TrueLearn #1 Flashcards
What kind of drug is Levamisole?
[True Learn]
An Immunomodulator (immune system stimulator)
[It was given in combination with fluorouracil as adjuvant therapy for patients with colon cancer within 1 month after surgical resection and extended for 1 year. It was withdrawn from the U.S. and Canadian markets in 1999 and 2003, respectively, due to the risk of serious side effects and the availability of more effective replacement medications. The most serious side effect is agranulocytosis. It can also cause encephalopathy-like syndromes, and disulfuram-like reactions.]
Ventricular septal defects cause symptoms related to congestive heart failure and can initially be treated with what?
[True Learn]
Digoxin and diuretics
[Patients with large defects who have refractory heart failure should undergo surgical correction immediately, regardless of age. Up to 50% of VSD’s close spontaneously, and small defects may not cause symptoms and do not warrant correction.]
Can nonoperative management be used in a hemodynamically stable child with a splenic injury?
[True Learn]
Yes
[More emphasis is being placed on splenic preservation as long as the child is alert and hemodynamically stable. Therefore, proceeding immediately to splenectomy and splenorraphy is often not indicated an leads to further unnecessary morbidity.]
PTEN (Tumor suppressor gene) mutation is associated with which condition?
[True Learn]
Cowden syndrome
[This is a rare autosomal dominant inherited disorder characterized by multiple hamartomas and an increased risk of certain forms of cancer]
How are injuries to the middle third of the ureter repaired?
[True Learn]
Ureteroureterostomy is performed by connecteing the two spatulated ends of the injured ureter
[A large defect that prevents tension free repair requires a transureteroureterostomy (The suture of the transected end of one ureter into the intact opposite ureter)]
Which 2 antigens are usually responsible for delayed immune hemolytic reactions?
[True Learn]
- RhD
- Kell
[Delayed immune hemolytic reactions occur when an unexpected antibody is formed by the patient to a previous blood transfusion. This is usually due to an RhD or Kell antigen that causes this.]
What is the definition of a Grade IV splenic injury?
[True Learn]
Laceration: Involving segmental or hilar vessels producing major devascularization (greater than 25% of spleen)
Which drug that is administered to correct for hyperkalemia works by causing an intracellular shift of potassium?
[True Learn]
Insulin
[10-20 units of IV insulin is usually administered. This dose must be accompanied by the administration of glucose to avoid hypoglycemia.]
Under which circumstances should a lumbar hernia be repaired?
[True Learn]
When they are large or symptomatic
[Prosthesis or a tissue flap of some kind is essential for a successful repair. Surgeons may use a rotation flap of fascia lata for repair of these defects as well. Typically, a preperitoneal stoppa-type repair is used.]
What kind of burns is Bacitracin used to treat?
[True Learn]
Superficial (first degree) burns
[It is also used to treat raw wounds with injured or disrupted epithelium. It helps to keep wounds moist.]
What is the preferred site of placement of an interossous line?
[True Learn]
Anteromedial tibia
[Alternative sites include sternum, distal femur, lateral or medial malleoli, iliac crest, and distal radius.]
Thoracic outlet syndrome occurs in what percent of the population?
[True Learn]
5%
[It is characterized by compression of the brachial plexus, subclavian artery, or subclavian vein where these structures pass between the first rib and scalene muscles]
The axillary lymph node groups are assigned levels according to their anatomic relationship to which muscle?
[True Learn]
Pectoralis minor muscle
[Level I = Lateral or below lower border of pectoralis minor Level II = superficial or deep to the pectoralis minor Level III = Medial to or above upper border of pectoralis minor]
How should one proceed when a patient is taken to the OR for appendicitis but found to have acute ileitis intraoperatively?
[True Learn]
Proceed with an appendectomy as long as there is no cecal involvement
[Acute ileitis can often mimic acute appendicitis. The recommendation is to proceed with an appendectomy to rule out the appendix as a future source of abdominal pain. The ileitis is likely secondary to a bacterial infection that does not warrant any surgical resection.]
Which test is performed to diagnose thoracic outlet syndrome?
[True Learn]
Adson test (scalene test)
[performed by having the patient maximally extend their neck and turn their head toward the effected extremity. The ipsilateral radial pulse is palpated. The test is considered positive if the pulse decreases or disappears.]
What is the definition of a Grade V splenic injury?
[True Learn]
- Laceration: Completely shattered spleen
- Vascular: Hilar vascular injury with devascularized spleen
Where is the most common location for a perforated duodenal ulcer?
[True Learn]
Anterior aspect of the 1st portion of the duodenum
[Perforation is an increasingly less common, though often fatal, complication of duodenal ulcers. The most common presentation is the sudden onset of severe and diffuse abdominal pain with pneumoperitoneum on radiography.]
