ABSITE 2022 Flashcards
Appendectomy: Risk factors associated with conversion to open
- severe inflammation obscuring view of anatomy
- peritonitis
- presence of large intra-abd abscess
3 types of rectus sheath hematomas
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
Common rectus sheath hematoma symptoms
- sudden abd p
- pain on trunk flexion/rotation
- greatest comfort in a supported flexed position
- anticoagulation/women
- 29% assoc w cough
Stimuli for ductus closure in neonate
ductus arteriosus - bw PA + aorta
- incr O2 tension
- drop in pulm vascular resistance
- decr prostaglandin levels
What shunt does a PDA cause
left to right shunt … can cause HF if left untreated
What induces pharmacologic closure of DA?
indomethacin (decr PG’s)
What surgery is used to close a PDA
L posterolateral thoracotomy (can do bedside) and close PDA with clips
Life threatening bleeding + vW disease .. what do you give?
type 1 (AD; low qty): desmopressin type 2 (AD; low quality): desmopressin type 3 (AR; absence of): vWf/F8 concentrate
How calculate ABI
Higher of 2 ankle pressures (dp, pt) / higher of 2 brachial pressures
How are the following absorbed?
fructose
glucose
galactose
fructose - facilitated diffusion (GLUT5 in, GLUT2 out)
glucose - active (SGLT1, GLUT2)
galactose - active (SGLT1, GLUT2)
When to consider EMR for gastric cancer?
tumor <2 cm no ulceration no LVI well or mod-well diff histology limited to mucosa
Where do carcinoids usually occur?
How do they usually present?
appendix …. small bowel
abd pain
What is vimentin assoc with
melanoma, colon CA, esophageal CA, gastric CA
What is S100 assoc with
melanoma
schwannoma
neurofibroma
How do you perform water soluble esophagography for traumatic esoph perf?
pt in R lat decub
if pt HD stable and nothing seen on esophagography but high suspicion for injury –> EGD
unstable pelvic fracture … gets angioembo’ed by IR … still unstable and repeat FAST is negative. Now what?
external fixation (If FAST + --> ex lap)
radial nerve is responsible for __ of the thumb and ___
abduction
supination
Injury to RLN is more common when it is running __
anterior to or bw the ITA
Injuries assoc with BCVI
Le Fort 2 and 3 facial fx mandibular fx c spine fx basilar skull fx DAI or GCS =8 severe thoracic chest trauma
What are cells that stain CD3 + and recognize HLA-I molecules?
CD8 cytotoxic T cells
After recurrent ing hernia, which lap repair is preferred?
totally extraperitoneal repair
lower risk of re recurrence
what defines “severe acute pancreatitis” ?
- 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
Highest risk popul for OPSI ??
highest risk within 2 yr postop
MC pathogen?
Pts w/ hem malignancies who undergo splenectomy
Strep pneumo
MC inherited hypercoag disorder?
factor V leiden - factor V cannot respond to protein C … propensity to clot
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
Best way to repair umb hernia in a cirrhotic?
primary repair with nonabsorbable sutures
resuscitate w/ 25% albumin
clinically + LN in pt dx with melanoma … what to do?
FNA … neg: proceed to SLNB
pos: ax dissection
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)
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
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
How does Mg cause hypoCa?
Produces PTH resistance / decrease PTH secretion
Thus - have to replete Mg first
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
recurrent malignant effusion … treatment if there’s:
- complete lung expansion
- lung does not completely expand
- talc pleurodesis
- pleurX
Major fuel source for small bowel enterocytes?
glutamine
Major fuel source for large bowel enterocytes?
SCFA
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
Best mgmt for pts with ventral hernia req PD catheter placement?
Repair of hernia with extraperitoneal prosthetic mesh at time of PD catheter placement
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
BRCA2 - which chromosome?
13
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%
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
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
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
Which extraintestinal manifestations of Crohns will most likely resolve with medical/surgical tx?
erythema nodosum
peripheral arthritis
aphthous ulcers
episcleritis
What is the order of preferred AV fistulas?
