FIsher Flashcards
(174 cards)
1
Q
DPL criteria
A
>10cc blood >100,000 pRBC food particles bile bacteria WBC >500
2
Q
Lefort fractures
A
I- maxillary
II- lateral to nasal bone, under eyes
III- lateral orbital walls
3
Q
UE fractures - associated n/a injury ant shoulder dislocation- post shoulder dislocation- proximal humerus fx midshaft humerus fx supracondylar humerus fx elbow dislocation distal radius fx
A
ant shoulder - axillary n post shoulder- axillary a prox humerus fx- axillary n midshaft humerus fx- radial n supracondylar humerus- brachial a elbow dislocation- brachial a distal radius fx- median n
4
Q
LE fractures- associated n/a injury ant hip dislocation post hip dislocation supracondylar femur fx posterior knee dislocation fibula neck fx
A
ant hip dislocation- femoral a post hip dislocation- sciatic n supracondylar femur fx- popliteal a posterior knee dislocation- popliteal a fibular neck fx- common perineal n
5
Q
RAAS system
A
renin (from kidney)
convertns angiotensinogen (from liver) –> angiotensin I
ACE (from lung) converts AT I –> AT II
angiotensin II –> aldosterone release from adrenal cortex
6
Q
acid vs alkalotic burns
A
acid- coagulation necrosis
alkali- liquefaction necrosis
7
Q
nutrition needs in burns
A
25 cal/kg/day + (30cal x %burn)
protein 1g/kg/day + (3g x %burn)
8
Q
steps in graft take
A
imbibation 0-3d
neovascularization after 3 d
9
Q
side effects
silvadene
silver nitrate
sulfamylon (mafenide)
A
silvadene- neutropenia, thrombocytopenia
silver nitrate- hyponatremia, hypochloremia
sulfamylon- metabolic acidosis
10
Q
azygous v and thoracic duct course
A
azygous- right (behind IVC), dumps into SVC
thoracic duct- right side, crosses midline T4/T5, dumps into left subclavian (near IJ)
11
Q
lung resection PFTs
A
FEV1 >0.8 postresection (if borderline, consider V/Q scan to see which part of lung is shitty)
DLCO >10 postresection
(or >40% predicted postop value)
or preop pCO2>50, pO2<60
12
Q
lung cancer stage and management
A
obtain bx, staging PET/CT, if stage I or II –> surgery; if + spread –> mediastinal eval (mediastinoscopy v EBUS)
Stage I and II - resection (node negative) Stage III (node +) - chemo and resection vs definitive chemo/XRT
(+ nodes –> at least stage III)
T3 (still can be resectable, stage II)- invades chest wall, pericardium, diaphragm, <2cm from carina
T4 (unresectable) - invasion to mediastinum, esophagus, trachea, vertebra, heart, great vessels
13
Q
mediastinal tumors (by location)
A
Anterior- thymoma, thyroid CA, t cell lymphoma, teratoma (other germ cell tumors), parathyroid adenomas
Middle (heart trach aorta) - bronchiogenic cysts, pericardial cysts, enteric cysts, lymphoma
Posterior (esophagus, desc aorta)- enteric cysts, neurogenic tumors, lymphoma
14
Q
risk factor for tracheo-innominate fistula? tx?
