all right let's move on now to our complete surgery review now in this video we're gonna have 120 surgery review questions you will be prepared for shelf in step two and of course you will have fun along the way now let me begin with the following introduction here is your surgery attending now you have to use your surgeon attending to your advantage now what I mean by this is that you have to imagine him screaming at you I mean I know you're used to this but you need to imagine him screaming at you things that you want to remember for example the Parkland formula for burns four times body weight time surface area and then you remember for the rest of your life not the nasty things that he would say about you but instead the Parklands formula for Burns and everything else that you need to know for surgery and with this introduction let's begin with question one question one which medication Must Be Stopped seven days before surgery now of these choices the only one that must be stopped seven days before surgery is naproxen one of the NSAIDs all NSAIDs and cox-2 Inhibitors Must Be Stopped seven days before surgery and another one that I wrote over here are herbal supplements these Must Be Stopped a week before surgery beta blockers don't need to be stopped they can be continued along with calcium channel blockers diuretics we stop on the day of surgery and long-acting Insulin we don't stop but short acting ones we do on the day of steroids of course we don't stop we get a higher dose and we'll talk about stress dosing later let's move on question two which intraoperative cardiac risk is worse a a patient with ef under 35 percent or B a patient with a transmutual mi six months ago and the answer is a a patient with an EF under 35 this has a 75 mortality rate during surgery as for B patients with a transmitter LMI six months ago don't have a relatively High mortality rate only six percent and that's exactly why we recommend waiting until six months post Mi to get surgery question three why do surgeons beg their patients to stop smoking eight weeks before surgery compromise ventilation or oxygenation and the answer is compromise ventilation patients with compromised ventilation May develop high pco2 with low fev1 they can't get the carbon dioxide out I wrote a note over here that smoking is the most common by far the most common cause of increased pulmonary risk during surgery and that's why we convince patients to no avail to stop smoking to use nicotine replacement therapy and if not bupropion or varenaclean question 4 which person has the highest risk of dying during surgery a patient with significant aortic stenosis a patient over 70 or a patient with jvd and the answer is c a patient with jvd because signs of heart failure jvd which represents heart failure is the absolute worst finding and if possible we treat with ACE inhibitors beta blockers question 5 surgical timeouts I'm not going to read the whole thing because the answer is all of the above are true they occur just prior to skin incision it includes the patient identity and it includes a site and laterality I.E the side of the operation now I wrote other patient safety reminders on the bottom over here pre-operative patient identity occasionally holding area along with verification of operation type and laterality documentation by at least two providers and we use permanent markers during surgery for operative sight and we never mark non-operative sites question six what are causes of post-operative fever and the answer is all the above we know the mnemonic now right on the top over here that atelectas is the most common cause of fever first day post-op and we prevent this with deep breathing exercises and if we need to we go with bronchoscopy pneumonia follows three days later if the atelectasis is not resolved UTI presents usually on day three DBT on day five wound infection on day seven and abscess post-operative day 10 to 15. question 7 wounds that have been freshly debrided are treated with wet to dry dressings we want to kind of dry them out it's only once they're healthy and we have beautiful granulation tissue do we get moisture retaining dressings question 8 what's the treatment for a linear skull fracture and the answer is observation if they're linear we don't go with surgery that's only with open fractures question 9 a patient develops sudden pleuritive chest pain seven days after surgery the ABD shows hypoxemia and hypocapnia this sounds like pulmonary embolism after confirming the diagnosis what is the next step and the answer is we give Heparin we only go with the IVC filter if the peas recur during anticoagulation or if the anticoagulation is contraindicated question 10 which cranial nerve can be damaged during Nissen fund application to treat GERD and the answer is during this procedure the vagus nerve cranial nerve 10 can be damaged and this leads to gastroparesis in which we see early satiety bloating and weight loss and management includes dietary modifications such as small meals low in fat and metaclopramide which promotes motility 11. in paralytic ileus what do we see bowel sounds are absent we don't hear bowel sounds there's usually not pain but bowel sounds are absent