ABSITE deck Flashcards
(449 cards)
1
Q
How do you treat chylothorax?
A
IF postop: conservative mgmt + thoracic duct ligation (usualy thorascopically)
IF lymphoma-related: conservative mgmt (NPO, TPN) + drainage + tx of underlying cause (chemotherapy)
First line therapy fails: thoracoscopic talc pleurodesis, thoracic duct ligation or pleuroperitoneal shunting
2
Q
What is dermatofibrosarcoma?
A
Soft tissue tumor arising from fibroblasts
Spindle like cells, CD34 +
Need adequate WLE
+microscopic lateral extension of tumor cells … so there’s high rate of local recurrence
3
Q
Primary cancer that is most likely to mets to adrenal gland?
A
Lung cancer
4
Q
Tx for biliary atresia?
A
Kasai procedure (Roux en Y hepatic portoenterostomy) - remove extrahepatic biliary system, and connect portal system to small intestine
5
Q
What is max size for ligasure / bipolar cautery?
A
Less than and equal to 7mm
6
Q
What separates the anterior and posterior liver?
A
Right portal vein
7
Q
Describe Familial Hypercalcemic Hypocalciuria
A
auto dom
Increased Ca resorption in kidney 2/2 defective PTH receptor
Normal PTH levels, mild hyperCa, low urine Ca
8
Q
VIPoma (WDHA)
A
watery diarrhea, hypoK, achorhydria or acidosis
Usually distal pancreas
9
Q
Describe where the following are located in the pancreas:
- VIPoma
- SSoma
- insulinoma
A
- distal pancreas
- head of pancreas
- evenly distributed throughout
10
Q
Does spironolactone cause metabolic acidosis or alkalosis?
A
hyperchloremic (non AG) metabolic acidosis
11
Q
How do you treat metabolic alkalosis caused by diuretics?
A
Metabolic alkalosis due to diuretics use can be abolished by fluid replacement using normal saline, unless the patient is fluid overloaded and the use of diuretics is ongoing. Under the latter circumstances potassium sparing diuretic can be used such as acetazolamide to offset the hypokalemic and alkalotic effects of loop diuretics.
12
Q
How do you treat
1) chloride resistant metab alk
2) chloride sensitive metab alk
A
1) treat underlying cause
2) fluid replacement (NS)
13
Q
What is the primary treatment strategy for anal melanoma?
A
Surgical excision.
APR confers no survival benefit vs WLE
14
Q
Most common benign neoplasm of spleen?
A
Hemangioma
15
Q
Largest risk factor for post-operative cardiac complications?
A
Active CHF
16
Q
Tensile strength in a wound depends on __
A
Covalent collagen cross-linking (of lysine residues)
17
Q
How does scurvy (vit C deficiency) affect wound healing
A
proline hydroxylation is inhibited –> unstable triple helices
gradual loss of preexisting normal collagen, which leads to fragile blood vessels and loose teeth
18
Q
Inflammatory phase of wound healing marked by ?
A
increased vascular permeability, migration of cells into the wound by chemotaxis, secretion of cytokines and growth factors into the wound, and activation of the migrating cells
19
Q
Most imp factor in wound healing of …
open incision?
closed incision?
A
- epithelial integrity (granulation tissue)
- tensile strength (collagen cross linking)
20
Q
What is the defect in osteogenesis imperfecta?
A
type I collagen
21
Q
What is the defect in Marfan’s syndrome?
A
fibrillin
22
Q
___ is seen in 50% of patients after congenital diaphragmatic hernia repair.
A
Chronic pulmonary disease
23
Q
What is the Mattox maneuver?
A
Left medical visceral rotation
left colon, kidney, spleen, tail of pancreas, fundus of stomach —> all moved to midline
24
Q
What structures can you access with the Mattox maneuver?
A
Suprarenal aorta, celiac axis, proximal superior mesenteric artery, or proximal renal artery
25
What is the Cattell-Braasch maneuver?
Right medical visceral rotation
26
What does the Cattell-Braasch maneuver expose?
Retrohepatic vena cava
27
What are the 2 types of esophageal diverticula?
Traction (true, mid esoph)
| Pulsion (ie Zenker, distal esoph)
28
Side effects of burn meds:
- silver sulfadiazine
- silver nitrite
- mafenide acetate
- neomycin/baci/poly
- polymyxin B
- transient neutropenia
- hypoNa; metHgb-emia
- metab acidosis
- nephrotoxicity
- nephrotoxicity
29
What kind of immunosuppresive agent is infliximab?
TNF inhibitor
30
Describe the Strasberg classification of injuries.
A: bile leak from cystic duct stump
B: ligation of aberrant R hepatic duct
C: transection of aberrant R hepatic duct
D: lateral injury to major duct
E: parallels Bismuth classification of biliary strictures; complex
31
Refeeding syndrome - which 3 electrolytes are down?
Phos, K, Mg
K + Mg being low --> cardiac problems
Phos low --> muscle weakness, encephalopathy
32
Most common metastatic tumor to small bowel via hematogenous spread?
Melanoma
33
Most common indication for parotidectomy?
neoplasm
34
What does the leg look like in a posterior hip dislocation? What can be injured?
Flexed, shortened, internally rotated, adducted
Sciatic, femoral, or obturator NERVES
35
```
Injuries associated with ...
Midshaft humeral fracture
Supracondylar humerus fracture
Distal radius fracture
Anterior shoulder dislocation
Posterior shoulder dislocation
Posterior hip dislocation
Posterior knee dislocation
Pelvic fractures
```
Midshaft humeral fx - radial nerve
Supracondylar humerus fx - Brachial artery (may lead to Volkmann's ischemic contracture) or median nerve
Distal radius fx - Median nerve compression
Anterior shoulder disloc - axillary nerve
Posterior shoulder disloc - axillary artery
Posterior hip disloc - Sciatic nerve (peroneal division)
Posterior knee disloc - Popliteal artery
Pelvic fx - bladder, obturator artery
36
What are indications for intervention on depressed skull fx?
- open wound with evidence of dural penetration
- open wound with significant complications (intracranial hematoma
- severe wound infection
- frontal sinus involvement)
- inner and outer table violation or overlap
- skull depression greater than 1 cm
37
How does pneumocystis carinii usually present?
- in lungs of healthy ppl; can cause a fatal PNA in immunocompromised
- several weeks of dry cough, difficulty taking a breath, fever with sweats
- exam: tachypnea, tachy, fine crackles
- can be disseminated, esp in lymph tissue/organs
- ppx: Bactrim
38
What are major causes of vit K deficiency?
- Inadequate dietary intake (including pts not supplemented during parenteral feeding)
- Insufficient adsorption (pts with biliary tract obstruction)
- Loss of stroage sites as result of hepatic dysfunction
*fat emulsions during TPN allows vit K to be absorbed
39
SBP - how many orgs, which gram type?
Most cases of SBP can be linked to one organism on culture of ascitic fluid. If the ascitic fluid grows multiple organisms then a diagnosis other than SBP should be sought, in particular, perforated viscus must be ruled out.
40
Which types of cirrhotics deserve ppx SBP abx?
Those with:
- GI hemorrhage
- low protein ascites (<15)
- history of SBP
41
What is a LOW vs HIGH rectovaginal fistula?
Low: perianal repair
High: transabdominal repair
42
What is treatment for low, simple rectovag fistula?
Wait 3-6 months, see if closes (also, inflammation subsides in case of need for surgical repair)
Still present, then: Endorectal flap advancement
43
What is management of high grade dysplasia in a person with barrett's?
Initial mgmt: PPI + serial endoscopies
Low/mod grade dysplasia: endoscopies q3-6 months
High grade dysplasia: ablation
44
Describe treatment for achalasia
Heller myotomy - longitudinal myotomy to submucosa, extend 5-6cm on esophagua, 2cm onto stomach
*Also do a partial fundal wrap (not nissen)
45
Pressor of choice for septic shock?
1st: neo
2nd: vasopressin
46
Most common and 2nd most common non-iatrogenic causes of esophageal perforation?
1. Boerhaave syndrome
| 2. Foreign body ingestion
47
MCC esoph perf?
endoscopic instrumentation
48
What is short segment disease?
nerve cells missing from the last segment of the lg intestine - most common type, present in 80% of ppl with Hirschsprung's disease
- most common among breast fed infants --> present with constipation after weaning from breast feeding
49
Intestinal malrotation
chronic (intermittent) abd pain, intermittent epi's of emesis, early satiety, wt loss, failure to thrive
*acute onset of bilious emesis in a particularly somnolent or lethargic newborn is an ominous sign
50
Treatment for spontaneous bacterial peritonitis?
