ABSITE 2022 Flashcards
1
Q
Appendectomy: Risk factors associated with conversion to open
A
- severe inflammation obscuring view of anatomy
- peritonitis
- presence of large intra-abd abscess
2
Q
3 types of rectus sheath hematomas
A
Type 1: unilat, within the muscle
2: uni or bi ; w/in the muscle or bw the muscle and transversalis fascia
3: extends in peritoneum and prevesical space
3
Q
Common rectus sheath hematoma symptoms
A
- sudden abd p
- pain on trunk flexion/rotation
- greatest comfort in a supported flexed position
- anticoagulation/women
- 29% assoc w cough
4
Q
Stimuli for ductus closure in neonate
ductus arteriosus - bw PA + aorta
A
- incr O2 tension
- drop in pulm vascular resistance
- decr prostaglandin levels
5
Q
What shunt does a PDA cause
A
left to right shunt … can cause HF if left untreated
6
Q
What induces pharmacologic closure of DA?
A
indomethacin (decr PG’s)
7
Q
What surgery is used to close a PDA
A
L posterolateral thoracotomy (can do bedside) and close PDA with clips
8
Q
Life threatening bleeding + vW disease .. what do you give?
A
type 1 (AD; low qty): desmopressin type 2 (AD; low quality): desmopressin type 3 (AR; absence of): vWf/F8 concentrate
9
Q
How calculate ABI
A
Higher of 2 ankle pressures (dp, pt) / higher of 2 brachial pressures
10
Q
How are the following absorbed?
fructose
glucose
galactose
A
fructose - facilitated diffusion (GLUT5 in, GLUT2 out)
glucose - active (SGLT1, GLUT2)
galactose - active (SGLT1, GLUT2)
11
Q
When to consider EMR for gastric cancer?
A
tumor <2 cm no ulceration no LVI well or mod-well diff histology limited to mucosa
12
Q
Where do carcinoids usually occur?
How do they usually present?
A
appendix …. small bowel
abd pain
13
Q
What is vimentin assoc with
A
melanoma, colon CA, esophageal CA, gastric CA
14
Q
What is S100 assoc with
A
melanoma
schwannoma
neurofibroma
15
Q
How do you perform water soluble esophagography for traumatic esoph perf?
A
pt in R lat decub
if pt HD stable and nothing seen on esophagography but high suspicion for injury –> EGD
16
Q
unstable pelvic fracture … gets angioembo’ed by IR … still unstable and repeat FAST is negative. Now what?
A
external fixation (If FAST + --> ex lap)
17
Q
radial nerve is responsible for __ of the thumb and ___
A
abduction
supination
18
Q
Injury to RLN is more common when it is running __
A
anterior to or bw the ITA
19
Q
Injuries assoc with BCVI
A
Le Fort 2 and 3 facial fx mandibular fx c spine fx basilar skull fx DAI or GCS =8 severe thoracic chest trauma
20
Q
What are cells that stain CD3 + and recognize HLA-I molecules?
A
CD8 cytotoxic T cells
21
Q
After recurrent ing hernia, which lap repair is preferred?
A
totally extraperitoneal repair
lower risk of re recurrence
22
Q
what defines “severe acute pancreatitis” ?
A
- necrosis of > 1/3 pancreas
- MOF indic by hypotension, renal failure (Cr >2.9), GIB, resp failure (paO2 <60), and development of local complic like abscess, hemorrhage, pseudocyst
23
Q
Highest risk popul for OPSI ??
highest risk within 2 yr postop
MC pathogen?
A
Pts w/ hem malignancies who undergo splenectomy
Strep pneumo
24
Q
MC inherited hypercoag disorder?
A
factor V leiden - factor V cannot respond to protein C … propensity to clot
25
what is lugano stage IV disease?
- lugano system - for NHL of GI tract classification
- stomach > SB > colon
- stage IV = disease is present above and below the diaphragm
26
Best way to repair umb hernia in a cirrhotic?
primary repair with nonabsorbable sutures
| *resuscitate w/ 25% albumin*
27
clinically + LN in pt dx with melanoma ... what to do?
FNA ... neg: proceed to SLNB
| pos: ax dissection
28
hypoK assoc with hypoMag can be K repletion resistant... mechanism?
- To do with ROMK (renal outer medullary K channel)
| - low intracellular mag causes K efflux (IC mag inhibits K secretion)
29
Endpoints for resuscitation - on ABG
```
pH 7.35-7.45
PaCO2: 35-45
HCO3: 21-27
paO2: >80
SaO2 >95
base excess/deficit: -2 to +2
lactate <2
```
30
Endpoints for resuscitation - on lyte panel
K 3.5 - 5.5
Mg 1.4-2
Ca 2.25 - 2.5 mmol/L
Phos 0.8-1.6
31
How does Mg cause hypoCa?
Produces PTH resistance / decrease PTH secretion
| Thus - have to replete Mg first
32
What happens at diff temps (energy source)
```
45 C (113 F): collagen uncoils and realigns to form covalent bonds bw opposing surfaces
60 C (140F): irrev protein denat; coag necrosis; blanching
80 C (176F): carbonization; drying/shrinking of tissue
100 C (212F): vaporization; complete cell death
above: eschar formation
```
33
recurrent malignant effusion ... treatment if there's:
- complete lung expansion
- lung does not completely expand
- talc pleurodesis
| - pleurX
34
Major fuel source for small bowel enterocytes?
glutamine
35
Major fuel source for large bowel enterocytes?
SCFA
36
What do you find for phyllodes? that makes it similar to fibroadenoma?
mixed connective tissue and epithelium
phyllodes: stromal overgrowth and hypercellularity
+vimentin, +actin in phyllodes
37
Best mgmt for pts with ventral hernia req PD catheter placement?
Repair of hernia with extraperitoneal prosthetic mesh at time of PD catheter placement
38
Contraindic to PD catheter placement
Absolute:
- lack of functional peritoneal membrane
- severe protein malnutrition or proteinuria >10g/day
- active intraabd/abd wall infection
- freq epi's of diverticulitis
Relative:
- ostomy
- obese
- peritoneal scarring
- large abd wall hernia
- physical or psych impairment
- lack of appropriate environment
- anuria
- active inflamm process
- VP shunt
39
BRCA2 - which chromosome?
13
40
At what age offer ppx SPO for BRCA 1 and 2 mutations?
BRCA1: 35-40
BRCA2: 40-45
*once childbearing complete
*reduces ovarian CA risk by 80%
41
Screening for BRCA1/2
```
BREAST
--monthly self exam start at age 18
--MRI at age 25
--annual mammo at age 30
OVARIAN
--transvaginal US and CA 125 q6 mo starting age 30
```
42
Differential dx for nonpainful groin mass in males
Inguinal hernia (size incr w/ valsalva
Hydrocele (communicating hydrocele can incr w/ valsalva)
Testic cancer
Can distinguish first 2 via transillumination
43
What can pop up after breast cancer radiation?
(secondary) angiosarcoma - median survival 2 yr!
tx: total mastectomy (radiation causes a field defect & these are usually multifocal - get as much skin as poss) + adjuvant chemo
spread: hematog to lung, bone ... no need for SLNB
44
Which extraintestinal manifestations of Crohns will most likely resolve with medical/surgical tx?
erythema nodosum
peripheral arthritis
aphthous ulcers
episcleritis
45
What is the order of preferred AV fistulas?
