Absite book Flashcards
MC anaerobe and aerobe for colon cancer
anaerobes- bacteroides
aerobes- e coli
E coli toxin
endotoxin
LPS lipid A
triggers TNF alpha release
SSI risk by surg class
Clean 2%
Clean contaminated 3-5%
Contaminated 5-10%
Gross contaminated 30%
biofilm
from staph
exopolysaccharide matrix
what if bacteroides grows from SSI?
necrosis or abscess (anaerobe)
implies translocation from gut
MC postop infection –> death, also MC organism
pneumonia
staph aureus #1 in ICU (pseudomonas #2)
Line infection organisms
1 staph epidermidis #2 staph aureus
Endo v exotoxin
E coli has endotoxin
GAS exotoxin
cperfringens toxin
alpha toxin
aspergillosis tx
voriconazole
SBP bug, protein, wbc, tx
low protein, ecoli (strep 2, kleb 3), PMN >500, ceftriaxone
beta lactams- drugs and MOA
pcn, cephalosporins, carbapenems, vanco
inhibit cell wall synthesis
30s ribosomal inhibitors
tetracyclines
aminoglycosides (-micins)
linezolid
50s ribosomal inhibitors
clindamycin
azithromycin (macrolides)
fluoroquinolone moa
inhibit DNA helicase
rifampin moa
inhibits rna polymerase
peak vs trough dosing
peak too high- decrease amount of each dose
trough too high- decrease frequency
Nutrition recs daily by type
20% protein (4cal/g) (1g/kg/day)
30% fat (9cal/g)
50% carb (4cal/g)
burns nutrition recs
25cal/kg + (30cal x %tbsa)
protein 1 + (3g x %tbsa)
albumin v prealbumin half life
18 days albumin
2 days prealbumin
Resp Quotient?
CO2 produced to O2 consumed
RQ>1 = too much feed
RQ<0.7 = ketosis and fat oxidation
Refeeding syndrome- electrolyte imbalances
decreased K, Mg, PO4
wound healing steps
inflamm 1-10d (epithelialization at 1-2mm/day)
proliferation- 5d-3wks (collagen deposition, neovascularization, granulation tissue formation, type III collagen –> type I)
remodeling- 3wk-1yr (collagen cross-linking, but no further collagen production)
wound healing cell type by day?
Day 0-2 PMN
Day 3-4 macrophages (release growth factors and shit for healing)
Day 5 + fibroblasts
open vs closed incision healing
open- epithelial integrity, dependent on granulation tissue
closed- tensile strength, dependent on collagen deposition and cross linking
when does wound reach max strength?
8 weeks (80% original strength)
aortic arch anatomy
innominate (becomes right subclav and right common carotid)
left common carotid
left subclav
aortic aneurysm repair indications
ascending: >5.5 or >0.5/yr
descending: >5.5 can do endovascular repair, >6.0 open
aortic dissection classifications
stanford:
Class A- any ascending
Class B- descending only
DeBakey:
Type I- ascending and descending
Type II- ascending only
Type III- descending only
usual causes of death (3) in aortic dissection?
aortic insufficiency –> cardiac failure
cardiac tamponade
rupture
indications for aortic dissection repair
all ascending (open repair only) descending if with visceral/extremity ischemia or if contained rupture (endograft is option)
artery of adamkiewicz
comes of anterior spinal artery ~T9
can be injured during descending thoracic aortic surgery –> paraplegia
what divides ascending and descending aortic dissections?
left subclavian
sidedness of liver abscesses
amebic, echinococcus, pyogenic usu in right lobe
amebic liver abscess pathophys
colonic infection –> liver via portal vein
amebic liver abscess workup and management
CT usu, culture will be sterile
flagyl
echinococcus workup and management
casoni skin test
CT shows ectocyst (calcified), endocyst (double walled cyst)
perform pre-op ERCP if elevated LFT/bili/cholangitis (check for biliary communication)
albendazole x2 weeks, then surgical removal
schistosomiasis tx
praziquantel for liver abscess
can cause variceal bleeding
pyogenic abscess dx and amangement
dx aspirate (usu e coli) drain and abx
FAP gene and inheritance
APC (chromo 5)
auto dom
FAP management
prophylactic colectomy at 20
endoscopy q2 yrs for duodenal polyps
lifetime rectal surveillance
Gardner v Turcot
both colon CA, APC gene
gardner- desmoid tumors/osteomas
Turcot- brain tumors
lynch syndrome gene and inheritance
auto dom
DNA MMR gene
lynch I vs II
I- colon CA only
II- also ovarian, endometrial, bladder, stomach
Amsterdam criteria for lynch syndrome
3,2,1
3 first degree relatives
2 generations
1 with cancer before 50
lynch syndrome management
surveillance colonoscopy at 25 or earlier (10yrs before first primary relative)
do total colectomy at first cancer sx
MC cancer and cancer deaths?