RC > BC > BB > prosthetic (brachioaxillary)
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
What is a cimino fistula?
radiocephalic fistula
what do you see on path of well diff neuroendocrine/carcinoid tumor?
bland cytologic features
rare mitotic figures that stain +chromogranin
cardiac impact of reverse T
increase venous pooling … decreased CO and hypotension
Common orgs in CLABSI
GP (coag neg staph, enterococci, staph aureus) > GN > Candida
MC cause of fat necrosis in breast?
idiopathic
male breast cancer, stage for stage, carries the same prognosis as female breast cancer - T or F ?
true
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
metabolic disturbance caused by NS resuscitation
non AG hyperchloremic metabolic acidosis
excess Cl, low bicarb, normal AG
formula for anion gap
Na - (Cl + HCO3)
What does thoracodorsal nerve injury cause?
weakened arm pullups and adduction
lat dorsi
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
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
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
what causes the hypoNa in DKA?
pseudohypoNA due to influx of water (bc hyperosmolar) diluting Na
What cells are LPS found on? What cells do they activate?
found on GN bacteria
activate monocytes / macrophages
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
> 75% spontaneous bact peritonitis is caused by __, of which 50% is __
aerobic GN rods
E coli
preferred mode for fecal diversion in rectal trauma pt
loop colostomy (»> end colostomy; easier to reverse)
procedure done for emergency surgery of UC
TAC with end ileostomy
indic’s for emergency surgery in UC pt
perforation
life threatening hemorrhage
toxic megacolon
fulminant colitis refractory to medical therapy
Initial mgmt for severe UC
NGT, bowel rest
IV hydration, lytes
+/- abx (+peritoneal signs, fulminant colitis, toxic megacolon)
Definition of obesity hypoventilation syndrome - DAYTIME hypoxia and hypercapnia in obese pt
- Obesity, BMI>30
- Daytime hypoventilation (paCO2 > 45)
- Absence of other known causes
*caused by apnea/hypopnea due to change in central chemoreceptor set points, not alveolar collapse
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
Where are mucinous cystic neoplasms usually located in pancreas?
body / tail»_space;> head
histologic hallmark of Paget disease
malignant intraepithelial adenocarcinoma cells
pale clear cytoplasm
high grade nuclei, visible nucleoli
example of horizontal gene transfer
conjugation, transformation, transduction
via plasmids
example of vertical gene transfer
gene resistance passed from parent –> offspring
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
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
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”
What is Six Sigma?
honestly idk but it aims to eliminate or streamline (vs add something, such as in PDSA)
what converts trypsinogen to trypsin
enterokinase on intestinal brush border
Key aspects of lichtenstein repair
- large sheet of mesh - 3-4cm above hesselbach’s triangle, 2cm medial to pubic tubercle, 5-6cm lat to internal ring
- cross tails of mesh behind spermatic cord to prevent recurrence lateral to internal ring
- keep mesh lax
- secure mesh medially to conjoint tendon with 2 interrupted sutures & laterally to ing lig with 1 continuous suture
- identify and protect the nerves throughout
what’s most likely to be injured when suturing mesh into the shelving edge of ing lig
external iliac vein
what are primary lymphoid organs
bone, thymus, liver
what are secondary lymphoid organs
lymph nodes, spleen, Peyer patches, tonsils, adenoids
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
what are antidotes for cyanide toxicity?
amyl nitrite
hydroxocobalamin
sodium nitrite
sodium thiosulfate
sx: weakness, confusion, pulm edema
check: thiocyanate
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
what are howell jolly bodies
nuclear remnants - you see them post splenectomy
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
hallmarks of HRS
spanchnic vasodilation
activation of sympathetic nervous system + RAAS
renal vasoconstriction
“poorly controlled diabetic” + pic of RUQ US + cholecystitis …. dx?
emphysematous cholecystitis
surgical emergency or perc drain if unable to tolerate surgery
After RYGB, where is marginal ulcer usually located?
jejunal side of GJ (irritation from gastric acid)
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
Characteristics of CMV colitis (transplant pt)
- punched out ulcers
- Cowdry bodies (eosinophilic inclusion bodies)
- may or may not have +blood serology
gold std for dx of bladder rupture?