RC > BC > BB > prosthetic (brachioaxillary)
46
If you were planning a BC fistula but there is short segment cephalic vein occlusion ... what do you do
BB fistula instead is next step
| If concern for central venous occlusion (not short segment) - do intraop venogram/mapping
47
What is a cimino fistula?
radiocephalic fistula
48
what do you see on path of well diff neuroendocrine/carcinoid tumor?
bland cytologic features
| rare mitotic figures that stain +chromogranin
49
cardiac impact of reverse T
increase venous pooling ... decreased CO and hypotension
50
Common orgs in CLABSI
GP (coag neg staph, enterococci, staph aureus) > GN > Candida
51
MC cause of fat necrosis in breast?
idiopathic
52
male breast cancer, stage for stage, carries the same prognosis as female breast cancer - T or F ?
true
53
When to remove pancreatic drains?
drain amylase no longer suggestive of a fistula and output decreasing
leave drains till enteral feeding to see if output worsens
54
metabolic disturbance caused by NS resuscitation
non AG hyperchloremic metabolic acidosis
| excess Cl, low bicarb, normal AG
55
formula for anion gap
Na - (Cl + HCO3)
56
What does thoracodorsal nerve injury cause?
weakened arm pullups and adduction
| lat dorsi
57
nondisplaced scaphoid fx - mgmt?
- XR can have false neg result for up to 6 wks
| - thumb spica cast (hand to elbow) for 6-12 wks, with f/u XR in 2 wks .... OR immediate CT / MRI
58
ovarian cancer - staging
I: involve 1 or both ovaries
II: pelvic extension (uterus, tubes, pelvic tissue)
c: denotes +malignant cells on washings
III: peritoneal mets (micro or macro-scopic)
IV: distant mets
59
What happens to intrathoracic pressure with a tension ptx?
becomes increasingly positive (normal = neg) --> decreased venous return, decreased stroke volume --> body compensates by incr HR and SVR --> hypotension, poss death
60
what causes the hypoNa in DKA?
pseudohypoNA due to influx of water (bc hyperosmolar) diluting Na
61
What cells are LPS found on? What cells do they activate?
found on GN bacteria
| activate monocytes / macrophages
62
What's bad about meperidine?
mu opioid agonist
toxic metabolite, normeperidine --> can reach toxic levels in pts with renal failure --> CNS irritability, seizures
*resp depression is dose dep
63
>75% spontaneous bact peritonitis is caused by __, of which 50% is __
aerobic GN rods
| E coli
64
preferred mode for fecal diversion in rectal trauma pt
loop colostomy (>>> end colostomy; easier to reverse)
65
procedure done for emergency surgery of UC
TAC with end ileostomy
66
indic's for emergency surgery in UC pt
perforation
life threatening hemorrhage
toxic megacolon
fulminant colitis refractory to medical therapy
67
Initial mgmt for severe UC
NGT, bowel rest
IV hydration, lytes
+/- abx (+peritoneal signs, fulminant colitis, toxic megacolon)
68
Definition of obesity hypoventilation syndrome - DAYTIME hypoxia and hypercapnia in obese pt
1. Obesity, BMI>30
2. Daytime hypoventilation (paCO2 > 45)
3. Absence of other known causes
*caused by apnea/hypopnea due to change in central chemoreceptor set points, not alveolar collapse
69
ERCP facts
- fast 6-8 hr before
- ppx abx usually given esp if biliary obstruction anticipated
- left lat decub --> (reach D2) --> prone
- side viewing endoscope
- a of vater at 12 -1 o clock
- CBD orifice at 11 o clock in ampulla
- PD orifice at 1 o clock in ampulla
70
Where are mucinous cystic neoplasms usually located in pancreas?
body / tail >>> head
71
histologic hallmark of Paget disease
malignant intraepithelial adenocarcinoma cells
pale clear cytoplasm
high grade nuclei, visible nucleoli
72
example of horizontal gene transfer
conjugation, transformation, transduction
| via *plasmids*
73
example of vertical gene transfer
gene resistance passed from parent --> offspring
74
Absolute CI to liver transplant
- recent ICH
- increased ICP
- active substance/ETOH use
- current or recent extrahepatic malignancy
- uncontrolled sepsis
- lack of social support
- prohibitive cardiopulmonary disease including R HF
75
Workup for stage 1, 2 3, 4 melanoma
1, 2: nothing
3: CBC, LDH, CXR (consider CT's)
4: consider PET/CT + MRI brain + above
76
Mechanism of flail chest
*inspiration: chest wall collapses inward --> air moves from bronchus of involved lung into trachea and bronchus of uninvolved lung --> mediastinal shift towards involved side
*expiration: chest wall balloons outward --> air from uninvolved side to involved side --> mediastinal shift AWAY
"paradoxical chest wall motion"
77
What is Six Sigma?
honestly idk but it aims to eliminate or streamline (vs add something, such as in PDSA)
78
what converts trypsinogen to trypsin
enterokinase on intestinal brush border
79
Key aspects of lichtenstein repair
1. large sheet of mesh - 3-4cm above hesselbach's triangle, 2cm medial to pubic tubercle, 5-6cm lat to internal ring
2. cross tails of mesh behind spermatic cord to prevent recurrence lateral to internal ring
3. keep mesh lax
4. secure mesh medially to conjoint tendon with 2 interrupted sutures & laterally to ing lig with 1 continuous suture
5. identify and protect the nerves throughout
80
what's most likely to be injured when suturing mesh into the shelving edge of ing lig
external iliac vein
81
what are primary lymphoid organs
bone, thymus, liver
82
what are secondary lymphoid organs
lymph nodes, spleen, Peyer patches, tonsils, adenoids
83
modifiable risk factors for SSI prevention
- glycemic control (110-150 or <200)
- smoking cessation 4-6 wk before
- dyspnea
- preop albumin <3.5
- bili >1
- obesity
- immunosuppression
84
what are antidotes for cyanide toxicity?
amyl nitrite
hydroxocobalamin
sodium nitrite
sodium thiosulfate
sx: weakness, confusion, pulm edema
check: thiocyanate
85
Antidotes for OD's:
- tylenol
- hydrofluoric acid, CCB
- malignant hyperthermia, NMS
- iron
- BZ's
- methotrexate
- metHBemia
- antichol toxicity
- heparin reversal
- acetyl-cysteine
- Ca gluconate
- dantrolene
- deferoxamine mesylate
- flumazenil
- leucovorin calcium
- methylene blue
- physostigmine
- protamine
86
what are howell jolly bodies
nuclear remnants - you see them post splenectomy
87
major diagnostic criteria for hepatorenal syndrome
- Cr > 1.5 or 24 hr Cr clearance 40 mL/min
- absence of shock, fluid losses, nephrotoxins, or bacterial infection
- no improvement w/ 1.5L IVF
- proteinuria >500 mg/day
- no US evidence of parenchymal ds or obstructive uropathy
88
hallmarks of HRS
spanchnic vasodilation
activation of sympathetic nervous system + RAAS
renal vasoconstriction
89
"poorly controlled diabetic" + pic of RUQ US + cholecystitis .... dx?
emphysematous cholecystitis
| surgical emergency or perc drain if unable to tolerate surgery
90
After RYGB, where is marginal ulcer usually located?
jejunal side of GJ (irritation from gastric acid)
91
pregnant patients with breast cancer - mgmt by trimester
First trimester: mastectomy + axillary LN dissection (not SLNB bc cannot use inj … actually can use radioisotope but later I think??)
Second: ideally <2 months from surgery to radiation
Third: mastectomy vs lumpectomy/SLNB ... radiation postpartum
92
Characteristics of CMV colitis (transplant pt)
- punched out ulcers
- Cowdry bodies (eosinophilic inclusion bodies)
- may or may not have +blood serology
93
gold std for dx of bladder rupture?