women breast
women lung death
men prostate
men lung death
CEA/AFP/CA19-9/CA 125
CEA- colon CA
AFP- liver CA
CA 19-9- pancreatic CA
CA 125- ovarian CA
Tumor markers: beta HCG? NSE? chromagranin A? Ret oncogene?
bHCG- testicular CA, choriocarcinoma
NSE- small cell lung CA, neuroblastoma
Chromagranin A- carcinoid
ret oncogene- thyroid medullary CA
EBV associated malignancy
nasopharyngeal CA
burkitts lymphoma
side effects: cisplatin carboplatin vincristine vinblastine
cisplatin- nephro, neuro, ototoxic
carBoplatin- Bone myelosuppression
vincristine- peripheral neuropathy
vinBlastine- Bone myelosuppression
cyclophosphamide side effects
hemorrhagic cystitis (can be helped with mesna) SIADH gonadal dysfunction
sweets syndrome
acute febrile neutropenic dermatitis
side effect of GCSF admin (used for neutrophil recovery after chemo)
Li Fraumeni syndrome- gene and cancers
p53
sarcomas, breast CA, brain, leukemia, adrenal CA
suspicious axillary node- primary? top3
lymphoma #1
breast
melanoma
krukenberg tumor
ovarian tumor (met from stomach)
bony mets- MC primaries?
breast and prostate
small bowel mets- MC primary?
melanoma
induction v neoadjuvant v adjuvant v salvage chemo?
induction- chemo only
neoadjuvant- chemo first
adjuvant- chemo later
salvage- when initial chemo doesnt work
empyema phases
exudative phase (1 wk)- chest tube and abx fibroproliferative phase (wk 2)- CT and abx, maybe VATS organized phase (wk 3)- decortication
normal aorta size (Abdom)
2-3cm
cause of AAA
degen of medial layer
AAA rupture- most likely to rupture where?
left posterolateral wall, 2-4cm below renals
when to reimplant IMA with AAA repair?
if backpressure <40
prior colonic surgery
stenosis at SMA
inadequate flow to colon
1 cause of death after AAA repair (early and late)?
early- MI
late- renal failure
complications of AAA repair
impotence (make sure at least one internal iliac has good flow)
MI, renal failure (#1 cause of death, early and late)
graft infection 1%
pseudoaneurysm 1%
atherosclerotic occlusion (MC late complication)
left colon ischemia (bloody diarrhea)
Criteria for EVAR
neck length >15mm neck diam 20-30mm common iliac length >10mm common iliac daim 8-18mm neck angle <60deg no calcs, no neck thrombus
endoleak type
type I- at attachment sites
type II- collaterals bleeding (observe)
type III- at overlap sites (if using multiple grafts or if graft tears)
type IV- porous graft wall (observe)
inflammatory AAA
not infection
10% of AAA
can get adhesions to duodenum, and ureters
thickened rim on CT
mycotic (AAA) aneurysm- bugs, tx
salmonella (#1), staph
infection of atherosclerotic plaque
bypass and resection of infected aorta
aortic graft infection bugs and tx
staph #1, e coli #2
bypass and resect infected graft
aortoenteric fistula- presentation, location, management
> 6mo after surgery (AAA repair)
hematemesis, then blood per rectum
erosion into 3rd/4th portion of duodenum
bypass, resect graft, close duodenal hole
conjoined tendon
transversalis and internal oblique
Basssini repair
conjoined tendon to inguinal
howship romberg
inner thigh pain with internal rotation
obturator hernia sign
desmoid tumor syndromw?
gardners (+colon ca)
mesenteric tumors- benign v malignant location, type of malignant common?
benign- more peripheral
malignant- closer to root
usu liposarcoma, leiomyosarcoma
RP tumors MC type?
