Clinical mastery series surgery form 2

[PEPISSESCE]

If anybody would explain the answer to these questions from CMS surgery form 2.Thanks

1)77 year old resident of skilled nursing care facility is brought to the emergency department because of fever vomiting for the past 2days. She is alert but unable to give history.She asks repeatedly for a drink of water.her temp 101.5F, BP 100/ 60.Examination shows distended non tender abdomen with sparse high pitched bowel sounds.A supine X ray of abdomen shows multiple dilated loops of small bowel and gas within small bowel lumen and within liver. Which of the following is the most likely cause of these findings?
A) Bacterial cholangitis caused by kleibsella
B) Cholecystoduodenal fistula with an an impacted gall stone
C) Emphysematuos cholecystitis with intrahepatic perforation
D) Perforated duedenal ulcer with subhepatic abscess
E) Pyelephlebitis caused by sigmoid diverticulitis


2)A 72 year old man extubated and taken to recovery room after 4 hr operation of bleeding duodenal ulcer.ABG on an fio2 40% by face mask shows.
Ph-7.24
Pco2-85mm Hg
po2-60mm Hg

Next step in management
A)encouraging deep breathing and cough
B)increase fio2 to 80%
C)i.v. Administration of 1 L RL over 30 mins
D)i.v. Nalaoxone
E) reintubation and mechanical ventilation

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[doc0610]

If anybody would explain the answer to these questions from CMS surgery form 2.Thanks

1)77 year old resident of skilled nursing care facility is brought to the emergency department because of fever vomiting for the past 2days. She is alert but unable to give history.She asks repeatedly for a drink of water.her temp 101.5F, BP 100/ 60.Examination shows distended non tender abdomen with sparse high pitched bowel sounds.A supine X ray of abdomen shows multiple dilated loops of small bowel and gas within small bowel lumen and within liver. Which of the following is the most likely cause of these findings?
A) Bacterial cholangitis caused by kleibsella
B) Cholecystoduodenal fistula with an an impacted gall stone
C) Emphysematuos cholecystitis with intrahepatic perforation
D) Perforated duedenal ulcer with subhepatic abscess
E) Pyelephlebitis caused by sigmoid diverticulitis

I thought of ileus for this one. Also, honestly, nothing else seemed to make sense.

2)A 72 year old man extubated and taken to recovery room after 4 hr operation of bleeding duodenal ulcer.ABG on an fio2 40% by face mask shows.
Ph-7.24
Pco2-85mm Hg
po2-60mm Hg

Next step in management
A)encouraging deep breathing and cough
B)increase fio2 to 80%
C)i.v. Administration of 1 L RL over 30 mins
D)i.v. Nalaoxone
E) reintubation and mechanical ventilation

CO2 is too high and o2 low, he isn't breathing properly, rest arrest is happening, so intubate back.

hey, if you could tell me about the nasogastric question, i thought nasogastric suction caused metabolic alkalosis and the patient had acidodis?

 

[PEPISSESCE]

hey, if you could tell me about the nasogastric question, i thought nasogastric suction caused metabolic alkalosis and the patient had acidodis?

Hi.
Nasogastric sunction would cause metabolic alkalosis due to loss of HCl . BP and K+ fine so not adrenal insufficiency
Patient has Normal AG Metabolic acidosis with resp. Compensation and normal po2 so not increased lactic acid production .Injury to tubules or loss of HCO3 from kidney as in RTA would cause potassium to change but pt has normal K +
So finally , i think answer would be loss of hco3 from gi tract as it is mentioned that pat. has right quadrant drain containing high amylase .

 

[sozme]

17.) A 72-year old man is extubated and taken to the recovery room after a 4-hour operation for a bleeding duodenal ulcer. Arterial blood gas analysis on FIO2 of 40% by face mask shows:

• pH 7.24
• PCO2 85mmHg
• PO2 60mmHg

Which of the following is the most appropriate next step in management?

A) Encourage deep breathing and cough
B) Increase FIO2 to 80%
C) IV 1L lactated Ringer solution over 30 minutes
D) IV naloxone
E) Reintubation and mechanical ventilation


I got this question wrong as well. I answered "D - Naloxone." I don't know why it was wrong. He is going into hypercapnic respiratory failure. Would make sense it is from the narcotics (fentanyl, hydromorphone, whatever). Increasing FIo2 would be pretty worthless as far as ventilation is concerned and C is a non-sensical answer. Don't know how you are gunna wake the guy up to take "Deep breaths". E is a viable option, but more invasive. I figured he is an old guy, so naloxone made the most sense. Maybe one of the anesthesiologists wouldn't mind helping with this question. @IlDestriero @fakin' the funk @michigangirl @pgg

 

[sozme]

ANother 2 questions I had problems with...

6. A previously healthy 42-year-old man comes to the physician because of a 2-day history of right knee pain and an inability to extend the right knee. The symptoms began when he was getting up from a low chair. His temperature is 37 degrees C (98.6 degrees Fahrenheit). Exam of the knee shows tenderness to palpation along the medial joint line and a joint effusion. Ligament stability is normal. Range of motion is from 15 to 110 degrees. An x-ray of the knee shows no abnormalities. Which of the following is the most likely diagnosis?