and here we just have an x-ray of paralytic ileus I wrote a note over here that paralytic ileus is prolonged by hypokalemia in this condition there may be mild distension but it's usually self-resolving so conservative management and serial exams is what we do question 12 a physician thought it was paralytic ilius but now it's been six days with no resolution what's the most likely diagnosis and the answer is mechanical bowel obstruction due primarily to adhesions x-rays show dilated Loops of small bowel and airflow levels and we confirm this diagnosis with a domino CAT scan and we treat it with surgery question 13 which of the following interventions is recommended during intubation to reduce the risk of pneumonia for example due to aspiration and the answer is all of these are appropriate if we minimize patient transport in order to avoid movement of the endotracheal tube we suction subgladic secretions and we Elevate to a semi-recumbent position I.E 30 to 45 degrees elevation all of these prevent aspiration pneumonia associated with the intubation question 14 shortly after a duodenal switch operation the patient can expect to be significantly lighter probably not yet they have to wait some time and the answer is no longer need his type 2 diabetic medications it's quite fascinating that duodenal switch operation kind of gets rid of diabetes in over 95 of patients they don't need their medications anymore and they're no longer hyperlipidemic and why of course don't all diabetic patients get this at least the ones that are obese and the answer is because there are lots of associated issues 15. how do these things lead to shock and the answer is these things lead to anaphylaxis and there's dilation of blood vessels in which there's reduced blood flow and here we just compare the various types of shocks question 16 a two-year-old child has chronic constipation and when a rectal exam is done there is explosive expulsion of stool barium enema shows dilated proximal colon what's the next step and this is Hirschsprung's disease and the next step is a full thickness biopsy of the raccoonucosa her sprung's disease is also known as congenital a ganglionic megacolon because that's what's going on it's a ganglionic question 17 a 69 year old man can't sleep because of pain in his calves he can't walk a block without getting the same pain pe shows loss of hair muscle atrophy and no pulses in the foot what's the next step so here we see intermittent qualification and here we want to get an ABI I.E we calculate the lower and upper systolic pressure that's what ABI does it uses an ultrasound we get this systolic pressure at the angle and we divide it by the systolic pressure in the arm if it's less than 0.9 that's a diagnosis of pad peripheral artery disease and we follow the CT angiogram or MRI angiogram to assess and plan revascularization question 18 what should be avoided in a patient with acute subdural hematoma assuming there's no midline deviation and the answer is warm fluid infusion we want to give cold water infusion we want to induce hypothermia in this Hemorrhage to reduce the oxygen demand and by the way I wrote a note over here that hypertonic Solutions can also reduce intracranial pressure question 19 a patient with breastfeed with a puncture wound and broken ribs during positive pressure ventilation he develops tachycardia hypotension and unilaterally absent breath sounds what's the diagnosis so this is a complication of positive pressure ventilation and that is tension pneumothorax and that's why he has his tachycardia hypotension and the abs and breath sounds on one side in this condition we temporarily manage with needle compression and formal chest tubes are placed in later now I want to draw your attention to this chart I made over here where I compare regular pneumothorax with Tangent pneumothorax in tension with RX we see air in the plural space through a one-way leak now in this condition we contrast with atelectasis because an atelectasis the tracheal deviation is towards the effects of lung because the problem is the collapse of the lung as opposed to intention pneumothorax we see tracheal deviation away from the evolved lung because we see a balloon filling up on the affected side question 20 a 19 year old woman endures a motorcycle accident she has rib fractures two days later she suddenly develops hypoxemia and hypercapnia the cxr is shown what's the diagnosis so here we see this whitening over here and this represents a pulmonary contusion pulmonary contusion doesn't only happen at the time of the injury it could happen up to 48 hours later it's delayed in 40 of cases this is not pulmonary embolism pulmonary embolism chest x-ray often doesn't show much but we may see various findings such as the fleischner sign and the Hampton hump and the fat embolism we perhaps see bilateral haziness on chest x-ray we don't see this one-sided whitening question 21 if peripheral Ivory ions are unsuccessful in the trauma setting what's the next step in adults or interosseous do we go with a percutaneous femoral vein catheter or intraosseous cannulation of the proximal tibia and the answer is procutaneous Emerald vein catheter Choice B is what we do