Which cell type mediates graft-versus-host disease (GVHD)?
[True Learn]
T-cells
[Donor-derived T and B cells can be stimulated by host alloantigen and transiently repopulate the host. CD8+ T cells from the graft directly damage host cells. Cytokines from graft CD4+ T cells recruit macrophages which damage host cells. The antihost reactive cells can cause T-cell-mediated lesions, such as hepatitis, dermatitis, or gastrointestinal mucosal lesions. as seen in bone marrow transplant recipients with GVHD.]
Below the vocal folds, the sensory innervation of the larynx is provided by which nerve?
[True Learn]
Branches of the recurrent laryngeal nerve
[This is a branch of the vagus nerve. Above the vocal folds, the sensory innervation of the larynx is provided by the internal laryngeal nerve (this is a branch of the superior laryngeal nerve, which is a branch of the vagus nerve). The vocal fold itself receives innervation from both nerves.]
Which 2 measurements are required to make the diagnosis of Zollinger-Ellison Syndrome (gastrinoma)?
[True Learn]
- Fasting serum gastrin level greater than 100 pg/mL
- Basal acid output greater than 15 mEq/Hr
[Measurement of the fasting serum level of gastrin is the initial study to diagnose ZES. Of patients with ZES, virtually 100% will have a fasting serum gastrin level greater than 100 pg/ml. However, fasting serum gastrin levels in individuals with renal failure, pernicious anemia, or atrophic gastritis may exceed pg/ml, and therefore concomitant measurement of basal acid output is necessary to confirm the diagnosis of ZES.]
Multiple cerebellar hemangioblastomas, bilateral renal lesions consistent with renal cell carcinoma, and multiple pancreatic cysts are a combination of symptoms seen in which disease?
[True Learn]
Von Hippel-Lindau syndrome
[This is caused by a germline mutation in the gene VHL, with an incidence of 1 in 36,000 live births.]
Which 5 criteria must be met for a patient with an ectopic pregnancy to be a candidate for Methotrexate treatment instead of surgical treatment?
[True Learn]
- No evidence of rupture and hemodynamic stability
- Beta-HCG less than 15,000
- Fetus size less than 3.5cm
- No evidence of intrauterine pregnancy
- Medication compliance
A germline mutation in the gene VHL causing Von Hippel-Lindau syndrome predisposes patients to what?
[True Learn]
- Hemangioblastomas of the CNS and retina
- Pheochromocytomas
- Clear cell renal cell cancer
- Endolymphatic sac tumors
- Cystadenomas and neuroendocrine tumors of the pancreas
- Papillary cystadenomas of the epididymis and broad ligament
In regards to lower GI bleeding, when should a colonoscopy be performed for the highest diagnostic yield?
[True Learn]
Early colonoscopy within 12 hours of bleeding onset results in higher diagnostic yields (53-97% overall) and increased opportunity for endoscopic intervention
[Colonoscopy has a higher dianostic yield and a lower complication rate than arteriography in this setting.]
Why is lymph node metastatis of gallbladder cancer uncommon (Less than 10%) in T1 disease?
[True Learn]
T1 tumors have not yet invaded the subserosal layer, which contains lymphatics
Nitroprusside can cause cyanide toxicity. Which 3 agents can be used as antidotes to cyanide toxicity?
[True Learn]
- Amyl nitrite
- Sodium nitrite
- Sodium thiosulfate
[Cyanide toxicity manifests as weakness and confusion, followed by pulmonary edema. Thiocyanate levels can be checked to ensure the patient does not have a toxic level of cyanide.]
Which test is the gold standard for diagnosing achalasia?
[True Learn]
Manometry
[It will show a hypertensive lower esophageal sphincter with failure of relaxation during swallowing. The esophageal body will show pressure above baseline, mirrored contractions with no progressive peristalsis, and low amplitude waveforms.]
What is the most important indicator of prognosis in gallbladder cancer?
[True Learn]
Nodal involvement
[Lymph node status is considered the most important indicator, however, nodal involvement in 5-year survivors has been documented.]
What is the physiology of a Type II hypersensitivity reaction?
Cytotoxic-mediated hypersensitivity reaction associated with immunoglobulins attached to a surface antigen with subsequent complement fixation or autoantibodies attached to cell surface receptors
[I.E Hashimoto’s thyroiditis or Grave’s disease.]
Which test should be ordered to assess the condition of the rectum prior to any intervention for a radiation induced rectovaginal fistula?
[True Learn]
Rigid proctoscopy
[The quality of the rectal tissue (fibrosis, friability, etc.) and its associated compliance will help determine what type of operation should be performed, and it may help to localize the fistula. CT scan, transvaginal U/S, transrectal U/S, and barium enema cannot reliably assess the condition of the rectal tissue like endoscopy can.]
