Black Book Flashcards
(1425 cards)
1
Q
what is the purpose of cholesterol in the cell membrane?
A
to increase membrane fluidity
2
Q
what makes cell negative inside?
A
Na/K ATPase, 3Na out for every 2K in
3
Q
what is the most common intracellular cation?
A
K
4
Q
what are desmosomes?
A
cell-cell anchor
5
Q
what are hemidesmosomes?
A
cell-extracellular matrix anchor
6
Q
what is the most variable part of the cell cycle?
A
G1
7
Q
what is the largest site of gluconeogenesis?
A
liver
8
Q
what activates protein kinase C?
A
calcium
9
Q
what are the initial responses to vascular injury?
A
vasoconstriction by TXA, platelet adhesion, thrombin generation (forms platelet plug)
10
Q
what is the mechanism of thrombin?
A
converts fibrinogen to fibrin, activates factor 5 & 8, activates platelets
11
Q
which coagulation factor has the shortest half life?
A
7
12
Q
which factor is not synthesized in the liver?
A
8
13
Q
which factors are synthesized in the endothelium?
A
8 and wvf
14
Q
which factors are vitamin k dependent?
A
2, 7, 9, 10, c, s
15
Q
how to reverse INR?
A
FFP is immediate and lasts 6 hours, IV vit K takes 6 hours to take effect
16
Q
what is the mechanism of AT-III?
A
binds and inhibits thrombin, factor 9, 10, 11
17
Q
what is the mechanism of heparin?
A
binds AT-III to increase its activity 1000x
18
Q
what is the mechanism of protein C?
A
degrades factor 5 and 8, and fibrinogen
19
Q
what is the mechanism of TPA?
A
converts plasminogen to plasmin
20
Q
what is the mechanism of plasmin?
A
degrades factor 5 and 8 and converts fibrinogen to fibrin
21
Q
which coagulation factors are in extrinsic pathway?
A
2, 5, 7, 10, fibrinogen
22
Q
which coagulation factors are in intrinsic pathway?
A
8, 9, 11, fibrinogen
23
Q
which ACT is desirable for routine anticoagulation?
A
150-200
24
Q
which ACT is desirable for cardiac bypass?
A
> 460
25
what is the most common congenital hypercoagulable disorder?
factor 5 leiden mutation (resistance to activated protein C)
26
what is the most common acquired hypercoagulable disorder?
smoking
27
what is the key element in development of arterial thromboembolism?
endothelial injury
28
what is virchow's triad?
stasis, endothelial injury, hyercoagulation
29
which blood product is used if needing AT-III?
FFP
30
why is DVT more common in left leg?
iliac artery compresses vein
31
what anticoagulant should you use if someone has HITT?
argatroban
32
how do you diagnose HITT?
platelet drop below 100 or 50% decrease from baseline, ELISA for PF4 ab (if only mildly positive, perform serotonin release assay)
33
what is the most common congenital bleeding disorder?
von willebrand's disease
34
what is the most common symptom of von willebrand's disease?
epistaxis
35
what is the blood test for von willebrands?
prolonged bleeding time, aka ristocetin test (PT and PTT are normal)
36
what is the treatement for von willebrand's disease?
DDAVP (except type 3), or factor VIII-wvf complex, or cryoprecipitate
37
what are the 3 types of von willebrand disease?
1: not enough vwf 2: vwf doesnt work well 3: no vwf
38
what is hemophelia A and what is dx/tx?
factor 8 deficiency; dx by prolonged PTT and normal PT. tx is recombinant factor 8 (other options are DDAVP or cryo). want levels at 100% preop and 50% postop for 3-5 days
39
what is hemophelia b and what is dx/tx?
factor 9 deficiency; dx by prolonged PTT and normal PT; tx is recombinant factor 9 or FFP
40
what are the rules for plavix after stents?
bare metal = 6 weeks, drug eluding = 1 year
41
what is the antidote for dabigatran?
idarucizumab (praxbind)
42
what is the tx for thrombolitic overdose?
aminocaproic acid
43
what are the contraindications to TPA?
absolute: active internal bleeding, recent CVA <2mo ago, crainal pathology; relative: surgery/biopsy within 10 days, ob delivery, major trauma, left heart thrombus, recent GI bleed <90 days ago, uncontrolled HTN; minor: minor surgery, recent CPR, bacterial endocarditis, hemostatic problems such as renal/liver disease, diabetic hemorrhage, retinopathy, pregnancy
44
what is the half life of heparin?
60-90 minutes
45
what are the side effects of long term heparin?
osteoporosis, alopecia
46
what is the dose of protamine to reverse heparin?
1.5mg/100U of heparin
47
what is the mechanism of warfarin?
vitamin K dependent decarboxylation of glutamic residues
48
how do SCDs work?
improve venous return but also induce fibrinolysis with compression by releasing endogenous TPA
49
how does DDAVP work?
stimulates factor 8 and vwf release from endothelium?
50
how long to hold aspirin?
7 days
51
how long to hold plavix?
5-7 days
52
how long to hold warfarin?
7 days
53
what level do you want platelets at before surgery?
50,000
54
why does calcium decrease with PRBC transfusion?
PRBC stored in citrate and citrate binds Ca
55
when should you transfuse platelets?
<10k, <20k with infection or bleeding risk, or <50k if active bleeding or pre-procedure
56
what should you consider if platelets dont increase after transfusion?
allo-immunization, try HBO matched platelets. if still not working, check for HLA antibodies
57
what is in cryoprecipitate?
vwf, factor VIII, fibrinogen, and favor XIII
58
when to give cryoprecipitate?
fibrinogen <100 or bleeding in VWD
59
what is the most common transfusion reaction? details?
febrile non-hemolytic transfusion reaction; fever/rigors after transfusion from preformed recipient abs against donor wbcs. stop transfusion and give tylenol.
60
what is the most common symptom of blood product allergic reaction?
rash; rarely anaphylaxis can occur. MCC is IgA deficiency.
61
what is the cause of delayed hemolytic transfusion reaction?
preformed recipient abs against donor minor RBC antigens (HLA)
62
what causes TRALI?
donor Abs bind recipient WBCs and lodge in lung
63
what causes acute hemolytic transfusion reaction? s/sx/tx?
ABO incompatibility; preformed recipient Abs against donor RBCs. fever, hypotension, tachy, hematuria, renal failure, shock DIC, bleeding. tx with stop transfusion, fluids, diuretics, bicarb, pressors
64
what is the most common cause of death from a blood transfusion?
ABO incompatibility from clerical error.
65
what is the most common blood product with bacterial contamination, and why?
platelets, because they are not refrigerated. MC bug is gram negative rods, usually e. coli
66
which blood products do NOT have risk of HIV/hepatitis?
albumin and immunoglobulins, because they are heat treated
67
what is the first cell type to arrive in wound healing process?
Platelets
68
what is the dominant/most essential cell type in inflammation/wound healing?
macrophages
69
what are the steps of wound healing?
1) inflammation 2) proliferation 3) remodeling
70
what are the predominant cell type in wound healing from 0-2 days?
PMNs
71
what are the predominant cell type in wound healing from 3-4 days?
macrophages
72
what are the predominant cell type in wound healing from 5+ days?
fibroblasts
73
what is the key growth factor in wound healing?
PDGF
74
where are most cytokines produced?
macrophages
75
why does atelectasis cause fever?
alveolar macrophages release IL-1
76
which interleukin DOWNregulates inflammatory response?
IL-10
77
what is the main cell type in type 1 hypersensitivity reaction?
#1 is mast cells (as well as basophils)
78
which cell type responds to intracellular infection?
natural killer cells
79
how long does the inflammation phase of wound healing last?
1-10 days
80
how long does the proliferation phase of wound healing last?
5 days to 3 weeks
81
when does collagen deposition peak in wound healing?
3 weeks
82
how long does maturation/remodeling phase of wound healing last?
3 weeks to 1 year
83
what happens to collagen during wound maturation?
type 3 is replaced with type 1
84
what/when is the most strength a wound ever gets?
80%, hits this at 8-12 weeks
85
how quickly do peripheral nerves regenerate?
1mm/day
86
order of cell arrival in wound?
platelet, PMNs, macrophages, fibroblasts, lymphocytes
87
what is the #1 source for migration of epithelial cells for wound edges?
hair follicles
88
what is the most common collagen type in the body?
type 1
89
what is the most common collagen in cartilage?
type 2
90
what is the collagen of granulation tissue?
type 3
91
what is the primary collagen type in a healing wound?
type 1
92
what is optimal transcutaneous oxygen measurement for wound healing?
>25mmhg
93
what defines a wound infection?
>10^5/cm^2 bacteria
94
what vitamin can counteract the effects of steroids on wound healing?
Vit A
95
what is the largest risk factor for wound dehisence?
deep wound infection
96
what determines leak vs fistula?
leak if less than 7 days, fistula if 7 or more
97
what is the major cytokine produced from th1 cells?
INF-gamma
98
what is the main target cell of th1 cells?
macrophages
99
what is the major cytokine produced by th2 cells?
IL-4
100
what is the main target cell of th2 cells?
B cells
101
what type of immune response comes from th1 cells?
cell mediated
102
what type of immune response comes from th2 cells?
antibody mediated
103
what is the most common ab in the spleen?
IgM
104
what is the largest antibody?
IgM
105
what is the primary antibody against A and B antigens on RBCs?
IgM
106
what is the most common antibody overall?
IgG
107
what antibody is responsible for secondary immune response?
IgG
108
which antibody crosses the placenta?
IgG
109
which antibody plays a role in mucosal immunity?
IgA
110
which antibody is involved in type 1 hypersensitivity?
IgE
111
which interleukin is associated with type 1 hypersensitivity?
IL-5 (overproduction)
112
what is a type 2 hypersensitivity?
antibody dependent cytotoxicity (acute hemolytic transfusion reaction, hyperacute rejection, ITP)
113
what is a type 3 hypersensitivity?
immune complex deposition (serum sickness, SLE)
114
what is a type 4 hypersensitivity?
delayed type aka t-cell mediated/antibody independent (chronic rejection, PPD, graft vs host disease, contact dermatitis)
115
what is the most common immune deficiency?
malnutrition
116
what is the main source of histamines in tissues?
mast cells
117
what is the main source of histamines in blood?
basophils
118
what is the most important antigen in donor/recipient matching?
HLA-DR
119
what type of rejection occurs if incompatible ABO?
hyperacute
120
what are some ways to try to decrease the PRA% of a person awaiting transplant?
plasmapheresis, IV-IG, or rituximab
121
when does hyperacute rejection occur?
minutes to hours after txp
122
what causes hyperacute rejection?
preformed recipient abs to donor antigens
123
when does accelerated rejection occur?
within 1 week
124
what causes accelerated rejection?
T cell sensitization from previous transfusion, childbirth, previous txp etc
125
when does acute rejection occur?
1 week to 6 months
126
what causes acute rejection?
recipient T cells against donor antigens
127
what is the main mechanism of chronic rejection after heart transplant?
chronic allograft vasculopathy
128
how to diagnose antibody mediated rejection?
HLA serum antibody levels and C4d tissue staining on biopsy
129
how can you treat antibody mediated rejection?
IVIG, plasmapheresis, rituximab, splenectomy
130
what is cyclosporin and what are its main side effects?
calcineurin inhibitor; nephro/hepatotoxic, HUS, tremors, seizures
131
what is the mechanism of tacrolimus?
binds FK binding protein to inhibit IL-2 (similar to cyclosporin but 50x more potent, same side effects) generally less rejection than with cyclosporin
132
what is the mechanism of sirolimus?
mTOR inhibitor that binds FK binding protein to inhibit response to IL-2 (advantage is that it is not nephrotoxic)
133
what are the side effects of sirolimus?
increased triglycerides, impaired wound healing, pancytopenia
134
what are the side effects of azathioprine?
myelosuppression, GI intolerance, pancreatitis, hepatotixic, neoplasia, anemia, pulmonary fibrosis
135
what are the side effects of mycophenolate (aka Cellcept)?
GI upset, pancytopenia
136
which monoclonal antibody drugs are used for immunosuppression?
daclizumab, basilximab (work against IL-2)
137
what is the mechanism of thymoglobulin?
ab directed against antigens on T cells (cytolytic)
138
what is the most common malignancy following transplant?
squamous cell CA of skin
139
who is at the highest risk of post-transplant lymphoproliferative disorder?
children and heart transplants
140
what causes post-transplant lymphoproliferative disorder?
EBV mediated B cell proliferation
141
what is the most common infection after transplant AFTER 1 month?
CMV
142
what is the most common manifestation of CMV in post transplant patients?
febrile mononucleosis (though can present as gastritis, colitis, ophthalmitis)
143
what is the treatment for CMV?
gangciclovir or IVIG
144
what is the most common cause of ESRD leading to kidney txp?
diabetes
145
what is the most common cause of post-op oliguria after renal transplant?
ATN
146
what is the most common cause of new proteinuria after renal transplant?
renal vein thrombosis
147
what is the most common complication after renal transplant?
urine leak
148
what is the definition of early graft dysfunction in renal transplant?
needing HD within the first week of transplant
149
when is lymphocele most likely to form post renal transplant?
3 weeks post op (decreased UOP late)
150
what does the path for CMV look like?
inclusion bodies in leukocytes
151
what is the most common cause of mortality after kidney transplant?
myocardial infarction
152
what is the workup for a post-transplant patient with increasing Cr and decreasing UOP?
duplex US and biopsy
153
what is the most common complication in living kidney donors?
wound infection
154
what is the most common cause of death in living kidney donors?
fatal PE
155
what is the most common indication for liver transplant?
Hep C
156
what is the most common indication for liver transplant in children?
biliary atresia
157
what is the Milan criteria?
defines who with HCC and get a transplant: 1 tumor less than 5cm, or 3 tumors each less than 3cm, or favorable histology. CANNOT have mets, vascular invasion, or cholangiocarcinoma.
158
what is the best predictor of liver transplant primary non-function?
macrosteatosis
159
what is the utility of the MELD score?
if 15 or higher, more likely to benefit from liver transplant; if less than 15, more likely to die from liver transplant than to benefit from it.
160
what is the most common arterial anomaly in liver transplant?
aberrant right hepatic artery coming off SMA
161
what is the most common complication of liver transplant?
biliary leak
162
how do you treat primary non-function after liver transplant?
must re-transplant
163
what is the most common early vascular complication after liver transplant?
hepatic artery thrombosis
164
what is the difference between early and late hepatic artery thrombosis after liver txp?
early leads to fulminant liver failure; late leads to biliary strictures and abscess
165
what is the most common cause of hepatic abscess after liver txp?
hepatic artery thrombosis
166
how can you tell cholangitis vs rejection on path?
cholangitis is JUST PMNs, rejection is mixed endothelitis infiltrate
167
what does path show in chronic liver rejection?
disappearing bile ducts
168
what is the most common complication of a living liver donor?
bile leak
169
what is the recurrence rate of PBC after txp?
20%
170
what is the recurrence rate of PSC after txp?