A
trach below 3rd tracheal ring
hold pressure, median sternotomy, ligate innominate
15
Q
sensory skin nerve cells- pacinian, ruffini, krause, meissner
A
pacinian- pressure
ruffini- warmth
krause- cold
meissner- tactile
16
Q
TRAM flap- main vessels
A
superior epigastrics
periumbilical perforators important determinant of viablity
17
Q
pressure sore grading
A
I erythema
II partial skin loss- keep pressure off
III full thickness skin loss- debridement
IV involves bone or muscle- myocutaneous flaps
18
Q
when to stage melanoma
A
> 1mm depth (panscan)
19
Q
head and neck melanoma considerations
A
superficial parotidectomy if >1mm for anterior H&N melanoma
20
Q
peripheral palisading nuclei
stromal retraction
(skin)
A
basal cell carcinoma
21
Q
most aggressive type of basal cell carcinoma
A
morpheaform type
22
Q
margins for basal cell and squamous cell carcinoma
A
basal cell- 3-4mm
squamous cell 5-10mm
23
Q
sarcoma management
A
WLE (1cm), try to get one uninvolved fascial plane
XRT postop, consider preop if really large
24
Q
risk factors for angiosarcoma
A
PVC and arsenic
25
merkel cell carcinoma management
WLE + SLN biopsy
| >2cm (stage II) - get adjuvant radiation
26
bowens disease
squamous cell carcinoma in situ
associated with HPV
imiquimod and ablation
avoid WLE if possible
27
dermoid cyst management
resect d/t malignancy risk
28
Frey syndrome
auriculotemporal nerve injury after parotidectomy
| gustatotry sweating
29
thyrocervical trunk
```
STAT
suprascapular
transverse cervical
ascending cervical
inferior thyroid
```
30
trap and pec major flaps- artery?
trap- transverse cervical a
| pec major- thoracoacromial or IMA
31
modified radical neck dissection vs radical
MRND- omohyoid, submandibular gland, C2-C5, facial n cervical br, ipsi thyroid
radical- also take CN XI, SCM, IJ
32
MC oral cancer location
lower lip
33
oral cavity cancer management
WLE
| MRND + radiation if >4cm, clinical nodes, or bony invasion
34
pharyngeal cancer management
- XRT only if <4cm
- combine sx, xrt for >4cm or bony/nodal invasion
- angiofibroma, embolize b/f resection
- nasopharyngeal XRT only
35
salivary cancer management
resection
MRND
postop XRT
36
CSF rhinorrhea indicator
tau protein
37
peritonsillar vs retropharyngeal vs parapharyngeal abscess
peritonsillar- >10yo
retropharyngeal- <10yo ; airway emergency
parapharyngeal (dental infection)- mediastinal spread concern, lateral neck drainage
38
cleft lip vs palate timing of repair
lip- 10wks, 10lbs, hgb 10
| palate- 12mo
39
medical management for pituitary tumors
```
dopamine agonists (bromocriptine or cabergoline)
consider before transphenoidal resection
```
40
nelsons syndrome
hypertrophy of pituitary after bilateral adrenalectomy
amenorrhea, visual problems, hyperpigmentation (MSH)
Tx steroids
41
adrenal vasculature
superior adrenal a (inferior phrenic)
middle adrenal a (aorta)
inferior adrenal a (renal a)
42
incidentaloma workup
urine metanephrines/VMA/catecholamines
urine hydroxycorticosteroids
K, renin, aldosterone
43
management of incidentaloma
resect if >4cm, >10HF units, slow washout <50%
| biopsy if hx of cancer (lung MC, breast, melanoma)
44
primary hyperaldosteronism (conn syndrome)- dx and management
salt load suppression test (wont suppress)
Renin:aldosterone >20
adrenalectomy
if hyperplasia, consider med management (spironolactone, CCB, potassium replacement); if bilateral adrenalectomy will need lifelong steroid replacement
45
adrenal insufficiency test
```
cosynotropin test
(in acute setting give dex before doing this test)
```
46
adrenocortical carcinoma management
open adrenelectomy, debulking
| mitotane
47
pheochromocytoma rule of 10%
```
malignant
bilateral
children
familial
extraadrenal (organ of zuckerkandle, RP)
```
48
diagnosis of pheochromocytoma
VMA, urine metanephrines
MIBG scan
clonidine suppression test (does not suppress)
49
management of pheo