CT cystogram
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
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)
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
at which GFR do you need emergent dialysis
=6, regardless of symptoms
at GFR 10-15 + uremic symptoms –> elective dialysis
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)
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
mechanism of action of first line tx for PTLD?
anti CD20 (rituximab)
*B cell prolif!
which side of bowel is at highest risk of ischemia - mesenteric or antimesenteric?
antimesenteric
vasa recta originate from peripheral arcades in mesentery
what is a 2 layer anastomosis of bowel
inner running absorbable (ie vicryl)
outer interrupted nonabsorbable (ie silk)
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
SE of silver nitrate
metHBemia
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
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)
“lobular lesion with increased fibrous tissue and glandular cells”
sclerosing adenosis
signs of AIP
lymphoplasmacytic sclerosing pancreatitis
periductal lymphoplasmacytic infiltrate
obliterative phlebitis
acinar fibrosis
MAP goal during septic shock
65 +
when can use broselow tape
up to age 12, <80 lbs/36 kg
thiamine deficiency –> beri beri –> AG metab acidosis
WHY?
thiamine (cofactor for pyruvate dehydrogenase) –> pyruvate build up –> shifted to lactate –> refractory metab acidosis
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.
mechanism of lithium toxicity in wt loss pts
decreased GFR after weight loss –> lithium toxicity –> (unknown mechanism) hyperCa, hyperMg, hypocalciuria
what drugs have increased absorption after RYGB
digoxin, PCN, atorvastatin, lithium
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
best way to dx portal HTN
hepatic vein pressure gradient >6
gradient bw wedged pressure and free pressure
functions of leukotrienes?
leukocyte attraction and adhesion bronchoconstriction mucus production increased capillary permeability release of PAF
(made from AA; released from leukocytes/myeloid cells)
what kind of organism is c diff
anaerobic gram positive bacilli
name 3 gram negative bacilli
pseudomonas
klebsiella
escherichia
delayed immune hemolytic transfusion reaction … what can prevent this
retyping and screening the pt
- pathophys: Ab to minor antigens
- hemolysis –> unconj bilirubin
- fever
best incision to gain prox and distal control of L subclav artery
left anterior thoracotomy + separate supraclavicular incision
what is winters formula
check expected PaCO2 in metab acidosis
paCO2 = 1.5 (bicarb) + 8
How calculate AG
(Na + K) - (bicarb + Cl)
treatment for subclavian vein thrombosis 2/2 thoracic outlet syndrome
catheter directed lysis
venogram
remove first rib/decompress + balloon angioplasty for venous narrowing
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
nerve(s) commonly injured during laparoscopic ing hernia repair
genitofemoral
lat fem cutaneous
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
MCC hyperaldo
b/l adrenal hyperplasia
what’s going on in DI
alcohol abuse/TBI –> reduced ADH –> polyuria, hyperNa
- tx for acute: desmopression
- tx for chronic: free water
what is pseudohyponatremia?
water is drawn into intravascular compartments by hyperglycemia
approx for every 100 above normal, add 2 to Na
what is included in
- cryo
- FFP
cryo: fibrinogen (factor I), factors 8 and 13, vWf
FFP: clotting factors
what does a prolonged R time need
FFP (clotting factors)
nml: 4-8 min
what does a prolonged alpha angle need
cryo (fibrinogen)
normal: ~55-70
low MA
plts (clot strength)
normal: 50-70 mm
what does a prolonged LY30 need
TXA
normal: 0-8%
If have PCN anaphylaxis … what cross-reactivity is there?
cephalosporins: 6%
aztreonam: not signif EXCEPT ceftazidime
carbapenems: 1-9%
what abx to give someone undergoing L hemi, anaphylaxis to PCN
metronidazole or clindamycin +
aminoglycoside (-mycin) or fluoroquinolone (levo, cipro, moxi)
OR clinda + aztreonam
What is the McVay repair (femoral hernias)
suture conjoint tendon to Cooper’s ligament
- incise transversalis fascia to enter preperitoneal space
- suture conjoint tendon to Cooper’s at pubic tubercle extending laterally to femoral sheath
- can do a relaxing incision to release tension - 6cm incision on ant rectus sheath behind EO aponeurosis
In which hernia would you primarily repair the transversus and IO muscles
spigelian
What is a Bassini repair
suture conjoint tendon to inguinal ligament (closes direct and indirect spaces)
What is a Shouldice repair
Multi layer repair with running suture to obliterate the hernia defect
MCC of Zone III bleeding
presacral or prevesical veins
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
Donor hepatectomy occurs during __ perfusion.