20%
171
what is the most common cause of mortality after heart transplant within one year?
infection
172
what is the most common cause of mortality after heart transplant after 5 years (and overall)?
chronic allograft vasculopathy (aka accelerated atherosclerosis of small coronary vessels)
173
what is the most common cause of mortality after lung transplant within one year?
reperfusion injury
174
what is the most common cause of mortality after lung transplant after one year (and overall)?
bronchiolitis obliterans (aka chronic rejection)
175
which complication of diabetes does not improve after pancreatic transplant?
vascular disease
176
what is the most common complication after pancreatic transplant?
vessel thrombosis
177
how does acute rejection of small bowel transplant present?
diarrhea
178
what is the most common organism in surgical site infection?
staph aureus
179
what is the most common organism in vent associated penumonia?
staph aureus
180
what is the mechanism that makes MRSA resistent?
altered penicillin binding protein
181
what is the most common organism in line infection?
staph epidermidis
182
what is enteroccus resistant to?
all cephalosporins
183
what is the mechanism of enterococcus to vanco?
mutation of the cell wall binding protein
184
what is the most common organism in the gut?
bacteroides fragillis
185
what is the most common organism in burn wound infections?
pseudomonas
186
what is the most common aerobic bacteria in the colon?
e. coli
187
what causes the SIRS response in gram negative infections?
lipid A (LPS) is potent stimulant of TNF-a
188
what are ways to prevent SSI during OR?
stop tobacco, clippers (not razor), abx within 1 hour before incision, maintain blood glucose, keep O2 high, keep patient warm
189
what wound class is prepped bowel?
clean contaminated
190
which wound types should theoretically be left open?
contaminated and dirty
191
what is the most common organism in SSI?
staph aureus
192
what defines a surgical site infection (bacteria load)?
10^5 bacteria
193
what is the glucose goal in critically ill patients?
120-180
194
what is the most common organism in ventilator associated pneumonia?
staph aureus, but must cover for pseudomonas too
195
what is mendelson's syndrome?
chemical pneumonitis from aspiration of gastric secretions (ARDS picture)
196
which central line placement has the lowest risk of infection?
subclavian
197
what is the abx regimen of choice if nec fasc is due to strep pyogenes?
high dose IV penicillin and clindamycin
198
how do you treat lung abscess?
usually abx alone, rarely need drainage or surgery
199
what test is the gold standard for c. diff?
stool cytotoxin assay
200
what test is the rapid check for c. diff?
stool ELISA for toxin A or B
201
what is the best initial treatment if fungemia is suspected?
anidulafungin (eraxis)
202
how do you treat candiduria?
remove foley; usually dont need abx
203
what is the abx tx of choice for actinomyces?
IV penicillin
204
what is the abx of choice for nocardia?
bactrim
205
what are the diagnostic criteria for SBP?
WBC >500, PMNs >250, positive cultures
206
what is the abx ppx for SBP?
norfloxacin (be sure to give to those with ascites and variceal bleed)
207
what is the most common organism in infected peritoneal dialysis catheter?
staph aureus
208
what is the tx of choice for infected peritoneal dialysis catheter?
IV/peritoneal vanco and gentamycin; intraperitoneal heparin can help; if not resolving in 4-5 days then remove catheter (though must remove if fungus, pseudomonas, or TB)
209
best diagnostic test for osteomyelitis?
bone biopsy
210
who should get tetanus toxoid if previously vaccinated?
clean/minor wounds if >10 years ago or dirty wounds if >5 years
211
what happens if you get needle stick from HIV patient?
HAART tx within 1 hour and for 4 weeks; ELISA test at time of stick and at 4 weeks
212
what is the most common condition in HIV requiring laparotomy?
CMV colitis (bleeding, perforation)
213
what is the most common location of lymphoma in HIV?
stomach
214
what is the symptom and tx of brown recluse spider bite?
necrosis; PO dapsone
215
what is the most common organism in human bites?
strep pyogenes; though eikenella is ONLY found in human bites
216
what is the most common organism in SBP?
e. coli
217
what is hoffman elimination?
drug is metabolized in blood and does not require organ metabolism (good for liver/renal failure, example is cisatricurium)
218
mechanism of zofran?
blocks serotonin (5 HT) receptor
219
what is alvimopan?
Entereg... mu opiod antagonist for post op ileus
220
how to treat SVT?
adenosine
221
what is the single best agent to decrease mortality in CHF and after MI?
ACE inhibitor
222
which diuretic can cause hyperkalemia?
spironolactone
223
what is the only agent found to improve survival in severe COPD?
home oxygen
224
what is the mechanism of infliximab (remicade)?
antibody to TNF-a
225
what is the antidote to tylenol overdose?
n-acetylcystine
226
what is the antidote to benzo overdose?
flumazenil
227
what is the antidote to wilson's disease (copper)?
penicillamine
228
what is the antidote to overproduction/ingestion of iron?
deferasirox
229
what does a small MAC mean in anesthesia?
more lipid soluble, more potent, slower onset
230
what does a high MAC mean in anesthesia?
less lipid soluble, less potent, faster onset
231
what is the notable side effect of halothane?
hepatitis
232
what is the main side effect of etomidate?
adrenal insuffiency
233
what is the best indicator for successful intubation?
end tidal CO2
234
what causes rapid drop in end tidal CO2?
disconnected from vent, PE, CO2 embolus
235
what is the mechanism of dexmedetomidine?
CNS alpha 2 agonist
236
what is benefit of fentanyl over morphine?
no histamine release so shouldnt drop BP
237
what is the last muscle to become paralyzed (and first to recover)?
diaphragm
238
which muscle is the first to go down (and last to recover)?
face/neck
239
what is the first sign of malignant hyperthermia?
increase in end tidal CO2
240
what is the mechanism of dantrolene?
inhibits Ca release from muscle
241
how is rocuronium metabolized?
liver
242
how is pancuronium metabolized?
kidney
243
how is cisatricurium metabolized?
hoffman elimination
244
what is main side effect of cisatricurium?
hypotension
245
how is vecuronium metabolized?
heatic-biliary
246
how do neostigmine and edrophonium work?
block acetylcholineesterase
247
what is the maximum dose of local lidocaine?
5mg/kg (7 if with epi), so if 1% lidocaine can use 0.5cc/kg
248
what is ASA class 1?
healthy patient
249
what is ASA class 2?
mild disease without limitation
250
what is ASA class 3?
severe disease
251
what is ASA class 4?
disease is a severe constant threat to life
252
what is ASA class 5?
moribund, impending death
253
what is ASA class 6?
organ donor
254
when does a person who has had a CABG need pre-op testing?
if >5 years since CABG
255
when does someone who had cardiac stents placed need pre-op testing?
if >2 years since stents
256
how long to wait after MI for elective surgery?
6-8 weeks
257
what is the usual origin and location of replaced right hepatic artery?
off of SMA, coursing posterior/lateral to CBD
258
how long after cardiac stents requires preop cardiac workup?
> 2 years
259
how long after CABG requires preop cardiac workup?
>5 years
260
what is the blood supply to the thymus?
inferior thyroid artery and internal mammary artery
261
what is pyridostigmine?
cholinesterase inhibitor, used for myesthenia gravis
262
what is the composition of normal saline?
154 Na and 154 Cl
263
what is the composition of LR?
130 Na, 4 K, 2.7 Ca, 109 Cl, 28 lactate
264
what is the equation for plasma osmolarity?
(2 x Na) + (glucose/18) + (BUN/2.8)
265
what is the standard dose of maintenance fluid?
4:2:1 rule (by 10kg increments)
266
what is the best indicator of adequate fluid resuscitation?
urine output
267
what are the benefits of adding dextrose to IVF?
stimulates insulin release to increase glucose and amino acid uptake, protein synthesis, and prevent protein catabolism
268
what metabolic abnormality can be caused by normal saline?
non-anion gap metabolic acidosis
269
what is the maximum does of bupivicaine?
2 (or 2.5) mg/kg
270
what is the pressor of choice if hypotension is due to epidural?
phenylephrine
271
order of rapid sequence intubation?
preoxygenate, induction, muscle relaxant/paralytic, intubation
272
what comorbidities are most associated with post op death?
#1 renal failure, #2 CHF
273
what is the proper replacement fluid for sweat?
1/2 NS
274
what electrolyte is concentrated in saliva?
K
275
how much fluid is secreted by the stomach daily?
1-2 L
276
what electrolytes are lost in stomach fluid?
H and Cl
277
what is the proper replacement fluid for stomach losses?
D5 1/2 NS with 20K
278
how much fluid is secreted by the pancreas daily?
500cc - 1 L
279
what is the main electrolyte secreted in pancreatic fluid?
bicarb
280
what is the replacement fluid of choice for pancreatic secretion?
LR
281
what is the replacement fluid for biliary losses?
LR
282
how much fluid is secreted by the biliary system daily?
500cc - 1L
283
what is the main electrolytes lost in small bowel fluid (ie fistula, ileostomy?)
bicarb and K
284
what is the replacement fluid of choice for small bowel losses?
LR
285
what is the main electrolyte lost from the colon?
K
286
what is the replacement fluid of choice for colonic losses?
LR
287
what is the equation for FeNa?
((plama Cr x urine Na) / (Urine Cr x plasma Na)) x 100
288
what causes hypernatremia the majority of the time?
dehydration
289
what is the amount Na can be corrected in hypernatremia?
0.7 meq/L/h
290
how do you calculate free water deficit?
0.6 x kg x ((Na/140) - 1)
291
what is the usual cause of hyponatremia?
fluid overload
292
what is the amount Na can be corrected in hyponatremia?
0.5 meq/L/h
293
what are the most common causes of hypercalcemia?
hyperparathyroidism, then malignancy
294
which cancers cause hypercalcemia?
lung and breast
295
how do you treat hypercalcemic crisis?
NS rapid infusion, lasix, dialysis
296
what is the best treatment of hypercalcemia caused by malignancy?
bisphosphonates
297
what EKG change is seen in hypercalcemia?
shortened QT
298
what EKG change is seen in hypocalcemia?
prolonged QT
299
how to correct Ca for low albumin?
add 0.8 for each 1 below 4
300
what is the best treatment for hypermagnesemia?
calcium
301
what metabolic derangement is seen with excessive gastric loss?
hypochloremic hypokalemic metabolic alkalosis with paradoxical aciduria
302
how many calories are in fat?
9 kcal/g
303
how many calories are in protein?
4kcal/g
304
how many calories are in carbs?
4 kcal/g
305
how many calories are in dextrose?
4 kcal/g
306
how many calories are in alcohol?
7 kcal/g
307
how many calories does the average person need per day?
25 kcal/kg/d
308
how much protein does the average person need per day?
1-1.5g/kg/d (about 20% of daily intake)
309
how much does severe illness/trauma increase caloric need?
20-60%
310
how much does pregnancy increase caloric need?
300 kcal/d
311
how much does lactation increase caloric need?
500 kcal/d
312
how much does burns increase caloric need?
add 30 kcal/d x % burned to the standard requirement
313
how much does burns increase protein requirement?
add 3g x % burned to the standard requirement
314
what factors are included in the harris benedict equation?
weight, height, age, gender
315
how does fever change energy expenditure?
basal metabolic rate increases 10% for each degree over 38.0
316
what is the primary energy source for the brain?
glucose
317
how long does it take for the body's glycogen stores to be gone?
18-24 hours
318
what activates trypsinogen?
enterokinase from duodenum
319
what is the major fuel source of the stomach?
glutamine
320
what is the main fuel source of small bowel enterocytes?
glutamine
321
what is the main fuel source of the pancreas?
glutamine
322
what is the main fuel source of the spleen?
glutamine
323
what is the major fuel source of the liver?
ketones
324
what is the main fuel source of large bowel colonocytes?
short chain fatty acids (butyrate)
325
what is the main fuel source of the heart?
short chain fatty acids
326
what is the main fuel source of skeletal muscle?
glucose
327
what is the main fuel source of the brain?
glucose
328
what is the main fuel source of kidney?
glucose
329
what is the main fuel source of peripheral nerves?
obligate glucose
330
what is the main fuel source of the adrenal medulla?
obligate glucose
331
what is the main fuel source of RBCs?
obligate glucose
332
what is the main fuel source of PMNs?
obligate glucose
333
what is the main fuel source of lymphocytes and macrophages?
glutamine
334
what is the main fuel source of cancer cells?
glutamine
335
what is the equation for respiratory quotient?
CO2 produced / O2 consumed
336
what respiratory quotient is indicative of overfeeding?
>1
337
what respiratory quotient is indicative of starvation?
<0.7
338
what respiratory quotient is indicative of pure fat metabolism?
0.7
339
what respiratory quotient is indicative of pure protein metabolism?
0.8
340
what respiratory quotient is indicative of pure carb metabolism?
1.0
341
what respiratory quotient is considered "balanced feeding"?
0.825
342
what is the half life of albumin?
20 days
343
what is the half life of transferrin?
8 days
344
what is the half life of prealbumin?
2 days
345
what is the primary substrate of gluconeogenesis?
alanine
346
what inflammatory marker mediates cachexia?
TNF-a
347
what are the symptoms of chromium deficiency?
hyperglycemia, confusion, neuropathy
348
what are the symptoms of selenium deficiency?
cardiomyopathy, hypotheyroidism, neuro changes
349
what are the symptoms of copper deficiency?
pancytopenia, neuropathy/ataxia
350
what are the symptoms of zinc deficiency?
rash, blisters, chronic wounds, wasting
351
what are the symptoms of thiamine (B1) deficiency?
wernicke's enceophalopathy, gaze palsy, cardiomyopahty, neuropathy
352
what are the symptoms of pyridoxine (B6) deficiency?
seizures, cheilitis, neuropathy
353
what are the symptoms of cobalmin (B12) deficiency?
megaloblastic anemia, beefy tongue, neuropathy
354
what are the symptoms of folate deficiency?
megaloblastic anemia, beefy tongue
355
what are the symptoms of niacin deficiency?
pellagra (diarrhea, dementia, dermatitis)
356
what are the symptoms of essential fatty acid deficiency?
thrombocytopenia, dermatitis, hair loss, poor wound healing
357
what are the symptoms of vitamin A deficiency?
night blindness
358
what are the symptoms of vitamin D deficiency?
rickets, osteomalacia
359
what are the symptoms of vitamin E deficiency?
neuropathy, spinocereballar ataxia
360
what are the symptoms of vitamin K deficiency?
coaguloapthy
361
where does the majority of the body's vitamin K come from?
produced by bacteria in the intestines
362
what is the most common cancer in women?
breast
363
what is the most common cause of cancer related death in women?
lung
364
what is the most common cancer in men?
prostate
365
what is the most common cause of cancer related death in men?
lung
366
what cancers are caused by EBV?
burkitt's lymphoma, nasopharyngeal CA, and post-transplant lymphoproliferative disorder
367
what cancers are caused by coal tar?
larynx, skin, bronchial
368
what cancer is caused by beta-naphthylamine?
urinary tract
369
what cancer is caused by benzenes?
leukemia
370
what is the most common cancer in a suspicious axillary lymph node?
lymphoma
371
what is the most common cancer to metastasize to the small bowel?
melanoma
372
what is the most common cancer to metastasize to the spleen?
colorectal
373
what is the most common cancer to metastasize to the brain?
lung
374
what is the most common cancer to metastasize to the adrenal gland?
lung
375
what is the most common cancer to metastasize to the kidney?
breast
376
what are the side effects of cisplatin?
nephrotoxic, neurotoxic, ototoxic
377
what are the side effects of carboplatin?
myelosupression
378
what are the side effects of oxaloplatin?
nephrotoxic, neuropathy, ototoxic, cold sensitivity
379
what is the side effect of busulfan?
pulmonary fibrosis
380
what is the treatment medication for metastatic melanoma?
dacarbazine
381
what is the medication tx for pancreatic islet cell tumors?
streptozocin
382
what are the side effects of methotrexate?
renal toxicity, radiation recall
383
what is the tx of methotrexate toxicity?
leucovorin
384
what is the mechanism of methotrexate?
inhibits dihydrofolate reductase to inhibit purine and DNA synthesis
385
what is the mechanism of 5FU?
inhibits thymidylate synthase to inhibit purine and DNA synthesis
386
what are the side effects of tamoxifen?
blood clots, endometrial cancer
387
what are the side effects of aromatase inhibitors?
bone fractures
388
what cancers are treated with bevacizumab?
colorectal and non-small cell lung
389
what cancer is treated with rituximab?
non-hodgkins lymphoma
390
what cancer is treated with imatinib?
