TrueLearn All Flashcards
1
Q
What is nodular lymphoid hyperplasia?
A
numerous polyps in the small and large intestine associated with immunosuppression (tumors, IgA deficiency, HIV)
colorectal- not associated with malignancy
small intestine - associated w increased incidence of lymphoma
2
Q
What are guidelines for placing an ICP monitor w severe brain injury?
A
- GCS = or <8 who EITHER
1. abnormal CT OR
2. normal CT with >2 of following: age >40yrs, any hx of hypotension, abnormal motor posturing
3
Q
equation for CPP
A
CPP = MAP - ICP
4
Q
Name 4 etiologies of chylous ascites
A
- Malignancy- end stage pancreatic cancer
- Congenital Lymphangiectasia
- Thoracic duct obstruction
- Lymph peritoneal fistula
5
Q
what is the most common causative organism of necrotizing fasciitis?
A
group A strep
6
Q
What is the indication for a SLN bx in malignant melanoma?
A
primary melanoma = or >1mmm thickness and clinically negative nodes (for those 0.75 to 1.0mm, consider SLN in younger pts, evidence of ulceration or LVI, extensive dermal regression, or 1 or >mitosis/mm2)
7
Q
tumor lysis syndrome occurs most often in what 2 cancers?
A
- Acute leukemia with high WBC counts
2. High grade lymphomas
8
Q
what are 3 patient risk factors for tumor lysis syndrome?
A
- Bulky tumors sensitive to chemo
- Elevated LDH
- Renal insufficiency
9
Q
what is the most common surgical option for SMA syndrome?
A
duodenojejunostomy
10
Q
When repairing umbilical hernias, for what size defect do you place a mesh?
A
> 3cm defect
11
Q
MOA of succinylcholine
A
nicotinic acetylcholine receptor agonist -> depolarization of the motor end plate
12
Q
what are 5 side effects of succinylcholine?
A
- Hyperkalemia
- Muscle pain
- Transient ocular HTN
- Anaphylaxis
- Malignant hyperthermia
13
Q
what are 3 contraindications to use of succinylcholine?
A
- Neuromuscular disease
- Closed head injury
- Burns
14
Q
treatment of malignant hyperthermia?
A
dantrolene
15
Q
what are the indications for elective repair of a AAA?
A
> 5.5cm or growing >0.5cm per 6 months
16
Q
what is the most common indication for parotidectomy?
A
neoplasm
17
Q
what is the problem with an ascending end colostomy?
A
leaves an end of the colon undrained leading to septic complications or perforation
18
Q
serious side effect of neostigmine
A
bradycardia
19
Q
Five Types of choledochal cysts
A
Type I: fusiform/saccular dilation of some or all extrahepatic ducts
Type II: isolated diverticulum protruding from the wall of the CBD
Type III: arises from intraduodenal portion of CBD
Type IV: multiple dilatations of either both the intra and extrahepatic ducts (A) or only the extrahepatic ducts (B)
Type V: Caroli’s disease: multiple dilatations limited to the intrahepatic bile ducts
20
Q
treatment of type I choledochal cyst?
A
excision with roux-Y hepaticojejunostomy
21
Q
treatment of type III choledochal cyst?
A
marsupialization or excision of the cyst
22
Q
treatment of type II choledochal cyst?
A
excision and primary closure of the choledochotomy
23
Q
what is thrombotic thrombocytopenia purpura? (classic pentad)
A
aka moschcowitz syndrome, widespread thrombosis of arterioles, pentad:
- Thrombocytopenic purpura
- Neurologic manifestations due to microvascular disease in the brain
- Kidney injury or hematuria
- Hemolytic anemia
- Fever
24
Q
what is immune thrombocytopenia purpura
A
auto antibodies produced against platelets with resultant platelet destruction and thrombocytopenia
25
what is felty syndrome?
autoimmune neutropenia
| triad of: rheumatoid arthritis, neutropenia, splenomegaly
26
what is wiskott-aldrich syndrome? (triad)
hereditary X linked disease
1. Low platelet counts
2. Combined B and T cell deficiency
3. Eczema
27
what is the composition of lactose?
glucose and galactose
28
what is the composition of sucrose?
glucose and fructose
29
what is the composition of maltose?
glucose + glucose
30
what is budd chiari syndrome? how do you diagnose it?
hepatic venous obstruction- can be seen in hyper-coagulable states
diagnose: duplex US
31
What is WAGR syndrome?
```
-deletion of chrom 11
Wilms tumor
Aniridia
GU abnormalities (cryptorchidism, streak ovaries)
Retardation (mental)
```
32
what chromosome is associated with WAGR syndrome?
deletion of short arm of chrom 11
33
most common organ to become injured in pediatric blunt trauma patients
jejunum and ileum
34
what is local recurrence rate for rectal adenocarcinoma after total pelvic exenteration?
3-8%
35
what are the different stages of hypothermia?
mild: 90-94*F, shivering, tachy
moderate: 84-89*F, agitation and combative, a fib and hypotension
severe: 70-84*F, prolonged QRS and osborn waves, vfib
profound: <70*F, loss of vitals
36
what is cullen sign?
evidence of retroperitoneal hemorrhage w blue around umbilicus
37
what is grey turner sign?
evidence of retroperitoneal hemorrhage w blue at flank
38
what is fox sign?
evidence of retroperitoneal hemorrhage with blue at the inguinal area
39
What is the definition of severe acute pancreatitis?
1. necrosis of greater than 1/3 of pancreas
| 2. multiple organ failure (see hypotension SBP<90, renal failure (Cr >2.9), GI bleeding, resp failure (PaO2<60))
40
what are risk factors that predict poor survival in patients with hepatic mets from colorectal cancer? (5)
1. node positive primary tumor
2. disease free interval <12 months
3. multiple liver mets
4. largest hepatic met >5cm
5. serum CEA >200
41
what study is the gold standard for evaluation of a AAA?
