ABSITE 2022 Flashcards

Question

Cowden's mutation and cancers

Answer 1

Mutation: pten Ca: breast, thyroid ca, hamartomas, endometrial

Answer 2

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

Answer 3

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

Answer 4

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

Answer 5

1. TOTAL thyroidectomy 2. Bilateral central/level 6 dissection - if > 1cm or < 1cm w/ bilobar disease 3. Lateral neck dissection on that side if central+ 4. Start T4 postop. Monitor w/ calcitonin AND CEA - RAI is c/i! (C cell origin)

Answer 6

1. Acute w/ any sx's: hypertonic saline bolus 2. Chronic and asxatic: free water restriction 3. Hyper or euovolemic: free water restriction 4. Hypovolemic: can give NS or LR (no 3% unless sxs!)

Answer 7

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

Answer 8

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

Answer 9

1. Dx: - Mammo: spiculated mass with central sclerosis (lucency) and surrounding distortion - Histo: fibroelastic core w/ entrapped ducts 2. Tx: core bx ➡ excisional bx (to r/o ca)

Answer 10

1. Prealbumin: >15; t1/2 is 1-2 days; good post-op marker 2. Albumin: >3.5; t1/2 is 21 days; good pre-op marker

Answer 11

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

Answer 12

1. Stable, HCG < 5k, no cardiac activity ➡ methotrexate - MTX: absolute c/i if the patient is breast-feeding 2. Stable, otherwise ➡ salpingotomy 2. Unstable, free fluid, ongoing pain/bleeding ➡ salpingectomy - loose future fertility

Answer 13

- hyperK: peaked T wave, eventual SINE - hypoK: QT prolongation, U waves

Answer 14

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

Answer 15

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

Answer 16

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

Answer 17

1. Confined to appendix: appe only (no LADN'y) - must have negative margin - scope in 6w to r/o sync lesions 2. Involving the base, ruptured, or +margin: usually R hemicolectomy +/- LADN'y 3. Peritoneal dissemination: can dx with perc bx - if appendicitis: just remove ruptured segment + directed peritoneal bx - if no appendicitis can postpone appe until cytoreductive surgery - do not do hipec/cancer operation until properly staged **need post-op scope to r/o synchronous lesions

Answer 18

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

Answer 19

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

Answer 20

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

Answer 21

- < 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)

Answer 22

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

Answer 23

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

Answer 24

HCC: rapid enhancement. rapid w/out. Pseudocapsule on w/out. "hot" on nuclear imaging Mets: Hypoattenuation Adenoma: rapid enhancement. rapid w/out. "cold" on nuclear imaging Hemangioma: peripheral nodular enhancement. delay: centripetal fill-in FNH: Centrifugal enhancing. w/out except for scar enhancement. take up sulfer colloid **If unclear, MRI can distinguish benign from malig

Answer 25

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

Answer 26

Runs under the vas/uterine arteries Runs over the iliacs

Answer 27

1. ASA lifelong 2. Plavix - BMS: 1 month - DES: 6 months (ideally). Can be 1 month if needed for urgent surgery (cancer) **Postpone elective surgery until these times **If surgery is needed (i.e. cancer) wait at least 1m for DES

Answer 28

1. supracondylar humerus- brachial artery 2. DRF- median nerve 3. Mid shaft- radial nerve 4. ant shoulder disloc- ax. nerve 5. post shoulder disloc- ax. artery

Answer 29

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%

Answer 30

Score: 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

Answer 31

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

Answer 32

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

Answer 33

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

Answer 34

Px: post-mastectomy lymphangiosarcoma - 2/2 chronic lymphedema - rare and highly malignant Dx: incisional bx Tx: wide local excision (total mastectomy) w/ 3-6 cm margin + chemotherapy - don't need to stage nodes (hematog spread)

Answer 35

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

Answer 36

Tyrosine kinase inhibitor Tx of HCC

Answer 37

1. Heineke: <10cm; open long and close transversely 2. Finney: > 10cm; segment folded on itself and common wall created 3. Side2Side isoperistaltic (Michellassi): > 20 cm; overlap stricture/dilated area; 2x enterotomy/sew bowel together - can't be performed in proximal duo (would require G-J bypass) - perform resection instead if this is first episode

Answer 38

Scintigraphic gastric emptying

Answer 39

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; no blanch 3D burn: subcutaneous fat, leathery 4D: fat/muscle/bone; surg

Answer 40

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

Answer 41

IL1: fever IL2: CD4 T cell proliferation IL4: B cell proliferation IL5: eosinophil growth, asthma, allergic rxns IL 10: anti-inflammatory

Answer 42

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

Answer 43

MOA: Plasmin inhibitor Use: DIC, excess tpa

Answer 44

1. carb: immunosuppression, resp failure 2. lipid: pro inflammatory 3. protein: false neurotransmitters, rise in ammonia/urea - can worsen hepatic encephalopathy (use branched chain AA instead of aromatic AA)

Answer 45

- Dx: red, crusty, weeping lesion - Bx: PARTIAL thickness pleomorphism (full = SqCC in Situ) - Tx: cryotherapy, photodynamics, imiquimod, cautery (no margin)

Answer 46

- 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.

Answer 47

- If less than 3 nodes positive on SLN and T1 or T2 disease, BCT is OK - if >70, t1, ER+ and SNLBx neg ➡ can consider no XRT after lumpectomy

Answer 48

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

Answer 49

1. Submucosal invasion > 1mm 2. Poorly differentiated 3. <1 mm margin 4. LV invasion 5. Tumor budding 6. Taken piecemeal

Answer 50

anemia, glossitis, brittle nails, cardiomegaly

Answer 51

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

Answer 52

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

Answer 53

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

Answer 54

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

Answer 55

- 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

Answer 56

Bloody stools after 1st feed tx- resuscitation, abx (no surgery)

Answer 57

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

Answer 58

Tx: simple mastectomy w/ SLNBx - BCT usually can’t be done b/c not enough tissue - if ER+: tamoxifen (Her2+ is rare). consider orchiectomy if metastatic. - Prognosis similar to W but delay in px - a/w BRCA 2/Chromosome 13

Answer 59

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

Answer 60

1. DM, 2. HTN, 3. PCKD

Answer 61

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 - Repair in 6-8 weeks

Answer 62

1. LGD- scope q6-12m lifetime (even if fundoplication)- - OK for fundoplication 2. HGD- ablation + Q3m scope - fundoplication c/i 3. T1a- ablation 4. t1b (or low risk T2)- esophagectomy *Fundoplication does not decrease cancer risk

Answer 63

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

Answer 64

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

Answer 65

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

Answer 66

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

Answer 67

Tx- recombinant at3 or FFP followed by heparin then warfarin

Answer 68

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

Answer 69

1. Neoadjuvant: Stage 2 and above Stage 2: at least t3 (crossing muscularis prop) or any n (stage 3) 2. Adjuvant chemo as well for Stage 3+ (nodes) **XRT either pre or post-op (not both)

Answer 70

Risks: - High risk pt: afib, MHV, recent TE event (3m) - High risk surgery: nsurg, optho, cards Tx: - 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 (Dabigatran require CrCl 1st to determine days to hold) - continue ASA for low/moderate risk - stop Plavix 5 days before

Answer 71

Adrenal mass Ectopic mass (small cell cancer)

Answer 72

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

Answer 73

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

Answer 74

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

Answer 75

1. dx: of exclusion- increased megakaryocytes, petechia, TCPenia 2. tx: steroids → IVIG 2nd line → splenectomy - do not tx unless PLT < 30k or 20k in low risk

Answer 76

G+/aerobe/clusters coag+ → staph aureus coag- → staph epidermidis

Answer 77

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

Answer 78

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+

Answer 79

dx: - CT: displacement of renal parenchyma (vs. Wilm's). - usually adrenal. Can also find in the neck, chest, spine, tx: - S1-2 (low risk) → surg alone - S3+ (high risk) → surg + chemo/XRT

Answer 80

- MOA: G cells of antrum signal EC cells ➡ Histamine ➡ Parietal cell ➡ H/K exchange (ATP) ➡ HCl (+ intrinsic factor) - Stimulation: ACh, beta ago, AA

Answer 81

1. Internal: superior rectal and hypogastric plexus (sns/psns) 2. External: Internal pudendal nerve

Answer 82

1. Cervical- inf thyroid 2. Thoracic- aortic branches 3. Abd- left gastric/inferior phrenic

Answer 83

- CBD at 11'. Blood supply 9' and 3'. - PD at 1' to 3'

Answer 84

Grade: 1/2- contusion/stretch ➡ foley 3- part disruption ➡ foley +/- cystostomy/repair 4/5-complete disruption ➡ cystostomy + delayed repair - can try urethral cath with cysto assistance - must get a CTAP to r/o concomitant injuries that would require delayed repair

Answer 85

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

Answer 86

1. CT or scope to confirm dx. R/o obstruction. 2 supportive, dc narcotics, ng tube, neostigmine 3. if > 10cm ➡ scope decompression and neostigmine 4. failure ➡ OR

Answer 87

Px: bitemporal hemianopsia, galactorrhea, amenorrhea, ED, osteopenia Tx: 1. Bromocriptine or carbegoline (both dopa agonists) - bromo is safe in pregnancy 2. Surgery if failure

Answer 88

- Sevo: rapid induction, less pungent. Good for kids. - Isoflurane: good for neurosurgery; no increase in ICP - Halothane: slow onset/offset, cards depression, hepatitis. - NO: least cardiac depression b/c sympathomimetic. c/i in SBO. Highest MAC.