GIST tumors
391
what drug is used to treat metastatic or unresectable adrenal cancer?
mitotane
392
what phase of the cell cycle is most vulnerable to radiation?
m phase
393
tumor marker: ABC-B5
melanoma
394
tumor marker: S-100
melanoma
395
tumor marker: CEA
colon cancer
396
tumor marker: AFP-L3
HCC
397
tumor marker: DCP (des gamma carboxyprothrombin)
HCC
398
tumor marker: CA 19-9
pancreatic CA
399
tumor marker: CA 125
ovarian CA, endometrial CA
400
tumor marker: b-HCG
testicular CA, choriocarcinoma
401
tumor marker: PSA
prostate CA
402
tumor marker: NSE
small cell lung CA, neuroblastoma
403
what is the most important prognostic factor in breast CA?
nodal status
404
what is the most important prognostic factor for sarcomas?
tumor grade
405
what is the main side effect of trastuzumab?
cardiomyopathy
406
how much IVF to give kids in trauma bay?
20cc/kg bolus of LR
407
how much blood to give kids in trauma bay?
10cc/kg
408
where to incise pericardium during ED thoracotomy?
longitudinally anterior to phrenic nerve
409
what maneuver is best for retroperitoneal aorta exposure?
mattox
410
what maneuver is best for retroperitoneal IVC exposure?
cattel braasch
411
what is the supposed indication for DPL?
blunt trauma with hypotension
412
what indicates a positive DPL?
>10cc blood, >100,000 RBCs/cc, food particles, bile, bacteria, >500 WBC/cc
413
what is the cause of traumatic subdural hematoma?
tearing of bridging veins between dura and arachnoid plexus
414
what are indications for operating on a subdural?
midline shift >1cm or significant neuro degeneration
415
what is the cause of traumatic epidural hematoma?
usually middle meningeal artery injury
416
what are the indications for operating on an epidural hematoma?
midline shift >5mm or neuro degeneration
417
where on the skull do you drill burr holes?
5cm anterior and superior to external auditory canal
418
what is equation for cerebral perfusion pressure?
MAP minus ICP (ideal is >60)
419
what is the treatment for diabetes insipidus?
replace with D5, DDAVP
420
what is the treatment for SIADH?
fluid restriction first, diuresis, treat underlying cause, if refractory then 3% hypertonic saline
421
GCS motor function?
6= follows commands, 5= localizes to pain, 4= withdraws from pain, 3= decorticate flexion to pain, 2= decerebrate extension to pain, 1= no response
422
GCS verbal response?
5= oriented x3, 4= confused by responds, 3= inappropriate words, 2= incomprehensible sounds/grunting, 1= no response
423
GCS eye score?
4= spontaneous opening, 3= opens to command, 2= opens to pain, 1= nothing
424
what is the most important prognostic indicator in GCS?
motor score
425
type 1 dens fracture, and tx?
stable through tip of dens, rigid collar
426
type 2 dens fracture, and tx?
unstable through dens base, needs halo for 3 months or internal fixation
427
type 3 dens fracture, and tx?
unstable through vertebral body, halo for 3 months or internal fixation
428
what is the most common cervical spine fracture?
dens
429
what deems a spine fracture unstable?
2 of 3 columns fractured
430
what is type 1 le fort fracture and tx?
- across maxilla, maxillo mandibular fixation (MMF) +/- miniplates
431
what is type 2 le fort fracture and tx?
/ \ lateral to nasal bone, underneath eyes, down towards maxilla, MMF +\- miniplates
432
what is type 3 le fort fx and tx?
- - lateral to orbital wall, MMF and miniplates
433
timing of nerve repair (ex: facial nerve)?
within 3 days; if contaminated then washout and tag ends, repair in 30 days
434
what is the most common cause of facial nerve injury?
temporal bone fracture
435
tx for refractory nose bleeds?
embolization of internal maxillary artery or ethmoidal artery
436
what is zone 1 of the neck?
clavicle to cricoid cartilage
437
what is zone 2 of the neck?
cricoid cartilage to angle of mandible
438
what is zone 3 of the neck?
angle of mandible to base of skull
439
zone 1 neck injury tx?
angio, bronch, EGD, swallow study.
440
incision for zone 1 neck injury?
median sternotomy
441
zone 2 neck injury tx?
explore all if penetrates platysma
442
incision for zone 2 neck injury?
lateral neck incision
443
zone 3 neck injury tx?
angio and laryngoscopy
444
incision for zone 3 neck injury?
jaw subluxation, release of SCM and digastric mm., may need to resect mastoid sinus
445
diagnosis for esophageal injury?
EGD and barium swallow
446
how to repair esophageal injury?
2 layers (absorbable mucosa, nonabsorbable outer layer) with muscle flap covering
447
tx for carotid dissection?
if symptomatic, stent. if asymptomatic, anticoagulate
448
tx for carotid thrombosis?
if still flow, then open repair (primary or graft), if no flow, anticoagulate to prevent propegation
449
incidence of stroke after ligation of carotid artery?
20%
450
tx for vertebral artery dissection or thrombosis?
anticoagulate
451
tx for vertebral artery bleed?
angioembolization
452
what are the boarders of the "box" in chest trauma?
xiphoid, nipples, clavicles
453
indications for OR thoracotomy after chest tube placement?
>1000-1500 initial output, >250cc/h for 3 hours, unstable pt
454
what is the cause of respiratory impairment in flail chest?
underlying pulmonary contusion
455
approach to diaphragm repair based on timing?
if < 1 week, transabdominal. if >1 week, chest
456
most common location of tear in aortic transection?
ligamentum arteriosum (slightly distal to left subclavian artery)
457
which injuries should be addressed through a left thoracotomy rather than sternotomy?
distal left subclavian, descending thoracic aorta
458
what is the incision for distal right subclavian injury?
right mid-clavicular incision with possible clavicle
| resection
459
what is the most common cause of death after heart contusion?
v-fib
460
what is the most common arrhythmia after heart contusion?
black book says SVT, score says PVCs
461
how to fix CBD injuries with <50% circumference damage?
primary repair over a stent
462
how to fix CBD injuries with >50% circumference damage?
choledochojejunostomy
463
what is the most common cause of hemobilia?
hepatic artery to biliary duct fistula, usualy 4 weeks after a trauma
464
what is the tx of choice for hemobilia from fistula?
angioembolization
465
what immunizations are required after splenectomy?
pneumococcus, H. influenza, meningitis
466
what determines whipple vs distal pancreatectomy in trauma (based on location)?
whether proximal or distal to SMV
467
when is graft required for arteries instead of primary repair?
if >2cm
468
what mediates reperfusion injury?
PMNs
469
what structures are in the anterior compartment of the calf?
anterior tibial artery, deep peroneal nerve
470
what structures are in the lateral compartment of the calf?
superficial peroneal nerve
471
what structures are in the deep posterior compartment of the calf?
posterior tibial artery, peroneal artery, tibial nerve
472
what structures are in the superficial posterior compartment of the calf?
sural nerve
473
how does the trifurcation appear on angio?
anterior tibial artery branches off first and goes laterally, peroneal artery is middle, posterior tibial artery is medial
474
structure most likely damaged with: anterior humerus dislocation?
axillary nerve
475
structure most likely damaged with: posterior humerus dislocation?
axillary artery
476
structure most likely damaged with: proximal humerus fx?
axillary nerve
477
structure most likely damaged with: midshaft humerus fx?
radial nerve
478
structure most likely damaged with: distal (supracondylar) humeral fx?
brachial artery
479
structure most likely damaged with: elbow dislocation?
brachial artery
480
structure most likely damaged with: distal radial fx?
median nerve
481
structure most likely damaged with: anterior hip dislocation?
femoral artery
482
structure most likely damaged with: posterior hip dislocation?
sciatic nerve
483
structure most likely damaged with: distal femur fx?
popliteal artery
484
structure most likely damaged with: posterior knee dislocation?
popliteal artery
485
structure most likely damaged with: fibular neck fracture?
common peroneal nerve
486
median nerve innervation in the hand?
sensation 1st 3.5 fingers on palmar side, motor finger flexors and thumb flexion
487
ulnar nerve innervation in the hand?
sensory to 5th and 0.5 of 4th digit, motor to wrist flexion and intrinsic hand muscles
488
radial nerve innervation in the hand?
sensory to 1st 3.5 digits on back of hand, motor to wrist and finger extensors
489
what nerve innervates the deltoid?
axillary
490
what is deficit with L3 nerve?
weak hip flexion
491
what is deficit with L4 nerve?
weak knee extension and weak patellar reflex
492
what nerve causes foot drop?
deep peroneal nerve, (L5 root). check sensation at big toe web.
493
best initial test for ureteral injury?
IV pyelogram
494
which ureteral injuries can be primarily repaired?
<2cm in top 2/3; lower 1/3 still reimplant into bladder
495
how to repair ureter if >2cm and in top 1/3 or middle?
trans-ureteroureterostomy
496
how to repair ureter if >2cm and in lower 1/3?
reimplant into bladder (5-0 PDS), may need psoas hitch to help reach
497
how to handle partial transection of ureter?
repair over stent
498
where is right renal artery in relation to IVC?
posterior to IVC
499
where is left renal vein in relation to aorta?
usually anterior, but beware for posterior location when clamping aorta
500
which renal vein can be ligated vs must be repaired?
left can be ligated due to collaterals via adrenal; right must be repaired
501
what is the best test for urethral injury?
retrograde urethrogram
502
how to treat significant urethral injury?
suprapubic tube for 2-3 months then delayed repair
503
how to treat small, partial urethral injury?
foley across tear for 3 weeks
504
what is the cutoff for fetus viability in trauma?
24 weeks
505
how to assess fetal maturity in pregnant trauma patient?
LS ratio >2:1, positive phosphatidylcholine
506
what is the most common cause of placental abruption in pregnant trauma patient?
shock; 2nd is mechanical disruption
507
what is the utility of kleihauer betke test?
detects fetal blood in maternal circulation to identify placental abruption or hemorrhage in pregnant trauma patient
508
where is the most common site for uterine rupture?
posterior fundus
509
what temperature in hypothermia qualifies for cardiac bypass?
<27 degrees
510
what is the most common cause of immediate death in electrical injuries?
cardiac arrest
511
what is the most common cause of immediate death in lightening strike?
electrical paralysis of brainstem
512
what is the most common cause of death overall in electrical injuries?
infection
513
what is the difference between AC and DC electricution?
AC has same entrance and exit site, more damaging. DC has different entrance and exit sites
514
which abdominal zone 1 hematomas should be explored?
all
515
which abdominal zone 2 hematomas should be explored?
penetrating only
516
which abdominal zone 3 hematomas should be explored?
penetrating only
517
what landmark differentiates abdominal zone 1 from 2?
psoas
518
what class of shock demonstrates tachycardia?
class 2+
519
what class of shock demonstrates hypotension?
class 3+
520
what is the definition of shock?
inadequate tissue oxygenation
521
what is the body's first response to hemorrhagic shock?
increased diastolic pressure due to vasoconstriction
522
what is the last vital sign to change in shock with kids?
blood pressure
523
what is the most common organ injured in penetrating abdominal trauma?
small bowel
524
what is the most common organ injured in blunt abdominal trauma?
spleen (some say liver)
525
what is the tx for brown recluse spider bite?
dapsone
526
what is the best way to approach the left mainstem bronchus?
right thoracotomy
527
indications for perimortum c section?
fetus >24 weeks, aim for c section within 4 minutes of arrest but is contraindicated after 20 min of CPR
528
what is normal cardiac output?
4-8L/min
529
what is normal cardiac index?
2.5-4L/min
530
what is normal systemic vascular resistqnce?
800-1400 (1100)
531
what is normal pulmonary capillary wedge pressure?
7-11
532
what is normal CVP?
3-7
533
what is the best pressor for septic shock?
norepinephrine
534
what is the best pressor for cardiogenic shock?
dobutamine
535
what is the initial finding on ECHO in early tamponade?
impaired right atrial filling in diastole
536
what is the best pressor for neurogenic shock?
phenylephrine
537
what is the most common cause of adrenal insuffiency?
withdrawal of exogenous steroids
538
what is waterhouse-friederichsen syndrome?
bilateral adrenal hemorrhage leading to adrenal insuffiency
539
which steroid does not interfere with cosyntropin stim test?
dexamethasone
540
what is the clinical presentation of an intubated patient with acute PE?
sudden crease in end tidal CO2 and hypotension
541
which DVT is most likely to result in PE?
iliofemoral
542
what are the systemic alpha 1 effects?
arterial and venous vasoconstriction; gluconeogenesis and glycogenolysis
543
what are the alpha 2 systemic effects?
venous vasoconstriction
544
what are the beta 1 systemic effects?
increased contractility and HR
545
what are the beta 2 systemic effects?
vasodilation, bronchodilation, increased glucagon and renin
546
what are the systemic effects of dopamine?
renal blood vessel relaxation, sphlanchnic smooth muscle relaxation
547
what are the effects of V1 receptors?
vascular smooth muscle constriction
548
what are the effects of V2 receptors?
water resorption from the collecting ducts
549
what are the effects of V3 receptors?
VIII and vWF release from endothelium
550
what is the mechanism of milrinone?
inhibits cAMP phosphodiesterase
551
dopamine action based on dose?
low: DA receptors, medium: contractility and increase HR; high: alpha 1
552
what receptors does dobutamine act on?
mostly B1, some B2 at high doses
553
what receptors does phenylephrine act on?
just alpha 1
554
what receptors does norepinephrine act on?
mostly alpha 1 and 2, some beta 1
555
what receptors does epinephrine act on?
low: beta 1 and 2, high: alpha 1 and 2
556
what receptors does vasopressin act on?
V1
557
what is the tx of nipride toxicity?
amyl nitrite first then sodium nitrite
558
what is the most common cause of delayed discharge after cardiac surgery?
a-fib
559
what is the most renally protective measure when someone with CKD needs contrast study?
pre-hydration
560
what is the most common cause of post-op ATN?
intraoperative hypotension
561
why does atelectasis cause fever?
IL-1 released from macrophages
562
what NIF is suitable for extubation?
>20
563
what RSBI is suitable for extubation?