CT angiogram
42
what is the major cause of pyogenic liver abscess?
cholangitis, 2/3 of pathogens are gram negative aerobes
43
GIST: what is most prognostic factor to determine odds of recurrence? what is considered to have a high risk of aggressive clinical behavior?
Number of mitoses per HPF and tumor size
Aggressive behavior:
- >5cm with mitotic ct >5/HPF
44
what are the two types of proteolytic enzymes secreted by the acinar cells of the pancreas?
1. Endopeptidases (trypsin and chymotrypsin- act on internal peptide bonds of proteins/polypeptides)
2. Exopeptidases (carboxypeptidases- act on free terminal ends of proteins)
45
when should you consider a femoral aneurysm for operative repair?
when they reach 2.5cm in diameter
46
when should you repair a ventral incisional hernia with mesh?
>4cm
47
what are the stages of ovarian cancer?
stage I: one or both ovaries only
stage II: extended involvement of tumor but limited to pelvis
stage III: involvement into the abdomen
stave IV: distant mets
48
what is the pathophysiology of flail chest and where does mediastinum shift?
during the inspiratory phase, the chest wall collapses in causing air to move out of the bronchus of the involved lung and into the trachea/bronchus of the uninvolved lung causing a shift of the mediastinum to the UNINVOLVED side (and then opposite during expiration)
49
4 epidemiological facts about gastric cancer
1. 1.5-2.5 x M>F
2. Incidence peaks in 70's
3. Blood group A more likely
4. AA, Hispanic and native americans more likely
50
what is the suggested margin of resection for gastric adenocarcinomas?
5cm
51
whats the cattell brasch maneuver?
right medial visceral rotation (aka extended Kocher maneuver)
- provides access to the infrahepatic IVC, right kidney, right hilum, infrarenal aorta and iliac vessels
52
whats the Mattox maneuver?
left medial visceral rotation- mobilization of the descending colon to the midline to expose the abdominal aorta
53
whats the kocher maneuver?
dissection of the lateral peritoneal attachments of the duodenum to allow inspection of the duodenum, pancreas, and other RP structures over to the great vessels
54
how does the WHO classify colorectal tumors?
epithelial (adenoma, carcinoma, carcinoids)
non-epithelial (lipoma, leiomyoma, GIST, angiosarcoma, melanoma, Kaposi)
polyps (hyperplastic, peutz-jeghers, juvenile)
secondary
55
what are the basic anatomic requirements for EVAR? (5)
1. aortic diameter <32mm
2. Neck angle <45 to 60 degrees
3. Neck length at least 10mm
4. Iliac diameter at least 7mm
5. Lack of thrombus or calcification
56
what is congenital lobar emphysema?
overdistention of one or more lobes within a histologically normal lung due to abnormal cartilaginous support of the bronchus causing air trapping and increase in lobar distention
if in resp distress- immediate thoracotomy w resection
57
how often should u do surveillance EGD in a pt w familial polyposis?
every 1-2 years
58
how often should u do surveillance EGD in a pt w esophageal varices s/p banding and sclerotherapy?
every 6-8 weeks
59
how often should u do surveillance EGD in a pt w gastric ulcer?
every 6-8 weeks until ulcer healed
60
how often should u do surveillance EGD in a pt w barretts esophagus low risk (short segment <3cm)?
every 2 years
61
how often should u do surveillance EGD in a pt w barretts esophagus high risk (long segment (>3cm), circumferential)?
every 1 year
62
how often should u do surveillance EGD in a pt w barretts esophagus (high risk w low grade dysplasia) ?
every 6 months
63
what is the minimum number of lymph nodes required for accurate staging of colon cancer?
12
64
what is the predominant artery supplying blood to the hand?
ulnar artery
65
what artery supplies the superficial palmar arch?
ulnary artery
66
what artery supplies the deep palmar arch?
radial artery
67
what is reynolds pentad?
```
fever
jaundice
RUQ pain
shock/hypotension
AMS
```
68
what is the pringle maneuver and what structures does it occlude?
clamping of the portal triad via clamping of the hepatoduodenal ligament
1. portal vein
2. hepatic artery
3. common bile duct
69
what effect do omega 3 fatty acids play in the perioperative period? 3
1. Modulation of leukocyte function
2. Regulation of cytokine release
3. Accelerating the resolution of the proinflammatory state
70
what role do omega 6 fatty acids play in the periop period?
1. associated w higher inflammatory response
2. precursors to leukotrienes, thromboxane -> vasocontriction
3. Induce platelet aggregation
71
give an example of an omega 6 fatty acid?
linoleic acid
72
give an example of an omega 3 fatty acid?
linolenic acid
73
what is the blood supply for the right colon?
via the SMA and include the ileocolic, right colic and middle colic (right branch) aa
74
what are the resection margins for colon cancer?
5cm on either side
75
how can you differentiate between nephrogenic and central diabetes insipidus?
DDAVP (central responds, nephrogenic does not)
76
what is central vs nephrogenic diabetes insipidus?
central: decreased secretion of ADH, usually due to injury to hypothalamus
nephrogenic: kidneys are resistant to action of ADH
77
what is the hallmark electrolyte imbalance in refeeding syndrome?
hypophosphatemia
78
What are the absolute contraindications to liver transplant? (3)
1. Recent ICH
2. CV/pulm issues wont survive surgery
3. Untreated extrahepatic malignancy
79
most common cause of hemobilia?
iatrogenic trauma to liver/biliary tree
80
what does a V/Q of 0 represent
loss of ventilation aka shunting
81
what muscle must you divide to visualize the distal internal carotid?
digastric
82
manamagement of melanoma in situ? margins?
wide local excision with 0.5-1cm margins
83
incidence of post op gastroparesis in pts w partial gastrectomy and vagotomy?