What can cause bleeding as well as thrombosis of small and large vessels?
[True Learn]
Disseminated intravascular coagulation (DIC)
Most gastrointestinal stromal tumors (GIST) occur sporadically from which cells?
[True Learn]
Interstitial cells of Cajal
[Rarely, they are inherited on an autosomal dominant basis.]
The lingula is part of which lobe of the lungs?
[True Learn]
The upper lobe of the left lung
Which repair is well suited for a strangulated femoral hernia?
[True Learn]
McVay (or Cooper’s) repair
[This is because the McVay repair closes the femoral canal defect without incorporating mesh. The technique consists of approximating the transversus abdominis aponeurosis to Cooper’s ligament.]
What is the definition of a Grade III splenic injury?
[True Learn]
- Hematoma: Subcapsular, greater than 50% surface area or expanding; ruptured subcapsular or parechymal hematoma; intraparenchymal hematoma greater than or equal to 5 cm or expanding
- Laceration: Greater than 3 cm parenchymal depth or involving trabecular vessels
Which nerve innervates the upper epiglottis and is responsible for the gag reflex?
[True Learn]
Glossopharyngeal nerve (CN IX)
[The upper epiglottis nerve supply is via CN IX, which provides the sensory pathway of the gag reflex.]
Which 2 criteria must be met before a child with a splenic injury should be allowed to get out of bed?
[True Learn]
- Abdominal pain has resolved
- Hematocrit is stable
What are the indications for operative management in a chronic aortic dissection?
[True Learn]
- Impending or actual rupture
- Symptoms (congestive heart failure, angina, aortic regurgitation, stroke, pain.)
- Malperfusion
- Aortic expansion greater than 1 cm/year
- Type A Aneurysm size: Greater than 5.5 cm
- Type B Aneurysm size: Greater than 6.5 cm
Refeeding syndrome is associated with low levels of which 3 electrolytes?
[True Learn]
- Phosphorus
- Magnesium
- Potassium
Which chemotherapy agent causes pulmonary fibrosis?
[True Learn]
Bleomycin
[Bleomycin commonly causes interstitial pneumonitis which can progress to pulmonary fibrosis. This effect is dose related and occurs in approximately 10% of patients treated with cumulative doses of greater than 350 to 400 U.]
At 6 weeks, what is the tensile strength of a wound?
[True Learn]
80% of its final tensile strength
[Final tensile strength of a wound is never as strong as the skin’s pre-wound strength.]
Where are level I axillary lymph nodes located?
[True Learn]
Lateral or below the lower border of the pectoralis minor muscle
[This includes the axillary vein, external mammary, and scapular groups Level II = superficial or deep to the pectoralis minor Level III = Medial to or above upper border of pectoralis minor]
What is the appropriate treatment for autoimmune pancreatitis (AIP)?
[True Learn]
Corticosteroids for 2-4 weeks or until symptoms resolve
[AIP responds rapidly to steroids and therefore surgery is not necessary. AIP is rarely refractory to corticosteroids and rarely recurs, therefore lifelong corticosteroid treatment is not necessary. A minority of patients will require maintenance therapy.]
What is the potential benefit of placing ureteral stents peroperatively?
[True Learn]
Ureteral stents help identify ureteral injuries once they have occured
[Ureteral stents have not been definitively shown to prevent injuries, but this could change as more studies are done with new lighted stents]
Cricothyroidotomy is contraindicated in which population of patients?
[True Learn]
Children 10-12 years of age or younger
[The cricothyroid membrane is very delicate in this age group]
Does postoperative adjuvant chemoradiation improve survival in rectal cancer?
[True Learn]
Yes
[3 large randomized trials of postop chemoradiation have shown a survival benefit.]
Overfeeding is associated with a respiratory quotient of what value?
[True Learn]
Greater than 1.0
What is the Parkland formula and what is it used for?
[True Learn]
It is the formula used to calculate the total required volume of resuscitation Total volume of resuscitation = weight in Kg x % total body surface area burned x 4
[The total volume calculated is given over 24 hours with half of this volume given over the first 8 hours and the remaining half over the next 16 hours. Even when using the Parkland formula, urine output must be closely followed to determine whether fluid rates must be altered.]
Can iatrogenic injuries to the colon be repaired primarily at the time of injury?
[True Learn]
Yes
[Full thickness large bowel injuries in the setting of minimal fecal contamination should undergo simple repair. The suture line failure rate for primary repair is approximately 1%, which is less than the rate generally reported for elective colon and rectal surgery. Mortality associated with suture line failure in this setting is uncommon.]