lymphoma #1
liposarcoma #2
CO2 embolus tx
head down
turn to left
aspirate CO2 through central line
basal cell appearance and path
pearly, rolled borders
peripheral palisading nuclei, stromal reaction
basal cell treatment
0.3-0.5cm margins
xrt and chemo
squamous cell skin cancer
0.5-1.0cm margins
Mohs sx for high risk
xrt chemo
which pain med to avoid in pancreatitis?
morphine
can cause sphincter of oddi contraction
indications for cystgastrostomy in pancreatic pseudocyst
no resolution with conservative management (3mo?)
growing (maybe resect to r/o cancer)
med for pancreatic fistula or pleural effusion/ascites 2/2 pancreatitis
octreotide (decreases secretions)
dx of chronic pancreatitis
CT- shrunken pancreas, calcs
ERCP
chain of lakes on imaging
Puestow v frey procedure indicaton
puestow- pancreatic duct >8mm
frey- core out if narrow duct
MC cause of splenic vein thrombosis, and tx?
chronic pancreatitis (can cause gastric varices) tx splenectomy
dx pancreatic insufficiency
fecal fat testing
peritoneovenous shunts- indications and contraindications
refractory ascites with venous anatomy that precludes TIPS
contraindicated in liver transplant candidates
mc gallbladder ca met?
liver (IV and V)
gallbladder ca tx
no muscle involved - chole
muscle involved- wedge resectionof seg IVb and V
tumor can implant to trocar sites
improved extracolonic symptoms after proctocolectomy in UC
erythema nodosum
uveitis
arthritis
papillary thyroid cancer pathology
psammoma bodies
orphan annie nuclei
papillary thyroid cancer managemetn
<1cm- lobectomy
>1cm, bilateral lesions, hx of XRT- total thyroidectomy
need radioactive iodine if residual dz
spread of thyroid cancers
follicular- hematogenous (MC to bone)
papillary and medullary- lymphatic
follicular thyroid cancer managemetn
lobectomy (dx)
if cancer >1cm, need total thyroidectomy
radioiodine if >1cm or extrathyroidal dz
medullary thyroid cancer pathology
parafolicular c cells (secrete calcitonin)
amyloid deposition
medullary thyroid cancer- presentation
usually diarrhea (secrete calcitonin –> flushing and diarrhea
prophylactic throidectomy for men2a vs men2b
2a- at 6yo
2b- at 2yo
radioactive iodine therapy
4-6wks after thyroidectomy
for follicular and papillary only
thoraic outlet anatomy
subclavian vein between clavicle and first rib, anterior to anterior scalene
subclavian artery and brachial plexus posterior to anterior scalene
symptoms of thoracic outlet syndrome
neuro mc (usu ulnar distribution)
tinsels test
venous: effort induced thrombosis (paget von schrotter), give thrombolytics and resect rib
arterial: usu d/t anterior scalene hypertroph, ischemia, adsons test, resection or bypass
CA19-9
CA125
CA19-9 pancreatic cancer
CA125 ovarian CA
beta HCG
testicular CA and choriocarcioma
NSE tumor marker
small cell lung CA
neuroblastoma
chromagranin A
carcinoid tumor
cisplatin and carboplatin side effects
cisplatin- nephrotoxic, neurotoxic, ototoxic
carboplatin- Bone (myelo)suppresion
vincristine and vinblastine side effect
vincristine peripheral neuropathies vinblastine bone (myelo)suppression
cyclophosphamide side effect
SIADH hemorrhagic cystitis (give mesna to help alleviate)
Rb1, p53, APC, DCC
all tumor suppressors Rb1 Chr13 p53 chr 17 APC chr 5 DCC chr18
Li Fraumeni
p53 defect
sarcomas, breast CA, brain tumors, leukemia, adrenal CA
krukenburg tumor
stomach tumor or colon tumor (from ovarian mets)
Phase I, II, III, IV
Phase I: safe and at what dose
Phase II: effective?
Phase III: controlled trial
Phase IV: implement and marketing
prognostic indicators for hepatic colorectal mets
disease free interval >12mo tumor # <3 CEA <200 size <5cm negative nodes
primary mortality periop kidney transplant
MI and stroke
kidney rejection workup and management
duplex ultrasound
biopsy
decrease CSK and FK (these can be nephrotoxic)
pulse steroids
MELD score
liver transplant vs medical therapy (if >15, transplatn is better)
involves creatinine, INR, bilirubin
liver transplant for hep B, how to prevent reinfection?