2-3%
84
treatment of post op gastroparesis in pts w partial gastrectomy and vagotomy?
surgical tx w near completion gastrectomy and roux-en-y gastrojejunostomy
85
what is the pars-flaccida technique regarding gastric bands?
dissection through the fatty tissue posterior to the GE junction to create a tunnel in which the band sits, decreases incidence of band slippage
86
treatment for seminoma?
orchiectomy via an inguinal approach (do not biopsy or remove via scrotal approach to avoid disrupting the lymphatic drainage)
87
why dont you biopsy germ cell tumors?
will expose the tumor to the immune response
88
lab values seen in seminomas
normal AFP and RARELY elevated beta-HCG (90%normal level)
89
what is the preferred fuel source for enterocytes and immunocytes?
glutamine
90
what organism causes amoebic liver abscesses?
E. histolytica: non-flagellated pseudopod forming protozoan
91
how do amaebic trophozoites reach the liver in amebiasis?
fecal-oral transmission then mesenteric veins then portal vein to liver
92
what two hormones regulate secretion of pancreatic juice?
secrtin and cholecystokinin (CCK)
93
what is the composition of pancreatic fluid? (Na, K, Cl, HCO3)
```
Na = 140
K = 5
Cl = 75
HCO3 = 75
```
94
amount of air moved in a normal breath
tidal volume
95
maximum volume of air that can be expired after a maximal inhalation?
vital capacity
96
the amount of air left after maximal exhalation
residual volume
97
the amount of air left after exhaling a normal breath
expiratory reserve volume
98
most common site of hematogenous metastasis of sarcomas?
lung
99
what is malignant fibrous histiocytoma?
type of sarcoma, most common type of soft tissue sarcoma of the extremity
100
which types of sarcomas would you want to obtain a CT of the abdomen? (aka most commonly metastasize to abdomen) 4
1. myxoid liposarcoma
2. epitheliod
3. Angiosarcoma
4. synovial sarcoma
101
how do you calculate the ABI?
divide the systolic blood pressure at the ankle by the systolic blood pressure in the arm
102
ABI range of pts w claudication
0.7-0.9
103
ABI range of patients with rest pain
0.4-0.7
104
ABI range of patients with gangrene/wound complications
<0.4
105
what does fluid analysis show for IPMNs?
- high viscosity
- high CEA
- high amylase
106
what does fluid analysis for serous cystadenocarcinoma show?
- low viscosity
- low CEA
- low amylase
107
what does fluid analysis show for mucinous cystadenocarcinoma?
- high viscosity
- high CEA
- low amylase
108
what age cutoff is used for surgical cricothyroidotomy in pediatric patients?
>11yrs: surgical cric
| <11yrs: needle cric w 14 or 16G needle or tracheotomy
109
proposed etiology of TRALI?
donor antibodies attack recipient leukocytes causing leaky capillaries and pulmonary edema
110
what is proposed etiology of transfusion related febrile illness?
host antibody response to donor leukocytes
111
treatment of leiomyomas <8cm without annular characteristics?
surgical extramucosal enucleation and subsequent closure of the myotomy
mid esophageal: right chest approach
lower esophagus: left chest or abdomen
112
treatment of asymptomatic esophageal cysts?
removal! even when asymptomatic due to risk of infection
113
management of benign appearing asymptomatic esophageal lesions?
observed with serial endoscopic US WITHOUT biopsy
| - biopsy can increase risk of perforation at time of surgical enucleation
114
lidocaine:
speed of onset (min):
duration of action (min):
maximal dose (mg/kg):
speed of onset (min): 10-20
duration of action (min): 60-180
maximal dose (mg/kg): 4.5mg/kg
115
mepivacaine-
speed of onset (min):
duration of action (min):
maximal dose (mg/kg):
speed of onset (min): 10-20
duration of action (min): 60-180
maximal dose (mg/kg): 5mg/kg
116
Bupivacaine:
speed of onset (min):
duration of action (min):
maximal dose (mg/kg):
speed of onset (min): 15-30
duration of action (min): 180-360
maximal dose (mg/kg): 2.5mg/kg
117
lidocaine WITHOUT epinephrine max dose
4.5mg/kg
118
lidocaine WITH epinephrine max dose
7mg/kg
119
what is achalasia and how do you diagnose?
esophageal motility disorder w lack of peristalsis and failure of LES to relax
dx: manometry
120
what are the three main types of small intestine adenomas?
1. villous
2. tubular
3. Brunners gland adenomas
121
what type of malignancy is associated with signet ring cells on pathology?
gastric cancer
122
what is the most common malignancy of the thyroid?
papillary carcinoma
123
what are the characteristic pathologic findings of papillary thyroid cancer?
orphan annie nuclei and psammoma bodies
124
buzzword: lateral aberrant thyroid tissue
think Papillary thyroid cancer!
125
what is the greatest risk factor for the development of gastric cancer?
H. pylori infection
126
most common side effect of topical silver sulfadiazine?
transient neutropenia
| also thrombocytopnia
127
side effects of topical silver sulfadiazine?
1. Neutropenia
2. Thrombocytopenia
3. methemoglobinemia
4. Contraindicated in pts w G6PD deficiency
128
most common side effect of mafenide acetate? why?
metabolic acidosis
| MOA: inhibits carbonic anhydrase leading to a metabolic acidosis
129
side effects of silver nitrate?
electrolyte disturbances:
- hyponatremia
- hypochloremia
- hypocalcemia
- hypokalemia
130
which topical burn rx penetrates eschar? which on does not?
penetrates: mafenide acetate
| doesn't: silver sulfadiazine
131
5 ligaments of the liver to diaphragm
1. left coronary
2. left triangular
3. falciform
4. right coronary
5. right triangular
132
treatment of thyroid storm (4 drugs)
1. PTU* (inhibits peripheral conversion of T4 to T3)
2. Methimazole
3. steroids
4. Beta blocker
133
resting pressure of the LES
10-20mmHg
134
resting pressure of the upper ES
50-70mmHg
135
which two pelvic fractures are associated with bladder injuries?