Answer 89

- competitive inhibitor of ACh at muscarinic receptor - liver metabolism

Answer 90

Dx: string of beads on angiogram Tx: angio + balloon (no stent)

Answer 91

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

Answer 92

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 **discordance: perform repeat bx w/ surgical excision or core bx (if there was a correctable error)

Answer 93

1. Fluconazole: ergosterol synth inhibitor - Non-systemic candida (yeast infection, c. albicans) - s/e: liver toxic, GI upset 2. Voriconazole: ergosterol synth inhibitor - aspergillosis, C. krusei - s/e: visual changes, psychosis 3. Micafungin: echinocandin; inhibit glucan production - invasive/disseminated candidiasis (c. glabrata) - s/e: TCPenia 4. Amphotericin: binds ergosterol and inhibits cell membrane; lipid soluble (brain access) - invasive mucor or cryptococcal meningitis - s/e: nephrotoxic, hypoK

Answer 94

motor to larynx except circothryoid injury: hoarsness, airway compromise, cord paralysis (permanent ADduction) - If bilateral may need a trach Normal anatomy: - Superior PT runs posterior - Inferior PT runs anteriorly Abbarent anatomy: - NR right a/w: arteria lusoria ➡ absent innominate + right SC takes off from left aortic arch + travers retr-eso - NR left a/w R sided arch

Answer 95

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

Answer 96

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

Answer 97

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

Answer 98

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

Answer 99

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

Answer 100

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

Answer 101

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 complication (preferred)

Answer 102

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

Answer 103

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

Answer 104

neonates- duododuodenostomy (mobile duo) adults- duodenojejunostomy

Answer 105

TNF-a: produced by PMNs, mphes -cachexia, inflammation IF-gamma: produced by T lymphos - activate PMNs, mphages

Answer 106

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

Answer 107

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

Answer 108

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

Answer 109

1. 100% O2 w/ facemask or intubation (not hi flo) - Hyperbaric O2 if C-Hb > 25% 2. intubate if comatose, severe acidosis

Answer 110

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

Answer 111

- 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

Answer 112

1. Ivor-Lewis (Trans-thoracic): abdominal + R thoracotomy - anastomosis: thoracic - theoretically more thorough oncologic resection - less overall leak rate - may be better in more fit patients 2. Transhiatal: abdominal + L neck - anastomosis: cervical - theoretically less chance of mediastinal leak, shorter operation BUT more overall leak rate - 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)

Answer 113

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

Answer 114

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

Answer 115

1. AFP, HCG, LDH - Seminoma: no AFP!` - Non-seminoma: high 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

Answer 116

1. Pyogenic: after div's; - drain and abx (+mica if fungal) 2. Amoebic: after mexico trip (or aMazon) - metronidazole (no drain) 3. Echinococcal: wall Ca+ and sub-cysts - albendazole and resect/PAIR

Answer 117

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

Answer 118

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

Answer 119

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

Answer 120

MLH1, MSH2, MSH6, PMS2, EPCAM DNA MM repair gene causing microsatellite instability

Answer 121

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

Answer 122

1. Hemangioma: only if sxatic or KM syndrome - enucleate (or resect); angioembo if active bleed 2. FNH: NTD 3. Adenoma: resect if < 4cm w/out OCP response or > 4 cm, male, or growing

Answer 123

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

Answer 124

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

Answer 125

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

Answer 126

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 fibrinolytic therapy

Answer 127

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

Answer 128

1. TOF 2. Transposition of GVs 3. Truncus art 4. Tricuspid atresia 5. TAPVC

Answer 129

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

Answer 130

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

Answer 131

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

Answer 132

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

Answer 133

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

Answer 134

Ampicillin/Amoxacillin Vancomycin Zosyn (Resistant to all cephalosporins)

Answer 135

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

Answer 136

HypoCl, HypoK metabolic alk - Mech: Loose HCl and fluid ➡ turn on RAA system Retain Na/Excrete acid (paradoxic acidurea)

Answer 137

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

Answer 138

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

Answer 139

Infected pancreatic necrosis (WBC + gas on CT) 1. Carbanem 2. FNA 3. Perc drain OR endo drain (if stomach is close to pancreas) 4. Upsize drain 5. Video, Lap, or Endo assisted retrop necrosectomy 6. Lap/open necrosectomy

Answer 140

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

Answer 141

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

Answer 142

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

Answer 143

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

Answer 144

1. Punch bx or excisional bx (if small, non-sensitive area) - MIS- 5mm margin - <1mm- 1cm - 1-2mm- 1-2cm - >2mm- 2cm 2. Clinical positive nodes (stage 3) require FNA for confirmation - negative: SLNBx - positive: completion LN dissection 3. SLNBx: > 1mm (T2) or if .75-1 mm w/ ulceration or mitotic rate > 1 (T1b) 4. If SLNBx+ (stage 3): q4m US surveillance OR completion LN dissection - LN dissection: superficial 1st. Deep if cloquets+, clinically+ positive, >3+ on SLNBx, or CT+ for deep nodes **MOHS can be used for in-situ disease. Need 5 mm margin.

Answer 145

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

Answer 146

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

Answer 147

MAP - ICP normal CPP > 60 Normal ICP < 20 - would prefer low MAP with CPP of 60 then higher MAP for brain bleed

Answer 148

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

Answer 149

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

Answer 150

Biconvex MMA DOES NOT suture lines

Answer 151

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

Answer 152

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

Answer 153

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

Answer 154

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

Answer 155

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

Answer 156

Px: nitrites, Hurricaine spray, fertilizers - Fe2+ to Fe3+ impairing O2 binding - G6PD def or serotonergic drugs - Dx: blood gas measurement and pulse ox says 85% - Tx: vitamin C (for g6pd or ser) or methylene blue

Answer 157

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

Answer 158

- small: patch plasty - large: contralateral GSV (must maintain venous system b/c deep vein may be injured) - limited time/unstable: shunt

Answer 159

after epidural tx with blood patch

Answer 160

1. unprovoked: malignancy, inherited ➡ indefinite 2. provoked: surgery, travel, preg, OCP, immbility ➡ 3m Special cases: - ileofemoral: cather directed thrombolysis - open thrombectomy ➡ extensive (ileofemoral) DVT OR phlegmasia - Superficial femoral vein is a DVT - Pregnant ➡ use Lovenox. NOAC and Coumadin are c/i

Answer 161

- loop: furosemide - Ca sparing: thiazides

Answer 162

Dx: EGD + bx - CD20+, lympho infiltration - associated w/ h. Pylori. Tx: - Low grade: triple therapy (eradicate HP) - High grade: chemo and XRT (CHOP) +/- rituximab (CD20)

Answer 163

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

Answer 164

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

Answer 165

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

Answer 166

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

Answer 167

- Case: HSV8 - Px: Violet/brown papules

Answer 168

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

Answer 169

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

Answer 170

1. 1st line: fiber/bulking, exercises 2. Refractory: endoanal U/S - defect: overlapping sphincteroplasty - no defect or refractory: sacral modulator

Answer 171

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

Answer 172

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

Answer 173

- chromosome 5 - 1st mutn in adenoma to carcinoma - mc mutation in colon ca - a/w FAP

Answer 174

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

Answer 175

1. age 2. age 1st period (earlier is worse) 3. age 1st birth (earlier is better) 4. 1d relative 5. previous bx 6. race

Answer 176

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

Answer 177

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

Answer 178

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

Answer 179

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

Answer 180

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

Answer 181

Synercid, linezolid

Answer 182

Milrinine- PD inhibitor, contractility with vasodilation - c/i in renal failure Midodrine- a1 agonist

Answer 183

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

Answer 184

dx- ↑ascitic PMN and + culture; e. coli is MC tx- 3GC abx AND albumin (survival benefits)

Answer 185

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

Answer 186

1. Octreotide + antibiotics 2. Endoscopic intervention (ligation/sclerotherapy) 3. Blakemore 4. TIPS

Answer 187

1. Elevate HOB 2. CXR and CTA 3. Consider bronch 4. Assess sxs A. Life-threatening sxs: secure airway ➡ consider AC (if thrombus) ➡ venogram ➡ endovascular stenting B. Mild sxs ➡ tissue bx ➡ decide on XRT/chemo