CT cystogram
94
Indications for operative repair of bladder injury
- intraperitoneal rupture
- bladder neck injury
- concomitant rectal or vaginal injuries
- open pelvc fx or those with fragments
- foreign body w/in bladder
95
ischemic monomelic neuropathy
- women and diabetics
- shunting of blood away from nerves of distal UE
- sx: pain out of proportion after procedure
- dx: clinical tho can do nerve conduction studies (shows axonal damage)
96
neurogenic shock vs spinal shock
neurogenic shock: "distributive shock" - warm extremities
- spinal cord injury above T6 --> disruption of autonomic pathways in spinal cord --> blood pools in LE lacking sympathetic tone --> decreased SVR --> hypotension
- bradycardia from unopposed vagal activity
spinal shock:
- motor deficits below level of injury, loss of spinal reflexes
- describes neuro injury, no cardio effects
*possible to have spinal shock w/o neurogenic shock
97
at which GFR do you need emergent dialysis
=6, regardless of symptoms
| at GFR 10-15 + uremic symptoms --> elective dialysis
98
absolute indications for dialysis
```
uremic pericarditis
pleuritis
encephalopathy
^^^ all are no matter the GFR
A - acidosis (<7.1)
E - lytes (refractory hyperK)
I - intoxication (salicylates, methanol)
O - overload (refractory to diuretics, esp causing pulm edema and incr O2 needs)
U - uremia (with sx)
```
99
what is a chance fx
"seatbelt fracture"
- unstable spine fx at thoracolumbar region
- sx: back pain +/- neuro deficits (paraplegia) ... seatbelt sign on exam
- tx: urgent NSG eval
100
mechanism of action of first line tx for PTLD?
anti CD20 (rituximab)
*B cell prolif!
101
which side of bowel is at highest risk of ischemia - mesenteric or antimesenteric?
antimesenteric
| vasa recta originate from peripheral arcades in mesentery
102
what is a 2 layer anastomosis of bowel
inner running absorbable (ie vicryl)
| outer interrupted nonabsorbable (ie silk)
103
MOA mafenide acetate
carbonic anhydrase inhibitor
- hyperCl metab acidosis
- good eschar penetration
- pain w application
- good against GP and GN, but not staph or fungi
104
SE of silver nitrate
metHBemia
105
difference bw competency and capacity
```
competency = legal decision made in court; global (financial, medical etc)
capacity = medical decision made by physician; only for medical decision making
```
106
breast lesion of "central lucency with surrounding architectural distortion"
--> what is it and what histology findings??
- radial scar
| - fibroelastic core w/ entrapped ducts and surrounding adenosis (adenosis = enlg'ed lobules)
107
"lobular lesion with increased fibrous tissue and glandular cells"
sclerosing adenosis
108
signs of AIP
lymphoplasmacytic sclerosing pancreatitis
periductal lymphoplasmacytic infiltrate
obliterative phlebitis
acinar fibrosis
109
MAP goal during septic shock
65 +
110
when can use broselow tape
up to age 12, <80 lbs/36 kg
111
thiamine deficiency --> beri beri --> AG metab acidosis
| WHY?
thiamine (cofactor for pyruvate dehydrogenase) --> pyruvate build up --> shifted to lactate --> refractory metab acidosis
112
type 1 vs type 2 respiratory failure
HYPOXIA, PaO2<60. ie - ARDS. Caused by VQ mismatch or shunts.
HYPERCAPNIA. PCO2>50, pH<7.3. Caused by TBI, CNS depression, intoxication.
113
mechanism of lithium toxicity in wt loss pts
decreased GFR after weight loss --> lithium toxicity --> (unknown mechanism) hyperCa, hyperMg, hypocalciuria
114
what drugs have increased absorption after RYGB
digoxin, PCN, atorvastatin, lithium
115
pancreatic trauma grades
```
I: small hematoma, no duct injury
II: large hematoma, no duct injury
III: distal lac with duct disruption
IV: proximal injury (right of SMV)
V: massive disruption of head
```
116
best way to dx portal HTN
hepatic vein pressure gradient >6
| gradient bw wedged pressure and free pressure
117
functions of leukotrienes?
```
leukocyte attraction and adhesion
bronchoconstriction
mucus production
increased capillary permeability
release of PAF
```
(made from AA; released from leukocytes/myeloid cells)
118
what kind of organism is c diff
anaerobic gram positive bacilli
119
name 3 gram negative bacilli
pseudomonas
klebsiella
escherichia
120
delayed immune hemolytic transfusion reaction ... what can prevent this
retyping and screening the pt
- pathophys: Ab to minor antigens
- hemolysis --> unconj bilirubin
- fever
121
best incision to gain prox and distal control of L subclav artery
left anterior thoracotomy + separate supraclavicular incision
122
what is winters formula
| check expected PaCO2 in metab acidosis
paCO2 = 1.5 (bicarb) + 8
123
How calculate AG
(Na + K) - (bicarb + Cl)
124
treatment for subclavian vein thrombosis 2/2 thoracic outlet syndrome
catheter directed lysis
venogram
remove first rib/decompress + balloon angioplasty for venous narrowing
125
hormone receptor +, small (<2cm) breast tumor, clinically neg axilla .... what can you do diff?
(in older person I think???)
no axillary surgery
no radiation
use aromatase inhibitors
126
nerve(s) commonly injured during laparoscopic ing hernia repair
genitofemoral
| lat fem cutaneous
127
what is a verrucous carcinoma
large >8cm, symptomatic, slow growing warty growth that is soft and cauliflower like (comes from active HPV)
-tx: WLE or APR if involving sphincters... rarely mets, do recur locally
128
MCC hyperaldo
b/l adrenal hyperplasia
129
what's going on in DI
alcohol abuse/TBI --> reduced ADH --> polyuria, hyperNa
- tx for acute: desmopression
- tx for chronic: free water
130
what is pseudohyponatremia?
water is drawn into intravascular compartments by hyperglycemia
approx for every 100 above normal, add 2 to Na
131
what is included in
- cryo
- FFP
cryo: fibrinogen (factor I), factors 8 and 13, vWf
FFP: clotting factors
132
what does a prolonged R time need
FFP (clotting factors)
| nml: 4-8 min
133
what does a prolonged alpha angle need
cryo (fibrinogen)
| normal: ~55-70
134
low MA
plts (clot strength)
| normal: 50-70 mm
135
what does a prolonged LY30 need
TXA
| normal: 0-8%
136
If have PCN anaphylaxis ... what cross-reactivity is there?
cephalosporins: 6%
aztreonam: not signif EXCEPT ceftazidime
carbapenems: 1-9%
137
what abx to give someone undergoing L hemi, anaphylaxis to PCN
metronidazole or clindamycin +
aminoglycoside (-mycin) or fluoroquinolone (levo, cipro, moxi)
OR clinda + aztreonam
138
What is the McVay repair (femoral hernias)
suture conjoint tendon to Cooper's ligament
1. incise transversalis fascia to enter preperitoneal space
2. suture conjoint tendon to Cooper's at pubic tubercle extending laterally to femoral sheath
3. can do a relaxing incision to release tension - 6cm incision on ant rectus sheath behind EO aponeurosis
139
In which hernia would you primarily repair the transversus and IO muscles
spigelian
140
What is a Bassini repair
suture conjoint tendon to inguinal ligament (closes direct and indirect spaces)
141
What is a Shouldice repair
Multi layer repair with running suture to obliterate the hernia defect
142
MCC of Zone III bleeding
presacral or prevesical veins
143
optimum and maximum cold ischemia times for transplantation
heart: up to 4 hr; 4-6 hr
lungs: up to 6 hr; 6-8 hr
intestine: up to 6 hr; 6-18 hr (small bowel procured 1st; very susceptible to ischemia)
liver: up to 8 hr; 10-12 hr
pancreas: up to 12 hr; 12-18 hr
kidney: up to 24 hr; 72 hr
144
Donor hepatectomy occurs during __ perfusion.
| Preserve the __ vein during dissection to perfuse the liver.
cold
| IMV
145
One technique for minimizing cold ischemia time?
en bloc multi organ procurement with back table separation
146
MCC esophageal stricture
GERD
147
MC side effects after EMR?
| Strictures are __ after RFA.
EMR: bleeding, strictures (Tx: dilations)
| uncommon after RFA
148
When do you consider chemo and adjuvant radiation for endometrial CA?
chemo: when disease has spread beyond uterus (metastatic disease)
radiation: high risk of recurrence (+LVI)
149
what causes periumbilical pain in appendicitis?