1. pubic diastasis
| 2. obturator ring fx
136
whats the strongest determinant of serum osmolarity?
sodium!
137
how do you determine serum osmolarity? (formula)
2xNa + Glucose/18 + urea/2.8
138
standard treatment of infants with biliary atresia?
Kasai Procedure: roux-en-y hepatic portoenterostomy
139
what is the kasai procedure?
roux-en-y hepatic portoenterostomy,
| standard tx in infants w biliary atresia
140
what are the structures of the renal hilum from anterior to posterior?
renal vein, renal artery, ureter
141
when is FENa unreliable when diagnosing ARF?
in pts on diuretics
142
what are the nutrients for colonocytes?
short chain fatty acids
143
what is the puestow procedure?
longitudinal pancreaticojejunostomy: used in patients with severe symptomatic chronic pancreatitis
144
what is the Frey procedure?
coring out of the pancreatic head and a roux-en-Y pancraticojejunostomy
145
what is the Beger procedure?
resection of pancreatic head with a roux-en-Y jejunal loop as side-to-end and side-to-side pancreaticojejunostomy
146
how are bladder lacerations repaired?
two layers using absorbable suture
1st: mucosa and muscularis
2nd: muscularis and serosa
147
how is epinephrine synthesized from tyrosine?
Tyrosine -> L-dopa -> dopamine -> norepinephrine -> epinephrine
148
biopsy of soft tissue tumor shows spindle cells and positive CD-34 staining
dermatofibrosarcoma
149
what are the 3 types of gastric carcinoids?
type I: assoc w chronic atrophic gastritis, slow growing
type II: assoc w ZES and MEN type I, more likely to mets
type III: most biologically aggressive, frequently mets, not assoc w hypergastrinemia
150
what type/duration of anticoagulation is required for drug eluting stents vs bare metal stents?
drug: 1 year of dual antiplatelet therapy then ASA forever
bare: 3 months of dual therapy then ASA forever
151
how do you repair a tracheal injury?
single layer of interrupted absorbable sutures + tissue flap using strap muscle buttress
152
what are 3 relative contraindications to lap chole?
1. untreated coagulopathy
2. gallbladder cancer
3. frozen abdomen from previous surgery
153
whats the difference between the Sengstaken-Blakemore and Minnesota tubes?
Minnesota tube has a proximal port that allows for drainage of salivary secretions
154
what is the most accurate method of diagnosing portal hypertension?
hepatic vein pressure gradient = reflects hepatic sinusoidal pressure, diagnostic when >6mmHg
155
when can you use punch biopsy when suspecting melanoma?
- lesion >2cm
| - over areas that are difficult to close (face)
156
what are the 3 P's of ZES?
Prolactinoma -> galactorrhea
PUD (refractory)
hyperParathyroidism -> hyprcalcemia
157
what's the vitamin or mineral deficiency?
| poor glycemic control
low chromium
158
what's the vitamin or mineral deficiency?
| pancytopenia
low copper
159
what's the vitamin or mineral deficiency?
| sideroblastic anemia and peripheral neuropathy
vitamin B6/pyridoxine
160
what's the vitamin or mineral deficiency?
| cardiomyopathy
selenium
161
what's the vitamin or mineral deficiency?
| skin rashes and hair loss
zinc
162
whats the origin of the phrenic nerve?
C3,C4,C5
163
what organism causes emphysematous cholecystitis?
clostridium perfringens, seen in poorly controlled diabetics
164
what part of the small intestine is responsible for fat soluble vitamin absorption?
ileum: ADEK
165
classification of aortic dissections
type A: dissections proximal to the left subclavian aa (acute surgical emergency)
type B: distal to the left subclavian aa, usually medically tx
166
difference in venous drainage of left and right adrenal veins
left: joins inferior phrenic vein and empties into the left renal vein
right: drains directly into the IVC
167
what are the layers of the adrenal cortex and what do they produce?
GFR = salt, sugar, sex steroids
Glomerulosa: aldosterone
Fasciculata: glucocorticoids
Reticularis: androgrens/estrogens
168
2 main functions of aldosterone
1. Renal sodium reabsorption
| 2. Secretion of K and H ions
169
difference between primary and secondary hyperaldosteronism
- check Renin levels
Primary: low
Seconday: high
170
what is conn's syndrome?
primary hyperaldosteronism
- HTN
- hypokalemia
- metabolic alkalosis
171
what is Addison's disease?
adrenal insufficiency -> hypocortisolism (ACTH will b high) and decreased aldosterone
172
how do you test for Addison's disease?
cosyntropin test: give ACTH, measure cortisol and it will still be low
173
which chemotherapeutic agent is used for adrenocortical carcinoma?
mitotane: toxic for adrenocortical cells
174
what is the "rule of 6's" in regards to HD fistula access?
- diameter of fistula should be at least 6mm
- fistula should be at least 6mm below skin
- flow should be at least 600mL/min
175
what are the depths of invasion for esophageal cancer? T1a, T1b, T2, T3, T4
```
T1a: mucosa (could perform EMR)
T1b: submucosa (NAC, esophagectomy)
T2: muscularis propria
T3: adventitia
T4: adjacent structures
```
176
when can you follow branch duct-IPMNs?
when <3cm, asymptomatic, no cytology or imaging concerning for malignancy
- follow with serial cross-sectional imaging
177
go through the components of GCS
dont be lazy... DO IT!