<105
564
what is the most common cause of ARDS?
pneumonia
565
what is considered a positive apnea test for brain death?
increase of CO2 to >60 or increase by 20; negative if BP drops below 60 or pt desaturates
566
what reflex can remain present in brain death?
deep tendon reflexes
567
what bladder pressure indicates abdominal compartment syndrome?
>20
568
what complication can topical benzocaine cause during EGD?
methemoglobinemia
569
how does harmonic scalpel cause coagulation?
disrupts the protein hydrogen bonds
570
how does dabigatran affect coags?
prolonged PTT
571
which burns need grafting?
deep 2nd degree and above
572
how do 1st and superficial 2nd degree burns heal?
epithelialization from hair follicles
573
what is the parkland formula for burns?
4cc x kg x % burn (besides 1st degree). give 1/2 in first 8 hours and the rest in the remaining 16h of 24h period, if total is >20%
574
what topical burn tx should be put over cartilage?
sulfamylon
575
when is a burn considered infected?
>10^5 bacteria on culture OR if the cx shows any B hemolytic strep
576
what are the benefits of STSG?
more likely to survive, can cover larger area
577
what are the benefits of FTSG?
less wound contraction, better color match
578
how do skin grafts survive depending on time frame?
imbibition 0-3 days, neovascularization day 3+
579
what is the most common cause of skin graft loss?
seroma/hematoma under graft
580
what nutrient do burn wounds need?
obligatory glucose user
581
what is the most common infection in significant burn patients?
pneumonia
582
what is the most common organism in burn wound infection?
pseudomonas
583
most common viral infection in burn wound?
HSV
584
what is the best tx for an infected burn wound?
excision with allograft and systemic antibiotics
585
which topical burn tx is good for eschar?
sulfamylon (mafenide sodium)
586
what are the side effects of silvadene (silver sulfadiazine)?
neutropenia and thrombocytopenia
587
what are the side effects of silver nitrate?
electrolyte imbalances and methemoglobinemia
588
which topical burn tx is good for pseudomonoas?
sulfamylon
589
what are the side effects of sulfamylon?
metabolic acidosis due to carbonic anhydrase inhibition, hypersensitivity reactions
590
what is a normal carbon monoxide (carboxyhemoglobin) level?
10% in normal people and 20% in smokers
591
what is the tx for carbon monoxide poisoning?
100% O2 and consider hyperbarics
592
what are the clinical suspicions for cyanide poisoning?
lactic acidosis and elevated O2 on ABG
593
what is the tx for cyanide poisoning?
methylene blue and 100% O2
594
what is the tx for corneal abrasion/eye burn?
topical fluoroquinolone ointment
595
what is a marjolin ulcer?
squamous cell carcinoma in an old burn/chronic wound
596
what kind of necrosis occurs with alkaline materials?
liquefaction necrosis
597
what kind of necrosis occurs with acidic materials?
coagulation necrosis
598
how do you treat hydrofluoric acid burns?
topical calcium to neutralize
599
what is the difference between TEN and SJS?
TEN is >30%, SJS is <10%; though both are detachment of epidermis from dermis
600
what are the borders of the anterior neck traingle?
anterior border of SCM, sternal notch, inferior border of digastric, and trachea
601
what structures are in the anterior neck triangle?
carotid, IJ, an vagus
602
what are the borders of the posterior neck triangle?
posterior border of SCM, trapezius, clavicle
603
what structures are in the posterior neck triangle?
spinal accessory nerve and brachial plexus
604
what is frey's syndrome?
gustatory sweating from injury to auriculotemporal nerve that crosses with sympathetic nerve fibers
605
what are the branches of the thyrocervical trunk?
"STAT": supracervical artery, transverse cervical artery, ascending cervical artery, inferior thyroid artery
606
what is the first branch of the external carotid artery?
superior thyroid artery
607
what is the blood supply to a trapezius muscle flap?
tranasverse cervical artery
608
what is the blood supply to a pectoralis major muscle flap?
thoracoacromial artery
609
what is the most common CA in a metastatc cervical lymph node?
squamous cell CA
610
what is the most common site of oral cavity cancer?
lower lip (usually squamous)
611
what is the tx for nasopharyngeal SCC?
chemo + radiation
612
what margin is needed for oral cavity cancers?
1cm except for tongue needs 2cm
613
what is the chemo regimen. of choice for oral cancers?
5fu and cisplatin
614
what is commando procedure?
removal of tongue ca with partial mandible resection
615
what is the most common benign tumor of the nasopharynx and larynx?
papilloma
616
what is the most common tumor of the nasopharynx in kids?
lymphoma
617
what is the tx for nasopharyngeal angiofibroma?
angioembolization (usually internal maxillary artery) then resection
618
what is the most common benign parotid tumor?
pleomorphic adenoma
619
what is the most common malignant tumor of the salivary glands?
mucoepidermoid CA
620
what is the most commonly injured nerve in parotid surgery?
greater auricular nerve
621
what is the most common malignant tumor of minor salivary glands?
adenoid cystic CA
622
what is a modified radical neck dissection?
resection of omohyoid, submandibular gland, sensory nerves C2-C5, cervical branch of facial nerve, and cervical chain LNs. attempt to spare 1 or 2 of spinal accessory nerve, IJ, or SCM. radical neck dissection takes all of these, rarely done.
623
what is the origin of thyroglossal duct cyst?
foramen cecum
624
where are 1st bronchial cleft cysts located?
angle of mandible
625
where are 2nd bronchial cleft cysts located?
anterior to SCM (goes through carotid bifurcation and into tonsillar pillar
626
where are 3rd bronchial cleft cysts located?
deep in SCM, emerge from pyriform sinus
627
where are cystic hygromas found?
posterior neck triangle, often on the left
628
what is the most common organism in suppurative parotitis?
staph
629
what is the most common organism in ludwig's angina?
actinomyces
630
what is the most common benign head and neck tumor in adults?
hemangioma
631
what is the most common organism of mastoiditis?
strep pneumo
632
what organism causes epiglottitis?
h. d e
633
what is secreted by the adrenal glomerulosa?
aldosterone
634
what is secreted by the adrenal fasiculata?
glucocorticoids
635
what is secreted by the adrenal reticularis?
androgens and estrogens
636
what is the role of tyrosine hydroxylase?
converts tyrosine to dopa
637
what is the role of PNMT?
converts norepi to epi
638
what is the most common extra-adrenal site of neural crest tissue?
organ of zuckerkandl
639
what is the most common cause of congential adrenal hyperplasia?
21 hydroxylase deficiency
640
what is the most common casue of malignant incidental adrenal mass?
mets from lung cancer
641
what size indicates need for resection in incidental adrenal tumor?
4cm
642
what CT features are suspicious for malignancy in adrenal tumor?
>10 houndsfield units, washout takes more than 10 minutes, irregular bordersheterogenous, dense, hemorrhagic areas
643
what drug is used for medical treatment of adrenal tumor?
mitotane
644
what is the best test for diagnosis of pheochromocytoma?
24h urine collection
645
what do you ligate first when resecting pheochromocytoma?
adrenal vein, to prevent cathecholamine spillage
646
what is the surgery of choice for adrenal cancer?
OPEN not MIS
647
what hormones are secreted by the posterior pituitary?
ADH and oxytocin
648
what is the most common pituitary tumor?
prolactinoma
649
where is the thyroid derived from?
1st and 2nd pharyngeal pouch
650
where is the ligament of berry?
posterior, medial
651
where is the tubercle of zukerkandl?
posterior, lateral
652
what gives rise to the superior thyroid artery?
first branch of external carotid
653
what does the inferior thyroid artery supply?
both inferior and superior parathyroids
654
where does the thyroid ima artery come from?
aorta or inominate
655
where do superior and middle thyroid veins drain to?
IJ
656
where does inferior thyroid vein drain to?
innominate
657
what does the recurrent laryngeal nerve innervate?
motor to all of larynx except cricothyroid mm.
658
what innervates the cricothyoid muscle?
superior laryngeal nerve (external branch)
659
where is the recurrent laryngeal nerve found at the thyroid area?
posterior in the tracheoesophageal groove, can track with the inferior thyroid artery
660
what is non-recurrent laryngeal nerve associated with?
right aberrant subclavian artery off the descending thoracic aorta
661
where is the superior laryngeal nerve found?
superior and lateral to thyroid lobes; runs with superior thyroid artery
662
what is the ratio of T4:T3 in serum?
20:1
663
where does most T3 come from?
produced in the periphery from T4 by deiodinases
664
which is more potent, T3 or T4?
T3 is 4x more potent
665
what test is the most sensitive for thyroid gland function?
TSH
666
what is the best initial test for thyroid nodule?
FNA via US
667
what tests help predict prognosis of thyroid lymphoma?
LDH and b-2 microglublin, worse prognosis
668
what is the treatment for thyroid lymphoma?
chemo and radiation
669
what is linked to causing thyroid lymphoma?
hashimotos
670
what is the most common type of thyroid cancer?
papilary (PTC)
671
what is the problem with FNA if it shows follicular cells?
cant differentiate adenoma vs cancer
672
what US features are concerning for malignancy in thyroid nodule?
hypoechoic, irregular margins, hypervascular, microcalcifications, taller than wide
673
how to treat thyroid adenoma?
must do lobectomy to prove it isnt cancer
674
what is bethesda 1 in thyroid nodule?
non-diagnostic, unsatisfactory requiring repeat FNA
675
what is bethesda 2 in thyroid nodule?
benign, clinical f/u
676
what is bethesda 3 in thyroid nodule?
atypia, repeat FNA, cllnical follow up, maybe lobectomy
677
what is bethesda 4 in thyroid nodule?
follicular neoplasm, requires lobectomy
678
what is bethesda 5 in thyroid nodule?
suspicious for CA, requires lobectomy with frozen section and if + then proceed with CA operation
679
what is bethesda 6 in thyroid nodule?
malignant, requires CA operation
680
what are the pathologic hallmarks of papillary thyroid carcinoma?
psammoma bodies, orphan annie nuclei
681
how does papillary thyroid carcinoma spread?
lymphatics, often to lung
682
what is the most common cause of death in papillary thyroid carcinoma?
local invasion (predicts prognosis)
683
what are the indications for total thyroidectomy in Papillary and follicular thyroid CA?
>1cm, extrathyroidal disease (capsular invasion, positive nodes, mets), multicentric or bilateral, previous XRT
684
when is radiation indicated for thyroid carcinoma?
unresectable not responsive to radioactive iodine
685
what lab test can be followed after surgery to eval for recurrence of thyroid cancer?
thyroglobulin
686
what if you have an enlarged neck lymph node that shows thyroid tissue on biopsy?
this is papillary thyroid cancer with lymphatic spread
687
how does follicular thyroid cancer spread?
hematogenous, goes to bone (50% have mets at time of diagnosis)
688
what are the risk factors for mets/recurrence in thyroid cancer?
grade, age <20 or >50, mets, male gender, extrathyroidal disease, size >1cm (GAMES)
689
what calcitonin level is concerning for metastatic medullary thyroid CA?
>400 preop; do staging imaging
690
what MEN syndrome has worst prognosis for medullary thyroid CA?
MEN 2B
691
what are the symptoms of medullary thyroid CA?
diarrhea, flushing
692
what is the pathologic evaluation of medullary thyroid cancer?
neural crest cells, from parafollicular C cells that secrete calcitonin; gastrin causes increased calcitonin; amyloid seen on path
693
what is the treatment for medullary thyroid CA?
total thyroid with central LN dissection and MRND on side of tumor
694
when should prophylactic thyroidectomy be done in MEN2a?
6 years old (include central node dissection)
695
when should prophylactic thyroidectomy be done in MEN2b?
at 2 years old (include central node dissection)
696
what lab can be tracked for recurrence of medullary thyroid CA?
calcitonin
697
what is the path of hurthle cell carcinoma of the thyroid?
ashkenazi cells, must do lobectomy to confirm benign
698
which thyroid cancers are responsive to radioactive iodine?
papillary and follicular
699
who can not get radioactive iodine?
kids, pregnant women, breast feeding women
700
what is the most common cause of hyperthyroidism?
grave's disease
701
what causes grave's disease?
IgG antibodies that stimulate thyroid
702
what are the side effects of PTU and methimazole?
aplastic anemia and agranulocytosis (also methimazole is toxic to baby in pregnancy)
703
which anti-thyroid medication can be used in hyperthyroidism in pregnancy?
PTU
704
what is the most common casue fo death in thyroid storm?
high output cardiac failure
705
what is the most common casue of hypothyroidism in adults?
hashimoto's
706
where are the superior parathyroids?
posterior, lateral to RLN
707
what is the embryologic origin of the superior parathyroids?
4th pharyngeal pouch
708
where are the inferior parathyroids?
anterior, medial to RLN
709
what is the embryologic origin of the inferior parathyroids?
3rd pharyngeal pouch
710
what is the most common cause of hypoparathyroidism?
previous thyroid surgery
711
what electrolyte changes are seen in hyperparathyroidism?
increased calcium, decreased phosphorus; Cl to Phos >33:1
712
which cancer has the highest risk of causing hypercalcemia?
squamous cell lung CA
713
what gene increased risk of parathyroid adenoma?
PRAD-1 oncogene
714
what are indications for parathyroidectomy in ASYMPTOMATIC people?
Ca >13, (or >1 of higher than normal), Cr clearance decreased >30%, osteoporosic aka t score -2.5, urinary calcium >400mg in 24h, age <50, patient preference
715
when should you operative. on parathyroid cancer in pregnant woman?
2nd trimester, dont wait until baby is born
716
how to interpret intraop PTH level?
should drop >50% in 10 minutes
717
what is the most common ectopic location of parathyroid tissue?
thymus
718
what is the surgery of choice for parathyoid in MEN syndrome?
remove all 4 and reimplant one into forearm
719
what is the most common cause of secondary hyperparathyroidism?
chronic renal failure
720
what are the electolyte findings in secondary hyperparathyroidism?
^PTH, decreased Ca and ^ phos, ^ urine Ca cus kidney cant reabsorb it
721
how do you diagnose calciphylaxis?
skin biopsy
722
what causes death in parathyroid cancer?
the hypercalcemia
723
what lab values are elevated in parathyroid CA?
PTH, Ca, and alk phos
724
what is the most common site of mets in parathyroid CA?
lung
725
what is the surgical tx of parathyroid cancer?
parathyroidectomy, ipsilateral thyroidectomy, probably/usually central neck dissection
726
how does parathyroid CA differ clinically from adenoma?
usually Ca level is higher and the mass is palpable
727
what is the most common malignant cause of hypercalcemic crisis?
breast CA
728
what is the initial tx of hypercalcemic crisis?
IVF (not LR cus there is calcium in it) then lasix (not thiazide cus it absorbs calcium)
729
what gene is associated with MEN1?
Menin
730
what are the findings in MEN1?
pituitary tumors, parathyroid hyperplasia, pancreatic tumors
731
what is the most common pancreatic tumor in MEN1?
gastrinoma
732
what is the most common pituitary tumor in MEN1?
prolactinoma
733
what is the most common cause of death in MEN1?
the pancreatic tumor
734
if simultaneous tumors in MEN1, which do you operate on first?
hyperparathyroidism
735
what gene is associated with MEN 2a/b?