Preserve the __ vein during dissection to perfuse the liver.
cold
IMV
One technique for minimizing cold ischemia time?
en bloc multi organ procurement with back table separation
MCC esophageal stricture
GERD
MC side effects after EMR?
Strictures are __ after RFA.
EMR: bleeding, strictures (Tx: dilations)
uncommon after RFA
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)
what causes periumbilical pain in appendicitis?
VISCERAL pain from luminal distension
this pain can be present in retrocecal
what causes RLQ in appendicitis?
SOMATIC nerve fibers from contact of distended appendix with parietal peritoneum
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
inf thyroid artery supplies PTH glands from __ side
medial
normocalcemic high PTH .. what is it?
early primary hyperthyroidism
1 splenic tumor overall
hemangioma
1 splenic malignant tumor and also MCC splenomegaly
Non hodgkins lymphoma
What “margins” do you need for a whipple
R0
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
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
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
1st line pressor for septic shock
norepi
2nd: vasopressin
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
an age population associ with cecal volvulus?
middle aged women
pathophysio of cocaine induced mesenteric ischemia 2/2 vasoconstriction
inhibition of NE reuptake at presynaptic terminals –> more NE at postsynaptic terminal –> tachy, HTN, vasocons
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
what is removed in a whipple
distal stomach, panc head, duo, 15cm jej, GB, CBD
histology: high nucleus to cytoplasm ratio, and absent nucleoli ….. what lung cancer is this?
small cell
assoc w/ paraneoplastic syndromes like SIADH
what is SCC of the lung assoc with?
hypercalcemia (PTHrP)
what promotes gluconeogenesis?
what are the precursors?
promoted by: glucagon, epi, cortisol
precursors: alanine (PRIMARY), lactate, glycerol, other aa (ie glutamine)
when do you use MVA (analyses) ?
eval relationship bw variables and outcomes while controlling for the impact of other measured variables
when is linear regression used
continuous variables (ie cholesterol or BP) and assumed to be normally distributed output = risk difference
how do you repair the trachea?
1 layer with absorbable suture and strap muscle buttress
what is cantlie’s line
imaginary line that runs from GB foss to IVC (divides liver into R and L)
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
what is normal urinary cortisol level
<90 mcg/24 hr (250 nmol/day)
>300 mcg = cushing syndrome
how are brown recluse spider bites usually tx’ed?
observation and elevation
can get necrosis, injury to nerves, secondary bact infection
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
when to consider flaps in pilonidal disease?
extensive (stage 4 - multiple pits bilaterally) or recurrent pilonidal disease
where are majority of active bile salts R
TI, 80%
What is
Sheehan syndrome
Waterhouse-F syndrome
- sheehan: ant pit ischemia after hemorrhage/hypotension postpartum
- WF: adrenal hemorrhage after meningococcal infec
HV pressure gradient reqd for variceal rupture
at least 12
what makes up child pugh turcotte score
bili PT albumin encephalopathy ascites
MELD score at which pt will have survival benefit from transplant surgery
15
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)
test to determine a/c during CABG?
acceptable levels?
ACT
400-500 secs
determines amount of protamine to reverse heparin
which open tissue based ing hernia repair has lowest recurrence rates?
shouldice
is tx with anti-TNF in 3 months prior to surgery associ with poor wound healing?
no
does switching to azathioprine within 6 wks of surgery affect wound healing?
yeah; incr postop morbidity (leak, sepsis)
UPJ injury with trauma … more common in kids or adults? blunt or penetrating trauma?
kids (hyperflexibility of spine)
blunt
mechanism of graft v host disease?
- damage of recipient tissue
- 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)
- tissue dysregul from cytokines prevents tissue regeneration in host (ie skin, gut)
pathophysio behind chronic GVHD
dysregulation of donor Tregs leading to fibrosis
2 major causal factors for hepatic angiosarcoma
vinyl chloride
arsenic
(bladder cancer - aromatic amines)
formula for calculating nitrogen balance -__-
(protein in grams/6.25) - (nitrogen excreted in urine + 4)
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)
primary tx modality for advanced cervical cancer?