alpha before beta
adrenalectomy (ligate vein first)
metyrosine (inhibits tyrosine hydroxylase)
50
ima artery
occurs in 1%
| from innominate or aorta --> thyroid
51
nerves in thyroidectomy
superior laryngeal nerve - circothyroid only, runs superior and lateral to thyroid; loss of projection, easy fatigue
recurrent laryngeal nerve- all other layrngeal mm, in tracheoesophageal groove, hoarseness, airway obstruction if bilateral injury
52
tubercle of zuckerkandl
lateral portion of thyroid
recurrent laryngeal n will be behind this
tubercle is left if subtotal thyroidectomy (ti keep RLN safe)
53
wolff chaikoff effect
thyroid suppression with iodine loading
| useful thyroid storm
54
PTU and methimazole side effects
PTU - aplastic anemia, agranulocytosis
MMA- cretinism in preggo, same as PTU
also dont give radioactive iodine to preggo
55
thyroid cancers
PTC- MC, psammoma body, orphan annie nuclei
Follicular- hematogenous spread (usu to bone)
MTC- parafollicular c cells (calcitonin), amyloid deposition
ATC-
MRND for nodal dz or local dz
XRT for unresectable dz
56
indications for surgery in primary hyperparathyroidism
symptomatic
| Ca>13, decreased creatinine clearance, kidney stones, low bone mass
57
tertiary hyperparathyroidism
persistent hyperPTH after renal transplant
58
MEN syndrome genetics
Auto dom
MEN I - MENIN gene
MEN IIa, IIb - ret proto oncogene
59
MEN I
```
parathyroid hyperplasia (usu first sign)
pancreatic (usu gastrinoma)
pituitary adenoma (usu prolactinoma)
```
60
MEN IIa
parathyroid hyperplasia
medullary CA- most will have, diarrhea, ppx thyroidectomy at 6yo
pheo
61
MEN IIb
pheo
medullary Ca- most will have, diarrhea, ppx thyroidectomy at 2yo
mucosal neuromas
marfans
62
LCIS management options
observation
tamoxifen ppx
bilateral ppx mastectomy
63
BRCA I vs II
I 60% breast, 40% ovarian
| II 60% breast, 10% ovarian, 10% male breast, 10% pancreatic
64
inflammatory breast cancer management
neoadjuvant chemo --> MRM --> adjuvant chemoXRT
65
contraindications for breast conserving therapy
2+ tumors
pregnancy
prior radiation to breast
66
pagets disease of breast management
mastectomy or BCT + radiation
| SLN biopsy
67
stewart treves syndrome
upper inner arm
lymphangiosarcoma from chronic lymphedema (after axillary dissection)
usu 5-10 yrs after surgery
68
type I vs II pneumocytes
I gas exchange
| II surfactant production
69
MC lung cancer met?
to brain
70
horners syndrome
pancoast tumor
| ptosis, miosis, anhidrosis
71
mediastinal GCT management
teratoma- resection
seminoma (beta HCG some, no AFP)- XRT
nonseminoma (most will have beta HCG and AFP)- chemo
72
management of pericardial vs bronchiogenic cysts
resect bronchiogenic
| leave pericardial cysts
73
lung abscess management
abx usu will resolve
| drain only if unsuccessful
74
left vs right chylothorax
injury above T5/6 = left
| injury below T5/6 = right
75
chest wall tumors MC (benign and malignant)
benign- osteochondroma
| malignant- chondrosarcoma
76
ductus arteriosus and ductus venosum
areriosus- desc aorta to left PA (shunts away from lungs)
| venosum- portal vein to IVC (shunts away from liver)
77
Tetralogy of fallot
VSD, pulmonic stenosis, overriding aorta, RVH
78
indications for CABG
left main >50%
| >70% in other vessels
79
indications for Aortic valve repair
peak gradient >50
valve area <1cm2
or symptomatic
80
endocarditis valves involved, bugs involved
```
aortic valve- prosthetic
mitral- native
tricuspid- drug abusers
staph MC, pseudomonas in drug abusers
(abx first, surgery if fails)
```
81
MC cardiac tumors- benign, malignant, met
myxoma
angiosarcoma
lugn CA
82
SVC syndrome management
usu lung CA mets
| emergent XRT
83
CEA nerve injuries
vagus n (MC from vascular clamp)- hoarseness
hypoglossal
glossopharyngeal (rare, if high dissection)
ansa cervicalis (no deficits)
facial n mandibular br
84
aortic dissection into which layer?