RET proto-oncogene
736
what are the findings in MEN2a?
parathyroid hyperplasia, pheochromocytoma, medullary thyroid CA
737
what is the most common symptom of medullary thyroid CA?
diarrhea
738
what is the most common cause of death in MEN2a?
medullary thyroid CA
739
if simultaneous tumors in MEN2a, which do you operate on first?
pheochromocytoma
740
when do you operate on the thyroid in MEN2a?
6 years old
741
what are the findings in MEN2b?
mucosal ganglioneuromas and pheochromocytoma; also medullary thyroid CA and marfanoid habitus
742
what is the most common cause of death in MEN2b?
medullary thyroid CA
743
when to operate on thyroid in MEN2b?
2 years old (more aggressive than 2a)
744
if simultaneous tumors in MEN2b, which do you operate on first?
pheochromocytoma
745
are the pheochromocytomas of MEN2 usually malignant or benign?
benign
746
what does the long thoracic nerve innervate?
serratus anterior
747
what is the resultant deficit from long thoracic nerve injury?
winged scapula
748
what artery supplies the serratus anterior?
lateral thoracic artery
749
what does the thoracodorsal nerve innervate?
latissimus dorsi
750
what does the medial pectoral nerve innervate?
pec major and minor
751
what does the lateral pectoral nerve innervate?
pec major
752
what is the most commonly injured nerve with mastectomy or axillary dissection?
intercostobrachial nerve
753
where is the intercostobrachial nerve encountered?
just below the axillary vein in the axilla
754
what cancers an spread via batson's plexus?
rectal, prostate, and breast
755
what is the most common cause of malignant axillary adenopathy?
lymphoma
756
what is the most common organism in mastitis?
staph aureus
757
what is poland's syndrome?
hypoplasia of chest wall with amastia and no pec muscle, hypoplatic shoulder, and webbing of fingers
758
what is mondor's disease? tx?
sclerosing superficial vein thrombophlebitis. of breast; NSAIDS
759
what is the most common breast lesion in adolescents and young women?
fibroadenoma
760
what breast lesion has "popcorn lesions" on mammography?
fibroadenoma
761
how to work up a mass suspected to be fiboadenoma?
if <30, US with FNA, and must feel clinically benign. if >30 mammogram, US, and excisional biopsy
762
what is the path description of a fibroadenoma?
prominent fibrous tissue compressing epithelial cells
763
what is the most common cause of bloody nipple discharge?
intraductal papilloma
764
which type of fibrocystic breast disease has cancer risk?
atypical ductal or lobular hyperplasia
765
how to treat atypical ductal hyperplasia?
resect suspicious area (do not need negative margins)
766
what is the cancer risk of LCIS?
30% in BOTH breasts; usually DUCTAL carcinoma that develops
767
how to treat LCIS?
resect suspicious area but do not need negative margins; then either close follow up or add tamoxifen/raloxifene (50% cancer reduction with these meds)
768
how is LCIS usually diagnosed?
generally not palpable or seen on mammogram *does not have calcifications* is incidentally found on bx for something else
769
how is DCIS usually diagnosed?
cluster of calcifications on mammogram
770
what is the cancer risk of DCIS?
50% in same breast
771
what are the variants of DCIS?
solid, cribiform, papillary, and comedo
772
what is the worst form of DCIS?
comedo
773
what is the required margin for DCIS?
2mm
774
what are the tx options for DCIS?
lumpectomy and radiation OR simple mastectomy and consider tamoxifen
775
what is the role of radiation. in DCIS?
decreases recurrence but does not change overall survivial
776
which DCIS need mastectomy instead of lumpectomy?
COMEDO, multi-focal or multi-centric, diffuse, re-resected and still + margins, cant get more XRT, high grade, recurrence, or male pt
777
what is the best way to diagnose intraductal papilloma?
ductogram
778
what is the cancer risk of diffuse papillomatosis?
40%, must excise
779
what factors are included in the GAIL risk assessment for breast cancer?
age, race, age at menarche, age of 1st live birth, number of 1st degree relatives with breast CA, and number of previous bx ; if >10% then do BRCA testing
780
which BRCA mutation has higher risk of ovarian CA?
BRCA 1 (40% compared to 10%)
781
which BRCA has higher risk of male breast CA?
BRCA 2 (10% compared to 1%)
782
what screening is required for someone with BRCA?
yearly mammogram and MRI starting at age 25, yearly pelvic with US and CA-125 starting at age 25
783
what is BIRADS 1?
normal mammogram, routine F/U
784
what is BIRADS 2?
benign finding, routine f/u
785
what is BIRADS 3?
probably benign, 6 month f/u imaging
786
what is BIRADS 4?
suspicious, rec core needle bx (will also end up resected)
787
what is BIRADS 5?
very highly suspicious, rec excisional bx
788
what is BIRADS 6?
biopsy proven cancer
789
what is a T1 breast mass?
<2cm
790
what is a T2 breast mass?
2-5cm
791
what is a T3 breast mass?
>5cm
792
what is a T4a breast mass?
chest wall involvement (not include pec muscle)
793
what is a T4b breast mass?
involves skin, peau d'orange
794
what is T4c breast mass?
both T4a and b combined
795
what is T4d breast mass?
inflammatory breast CA (erythema)
796
what is N1 breast lesion?
ipsilateral movable axillary nodes or 1-3 nodes
797
what is N2a breast CA?
fixed ipsilateral axillary nodes (N2 includes 4-9 nodes)
798
what its N2b breast CA?
clinically positive internal mammary nodes without axillary nodes
799
what is N3a breast CA?
ipsilateral infraclavicular nodes (N3 includes 10 or more nodes)
800
what its N3b breast CA?
ipsilateral axillary AND internal mammary nodes
801
what is N3c breast CA?
ipsilateral supraclavicular nodes (considered non-operable)
802
what is the most important prognostic factor in breast CA?
node status
803
how do the breast cancer receptors predict prognosis?
PR best, ER good, HER2/neu bad
804
what is the most common site of breast cancer mets?
bone
805
what is the most common type of breast cancer?
ductal carcinoma
806
what is stage 1 breast CA?
T1N0M0
807
what is stage 2a breast CA?
T0-1, N1, M0 or T2, N0, M0
808
what is stage 2b breast CA?
T2N1M0 or T3N0M0
809
what is stage 3a breast CA?
T0-3, N2, M0 or T3N1M0
810
what is stage 3b breast CA?
T4 N0-2 M0
811
what is stage 3c breast CA?
any N3
812
what is stage 4 breast CA?
any M1
813
what is the required margin for breast CA?
negative is negative
814
when is SLND indicated?
malignant tumor >1cm or DCIS undergoing total mastectomy
815
when is SLND contraindicated?
pregnancy, multicentric disease, neoadjuvant therapy, palpable nodes, advanced disease, previous ax dissection, tumor >5cm
816
what are the borders for axillary dissection?
axillary vein superior, chest wall medial, skin lateral, pec minor anterior, latissimus posterior
817
what are the lymph node levels 1-3 in breast surgery?
1- lateral to pec minor, 2- beneath pec minor, 3- medial to pec minior
818
what are rotters nodes?
nodes between pec major and minor
819
when is level 3 LND required?
only if grossly involved in breast CA, always for melanoma
820
what risk is increased with level 3 LND for breast CA?
lymphedema
821
what is included in a modified radical mastectomy?
all breast tissue, fascia of the muscle, nipple-areolar complex, and level 1-2 ax dissection
822
what is included in radical mastectomy in addition to the MRM?
pec major and minor and level 3
823
how are stage 1, 2, and 3a/3c breast CA treated?
surgery first, then radiation, and adjucant chemo if >1cm, +nodes, or ER/PR negative; consider trastuzumab if HER2 1cm or +nodes, give tamoxifen or aromatase inhibitor for ER/PR+
824
what is the treatment for stage 3b breast CA?
neoadjuvant chemo then surgery then chemo-XRT and consider hormonals
825
which breast cancers are non-operable?
stage 3c and 4
826
how to treat non-operable breast CA?
hormonal therapy and chemo
827
what is the standard chemo regimen for breast CA?
TAC (taxane aka paclitaxel, adriamycin, cyclophosphamide)
828
what is the main side effect of paclitaxel?
neuropathy
829
what is the main side effect of adriamycin?
cardiomyopathy
830
what is the main side effect of cyclophosphamide?
hemorrhagic cystitis
831
what is the main side effect. of trastuzumab?
cardiac disease (contraindicated if previous cardiac dz)
832
how does trastuzumab work?
blocks HER2/neu receptor tyrosine kinase
833
which hormonal is given pre-menopause in breast CA?
tamoxifen
834
which hormonal is given post-menopause in breast CA?
aromatase inhibitor (anastrozole)
835
what are the main side effects of tamoxifen?
blood clots and endometrial CA
836
what is the main side effect of aromatase inhibitor?
fractures
837
who still needs radiation after MRM?
skin or chest wall involvement, positive margins, tumor >5cm, inflammatory CA, 4 or more nodes +, extracapsular invasion, N2 or 3
838
what are contraindications to radiation in breast CA?
scleroderma, collagen vascular disease, previous XRT, pregnancy, lupus, active RA
839
what is the standard follow up surveillance after breast CA tx?
annual mammogram and breast exam
840
what are the subtypes of ductal CA of breast?
medullary, tubular, mucinous, scirrhotic
841
which subtype of ductal breast CA has worst prognosis?
scirrhotic
842
what designates worse prognosis in lobular breast cancer?
signet ring cells
843
what deems a cystosarcoma phyllodes malignant?
>5-10 mitoses per high power field
844
how does cystosarcoma phyllodes spread?
hematogenous; not via lymph nodes
845
what is the tx for cystosarcoma phyllodes?
WLE with 1cm margin, NO NODE DISSECTION
846
what does pathology show for cystosarcoma phyllodes?
stromal and epithelial elements, mesenchymal tissue
847
what are risk factors for male breast CA?
BRCA, steroids, previous XRT, family history, klinefelters syndrome
848
what is tx for male breast CA?
MRM and tamoxifen and systemic tx if indicated
849
what is tx of Pagets of breast?
MRM if CA, mastectomy if DCIS (cant do breast conservation because must take nipple)
850
what is stewart treves syndrome?
lymphangiosarcoma from chronic lymphedema after axillary dissection (dark purple nodule or lesion on arm 5-10 years after surgery)
851
what is the best indicator of TRAM flap survival?
good peri-umbilical muscle perforators
852
what are contraindications to a TRAM flap?
smoking, transverse laparotomy incision, ipsilateral CABG that used the IMA
853
how to treat DCIS diagnosed. in pregnancy?
lumpectomy under local, then wait til post-partum to do XRT
854
what. is BIRADS 0?
insufficient test, repeat
855
what is the significance of the Z11 trial?
women with breast CA <5cm and < 3 (+) sentinel nodes do not need axillary dissection, can get radiation instead with equivalent outcomes
856
what can be used for sentinel node localization in pregnancy?
radiotracer; can NOT use methylene blue
857
what is the preferred breast reconstruction option if radiation is done?
TRAM flap
858
what is the preferred breast reconstruction option if radiation is required but pt wants immediate recon?
tissue expander
859
What is one key pathologic finding that distinguishes lobular carcinomas from ductal carcinomas?
key pathologic feature of lobular carcinoma is lack of epithelial cadherin expression
860
what hormone tx do men get after breast cancer surgery?
tamoxifen
861
what surgery is done for inflammatory breast CA?
MRM after chemo
862
what surgery is done for male breast CA?
always mastectomy; never lumpectomy
863
what is the single most important predictor of difficult intubation?
chest xray
864
what is the blood supply to the trachea?
upper 2/3 = inferior thyroid arteries, lower 1/3 = bronchial arteries
865
what is the blood supply to the lung parenchyma?
bronchial arteries
866
where does the thoracic duct cross midline?
T4-5
867
what is the role of type 1 pneumocytes?
gas exchange
868
what is the role of type 2 pneumocytes?
surfactant production
869
what predicted post-op FEV1 is needed before lung resection?
>0.8 L (>40% predicted); if close then get split function V/Q scan
870
what is the single best predictor of being able to be weaned off ventilator after lung resection?
FEV1
871
what is the most common complication following lung resection?
atelectasis
872
what is the most common cause of empyema?
pneumonia with subsequent infection of parapneumonic effusion
873
what are the 3 stages of empyema?
exudative, fibrinopurulent, and organizing (chronic)
874
what is the most common benign lung tumor in adults?
hamartoma
875
how to hamartomas of lung appear on CT?
popcorn lesion calcifications
876
what is the tx of lung hamartoma?
nothing
877
what is the most common benign upper airway tumor in kids?
hemangioma
878
what is the most common malignant upper airway tumor in kids?
carcinoid
879
what is the most common benign upper airway tumor in adults?
papilloma
880
what is the most common malignant upper airway tumor in adults?
SCC
881
what do you do FIRST if suspected bleed of tracheoinnominate fistula?
overinflate balloon
882
tx of tracheoinnominate fistula?
sternotomy and ligation of innominate artery; place strap muscle in between. do not use grafts
883
what is the proper location of tracheostomy?
between 2nd and 3rd rings
884
what is the most common cause of lung abscess?
aspiration pneumonia
885
what is the most common organism in lung abscess?
staph aureus
886
what is the tx of lung abscess?
usually just abx, rarely will need CT guided drainage or surgery if not resolving with abx
887
what defines an exudative effusion?
lights criteria: fluid to serum LDH >0.6, fluid to serum protein >0.5, or fluid LDH >2/3 of serum
888
how does pleurodesis differ for effusion if benign vs malignant?
benign: mechanical, malignant: talc
889
what defines a solitary pulmonary nodule?
single, <3cm, surrounded by normal lung tissue without adenopathy or effusion
890
what is the most common cause of lung mets?
breast CA
891
what is the #1 predictor of survivability in lung CA?
nodal involvement
892
what is the biggest risk factor for lung CA?
of pack years
893
where is lung cancer most likely to mets to?
brain
894
which nodes can not be assessed via mediastinoscopy?
AP window; must do chamberlin procedure (2nd rib) or VATS
895
what is a T1 lung tumor?
<3cm
896
what is a T2 lung tumor?
>3cm, or invading visceral pleura, or main bronchus tumor >2cm away from carina
897
what is a T3 lung tumor?
direct invasion of chest wall, mediastinal pleura, or pericardium; or main bronchus within 2cm of carina
898
what is a T4 lung tumor?
organ or great vessel invasion
899
which lung cancer N stage is considered resectable?
N1
900
what is N1 in lung cancer?
ipsilateral peribronchial or perihilar
901
what is N2 in lung cancer?
ipsilateral mediastinal or bronchial, AP window, esophageal, periaortic
902
what is N3 in lung cancer?
contralateral nodes or supraclavicular/scalene nodes
903
what is stage 1 lung CA?
1a: T1N0M0; 1b: T2N0M0
904
what is stage 2 lung CA?
2a: T1N1M0; 2b: T2N1M0 or T3N0M0
905
what is stage 3 lung CA?
3a: T3N1M0 or T1-3N2M0, 3b: any T4 or any N3
906
what is stage 4 lung CA?
any M (which includes malignant effusion)
907
at what lung cancer stage does neoadjuvant tx come before resection?
