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ABSITE deck Flashcards

1
Q

How do you treat chylothorax?

A

IF postop: conservative mgmt + thoracic duct ligation (usualy thorascopically)
IF lymphoma-related: conservative mgmt (NPO, TPN) + drainage + tx of underlying cause (chemotherapy)
First line therapy fails: thoracoscopic talc pleurodesis, thoracic duct ligation or pleuroperitoneal shunting

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2
Q

What is dermatofibrosarcoma?

A

Soft tissue tumor arising from fibroblasts
Spindle like cells, CD34 +
Need adequate WLE
+microscopic lateral extension of tumor cells … so there’s high rate of local recurrence

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3
Q

Primary cancer that is most likely to mets to adrenal gland?

A

Lung cancer

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4
Q

Tx for biliary atresia?

A

Kasai procedure (Roux en Y hepatic portoenterostomy) - remove extrahepatic biliary system, and connect portal system to small intestine

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5
Q

What is max size for ligasure / bipolar cautery?

A

Less than and equal to 7mm

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6
Q

What separates the anterior and posterior liver?

A

Right portal vein

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7
Q

Describe Familial Hypercalcemic Hypocalciuria

A

auto dom
Increased Ca resorption in kidney 2/2 defective PTH receptor
Normal PTH levels, mild hyperCa, low urine Ca

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8
Q

VIPoma (WDHA)

A

watery diarrhea, hypoK, achorhydria or acidosis

Usually distal pancreas

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9
Q

Describe where the following are located in the pancreas:

  • VIPoma
  • SSoma
  • insulinoma
A
  • distal pancreas
  • head of pancreas
  • evenly distributed throughout
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10
Q

Does spironolactone cause metabolic acidosis or alkalosis?

A

hyperchloremic (non AG) metabolic acidosis

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11
Q

How do you treat metabolic alkalosis caused by diuretics?

A

Metabolic alkalosis due to diuretics use can be abolished by fluid replacement using normal saline, unless the patient is fluid overloaded and the use of diuretics is ongoing. Under the latter circumstances potassium sparing diuretic can be used such as acetazolamide to offset the hypokalemic and alkalotic effects of loop diuretics.

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12
Q

How do you treat

1) chloride resistant metab alk
2) chloride sensitive metab alk

A

1) treat underlying cause

2) fluid replacement (NS)

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13
Q

What is the primary treatment strategy for anal melanoma?

A

Surgical excision.

APR confers no survival benefit vs WLE

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14
Q

Most common benign neoplasm of spleen?

A

Hemangioma

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15
Q

Largest risk factor for post-operative cardiac complications?

A

Active CHF

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16
Q

Tensile strength in a wound depends on __

A

Covalent collagen cross-linking (of lysine residues)

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17
Q

How does scurvy (vit C deficiency) affect wound healing

A

proline hydroxylation is inhibited –> unstable triple helices

gradual loss of preexisting normal collagen, which leads to fragile blood vessels and loose teeth

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18
Q

Inflammatory phase of wound healing marked by ?

A

increased vascular permeability, migration of cells into the wound by chemotaxis, secretion of cytokines and growth factors into the wound, and activation of the migrating cells

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19
Q

Most imp factor in wound healing of …
open incision?
closed incision?

A
  • epithelial integrity (granulation tissue)

- tensile strength (collagen cross linking)

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20
Q

What is the defect in osteogenesis imperfecta?

A

type I collagen

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21
Q

What is the defect in Marfan’s syndrome?

A

fibrillin

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22
Q

___ is seen in 50% of patients after congenital diaphragmatic hernia repair.

A

Chronic pulmonary disease

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23
Q

What is the Mattox maneuver?

A

Left medical visceral rotation

left colon, kidney, spleen, tail of pancreas, fundus of stomach —> all moved to midline

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24
Q

What structures can you access with the Mattox maneuver?

A

Suprarenal aorta, celiac axis, proximal superior mesenteric artery, or proximal renal artery

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25
Q

What is the Cattell-Braasch maneuver?

A

Right medical visceral rotation

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26
Q

What does the Cattell-Braasch maneuver expose?

A

Retrohepatic vena cava

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27
Q

What are the 2 types of esophageal diverticula?

A

Traction (true, mid esoph)

Pulsion (ie Zenker, distal esoph)

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28
Q

Side effects of burn meds:

  • silver sulfadiazine
  • silver nitrite
  • mafenide acetate
  • neomycin/baci/poly
  • polymyxin B
A
  • transient neutropenia
  • hypoNa; metHgb-emia
  • metab acidosis
  • nephrotoxicity
  • nephrotoxicity
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29
Q

What kind of immunosuppresive agent is infliximab?

A

TNF inhibitor

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30
Q

Describe the Strasberg classification of injuries.

A

A: bile leak from cystic duct stump
B: ligation of aberrant R hepatic duct
C: transection of aberrant R hepatic duct
D: lateral injury to major duct
E: parallels Bismuth classification of biliary strictures; complex

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31
Q

Refeeding syndrome - which 3 electrolytes are down?

A

Phos, K, Mg
K + Mg being low –> cardiac problems
Phos low –> muscle weakness, encephalopathy

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32
Q

Most common metastatic tumor to small bowel via hematogenous spread?

A

Melanoma

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33
Q

Most common indication for parotidectomy?

A

neoplasm

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34
Q

What does the leg look like in a posterior hip dislocation? What can be injured?

A

Flexed, shortened, internally rotated, adducted

Sciatic, femoral, or obturator NERVES

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35
Q 
Injuries associated with ...
Midshaft humeral fracture
Supracondylar humerus fracture 
Distal radius fracture 
Anterior shoulder dislocation
Posterior shoulder dislocation
Posterior hip dislocation
Posterior knee dislocation
Pelvic fractures
A

Midshaft humeral fx - radial nerve
Supracondylar humerus fx - Brachial artery (may lead to Volkmann’s ischemic contracture) or median nerve
Distal radius fx - Median nerve compression
Anterior shoulder disloc - axillary nerve
Posterior shoulder disloc - axillary artery
Posterior hip disloc - Sciatic nerve (peroneal division)
Posterior knee disloc - Popliteal artery
Pelvic fx - bladder, obturator artery

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36
Q

What are indications for intervention on depressed skull fx?

A
  • open wound with evidence of dural penetration
  • open wound with significant complications (intracranial hematoma
  • severe wound infection
  • frontal sinus involvement)
  • inner and outer table violation or overlap
  • skull depression greater than 1 cm
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37
Q

How does pneumocystis carinii usually present?

A
  • in lungs of healthy ppl; can cause a fatal PNA in immunocompromised
  • several weeks of dry cough, difficulty taking a breath, fever with sweats
  • exam: tachypnea, tachy, fine crackles
  • can be disseminated, esp in lymph tissue/organs
  • ppx: Bactrim
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38
Q

What are major causes of vit K deficiency?

A
  • Inadequate dietary intake (including pts not supplemented during parenteral feeding)
  • Insufficient adsorption (pts with biliary tract obstruction)
  • Loss of stroage sites as result of hepatic dysfunction

*fat emulsions during TPN allows vit K to be absorbed

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39
Q

SBP - how many orgs, which gram type?

A

Most cases of SBP can be linked to one organism on culture of ascitic fluid. If the ascitic fluid grows multiple organisms then a diagnosis other than SBP should be sought, in particular, perforated viscus must be ruled out.

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40
Q

Which types of cirrhotics deserve ppx SBP abx?

A

Those with:

  • GI hemorrhage
  • low protein ascites (<15)
  • history of SBP
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41
Q

What is a LOW vs HIGH rectovaginal fistula?

A

Low: perianal repair
High: transabdominal repair

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42
Q

What is treatment for low, simple rectovag fistula?

A

Wait 3-6 months, see if closes (also, inflammation subsides in case of need for surgical repair)
Still present, then: Endorectal flap advancement

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43
Q

What is management of high grade dysplasia in a person with barrett’s?

A

Initial mgmt: PPI + serial endoscopies
Low/mod grade dysplasia: endoscopies q3-6 months
High grade dysplasia: ablation

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44
Q

Describe treatment for achalasia

A

Heller myotomy - longitudinal myotomy to submucosa, extend 5-6cm on esophagua, 2cm onto stomach
*Also do a partial fundal wrap (not nissen)

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45
Q

Pressor of choice for septic shock?

A

1st: neo
2nd: vasopressin

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46
Q

Most common and 2nd most common non-iatrogenic causes of esophageal perforation?

A
  1. Boerhaave syndrome

2. Foreign body ingestion

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47
Q

MCC esoph perf?

A

endoscopic instrumentation

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48
Q

What is short segment disease?

A

nerve cells missing from the last segment of the lg intestine - most common type, present in 80% of ppl with Hirschsprung’s disease
- most common among breast fed infants –> present with constipation after weaning from breast feeding

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49
Q

Intestinal malrotation

A

chronic (intermittent) abd pain, intermittent epi’s of emesis, early satiety, wt loss, failure to thrive
*acute onset of bilious emesis in a particularly somnolent or lethargic newborn is an ominous sign

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50
Q

Treatment for spontaneous bacterial peritonitis?

A

3rd gen cephalosporin (Cefotaxime)

IV albumin decreases in-hospital mortality (1.5 g/kg given within 6 hours and repeated as a 1.0 g/kg dose on day 3)

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51
Q

What incision, to obtain proximal control of the inominate artery?

A

median sternotomy

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52
Q

A __ __ is used for injuries to the ascending aorta, aortic arch, innominate, right subclavian, and left common carotid arteries.

