Surgery NBME Form 3 - Questions and Answers

Surgery NBME Form 3 - Questions and Answers 3 wk old - 18 days of inc yellow skin/eyes born to 24 yo woman, G2P2, uncomplicated preg/delivery > 3175g at birth breast-fed exclusively today weights 3345g BR = 15 (direct - 13) most likely dx? biliary artesia suspected in 6-8 wk old babies - persistent, prog inc jaundice (more conj) dx: 1 wk of phenobarbital > HIDA scan if no bile reaches duodenum w/ phenobarbital > surgical exploration 22 yo - pain/edema of R.upper ext > 10 days after hospital admission PMHx: acute leukemia 3 days ago: completed 7 days of chemo admission: NaHCO3 and allopurinol; placement of RA catheter PE: R.upper ext 1.5xlarger than L. venous duplex US: occlusion of R.axillary and subclavian viens most likely cause of symptoms? complication of the right atrial catheter usually these are image-guided to make sure complications like these don't happen potential complications: hemorrhage and pneumothorax during insertion; thrombosis/infection at later stages pts w/ Hickman line - require reg flushes of catheter w/ normal saline > prevent line from becoming blocked by blood clots #1 cause of upper ext DVT: venous catheter 27 yo - ED after gunshot wound to R.mid thigh alert and orientedx3 pain in R.thigh RR: 24/min PE: single entry wound in R.mid thigh w/ swelling; R.politeal, post tibial, and dorsalis pedis pulses - absent O2 and IV 0.9% saline begun X-ray of R.lower ext: comminuted fx of femur reduction and immobilization of fx + what else is next step in mgnt? surgical exploration of the right femoral artery comminuted fx = break or splinter of the bone into 2+ fragments any comminuted fx goes to the OR since the bone is broken into so many pieces - you're going got have to check to see how the BVs are doing > PE shows absent pulses so esp worrisome in this pt in traumatic injuries where there is mult damages, you fix in this order: 1. bone > 2. vascular > 3. Nerve 77 yo - mild confusion - 24 hrs after surgery repair of AAA urine output: 10 mL/hr over past 3 hrs diaphoretic; orientedx1 100.8 F P: 110/min RR: 20/min BP: 80/60 mmHg PE: upper/lower ext - cold/clammy pulm art cath: inc PCWP 23 mmHg most likely explanation of these findings? myocardial infarction homeboy is in cardiogenic shock > signs: cold and clammy ext; inc HR; dec BP > dec cardiac output; inc PCWP shocks vs swan-ganz Cath parameters (cardiac index, CVP, PCWP, SVR) 1. cardiogenic - everything inc except cardiac index low 2. hypovolemic - everything low except SVR inc 3. septic - everything low except cardiac index high 4. PE - cardiac index and PCWP low; CVP and SVR high 42 yo - ED 17 min after MVA > abd and L.flank pain > hemodynamically stable PE: tenderness over L.flank but no ext marks UA: gross blood next step in mgnt? CT scan of the abdomen and kidneys honestly none of the other answers make sense > hematuria - IVP, cystourethrogram, US, CT make sure it's contrast bc you need to differentiate bet fluid vs blood peritoneal lavage: determine if there is free floating fluid (most often blood) in the abd cavity renal blood flow scan: examine kidneys and assess their fxn obese 10 yo - 3 hrs after uncomplicated tonsillectomy for OSA - 104.9 F P: 130/min RR: 30/min; deep breathing BP: 90/60 mmHg > BP perioperatively: 105/70 mmHg PE: mottled skin; tonsillar bed intact; no excessive bleeding; thyroid gland not enlarged; BL basilar crackles; precordium hyperdynamic w/o rubs/gallops; cool ext; gen muscle rigidity coag: inc PT, PTT (INR 1.5) UA: 2+ blood/protein; no RBC/WBC/organisms ECG: nonspecific ST changes most likely dx? malignant hyperthermia mottled skin (aka livedo reticularis) = skin that has patchy and irregular colors features: sudden-onset tachypnea, tachycardia, myoglobinuria (brown-colored urine), and masseter/ generalized muscle rigidity > follows exposure to succinylcholine or a volatile anesthetic > due to excessive Ca release urgent tx: dantrolene + supportive care causes of immediate (w/in few hrs) post-op fever: > febrile nonhemolytic transfusion rxn > prior infection/trauma > inf due to surgery > malignant hyperthermia > meds – anesthetics 22 yo - ED 1 hr after MVA P: 120/min BP: 100/70 mmHg multiple faial lacerations what imaging study is best for screening cervical trauma? lateral X-ray extend CT head to include neck ~but~ homeboy is "hemodynamically unstable" > lat X-ray best option bc you can do this while you resuscitate > if you wanna argue that he's not rlly unstable - I'm gonna assume X-ray is the better "screening" imaging tool CT and MRI would take longer - use X-ray to screen first and then f/u w/ these more sensitive imaging studies (esp when the pt is more stabilized) 64 yo - elective surgeries repair of AAA > retroaortic renal vein lacerated - lots of blood lost > RL retained by cell-saver auto transfusion device + 22 units of pRBCs replaced hemodynamically stable - but blood oozing from each surface in operative field and from IV/art cath sites most likely dx (bleeding disorder)? thrombocytopenia aka low plt count pt only received pRBCS for replenishment aka low/diluted plts - so nothing to help him w/ acute bleeding pts who require large transfusions > will become coagulopathic > FFP usually infused - esp after 6-8 units of pRBCS ~ since plts depleted w/ large transfusions basically the transfusions diluted the pt's plts 22 yo - swollen, painful, and slightly plethoric R.lower ext > 2 episodes of sup thrombophlebitis of R.lower ext (30 months, 18 months ago) venous duplex scan: DVT involving infrapopliteal veins most likely dx (bleeding disorder)? antithrombin III deficiency antithrombin III - inactivates thrombin (which is what clots are made offfff) homeboy has recurrent clots suggesting clot problem antithrombin III: protein in the blood that blocks abnormal blood clots from forming pt clearly has hypercoagulable state > presents w/ recurrent thrombotic complications - DVT, PE, art thrombosis, MI, and stroke; women - recurrent miscarriages