VISCERAL pain from luminal distension
| this pain can be present in retrocecal
150
what causes RLQ in appendicitis?
SOMATIC nerve fibers from contact of distended appendix with parietal peritoneum
151
Patients in which carotid artery stenting may be considered due to "high risk" status versus CEA
```
recent MI
contralat carotid occlusion
CHF III/IV
LVEF <30%
unstable angina
previous CEA with recurrent stenosis
previous radiation tx to neck
```
152
inf thyroid artery supplies PTH glands from __ side
medial
153
normocalcemic high PTH .. what is it?
early primary hyperthyroidism
154
#1 splenic tumor overall
hemangioma
155
#1 splenic malignant tumor and also MCC splenomegaly
Non hodgkins lymphoma
156
What "margins" do you need for a whipple
R0
157
someone w liver disease ... which paralytic agent do you want?
cis or atracurium
| most NMB agents are hepatically metabolized but cis is eliminated by Hofmann elimination and ester degradation
158
```
CI to these paralytic agents:
atracurium
cisatracurium
pancuronium
roc
succ
vecuronium
```
- HD unstable pts, 2/2 histamine release
- none
- short surgical procedures (<60 min); longest acting; not recommended for continuous infusion
- none
- high K, burn pts, malignant hyperthermia
- none
159
How are these paralytic agents metabolized:
- succ
- roc
- vecuronium, pancuronium
- atracurium, cis
- succ: only depolarizing NMB agent; pseudocholinesterase
- roc: liver mostly
- vecuronium, pancuronium: liver + kidneys
- atracurium, cis: Hofmann elimination
160
1st line pressor for septic shock
norepi
| 2nd: vasopressin
161
What to do with DAPT peri-op?
low risk of bleeding: hold plavix x5 d and continue ASA
| higher risk of bleeding: hold both for 5 days preop
162
an age population associ with cecal volvulus?
middle aged women
163
pathophysio of cocaine induced mesenteric ischemia 2/2 vasoconstriction
inhibition of NE reuptake at presynaptic terminals --> more NE at postsynaptic terminal --> tachy, HTN, vasocons
164
two types of protein c deficiency
type I: quantitative
type II: qualitative
deficiency results in loss of normal cleaving of factors 5/8. mechanism THO is that protein c (anticoag) has a short half life and is rapidly depleted by warfarin, resulting in a transient hypercoag state --> skin necrosis
165
what is removed in a whipple
distal stomach, panc head, duo, 15cm jej, GB, CBD
166
histology: high nucleus to cytoplasm ratio, and absent nucleoli ..... what lung cancer is this?
small cell
| assoc w/ paraneoplastic syndromes like SIADH
167
what is SCC of the lung assoc with?
hypercalcemia (PTHrP)
168
what promotes gluconeogenesis?
| what are the precursors?
promoted by: glucagon, epi, cortisol
| precursors: alanine (PRIMARY), lactate, glycerol, other aa (ie glutamine)
169
when do you use MVA (analyses) ?
eval relationship bw variables and outcomes while controlling for the impact of other measured variables
170
when is linear regression used
```
continuous variables (ie cholesterol or BP) and assumed to be normally distributed
output = risk difference
```
171
how do you repair the trachea?
1 layer with absorbable suture and strap muscle buttress
172
what is cantlie's line
imaginary line that runs from GB foss to IVC (divides liver into R and L)
173
what symptoms would prompt a chronic adrenal insuff workup? what do you do to test for acute and chronic adrenal insuff?
```
chronic fatigue, anorexia, abd pain
rapid corticotropin (ACTH) stim test
```
174
what is normal urinary cortisol level
<90 mcg/24 hr (250 nmol/day)
| >300 mcg = cushing syndrome
175
how are brown recluse spider bites usually tx'ed?
observation and elevation
| can get necrosis, injury to nerves, secondary bact infection
176
what is arteria lusora
aberrant right sided subclavian artery (originates from aortic arch - leftmost artery) that loops behind the esophagus usually to get to the R side ..... this results in a non recurrent laryngeal nerve
177
when to consider flaps in pilonidal disease?
extensive (stage 4 - multiple pits bilaterally) or recurrent pilonidal disease
178
where are majority of active bile salts R
TI, 80%
179
What is
Sheehan syndrome
Waterhouse-F syndrome
- sheehan: ant pit ischemia after hemorrhage/hypotension postpartum
- WF: adrenal hemorrhage after meningococcal infec
180
HV pressure gradient reqd for variceal rupture
at least 12
181
what makes up child pugh turcotte score
```
bili
PT
albumin
encephalopathy
ascites
```
182
MELD score at which pt will have survival benefit from transplant surgery
15
183
signs of renal cancer?
incidentally during an imaging procedure
"classic triad" (10%): hematuria, flank pain, palp abd mass
may have paraneoplastic manifestations (hyperCa, cachexia, fever etc)
184
test to determine a/c during CABG?
| acceptable levels?
ACT
400-500 secs
determines amount of protamine to reverse heparin
185
which open tissue based ing hernia repair has lowest recurrence rates?
shouldice
186
is tx with anti-TNF in 3 months prior to surgery associ with poor wound healing?
no
187
does switching to azathioprine within 6 wks of surgery affect wound healing?
yeah; incr postop morbidity (leak, sepsis)
188
UPJ injury with trauma ... more common in kids or adults? blunt or penetrating trauma?
kids (hyperflexibility of spine)
| blunt
189
mechanism of graft v host disease?
1. damage of recipient tissue
2. differentiation of donor T lymphocytes into Th1 and Th17 effector lineages --> recognize host as foreign --> proinflamm cytokines --> host tissue destruction (ie donor NK cells target MHC-I cells)
3. tissue dysregul from cytokines prevents tissue regeneration in host (ie skin, gut)
190
pathophysio behind chronic GVHD
dysregulation of donor Tregs leading to fibrosis
191
2 major causal factors for hepatic angiosarcoma
vinyl chloride
arsenic
(bladder cancer - aromatic amines)
192
formula for calculating nitrogen balance -__-
(protein in grams/6.25) - (nitrogen excreted in urine + 4)
193
mgmt for uncomplic and complic type B aortic dissection
uncomplic (no pain or evidence of malperfusion): esmolol drip to SBP<120
complic: impulse control, surgery (TEVAR with any reqd interventions for branches - stenting etc)
194
primary tx modality for advanced cervical cancer?
| I think anything IB or further
chemo + radiation (ext beam + brachytherapy)
| *pelvic, aortic LN basins
195
MC myeloprolif disorder assoc with budd chiari?
polycythemia vera
196
critical contributor to post splenectomy sepsis?
loss of Ab (IgG) and complement controlled (C3b) clearance
197
what are heinz bodies and are they assoc with splenectomy
denatured Hb
| no - assoc with G6PD def
198
what do you do with someone's warfarin preop?
stop 5d before, no bridge if low/moderate risk with hx afib (unless high risk)
199
CI to stenting and poss covering L subclavian artery (ie for PSA distal to L subclav takeoff)
CABG using L IMA as bypass
aberrant L vertebral artery
dominant L vertebral artery
functioning AVF in LUE
200
what to do with ABO incompatible blood transfusion by mistake?!
stop transfusion immediately
fluids for goal UOP 100cc/hr
(diuretics if pt can tolerate)
+/- dialysis for renal failure
201
MC transfusion reaction
nonhemolytic febrile reaction
2/2 WBC in blood
can cause anaphylaxis if bad enough
tx: antipyretics, antihistamines, epinephrine, steroids
(** prevent in future with leukocyte filters)
202
when someone comes with mallory weiss, what infusion should you start immediately
PPI
| acidic environment impairs coag cascade and platelet plugs ... PPI's yo
203
why is upper outer quadrant most likely place for breast CA and benign disease?