A

median sternotomy

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53
Q

Stage __, ___, and ___ classified as “low risk” undergo surgery alone as treatment.

A

I, IIA, and IIB

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54
Q

What is amrinone?

A 
phosphodisterase inhibitor (block breakdown of cAMP; increase in Ca uptake by SR in heart) --> increase contractility
vasodilator --> relaxation of vascular smooth muscle
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55
Q

What characterizes toxic megacolon?

A

Total or segmental nonobstructive colonic dilatation

+ Systemic toxicity

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56
Q

Gold standard surgical treatment for UC?

A

Restorative proctocolectomy with ileal pouch anal anastomosis (RPC - IPAA)

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57
Q

What is RPC - IPAA

A

Restorative proctocolectomy with ileal pouch anal anastomosis

rectum + colon removed, pouch made, pouch anal anastomosis

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58
Q

MC late post op complication of RPC-IPAA ?

A

Pouchitis (up to 50%)
SBO (up to 20%)
Others: anastomotic leak, fistula, stricture

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59
Q

How does pouchitis present?

A

Pouchitis is a non-specific inflammation in the pouch that presents with increased stool frequency, urgency, incontinence, abdominal pain, and bleeding.

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60
Q

How do you treat phimosis?

A

Dilation
Dorsal slit circumcision (temporizing measure)
Complete circumcision

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61
Q

MOST common benign tumor of the lung?

A

hamartoma

slow growing, solitary pulm nodule with popcorn calcifications; M>F

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62
Q

Mesenteric cysts - treatment?

A

Usually in small bowel mesentery

Enucleation (resect)&raquo_space;> unroofing (high rec rate)

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63
Q

MC forms of thoracic outlet syndrome?

A
  1. Nerve compression
  2. Paget Schroetter (venous)
  3. Arterial
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64
Q

How do you treat Paget Schroetter disease?

A

Iv heparin and thrombolysis with catheter directed thrombolysis (if <2 wks of sx)
+ definitive surgery: “thoracic outlet decompression” (remove 1st rib, cervical rib, or scalene) +/- venoplasty

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65
Q

Signs of a tracheobronchial injury?

A
  • persistent pneumothorax, despite a well-placed chest tube

- continuous air leak thru-out the entire respiratory cycle

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66
Q

Pancreatic lesions:
serous cystic
mucinous cystic
IPMN

A
  • serous cystic: usually benign
  • mucinous cystic: high risk for malignancy, resect regardless of size
  • IPMN (papillary): main duct: resect based on risk of malignancy
    branched duct: resect if >3cm, symptomatic, or assoc with radiographic (mural nodules) or cytological signs concerning for malignancy …. o/w follow w/ serial imaging
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67
Q

What’s the side effect of bleomycin?

A

Interstitial pulmonary fibrosis

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68
Q

Light’s criteria

A

1) pleural fluid–to–serum protein ratio > 0.5
2) A pleural fluid–to–serum LDH ratio > 0.6
3) A pleural fluid LDH [ ] > 2/3 upper limit of serum reference range.

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69
Q

Treatment of type II choledochal cysts

A

Excision of cyst + primary closure

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70
Q

Types of choledochal cysts

A

Type I: Most common (80-90%); involving saccular or fusiform dilatation of a portion or entire common bile duct (CBD) with normal intrahepatic duct.
Type II: Isolated diverticulum protruding from the CBD.
Type III or Choledochocele: Arise from dilatation of duodenal portion of CBD or where pancreatic duct meets.
Type IVa: Characterized by multiple dilatations of the intrahepatic and extrahepatic biliary tree.
Type IVb: Multiple dilatations involving only the extrahepatic bile ducts.
Type V or Caroli’s disease: Cystic dilatation of intra hepatic biliary ducts

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71
Q

Treatment of type I choledochal cysts

A

Primary cyst excision with Roux-en-Y hepaticojejunostomy reconstruction

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72
Q

Treatment of type III choledochal cysts

A

transduodenal approach with either marsupialization or excision of the cyst

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73
Q

Explain mechanism for malignant hyperthermia

A

auto dom abnormality with Ca regulation in skeletal muscle –> inhaled anesthetic (-flurane) / depolarizing muscle relaxants (succ, sux) –> rise in myoplasmic Ca –> abnormal release Ca –> rigidity

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74
Q

What is protein C?

A
  • vit K dependent factor (so it is inhibited by warfarin)
  • deactivates factors Va and VIIIa into its inactive forms V and VIII by proteolysis ….. basically inhibits the function of Factors V and VIII and also degrades fibrinogen
  • short half life … leading to interval prothrombic state in pts who are started on coumadin
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75
Q

Is Tc99m (used for breast SNB) safe in pregnancy?

A

yes

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76
Q

What is peterson’s defect?

A

mesenteric defect between mesenteries of transverse colon + roux/alimentary limb, at the level of the jejunojejunostomy

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77
Q

What is the alimentary limb? (aka Roux limb)

A

limb that food passes through

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78
Q

General tx of rectal cancer?
Stage 1/2
Stage 3+

A

Stage 1/2: surgery + adjuvant
Stage 3+: neoadjuvant chemorad + surgery
Stage 3 specifically: neoadj chemoRAD … surgery … adjuvant chemo only (no radiation)
*if radiation given preop, not generally given postop

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79
Q

How many lymph nodes/margins do you want for a true oncologic resection, for colon CA?

A

12 negative LN

2-5 cm margins

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80
Q

What does Mycophenolate Mofetil inhibit?

A

purine metabolism

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81
Q

What does recurrent acute thyroiditis make you think?

A

fistulous communication with the pyriform sinus (would need surgery)

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82
Q

What are 2 things assoc with the thyroid that would make you more suspicious for malignancy?

A

nodules

rapid growth

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83
Q

Absolute contraindications to liver transplant?

A

Inability to withstand the procedure (usually for cardiac/pulm reasons)
Recent ICH (during sx, coagulopathy + alterations in BP)
Untx’ed extrahepatic malignancy

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84
Q

Cell findings of acute vs chronic rejection?

A

acute (days-months): lymphocytic infiltrate, apoptosis of graft cells
chronic: atrophy, fibrosis, arteriosclerosis

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85
Q

Most common site of perf from C scope?

A

sigmoid colon

Perforations follow 3 principal mechanisms: mechanical perforation by the endoscope’s tip, barotrauma from overinsufflation, and therapeutic procedures

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86
Q

What % of phyllodes tumors are malignant, and how do they spread?

A

10%

hematogenous

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87
Q

Review the hyperSn reactions.

A

I: IgE (anaphylaxis)
II: Ab mediated - IgG, IgM (Goodpasture which is anti-GM BM ds (lung/kidneys), AHA)
III: deposition of Ab-Ag complexes
IV: cell mediated (dermatitis, PPD)

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88
Q

What is fulminant hepatic failure?

A

progression from good health to liver failure with hepatic encephalopathy within 8 weeks

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89
Q

Hx roux en Y gastric bypass … epigastric pain. Thoughts?

A

marginal ulcer

upper endoscopy

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90
Q

Where does the abdominal esophagus lymph drain?

A

cardiac + celiac nodes –> cisterna chyli (dilated collecting sac that forms the thoracic duct)

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91
Q

What kind of incision would you make for a loop colostomy reversal?

A

peristomal circumferential incision

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92
Q

What is the primary fuel of neoplastic cells?

A

glutamine

primary fuel for rapidly dividing cells

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93
Q

nodular lymphoid hyperplasia -

what is it associated with?

A

immunosuppressive states (if seen on C scope, consider HIV testing)

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94
Q

nodular lymphoid hyperplasia is not assoc w/ malignancy if found in __ but IS assoc w/ lymphoma if found in __.

A 
colon
small intestine (assoc with lymphoma)
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95
Q

Where can the splenic artery be ID’ed for quick ligation?

A

superior to pancreas

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96
Q

Where can the splenic vein be ID’ed for quick ligation?

A

within or posterior to pancreas

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97
Q

How to treat incontinence following obstetric trauma from spontaneous vag delivery?

A

wrap around sphincteroplasty (ID sphincter, mobilize approximate w/o tension)

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98
Q

What can an abscess in the ischiorectal space do?

A

track around rectum to form horseshoe abscess

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99
Q

What is tx for metastatic prostate cancer?

A

External beam radiation + hormonal therapy

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100
Q

Difference between hematoma and pseudoaneurysm?

A

Pseudoaneurysm has active arterial flow on arterial duplex

pain at puncture site, with pulsatile mass

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101
Q

How to treat pseudoaneurysm?

A

If small: ultrasound guided compression x10 min (can also do longer times if flow remains)
Other: thrombin injection into sac under US guidance
BUT if skin tense + threatened! surgical repair + decompression (concern for skin necrosis)

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102
Q

What is surgical repair of pseudoaneurysm when skin is tense and threatened?

A

prox and distal control, then direct suture repair of arteriotomy site (include arterial wall in repair) … hematoma evacuated after

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103
Q

What is the cori cycle?

A

Recycling of lactate (from skeletal muscle / RBCs) to glucose in the liver

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104
Q

Precursors of gluconeogenesis?

A

lactate, pyruvate, glycerol, and amino acids

5-7 days of starvation –> primarily alanine, not all the above -> -_-

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105
Q

For sarcomas that have close excision margins, post-operative ___ (not ___) has been shown to decrease local recurrence.

A

radiation

not chemo

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106
Q

Indications for neoadjuvant chemo in pts with sarcoma?