In statistics, what is the definition of the p value?
[True Learn]
The probability of obtaining a result as/or more extreme than the one observed if the null hypothesis is true
[It provides a measure of inductive evidence against the null hypothesis.]
What is the best method of determining diaphragm injury in blunt trauma?
[True Learn]
CT scan (63% sensitivity and 100% specificity)
[Those injuries that occur without herniation may be missed but these are more common in penetrating trauma than in blunt trauma.]
What is the most common congenital anomaly of the GI tract, occurring in approximately 2% of the population?
[True Learn]
Meckel’s diverticulum
[It occurs when the omphalomesenteric duct fails to close during gestation and is located along the antimesenteric border of the ileum.]
What is the physiology of a Type IV hypersensitivity reaction?
[True Learn]
Cell mediated immunity
[I.E. contact dermatitis such as poison Ivy contact dermatitis.]
What is the treatment for Ogilvie syndrome (colonic pseudoobstruction)?
[True Learn]
- Conservative treatment
- Stop narcotics
- Correct electrolyte abnormalities
- Bowel rest
- NG tube decompression
[If these measures fail, 2.5mg of neostigmine should be administered intravenously over 3 minutes. Resolution of the condition is indicated within less than 10 minutes of administration of the drug by the passage of stool and flatus.]
What occurs when the omphalomesenteric duct fails to close during gestation?
[True Learn]
Meckel’s diverticulum
[2% may become symptomatic, usually within the first 2 years of life. The most common symptom in kids is bleeding. Diagnosis in the pediatric patient is with Meckel’s scintigraphy (85% sensitive in pediatric patients) due to concentrated heterotopic gastric mucosa within the diverticulum. This becomes much less sensitive in the adult population due to atrophic gastric mucosa.]
Innominate (brachiocephalic) artery injuries are best treated surgically through which approach?
[True Learn]
Median sternotomy
[The innominate vein can be safely ligated for better visualization. Blunt traumatic injuries can present with an avulsion at the origin with the aortic arch. These are most often repaired with a direct bypass from the arch to an area distal to the innominate injury. The injured site can then be oversewn. Rarely, patients will need to go on cardiopulmonary bypass for the procedure.] - If exposure is necessary, the incision can be extended up into the (left or right?) cervical region.]
Who is a good candidate for a nipple sparing mastectomy?
[True Learn]
- Women undergoing a prophylactic mastectomy
- Women with small, peripheral tumors or in situ disease
[The oncological safety of NSM is unkown secondary to lack of long-term follow up data. Nipple or areolar necrosis is one of the most serious complications of this procedure. Additional complications include lack of sensation to the nipple, change in nipple pigmentation, and improper nipple positioning following reconstruction.]
Which two chemotherapy agents cause neurotoxicity?
[True Learn]
- Vincristine
- Cisplatin
[Vincristine can lead to constipation and hepatotoxicity.]
Where is the most common point of obstruction in a patient with gallstone ileus?
[True Learn]
Terminal ileum
[Gallstone ileus occurs secondary to inflammation that causes a fistula tract between the gallbladder and the small bowel. This tract allows the passage of gallstones into the small bowel, which can lead to an obstruction. Obstructions most commonly occur at the terminal ileum.]
How is GERD complicated by Barrett’s esophagus treated?
[True Learn]
It is treated based on the presence or absence of dysplasia
- No dysplasia = Nissen fundoplication
- High grade dysplasia or adenocarcinoma = Esophagectomy
Where does the superior lumbar hernia of Grynfeltt occur?
[True Learn]
In the space between the latissimus dorsi, the serratus posterior inferior, and the posterior border of the internal oblique muscle
[I think serratus posterior inferior is wrong.]
[SCORE: Lumbar hernias can be congenital or acquired after an operation on the flank and occur in the lumbar region of the posterior abdominal wall. Hernias through the superior lumbar triangle (Grynfeltt triangle) are more common. The superior lumbar triangle is bounded by the 12th rib, paraspinal muscles, and internal oblique muscle. Less common are hernias through the inferior lumbar triangle (Petit triangle), which is bounded by the iliac crest, latissimus dorsi muscle, and external oblique muscle. Weakness of the lumbodorsal fascia through either of these areas results in progressive protrusion of extraperitoneal fat and a hernia sac. Lumbar hernias are not prone to incarceration. Small lumbar hernias are frequently asymptomatic. Larger hernias may be associated with back pain. CT is useful for diagnosis.]
[UpToDate: The superior lumbar triangle (Grynfeltt) is an inverted triangle, its base is the twelfth rib, its posterior border is the erector spinae, and its anterior border is the posterior margin of the external oblique; its apex is at the iliac crest inferiorly.]