178
when do you consider evacuation in a subdural hematoma?
when larger than 1cm with a MLS (perform within 4 hours)
179
dose of mannitol for ICHs?
1g/kg
180
what is the major source of energy during stress and starvation?
Fats!
181
mutation in what structural protein is associated with Marfan's syndrome?
fibrillin
autosomal dominant
FBN1 gene
182
bile aids in the absorption of what vitamin?
vitamin K
183
MOA and side effect of Promethazine
- antiemetic thats inhibits dopamine receptors
| - SE: tardive dyskinesia (tx w benadryl)
184
What is Kehr's sign?
left upper quadrant pain with referred left shoulder pain
| - seen in splenic lacs
185
name 5 medications that are associated with prolonged QT interval?
1. Haloperidol
2. Erythromycin
3. Methadone
4. Lithium
5. Amiodarone
186
how do you reverse plavix (clopidogrel)?
administration of pooled platelets
187
treatment of hepatoblastoma in children?
resection + chemotherapy (NO role for XRT)
188
What is the Nigro protocol and when do you use it?
Nigro: 5FU, mitomycin C + XRT
used: squamous cell carcinomas of the anus
189
chemotherapy for colon ca w nodal disease?
FOLFOX =
| 5FU, Leucovorin, Oxaliplatin
190
what is the triad of electrolyte abnormalities of refeeding syndrome?
Hypophosphatemia
hypokalemia
hypomagnesemia
191
what are the boundaries of the inguinal canal?
roof: internal oblique and transverses abdominis
floor: inguinal ligament
ant: external oblique and transversalis fascia
post: conjoint tendon
192
what are the contents of the inguinal canal? 3
- ilioinguinal nerve
- genital branch of the genitofemoral nerve
- spermatic cord
193
chemotherapy agent for GIST tumors and indications (4)
imatinib
1. positive margins
2. metastatic disease
3. recurrence
4. any tumor >3cm
194
surgical management of GIST tumor of small bowel vs carcinoid small bowel?
GIST: segmental resection (no tumor on ink, do not go to lymph node)
Carcinoid: resection w full lymph node dissection
195
what is the gilbert repair for inguinal hernias?
- two layer mesh repair
| - anterior mesh is sutured but posterior is placed in retromuscular space as a sublay
196
where do most iatrogenic perforations of the esophagus occur?
level of the cricopharyngeal muscle
197
management of carcinoids <2cm vs >2cm
<2cm: excisional biopsy alone
| >2cm: APR or LAR
198
what are the structures within hunters canal?
1. superficial femoral aa and v
| 2. saphenous nerve
199
which structures border hunters canal?
vastus medialis
adductor magnus
sartorius
adductor longus
200
describe the process of absorption of vitamin B12?
intrinsic factor secreted by parietal cells of the stomach binds to vit b12, then is absorbed in the TI
201
mediastinal masses, how do you classify and what do thy include?
posterior: neurogenic
middle: lung cancer and cysts
anterior: thymomas, teratoms, lymphoma and goiter
202
what are the steps of skin graft healing?
1. Imbibition: diffusion of nutrients
2. Inosculation: alignment of capillary beds
3. Revascularization: 5 days
203
MOA dobutamine
purely beta-adrenergic
low doses = beta 1 (cardiac contractility)
high doses = beta 2 (vasodilation)
204
What is light's criteria?
determination of transudate vs exudate, exudative is:
- pleural protein:serum protein ratio >0.5
- Pleural LDH: serum LDH ratio > 0.6
- Pleural LDH > 2/3 the upper limit of serum LDH
205
What is exudative effusion
result from inflammation or neoplastic processes that causes leakage across capillary membrane (thus bigger proteins can leak across)
206
examples of exudative effusion vs transudative
Exudative: lupus, esophageal perf, abscess, ARDS, pancreatitis, chylothorax, malignancy
Transudative: atelectasis, CHF, hypoalbuminemia
207
what are the grades of liver lacerations?
Grade I: <10% hematoma, or <1cm tear
Grade II: 10-50% hematoma, 1-3cm deep lac
Grade III: >50% hematoma, >3cm deep lac
Grade IV: ruptured hematoma, or lac involving 1-3 couinaud segments
Grade V: >3 couniaud ligaments
Grade VI: hepatic avulsion
208
```
Breakdown of fluid produced each day:
Saliva:
Stomach:
Biliary:
Pancreatic:
Small Bowel:
```
```
Saliva: 1500mL
Stomach: 1-2L
Biliary: 500mL
Pancreatic: 500mL-1.5L
Small Bowel: 1.5L
```
209
Location and function of Renin
JG cells of afferent arterioles in kidney
- cleaves angiotensinogen to angiotensin I
- causes increase in extracellular volume and BP
210
action of angiotensin II
acts locally to increase vascular tone and BP
211
what 4 things activate renin?
1. Changes in arterial pressure
2. Na delivery to macula densa
3. Increased Beta adrenergic activity
4. Increases in cAMP
212
management of SCC of lower lip?
usually lower vermillion border, wide local excision with 3mm margin
- if advanced stage, add XRT
213
what gene is most commonly associated with familial and long segment Hirschsprung's disease?
RET proto-oncogene
214
pathogenesis of meckel's diverticulum
occurs when the omphalomesenteric duct fails to close during gestation
215
management of incidentally found meckels diverticulum
children: resect
adults: leave alone
216
management of hydatid cyst?
albendazole followed by surgical resection
217
which two pathways regulate apoptosis?