A

Rhabdomyosarcoma
Ewing sarcoma
High-grade tumors >10 cm in size
Tumors 5-10 cm with chemosensitive histology

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107
Q

Mainstay of soft tissue sarcoma treatment?

A

surgical resection

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108
Q

When using an ICP monitor in a brain injury patient, what is goal CPP?

A

60mmHg

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109
Q

Chronic radiation injury takes __ months, and is secondary to ___.

A

6-12 months
obliterative arteritis
(endothelial thickening leads to nonhealing ulcerations, telangiectasias)

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110
Q

What are 2 main mechanisms that radiation therapy causes damage?

A

Direct damage to DNA

Free oxygen radicals

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111
Q

What do you call B cell proliferation after immunosuppression for organ transplant?

A

Post transplant lymphoproliferative disorder

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112
Q 
TRUE OR FALSE
Actinic keratosis (or solar keratosis) is a precursor to SCC.
A

true

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113
Q

When fulgurating and excising anal condyloma, it is essential to also remove which skin layer?

A

epidermis

HPV lives and replicates in the epidermal layer

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114
Q

Most important factor indicating malignant potential and poor prognosis in GISTs?

A

high mitotic index

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115
Q

Series of events, with skin graft healing?

A

Imbibition (diffusion of nutrients)
Inosculation (donor and recipient capillary beds come into alignment with each other)
Revascularization (after ~ 5 days; when art and venous inflow can be detected)

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116
Q

MOST common genetic alteration in pancreatic CA?

A

K-ras

Activating point mutations

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117
Q

In total proctocolectomy with IPAA (J pouch under tension):
Superficial incision of the mesentery along the course of the __ and mobilization of the small bowel mesentery up to and anterior to the __ can reduce tension on the anastomosis.

A

SMA

duodenum

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118
Q

Longstanding neck mass that enlarges rapidly … is large and fixed …

A

Anaplastic thyroid cancer

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119
Q

in LAGB:

The band is placed along a space created __ to the proximal __ through the avascular portion of the __ ligament

A

posterior
stomach
gastrohepatic

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120
Q

In lap assisted gastric banding:

Is band slippage a surgical emergency?

A

yes

herniated stomach must be manually reduced and band must be re-secured

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121
Q

What is primary contraction?

A

degree to which a graft shrinks in surface area after harvesting and before grafting

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122
Q

What is secondary contraction?

A

degree to which a graft shrinks during healing

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123
Q

Upsides and downsides to STSG?

split thickness skin graft

A

Upsides: less primary contraction, better chance of survival, can be meshed
Downsides: more secondary contraction, poor pigmentation

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124
Q

Advantages of Duhamel procedure over Swenson or Soave?

A

Easier, safer
Less pelvic dissection
Large anastomosis (less risk of anastomotic stricture)

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125
Q

Swenson procedure

A

Remove entire aganglionic colon

End to end anastomosis of normal colon to low rectum

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126
Q

Soave procedure

A

Remove mucosa and submucosa of aganglionic portion, and pull ganglionic colon through aganglionic muscular cuff

  • preserve internal sphincter integrity
  • avoid injury to pelvic nerves
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127
Q

Duhamel procedure

A

Bring normal colon retro-rectal (bloodless plane)
Resect aganglionic colon up to rectum
End to side anastomosis

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128
Q

“Soap bubble” or “paintbrush sign” - pathognomonic for ?

A

villous adenoma

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129
Q

Side effect of pancuronium?

A

tachycardia

contraindic in CAD pts

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130
Q

Where do you inject contrast for intra op cholangiogram?

A

infundibulum of GB

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131
Q

Liver makes all of the coagulation factors except Factor __ ?

A

VIII (produced by endothelium)

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132
Q

Vitamin K is a cofactor for Factors __ and proteins ___?

A

factors II, VII, IX, and X

proteins C and S

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133
Q

Common reason for urinary retention after hemorrhoidectomy?

A

spasms of the pelvic floor musculature
epidural or spinal anesthesia
pain
excessive IVF

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134
Q

Efferent loop syndrome -

how is it causes + how does it present?

A

consists of gastric outlet obstruction caused by kinking of the efferent jejunal limb, often because of herniation of the limb posterior to the anastomosis
**usually w/in 1st post-op month

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135
Q

Efferent loop syndrome -

treatment??

A

conversion to a Billroth I anastomosis, conversion to a Roux-en-Y anastomosis, or performing an enteroenterostomy from the afferent limb to the efferent limb (Braun anastomosis)

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136
Q

What is GIST tumor prognosis based on?

A

size + mitotic index

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137
Q

Tumor lysis syndrome -

lyte abnormalties?

A

hyper PUK (phos, uricemia, K)
hypoCa
ARF

*aggressive IV hydration

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138
Q

MC error during truncal (complete) vagotomy?

A

Failure to ID posterior vagus nerve

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139
Q

Tx of benign/borderline/malignant phyllodes tumor?

A

WLE w/o axillary staging

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140
Q

Tx for inflammatory breast cancer?

A

neoadjuvant chemo, modified radical, radiation

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141
Q

Last line of therapy for stress gastritis?

A

total gastrectomy

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142
Q

What is order of testing for pheo?

A

plasma free metanephrines (Sn, not Sp)
If + –> 24 hr urine metanephrines
CT&raquo_space; MRI for localizing
MIBG good for localizing in setting of multifocal ds

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143
Q

Most common collagen type in body?

A

Type I

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144
Q

What is Cushing’s disease?

Treatment?

A

ACTH-secreting pit adenoma

Transsphenoidal resection of the pituitary –> reoperation or radiation for residual disease (cortisol still high)

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145
Q

3 methods for anastomosis in liver transplant

A

Bicaval – clamp supra/infrahepatic IVC
Piggyback – 1 vena caval anastomosis
Cavocavostomy (side to side caval technique)

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146
Q

Advantages of cavocavostomy (side to side caval technique) in liver transplant ?

A

shorter vena caval clamping time
minimal or no changes in recipient’s HD’s as the vena caval clamp is placed longitudinally, only occluding the anterior third of the vena cava
lower incidence of caval stenosis as cavoplasty is performed
lower risk for hepatic vein outflow complic’s due to longer anastomoses

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147
Q

Collagen evolution in wound healing?

A

Type III collagen synthesis begins within 10 hours, predominates early till day 5 … replaced by Type I at day 7 … collagen deposition peaks at week 3, which is also when collagen degradation occurs

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148
Q

Most imp types of collagen for wound healing?

A

Types I and III

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149
Q

What is messed up in osteogenesis imperfecta?

A

Type I collagen

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150
Q

Acrodermatitis enteropathica - inability to absorb __?

A

zinc

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151
Q

Which mab can you use to treat PTLD ?

A

rituximab (anti CD20)

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152
Q

Most common site of small bowel lymphoma?

A

TI

poor prognosis

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153
Q

Treatment for popliteal artery aneurysms?

A

If >2cm: bypass + ligate the aneurysm

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154
Q

What is “sniffing position” ?

A

sit upright

atlanto-occipital extension with head elevation of 3-7 cm

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155
Q

Most common presentation of extrahepatic lower duct cholangiocarcinoma ?

A

painless jaundice
[[ hard to differentiate from pancreatic CA - “hx of PSC” ]]
Axial imaging reveals dilation of the intrahepatic bile ducts, the gallbladder, and the extrahepatic bile ducts down to the level of the pancreatic head, where the dilatation terminates abruptly.

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156
Q

What is a contraindication to meperidine?

A

Significant hepatic or renal impairment

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157
Q

How do you locate the SMA?

A

cephalad movement of transverse colon

near ligament of treitz

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158
Q

Surgical tx for SMA embolus?

A

transverse arteriotomy with embolectomy via Fogarty balloon

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159
Q

What is pharmacokinetics?

A

study of what happens to drug in the body

what body does to drug

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160
Q

What is pharmacodynamics?

A

study of what the drug does to body

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161
Q

In questions that describe early post-op complications after “right upper lobectomy”, think about ___.

A

acute lobar torsion

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162
Q

Pt w difficulty breathing after starting TPN

A

Refeeding syndrome
Phos deficiency … worsened by surge of insulin where body uses carbs (instead of fat) which drives phos intracellularly
Inability to convert ADP –> ATP
Tx: Prevent! slow feeding rate + replete lytes (Mg, K, Ph)

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163
Q

At BMI __, benefit from preop weight loss before hernia repair

A

> 40

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164
Q

Tx for inflammatory breast cancer?

A
  1. Neoadjuvant chemo
  2. Modified radical mastectomy (Level 1+2 axillary LN, leave pec major)
  3. Radiation
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165
Q

Initial medical therapy for cirrhosis?

A

Negative sodium balance

Combination furosemide + spironolactone together

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166
Q

Criteria for RRT (renal replacement therapy)

A

(1) Anuria (no urine output for ≥ 6 hr)
(2) Oliguria (urine output < 200 ml/12 hr)
(3) Serum urea concentration > 28 mmol/L or BUN > 80 mg/dl Serum creatinine concentration > 3 mg/dl (265 µmol/L)
(4) Serum potassium concentration ≥ 6.5 mEq/L or rapidly rising
(5) Pulmonary edema unresponsive to diuretics
(6) Uncompensated refractory metabolic acidosis (pH < 7.1)
(7) Any uremic complication (encephalopathy, myopathy, neuropathy, or pericarditis)
(8) Temperature ≥ 40° C (104° F)
(9) Overdose with a dialyzable toxin (e.g., lithium or salicylates)

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167
Q

What level serum albumin is a risk factor for anastomotic leak after colonic surgery?