A) Anterior cruciate ligament injury
B) Bursitis
C) Chondromalacia
D) Collateral ligament injury
E) Patellar dislocation
F) Patellar tendon rupture
G) Posterior cruciate ligament injury
H) Torn meniscus

43. A previously healthy 19-year old woman is brought to the E.D. because of a 4-hour history of constant severe abdominal pain. Her symptoms began 3 weeks ago as intermittent, colicky pain; examination 1 week ago showed a 5-cm right ovarian cyst. Abdomianl examination now shows tenderness with rebound and guarding in the right lower quadrant. There is a palpable, tender, 10-cm right adnexal mass. X-rays of the chest and abdomen show no abnormalities. Pelvic ultrasonography confirms a complex, cystic mass. Her leukocyte count is 12,000/mm3. Urinalysis shows no abnormalities. A pregnancy test is negative. Which of the following is the most appropriate next step in management?

A) Admission for observation
B) Antibiotic therapy
C) Colposcopy
D) CT scan-guided drainage
E) Exploratory operation

 

[cbrons]

6) A previously healthy 42-year old man comes to the physician because of a 2-day history of right knee pain and an inability to extend the right knee. The symptoms began when he was getting up from a low chair. His temperature is 37° C (98.6°F). Exam of the knee shows tenderness to palpation along medial joint line and a joint effusion. Ligament stability is normal. Range of motion is from 15 to 110 degrees. X-ray of knee shows no abnormalities. What is the most likely diagnosis?

A) ACL injury
B) Bursitis
C) Chondromalacia
D) Collateral ligament injury
E) Patellar dislocation
F) Patellar tendon rupture
G) PCL injury
H) Torn meniscus


@Tired halp ^^^

I picked bursitis by the way (noob incorrect answer).

 

[cbrons]

Which test is this from? Just curious.

Like most questions it would be much easier if they gave your more info. In this case, the exam is really incomplete, but whatevs.

I would take (H).

But from a test-taking standpoint, here's how I'd get there.

(A), (D), and (G) are all ligaments. The stem says ligaments are stable, so those are out.

(E) and (F) tend to be a higher energy injuries, so unlikely to be that in a guy standing up from a chair.

(C) is a chronic problem as well, and while it can be exacerbated by low-energy mechanisms, you think they'd give you a different story. Plus it typically doesn't affect ROM until it's advanced osteoarthritis.

That leaves bursitis and the meniscus tear. I think bursitis is a very reasonable answer, though usually questions about bursitis give you a story about recent increases in activity or some kind of repetitive stress injury.

Loss of ROM can occur with bursitis, especially when it is very large, though usually it is loss of flexion with intact extension.

An effusion, however, is pretty specific to intraarticular injury. Bursae are extraarticular structures (mostly). Mensici are intraarticular.

Couple that with the joint line tenderness, which is almost universally a meniscus finding on tests (but not in real life), and you've got (H).

Ty. This is from the NBME Surgery shelf exam practice test issued by NBME

 

[michigangirl]

17.) A 72-year old man is extubated and taken to the recovery room after a 4-hour operation for a bleeding duodenal ulcer. Arterial blood gas analysis on FIO2 of 40% by face mask shows:

• pH 7.24
• PCO2 85mmHg
• PO2 60mmHg

Which of the following is the most appropriate next step in management?

A) Encourage deep breathing and cough
B) Increase FIO2 to 80%
C) IV 1L lactated Ringer solution over 30 minutes
D) IV naloxone
E) Reintubation and mechanical ventilation


I got this question wrong as well. I answered "D - Naloxone." I don't know why it was wrong. He is going into hypercapnic respiratory failure. Would make sense it is from the narcotics (fentanyl, hydromorphone, whatever). Increasing FIo2 would be pretty worthless as far as ventilation is concerned and C is a non-sensical answer. Don't know how you are gunna wake the guy up to take "Deep breaths". E is a viable option, but more invasive. I figured he is an old guy, so naloxone made the most sense. Maybe one of the anesthesiologists wouldn't mind helping with this question. @IlDestriero @fakin' the funk @michigangirl @pgg

Not a lot of info, but I would go with A. He may have gotten narcotics, yes, but giving naloxone to post-op surgery patients is no small deal-- it can lead to then profound pain and sympathetic overstimulation. For most post-op patients they are just not breathing effectively and too sleepy. Waking him up and encouraging incentive spirometry is the easiest first intervention as long as he is not actively desaturating or becoming bradypneic. Sometimes they are not breathing effectively due to splinting and pain (assuming he is post EGD so unlikely but may be an open surgery), so naloxone would be counterproductive.

 

[Instatewaiter]

Not a lot of info, but I would go with A. He may have gotten narcotics, yes, but giving naloxone to post-op surgery patients is no small deal-- it can lead to then profound pain and sympathetic overstimulation. For most post-op patients they are just not breathing effectively and too sleepy. Waking him up and encouraging incentive spirometry is the easiest first intervention as long as he is not actively desaturating or becoming bradypneic. Sometimes they are not breathing effectively due to splinting and pain (assuming he is post EGD so unlikely but may be an open surgery), so naloxone would be counterproductive.

Agree not a lot of info. I suspect they were telegraphing that they used propofol or some nonnarcotic when they were telling you they had a 4 hour surgery- otherwise narcan would be a good option. Given in 0.02-0.04 boluses you can very easily avoid profound pain

Regardless, with a pCO2 of 85, you should normally have plenty of respiratory drive. So "taking deep breaths and coughing" probably isn't going to cut it. Re-tube this guy.