I think anything IB or further
chemo + radiation (ext beam + brachytherapy)
*pelvic, aortic LN basins
MC myeloprolif disorder assoc with budd chiari?
polycythemia vera
critical contributor to post splenectomy sepsis?
loss of Ab (IgG) and complement controlled (C3b) clearance
what are heinz bodies and are they assoc with splenectomy
denatured Hb
no - assoc with G6PD def
what do you do with someone’s warfarin preop?
stop 5d before, no bridge if low/moderate risk with hx afib (unless high risk)
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
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
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)
when someone comes with mallory weiss, what infusion should you start immediately
PPI
acidic environment impairs coag cascade and platelet plugs … PPI’s yo
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)
how is SJS described
maculopapular rashes that evolve into painful blisters and sloughing of the skin. Also tend to involve mucous membranes
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
do hurthle cells take up radioiodine?
not well
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
if peak levels of a drug are high, what adjustment do you make?
decrease amount of dose
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
tx for stewart treves?
dx: incisional bx
tx: WLE +/- chemorads for advanced disease
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
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
RF for invasive fungal infection
prolonged abx solid organ transplantation TPN GI perforation HD ICU stay >7 days
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
posterior pharyngeal neck mass … with no other sx … thoughts? how dx?
lingual thyroid
RI uptake scan
4 proven effects of physician in leadership (QI etc)
improve pt outcomes
improved efficiency
increased staff satisfaction
decrease expenditures
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
what is included in proximal DVT?
popliteal
superficial femoral
iliac
an indication for catheter-directed thrombolysis?
acute iliofemoral DVT
pathology of radial scar
fibroelastic core with entrapped ducts with surrounding radiating ducts and lobules
what things do you excisionally biopsy?
radial scar LCIS ADH Atypical lobular hyperplasia papillary lesions phyllodes tumors (hard to distinguish from fibroadenoma)
what is iron bound to for storage and transport?
ferritin - storage
transferrin - transport
which breast recon method wont do well in face of radiation
autologous tissue graft
delayed recon best
difference bw fibroadenomas and adenomas?
adenomas have sparse stromal elements
dextrose - what is the kcal/g?
3.4
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)
common hipec agents
doxorubicin
mitomycin C*
oxaliplatin
surgical treatment for duodenal ulcers causing GOO?
- acid reduction
- tx mechanical obstruction
ie - highly selective vagotomy with GJ
or - vagotomy antrectomy with Bilroth I or II
high risk factors for BCC
recurrent lesion
>2cm
poorly defined
immunocompromised
MC site of mets for HCC
also, do you do PET?
lung
no
enzyme issue in gilbert’s? cirgler najjar?
glucuronyl transferase, mild defect (Gilbert)
glucuronyl transferase, severe (C-N)
Dubin-Johnson defect?
Rotor’s syndrome defect?
D-J: secretion deficiency; high conjug
R: storage deficiency; high conjug
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)
Oliguria after kidney transplant … what do you evaluate?
- vascular anastomoses via US doppler
- ureteral anastomosis (hydro, bladder decompressed)
- bladder outlet obstruction (bladder not decompressed) - can check US or just test out foley to ensure return of irrigation fluid
preferred IVF for pt with hyperkalemia?
LR (K [ ] =4)»_space;» NS
what do you do with a retrorectal mass?
MC mass?
MC malignant presacral tumor?
TRICK QUES - surgically resect all retrorectal masses no matter what
- congenital masses
- chordoma
* * try to preserve at least unilat S3 nerve roots **
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)
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)
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
child (<5 yr) with neck mass and Horner syndrome - dx??
cervical neuroblastoma
what is effect modification?
when the magnitude of the effect of the primary exposure on the outcome differs based on a third variable
what is lead time bias
when ds is dx earlier with a screening test but no actual impact on ds outcome
latent period?
time bw exposure and development of sx
what do fluoroquinolones have interactions to?
calcium, aluminum, mag (laxatives)
how does cipro work?
inhibition of bacterial DNA gyrase and topo IV –> inhibit DNA synthesis
which abx inhibit protein synthesis by binding to … 30S? 50S?