in children under six years of age but an adult we go with percutaneous feminal vein or saphenous vein catheter question 22 a woman develops DIC during surgery for an intra-abdominal Hemorrhage blood is oozing from the IV sites her body temperature is normal what's the next step this is DIC do we stop the surgery or go with ffp and platelets and the answer is equals ffp and platelets we don't stop surgery simply because of the DIC that's only of hypothermia and acidosis develop question 23 a man gets shot in his upper lateral thigh the bullet is embedded in the vastus lateralis which we see in the picture upon evaluation no major vascular injury has occurred what's next and the answer is tetanus tetanus prophylaxis arteriogram is only needed if there's vascular damage and removal of the bullet is generally not what we go with we go with prophylaxis for tetanus question 24 a patient has a pleural LDH of 70 and a serum of 80. so remember the formula lights criteria where we have to divide plural by serum and if it's more than 0.6 we call it an oxidative effusion and that's what's going on over here it's more than 0.6 so we know it's an oxidative effusion excitative effusions can be due to various things but over here we see milky white fluid and that scene in kylothorax in an anti EMA we see purulent fluid and in malignancy we see a clear or cloudy fluid and in Kyle fluorax we see milky fluid another question 24 a 73 Old Woman fell she's lying in pain with her right leg shortened and externally rotated this sounds like a fracture x-rays show an intracanteric fracture of the right hip what's the best treatment and the answer is open reduction and post-op anticoagulation we don't go with hip replacement we go with open reduction and the post-op and coagulation is important to prevent DBT and PE because she's not going to be moving much after the surgery question 25 a 34 year old woman with a pyloric obstruction secondary to acid ingestion has protracted non-billies and non-bloody vomiting she's visibly dehydrated and these are electrolytes What's Next Step so she keeps on vomiting because she once ingested acid and that caused bipolaric stricture so which fluid resuscitation do we give and the answer is normal saline with KCl because this is a metabolic alkalosis remember metabolic alkalosis is primarily caused by protracted vomiting so since she has a metabolic alkalosis we treat this with potassium chloride question 26 which is an absolute contraindication to surgery over 100 years of age nah you look in the news you'll see people who are over 100 who got surgery and the answer is diabetic coma we don't perform surgery on patients in diabetic coma we must rehydrate them regain urinary output and at least partially correct the acidosis and hyperglycemia before surgery question 27 halothane and succinylcholine can lead to and the answer is homolignant hyperthermia and we treat this condition with dantroline this is my little pneumonia inhaled in socks malignant hyperthermia oh shocks and dantroline Deluxe that inhaled anesthetics and succinylcholine can lead to malignant hypothermia and we treat with dantroline 28 four months after pelvic radiation therapy for cervical cancer a woman develops rectal bleeding and talangectages viewed via colonoscopy what's the diagnosis so this happened four months later this is chronic radiation proctitis acute occurs within eight weeks chronic occurs after three months and we see bleeding intellectages 29 a 19 year old male with a blunt lower abdominal trauma cannot void and has abdominal distension with a positive fluid wave the UN is 63 Creon is 4.2 temperature is normal what is the diagnosis so since he has this positive fluid wave we know this is a bladder rupture and P or urine is leaking into the abdominal space that's what's leading to this fluid wave in small bowel rupture we see fever and abdominal rigidity but in bladder rupture we see the fluid wave representing the urine and fluid floating in the abdomen and we confirm diagnosis with retrograde discography and we treat with surgical repair 30. fever flank pain in the dark urine 10 minutes after blood transfusion this is acute hemolytic transfusion reaction it has a classic Triad of fever flank pain and dark red urine the first step is the Coombs test and this condition may lead to acute kidney injury or DIC 31 large diabetic photo ulcers require which of the following pressurizing the wound no we try to give it space and the answer is Imaging with x-ray MRI we want to rule out osteomyelitis because diabetic fluid ulcers can lead to osteolitis other indications include if there are elevated inflammatory markers or Associated fever 32 what is the greatest risk factor for spinal medioma in which we would see for example spinal cord compression leading to bilateral arm and leg weakness and the answer is radiation is the greatest risk factor older age is also a risk as well as female and nf2 neurofibromatosis type 2 but radiation exposure to ionizing radiation is the greatest risk factor 33 a 23 year old woman got punched in the left eye by her boyfriend who is now detained by the cops which of the following is an indication for CT scan of the orbit and the answer