3a
908
what is the most common cause of SVC syndrome?
non-small cell lung CA
909
what is the tx for SVC syndrome?
emergent radiation
910
what is the most common paraneoplastic syndrome?
small cell ACTH release
911
what is the most common mediastinal tumor in adults and children?
neurogenic (usually in posterior mediastinum)
912
what is the most common tumor in the anterior mediastinum in adults?
thymoma
913
what is the most common anterior mediastinal tumor in kids?
germ cell (most common teratoma, but. if malignant than seminoma)
914
what is the most common tumor in the middle mediastinum (kids and adults)?
cyst
915
what is the most common cause of mediastinal lymphadenopathy?
lymphoma
916
how to differentiate seminoma from non-seminoma?
non have HCG and AFP positive
917
what lab value is prognostic for germ cell tumors of lung?
LDH
918
how is chylothorax diagnosed?
sudan red stain, TAGs>110
919
what is the tx for chylothorax?
1-3 weeks of NPO, TPN, chest tube, and octreotide. if doesnt work then ligate it low in R chest
920
where does the phrenic nerve run in the neck?
anterior to anterior scalene
921
where does the long thoracic nerve run in the neck?
posterior to middle scalene
922
what is the most common cause of bronchiectasis?
cystic fibrosis
923
what is the current lung cancer screening recommendation for smokers?
annual CT aged 55 to 80 with at least a 30 pack-year smoking history who either currently smoke or have quit in the past 15 years
924
which node levels are in the AP window?
5 and 6
925
what is the most common congenital heart lesion?
VSD
926
what are the components. of tetralogy of fallot?
VSD, pulmonary stenosis, overriding aorta, R ventricular hypertrophy
927
what is the most common cause of death in the US?
coronary artery disease
928
what defines right dominant circulation of the heart?
posterior descending artery comes off of R coronary artery (most common)
929
what defines left dominant circulation of the heart?
posterior descending artery comes off of circumflex coronary artery
930
what are the branches of the left coronary artery?
LAD and circumflex
931
how long do CABG vessels last, based on the vessel chosen?
IMA- 90% at 20 years, saphenous 80% at 5 years
932
what phase does the heart freeze in during cardiac surgery?
diastole
933
what volume of pleural effusion is detectable on CXR?
300cc
934
which things are causes of exudative effusion?
```
Malignancy
Pneumonia/infection
Tuberculosis
Pancreatitis
Pulmonary embolism
Chylothorax
```
935
what is the best topical tx for MRSA in a burn wound?
mupirocen (bactroban)
936
what are the indications for aortic stenosis valve replacement?
symptomatic and severe (<1 sq cm) or asymtomatic and <0.6cm
937
what is the most common organism overall in endocarditis?
strep bovis
938
what is the most common organism in acute endocarditis?
staph
939
what is the most common organism in endocarditis that. is from IVDA?
pseudomonas
940
which layer of the aorta is a dissection in?
media
941
what is standford type a vs b aortic dissection?
A= ascending included, B-= no ascending (boundary is proximal innominate artery)
942
what is the debakey classification of aortic dissection?
1= both ascending and descending, 2= ascending only, 3= descending only
943
where should the a line go in an aortic dissection patient?
right radial, because dissection may make the left side inaccurate
944
which aortic dissections need to be repaired?
all type As, any B that has complications (rupture, expansion, limb/organ ischemia, etc)
945
what is the most common cause of ascending aortic aneurysm?
cystic medial necrosis
946
which ascending aortic aneurysms should be repaired?
symptomatic, rapid increase in size (>0.5cm/y), or >5.5cm
947
what is the most common cause of descending aortic aneurysm?
atherosclerosis
948
where is the majority of foci of afib?
pulmonary vein
949
what is the first sign of cardiac tamponade on ECHO?
right atrial diastolic compression
950
wha is the most common cardiac tumor?
myxoma; usually in left atrium
951
what is the most common primary malignant tumor of the heart?
angiosarcoma
952
what is the most common metastatic tumor to the heart?
lung CA
953
what is the most common primary pediatric heart tumor?
rhabdomyoma
954
what is the treatmetn for post CABG pericarditis?
NSAIDs, steroids
955
should carotid or CABG be done first if pt needs both?
carotid; then CABG 4 weeks later
956
what is the best preventative agent for atherosclerosis?
statins
957
what is the most important risk factor for CVA?
HTN
958
what is the first branch of internal carotid?
ophthalmic artery
959
what is the first branch of external carotid?
superior thyroid
960
what is amaurosis fugax?
transient occlusion of opthalmic artery
961
what is the best treatment for vertebral artery stenosis?
PTA with stent
962
what is the criteria for shunting during CEA?
if stump pressure <40 do a shunt
963
what is the most commonly injured nerve during CEA?
vagus
964
which nerve gets injured from retracting at the angle of the jaw during carotid?
marginal mandibular branch of facial nerve
965
what causes severe post op HTN after carotid?
injury to carotid body
966
what velocity on US is considered indication for CEA?
>230 cm/s
967
what is the most common cause of mortality after CEA?
MI
968
what is the triad of Leriche syndrome?
buttock claudication, lack of femoral pulses, impotence
969
what structures are in the anterior compartment of the leg?
deep peroneal nerve and anterior tibial artery
970
what structure are in the lateral compartment of the leg?
superficial peroneal nerve
971
what structures are in the deep posterior compartment of the leg?
posterior tibial artery, peroneal artery, tibial nerve
972
what structures are in the superficial posterior compartment of the leg?
sural nerve
973
what is the first symptom of compartment syndrome?
pain with passive movement
974
what is the treatment of popliteal entrapment syndrome?
resection of medial head of gastrocnemius
975
what bug is most common cause of early vascular graft infection (<1 month)?
staph aureus
976
what bug is the most common cause of late (and overall) vascular graft infection?
staph epidermidis
977
what is the most sensitive test for diagnosing vascular graft infection?
tagged WBC scan
978
what is the most common cause of AAA?
atherosclerosis causes degeneration of medial layer
979
what size criteria deems need for fixing a AAA?
>5.5 cm or growing >0.5cm/year
980
what is the most common cause of death after AAA repair?
early: MI, late: renal failure
981
what vessel is at risk when cross clamping aorta for AAA repair?
retroaortic L renal vein
982
how do you precent an aortoenteric fistula?
cover proximal suture line with aneruysm sac
983
what is the anticoagulant of choice in pregnancy?
LMWH
984
what are the size criteria for EVAR?
proximal and distal neck must be at least 1-3cm (no more, no less), diameter at landing zone at least 3.2cm, angle must be <60, iliac must be >7mm
985
what is a type 1 endoleak?
leak at proximal or distal graft attachments
986
what is a type 2 endoleak?
retrograde flow from collateral branches, such as lumbar arteries
987
what is a type 3 endoleak?
leaking from different parts of the graft
988
what is a type 4 endoleak?
leaking through graft wall (endotension)
989
what is a type 5 endoleak?
cant identify the cause
990
which types of endoleaks need immediate repair?
type 1 and 3
991
what are the common complications of vessel aneurysms?
above inguinal ligament rupture, below inguinal ligament thrombose/embolize
992
what is the criteria for fixing iliac aneurysms?
symptomatic, >3cm, or infected
993
what is the criteria for fixing femoral aneurysms?
symptomatic, >2.5cm, or infected
994
what is the criteria for fixing popliteal aneurysms?
symptomatic, >2cm, or infected
995
how likely is someone with a popliteal aneurysm to have another one somewhere else?
50% bilateral, 50% elsewhere
996
how to treat arterial pseudoaneurysm?
if from percutaneous procedure, try thrombin injection first. if at graft site, repair surgically
997
what is the criteria for fixing visceral aneurysms?
>2cm (1.5 for renal)
998
what is the most common visceral artery aneursym?
splenic
999
which splenic artery aneurysms should be fixed?
symptomatic, pregnant, plan to become pregnant, or >3-4cm
1000
what is the most common cause of arterial emboli?
a fib
1001
what is the most common site of arterial emboli to get stuck?
common femoral artery
1002
when to consider EKOS instead of embolectomy?
if clot is at trifurcation (more distal than femoral) in an acute embolus, or if chronic progressive atherosclerotic disease in any part of the leg
1003
why might a person with kawasaki's need a CABG?
coronary artery aneurysms are common
1004
what is the most common cause of AV graft failure?
intimal hyperplasia
1005
what is the most common organism in suppurative thrombophlebitis?
staph aureus
1006
what is the usual tx of fibromuscular dysplasia of the renal arteries?
angioplasty
1007
what is the minimal vein size for AVF?
2.5-3mm
1008
what is the Rutherford classification of acute limb ischemia?
Stage I: viable limb that is not immediately threatened (intact motor/sensory with +pulses)
Stage IIa: marginally threatened/salvageable limb (intact motor but lost sensory)
Stage IIb: immediately threatened limb that is salvageable only with immediate revascularization (mild to moderate motor loss with significant sensory loss)
Stage III: Irreversibly damaged limb with major tissue loss or permanent nerve damage (profound motor and sensory loss, generally with paralysis)
1009
where is gastrin produced?
g cells in antrum and duodenum
1010
what cells does gastrin target?
parietal and chief cells
1011
what are the responses of gastrin?
secretion of HCl, IF, and pepsinogen
1012
what is released from parietal cells?
HCl and IF
1013
what is released from chief cells?
pepsinogen
1014
where is somatostatin produced?
d cells in antrum
1015
what stimulates somatostatin release?
acid in the duodenum
1016
what does somatostatin do?
inhibits everything
1017
what is octreotide?
somatostatin analog
1018
where is GIP produced?
k cells in duodenum
1019
what stimulates GIP?
glucose in the stomach
1020
what is the target and reaction of GIP?
insulin released by pancreatic beta cells
1021
where does CCK come from?
I cells in duodenum and jejunum
1022
what stimulates CCK?
protein and fat in duodenum
1023
what are the effects of CCK?
gallbladder contraction, relaxation of oddi sphincter, increased pancreatic enzyme secreation, increased intestinal motility, hepatic bile synthesis, satiety
1024
where does secretin come from?
S cells in duodenum
1025
what stimulates secretin?
acidity (pH <4), fat, bile
1026
what inhibits secretin?
pH >4, gastrin
1027
what are the responses to secretin?
inhibits gastrin and HCl, increases pancreatic bicarb release, increases bile flow, increases bicarb from brunners glands in duodenum
1028
what stimulates VIP release?
fat, acetylcholine
1029
where does VIP come from?
cells in gut and pancreas
1030
what are the responses to VIP?
increased gut motility, decreased gastrin release, and increased intestinal secretion of water/lytes
1031
where does glucagon come from?
alpha cells in pancreas (a little from stomach and intestine too)
1032
what stimulates glucagon secretion?
decreased serum glucose, increased amino acids, cagal acetylcholine, GRP, cathecholamines
1033
what are the responses to glucagon?
gluconeogenesis, glycogenolysis, lipolysis, ketogenesis, proteolysis, decreases gastric acid, pancreatic secretion, intestinal/stomach motility, and MMC
1034
where does insulin come from?
beta cells of pancreas
1035
what stimulates insulin release?
serum, glucose, glucagon, CCK, protein ingestion
1036
what is the response to insulin?
cellular glucose uptake, synthesis of protein, glycogen, and triglycerides
1037
where does pancreatic polypeptide come from?
islet cells in pancreas
1038
what stimulates pancreatic polypeptide secretion?
fasting, exercise, and hypoglycemia
1039
what does pancreatic polypeptide do?
decrease pancreatic function
1040
where does peptide YY come from?
terminal ileum and colon
1041
what is the response to peptide YY?
decreased gastric emptying and acid secretion, pancreatic function, and GB contraction; suppresses appetite and increases water/lyte absorption from colon
1042
where does gastrin-releasing peptide come from?
post-ganglionic fibers of vagus nerve
1043
what are the responses to gastrin-releasing peptide?
increased gastric acid secretion, intestinal motor activity, and pancreatic enzyme secretion
1044
where does motilin come from?
M cells in duodenum
1045
where are motilin receptors present?
antrum, duodenum, colon
1046
what stimulates motilin secretion?
duodenal acid and vagus input
1047
what inhibits motilin secretion?
somatostatin, secretin, pancreatic polypeptide, and duodenal fat
1048
what is the main response of motilin?
increased antrum and duodenal motility
1049
what hormones are involved in anorexia?
CCK and peptide YY
1050
what are the layers of the esophagus?
mucosa, submucosa, muscularis propria, NO SEROSA
1051
what is the blood supply to the esophagus?
cervical- inferior thyroid a, thoracic-directly off aorta, abdominal- mainly left gastric and some inferior phrenic
1052
where does the criminal nerve of grassi come from?
right vagus
1053
what part of vagus heads toward liver/biliary tree?
left vagus
1054
what is normal pharyngeal contraction pressure with food bolus?
70-120mmHg
1055
what is normal upper esophageal sphincter pressure?
60 at rest and 15 with food
1056
what is normal LES pressure?
15 at rest and 0 with food
1057
what is normal esophageal contraction pressure with food?
30-120mmHg; <10 is "burned out"
1058
what are the anatomic distances of the esophagus?
from incisors: 15cm to cricopharyngeus, 25cm to aortic arch, 45cm to diaphragm hiatus
1059
what makes the upper esophageal sphinter?
cricopharyngeus muscle
1060
what is the most common site of esophageal perforation?
cricopharyngeus
1061
where are the surgical approaches to the esophagus based on location?
neck = left, upper 2/3 thoracic = right thoracotomy, lower 1/3 thoracic = left thoracotomy
1062
what is the best initial test for dysphagia?
esophagogram
1063
what is the best test for diagnosis of achalasia?
manometry (will see high LES pressure and lack of peristalsis)
1064
why do patients with achalasia need an EGD?
rule out cancer
1065
what is the standard length for myotomy in heller?
7cm onto esophagus and 2cm onto stomach below GEJ
1066
what is seen on esophogram with diffuse esophageal spasm?
corkscrew esophagus
1067
what is seen on manometry with diffuse esophageal spasm?
high amplitude, repetitive, non-peristaltic contractions with normal LES relaxation
1068
what is the tx of diffuse esophageal spasm?
calcium channel blocker, trazadone, psych exam
1069
what is seen on manometry for achalasia?
LES does not relax, loss of peristalsis
1070
what is the tx of achalasia?
CCB, balloon dilation, surgery is myotomy and fundoplication
1071
what is seen on manometry in nutcracker esophagus?
normal LES with high amplitude peristalsis
1072
what is seen on manometry with scleroderma?
aperistalsis, weak contractions, low/absent LES tone
1073
what is the most common cause of epiphrenic diverticulum?
achalasia
1074
what is the tx of zenkers?
cricopharyngeal myotomy via left neck
1075
what is the best test for esophageal perforation?
gastrograffin esophogram
1076
what is the most common location and cause of esophageal perforation?
EGD at cricopharyngeus
1077
which esophageal perfs need esophagectomy instead of primary repair?
>48 hours, septic, or gross contamination
1078
what is the #1 cause of non-iatrogenic esophageal perforation? #2?
boerhaaves; then foreign body
1079
what is the workup of caustic esophageal injury?
first EGD, then swallow study
1080
what is the best test for GERD?
pH test
1081
what demester score indicates surgery?
14.72
1082
what is the histology of barretts?
squamous to columnar metaplasia with goblet cells
1083
what is the surveillence stndard for Barretts?