30S: aminoglycosides
50S: macrolides
which abx inhibits cell wall synthesis?
vancomycin
which abx inhibits dihydropteroate synthetase?
bactrim
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
MC site of mets for cutaneous melanoma?
liver –> small bowel –> colon
stomach, duo, rectum, esoph, anus
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
min length of roux limb to prevent bile reflux
40cm
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
the risk of an intussusception 2/2 to specifically a pathologic lead point increases with ___
age
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
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
How is tamoxifen metabolized and what drug should you not give with it?
CYP2D6 –> metabolizes tamoxifen into active metabolites
SSRI’s
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
s/p lung transplant … persistent air leak, pneumomediastinum, pneumopericardium, empyema
bronchial dehiscence
dx - bronchoscopy
what does the duodenum absorb?
Ca, iron, phos, fat soluble vits (ADEK)
optimal diet for hepatic encephalopathy?
low AAA, methionine
higher BCAA
(liver metabolizes aromatic amino acids normally)
diabetics who need enteral feeding - what formula do you start with
standard (non diabetic) fiber containing formula, with moderate fat and carbs
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 -
histology of BCC
basophilic staining basal cells infiltrating the dermis
What cancer is common with Crohns?
NHL, esp due to immunosupp meds
*can be assoc with tumor lysis syndrome (w/ tx)
which pain meds can you use for someone with renal issues?
tylenol
fentanyl
hydromorphone (dilaudid) – liver metabolized
tell me about pancoast tumors
- usually NSCLC, near thoracic inlet at apex
- sx: shoulder pain, ulnar distribution weakness
What is preferred 1st line HAART regimen
tenofovir, lamivudine, efavirenz
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
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)
what is prednisone dose at which they don’t need stress dose
10mg or less, >2 wks
abx for pancreatic necrosis
carbapenems (ie erta)
fluoroquinolones
metronidazole
1st line pressor for septic shock
norepi
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)
lung abscess … hemoptysis a couple days later. what does that mean? what is tx?
abscess eroded into vessel and airway
need surgical resection
lung abscess that does not improve w/ appropriate abx tx in 7-10 days - what next?
catheter drainage - perc (peripheral) pr bronchoscopic (central)
lung abscess - what indics for surgery?
BP fistula empyema bleeding (ie - hemoptysis) concern for malignancy failure of medical therapy
reversal for dabigatran (pradaxa)
idarucizumab
muscles used for forced expiration?
abd muscles (EO, IO, rectus, transverse abdominal) internal and external intercostals (NOT "innermost intercostals")
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
describe gram and shape of clostridia
gram pos, anaerobic, rods
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
Normal HU of pancreas parenchyma
100-150
pseudomonas ..
gram neg aerobic bacilli
1st line abx of choice for infected pancr necrosis?
MC pathogens?
carbapenem
MC pathogens: e coli, pseudomonas, klebsiella, enteroccocus
MC sites of melanoma recurrence
skin, subQ, distant LN, visceral (lung, liver, brain etc)
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)
1st step in evaluating fectal incontinence 2/2 incompetent anal sphincter?
endoanal ultrasound
what causes …
direct ing hernia
indirect ing hernia
direct: weakness of conjoint tendon / transversalis
indirect: patent processus vaginalis (defect in deep ring)
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
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
RF for BK virus?
high immunosuppression
pulse steroids (to tx rejection)
ischemia reperfusion injury
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
can you do a nissen if pt has barrett’s with low grade dysplasia
yes
what is silver sulfadiazine assoc with?
transient neutropenia and thrombocytopenia
rarely - metHGBemia (watch out for G6PD)
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
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
complications following VARD?
hemorrhage - early or delayed (ie from a pseudoaneurysm)
colonic injury
RP abscess with fistulization
iatrogenic ptx
what is the strongest indicator of poor preop nutritional status?
albumin <3
absolute CI to PV embo to increase FLR
overt clinical portal HTN
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
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
List causes of portal HTN
prehepatic
hepatic
posthepatic
pre: PV thrombosis
hepatic: cirrhosis
post: budd chiari, congestive cardiac failure
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
inflamed TI, normal appendix + cecum, pt in OR for appendicitis … what do you do
appy IF cecum normal
what is chromosome for FAP
5q21
auto dom
may be de novo in 25%
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
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)
pulm findings on CT: >2cm, spiculated, growing, part of solid, invasive
NSCLC
pulm findings on CT: rapid growth, LAD, direct invasion, SVC obstruction, necrosis/hemorrhage common
small cell lung cancer
hypodense, homogenous, well defined, contained, stable
lipoma
perianal condyloma (genital warts) - tx?