HBIG and lamivudine (reduces reinfection rate by 20%)
acute vs chronic rejection of liver transplant
acute- first 1-2 months, portal triad lymphocytosis, endotheliitis, bile duct injury (t cell mediated0
chronic (rare)- disappearing bile ducts
What does KP transplant fix (and not fix)
decreases retinopathy and neuropathy
decreases autonomic dysfunction (gastroparesis)
Does NOT reverse vascular disease
1 cuase of early mortality for lung transplant
reperfursion injury (similar to ARDS)
path for heart or lung acute rejection
perivascular lymphocytosis
MCC cuase of late mortality for lung transplant
briochiolitis obliterans (chronic rjeectION) MC cause of death overall
trauma hemorrhage- BP when decomp and fluid resus
BP ok until 30% body volume loss
2L LR , then give blood
DPL positive criteria
> 10cc blood, >100,000 RBC/cc, food, bile, bacteria, >500wbc/cc
DPL misses?
RP bleeds
contained hematomas
ER thoracotomy indications
Blunt- if pressure lost in ER
penetrating- if pressure lost on the way to ED
ED thoracotomy incisions
right fourth and fitfth intercostal spaces
clamp descending thoracic aorta (if abdom injury)
open pericardium anterior to phrenic nerve in longitiudinal fashion
decreasing ICP
raise HOB sedation/paralysis relative hyperventilation (CO2 30-35) hypertonic saline (Na 140-150) mannitol
C1 and C2 named fractures and management
C1 burst (jefferson)- axial loading (rigid collar) C2 hangmans (bilateral pedicles)- traction and halo C2 odontoid- above base = stable, at base (will need fusion and halo), extension into vetebral body (will need fusion and halo)
epistaxis management
anterior packing
pstieror- may need to embolize internal maxillary artery
neck zone borders
Zones I- clavicle to cricoid cartilage
zone II- to angle of mandible
management of esophageal neck injuries
small- primary clsoure big neck- place drains big chest- spit fistula and then esophagectomy later Neck- left side upper 2/3 thoracic- right thoracotomy lower 1/3 thoracic- left thoracotomy
chest tube indications for thoracotomy
> 1500cc at insertion
250cc/hr for 3 hrs
2500cc/24 hrs
diaphragmatic injuries- repair approach
transabdominal if <1 week
thoracic if >1 week (will need to take down adhesions)
aortic injuries and appropriate incision/approaches
median sternotomy- ascending aorta, innominate, proximal right subclav, proxima left common carotid
left thoracotomy- left subclavian, descending aorta
midclavicular incision with clavicular resection- distal right subclavian
penetrating box injury
clavicles/xiphoid/nipples
need pericardial window, bronchoscopy, esophagogoscopy , barium swallow
management of paraduodenal hematomas
usu in third portion
if intraop >2cm, open
if found on CT- TPN and NGT, usu cure within 2-3 wks
management of duodenal injury
try for primary repair
if not, jejunal serosal patch
if not, pyloric exclusion or gastrojejunostomy
distal feeding J and proximal draining J
conservative management failure for liver and splenic injury?
hypotension or hct <25 after 4 units pRBC for liver, 2units pRBC for spleen
hematuria after trauma?
get CT scan and IVP if you can
extraperitoneal vs intraperitoneal bladder rupture
extraperitoneal- just leave foley in for 1-2 weeks
intraperitoneal- need repair
urethral tear management
large tear- suprpubic cystostomy and repair in 2-3 months
small tear- urethral catheter and repair in 2-3 months
kleihauer betke test
test for fetal blood in maternal circulation (placental disruption)
pressure sore stages
I- erythema only
II- partial skin loss
III full thickness (subQ fat)
IV- involves bone and muscle
types of melanoma
lentigo maligna- least aggressive
superficial spreading- MC
nodular- most aggressive
acral lentiginous- aggressive, african american, soles/palms
melanoma thickness and resection margins
<1mm = 1cm margins 1-2mm = 1-2cm margins >2mm = 2cm margins
management of anteiror neck and head melanoma
if >1mm - need to do superficial parotidectomy
soft tissue sarcoma staging based on?
grade (not sz)
recurrent laryngeal nerve innervates?
larynx (except circothyroid muscle)
superior laryngeal innervates cricothyroid
larynx inervation?