[Wikipedia: The lumbar triangle can refer to either the inferior lumbar (Petit) triangle, which lies superficially, or the superior lumbar (Grynfeltt) triangle, which is deep and superior to the inferior triangle. Of the two, the superior triangle is the more consistently found in cadavers, and is more commonly the site of herniation; however, the inferior lumbar triangle is often simply called the lumbar triangle, perhaps owing to its more superficial location and ease in demonstration.
The margins of the inferior lumbar (Petit’s) triangle are composed of the iliac crest inferiorly and the margins of two muscles – latissimus dorsi (posteriorly) and external abdominal oblique (anteriorly). The floor of the inferior lumbar triangle is the internal abdominal oblique muscle. The fact that herniations occasionally occur here is of clinical importance.
The superior lumbar (Grynfeltt-Lesshaft) triangle is formed medially by the quadratus lumborum muscle, laterally by the internal abdominal oblique muscle, and superiorly by the 12th rib. The floor of the superior lumbar triangle is the transversalis fascia and its roof is the external abdominal oblique muscle.]
What is the most common anomaly associated with tracheoesophageal fistula (TEF)?
[True Learn]
Cardiovascular defects
[Genitourinary, gastrointestinal, skeletal, neurologic, and craniofacial defects are found with increased frequency in patients with esophageal atresia as well.]
Which artery supplies blood to the cervical esophagus?
[True Learn]
The inferior thyroid artery
[The inferior thyroid artery is a branch of the thyrocervical trunk which is a branch of the subclavian artery. Cervical esophageal lymphatics drain into recurrent laryngeal, paratracheal, jugular, and superior mediastinal nodes.]
Which cells do carcinoid tumors originate from?
[True Learn]
Enterochromaffin-like cells (also known as Kulchitsky cells)
What is the first treatment that should be administered to a patient with hyperkalemia and ECG changes?
[True Learn]
Administration of calcium gluconate
[Cardiac complications such as ventricular fibrillation and cardiac arrest may occur with untreated hyperkalemia. Calcium stabilizes the membrane potentials an prevents further cardiac sequelae. The effect of calcium is only transient and further steps are required to correct the patient’s hyperkalemia.]
Which type of reaction occurs when ABO-compatible red cells containing a specific antigen (I.E. RhD or Kell) are transfused into a patient who has preformed alloantibodies?
[True Learn]
Delayed immune hemolytic reactions
[This occurs after a second transfusion (antibodies are formed after the first transfusion). Symptoms of hemolysis appear within 3 to 10 days and include fever, malaise, unconjugated hyperbilirubinemia, or a declining hemoglobin/hematocrit.]
What are the 4 surgical indications in a patient with a lung abscess?
[True Learn]
- Failure of 8 weeks of medical management
- Large cavity over 4-6cm
- Hemoptysis
- Rule out malignancy
What is the appropriate management of symptomatic Focal Nodular Hyperplasia of the liver?
[True Learn]
Symptomatic patients should be worked up and patients with persistent symptoms or an enlarging mass need to be considered for resection.
[Even symptomatic patients should be managed conservatively at first as the symptoms are likely to resolve. Because FNH is a benign diagnosis, resection must be performed with minimal morbidity and mortality]
What is the standard treatment for DCIS of the breast?
[True Learn]
Wide local excision with postoperative radiation
[Sentinel lymph node biopsy is indicated, especially if a total mastectomy is performed.]
Which pancreatic anomaly presents with a double bubble sign on abdominal x-ray?
[True Learn]
Annular pancreas
[Duodenal atresia also presents with a double bubble sign.]
Which surgical procedure for constipation has the best results?
[True Learn]
Subtotal colectomy with ileorectal anastomosis
What is the likely diagnosis of a pancreatic lesion with fluid analysis showing low viscosity, low CEA, and high amylase?
[True Learn]
Pancreatic pseudocyst
[pseudocysts have markedly elevated Amylase.]
Pure fat metabolism is associated with a respiratory quotient of what value?
[True Learn]
0.7
What is the maximal dose of Bupivacaine that can be given?
[True Learn]
3mg/kg
What is the best management approach to a gallstone ileus located in the terminal ileum?
[True Learn]
Laparotomy, proximal enterotomy, stone removal, and cholecystectomy
[The recommended treatment approach is surgical removal of the gallstone, and obliteration of the biliary-enteric fistula tract. A proximal enterotomy is preferred to avoid disruption of the ileocecal junction. With the proximal approach, the gallstone must be milked toward the enterotomy and then removed. Then a cholecystectomy can be performed with closure of the fistula tract in the small bowel.]
What has been proven to greatly increase the chances of a patient’s survival when they have severe second and third degree burns?