highest abundance of epithelial tissue
| Most benign and malignant disease derives from epithelial tissue (comprises ~10% of breast mass)
204
how is SJS described
maculopapular rashes that evolve into painful blisters and sloughing of the skin. Also tend to involve mucous membranes
205
preferred biopsy for melanoma?
excisional biopsy with 1-3mm margins ... go back for correct margins later
IF on surface (face etc) where hard to excise completely, or >2cm, can do incisional biopsy
206
do hurthle cells take up radioiodine?
not well
207
treatment for hurthle cells on biopsy
if a lot, then more signif for hurthle neoplasm
- total thyroidectomy (do not respond well to RI)
- MRND if +nodes
208
if peak levels of a drug are high, what adjustment do you make?
decrease amount of dose
209
indics for sterotactic biopsy breast
nonpalp; cannot see on ultrasound; gotta be visible on mammo
| relative CI: very large or thin breasts, lesions abutting chest wall, some subareolar lesions
210
tx for stewart treves?
dx: incisional bx
tx: WLE +/- chemorads for advanced disease
211
reduce a baby's incarcerated hernia... what is timing of surgery?
within 24-48 hr after (not immediately, to let edema die down)
*80% of initially incarcerated hernias can be reduced
212
stages of adrenocortical cancer
stage I: localized, <5cm T1N0M0
II: localized, >5cm T2N0M0
III: locally invasive tumors any T, N1, M0
IV: tumors invading local organs, distant mets, venous tumor thrombus in vana cava or renal veins
213
RF for invasive fungal infection
```
prolonged abx
solid organ transplantation
TPN
GI perforation
HD
ICU stay >7 days
```
214
correl of visceral art stenosis with PSV
SMA: >70% --> PSV > 275
celiac: >70% --> PSV > 200
renal: >60% --> renal:aortic ratio > 3.5
renal: >80% --> renal: aortic ratio > 3.5 and renal artery end-distaolic velocity > 150
215
posterior pharyngeal neck mass ... with no other sx ... thoughts? how dx?
lingual thyroid
| RI uptake scan
216
4 proven effects of physician in leadership (QI etc)
improve pt outcomes
improved efficiency
increased staff satisfaction
decrease expenditures
217
2 main surgical indics for CRS HIPEC
appendiceal disseminated adenomucosis (not nec better resection rate but this surgery is standard for this ds)
malignant peritoneal mesothelioma
218
what is included in proximal DVT?
popliteal
superficial femoral
iliac
219
an indication for catheter-directed thrombolysis?
acute iliofemoral DVT
220
pathology of radial scar
fibroelastic core with entrapped ducts with surrounding radiating ducts and lobules
221
what things do you excisionally biopsy?
```
radial scar
LCIS
ADH
Atypical lobular hyperplasia
papillary lesions
phyllodes tumors (hard to distinguish from fibroadenoma)
```
222
what is iron bound to for storage and transport?
ferritin - storage
| transferrin - transport
223
which breast recon method wont do well in face of radiation
autologous tissue graft
| delayed recon best
224
difference bw fibroadenomas and adenomas?
adenomas have sparse stromal elements
225
dextrose - what is the kcal/g?
3.4
226
funtions of the Ig's
IgA: breastmilk
IgD: B cells
IgE: allergy
IgG: opsonization, complement; longterm immunologic memory
IgM: 1st Ab produced for immune response; produced by naive B cells (before Ag activ)
227
common hipec agents
doxorubicin
mitomycin C*
oxaliplatin
228
surgical treatment for duodenal ulcers causing GOO?
1. acid reduction
2. tx mechanical obstruction
ie - highly selective vagotomy with GJ
or - vagotomy antrectomy with Bilroth I or II
229
high risk factors for BCC
recurrent lesion
>2cm
poorly defined
immunocompromised
230
MC site of mets for HCC
| also, do you do PET?
lung
| no
231
enzyme issue in gilbert's? cirgler najjar?
glucuronyl transferase, mild defect (Gilbert)
| glucuronyl transferase, severe (C-N)
232
Dubin-Johnson defect?
| Rotor's syndrome defect?
D-J: secretion deficiency; high conjug
| R: storage deficiency; high conjug
233
ejaculatory dysfxn after L colectomy ... injury to what? inability to maintain erection - from what?
ejaculation: superior hypogastric plexus (during high ligation of IMA)
erection: inf hypogastric plexus (deep w/in pelvis)
234
Oliguria after kidney transplant ... what do you evaluate?
1. vascular anastomoses via US doppler
2. ureteral anastomosis (hydro, bladder decompressed)
3. bladder outlet obstruction (bladder not decompressed) - can check US or just test out foley to ensure return of irrigation fluid
235
preferred IVF for pt with hyperkalemia?
LR (K [ ] =4) >>>> NS
236
what do you do with a retrorectal mass?
MC mass?
MC malignant presacral tumor?
TRICK QUES - surgically resect all retrorectal masses no matter what
2. congenital masses
3. chordoma
* * try to preserve at least unilat S3 nerve roots **
237
single most imp molecule for determining intestinal wall strength?
theory for anastomotic leaks (usually after POD3)?
- collagen
- collagen degradation + lower level of tensile strength while scar is still maturing
- MMP start breaking down newly laid collagen only 24 hr after anastomosis formation (process of degradation and buildup for 4 days)
238
incisions for exploration of injury to prox 2/3 trachea and distal 1/3 trachea?
prox 2/3 trachea: cervical incision
| distal 1/3: R posterolat thoracotomy (also R mainstem and prox L mainstem bronchi)
239
tx for Access Related Hand Ischemia (ARHI), or steal syndrome
- grades 1-3 (2: ischemia with activity/HD; 3: significant pain, numbness, loss of radial flow, etc)
- tx for chronic ARHI: distal revascularization-interval ligation (DRIL) ... create bypass originating prox to access anastomosis and terminating distal to it, with ligation of artery distal to anastomosis
240
child (<5 yr) with neck mass and Horner syndrome - dx??
cervical neuroblastoma
241
what is effect modification?
when the magnitude of the effect of the primary exposure on the outcome differs based on a third variable
242
what is lead time bias
when ds is dx earlier with a screening test but no actual impact on ds outcome
243
latent period?
time bw exposure and development of sx
244
what do fluoroquinolones have interactions to?
calcium, aluminum, mag (laxatives)
245
how does cipro work?
inhibition of bacterial DNA gyrase and topo IV --> inhibit DNA synthesis
246
which abx inhibit protein synthesis by binding to ... 30S? 50S?
30S: aminoglycosides
50S: macrolides
247
which abx inhibits cell wall synthesis?
vancomycin
248
which abx inhibits dihydropteroate synthetase?
bactrim
249
after hep C needlestick exposure - do you start tx right away?
no. ppx antivirals not recommended, bc rate of infection is low (0.1 - 1.8%). start tx if confirmed +infection to provider who was exposed
250
MC site of mets for cutaneous melanoma?
liver --> small bowel --> colon
| stomach, duo, rectum, esoph, anus
251
What is TURP syndrome?
Absorption of irrigation fluid during prostate surgery (ESP if prostate capsule is violated) ... causes hyponatremia
* severity of hypoNa directly related to vol of irrigation fluid retained
* decrease of Na by 10+ --> neuro sx
* symptomatic pts, tx = hypertonic saline
252
min length of roux limb to prevent bile reflux
40cm
253
describe traumatic urethral injury grading scale
grade I: contusion
II: stretch injury
III: partial disruption
IV: complete disruption, no extensive separation
V: complete disruption, +extension separation
tx = urinary diversion.. can do delayed repair
254
the risk of an intussusception 2/2 to specifically a pathologic lead point increases with ___
age
255
anatomy of inguinal lig LAD:
- saphenous vein
- obturator nerve
- lat fem cutaneous nerve
- femoral triangle
- at junction of sartorius and adductor muscles
- runs bw int and ext iliac vessels
- runs under fascia of sartorius
- borders = ing lig, sartorius, adductor longus (contains fem a/v/n)
- within fem canal ... gateway to deep inguinal LAD
256
how do you close femoral canal after ing LAD?
suture ing lig to pectineal lig with interrupted nonabsorbable suture ... can use mesh or sartorius muscle flap
257
How is tamoxifen metabolized and what drug should you not give with it?
