ABSITE 2021

Question 1

Dx of Fibrolamellar HCC

Answer 1

• Labs: normal AFP and elevated neurotensin (vs. FNH)

- Imaging: well circumscribed w/ central scar. Similar to FNH

Question 2

Hemodyamic parameters:

Septic shock
Neurogenic shock
Cardiogenic shock

Answer 2

Septic: high CI, low SVR, +/- wedge

Neurogenic: high CI, low SVR, low wedge

Cardiogenic: low CI, high SVR, high wedge

Question 3

Pheo w/up:

Answer 3

1. plasma or urine metanephrine (se)
2. 24-urine metanephrine (sp)
3. CT (> MRI)
4. MIBG (if multi-focal)

Question 4

Mucinous cystic neoplasm dx and tx

Answer 4

• dx: EUS-FNA w/ high CEA (>190), low Amylase

- tx: resect

Question 5

Tx pelvic fx

Answer 5

1. Binder
2. Angio OR packing w/ fixation (especially if IR n/a)
3. Fixation
   - refractory bleed after angio → packing + fixation

Question 6

STSG vs. FTSG

Answer 6

1. STSG: epi + part dermis
   - higher survival/less resistant
   - more 2’ contxn. (don’t use over joints)
   - ideal use: large wounds (trunk, extremities)
2. FTSG: epi + full dermis
   - lower survival/more resistant
   - more 1’ contxn
   - ideal use: small, cosmesis, functional area (joints)

Question 7

F5 Leiden Mechanism

Answer 7

• acts w/ Xa to convert prothrombin to thrombin
• protein C/S acts by inhibiting factor 5 and 8
• mutated factor 5 can’t be inactivated by protein C/S

Question 8

W/up of gastrinoma…

Answer 8

Dx:

1. Off PPI: G > 1000 or >200 w/ secretin stimlation
2. Can’t get off PPI: SS Scintigraphy

Localize:

1. Triphasic CT/MRI
2. SS Scintography (Dotatate PET/CT)
3. Endoscopic US
4. Selective intra arterial Ca
5. OR: Intra-Op US, transduodenal palpation, duodenotomy, palpate HOP

Question 9

Tx pseudocyst/WON

Answer 9

Dx: US or CT
- if can’t r/o cystic neoplasm on imaging must get EUS-FNA

Tx: Only drain if there are persistant sxs. Wait 4-6 weeks for wall to mature

• near stomach/duo, > 6cm: endoscopic cystogastrostomy/duodenostomy
• open cysto-enterostomy

Question 10

Post trx lymphoproliferative disorder - path, px, and tx

Answer 10

Path- EBV positive B cell proliferation
Px- B sxs (fever, fatigue, weight loss)
- may cause lymphoma
Tx- reduce IS, rituximab

Question 11

Tx of Thrombosed external HMHD

Answer 11

1. w/in 48h- excision

2. after 48h- medically manage

Question 12

Free water deficit

Answer 12

TBW x [(Na-140)/140]

TBW = weight x .6 (men) or .5 (women)

Question 13

Order of contents in thoracic outlet

Answer 13

1. Subclavian VEIN
2. Phrenic NERVE
3. Anterior scalene MUSCLE
4. Subclavian ARTERY
5. Brachial plexus NERVE
6. Middle scalene MUSCLE

Question 14

Corrected Ca

Answer 14

• serum Ca + [ (4 - patient’s albumin) x .8]

- Always falsely low (not high)

Question 15

Tx of pancreatitis masses

1. WON sterile
2. WON infected
3. Pseudocyst
4. Infected pseudocyst

Answer 15

1. WON sterile: conservatively
2. WON infected: step-up approach
3. Pseudocyst: tx if sxs (infxn, obstruction, pain)
   - - 4-6w → internal drain → cystenterostomy
4. Infected pseudocyst: drainage (internal, external, endoscopic)

Question 16

Indications to tx ICA stenosis

Answer 16

1. Asx: > 60%
2. Sxs: > 50%
   - Sxs: contralateral motor/sensory sxs, ipsi vision sxs

Question 17

Distal pancreatectomy in a trauma situation

Answer 17

Always do splenectomy unless stable and young (<30)

Question 18

EBV associated with

Answer 18

1. B cell lymphoma (Burkitt)
2. n/ph cancer
3. PTLD

Question 19

Medications for hyperthyroidism - MOA and s/e

Answer 19

1. PTU: thyroperoxidase and de-iodinase inhibitor
   - s/e of aplastic anemia or agranulocytosis. OK for preggo.
2. Methimazole: thyroperoxidase inhibitor
   - s/e of cretinism, aplastic anemia and agranulocytosis

Question 20

Mechanism:

VWF
Fibrin

Answer 20

• VWF: binds GP1b on PLTs and attaches them to endothelium

- Fibrin: Links Gp2b/3a to form PLT plug

Question 21

MRSA tx

Answer 21

1. Vancomycin, Linezolid (best)
2. Clind, bactrim, and doxy have partial coverage
3. Ceftaroline (new 5G cephalosporin)
4. Muporicin for skin burn

Question 22

Neostigmine

Answer 22

MOA: AChE inhibitor

Use: reversal of non-depol muscle relaxants

Question 23

Bethesda criteria for thyroid

Answer 23

**1 cm is cutoff to get an FNA

1. Non-diagnostic → repeat FNA
2. Benign → follow-up
3. Undetermined significance → repeat FNA
4. Follicular neoplasm → lobectomy, repeat FNA, or genetic testing (no core needle)
5. Suspicious for malignancy → lobectomy vs. thyroidectomy
6. Malignant → thyroidectomy

Question 24

Achalasia - Dx and Tx

Answer 24

Dx:

• no peristalsis
• high LES pressure > 15 (vs. scleroderma, low)
• incomplete relaxation

Tx:
- myotomy (6 eso, 2 stomch) is 1st line (avoid Nissen).

• botox or dilation if high risk.

Question 25

Ab reactions: 1. Non-hemolytic 2. Hemolytic 3. Urticaria 4. TRALI 5. Anaphylaxis

Answer 25

1. Non-hemolytic: fever; cytokine from donor leukocytes 2. Hemolytic: fever + HOTN; recipient Ab attack donor leukocytes 3. Urticaria: recipient Ab attack donor plasma 4. TRALI: donor Ab attack recipient WBC 5. Anaphylaxis: recipient Ab attack donor IgA

Question 26

Cowden's mutation and cancers

Answer 26

Mutation: pten Ca: breast ca + thyroid ca + hamartomas

Question 27

TLV

Answer 27

TLV = RV + ERV + TV + IRV ``` FRC = RV + ERV IC = TV + IRV ```

Question 28

Umbo ligs remnants: - Round - Median - Medial - Omph/M

Answer 28

- Round: umbo vein - Median: urachus - Medial: umbo artery - Omph/M: vitelline duct (Meckel’s)

Question 29

Octreotide

Answer 29

- Somatostatin analogue | - Inhibits exocrine function of pancreas and CCK release

Question 30

Drainage of gonadal veins

Answer 30

1. Right- IVC | 2. Left- Left renal vein

Question 31

Tx Medullary thyroid cancer

Answer 31

1. TOTAL thyroidectomy 2. Bilateral central/level 6 dissection VI dissect 3. Lateral neck dissection on that side if central+ 4. Start T4 postop. Monitor w/ calcitonin AND CEA

Question 32

Tx for hyponatermia

Answer 32

1. Acute w/ any sx's: hypertonic saline bolus | 2. Chronic and asxatic: free water restriction

Question 33

Ulcers: - Marginal - Cameron - Marjolin ulcer - Cushing's ulcer

Answer 33

- Marginal: REYGB at GJ anastomosis - Cameron: on lesser curve of large hiatal hernia - Marjolin ulcer: chronic wound - Cushing's ulcer: elevated ICP

Question 34

Tx facial nerve inj

Answer 34

relative to lateral canthus of eye 1. Medial- non op OK (arborization) 2. Lateral- OR!

Question 35

Radial scar- Dx and Tx

Answer 35

- Dx: spiculated mass with central sclerosis | - Tx: excisional bx

Question 36

preA vs. Albumin

Answer 36

1. Prealbumin: >15; t1/2 is 1-2 days | 2. Albumin: >3.5; t1/2 is 21 days

Question 37

Tx pop aneurysm

Answer 37

>2cm- ligation and bypass <2cm- observation; avoid stents

Question 38

Tx for ectopic pregnancy

Answer 38

1. Stable – methotrexate or salpingotomy - MTX: absolute c/i if patient is breast-feeding 2. Unstable – salpingectomy

Question 39

Hyperkalemia EKG Hypokalemia EKG

Answer 39

- hyperK: peaked T wave, prolonged PR, eventual SINE | - hypoK: QT prolongation, ST depression, U waves

Question 40

HS reactions

Answer 40

``` 1- IgE allergic rxn 2- Ab rxn 3- immune cx; ex- serum sickness 4- delated; t-cell mediated 5- auto-immune ```

Question 41

Tx Pap thyroid ca in preggo

Answer 41

- Postpone until 2T if advanced - If stable, postpone until after delivery - RAI is c/i

Question 42

Mastodynia tx

Answer 42

1. OCP/NSAIDS 2. non-cyc + >30 OR cyclic + mass - mammo

Question 43

Tx Mucinous neoplasm of appendix

Answer 43

1. Confined to appendix: appe only 2. Involving the base or ruptured: usually R hemicolectomy 3. Peritoneal disseimation: can dx with perc bx - if no appendicitis can postpone appe until cytoreductive surgery

Question 44

GCS eye opening

Answer 44

4- spon 3- to voice 2- to pain 1- none

Question 45

Torsades

Answer 45

"polymorphic ventricular tachycardia" 2/2 hypoK, hypoCa, hypoMg all cause qt prolongation

Question 46

Normal values: CVP, WP, SVR, CI

Answer 46

CVP 2-6 WP 4-12 SVR 700-1500 CI 2.5-4

Question 47

When to excise burns

Answer 47

- < 72 hours but not until after appropriate fluid resuscitation - Used for deep 2nd-, 3rd-, and some 4th-degree burns - Viability is based on punctate bleeding (#1), color, and texture after removal (use dermatome) - Wait 1 week for face, palms, genitals, soles

Question 48

TTP - Path, Px, Tx

Answer 48

Path- def in ADAMtS13 Px- TCP purpura, neuro sx, kidney dz, hemo anemia, fever Tx- plasmapheresis → splenectomy if failed

Question 49

LE angio

Answer 49

AT comes off first and goes lateral | TP trunk- PT behind tibia, peroneal behind fibula

Question 50

``` Liver lesions on arterial phase: HCC Mets Adenoma Hemangioma FNH ```

Answer 50

HCC- Homogeneous enhancement. Rapid w/out. Mets- Hypoattenuation Adenoma- Heterogeneous enhancement Hemangioma- Periph enhancing FNH- Centrifugal enhancing **If unclear, MRI can distinguish benign from malig

Question 51

Methanol and Ethylene glycol toxicity - Px and Tx

Answer 51

Px: profound AG metabolic acidosis - metabolized in the liver - oxalate stones → renal failure Tx: NaB + fomipazole (ADH inhibitor) - consider iHD

Question 52

Ureter anatomy

Answer 52

Runs under the vas/uterine arteries  | Runs over the iliacs

Question 53

Elective surgery after stent

Answer 53

``` ASA lifelong Plavix - BMS: 6w - DES: 6m Post pone elective surgery until these times ``` If surgery is needed (i.e. cancer) wait at least 1m for DES

Question 54

UE Injuries: 1. supracondylar humerus 2. DRF 3. Mid shaft 4. ant shoulder disloc 5. post shoulder disloc

Answer 54

``` supracondylar humerus- brachial artery DRF- median nerve Mid shaft- radial nerve ant shoulder disloc- ax. nerve post shoulder disloc- ax. artery ```

Question 55

``` Teg interpretation: R time K time a angle MA LY 30 ```

Answer 55

``` R time- FFP K time- cryo a angle- cryo MA- PLTs LY 30- TXA ``` ``` Rule of 6's: R > 6 minutes alpha angle > 60 degrees MA < 60 mm LY30 > 6% ```

Question 56

DeMeester score and indications

Answer 56

pH <4 , changes in position, duration, # of episodes > 14.7 is positive Indications: 1. Scope negative but has sxs 2. Max medical therapy by has sxs 3. Post op but has sxs

Question 57

SD

Answer 57

1, 2, and 3 SD = 67%, 95%, and 99.7% of the data

Question 58

s/e of ileal conduit

Answer 58

Hyperchloremic metabolic acidosis (urine high in Cl is exchanged for bicarb which is excreted)

Question 59

Angiodysplasia of the colon - Dx and Tx

Answer 59

Dx: usually found in cecum and ascending colon -2nd MC CO gi bleed (vs. div's) Tx: if bleeding or iron deficiency 1. Endoscopic 2. Surgery if refractory

Question 60

Stewart-Treves syndrome

Answer 60

Post mastectomy lymphangiosarcoma - rare and highly malignant Tx- wide local excision w/ 3-6 cm margin

Question 61

Tx for gallstone ileus

Answer 61

Stable and healthy- stone removal and take down fistula | Unstable, old/frail- stone removal only!

Question 62

Sorafenib

Answer 62

TK inhibitor | Tx of HCC

Question 63

Stricturoplasties - Heineke s’plasty - Finney s’plasty - Side2Side isoperistaltic s’plasty

Answer 63

Heineke s’plasty: <10cm; open long and close transversely Finney s’plasty: > 10cm; segment folded on itself and common wall created Side2Side isoperistaltic (MIchellassi): > 20 cm; overlap stricture/dilated area; 2x enterotomy/sew bowel together **These can't be performed in proximal duo. If stricture is in the proximal-duo perform a G-J bypass

Question 64

Best test to dx gastroparesis

Answer 64

Scintigraphic gastric emptying

Question 65

Burn degrees

Answer 65

1D: epidermis 2D superficial: pap dermis, painful, blebs and blisters; hair follicles intact; blanches 2D deep: retic dermis, decreased sensation; loss of hair follicles, need skin grafts 3D burn: subcutaneous fat, leathery 4D: fat/muscle/bone; surg

Question 66

Tx of ARDS

Answer 66

``` TV at 4-6 ml/kg Permissive hypercapnia Survival benefit: prone, pralayze -P/F < 100 = severe **Must get echo to r/o cardiogenic edema ```

Question 67

Interleukins 1, 2, 4, 6

Answer 67

IL1: fever IL2: T cell prolif and Ig production IL4: T/B cell maturation IL6: hepatic acute phase reactant

Question 68

Glucagonoma - loc, px, dx, tx

Answer 68

Loc: distal (a cells) Px: dermatitis, DRH, DM, nec mig erythema - most malignant Dx: gluc > 1000 Tx: distal panc + splenectomy + LADN'y + CC'y

Question 69

Aminocaproic acid

Answer 69

Plasmin inhibitor | Use: DIC, excess tpa

Question 70

s/e of carb, protein, and lipid

Answer 70

carb- immunosuppression, resp failure lipid- pro inflammatory protein- false neurotransmitters, rise in ammonia/urea

Question 71

Bx and Tx actinic keratosis

Answer 71

- Bx: PARTIAL thickness pleomorphism (full = SqCC in Situ) - Tx: topic 5FU. Photodynamics, imiquimod, cautery no margin

Question 72

Hirschsprung surgeries - Duhamel - Soave - Swenson

Answer 72

Duhamel: agang stump in place/gang colon pulled behind; neo-rectum; less dissection/stricture Soave: pull-through; “reverse alte”; remove M/SM; pull bowel within an aganglionic cuff; least dissection Swenson: original; aganglionic segment resected to sigmoid colon; oblique anastomosis- colon x rectum.

Question 73

z11 trial implications

Answer 73

If less than 3 nodes positive on SLN and T1 or T2 disease, BCT is OK

Question 74

Hard signs of vascular injury

Answer 74

``` shock expanding hematoma pulsatile bleed thrill/bruit absent pulse ischemia ``` If negative --> ABI -- if positive --> CTA (to localize)

Question 75

Polyps that require surgery instead of endoscopic resection

Answer 75

``` Submucosal invasion > 1mm Poorly differentiated <1 mm margin LV invasion Tumor budding Taken piecemeal ```

Question 76

Iron def sxs

Answer 76

anemia, glossitis, brittle nails, cardiomegaly

Question 77

T staging indications for neoadjuvant - eso - stomach - colon - rectal - lung

Answer 77

- eso: select t1b (SM) or T2 (MP) - stomach: t2 (MP) - colon: t4b (adjacent organs) - rectal: t3 (through MP) - lung: n2 nodes

Question 78

Atlanta classification pancreatits

Answer 78

1. Interstitial: <4w- acute peripanc collection >4w pseudocyst 2. Necrotic: <4w- acute necrotic collection >4w- walled of necrosis

Question 79

Fuel for SB and LB

Answer 79

SB- glutamine | LB- SCFA (acetate, butyrate)

Question 80

Motilin

Answer 80

Motilin – released by intestinal cells of gut; ↑ intestinal motility (erythromycin acts on this receptor)

Question 81

Screening in IBD patients

Answer 81

Start 8 years after sx onset 2-4 random bx every 10 cm throughout the colon + suspicious areas Repeat schedule: - normal: q1-3 years - PSC, stricture, or dysplasia w/out colectomy: q1 year Any dysplasia usually gets a colectomy - if resectable with negative can consider endoscopic resection with close surveillance

Question 82

NEC

Answer 82

Bloody stools after 1st feed | tx- resuscitation, abx

Question 83

W/up of thyroid nodule found on exam or incidental imaging

Answer 83

1. U/S and TSH a. Nodule + Low TSH ➡ RAI uptake scan - hot/functioning: thyrotoxicosis (no cancer) - cold: FNA b. Nodule + Normal/High TSH ➡ FNA c. Any nodule > 1 cm gets an FNA

Question 84

Tx male breast ca

Answer 84

Tx: simple mastectomy w/ SLNBx - BCT usually can’t be done b/c not enough tissue - if ER+: can use tamoxifen (Her2+ is rare). consider orchiectomy if metastatic. - Prognosis similar to W but delay in presentation is common

Question 85

Nutcracker eso manometery

Answer 85

high amplitude/long peristalsis normal LES pressure normal relaxation  Tx- (identical to DES) 1. PPI, CCB, TCA 2. Long segment myotomy if refractory

Question 86

MC etiology of ESRD leading to kidney trx

Answer 86

1. DM, 2. HTN, 3. PCKD

Question 87

Repair of Bile Duct Injury

Answer 87

1. Intro-op: - convert to open, intra-op cholangio, repair OR - widely drain and send to specialty center 2. Post-op: - Perc cholangiography to define the anatomy - Control spillage: external drain +/- stent +/- PTC c. Repair in 6-8 weeks Treatment approach base on Strasburg class: A- CD stump leak: - Intraop: clip/ligate and leave drain - Postop: perc drain + ERCP plasty/stent B- Aberrant right hepatic ligation: Asx and < 3mm- ntd Sxs (cholangitis from occluded seg)- REYHJ C- Transect aberrant right hepatic: - External drain if post op - Sxs: REY-HJ D- Lateral injury to CHD/CBD: - No devascularization and small: 1' T-tube closure - Devascularized: REY-HJ E- full transection of CHD/CBD - < 1cm or distal w/out tension: 1' T-tube closure - > 1cm OR proximal injury: REY-HJ ``` e1- > 2cm e2- <2cm e3- at confluence (confluence intact) e4- at confluence (confluence separated) e5- abbarent RH duct injury w/ CBD stricture ```

Question 88

Eso dysplasia tx

Answer 88

1. LGD- scope q6-12m lifetime (even if fundoplication) 2. HGD- ablation + Q3m scope 3. T1a- ablation 4. t1b- esophagectomy *Fundoplication does not decrease cancer risk

Question 89

Superior epigastrics | Inferior epigastrics

Answer 89

SE: runs between rectus and posterior rectus sheath; branch of int mammary IE: runs between transversalis fascia and parietal perit; branch of EI

Question 90

When to intubate burn patients:

Answer 90

- hypoxia, hypercarbia, severe upper airway edema - If stable and level of injury unknown ➡ ABG ➡ nasoendoscopy/bronchoscopy to visualize cords ➡ intubate for swelling

Question 91

Tx hemobilia after trauma

Answer 91

1. EGD → CTA (if stable) 2. angio embolization (no surgery) - catheterize the celiac artery first ➡ R/L hepatic ➡ SMA

Question 92

Paget Von Schroetter syndrome - path, px, tx

Answer 92

path- narrowing of SC/Ax vein 2/2 mech compression px- acute swelling Tx- catheter directed thrombolysis before anything else (NOT open thrombectomy)

Question 93

Tx of AT3 def

Answer 93

Tx- recombinant at3 or FFP followed by heparin then warfarin

Question 94

Vitamin C mechanism

Answer 94

hydroxylation of lysine and proline | type 3 collagen cross-linking

Question 95

Inidications for neoadjuvant chemotherapy for rectal cancer

Answer 95

Stage 2 and above | Stage 2: at least t3 (crossing musc prop) or any n (stage 3)

Question 96

Periop anticoagulation

Answer 96

- High risk pt: afib, MHV, recent TE event (3m) - High risk surgery: nsurg, optho, cards - Med risk surgery: abdominal operations - Low risk surgery: dental - bridge for high risk patients - stop warfarin 5 days before surgery if not bridging, resume on day of surgery - Hold Noac 2 days before surgery and resume 1 day after - continue aspirin for low/moderate risk surg - stop Plavix 5 days before

Question 97

What is not suppressed by high dose dexa

Answer 97

``` Adrenal mass Ectopic mass (small cell cancer) ```

Question 98

Metabolic alkalosis - chloride responsiveness

Answer 98

1. Cl responsive (Ur Cl < 20) - temporary loss, replaceable - vomiting 2. Cl resistant (Ur Cl > 20) - hormonal, continuous loss - conn’s, steroids, hyperaldosterone

Question 99

Heller myotomy margins

Answer 99

6 cm proximal, 2 cm distal | Eso- vertical fibers first (outside), then circular (inside)

Question 100

Margin for invasives cancer vs. dcis

Answer 100

Invasive cancer- no tumor on ink dcis- 2 mm **if both in specimen, margin is no tumor on ink

Question 101

Tx hypertrophic cardiomyopathy

Answer 101

beta blockers avoid inotropes use neo if needed

Question 102

ITP- dx and tx

Answer 102

dx- of exclusion tx- steroids → IVIG 2nd line → splenectomy do not tx unless PLT < 30k or 20k in low risk

Question 103

Staph species

Answer 103

G+/aerobe/clusters; coag+ → aureus | coag- → epidermidis

Question 104

Cryptorchidism tx

Answer 104

- wait until 6m old - if no resolution: elective orchiopexy to decrease r/o torsion, infertility, seminoma - risk of ca higher in both testes.