1. Extrinsic: binding of death receptors -> activation of caspase 3
2. Intrinsic: protein regulated via mitochondria releasing protein C and activating caspases
218
buzzword: corkscrew esophagus
diffuse esophageal spasm
219
buzzword: birds beak on esophagram
achalasia
220
staging of gallbladder cancer
T1a: invades lamina propria
T1b: invades muscle layer
T2: invades perimuscular connective tissue (but doesn't go through serosa)
T3: perforates the serosa and/or directly into one adjacent organ/structure
T4: extends >2cm into the liver or into 2 or more adjacent organs
221
what is the normal response to ACTH stimulation test?
give ACTH, wait 30-60minutes, measure cortisol level, if >18mcg/dL then its normal
222
how do you diagnose cushings syndrome?
-24hr urine collection for urinary free cortisol excretion, normal values are <90mcg per 24hrs, cushings >300mcg
223
treatment of pancoast tumor causing shoulder pain and weakness?
neoadjuvant radiation
224
what is myasthenia gravis?
autoimmune disorder where antibodies are directed against acetylcholine receptors at the neuromuscular junction
sx: ptosis, diplopia, weakness w repetitive movements, fatigue
225
where are first branchial cleft cysts located?
anywhere between the external auditory canal and submandibular area, close to the parotid gland and facial nerve
226
where do you commonly find second branchial cleft cysts?
the most common lesions, arise in the mid to lower neck along the anterior border of the SCM close to the glossopharyngeal and hypoglossal nerves
227
symptoms of hypermagnesemia?
- loss of deep tendon reflexes
- Flaccid paralysis
- hypotension
- AMS/Coma
228
what electrolyte antagonizes the effect of magnesium on neuromuscular function?
calcium
229
resection margin of colon cancer?
2.5cm
230
at what tim period does a wound achieve its greatest tensile strength?
8 weeks (which is about 80% of its pre-wound strength)
231
types of collagen in wound healing
initially type III then quickly replaced with type I
232
which type of heart valve does NOT require anticoagulation?
bioprosthetic
233
when should you perform cholecystectomy in pts w a GB polyp(s)?
polyps are common, resect if:
1. Single polyps
2. Size >1cm
and 3. Age >50
234
differences in management between upper, middle and lower ureteral injuries
upper: debridement, primary anastomosis, stenting
middle: ureteroureterostomy
lower: reimplantation into the urinary bladder
235
what are the borders of dissection for superficial inguinal lymphadenectomy?
lateral: sartorius muscle
medial: adductor magnus
superior: inguinal ligament
236
what size of thyroid nodule dictates need for FNA?
1. All solid nodules >1.5cm
2. All Mixed Solid-cystic >2cm
if suspicious sonographic features are present-
1. Solid nodules >1cm
2. Mixdd >1.5cm
237
what are suspicious sonographic features of thyroid nodules?
1. Hypoechoic nodule
2. Infiltrative margins
3. Increased vascularity
4. Taller than wide
238
where is the endarterectomy plane?
between the layers of the tunica media
239
blood supply of the splenic flexure?
marginal artery of brummond
240
what is the hill esophagogastropexy?
plication of the lesser gastric curvature around the right side of the esophagus and performing an esophagogastropxy to the median arcuate ligament (must use intraoperative manometry)
241
what is the nissen fundoplication?
complete 360 degree fundoplication
242
most common complication of popliteal aneurysm
acute limb ischemia
243
what does merkel cell carcinoma usually stain for?
CK-20 (same as small cell ca of lung)
| MCC is negative for TFF-1 and Small cell ca is positive
244
what IHC staining differentiates small cell carcinoma of lung from merkel cell carcinoma?
Thyroid Transcription Factor-1 (TFF-1)
SCC is positive for it
MCC is not
both stain for CK-20
245
most specific us finding for cholecystitis?
sonographic murphys sign
246
which genetic abnormality is associated with MEN II syndrome?
RET proto-oncogene
247
which genetic abnormality is associated with MEN I syndrome?
MENIN (encoded by the MEN1 gene)
248
what approach to expose the left subclavian aa?
lateral thoracotomy
249
what approach to expose proximal right subclavian aa?
median sternotomy
250
which cytokines are responsible for proliferation of B lymphocytes?
IL 2,4,5,6,7
251
what is function of IL-2?
released by T cells and promotes T cell proliferation, B cell proliferation and in vitro antibody production
252
what cytokines are released from T cells and promote proliferation and maturation of B cells?
IL 4,5,6
253
What is the function of IL-7?
produced by the bone marrow and is essential for stimulation of hematopoietic stem cell differentiation into both B and T cells
254
What is the function of TGF-beta?
inhibits T and B cell proliferation
255
whats the cause of post transplant lymphoproliferative disorder?
Proliferation of EBV positive B cells (can cause a mononucleosis like illness)
256
what are the only essential fatty acids?
linoleic and linolenic (unsaturated, cis-configuration)
257
what is the expected excess weight loss after 2 years of lap band?
40-55%
258
```
what are the estimated weight loss for the following procedures:
lap band:
sleeve gastrectomy:
gastric bypass:
duodenal switch:
```
lap band: 40-55%
sleeve gastrectomy: 55-70%
gastric bypass: 60%
duodenal switch:70%
259
what muscle is divided when creating a diverting loop ileostomy?
rectus abdominis
260
when you create a loop ileostomy, what layer is used to secure it to the skin?
seromuscular bites!
261
treatment of carotid body tumors?
1. CT angio for operative planning
| 2. Excision of just about all tumors! if pt cant tolerate surgery then XRT, if >3cm then embolize the day before surgery
262
management of necrotizing pancreatitis?