3rd gen cephalosporin (Cefotaxime)
| IV albumin decreases in-hospital mortality (1.5 g/kg given within 6 hours and repeated as a 1.0 g/kg dose on day 3)
51
What incision, to obtain proximal control of the inominate artery?
median sternotomy
52
A __ __ is used for injuries to the ascending aorta, aortic arch, innominate, right subclavian, and left common carotid arteries.
median sternotomy
53
Stage __, ___, and ___ classified as "low risk" undergo surgery alone as treatment.
I, IIA, and IIB
54
What is amrinone?
```
phosphodisterase inhibitor (block breakdown of cAMP; increase in Ca uptake by SR in heart) --> increase contractility
vasodilator --> relaxation of vascular smooth muscle
```
55
What characterizes toxic megacolon?
Total or segmental nonobstructive colonic dilatation
| + Systemic toxicity
56
Gold standard surgical treatment for UC?
Restorative proctocolectomy with ileal pouch anal anastomosis (RPC - IPAA)
57
What is RPC - IPAA
Restorative proctocolectomy with ileal pouch anal anastomosis
rectum + colon removed, pouch made, pouch anal anastomosis
58
MC late post op complication of RPC-IPAA ?
Pouchitis (up to 50%)
SBO (up to 20%)
Others: anastomotic leak, fistula, stricture
59
How does pouchitis present?
Pouchitis is a non-specific inflammation in the pouch that presents with increased stool frequency, urgency, incontinence, abdominal pain, and bleeding.
60
How do you treat phimosis?
Dilation
Dorsal slit circumcision (temporizing measure)
Complete circumcision
61
MOST common benign tumor of the lung?
hamartoma
| slow growing, solitary pulm nodule with popcorn calcifications; M>F
62
Mesenteric cysts - treatment?
Usually in small bowel mesentery
| Enucleation (resect) >>> unroofing (high rec rate)
63
MC forms of thoracic outlet syndrome?
1. Nerve compression
2. Paget Schroetter (venous)
3. Arterial
64
How do you treat Paget Schroetter disease?
Iv heparin and thrombolysis with catheter directed thrombolysis (if <2 wks of sx)
+ definitive surgery: "thoracic outlet decompression" (remove 1st rib, cervical rib, or scalene) +/- venoplasty
65
Signs of a tracheobronchial injury?
- persistent pneumothorax, despite a well-placed chest tube
| - continuous air leak thru-out the entire respiratory cycle
66
Pancreatic lesions:
serous cystic
mucinous cystic
IPMN
- serous cystic: usually benign
- mucinous cystic: high risk for malignancy, resect regardless of size
- IPMN (papillary): main duct: resect based on risk of malignancy
branched duct: resect if >3cm, symptomatic, or assoc with radiographic (mural nodules) or cytological signs concerning for malignancy .... o/w follow w/ serial imaging
67
What's the side effect of bleomycin?
Interstitial pulmonary fibrosis
68
Light's criteria
1) pleural fluid–to–serum protein ratio > 0.5
2) A pleural fluid–to–serum LDH ratio > 0.6
3) A pleural fluid LDH [ ] > 2/3 upper limit of serum reference range.
69
Treatment of type II choledochal cysts
Excision of cyst + primary closure
70
Types of choledochal cysts
Type I: Most common (80-90%); involving saccular or fusiform dilatation of a portion or entire common bile duct (CBD) with normal intrahepatic duct.
Type II: Isolated diverticulum protruding from the CBD.
Type III or Choledochocele: Arise from dilatation of duodenal portion of CBD or where pancreatic duct meets.
Type IVa: Characterized by multiple dilatations of the intrahepatic and extrahepatic biliary tree.
Type IVb: Multiple dilatations involving only the extrahepatic bile ducts.
Type V or Caroli's disease: Cystic dilatation of intra hepatic biliary ducts
71
Treatment of type I choledochal cysts
Primary cyst excision with Roux-en-Y hepaticojejunostomy reconstruction
72
Treatment of type III choledochal cysts
transduodenal approach with either marsupialization or excision of the cyst
73
Explain mechanism for malignant hyperthermia
auto dom abnormality with Ca regulation in skeletal muscle --> inhaled anesthetic (-flurane) / depolarizing muscle relaxants (succ, sux) --> rise in myoplasmic Ca --> abnormal release Ca --> rigidity
74
What is protein C?
- vit K dependent factor (so it is inhibited by warfarin)
- deactivates factors Va and VIIIa into its inactive forms V and VIII by proteolysis ..... basically inhibits the function of Factors V and VIII and also degrades fibrinogen
- short half life ... leading to interval prothrombic state in pts who are started on coumadin
75
Is Tc99m (used for breast SNB) safe in pregnancy?
yes
76
What is peterson's defect?
mesenteric defect between mesenteries of transverse colon + roux/alimentary limb, at the level of the jejunojejunostomy
77
What is the alimentary limb? (aka Roux limb)
limb that food passes through
78
General tx of rectal cancer?
Stage 1/2
Stage 3+
Stage 1/2: surgery + adjuvant
Stage 3+: neoadjuvant chemorad + surgery
Stage 3 specifically: neoadj chemoRAD ... surgery ... adjuvant chemo only (no radiation)
*if radiation given preop, not generally given postop
79
How many lymph nodes/margins do you want for a true oncologic resection, for colon CA?
12 negative LN
| 2-5 cm margins
80
What does Mycophenolate Mofetil inhibit?
purine metabolism
81
What does recurrent acute thyroiditis make you think?
fistulous communication with the pyriform sinus (would need surgery)
82
What are 2 things assoc with the thyroid that would make you more suspicious for malignancy?
nodules
| rapid growth
83
Absolute contraindications to liver transplant?
Inability to withstand the procedure (usually for cardiac/pulm reasons)
Recent ICH (during sx, coagulopathy + alterations in BP)
Untx'ed extrahepatic malignancy
84
Cell findings of acute vs chronic rejection?
acute (days-months): lymphocytic infiltrate, apoptosis of graft cells
chronic: atrophy, fibrosis, arteriosclerosis
85
Most common site of perf from C scope?
sigmoid colon
Perforations follow 3 principal mechanisms: mechanical perforation by the endoscope’s tip, barotrauma from overinsufflation, and therapeutic procedures
86
What % of phyllodes tumors are malignant, and how do they spread?
10%
| hematogenous
87
Review the hyperSn reactions.
I: IgE (anaphylaxis)
II: Ab mediated - IgG, IgM (Goodpasture which is anti-GM BM ds (lung/kidneys), AHA)
III: deposition of Ab-Ag complexes
IV: cell mediated (dermatitis, PPD)
88
What is fulminant hepatic failure?
progression from good health to liver failure with hepatic encephalopathy within 8 weeks
89
Hx roux en Y gastric bypass ... epigastric pain. Thoughts?
marginal ulcer
| upper endoscopy
90
Where does the abdominal esophagus lymph drain?
cardiac + celiac nodes --> cisterna chyli (dilated collecting sac that forms the thoracic duct)
91
What kind of incision would you make for a loop colostomy reversal?
peristomal circumferential incision
92
What is the primary fuel of neoplastic cells?
glutamine
| primary fuel for rapidly dividing cells
93
nodular lymphoid hyperplasia -
| what is it associated with?
immunosuppressive states (if seen on C scope, consider HIV testing)
94
nodular lymphoid hyperplasia is not assoc w/ malignancy if found in __ but IS assoc w/ lymphoma if found in __.
```
colon
small intestine (assoc with lymphoma)
```
95
Where can the splenic artery be ID'ed for quick ligation?
superior to pancreas
96
Where can the splenic vein be ID'ed for quick ligation?
within or posterior to pancreas
97
How to treat incontinence following obstetric trauma from spontaneous vag delivery?
wrap around sphincteroplasty (ID sphincter, mobilize approximate w/o tension)
98
What can an abscess in the ischiorectal space do?
track around rectum to form horseshoe abscess
99
What is tx for metastatic prostate cancer?
External beam radiation + hormonal therapy
100
Difference between hematoma and pseudoaneurysm?
Pseudoaneurysm has active arterial flow on arterial duplex
| pain at puncture site, with pulsatile mass
101
How to treat pseudoaneurysm?
If small: ultrasound guided compression x10 min (can also do longer times if flow remains)
Other: thrombin injection into sac under US guidance
BUT if skin tense + threatened! surgical repair + decompression (concern for skin necrosis)
102
What is surgical repair of pseudoaneurysm when skin is tense and threatened?
prox and distal control, then direct suture repair of arteriotomy site (include arterial wall in repair) ... hematoma evacuated after
103
What is the cori cycle?
Recycling of lactate (from skeletal muscle / RBCs) to glucose in the liver
104
Precursors of gluconeogenesis?
lactate, pyruvate, glycerol, and amino acids
5-7 days of starvation --> primarily alanine, not all the above -> -_-
105
For sarcomas that have close excision margins, post-operative ___ (not ___) has been shown to decrease local recurrence.
radiation
| not chemo
106
Indications for neoadjuvant chemo in pts with sarcoma?