4 quadrant bx at 1cm intervals annually
1084
what is the tx of choice. for high grade dysplasia in setting of barretts?
RFA
1085
how much free esophagus do you need when doing fundoplication?
5cm in mediatinum, 2cm in abdomen
1086
what is a type 1 hiatal hernia?
GE junction above diaphragm
1087
what is a type 2 hiatal hernia?
paraesophageal, GEJ in normal position
1088
what is type 3 hiatal hernia?
type 1 and 2 combined
1089
what is type 4 hiatal hernia?
includes another organ besides the stomach
1090
what is borchardts triad?
chest pain, retching without vomit, inability to pass NGT
1091
what is the most common form of rotation for gastric volvulus?
organoaxial
1092
what is the most common benign tumor of the esophagus?
leiomyoma
1093
what layer of the esophagus forms leiomyoma?
muscularis propria (submucosal)
1094
what is the best test to diagnose an esophageal leiomyoma?
barium swallow followed by EGD with EUS (do not biopsy though)
1095
what are the indications for surgery in an esophageal leiomyoma?
>5cm, symptomatic, intraluminal, pedunculated, or mobile
1096
what surgery do you do for an esophageal leiomyoma?
thoracotomy and enucleation (but can try endoscopic removal if <5cm)
1097
what surgery do you do for a leiomyosarcoma?
esophagectomy
1098
what is the diagnostic test for fibrovascular polyp of esophagus?
barium swallow; dont do EGD because it is intraluminal and can obstruct airway
1099
what is tylosis?
combo of hyperkeratosis of hands/feet and esophageal cancer
1100
what is the best test for T stage of esophageal CA?
EUS
1101
what is the best test for determining overall resectability of esophageal CA?
CT chest
1102
what is the most important prognostic factor fo esophageal CA?
nodal spread
1103
what is the worst tumor marker for prognosis of esophageal CA?
EGFR
1104
what is the most common esophageal cancer?
adenocarcinoma; linked to barretts and spreads to liver
1105
where does esophageal squamous cell CA mets to?
lung
1106
what is the neoadjuvent regimen for esophageal CA?
cisplatin and 5fu and radiation
1107
what margin is required for esophagectomy in CA?
10cm
1108
what artery supplies blood to the gastric conduit after esophagectomy?
right gastroepiploic
1109
what is the benefit of ivor lewis esophagectomy?
anastomosis in chest has lower leak rate
1110
what is the most common colon segment used for esophageal reconstruction?
left colon based off left colic artery
1111
which esophageal cancers can be treated with EMR/ablation?
T1a only if favorable grade, the rest need esophagectomy
1112
which esophageal cancers get neoadjuvant?
all T2 and greater, some T1b depending on details/grade of the tumor. or any positive nodes
1113
which esophageal cancer can get esophagectomy without neoadjuvant tx?
T1b if favorable grade
1114
what is T1a esophageal CA?
invades lamina propria/muscularis mucosa
1115
what is T1b esophgeal CA?
invades the submucosa, thus reaches the lymphatics
1116
what is T2 esophageal CA?
invades the muscularis propria
1117
what is T3 esophageal CA?
invades the adventitia (there is no serosa)
1118
what is T4 esophageal CA?
invades adjacent structures (a: resectable structures, b: unresectable structures)
1119
what is the N staging of esophageal cancer?
1: 1-2 nodes, 2: 3-6 nodes, 3: 7 or more nodes
1120
where does the left gastroepiploic artery come from?
splenic
1121
where does the right gastroepiploic artery come from?
GDA
1122
where. does the right gastric artery come from?
common hepatic
1123
what cells are in the fundus/body of stomach?
chief cells, parietal cells
1124
where is b12 absorbed?
terminal ileum
1125
what is pernicious anemia?
loss of parietal cells, thus no IF so cant absorb B12
1126
what cells are in the antrum?
g cells, d cells, mucus and bicarb secreting glands
1127
what is the role of brunners glands?
(found only in duodenum) secrete pepsinogen and alkaline mucus to protect the duodenum from acid
1128
what is a billroth 1?
antrectomy with gastroduodenal anastomosis
1129
what is a billroth 2?
antrectomy with gastrojejunal anastomosis
1130
which gastric ulcers have normal acid?
1 & 4 (and 5 due to nsaids)
1131
which gastric ulcers have increased acid production?
2 and 3
1132
what is the best test for h pylori?
biopsy of antrum
1133
what is type 1 gastric ulcer?
on lesser curve in body of stomach
1134
what is type 2 gastric ulcer?
2 ulcers, lesser curve and duodenum
1135
what is type 3 gastric ulcer?
pre-pyloric
1136
what is type 4 gastric ulcer?
lesser curve high along cardia
1137
what is type 5 gastric ulcer?
anywhere, due to NSAIDs
1138
which stomach ulcers are associated with Type A blood?
type 1
1139
which stomach ulcers are associated with type O blood?
2-4
1140
are duodenal ulcers more likely anterior or posterior?
anterior
1141
what is the most common complication of duodenal ulcers?
bleeding
1142
what is standard triple therapy for H pylori?
PPI, clarithromycin, and amoxicillin for 14 days
1143
what is quadruple therapy for h pylori?
PPI, flagyl, tetracycline, and bismuth salts
1144
which tests are used to confirm h pylori eradication?
urea breath test or stool antigen (not ELISA serology because it stays positive)
1145
which arteries are ligated when oversewing a bleeding duodenal ulcer?
GDA and pancreaticoduodenal artery
1146
what is the main side effect of TIPS?
encephalopathy
1147
what are the advantages of roux en y over billroths?
no bile reflux and decreased dumping syndrome
1148
what is the most common complication after vagotomy or gastrectomy?
diarrhea, from non-conjugated bile salts in colon
1149
what causes dumping syndrome?
rapid entrance of carbs into jejunum (phase 1 is hyperosmotic load causing fluid shifts = hypotension; phase 2 is delayed from reactive increase in insulin leading to hypoglycemia)
1150
what is the best test for dumping syndrome?
gastric emptying study
1151
what is the tx for dumping syndrome?
small, high protein/low carb/low fat meals, can give octreotide before meals; if refractory can convert to roux en y
1152
what are the symptoms of alkaline reflux gastritis?
n/v, post-prandial pain not relieved by vomiting
1153
what is the best test for alkaline reflux gastritis?
EGD
1154
what is the tx for alkaline reflux gastritis?
PPI, cholestyramine, reglan; convert to roux en y if refractory
1155
what is afferent loop syndrome?
obstruction of biliary limb in B2 or roux en y
1156
what are the symptoms of afferent loop syndrome?
non-bilious vomiting and pain, relieved with bilious emesis
1157
what is the best test for afferent loop syndrome?
CT, PO contrast does not fill the limb
1158
what is the tx of afferent loop syndrome?
can try balloon dilation, otherwise OR for re-anastomosis with shorter limb and tx of the problem causing the obstruction (ex: adhesions)
1159
what is blind loop syndrome?
stasis in biliary limb leading to bacterial overgrowth
1160
what are the symptoms of blind loop syndrome?
pain, malabsorption, B12 deficiency from bacteria using it all up, steatorhea
1161
what is the best test to dx blind loop syndrome?
EGD with aspiration/culture
1162
what is the tx of blind loop syndrome?
tetracycline and flagyl, with reglan or erythromycin; can do sx to make limb shorter
1163
how is the emptying of the stomach altered by a vagotomy?
relaxation is impaired; increased liquid emptying but decreased solid emptying (thus need to do pyloroplasty)
1164
what is the most common cause of recurrent peptic ulcer disease after surgery?
incomplete vagotomy (such as criminal nerve of grassi, or poorly performed HSV)
1165
what is the cause of isolated gastric varices? tx?
splenic vein thrombosis from pancreatitis, tx is splenectomy
1166
what BMI is criteria for gastric bypass surgerry?
>40 or >35 with comorbidities such as HTN, DM, OSA
1167
how long should the roux limb be in RNYGB?
75-100cm
1168
how long should the y (biliary) limb be in RNYGB?
30-50cm
1169
why isn't jejunoileal bypass performed anymore?
liver cirrhosis, kidney problems, and osteoporosis (if encountered, convert to RNYGB)
1170
what is the most common cause of leak after RNYGB?
ischemia (though if early leak, this is technical error)
1171
how much excess weight loss % is lost with each type of bypass surgery?
lap band: 40-55%, sleeve 54-69%, RNYGB 61%, duodenal switch 70%
1172
what is the most common benign gastric neoplasm?
GIST tumor
1173
what is the best test for GIST?
EGD with biopsy, send for c-kit staining
1174
what is the path seen with GIST tumor?
spindle cells, interstitial cells of cajal, autonomic pacemaker cells
1175
where is the most common location of GIST?
stomach (70%)
1176
where is the most common site of mets for GIST?
liver
1177
what makes a GIST malignant?
>5-10 mitoses / 50 HPFs or size >5cm
1178
what is the surgical tx of GIST?
wedge resection with 1cm margin, NO nodal dissection
1179
which GIST need chemo?
all malignant (imatinib)
1180
what is mALT lymphoma?
low grade B cell NHL from h pylori
1181
what is the most common organ involved in extra-nodal lymphoma?
stomach
1182
what is the dx modality for gastric lymphoma?
EUS with bx
1183
which gastric lymphomas get surgery?
only stage 1 (submucosal) the rest get chemo +/- XRT
1184
what is the most common location of gastric cancer?
antrum
1185
what is the best test for gastric CA?
EGD with bx
1186
what are the two types of gastric cancer?
intestinal (adenocarcinoma) and diffuse (linitis plastica)
1187
which type of gastric cancer shows glands on path?
intestinal
1188
what margin is required for gastric cancer?
5cm
1189
how do you treat GE junction gastric cancer?
like esophageal cancer; esophagectomy and 5cm stomach margin
1190
how do you treat gastric cancer in upper 1/3 of stomach?
total gastrectomy and esophagojejunal anastomosis
1191
how. doyou treat middle or lower 1/3 gastric cancers?
distal gastrectomy and gastrojejunostomy
1192
how do you treat diffuse gastric cancer?
total gastrectomy and esophagojejunal anastomosis
1193
what is the chemo regimen for gastric cancer?
5FU, doxorubicin, and mitomycin
1194
which gastric cancers need chemo?
anything stage 2 or higher get adjuvant chemo
1195
what is the T stage of gastric CA?
T1: lamina propria or submucosa, T2: muscularis propria or subserosa T3: into serosa T4: adjacent structures
1196
what is the N stage of gastric CA?
N1: 1-6 nodes, N2: 7-15 nodes, N3: >15 nodes
1197
how many nodes are needed when resecting gastric CA?
15
1198
what is D1 resection in gastric CA?
perigastric nodes
1199
what is D2 resection in gastric CA?
D1 plus celiac nodes
1200
what is D3 resection in gastric CA?
D2 plus hepatoduodenal nodes
1201
what is D4 resection in gastric CA?
D3 plus periaortic and pericolic nodes
1202
what gastrin level is pathoneumonic for ZE?
1,000
1203
what protoncogene is associated with GIST/ckit?
CD-117
1204
what is the most common hepatic artery variant?
R hepatic off SMA
1205
where is replaced R hepatic artery found?
behind neck of pancreas posterior/lateral to CBD
1206
where is replaced left hepatic artery found?
gastrohepatic ligament, off of L gastric
1207
what veins form the portal vein?
SMV and splenic
1208
What is the orientation of the structures in the hepatoduodenal ligament?
CBD lateral, proper hepatic artery medial, and portal vein posterior
1209
Where does the falciform divide the liver?
Between medial and lateral left lobe
1210
What is inside the falciform ligament?
Remnant umbilical vein
1211
What is the orientation of the structures in the hepatoduodenal ligament?
CBD lateral, proper hepatic artery medial, and portal vein posterior
1212
Where does the falciform divide the liver?
Between medial and lateral left lobe
1213
What is inside the falciform ligament?
Remnant umbilical vein
1214
what separates the right and left lobes of the liver?
cantile's line: line through the GB fossa to IVC
1215
which coagulation factor is not made in the liver?
8
1216
what is the only water soluble vitamin stored in the liver?
B12
1217
what are kupffer cells?
macrophages in the liver
1218
what are the most common complications in hepatic resection?
bleeding and bile leak
1219
which hepatocytes are most sensitive to ischemia?
centra lobar (zone 3)
1220
where does urobilinogen come from?
breakdown of bilirubin by bacteria in terminal ileum
1221
what is the rate limiting step for cholesterol synthesis?
HMG CoA reductase
1222
what causes gallstones in obese patients?
overactive HMG CoA reductase
1223
what causes gallstones in thin people?
underactive 7-alpha-hydroxylase
1224
what is the most common cause of jaundice?
Gilbert's disease (abnormal conjugation)
1225
what is the best indicator of synthetic function of the liver with cirrhosis?
INR
1226
what is normal portal vein pressure?
<12mmhg
1227
what factors are included in Child Pugh score?
ascites, encephalopathy, INR, bilirubin, albumin
1228
what factors are included in MELD score? significance?
bilirubin, INR, Cr; >15 likely to benefit from txp, <15 likely to die of liver txp before liver disease
1229
what is the milan criteria for liver txp?
HCC with 1 lesion <5cm or 3 lesions <3cm
1230
what medication is used for bleeding prophylaxis in someone with varices?
propanolol
1231
what are the benefits of TIPS?
decreases ascites, variceal bleeding, increases txp free survival, and improves Cr clearance
1232
what is a denver shunt?
peritoneal-venous shunt to R IJ
1233
what is the unique complication of denver shunt?
DIC
1234
what is the benefit and complication of splenorenal shunt? (aka warren shunt)
good for varices, but makes ascites worse
1235
how can you increase hepatic reserve prior to liver resection?
portal vein embolization
1236
how does hepatic vein thrombosis happen after pregnancy? tx?
ovarian vein thrombosis propagates to IVC then hepatic veins; heparin and abx
1237
what is the most common casue of portal vein thrombosis in children?
umbilical vein infection
1238
what is the most common cause of massive hematemesis in children?
portal vein thrombosis
1239
what is budd chiari syndrome? most common cause?
hepatic vein thrombosis; polycythemia vera
1240
what is the most common symptom of budd chiari syndrome?
ascites
1241
what is the diagnosis and tx of budd chiari?
retrograde hepatic vein angiogram (diagnostic and therapeutic)
1242
what is seen on liver bx with budd chiari?
sinusoidal dilatation and hepatic centrilobular congestoin
1243
what liver disease is associated with ulcerative colitis?
PSC (DOES NOT GET BETTER WITH COLECTOMY)
1244
what is the best test to diagnose PSC?
ERCP
1245
what is the main risk of having PSC?
cholangiocarcinoma
1246
what is the treatment for PSC?
transplant; though 20% will recur
1247
what lab tests are diagnostic of PBC?
increased anti-mitochondrial abs (m2IgG most sensitive) and LFTs (diagnostic enough to not need biopsy)
1248
does PBC have increased cancer risk?
no
1249
what is the suspected diagnosis if a liver cyst has "frong like projections"?
cystadenoma/cystadenocarcinoma
1250
which side of the liver is more likely to have ecchinococal cyst?
right side
1251
how do you diagnose an ecchinococcal cyst?