Question 105

Sarcoma stage and grade

Answer 105

1. Grade ~ differentiation, mitotic count, and necrosis - - more important than size, nodal/distal mets for prognosis ``` 2. Stage Stage 1- G1 w/ any T stage Stage 2- G2/3 and T1 Stage 3- G2/3 and T2+ Stage 4- N+ ```

Question 106

Neuroblastoma dx and tx

Answer 106

dx - CT: displacement of renal parencyma (vs. Wilm's). tx: - S1-2 (low risk) → surg alone - S3+ (high risk) → surg + chemo/XRT

Question 107

Gastrin MOA

Answer 107

G cells of antrum signal EC cells ➡ Histamine ➡ Parietal cell ➡ HCl Stimulated by ACh, beta ago, AA

Question 108

Innervation to internal and external anal sphincter

Answer 108

1. Internal: SNS/PSNS fibers from superior rectal and hypogastric plexus 2. External: Internal pudendal nerve from 4th sacral nerve

Question 109

Esophagus blood supply

Answer 109

Cervical- inf thyroid Thoracic- aortic branches Abd- left gastric/inferior phrenic

Question 110

CBD and PD on ERCP

Answer 110

CBD at 11' | BD at 1' to 3'

Question 111

Tx Urethral injury

Answer 111

Grade: 1/2- contusion/stretch ➡ cath 3- part disruption ➡ OR 4/5-complete disruption ➡ cystostomy + OR

Question 112

TEF - MC types - dx and tx

Answer 112

1. Type C – most common type (85%) - Proximal esophageal atresia (blind pouch) and distal TE fistula - dx: AXR: distended, gas-filled stomach 2. Type A – second most common type (5%) - Esophageal atresia and no fistula - dx: XR: gasless abdomen Tx: 1. Resuscitate w/ repogle tube 2. G-tube placement to decompress and feed 3. Delayed right extra-pleural thoracotomy

Question 113

Tx of Ogilvie's

Answer 113

1. supportive, dc narcotics, ng tube, neostigmine 2. if > 10cm ➡ scope decompression and neostimgine 3. failure ➡ OR **scope or enema before giving neo to r/u obstruction

Question 114

Tx of prolactinoma

Answer 114

1. Bromocriptine or carbegoline (both dopa agonists) - bromo is safe in pregnancy 2. Surgery if failure

Question 115

Pros/Cons: - Sevoflurane - Isoflurane - Halothane - NO

Answer 115

- Sevo: rapid induction, less pungent. Good for kids. - Isoflurance: good for neurosurgery; no increase in ICP - Halothane: slow onset/offset, cards depression, hepatitis. - NO: least cardiac depression b/c sympathomimetic (don't use in cardiac failure). c/i in SBO. Highest MAC.

Question 116

Atropine MOA

Answer 116

competitive inhibitor of ACh at muscarinic receptor liver metabolism

Question 117

Tx FMD

Answer 117

angio + balloon (no stent)

Question 118

MEN1/MEN2 genes

Answer 118

MEN1: MENIN gene, TSGene MEN2: RET gene, receptor TK protein, proto-oncogene

Question 119

Birads score

Answer 119

``` 0- redo imaging OR require U/S 1- negative, NTD 2- benign, NTD 3- benign, repeat q6m 4- suspicious, bx 5- highly suspicious, bx 6- confirmed, excise ```

Question 120

MOA and use of antifungals: Azoles Micafungin Amphotericin

Answer 120

Azoles: ergosterol synth inhibitor - non systemic candida (yeast infection) Micafungin: echinocandin; inhibit glucan production - dissemintated candiasis Amphotericin: binds ergosterol and inhibits - invasive mucor or cryptococcal meningitis

Question 121

Recurrent laryngeal nerve

Answer 121

motor to larynx except circothryoid injury: hoarsness, airway compromise, cord paralysis (permanent ADduction) - If bilateral may need a trach

Question 122

PFTs for lung resection

Answer 122

1. Preop FEV1 and DLCO predicted > 80% ➡ no further testing - >.8L wedge, >1.5L lobe, >2L pneumo - < 80% ➡ lung scan for PPO FEV1, DLCO 2. PPO FEV1, DLCO > 60% ➡ no further testing - < 60% ➡ exercise test 3. VO2 > 10 ml/min/kg ➡ OK for surgery - < 10 ➡ high risk for surgery

Question 123

Origins of medullary thyroid cancer

Answer 123

- 4th pharyngeal arch releases NCC which form parafollicular C cells

Question 124

Gastrinoma - loc, px, dx, tx

Answer 124

Loc: gastrinoma triangle (CBD, panc neck, 3D) Px: refractory PUD - Mostly malignant Dx: G > 1000 (off PPI) or >200 w/ secretin (off PPI) - SS Scintigraphy (dotatate scan) if can't get off PPI Tx: Screen for MEN1 - <2 cm: enucleate w/ LADN'y - > 2cm: resect w/ LADN'y

Question 125

qSOFA score

Answer 125

1. AMS (<15) 2. RR > 22 3. SBP < 100

Question 126

MC Benign and Malignant H/N tumors - tx

Answer 126

1. Benign: Pleomorphic adenoma - Tx: superficial parotidectomy even if asx 2. Malignant: mucoepidermoid carcinoma tx - Tx: total parotidectomy (facial nerve preservation) + MRND + XRT

Question 127

Tx frostbite

Answer 127

Frostnip: rapid re-warming 2d: clear/milky blister- drain 3d: HMHG blister- leave intact 4d: bone- prostacyclin/TPA, amputate

Question 128

Tx of Pilonidal cyst

Answer 128

1. ASx: NTD 2. Acute abscess: drain only 3. Chronic cyst: offer surgery if effecting QOL - - marsupialization and leave open: lower recurrence - - primary closure: faster healing. Off midline- less comps (preferred)

Question 129

MCCO Cancer

Answer 129

Male- prostate, lung, CRC - death: lung, prostate, CRC Women- breast, lung , CRC - death: lung, breast, CRC

Question 130

Tx TCPenia

Answer 130

<10k if asx <20k if septic, chemo/rads, RF’s <50K if elective surgery

Question 131

Tx Annular pancreas

Answer 131

neonates- duododuodenostomy (mobile duo) | adults- duodenojejunostomy

Question 132

TNFa

Answer 132

produced by macrophages | causes cachexia

Question 133

``` W/up of pancreatic cystic neoplasms: Pseudocyst Serous cystadenoma MCN IPMN ```

Answer 133

1. MRI 2. EUS w/ FNA (If unclear): - High CEA > 190 Pseudocyst- high Am, low CEA Serous cystadenoma- low Am, low CEA MCN- low Am, high CEA (>200) IPMN- high Am, high CEA (>200)

Question 134

Propofol - pros and cons

Answer 134

Pros - rapid distribution and on/off - decreases ICP Cons - s/e: hypotension, resp depression, meta acid - no analgesia - metabolism: liver

Question 135

Enterohepatic circulation

Answer 135

Liver → P BSalts → hepatocytes → conjugated BS: 1. 80% active ileum absorbed 2. 20% deconjugated by bacteria → passive colon absorbed 3. 5% out in stool

Question 136

Tx CO poison

Answer 136

1. 100% O2 w/ facemask or intubation (not hi flo) - Hyperbaric O2 is controversial 2. intubate if comatose, severe acidosis

Question 137

Indication for APR

Answer 137

1. Rigid proctoscopy: w/ in 2cm of anal verge (levators) 2. PE: baseline sphincter dysfxn 3. Recurrent SqCC (s/p Nigro)

Question 138

``` Cancer associations: CEA AFP CA 19-9 CA 125 Beta-HCG PSA NSE BRCA I and II Chromogranin A Ret oncogene ```

Answer 138

``` CEA – colon CA AFP – liver CA CA 19-9 – pancreatic CA CA 125 – ovarian CA Beta-HCG – testicular CA, choriocarcinoma PSA – prostate CA NSE – small cell lung CA, neuroblastoma BRCA I and II – breast CA Chromogranin A – carcinoid tumor Ret oncogene – medullary thyroid CA ```

Question 139

Types of esophagectomy compared

Answer 139

1. Ivor-Lewis (Trans-thoracic): abdominal + R thoracotomy - anastomosis: thoracic - theoretically more thorough oncologic resection - may be better in more fit patients 2. Transhiatal: abdominal + L neck - anastomosis: cervical - theoretically less chance of mediastinal leak, shorter operation - may be better if old/frail and distal esophagus tumors 3. McKeown: abdominal + L neck - anastomosis: cervical ***Gastric conduit supply- R gastroepiploic (off GDA/CHA)

Question 140

Somatostatinoma - loc, px, dx, tx

Answer 140

``` Loc: head Px: DM, GALLSTONES (> glucagonoma), steatorrhea, block exo/endo pancreas - most malignant Dx: sx's + high fast SS Tx: resect + LADN'y + CC'y ```

Question 141

Specific to UC

Answer 141

Crypt abscess | Psuedopolyps

Question 142

Etomidate - Pros and Cons

Answer 142

Pros- Fewer hemodynamic changes, fast acting, fewest cards s/e Cons- adrenocortical suppression

Question 143

W/up and Tx testicular ca: - Seminoma - Non-seminomatous

Answer 143

1. AFP, HCG, LDH 2. U/S 3. Inguinal orchiectomy : based on path/markers decide on RPND - Seminoma: XRT - Non-seminomatous: retroperitoneal node dissection **ligate cord at level of internal ring so it can later be removed with retroperitoneal node dissection

Question 144

Liver collection dx and tx: Pyo Amoebic Echino

Answer 144

Pyogenic- after div's; - drain and abx (+mica if fungal) Amoebic- after mexico trip - metronidazole (no drain) Echinococcal- wall Ca+ and sub-cysts - albendazole and resect/PAIR

Question 145

Maneuvers

Answer 145

1. Kocher- lateral peritoneal attachment of D2 2. Maddox- white line from sigmoid to splenic flex - abdominal aorta, left renals, celiac, SMA, left iliac 3. Cattell- continuation of kocher; from D2 to sigmoid - IVC, right renals, right iliac

Question 146

EVAR specs

Answer 146

``` Proximal landing: > 1.5 cm - diameter < 3cm Common iliac (distal landing): > 1 cm - diameter > 8 mm Neck angulation < 60 degrees ``` EI diameter> 7mm

Question 147

Tx of anal fissure

Answer 147

1. Sitz bath, fiber, topical nifedipine/nitroglycerin 2. Good sphincter tone: LATERAL, INTERNAL sphincterotomy 3. If poor sphincter tone: botox injection **If 2/2 crohn's dz: optimize medical management

Question 148

Lynch genes

Answer 148

DNA MM repair gene (MLH1, MSH2, MSH6, PMS2) | EPCAM

Question 149

Condyloma types

Answer 149

1. acuminatum- HPV (6, 11- benign; 16, 18- Ca) | 2. lata- syphilis

Question 150

Tx of liver lesions: Hemangioma FNH Adenoma

Answer 150

Hemangioma: only if sxatic or KM syndrome FNH: NTD Adenoma: < 4cm w/out OCP response or > 4cm 

Question 151

REY limbs

Answer 151

Roux- 75 to 150 cm | BP- 15 to 50 cm

Question 152

Dx and Tx congential DPGM hernia

Answer 152

-Dx: prenatal dx on US - Tx: 1. intubate (in delivery rm) 2. NGT +/- ECMO 3. delay OR when stable

Question 153

Indications for neoadjuvant therapy for stomach cancer

Answer 153

Any T2 lesion or LN involvement | T2: growth into the muscularis propria

Question 154

Stages of empyema formation

Answer 154

1. Exudative --> drainage or VATS (1-7 days) 2. Fibrinopurulent --> VATS (7-21 days) 3. Organizing --> thoracotomy (21+) * *VATS between days 3-7 - Preferred over 2nd CT placement or fibrinolytics.

Question 155

Vertebral artery occlusion px

Answer 155

posterior circulation | sxs- dizziness, diplopia, dysphagia, dysarthria, ataxia

Question 156

5Ts of cyanosis

Answer 156

``` TOF Transposition of GVs Truncus art Tricuspid atresia TAPVC ```

Question 157

DES - Manno and Tx

Answer 157

unorganized peristalisis normal LES pressure normal relaxation  Tx: 1. CCB (+TCA if chest pain) 2. Botox injection (endoscopic) 3. Last resort: long segment myotomy

Question 158

Supraceliac aortic control

Answer 158

1. HDUS: Enter lesser sac through gastrohepatic ligament, divide posterior crus of diaphram 2. Stable: left medial visceral rotation is preferred

Question 159

Mondor disease - px and tx

Answer 159

px- tender, “cord-like” structure | tx- NSAIDs

Question 160

Dx and Tx Phyllodes

Answer 160

Dx: -Bx w/ stromal overgrowth, atypia, high MI, "leaf-like" Tx: WLE w/ 1 cm margin - can spread hematogenous to lung

Question 161

Replaced R and L hepatic

Answer 161

Right- SMA (behind pancreas and CBD) | Left- left gastric (in gastrohepatic ligament)

Question 162

Effective for enteroccous

Answer 162

Ampicillin/Amoxacillin Vancomycin Timentin/Zosyn (Resistant to all cephalosporins)

Question 163

Loss in excess weight for each surgery

Answer 163

REYGB- 75% SG- 60% Lap band- 50%

Question 164

Acid/Base of Ng suctioning

Answer 164

HypoCl, HypoK metabolic alk Loose HCl and fluid Turn on RAA system Retain Na/Excrete acid (paradoxic acidurea)

Question 165

Types of vagotomy

Answer 165

1. Truncal vagotomy: transect ant/post @ distal eso - removes lesser curve and pylorus nerve - need pyloroplasty. high r/o dumping syndrome 2. Highly selective: transect @ crow’s ft, preserve laterjet - removes innervation to lesser curvature - preserves pylorus → no drainage procedure

Question 166

Indications for total thyroidectomy (pap and follicular)

Answer 166

Indications for total thyroidectomy: - Tumor > 4cm - Tumor 1-4cm and patient preference - Distant mets or extra-thyroid disease - Nodal disease - Poorly differentiated - Prior radiation *micro-mets do not count as distant disease

Question 167

Tx Soft tissue sarcoma

Answer 167

dx: - < 3cm: excisional bx - > 3 cm: incisional bx or core needle tx: - resect w/ 2 cm marg - neoadj: rhabdomyo, Ewing, high grade, > 10 cm - adj XRT: > 5cm, high grade, recurrence, close marg - adj chemo: never

Question 168

Step up approach

Answer 168

Infected pancreatic necrosis (WBC + gas on CT) 1. IV abxs 2. Perc drain OR endo drain (if stomach is close to pancreas) 3. 2nd drain 4. VARD/DEN 5. lap necrosectomy

Question 169

CN11

Answer 169

spinal accessory nerve exit jugulars foramen innervates SCM and trapezius goes along post triangle

Question 170

1. Central cord syndrome | 2. Anterior cord syndrome

Answer 170

1. Central cord: loss of pain, temp, motor - motor UE> LE loss (vs. anterior syndrome) - hyperextension in the setting of SS 2. Anterior cord: loss of pain, temp, motor - below the level of the lesion - ASA injury or anterior cord compression

Question 171

Tx SVT

Answer 171

types: af, aflutter, paroxysmal SVT, WPW 1. vagal → adenosine - may unmask afib/flutter 2. HDS: BB, CCB ➡ sync cardioversion 3. HDUS ➡ sync cardioverison

Question 172

Von Hippel Lindau - mechanism and surveillance

Answer 172

VHL gene - upreg. of VEGF 1. Brain/retinal hemangioblastoma- q2y brain MRI 2. Clear cell RCC- q1y US/MRI of abdomen 3. Pheochromocytoma- yearly metanephrines

Question 173

Melanoma w/up and tx

Answer 173

1. Punch bx - Tumor thickness is strongest prognostic indicator: - - MIS- 5mm margin - - <1mm- 1cm - - 1-2mm- 1-2cm - - >2mm- 2cm 2. SLNBx: > 1mm (T2) or if .75-1 mm w/ ulceration or mitotic rate > 1 (T1b) 3. If SLNBx+ or Cx positive nodes: q4m US surveillance OR completion LN dissection - LN dissection: superficial 1st. Deep if cloquets+, clinically+ positive, >3+ on SLNBx, or CT+ for deep nodes * *In-transit disease: lesions > 2cm from primary but not beyond regional tumor basin - immunotherapy or BRAF inhibitor - only excise if feasible (few lesions) **MOHS can be use for in-situ disease. Need 5 mm margin.

Question 174

Steps of rapid sequence intubation

Answer 174

c-spine stabilize → preO2 → fentanyl → etomidate → succinylcholine

Question 175

PSC vs. PBC

Answer 175

PSC: Male; intra/extra hepatic; onion fibrosis; chain of lakes a/w UC, cholangioca PBC: Female; intra hepatic; granulomas; +AMA; a/w Sjogren, RA tx both- trx, cholesty., UDCA

Question 176

CPP

Answer 176

MAP - ICP normal CPP > 60 Normal ICP  < 20

Question 177

Draining peri-rectal abscess

Answer 177

1. Perianal, intersphincteric, horseshow, and ischiorectal: through the skin (all are below the levator muscles) 2. Supralevator abscesses need to be drained trans-rectally

Question 178

Dx and Tx malrotation

Answer 178

Px: Any child with bilious vomiting needs an emergent UGI to rule out malrotation Dx: UGI – duodenum does not cross midline Tx: 1. resect Ladd’s bands 2. widen the mesentery (resect central bands) 3. counterclockwise rotation 4. place cecum in LLQ (cecopexy), duodenum in RUQ 5. appendectomy

Question 179

Epidural hematoma

Answer 179

Biconvex MMA DOES NOT suture lines

Question 180

MEN syndromes

Answer 180

1- pancreatic (gastrin), pituitary, parathyroid; menin; AD 2a- Parathyroid, MTC, Pheo; ret; AD 2b- Pheo, MTC, marfanoid/neuroma; ret; AD

Question 181

CRC staging

Answer 181

stage 1- t1 to t2, n0 stage 2- t3 to t4, n0 stage 3- node involvement stage 4- m1

Question 182

Nitrogen balance

Answer 182

``` Protein intake (grams)/6.25 - (UUN + 4 grams) UUN = grams of nitrogen excreted in the urine over a 24 hour period 4 = stool and insensible losses ``` Recommended protein = 1g/kg/day Nitrogen = protein intake/6.25

Question 183

Periop Warfarin

Answer 183

stop 5 days before | Indications to bridge- mech valve, h/o TE event, afib only if CHAD/VASC 5-6

Question 184

Management of PE

Answer 184

1. no RH strain → acoag 2. RH strain → IR catheter 3. RH strain + HDUS → systemic tPA

Question 185

Methemoglobinemia - px, dx and tx

Answer 185

Px: from nitrites such as Hurricaine spray, fertilizers - Fe2+ becomes Fe3+ impairing O2 binding - can be induced w/ G6PD def or serotonergic drugs - Dx: blood gas can measure OR pulse ox says 85% - Tx: 1. G6PD def or serotonergic drugs: vitamin C 2. Otherwise: methylene blue

Question 186

Layers of colon/rectum

Answer 186

1. mucosa 2. sub-mucosa (strongest) 3. muscularis propria 4. serosa

Question 187

LE vascular trauma

Answer 187

small- patch plasty large- contralateral GSV limited time/unstable- shunt

Question 188

Tx Post dural puncture headache

Answer 188

after epidural | tx with blood patch

Question 189

Tx for DVT

Answer 189

1. unprovoked: malignancy, inherited --> indefinite 2. provoked: surgery, travel, preg, OCP, immbility --> 3m **open thrombectomy --> last resort for threatened limb loss secondary to extensive (ileofemoral) DVT OR phlegmasia **IVC filter: if recent intracranial/spine surgery, evidence of ongoing post op bleeding

Question 190

Loop diuretics vs. Ca sparing diuretics

Answer 190

loop- furosemide | Ca sparing- thiazides

Question 191

MALT lymphoma tx

Answer 191

associated w/ h. Pylori. Tx: - Low grade: triple therapy (eradicate HP) - High grade: chemo and XRT (CHOP) +/- rituximab

Question 192

lower extremity bypass graft failure depends on temporal relation to the surgery.