is all of these are indications for CT scan of the orbit a palpable bony step off that's a sign of fracture limited or painful ocular movements as well as decreased visual Acuity question 34 acute angle closure glaucoma where we see sudden onset Headache nausea ocular pain decrease vision and conjunctival redness is initially treated systematically with and the answer is carbonic anhydrous inhibitor acetazolamide in addition to the topicals timolol apriconidine and pilocarpine but the definitive treatment is laser iridotomy 35 the first step in managing acute upper GI bleed is to establish vascular access with two large bore IV lines 14 or 16g these are the big ones that we want to use again two of them so if we only have one of them the answer would be to add another question 36 a 64 year old woman has right heel pain worsened by passive dorsiflexion of the big toe foot X ratios a calcaneal bone spur but no fracture what's the next step so this sounds like plantar fasciitis and the next step is heel inserts that's first line along with activity amount application and stretches his first line for plantar fasciitis these spurs by the way are seen often in patients with plantar fasciitis steroid injection would be second line if the initial treatments with activity modification stretches didn't work 1037 a week after ruin y bypass a 37 year old woman develops fever abdominal pain a lot of tachypnea heart rate is 125 and what's the next step so here we need to be concerned about a leak of the anastomoses we gotta get a CT scan to assess for anesthematic leak question 38 which medication is contraindicated patient in the history of aortic aneurysm and the answer is levofloxacin because fluoroquinolones because fluoroquinolones not only have a risk of tendon rupture but also of aortic aneurysm question 39 the ideal placement of essential venous catheter should be in the lower SVC smaller veins predisposed to venous preparation that's why we go with the lower SVC we need to get a portable chest x-ray to confirm the placement and it should be just proximately the angle between the trachea and the right mainstem bronchus question 40 a patient has symptoms of diverticulitis but now is fever guarding and rebound tenderness bowel sounds are reduced what will be seen on Imaging of the abdomen free air is what we see in diverticular perforation dilated small bowel is what we see in SPO there we see high pitched bowel sounds and no signs of peritonitis such as guarding 41. a patient assigns of a spinal epidural abscess I.E back pain fever and an amateur compromised patient what's the next step and the answer is MRI with contrast that allows us to properly see the tissues and the extent of infection by the way fever is not always present in spinal epidural lapisis that's just important to know a tender mask near the top of the toxus in a hairy 25 year old man is treated with so there's of course pilonidal cyst and we treat this with drainage along with excision of sinus tracts question 43 conductive hearing loss for example improved understanding in noisy places in young patients with a family of history is due to the answer to this is stapes stiffening because this is otosclerosis it may be either sporadic or as in this case autosomal dominant 44 after laparoscopic surgery a patient develops fever abdominal pain with Guardian leukocytosis so what's the next step these findings should be further assessed with abdominal CAT scan to assess for laparoscopy Associated bowel injury for example perforation or burn of the instruments used during the procedure question 45 asymptomatic glittery cysts are treated with surgery due to a huge risk for malignancies of the biliary ducts gallbladder and pancreas 46 CT Imaging of ischemist colitis for example a patient has abdominal pain hematochezia diarrhea and lactic acidosis shows and the answer is it shows colonical thickening and Air in the bowel wall that's what we see in CT Imaging of ischemicalitis we treat ischemicalitis with fluids antibiotics and surgical resection is done if necrosis develops question 47 which features favor purely pericardial Fusion over viral why would we think that it's purulent and the answer is we see a severely sick patient with marked leukocytosis we don't see these in pericardial Fusion but as for Choice B distant heart sounds and fever that seen in both conditions 48 a young Pace with decreased urinary flow and a feeling of incomplete emptying that is due to urethral stricter that's why a young patient could develop these symptoms question 49 what is the cause of kidney stones in Crohn's disease or gastric bypass and the answer is patients with these conditions get hyperoxyloria and what happens is fatty acids aren't absorbed in these conditions so calcium binds the fatty acids so calcium is not available to bionoxylate oxalate can now be reabsorbed and it's dumped into the urine leading to hyperoxyloria now the oxalate in the urine combines of the calcium to produce the stones question 50 High PA CO2 in a surgical patient reflects and the answer is alveolar hypoventilation in other pulmonary conditions such as PE pleural fusion and pulmonary edema there is a decrease in paco2 not an increase