medial layer
85
AAA d/t degen of which layer?
medial layer
86
where does AAA rupture most commonly?
left posterolateral wall, 2-4cm below renals
87
Complications after AAA repair
impotence
MI (MC acute death reason)
kidney failure (MC chronic death reason)
88
AAA endovascular repair criteria
```
neck length >15mm
neck diameter 2-3cm
neck angle <60
common iliac length >1cm
common iliac diameter 8-18mm
```
89
endoleak types
```
I at attachment sites
II collaterals
III overlap sites
IV porosity
V aneurysm expansion without leak
```
90
common infections in aortic aneurysms
graft infection- staph #1, e coli #2
mycotic aneurysm - salmonella #1, staph #2 (bacteria invades plaque)
(management same, bypass and resect)
91
aortoenteric fistula- presentation and location
hematemesis herald bleed, blood per rectum
| erosion to 3/4 duodenum at proximal suture line
92
compartment syndrome mediated by which cell type; also which compartment usually?
PMNs
| anterior compartment
93
popliteal entrapment syndrome
claudication with plantar flexion (loses pulses)
| resect gastroc muscle
94
most common site of embolic disease
common femoral a
95
arterial emboli vs thrombosis management
emboli- embolectomy
| thrombi- heparin and thrombectomy if limb threatened, otherwise angio and thrombolytics
96
subclavian steal syndrome
subclavian artery stenosis --> reversed flow through vertebral artery
angio w stent; common carotid to subclav artery bypass if stent fails
97
median arcuate ligament syndrome
median arcuate compresses celiac artery
| transect liagment
98
aneurysm complciations
rupture (above inguinal ligament)
| thrombosis/emboli (below inguinal ligament)
99
when to repair splanchnic artery aneurysms, how
>2cm
except splenic (MC)- symptomatic or childbearing age or >3-4cm
covered stent
100
renal artery, iliac artery, femoral artery, popliteal- when to treat
```
renal 1.5cm
iliac 3
femora 2.5
popliteal (MC) 2cm
(all repair with covered stent, except popliteal (bypass!)
```
101
pseudoaneurysms- management
if from percutaneous interventions- compression w thrombin injection, if fails, surgical repair
if at suture line after surgery --> surgical repair
if later complication after surgery, probably graft infection
102
dialysis graft failure MC reason
venous obstruction 2/2 intimal hyperplasia
103
migratory thrombophlebitis sign?
pancreatic cancer
104
which side more common DVT
left more common
105
MC lymphedema bug
strep
106
lymphocele management
first try perc drainage
resection if fails
isosulfan blue dye to foot to ID channels
107
gastrin, somatostatin, CCK, secretin
gastrin (g cells, antrum) --> increase HCl
somatostatin (D cells, antrum) --> inhibits
CCK (I cells, duo) --> GB contract, panc enzyme secretion
Secretin (S cells, duo)--> panc bicarb secretion
108
pancreatic polypeptide action
islet cells of pancreas
| decrease panc and GB secretions
109
peptide YY
```
term ileum
inhibs gastric acid secretion
GB contraction
gastric contraction
panc secretions
```
110
bowel turnover - stomach, SB, colon
stomach 48hrs
SB 24 hours
colon 3-5days
111
esophagus vascular supply
mostly directly off aorta
cervical- inferior thyroid a
abdominal- left gastric
venous- azygous and hemiazygous
112
MC location of esophageal perf
at cricopharyngeus
113
distance from incisors- UES and LES
15cm 40cm
114
surg approach to esophagus
cervical left
upper 2/3 right (to avoid aorta)
lower 1/3 left
115
traction diverticulum etiology and management