Answer 192

- <30d: technical error - 1m-2y: intimal hyperplasia, (at the distal anastomosis) - >2y: progressive atherosclerotic disease

Question 193

Tx Parathyroid ca

Answer 193

1. Control hypercalcemia: - IV fluids 1st! Then bisphosphonates - cinacalcet (sensipar - ca mimetic) 2. Parathyroidectomy w/ hemithyroidectomy + L6/central neck dissection + XRT - no chemo - some don't perform the L6

Question 194

Tx infected pseudocyst

Answer 194

aspirate/gram stain to dx → drainage (internal, external, endoscopic)

Question 195

Tx Melanoma of anal canal

Answer 195

Px- S100+, pigmented. NO chemo-XRT Tx: - WLE (1 cm). No SLNBx - APR if sphincter involved, LADN, or > 4mm * *5y-S is 20% w/ R0 * *WLE = APR

Question 196

Kaposi's sarcoma - cause and px

Answer 196

HSV8 | Violet/brown papules

Question 197

Mechanism and Tx of thyroid dz: 1. Graves 2. TMN 3. Hashimoto's 4. DeQuervains/Subacute 5. Reidels

Answer 197

1. Graves: IgG stimulates TSHr ➡ hyperT - BB, PTU ➡ RAI ➡ thyroidectomy 2. TMN: chronic TSH stimulation ➡ hyperT - BB ➡ RAI and/or PTU ➡ total/subtotal thyroidectomy 3. Hashimoto's: antiTPO/TG Ab ➡ hypoT - thyroxine ➡ partial thyroidectomy 4. DeQuervains/Subacute: viral URI - NSAIDS/ASA ➡ steroids 5. Reidels: autoimmune inflammation - steroid, thyroxine ➡ extensive fibrosis often need surgery for compression

Question 198

Sonograph FNA recs

Answer 198

cystic- no bx isoech/hyperech- FNA if > 2cm hypoech (high sus)- FNA if > 1cm

Question 199

Tx anal incontinence

Answer 199

1st line- fiber/bulking, exercises | refractory- overlapping sphincteroplasty

Question 200

s/e of silver nitrate, silver sulfadiazene, mafenide, bacitracin

Answer 200

Silver nitrate- eletrolytes disturbace (no sulfa) Silver sulfadizene- neutropenia, sulfa Mafenide- met acidosis, sulfa (covers pseudo and eschar) Bacitracin: G+; nephrotoxic

Question 201

Triple therapy

Answer 201

PP1 + 2 antibiotics abxs: amoxicillin, metronidazole, tetracycline, clarithromycin for 2 weeks

Question 202

APC gene

Answer 202

chrom5 1st mutn in adenoma to carcinoma mc mutation in colon ca a/w FAP.

Question 203

Contents of post triangle

Answer 203

1. CN 11 2. subclavian artery 3. EJV 4. brachial plexus trunks

Question 204

Gail model

Answer 204

1. age 2. age 1st period 3. age 1st birth 4. 1d relative 5. previous bx 6. race

Question 205

Associated orthopedic injuries: 1. post hip disloc’n 2. post knee disloc’n 3. DRF 4. Supracondylar humerus fx 5. Anterior shoulder disloc'n

Answer 205

1. post hip disloc’n- sciatic nerve (peroneal branch) 2. post knee disloc’n- popliteal atery 3. DRF- median nerve 4. Supracondylar humerus fx- brachial artery 5. Anterior shoulder disloc'n-- axillary nerve

Question 206

Anti-staph Penicillins

Answer 206

Oxacillin Methicillin Nafcillin

Question 207

Dobutamine

Answer 207

B1 at low dose - inotropy B2 at high dose - vasodilation

Question 208

types of endoleak and tx

Answer 208

1. proximal/distal seal- balloon expansion of distal/proximal attachments + stent 2. back bleeding- coil embolization 3. graft defect (tear or overlap leak)- additional graft coverage 4. porosity- resolves on its own

Question 209

Carcinoid vs. GIST vs. Desmoid

Answer 209

1. Carcinoid- Kulchinsky cells (enterochromaffin-like) tx- < 2cm ➡ appendectomy; > 2cm ➡ R hemi/oncologic resection; chemo if unresectable 2. GIST- cajal cells tx- resection, imantinib   3. Desmoid- spindle cells tx- resect if extra-abdominal. NSAID/estrogen if intra

Question 210

Meckel's Diverticulum Pathophys

Answer 210

Anti-mesenteric border of SB 2/2 peristant viteline duct pancreatic and gastric tissue  2 feet from IC valve

Question 211

VRE (vancomycin-resistant Enterococcus)

Answer 211

Synercid, linezolid

Question 212

Acetazolamide MOA

Answer 212

Inhbitis carbonic anhydrase | non-AG metabolic acidosis

Question 213

Milrinone | Midodrine

Answer 213

Milrinine- PD inhibitor, contractility with vasodilation | Midodrine- a1 agonist

Question 214

Hyperaldosterone w/up

Answer 214

Px: resistant HTN and hypokalemia 1. AM plasma aldo AND plasma renin - A/R < 20: 2nd hyperaldo - A/R > 20: primary hyperaldo ➡ 2. Confirmatory test: salt load suppression test - give salt load ➡ 24h urine aldo remains elevated 3. Discern laterality: CT scan A. Unilateral: adenoma, unilateral hyperplasia, carcinoma ➡ offer lap adrenal B. Bilateral or negative ➡ adrenal vein sampling - Lateralization: offer lap adrenal - No lateralization: idiopathic hyperplasia ➡ tx medically

Question 215

Tx and Dx of SBP

Answer 215

dx- ↑ascitic PMN and + culture; | tx- 3GC abx AND albumin (survival benefits)

Question 216

HLA test

Answer 216

- Donor organ: carries Ag (on WBC) - Recipient body: carried Ab Recipient serum with donor wbc

Question 217

Tx acute variceal HMHG

Answer 217

octreotide + antibiotics → endoscopic intervention (ligation/sclerotherapy) → TIPS

Question 218

Tx SVC syndrome tx

Answer 218

1. Elevate HOB 2. CXR and CTA 3. Assess sxs A. Life-threatening sxs: secure airway ➡ consider AC ➡ venogram ➡ endovascular stenting B. Mild sxs ➡ tissue bx ➡ decide on XRT/chemo

Question 219

Crystalloid and colloid for trauma kids

Answer 219

Crystalloid: 20cc/kg PRBC: 10cc/kg

Question 220

``` Melanoma characteristics: superficial spreading lentigo nodular acra ```

Answer 220

superficial spreading- MC lentigo- sun exposed, best prog nodular- worst prog acral- AA **thickness is most indicative of prognosis

Question 221

Tx appendicitis

Answer 221

1. Uncomplicated: no perforation, abscess, mass 2. Septic/Unstable: immediate lap appe 3. Stable w/ abscess - < 3cm: lap appe - > 3cm: IR drain ➡ interval appe in 6-8 weeks; lap appe if no cx imporvement 4. Phlegmon: - ileocecal resection likely: abx trial 1st - ileocecal resection unlikely: lap appe **Lap appe a/w higher intra-abdominal abscess and OR time (lower overall complication rate)

Question 222

Tx MEN2A/B

Answer 222

1. urine metanephrine to r/o pheo 1st 2. tx pheo 1st w/ adrenalectomy 3. Address thyroid - 2A: total thyroid at 5y - 2B: total thyroid at 6m

Question 223

Tx MEN1

Answer 223

1. HyperPTH 1st w/ 4-gland resection (hyperplasia not adenoma) + thymectomy (remove ectopics) 2. Asses other lesions

Question 224

Tx anaplastic thyroid ca

Answer 224

aggressive, undiff mort ~ 100%; no tx tx- XRT improves short-term survival +/- surg

Question 225

Hepatitis seromarkers

Answer 225

Vaccinated: surface Ab+ Resolved Hb infection: surface Ab+ and core Ab+ Active: surface Ag+, surface Ab+, and core Ab+ (IgM) Chronic: surface Ag+, surface Ab+, and core Ab+ (IgG)

Question 226

GI Hormone Release and action: Glucagon Insulin

Answer 226

Glucagon – alpha cells of pancreas - glycogenolysis, gluconeogenesis Insulin – beta cells of the pancreas - cellular glucose uptake; promotes protein synthesis

Question 227

TASC classifcation

Answer 227

TASC a and b usually get endovascular repair A- < 3cm B- 3-10 cm

Question 228

Criteria for transanal excision of adenocarcinoma

Answer 228

T0 or T1 (submucosa) < 3 cm < 30% circumference Palpable on DRE (<8cm from anal verge) **local recurrence rate is higher

Question 229

Merkel cell ca - dx and tx

Answer 229

Dx: - rare neuroendocrine tumor of the skin - looks like BCC w/out rolled edges Tx: - highly radiosensitive - Tx (like melanoma): surgical excision + SLNBx! + XRT

Question 230

Breast abscess tx

Answer 230

US aspiration BEFORE I/D if refractory | Bx if > 2 weeks to r/o ca

Question 231

5 steps to LADDS procedure

Answer 231

``` resect Ladd’s bands widen the mesentery counterclockwise rotation place cecum in LLQ (cecopexy), place duodenum in RUQ appendectomy ```

Question 232

Beta lactamase inhibitors

Answer 232

Sulbactam/Tazobactam | Clavulanic acid 

Question 233

Entamoeba vs. echinococcus - dx and tx

Answer 233

1. Entamoeba dx: from mexico; microscopy, antigen testing, or PCR - CT: rim enhancement tx: even if asx 1. MEtronidazole 2. Surgery if refractory 2. Echinococcus dx: enzyme-linked immunosorbent assay - CT: calcification + endocyst tx: albendazole x2 weeks then PAIR - 'pair' - puncture, aspiration, injection (etoh), re-aspiration

Question 234

HNPCC screening and treatment

Answer 234

1. CRC: scope q1-2y starting at 20-25 - Surgery if: CRC or endoscopically unresectable lesions - TAC with IRA w/ q1y rectum surveillance 2. Endometrial ca - childbearing: endometrial sampling q1y - completed children: TAH-BSO 3. Ovarian ca: annual pelvic exam and TVUS

Question 235

Tx choeldochoal cyst

Answer 235

1. fusiform dilation: REY-HJ 2. diverticulum: simple excision 3. choledococele: transduo excision/sphincteroplasty 4a. intra + extra dilation: hepatic resection + recon 4b. extra only: excision + recon 5. intra only: transplant

Question 236

Vit D vs. PTH

Answer 236

Vit D: increase Ca and Ph | PTH: increase Ca and decrease Ph

Question 237

Arterial content

Answer 237

(1.34 x Hb x Sa02) + (.003 x PaO2)

Question 238

Px, Dx, and Tx: ``` Duo atresia TEF Pyloric stenosis Intussusception Malro ```

Answer 238

Duo atresia: newborn; bilious emesis directly after birth - a/w down syndrome - dx: AXR- doube bubble - tx: duodenoduodenostomy TEF: newborn, spit ups. can't place NG. resp sxs - dx: AXR- gasless (A), gas (C) - tx: right extra-pleural thoracotomy Pyloric stenosis: 1-3 months; NB projectile vomiting - dx: U/S- 4mm thick, 14 mm long - tx: pyloromyotomy Intussusception: 3m-3y; currant jelly stool - dx: U/S w/ bull's eye - tx: air contrast enema Malro: 1y-5y; sudden onset bilious emesis - dx; UGI- no duo sweep (any child w/ bilious emesis) - tx: ladd's procedure

Question 239

Cori cycle

Answer 239

recycling of lactate and pyruvate to liver for gluconeogenesis and glucose production provides 40% of glu when starving

Question 240

Tx of GB cancer

Answer 240

1a: LP only - lap chole only 1b: muscle inovlved - lap chole + seg 4b and 5 + LADN - CD margin positive: REY-HJ

Question 241

Layers of mucosa

Answer 241

Epithelium Lamino Propria Muscularis mucosa

Question 242

Stage 3 breast cancer and tx

Answer 242

3a- 4 to 9 nodes ➡ +/- neoadj 3b- chest wall (not pec wall) or breast skin ➡ +/- neoadj 3c- supra clavicular nodes ➡ neoadj required

Question 243

Tx of CBD stone intra-operatively

Answer 243

1. Flush ➡ glucagon x 2 2. Lap exploration A. Transcystic: stone < 1 cm, <8 stones, CD > 4 mm, no CHD stones, normal anatomy B: Lap CBD: stone > 1cm, > 8 stones, CBD > 7 mm, CHD or junction stones, abnormal anatomy 3. Open exploration: if lap exploration failed - CBD < 2 cm: trans-duo sphincteroplasty - multiple stones, CBD > 2 cm: biliary-enteric drainage. - Leave T-tube- avoid spasm and back pressure that could blow out your stump

Question 244

W/up Hurthle Cell Cancer

Answer 244

1. FNA- hurthle cells 2. lobectomy 1st for diagnosis 3. If malig: total thyroidectomy +/- L6 nodes 4. If palpable nodes: MRND No RAI

Question 245

Conduit after esophagectomy

Answer 245

Stomach and Right gastroepiploic - if you notice this is out then stop the procedure and discuss conduit options at a later time (don't go for colon or jejunum b/c needs to be prepped)

Question 246

``` Cancer Markers: Ca 126 bHCG AFP Inhibin ```

Answer 246

Ca 125- epithelial bHCG- choriocarcinoma AFP- germ cell/endodermal/yolk sac Inhibin- granulosa/sex-cord

Question 247

Tx of High grade AIN/bowen’s disease of anal margin

Answer 247

1. Excise if > 3cm, sxatic, atypical w/ 4-6 mm margin - otherwse: cryo, curettage, 5-FU, laser 2. Lifetime surveillance even if tx! - Bowen disease = SqCC in situ = high grade AIN - Actinic keratosis is precursor

Question 248

Types of rejection - px, path, and tx

Answer 248

1. hyper-acute: w/in 1 hour - path: ABO Ab (t2 HS) - px: mottled organ - tx: remove organ 2. acute cellular: days-weeks; change in organ function - path: B or T (t4 HS) - px: - - kidney: decrease UOP, elevated Cr; tubulitis - - liver: elevated enzymes; endothelitis, portal triad lymphocytosis - tx: increase IS, steroids, IVIG 3. chronic: months-years - path: B or T (t4 HS) - px: organ dysfunction after months-years - - kidney: interstitial fibrosis, tubular atrophy - - liver: bile duct atrophy - - heart: vasculopathy and atherosclerosis; 1/2 @ 10y - - lung: bronchiolitis obliterans; 1/2 @ 5y - tx: increase IS or re-trx (no good options)

Question 249

Tx DPGM injury

Answer 249

- All left sided and most right sided should be repaired - Abdominal approach - Debride devitlized tissue - Repair with absorbable or non-abs monofilament - If too large to close primarily can use mesh or tissue flap (if contamination)

Question 250

Tx of liver abscess: - fungal - hydatid cyst - amoebic - pyogenic

Answer 250

- fungal: perc drain + micafungin (ampho is 2nd line) - hydatid cyst: albendazole qwks then PAIR - amoebic: metronidazole - pyogenic: DRAIN! and Abxs (even if multi-loculated)

Question 251

Periop NOAC

Answer 251

stop 2 days before elective surgery

Question 252

Strep species

Answer 252

G+/aerobe/chains; a hemo- pneumo, viridans b hemo- GAS(pyo)/GBS(aga) non hemo- enterococci

Question 253

Hypocalcemia vs. Hypercalcemia - sxs and ekg

Answer 253

1. HypoCa: tingling, chvostek/trousseau sign - EKG: qt prolongation 2. HyperCa: stones, bones, groans, overtones - EKG: shortened QT

Question 254

Calcitonin

Answer 254

Parafollicular C cells Inhibits osteoclast resorption Increases Ph excretion

Question 255

Types of Shunts

Answer 255

1. Total: porto-caval, meso-caval - Relieves bleeding and ascites - More hepatic encephalopathy 2. Partial: distal spleno-renal - Relives bleeding only

Question 256

Crohn's drugs MOA: Azathioprine/6-MP Sulfasalazine/5-ASA Infliximab

Answer 256

Azathioprine/6-MP: inhibit DNA synthesis Sulfasalazine/5-ASA: COX/LOX inhibitor Infliximab: monoclonal Ab to TNF; moderate crohns, recurrent perianal fistula!

Question 257

``` GI Hormone Release and action: Gastrin Somatostatin CCK Secretin VIP ```

Answer 257

1. Gastrin - G cells in antrum - ↑ HCl, IF, and pepsinogen 2. Somatostatin – D cells in antrum - inhibits gastrin, HCl, insulin, glucagon, secretin, CCK, motilin, pancreatic/biliary/stomach output 3. CCK – I cells of duodenum - gallbladder contraction, relaxation of sphincter of Oddi, ↑ pancreatic enzyme secretion (acinar cells) 4. Secretin – S cells of duodenum - ↑ pancreatic HCO32 release (ductal cells), inhibits gastrin release (this is reversed in patients with gastrinoma), and inhibits HCl release 5. VIP – pancreas and gut - ↑ intestinal secretion (water and electrolytes) and motility

Question 258

Anal canal Dentate line Anal verge Anal margin

Answer 258

Anal canal- from levators to verge Dentate line- w/in the canal; columnar/sq. jxn Anal verge- sqamous/myoc. jxn Anal Margin- 5-6 cm from the anal verge

Question 259

Tx Galactocele

Answer 259

dx/tx- aspiration | no tx if asxatic, continue bfeeding

Question 260

T and N staging for gastric cancer

Answer 260

``` t1- SM t2- MP t3- xMP/subserosa t4- invade n1: 1-2, n2: 3-6, n3: >7 ```

Question 261

Stages of graft healing

Answer 261

1. imbibition (direct diffusion) 2. inosculation (cap beds meet) 3. revascularization

Question 262

``` Hernia repairs: Bassini McVay Lichtenstein Shouldice ```

Answer 262

Bassini: conjoint tendon to inguinal ligament (from pubic tubercle medially to internal ring laterally) - may need relaxing incision in anterior rectus sheath McVay: open the floor to ➡ conjoint tendon to cooper's/pectineal ligament. - transitional stitch from conjoint, cooper's, and femoral sheath at medial aspect of femoral vein - re-approximate the rest of the inguinal floor by suturing the conjoint tendon to the inguinal ligament - may need relaxing incision Lichtenstein: mesh to inguinal ligament and conjoint tenown Shouldice: divide the floor ➡ 4-layer tissue closure

Question 263

EBUS accesible nodes:

Answer 263

2, 3, 4, 7, 10, 11, 12 - innominate seperates level 3, 4 - 4: carinal - 7: sub-carinal - 10: R/L hilar - n2 nodes: 1-9 - n1 nodes: 10-14 - cannot sample 5, 6 (sub-aortic/AP window) ➡ chamberlain procedure (Parasternal mediastinotomy) - 8 (para-eso), 9 (IPL) ➡ EUS or VATS

Question 264

Child's Pugh Score

Answer 264

Billirubin, Albumin, INR, Ascites, Encephalopathy

Question 265

Order of cells in healing:

Answer 265

1. Hemostasis: PMNs (24-48h) 2. Inflammatory: macrophages (48-96h) 3. Proliferative: lymphocytes (3d) 4. Maturation: fibroblasts (10d)

Question 266

Hemophilia A

Answer 266

f8 deficiency, SLR MC inherited disorder tx- DDAVP (mild), f8 concentrate (severe)

Question 267

Adenoid cystic carcinoma - px and tx

Answer 267

Px: MC minor salivary gland tumor (SM gland) - Spread along nerves - Remains quiescent for years then metastasizes Tx: Total parotidectomy w/ facial nerve preservation + MRND + XRT - don't aggressively resect b/c very XRT responsive

Question 268

Tx for cholangiocarcinoma

Answer 268

1. Resectable if: - contralateral hemi-liver with intact HA, PV, and biliary drainage with no tumor - no distant mets or organ invasion 2. Consider location Upper ⅓ (Klatskin): lobectomy and stenting of contra lobe Middle ⅓: hepaticojejunostomy Lower ⅓: pancreaticoduodenectomy (Whipple) 3. Consider chemo + transplant if unresectable

Question 269

acid and alkali burns

Answer 269

1. Alkalis (Liquid Plumr, Drano) produce deeper burns than acid due to liquefaction necrosis 2. Acid burns (battery acid) produce coagulation necrosis ** copious water irrigation as soon as possible

Question 270

IPMN - dx and tx

Answer 270

dx- MRI then EUS/FNA; high CEA, high amylase tx- 1. Branched - resect if >3 cm, sxs, or signs of malig (nodule) - Otherwise surveillance 2. Main duct - resect if > 1 cm or sxs (60% chance of Ca) - 5-9 mm EUS/FNA. Resect if SOMalig - < 5mm, surveillance MRIs

Question 271

Tx PDA

Answer 271

to close- indomethacin | to open- PGE1

Question 272

Airway management - trach vs. crich

Answer 272

1. Elective trach: between 2nd and 3rd trach rings 2. Crich: CT membrane between thyroid cart and cric - Thyroid cart ➡ cricoid cart ➡ rings - Avoid nasotracheal intubation w/ basal skill fractures - hemotympanum, CSF rhinorrhea/otorrhea