gross excision of disease
no further screening
HPV vaccination (good for before or after exposure)
treatment for dumping syndrome
dietary modifications –> meds (acarbose, octreotide) –> surgery (convert to roux en y)
tx for triple neg breast CA after lumpectomy?
radiation obv
+ adjuvant chemo for tumors>0.5cm
considerations for neoadjuvant chemo, breast cancer
triple neg breast cancer
HER2+
RF for septic complics in ICU pts
male gender
prolonged ICU stay
prolonged ventilator req
increased age
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)
what is a positive apnea test
paCO2 rises to 60 (or >20 above baseline) after 10min off vent
for pts undergoing ventral hernia repair, __ is assoc w/ SSIs. using __ instead of __ for hair removal is BETTER.
preop bowel prep
clippers»_space;» razors (latter is assoc with SSI)
where is AFP high?
germ cell tumors
HCC
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
MCC pseudomyxoma peritonei
appendix
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??)
MC genetic alteration in thyroid cancer
BRAF V600E
dysphagia to both liquids and solids is suggestive of __
functional disorder (like achalasia)
What are omega 3 and 6’s
3: ALA, DHA, EPA
6: LA, AA
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
which burn meds to avoid if +sulfa allergy
mafenide acetate
silver sulfadiazine
use silver nitrate (solution) for eschars and +sulfa allergy
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
signs of bb overdose
hypotension
bradycardia
abx tx for pouchitis
flagyl or fluoroquinolone
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
hematochezia + HD instability … tx?
r/o UGI sources with NGT
if HD stable –> resuscitate and then Cscope
early HA thrombosis post transplant causes __
late HAT causes __
primary graft nonfunction + hepatic failure
late: biliary strictures, abscesses, recurring bacteremia
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
what is order of unclamping after CEA?
ECA
CC
ICA
finish patch angioplasty
1 month s/p nissen, p/w mild reflux, postprandial bloating, progressive nausea … ?
barium swallow 1st –> if normal, then vagal nerve injury
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
infant >2 wk old with persistent jaundice (conjugated hyperbili) … what do you rule out?
biliary atresia
differential: hepatitis
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
what kind of washout for benign incidental adrenaloma
> 50% at 10min
<10 HU
how to tx the following:
C krusei
C glabrata
C albicans
voriconazole
micafungin
fluconazole
what pain med to avoid for post dural puncture headache
NSAIDs (affect plt function)
tx for C diff assoc toxic megacolon
cecal dia >12 or colonic dia >6
TAC with end ileo
high mortality
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
absolute CI to PEG placement
coagulopathy massive ascites completely obstructing esophageal mass severe malnutrition (sepsis, MOF)
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
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
how long to wait before surgical repair of rectovaginal fistula
3-6 months
what does sclerosing adenosis look like histologically
central cellularity with lobules and intact myoepithelial contents
MC defect assoc with colon cancer
APC
what innervates …
thumb mostly
thumb aDduction
palmar and dorsal interossei
median nerve
ulnar nerve for thumb aDduction
ulnar nerve
recurrent reflux and wt gain after hx RYGB
gastrogastric fistula
dx: CT w/PO con or upper GI series
potential reactions to protamine?
hypotension
pulm vasoconstriction
pulm HTN
which veins need to be repaired
IVC femoral popliteal BC subclav axillary
MCC late death in …
- heart transplant
- lung transplant
- kidney transplant
heart: “chronic allograft vasculopathy” (coronary atherosclerosis)
lung: bronchiolitis obliterans
kidney: MI
how long try medical therapy for gastric ulcers, before surgical intervention?