Rhabdomyosarcoma
Ewing sarcoma
High-grade tumors >10 cm in size
Tumors 5-10 cm with chemosensitive histology
107
Mainstay of soft tissue sarcoma treatment?
surgical resection
108
When using an ICP monitor in a brain injury patient, what is goal CPP?
60mmHg
109
Chronic radiation injury takes __ months, and is secondary to ___.
6-12 months
obliterative arteritis
(endothelial thickening leads to nonhealing ulcerations, telangiectasias)
110
What are 2 main mechanisms that radiation therapy causes damage?
Direct damage to DNA
| Free oxygen radicals
111
What do you call B cell proliferation after immunosuppression for organ transplant?
Post transplant lymphoproliferative disorder
112
```
TRUE OR FALSE
Actinic keratosis (or solar keratosis) is a precursor to SCC.
```
true
113
When fulgurating and excising anal condyloma, it is essential to also remove which skin layer?
epidermis
| HPV lives and replicates in the epidermal layer
114
Most important factor indicating malignant potential and poor prognosis in GISTs?
high mitotic index
115
Series of events, with skin graft healing?
Imbibition (diffusion of nutrients)
Inosculation (donor and recipient capillary beds come into alignment with each other)
Revascularization (after ~ 5 days; when art and venous inflow can be detected)
116
MOST common genetic alteration in pancreatic CA?
K-ras
| Activating point mutations
117
In total proctocolectomy with IPAA (J pouch under tension):
Superficial incision of the mesentery along the course of the __ and mobilization of the small bowel mesentery up to and anterior to the __ can reduce tension on the anastomosis.
SMA
| duodenum
118
Longstanding neck mass that enlarges rapidly ... is large and fixed ...
Anaplastic thyroid cancer
119
in LAGB:
| The band is placed along a space created __ to the proximal __ through the avascular portion of the __ ligament
posterior
stomach
gastrohepatic
120
In lap assisted gastric banding:
| Is band slippage a surgical emergency?
yes
| herniated stomach must be manually reduced and band must be re-secured
121
What is primary contraction?
degree to which a graft shrinks in surface area after harvesting and before grafting
122
What is secondary contraction?
degree to which a graft shrinks during healing
123
Upsides and downsides to STSG?
| split thickness skin graft
Upsides: less primary contraction, better chance of survival, can be meshed
Downsides: more secondary contraction, poor pigmentation
124
Advantages of Duhamel procedure over Swenson or Soave?
Easier, safer
Less pelvic dissection
Large anastomosis (less risk of anastomotic stricture)
125
Swenson procedure
Remove entire aganglionic colon
| End to end anastomosis of normal colon to low rectum
126
Soave procedure
Remove mucosa and submucosa of aganglionic portion, and pull ganglionic colon through aganglionic muscular cuff
- preserve internal sphincter integrity
- avoid injury to pelvic nerves
127
Duhamel procedure
Bring normal colon retro-rectal (bloodless plane)
Resect aganglionic colon up to rectum
End to side anastomosis
128
"Soap bubble" or "paintbrush sign" - pathognomonic for ?
villous adenoma
129
Side effect of pancuronium?
tachycardia
| contraindic in CAD pts
130
Where do you inject contrast for intra op cholangiogram?
infundibulum of GB
131
Liver makes all of the coagulation factors except Factor __ ?
VIII (produced by endothelium)
132
Vitamin K is a cofactor for Factors __ and proteins ___?
factors II, VII, IX, and X
| proteins C and S
133
Common reason for urinary retention after hemorrhoidectomy?
spasms of the pelvic floor musculature
epidural or spinal anesthesia
pain
excessive IVF
134
Efferent loop syndrome -
| how is it causes + how does it present?
consists of gastric outlet obstruction caused by kinking of the efferent jejunal limb, often because of herniation of the limb posterior to the anastomosis
**usually w/in 1st post-op month
135
Efferent loop syndrome -
| treatment??
conversion to a Billroth I anastomosis, conversion to a Roux-en-Y anastomosis, or performing an enteroenterostomy from the afferent limb to the efferent limb (Braun anastomosis)
136
What is GIST tumor prognosis based on?
size + mitotic index
137
Tumor lysis syndrome -
| lyte abnormalties?
hyper PUK (phos, uricemia, K)
hypoCa
ARF
*aggressive IV hydration
138
MC error during truncal (complete) vagotomy?
Failure to ID posterior vagus nerve
139
Tx of benign/borderline/malignant phyllodes tumor?
WLE w/o axillary staging
140
Tx for inflammatory breast cancer?
neoadjuvant chemo, modified radical, radiation
141
Last line of therapy for stress gastritis?
total gastrectomy
142
What is order of testing for pheo?
plasma free metanephrines (Sn, not Sp)
If + --> 24 hr urine metanephrines
CT >> MRI for localizing
MIBG good for localizing in setting of multifocal ds
143
Most common collagen type in body?
Type I
144
What is Cushing's disease?
| Treatment?
ACTH-secreting pit adenoma
| Transsphenoidal resection of the pituitary --> reoperation or radiation for residual disease (cortisol still high)
145
3 methods for anastomosis in liver transplant
Bicaval -- clamp supra/infrahepatic IVC
Piggyback -- 1 vena caval anastomosis
Cavocavostomy (side to side caval technique)
146
Advantages of cavocavostomy (side to side caval technique) in liver transplant ?
shorter vena caval clamping time
minimal or no changes in recipient's HD's as the vena caval clamp is placed longitudinally, only occluding the anterior third of the vena cava
lower incidence of caval stenosis as cavoplasty is performed
lower risk for hepatic vein outflow complic's due to longer anastomoses
147
Collagen evolution in wound healing?
Type III collagen synthesis begins within 10 hours, predominates early till day 5 ... replaced by Type I at day 7 ... collagen deposition peaks at week 3, which is also when collagen degradation occurs
148
Most imp types of collagen for wound healing?
Types I and III
149
What is messed up in osteogenesis imperfecta?
Type I collagen
150
Acrodermatitis enteropathica - inability to absorb __?
zinc
151
Which mab can you use to treat PTLD ?
rituximab (anti CD20)
152
Most common site of small bowel lymphoma?
TI
| poor prognosis
153
Treatment for popliteal artery aneurysms?
If >2cm: bypass + ligate the aneurysm
154
What is "sniffing position" ?
sit upright
| atlanto-occipital extension with head elevation of 3-7 cm
155
Most common presentation of extrahepatic lower duct cholangiocarcinoma ?
painless jaundice
[[ hard to differentiate from pancreatic CA - "hx of PSC" ]]
Axial imaging reveals dilation of the intrahepatic bile ducts, the gallbladder, and the extrahepatic bile ducts down to the level of the pancreatic head, where the dilatation terminates abruptly.
156
What is a contraindication to meperidine?
Significant hepatic or renal impairment
157
How do you locate the SMA?
cephalad movement of transverse colon
| near ligament of treitz
158
Surgical tx for SMA embolus?
transverse arteriotomy with embolectomy via Fogarty balloon
159
What is pharmacokinetics?
study of what happens to drug in the body
| what body does to drug
160
What is pharmacodynamics?
study of what the drug does to body
161
In questions that describe early post-op complications after "right upper lobectomy", think about ___.
acute lobar torsion
162
Pt w difficulty breathing after starting TPN
Refeeding syndrome
Phos deficiency ... worsened by surge of insulin where body uses carbs (instead of fat) which drives phos intracellularly
Inability to convert ADP --> ATP
Tx: Prevent! slow feeding rate + replete lytes (Mg, K, Ph)
163
At BMI __, benefit from preop weight loss before hernia repair
>40
164
Tx for inflammatory breast cancer?
1. Neoadjuvant chemo
2. Modified radical mastectomy (Level 1+2 axillary LN, leave pec major)
3. Radiation
165
Initial medical therapy for cirrhosis?
Negative sodium balance
| Combination furosemide + spironolactone together
166
Criteria for RRT (renal replacement therapy)
(1) Anuria (no urine output for ≥ 6 hr)
(2) Oliguria (urine output < 200 ml/12 hr)
(3) Serum urea concentration > 28 mmol/L or BUN > 80 mg/dl Serum creatinine concentration > 3 mg/dl (265 µmol/L)
(4) Serum potassium concentration ≥ 6.5 mEq/L or rapidly rising
(5) Pulmonary edema unresponsive to diuretics
(6) Uncompensated refractory metabolic acidosis (pH < 7.1)
(7) Any uremic complication (encephalopathy, myopathy, neuropathy, or pericarditis)
(8) Temperature ≥ 40° C (104° F)
(9) Overdose with a dialyzable toxin (e.g., lithium or salicylates)
167
What level serum albumin is a risk factor for anastomotic leak after colonic surgery?