Answer 188

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

Answer 189

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

Answer 190

1. Uncomplicated: lap appe 2. Septic/Unstable: immediate lap appe 3. Stable w/ abscess - < 3cm: lap appe - > 3cm: IR drain ➡ interval appe 4. Phlegmon: - ileocecal resection likely: abx trial 1st - ileocecal resection unlikely: lap appe 5. Crohn's ileitis - intra-op with normal appendix AND cecum ➡ appe to r/o dx uncertainty **Lap appe a/w higher intra-abdominal abscess and OR time (lower overall complication rate)

Answer 191

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

Answer 192

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

Answer 193

Prognosis: - aggressive, undiff - mort ~ 100%; no tx Tx: XRT improves short-term survival +/- surg - BRAF inhibitor for chemo

Answer 194

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

Answer 195

1. T0 or T1 (submucosa) 2. < 3 cm 3. < 30% circumference 4. Palpable on DRE (<8cm from anal verge) 5. No high-risk features (poorly diff, LV invasion) **local recurrence rate is higher

Answer 196

Dx: -rare neuroendocrine tumor of the skin -purple raised; looks like BCC w/out rolled edge - CK20+ Tx: -highly radiosensitive -Tx (like melanoma): surgical excision + SLNBx! + XRT

Answer 197

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

Answer 198

1. Resect Ladd’s bands 2. Widen the mesentery 3. Counterclockwise rotation 4. Cecum in LLQ (cecopexy), place duodenum in RUQ 5. Appendectomy

Answer 199

1. Entamoeba - dx: from mexico; microscopy, antigen testing, or PCR - CT: rim enhancement - tx: even if asx ➡ MEtronidazole...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

Answer 200

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 - after children: TAH-BSO 3. Ovarian ca: annual pelvic exam and TVUS

Answer 201

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

Answer 202

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

Answer 203

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

Answer 204

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

Answer 205

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

Answer 206

1a: LC only - lap chole only - excise to negative CD margin 1b: muscle involved - OPEN chole + seg 4b and 5 + portal LADN - CD margin positive: REY-HJ **high suspicion for GB Ca should also get an open chole (polyp > 2cm)

Answer 207

Epithelium Lamino Propria Muscularis mucosa

Answer 208

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

Answer 209

1. Flush ➡ glucagon x 2 2. Lap exploration A. Transcystic: stone < 1 cm, <8 stones, CHD > 4 mm, no CHD stones, normal anatomy B. Lap CBD: stone > 1cm, > 8 stones, CHD or junction stones 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

Answer 210

1. FNA- hurthle cells (can be seen in other conditions) 2. Lobectomy 1st for diagnosis 3. If malig: total thyroidectomy +/- L6 nodes 4. If palpable nodes: MRND No RAI

Answer 211

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)

Answer 212

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

Answer 213

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

Answer 214

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)

Answer 215

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

Answer 216

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

Answer 217

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

Answer 218

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

Answer 219

Parafollicular C cells Inhibits osteoclast resorption Increases Ph excretion

Answer 220

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

Answer 221

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

Answer 222

1. Gastrin - G cells in antrum - ↑ HCl, IF, and pepsinogen 2. Somatostatin – D cells in pancreas - 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

Answer 223

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

Answer 224

Px: breast mass that looks like abscess w/ no infectious signs Dx/tx: u/s ➡ aspiration; continue bfeeding

Answer 225

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

Answer 226

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

Answer 227

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

Answer 228

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

Answer 229

1. Hemostasis: PMNs (24-48h) - PMNs: remove necrotic tissue, release ROS's 2. Inflammatory: monocytes/macrophages (48-96h) - mphage: growth factors, angiogenesis, cell proliferation - chronic wounds arrest in this stage 3. Proliferative: fibroblasts (3d+) - fblasts: collagen production and secretion 4. Maturation: fibroblasts (10d) - myofibroblasts for wound contraction

Answer 230

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

Answer 231

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

Answer 232

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

Answer 233

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 - cagluc if HF acid

Answer 234

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

Answer 235

to close- indomethacin to open- PGE1

Answer 236

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

Answer 237

low- d1/2 ago (renal dose) medium- B ago high- A ago **s/e: high UOP. difficult to titrate. tachyarrythmias

Answer 238

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

Answer 239

>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

Answer 240

Dx- UGI (don't do EGD) Tx- open or scope approach: - small (1 cm) symptomatic pouches are very likely well suited to myotomy alone - moderate-sized diverticula (1 to 4 cm) are best treated by myotomy with suspension or inversion - larger pouches probably warrant diverticulectomy with myotomy

Answer 241

Acute – vaptan, demeclocycline Chronic – fluid restriction, diuresis

Answer 242

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

Answer 243

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

Answer 244

- neo-adj chemo for T2+ or N - proximal- total gastrectomy - distal- partial - 5 cm margin; 15 nodes - Can consider endoscopic mucosal resection: if < 2cm, well-differentiated, mucoa only, no LV invasion

Answer 245

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

Answer 246

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% indications for trx of cholangioca - cant be intrahepatic - must be unresectable, perihilar, < 3cm - no distant mets

Answer 247

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

Answer 248

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

Answer 249

1. dx- oil cyst w/ Ca+ rim 2. tx: no trauma- bx trauma- watch

Answer 250

- Only tx if sxs - ERCP sph’otomy of MINOR papilla (Santorini/Superior) - Refractors: resect HOP (duo preserving)

Answer 251

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

Answer 252

1. Marfans- Fibrillin-1 defect (elastin); - AD; mitral regurg, aortic root dilation, lens defect, arachnodactyly 2. Ehlers Danlos- t3 collagen defect - hyper elastic skin, hypermobile joints, aortic root dilation **Both need CTA of aorta to r/o aortic root``

Answer 253

px- hematuria in a smoker dx- CT urogram 1st (bladder, kidney, or ureter ca) 1. T1a- no muscle tx- endoscopic resexn + BCG/mitoM 2. T2a- muscle/beyond LP tx- cystectomy + chemo + LND 3. T3- fat/nodes) tx- neoadjuvant

Answer 254

Small ➡ absorbable in 1 LAYER w/ strap buttress - 2 layer leads to tracheal stenosis - primary repair up to 5-6 rings - bilateral injury ➡ bilateral SCM incisions and join ("U" incision) Large and above 3rd ring → tracheostomy through the defect - avoid below 3rd ring (TI fistula)

Answer 255

1. Crohn's: - Creeping fat - Skip lesions - Transmural - Cobblestoning - Granulomas - Fistulas 2. UC: - Crypt abscess - Pseudopolyps

Answer 256

Px- 2/2 renal disease. dx- normal coags. elevated BT only. tx- ddavp

Answer 257

- 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

Answer 258

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

Answer 259

Emergent: 1. Steroids +/- abxs 2. Infliximab, Cyclosporine 3. No response, megacolon (> 6 cm), HDUS, or perf ➡ TAC with end-ileostomy - When stabilized can perform 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

Answer 260

- hemangioma + thrombocytopenia - usually infants - resect!

Answer 261

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

Answer 262

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

Answer 263

1. Hemolytic: rapid RBC destruction by host IgM/IgG - +direct coomb’s. ABO incompatibility - px: flushing, bleeding - tx: stop trx. Fluids. 2. non-hemolytic: cytokines from donor WBC - px: fever and rash (no bleeding) - tx: antihistamine, epi, steroids

Answer 264

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

Answer 265

- Contents: VWF, f8, fibrinogen - Uses: 1. VWD 2. Fibrinogen def 3. Hemophilia A

Answer 266

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

Answer 267

1. neurogenic PT: PT --> rib resection, scalenectomy, BPlex dissection 2. venous- catheter-directed thrombolysis → surgical decompression 3. arterial- C7/1r resection, subc artery resection/reconstruction

Answer 268

AD; APC mutation Dx: > 100 adenoma or < 100 w/ fam hx - CA by 40 - desmoid tumors (slow growing abdominal wall mass) Tx: - sigmoidoscopy q1y at 10 (don't need colonoscopy) - EGD @ 20 or when polyps start - 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 - desmoid: resect. Anti-E if intra-abdominal

Answer 269

female breast, ovarian, male breast I (ch17)- 60, 40, 1 II (ch13)- 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!