recurrent laryngeal most
cricothyroid is innervated by superior laryngeal
thyrocervical trunk branches
STAT suprascapular transverse cervical ascending cervical inferior thyroid
trapezius flap artery?
transverse cervical
most common site of oral cavity cancer?
lower lip (sun exposure)
plummer vinson syndrome
glossitis, esophageal web, spoon fingers, IDA
naspharyngeal, oropharyngeal, hypopharyngeal SCCA –> nodes?
naso and oro –> posterior cervical
hypopharyngeal –> anterior nodes
nasopharyngeal, oropharyngeal, hypopharyngeal SCCA- management?
naso- XRT only
oro and hypo- XRT if <4cm and no nodes, otherwise XRT + surgery
parotid surgery - injured nerve?
greater auricular nerve (numb to lower ear)
MC salivary gland tumor in kiddos?
hemangiomas
csf rhinorrhea indicative of?
cribriform plate fx
peritonsilar abscess vs retropharyngeal abscess vs parapharyngeal abscess?
peritonsillar in older kids >10yo
retropharyngeal <10yo, airway emergency
parapharyngeal- dental infections, morbiditiy from mediastinal spread, drain through lateral neck and leave drain
ludwigs angina- involved muscle?
mylohyoid
usu 2/2 dental ifnection
preauricular tumor- most common?
parotid
usually benign
mc benign is pelomorphic adenoma
head and neck mets to ?
lung
posterior neck mass is what?
lymphom until proven otherwise
get FNA
neck mass workup-
laryngoscopy and FNA (maybe do abx x2wk trial)
panendoscopy and neck/chest CT
excisional bx
benefits of tracheostomy
decreased secretions
easier ventilation
decreased pna risk
cleft lip v cleft palate management
cleft lip- repair at 10wks/10lb/10hgb
cleft palate- repaire at 12mo
anterior vs posterior pituitary
anterior- ACTH, TSH, GH, LH, FSH
posterior- ADH, oxytocin
med to give for pituitary tumor?
bromocriptine (dopamine agonist0)
acromegaly 2/2 pituitary adenoma- dx, management and mc complication
elevated IGF1
octreotide and resection
worry about cardiac symptoms
nelsons syndrome
after bilateral adrenalectomy increased CRH --> pituitary enlargement causes amenorrhea and bitemp hemianopia hyperpigmentation give steroids
sheehans vs waterhouse friedrichsen
sheehands- post preg, pituitary ischemia
waterhouse- adrenal gland hemorrhage post meningicoccus infection
both cause adrenal insufficiency
adrenal vasculature-
superior adrenal (inferior phrenic) middle adrenal (aorta) inferior adrenal (renal)
incidentaloma-management
urine metanephrines, urine hydroxycorticosteroids, renin/aldosterone levels
Surgery needed if >4cm, nonhomogenous or >10% functioning, <60% washout, enlarging
otherwise follow
also need bx if any cancer history
common primary that mets to adrenal?
lung CA #1
breast, melanoma, renal ca
adrenal cortex layers
GFR- salt, sugar, sex
glomerulosa- aldosterone
fasciculata- glucocorticoids
reticularis- androgens
21 vs 11 hydroxylase deficiency
21 is MC both cause congenital adrenal hyperplasia - virilization 21 is slat wasting --> hypotension 11 is salt saving --> hypertension both require cortisol for tx
RAS pathway
renin from JXA of kidneys
angiotensinogen to angiotensin I by renin (in liver)
angiotensin I to II by ACE in lung
angiotensin II causea vasoconstriction and induces aldosterone release from adrenals
primary hyperaldosteronism diagnosis
salt load suppression test (urine aldosterone will stay high)
aldosterone:renin >20
CT with thin cuts
if nothing on CT, get adrenal venous sampling
primary hyperaldosteronism treatment
adenoma- adrenalectomy
hyperplasia- medical therapy (spironolactone, CCB, potassium replacement)
Cushing syndrome- MC causes
MC pituitary adenoma #2 ectopic ACTH #3 adrenal adenoma
cushing syndrome workup
24hr cortisol urine
low dose dexamethasone test- if low ACTH then adrenal source, if ACTH high pituitary vs ectopic source
high dose dexamethasone - low ACTH pituitary source, high ACTH ectopic source
MC causes of hypocortisolism
withdrawal from exogenous
MC primary dz = autoimmune (TB wordwide)
acute addisonian crisis dx and tx
cosynotropin test (give ACTH and measure urine cortisol which will stay low) give dex (will not f up your test) (treat before test confirmation)
concerning characteristics of incidentaloma
heterogenous
>10 houdsfeld units
<60% washout
adrenocortical carcinoma
bimodal distribution age
50% functioning
open adrenalectomy
Mitotane for unresectable dz
catecholamine production
tyrosine –> dopa –> dopamine –> norepi –> epi
epinephrine is only created in adrenal medulla via PMNT (so only adrenal pheo will produce epi)
pheo rule of 10s
10% malignant 10% bilateral 10% in kiddos 10% familial 10% extraadrenal (will produce norepi, but no epi)
pheo diagnosis
initial plasma metanephrine screening
then urine test
then CT and MIBG
preop for pheo
volume replacement alpha blocker (phenoxybenzamine) then beta blocker (appropriate dosage = mildly orthostatic or dry nasal mucosa)
most common extramedullary pheo?