Question 273

Dopamine dosing

Answer 273

low- d1/2 ago (renal dose) medium- B ago high- A ago

Question 274

Parkland formula

Answer 274

4 x weight x TBSA 1st 1/2 in 1st 8h 2nd half next 16 arm = 9, leg = 18, each torso = 18, head = 9, each hand = 1, genitals = 1 UOP: .5-1 cc/hr. 1-2 cc/hr if child < 30 kg

Question 275

Who needs stress dose steroids and how to dose

Answer 275

>20 mg of steroids for > 3 weeks Surgery: continue regular dose the day of surgery + 1. Low risk (inguinal hernia): just continue regular dose day of surgery 2. Moderate risk: 50 mg HC pre-proc. Then 25q8 x 3 3. High risk: 100 mg HC pre-proc. Then 50q8 x 3

Question 276

Tx of Zenkers

Answer 276

Dx- UGI (don't do EGD) <3cm- open myotomy (left neck incision) +/-diverticulectomy >3cm- rigid scope division of UES (common lumen)

Question 277

Tx SIADH

Answer 277

Acute – vaptan, demeclocycline | Chronic – fluid restriction, diuresis

Question 278

Spinal vs. Epidural

Answer 278

Spinal- below l1/l2; SA space; fast; n/m block | Epidural- any level; epidural space; slow; no block

Question 279

VIPoma - loc, px, dx, tx

Answer 279

``` Loc: distal Px: watery DRH- hypoK, met acid. achlorhydria, inhibits gastrin - most malignant Dx: high VIP Tx: resct + LADN'y + CC'y ```

Question 280

Gastric CA tx

Answer 280

neo-adj chemo for T2+ or N proximal- total gastrectomy distal- partial 5cm margin; 15 nodes

Question 281

DDAVP/Vasopressin

Answer 281

Made in SON of HT. Stored PP. | Cause endothelium to release f8 and vWF

Question 282

ASD

Answer 282

L to R shunt Paradoxical emboli surg if sxs or asx < 5 yo surg before school

Question 283

Milan criteria

Answer 283

indications for trx w/ HCC - Single tumor < 5cm - No more than 3 tumors each < 3 cm **Hepatectomy if compensated cirrhosis (no portal HTN), low MELD, and solitary mass < 3 cm is still preferred **5-year transplant pt survival is 65-90%

Question 284

Posterior and anterior vagal trunk branches

Answer 284

Posterior trunk- criminal nerve (post), celiac branch (ant), post laterjet Anterior trunk- hepatic branch, ant laterjet

Question 285

Tx of SqCC of anal margin

Answer 285

tx like SqCC of the skin

Question 286

half-life acoags: war hep noac

Answer 286

war - 36h noac- 12h hep- 1.5h 3.5 half lives to ss

Question 287

Insulinoma - loc, px, dx, tx

Answer 287

``` Loc: throughout (B cells) Px: whipple's triad. Most benign. Dx: I/G > .4 and high C-pep Tx: < 2cm encucleate, >2cm resect. - Diazoxide if can't tolerate surgery  - LADN'y if suspect malignancy ```

Question 288

Dx and Tx fat necrosis

Answer 288

dx- oil cyst w/ Ca+ rim tx no trauma- bx trauma- watch

Question 289

Tx Panc divisum

Answer 289

ERCP sph’otomy of MINOR papilla (Santorini/Superior)

Question 290

Indications for neoadjuvant therapy eso cancer

Answer 290

high grade t1b or T2 and above OR any nodal involvement | Also get XRT

Question 291

Marfans vs. Ehlers-Danlos

Answer 291

Marfans- Fibrillin defect (elastin); - AD; tall, aortic root dilation, lens defect, arachnodactyly Ehlers Danlos- t1, t3 , t5 collagen defect - hyper elastic skin, hypermobile joints

Question 292

Bladder ca dx and tx

Answer 292

dx- CT urogram is 1st step for any bladder, kidney, or ureter cancer suspected 1. T1a- no muscle tx- endoscopic resexn + BCG/mitoM 2. T2a- muscle/beyond LP tx- cystectomy + chemo + LND 3. T3- fat/nodes) tx- neoadjuvant

Question 293

Tx tracheal inj

Answer 293

Small ➡ absorbable in 1 LAYER w/ strap - primary repair up to 5-6 rings Large → tracheostomy - avoid below 3rd ring (TI fistula)

Question 294

Specific to Crohn's

Answer 294

``` Creeping fat Skip lesions Transmural Cobblestoning Granulomas Fistulas ```

Question 295

Uremic PLT dysfunction

Answer 295

2/2 renal disease reversible dysfunction tx- ddavp

Question 296

Escharotomy indications

Answer 296

- Circumferential deep burns - Low temperature, weak pulse, ↓ capillary refill, ↓ pain sensation, or ↓ neurologic function in extremity - Problems ventilating patient with significant chest torso burns * *Perform within 4–6 hours * *May need fasciotomy if compartment syndrome suspected after escharotomy

Question 297

Gastric ulcers: elective classification and management

Answer 297

Dx- EGD and Bx (Bx needed to r/o ca!) Tx-only tx if refractory to max medical management after 12 weeks. 1. lesser curve/antrum; normal acid ➡ distal gastrectomy w/ bil 2 2. gastric + duo; high acid ➡ antrectomy + vagotomy 3. pre pyloric: high acid ➡ antrectomy + vagotomy 4. GE junction: normal acid ➡ sub-total gastrectomy + REY

Question 298

Emergent vs. Elective UC Tx

Answer 298

Emergent: 1. Steroids +/- abxs 2. Infliximab, Cyclosporine 3. TAC with end-ileostomy - When stabilized can perform completion proctectomy and IPAA - Don't do proctectomy in emergent situations Elective: - Indications: dysplasia, cancer, refractory disease - PC w/ IPAA * * Surgery reduces: erythema nodosum, arthritis - - no effect on PSC or ank spondy

Question 299

Kasabach-Merritt Syndrome

Answer 299

hemangioma + thrombocytopenia usually infants resect!

Question 300

peri-op anti-PLT therapy in pt with stent/PCI

Answer 300

No CV dz: - stop ASA 7-10 days before surgery. - Restart after 24-72h depending on bleeding in surgery Known CV dz Elective surgery: - delay surgery until after optimal time (6w for BMS, 6-12m for DES) Emergent surgery: - c/w DAPT unless high bleeding risk

Question 301

Peutz-Jeghers - px and screening

Answer 301

Px- intestinal hamartomas, pigmented oral mucosa, polyposis, breast/pancreatic ca - AD, STK11 mutation Screening 1. Scope @ 25y then q2 years b/c high r/o GI/pancreas ca

Question 302

Acute hemolytic trx reaction

Answer 302

rapid RBC destruction by host IgM/IgG | +direct coomb’s

Question 303

Omphalocele

Answer 303

``` 2/2 failure of umbo ring closure 11th week gut returns to abdominal cavity normal bowel (protected) Other congenital defect are more common ```

Question 304

Cryo used to treat?

Answer 304

1. VWD 2. Fibrinogen def 3. Hemophilia A

Question 305

Zone injuries

Answer 305

penetrating: - zone 1-3 --> explore blunt: - zone1 --> explore - zone 2-3 --> do not explore

Question 306

TOS tx

Answer 306

neurogenic PT: PT --> rib resection, scalenectomy, BPlex dissection Venous- catheter directed thrombolysis → surgical decompression Arterial- C7/1r resection, subc artery resection/reconstruction

Question 307

Contents of FFP and Cryo

Answer 307

FFP: all clotting factors Cryo: VWF, f8, fibrinogen

Question 308

FAP Dx and Tx

Answer 308

AD; APC mutation Dx: > 100 adenoma or < 100 w/ fam hx CA by 40 Tx: - sigmoidoscopy q1y at 10 (don't need colonscopy) - TAC w/ IRA or PC w/ IPAA depending on rectal involvement at about 20 (or once florid polyposis is seen) - q1y scope post op for duodenal cancer (MC COD) - polyposis/high grade dysplasia @ stump → proctectomy +/- pouch

Question 309

BRCA risks and tx

Answer 309

female breast, ovarian, male breast I- 60, 40, 1 II- 60, 10, 10 Tx: - pre meno: offer bilateral mastectomy OR q1 MRI starting @ 25 - post meno: bilateral mastectomy + SOO + HRT until 50 (no TAH) **SOO decrease r/o OVARIAN Ca (80%) for BRCA1/2 AND breast Ca for BRCA2 only (50%) **No TAH!

Question 310

When to operate on adrenal mass

Answer 310

OR: - all functioning tumors - all > 6 cm --> open resection (no lap) - if < 6cm with suspicious features - >10HU, <50% @ 10m w/out --> open resection (no lap)

Question 311

Tx Neck trauma

Answer 311

OR if platysma violation + crepitus, odynophagia, pulsatile bleed, expanding h’oma, bruit, thrill Non-op w/up: 4V angio, doppler or CTA, UGI (esophagography) or esophagoscopy, bronchoscopy

Question 312

Adjuvent chemo for breast ca

Answer 312

1. Adjuvent chemo: tumor > 1cm, nodal dz, aneuploidy - echo before for cardiotox 2. Tamoxifen/Anastrazole: 5y for HR+ tumors - Tamox for men too 3. Trastuzumab- 1y for Her2/neu+ tumors - echo before for cardiotox

Question 313

FNH

Answer 313

path- CENTRAL STELLATE SCAR! bright on arterial phase homogenous tx- resect if sxatic. no malignant potential.

Question 314

Secretin vs. CCK

Answer 314

Both released by duo S cells ➡ Secretin- duct cells ➡ bicarb I cells ➡ CCK- acinar cells ➡ enzymes

Question 315

Pancreas drainage procedures

Answer 315

1. duct > 7mm- Peustow, pancreaticojej (for large duct) 2. duct > 7mm and large head- Frey, pancreasticojej + core out head 3. duct < 7mm and large head- Berger, pancreatic head resection

Question 316

Tx papillary/follicar thyroid ca

Answer 316

1. Indications for total thyroidectomy: - Tumor > 4cm - Tumor 1-4cm and patient preference - Distant mets or extra-thyroid disease - Cervical or central nodes - Poorly differentiated - Prior radiation 2. Nodes dissection: A. Therapeutic lateral neck dissection: of involved compartments if palpable or bx+ nodes B. Prophylactic neck dissection (level 6): if > 4cm, extra-thyroid invasion, +lateral nodes. - Usually not performed for follicular 3. Radio iodine indications (6w post op, want TSH high) - Only after total thyroidectomy to be effective - Tumor > 1 cm - Extra-thyroidal disease

Question 317

Heparin - MOA

Answer 317

accelerates AT3 activity and INDIRECTLY inhibits thrombin

Question 318

Screening guidelines for breast ca

Answer 318

Mammogram every 2–3 years after age 40 then yearly after 50 High-risk screening - mammogram 10 years before the youngest age of diagnosis of breast CA in first-degree relative

Question 319

Tx SDH

Answer 319

1. Nonop- HDS, <10 mm, <5 mm shift | 2. Evac- > 10mm, >5mm shift, delta GCS > 2, cx signs of ICP

Question 320

Central venous O2 vs. mixed venous O2

Answer 320

Mixed venous: from PA | Central venous: from SVC only (estimation of mixed)

Question 321

``` Reversals: BB CCB Tylenol Benzos CN/Nitroprusside Vecuronium/Rocuronium Ethylene glycol Methemoglobinemia ```

Answer 321

``` BB overdose: fluids/atropine → glucagon CCB: Ca + Insulin + Atropine + Pressor Tylenol: NAC Benzos: flumazenil CN/Nitroprusside: sodium thiosulfate, amyl nitrite Vecuronium/Rocuronium: sugammadex Ethylene glycol: femopizole and bicarb OR ethanol; iHD Methemoglobinemia: methylene blue ```

Question 322

Orientation of portal triad

Answer 322

Bile duct lateral Hepatic artery medial Portal vein posterior

Question 323

Cryoptococcus Coccidiomycosis Histoplasmosis Mucormycosis

Answer 323

1. Crypto- CNS sxs in AIDs pt tx- amphotericin 2. Coccidio- pulm sxs in the southwest tx- amphotericin 3. Histo- pulm sxs in ohio river valley tx- itraconazole → ampho B 4. Mucormycosis- burns/trauma w/ bloody cough tx- emergent debride, ampho

Question 324

Polyps that require surgery instead of endoscopic resection

Answer 324

1. Submucosal invasion > 1mm 2. Poorly differentiated 3. <1 mm margin 4. Lymphovascular invasion 5. Tumor budding 6. Sessile polyp (if you can't get it all)

Question 325

``` LN harvest/margin eso stomach colon rectum ```

Answer 325

eso- 15/7cm stomach- 15/5cm colon-12/5 cm rectum- 12/5 cm

Question 326

Succinylcholine

Answer 326

``` ONLY depolarizing short half life and rapid onset (RSI) Used for "full stomach" degraded by plasma CE s/e: rhabdo, hyperK, M/H c/i: spinal cord injury, renal failure, large burns ``` tx of M/H: stop drug, dantrolene, Bicarb, cooling, tylenol

Question 327

``` Breast nerve: Thoracodorsal Intercosto-brachial Lateral petoral Medial pectoral Long thoracic (medial) ```

Answer 327

``` Thoracodorsal (lateral)- LD, ADduct Intercosto-brachial- hypesthesia Lateral petoral- p major Medial pectoral- p major/minor Long thoracic (medial)- SA, wing scap ```

Question 328

Cohort study vs. Case control

Answer 328

Cohort: prosepective; exposed vs. non-exposed RR- [a/a+b]/[c/c+d] Case control: retrospective; diseased vs. non-diseased OR- (a/b)/(c/d)

Question 329

Tx acute limb ischemia

Answer 329

Tx: Rutherford 1- no deficits ➡ hep gtt. imaging. eventual revasc 2a- motor intact ➡ imaging. hep gtt (motor intact, sensation). eventual revasc 2b- any weakness, rest pain ➡ hep gtt and immediate revasc (don't image if delay in tx) 3- paralysis ➡ amputation Revasc options: 1. Endovascular: short segment, single lesion 2. Open: long segment, multiple lesions

Question 330

Warthin tumor/Papillary cystadenoma

Answer 330

benign tumor of salivary gland often BILATERAL and 2/2 smoking Slow growing Tx- complete resection with uninvolved margins even if ASx

Question 331

Hemangioma - path and tx

Answer 331

path- PERIPHERAL ENHANCEMENT | tx- if rupture, size change, or KM syndrome

Question 332

Pancreatic ducts

Answer 332

Wirsung- major, lies inferior | Santorini- minor, lies superior

Question 333

Gluconeo precursors

Answer 333

lactate , pyruvate, AA

Question 334

Sirolimus

Answer 334

``` MOA: mTOR inhibitor Less nephrotoxic s/e - lymphocele (w/ obstruction) - wound complications/poor wound healing: held or switched to tacro before hernia repairs ```

Question 335

Tx of rectal prolpase

Answer 335

Not past the verge- biofeedback, fiber Many comorbidities- Altemeir (perineal rectosigmoid'y) Prolpase < 50cm- Delorme (plication) Young/healthy- rectopexy +/- resection

Question 336

Px and Tx of Hypertrophic scar

Answer 336

Px: 3–4 months after injury secondary to ↑ neovascularity - More likely to be deep thermal injuries Tx: steroid injection into lesion (best), silicone, compression; wait 1–2 years before scar modification surgery

Question 337

Li Fraumeni

Answer 337

p53 mutation - TSG on Ch17 cell cycle regulation and apoptosis breast ca + soft tissue sarcoma b4 45

Question 338

Chylothorax dx and tx

Answer 338

- dx: fluid TG > 110 - tx: chest tube and NPO - - < 1L/day: MCT diet, octreotide, TPN → 7d: thoracic duct lig (Open R chest or IR) - - > 1L/day: thoracic duct ligation (Open R chest or IR)

Question 339

Chemotherapy indications for breast ca

Answer 339

- Tumors >1cm - Positive nodes - Triple negative tumors

Question 340

Tumor lysis syndrome

Answer 340

hyperU, K, Ph w/ hypoCa CaPh crystal ➡ renal failure + hypoCa tx: IV hydration ➡ iHD

Question 341

CRC T and N

Answer 341

``` t1- SM t2- MP t3- xMP/subserosa t4- invade n1- 1-3, n2- >=4 ```

Question 342

Rectovaginal fistula tx

Answer 342

wait 3-6m low- endorectal advancement flap high- abdominal approach

Question 343

Schiatzki's Ring - Tx

Answer 343

Associated with hiatal hernia | Tx- only if sxatic. dilation only and PPI

Question 344

NNT`

Answer 344

``` NNT = 1/absolute risk reduction (ARR) ARR = event rate in intervention group - rate in control group AR = event rate in intervention / rate in null group RRR = (rate control - rate experimental) / rate control ```

Question 345

``` Tx childhood GI disease: Pyloric stenosis Intussusception Duo atresia TEF Malro ```

Answer 345

``` Pyloric stenosis: pyloromyotomy Intussusception: air contrast enema Duo atresia: DD or DJ TEF: right extrapleural thoracotomy Malro: LADDS proc ```

Question 346

Tx Panc fistula

Answer 346

tx- NPO, TPN x 4-6 wks → ERCP w/ stent → surgery

Question 347

Max dose of lido and bupiv

Answer 347

lido = 5mg/kg (7 w/ epi) bupiv = 2.5 mg/kg tx- lipid emulsion

Question 348

Tx Aspergillosis

Answer 348

MC fungal infxn in IC patients aspergilloma- resect aspergillosis- voriconazole!

Question 349

Dx and Tx of GIST

Answer 349

1. Dx- MC GI Sarcoma - - EGD: SM smooth EGD mass with normal overlying mucosa and central ulcer. Stomach MC. - - Bx: cajal cells. c-KIT+ 2. Dx/Tx- wedge resection (gross). no bx unless neoadj - can be R0 or R1 resection 3. Imatinib (TK inhibitor) - > 5cm or >5 mitosis/50 hpf

Question 350

Vitamin K

Answer 350

``` gamma CARBOXYLATION (not decarb) of GLUTAMATE on 2, 7, 9, 10, c, s Px- coagulopathy, suspect if obstructive jaundice ```

Question 351

Rectum: 1. Arterial supply 2. Venous drainage

Answer 351

1. Arterial supply: - IMA to superior rectal a. - II to middle rectal a - II to internal pudendal a. to inferior rectal a. 2. Venous drainage- - SRV ➡ IMV ➡ PV (portal) - MRV/IRV --> internal pudendal --> internal iliac (systemic)

Question 352

Kcal per macronutrient

Answer 352

``` protein = 4 kcal/g dextrose = 3 kcal/g lipid = 9 kcal/g carb = 4 kcal/g ```

Question 353

Hinchey

Answer 353

1- pericolic abscess 2- pelvic abscess 3- purulent 4- feculent

Question 354

Contents of ant triangle

Answer 354

Carotid sheath, anca cervicalis, CN 12 (hypoglossal) Contents of carotid sheath: CN10 (vagus), CCA, ICA, internal jugular Facial vein is the gateway

Question 355

Tx for Leriche syndrome

Answer 355

aortobifemoral bypass

Question 356

Benign lesions that require excisional bx

Answer 356

``` Atypical DH/LH LCIS/DCIS radial scar papillary lesion any atypia ```

Question 357

Future Liver Remnant

Answer 357

minimum 20% if normal liver pre-op chemo/some dysfxn = 30% cirrhosis = 40%

Question 358

Cervical neoplasia

Answer 358

CIN1- tx infection, close f/up CIN2- cryo or leep CIN3- cryo or leep

Question 359

type 1 vs. type 2 error

Answer 359

type 1: false positive - say something is true (reject the null) when it's not - minimize by including stat significance type 2: false negative - say something is false (do not reject the null) when it's true - minimize by increasing sample size - increases with higher P-value (more likely to make a false negative) power = 1 - type2

Question 360

clostridium - px and tx

Answer 360

anaerobic, GPR MC CO emphysematous cholecystitis MC CO gas gangrene tx- PCN, clinda 2nd line

Question 361

Early excision and graftingf

Answer 361

- Day 1 of burn - Can be considered in stable patients with limited burns (< 20%) that are clearly 3rd degree - Saves costs; minimizes pain, suffering, and complications

Question 362

hepatic adenoma

Answer 362

path- EARLY HETEROGENEOUS enhancement on A phase w/ rapid washout tx- stop OCP use. resect if > 5cm or sxatic

Question 363

DVT tx

Answer 363

ileofemoral- cather directed thrombolysis | other- anticoagulation

Question 364

Types of mastectomy

Answer 364

1. Simple/Total mastectomy: removal of all breast tissue, NAC, most of skin 2. MRM: removal of breast parenchyma, NAC, skin, AND level 1-2 nodes 3. BCT: partial mastectomy + XRT

Question 365

Pyoderma gangrenosum

Answer 365

associated w/ IBD RESOLVES after resection pre-tibial tx- steroids

Question 366

AG

Answer 366

Na - (Cl+Bic) NaCl = non-AG, metabolic acidosis Causes of AG MA: Methanol, Uremia, Diabetes, Paraldehyde, Iron/INH, LA, Ethanol/Glycol, Salicylates