<3.5
168
Risk factors for anastomotic leak?
- poor vascular supply
- tension on the suture line
- septic environment
- location in GI tract (highest leak is found in anastomoses in the distal rectum, about 6-8 cm from the anal verge)
- technical aspects (e.g., ensuring sutures and staplers include all layers and the entire circumference)
- Crohn's disease
169
Solitary rectal ulcer syndrome
sx: bleeding, mucus, pain, difficulty passing stool
conservative tx first
should biopsy
ant rectal wall, just above anorectal ring
result of chronic inflamm or trauma
170
How does stress cause hyperglycemia and insulin resistance?
(As seen in post-op and post-trauma pts)
- hepatic glucose production
- inhibition of insulin secretion
- decrease in glucose uptake.
171
What are normal fibrinogen levels?
200-400
172
MCC bacterial hepatic abscesses?
Hepatobiliary malignancies and biliary tree instrumentation
173
MC pt popul for fungal hepatic abscesses?
pts with heme malignancies recovering from chemotherapy induced neutropenia
174
Most common type of renal stone?
calcium oxalate
175
Ranson’s criteria ?
On admission
After 48 hours
```
Age >55
WBC>16
Glu >200
AST>250
LFH>350
```
```
After 48 hr:
Hct drop by 10%
BUN rise by 5
Ca<8
PaO2<60
Base deficit >4
Fluid sequestration >6 L
```
176
Insulinoma - tx?
<2cm: enucleate
>2cm: formal resection
metastatic disease: 5FU, streptozocin; ostreotide
diazoxide for sx
177
Gastrinoma - tx?
50% malignant, 50% multiple
75% spontaneous, 25% MEN-1
<2cm: enucleation
>2cm: formal resection
malignant disease: excise suspicious nodes
cannot find tumor: duodenostomy & look inside duodenum
duo tumor: resect w/ primary closure; may need Whipple if extensive
178
Glucagonoma - sx + location?
4D's (diabetes, dermatitis, DVT, depression)
| distal pancreas
179
Somatostatinoma - tx?
very rare
usually in head of pancreas
resect + cholecystectomy
180
Nerve most injured in OPEN vs LAP inguinal hernia repair?
OPEN: ilioinguinal (root of penis, medial thigh), iliohypogastric (sensory: lat gluteal + lower RA // motor: internal/TA muscle)
LAP: gf (cremaster muscle, upper scrotum), lat fem cutaneous (sensory: lat thigh)
181
In what order should quadrants be explored?
inframesocolic including pelvis (bowel from Lig of Treitz --> rectum + pelvic organs)
Supramesocolic region (R to L: liver/GB/R kidney .. stomach/duo .. spleen/L kidney)
RP
Lesser sac (pancreatic, posterior stomach)
182
Vascular trauma - ideal conduit for below knee injuries that need repair?
HDS: c/l greater saphenous vein
HD unstable: temp intravascular shunt + delayed repair
If no adequate vein: can use PTFE (not best for below knee)
183
Left hemicolectomy - steps
Mobilize white line of toldt
Mobilize spleen (including pancreaticocolic and gastrocolic ligament)
Ligate & divide IMV, IMA.
184
Reasons to bridge a/c ...
significant bleeding risk for which an INR <1.5 is considered essential, and patients who have a mechanical aortic valve plus either:
- an additional thromboembolic risk factor (afib, previous thromboembolism, hypercoagulable condition, LVEF <30%, or >1 mechanical valve)
- an older generation mechanical aortic valve
- or a mechanical mitral or tricuspid valve
185
Default surrogate decision makers of incapacitated pts are ___ - appointed
physician
186
Differential for liver lesions + tx!
```
Pyogenic liver abscess (E coli, Klebsiella): drainage + abx
Amebic abscess (Mexcio; E histolytica; RLL): Flagyl ... aspiration ONLY if refractory ... surgery ONLY if free rupture
Hydatid cyst (Echinococcus; sheep/dogs; RLL): albendazole + surgical removal in 2 wks (can inject cyst to kill the suckers)
```
187
What causes the following w/ blood transfusions:
- fever
- anaphylaxis
- urticaria
- TRALI
- cytokines from donor leukocytes
- recipient Ab to donor IgA
- recipient Ab to donor plasma proteins
- donor Ab to recipient WBCs
188
What order do you address potential diseases in ED thoracotomy?
After thoracotomy, reversible causes for cardiac arrest must be addressed in the following order:
- release of pericardial tamponade
- control of intrathoracic or cardiac hemorrhage
- open cardiac massage
- occlusion of descending aorta
- evacuation of bronchovenous air
189
Proximal fistulas tend to be high in ___ and result in metabolic ___.
bicarbonate
| metabolic acidosis
190
Steps of a hepatectomy?
1. Cholecystectomy, cannulate cystic duct for IOC (to detect bile leakage after resection)
2. Ligate hepatic artery
(left PV last structure to be divided)
191
Mgmt of BCVI?
```
Grade 1/2: antithrombotic/antiplatelet (heparin is reversible; aspirin)
Grade 3 (PSA)
Grade 4 (complete occlusion): surgery
Grade 5 (transection + active extrav): ligate ?
```
192
Imaging findings of hepatic hemangioma
nodular peripheral enhancement with centripetal fill-in
193
Imaging findings of hepatic mets
- hypoattenuating
| - multiple and diffuse
194
Imaging findings of hepatic adenoma
- central changes consistent w/ hemorrhage
- no lighting up of central scar on art phase (like in FNH) - homogeneous enhancement in arterial phase
- related to OCPs, anabolic steroids
195
Imaging findings of FNH
- hypo- or isodense on non-con imaging with a central scar in one-third of patients
- hyperdense during the arterial phase due to arterial origin of its blood supply
- isodense during the portal venous phase
- central scar may become hyperdense as contrast diffuses into the scar
196
Imaging findings of HCC
- increased vascularity compared with liver parenchyma during the arterial phase of contrast administration
- washout of the contrast during later phases of imaging.
197
Imaging findings of cholangiocarcinoma
- hypodense with peripheral (rim) enhancement
- biliary dilatation
- contrast enhancement on delayed images
198
Different bw z and t test?
both compare means of 2 data sets
t test: estimated parameters
z test: known population parameters
199
What are the most radiosensitive tumors?
seminomas
| sarcomas = more resistant
200
MCC of pelvic fractures?
MVC/MCC's
(Then falls, peds struck by vehicle)
imaging: CT
201
First line tx for complicated infantile hemangioma?
propanolol
| peri orbital, compromising airway, disfiguring, ulcerated
202
What is kasabach merritt syndrome?
rapidly growing hemangioma + thrombocytopenia (consumptive coagulopathy)
dangerous
203
Indics for adjuvant chemo with breast cancer
>0.5 cm
+ LN
triple negative
204
Indics for neoadjuvant therapy in breast cancer?
Inflammatory breast cancer (needs MRM + adjuvant CR)
| Stage 3A or 3B
205
Modified Hanley maneuver (horseshoe abscess tx)
small incision between the tip of the coccyx and the anal verge, the tissues of the external sphincter are then gently separated using a hemostat to get into the postanal space, the abscess is drained, a seton is placed around the sphincter complex, two lateral counterdrainage incisions are made with setons placed in each.
206
trocar location
lap appy in 1st trimester
same as normal:
| umbilicus, LLQ, suprapubic
207
trocar location
lap chole in 1st trimester
umbilicus, subxiphoid, 2 at right costal margin
208
trocar location
lap appy in 2nd trimester
umbilicus, LLQ, RLQ
209
trocar location
lap appy, 3rd trimester
umbilicus, R mid abdomen, RLQ
210
What are the milan criteria?
one lesion, = 5cm
3 or less lesions, = 3cm
no angioinvasion
no extrahepatic disease
211
Treatment for hypermag?
calcium supplementation 1st
| then hydration + diuresis (renal excretion)
212
Tx for ER+ breast cancer in males?
| For metastatic breast cancer in males?
Tamoxifen (not really AI's)
| Orchiectomy (second line hormonal manipulation)
213
Criteria for neoadjuvant tx in gastric cancer?
Locally advanced (T2 +)
or
Node positive
214
Best abx for resistant MRSA?
Linezolid (otherwise vanco for normal MRSA)
215
With pleomorphic LCIS - do you need to re-excise for neg margins?
Yes
| you don't for classic LCIS
216
Nml size of:
- small bowel
- transverse colon
- cecum
3
6
9
217
name of reversal agent for pradaxa (dabigatran)?
idrarucizumab
218
polyomavirus (BK virus) - effect on post transplant pt?
```
Multiple late strictures
Asymptomatic rise in Cr
US: hydronephrosis
ACUTELY: perc nephrostomy
LONGTERM: surgical intervention
```
219
Types of hemorrhoidectomy?