A

<3.5

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168
Q

Risk factors for anastomotic leak?

A
  • poor vascular supply
  • tension on the suture line
  • septic environment
  • location in GI tract (highest leak is found in anastomoses in the distal rectum, about 6-8 cm from the anal verge)
  • technical aspects (e.g., ensuring sutures and staplers include all layers and the entire circumference)
  • Crohn’s disease
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169
Q

Solitary rectal ulcer syndrome

A

sx: bleeding, mucus, pain, difficulty passing stool
conservative tx first
should biopsy
ant rectal wall, just above anorectal ring
result of chronic inflamm or trauma

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170
Q

How does stress cause hyperglycemia and insulin resistance?

A

(As seen in post-op and post-trauma pts)

  • hepatic glucose production
  • inhibition of insulin secretion
  • decrease in glucose uptake.
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171
Q

What are normal fibrinogen levels?

A

200-400

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172
Q

MCC bacterial hepatic abscesses?

A

Hepatobiliary malignancies and biliary tree instrumentation

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173
Q

MC pt popul for fungal hepatic abscesses?

A

pts with heme malignancies recovering from chemotherapy induced neutropenia

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174
Q

Most common type of renal stone?

A

calcium oxalate

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175
Q

Ranson’s criteria ?
On admission
After 48 hours

A 
Age >55
WBC>16
Glu >200
AST>250
LFH>350
After 48 hr:
Hct drop by 10%
BUN rise by 5
Ca<8
PaO2<60
Base deficit >4
Fluid sequestration >6 L
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176
Q

Insulinoma - tx?

A

<2cm: enucleate
>2cm: formal resection
metastatic disease: 5FU, streptozocin; ostreotide
diazoxide for sx

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177
Q

Gastrinoma - tx?

A

50% malignant, 50% multiple
75% spontaneous, 25% MEN-1

<2cm: enucleation
>2cm: formal resection
malignant disease: excise suspicious nodes
cannot find tumor: duodenostomy & look inside duodenum
duo tumor: resect w/ primary closure; may need Whipple if extensive

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178
Q

Glucagonoma - sx + location?

A

4D’s (diabetes, dermatitis, DVT, depression)

distal pancreas

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179
Q

Somatostatinoma - tx?

A

very rare
usually in head of pancreas
resect + cholecystectomy

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180
Q

Nerve most injured in OPEN vs LAP inguinal hernia repair?

A

OPEN: ilioinguinal (root of penis, medial thigh), iliohypogastric (sensory: lat gluteal + lower RA // motor: internal/TA muscle)
LAP: gf (cremaster muscle, upper scrotum), lat fem cutaneous (sensory: lat thigh)

181
Q

In what order should quadrants be explored?

A

inframesocolic including pelvis (bowel from Lig of Treitz –> rectum + pelvic organs)
Supramesocolic region (R to L: liver/GB/R kidney .. stomach/duo .. spleen/L kidney)
RP
Lesser sac (pancreatic, posterior stomach)

182
Q

Vascular trauma - ideal conduit for below knee injuries that need repair?

A

HDS: c/l greater saphenous vein
HD unstable: temp intravascular shunt + delayed repair

If no adequate vein: can use PTFE (not best for below knee)

183
Q

Left hemicolectomy - steps

A

Mobilize white line of toldt
Mobilize spleen (including pancreaticocolic and gastrocolic ligament)
Ligate & divide IMV, IMA.

184
Q

Reasons to bridge a/c …

A

significant bleeding risk for which an INR <1.5 is considered essential, and patients who have a mechanical aortic valve plus either:

  • an additional thromboembolic risk factor (afib, previous thromboembolism, hypercoagulable condition, LVEF <30%, or >1 mechanical valve)
  • an older generation mechanical aortic valve
  • or a mechanical mitral or tricuspid valve
185
Q

Default surrogate decision makers of incapacitated pts are ___ - appointed

A

physician

186
Q

Differential for liver lesions + tx!

A 
Pyogenic liver abscess (E coli, Klebsiella): drainage + abx
Amebic abscess (Mexcio; E histolytica; RLL): Flagyl ... aspiration ONLY if refractory ... surgery ONLY if free rupture
Hydatid cyst (Echinococcus; sheep/dogs; RLL): albendazole + surgical removal in 2 wks (can inject cyst to kill the suckers)
187
Q

What causes the following w/ blood transfusions:

  • fever
  • anaphylaxis
  • urticaria
  • TRALI
A
  • cytokines from donor leukocytes
  • recipient Ab to donor IgA
  • recipient Ab to donor plasma proteins
  • donor Ab to recipient WBCs
188
Q

What order do you address potential diseases in ED thoracotomy?

A

After thoracotomy, reversible causes for cardiac arrest must be addressed in the following order:

  • release of pericardial tamponade
  • control of intrathoracic or cardiac hemorrhage
  • open cardiac massage
  • occlusion of descending aorta
  • evacuation of bronchovenous air
189
Q

Proximal fistulas tend to be high in ___ and result in metabolic ___.

A

bicarbonate

metabolic acidosis

190
Q

Steps of a hepatectomy?

A
  1. Cholecystectomy, cannulate cystic duct for IOC (to detect bile leakage after resection)
  2. Ligate hepatic artery
    (left PV last structure to be divided)
191
Q

Mgmt of BCVI?

A 
Grade 1/2: antithrombotic/antiplatelet (heparin is reversible; aspirin)
Grade 3 (PSA) 
Grade 4 (complete occlusion): surgery
Grade 5 (transection + active extrav): ligate ?
192
Q

Imaging findings of hepatic hemangioma

A

nodular peripheral enhancement with centripetal fill-in

193
Q

Imaging findings of hepatic mets

A
  • hypoattenuating

- multiple and diffuse

194
Q

Imaging findings of hepatic adenoma

A
  • central changes consistent w/ hemorrhage
  • no lighting up of central scar on art phase (like in FNH) - homogeneous enhancement in arterial phase
  • related to OCPs, anabolic steroids
195
Q

Imaging findings of FNH

A
  • hypo- or isodense on non-con imaging with a central scar in one-third of patients
  • hyperdense during the arterial phase due to arterial origin of its blood supply
  • isodense during the portal venous phase
  • central scar may become hyperdense as contrast diffuses into the scar
196
Q

Imaging findings of HCC

A
  • increased vascularity compared with liver parenchyma during the arterial phase of contrast administration
  • washout of the contrast during later phases of imaging.
197
Q

Imaging findings of cholangiocarcinoma

A
  • hypodense with peripheral (rim) enhancement
  • biliary dilatation
  • contrast enhancement on delayed images
198
Q

Different bw z and t test?

A

both compare means of 2 data sets
t test: estimated parameters
z test: known population parameters

199
Q

What are the most radiosensitive tumors?

A

seminomas

sarcomas = more resistant

200
Q

MCC of pelvic fractures?

A

MVC/MCC’s
(Then falls, peds struck by vehicle)
imaging: CT

201
Q

First line tx for complicated infantile hemangioma?

A

propanolol

peri orbital, compromising airway, disfiguring, ulcerated

202
Q

What is kasabach merritt syndrome?

A

rapidly growing hemangioma + thrombocytopenia (consumptive coagulopathy)
dangerous

203
Q

Indics for adjuvant chemo with breast cancer

A

> 0.5 cm
+ LN
triple negative

204
Q

Indics for neoadjuvant therapy in breast cancer?

A

Inflammatory breast cancer (needs MRM + adjuvant CR)

Stage 3A or 3B

205
Q

Modified Hanley maneuver (horseshoe abscess tx)

A

small incision between the tip of the coccyx and the anal verge, the tissues of the external sphincter are then gently separated using a hemostat to get into the postanal space, the abscess is drained, a seton is placed around the sphincter complex, two lateral counterdrainage incisions are made with setons placed in each.

206
Q

trocar location

lap appy in 1st trimester

A

same as normal:

umbilicus, LLQ, suprapubic

207
Q

trocar location

lap chole in 1st trimester

A

umbilicus, subxiphoid, 2 at right costal margin

208
Q

trocar location

lap appy in 2nd trimester

A

umbilicus, LLQ, RLQ

209
Q

trocar location

lap appy, 3rd trimester

A

umbilicus, R mid abdomen, RLQ

210
Q

What are the milan criteria?

A

one lesion, = 5cm
3 or less lesions, = 3cm
no angioinvasion
no extrahepatic disease

211
Q

Treatment for hypermag?

A

calcium supplementation 1st

then hydration + diuresis (renal excretion)

212
Q

Tx for ER+ breast cancer in males?

For metastatic breast cancer in males?

A

Tamoxifen (not really AI’s)

Orchiectomy (second line hormonal manipulation)

213
Q

Criteria for neoadjuvant tx in gastric cancer?

A

Locally advanced (T2 +)
or
Node positive

214
Q

Best abx for resistant MRSA?

A

Linezolid (otherwise vanco for normal MRSA)

215
Q

With pleomorphic LCIS - do you need to re-excise for neg margins?

A

Yes

you don’t for classic LCIS

216
Q

Nml size of:

  • small bowel
  • transverse colon
  • cecum
A

3
6
9

217
Q

name of reversal agent for pradaxa (dabigatran)?

A

idrarucizumab

218
Q

polyomavirus (BK virus) - effect on post transplant pt?