Question 367

MOA reglan and erythromcyin

Answer 367

reglan: dopamine antagonist erythromycin: motlin receptor agonist causing SM contraction

Question 368

VIPoma

Answer 368

Loc: distal Px: watery DRH, hypoK, achlorhydria, inhibits gastrin Tx: resect (distal panc)

Question 369

Thyroid ima

Answer 369

supplies medial aspect of both lobes of the thyroid | come off the innominate/brachiocephalic

Question 370

T and N staging eso cancer

Answer 370

``` t1a- LP and MM t1b- SM (where it spreads) t2- MP t3- adventitia t4a- resectable structures t4b- unresectable structures n1: 1-2 nodes, n2: 3-6 node, sn3: 7+ ```

Question 371

``` Tx of burn types: Acid burn Alkalia burn Hydrofluoric acid burns Powder burns Tar burns ```

Answer 371

``` Tx of burn types: Acid burn: irrigation Alkalia burn: irrigation Hydrofluoric acid: spread calcium Powder burns: wipe away before irrigation Tar burns: wipe with lipophylic glycerol ```

Question 372

Barrett’s eso surveillance

Answer 372

Bx- Goblet cells and columnar cells No dysplasia- 4 quad every 2 cm q 3-5y Dysplasia/Nodule- 4 quad every 1 cm q 3-6m *Fundoplication is only c/i in HGD

Question 373

HNPCC vs. Lynch S Dx and Screening

Answer 373

HNPCC- fulfill amsterdam criteria - 3+ relatives with Lynch syndrome-associated cancers (CRC, cancer of the endometrium or small bowel, transitional cell carcinoma of the ureter or renal pelvis), - 2 generations - 1 ca dx < 50 yo Lynch syndrome- refers to mutation in DNA MM repair gene (MLH1, MSH2, MSH6, PMS2) or the EPCAM gene.

Question 374

Serum osmolarity

Answer 374

Osm = 2xNa + Glu/18 + urea/2.8

Question 375

Superior laryngeal nerve

Answer 375

motor to cricothyroid injury: trouble w/ high pitch, voice remins clear Cord looks normal on laryngoscopy tx- none

Question 376

``` Cause of stones: CaOx Uric Acid Cysteine CaPh MgAmPh ```

Answer 376

``` CaOx- diet Uric Acid- protein Cysteine- AA metab. error CaPh- high pH MgAmPh- urease infxn ```

Question 377

Location of vagus nerve

Answer 377

LARP | left anterior, right posterior to esophagus

Question 378

GCS motor

Answer 378

``` 6- obeys commands 5- localized 4- w/draws 3- flexion (decort) - 'flex your core' 2- extension (decErebrate) 1- none ```

Question 379

LeFort fxs

Answer 379

I- palate II- nose and palate III- entire face

Question 380

Human bite tx

Answer 380

amox/clavulanate (augmentin) | MC for human bites- eikenella

Question 381

tx flank wound

Answer 381

HDS- CT w/ triple contrast (oral, IV, rectal) | HDUS- OR

Question 382

Indics and steps for ED thorac

Answer 382

trauma with witnessed loss of vital but SOL SOL = ECG activity, reflexes, GCS > 3 1. Access thoracic cavity 2. Pericardiotomy - staple, suture, clamp 3. Thoracic aorta cross clamp 4. Cardiac massage +/- defib

Question 383

TRALI

Answer 383

DONOR Ab attacks recipient WBC

Question 384

Amphotericin

Answer 384

MOA: binds ergosterol and alters permeability lipid soluble (CNS) s/e- nephrotoxic, hypoK

Question 385

``` MCCO healthcare infection: HAP central line infection SSI UTI GI infection SBP NSTI ICU infection ```

Answer 385

``` HAP: staph aureus (pseudomonas #2) central line infection- coag negative staph (staph epi) SSI- staph aureus UTI- e. Coli GI infection- c. diff SBP- e. coli NSTI- polymicrobial ICU infection- VAP ```

Question 386

Tx of trx of great vessels

Answer 386

1st give PGE1 → ballon atrial septostomy

Question 387

Tx SqCC of anal canal

Answer 387

Nigro protocol- RTx (of Ca + inguinal/pelvic nodes) + 5FU + MitoC Recurrence- APR SqCC equivalents- large cell ker. (SqCC), transitional zone, LCl non-ker, basaloid, mucoepidermoid

Question 388

TOF

Answer 388

``` Most common cyanotic defect 1. VSD 2. Pulmonary outflow obstruction 3. Over-riding aorta 4. RVH tx- beta blocker; surgery at 3-6m ```

Question 389

Spigelian hernia | Richter's hernia

Answer 389

spigelian- found along semilunar line lateral to rectus | richters- protrusion and/or strangulation of part of the intestine's anti-mesenteric border

Question 390

Cutoff for low risk lung nodules not requiring follow-up

Answer 390

1. 6mm ➡ NTD 2. 6-8 mm ➡ q6-12m CT 3. > 8mm - low risk pt- q3m CT - high risk pt- bx or resection

Question 391

Light's criteria

Answer 391

PL protein/serum Pr >.5 PL LDH/serum LDH > .6 PL LDH > 2/3 ULN

Question 392

Treatment of colo-cutaenous fistula

Answer 392

1. Start with conservative tx 2. Quantify output: - High output: > 500 cc/day ➡ likely OR - Low Output: < 200 cc/dayt ➡ likely conservative 3. OR if failed after about 6 weeks 

Question 393

Most abundant bacteria in the colon

Answer 393

Bacteroides fragiles

Question 394

T staging for esophageal cancer

Answer 394

``` t1a- muscularis mucosa: endo resection t1b- SM: upfront esophagectomy t2- muscularis propria: neoadjuvant t3- adventitia: neoadjuvant *no serosa. Ca spread through SM lymphatics ```

Question 395

Exposing the pancreas

Answer 395

Head: kocherize Body: incise gastrocolic ligament ➡ lesser sac Tail: mobilize spleen

Question 396

Thoracic duct course

Answer 396

1. originates at L1-L2 @ c. chyli 2. cross from R to L at T4-5 3. empties into L SC/IJ jxn

Question 397

Duo vs. stomach ulcer px

Answer 397

Duo ulcer: pain 2-3h after meal - 90% H. pylori, 10% NSAIDS/ASA Stomach ulcer: pain right after meal - 75% H. pylori, 25% NSAIDS/ASA **NSAID/ASA: decrease mucosal mucus secretion and bicarb secretion

Question 398

Effective for Pseudomonas

Answer 398

1. Ticarcillin, Zosyn 2. 3/4G cephalosporin (ceftriaxone, cefepime) 3. Aminoglycodies (genta, tobra) 4. Flouroquinolones (cipro) 5. Meropenem/Imipenem  **Not linezolid (good for G+/MRSA)

Question 399

Tx hypertrophic cardiomyopathy

Answer 399

beta blockers avoid inotropes use neo if needed

Question 400

most common organism in burn wound infection | most common viral burn wound infection

Answer 400

Pseudomonas (< 10^5 organisms – not a burn wound infection) | HSV

Question 401

Tx Infected panc necrosis

Answer 401

stable- wait 4 weeks, IR retroP drain unstable- debride Debride: VARD (video-assist retroP)- utilize retoP drain, DEN (endoscope), open necrosectomy

Question 402

Cuff size for kids

Answer 402

age/4 + 4

Question 403

Grading and tx of BCVI

Answer 403

``` 1- <25% narrowing ➡ ASA 2- > 25% narrowing ➡ ASA 3- PsA ➡ ASA + IR stent 4- complete occlusion ➡ ASA only 5- transection ➡ OR if accessible. Otherwise IR. ``` *most are not surgically accessible

Question 404

Ectopic parathyroids

Answer 404

1. Superior parathyroids - usual location: jxn of RLN and INFERIOR thyroid artery. Posterior to RLN. - Not found: explore retro-esophogeal and para-esophogeal space ➡ open carotid sheath. 2. Inferior parathyroids - usual location; along inferior thyroid vein. Anterior to RLN. - Not found: explore thymus and thyroid ➡ consider thymectomy or ipsi thyroidectomy even if no palpable mass 3. 4 normal appearing galnds - supranumary PT in the thymus **Overall, thymus is MC location or ectopic gland

Question 405

Trauma to the pancreas

Answer 405

1. Head - main duct: drain w/ staged resection - no duct: drain 2. Tail - main duct (grade 3+): resect w/ splenectomy (unless young and HDS) - no duct (grade 1-2): drain

Question 406

S/e and medications of trx meds - Tacro - Azathioprine - Mycophenolate - Sirolimus - Cyclosporine

Answer 406

Tacro: calcineurin inhibitor; bind fK --> calcineurin --> block IL2 - 100x more potent than cyclosporine - neuro sxs (tremor), nephrotox, hepatotoxic, GI sxs - alopecia Cyclosporine: calcineurin inhibitor; bind cyclophillin --> calcineurin --> block IL2 - nephrotox, hepatotox, neuro sxs - gingival hyperplasia, hypertrichosis Sirolimus: bind fK --> mTor inhibitor (IL2 inhibitor) - impaired wound healing, interstitial lung disease, hyperlipidemia, thrombocytopenia - anti neoplastic effects (good for cancer) MMF: purine (T cell) inhibitor - GI sxs, myelosuppression, anemia Basilixamab: il2 inhibitor - GI sxs Azathioprine: purine (T cell) inhibitor - myelosuppression, marrow suppression, pulm fibrosis

Question 407

Interossei and lumbrical innervation

Answer 407

palmar- ulnar n, adduct dorsal- ulnar n, abduct lumbricals- median (1-2)/ulnar (3-4)

Question 408

S/e of tamoxifen

Answer 408

dvt/pe | uterine cancer

Question 409

DCIS tx

Answer 409

lumpectomy (2mm) + XRT +/- boost +/- endocrine - no SLNBx (does not metastesize) - no chemotherapy if XRT c/i → mastectomy AND SLNBx (b/c 20% have invasive ca)

Question 410

DCIS SLNBx

Answer 410

- does not metastasize - not w/ l’omy unless >4cm, multicentric, palpable, high grade - required w/ mastectomy b/c 20% have invasive ca

Question 411

Dx and Tx of Cystadenoma

Answer 411

low CEA, low Amylase | tx- resect if sxs

Question 412

Post polypectomy screening

Answer 412

1. 1-2 tubular adenomas <5mm in size → 5 years 2. 3 or more adenomas → 3 years 3. Advanced adenomas - >1cm, HGD, or villous elements) → 3 years 4. Hyperplastic polyps → 10 years. 3-5 years if > 1cm. 5. Piecemeal removal → 2-6 month scope

Question 413

Encapsulate organisms

Answer 413

Strep pneumo (MC) Neisseria Haemophilus

Question 414

Casues of increased ET CO2

Answer 414

Increased muscle activity (shivering) Increased metabolism (sepsis, fever, malignany hyperT) Increased CO Decreased minute ventilation

Question 415

tx of Meckels

Answer 415

tx- resection if sxs base < 2 cm → diverticulectomy > 2 cm or wide base → seg resection if appendicits leave Meckel's alone - Only consider taking out incidentally found asx Meckel's in young/healthy pt - Leave if asx in adults or concern for ca

Question 416

Products of posterior pituitary

Answer 416

"PAO in the POST" | ADH, Oxytocin2/2 direct stem from neurosecretory cell

Question 417

Hereditary pancreatitis

Answer 417

PRSS1 trypsinogen mut'n AD smoking cessation is important

Question 418

Cilostazol - MOA and use

Answer 418

MOA- PDi, inhibits PLT aggregation tx for periph claudication - c/i in any degree of HF (PDi)

Question 419

Esophagus and Trachea access

Answer 419

Proximal eso- L cervical Mid eso/prox thoracic eso- R thoracotomy Distal eso- L thoractomy Carina/Either main-stem- R thoracotomy Aorta- L thoracotomy

Question 420

Ureter injuries

Answer 420

proximal ⅓ (U/P jxn and above) → primary ureterourostomy middle ⅓ → primary or tran uretero urosotomy lower ⅓ → re-implanation +/- hitch 1. early: w/in 5 days- stent, explore, or repair 2. late: > 10 days- perc nephro and delayed repair

Question 421

Vitamin D processing

Answer 421

7-DHC + sunlight ➡ d3 liver ➡ 25-d3 kindey ➡ 1,25-d3

Question 422

Tx papillary/follicar thyroid ca

Answer 422

Start with lobectomy Indications for total thyroidectomy: - Tumor > 4 cm (1-4 cm, close observation or total) - Extra-thyroidal disease - Multi-centric or bilateral lesions - Previous XRT Indications for MRND - extra thyroid extension Radio iodine indications (6w post op, want TSH high) - Consider for 1-4 cm, definitely > 4cm - Extra-thyroidal disease - Need total thyroidectomy to be effective

Question 423

Tx for hemobilia

Answer 423

angioembolization

Question 424

Tx Odontoid fx

Answer 424

1- upper D, stable, non-op 2- base of D, unstable, worst, +/- surg 3- c2 vert, usually no OR

Question 425

GCS verbal

Answer 425

``` 5- normal 4- confused 3- inappropriate words 2- incomprehensible 1- none ```

Question 426

MELD

Answer 426

1. Bili 2. INR 3. Creatinine  - At least 15 for trx - Pts added for HCC, hilar cholangiocarcinoma - HCC gets automatic score of 22

Question 427

Intraductal papilloma dx and tx

Answer 427

MCCO bloody nipple dc dx- contrast ductogram tx- resection

Question 428

Tx Umbo and Inguinal hernia in child

Answer 428

most close by 2 <3cm- primary repair >3cm- mesh repair by 5 Inguinal- repair by 2 weeks if reducible - otherwise, OR then

Question 429

Gastroschisis

Answer 429

GastRoschisis to the Right of midline | rare defects...EXCEPTION- instestinal atResia

Question 430

Mineral def: - Zn - Sel - Chromium - Copper - B1 - B3

Answer 430

- Zn: wound heal/skin - Sel: cardiomyopathy - Chromium: hyperglycemia - Copper: micro anemia - B1 (thiamine): wernicke’s encephalopathy, p. Neuropathy - B3 (niacin): pellagra (DRH, demetnia, dermatitis)

Question 431

MC aortic infections

Answer 431

aneurysmal- staph | non-aneurysm- salmonella

Question 432

Effective for VRE

Answer 432

Synercid | Linezolid

Question 433

Predictors of good outcome after reflux surgery

Answer 433

1. Typical sxs 2. DeMeester Score > 14.72 3. Improvement w/ acid suppression

Question 434

UES vs LES

Answer 434

UES- cricopharyngeus; higher resting pressure (70) | LES- lower resting pressure (15)

Question 435

Stiewert-Stein Class and Tx

Answer 435

Relation to GEJ: 1. 1-5 cm above; Ivor-lewis 2. 1 cm above-2 cm below; esophagectomy and prox gastrectomy 3. 2-5 cm below GEJ; total gastrectomy *Require 5 cm eso margin, 4 cm gastric margin, 15 nodes for eso CA

Question 436

Esophageal CA tx

Answer 436

HGD, TIS, T1a: endoscopic ablation/resection T1b: upfront esophagectomy T2 or N: neoadjuvant then esophagectomy T4b or M: definitive chemo-XRT < 5cm from cricoP: definitive chemo-XRT > 5 cm from cricoP: esophagectomy

Question 437

Absolute C/I to anti-reflux surgery

Answer 437

1. Cancer | 2. Barrett's w/ HGD

Question 438

Alarm sxs for GERD

Answer 438

1. dysphagia 2. odynophagia 3. bleeding 4. weight loss 5. anemia *Require EGD

Question 439

Tx of Leiomyoma

Answer 439

1. sxs or > 4cm- enucleate 2. < 4cm- observe 3. >8cm or circumferential- esophagectomy Approach: Cervical- L Mid eso- R Distal eso- L

Question 440

W/up for trauma to the esophagus

Answer 440

1. CT: para-eso air/fluid, subc air, trajectory - if negative can trial clear. If +: 2. Endoscopy: - if negative can trial clears. If dysphagia w/ clears: 3. GG esophagography (UGI): if negative: 4. Thin barium

Question 441

Required for staging esophageal CA

Answer 441

1. CT of chest, abdomen- M 2. Whole-body PET scan- M 3. EUS- T and N stage

Question 442

Caustic injury w/up

Answer 442

0. Avoid NGT. No neutralizing agents 1. CT scan if stable 2. Early endoscopy (AFTER CT) 3. OR if unstable. Otherwise, restart orals in 48h. * alkali- liquefaction necrosis. worse outcome * acid- coagulation necrosis

Question 443

Steps of Heller myotomy

Answer 443

1. Divide G-H ligament 2. ID R crus and posterior vagus 3. ID L crus and anterior vagus 4. Divid short gastric vessels 5. Expose GEJ (excise eso fat pad) 6. Myotomy (6 eso, 2 stomach) 7. Nissen, dor, or toupet wrap

Question 444

How to mobilize the stomach for intra-thoracic anastamosis

Answer 444

1. Divide G-H ligament 2. Transect the L gastric. Keep the R gastric. - --- Lesser Curve Mobilized---- 3. Transect gastro-colic until prox duo. Avoid R gastro-epiploic! 4. Extend gastro-colic to take the L gastro-epiploic, short gastric vessels, and gastrophrenic vessels - --- Grater Curve Mobilized ---- To gain extra length: 1. Kocher maneuver 2. Divide the R gastric artery Greater omentum = gastro-colic + gastroc-splenic + gastro-phrenic ligaments

Question 445

Epiphrenic divertciulum

Answer 445

Loc: distal eso. R > L. Pulsion Tx: only if sxs. - L diverticulectomy w/ contra myotomy

Question 446

Dx and Tx of Eso perf

Answer 446

Dx- XR then contrast esophogography (GG then Ba) Tx- 1. abxs (fungus) 2. Cervical: open neck and place drains 3. Thoracic: L thoracotomy, extended myotomy, cover w/ 2 layers, buttress, NG, chest tube - if achalsia: contra myotomy 4. Very unstable: exclusion and diversion Selective non-op: 1. Contained perf 2. Minimal signs of sepsis Stenting: contained perf or minimal extrav after EGD

Question 447

Causes of hyperPh and hypoPh

Answer 447

- HyperPh: hypoPTH, renal failure | - HypoPh: hyperPTH, liver resection

Question 448

FeNa

Answer 448

``` (Serum Cr x Urine Na) / (Serum Na x Urine Cr) x 10 "USC/UC's" <1% = Pre-renal >1% = Intrinsic >4% = Post-renal ```

Question 449

Fluid Production/Absorption: - Saliva - Stomach - Biliary - Pancreatic - SB - LB

Answer 449

Fluid Production: - Salive: 1500 - Stomach: 1500 ml - Biliary: 500 ml - Pancreatic: 1500 ml - SB: 1500 ml Absorption: - SB: 8.5L - LB: 500 ml

Question 450

TBW

Answer 450

TBW = 42L - 2/3 ICF - 1/3 ECF: 3/4 interstitia, 1/4 blood

Question 451

LR formula

Answer 451

``` 130 Na 4 K 109 Cl 2.7 Ca 28 Lactate ```

Question 452

Refeeding Syndrome

Answer 452

HypoMg, Ph, K | Sxs- paresthesia, confusions, RD, cardiac failure

Question 453

pH relation to pCO2

Answer 453

10 mmHg increase in pCO2 = .08 decrease in pH

Question 454

Tx of DI

Answer 454

1. Central- DDAVP | 2. Peripheral- tx underlying causes (stop Li), amiloride, HCTZ

Question 455

Tx of endometrial CA

Answer 455

Hysterectomy, bilateral BSO, peritoneal w/out, LN sampling | Required for Tx AND staging!

Question 456

Pregnant lap appe

Answer 456

Left lateral decubitus position Entry port: - take into account fundal height (6cm above) - P/S @ 12 wks, half-way @ 16 weeks, umbo @ 20 weeks - 2T-3T: supra-umbo if possible otherwise LUQ or RUQ

Question 457

Px and Tx of ovarian torsion

Answer 457

Sudden pain + adnexal mass w/out bleeding - vs. ectopic which usually has bleeding Lap detorsion Oopherectomy only if- necrosis, CA, recurrent

Question 458

Monitor and reverse TPA

Answer 458

``` Fibrinogen level (<100 = r/o bleeding) Reverse: a-CA ```

Question 459

Tx of Warfarin skin necrosis

Answer 459

Stop Coumadin Give vitamin K Start hep gtt

Question 460

Intrinsic vs. Extrinsic Pathways

Answer 460

Intrinsic: 8, 9, 11, 12 Extrinsic: 7 (shortest t 1/2), Tissue factor Common: 1, 2, 5, 10

Question 461

Reversal of NOACs: Apixaban Rivoroxaban Dabigatran

Answer 461

Apixaban: andexanet Rivoroxaban: andexanet Dabigatran: idarucizumab (+iHD)

Question 462

VWD dx and tx

Answer 462

dx: normal PLTs. Abnormal BT, PTT - ristocetin test or measure vWF level tx- type 1: not enough; ddavp --> cryo type 2: qualitative; ddavp --> cryo type 3: none; VWF/f8 concentrate, cryo

Question 463

Tx of hepatic encephalopathy

Answer 463

0. Correct precipitating cause 1. Lactulose (goal 2-3 stools/day) 2. Rifaximin 3. Neomycin

Question 464

PEP: 1. HIV 2. HBV 3. HCV

Answer 464

1. HIV- 4wks of anti-retroviral combo 2. HBV- HBIG. +Vaccine if not vaccinated 3. HCV- No recommendations.

Question 465

Segmental liver anatomy

Answer 465

7 - 8 - 4a - 2 | 6 - 5 - 4b - 3

Question 466

Dx and Tx of Budd-Chiari Syndrome

Answer 466

``` Dx: doppler Tx: 1. Lifelong AC 2. < 4 weeks: thrombolytics 3. > 4 weeks: angioplasty/stenting 4. Refractory: TIPS, transplant, surgical shunt ```

Question 467

Tx of Isolated Gastric Varices

Answer 467

2/2 chronic pancreatitis induced splenic vein thrombosis | tx- Splenectomy

Question 468

PPx for variceal bleeding

Answer 468

1. Varices < 5 mm. Pugh A - no tx 2. Varices < 5 mm. Pugh B/C- b block 3. Varices > 5 mm. b-block +/- endo ligation **TIPS not use for prevention.