ELISA for IgG antibodies
1252
how do humans get echinococcal cyst?
dogs that are infected by sheep
1253
how does echinococcal cyst appear on CT?
calcified with double cyst wall and daughter cysts
1254
how do you treat echinococcal cyst?
first consider ERCP to r/o duct communication, do not aspirate cyst! (risk of anaphylaxis); pre-op albendazole for 2 weeks then either PAIR or resection with hypertonic saline packs and ETOH injection
1255
what is the most common organism in liver abscess?
e. coli
1256
what is the most common cause of liver abscess?
biliary tract disease
1257
what is the treatment for liver abscess?
percutaneous drain and abx
1258
how does entomeoba hstolytica reach the liver?
from colon via portal vein
1259
what lab test can prove entomeoba histolytica?
agglutinin and immunoeletrophoresis antibody test
1260
what is the treatment for liver abscess caused by entomeoba histolytica?
flagyl for 10 days (usually dont need drainage)
1261
what are the signs/symptoms of schistosomiasis liver abscess?
maculopapular rash, variceal bleeding, travel to middle east, RUQ pain
1262
what lab test can prove schistosomiasis?
agglutinin and immunoeletrophoresis antibody test, eosinophils, stool and urine O+P
1263
what is the treatment for schistosomiasis?
praziquantel (usually dont need drainage)
1264
what are the risk factors for hepatic adenoma?
women on OCPs, steroids, autoimmune disease
1265
what will sulfer colliod scan show in hepatic adenoma?
negative because no kupffer cells in adenoma
1266
which hepatic adenomas should be resected?
>4cm, dont go away with d/c of OCPs/steroids, increasing in size, worsening symptoms, not on OCPs/steroids
1267
how does FNH appear on CT?
hypervascular, homogenous, fills in arterial phase, central stellate scar
1268
which liver mass has positive sulfur colloid scan?
FNH
1269
what is tx of FNH?
not surgery; d/c OCPs/steroids and monitor
1270
what is the most common benign liver tumor?
hemangioma
1271
what is seen on CT with liver hemangioma?
peripheral to central enhancement
1272
which liver mass has positive tagged RBC scan?
hemangioma
1273
what is the tx for liver hemangioma?
no resection, conservative unless symptomatic (then youd resect it and pre-op embolization. if kid or unresectable, do steroids/XRT
1274
how does HCC appear on CT?
vascular in arterial phase and washes out in portal venous phase, heterogeneous with necrotic areas
1275
what lab tests can help diagnose HCC?
AFP and DCP (des-gamma carboxyprothrombin)
1276
which type of HCC has the worst prognosis?
diffuse nodular
1277
how much liver remnant is needed with normal liver function?
20%
1278
how much liver remnant is needed with an degree of liver dysfunction?
30%
1279
how much liver remnant is needed with cirrhosis?
40%
1280
what margin is required for liver resection?
1cm
1281
what drug is used for unresectable liver cancer?
sorafenib
1282
what is the best diagnostic study for liver mets?
intraop ultrasound
1283
how do primary liver tumors vs mets differ on imaging?
primary are hypervascular, mets are hypovascular
1284
what fascia forms the inguinal ligament?
external oblique
1285
what layer forms the roof of the inguinal canal?
external oblique
1286
what is the floor of the inguinal canal?
internal oblique fascia combined with transversalis fascia
1287
what forms the conjoined tendon?
internal oblique fascia combined with ransversalis facia
1288
what layer forms the cremasteric muscles?
internal oblique
1289
what is the inguinal ligament attached to?
ASIS and pubis
1290
what forms the inferior portion of the inguinal canal?
inguinal ligament
1291
what is the lacunar ligament?
where the inguinal ligament splays onto pubis, connects the inguinal and pectineal ligaments
1292
what is the pectineal ligament?
aka cooper's ligament, periosteum of superior pubic ramus and transversalis fascia
1293
what are the boundaries of hesselbach's triangle?
rectus, inferior inguinal ligament, inferior epigastric vessels
1294
what is the most common type of hernia?
indirect inguinal
1295
which are more likely to recur: direct or indirect hernia?
direct
1296
what causes indirect hernia?
patent processus vaginalis
1297
what causes direct hernia?
weakness in abdominal wall
1298
how to treat a sliding hernia with ovary in it?
ligate round ligament to return ovary into abdomen
1299
where is the vas deferens in the cord?
medial
1300
what is a bassini hernia repair?
conjoined tendon and transversalis fascia approximated to inguinal ligament
1301
what is a mcvay hernia repair?
conjoined tendon and transversalis fascia approximated to cooper's
1302
what is a Lichtenstein hernia repair?
mesh reforms floor and between conjoined tendon and inguinal ligament
1303
what is the treatment of ostitis after hernia repair?
NSAIDs
1304
where do you make the relaxing incision for a hernia repair?
1cm above pubic tubercle at lateral border of rectus
1305
whre do hernias usually recur?
medial to mesh
1306
how to treat hernias you cant reduce during operation?
divide the inguinal ligament
1307
what is the most common EARLY complication after hernia repair?
urinary retention
1308
what causes testicular atrophy after hernia repair?
injury to spermatic veins
1309
what is the most common cause of pain after inguinal hernia repair?
compression of ilioinguinal nerve
1310
where is the ilioinguinal nerve encountered during inguinal hernia repair?
anterior to cord structures
1311
what are the symptoms of ilioinguinal nerve injury?
loss of cremasteric reflex, numbness of ipsilateral penis, scortum, and medial thigh
1312
where is the genital branch of the genitofemoral nerve encountered?
posterior and inferior to cord
1313
what does the genital branch of geniteofemoral nerve innervate?
motor to cremasters and sensory to scrotum
1314
what does the femoral branch of the genitofemoral nerve innervate?
sensory to lateral thigh
1315
where does the femoral branch of the genitofemoral nerve run?
lateral to iliac vessels
1316
how do you repair femoral hernia?
open = mcvay, or can do laparoscopic
1317
when should you repair an umbilical hernia in children?
5 years old (before starting school)
1318
what hernia has inner thigh pain with internal rotation of thigh?
obturator
1319
what is a petit hernia?
inferior lumbar triangle: external abdominal oblique, lumbodorsal aponeurosis or lattisimus dorsi, and iliac crest
1320
what is a grynfelt-lesshaft hernia?
superior lumbar triangle: internal abdominal oblique, lumbodorsal aponeurosis, and 12th rib
1321
what is fothergills sign?
rectus sheath hematoma mass gets more prominent with rectus muscle flexion
1322
where is the triangle of doom?
inferior, lateral
1323
what is unique about the layers of the gallbaldder wall?
no submucosa
1324
why does a person get gallstones after terminal ileum resection?
poor absorption of bile acids, so more unconjugated bilirubin is aborsbed
1325
what disorders cause black gallstones?
sickle cell, spherocytosis, hemolytic anemia, TPN, terminal ileum resection
1326
why does e. coli cause brown gallstones?
produces beta glucoronidase, which deconjugates bilirubin leading to formation of calcium bilirubinate
1327
what is the most common organism in cholecystitis?
e coli
1328
what is the most sensitive test for cholecystitis?
HIDA
1329
what is the most common kind of gallbladder polyp?
cholesterol
1330
what are the indications for cholecystectomy in gallbladder polyps?
>1cm, stones also present, sessile, malignant looking, have PSC
1331
what is the most common cause of CBD injury during cholecystectomy?
excess cephalad retraction
1332
what is the surgery for upper 1/3 bile duct CA?
hepatic resection
1333
what is the surgery for middle 1/3 bile duct CA?
hepaticojejunostomy
1334
what is the surgery for lower 1/3 bile duct CA?
whipple
1335
what is the tx for stage T1a gallbladder CA?
open chole (mucosa/lamina propria only)
1336
what is the tx for T1b gallbladder CA?
GB and wedge resection of segments 4-5 with 2-3cm margin (invades muscularis) and stripping of nodes
1337
what is the tx for any gallbladder CA beyond the muscularis (T12and greater) ?
formal 4b and 5 liver resection in addition to nodes/GB
1338
what is the first branch off the SMA?
inferior pancreaticoduodenal
1339
where are the superior mesenteric vessels (vein vs artery)?
vein is to right of artery
1340
what causes annular pancreas?
failure of clockwise rotation. ofthe ventral pancreatic bud
1341
what is seen on imaging with annular pancreas?
double bubble sign, stenosis on UGI
1342
what is the tx of choice for annular pancreas?
duodeno-jejunostomy (can also do duodenoduodenostomy)
1343
what is the tx of choice for symptomatic pancreatic divisum?
ERCP/sphincterotomy
1344
what is the most common location of heterotopic pancreas?
duodenum
1345
what is the tx of hemorrhagic pancreatitis?
angioembolization
1346
what is peustow procedure?
longitudinal pancreaticojejunostomy when duct is dilated (8mm or more)
1347
what is beger procedure?
pancreatic head resection
1348
what is Frey procedure?
combo of peustow and beger
1349
what is the cytology findings of pancreatic pseudocyst?
no glycogen, no mucin, high amylase
1350
what is the cytology seen with serous cystadenoma of pancreas?
high glycogen, low mucin
1351
what is the cytology seen with mucinous cystadenoma?
high mucin (premalignant, must resect)
1352
what is the #1 risk factor for pancreatic adenocarcinoma?
smoking
1353
what tumor markers are seen in pancreatic cancer?
CA 19-9, K-ras, p53, CDKN2A, and SMAD4
1354
what is the most common complication after whipple?
delayed gastric emptying
1355
which pancreatic neuroendocrine tumors can not be found with octreotide scan?
insulinoma
1356
which pancreatic neuroendocrine tumors do not respond to octreotide?
somatostatinoma
1357
where to pancreatic neuroendocrine tumors spread to ?
liver
1358
what is the most common functional neuroendocrine pancreatic tumor?
insulinoma
1359
where are insulinomas found? are they malignant?
evenly throughout pancreas, 90% benign
1360
what is whipple's triad?
classic presentation of insulinoma: fasting hypoglycemia, sx of hypoglycemia, relief with glucose
1361
what is the surgical tx of insulinoma?
if <2cm enucleate, if >2cm formal resection
1362
what is the most common pancreatic neuroendocrine tumor in MEN1?
gastrinoma
1363
where are gastrinomas found? are they malignant?
gastrinoma triangle; 50% malignant
1364
what is the gastrinoma triangle?
CBD, neck of pancreas, 3rd portion of duodenum
1365
what are the symptoms of gastrinoma?
complicated ulcer disease, diarrhea improved with PPI
1366
how do you diagnose gastrinoma?
fasting serum gastrin (>200 suspicious, >1000 diagnostic), basal acid output >15, secretin stimulation test shows increased gastrin level, CT, octreotide scan
1367
where are somatostatinomas found? are they malignant?
head of pancreas, most are malignant (worst prognosis of all pancreatic neuroendocrine tumors)
1368
what are the symptoms of somatostatinoma?
DM, gallstones, steatorrhea
1369
where are glucagonomas found? are they malignant?
distal pancreas, most are malignant
1370
what are the symptoms of glucagonoma?
diabetes, dermatitis (necrolytic migratory erythema), weight loss, stomatitis
1371
where are VIPomas usually found? are they malignant?
distal pancreas, most. are malignant
1372
what are they symptoms of VIPoma?
watery diarrhea not improved with PPI, hypokalemia, achlorhydria
1373
what size of pancreatic duct is considered dilated?
>7mm
1374
where is the splenic vein in relation to splenic artery?
posterior and inferior
1375
what are the ligaments to the spleen?
gastrosplenic, splenocolic, splenonephric, and splenophrenic
1376
what are howell jolly bodies?
nuclear remnants
1377
what are heinz bodies?
hemoglobin (siderocytes)
1378
what are pappenheimer bodies?
iron
1379
what is the most common immunoglobulin in spleen?
IgM; largest producer of IgM in body
1380
where is the. mostcommon site of accessory spleen?
splenic hilum
1381
what is the most common condition, aside from trauma, requiring splenectomy?
ITP
1382
what is the most common splenic tumor?
hemangioma
1383
what is the most common malignant splenic tumor?
lymphoma
1384
which splenic cysts should be removed?
>10cm becomes cancer risk
1385
what size is the spleen in ITP?
normal
1386
what is the treatment for ITP?
steroids first, then IVIg, anti-rh abs, splenectomy if fials medical management
1387
when do you give platelets if needed during splenectomy?
after ligation of splenic artery
1388
what organism is most likely to cause infection after splenectomy?
strep pneumoniae
1389
who should get prophylactic augmentin after splenectomy?
children <10yo
1390
what causes TTP?
deficiency of enzyme ADAMTS13
1391
what is the tx for TTP?
plasmapheresis, usually NOT splenectomy
1392
which causes of splenectomy are most susceptible to OPSI?
non-trauma, thalassemia high and trauma least. Wiskott-Aldrich is most
1393
how often does pneumococcal and meningitis vaccine need to be boostered after splenectomy?
pneumo: every 3 years, meningitis: every 5 years
1394
what is the most common cause of chylous ascites?
lymphoma
1395
what is the most common congenital reason for splenectomy?
hereditary spherocytosis
1396
what is the tx for hereditary spherocytosis?
splenectomy and cholecystectomy
1397
what is felty syndrome?
RA, neutropenia, splenomegaly
1398
what is the most common splenic cyst? tx?
echinococcal, splenectomy
1399
what is the most common organism in splenic abscess?
streptococcus
1400
what do goblet cells secrete?
mucin
1401
what is the serology test for celiac?
anti-transglutamase abs
1402
what is the most common symptom of crohns?
anal disease
1403
what is the best test for diagnosing crohns?
colonoscopy with biopsies
1404
what kind of kidney stones are seen in crohns disease?
calcium oxalate
1405
what is the best test for finding a carcinoid tumor?
octreotide scan
1406
what tests should be checked with suspected carcinoid?
urine 5HIAA and chromogranin A
1407
what kind of cells are found in carcinoid tumor?
kulchitsky cells (APUD, neuroendocrine)
1408
what is the most common site of carcinoid tumor?
appendix; then ileum, then rectum
1409
what are the chemo options for carcinoid?
octreotide, interferon, streptozocin, 5fu
1410
what is the most common small bowel tumor?
leiomyoma, usually extra-luminal
1411
what is the most common cancer with puetz jegher?
breast CA
1412
what is the most common cause of intussuception in adults?
cecal adenocarcinoma
1413
what is the most common casue of stomal infection?
candida
1414
what. isthe most common casue of acute abdominal pain in first trimester?
appendicitis
1415
when is appendicitis most likely to occur in pregnancy?
2nd trimester
1416
what is the tx for benign appendix mucocele?
open appy
1417
what is the tx for malignant appendix mucocele?
R hemi
1418
which part of the colon does not have serosa?
rectum
1419
where does middle rectal artery come from?
internal iliac
1420
where does inferior rectal artery come from?
internal pudendal
1421
which muscle forms external anal sphincter?
puborectalis
1422
what nerves innervate the external anal sphincter?
internal pudendal (sympathetic) and perineal branch of S4
1423
what is the nerve supply to internal anal sphincter?
pelvic splanchnics (s2-s4 parasympathetic)
1424
what layer makes up internal anal sphincter?
muscularis propria
1425
what is the treatment for disuse pouchitis compared to infectious pouchitis?
disuse: SCFA enema; infectious = cipro/flagyl