[True Learn]
Early debridement and grafting
Which two chemotherapy agents are known to cause cardiomyopathy?
[True Learn]
- Doxorubicin
- Daunorubicin
[The anthracyclines, notably Doxorubicin and daunorubicin, are well-known causes of late-onset cardiomyopathy, characterized by increased afterload followed by development of a dilated, thin-walled left ventricle that eventually becomes poorly compliant.]
Should the doppler signal in the outflow vein of an arteriovenous fistula be continuous or pulsatile?
[True Learn]
Continuous
[Continuous doppler signal in the outflow vein indicates good flow and pulsatile signal indicates outflow obstruction.]
What is the first line treatment for patients with new onset atrial fibrillation who are hemodynamically stable, symptom free, and have no severe underlying lung disease?
[True Learn]
Rate control with a beta-blocker
[Patients with new onset atrial fibrillation who are hemodynamically stable and have no or minimal symptoms should be treated with rate control first. The rate control agent of choice is beta-blocking agents as long as there is no evidence of underlying lung disease. Diltiazem should only be used as a first line rate control agent in the presence of severe underlying COPD or bronchospasm. Chemical cardioversion should only be used after unsuccessful attempt of rate control first. Electrical cardioversion is only indicated in hemodynamically unstable patients and those with recurrent or persistent A-fib despite unsuccessful chemical cardioversion.]
What is the physiology of transudative vs exudative effusions?
[True Learn]
- Transudative: Results from a poorly balanced hydrostatic and/or osmotic pressure across the pleural membrane
- Exudative: Results from inflammation or neoplastic processes that cause increased capillary leakage at the pleural membrane
What is the likely diagnosis of a pancreatic lesion with fluid analysis showing high viscosity, high CEA, and high amylase?
[True Learn]
Intraductal papillary neoplasm (IPMN)
What is a malignant primary bone tumor of children that mainly arises in the diaphysis of long bones?
[True Learn]
Ewing Sarcoma
[It often presents with a soft tissue mass, pain, fever, and weight loss. Ewing sarcomas have a classic “onion skin” periosteal reaction, and underlying bone often appears mottled.]
What is the definition of a Grade I splenic injury?
[True Learn]
- Hematoma: Sucapsular, less than 10% of suface area
- Laceration: Capsular tear, Less than 1 cm parenchymal depth
Balanced feeding is associated with a respiratory quotient of what value?
[True Learn]
0.825
What is the gold standard for diagnosing pancreas divisum?
[True Learn]
ERCP
[The prevalence of pancreas divisum is 10-20%. Rarely it is the primary cause of pancreatitis.
What is the innominate artery?
[True Learn]
It is also known as the brachiocephalic artery. It is the first branch off the aortic arch. [There is typically no branch arteries from the innominate artery, but the thyroid ima artery, which supplies the medial aspects of both lobes of the thyroid gland, may originate from here]
What is the appropriate course of management of a young reproductive-age female who presents with a painful mass, redness, and swelling of the breast?
[True Learn]
Core needle biopsy including the skin
[This is required to rule out inflammatory breast cancer. Other possible diagnoses include mastitis or an abscess.]
What is the maximal dose of lidocaine that can be given with and without epinephrine?
[True Learn]
- Lidocaine: 5mg/kg
- Lidocaine + Epinephrine: 7mg/kg
[Doses of lidocaine and mepivacaine can be increased to 7 mg/kg if epinephrine is added. Lower doses may be toxic if infiltrated subcutaneously. With intercostal nerve blocks, larger doses of lidocaine and mepivacaine may be tolerated if given by epidural injection.]
What are the 3 most common locations for carcinoid tumors to occur?
[True Learn]
- Appendix (45%)
- Small bowel (28%)
- Rectum (16%)
[Carcinoid tumors occur most commonly in the appendix, but carcinoid syndrome occurs most commonly from a small bowel primary]
[UpToDate: The distribution of carcinoids has shifted over time in the United States. In a report from the SEER database of 11,427 carcinoid cases treated between 1973 and 1997, the majority were located in the gastrointestinal (GI) tract (55%) and bronchopulmonary system (30%). Within the GI tract, most carcinoids arose in the small intestine (45%, most commonly in the ileum), followed by the rectum (20%), appendix (16%), colon (11%), and stomach (7%). However, since the implementation of screening colonoscopy (approximately in the year 2000), the proportion of patients diagnosed with rectal carcinoids has been greater than the proportion of those diagnosed with small intestinal carcinoids in 12 of 13 SEER registry reporting agencies.
Distribution may differ in other geographic areas. As an example, colorectal carcinoids may be more frequent in the Asia/Pacific region as compared with Europe, where carcinoids are more commonly found in the stomach and ileum. An important point is that the SEER database may be inconsistent in recording tumors that are not considered “malignant” (ie, trivial gastric carcinoids that are encountered at endoscopy in patients with chronic atrophic gastritis).]