Question 469

Effects of pneumoperitoneum

Answer 469

Increase preload initially, then decrease Increase afterload. Decrease CO Increased PCO2. Decrease FRC Decrease renal function

Question 470

Steps to Peustow

Answer 470

1. Upper midline incision 2. Enter the lesser sac 3. Kocherize the duodenum 4. Split open the duct AT LEAST 7 cm 5. Side-to-side REY-PJ in 2 layers *For main duct > 7 mm

Question 471

Pancreas blood supply and anatomy

Answer 471

Head- Superior PD (Off GDA, off CHA, off CeT) and Inferior PD (off SMA) Body/Tail- Branches of the splenic artery Head- right of SMA (SMV is right of SMA also) Uncinate- hugs the SMV and SMA Neck- over the SMA Body/tail- left of SMA

Question 472

Indication for ERCP w/ GB dz

Answer 472

1. Bili > 4 2. CBD stone on U/S 3. CBD > 6 mm and Billi > 2 4. Ascending cholangitis

Question 473

Autoimmune pancreatitis

Answer 473

Px: pancreatitis w/ normal Lipase and LFTs Dx: elevated IgG, biopsy to prove. - CT: dilated w/ no Calcs - Brush biliary tree if concern for malignancy Tx: steroids

Question 474

W/up of pancreatic cancer

Answer 474

1. Pancreatic protocol CT 2. EUS: if questionable LN or vessel involvement 3. PET/CT: selectively if suspicion for malignancy. 4. Staging scope: if suspect disseminated dz 5. Bx: Not if resectable. Only if neo-adj chemo 6. ERCP: if jaundice or dx uncertainty

Question 475

Tx of chronic pancreatitis

Answer 475

1. Lifestyle changes (EtOH, smoking) 2. Oral analgesics 3. Endoscopic sphincterotomy 4. Surgery

Question 476

Tx of pancreatic ascites

Answer 476

1. NPO, IVF, NGT, TPN, SS (60% resolve) 2. Endoscopic sphincterotomy/stent 3. Surgery (REY P-enterosotmy or tail resection)

Question 477

Tx of acute mesenteric ischemia

Answer 477

Thrombotic: at origin of SMA; prox. jejunum to transverse colon Embolic: distal SMA; jejunal sparring 1. no peritonitis- endovascular embolectomy 2. peritonitis- ex lap to evaluate bowel, embolectomy/bypass

Question 478

Dx and Tx of chronic mesenteric ischemia

Answer 478

- Dx: 1. duplex (Celiac > 200, SMA > 275) is 1st line for screening 2. CTA (>70%) for definitive dx - Tx: Sxs + stenosis of > 70% 1. Endovascular plasty/stent is 1st line. 1V stenting is enough (SMA > celiac) 2. Open surgery: if can't tolerate endovascular - aorto-mesenteric/celiac bypass graft vs. endarterectomy vs. mesenteric re-implantation

Question 479

Tx of renovascular stenosis

Answer 479

1. BB 2. ACEi: unless 1 kidney or bilateral dz - efferent dil'n can worsen kidney dz 2. PTA: perc trans-luminal angio +/- stent 3. Nephrectomy

Question 480

Open SMA embolectomy

Answer 480

1. Lift transverse mesocolon 2. Trace MCA. Palpate the SMA at root of mesentery along inferior margin of pancreas 3. Incise peritoneum and dissect down to the artery (left of the SMV) 4. Therapeutic heparinize 5. Proximal and distal control 6. Transverse arteriotomy at infra-pancreatic segment 7. 2 or 3 Fogarty balloon passed proximal and distal 8. Close arteriotomy with interrupted proline

Question 481

Tx of air embolism

Answer 481

1. LEFT lateral decubitus and Trendelenburg (trap air in the RV) 2. Aspirate central line

Question 482

Timing of endarterectomy after a stroke

Answer 482

1. Non-disabling stroke or TIA: 2d-2w | 2. Big stroke: no consensus

Question 483

Do not cardiovert if

Answer 483

1. High likelihood of cardiac emboli | 2. Afib > 48 hours

Question 484

When to consider ppx fasciotomy

Answer 484

6+ hours of warm ischemia

Question 485

Femoral embolectomy

Answer 485

- Longitudinal incision over the groin - Expose femoral common, SFA, and profunda - Control with vessel loops - Ensure ACT > 250 - 4-5F fogarty proximal, then distal to SFA and profunda (2x clean pass for each) - Infuse hep saline - Close arteriotomy w/ interuppted prolene

Question 486

Exposure of LE arteries: 1. Femoral 2. AK Pop 3. BK Pop 4. TP Trunk

Answer 486

1. Femoral: vertical incision over the artery from inguinal ligament 2. AK Pop: frog-leg position. 10 cm MEDIAL incision along groove between Sartorius and vastus lateralis. Incise deep fascia superior to sartorius muscle. Watch out for GSV. 3. BK Pop: frog-leg position. MEDIAL incision below the tibia (along the GSV). Dissect to the deep compartment. 4, TP trunk: MEDIAL incision below the tibia. Dissect to deep compartment. Divide medial solus origin of the tibia to get to the deep compartment.

Question 487

Preference for peripheral fistula

Answer 487

Location: 1. Rad/Ceph 2. Rad/Bas 3. Bra/Ceph 4. Bra/Bas 5. Prosthetic Rule of 6's: - flow > 600/min - diameter > 3mm before placement. > 6mm after placement - depth of 6mm

Question 488

SC Steal syndrome - path and tx

Answer 488

Path- Prox SC stenosis. Reversal of flow through ipsilateral vertebral to SC Tx: if V/B sxs (diplopia, vertigo, dysphagia, ataxia) 1. PTA w/ stent to SC artery 2. Carotid to SC bypass

Question 489

Vertebral/Cervical to COW

Answer 489

R carotid: off innominate ➡ IC ➡ AC/MC ➡ COW L carotid: off aorta ➡ IC ➡ AC/MC ➡ COW R vertebral: off R SC ➡ Basilar ➡ PC ➡ COW L vertebral: off L SC ➡ Basillar ➡ PC ➡ COW

Question 490

Branches of the external carotid

Answer 490

1. superior thyroid artery 2. ascending pharyngeal artery 3. lingual artery 4. facial artery 5. occipital artery 6. posterior auricular artery 7. maxillary artery 8. superficial temporal artery "Some Anatomists Like Freaking Out Poor Medical Students"

Question 491

major branches of internal carotid

Answer 491

1. ophthalmic 2. anterior choroidal 3. anterior cerebral 4. middle cerebral 5. posterior communicating artery **posterior cerebral comes off of the vertebro-basillar system

Question 492

Tx of type B dissection

Answer 492

1. Uncomplicated: b-blocker for impulse control, elective repair - Then surveillance q3, 6, 12m. TEVAR if progression 2. Complicated: impending rupture, propagation, expansion, malperfusion of aortic branch, refractory pain, refractory HTN ➡ TEVAR

Question 493

Tx of splenic aneurysm

Answer 493

1. > 2cm, sxatic, or fertile age female - embolize distal AND proximal (back bleeding from short gastric) 2. Otherwise, monitor

Question 494

Tx of aneurysms - splenic - renal - iliac - femoral - pop

Answer 494

- splenic: > 2cm or sxs ➡ embolize - renal: > 1.5 cm ➡ covered stent - iliac: > 3 cm ➡ covered stent - femoral: > 2.5 cm ➡ covered stent - pop: > 2 cm ➡ exclusion and bypass

Question 495

Tx of psuedoaneurysm

Answer 495

tx- compress 20m → thrombin | immediate surg- infxn, HDUS, pulsatile, skin changes, ischemia, AMS

Question 496

Nerve injuries during CEA: - Recurrent laryngeal - Marginal mandibular - Hypoglossal nerve - G/Ph nerve - Superior laryngeal - Accessory

Answer 496

- Recurrent laryngeal: MC cranial nerve; 2/2 clamping; hoarseness - Marginal mandibular: excessive retraction and angle of jaw; Ipsilateral lip palsy - Hypoglossal nerve: ipsilateral tongue deviation - G/Ph nerve: from high dissection; difficult swallowing - Superior laryngeal: high-pitch - Accessory: failure to shrug shoulders

Question 497

Tx of Type A dissection

Answer 497

- Treat with immediate surgery - Put patient on bypass - Median sternotomy

Question 498

May-Thurner Syndrome

Answer 498

Iliofermoal dvt 2/2 R iliac artery compressions L iliac vein against lumbar spine tx- venogram, thrombolysis and stenting

Question 499

W/up of non-variceal UGI bleed (M/W tear)

Answer 499

1. NGT+ ➡ EGD w/in 24h- clips, coags, banding, sclerose 2. NGT-: - HDUS: IR angio (must be brisk) - HDS- C'scope/consider RBC scan, surgery

Question 500

Surgical options for acid reduction surgery

Answer 500

Surgical options: 1. Truncal vagotomy and drainage 2. Truncal vagotomy and antrectomy 3. Proximal gastric vagotomy Elective indications: - refractory to medical management - suspicion of a malignancy within an ulcer Acute indications: HDS, minimal contamination AND: 1. PUD w/ unknown h. pylori status (if known can just be tx medically) OR 2. Unable to stop NSAID therapy (NSAID ulcer)

Question 501

Acute surgical options for duodenal ulcer disease

Answer 501

Indications: bleeding, perforation, obstruction 1. Bleeding: EGD ➡ EGD ➡ duodenotomy/gastrotomy w/ over-sewing of ulcer bed - can tie off the GDA if continues to bleed - close transversely - vagotomy not general performed 2. Perforation: get h pylori status! ➡ omental patch w/ post op h. pylori treatment - If close to pylorus: pyloroplasty (+/- truncal vagotomy) - If giant ulcer (> 2 cm): controlled duodenostomy, jejunal or omental graft/patch, partial gastrectomy 3. Obstruction: NGT, resuscitation, anti-secretory ➡ EGD w/ balloon dilation ➡ antrectomy - Only do acid surgery acutely (vagotomy/drainage) if: - -- HDS, minimal contamination AND - -- PUD w/h. pylori status negative, unknown, refractory OR - -- Unable to stop NSAID therapy (NSAID ulcer) **EGD does not require bx for duodenal ulcers

Question 502

Tx of gastric ulcer disease

Answer 502

Indications for surgery: bleeding, perforation, refractory, can't rule out malignancy - must have a biopsy of some kind (r/o malig is higher than with duo ulcers) 1. GC, antrum, body: wedge resection 2. Lesser curve: distal gastrectomy w/ bil 2 3. GEJ: - -- bleeding: anterior gastrotomy, over-sew, send biopsy - -- perf: sub-total gastrectomy w/ REY reconstruction **Can't wedge lesser curve b/c prominent L gastric arcade and subsequent deformed stomach

Question 503

Tx of Complications after Billroth 2

Answer 503

1. Afferent limb obstruction - convert Bil 1 or REY 2. Bacterial overgrowth: 2/2 short ante-colic limb - try abxs 1st. convert to REY 3. Duping syndrome: small meals, no sugar --> octreotide 4. Alkaline reflux gastritis: prevent w/ 50+ roux limb. - pro-kinetics, bile-acid binding ➡ convert to REY

Question 504

How to confirm H. pylori eradication

Answer 504

4-weeks after triple therapy: 1. Urea breath test: preferred 1st line 2. EGD + Bx: preferred if known gastric ulcer (r/o CA) 3. Fecal Ag test

Question 505

Mesenteric Defects after REYGB

Answer 505

1. Mesocolic: from retrocolic roux limb whole in the mesocolon 2. J-J defect 3. Peterson's defect: mesentery of roux limb and transverse mesocolon

Question 506

Primary fuel source in fasting state

Answer 506

1. 1st 4 hours: exogenous glucose 2. 4h-1d: Liver glycogen 3. 1d-1w: gluconeogenesis phase - brain uses protein from gluconeo (switches to ketone by day 4) - body uses ketones 4. 1w+: proteins-sparing phase - FA/Ketones are used everywhere - Only RBCs use glucose

Question 507

Dx and Tx of rectus sheath hematoma

Answer 507

``` Dx- mass unchanged with contraction Tx- CTA if HDS. OR if unstable: 1. Observation- no active bleed 2. IR- if active bleeding or T3 (pre-vesicle space) 3. OR- if HDUS or skin necrosis ```

Question 508

Removal of perc chole tube

Answer 508

1. Remain in place for 3-6 weeks for tract to form 2. Cholangiogram to assess CD patency 3. Clamp tube or elective chole if surgical candidate

Question 509

Essential fatty acids and immuno-nutrition

Answer 509

1. Linoleic acid- omega-6 (Cis, Unsturated) 2. α-linolenic acid- omega-3 (Cis, Unsturated) Immuno-nutrition = arginine, omega-3 FA - a/w less infections, shorter LOS

Question 510

Effects of hypomg

Answer 510

Sxs- similar to hypoCa ~ chvostek (tetany), tremor, fasciculations 1. PTH resistance: hypoCa and hypoVitD 2. NAK ATPase (ROMK) release of K: hypoK 3. HypoPh

Question 511

RQ interpretation (metabolic cart)

Answer 511

CO2/O2 ``` < .7 = underfeeding .7 = pure fat .8 = pure protein .8-.9 = desired 1 = pure carb >1 = overfeeding ```

Question 512

BSC vs. SqCC - dx and tx

Answer 512

BSC: most common malignancy in US; pearly, rolled borders, peripheral palisading; MC upper lip ca SqCC : scaly patch; keratin pearls, parakeratosis, full-thickness pleomorphism (partial = AK); MC lower lip ca Tx: - 4 mm for unaggressive - 8 mm for aggressive tumors - 1 mm for MOHS - LADN'y for clinical positive nodes - Can consider SLNBx for high risk SqCC - Limited role for chemo/XRT

Question 513

Tx of paronychia and felon

Answer 513

1. Pronychia: non-purulent infection of nail fold - Non-purulent: clinda only - Purulent: lateral incision to nail bed 2. Felon: fingertip pulp abscess - vertical incision over the pulp - abxs only if not tense

Question 514

Dx and Tx of Nac Fac

Answer 514

- LRINEC score: Na. glucose, WBC, CRP, Hb, Cr; >8 = 95% PPV - CT: gas, thick fascia - abxs: carbapenem OR broad spectrum w/ clinda (anti-toxin effect) and MRSA coverage - surgery

Question 515

SAAG score

Answer 515

Albumin Serum - Albumin in ascites > 1.1 = portal HTN (cirhosis, HF, budd-chiari, PVT) < 1.1 = TB, pancreatitis, infection, chylous - chylous if milky and TG > 200

Question 516

Dx and Tx of pancoast tumor

Answer 516

1. Perc bx- usually sqcc 2. Mediastinoscopy (or EBUS) 3. Induction chemo-XRT 4. Surgical evaluation - c/i to oncologic resection: extra-thoracic mets, n2 disease, brachial plexus above T1, spinal canal (vessels are not a c/i) - vascular involvement is not c/i

Question 517

Dx and Tx of pancreatic leak

Answer 517

``` Dx: complication of splenectomy - drain collection and send for amylase Tx: 1. ASx: observe 2. Sxs: perc drain, NPO, TPN 3. ERCP, sphincterotomy, internal drain 4. Distal panc ```

Question 518

Types of hyperPTH

Answer 518

1- High Ca/Low Ph: over-secretion 2- Low Ca/High Ph: CKD or VitD def (physiologic) 3- High Ca/High Ph: kidney transplant

Question 519

Dx and Tx of Ewing Sarcoma

Answer 519

Dx- "onion skin" in diaphysis | Tx- chemotherapy (1st line) + surgery or XRT

Question 520

Pulmonary sequestration

Answer 520

No bronchial commmunication 1. Intra-lobar: MC; blood from aorta; pulmonary veins 2. Extra-lobar: systemic arteries and veins Tx- lobectomy or segmentectomy

Question 521

Lung anatomy: R vs. L

Answer 521

Right: - oblique/major fissure: separates lower from middle/upper - horizontal/minor: separates middle from upper - main bronchus 90-degrees; 2 bronchi Left: - oblique/major fissure; 1 bronchus

Question 522

RF and Tx of T/I fistua

Answer 522

RF- trach below 4th ring OR, high pressure cuff, high innominate cross 1. Over-inflate the cuff 2. Intubate from above 3. Compress against the sternum 4. Median sternotomy 5. Ligation AND division of innominate artery 6. Buttress tracheal hole w/ muscle

Question 523

Indications for pleurodesis

Answer 523

1. Air Leak > 5 days 2. Recurrent (even if contra side) 3. High risk occupation (scuba, pilot) 4. IC (AIDS)

Question 524

Px, dx and tx Lymphocele

Answer 524

Px- sudden decrease in UOP weaks after trx ---2/2 lymphatic leak from iliac dissection ---Sirolimus is a RF Dx- US Tx- perc drain ➡ peritoneal window

Question 525

Px, Dx, Tx of RAS and thrombosis after kidney transplant

Answer 525

1. Thrombosis: sudden cessation of UOP immediately post op - Dx: U/S - Tx: nephrectomy unless small branch 2. Stenosis: refractory HTN and elevated Cr - Dx: US (vel > 180, 70%) - Tx: perc angio/stent **No pain with arterial issue (pain = venous issue)

Question 526

Causes of low UOP after kidney trx

Answer 526

1. Immediate: arterial thrombosis- nephrectomy 2. Weeks: lymphocele- open/lap peritoneal window 3. Months: polymovirus (BK)- nephrostomy + reconstruction

Question 527

Px, Dx, Tx of PTLD

Answer 527

Px- LADN, fevers w/in 1 year - B cells proliferation 2/2 T cell suppression from IS Dx- PCR+ for EBV Tx- reduce IS

Question 528

Inflow and outflow for pancreas transplant

Answer 528

1. Inflow: iliac vessels (kidney- left, pancreas- right) - -donor SMA and splenic artery are connected with donor iliac artery Y graft to be plugged into the right iliiac 2. Outflow: iliac vessels - -donor SMV/splenic vein are already connected. Plugged into R iliac vein (or SMV/PV) **Duo can be connected to SB or bladder

Question 529

w/up of kidney graft dysfunction

Answer 529

1. Elevated Cr. Low UOP. 2. US: high RI is a non-specific finding - Vascular abnormality ➡ angio, stent, or surg - Lymphocele/Urinoma ➡ perc drain ➡ perit window - Negative: graft dysfunction ➡ Core needle bx

Question 530

Post transplant hepatic artery vs. PV thrombosis

Answer 530

1. HA thrombosis: MC - Early: days/weeks- hepatic failure ➡ thrombectomy OR re-trx - Late: months- abscess, strictures ➡ temporize, re-trx - Stenosis: angio and stent 2. PV thrombosis: rare - Early: days/weeks- FHF ➡ thrombectomy or re-trx - Late: months- encephalopathy, varices ➡ AC - Stenosis: angio and stent

Question 531

GVHD - px, dx, tx

Answer 531

- Px: hepatitis, dermitis, GI sxs after stem-cell/marrow trx - - WBC from donor recognize recepient as foreign - - B+T cells - Dx: bx - Tx: steroids + IS

Question 532

Tx of testicular torsion

Answer 532

1. Surgical de-torsion of involved testes - If doubtful viability: <10 keep, >10yo orchiectomy 2. Exploration and fixation of uninvolved testis as well! **don't delay OR for U/S if suspicion is high

Question 533

Dx and Tx of RCC

Answer 533

Dx: triple phase CT (don't need tissue bx unless mets) - do cystoscopy after CT Tx: Radical nephrectomy + LND +/- chemo +/- XRT - TK inhibitor is 1st line chemo

Question 534

Types of hydrocele and Tx

Answer 534

1. Communications: children. 2/2 patent processes - <2yo: conservative; >2yo: surgical excision 2. Non-communicating: adults. 2/2 secretions not connected to peritoneum - dont tx if asx. tx w/ excision.