CYP2D6 --> metabolizes tamoxifen into active metabolites
| SSRI's
258
preop abx for colon surgery?
```
cephalosporin + (flagyl or unasyn)
if PCN or cephalo allergy: combine the below
- clinda or vanco
plus
- gent, levo, cipro, aztreonam
```
259
s/p lung transplant ... persistent air leak, pneumomediastinum, pneumopericardium, empyema
bronchial dehiscence
| dx - bronchoscopy
260
what does the duodenum absorb?
Ca, iron, phos, fat soluble vits (ADEK)
261
optimal diet for hepatic encephalopathy?
low AAA, methionine
higher BCAA
(liver metabolizes aromatic amino acids normally)
262
diabetics who need enteral feeding - what formula do you start with
standard (non diabetic) fiber containing formula, with moderate fat and carbs
263
what is dermatofibrosarcoma protuberance?
- rare sarcoma, flesh colored mass on back
- dermal/subdermal tumor with epidermis sparing (spindle shaped cells)
- microscopic tentacles .. so need a wide excision (2-4cm margin)
- can use imatinib (TKi) to downstage locally adv tumor
- CD34 and vimentin + ... F8a and aSMA -
264
histology of BCC
basophilic staining basal cells infiltrating the dermis
265
What cancer is common with Crohns?
NHL, esp due to immunosupp meds
| *can be assoc with tumor lysis syndrome (w/ tx)
266
which pain meds can you use for someone with renal issues?
tylenol
fentanyl
hydromorphone (dilaudid) -- liver metabolized
267
tell me about pancoast tumors
- usually NSCLC, near thoracic inlet at apex
| - sx: shoulder pain, ulnar distribution weakness
268
What is preferred 1st line HAART regimen
tenofovir, lamivudine, efavirenz
269
For internal carotid artery, what is PSV assoc w/:
- 50% occlusion
- 50-69% occlusion
- >70% occlusion
125
125-230
>230
*ext carotid art triphasic; int carotid artery is biphasic
270
MC problem assoc with local anesthetic use (ie lidocaine) in neuraxial (spinal or epidural) anesthesia?
hypotension, 2/2 vasodilation and pooling of blood in LE
OTHER = bradycardia (esp above T5)
(1st blocked = postgang symp nerve fibers ... next = sensory + motor)
271
what is prednisone dose at which they don't need stress dose
10mg or less, >2 wks
272
abx for pancreatic necrosis
carbapenems (ie erta)
fluoroquinolones
metronidazole
273
1st line pressor for septic shock
norepi
274
factors w/ highest DVT risk (caprini score pts)
```
major surgery >6 hr
elective arthroplasty
fracture of hip, pelvis, leg
acute spinal cord injury (in last month)
stroke (last month)
multiple traumas (last month)
```
275
lung abscess ... hemoptysis a couple days later. what does that mean? what is tx?
abscess eroded into vessel and airway
| need surgical resection
276
lung abscess that does not improve w/ appropriate abx tx in 7-10 days - what next?
catheter drainage - perc (peripheral) pr bronchoscopic (central)
277
lung abscess - what indics for surgery?
```
BP fistula
empyema
bleeding (ie - hemoptysis)
concern for malignancy
failure of medical therapy
```
278
reversal for dabigatran (pradaxa)
idarucizumab
279
muscles used for forced expiration?
```
abd muscles (EO, IO, rectus, transverse abdominal)
internal and external intercostals (NOT "innermost intercostals")
```
280
histology of paget's disease (breast)
clear cells with oval nuclei and lg nucleoli ... interspersed between normal nipple epidermis keratinocytes
tx: mastectomy with SLNB (excise nipple/areolar complex) ... if palpable nodes, then MRM
281
describe gram and shape of clostridia
gram pos, anaerobic, rods
282
radiation ulcers ... sigh
presentation: hx radiation + refractory sx (pruritus, pain)
dx: biopsy (epidermal atrophy, dermal sclerosis, dilated superficial vessels, loss o' adnexal structures like hair follicles, atypical stellate shaped fibroblasts)
tx: conserv wound mgmt first ... if fails, then aggressive radical excision with flap
283
Normal HU of pancreas parenchyma
100-150
284
pseudomonas ..
gram neg aerobic bacilli
285
1st line abx of choice for infected pancr necrosis?
| MC pathogens?
carbapenem
| MC pathogens: e coli, pseudomonas, klebsiella, enteroccocus
286
MC sites of melanoma recurrence
skin, subQ, distant LN, visceral (lung, liver, brain etc)
287
what is cerebral salt wasting?
unknown etiology .. usually after CNS insult (usually aneurysmal SAH)
hypovolemic hypoNa, with increased urine Na
tx: iso or hyper tonic saline
*don't confuse with SIADH (where you fluid restrict + vaptan)
288
1st step in evaluating fectal incontinence 2/2 incompetent anal sphincter?
endoanal ultrasound
289
what causes ...
direct ing hernia
indirect ing hernia
direct: weakness of conjoint tendon / transversalis
indirect: patent processus vaginalis (defect in deep ring)
290
Describe altemeier and delorme procedures!
Altemeier (for larger prolapse >5cm; rectosigmoid resection): exteriorize prolapse --> circumf full thickness incision 1cm above dentate line --> amputate redundant sigmoid transanally --> stapled or handsewn coloanal anastomosis
Delorme (for small prolapse <5cm): circumf full thickness incision 1cm above dentate line --> remove mucosa (from incision up to proximal extent of prolapse) --> longitud plication of m.p. --> anastomose mucosal edges
291
what is involved in extrinsic and intrinsic pathways of apoptosis?
extrinsic: death receptors, death domain proteins
intrinsic: protein mediators (Bcl-2), incr mito membrane permeability, cytochrome C
292
RF for BK virus?
high immunosuppression
pulse steroids (to tx rejection)
ischemia reperfusion injury
293
what is monitoring for barrett's?
no dysplasia: EGD q3-5 yrs
low grade dysplasia: EGD q6 mo +/- endoscopic RFA
high grade dysplasia: endoscopic eradication
294
can you do a nissen if pt has barrett's with low grade dysplasia
yes
295
what is silver sulfadiazine assoc with?
transient neutropenia and thrombocytopenia
| rarely - metHGBemia (watch out for G6PD)
296
rapid correction of chronic hyponatremia (>5 mEq/L/hr) ... causes?
osmotic demyelination syndrome (ODS)
- usually hx chronic alcoholism, malnutrition, cirrhosis, refeeding syndrome
- clinical signs delayed 2-6 days after rapid correction has occurred - dysarthria, paresis, behav disturbances, seizures, lethargy, confusion, coma
297
pt s/p VARD for pancr necrosis ... now w/ hematemsis. Thoughts?
splenic artery or GDA pseudoaneurysm
| -pancr enzymes extravasate into RP space --> autodigestion of blood vessel walls --> PSA
298
complications following VARD?
hemorrhage - early or delayed (ie from a pseudoaneurysm)
colonic injury
RP abscess with fistulization
iatrogenic ptx
299
what is the strongest indicator of poor preop nutritional status?
albumin <3
300
absolute CI to PV embo to increase FLR
overt clinical portal HTN
301
what would rule out a BCI (blunt cardiac injury)?