Answer 270

1. all functioning tumors 2. all > 6 cm ➡ open resection 3. if < 6cm with suspicious features - >10HU, <50% @ 10m w/out ➡ open resection **DO NOT biopsy first

Answer 271

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

Answer 272

1. Adjuvent chemo: tumor > 1cm, nodal dz, triple neg - 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

Answer 273

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

Answer 274

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

Answer 275

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

Answer 276

1. Indications for total thyroidectomy: - Tumor > 4cm - Tumor 1-4cm and patient preference - Distant mets or extra-thyroid disease - Poorly differentiated - Prior radiation 2. Nodes dissection: A. 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 - For high risk tumors: tumor > 1 cm, extra-thyroidal disease

Answer 277

MOA: Accelerates AT3 activity and INDIRECTLY inhibits thrombin Measurement: - PTT - ACT: better intra-op if high doses of hep given

Answer 278

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

Answer 279

1. Nonop: HDS, <10 mm, <5 mm shift 2. Evacuate: > 10mm, >5mm shift, delta GCS > 2, cx signs of ICP

Answer 280

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

Answer 281

- 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

Answer 282

Bile duct lateral Hepatic artery medial Portal vein posterior

Answer 283

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

Answer 284

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)

Answer 285

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

Answer 286

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

Answer 287

- Thoracodorsal (lateral): Lat Dorsi, ADduct/extension/IR - Intercosto-brachial: hypesthesia - Lateral petoral: p major, arm flexion - Medial pectoral: p major/minor, ADduct/extension/IR - Long thoracic (medial): SA, wing scap

Answer 288

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) - good initial study to show an association

Answer 289

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

Answer 290

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

Answer 291

path- PERIPHERAL ENHANCEMENT px- young women tx- if rupture, size change, or KM syndrome

Answer 292

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

Answer 293

lactate , pyruvate, AA

Answer 294

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

Answer 295

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

Answer 296

- gene: p53 mutation; TSG on Ch17; AD inheritance - mech: cell cycle regulation and apoptosis - px: breast ca + sarcoma b4 45

Answer 297

1. dx: fluid TG > 110 2. 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)

Answer 298

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

Answer 299

Px: Common 2/2 B cell lymphoma - hyperU, K, Ph w/ hypoCa Path: CaPh crystal ➡ renal failure + hypoCa tx: IV hydration ➡ iHD

Answer 300

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

Answer 301

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

Answer 302

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

Answer 303

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

Answer 304

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

Answer 305

dx: drain amylase 3x serumo amylase tx: - NPO, TPN x 4-6 wks - remove drain if amylase and output decrease - enteral nutrition can stimulate output - octreotide may decrease output but does not accelerate healing - consider ERCP w/ stent after 6 weeks

Answer 306

lido = 5mg/kg (7 w/ epi) bupiv = 2.5 mg/kg (3 w/ epi) tx- lipid emulsion **epi can help ID intravascular access b/c quick changes in heart dynamics **local anesthetic can cause hypotension in an epidural

Answer 307

- aspergilloma: resect - aspergillosis: voriconazole **MC fungal infxn in IC patient

Answer 308

1. Dx- MC GI Sarcoma - EGD + FNA: SM smooth EGD mass with normal overlying mucosa and central ulcer. Stomach MC. - Bx: cajal cells. c-KIT+ - don't require bx if high suspicion 2. Tx- wedge resection (gross margin) - can be R0 or R1 resection - Imatinib (TK inhibitor) ➡ 5cm or >5 mitosis/50 hpf - neoadjuvant if need to down-stage for resection - adjuvant for 3 years

Answer 309

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

Answer 310

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)

Answer 311

1. protein = 4 kcal/g 2. dextrose = 3.4 kcal/g 3. lipid = 9 kcal/g 4. carb = 4 kcal/g total req = 25-30 kcal/kg - use ideal body weight if BMI > 25 - 50% carb, 30% fat, 20% protein

Answer 312

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

Answer 313

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

Answer 314

aortobifemoral bypass

Answer 315

Core need returns ➡ - Atypical - DH/LH - LCIS/DCIS - radial scar - papillary lesion - any atypia **can use sterotactic needle bx if mass in visible on mammo but otherwise difficult to find

Answer 316

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

Answer 317

type 1: false positive - say something is true (reject the null) when it's not - alpha = prob of type 1 error. Set at .05 - minimize by decreasing stat significance type 2: false negative - say something is false (do not reject the null) when it's true - beta = prob of type 2 error. Set at .2 - minimize by increasing sample size/power **power = 1 - type 2 **reject the null = "a difference exists"

Answer 318

path- EARLY enhancement on arterial phase w/ rapid washout. well-circumscribed. **vs hemangioma: peripheral enhancement over time tx- stop OCP use. resect immediately if > 5cm, sxatic, male gender risks: 1. rupture MC 2. malig transformation

Answer 319

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

Answer 320

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

Answer 321

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

Answer 322

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

Answer 323

If CT and PET: no distance disease ➡ Endoscopic U/S for T and N: 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+

Answer 324

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 *No screening if asx

Answer 325

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.

Answer 326

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

Answer 327

fxn: motor to cricothyroid injury: trouble w/ high pitch, voice remins clear - cord looks normal on laryngoscopy tx: none **MC nerve injury w/ a total thyroid

Answer 328

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

Answer 329

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

Answer 330

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

Answer 331

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

Answer 332

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

Answer 333

DONOR Ab attacks recipient WBC

Answer 334

- 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 - Cholangitis: e. coli - NSTI: polymicrobial - ICU infection: VAP

Answer 335

1st give PGE1 → ballon atrial septostomy

Answer 336

Nigro protocol- RTx (of Ca + inguinal/pelvic nodes) + 5FU + MitoC Recurrence (10-20%)- must wait at least 6 month to diagnose. APR SqCC equivalents- large cell ker. (SqCC), transitional zone, LCl non-ker, basaloid, mucoepidermoid

Answer 337

Most common cyanotic defect 1. VSD 2. Pulmonary outflow obstruction 3. Over-riding aorta 4. RVH (2/2 RV outflow obstruction w/ harsh murmur) tx- beta blocker; surgery at 3-6m

Answer 338

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

Answer 339

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

Answer 340

Exudate if: PL protein/serum Pr >.5 PL LDH/serum LDH > .6 PL LDH > 2/3 ULN - Exudate: capillary damage from inflammation, neoplasm, trauma - Transudate: change in oncotic pressure;

Answer 341

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

Answer 342

Bacteroides fragiles

Answer 343

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

Answer 344

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

Answer 345

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

Answer 346

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

Answer 347

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

Answer 348

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

Answer 349

stable- wait 4 weeks, IR retroP drain unstable- debride Debride: VARD (video-assist retroP)- utilize retoP drain, DEN (endoscope), open necrosectomy **VARD can be c/b pseudoaneurysm of GDA/splenic artery requiring angioembo

Answer 350

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

Answer 351

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

Answer 352

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

Answer 353

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, gallstones - cycled in bile Sirolimus: bind fK --> mTor inhibitor (IL2 inhibitor) - impaired wound healing, interstitial lung disease - lymphocele MMF: purine (T cell) inhibitor - GI sxs, myelosuppression, anemia Basilixamab: il2 inhibitor - GI sxs Azathioprine: purine (T cell) inhibitor - myelosuppression, marrow suppression, pulm fibrosis

Answer 354

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

Answer 355

- dvt/pe - endometrial cancer - cant take with SSRI (CYP inhibitors)

Answer 356

BCT: 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)

Answer 357

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

Answer 358

low CEA, low Amylase tx- resect if sxs

Answer 359

-2-6m: piecemeal removal -1 year: > 10 adenomas -3 years: 3+ adenomas, HGD, > 1cm, villous elements -5 years: 1-2 tubular adenomas (< 1cm) -10 years: hyperplastic polyps (<20)

Answer 360

Strep pneumo (MC) Neisseria Haemophilus “Shin”

Answer 361

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

Answer 362

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

Answer 363

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

Answer 364

PRSS1 trypsinogen mut'n AD smoking cessation is important

Answer 365

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

Answer 366

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

Answer 367

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

Answer 368

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

Answer 369

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

Answer 370

angioembolization

Answer 371

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

Answer 372

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

Answer 373

Meld: 1. Bili 2. INR 3. Creatinine - designed for mortality over 3 months after TIPS - At least 15 for trx - HCC gets automatic score of 22 CTP: Billirubin, Albumin, INR, Ascites, Encephalopathy

Answer 374

MCCO bloody nipple dc dx- dx mammo 1st ➡ contrast ductogram tx- complete excisional biopsy including the ductal segment

Answer 375

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

Answer 376

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

Answer 377

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

Answer 378

aneurysmal- staph non-aneurysm- salmonella

Answer 379

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

Answer 380

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

Answer 381

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

Answer 382

1. HGD, TIS, T1a: endoscopic ablation/resection 2. T1b: upfront esophagectomy or endo ablation (if low risk) 3. T2 or N: neoadjuvant then esophagectomy - Low grade T2 (< 3cm, no L/V invasion, well diff): upfront eso 4. T4b or M: definitive chemo-XRT < 5cm from cricoP: definitive chemo-XRT > 5 cm from cricoP: esophagectomy

Answer 383

C/I: 1. Cancer 2. Barrett's w/ HGD Indications: 1. Extra-eso complications: cough, aspiration, CP 2. Persistant sxs 3. C/i to antireflux meds 4. Barrett's w/out HGD 5. Strictures

Answer 384

Classic sxs: heart burn + regurg Alarm: 1. dysphagia (not regurgitation) 2. odynophagia 3. bleeding 4. weight loss 5. anemia *Require EGD

Answer 385

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

Answer 386

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

Answer 387

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

Answer 388

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. Partial wrap

Answer 389

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

Answer 390

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

Answer 391

Dx- XR then contrast esophogography (GG then Ba) - EGD if UGI is negative but still high suspicioun 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 w/ minimal signs of sepsis OR 2. Very poor operative candidate Stenting: contained perf or minimal extrav after EGD

Answer 392

<1% = Pre-renal >1% = Intrinsic >4% = Post-renal

Answer 393

- Mech: fat to carb metabolism ➡ resumption of ATP production causes Ph influx into cells ➡ hypoPh - Px: HypoMg, Ph, K; paresthesia, confusions, RD - COD is cardiac failure

Answer 394

10 mmHg increase in pCO2 = .08 decrease in pH

Answer 395

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

Answer 396

W/up: Post-meno bleeding ➡ TVUS ➡ endo bx Tx: Hysterectomy, bilateral SO, peritoneal w/out, LN sampling - Required for Tx AND staging!