Question 535

Dx and Tx of LCIS

Answer 535

Dx - usually incidental. pre-menopausal women. mammo negative - R/o breast ca is .5% per year Tx - Must perform lumpectomy bc 10-20% chance of surrounding DCIS or CA - Don't need negative margins as long as dx can be made - No SLNBx PPx - Surgery can be done for prophylaxis - Can get hormonal therapy - Surveillance w/ MRI or mammo q6m

Question 536

Dx and Tx of inflammatory breast ca

Answer 536

Dx: skin punch bx Tx: 1. Neo-adjuvant 2. MRM 3. XRT 4. Endocrine tx

Question 537

TRAM vs. DIEP flap

Answer 537

TRAM- skin, fat, and rectus; more functional loss | DIEP- skin, fat only; preferred; slightly more flap loss; less morbidity

Question 538

Fibroadenoma - px, dx, tx

Answer 538

Px- pain w/ periods Bx- fibro-epithileal lesions (if "aggressive" concern for phyllodes) Tx- resect if > 3cm, sxs, growth, anxiety, discordance

Question 539

Tx of breast ca in preg

Answer 539

1T (13w)- mastectomy + SLNBx (radioactive sulfer) +/- chemo at 2T 2-3T- lumpectomy + SLNBx (radioactive sulfer) +/- chemo + post delivery XRT

Question 540

Indications for post-mastectomy radiation

Answer 540

1. > 5cm 2. 4+ nodes 3. + margin 4. skin involvement

Question 541

Boundaries of ax dissection

Answer 541

- medial: p. minor - lateral: lat dorsi - superior: ax vein - posterior: subscapularis

Question 542

Trauma to the chest and abdomen. HDUS.

Answer 542

General start with ex-lap b/c significant cardiac or above DPGM bleed would have killed the patient already

Question 543

Bolus fluid and blood in children

Answer 543

Fluid: 20cc/kg Blood: 10cc/kg

Question 544

Repair aortic trauma

Answer 544

Access usually with Mattox maneuver If < 50% closure primary with polypropylene suture If > 50% perform a PTFE patch

Question 545

Visceral artery trauma

Answer 545

Celiac- Mattox; try to reconstruct; can be ligated SMA- Mattox of follow root of mesocolon; cannot ligate IMA- Mattox; try to recontruct; can be ligated

Question 546

Proximal Control and Access

Answer 546

1. Supra-celiac: G-H ligament ➡ lesser sac ➡ R 2. Supra-mesocolic: supra-celiac aorta; mattox 3. Infra-mesocolic: infra-renal aorta; trans-peritoneal

Question 547

Small bowel trauma

Answer 547

1. Serosal tear: interrupted, non-absorbable 2. <50%: 1 or 2 layer closure 3. >50%: resection and anastaoisis 4. Multiple short segments: resection and anastamoisis

Question 548

Access to neck zones

Answer 548

Zone 1: thoracic inlet to cric ➡ median sternotomy with left neck incision Zone 2: cric to angle of mand ➡ left neck incision Zone 3: angle of mand to skull base ➡ IR

Question 549

Causes of R-shift/decrease affinity on Oxy-Hb curve

Answer 549

2,3 DPG Elevated temp Higher paCO2 Acidosis

Question 550

Shock class

Answer 550

1. No VS changes 2. Tachycardia 3. Hypotension and combative 4. No UOP and obtunded

Question 551

Lung cancer staging

Answer 551

T1: <3 cm with no main bronchus T2: 3-5 cm w/ invasion of main bronchus or pleura T3: 5-7 cm with chest wall, pericardium T4: >7cm w/ mediastinum, great vessels, DPGM, trachea, esophagus n1: ipsi peri-bronchial nodes - n1 nodes: 10-14 n2: ipsi mediastinal/subcarinal nodes - n2 nodes: 1-9 n3: contra mediastinal/hilar; any-supraclavicular * *Need at least least 3x N1 and 3x N2 (6 total) for staging S1: T1 or T2. No N. S2: T3 or N1 S3: T3 and N1 or T4 or N2 S4: M1

Question 552

Ketamine c/i

Answer 552

1. MI (b/c increases SNS activtiy and cardiac demand) | 2. Space occupying brain lesion

Question 553

SCIP Quality Measures

Answer 553

1. abx 1h prior to incision (for approrpaite pts) - include G negative coverage for GI procedures 2. abx dc w/in 24h 3. appropriate hair removal 4. controlled 6am glucose in cards pts 5. dc foley on POD1-2 6. normothermia

Question 554

Insulin peri-op

Answer 554

On morning of surgery: - Don't take oral hypo-glycemics - Don't take short-acting insulin - Take 1/2 of long-acting insulin

Question 555

Indications for pre-op spiromtery

Answer 555

- all lung resections - smoking > 20 years - suspected pulmonary disease (COPD, ILD) - reduced exercise tolerance, unexplained dyspnea

Question 556

Appendicitis PE maneuvers

Answer 556

1. Obturator- pain w/ internal rotation = Pelvic appe 2. Psoas- pain w/ extension = retrocecal 3. Rovsing- pain on the right with left push

Question 557

Absolute c/i to PEG

Answer 557

1. Uncorrectable coagulopathy 2. Unctronolled ascites 3. Unable to oppose stomach to abdominal wall (inability to transilluminate is only relative) 4. Survival < 4 weeks

Question 558

Tx of sublgottic stenosis

Answer 558

2/2 to traumatic cric placement | tx- resection with re-anastamosis (dilation doesn't work)

Question 559

Frey Syndrome

Answer 559

Gustatory sweating | 2/2 auriculotemporal nerve

Question 560

Dx and Tx: TG duct cyst brachial cleft cyst cystic hygroma

Answer 560

1. TG duct: midline through hytoid bone; sistrunk procedure - if infected tx w/ abxs first 2. Brachial cleft: anterior SCM; resection 3. Cystic hygroma: posterior triangle; resection (avoid infection)

Question 561

Component separation

Answer 561

1. Anterior: EP aponeurosis 2cm lateral to semilunar line from costal margin to inguinal ligament 2. Posterior: Cut posterior rectus sheath and mobilize retrorectus plane

Question 562

Mesh choices

Answer 562

1. Heavy weight polyprop: micro-porous; lower recurrence but more infections 2. Light weight polyprop: macro-porous; less infections but high risk of adhesions (coat bottom with PTFE) Based on contamination: - clean: synthetic - clean/contaminated: synthetic is preferred! ( even w/ controlled enterotomy w/out gross pillage) - contaminated: biologic mesh if > 3 cm - dirty/infected: biologic mesh if > 3 cm

Question 563

STITCH trial

Answer 563

5 mm bites every 5 mm

Question 564

Boundaries of femoral canal

Answer 564

floor- cooper's/pectineal ligament anterior- inguinal ligament medial- lacunar ligament latera- femoral vein

Question 565

Tx of parastomal hernia

Answer 565

1. ASx- can observe 2. Sxs- sugarbaker (preferred), or keyhole - do not relocate - Only repair for obstruction or strangulation - LB herniates more than SB

Question 566

Boundaries of triangle of doom/pain

Answer 566

Doom: Apex- internal ring. Medial- vas. Lateral-spermatic vessels Pain: (inverted triangle): Base- inguinal ligament. Medial- spermatic vessels. Lateral- reflected peritoneaum - Nerves (medial to lateral): femoral, FBFG, AFC, LFC

Question 567

Tx of hiatal hernia

Answer 567

Type 1- asx: NTD; sxatic: PPI; Surgery if refractory | Type 2-4: surgery even if asx

Question 568

Type of ventral hernia repair

Answer 568

1. < 2cm: suture repair +/- mesh 2. 2-10 cm: sublay or underlap w/ mesh - Sublay: retro-rectus aka rives-stoppa (under the peritoneum) - Underlay: aka IPOM (intra-perionteal only) under the peritoneum 3. > 10 cm: component seperation w/ mesh

Question 569

Dx and Tx Ischemic Orchitis

Answer 569

dx- venous congestions from damage to pamp plexus after open hernia repair. POD 2-5 tx- NSAID and pain meds. Orchiectomy is last resort.

Question 570

MCCO Cushing syndrome

Answer 570

1. Exogenous steroids 2. ACTH pituitary adenoma- lap adrenalectomy 3. Cortisol secreting adrenal adenoma- trans-sphenoidal resection 4. ACC- open adrenalectomy

Question 571

Tx of ACC

Answer 571

OPEN adrenalectomy + mitotane

Question 572

Dx and Tx of Addison's

Answer 572

Cause- AI attack of adrenal cx Dx- cosyntropin test - cortisol remains low - deceased cortisol and aldo with high ACTH Tx- steroids

Question 573

Relative strength of steroids

Answer 573

1. Dex 2. M-pred 3. Pred 4. H-cort

Question 574

w/up of Hypercortisolism

Answer 574

1. Initial tests: choose 1-2 - 24h urine free cortisol (most se) - late night salivary cortisol - overnight 1 mg dexa suppression 2. ACT Level A. ACTH normal/high - high dose dexa suppresion - no suppression: small cell lung ca - supperessed: pituitary adenoma B. ACTH low - CT positive: adrenal mass - CT negative: exogenous

Question 575

Dx and Distribution of carcinoid tumors

Answer 575

Dx: 24H urine HIAA or serum chromo A - Octreotide scan if can't locate Distribution: 1. Rectum 2. SI (ileum) 3. Appendix 4. Colon

Question 576

Tx of mesenteric vein thrombosis

Answer 576

1. AC 2. Surgery if peritonitis or failure to improve - can also consider endovascular thrombolytics 3. 2nd look operation 24-48 hours

Question 577

Tx of Grave's disease

Answer 577

1. Beta blocker 2. Methimazole. PTU if preggo 3. RAI once euthyroid- worsens opthalmopathy and c/i in pregnancy 4. Surgery if refractory, opthalmotaphy, compressive sxs, RAI and methimazole/PTU c/i **Preggo: beta blocker, PTU. Avoid RAI. Surgery if can't tolerate PTU

Question 578

W/up of Hashimoto's disease

Answer 578

1. FNA- r/o ca 2. Bloodwork- antiTPO/TG Ab 3. Tx- thyroxine ➡ partial thyroid **MCCO hypoT in the US

Question 579

Tetanus ppx

Answer 579

1. Full immunized (>= 3 toxoid doses) - clean/minor: toxoid vaccine if dose >= 10 years - dirty or > 1cm: toxoid vaccine if dose >= 5 years 2. Unknown or not fully immunized - clean/minor: toxoid vaccine - dirty or > 1 cm: toxoid vaccine + Ig

Question 580

Dx and Tx of CMV colitis

Answer 580

Dx - usual CD4 < 50 - PCR is unreliable b/c does not prove end-organ disease - must scope and bx to confirm dx Tx: gancylovir - initiate HAART - opthalmic exam to r/o retinitis

Question 581

Standard w/up for lung ca

Answer 581

1. PET/CT 2. PFTs 3. Bronchoscopy (can be intra-op) 4. Mediastinal eval- EBUS or mediastinoscopy

Question 582

Indications for ICP monitor

Answer 582

1. GCS <= 8 AND: - CT evidence of pathology OR - 2/3: age > 40, HoTN, abnormal posturing **IF GCS <= 8 with normal CT of the head, 2/3 (age > 40, HoTN, abnormal posturing) to get an ICP

Question 583

Bronchiolitis obliterans

Answer 583

MCCO long term lung trx failure 2/2 bronchiole inflammation Px- serial decline in PFTs. Normal tacro. CT- ILD Dx- of exclusion Tx- steroids, IS, reTrx (very poor outcomes)

Question 584

Endovascular head-induced thrombus tx (after RFA)

Answer 584

1. Stop at saph-fem/saph-pop jxn: no tx 2. <50% of deep vein occluded: surveillance 3. >50% of deep vein occluded: AC until clot resolves 4. Occlusive deep vein: tx as a dvt (3m of AC) **Prevent by ablating > 2.5 cm from the jxn

Question 585

Pressor for neurogenic shock

Answer 585

1. Above T6: nor-epi (b/c HoTN and brady) | 2. Below T6: Phenylephrine (may worsen brady above T6)

Question 586

Discerning idiopathic constipation: 1. Dyssynergic 2. Slow transit

Answer 586

Discerning idiopathic constipation: 1. Dyssynergic: lack of external relax w/ push 2. Slow transit: retained 6+ markers on day 6

Question 587

Vitamin A

Answer 587

- wound healing especially in steroid patients | - def: night blindness

Question 588

PPV and NPV

Answer 588

``` PPV = of those who test + how many have the dz NPV = of those who test - how many do not have the dz ``` Increasing prevalence = increase PPV and decrease NPV

Question 589

Pearson's R Value

Answer 589

Correlation coeff between -1 and 1 1 = very strong positive (direct proportion) > .7 = strong positive 0 = no correlation - .7 = strong negative Do not determine causation

Question 590

Phases of clinical trail

Answer 590

1. Safety in a small group of humans 2. How well does the drug work 3. RCT compared to standard of care 4. Long term safety and monitoring

Question 591

Chest exposures

Answer 591

1. Median sternotomy: ascending aorta, innominate, bilateral carotids, RIGHT subclavian, precordium - add neck/supraclav extension for distal control 2. Left Anterolateral thoracotomy: left subclavian (high), trauma/extremis (heart, lung, aorta) - can extend to clambshell in trauma - can extend to neck/supraclav for LEFT subclavian 3. Right Anterolateral: SVC, IVC 3. Right Posterolateral: - airway: distal tracheal, R main bronchus, - GI: thoracic esophagus - Vasculature: azygous vein 4. Left posterolateral: - airway: L main bronchus - GI: cervical and distal esophagus - vascular: descending aorta

Question 592

Indications for hepatectomy instead of liver trx in HCC patient who meets Milan criteria

Answer 592

Compensated cirrhosis, no portal HTN, low MELD, and solitary mass < 3 cm

Question 593

Mucor/Rhizopus vs. Aspergillus - path and tx

Answer 593

1. Mucor: DM or IS patients Path- broad hyphae w/ irregular branching tx- intubation, ampho, and surgery 2. Aspergillus Path- narrow hyphae w/ regularbranching tx- voriconazole. resect if aspergilloma.

Question 594

SMA embolus vs. thormbosis

Answer 594

Embolus- lodges after the middle colic. Jejunal sparring | Thrombus- at ostium; pan-bowel

Question 595

SMA embolectomy steps

Answer 595

1. Retract transverse colon cephalad 2. Identify SMA 3. Arteriotomy proximal to middle colic 4. Fogarty cathter 5. Close arrteriotomy

Question 596

Bilateral adrenal trauma

Answer 596

Suspect adrenal crisis | Tx- 4mg IV dexamethasone

Question 597

Desmoid Tumor - path and tx

Answer 597

A/w FAP (after surgery, 2nd MCCO death) Path- non calcified, fibrotic, low mit index, spindle cells Tx- WLE for extra-abd; NSAID, anti-Estrogen if intra!

Question 598

Pseudomyxoma peritonei - px and tx

Answer 598

Px- mucinous adenoca 2/2 appendix; scalopped liver | Tx- debulk anything > 2mm + HIPEC (@ 41C)

Question 599

MCCO PD catheter malfunction

Answer 599

1. Infection | 2. Outflow failure- MC 2/2 constipation

Question 600

Superior and Inferior epigastric anatomy

Answer 600

Superior Epigatric - from int thoracic (mammary) - Between rectus sheath and trans fascia Inferior Epigastric - from ext iliac - Between rectus and transc fascia

Question 601

Serologic work-up for adrenocortical mass

Answer 601

1. Dexa suppression (cortisol) 2. Urine androgens (sex hormones) 3. Plasma metanephrines (pheo) 4. aldo/rennin ratio > 30 (salts)

Question 602

Dx and Tx endometriosis

Answer 602

Dx- often require laparoscopy Tx- 1. Medical therapy 2. Surgery if unresponsive. Ablation if young.

Question 603

Staging laparoscopy

Answer 603

1. Perform before neo-adjuvant, before surgery, or high risk for metastatic disease (especially if CT is resectable but patient seems high risk) 2. Obtain histo sample, peritoneal lavage, U/S of nodal basins, explore lesser sac

Question 604

MCCO primary hyper-aldosteronism and tx

Answer 604

1. Bilateral adrenal hyperplasia (60%)- medical 2. Adrenal adenoma (Conn's syndrome)- lap adrenal 3. Adrenal adenoca- open adrenal + mitotane * Can use adrenal vein sampling to distinguish

Question 605

Dx and Tx of chronic mesenteric ischemia

Answer 605

Dx- CT + duplex; SMA > 275 cm/s, Celiac > 200 cm/s | Tx- angio + stent or surgery

Question 606

Resectability of pancreatic tumor

Answer 606

1. Unresctable- distant met, >180 SMA/celiac, - EUS/FNA for tissue dx for neoadjuvant 2. Borderline- <180 SMA/celiac - EUS/FNA for tissue dx for neoadjuvant 3. Resectable- dx lap + whipple

Question 607

Tx of horseshoe abscess

Answer 607

Midline drainage incision of deep posterior space | Bilateral lateral counter-incisions for ischiorectal space

Question 608

Tx of anorectal fistula

Answer 608

<30% sphincter- fistulotomy or cutting seton | >30% sphincter- draining setons + ARAF or LIFT

Question 609

Tx of Internal HMHDs

Answer 609

G1- bleeding, G2- spontaneous reduce, G3- manual reduce: -1st line: sitz, stool softener, bowel reg, fiber, fluids -2nd line: rubber band, sclerotherapy, coag. G4- cant reduce -1st line: surgical HMHD'ectomy

Question 610

Tx of External HMHDS

Answer 610

1st line: sitz, stool softener, bowel reg, fiber, fluids 2nd line: surgical HMHD'ectomy Thrombosed: incise or excision if w/in 48h

Question 611

Paget's disease of the anus (px and tx)

Answer 611

Px- intractable pruritis, eczematoid rash | Tx- colonscopy (r/u malignancy) + WLE + perianal bx

Question 612

ARAF vs. LIFT

Answer 612

ARAF- elevate flap of M/SM, curette the tract from external opening, cover internal opening w/ flap LIFT- dissect I/S tract, ligate the tract, curette the tract from external opening, +/- core out the tractanal

Question 613

Px Tx of Carcinoid of the rectum, appendix, and small bowel

Answer 613

Px: - GI tract > pulm > GU - Rectal is now > midgut b/c screening scopes - Midgut a/w flushing - Right sided valvular plaques (lung protects the left heart) Tx: < 2 cm- local excision (transanal, appendectomy, segmental) > 2 cm- formal resection (APR, R hemi-colectomy, cancer resection WITH mesentery)

Question 614

Unresectable cholangiocarcinoma

Answer 614

Criteria - bilateral HA or PV - unilateral HA with extensive contra duct Tx - no extrahepatic dz ➡ neoadj chemo-XRT + liver trx - extrahepatic dz ➡ chemo-XRT

Question 615

Bismuth classification and tx

Answer 615

For hilar cholangioca. Only t4 unresectable. 1: CH duct- REYHJ + LADN +/- lobectomy 2: bifurcation- REYHJ + LADN +/- lobectomy 3: R or L HD- REYHJ + LADN + lobectomy 4: Both ducts- chemo-XRT + liver trx

Question 616

Lap CBD exploration

Answer 616

1. Dissect CD to the level of the duo 2. Cholodochotomy distal to the CD/CBD junction 3. Fush, basket, or fogarty balloon the stone out 4. Close primarily, over a T-tube, or over a stent

Question 617

Advantage of T-tube closure

Answer 617

- Does not prevent leak better than primary closure - Allow for future cholangiogram - Allow for perc stone removal once tract matures

Question 618

Indications and technique for biliary enteric drainage

Answer 618

- Retained stoned that cannot be cleared with lap CBD exploration - Transduo sphincteroplasty c/i b/c CBD > 2cm and there are multiple stones

Question 619

Px and Tx of Chalangitis

Answer 619

``` Dx: fever, RUQ, and jaundice - stones > malignancy > stricture Tx: - signs of sepsis: resuscitate/abx then urgent ERCP - no sick: US/MRCP ```

Question 620

Px and Tx of Sphincter of Oddi dysfunction

Answer 620

Px: Biliary pain with normal RUQ U/S after years lap chole Dx: mannometry (no MRCP or CT 1st) Tx: endoscopic sphincterotomy at 11' (CCB usually ineffective) - CBD at 11', PD at 1-3' - h/o REY: open transduo sphincterotomy

Question 621

Ideal setting for stone formation

Answer 621

Low bile salts Low lecithin High cholestersol

Question 622

Mirizzi syndrome tx

Answer 622

``` px- GB neck/CD stone compresses CHD types: 1: no fistula- cholecystectomy 2: < 1/3 circ- CC'ectomy + CBD repair w/ T-T 3: < 2/3 circ- CC'ectomy + REY-HJ 4: full circ- CC'ectomy+ REY-HJ ```

Question 623

Types of GB polyp

Answer 623

1. Cholesterolosis: MC; CE mphages in LP; benign 2. Adenomyomatosis: benign 3. Adenoma: malignant; >1cm is RF for CA (resect)

Question 624

Tx strategy for CBD transections

Answer 624

1. Intra-op - <50%, not cautery: primary repair - >50%, or cautery: REY-HJ 2. Late phase - Place drain - Define anatomy w/ ERCP, PTC, or MRCP - Place PTC tube - CTA to assess for R/L HA injury - Delayed reconstruction 6-8 weeks once optimized

Question 625

Open CBD exploration steps

Answer 625

1. Begin LATERALLY on the HD ligaments to ID CBD 2. Stay sutures at 3' and 9'. Choledochotomy 3. Remove stones (forceps, balloon, milking) 4. Cholangiogram 5. Close over a T-tube

Question 626

Conditions for trans-cystic CBD exploration:

Answer 626

1. CD > 4 mm, CBD < 7 mm 2. < 8 stones, < 10 mm 3. No stones in CHD (distal to CD/CBD junction) 4. Normal anatomy (no REY-GB)

Question 627

Conditions for lap or open CBD exploration

Answer 627

1. CD < 4 mm, CBD > 7 mm 2. > 8 stones, > 10 mm 3. CHD stones (proximal to CD/CBD junction) 4. Failed trans-cystic or abnormal anatomy (REYGB)

Question 628

Management of GB polyps

Answer 628

