aspirate: inc megakaryocytes most likely explanation? formation of antiplatelet antibodies homegirl has ITP AI dz - dx of exclusion IgG Abs coat/damage plts > removed by splenic macrophages most acute cases preceded by viral infection chronic: mostly women 20 -40 yo symptoms: petechiae and ecchymoses on skin; bleeding of mucous membranes bone marrow aspiration: inc m egakaryocytes peripheral smear: dec plts inc plt -ass IgG tx: steroids; IVIg started acutely to get plts up faster; splenectomy if steroids fail; romiplostim and eltrombopag - for splenectomy -res pts 67 yo - operative formation of AV conduit in L.forearm for vasc access performed under axillary block anesthesia PMHx: end -stage renal dz, atherosclerotic CAD, T2DM 24 hrs later - SOB P: 129/min RR: 38/min, shallow BP: 100/55 mmHg PE: JVD; crackles BL bases; S1/S2 normal; S3 and S4 present; no edema of sacrum/ ext begin 300 mL of fluids most likely dx? high-output congestive heart failure AV fistulas - blood takes path of least resistance into venous system lots of arterial blood going into venous system > inc preload > inc CO > CHF crackles in lungs, JVD, S3/S4 - due to fluid buildup in CHF 46 yo - ED due to 12 hrs of N/V and mid abd that radiates to the back PMHx: chronic alcoholism P: 120/min RR: 20/min BP: 110/60 mmHg abd exam: tenderness to palp over upper quadrants; bowel sounds absent CBC: dec Hgb (10.1) ; inc WBC; WNL plt CMP: inc amylase (1842), glucose (248); dec Ca; WNL albumin next step is IV administration of ? lactated Ringer solution supportive care for acute pancreatitis MC causes: alcohol abuse and gallstones recurrences common in alcoholic pancr eatitis symptoms: abd pain (epigastric > back); N/V; anorexia dec/absent bowel sounds = partial ileus labs: lipase > amylase tx: bowel rest (NPO); IVF; pain control (fentanyl and meperidine) 27 yo - ED 4 hrs after onset of bloody diarrhea > int nonbloody diarrhea - 6 months > 4 days of and cramps > last week: dec appetite > 15 lb weight loss PMHx: HIV+; 2 hospitalizations for PCP during last yr meds: didanosine, indinavir, stavudine, TMP -SMX 103 F P: 130/min RR: 24/min BP: 80/60 mmHg PE: diffuse crackles BL; rigid, tympanic, distended abd w/ diffuse rebound tenderness; dec bowel sounds; DRE - gross blood CBC: dec Hgb (8), Hct (24%), WBC (3500) fluid resuscitation w/ 0.9% saline and transfusion of 2 units of pRBCs > total and colectomy w/ ileostomy for perf orated cecum path: diffuse mucosal inf w/ nuclear inclusion bodies most likely causal org? Cytomegalovirus symptoms: freq, small volume diarrhea; hematochezia; abd pain; low -grade fever; weight loss nuclear inclusion bodies = virus PNA symptoms + diarrhea > if immunosup - CMV > if immunocomp - legionella MC causes of diarrhea in pts w/ AIDS: crypto -/micro -/iso-sporidium; MAC; CMV 47 yo - 2 wks of fatigue and prog abd swelling abd exam: shifting dullness and distention; bowel sounds normal; no tenderness/masses/organomegaly dx paracentesis - 50 mL of milky chylous fluid most likely cause? lymphoma chylous acites > look for malignancy obstructing lymphatic flow MC cause of chylous a scites: > in the U.S.= lymphoma > in the developing world = TB intra-abd malignancy can invade or externally compress retroperitoneal lymph vessels > obstruction of lymph flow into the thoracic duct > lymphedema = leakage of lymph into the peritoneal cavit y
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