Answer 397

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

Answer 398

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

Answer 399

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

Answer 400

Cause: protein C def (not S!) Tx: Stop Coumadin Give vitamin K Start hep gtt or argatroban

Answer 401

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

Answer 402

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

Answer 403

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

Answer 404

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

Answer 405

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

Answer 406

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

Answer 407

Dx: doppler (usually 2/2 to p. vera) Tx: 1. Lifelong AC 2. < 4 weeks: thrombolytics 3. > 4 weeks: angioplasty/stenting 4. Refractory: TIPS, transplant, surgical shunt

Answer 408

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

Answer 409

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

Answer 410

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

Answer 411

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

Answer 412

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

Answer 413

Px: pancreatitis w/ normal Lipase and LFTs Dx: elevated IgG, biopsy to prove. - CT: dilated w/ no Calcs. "sausage" appearance. - Brush biliary tree if concern for malignancy Tx: 0. Bx first! 1. ERCP if stricutre: r/o ca, relieve obstruction 2. Steroids

Answer 414

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

Answer 415

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

Answer 416

- 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

Answer 417

1. BB 2. ACEi: unless 1 kidney or bilateral dz - efferent dil'n can worsen kidney dz 2. PTA: perc trans-luminal angio +/- stent (or open revascularization) 3. Nephrectomy **CORAL trial: PTA is not better than maximum medical theraphy

Answer 418

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

Answer 419

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

Answer 420

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

Answer 421

6+ hours of warm ischemia Steps: - lateral incision: between tibia and fibula ➡ open anterior and lateral compartment - medial incision: 1 finger posterior to tibia ➡ open fascia over the gastric ➡ peel soleus off of the tibia ➡ open deep posterior fascia

Answer 422

- 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

Answer 423

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.

Answer 424

Location: 1. Rad/Ceph 2. Rad/Bas 3. Bra/Ceph 4. Bra/Bas 5. Prosthetic peripheral 6. Prosthetic ax-brachial 7. Prosthetic femoral **Upper extremity preferred to LE Rule of 6's: - flow > 600/min - diameter > 3mm before placement. > 6mm after placement - depth of 6mm

Answer 425

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

Answer 426

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 - Need at least 2 cm landing zone distal to L SC

Answer 427

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

Answer 428

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

Answer 429

tx: < 2cm observe > 2cm: - skinny neck: thrombin injection - wide neck: operative intervention immediate surg- infxn, HDUS, pulsatile, skin changes, ischemia, AMS

Answer 430

- 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

Answer 431

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

Answer 432

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

Answer 433

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

Answer 434

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)

Answer 435

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 - no vagotomy 2. Perforation: get h pylori status! ➡ omental patch w/ post op h. pylori treatment (90% H.pylori related) - 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: 1. HDS, minimal contamination AND 2. PUD w /h. pylori status negative, unknown, refractory OR unable to stop NSAID therapy (NSAID ulcer) **EGD does not require bx for duodenal ulcers

Answer 436

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

Answer 437

1. Afferent limb obstruction: prevent with afferent limb < 20 cm - acute: convert Bil 1 or REY (STAT!) - chronic: Bacterial overgrowth: try abxs 1st (Rifaximin) . convert to REY 2. Dumping syndrome: small meals, no sugar --> octreotide 3. Alkaline reflux gastritis: prevent w/ roux limb > 40 cm. - pro-kinetics, bile-acid binding ➡ convert to REY with long roux

Answer 438

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

Answer 439

1. 1st 4 hours: exogenous glucose 2. 4h-1d: Liver glycogen 3. 1d-1w: gluconeogenesis phase 4. 1w+: protein-sparing phase - FA/Ketones are used everywhere - Only RBCs use glucose

Answer 440

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

Answer 441

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

Answer 442

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

Answer 443

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

Answer 444

BSC: most common malignancy in USA; pearly, rolled borders, peripheral palisading; MC upper lip ca SqCC : scaly patch; keratin pearls, parakeratosis, full-thickness pleomorphism (partial = AK); MC lower lip ca - MC ca after trx 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

Answer 445

Dx: - LRINEC score: Na. glucose, WBC, CRP, Hb, Cr; >8 = 95% PPV - CT: gas, thick fascia Bacteria profile: - MC polymicrobial -if monomicrobial, MC GAS/strep pyogenes: M protein virulence Tx: - abxs: carbapenem OR broad spectrum w/ clinda (anti-toxin effect) and MRSA coverage - surgery

Answer 446

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, >50% vertebral body, eso/trachea involvement - vascular involvement is not c/i

Answer 447

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

Answer 448

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

Answer 449

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

Answer 450

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

Answer 451

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 **aorto-enteric fistula should also be treated aggressively with operative takedown and extra-anatomic bypass

Answer 452

- Air Leak > 5 days - Recurrent (even if contra-side) - High risk occupation (scuba, pilot)

Answer 453

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

Answer 454

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)

Answer 455

w/up: 1. doppler U/S: check vasc/urteter mosis, bladder outlet obstruction 2. empiric fluid bolus Causes 1. Immediate: arterial thrombosis- nephrectomy 2. Weeks: lymphocele- open/lap peritoneal window 3. Months: polymovirus (BK)- nephrostomy + reconstruction

Answer 456

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

Answer 457

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

Answer 458

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

Answer 459

-Px: hepatitis, dermitis, GI sxs after stem-cell/marrow trx -Path: DONOR T cells morph into Th cells; target host -Dx: bx -Tx: steroids + IS

Answer 460

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

Answer 461

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

Answer 462

1. Communicating: 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.

Answer 463

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 - Can use tamoxifen if to prevent hormone+ cancers in the future PPx - Surgery can be done for prophylaxis - Can get hormonal therapy - Surveillance w/ MRI or mammo q6m

Answer 464

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

Answer 465

Px: painful/larger w/ periods or pregnancy Dx: - imaging: well-circumcribed; coarse ca+ - bx: fibro-epithileal lesions (if "aggressive" concern for phyllodes) Tx: -can obesrve if: mobile, concordant imaging/bx -resect if: > 3cm, sxs, growth, anxiety, discordance - fibroepithelial lesion that is not further defined should be excised for definitive classification (vs. phylodes)

Answer 466

1T (13w)- mastectomy + SLNBx (radioactive sulfer) +/- chemo at 2T 2-3T- lumpectomy + SLNBx (radioactive sulfer) +/- chemo + post delivery XRT - chemo is safe in 2nd/3rd trimesters. XRT is not - XRT is c/i throughout preg

Answer 467

1. > 5cm 2. 4+ nodes 3. + margin 4. skin involvement **if prefer recon must be delayed or used a tissue expander for immediate recon

Answer 468

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

Answer 469

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

Answer 470

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

Answer 471

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

Answer 472

2,3 DPG Elevated temp Higher paCO2 Acidosis

Answer 473

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

Answer 474

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

Answer 475

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

Answer 476

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 **Bowel prep a/w increased r/o infection

Answer 477

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

Answer 478

Gustatory sweating 2/2 auriculotemporal nerve

Answer 479

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)

Answer 480

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

Answer 481

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

Answer 482

5 mm bites every 5 mm

Answer 483

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

Answer 484

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

Answer 485

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

Answer 486

1. Exogenous steroids 2. ACTH pituitary adenoma 3. Cortisol secreting adrenal adenoma 4. ACC

Answer 487

Cause- AI attack of adrenal cx Labs- hypoNa, hyperK Dx: cosyntropin stim test - cortisol remains low - deceased cortisol and aldo with high ACTH Tx- steroids

Answer 488

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

Answer 489

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

Answer 490

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

Answer 491

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

Answer 492

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

Answer 493

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

Answer 494

Dx - usual CD4 < 50 - PCR is unreliable b/c does not prove end-organ disease (can be falsely negative) - must scope and bx: Cowdry bodies, punched out ulcers Tx: gancylovir - initiate HAART - opthalmic exam to r/o retinitis

Answer 495

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

Answer 496

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)

Answer 497

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

Answer 498

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

Answer 499

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

Answer 500

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

Answer 501

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

Answer 502

1. Median sternotomy: right 2. Left Anterolateral thoracotomy: left subclavian - trap door supraclav incision for distal access

Answer 503

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

Answer 504

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.