Ferguson: excision with CLOSURE of mucosa
Milligan-Morgan: leave OPEN
Stapled hemorrhoidectomy: higher rate of recurrence and reoperation
Stapled hemorrhoidopexy: circular device
220
What are side effects of increased ACh?
DUMBBELSS
diarrhea, urination, miosis, bradycardia, bronchospasm, excitation of skeletal muscle & CNS, lacrimation, sweating, salivation
221
What hormones regulate the incretin effect?
| greater insulin response to ORAL glucose >> IV glucose
GLP-1
| GIP
222
Mucor vs Aspergillus
Mucor: broad hyphae, irreg branching
Aspergillus: narrow hyphae, regular branching
223
immunocompromised + poorly controlled diabetes --> fever, hemoptysis
pulmonary mucormycosis
| tx: IV amphotericin B + emergent lobectomy
224
treatment for small bowel carcinoid?
segmental resection of small bowel + associated mesentery resection + removal of at least 7 LN
225
Merkel cell carcinoma
small round blue cell neuroendocrine tumor
S100 -
Tx: surg excision with margins (similar to melanoma) + SLNB + radiation (it is radiosensitive)
226
Algorithm for IOC with transcystic exploration for stone
- attempt to flush stone
- attempt glucagon + flush
- gain wire access to CBD, insert balloon, choledoschoscope
- irrigation, capture stone, extract stone
- if stone too large, try transcholedochal
227
Therapies for metastatic RCC?
1st line: sunitinib, panzopanib
2nd line: TK inhibitors, mTOR
3rd line: everolimus, sorafenib
228
Etiology of chronic mesenteric ischemia?
Just tx if they're symptomatic. How?
What is "hemodynamically significant" stenosis?
- atherosclerosis (at mesenteric arteries' ostia OR spilling over from abd aorta
- need 2 of 3 mesenteric arteries
- tx: REVASC w/ endovascular mgmt of one mesenteric artery
> 70%
229
Melanoma T staging
T1: <1 mm
T2: 1-2 mm
T3: 2-4 mm
T4: >4 mm
a = NO ulceration ..... b = ulceration
N: 1, 2-3, 4+
Stage T1b + --> SLNB
230
most common place for accessor spleen?
```
splenic hilum
(2nd most common site = splenic vascular pedicle)
```
231
mgmt of ITP
dx of exclusion; young women; low plts, nml all else
GC, rituximab, IVIG
splenectomy --> should see postop diff by 2 wks
232
what type of imaging is best for pancreatic cysts?
dedicated MRI + MRCP
| (if can't tolerate MRI - pancreatic protocol CT or EUS
233
acute cholecystitis in child class c pt - mgmt?
stable: medically optimize and try to downgrade to class b for poss delayed chole
unstable: perc chole tube
234
acute mesenteric ischemia - tx for stable pt?
CTA --> a/c --> endovascular embolectomy 1st --> ex lap with bowel resection after
235
chronic pancreatitis tx
| progression
abstinence from alc/tobacco
NSAIDs
ERCP + sphinc, +/- PD stent
surgery
236
nec fasc - 2 types, tx?
type 1: polymicrobial (bacteroides, clostridium, e coli, klebsiella, toxin producing strep or staph)
type 2: hemolytic streoptococcal gangrene (s pyogenes
- virulence factor of M protein - with usually staph aureus co-infec)
237
which steroid does not interfere with the cosyntropin test?
dexamethasone
| hydrocortisone DOES affect the test
238
How to prevent secondary brain injury in intubated trauma pts?
avoid hypotension + hypoxia
| *single episode of hypotension (BP<90) associated with 50% increase in mortality
239
Goal cerebral perfusion pressure?
50-70
(MAP - ICP)
MAP at least 60 ... normal ICP 5-15
*can use mannitol or 3% saline
240
Most important predictors of survival in first 24 hr after severe head trauma?
- age
- pupillary activity
- best motor GCS score
- extra-ocular motility
241
Only situation in which you'd give tetanus Ig?
grossly dirty or large wound (>1cm) in unimmunized pt
242
Evaluation for adrenel incidentaloma?
Majority: benign, nonfxn-ing (<10 HFU, rapid >60% washout on 15min delayed phase CT)
{aldosterone, cortisol, pheo, mets}
***first, labs: lytes (K), dex suppression test, 24 hr urine cortisol/metanephrines/VMA
myelolipoma (can be large, 10cm - well circumscribed hypodense mass) or adrenal clearly benign cyst --> don't need to resect
IF nonfxn-ing: imaging 6,12,24 mo + annual hormonal testing x4 yr (If grows >1cm, excise)
IF fxn-ing OR >6cm: excise. Don't need to biopsy unless suspected mets.
4-6cm: meh gray area; individualized
243
Sedation agent of choice for pregnant pts in ICU?
propofol at low doses (at high doses, can affect fetus)
244
Most common location for undescended testes?
superficial inguinal ring
(2nd: superficial ing pouch
3rd: ing canal)
245
Controlled entry of GU, respiratory, GI or urinary tracts (uninfected) = ???
Gross spillage from GI tract / incision into acute nonpurulent inflammation encounter/major break sterile technique (ie GSW to colon) = ???
Perforated viscera/abscess = dirty
Clean/contaminated
Contaminated
Dirty
246
What predicts postop mortality in lung surgery?
FEV1
| DLCO
247
Bethesda criteria?
1. Nondx - repeat FNA
2. Benign - f/u US 6-12 months
3. AUS (aytpia undet signif) - repeat FNA up to 3x
4. follicular neoplasm or suspicious for - lobectomy
5. suspicious for malignancy - lobectomy w frozen (total if malignant)
6. malignant - total thyroidectomy
248
Name 2 radiosensitive tumors
seminoma
| lymphoma
249
Name 2 radio-resistant tumors
epithelial
| sarcomas
250
Indications for intubation in setting of smoke inhalation?
Mucosal ulcerations, blisters
ANY vocal cord edema
mucosal edema can progress to necrosis in 12-24 hr
251
Options for parastomal hernia repair?
Repair + mesh
1. Sugarbaker - ostomy exist bw mesh and peritoneum
2. Keyhole - defect made in mesh for bowel to exit thru
Sugarbaker - fewer recurrences
252
Tx for ...
neurogenic DI
nephrogenic DI
SIADH
- -desmopressin/ddavp
- -amiloride (increases responsiveness to ADH at CD's) (*also HCTZ, indomethacin per First Aid)
- -tolvaptan, demeclocycline
253
Bacteria assoc's:
- CLABSI
- PNA
- SSI
- UTI
- GI infec
- coagulase neg staph (s epidermidis)
- s aureus
- s aureus
- e coli
- c diff
254
Nodal mets for anorectal CA:
1. sup/middle rectum
2. lower rectum
3. anal canal
4. anal margin
1. IMA
2. IMA / int iliac
3. int iliac
4. inguinal
255
3 functions of ADH?
- water R at collecting ducts
- vasoconstriction
- release of F8 and vWF from endothelium
256
Req's for endovascular repair of AAA?
- ext iliac dia (access?)
- CI dia
- CI length
- aortic neck length (landing zone) and dia
- angulation
- min. 7mm
- 8-22mm
- 15-20 mm
- length 10-15mm, dia 7-10mm
- less than 60
257
```
Rates of
-wound infection
-wound separation
-seroma/hematoma
-lymphedema
-anaphylaxis to lymphazurin dye
in SLNB for melanoma pts.
```
- 4.6%
- 1.2%
- 5.5%
- 1%
- <1%
overall complication rate ~10%
258
What contributes to wall degen in AAA?
increased activity MMP
| decreased elastin and smooth muscle
259
When do you get a preop EKG?
prior cardiac hx, currently asx
260
explain type I and II errors briefly
```
type I (false +): rejecting the null hypoth when the null is true
type II (false neg): failing to reject the null hypoth when the null is false
```
261
What helps heal donor skin graft sites?
skin edges
| hair follicles
262
Most common reason for skin graft loss?
seroma or hematoma formation
263
Which topical burn medication tx's MRSA?
mupirocin
264
Common causes of death with ARDS
Multiorgan failure
| Infections/sepsis
265
Ideal tidal volume for ARDS pts
6mL/kg
266
prognostic factors for extremity soft tissue sarcomas ...
- for local recurrence
- for distal recurrence
- local: age>50, recurrent ds, fibrosarcoma, malignan periph nerve tumor, R1 resection
- distal: large size, deep location, high grade, recurrent ds, leiomyosarcoma, non liposarcoma histologies
267
pericardial effusion in setting of trauma? tx?
pericardial window - remember there's a stab wound and active bleeding you need to stop
268
what finding differentiates SMA embolus vs thrombosis?
sparing of proximal jejunum for EMBOLI
269
What are the different types of endoleaks?