true diverticulum
usu lateral, mid esophagus
inflammation, granulomatous dz, cancer
excision and closure if symptomatic
116
manometry- achalasia, DES, nutcracker
achalasia- increased LES pressure, incomplete LES relaxation, no peristalsis
DES- strong, nonperistaltic contractions, normal LES
Nutcracker- high amplitude peristalsis, normal LES
117
achalasia, DES, nutcracker management
achalasia- balloon dilation first + CCB/nitrates; consider heller (lower esophagus only)
DES and nutcracker- CCB/nitrates, consider heller (lower and mid esophagus)
118
achalasia causes
usu neuronal degeneration
| T cruzi can cause similar syndrome
119
esophageal cancer staging and management
```
TNM + grade, similar to colon cancer TNM
stage I (T1 or low grade T2) - esophagectomy only
stage II (high grade T2 or above) - neoadju chemorads
endomucosal resection for stage IA (low grade T1)
```
120
esophageal adeno vs squmous cell mets MC
adeno- liver
| squmous cell- lung
121
blood supply to stomach after esophageectomy
right gastroepiploic
122
leiomyoma esophageal- where from and management
muscularis propria
no biopsy
excision if >5cm or symptomatic
123
caustic esophageal injury management
no NGT, NPO, no vomiting
endoscopy to assess lesion (only do if there is no perf on CT)
primary burn (hyperemia)- conservative management
secondary (ulcers, sloughing)- attempt conservative management
tertiary (deep ulcers, charring) usu will need esopahgectomy
124
esophageal perforation management
contained perfs- conservative
<24hrs - consider pirmary repair, consider muscle flaps
>48hrs - if in neck (just place drains), if chest resect or divert...delayed gastric replacement
125
boerhaaves most common perf location
usu left lateral wall, 3-5cm above GE junction
| higher mortality than other perfs (like iatrogenic)
126
parietal cells
release H and IF (binds B12 in term ileum)
| stim by Ach (vagus), gastrin (G cells), histamine (mast cells)
127
gastric volvulus management
associated with type II hernias
| reduction and nissen
128
vagotomy postop problems
increased liquid emptying
decreased solid emptying for truncal vagotomy (always do pylorplasty or antrectomy with truncal vagotomY)
diarrhea (due to uncontrolled MMC )
129
anterior vs posterior duodenal ulcer
anterior- perforate
posterior- bleed
(anterior MC)
130
management of bleeding duodenal ulcer
EGD first
| surgery- duodenotomy and GDA ligation
131
gastric ulcer types
```
(types go from MC to least)
I lesser curve at antrum
II duo and gastric ulcer
III prepyloric
IV lesser curve higher up
V NSAID associated
```
132
gastric ulcer complication management
truncul vagotomy and antrectomy; resect ulcer
133
intestinal vs diffuse gastric cancer management
intestinal- subtotal gastrectomy 10cm margins
diffuse - total gastrectomy
no resection if metastatic dz
134
GIST- histo and management
ckit postive
malignant if >5cm, >5 mitosis/50HPF
resect w 1cm margins
imatinib
135
RNYGB risks
marginal ulcers
B12 definiciency (IF cant bind B12 if not acidic)
IDA (duo bypassed)
gallstones
136
intestinal vs diffuse gastric cancer management
intestinal- subtotal gastrectomy 10cm margins
diffuse - total gastrectomy
no resection if metastatic dz
137
hepatic veins drain what
left- II, III, IV (sup)
middle- V, IV (inf)
right- VI, VII, VIII
(middle hepatic usu off left hepatic vein)
138
RNYGB risks
marginal ulcers
B12 definiciency (IF cant bind B12 if not acidic)
IDA (duo bypassed)
gallstones
139
MC hepatic artery variants?