organ of zuckerkandle (near aortic bifurcation)
thyroid vasculature
superior thyroid a - external carotid
inferior thyroid a- thyrocervical trunk
superior/middle thyroid v - IJ
inferior thyroid- innominate v
thyroid storm tx
beta blockers
wolf chaikoff effect- high dose iodine, inhibits TSH induced release of T3 T4
workup of asymptomatic thyroid nodule
FNA
if indeterminate- get radionuclide scan
if hot nodule- PTU/iodine
if cold nodule- lobectomy
lingual thyroid vs thyroglossal cyst
lingual- in foramen cecum, dysphagia/dyspnea/dysphonia, tx with iodine, resect if this doesnt shrink thyroid
thyroglossal- moves with swallowing, resect
side effects PTU and MMA
PTU ok for pregnancy
both cause aplastic anemia and agranulocytosis
hashimotos vs bacterial thyroiditism, de quervains, reidels
hashimotos- autoimmune, lymphocytic infitrate, thyroxine
bacterial- usua after bacterial URI, abx
De quervains- hyperthyroid then hypo, after viral URI, high ESR, steroids
Reidels- woody fibrous, associated with PSC, steroids
criminal nerve of grassi
off right vagus (which comes of celiac branch)
acid secretion from stomach
parietal cells Vagus --> ach G cells --> gastrin histamine Ach/gastrin --> PKC Histamine --> cAMP --> PKA
Secretin
inhibits gastrin reelease
(from duodenum)
increases panc relase of bicarb
somato statin
aka octreotide from antrum hard stop decreases gastrin decreases insulin , glucagon decreases secretin
MMC phases
90min Phase I- rest Phase II- GB contraction Phase III- peristalsis Phase IV- decel
Medial v lateral pec n
medial both pec major and minor
lateral- pec minor only
Stewart treves
lymphangiosarcoma 2/2 chronic lymphadenima
will present as purple nodules 5-10yrs after ax dissection
Thoracic duct anatomy
right
crosses to left at T4
enters IJ/subclav
rectal vascular anatomy
superior rectal artery (from IMA)
middle rectal a (internal iliac)
inferior rectal a (internal pudendal)
rectal v colon cancer management
REctal: preop chemo/xrt if stage II/III
Colon: III, IV postop chemo
colorectal cancer staging
T1 submucosa
T2 to muscularis propria
T3 to serosa
STage I- T1/T2
STage II- T3/T4
Stage III- N+
Gardners vs turcot vs peutz jeghers
Gardners- colon + desmoid
Turcot- colon + brain
Peutz Jeghers- polyps + mucocutaneous lesions
Bowens dz=
SCCA in situ
Imiquimod (topical)
WLE if you have to
Heydes syndrome
angiodysplasia of colon
association with AS`
Zenkers where and management
Killians triangle (cricopharyngeus and pharyngeal constrictors) Myotomy
normal LES location and pressure
40cm from incisors
15-25 mmg/hg
DES management
CCB
blood supply s/p esophagectomy
right gastroepiploic
esophageal leiomyoma management
excision (do not bx first)
if >5cm or symptomatic
MC salivary gland tumors (malignant and benign)
1 mucoepidermoid ca
2 adenoid cystic ca
1 pelomorphic adenoma
2 warthins tumor
radical neck dissection involves
CN XII, SCM, IJ, submandibular gland
freys syndrome
auriculotemporal nerve injury
causes gustatory sweating
MC hepatic artery variants
R hepatic - SMA (20%)
Left- left gastric
Kupffer cells
liver macrophages
hemobilia
GIB + jaundice + RUQ pain
areriogram and embo
hepatic adenoma v hemangioma v FNH on imaging
adenoma- cold on liver scan (no kupffer cells)
FNH- central scar, hot on scan
hemangioma- peripheral to central enhancement
HCC- early arterial enhancement, early washout