A 
Multiple late strictures
Asymptomatic rise in Cr
US: hydronephrosis
ACUTELY: perc nephrostomy
LONGTERM: surgical intervention
219
Q

Types of hemorrhoidectomy?

A

Ferguson: excision with CLOSURE of mucosa
Milligan-Morgan: leave OPEN
Stapled hemorrhoidectomy: higher rate of recurrence and reoperation
Stapled hemorrhoidopexy: circular device

220
Q

What are side effects of increased ACh?

A

DUMBBELSS
diarrhea, urination, miosis, bradycardia, bronchospasm, excitation of skeletal muscle & CNS, lacrimation, sweating, salivation

221
Q

What hormones regulate the incretin effect?

greater insulin response to ORAL glucose&raquo_space; IV glucose

A

GLP-1

GIP

222
Q

Mucor vs Aspergillus

A

Mucor: broad hyphae, irreg branching
Aspergillus: narrow hyphae, regular branching

223
Q

immunocompromised + poorly controlled diabetes –> fever, hemoptysis

A

pulmonary mucormycosis

tx: IV amphotericin B + emergent lobectomy

224
Q

treatment for small bowel carcinoid?

A

segmental resection of small bowel + associated mesentery resection + removal of at least 7 LN

225
Q

Merkel cell carcinoma

A

small round blue cell neuroendocrine tumor
S100 -
Tx: surg excision with margins (similar to melanoma) + SLNB + radiation (it is radiosensitive)

226
Q

Algorithm for IOC with transcystic exploration for stone

A
  • attempt to flush stone
  • attempt glucagon + flush
  • gain wire access to CBD, insert balloon, choledoschoscope
  • irrigation, capture stone, extract stone
  • if stone too large, try transcholedochal
227
Q

Therapies for metastatic RCC?

A

1st line: sunitinib, panzopanib
2nd line: TK inhibitors, mTOR
3rd line: everolimus, sorafenib

228
Q

Etiology of chronic mesenteric ischemia?
Just tx if they’re symptomatic. How?
What is “hemodynamically significant” stenosis?

A
  • atherosclerosis (at mesenteric arteries’ ostia OR spilling over from abd aorta
  • need 2 of 3 mesenteric arteries
  • tx: REVASC w/ endovascular mgmt of one mesenteric artery
    > 70%
229
Q

Melanoma T staging

A

T1: <1 mm
T2: 1-2 mm
T3: 2-4 mm
T4: >4 mm

a = NO ulceration ….. b = ulceration
N: 1, 2-3, 4+

Stage T1b + –> SLNB

230
Q

most common place for accessor spleen?

A 
splenic hilum
(2nd most common site = splenic vascular pedicle)
231
Q

mgmt of ITP

A

dx of exclusion; young women; low plts, nml all else
GC, rituximab, IVIG
splenectomy –> should see postop diff by 2 wks

232
Q

what type of imaging is best for pancreatic cysts?

A

dedicated MRI + MRCP

(if can’t tolerate MRI - pancreatic protocol CT or EUS

233
Q

acute cholecystitis in child class c pt - mgmt?

A

stable: medically optimize and try to downgrade to class b for poss delayed chole
unstable: perc chole tube

234
Q

acute mesenteric ischemia - tx for stable pt?

A

CTA –> a/c –> endovascular embolectomy 1st –> ex lap with bowel resection after

235
Q

chronic pancreatitis tx

progression

A

abstinence from alc/tobacco
NSAIDs
ERCP + sphinc, +/- PD stent
surgery

236
Q

nec fasc - 2 types, tx?

A

type 1: polymicrobial (bacteroides, clostridium, e coli, klebsiella, toxin producing strep or staph)
type 2: hemolytic streoptococcal gangrene (s pyogenes
- virulence factor of M protein - with usually staph aureus co-infec)

237
Q

which steroid does not interfere with the cosyntropin test?

A

dexamethasone

hydrocortisone DOES affect the test

238
Q

How to prevent secondary brain injury in intubated trauma pts?

A

avoid hypotension + hypoxia

*single episode of hypotension (BP<90) associated with 50% increase in mortality

239
Q

Goal cerebral perfusion pressure?

A

50-70
(MAP - ICP)
MAP at least 60 … normal ICP 5-15
*can use mannitol or 3% saline

240
Q

Most important predictors of survival in first 24 hr after severe head trauma?

A
  • age
  • pupillary activity
  • best motor GCS score
  • extra-ocular motility
241
Q

Only situation in which you’d give tetanus Ig?

A

grossly dirty or large wound (>1cm) in unimmunized pt

242
Q

Evaluation for adrenel incidentaloma?

A

Majority: benign, nonfxn-ing (<10 HFU, rapid >60% washout on 15min delayed phase CT)
{aldosterone, cortisol, pheo, mets}
***first, labs: lytes (K), dex suppression test, 24 hr urine cortisol/metanephrines/VMA

myelolipoma (can be large, 10cm - well circumscribed hypodense mass) or adrenal clearly benign cyst –> don’t need to resect

IF nonfxn-ing: imaging 6,12,24 mo + annual hormonal testing x4 yr (If grows >1cm, excise)
IF fxn-ing OR >6cm: excise. Don’t need to biopsy unless suspected mets.
4-6cm: meh gray area; individualized

243
Q

Sedation agent of choice for pregnant pts in ICU?

A

propofol at low doses (at high doses, can affect fetus)

244
Q

Most common location for undescended testes?

A

superficial inguinal ring

(2nd: superficial ing pouch
3rd: ing canal)

245
Q

Controlled entry of GU, respiratory, GI or urinary tracts (uninfected) = ???
Gross spillage from GI tract / incision into acute nonpurulent inflammation encounter/major break sterile technique (ie GSW to colon) = ???
Perforated viscera/abscess = dirty

A

Clean/contaminated
Contaminated
Dirty

246
Q

What predicts postop mortality in lung surgery?

A

FEV1

DLCO

247
Q

Bethesda criteria?

A
  1. Nondx - repeat FNA
  2. Benign - f/u US 6-12 months
  3. AUS (aytpia undet signif) - repeat FNA up to 3x
  4. follicular neoplasm or suspicious for - lobectomy
  5. suspicious for malignancy - lobectomy w frozen (total if malignant)
  6. malignant - total thyroidectomy
248
Q

Name 2 radiosensitive tumors

A

seminoma

lymphoma

249
Q

Name 2 radio-resistant tumors

A

epithelial

sarcomas

250
Q

Indications for intubation in setting of smoke inhalation?

A

Mucosal ulcerations, blisters
ANY vocal cord edema

mucosal edema can progress to necrosis in 12-24 hr

251
Q

Options for parastomal hernia repair?

A

Repair + mesh

  1. Sugarbaker - ostomy exist bw mesh and peritoneum
  2. Keyhole - defect made in mesh for bowel to exit thru

Sugarbaker - fewer recurrences

252
Q

Tx for …
neurogenic DI
nephrogenic DI
SIADH

A
  • -desmopressin/ddavp
  • -amiloride (increases responsiveness to ADH at CD’s) (*also HCTZ, indomethacin per First Aid)
  • -tolvaptan, demeclocycline
253
Q

Bacteria assoc’s:

  • CLABSI
  • PNA
  • SSI
  • UTI
  • GI infec
A
  • coagulase neg staph (s epidermidis)
  • s aureus
  • s aureus
  • e coli
  • c diff
254
Q

Nodal mets for anorectal CA:

  1. sup/middle rectum
  2. lower rectum
  3. anal canal
  4. anal margin
A
  1. IMA
  2. IMA / int iliac
  3. int iliac
  4. inguinal
255
Q

3 functions of ADH?

A
  • water R at collecting ducts
  • vasoconstriction
  • release of F8 and vWF from endothelium
256
Q

Req’s for endovascular repair of AAA?

  • ext iliac dia (access?)
  • CI dia
  • CI length
  • aortic neck length (landing zone) and dia
  • angulation
A
  • min. 7mm
  • 8-22mm
  • 15-20 mm
  • length 10-15mm, dia 7-10mm
  • less than 60
257
Q 
Rates of 
-wound infection
-wound separation
-seroma/hematoma
-lymphedema
-anaphylaxis to lymphazurin dye 
in SLNB for melanoma pts.
A
  • 4.6%
  • 1.2%
  • 5.5%
  • 1%
  • <1%

overall complication rate ~10%

258
Q

What contributes to wall degen in AAA?

A

increased activity MMP

decreased elastin and smooth muscle

259
Q

When do you get a preop EKG?

A

prior cardiac hx, currently asx

260
Q

explain type I and II errors briefly

A 
type I (false +): rejecting the null hypoth when the null is true
type II (false neg): failing to reject the null hypoth when the null is false
261
Q

What helps heal donor skin graft sites?

A

skin edges

hair follicles

262
Q

Most common reason for skin graft loss?

A

seroma or hematoma formation

263
Q

Which topical burn medication tx’s MRSA?

A

mupirocin

264
Q

Common causes of death with ARDS

A

Multiorgan failure

Infections/sepsis

265
Q

Ideal tidal volume for ARDS pts

A

6mL/kg

266
Q

prognostic factors for extremity soft tissue sarcomas …

  • for local recurrence
  • for distal recurrence
A
  • local: age>50, recurrent ds, fibrosarcoma, malignan periph nerve tumor, R1 resection
  • distal: large size, deep location, high grade, recurrent ds, leiomyosarcoma, non liposarcoma histologies
267
Q

pericardial effusion in setting of trauma? tx?