1: prox or distal attachment site leak
2: retrograde flow from side branches
3: fabric tear or disconnection from modular overlap
4: graft wall porosity
270
mgmt of rectal carcinoids?
<1cm: local excision or endoscopic removal
1-1.9cm: full thickness excision (if invades muscularis or +LN -- need surgery + TME)
>/= 2cm: anterior proctosigmoidectomy vs APR
271
Main fuel source for colonocytes?
short chain FA
| acetate, butyrate, propionate
272
Main fuel source for enterocytes (small bowel)?
glutamine
273
MCC complication for endovascular repairs?
access issues
274
Which types of endoleaks need attention?
Type 1 and 3
275
Ischemic monomelic neuropathy
- females, diabetics
- + "axonal damage"
- usually ischemia to a nerve
VS steal syndrome (+loss of pulses or diminshed arterial dopplers)
276
Indications for cholecystectomy with GB polyp? (3)
1. Polyp > 1cm
2. PSC and polyp > 6mm
3. Polyp (any size/sx) assoc with stones
277
Ideal diet for hepatic failure pt ?
Increased BCAA, decreased AAA (aromatic amino acids)
| Downside to BCAA - act as false nuerotransmitters
278
Which pancreatic enzymes are released in active form?
amylase
lipase
ribonuclease / deoxyribonuclease
279
What types of surveillance are necessary for PSC?
C scope q1-2 yrs
Annual CA19-9 (cholangio)
MRCP q 6mo-1yr (cholangio)
RUQ US q 6mo-1yr (GB CA)
280
optimal renal enteral formula
low lytes
high essential to nonessential aa ratio
high calorie to nitrogen ratio
281
selenium deficiency side effects related to which enzyme??
glutathione peroxidase
282
tell me about propofol
- short acting lipophilic
- global CNS depression
- decreases ICP (and intraocular pressure) while maintaining normal CO2 autoregulation
- rapid onset
- antiemetic properties
- antipruritic, anticonvulsant
- metabolized by liver
Dose dep respiratory depression
Dose dep vasomotor activity (hypotension)
NO analgesia
283
What is alvimopan (entereg)?
Opioid mu antagonist
However cannot cross BBB
So it blocks opioid binding on bowel (prevent ileus) but does not interfere with opioid analgesic effect
284
Findings of autoimmune pancreatitis on CT and ERCP?
CT: diffusely enlarged, hypodense, low density capsule-like rim ... can have a focal mass
ERCP: segmental or diffuse irregular narrowing of main PD, usually with extrinsic appearing stricture of distal bile duct
*Need to r/o pancreatic adenoCA
285
30-day mortality for
- endovascular repair ELECTIVE
- open repair ELECTIVE
- ruptured - endovascular repair
- ruptured - open repair
- 1-2%
- 4-5%
- 25%
- 50%
286
Main APC?
dendritic cells
| take up Ag, present via MHC II, interact with CD4 helper T cells, activate adaptive immune response
287
What kind of incision do you make for a felon?
Vertical
| Blunt dissection after skin incision to avoid NV bundle
288
Most common postop complication + org?
UTI - E coli
289
4cm glucagonoma in tail - tx?
distal pancreatectomy + splenectomy (big tumor, high rate of mets; malignant)
290
What is a normal GB EF?
| Good test to find that?
>/= 35%
| CCK-HIDA
291
best agent for mask induction in kids?
sevoflurane
292
benefits of isoflurane?
good for NSG cases (no increase in ICP)
293
egg allergy - what CANNOT you use?
propofol
294
2 big cytokines in SIRS?
IL-1
| TNF-a
295
ideal diet for renal failure?
make sure getting essential aa (linoleic and alpha linoleic acids)
296
amount of protein necessary?
carbs?
fat?
1-2 g /kg/day PROTEIN
CARBS: 3/4 of nonprotein calories
FAT (9kcal/g): 1/4 of nonprotein calories
297
Why does TPN have worse outcomes?
```
line infections, PNA
atrophy of villi; lose gut mucosa integrity --> translocation of bacteria --> more infections
lyte abnormalities
hyperglycemic
cholestasis, liver failure
```
298
When start enteral feeds?
within 24-48 hrs of stability
if cannot tolerate --> TPN, start on day 7
299
what are good things to add to tpn?
| "immuno nutrition" - benefit = decreased infectious complic's in certain pts
glutamine
arginine
good fatty acids = omega 3 (bad = omega 6)
300
How to detect steal syndrome in UE?
diminished pulse exam that changes with graft compression when increased flow is directed to the hand
301
Possible indications for chemotherapy in breast cancer?
ER/PR-, HER2 +
3+ LN
High Ki67
302
What are the fluid findings in IPMN?
high amylase
high CEA
mucinous
303
Routine screening of MEN1 known pt?
Hyperparathyroidism: calcium and PTH levels
Pancreatic neuroendocrine tumors: fasting gastrin, glucagon, VIP, pancreatic polypeptide, chromogranin A, and insulin levels, as well as yearly imaging
Pituitary tumors: prolactin and insulin-like growth factor 1 (IGF-1) levels as well as pituitary magnetic resonance imaging every 3 to 5 years
304
Best way to image pancreas divisum
MRCP
305
What are branches of R vagus?
celiac branch
criminal nerve of grassi
confirm this lol
306
Most important vessel for esophagectomy conduit?
RIGHT gastroepiploic
307
Difference between somatic and visceral pain?
Visceral pain: dull localization, deep aching, no positional component, and referred pain
Somatic pain: clearly localized and sharp and pinpoint-like
308
In critically ill with AKI - still do __ supplementation bc benefits outweighs risk.
protein
309
Most common area of peripheral embolic lodgment?
common femoral bifurcation, AI bifurc, popliteal, SFA
310
How do you treat superficial vein thrombosis?
<5cm
>10cm
<5cm: NSAIDs, can repeat US in 1-2 wks to see if any extension
>10cm: anticoagulation
311
Most common site of atherosclerosis in UE?
subclavian artery
312
Mechanism of renovascular HTN?
decrease in MAP sensed by baroR at aff arteriole --> stimulate JGA (baroR) --> RAAS activation --> increase in renin causes HTN that's hard to treat medically
tx = PTA with stent
(for FMD - only PCA, no stent)
313
MC site of ectopic pregnancy
ampullary portion of fallopian tubes
314
MC site of endometriosis
ovaries
| tx: OCPs
315
What are 4 exceptions to informed consent?
1. Legal incompetence - pt lacks capacity
2. Emergent situation
3. Therapeutic privilege - disclosure would cause immediate harm or undermine pt's capacity for decision making or informed consent
4. Waiver - pt actively/explicitly waives right to IC
316
Pathophysiology of cocaine induced mesenteric ischemia?
Inhibition of NE uptake at presynaptic terminals, more NE at postsynaptic terminal --> tachy, HTN, vasoconstriction
317
What would be suggestive of mesenteric VEIN thrombosis?
- hx portal HTN, hypercoag state, hx vasculitis
- short segments of bowel involved, bloody diarrhea, crampy abd pain
- usually SMV, portal vein
tx: heparin, resect dead bowel if present
318
What would be suggestive of mesenteric ischemia due to arterial THROMBOSIS?
old person with PVD
more insidious onset, "food fear"
tx: thrombectomy (open v catheter directed), maybe PTA with stent or open bypass after vessel is opened for residual stenosis ... resect dead bowel
319
why is severe hypoCa life threatening?
Causes dysfxn of transmembrane depol
320
HyperPh causing hypoCa is most commonly seen in __, __, and __
Renal failure
Rhabdo
Tumor lysis syndrome
321
Which acute phase reactants are
increased
decreased
CRP, amyloid A, fg (incr)
| albumin, prealbumin, transferrin (decr)
322
Principles of shock in pediatric pts
- Bradycardia may be sign of impending CV collapse
- HR is 1st sign (but that may take 25% blood loss before being evident)
- SV is relatively fixed
- Total circulating blood vol is 80mL/kg
- Hypotension = late finding. <70 + (2 x age in yrs)
323
How to tx malignant hyperthermia?
1. Stop triggering agent (change anesthesia circuit)
2. Dantrolene!
2. Supportive care towards tx-ing hyperthermia, acidosis, organ dysfunction (hyperventilation to remove excess CO2, bicarb)
324
Indications for breast abscess I&D
Large
Skin necrosis
Loculations
325
Risk of stroke within 48 hr, after a TIA?
4-10%
326
What are absolute contraindications to thrombolytic use?
- active internal bleeding
- recent CVA/NSG (<3 mo)
- intracranial pathology
- recent GIB
327
Define TIA
neurologic deficit due to ischemia without acute infarction
328
What are the most radioSn cell cycles?
G2
| M
329
What impacts the effect of radiation?