in attitudes tachypnea 51 muscular rigidity altered mental status and fever five days after surgery are concerning for and the answer is haloperidol exposure this is not malignant hypothermia because we're talking about five days later later we're talking about neuroleptic malignant syndrome which can which occurs days later with similar symptoms of malignant hyperthermia and the treatment is to stop the antipsychotic or what's ever causing it give benzos and dandrillion if refractory question 52 how is acute triglyceride induced pancreatitis managed and the answer is insulin we get insulin this manages the triglyceridemia faster than fibrates and we give dextrose to prevent hypoglycemia question 53 facial dehiscence with eviscerization is treated with emergency surgery this is a problem there's a risk of strangulation 54 pain reproduced by medial lateral squeezing of the calcaneus this is calcaneal stress factor due to repetitive micro trauma and we confirm with imaging such as x-ray or MRI you could take a look at other choices over here 55 hemiprases and aphasian a child who fell while sucking on a lollipop so what we're concerned with over here is a carotid artery dissection it could happen while a child is also brushing his teeth now we confirm with Mr or CT angiogram question 56 abrupt onset Squirtle pain in an adolescent with absent cream aesthetic reflex this is testicular torsion and the Doppler confirms the diagnosis what's the next step we want to go with surgical detergent we only go to manual one if surgical detergent is not available yet but if it's available we want to go with surgery 57 recurrent fever abdominal pain and shortness of breath a week after laparoscopic appendectomy so what are these what are these symptoms concerning for abscess a subfrenic abscess 58 if melanoma is expected for example we see asymmetry border agulatory color variation diameter more than sex and evolving or we see the ugly duckling sign what's the next step so here we suspect melanoma the answer is full thickness excisional biopsy with initial margins of one to three millimeters of normal tissue this is versus nasal cell carcinoma or first line management is moles or a not a full thickness excisional biopsy 59 small bowel obstruction with hemodynamic stability what's the next step urgent surgical exploration for example we would see in a case of hematic instability fever tachycardia hypotension acidosis 60 bladder cancer where we would see hematory of the Syrian flank pain this is suspected what's next step we want to go with cystoscopy I'm not really sure why I wrote These choices of a prostate over here but the point is we go with hysteroscopy in order to evaluate for bladder cancer 61 abrupt down to dyspnea cough and hypoxemia in an hour after intubation Complicated by amethyst let's clear the suction so here we have aspiration we manage this with supportive care this is chemical pneumonitis aspiration due to inhalation of gastric acid which can occur within minutes to hours of intubation aspiration ammonia however would not develop an hour later that will develop days later and that street with antibiotics for example Ceftriaxone and azithromycin question 62 what is it contraindicated in a patient whose helps am I two days after surgery and the answer is TPA angioplasty and standing are not contraindicated in a patient Who develops Mi after surgery but TPA is and I wrote a note over here that remember in mi myocardial infarction can occur during operations 63 a 45 year old woman has had her gallbladder removed last year now she has persistent abdominal pain elevated llts and CBD dilation ultrasound what's the next step so we want to go with ercp to diagnose the ideology of her post cholecystectomy syndrome she had her gallbladder removed now she has this syndrome we want to evaluate the etiology 64 patients with chronic pancreatitis often require supplemental and the answer is insulin and a pancreatic enzyme replacement the pancreas is not working properly so we need to replace what it's supposed to provide now I wrote a note over here but the pain that people with chronic pancreatitis experience is resistant to most modalities of therapies and it's very debilitating 65 what separates acute from Subacute cardiac tamponade and the answer is cardiac silhouette jbd hypotension resistant heart sounds Bex try it are seen in both acute and substitute forms but the cardiac silhouette is generally Associated only with Subacute occurs after days to weeks here the cardiac silhouette is going to be abnormal as opposed to in the acute one 66 perennial skin swelling tenderness and crepitus with hypotension is initially managed with emergency surgery because over here we're dealing with forna gangrene which is very deadly and we debride immediately 67 patients on total parental nutrition develop gallstones do too so a person's not eating through their mouth why do they develop gallstones and the answer is gallbladder stasis now the reason for this is that the normal stimulus for ckk release and gallbladder contraction is absent in these patients bile becomes more concentrated since the gallbladder is responsible normally for absorbing water from the bile and