normal EKG + normal trop I level
any EKG abnormalities (ie - occasional PVCs) warrants hospital admission for observation
302
name mechanism of the following:
- acute hemolytic reaction
- delayed hemolytic reaction
- nonimmune hemolysis
- febrile non-hemolytic reaction
- urticaria
- TRALI
- ABO incompatibility (Ab mediated; type II HSN)
- minor Ag from donor (Ab mediated)
- idk not imp
- cytokines from donor WBC
- recipient Ab against donor plasma proteins or IgA in IgA in IgA-deficient patient
- DONOR ab to recipient WBC
303
List causes of portal HTN
prehepatic
hepatic
posthepatic
pre: PV thrombosis
hepatic: cirrhosis
post: budd chiari, congestive cardiac failure
304
how do you treat claudication
lifestyle + medical mgmt (stop smoking, exercise, antiplt (ASA, cilostazol-not in HF, or plavix), intensive statin) ...... if no improvement or progression of symptoms --> further therapy, consider revascularization
305
inflamed TI, normal appendix + cecum, pt in OR for appendicitis ... what do you do
appy IF cecum normal
306
what is chromosome for FAP
5q21
auto dom
may be de novo in 25%
307
FAP cancer screening
EGD at 20-25 or when colon polyps first appear
q1-2 yr colonoscopy starting at age 10-15
q2-5 yr thyroid US starting in late teenage yrs (papillary)
look out for desmoids
other: medulloblastoma, sebaceous cysts, lipomas, osteomas, supernumerary teeth, hypertrophy of retinal pigment epithelium
308
what is a complex fistula
simple: intersphincteric or low transsphincteric, involving <30% of external sphincter --> FISTULOTOMY
complex: >30% sphincter, ant fistulas in females, recurrent IBD, or radiation --> SETON, THEN DEFINITIVE PROCEDURE (ie - LIFT, or endoanal adv flap for high fistulas)
309
pulm findings on CT: >2cm, spiculated, growing, part of solid, invasive
NSCLC
310
pulm findings on CT: rapid growth, LAD, direct invasion, SVC obstruction, necrosis/hemorrhage common
small cell lung cancer
311
hypodense, homogenous, well defined, contained, stable
lipoma
312
perianal condyloma (genital warts) - tx?
gross excision of disease
no further screening
HPV vaccination (good for before or after exposure)
313
treatment for dumping syndrome
dietary modifications --> meds (acarbose, octreotide) --> surgery (convert to roux en y)
314
tx for triple neg breast CA after lumpectomy?
radiation obv
| + adjuvant chemo for tumors>0.5cm
315
considerations for neoadjuvant chemo, breast cancer
triple neg breast cancer
| HER2+
316
RF for septic complics in ICU pts
male gender
prolonged ICU stay
prolonged ventilator req
increased age
317
criteria for brain death exam
normothermia for >/= 6 hr
loss of all brainstem reflexes
positive apnea test (abort for decompensation: desat to <85 for >30 sec, hypotension)
if apnea test doesn't work, do confirmatory test (4 vessel angiogram is gold std ... radionuclide scintigraphy)
318
what is a positive apnea test
paCO2 rises to 60 (or >20 above baseline) after 10min off vent
319
for pts undergoing ventral hernia repair, __ is assoc w/ SSIs. using __ instead of __ for hair removal is BETTER.
preop bowel prep
| clippers >>>> razors (latter is assoc with SSI)
320
where is AFP high?
germ cell tumors
| HCC
321
3 tumor markers of testic cancer
AFP (seminomas never have high AFP)
b-HCG (seminomas have this high 10-20% of time)
LDH
**elevated in NONseminomatous germ cell tumors
322
MCC pseudomyxoma peritonei
appendix
323
tx for FMD of renal arteries
angioplasty alone
focal FMD: BP improves, no meds needed post procedure
multifocal FMD: still need meds post procedure
(I think renal atherosclerosis would need angio + stent??)
324
MC genetic alteration in thyroid cancer
BRAF V600E
325
dysphagia to both liquids and solids is suggestive of __
functional disorder (like achalasia)
326
What are omega 3 and 6's
3: ALA, DHA, EPA
6: LA, AA
327
digoxin + pt with n/v .... arrhythmia. how?
digoxin causes dysrhythmias at low K levels
| K and Na are thrown up ... kidneys R more Na at expense of H and K
328
which burn meds to avoid if +sulfa allergy
mafenide acetate
silver sulfadiazine
use silver nitrate (solution) for eschars and +sulfa allergy
329
pt with pheo, was hypertensive during case where it was being resected... unresponsive postop w/ normal vitals and labs except lactate is high. what is problem and tx?
```
cyanide toxicity (from nitroprusside used for HTN, tho it is CI in B12 def, anemia, kidney/liver ds, hypovolemia)
tx = hydroxocobalamin + sodium thiosulfate
```
330
signs of bb overdose
hypotension
| bradycardia
331
abx tx for pouchitis
flagyl or fluoroquinolone
332
hernia repair... enterotomy w/ no gross spillage successfully repaired - do you use mesh? how repair?
synthetic mesh if no evidence of strangulation or gross spillage
333
hematochezia + HD instability ... tx?
r/o UGI sources with NGT
| if HD stable --> resuscitate and then Cscope
334
early HA thrombosis post transplant causes __
| late HAT causes __
primary graft nonfunction + hepatic failure
| late: biliary strictures, abscesses, recurring bacteremia
335
are these before or after the event occurs:
- root cause analysis
- failure mode & effects analysis
- human factors analysis and classif system
- PDSA
-after (focuses on system, not individual)
-before (evaluate systems in stepwise fashion)
"Failure, Forward looking"
-after (human error assoc with event)
-before
336
what is order of unclamping after CEA?
ECA
CC
ICA
finish patch angioplasty
337
1 month s/p nissen, p/w mild reflux, postprandial bloating, progressive nausea ... ?
barium swallow 1st --> if normal, then vagal nerve injury
338
small bowel mass with mesentery tethering, liver mass with central necrosis (hypodense) ...... diarrhea .....
what is it and what do you test for?
urinary 5HAA (serotonin) .. >25 is dx
carcinoid syndrome
can check CgA but watch out for PPI use
339
infant >2 wk old with persistent jaundice (conjugated hyperbili) ... what do you rule out?
biliary atresia
| differential: hepatitis
340
indics for transanal excision of low-mid rectal CA/malignant polyps
T1, <3cm in size
<8cm from anal verge
mod well diff
< 1/3 circumference of bowel wall
341
what kind of washout for benign incidental adrenaloma
>50% at 10min
| <10 HU
342
how to tx the following:
C krusei
C glabrata
C albicans
voriconazole
micafungin
fluconazole
343
what pain med to avoid for post dural puncture headache
NSAIDs (affect plt function)
344
tx for C diff assoc toxic megacolon
| cecal dia >12 or colonic dia >6
TAC with end ileo
| high mortality
345
how to follow incidental thyroid nodules
<1cm and no alarming hx or features: repeat US in 6 mo
1-1.5cm + intermed/high risk features: FNA
1-1.5cm + low risk features: follow on US
1.5 or greater: FNA no matter what US shows
if small but concerning hx ... consider FNA
346
absolute CI to PEG placement
```
coagulopathy
massive ascites
completely obstructing esophageal mass
severe malnutrition
(sepsis, MOF)
```
347
aortoenteric fistula after AAA repair
usually occur 1-5 yr later
MC etio: graft infection w/ anastomotic PSA that erodes into bowel
tx: fistula takedown, graft excision, oversew distal aorta, extra-anatomic bypass
348
what are MCC and signs of venous HTN?
| in setting of someone with AVF
MCC: stenosis and/or thrombosis of central venous system 2/2 to previous catheterization
sx: extremity edema, varicosities, dermatosclerosis, ulceration
also: high pressure and/or prolonged bleeding at puncture site of dialysis
dx: venogram
tx: endovascular recanalization of stenotic or occluded area
349
how long to wait before surgical repair of rectovaginal fistula
3-6 months
350
what does sclerosing adenosis look like histologically
central cellularity with lobules and intact myoepithelial contents
351
MC defect assoc with colon cancer
APC
352
what innervates ...
thumb mostly
thumb aDduction
palmar and dorsal interossei
median nerve
ulnar nerve for thumb aDduction
ulnar nerve
353
recurrent reflux and wt gain after hx RYGB
gastrogastric fistula
| dx: CT w/PO con or upper GI series
354
potential reactions to protamine?
hypotension
pulm vasoconstriction
pulm HTN
355
which veins need to be repaired
```
IVC
femoral
popliteal
BC
subclav
axillary
```
356
MCC late death in ...