Radiation has LESS impact on: hypoxic cells and cells that are not dividing that freq
Protons: damage at end of path
Electrons: damage at surface of tissue contact (good for superficial tumor beds/skin cancer)
330
Most common venous drainage and arterial supply of intralobar sequestrations?
inferior pulmonary vein
| systemic arterial supply
331
Intralobar sequestrations are commonly found ___.
Within medial or posterior segments of lower lobes
2/3 on left side
*usually no bronchial communication
*usually tx'ed with lobectomy/segmentectomy > wedge
332
Indications for sclerotherapy of varicose veins?
| What agents can be used?
varicose veins <8mm
reticular veins 2-4mm
telangiectasias 0.1-2mm
STS
hypertonic saline (+/- dextrose)
glycerin
etc
333
Contraindications for sclerotherapy for vv?
| ie - where surgery is a better option
GSV is largely dilated (>15mmm), torturous
Previous thrombophlebitis
with endovascular laser ablation, if vein>8mm, increased risk of thrombus extension towards femoral vein
334
Why is vein stripping rare below the knee?
Greater risk of saphenous vein injury
335
CEAP classification of chronic venous disease
| Just the C part
```
C0: No visible/palpable signs
C1: telangiectasias or reticular veins
C2: varicose veins
C3: edema
C4: pigmentation and/or eczema
C5: lipodermatosclerosis and/or atrophy
C6: healed venous ulcer
C7: open venous ulcer
```
336
2 most common causes of chronic venous obstruction?
valvular incompetence
chronic venous obstruction (stenosis or occlusion)
GSV reflux = velocity >500
337
What is a bypass procedure for severe symptomatic isolated obstruction of femoral vein?
May Husni procedure
338
What is a bypass procedure for unilateral iliac common fem vein obstruction?
Palma procedure
339
1st line tx for varicose veins
```
RFA
EVLA (endovenous laser ablation)
```
of the GSV (more medial) or small saphenous vein (more lateral)
340
What to do with endovenous heat induced thrombosis?
- does not pass saphenofem jxn: nothing
- <50% occlusion of femoral vein lumen: weekly surveillance until gone
- >50% occlusion of femoral vein lumen: a/c till gone
- occlusive DVT: treat as a DVT
* best way to prevent: ablate >2.5cm away from saphenofemoral or saphenopopliteal jxn
341
Where do kidney cancers originate?
1. parenchyma
| 2. renal pelvis
342
Most common primary chest wall malignant tumor
chondrosarcoma (80% arise from ribs)
| TX: WLE
343
triad of glomus tumor
pain, point tenderness, cold intolerance
| Hildreth sign: relief of pain with tourniquet
344
What are the required FLR for
healthy
liver ds (fibrosis, post hepatic affecting chemo)
cirrhosis
20%
30%
40%
345
Brown Sequard
ipsilateral motor/proprioception
| c/l pain/temp
346
RF for invasive fungal infec's?
```
Solid organ transplantation
Prolonged ICU stay
LOS
Prolonged abx use
TPN
GI perf
Hemodialysis
```
347
What to do with portal vein thrombus?
Treat aggressively - systemic a/c
Risks?
- intestinal infarction due to loss of fwd flow
- if chronic: portal HTN + cirrhosis
348
Most commonly ID'ed gene mutation in hirshsprung?
RET -- high proportion of long segment HD or total colonic agangliosis assoc with MEN 2a
349
What are the general esophageal manometry findings in scleroderma?
Low amplitude, simultaneous contractions
| Normal or low pressure LES
350
What is the pathophysio of HRS?
renal vasoconstriction in setting of systemic and splanchnic vasodilation
351
Options for open CBD exploration, to get rid of stones?
1. Transduo sphincteroplasty
2. If dilated biliary tree (CBD>2cm) + multiple stones --> biliary enteric drainage (via side-to-side or end-to-side anastomosis of CBD with duodenum)
352
What cancers are assoc with VHL?
pheo!!!
| clear cell RCC, brain + retinal hemangioblastomas, PNETs
353
Budd Chiari system mgmt?
- lifelong a/c
- can balloon angioplasty short segment stenosis
- thrombolytic therapy if present w/in 3-4 wks
*90% pts die in 3 yrs w/o treatment
354
MC indication for esophageal replacement in kids?
long gap esophageal atresia
355
What is infliximab?
IgG mab, TNF-a
356
Name steps of wound healing
1. Inflammatory - clot formation
2. Proliferation - granul tissue, epithelialization
3. Remodeling - collagen remodeling, scar formation
357
Tests with the most radiation?
1. nuclear medicine - cardiac stress test (40)
2. PET/CT (25)
3. CT whole body
4. CTA, aorta w/ runoff (16)
5. CT colonoscopy
6. CT Abd
358
Causes of peroneal nerve injury? (3)
1. incorrect leg placement in lithotomy
2. crossing legs
3. fibula head fx
*movement/sensation to lower leg/foot/toes
359
Differential for acute lower GIB
```
Anatomic (diverticulosis)
Vascular (angiodysplasia, ischemic, radiation-induced)
Inflamm (infectious, IBD)
Neoplastic
Iatrogenic (polypectomy)
```
360
When is the Delorme procedure appropriate?
- mucosal rectal prolapse
- short segment full thickness rectal prolapse
* It's perineal. Good for old ppl.
* Abd approach (rectopexy) is for healthy ppl.
361
Surveillance after colon cancer?
Clinical exam + Biochemical markers (CEA): q3-6 mo x2 yr, then q6 mo for total 5 yr
Cscope - 1 yr postop ... (unless none preop, then at 3-6mo postop)
--adv adenoma? repeat in 1 yr
--no adv adenoma? 3 yrs, then q5 yr
Imaging: CT annual x3-5 yr
362
Parastomal hernias
- Most occur within first 2 years, only 20% progress to req repair
- Stoma relocation has best outcome but is not always req. Fascial repair has worst outcome.
- Lg bowel stoma herniate >>> sm bowel stomas
- Absolute indics for repair: obstruction, strangulation
363
Let's talk about lithium -_-
-Metab by kidneys, so any decrease in GFR can cause toxicity. Bypass surgery also incr lithium [ ].
-Sx of toxicity: incr Ca Mg R at loop of Henle --> hyperCa, Mg, hypocalciuria. Also hyperPTH.
-
364
Lithium toxicity vs primary hyperPTH
primary hyperPTH -- decr phosphate and high PTH
| lithium tox -- phosphate nml, high/nml PTH
365
Ureters cross __ the iliac vessels
over
366
Right renal artery crosses __ to IVC
| Left renal vein crosses __ to aorta
posterior
| anterior
367
Testicular torsion ... after detorsion, unclear whether testes is viable, with poor blood flow in US .... what to do?
<10 yrs old: leave in situ + c/l orchiopexy
| >10 yrs old: orchiectomy + c/l pexy
368
Lymphangitis
| MC org in person of normal immunity?
strep pyogenes
369
Injury to right ventricle should be repaired with ...
pledget'ed nonabsorbable sutures
370
MC gastric lymphoma?
1. DLBCL
2. MALToma
*non Hodgkin
371
How to treat thrombolytic (tPA etc) overdose?
Cryo first
| Aminocaproic acid if cryo unavailable
372
MC side effect of protamine?
hypotension
373
Predominant bacteria in colon?
| Predominante AEROBE in colon?
bacteria - Bacteroides fragilis
| aerobe - E coli
374
Desired vein size for AV fistula
2. 5mm (really, 3mm) - no stenosis or thrombosis
| artery: >/= 2mm
375
Placing a subclavian line, end tidal CO2 suddenly drops off, cardiac arrest
air embolism
376
TX for:
Primary C diff episode
Second recurrence
Multiple episodes
- PO vanco or fidaxomycin
- pulsed tapered vanco regimen OR fidaxomycin if vanco used initially
- Fecal transplant
377
How to suture posterior stomach and pseudocyst together?
running (OR closely spaced (<1cm) interrupted) absorbable suture with full thickness bites
378
What are signs/sx of fulminant C diff?
hypotension
fever
WBC>15
Cr>1.5
Appropriate tx: PO vanco, IV flagyl (AND vanco rectal enema if +ileus)
379
How does radiation exert its damage?
| Which cells are most sensitive?
- direct damage to DNA + oxygen free radicals
| - rapidly dividing crypt cells (villi of mucosa)
380
Adenoid cystic carcinoma of salivary gland
Slow insidious onset, with affinity for growth along perineural planes, and late presentation of distant mets (lung MC). More mets risk than mucoepidermoid.
381
What's included in the Gail model
- Age (model works for age 35-85)
- First menstrual period
- First live birth
- # FDR with breast cancer
- Previous breast bx and hx of bx with atypical hyperplasia
- Race/ethnicity
382
Best way to remove testicular cancer
Via INGUINAL approach (NOT scrotal)
383
What gets exception points for the MELD?