that's why we have the sludge and gallstones develop 68 which findings Support pseudogynecomastia over true gynecomastia is when a person's just very heavy so it looks like they have big breasts they don't really have gynecomastia and the answer is signs of pseudogynecomastia include soft fatty mass that are non-tender as opposed to True gynecomastia they're mobile we see rubbery mass and the breasts may be tender and we treat the and we treat pseudogenicomastia of course with weight loss 69 the most important thing to do in rib fracture management after chest x-ray rolls at pneumothorax and effusion is analgesics we want to provide pain relief this ensures appropriate ventilation and reduces the risk not the risk the risk of pneumonia question 70 a patient with asymptomatic open Anglo glaucoma should be managed with how do we treat asymptomatic open angular glaucoma again this is not painful we find it often incidentally and the answer is topical prostaglandins remember we treat closed angle glaucoma with acetazolamide and other medications but this one open angle we treat with topical prostaglandins for example as hadap roast beta blockers are second line and Laser trabecular plasti is third step third line 71 a 25 year old female has a palpable breast mask diagnosed as a fibroadenoma what's the next step so we want to go with ultrasound usually in adolescence we reassure them but there are more reasons to image an adult and removal is optional women want them out so we're happy to help them but if the malignancy is suspected we also get a mammogram 72 empyem is the most commonly caused by and the answer is strep and anaero and that's why it smells bad 73 stress hyperglycemia is treated with nothing only when the glucose goes above 190 milligrams or 200 are we concerned but if that 150 we're totally fine with that 74 fractures of ribs 9 through 12 visualize via chest x-ray requires the answer is CT of the abdomen because we need to be concerned for Oregon damage because ribs 9 through 12 cover the liver on the right and the spleen on the left and 12 covers the kidneys in the back 75 recurrent intoxication in a baby should be valued with and the answer is centigraphy question 76 a woman undergoes a hip dislocation policy don't attack no signs of hematoma fracture what's the next step we want to go with close reduction the open ones if we see a fracture in CT angiogram if there's a hematoma or we see no pulses 77 in refeeding syndrome we see muscle weakness arrhythmias for example in anorexic adolescent put on a feeding tube which lab value is seen and we see the hypos hypophosphatemia and hypokalemia this is due to the insulin secretion which promotes cellular optic of these electrolytes hypokalemia hypophosphatemia 78 besides the detail histogram P pre-operative evaluation in a young patient with no significant medical history undergoing a non-major surgery requires and the answer is nothing if however they have a mace risk of at least one percent meaning there's at least a one percent chance that they're going to have an adverse cardiac effect then we would get an 8kg 79 High riding fatality seen in well if it's high riding then the thing on the bottom got ripped and that's the patellar tendon in quadriceps tender rupture we would see a low rate Nutella and by the way patients with the tele10 Rapture can't extend the knee Against Gravity 80. paralytic ileoster the colon is called that's Ogilvy syndrome it occurs in elderly sedentary patients who have some non-abdominal surgery and now they develop large painless abdominal distension we treat with fluid electrolyte correction and colonoscopy to suck out the air 81 which brain herniation can compress the anterior cerebral artery without compromising brainstem structure function or cranial nerves that's the one at the top the cingulates a thousand one it's able to affect the anterior cerebral artery causing for example contralateral leg weakness without affecting the cranial nerves or the brain stem 82 a serotic patient with bleeding esophageal viruses undergoes a particle shunt he goes into a coma so why would a serotic patient go into a coma over here serum ammonium or reveal the etiology that's why these patients they go into a hepatacoma due to the ammonium 83 the bug which most commonly causes ostomylitis and sickle cell anemia patients is also the most common cause of the answer is osteomyelitis and puncture wounds this is pseudomonas by the way this is why Sickle Cell patients require clindamycin for staff coverage and Ceftriaxone that's for the pseudomonas coverage as opposed to other kids for example with oste mellitus they don't require ceteraxone clindamycin will be sufficient 84. perineal abscess with Associated fever is treated with incision drainage and antibiotics for example metronidazole and ciprofloxacin other indicators are antibiotics in perinealapsis besides fever is immunosuppression diabetes and cellulitis question 85 a smoker with a one month history of a palpable neck mask should first be assessed with and the answer is laryngopharyngoscopy because we need to visualize for head and neck squamous cell carcinoma 86 breast cancer and young women is generally aggressive it doesn't