12 weeks
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
MC fungal infection in immunosuppressed pts
MC fungal pulm infection overall
aspergillosis (invasive, allergic, aspergilloma)
overall: histoplasmosis (itraconazole)
flail chest or multiple rib fx … pt decompensates
pulm contusion!!!
what imaging to look for accessory spleen?
technetium sulfur colloid scan
what has the highest resolution rate s/p bariatric surgery?
pseudotumor cerebri
1st line pressor for septic shock?
norepi !!!
operative time > ___ minutes has been shown to increase risk of inc hernia
80
what does motilin cause
migrating myoelectric complex
ant hip disloc is assoc with __
femoral head fx
abduction + ext rotation
treatment for hep C
atezolizumab (aPD-L1) + bevacizumab (a-VEGFA)
indics for damage control surgery
base deficit > 15
ph < 7.2
temp < 34
refractory coagulopathy
tx for lower duct resectable CCA?
whipple
where make incision for SMA embolus
transverse arteriotomy PROX to origin of middle colic
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
MCC pelvic fx
MVC
imp mediator of chronic wounds
IFN gamma
what tissues are obligate glucose users
erythrocytes, neutrophils, peripheral neurons, adrenal medulla
neurogenic shock is loss of sympathetic tone to ___
vasculature (vasodilation)
Peterson defect
space bw roux limb and transverse colon mesentery
elective hernia repair not recommended for __, __, __
BMI>/=50
current smokers
HbA1c >/= 8
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
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
5 things to assess frailty
weight loss weak grip strength self reported exhaustion slow walking speed low energy expenditure
CI to lat internal sphincterotomy? Treatment?
Hypotonic sphincter (ie previous anorectal sx or obgyn trauma) Tx: fissurectomy w anocut adv flap
when would you consider botox»_space; lat internal sphincterotomy for fissure?
risk of incontinence
refused surgery
Ehlers Danlos - which defect?
collagen type 3
how to workup failure of AVF to mature?
duplex US (check for arterial inflow or venous outflow issues) then maybe fistulogram / angioplasty
max size for EV laser ablation
8mm (assoc with thrombus extension)
indic for sclerotherapy
varicose veins <8mm
reticular veins 2-4 mm
telangiectasias
what is time of chronic anal fissure
> 6 weeks
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
MOA of silver antimicrobial properties
ribosomal toxicity
intercalate into dna
denature proteins
disrupt bact cell membrane
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
__ has the highest 5 yr kidney graft survival rate
cystic kidney disease (it’s >85%)
treatment for RCC?
radical nephrectomy (w/ simultaneous intraop open IVC thrombectomy if needed)
traumatic transection (incomplete vs complete) of LAD … treatment?
incomplete: primary repair
complete: CABG
min time for DAPT for DES
6 mo
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
classic murmur of AI (aortic insufficiency)
high pitched decrescendo diastolic murmur, at 3-4th IC space at L sternal border
where do you hear aortic stenosis murmur
right upper sternal border
kid with liver mass and high AFP
hepatoblastoma
desmoid markers
+ : B-catenin, actin, vimentin,
- : cytokeratin, S-100
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
which splenic lig contains splenic artery?
splenorenal
what are the BCAA
isoleucine, leucine, valine
how to dx blind loop syndrome?
carb breath test (carbohydrate excreted earlier than 2-3 hr)
how do you dx dumping syndrome
monitored glucose challenge (incr HR or hypoglycemia)
2 absolute CI to lap chole
- uncorrected/uncontrolled coagulopathy
2. cannot tolerate insufflation
ideal CPP and ICP
CPP 60-70 (not above)
ICp <20
difference between delorme and altemeir
delorme: strip mucosa and plicate muscle layers
altemeier: perineal rectosigmoidectomy ( you resect stuff)
indications for damage control surgery
base deficit >15 temp <34 pH<7.2 refractory coagulopathy lg vol resusc > 12L
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)
tx for postthrombotic syndrome
compression
what to do for psotthrombotic syndrome and involvement of iliofemoral axis?
venogram
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
what suggests venous HTN in a fistula pt
prolonged bleeding, difficulty with dialysis
limb edema/varicosity
tx: endovascular venoplasty, venous bypass
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
primary predictor of failure of endoscopic pseudocyst drainage?
presence of moderate debris
3 factors in inflamm phase of wound healing (1-3d)
TNFa
IL1
PDGF
(also IFNs)
what is RQ
CO2 prod / O2 consumed
can you order a HIDA in a pregnant woman?
yeah
indic for catheter directed thrombolysis of DVT
low risk pts with iliofemoral DVT (reduces risk of post thrombotic syndrome)
what is normal urinary ca?
<400 mg