* pts listed at MELD 15 (bili, Cr, INR, Na)
- HCC
- hepatopulm syndrome
- portopulmonary HTN
- CF
- hilar cholangiocarcinoma
- primary hyperoxaluria
384
What needs a neg pressure room?
```
COVID!
Severe acute respiratory syndrome
TB
Varicella
Measles
Chickenpox
```
385
MC predisposing factor AND pathogen for acute paronychia
minor skin breakdown
| Staph aureus
386
What kind of skin graft is used to cover joints & face?
full thickness
387
How do you treat hypermagnesemia?
Ca gluc or Ca chloride
| definitive: hydration + diuresis ... maybe dialysis if renal fxn is impaired
388
Absolute contraindications to PEG placement?
```
Poorly controlled / massive ascites
Inability to oppose stomach and abd wall
Uncorrectable coagulopathy
Peritonitis
No endoscopic access
Expected survival < 4 weeks
Severe malnutrition
Systemic sepsis
```
389
MC abdominal pain after gastric bypass?
Cholelithiasis
Internal hernia
Marginal ulcer
390
Histologic findings of GIST
bland spindle cells with elongated nuclei
391
Fecal incontinence due to sphincter dysfunction after vaginal delivery - treatment?
Overlapping sphincteroplasty
392
Which is more predisposed to parastomal hernia - end or loop ileostomy?
loop, because the trephine incision has to be larger to accommodate both loops
393
Preferred AV fistula types
RC (aka Cimino) > RB > BC > BB > prosthetic (brachioaxillary)
394
Tx of choice for complicated Type B aortic dissections?
Thoracic endovascular repair
395
Tx for invasive aspergillosis?
| happens mostly in neutropenic pts or GC use
voriconazole
396
Potency of steroids?
hydrocortisone < prednisone < methylprednisolone < dexamethasone
397
hepatic encephalopathy in absence of significant hepatic dysfunction (MELD<15) ... what do you suspect?
portosystemic shunt (abnormal vein allowing for bypassing liver)
398
MC ectopic tissue in Meckel?
gastric
399
What arteries are ligated in an extended R hemi?
(TI until prox descending colon)
| MRI colic + left colic
400
What arteries are ligated in a normal R hemi?
ileocolic, right colic, right/hepatic branch of middle colic
401
```
Severe idiopathic chronic constipation can be:
1.
2.
3.
4.
5.
```
```
Normal colonic transit time
Slow transit constipation (radioopaque marker study ... >5 markers by day 6 = abnormal)
Dyssynergic defecation
Megacolon
Megarectum
```
402
How to treat the following conditions:
C. krusei
C. glabrata
C. albicans
voriconazole
micafungin
fluconazole
403
Why paradoxic aciduria?
dehydration --> sodium preferentially R --> K, H excreted --> paradoxic aciduria + hypokalemia
404
Basic steps of a resuscitative thoracotomy
1. Access the thoracic cavity
2. Pericardiotomy
3. THEN - if
- - beating heart: digital (literally w/ a digit) control of injury w/o worsening the injury
- -nonbeating heart w/ an injury or if cannot control hemorrhage with a digit: try tomanage cardiac injury
4. Cardiac massage +/- internal defibrillation for vfib only (if crossclamp aorta, can perfuse myocardium ad brain selectively)
405
Had a traumatic splenectomy ... 2 days later, febrile, tachy, peritonitic ... thoughts?
gastric perf (short gastric removal --> stomach wall necrosis)
406
Cardinal signs of Kanavel
| classic signs of tenosynovitis
Exquisite tenderness along flexor sheath
Semi flexed finger
Exquisite pain on extension
Fusiform swelling of entire finger
407
Treatment of tenosynovitis
1. Abx: vanco for GP, cipro for GN (incl pseudomonas)
| 2. +/- I&D (via 2 incisions)
408
What effect does immunomodulating preop nutritional supplements have postop?
Decreased infectious complications
| Decreased LOS
409
What vessels are taken with Whipple?
```
R gastroepiploic vein
GDA
R gastric artery
Inf/sup pd artery
Short mesenteric vessels
```
410
How do you calculate plasma osmolarity?
(2*Na) + (glu/18) + (BUN/2.8)
| normal = 280-295
411
Which abscesses should undergo drainage in the OR?
large abscesses
recurrent abscesses
intersphincteric +supralevator abscesses
b/l abscesses
412
What is considered borderline resectable pancreatic cancer?
Encasement of >180 deg PV
<180 of PV + contour irregularity
<180 of SMA
413
What brain things are associated with ALF?
Brain edema
| Intracranial HTN
414
Talk to me about desmoids
Requires a biopsy (bundles of spindle cells, fibrous stroma)
+ beta-catenin, actin, vimentin
- cytokeratin, S100
TX: WLE but radiation also acceptable if extreme circumstance
415
Shortened and externally rotated leg
Neck of femur fx / femoral neck fx
416
Patient with HIT and liver failure ... best anticoagulant?
BIVALIRUDIN (partially metb by liver and excreted by liver/kidney)
vs argatrobran (liver metab + excretion)
417
Mallory Weiss tear ... what infusion should be started immediately?
IV PPI
418
How to treat intersphincteric abscess?
OR
Drain internally, divide mucosa and internal sphincter along length of abscess cavity
(External drainage may result in fistula)
419
Which pt population should receive abx with anal absceses?
Immunocompromised
| Mechanical heart valves
420
preferred pressor for cardiogenic shock?
dobutamine
421
At what level does carboxyHb produce confusion?
Cause brain death?
What is normal level in healthy vs smoker?
5% - nonsmoker normal ----- 10% smoker normal
20% - confusion
60% - brain death
422
Asbestos exposure (ie shipyard) + peritoneal carcinomatosis ... diagnosis?
Malignant peritoneal mesothelioma
423
Changes during pregnancy?
DOWN: BP (due to decreased SVR), relative anemia
UP: total body volume, HR, renal blood flow, moderate leukocytosis
424
What is conservative mgmt of slow transit constipation?
laxatives
| high fiber diet
425
What surgery for a person with slow transit constipation who has failed conservative mgmt?
TAC with ileorectal anastomosis
426
How to diagnose slow transit constipation?
Nuclear medicine transit study
| Radio-opaque marker study
427
Acute chest syndrome - definition/criteria
| treatment
pulmonary sequestration of sickled RBCs in sickle cell pt
- new CXR finding
- chest pain
- fever > 38.5
- resp sx
- hypoxemia
TX: O2 >94%, IS, chest PT, empiric abx, judicious fluids (risk of pulm edema), non-opioid analgesics
428
Time to normalization of these 3 variables can help stratify pts and guide further IVF use
Initial base deficit
pH
lactate
429
Which is the most effective smoking cessation aid?
Chantix (varenicicline) >>> nicotine replacement
430
partial vs full thickness "nuclear pleomorphism" of a skin lesion - which diagnoses?
PARTIAL nuclear pleomorphism = actinic keratosis (cryotherapy or 5FU)
FULL thickness = SCC in situ
Invasion thru BM = SCC
431
MC lymphoma in AIDS popul?
Aggressive high grade B cell lymphoma
432
What are 2 targets therapies for CRC cancer?
cetuximab
panitumumab
*ensure KRAS wild-type present (NOT mutation)
433
How does flagyl work?
oxygen radicals which break up DNA helical structure
434
Ascites is due to ___ pressure.
high intravascular (from portal HTN)
435
What is the best route for esophageal substitution in esophageal replacement?
Posterior mediastinum
436
Perform a ___ before cardiac massage to improve perfusion to brain and heart.
thoracic aorta cross clamp
437
MC short-term and long-term complications after inguinal LN dissection?
wound infection
| lymphedema
438
Most common contributor to Mondor disease?
idiopathic
439
How to treat a nasal septal hematoma?
Early detection and I&D
| necrosis of septal cartilage
440
Most common site for supranumery parathyroid gland?
thymus
441
In kids <12 yrs old who need an airway (ETT failed), do not attempt cricothyrotomy, instead do ___.
jet ventilation (needle cricothyrotomy)
442
Radionuclide scanning: ___
| Mesenteric angiography: ___
0. 1 - 0.4 mL/min
| 0. 5-1 mL/min
443
Mechanism which increases risk of hyperK with succinylcholine
upregulation of acetylcholine nicotinic R
444
Postop parotitis is most commonly caused by ___ (which bug?)
Staph aureus
445
Radioactive iodine ___ Graves ophthalmopathy
worsens
446
In which patient popul will digoxin side effects be more apparent?
Hypokalemic
| Compete at the Na/K pump
447
Repair for PROXIMAL destructive CBD injury?
| DISTAL CBD?
proximal: roux en y HJ
distal: roux en y choledochoJ
448
What does a PPI inhibit?
H+/K+ pump of parietal cell
449
What can you give someone with antithrombin III deficiency when you want to tx them with heparin?
FFP