show up in young women very much but when it does it's often aggressive and by the way breast cancer is virtually unknown in teens 87 cystosarcoma phylloides are diagnosed with biopsy senior women in their 30s and 40s it grows very large distorting the breasts and we treat it with removal 88 ductal carcinoma inside to with lesions throughout the breast is managed with simple mastectomy if we do local excision will recur imagine 89 what is given to severe thermal burn patients and the answer is all the above of course we give fluids because they die of dehydration 10 is prophylaxis and pepperism tazobactam or meropenem and Vancomycin fluids as I mentioned in the beginning is four times surface area of the burns times weight 90 diverticulitis whereas the abdominal pain fever and vomiting that's diagnosed with and the answer is CT scan with contrast we treat this condition of diverticulitis with rest and antibiotics and we follow up with colonoscopy in six to eight weeks after resolution of the diverticulitis if it occurs we offer elective surgery to remove the affected zone of the diverticulitis 91 flail chest is defined as fracturing in at least three adjacent ribs in at least two locations these patients have impaired breathing often require ventilation support 92 a patient from Vietnam with fatigue bone pains and significantly elevated AFP most likely has hepatocellular carcinoma with metastasis the bones we may also see systemic symptoms and or abdominal pain and by the way the AFP is not always elevated when it is we think of hepatocellular carcinoma especially in a patient from an endemic area 93 learning Malaysia findings include and the answer is omega-shaped epiglottis the expertise writer no it's an inspiratory one in fact the condition is defined as an inspiratory collapse of glottic tissues during inspiration which is worse by the way when supine seen often in babies from 48 months and it usually dissolves by 20 months of age so we manage to it so we manage it with reassurance in most cases 94 acute severe chest pain in a short 17 year old girl with primary menorrhea this is aortic dissection singing Turner syndrome and we confirm with CT angiogram 95 acromegalies managed with transunional pituitary surgery just like by the way craniopharyngioma radiation is second line 96 a child with Sunset eyes paranoid syndrome may have which tumor pineal gland tumor Sunset eyes by the way are also seen in Ms 97 besides increased fiber intake and sits baths painful anal fissures are treated with topical anesthetics and topical vasodilators such as nifedipine or nitroglycerin they reduce pain and facilitate healing 98 swelling and pain at the shoulder joint after a subacromial serum injection is concerning for septic bursitis by the way the same thing can happen at a joint where at least aseptic arthritis when we diagnose the septicitis with ultrasound guided aspiration estion 99 fever right upper quadrant pain elevated LTS and in rounded dark area shown on see the contrast of the liver in a non-traveler so this sounds like a pyogenic liver abscess in iconococcus we see thin walled septate lesions you might be able to see that in this small picture over here and it's often asymptomatic unless the lesion is about to pop and amoeba looks just like a pyogenic liver abscess but it has to be in someone who traveled to these areas such as Mexico or India diagnosis by the way of pyogenic liver abscess is for continuous aspiration and this is also therapeutic 100 which form of fluid resuscitation and tremulations for example hemorrhagic shock reduces mortality the most and the answer is whole blood does we don't always give it because it's not always available but there are increasing efforts to make this more possible but even though blood products are administered only as is needed for tissue until we do definitive treatment surgery when blood products are given not whole blood they should be administered in a ratio of one to one to one fresh frozen plasma to pack up the red blood cells to platelets to reduce coagulopathy which is a major cause of mortality in trauma patients 101 pulmonary nodules hemoptysis and node was Weeds so this is Osler Weber endu syndrome and we treat these AV malformations with endovascular embolization 102 asymptomatic simple breasts are managed with observation FNA fine needle aspiration is only if it's symptomatic 103 a patient undergo surgery for example cabbage without infection or an organ entry requires which prophylactic antibiotics so if a person undergoes surgery they require prophylaxis against skin infections that's why you give cefazolin if a person's allergic to cefazolin I'm sorry cifazalin then we give clindamycin or Vancomycin 104 acute severe hyponatremia is managed with hypertonic three percent saline and the maximum of eight Milli equivalents per liter of Correction in 24 hours now since it's acute we're okay with giving the three percents alien because the neural adaptations in the brain have not yet occurred there's less of a worry in acute severe hyponatremia of osmological syndrome 105 wound healing provides greater stability to the affected area during which phase during the maturation phase where we see collagen 1 cross-linking not primary secondary hemostasis not during inflammation proliferation may be great but there we see type 3 collagen but remember the strongest type of collagen is collagen type 1. 