``` Sx: - sxs, stones, PSC, > 6mm: cc'ectomy For asx: - > 18 mm: tx as GB cancer - > 10 mm: CC'y - 6-10 mm: q6m U/S for 1 year. cc'ectomy if PSC ```

Question 629

PSC screening guidelines

Answer 629

Cholangioca: US/MRI/MRCP q6-12m. Annual CA 19-9 GB CA: US q6-12m CRC: colonscopy q1-2 years (regardless of UC) HCC: US/MRI/MRCP q6-12m

Question 630

Steps of intra-op cholangio

Answer 630

1. Clip juxn of infun. and CD (prevent reflux) 2. Linear incision along CD 3. Cathter placed 4. Shoot contrast and flouro * scope can be used to assess masses and remove stones if needed

Question 631

Tx strategy for major burns

Answer 631

1. Resuscitate 2. Early excision and coverage (day 3-4) 3. Fluid less than before: - UOP: .5 cc/hr in adult, 1-1.5/hr in children

Question 632

Airway burn management

Answer 632

Scope if: soot, facial/body burns, singed hairs | Tube if: edema, ulceration, blisters

Question 633

Dx/Tx hypothermia

Answer 633

``` Dx- temp < 35C/95F; 1'- environ., 2'- illness/substance Mild: < 94- shivering Moderate: < 89- agitation, afib Severe: <84- comatose, osborne waves Profound: <70- loss of vitals ``` **moderate = 84-89

Question 634

Thoracic compartment syndrome

Answer 634

Dx: Respiratory failure 2/2 circumferential chest wall burn - high peak pressures Tx: escharotomy - box incision along ant ax lines connected with sub-xiphoid transverse incision

Question 635

Dx and Tx of Colovesicular Fistula

Answer 635

1. CT w/ oral/rectal (no IV b/c will obscure bladder) (not cystoscopy or colonoscopy) 2. Colonoscopy to r/o malignancy 3. Cystoscopy if suspect cancer. Retrograde cysto if CT is equivocal or operative planning Tx- resect sigmoid even if asx; Don't need to repair the bladder, just drain

Question 636

Colon cancer and arterial resection

Answer 636

1. R hemi- IC, RC, RBMC - cecum/asc colon 2. Extended R- IC, RC, MC - hepatic flex/prox t colon 3. L hemi- LBMC, LC - Distal TV, splenic flex, prox descending 4. Extended L- LBMC, origin of IMA - splenic flex 5. Sigmoid- IMA (hi- b4 LC, low- after LC) - dist desc/sig

Question 637

Colon CA surveillance after curative resection

Answer 637

1. Exam and CEA q3-6m x 3 years 2. Colonoscopy @ q1, 3, and 5 years - No prior scopes: q3-6m (intra-op scope is difficult in un-prepped bowel) 4. CT CAP q1y x 3 years

Question 638

Staging w/up of rectal cancer

Answer 638

1. TRUS (avoid if > t2) or MRI- T/N stage - suspicous nodes on MRI count as clinical stage N (neo-adj) 2. CT CAP- M stage 3. C'Scope- for initial dx and sync lesion. not for T stage 4. Rigid Sig'Scope- for distance from anal verge No need for PET MRI- circumferential resection margin

Question 639

Tx of refractory Crohn's pan-colitis

Answer 639

1. Segmental colitis- partial colectomy 2. Rectal sparing pan-colitis- TAC w/ IRA 3. Pan-colitis w/ rectum- PC w/ end ileostomy - IPAA whether w/ or w/out loop should NOT be done on Crohn's b/c r/o pouchitis

Question 640

Tx of cecal volvulus

Answer 640

Stable- R hemi and primary mosis (no pexy) | Unstable- R hemi with end ileostomy

Question 641

Tx of radiation proctitis

Answer 641

1. Acute: < 6w, no bleeding; alter therapy, supportive, butyrate enema 2. Chronic: >6w, bleeding; anti-inf, sucralfate enema, laser coag, hyperbaric O2, surgery

Question 642

Lynch syndrome dx

Answer 642

AD; MMR gene (MLH, MSH, PMS, EPCAM) Amsterdam II Criteria - HNPCC/Lynch 1. Colon/HNPCC Ca b4 50 2. 2+ generations 3. 3+ relatives (1 is 1d) 4. Exclude FAP *HNPCC Ca: CRC, ovary, uterus, endometrial, gastric, renal/ureter, SB, brain, skin

Question 643

Dx of Juvenile polyposis

Answer 643

Dx: 5+ polyps or any polyps w/ family hx - SMAD4+ Non-adenomatous polyps ~ hamartomas

Question 644

Tx of Lynch Syndrome

Answer 644

1. CRC: q1y C-scope @ 20-25; TAC w/ IRA or TPC w/ IPAA if CA or unresectable adenoma. q1y scope post op (metachronous CA) 2. Endometrial: q1y endometrial sampling @ 30-35; ppx TAH-BSO after children 3. Ovarian: q1y TVUS and Ca-125 @ 30-35; ppx TAH-BSO after children 4. Stomach: EGD/Bx q2-3y @ 30-35 5. Renal: q1y UA and US @ 30-35

Question 645

Tx of FAP

Answer 645

``` q1y scope @ 10-12y Tx- TAC w/ IRA or PC w/ IPAA (rectum involved) Colectomy if: - suspected CRC - severe sxs/gi bleeding - HGD or multiple adenomas > 6 mm - marked increase in poylp number - inability to survey colon Surveillance of pouch/rectal cuff post op q1y ```

Question 646

APR vs. LAR

Answer 646

Tumors that require APR: 1. < 5cm for anal verge 2. Tumor at dentate line w/ sphincter involved 3. Tumor that can't get a 1 cm distal margin w/out sphincter 4. Poor pre-surgical anorectal function 5. Locally recurrent low-lying cancer

Question 647

Polyposis syndromes: - Muir-Torre - Gardner - Turcot - P/J - Cowden - JuP

Answer 647

- Muir-Torre: MLH/MSH; sebaceous gland tumor - Gardner: APC; desmoid tumors, osteomas, epidermal cysts/lipomas - Turcot: APC; Malignant CNS tumors - P/J: STK; myocutameous pigmentation - Cowden: PTEN; Hamartoma polyps, endometrial/breast/thyroid CA - JuP: SMAD4; epistaxis, AVM, telangiectasia

Question 648

Indications for colonic stent

Answer 648

1. Bridge to surgery in acute obstruction 2. Palliative measure * Usually for L-sided lesions

Question 649

Tx of ureter injury after sigmoidectomy

Answer 649

1. <7 days and healthy: re-explore and fix primarily | 2. >7 days or poor candidate: perc neph tube, stent; fix in 6-12 wks

Question 650

Dx/Tx of slow transit constipation

Answer 650

Dx- nuclear medicine colonic transit or radiopaque marker Tx- 1. Laxative, fiber, pelvic floor exercise 2. TAC w/ IRA (Not TPC w/ IPAA)

Question 651

Tx of C. diff

Answer 651

1. Primary: oral vanco or fidox 2. Fulminant: oral vanco w/ IV flagyl; +vanc enema if ileus 3. 1st-2nd recurrence: tapered vanco or fidox 4. Multiple recurrence: consider fecal transplant 5. Total colectomy if sepsis or toxic megacolon (colon > 6 cm, cecum > 10 cm)

Question 652

Dx and Tx of ischemic colitis

Answer 652

Dx- CT first to rule out non-ischemic colitis or infarction; C'scope to confirm - suspect in low flow state, HoTN Tx- usually supportive; OR if perf, sepsis

Question 653

Dx and Sx of PNETs 1. Glucagonoma 2. Inuslinoma 3. Gastrinoma 4. VIPoma 5. SSoma

Answer 653

1. Glucagonoma: glucagona > 1k; NME, DM, DVT 2. Inuslinoma: fasting I/G > .4 and high C-pep; whipple triad 3. Gastrinoma: G > 1k or increase G w/ sec; refractory PUD, HyperCa 2/2 MEN1 4. VIPoma: high fasting VIP (exclude other causes); DRH, Achlorhydria, hypoK (2/2 DRH) 5. SSoma: High fasting SS; DM, stones, steatorrhea *Do not perform imaging or go to the OR until biochemical diagnosis!

Question 654

Dx and Tx of Pancreatic cysts: 1. Serous cystadenoma 2. MCN 3. IPMN 4. Psuedocyst

Answer 654

- W/up: MRI/MRCP or PP CT ➡ >1.5 cm, sxs, dilated main duct, solid component, fam hx ➡ EUS/FNA 1. Serous cystadenoma: low M/CEA, low Am; resect if sxs 2. MCN: high M/CEA, low Am; resect 3. IPMN: high M/CEA, high Am; resect if main duct or > 3 cm 4. Pseudocyst: low M/CEA, high Am; observe x 6w; if sxs or > 6cm cystgastrostomy

Question 655

Tx of PNETs: 1. Glucagonoma 2. Inuslinoma 3. Gastrinoma 4. VIPoma 5. SSoma

Answer 655

1. Glucagonoma: distal panc w/ splenectomy + cc'y 2. Inuslinoma: enucleate 3. Gastrinoma: enucleate if < 2 cm; >2 cm, whipple 4. VIPoma: distal panc w/ splenectomy + cc'y 5. SSoma: resect w/ cc'y

Question 656

Perform splenectomy for distal panc PNET?

Answer 656

No only if low malig risk- insulinoma, non function < 2cm, gastrinoma < 2cm

Question 657

Steps to Whipple

Answer 657

0. Inspect. Frozen any lesions. Abort if + 1. Mobilize hepatic flexure. Expose 3D/4D 2. Kocherize duo and HOP to LOT 3. Palpate the SMA posteriorly from aortic origin 4. CC'y. CHD divided above CD entry 5. Dissect down the portal vein towards the pancreas developing plane. Ligate R gastric then GDA (branch of common hepatic) 6. PV turns into SMV behind the pancreas (where pancreatic vein joins). Create plane between SMV/pancreas 7. Divide the stomach at the antrum and duo 2cm past the pylorus 8. 2 index fingers are sea-sawed behind the duo and pancreas and in front for PV/SMV, developing a the plane. Transect pancreas using cautery. 9. Retract the pancreatic head lateral and PV/SMV medial. Ligate venous tributaries to PV/SMV. 10. Perform P-J (2-layer, end to side) 11. Perform H-J (1-layer) distal to P-J 12. G-J: Billroth 2 (2-layer, end to side)

Question 658

Arterial anatomy of the celiac trunk

Answer 658

1. CHA: gives off GDA then R gastric - GDA gives of SPDA and R gastroepi 2. Splenic: gives off short gastrics and L gastroepi

Question 659

ECG findings of PE

Answer 659

Sinus tach is MC | S1Q3T3 pattern w/ TWI

Question 660

Dx and Tx of Pulmonary Blastoma

Answer 660

MC primary lung tumor in children Dx- air/fluid filled cystic lesions. Looks like pneumo. Tx- Surgical resection +/- chemo-XRT

Question 661

Length time bias vs. lead time bias

Answer 661

1. Length time: screening by its very nature will pick up more indolent disease 2. Lead time: asymptomatic disease is caught earlier by screening, "starting the clock" sooner

Question 662

Brown-Sequard

Answer 662

Ipsi loss of motor | Contra loss of pain/temp

Question 663

Dx of biliary dyskinesia

Answer 663

Suspect if GB w/ normal US and EGD | Dx- HIDA scan w/ EF < 35%

Question 664

Px and Tx of epididymitis

Answer 664

Px- scrotal pain and pyuria usually 2/2 STD | Tx- IM CTX and oral azithromycin (STD tx)

Question 665

Tx of GB perf in acalculous chole

Answer 665

Early CC'y and IV abxs | Avoid perc chole drain even if very sick

Question 666

Dx and Tx of obturator hernia

Answer 666

Dx- groin pain that improves w/ flexion and bulge - DO NOT need CT scan for diagnosis Tx- urgent operative exploration (don't wait for CT eve if stable)

Question 667

Emergent ariway in a child

Answer 667

1. Try ETT placement with a miller blade | 2. Needle cric is preferred over open if < 12

Question 668

Tx of peptic stricture 2/2 GERD

Answer 668

1. Serial dilations 2. PPI 3. Consider stenting . Surgery is last resort (in contrast to achalasia)

Question 669

Exposure to bronchial tree in trauma

Answer 669

Carina or either mainsteim: RIGHT thoracotomy (aorta in the way on the left)

Question 670

CREST Trial

Answer 670

- Carotid stenting has higher incidence of stroke - CEA has high incidence of MI - Composite end-point of stroke, death, MI was the same

Question 671

Dx and Tx of Bacterial Overgrowth

Answer 671

- px: 2/2 bill2 or REYGB - -- watery stools, bloating, b12 deficiency - dx: d-Xylose test to - tx: abxs --> surg 2nd line

Question 672

Inguinal hernia nerves

Answer 672

1. Ilioinguinal: under to EO 2. Ilio-hypogastric: supero/medial to the ilio-inguinal. Passes EO superior to the external ring 3. GB of GF: runs within the spermatic cord

Question 673

Types of HRS

Answer 673

Type 1: rapidly progressive RF. May respond to diuretics. Type 2: slowly progressive renal failure. Ascites refractory to diuretics. Better prognosis.

Question 674

Treatment of lung ca

Answer 674

1. No N2 disease (stage 1-2) --> up-front surgery 2. N2 disease or T4 --> chemo-XRT first n1- ipsi bronchial/hilar nodes n2- ipsi mediatinal/subcarinal (2-9) t1- <3cm t2- >3cm t3- >5cm OR invading pleura, chest wall, phrenic n, pericardium OR nodule in same lobe t4- >7cm OR invading DPGM, mediastinum, heart, great vessels, trachea, RLN, esophagus, vert body, carina. OR different ipsi lobe

Question 675

Lung ca w/up

Answer 675

1. < 8mm ➡ surveillance 2. > 8 mm ➡ PET-CT - FDG- ➡ surveillance 3. FDG+ ➡ tissue dx (either intra-op frozen or CT-guided, bronchoscopy) - nodal disease --> EBUS 4. No N2 dz --> Segmentectomy or lobectomy - n2 disease --> chemo

Question 676

Ingested foreign body w/up

Answer 676

1. Abdominal XR! | 2. High risk: button batery,

Question 677

Steps of hiatal hernia repair

Answer 677

1. Complete dissection of hernia sac from mediastinum - avoid vagus nerve - can divide short gastrics to aid in mobilization 2. At least 3 cm of esophagus into the abdomen! - - Colis gastroplasty if insufficient 3. Close the hiatus with sutures or mesh (posterior and inferior) - - mesh has better short term outcomes only

Question 678

Pre-op regiments for aldosteronoma and pheo

Answer 678

1. Aldosteronoma: Spironolactone + ACEi/ARB +/- CCB +/- K sparing diuretic 2. Pheo: phenoxybenzamine then BB

Question 679

Window to the great vssels

Answer 679

innominate vein

Question 680

Tx of HCC

Answer 680

1. Solitary nodule, confided to the liver, < 5 cm (not strict), child A, no portal HTN, and adequate liver remnant - Consider portal vein embolization if remnant is insufficient - Consider pre-op TACE to as an adjunct 2. Un-resectable disease: child B+, > 5cm (not strict), portal HTN, inadequate liver remnant - Transplant if candidate: UNOS criteria - Otherwise: loco-regional therapy or systemic therapy

Question 681

When to re-implant the IMA in EVAR

Answer 681

1. Back-pressure < 40 2. Previous colon surgery 3. SMA stenosis 4. Inadequate left colon flow

Question 682

Lynch vs FAP Screening

Answer 682

1. FAP- chromosomal; APC - > 100 polyps, including duo - Surveillance: start at 10 2. HNPCC (Lynch)- microsatalite; MSH, MLH, PMS, EPCAM - <10 polyps in the colon - Surveillance: start at 20

Question 683

Surgical Tx of thyroid/PT cancers 1. Papillary/Follicular 2. MTC 3. Hurthle 4. Anaplastic 5. PT

Answer 683

1. Papillary: lobectomy +/- total + consider ppx L6 for high risk 2. Follicular: lobectomy +/- total (criteria) - no node dissection unless cx+ 2. MTC: total + bilateral L6 3. Hurthle: lobectomy then total + bilateral L6 4. Anaplastic: chemo-XRT +/- total if operable + central and lateral nodes 5. PT: hemi-thyroid + L6 (usually) **MRND if L6 is positive

Question 684

Confirmation of brain death

Answer 684

1. Neuro exam: - absent brain stem reflexes - no response to stimuli 2. Apnea test: CO2 > 60

Question 685

Bleeding during mesh fixation, inguinal hernia

Answer 685

1. Open: sewing mesh onto EO --> femoral vein | 2. TEP: tacking mesh medially --> corona mortis (obturator branch)

Question 686

Tx of H/N tumors

Answer 686

1. Mucoepidermoid: MC malignant - total parotid + ppx MRND + XRT 2. Adenoid cystic: malignant - total parotid + ppx MRND + XRT 3. Pleomorphic adenoma: MC benign - superficial parotidectomy 4. Warthin/Papillary cystadenoma - superficial parotidectomy

Question 687

W/up of UGI bleed/perf: 1. Boerhave 2. Traumatic esophogeal perf 2. UGI bleed

Answer 687

1. Boerhave: XR suggestive ➡ UGI (CT controversial) 2. Traumatic esophogeal perf: Trauma CT ➡ EGD or UGI 2. UGI bleed: +/- NGT ➡ EGD

Question 688

Tx of Cellular vs. Ab Rejection

Answer 688

1. Cellular: - mild: steroids - severe: TG 2. Ab: - Plasmaphoresis (clear Ab) - IVIG (so body thinks there are still ab) - Rituximab (CD20 Ab)

Question 689

IS for transplant

Answer 689

Induction: choose 1 1. Thymoglobulin - polyclonal Ab (potent) 2. Basiliximab - IL2 inhibitor (mild) Maintenance 1. Tacrolimus 2. MMF 3. Prednisone 4. Sirolimus

Question 690

Transplant ABX ppx

Answer 690

1. Bactrim- PCP, toxo gondi, listeria, nocardia 2. Diflucan- antifungal 3. Valganciclovir- CMV

Question 691

Transplant cross-matching

Answer 691

1. ABO Incompatibility - A, B, O Ab 2. Cross-match: recipient serum X donor lymphocytes - preformed HLA Ab (A, B, DR). DR is most important. * *Livers don't need a cross-match * *Can give A2 donors to O recipients * *Donor: Ags are important (WBC) * *Recipient: Abs are important

Question 692

MAC

Answer 692

Low MAC = lipid soluble High MAC = water soluble - NO has highest MAC

Question 693

CDH1

Answer 693

High r/o gastric ca | ppx gastrectomy by age 40

Question 694

px, dx, and tx of meconium ileus

Answer 694

px- failure to pass meconium dx- sweat chloride test tx- GG then NAC enemas - surgery: ostomy for antegrade enema

Question 695

Congenital thoracic disorders - px and tx 1. Pulm sequestration 2. Cystic adenoid malformation 3. Congenital lobar emphysema 4. CDH

Answer 695

1. Pulm sequestration: infection w/ abnormal CXR - tx: resection 2. Cystic adenoid malformation: similar to sequestrion but communications w/ TB tree - tx: lobectomy 3. Congenital lobar emphysema: XR looks like tension PTX - tx: lobectomy 4. CDH: Bochdalek- back/left, MC; Morgagni- rare, anterior - a/w pulm HTN, NTD, malrotation - tx: intubate +/- ECMO. Delayed repair.

Question 696

Ig crosses the placement

Answer 696

IgG

Question 697

Nutrition requirements per day 1. Protein 2. Fat 3. Carb

Answer 697

Nutritional requirements for average healthy adult male (70 kg) 1. 20% protein calories - 1 g protein/kg/day - burn: 1g/kg/day + 3 g/day x % BURN 2. 30% fat calories 3. 50% carbohydrate calories

Question 698

Wilcoxon test

Answer 698

Compare PAIRED ordinal variables between two groups | - ex: patient satisfaction before and after an intervention (1-5)

Question 699

COX proportion hazard modeling

Answer 699

Like a regression model but for survival analysis | Allow you to control for different factors

Question 700

Changes to VS with preggo

Answer 700

Increased HR increased SV Decreased SVR Decreased BP

Question 701

Afferent limb syndrome

Answer 701

- AKA bacterial overgrowth - px: steatorrhea, b12 deficiency - -MC w/ antecolic Bili2 - Dx: d-xylose breath test - tx: abxs --> REY/shorten the limb

Question 702

Medical tx for melanoma

Answer 702

Pd1 inhibitors- pembrozilumab, nivolumab If Braf+: braf inhibitor remains 2nd line

Question 703

MC benign/malignant thoracic tumors in adults/children

Answer 703

Adults - benign: hamartoma - malignant: sqcc Children - benign: hemangioma - malignant: carcinoid

Question 704

Tx of Rhabdomyosarcoma

Answer 704

MC soft tissue tumor in children | tx- chemo + XRT + surgery