What is the appropriate treatment for a patient with peritonitis, free air on CT, and who is found to have a small (4mm) perforation of the duodenum with minimal contamination during exploratory laparotomy?
[True Learn]
Primary repair of the lesion, proton pump inhibitors and H. pylori treatment
[Larger perforations require a Graham patch. This is performed by placing a tension free piece of omentum over the perforation and sewing it in place with absorbable sutures to the surrounding healthy tissue. Definitive treatment with an acid reducing and drainage procedure (such as truncal vagotomy and Billroth reconstruction) should be considered in patients unlikely to comply with medical treatment postoperatively or those who developed ulceration while on acid reduction therapy]
Neurologic manifestations, kidney injury or hematuria, hemolytic anemia, fever, and thrombocytopenic purpura make up the classic pentad of which condition?
[True Learn]
Thrombotic thrombocytopenic purpura (TTP)
[TTP (Moschcowitz syndrome) is characterized by widespread thrombosis of the arterioles and capillaries by hyaline membranes composed of platelets and fibrinogen. The classic pentad of symptoms includes thrombocytopenic purpura, neurologic manifestations due to microvascular disease in the brain, kidney injury or hematuria due to microvascular disease in the kidney, hemolytic anemia due to destruction of red cells, and fever. The precise etiology is unkown.]
What is the only proven way to reduce urinary and sexual dysfunction after total mesorectal excision?
[True Learn]
Careful anatomic dissection
[This procedure is associated with a considerable morbidity. Anastomotic leak rates in low anterior resections have been quoted from 10-30% which often prompts creation of diverting ostomies at the time of the operation. Urinary and sexual dysfunction may also occur. The only modality shown to reduce the risk of this complication is careful anatomic dissection at the time of surgery.]
Mupirocin should be strictly used in burn patients with what?
[True Learn]
MRSA infection
What are the inferior, lateral, medial, and anterior borders of the femoral ring? (Hint: 3 structures compose the 4 borders)
[True Learn]
Inferior: Superior pubic ramus
Lateral: Femoral vein
Anterior and medial: Iliopubic tract
[The femoral canal is the site of femoral hernias when a peritoneal sac protrudes through its ring. The femoral canal contains preperitoneal fat and lymph nodes. The canal is a 1-2cm blind pouch that begins at the femoral ring and extends to the level of the fossa ovalis.]
High PTT, INR and prolonged bleeding time would be seen in which condition?
[True Learn]
Disseminated intravascular coagulation
What is the treatment for disseminated intravascular coagulation (DIC)?
[True Learn]
Treatment of underlying disease
[Septic patients require empiric antibiotics and resuscitation. Blood products can transiently improve the abnormal laboratory values, but the definitive treatment of DIC is to correct its cause. Even with optimal therapeutic intervention, the outcomes in patients with DIC are poor.]
Which cranial nerve passes through the jugular foramen and innervates the sternocleidomastoid and trapezius muscles?
[True Learn]
The accessory nerve
[It is cranial nerve XI and it is solely a motor nerve.]
Which cells release Calcitonin?
[True Learn]
Parafollicular cells of the thyroid
[It acts to oppose parathyroid hormone (PTH). It is stimulated by high levels of calcium and acts to inhibit osteoclastic activity.]
Does a pericolonic abscess increase the recurrence rate of diverticulitis?
[True Learn]
No
[Surgical treatment can be delayed until after several episodes of diverticulitis without an increase in morbidity or mortality. Surgical resection for diverticulitis mandates that the entire sigmoid is removed down to the proximal rectum (even if not diseased) to prevent possible recurrent diverticulitis in the remaining segment.]
A smoothly contoured submucosal mass in the stomach or small bowel must raise suspicion for what?
[True Learn]
A gastrointestinal stromal tumor (GIST)
[GISTs are a relatively uncommon type of small bowel mass that is best demonstrated as a well-circumscribed mass on an upper GI series.]
What is the most common anorectal abscess?
[True Learn]
Perianal abscess
[Together with ischiorectal abscesses, they account for more than 90% of perianal infections. Other types of anorectal abscesses include supralevator and intersphincteric abscesses. They begin in the anal glands that surround the anal canal and empty into the anal crypts at the dentate line.]
By what mechanism of action does Metoclopramide augment gastric motility?
[True Learn]
It is a dopamine antagonist that acts by stimulating the release of acetylcholine
What is the likely diagnosis of a pancreatic lesion with fluid analysis showing high viscosity, high CEA, and low amylase?