A

pericardial window - remember there’s a stab wound and active bleeding you need to stop

268
Q

what finding differentiates SMA embolus vs thrombosis?

A

sparing of proximal jejunum for EMBOLI

269
Q

What are the different types of endoleaks?

A

1: prox or distal attachment site leak
2: retrograde flow from side branches
3: fabric tear or disconnection from modular overlap
4: graft wall porosity

270
Q

mgmt of rectal carcinoids?

A

<1cm: local excision or endoscopic removal
1-1.9cm: full thickness excision (if invades muscularis or +LN – need surgery + TME)
>/= 2cm: anterior proctosigmoidectomy vs APR

271
Q

Main fuel source for colonocytes?

A

short chain FA

acetate, butyrate, propionate

272
Q

Main fuel source for enterocytes (small bowel)?

A

glutamine

273
Q

MCC complication for endovascular repairs?

A

access issues

274
Q

Which types of endoleaks need attention?

A

Type 1 and 3

275
Q

Ischemic monomelic neuropathy

A
  • females, diabetics
    • “axonal damage”
  • usually ischemia to a nerve

VS steal syndrome (+loss of pulses or diminshed arterial dopplers)

276
Q

Indications for cholecystectomy with GB polyp? (3)

A
  1. Polyp > 1cm
  2. PSC and polyp > 6mm
  3. Polyp (any size/sx) assoc with stones
277
Q

Ideal diet for hepatic failure pt ?

A

Increased BCAA, decreased AAA (aromatic amino acids)

Downside to BCAA - act as false nuerotransmitters

278
Q

Which pancreatic enzymes are released in active form?

A

amylase
lipase
ribonuclease / deoxyribonuclease

279
Q

What types of surveillance are necessary for PSC?

A

C scope q1-2 yrs
Annual CA19-9 (cholangio)
MRCP q 6mo-1yr (cholangio)
RUQ US q 6mo-1yr (GB CA)

280
Q

optimal renal enteral formula

A

low lytes
high essential to nonessential aa ratio
high calorie to nitrogen ratio

281
Q

selenium deficiency side effects related to which enzyme??

A

glutathione peroxidase

282
Q

tell me about propofol

A
  • short acting lipophilic
  • global CNS depression
  • decreases ICP (and intraocular pressure) while maintaining normal CO2 autoregulation
  • rapid onset
  • antiemetic properties
  • antipruritic, anticonvulsant
  • metabolized by liver
    Dose dep respiratory depression
    Dose dep vasomotor activity (hypotension)
    NO analgesia
283
Q

What is alvimopan (entereg)?

A

Opioid mu antagonist
However cannot cross BBB
So it blocks opioid binding on bowel (prevent ileus) but does not interfere with opioid analgesic effect

284
Q

Findings of autoimmune pancreatitis on CT and ERCP?

A

CT: diffusely enlarged, hypodense, low density capsule-like rim … can have a focal mass
ERCP: segmental or diffuse irregular narrowing of main PD, usually with extrinsic appearing stricture of distal bile duct
*Need to r/o pancreatic adenoCA

285
Q

30-day mortality for

  • endovascular repair ELECTIVE
  • open repair ELECTIVE
  • ruptured - endovascular repair
  • ruptured - open repair
A
  • 1-2%
  • 4-5%
  • 25%
  • 50%
286
Q

Main APC?

A

dendritic cells

take up Ag, present via MHC II, interact with CD4 helper T cells, activate adaptive immune response

287
Q

What kind of incision do you make for a felon?

A

Vertical

Blunt dissection after skin incision to avoid NV bundle

288
Q

Most common postop complication + org?

A

UTI - E coli

289
Q

4cm glucagonoma in tail - tx?

A

distal pancreatectomy + splenectomy (big tumor, high rate of mets; malignant)

290
Q

What is a normal GB EF?

Good test to find that?

A

> /= 35%

CCK-HIDA

291
Q

best agent for mask induction in kids?

A

sevoflurane

292
Q

benefits of isoflurane?

A

good for NSG cases (no increase in ICP)

293
Q

egg allergy - what CANNOT you use?

A

propofol

294
Q

2 big cytokines in SIRS?

A

IL-1

TNF-a

295
Q

ideal diet for renal failure?

A

make sure getting essential aa (linoleic and alpha linoleic acids)

296
Q

amount of protein necessary?
carbs?
fat?

A

1-2 g /kg/day PROTEIN
CARBS: 3/4 of nonprotein calories
FAT (9kcal/g): 1/4 of nonprotein calories

297
Q

Why does TPN have worse outcomes?

A 
line infections, PNA
atrophy of villi; lose gut mucosa integrity --> translocation of bacteria --> more infections
lyte abnormalities
hyperglycemic
cholestasis, liver failure
298
Q

When start enteral feeds?

A

within 24-48 hrs of stability

if cannot tolerate –> TPN, start on day 7

299
Q

what are good things to add to tpn?

“immuno nutrition” - benefit = decreased infectious complic’s in certain pts

A

glutamine
arginine

good fatty acids = omega 3 (bad = omega 6)

300
Q

How to detect steal syndrome in UE?

A

diminished pulse exam that changes with graft compression when increased flow is directed to the hand

301
Q

Possible indications for chemotherapy in breast cancer?

A

ER/PR-, HER2 +
3+ LN
High Ki67

302
Q

What are the fluid findings in IPMN?

A

high amylase
high CEA
mucinous

303
Q

Routine screening of MEN1 known pt?

A

Hyperparathyroidism: calcium and PTH levels
Pancreatic neuroendocrine tumors: fasting gastrin, glucagon, VIP, pancreatic polypeptide, chromogranin A, and insulin levels, as well as yearly imaging
Pituitary tumors: prolactin and insulin-like growth factor 1 (IGF-1) levels as well as pituitary magnetic resonance imaging every 3 to 5 years

304
Q

Best way to image pancreas divisum

A

MRCP

305
Q

What are branches of R vagus?

A

celiac branch
criminal nerve of grassi
confirm this lol

306
Q

Most important vessel for esophagectomy conduit?

A

RIGHT gastroepiploic

307
Q

Difference between somatic and visceral pain?

A

Visceral pain: dull localization, deep aching, no positional component, and referred pain
Somatic pain: clearly localized and sharp and pinpoint-like

308
Q

In critically ill with AKI - still do __ supplementation bc benefits outweighs risk.

A

protein

309
Q

Most common area of peripheral embolic lodgment?

A

common femoral bifurcation, AI bifurc, popliteal, SFA

310
Q

How do you treat superficial vein thrombosis?
<5cm
>10cm

A

<5cm: NSAIDs, can repeat US in 1-2 wks to see if any extension
>10cm: anticoagulation

311
Q

Most common site of atherosclerosis in UE?

A

subclavian artery

312
Q

Mechanism of renovascular HTN?

A

decrease in MAP sensed by baroR at aff arteriole –> stimulate JGA (baroR) –> RAAS activation –> increase in renin causes HTN that’s hard to treat medically

tx = PTA with stent
(for FMD - only PCA, no stent)

313
Q

MC site of ectopic pregnancy

A

ampullary portion of fallopian tubes

314
Q

MC site of endometriosis

A

ovaries

tx: OCPs

315
Q

What are 4 exceptions to informed consent?

A
  1. Legal incompetence - pt lacks capacity
  2. Emergent situation
  3. Therapeutic privilege - disclosure would cause immediate harm or undermine pt’s capacity for decision making or informed consent
  4. Waiver - pt actively/explicitly waives right to IC
316
Q

Pathophysiology of cocaine induced mesenteric ischemia?

A

Inhibition of NE uptake at presynaptic terminals, more NE at postsynaptic terminal –> tachy, HTN, vasoconstriction

317
Q

What would be suggestive of mesenteric VEIN thrombosis?

A
  • hx portal HTN, hypercoag state, hx vasculitis
  • short segments of bowel involved, bloody diarrhea, crampy abd pain
  • usually SMV, portal vein

tx: heparin, resect dead bowel if present

318
Q

What would be suggestive of mesenteric ischemia due to arterial THROMBOSIS?

A

old person with PVD
more insidious onset, “food fear”

tx: thrombectomy (open v catheter directed), maybe PTA with stent or open bypass after vessel is opened for residual stenosis … resect dead bowel

319
Q

why is severe hypoCa life threatening?

A

Causes dysfxn of transmembrane depol

320
Q

HyperPh causing hypoCa is most commonly seen in __, __, and __

A

Renal failure
Rhabdo
Tumor lysis syndrome

321
Q

Which acute phase reactants are
increased
decreased

A

CRP, amyloid A, fg (incr)

albumin, prealbumin, transferrin (decr)

322
Q

Principles of shock in pediatric pts

A
  • Bradycardia may be sign of impending CV collapse
  • HR is 1st sign (but that may take 25% blood loss before being evident)
  • SV is relatively fixed
  • Total circulating blood vol is 80mL/kg
  • Hypotension = late finding. <70 + (2 x age in yrs)
323
Q

How to tx malignant hyperthermia?

A
  1. Stop triggering agent (change anesthesia circuit)
  2. Dantrolene!
  3. Supportive care towards tx-ing hyperthermia, acidosis, organ dysfunction (hyperventilation to remove excess CO2, bicarb)
324
Q

Indications for breast abscess I&D

A

Large
Skin necrosis
Loculations

325
Q

Risk of stroke within 48 hr, after a TIA?

A

4-10%

326
Q

What are absolute contraindications to thrombolytic use?

