so why do you think his urine is dark....?

One of my pts today had a laparoscopic cholecystectomy with cholangiogram 3 days ago and they found a stone in the common bile duct but it could not be removed because the OR nurses had not prepared the equipment for it. Anyway the guy went for an ERCP to remove the stone yesterday adn today he was still jaundiced and his urine was dark. My chief resident asked me why his urine was dark...very easy answer: urine is dark due to increased direct bilirubin due to obstruction of the common biloe duct by stone....yeah I knwo it is pretty easy but when you are not expectign the question and your chief resident asks you "so do you think he has hematuria?" and you are not sure if he is pushing to the right direction or toward a trap, ti makes thigns a bit more difficult...

pimp question during surgery

This is another pimp question I was asked during the formalization of a right BKA in an anuric guy who had chronic renal failure and was on dialysis:

CR (chief resident): so have you noticed how in a bad shape his bones are? Why do you think that is?
me: (thinking: here we go again for pimping firing squad #2)...hmmm because he is malnourished....? becasue he ahs osteoprosis???
CR: yeah possibly but he is way too young to be this bad in shape with hsi bones...so what else?
me: err....
CR: ok...I know you have been standing for 3 hours holding this leg and blood is not getting to your brain but you know the answer...jsut think about his biggest problem....
me:...he is anuric...he has kidney disease....
CR: bingo... so what.... ?
me: hhmmmmm...(light) he has chronic renal failure and in peopel with chronic renal failure you have renal osteodystrophy, that is you have high phosphate and low serum calcium...with low serum calcium, your parathyroid glands are activated and start secreting PTH to increase serum clcium adn the way PTH does that is by taking the calcium away from the bone and dump it into the blood to compensate...that is why his bones are in such a bad condition and easy to break...


always think about your pt's biggest disease ...dont look for zebras first...people wont pimp you on zebras they will pimp on things you know but that you could not connect the dots together in the right time....or they will in such a way that will amke you confuse because you are just not use to be asked about this topic in this angle....

pimp questions during surgery rotation

Hi there this is my first post, I am a third year medical student in the US and although at the end of my third year I thought it would be a great idea to write about pimp questions that you (if you are a medstudent too) will probably be asked too. So how about you learn and memorize the answers in advance? :) Than you'll just look like a star...I wish someone had done this for me :'(

Ok so today I was in surgery doing a formalization of a right BKA on a guy who had a big h/o of PVD, HTN, was anuric and was undergoing dialysis...my chief resident (CR) suddenly asked me:
CR: So have you noticed how much this guy is bleeding? You have any idea why
me: err.....because he has atherosclerosis (what a stupid answer in retrospect)
CR: that would make you think that he shouldn't bleed much right?
me: err....hummm.....yeaaahh......
CR: so why is he bleeding?
me:.....hmmmm because he has venous stasis and blood pools down in his lower extremity and thatis why he is bleeding like this?
CR: ....not what I wanna hear...so why is he bleeding
me: ......(heart pounding faster and faster)....hmmmm
CR:....ok think about his two biggest problems....
me:....PVD and he is anuric
CR:....here we go so PVD is out so how is being anuric linked to his bleeding problem?
me:....(light in my head)....because when you are anuric you do not excrete uric acid out of your system and an increase uric acid in your serum is linked to a decreased platelet count and that is why he is bleeding so much
CR:...so you knew it...too bad it was so laborious I almost lost patience....now keep that leg still....

so yeah if you CR asks you why an anuric guy going through dialysis is bleeding like hell, the answer is that he has an increase in serum uric acid that is associated with low platelet so coagulation is messed up and you bleed excessively