- heart transplant
- lung transplant
- kidney transplant
heart: "chronic allograft vasculopathy" (coronary atherosclerosis)
lung: bronchiolitis obliterans
kidney: MI
357
how long try medical therapy for gastric ulcers, before surgical intervention?
12 weeks
358
MC nosocomial infection in ICU
| leading cause of death 2/2 hosp acquired infection
PNA
| SSIs are also common ... both are more common than UTI
359
MC fungal infection in immunosuppressed pts
| MC fungal pulm infection overall
aspergillosis (invasive, allergic, aspergilloma)
| overall: histoplasmosis (itraconazole)
360
flail chest or multiple rib fx ... pt decompensates
pulm contusion!!!
361
what imaging to look for accessory spleen?
technetium sulfur colloid scan
362
what has the highest resolution rate s/p bariatric surgery?
pseudotumor cerebri
363
1st line pressor for septic shock?
norepi !!!
364
operative time > ___ minutes has been shown to increase risk of inc hernia
80
365
what does motilin cause
migrating myoelectric complex
366
ant hip disloc is assoc with __
femoral head fx
| *abduction + ext rotation*
367
treatment for hep C
atezolizumab (aPD-L1) + bevacizumab (a-VEGFA)
368
indics for damage control surgery
base deficit > 15
ph < 7.2
temp < 34
refractory coagulopathy
369
tx for lower duct resectable CCA?
whipple
370
where make incision for SMA embolus
transverse arteriotomy PROX to origin of middle colic
371
briefly, what is young-burgess classification of pelvic fx? (AP compression)
I: symphysis widening <2.5cm
II: widening > 2.5cm
III: SI disloc with vascular injury
372
MCC pelvic fx
MVC
373
imp mediator of chronic wounds
IFN gamma
374
what tissues are obligate glucose users
erythrocytes, neutrophils, peripheral neurons, adrenal medulla
375
neurogenic shock is loss of sympathetic tone to ___
vasculature (vasodilation)
376
Peterson defect
space bw roux limb and transverse colon mesentery
377
elective hernia repair not recommended for __, __, __
BMI>/=50
current smokers
HbA1c >/= 8
378
thoracic outlet syndrome ...
compression of subclav artery or vein and brachial plexus
MC sx = neurologic, ulnar distribution
first line tx = physical therapy
surgery if conserv therapy fails, or develop arterial complic or venous thrombosis
379
surviving sepsis bundle (1 hr)
- -measure lactate and repeat is >2
- -get blood cx before start abx
- -give broad spectrum abx immediately after blood cx drawn
- -give 30 cc/kg crystalloid for hypotension or lactate >4
- -pressors if hypotensive during/after fluid resusc to maintain MAP>65
380
5 things to assess frailty
```
weight loss
weak grip strength
self reported exhaustion
slow walking speed
low energy expenditure
```
381
CI to lat internal sphincterotomy? Treatment?
```
Hypotonic sphincter (ie previous anorectal sx or obgyn trauma)
Tx: fissurectomy w anocut adv flap
```
382
when would you consider botox >> lat internal sphincterotomy for fissure?
risk of incontinence
| refused surgery
383
Ehlers Danlos - which defect?
collagen type 3
384
how to workup failure of AVF to mature?
```
duplex US (check for arterial inflow or venous outflow issues)
then maybe fistulogram / angioplasty
```
385
max size for EV laser ablation
8mm (assoc with thrombus extension)
386
indic for sclerotherapy
varicose veins <8mm
reticular veins 2-4 mm
telangiectasias
387
what is time of chronic anal fissure
>6 weeks
388
name the HSN reactions
I: anaphylaxis
II: cytotoxic mediated ... Ig's attached to surface Ag --> complement
III: Ag-Ab complexes
IV: cell mediated, w/ local injury
389
MOA of silver antimicrobial properties
ribosomal toxicity
intercalate into dna
denature proteins
disrupt bact cell membrane
390
how to treat MALToma
check for h pylori
if +h pylori, check t(11;18) status
if t(11;18) POS --> h pylori tx + radiation (or rituximab if latter is contraindic)
NEG --> generally just standard course of tx
391
__ has the highest 5 yr kidney graft survival rate
cystic kidney disease (it's >85%)
392
treatment for RCC?
```
radical nephrectomy
(w/ simultaneous intraop open IVC thrombectomy if needed)
```
393
traumatic transection (incomplete vs complete) of LAD ... treatment?
incomplete: primary repair
complete: CABG
394
min time for DAPT for DES
6 mo
395
occlusion of artery of ademkiewicz can cause __ __
spinal ischemia
*it is the main blood supply to the spine from T8-conus
urinary and fecal incontinence, impaired motor fxn of legs
396
classic murmur of AI (aortic insufficiency)
high pitched decrescendo diastolic murmur, at 3-4th IC space at L sternal border
397
where do you hear aortic stenosis murmur
right upper sternal border
398
kid with liver mass and high AFP
hepatoblastoma
399
desmoid markers
+ : B-catenin, actin, vimentin,
| - : cytokeratin, S-100
400
steps for examining entire duo and pancreas
kocher maneuver
incise gastrocolic lig and enter lesser sac
divide RP inferior to pancreas (to see post pancreas)
right medial visceral rotation (C-B)
mobilize lig of treitz
401
which splenic lig contains splenic artery?
splenorenal
402
what are the BCAA
isoleucine, leucine, valine
403
how to dx blind loop syndrome?
carb breath test (carbohydrate excreted earlier than 2-3 hr)
404
how do you dx dumping syndrome
monitored glucose challenge (incr HR or hypoglycemia)
405
2 absolute CI to lap chole
1. uncorrected/uncontrolled coagulopathy
| 2. cannot tolerate insufflation
406
ideal CPP and ICP
CPP 60-70 (not above)
| ICp <20
407
difference between delorme and altemeir
delorme: strip mucosa and plicate muscle layers
altemeier: perineal rectosigmoidectomy ( you resect stuff)
408
indications for damage control surgery
```
base deficit >15
temp <34
pH<7.2
refractory coagulopathy
lg vol resusc > 12L
```
409
how does high PEEP cause decreased CO
high PEEP --> increased intrathoracic pressure --> decreased RV filling --> decreased LV preload --> decreased stroke volume --> decreased CO (CO=SVxHR)
410
tx for postthrombotic syndrome
compression
411
what to do for psotthrombotic syndrome and involvement of iliofemoral axis?
venogram
412
guidelines for hypotension in neurogenic shock
maintain MAP>85-90 for at least first 5-7 days after acute SCI
* lesions above T6: dopamine or norepi (bc anticipate hypotension and bradycardia 2/2 injury of cardiac accelerator nerves at T1-4)
* lesions below T6: phenylephrine
413
what suggests venous HTN in a fistula pt
prolonged bleeding, difficulty with dialysis
limb edema/varicosity
tx: endovascular venoplasty, venous bypass
414
what size must the base of the meckel diverticulum in order to do diverticulectomy
2cm
| if larger, palpable abnormality, or unhealthy tissue: segmental resection of ileum
415
primary predictor of failure of endoscopic pseudocyst drainage?
presence of moderate debris
416
3 factors in inflamm phase of wound healing (1-3d)
TNFa
IL1
PDGF
(also IFNs)
417
what is RQ
CO2 prod / O2 consumed
418
can you order a HIDA in a pregnant woman?
yeah
419
indic for catheter directed thrombolysis of DVT
low risk pts with iliofemoral DVT (reduces risk of post thrombotic syndrome)
420
what is normal urinary ca?
<400 mg