[True Learn]
Mucinous cystic neoplasm (MCN)
[MCNs have markedly elevated CEA. A positive mucin stain or a high viscosity reliably identify mucinous neoplasms from serous neoplasms. An intracystic CEA concentration greater than 250 ng/ml reliably differentiates mucinous from a serous neoplasm, whereas a value of less than 5ng/ml is quite sensitive for excluding a mucinous neoplasm. Other tumor markers like CA 19-9, CA 72-4, CA 125, and CA 15.3 may be present in MCN, however, their diagnostic and discriminatory values appear limited.]
What is the correct treatment of testicular torsion?
[True Learn]
Detorsion of the involved testicle and bilateral orchiopexy
[Surgery should be performed within 4-6 hours of the onset of pain. The testicular salvage rate if detorsion is performed within 6 hours of symptoms is 97%. An orchiopexy should be performed by fixing the testicle to the scrotal wall at three points. The anatomic predisposition to torsion affects both testicles; therefore the contralateral testicle should be similarly repaired.]
Is postoperative discomfort with a Transverse Rectus Abdominus Muscle (TRAM) flap better or worse than with other flap reconstructions?
[True Learn]
Worse
[Post op discomfort is worse with TRAM flap reconstruction because of the extent of abdominal wall dissection]
By what mechanism of action does Erythromycin augment gastric motility?
[True Learn]
It acts by binding and activating motilin receptors located on smooth muscle cells in the GI tract
Type A aortic dissections involve the ascending aorta and are best approached through which incision?
[True Learn]
Median sternotomy
[This can be modified with supraclavicular, cervical, or trapdoor incisions to gain exposure to the brachiocephalic vessels or descending thoracic aorta. When dissecting the distal arch, it is important to identify and protect both the left vagus nerve with its recurrent branch and the left phrenic nerve.]
What are the two most common and effective surgical procedures for gastroparesis?
[True Learn]
- Pyloroplasty
- Gastric pacer implantation
Which nerve innervates the lower epiglottis?
[True Learn]
The recurrent laryngeal nerve
[The recurrent laryngeal nerve also innervates all the muscles of the larynx except the cricothyroid. Injury to an unilateral recurrent laryngeal nerve can lead to hoarseness.]
Where does the inferior lumbar hernia of Petit occur?
[True Learn]
In the space bounded by the latissimus dorsi posteriorly, the iliac crest inferiorly, and the posterior border of the external oblique muscle anteriorly
[SCORE: Lumbar hernias can be congenital or acquired after an operation on the flank and occur in the lumbar region of the posterior abdominal wall. Hernias through the superior lumbar triangle (Grynfeltt triangle) are more common. The superior lumbar triangle is bounded by the 12th rib, paraspinal muscles, and internal oblique muscle. Less common are hernias through the inferior lumbar triangle (Petit triangle), which is bounded by the iliac crest, latissimus dorsi muscle, and external oblique muscle. Weakness of the lumbodorsal fascia through either of these areas results in progressive protrusion of extraperitoneal fat and a hernia sac. Lumbar hernias are not prone to incarceration. Small lumbar hernias are frequently asymptomatic. Larger hernias may be associated with back pain. CT is useful for diagnosis.]
[UpToDate: The superior lumbar triangle (Grynfeltt) is an inverted triangle, its base is the twelfth rib, its posterior border is the erector spinae, and its anterior border is the posterior margin of the external oblique; its apex is at the iliac crest inferiorly.]
[Wikipedia: The lumbar triangle can refer to either the inferior lumbar (Petit) triangle, which lies superficially, or the superior lumbar (Grynfeltt) triangle, which is deep and superior to the inferior triangle. Of the two, the superior triangle is the more consistently found in cadavers, and is more commonly the site of herniation; however, the inferior lumbar triangle is often simply called the lumbar triangle, perhaps owing to its more superficial location and ease in demonstration.
The margins of the inferior lumbar (Petit’s) triangle are composed of the iliac crest inferiorly and the margins of two muscles – latissimus dorsi (posteriorly) and external abdominal oblique (anteriorly). The floor of the inferior lumbar triangle is the internal abdominal oblique muscle. The fact that herniations occasionally occur here is of clinical importance.
The superior lumbar (Grynfeltt-Lesshaft) triangle is formed medially by the quadratus lumborum muscle, laterally by the internal abdominal oblique muscle, and superiorly by the 12th rib. The floor of the superior lumbar triangle is the transversalis fascia and its roof is the external abdominal oblique muscle.]
What is the definition of a Grade II splenic injury?
[True Learn]
- Hematoma: Subcapsular, 10-50% of surface area, intraparenchymal, less than 5 cm in diameter
- Laceration: Capsular tear, 1-3 cm parenchymal depth that does not involve a trabecular vessel