1. FNA to evaluate for bacteria
2. percutaneous drainage if bacteria present
3. if still deteriorating then endoscopic/lap drainage
263
what does the prothombin time (PT) measure?
extrinsic pathway of the coagulation pathway: Factors I, II, V, VII, and X
264
what does the aPTT measure?
the intrinsic pathway of the coagulation cascade: Factors I, II, V, VIII, IX, X, XI, and XII
265
what factor differentiates the intrinsic and extrinsic coagulation pathway?
factor VII is part of the extrinsic (PT) but not the intrinsic (aPTT)
266
intraoperative hypertension from pheochromocytoma is managed w what?
sodium nitroprusside drip
267
what are the boundaries of a central lymph node dissection?
superior: hyoid bone
inferior: innominate artery
lateral: carotid arteries
268
what is bowen's disease?
high grade squamous intraepithelial lesion (basically squamous cell carcinoma in situ), <10% chance to progress to invasive SCC, local excision
269
which velocities are indicative of the differing carotid stenoses?
Stenosis <50%: <125cm/s
Stenosis 50-69%: 100-230cm/s
Stenosis >70%: >230cm/s
270
what suture is used to repair aorta?
permanent: polypropylene
271
what also must be performed during distal pancreatectomy for malignancy?
splenectomy (dont need to do this for benign or traumatic disease)
272
order of EKG changes in hyperkalemia?
1. peaking of t waves
2. widening of QRS
3. widening of PR interval
4. disappearance of p wave
5. rhythm turns into a sine wave
273
characteristics of MEN I?
1. parathyroid hyperplasias
2. Pancreatic islet cell tumors
3. Pituitary adenomas
274
characteristics of MEN IIa?
1. Medullary thyroid cancer (often bilateral)
2. Pheochromocytomas (often bilateral)
3. 4 gland parathyroid hyperplasia
275
characteristics of MEN IIb?
1. Medullary thyroid cancer
2. Pheochromocytomas
3. Neuromas
+ marfinoid habitus
276
first line imaging for carotid disease?
duplex US
277
what are the three types of small intestine adehomas?
1. Villous
2. Tubular
3. Brunner's gland adenomas
278
which organism most commonly causes infected aortic aneurysms?
salmonella and staph aureus
279
what is the most common cause for large bowel obstruction in the US?
colorectal cancer
280
after adhesions, 2nd most common cause of SBO?
malignancy
281
whats the most common cancer cause of chylous ascites?
lymphoma
282
buzzword: apthous ulcer, IBD
crohns
283
buzzword: distorted vascular pattern, IBD
ulcerative colitis
284
what is amaurosis fugax?
due to an isolated embolism to the retinal or ophthalmic artery (first branch off internal carotid aa) causing transient monocular blindness
285
ABI for claudication?
0.7
286
what is the main blood supply to the rectosigmoid anastomosis in prolapse surgery?
superior rectal artery
287
what is a type IV endoleak?
transient trans-graft extravasation resulting from porosity of the graft
288
what two deficiencies cause microcytic anemia?
iron and Vitamin B6
289
what vitamin deficiency causes a waddling gate?
vit D deficiency
290
what vitamin deficiency is associated with hemolytic anemia?
vitamin E
291
what deficiency causes megaloblastic anemia?
folate
292
Five grades of pancreatic injury?
Grade I: small hematoma without duct injury
Grade II: large hematoma wo duct injury
Grade III: a distal laceration w duct injury
Grade IV: proximal transection
Grade V: massive disruption
293
what is a nissen fundoplication?
complete 360 degre fundoplication
294
what is a belsey mark IV fundoplication?
left thoracotomy -> proximal stomach is delivered through the esophageal hiatus then a 270 degree plication of the fundus and buttressed by the crura
295
what is an anterior dor fundoplication?
a 180-200 degree fundoplication
296
what is a watson fundoplication?
fixation of esophagus in an intra-abdominal location with plication of fundus along the left anterior esophagus
297
what is the hill repair?
plication of the lesser curvature around the right side of the esophagus with an esophagogastropexy to the median arcuate ligament
298
what is a posterior toupet fundoplication?
fundus is pulled posterior to the esophagus with suture of the leading edge of the wrapped fundus to the right anterolateral aspect of the esophagus
299
treatment of stenosis of lap sleeve gastrectomy?
endoscopic balloon dilation
300
child with downs syndrome and projectile vomiting with double bubble sign on KUB
duodenal atresia
301
order in which you should explore a packed abdomen? trauma ex lap
inframesocolic, supramesocolic, retroperitoneal, lesser sac
302
what is hemophilia A?
Factor VII deficiency
303
what is pellagra?
diarrhea, dermatitis, dementia
| Niacin deficiency! (vit B3)
304
What are the Milan criteria for txp of pt w HCC?
1. Single tumor <5cm
2. Up to 3 tumors all <3cm
3. No LVI/mets/nodes
305
management of dysplasia (any kind) found on colonoscopy of pt w UC?
total proctocolectomy with IPAA
306
most common cause of acute pancreatitis in the US?
gallstones
307
poor prognostic factors for parathyroid cancer?
1. Male gender
2. Older age at diagnosis
3. presence of metastatic disease
308
order of restoration of bowel motility
small intestine, stomach, colon
309
what is the only effective systemic medical therapy for HCC?
sorafenib: multikinase inhibitor (VEG-F, c-kit, PDGFreceptor)
310
indication for TIPS procedure?
transjugular intrahepatic portocaval shunt
| - perform when pt requires >2-3 paracentesis per month despite maximal medical therapy
311
innervation of thoracodorsal nerve
latissimus dorsi
312
innvervation of long thoracic nerve?
serratus anterior
313
growth of an axon and cells that help it grow
1-2mm/day, schwann cells play significant role in axon regeneration
314
calculating fluid resuscitation in a burned child and what fluid
cannot use parkland formula for kids <20kg, thus use TBSA Shriners-galveston formula (5L/m2 BSA burned + 2L/m2 BSA total)
- smaller glycogen stores so use 5% dextrose
315
MOA of omeprazole?
inhibition H+/K+ ATPase
316
rule of 9's: adults vs children
Adult: each arm = 9, each leg = 18, anterior trunk = 18, posterior trunk = 18, head = 9
child: all the same but each leg = 14, head = 18
317
MOA desmopressin
ddAVP = analogue of vasopessin, causes factor VIII and vWF to be released from the vascular endothelium
318
what is the classification system used for esophagitis? (A-D)
Modified Los Angeles Classification
A: mucosal break <5mm
B: mucosal break >5mm but doesnt extend between two mucosal folds
C: mucosal break that is continuous but <75% circumference
D: mucosal break(s) that involves at least 75% circumference
319
what sites does melanoma most likely like to metastasize to?