Cushings triad
increased ICP
HTN
bradycardia
Kussmausl respirs
ulnar, median, radial n
ulnar- intrinsic hand, wrist flexion, sensation to back of hand and digits 4/5
median- thumb, sensation palm, palmar 1/2
radial n- wrist finger extension, sensation to dorsum 1/2
volkmans contracture
supraconydlar humerus fracture
damage anterio interosseous artery
compartment syndrome
pain with forearm extension in flexor sheat (median nerve affected)
ewings sarcoma path
onion layering and pseudorossettes
MC panc tumors
insulinoma MC overall
gastrinoma in MEN1
gastrinoma triangle
CBD/cystic a junction
neck of panc
third duodenum
glucagonoma med tx
octreotide
pulmonary sequestration- extra and intralobar
extralobar- systemic a and v
intralobar- pulmonary v, systemic a
TEF classification
A- blind pouch x2 B- proximal fistula C- distal fistula (most common) D- fistula x2 E- fistula without esophageal pouch
VATER
vertebral
anorectal
TEF
radial/renal
Cantells pentology
omphalocele, cardiac, pericardium, sternum, diaphragm
PNMT
adrenal medulla
norepi –> epi
Pheo 10% rule
bilateral pediatriac malignant MEN extraadrenal
Nelsons syndrome
post adrenelectomy
increased acth and msh
stsg phasese
imbibiation
insoculation
neovascularization
melanoma types
superficial spreading (MC)
nodular (aggressive)
lentigo maligna
acral lentigimous
gastric ulcer types
I- lesser curve II- lesser curve and duodenum III- prepyloric IV_ less curve near cardia V- NSAID
chemo for carcinoid
streptozocin
doxorubicin
5fu
PTU vs MMA
PTU- cretinism and anaplastic anemia
MMA- agranulocytossis, avoid in first trimester
papillary vs follicular v medullary cancer
papillary- MC, lymphatic spread, psammoma bodies
follicular- hematogenous spread
medullary- lymphatic spread, amyloid on path, parafollicular c cells, gastrin secretion test
laryngeal muscle inn
superior laryngeal- cricothyroid
recurrent laryngeal
osteitis fibros cystica
hyperPTH
positive DPL
>10cc blood food bile bacteria >100,00rbc >500 WBC
silvadene- sulfamylon, silver nitrate adverse effects
SSD- neutropenia
sulfamylon- acidosis
silver nitrate- hyponatremia hypochloremia
seminoma vs nonseminoma
seminoma MC, XRT! (chemo if node +)
nonseminoma- express afp and bhcg
1 nerve injury CEA
vagus
atherosclerosis phases
foam cells (fat filled MAC) fibrointimal lesion (smooth m proliferation) intimal disurpion and thrombus formation
meigs syndrome
pelvic tumor __> ascites
howship romberg
obturator hernia
innerthigh pain with internal rotation
petits and grynfelts hernia
petits inferior (iliac crest eternal oblique) grynfelts superior (12 rib, internal oblique)
coag lab for liver failure?
PT (VII is shortlest half life)
cryo used for
vwd
hemophilia A
DIC
vwd types
I- MC, quantitative, AD, ddavp
II- qualitative, AD, cryo
III- quantitative, AR, cryo
heparin antidote
protamine
aminocaproic acid
procoagulant
for DIC and thrombolytic OD
digoxin dont use with
avoid in hypokalemia (inhibits K/Na pump) will worsen hypokealmiea
metyrapone and aminoglutethimide-
inhibit cortisol synth (for adrenal hyperplasia tx)
respiratory quotient
0.7fat
0.8 protein
1.0 carb
<0.7 = ketosis and fat oxidation
copper deficiency
pancytopenia
woundhealing course
inflammation- 1-10d (PMN 1-2d, MAC 3-4d)
proliferation 5d-3wks (fibroblasts) (neovasculrariation) granulation, @3wks collagen II–> I
Remodeling (>3wks)- stable collagen amount