right hepatic - SMA (behind CBD)
| left hepatic - left gastric a (in gastrohepatic ligament)
140
hepatic veins drain what
left- II, III, IV (sup)
middle- V, IV (inf)
right- VI, VII, VIII
141
coag factors not made in liver
vWF and factor VIII (from endothelium
142
crigler najar, dubin johnson
| gilberts and rotors
crigler najar and gilbert- indirect
| dbin johnson and rotors- direct
143
best lab for liver function
PT
144
best diuretic for ascites
aldactone
| aldosterone usu high, d/t poor hepatic cleranace
145
Spont bacterial peritonitis features
PMN >250
| usu e coli (mono organism MC)
146
esophageal varices med management
vasopressin (constricts)
octreotide
propranolol (prevents rebleed)
147
childs pugh score and mortality risk
A 2%
B 10%
C 50%
148
liver abscesses
amebic- entamoeba, tx w flagyl
echinococcus- ectocyst (calcification), endocyst (double walled), dont' aspirate!, albendazole and resect
pyogenic
149
kasabach merritt syndrome
coagulopathy and CHF 2/2 liver hemangioma
150
HCC margins
1cm
151
Meds to contract, relax sphincter of oddi
morphine contrascts
| glucagon relaxes
152
hormone from duo and stomach
gastrin (g cells, antrum) --> increase HCl
somatostatin (D cells, antrum) --> inhibits
CCK (I cells, duo) --> GB contract, panc enzyme secretion
Secretin (S cells, duo)--> panc bicarb secretion
153
CCK HIDA indications for cholecystectomy
no gallbladder filling
EF <40%
>60min to empty (chronic cholecystitis)
154
bile duct stricture causess
lap chole (ischemia)
chronic pancreatitis
cancer (until proven otherwise if non above)
155
hemobilia-
```
fistula bile duct and hepatic artery
UGI bleed, jaundice, RUQ pain
usu d/t trauma and iatrogenic
angiogram dx
angioembo tx
```
156
gallbladder cancer resection
gallbladder only if not into muscle
wedge resection if to muscle of 4b and 5
formal resection if past
157
bile duct cancer risk factors
c sinesis, UC, choledochal cysts, PSC, CBD infections
158
choledochal cyst types
```
I- fusiform
II- diverticulum
III intraduodneal
IV- intra and extrahepatic
V caroli
```
159
endocrine pancreatic cells
```
alpha- glucagon
beta- insulin
delta- somatostatin
F- pancreatic polypeptide
Islet- VIP
```
160
Pancreatic divisum ERCP findings
```
minor papilla (santorini) will be big
major papilla with be short (wirsung)
```
161
pancreas "chain of lakes"
chronic pancreaatitis
162
chronic pancreatitis surgical management
puestow- pancreaticojejunostomy (if large duct)
beger- head resection
frey- core out pancreas, pancreaticoJ
163
pancreatic endocrine tumors- malignant vs benign
```
nonfunctional- usu malignant
insulinoma- usu benign
gastrinoma 1/2 1/2
glucagonoma- usu malignant
somatostatinoma- usu malig
VIPoma- usu malig
```
164
management of NEC panc tumors
<2cm enucleat
>2cm formal resection
5FU and streptozocin
165
gastrinoma triangle
CBD, pancreas neck, D3
166
imaging for gastrinoma
octreotide scan
167
ITP vs TTP treatment
ITP - steroids and IVIG; try to avoid splenectomy before 10yo
TTP- plasmapheresis (usu wont require spelenctomy)
168
feltys syndrome
RA, hepatomegaly, splenomegatly
169
dentate line- differentiates
```
2cm from anal verge
divids upper 2/3 from lower third
columnar vs stratified squamous
superior rectal vs mid/inf rectal v
internal vs ext hemorrhoids
```
170
Crohns features
```
spares rectum
transmural involvement
skip lesions
cobblestoning
creeping fat
fistulas
```
171
small intestine carcinoid
5HT, bradykinin
octreotide scan to localize
chromagranin A
enterochromaffin cells
172
dentate line- differentiates
```
2cm from anal verge
internal iliac v superior inguinal LN
columnar vs stratified squamous
superior rectal vs mid/inf rectal v
internal vs ext hemorrhoids
```
173
rectum arteries and veins
superior rectal --> IMA
middle rectal --> interal iliac
inferior rectal --> interal pudendal (int iliac)
sup/mid rectal
174
colon main nutrient
Short chain FA