A
  • active internal bleeding
  • recent CVA/NSG (<3 mo)
  • intracranial pathology
  • recent GIB
327
Q

Define TIA

A

neurologic deficit due to ischemia without acute infarction

328
Q

What are the most radioSn cell cycles?

A

G2

M

329
Q

What impacts the effect of radiation?

A

Radiation has LESS impact on: hypoxic cells and cells that are not dividing that freq
Protons: damage at end of path
Electrons: damage at surface of tissue contact (good for superficial tumor beds/skin cancer)

330
Q

Most common venous drainage and arterial supply of intralobar sequestrations?

A

inferior pulmonary vein

systemic arterial supply

331
Q

Intralobar sequestrations are commonly found ___.

A

Within medial or posterior segments of lower lobes
2/3 on left side
*usually no bronchial communication
*usually tx’ed with lobectomy/segmentectomy > wedge

332
Q

Indications for sclerotherapy of varicose veins?

What agents can be used?

A

varicose veins <8mm
reticular veins 2-4mm
telangiectasias 0.1-2mm

STS
hypertonic saline (+/- dextrose)
glycerin
etc

333
Q

Contraindications for sclerotherapy for vv?

ie - where surgery is a better option

A

GSV is largely dilated (>15mmm), torturous
Previous thrombophlebitis

with endovascular laser ablation, if vein>8mm, increased risk of thrombus extension towards femoral vein

334
Q

Why is vein stripping rare below the knee?

A

Greater risk of saphenous vein injury

335
Q

CEAP classification of chronic venous disease

Just the C part

A 
C0: No visible/palpable signs
C1: telangiectasias or reticular veins
C2: varicose veins
C3: edema
C4: pigmentation and/or eczema
C5: lipodermatosclerosis and/or atrophy
C6: healed venous ulcer
C7: open venous ulcer
336
Q

2 most common causes of chronic venous obstruction?

A

valvular incompetence
chronic venous obstruction (stenosis or occlusion)

GSV reflux = velocity >500

337
Q

What is a bypass procedure for severe symptomatic isolated obstruction of femoral vein?

A

May Husni procedure

338
Q

What is a bypass procedure for unilateral iliac common fem vein obstruction?

A

Palma procedure

339
Q

1st line tx for varicose veins

A 
RFA
EVLA (endovenous laser ablation)

of the GSV (more medial) or small saphenous vein (more lateral)

340
Q

What to do with endovenous heat induced thrombosis?

A
  • does not pass saphenofem jxn: nothing
  • <50% occlusion of femoral vein lumen: weekly surveillance until gone
  • > 50% occlusion of femoral vein lumen: a/c till gone
  • occlusive DVT: treat as a DVT
  • best way to prevent: ablate >2.5cm away from saphenofemoral or saphenopopliteal jxn
341
Q

Where do kidney cancers originate?

A
  1. parenchyma

2. renal pelvis

342
Q

Most common primary chest wall malignant tumor

A

chondrosarcoma (80% arise from ribs)

TX: WLE

343
Q

triad of glomus tumor

A

pain, point tenderness, cold intolerance

Hildreth sign: relief of pain with tourniquet

344
Q

What are the required FLR for
healthy
liver ds (fibrosis, post hepatic affecting chemo)
cirrhosis

A

20%
30%
40%

345
Q

Brown Sequard

A

ipsilateral motor/proprioception

c/l pain/temp

346
Q

RF for invasive fungal infec’s?

A 
Solid organ transplantation
Prolonged ICU stay
LOS
Prolonged abx use
TPN
GI perf
Hemodialysis
347
Q

What to do with portal vein thrombus?

A

Treat aggressively - systemic a/c
Risks?
- intestinal infarction due to loss of fwd flow
- if chronic: portal HTN + cirrhosis

348
Q

Most commonly ID’ed gene mutation in hirshsprung?

A

RET – high proportion of long segment HD or total colonic agangliosis assoc with MEN 2a

349
Q

What are the general esophageal manometry findings in scleroderma?

A

Low amplitude, simultaneous contractions

Normal or low pressure LES

350
Q

What is the pathophysio of HRS?

A

renal vasoconstriction in setting of systemic and splanchnic vasodilation

351
Q

Options for open CBD exploration, to get rid of stones?

A
  1. Transduo sphincteroplasty
  2. If dilated biliary tree (CBD>2cm) + multiple stones –> biliary enteric drainage (via side-to-side or end-to-side anastomosis of CBD with duodenum)
352
Q

What cancers are assoc with VHL?

A

pheo!!!

clear cell RCC, brain + retinal hemangioblastomas, PNETs

353
Q

Budd Chiari system mgmt?

A
  • lifelong a/c
  • can balloon angioplasty short segment stenosis
  • thrombolytic therapy if present w/in 3-4 wks

*90% pts die in 3 yrs w/o treatment

354
Q

MC indication for esophageal replacement in kids?

A

long gap esophageal atresia

355
Q

What is infliximab?

A

IgG mab, TNF-a

356
Q

Name steps of wound healing

A
  1. Inflammatory - clot formation
  2. Proliferation - granul tissue, epithelialization
  3. Remodeling - collagen remodeling, scar formation
357
Q

Tests with the most radiation?

A
  1. nuclear medicine - cardiac stress test (40)
  2. PET/CT (25)
  3. CT whole body
  4. CTA, aorta w/ runoff (16)
  5. CT colonoscopy
  6. CT Abd
358
Q

Causes of peroneal nerve injury? (3)

A
  1. incorrect leg placement in lithotomy
  2. crossing legs
  3. fibula head fx

*movement/sensation to lower leg/foot/toes

359
Q

Differential for acute lower GIB

A 
Anatomic (diverticulosis)
Vascular (angiodysplasia, ischemic, radiation-induced)
Inflamm (infectious, IBD)
Neoplastic
Iatrogenic (polypectomy)
360
Q

When is the Delorme procedure appropriate?

A
  • mucosal rectal prolapse
  • short segment full thickness rectal prolapse
  • It’s perineal. Good for old ppl.
  • Abd approach (rectopexy) is for healthy ppl.
361
Q

Surveillance after colon cancer?

A

Clinical exam + Biochemical markers (CEA): q3-6 mo x2 yr, then q6 mo for total 5 yr
Cscope - 1 yr postop … (unless none preop, then at 3-6mo postop)
–adv adenoma? repeat in 1 yr
–no adv adenoma? 3 yrs, then q5 yr
Imaging: CT annual x3-5 yr

362
Q

Parastomal hernias

A
  • Most occur within first 2 years, only 20% progress to req repair
  • Stoma relocation has best outcome but is not always req. Fascial repair has worst outcome.
  • Lg bowel stoma herniate&raquo_space;> sm bowel stomas
  • Absolute indics for repair: obstruction, strangulation
363
Q

Let’s talk about lithium -_-

A

-Metab by kidneys, so any decrease in GFR can cause toxicity. Bypass surgery also incr lithium [ ].
-Sx of toxicity: incr Ca Mg R at loop of Henle –> hyperCa, Mg, hypocalciuria. Also hyperPTH.
-

364
Q

Lithium toxicity vs primary hyperPTH

A

primary hyperPTH – decr phosphate and high PTH

lithium tox – phosphate nml, high/nml PTH

365
Q

Ureters cross __ the iliac vessels

A

over

366
Q

Right renal artery crosses __ to IVC

Left renal vein crosses __ to aorta

A

posterior

anterior

367
Q

Testicular torsion … after detorsion, unclear whether testes is viable, with poor blood flow in US …. what to do?

A

<10 yrs old: leave in situ + c/l orchiopexy

>10 yrs old: orchiectomy + c/l pexy

368
Q

Lymphangitis

MC org in person of normal immunity?

A

strep pyogenes

369
Q

Injury to right ventricle should be repaired with …

A

pledget’ed nonabsorbable sutures

370
Q

MC gastric lymphoma?

A
  1. DLBCL
  2. MALToma

*non Hodgkin

371
Q

How to treat thrombolytic (tPA etc) overdose?

A

Cryo first

Aminocaproic acid if cryo unavailable

372
Q

MC side effect of protamine?

A

hypotension

373
Q

Predominant bacteria in colon?

Predominante AEROBE in colon?

A

bacteria - Bacteroides fragilis

aerobe - E coli

374
Q

Desired vein size for AV fistula

A
  1. 5mm (really, 3mm) - no stenosis or thrombosis

artery: >/= 2mm

375
Q

Placing a subclavian line, end tidal CO2 suddenly drops off, cardiac arrest

A

air embolism

376
Q

TX for:
Primary C diff episode
Second recurrence
Multiple episodes

A
  • PO vanco or fidaxomycin
  • pulsed tapered vanco regimen OR fidaxomycin if vanco used initially
  • Fecal transplant
377
Q

How to suture posterior stomach and pseudocyst together?

A

running (OR closely spaced (<1cm) interrupted) absorbable suture with full thickness bites

378
Q

What are signs/sx of fulminant C diff?

A

hypotension
fever
WBC>15
Cr>1.5

Appropriate tx: PO vanco, IV flagyl (AND vanco rectal enema if +ileus)

379
Q

How does radiation exert its damage?

Which cells are most sensitive?

A
  • direct damage to DNA + oxygen free radicals

- rapidly dividing crypt cells (villi of mucosa)

380
Q

Adenoid cystic carcinoma of salivary gland

A

Slow insidious onset, with affinity for growth along perineural planes, and late presentation of distant mets (lung MC). More mets risk than mucoepidermoid.