106 thyroid nodular workout begins with TSH and ultrasound if the TSH is normal or elevated we consider final aspiration if the nodule is bigger than one centimeter for example if there's low TSH we go with radioactive iodine centigraphy there's a hot nodule meaning there's increased isotope uptake we call this hyperthyroidism and we treat it question 107 sudden human instability we see hypotension attacker cardia and impsilateral flank plane after cardiac catheterization this should be diagnostically confirmed with and the answer is Imaging because this certain for retroperitinal hematoma so we get a CT with contrast to confirm the diagnosis retroperitino hematoma is a complication of cardiac Cath 108 CT without contrast in a hit trauma patient is unreviewing now the MRI shows punctuate hemorrhages in the white matter what's the diagnosis this is diffuse axonal injury where the impairment is way worse than the Imaging findings and is caused by acceleration or deceleration injuries and the prognosis is very poor 109 a two centimeter pulmonary nodule with irregular borders and a 67 year old female smoker should be surgically excised we don't reassess we use surgically excise because there are so many risk factors over here for malignancy and by the way once it's two centimeters it's already it already has a 50 malignancy probability 110 hypovolemic shock due to penetrating chest trauma leading to massive hemothorax is treated with emergency thoracotomy it prevents ex-sanguination tubes are when it's non-massive 111 suddenots and severe unilateral lower abdominal pain after a 39 year old woman exercises with pelvic free fluid so she exercises and now she gets into severe pain this is a rupture of ovarian cyst it's not always benign it can lead to big problems for example if the blood continues to leak into the abdominal cavity it can lead to hemogenic instability and we treat you with emergency surgery in that case another 111 patients with thyroid still iron for example set announced that fever attack cardiosphere hypertension die from high output cardiac failure where we see an increased cardiac output decreased svr and an increased pcwp because there's congestion from the insane venous return which The increased cardiac output of the heart can't even keep up with 112 sudden onset respiratory distress hypoxemia shock and cardiac arrest after central venous cathode replacement is due to the answer is a venous air embolism the air is introduced in circulation at least to these problems and we manage with left lateral through cubitis positioning and high flow or hyperbaric oxygen 113 idiopathic pulmonary fibrosis is mounted with smoking cessation and perphenidone and into danab these are anti-fibrotics they have revolutionized management of idiopathic pulmonary fibrosis now it doesn't restore lung function but it slows the progression of the disease 114 bloody nipple discharge with overlying skin retraction this is invasive ductal carcinoma bloody nipple discharge is also seen in intraductal papilloma but there we don't see skin retractions skin attractions are seen in an invasive ductal carcinoma 115 treatment of zechodiverticulum is myotomy cricopharyngeal myatomy 116 the underclass headache and hypotension and bilateral visual field of X is not subarach Hemorrhage there we would see hypertension generally rather this is pituitary apoplexy and the hypotension is a result of the adrenal crisis in this condition 117 which medication should an a splenic patient be told to take if he develops fever and the answer is amoxicillin clavulanate Augmentin and we tell the patient to go to the hospital to evaluate the fever after they take the antibiotics by the way if they have an allergy to moxicillin carbonate they can take levofloxacin 118 acute cholangitis in the city with also pancreatitis should be managed with ercp to relieve the billiard obstruction for example the stone extraction or perhaps put an Ascent 119 what is the treatment for a pancreatic pseudocyst where we see abdominal distension well subscribed Blue collection on CC scan in a patient with pancreatitis and the answer is endoscopic drainage and this is only if there are significant symptoms such as vomiting or pain otherwise we just give supportive care the same way we would do for the pancreatitis itself 120 a 24 year old man is brought in with a pelvic Factory endured when he fell off a small Cliff he has blood at the meatus along with hematoma is scrotum what is the first step in his Urologic workup and the answer is retrograde urethrogram he has urethral injury and this is typically associated with pelvic fracture we may see blood at meatus but of course we don't want to get a Foley because it exacerbate in a potentially existing injury all right now that I have completely lost my voice I'm gonna have some more high yield surgery points here we go [Music] thank you foreign [Music] [Music] [Music] foreign [Music] foreign [Music] [Music] 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