Answer 505

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

Answer 506

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

Answer 507

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 (tamoxifen) if intra! - XRT if sensitive area

Answer 508

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

Answer 509

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

Answer 510

1. Idiopathic 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

Answer 511

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

Answer 512

Triple phase CT: 1. Unresctable- distant met, >180 SMA/celiac, any aorta/IVC, unreconstructable pv/smv - EUS/FNA for tissue dx for neoadjuvant 2. Borderline- <180 SMA/celiac - EUS/FNA for tissue dx for neoadjuvant 3. Resectable - dx lap (to confirm resectability) + whipple

Answer 513

Hanley procedure: - Midline drainage incision of deep posterior space (through ano-coccygeal ligament) - Bilateral lateral counter-incisions for ischiorectal space **all external drainage

Answer 514

<30% sphincter- fistulotomy or cutting seton >30% sphincter- draining setons THEN ARAF or LIFT **Crohns patient: px w/ multiple fistulas - avoid fistolotomy. - draining setons. Can try infliximab if active infection has resolved.

Answer 515

G1- bleeding, G2- spontaneous reduce, G3- manual reduce: 1st line: sitz, stool softener, bowel reg, fiber, fluids 2nd line (office): band, sclerotherapy, coagulation - band is most effective - sclerotherapy if on blood thinners G4- can't reduce - surgical HMHD'ectomy

Answer 516

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

Answer 517

Px: intractable pruritis, eczematoid rash Tx: scope (r/o malignancy) - dc topical agents - perianal punch bx + WLE

Answer 518

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) --> no further w/up > 2 cm- formal cancer resection (APR, R hemi-colectomy, cancer resection WITH mesentery)

Answer 519

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

Answer 520

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

Answer 521

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

Answer 522

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

Answer 523

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

Answer 524

Low bile salts Low lecithin High cholestersol

Answer 525

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

Answer 526

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

Answer 527

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

Answer 528

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)

Answer 529

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

Answer 530

1. Cholangioca and HCC: US/MRI/MRCP q6-12m. Annual CA 19-9 2. GB CA: US q6-12m 3. CRC: colonscopy q1-2 years (regardless of UC)

Answer 531

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

Answer 532

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

Answer 533

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

Answer 534

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

Answer 535

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

Answer 536

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

Answer 537

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

Answer 538

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

Answer 539

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

Answer 540

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

Answer 541

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

Answer 542

-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

Answer 543

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

Answer 544

Gram: G+ bacillus, anaerobic Tx: 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. Sepsis/Megacolon: total colectomy (colon > 6 cm, cecum > 10 cm) Virulence: - Toxin A: intestinal necrosis - Toxin B: cytotoxin

Answer 545

Dx- CT first to rule out non-ischemic colitis or infarction; C'scope to confirm - suspect in low flow state, HoTN - CTA can't dx b/c its a microvascular disease Tx- usually supportive; OR if perf, sepsis

Answer 546

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!

Answer 547

-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

Answer 548

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

Answer 549

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

Answer 550

- Inspect. Frozen any lesions. Abort if + - Obtain plane between pancreatic neck and PV. If cannot then abort! - Cattel: expose 3D/4D, SMV/SMA (don't need to take down base of mesentery unless 4D lesion) - Kocherize duo: expose portal triad - Enter lesser sac from gastrocolic lig - Ligate the R gastric and GDA (ensure common hepatic flow first) - Follow R gastroepiploic vein to the SMV - Dissect SMV off inferior border of pancreas - CC'y. Divide CHD. - Antrectomy 2cm past the pylorus - Pancreatectomy at level of PV - Retract the pancreatic head lateral and PV/SMV medial. Ligate venous tributaries to PV/SMV and PDA. - Perform P-J (2-layer, end to side) - Perform H-J (1-layer) distal to P-J - G-J: Billroth 2 (2-layer, end to side) **No definite margin, just R0 resection **LN harvest not necessary

Answer 551

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

Answer 552

Sinus tach is MC S1Q3T3 pattern w/ TWI

Answer 553

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

Answer 554

Lead-time bias is due to early detection. Remember the "d" in lead is for early detection. Length-time bias is due to slow cases being detected more often simply because they are slowly progressing. Remember the "g" in length is for slowly progressing.

Answer 555

Ipsi loss of motor Contra loss of pain/temp

Answer 556

Suspect if GB w/ normal US and EGD Dx- HIDA scan w/ EF < 35% (c/i in pregnancy) Good responders if classic sxs (n/v, RUQ pain, w/ fatty meals)

Answer 557

1. Try ETT placement with a miller blade 2. Needle cric is preferred over open if < 12 - use cuffed tubes for everyone except newborns

Answer 558

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

Answer 559

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

Answer 560

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

Answer 561

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

Answer 562

1. Ilioinguinal: under to EO 2. Ilio-hypogastric: supero/medial to the ilio-inguinal. Between EO and IO 3. GB of GF: runs within the spermatic cord, under the cord structures MC injuries: - Open repair: II, GB of GF - Lap repair: lateral femoral cutaneous, GF

Answer 563

Path: liver failure ➡ sinusoidal portal HTN ➡ increase CO and splanchnic dilation (compensatory)➡ HoTN ➡ turn on RAA system ➡ renal constriction Px: - albumin + vasoconstrictive agents (terlipressin) - TIPS - transplant

Answer 564

1. No N2 disease (stage 1-2) ➡ up-front surgery - lobectomy + MLNDx. Can consider segmentectomy. - can wedge if 2:1 margin ratio 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

Answer 565

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

Answer 566

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 -- RELAXING incision if can't reapproximate

Answer 567

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

Answer 568

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

Answer 569

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

Answer 570

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

Answer 571

1. Papillary/Follicular: lobectomy +/- total + consider ppx L6 for high risk 2. MTC: total + bilateral L6 + T3 post op - RAI is c/i 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

Answer 572

1. Neuro exam: - absent brain stem reflexes - no response to stimuli 2. Apnea test: CO2 > 60 after 10 minutes - if test aborted OR CO < 60 ➡ 3. Confirmatory test: CTA, MRA or nuclear scan

Answer 573

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

Answer 574

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

Answer 575

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

Answer 576

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

Answer 577

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

Answer 578

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

Answer 579

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

Answer 580

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

Answer 581

High r/o gastric ca ppx gastrectomy by age 40

Answer 582

px- failure to pass meconium dx- sweat chloride test, "soap bubble sign" on XR tx- GG then NAC enemas - surgery: ostomy for antegrade enema

Answer 583

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.

Answer 584

1. IgG (small, y-shape) 2. IgA (two y's with joined tails) 3. IgM (pentad)

Answer 585

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...(usually 2-2.5g/kg/day) 2. 30% fat calories 3. 50% carbohydrate calories

Answer 586

Compare PAIRED ordinal variables between two groups when normal distribution cannot be assumed - ex: patient satisfaction before and after an intervention (1-5)

Answer 587

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

Answer 588

Increased HR increased SV Decreased SVR Decreased BP

Answer 589

1. Cause: affarent limb is too long from LOTz 2. Px: acute or chronic - Acute: complete obstruction requiring emergent OR - Chronic: partial obstruction w/ bacterial overgrowth - steatorrhea, B12 deficiency. MC w/ antecolic Bili2 3. Dx: - Acute: abdominal pain with dilated afferent limb in early post op - Chronic: d-xylose breath test 4. Tx - stat OR for REY revision - Chronic: abxs --> REY/shorten the limb

Answer 590

- Pd1 inhibitors: pembrozilumab, nivolumab + Anti-CTLA-4 Ab: ipilmumab - If Braf+: braf inhibitor remains 2nd line

Answer 591

Adults - benign: hamartoma (popcorn calcification) - malignant: sqcc Children - benign: hemangioma - malignant: carcinoid

Answer 592

MC soft tissue tumor in children tx: surgery + SLNBx - consider neo-adjuvent if unresectable - post-op chemo-XRT (very radiosensitive)

Answer 593

1. Aberrant or Dominant left vertebral a. 2. Previous CABG using LIMA (cardiac ischemia) 3. LUE AVF

Answer 594

px- asbestos exposure (shipyard) dx- CT then tissue dx tx- surgery, XRT, systemic chemotherapy, HIPEC

Answer 595

S/p REY GB On the jejunal side Dx- EGD Tx- PPI + sucralfate + stop smoking + avoid NSAID +/- tx H. pylori (if present)