1. Small intestine
2. Colon
3. Stomach
320
What type of bacteria is clostridium difficile?
Gram positie bacillus
321
management of rectal cancer T2 and above
neoadjuvant chemo XRT
322
margins for basal cell carcinoma
0.5cm
323
standard reconstruction after distal gastrectomy
Billroth I
324
which procedure for distract gastrectomy has the highest incidence of bile reflux gastritis?
billoth II
325
whats the difference between a billroth I and II?
Billroth I: has a gastroduodenostomy
| Billroth II: has a gastrojejunostomy
326
treatment of significant bile reflux gastritis after a billroth II?
conversion to roux-en-y gastrojejunostomy
327
types of gastric ulcrs
I: lessr curvatue
II: combination of stomach and duodenal
III: prepyloric
IV: near GE junction
328
indications for gastrectomy for gastric ulcers?
type II and III that have failed 12 weeks medical management
329
which types of gastric ulcers are associated with acid hypersecretion?
type II and type III (thus a vagotomy is performed in these patients)
330
how do you perform a heller myotomy?
divide all the circular muscle layers by extending the myotomy 2cm below GE junction and 5cm proximally
331
what is the strasberg classification system?
classifies bile duct injuries:
A: leakage from cystic stump or duct of luschka
B: ligation of aberrant right hepatic duct
C: transection of aberrant right hepatic duct
D: lateral injury to a major duct
E: complex, bad, vascular can be involved
332
what is the Ladd procedure? steps of the procedure?
for intestinal malrotation, Ladds bands attach cecum to abdominal wall compressing duodenum
1st: relief of midgust volvulus with counterclockwise rotation
2. Complete division of abnormal peritoneal attachments (Ladds bands)
3. Mobilize duodenum
4. Appendectomy
333
function of protein C
it inhibits factors V and VIII
334
diagnostic test for cushing syndrome
low dose dexamethasone suppression test, give 1mg at 11pm and check 8am levels- it should suppress cortisol to <5ug/dl
335
how do you calculate the prevalence of disease?
true positives plus false negatives divided by total number of tests
336
primary treatment for mucosa-associated lymphoid tissue?
associated w H. pylori so eradicate that!
337
celiacs disease that persists despite gluten free diet
think T cell lymphoma of the intestines
338
what do cytotoxic t-lymphocytes bind to?
CD8+/MHC class I cells
339
what medications can cause gynecomastia in men?
ACE inhibitors
| amiodarone
340
IBD: rectal sparing
crohns
341
whats the most common complication of traumatic liver injury?
biliary fistula
342
where should the medial incision be made in a 2-incision fasciotomy?
one fingerbreadth posterior to the tibia
343
where should the lateral incision be made in a 2-incision fasciotomy?
3cm fingerbreadths lateral to the tibia
344
which of the extra-intestinal manifestations of Crohn's disease will most likely resolve with successful medical or surgical treatment? (4)
1. erythema nodosum
2. Peripheral Arthritis
3. Aphthous ulcers
4. Episcleritis
345
which of the extra-intestinal manifestations of Crohn's disease will NOT resolve with successful medical or surgical treatment? (4)
1. Ankylosing spondylitis
2. Pyoderma gangrenosum
3. Uveitis
4. PSC
346
what is the best indicator of preoperative nutritional status?
albumin
347
half life of alumin versus prealbumin
albumin: 21 days
| pre-albumin: 2 days
348
what is the best indicator of POSToperative nutritional status?
pre-albumin
349
where do gastric carcinoids most commonly occur?
small bowel- ileum
350
what type of enema do u use to reduce intussusception in a child?
air enema! barium causes too many problems if pef occurs
351
where does a TRAM flap get its vascular pedicle?
inferior epigastric vessels
352
where does a latissimus dorsi flap get its vascular pedicle?
thoracodorsal vessels
353
what is the maximum size vessel you can seal w bipolar?
7mm
354
what is the best test to assess for the presence of a rectovaginal fistula?
mathylene blue tampon test
355
what is a psoas hitch and when is it performed?
distal ureter injury and remaining ureter doesn't reach the bladder, bladder is pulled up and secured to psoas muscle
356
what is a BOARI flap and when is it used?
the peritoneum of the bladder is used to create a flap that extends to the injured ureter, used in distal long segment ureteral injuries
357
What will shift the oxygen dissociation curve to the left?
```
HOLDING ONTO O2
Hypothermia
alkalosis
hypocapnea
Decreased 2,3 DPG
```
358
what will shift the oxygen dissociation curve to the right?
```
OFFLOADING O2
fever
acidosis
hypoxia/hypercapnea
increased 2,3 DPG
```
359
what hormone can be used in the treatment of hypercalcemic crisis?
calcitonin: inhibits osteoclast bone resorption and thus decreases serum Ca levels
360
how do you diagnose biliary dyskinesia?
HIDA showing gallbladder EF <20% at 20 minutes
361
what is function of CCK?
1. GB contraction
2. Relaxation of sphincter of oddi
3. pancreatic enzyme secretion
4. decreasing gastric emptying
362
what 2 hormones inhibit CCK?
1. Somatostatin
| 2. Pancreatic Polypeptide