Answer 596

1. Appendix (75%) 2. Mesothelioma (45%)

Answer 597

Low grade: condyloma, AIN1 High grade: AIN2, AIN3 --> should treat All patients: give HPV vaccine - High risk pt: homosexual, HIV, women w/ +pap --> screen with anal cytology or anal pap smears

Answer 598

1. Early (during chole): primary repair (<50%) or H-J (>50%) 2. Late (>72 hours) - define anatomy: MRCP, ERPC, or perc cholangio - control sepsis: abxs, drain collections - establish biliary drainage: PTC (complete transection) or ERCP w/ stent - CTA to r/o vascular injury - delayed repair (6-8 w) when optimized

Answer 599

<1 cm - endoscopic removal 1-2 cm- full thickness excision > 2cm- LAR or APR **Invasion into muscularis/LN involvement- require TME

Answer 600

1. Poor differentiation 2. Vascular/Lymphatic invasion 3. Invasion below the SM 4. < 2mm of surgical margin 5. Base involvement (Haggit 4)

Answer 601

1. CRC- q1-2y c'scope starting at 10 2. Duo/Stomach ca- EGD at 20 or when polyps occur 3. Pap thyroid ca- thyroid U/S q2-5y at 18 4. Desmoid fibromatosis- CTAP if famhx, palpable mass, or sxs

Answer 602

More common with liver mets (liver otherwise inactivates portal vein chemicals) - liver mets more common form small bowel Sxs: flushing, telangiectasia, DRH, bronchospasm Tx: SS analogues (octreotide) - liver resection/embolization for palliative,

Answer 603

-Don't need staging CT CAP for stage 1 or 2 disease - Stage 3+: CBC, LDH, CXR. Consider CT CAP or PET/CT - Stage 4: MRI brain + labs + PET/CT 1. Lungs 2. Small bowel! 3. Colon

Answer 604

High tie: ligate IMA @ origin - risk of hitting the hypogastric plexus - risk of worse perfusion Low tie: tie after the L colic branch takes off (turns into SRA) - theoretically less lymph nodes

Answer 605

Primary anastomosis with DLI (DIVERTI trial) or without DLI (LADIES trial) is safe except if: - HDUS - Acidosis - Acute/Chronic organ failure - I/S - Very old - Poor pre-op sphincter function

Answer 606

Killian's triangle Inferior to pharyngeal constrictor (thyropharygneous) Superior to cricopharyngeous

Answer 607

Lifetime PPI DO NOT convert to a Nissen b/c baseline achalasia

Answer 608

1. Criciopharyngeous 2. AA/Left mainstem bronchus 3. Hiatus

Answer 609

Gastroparesis Delayed gastric emptying Reflux DRH

Answer 610

1. EGD- r/o ca 2. 24h pH- prove reflux 3. Esophagram- r/o motility disorder (DES, eso web) 4. Manometry- r/o other motility disorders

Answer 611

A- xeropthalmia D- hypoca, hypoPh E- hemolytic anemia K- elevated INR **suspect with any fat malabsorption

Answer 612

NAD - "no denominator" (140 - current Na) * TBW TBW = .6 or .5 x (weight in kg) .9NS = 154 mEq per liter 3%NS = 514 mEq per liter replete 6 mEq/24 hours

Answer 613

Squamous cell- PTHrP Adenoca- hypertrophic osteodystrophy Small cell- SIADH

Answer 614

HyperCa, hypocalcuria HyperMg Elevated PTH, normal Ph **gastric bypass can elevate Li levels

Answer 615

Main storage protein of Iron Low in iron def anemia High in anemia of chronic dz (acute phase rxn)

Answer 616

Hypopituitarism (anterior pit) 2/2 gland necrosis from HoTN Usually px w/ hypoNa

Answer 617

1. Chlamydia: doxy 2. Gonorrhea: CTX 3. Trich/BV: flagyl

Answer 618

path- IgG to PF4 dx- 50% PLT fall --> Ser release assay tx- stop SQH. start fondaparinox (active SQH subunit)

Answer 619

Px: 30d after transfusion w/ fevers and pain Path: Ab to minor Ag's --> duffy, kell, Rh Tx: supportive

Answer 620

- CCK: I cell, SI - Gastrin: G cells, antrum and duo - Glucagon: alpha cells, pancreas - Histamine: ECL cells, stomach - Insulin: beta cells, pancreas - Motilin: Mo cells, SI - Secretin: S cells, SI - SS: delta cells, pancreas

Answer 621

1. Mobilize ligaments 2. CC'y and cannulate CD 3. Isolate vessels 4. Ligate HA ➡ PV ➡ HV 5. Divide parenchyma

Answer 622

1. Trx: tumor < 5cm or 3+ tumors < 3cm 2. Resection: early stage, preserved liver function 3. RFA: early-stage BUT poor OR candidate 4. TACE: intermediate stage disease 5. Sorafenib: advanced/Unresectable

Answer 623

2-3 paracentesis/month despite Na restriction and diuretics s/e: - increase r/o encephalopathy - no change in overall survival

Answer 624

kwashiorkor - moderate calorie intake; inadequate protein - large belly marasmus - insufficient calorie and protein - simian face

Answer 625

glucose: Na-dependent secondary active transport galactose: Na-dependent secondary active transport fructose: Na-independent facilitated diffusion

Answer 626

- Dx: EUS/FNA ➡ high CEA, low amylase - Location: body/tail - Distal pancreatectomy (usually can be spleen preserving) - No follow-up is needed (no increase r/o recurrence)

Answer 627

- Hypotension, Bradycardia - Administer slowly: 1 mg per 100 units of insulin - Has partial reversal on lovenox

Answer 628

Px- flesh-colored sarcoma resembling a keloid Histo- spindle cells, +cd34, +Vimentin Tx - imatinib to down-stage if needed - en block resection w/ 2-4 cm margin`

Answer 629

Lesions > 2cm from primary but not beyond regional tumor basin - immunotherapy or BRAF inhibitor - only excise if feasible (few lesions)

Answer 630

1- non-blanching erythema 2- dermis 3- full-thickness subcutaenous 4- muscle, bone fascia

Answer 631

H-J bodies and Target cells - If absent: accessory spleen (usually in hilum or tail of the pancreas) - HJ bodies: nuclear remnant (purple spot in cytoplasm) - Target cells (codocyte): deformed RBC with excess membrane ID: peripheral smear ➡ radionucleotide scan

Answer 632

Gastrosplenic ➡ short gastrics Splenorenal: ➡ splenic artery

Answer 633

causes: 1. H pylori, 2. Nsaid tx: 1. Hydration, NGT, PPI 2. H pylori testing and tx 3. EGD and bx (r/o cancer) 4. Balloon dilation! 5. Definitive operation: vagotomy + antrectomy + B1/2

Answer 634

Px- weight gain, reflux years after a bypass Dx- UGI or CT with oral contrast Tx- observation, resection of the involved segment

Answer 635

1. Laparoscopic-assisted ERCP or ERCP through a gastrostomy 2. Double balloon endoscopy

Answer 636

dx: neurogenic- schwannoma, neurofibroma - CT then MRI. Bx not needed tx: all require resection (even if asx)

Answer 637

- carina/contra trachea involvement is still resectable ➡ sleeve pneumonectomy - SVC involvement can still be resectable - c/i: N3 disease ➡ contralateral mediastinal LN involvement

Answer 638

- 1st branch off the SC - supplies anterior chest wall, breast - bifurcates to form superior epigastric and m/phrenic - gold standard for LAD bypass

Answer 639

1. Abxs 2. Cath drainage: perc (peripheral) or bronch (central) 3. Surgical resections Indications for surgery: - failed medical tx - BP fistula - hemoptysis - suspect cancer - empyema

Answer 640

Px- asx or abnormal PSA Dx: - Transrectal U/S guided bx - 12 samples - Gleason score 1-5

Answer 641

"salt and sex" 21: most common; sex - dx: high 17 levels 17: salt 11: salt and sex

Answer 642

amide- two "i's"; plasma cholinesterase metab; ester- one "i"; liver metab; PABA analogue --> allergic reactions

Answer 643

px: AD; ryanodine receptor type 1 tx: stop drug, dantrolene, Bicarb, cooling, tylenol - dantrolene: ryanodine rec antagonist

Answer 644

1. Early morning salivary or serum cortisol (screen) 2. High dose cosyntropin stim: give 250 ug and measure serum cortisol (positive if < 18) Tx- Resuscitation. IV dex 4 q24 or HC 100 q8

Answer 645

1. Tamoxifen: ER partial agonist - for ER/PR positive and < 70 - 5 years 2. Anastrazole: reversible aromatase inhibitor - for ER/PR positive and > 70 - 5 years 3. Trastuzumab: monoclonal Ab to Her2/Neu rec - for HER2 positive - 2 years

Answer 646

px - bilateral or unilateral tender mass - RF meds: digoxin, thiazides, estrogen - RF illnesses: cirrhosis, renal failure dx- us w/ hypoechoic mass tx: observation; surgery for cosmetic reasons or pain

Answer 647

px: scaly, ulcerated crust of the areola dx: nipple punch bx with clear cytoplasm w/ ovtal nuclei tx: total mastectomy (including NAC) and SNLBx - no breast conservation - total mastectomy even if small underlying lesion

Answer 648

- Symptomatic sinus bradycarias - Mobitz II (2nd degree) AV block - 3rd degree AV block - New L or R BBB **If transcutaneous is unsuccessful ➡ transvenous

Answer 649

- 1d- PR > 200 ➡ no tx if asx - 2d Mobitz 1- progressive PR prolongation, then dropped beat ➡ no tx if asx - 2nd Mobitz 2- random dropped beat. normal PR ➡ atropine and pacing - 3rd degree- A and V pump independently ➡ atropine and pacing

Answer 650

- W/up: labs ➡ RUQ US - Tx: IV abxs ➡ urgent/emergent ERCP **applies for cholangioca as well

Answer 651

MOA- inhibits N/K ATPase. Stimulated PSNS - increased contractility (Ca rushes in) - slows AV node conduction S/e: - fatal arrythmia (especially in the setting of hypoK) - beware of patients with n/v (hypoK met alk)

Answer 652

- Within 4 minutes of CPR for cardiac arrest - Fetus must be at least 24 weeks - Give O, Rh negative blood if needed

Answer 653

- LAD is MC - Primary repair is preferred - If too much loss of length then CABG - Do not ligate

Answer 654

1. EKG +/- trop - negative: can dc - positive: admit to tele 2. Persistant arrhythmia or HoTN ➡ echo

Answer 655

Dx: CT w/ rectal contrast is best Tx: 1. Intraperitoneal ➡ colonic injury 2. Extraperitoneal ➡ primary repair w/ loop sig colostomy - if inaccessible just leave open and divert - avoid presacral drainage or distal washout

Answer 656

- mobilize to see extent of injury - most commonly primary repair - if large along the greater curve can wedge staple - if very extensive can resect and reconstruct w/ REY or Billroth

Answer 657

Right: median sternotomy Left: - anterior thoracotomy: proximal control - supraclavicular incision: distal control - can connect with sternotomy for "trap door"

Answer 658

1. Central: disrupted ADH synthesis ➡ responds to DDAVP 2. Peripheral: genetic or Li induced defective ADH receptor ➡ low salt diet, amiloride

Answer 659

Px: pain and diminished pulse after AV fistula Tx: DRIL (distal revasc interval ligation) - bypass the fistula. Ligate the artery distal to the fistula.

Answer 660

Thrombus is in GSV, SSV 1. AND w/in 3 cm of Saph-fem jxn or saph-pop jxn ➡ therapeutic AC for 3-6 months 2. No near the jxns ➡ prophylactic AC for 45 days 3. Otherwise: surveillance **Superficial femoral vein is a DEEP vein

Answer 661

- RFA or EVLA are 1st line - Indications for surgery instead: high ligation and vein stripping: 1. proximal/dilated and tortuous GSV 2. previous thrombophlebitis 3. vein too large (RFA > 15mm, EVLA > 8 mm) - lower extremity telangiectasias, reticular veins, and small varicose veins ➡ sclerotherapy recommended

Answer 662

< 3 cm ➡ observe > 3 cm ➡ endovasc thrombin > 3 cm + infection or neuro def ➡ OR

Answer 663

- Dosal: superfial peroneal n. - 1st webspace: deep peroneal n. (is deeper) - Medial: saphenous n. - Lateral: sural n.

Answer 664

1. superficial mucosa (white) 2. deep mucosa (dark) 3. SM (white) 4. MP (dark) 5. Adventitia (white)

Answer 665

- HDS: perform a cancer resection - HDUS: resect and divert - Scope in 3-6 months to r/o synch lesion **Divert if unstable, contaminated, poor nutrition, etc.

Answer 666

- Cremasterics (vessels, muscle, lymphatics) - GB of GF - Testicular artery and veins - Vas deferens - Processus vaginalis **round ligament in women

Answer 667

AA ➡ 1. LOX ➡ leukotrienes ➡ bronchoconstriction, PLT aggregation, capillary permeability 2. COX ➡ - prostaglandins ➡ vasodilation - thromboxanes ➡ vasoconstriction

Answer 668

1- RCT or SR of RCT 2- Cohort study or SR of cohort studies 3- Case-control or SR of case-control 4- Case series 5- Expert opinion

Answer 669

- neoadjuvant if: hepatic v/portal v. involvement, extrahepatic, multifocal, tumor rupture, caudate involved, LNs, distance mets - otherwise upfront surgery if resectable - transplant if 4+ section involved/unresectable after chemo

Answer 670

Vertebral Anal Cardiac TE fistula Renal, Radial bone Limb defects

Answer 671

px: infant with bilirubinemia dx: HIDA with no contrast in the duo ➡ perc bx tx- REY-HJ vs. Kasai ➡ transplant if unsuccessful

Answer 672

Tyrosine ➡ L-dopa ➡ dopamine ➡ NE ➡ PNMT ➡ Epi

Answer 673

rf's- high IS, pulse steroids px- hematuria, nephritis after kidney trx tx- decrease IS, cysto/possible stent

Answer 674

- stop smoking 4-6 weeks b4 surgery - mechanical and abx prep before elective colectomy - perioperative glucose < 200 - clippers > razors - abxs 1h b4 incision; 2h for vanc or FQ - normothermia - closing tray for colorectal cases

Answer 675

MOA- inhibit 30s; bacteriocidal Coverage- GNRS, pseudomonas s/e- nephrotoxic, ototoxic

Answer 676

1. PTU or methimazole 2. Steroids **No alpha/beta blockade

Answer 677

- MutY: 10 R sided adenomas ➡ MUTYH - FAP: 100s of adenomas + desmoid ➡ APC - Peutz-Jeghers: hamartomas + skin lesions ➡ STK11 - Juvenile polyposis: hamartomoas + telangiectasias ➡ SMAD4 - Lynch/HNPCC: L sided adenomas ➡ MLH1, MSH2, MSH6, PMS2 - Cowden: hamartomas + breast/thyroid ➡ PTEN

Answer 678

Screening scopes 8 years after onset - Invisible HGD: repeat w/ high-def endoscopy q3-6m ➡ total proctocolectomy w/ IPAA - Visible HGD: 1. Resectable: endoscopic resection + serial scopes 2. Not-presectable: TC w/ IPAA - for Crohn’s can do segmental resection

Answer 679

Indications for surgery of brain bleeds: 1. Epidural: > 1.5 cm or > 5 mm shift 2. SDH: > 1 cm or > 5 mm shift 3. Intra-parenchymal: > 5mm shift

Answer 680

1. Abxs x 7-10 days 2. Perc drain if peripheral. Bronchoscopic if central. 3. Surgery if: B/P fistula, empyema, bleeding

Answer 681

- cant be intrahepatic (prognosis is too poor) - must be unresectable, perihilar, < 3cm - no distant mets

Answer 682

- Adults risk starts at < 180 cm - Infants risk starts at < 75 cm

Answer 683

- TAC w/ end ileostomy - Keep the ileocolic intact for future J pouch - Keep the SRA intact for good staple line flow - Divide rectum above the posterior peritoneal reflection at level of sacral promontory

Answer 684

A- CD stump leak: - Intraop: clip/ligate and leave drain - Postop: perc drain + ERCP plasty/stent B- Aberrant right hepatic ligation: - Only if sxs ➡ REYHJ C- Transect aberrant right hepatic: - Only if sxs ➡ REYHJ 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

Answer 685

1. Prior radiation 2. Radiation therapy contraindicated by pregnancy 3. Inflammatory breast cancer 4. Diffuse suspicious or malignant-appearing microcalcifications 5. Widespread disease that is multicentric 6. A positive pathologic margin after repeat re-excision MRM = removal of breast parenchyma, NAC, skin, AND level 1-2 nodes

Answer 686

CRAP GPs spend all day on SICKFACES.com. Inducers: Carbemazepines Rifampicin Alcohol Phenytoin Griseofulvin Phenobarbitone Sulphonylureas Inhibitors: Sodium valproate Isoniazid Cimetidine Ketoconazole Fluconazole Alcohol & Grapefruit juice Chloramphenicol Erythromycin Sulfonamides Ciprofloxacin Omeprazole Metronidazole

Answer 687

- double balloon, single balloon or spiral ERCP - percutaneous endoscopic ERCP (through remnant) - laparoscopic assisted ERCP (through remnant) - laparoscopic or open CBD exploration (transcystic or choledochotomy)

Answer 688

1. Superficial veins: abxs +/- surgery - surgery if: purulence, infection beyond vessel wall, failure of abxs 2. Deep veins: abxs + AC x 2-3 weeks ➡ thrombectomy and vein excision

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