381
Q

What’s included in the Gail model

A
  • Age (model works for age 35-85)
  • First menstrual period
  • First live birth
  • # FDR with breast cancer
  • Previous breast bx and hx of bx with atypical hyperplasia
  • Race/ethnicity
382
Q

Best way to remove testicular cancer

A

Via INGUINAL approach (NOT scrotal)

383
Q

What gets exception points for the MELD?

A
  • pts listed at MELD 15 (bili, Cr, INR, Na)
  • HCC
  • hepatopulm syndrome
  • portopulmonary HTN
  • CF
  • hilar cholangiocarcinoma
  • primary hyperoxaluria
384
Q

What needs a neg pressure room?

A 
COVID!
Severe acute respiratory syndrome
TB
Varicella
Measles
Chickenpox
385
Q

MC predisposing factor AND pathogen for acute paronychia

A

minor skin breakdown

Staph aureus

386
Q

What kind of skin graft is used to cover joints & face?

A

full thickness

387
Q

How do you treat hypermagnesemia?

A

Ca gluc or Ca chloride

definitive: hydration + diuresis … maybe dialysis if renal fxn is impaired

388
Q

Absolute contraindications to PEG placement?

A 
Poorly controlled / massive ascites
Inability to oppose stomach and abd wall
Uncorrectable coagulopathy
Peritonitis
No endoscopic access
Expected survival < 4 weeks
Severe malnutrition
Systemic sepsis
389
Q

MC abdominal pain after gastric bypass?

A

Cholelithiasis
Internal hernia
Marginal ulcer

390
Q

Histologic findings of GIST

A

bland spindle cells with elongated nuclei

391
Q

Fecal incontinence due to sphincter dysfunction after vaginal delivery - treatment?

A

Overlapping sphincteroplasty

392
Q

Which is more predisposed to parastomal hernia - end or loop ileostomy?

A

loop, because the trephine incision has to be larger to accommodate both loops

393
Q

Preferred AV fistula types

A

RC (aka Cimino) > RB > BC > BB > prosthetic (brachioaxillary)

394
Q

Tx of choice for complicated Type B aortic dissections?

A

Thoracic endovascular repair

395
Q

Tx for invasive aspergillosis?

happens mostly in neutropenic pts or GC use

A

voriconazole

396
Q

Potency of steroids?

A

hydrocortisone < prednisone < methylprednisolone < dexamethasone

397
Q

hepatic encephalopathy in absence of significant hepatic dysfunction (MELD<15) … what do you suspect?

A

portosystemic shunt (abnormal vein allowing for bypassing liver)

398
Q

MC ectopic tissue in Meckel?

A

gastric

399
Q

What arteries are ligated in an extended R hemi?

A

(TI until prox descending colon)

MRI colic + left colic

400
Q

What arteries are ligated in a normal R hemi?

A

ileocolic, right colic, right/hepatic branch of middle colic

401
Q 
Severe idiopathic chronic constipation can be:
1. 
2.
3.
4.
5.
A 
Normal colonic transit time
Slow transit constipation (radioopaque marker study ... >5 markers by day 6 = abnormal)
Dyssynergic defecation
Megacolon
Megarectum
402
Q

How to treat the following conditions:
C. krusei
C. glabrata
C. albicans

A

voriconazole
micafungin
fluconazole

403
Q

Why paradoxic aciduria?

A

dehydration –> sodium preferentially R –> K, H excreted –> paradoxic aciduria + hypokalemia

404
Q

Basic steps of a resuscitative thoracotomy

A
  1. Access the thoracic cavity
  2. Pericardiotomy
  3. THEN - if
    - - beating heart: digital (literally w/ a digit) control of injury w/o worsening the injury
    - -nonbeating heart w/ an injury or if cannot control hemorrhage with a digit: try tomanage cardiac injury
  4. Cardiac massage +/- internal defibrillation for vfib only (if crossclamp aorta, can perfuse myocardium ad brain selectively)
405
Q

Had a traumatic splenectomy … 2 days later, febrile, tachy, peritonitic … thoughts?

A

gastric perf (short gastric removal –> stomach wall necrosis)

406
Q

Cardinal signs of Kanavel

classic signs of tenosynovitis

A

Exquisite tenderness along flexor sheath
Semi flexed finger
Exquisite pain on extension
Fusiform swelling of entire finger

407
Q

Treatment of tenosynovitis

A
  1. Abx: vanco for GP, cipro for GN (incl pseudomonas)

2. +/- I&D (via 2 incisions)

408
Q

What effect does immunomodulating preop nutritional supplements have postop?

A

Decreased infectious complications

Decreased LOS

409
Q

What vessels are taken with Whipple?

A 
R gastroepiploic vein
GDA
R gastric artery
Inf/sup pd artery
Short mesenteric vessels
410
Q

How do you calculate plasma osmolarity?

A

(2*Na) + (glu/18) + (BUN/2.8)

normal = 280-295

411
Q

Which abscesses should undergo drainage in the OR?

A

large abscesses
recurrent abscesses
intersphincteric +supralevator abscesses
b/l abscesses

412
Q

What is considered borderline resectable pancreatic cancer?

A

Encasement of >180 deg PV
<180 of PV + contour irregularity
<180 of SMA

413
Q

What brain things are associated with ALF?

A

Brain edema

Intracranial HTN

414
Q

Talk to me about desmoids

A

Requires a biopsy (bundles of spindle cells, fibrous stroma)
+ beta-catenin, actin, vimentin
- cytokeratin, S100
TX: WLE but radiation also acceptable if extreme circumstance

415
Q

Shortened and externally rotated leg

A

Neck of femur fx / femoral neck fx

416
Q

Patient with HIT and liver failure … best anticoagulant?

A

BIVALIRUDIN (partially metb by liver and excreted by liver/kidney)

vs argatrobran (liver metab + excretion)

417
Q

Mallory Weiss tear … what infusion should be started immediately?

A

IV PPI

418
Q

How to treat intersphincteric abscess?

A

OR
Drain internally, divide mucosa and internal sphincter along length of abscess cavity
(External drainage may result in fistula)

419
Q

Which pt population should receive abx with anal absceses?

A

Immunocompromised

Mechanical heart valves

420
Q

preferred pressor for cardiogenic shock?

A

dobutamine

421
Q

At what level does carboxyHb produce confusion?
Cause brain death?
What is normal level in healthy vs smoker?

A

5% - nonsmoker normal —– 10% smoker normal
20% - confusion
60% - brain death

422
Q

Asbestos exposure (ie shipyard) + peritoneal carcinomatosis … diagnosis?

A

Malignant peritoneal mesothelioma

423
Q

Changes during pregnancy?

A

DOWN: BP (due to decreased SVR), relative anemia
UP: total body volume, HR, renal blood flow, moderate leukocytosis

424
Q

What is conservative mgmt of slow transit constipation?

A

laxatives

high fiber diet

425
Q

What surgery for a person with slow transit constipation who has failed conservative mgmt?

A

TAC with ileorectal anastomosis

426
Q

How to diagnose slow transit constipation?

A

Nuclear medicine transit study

Radio-opaque marker study

427
Q

Acute chest syndrome - definition/criteria

treatment

A

pulmonary sequestration of sickled RBCs in sickle cell pt

  • new CXR finding
  • chest pain
  • fever > 38.5
  • resp sx
  • hypoxemia

TX: O2 >94%, IS, chest PT, empiric abx, judicious fluids (risk of pulm edema), non-opioid analgesics

428
Q

Time to normalization of these 3 variables can help stratify pts and guide further IVF use

A

Initial base deficit
pH
lactate

429
Q

Which is the most effective smoking cessation aid?

A

Chantix (varenicicline)&raquo_space;> nicotine replacement

430
Q

partial vs full thickness “nuclear pleomorphism” of a skin lesion - which diagnoses?

A

PARTIAL nuclear pleomorphism = actinic keratosis (cryotherapy or 5FU)
FULL thickness = SCC in situ
Invasion thru BM = SCC

431
Q

MC lymphoma in AIDS popul?

A

Aggressive high grade B cell lymphoma

432
Q

What are 2 targets therapies for CRC cancer?

A

cetuximab
panitumumab

*ensure KRAS wild-type present (NOT mutation)

433
Q

How does flagyl work?

A

oxygen radicals which break up DNA helical structure

434
Q

Ascites is due to ___ pressure.

A

high intravascular (from portal HTN)

435
Q

What is the best route for esophageal substitution in esophageal replacement?

A

Posterior mediastinum

436
Q

Perform a ___ before cardiac massage to improve perfusion to brain and heart.

A

thoracic aorta cross clamp

437
Q

MC short-term and long-term complications after inguinal LN dissection?

A

wound infection

lymphedema

438
Q

Most common contributor to Mondor disease?

A

idiopathic

439
Q

How to treat a nasal septal hematoma?

A

Early detection and I&D

necrosis of septal cartilage

440
Q

Most common site for supranumery parathyroid gland?

A

thymus

441
Q

In kids <12 yrs old who need an airway (ETT failed), do not attempt cricothyrotomy, instead do ___.

A

jet ventilation (needle cricothyrotomy)

442
Q

Radionuclide scanning: ___

Mesenteric angiography: ___

A
  1. 1 - 0.4 mL/min

0. 5-1 mL/min

443
Q

Mechanism which increases risk of hyperK with succinylcholine

A

upregulation of acetylcholine nicotinic R

444
Q

Postop parotitis is most commonly caused by ___ (which bug?)

A

Staph aureus

445
Q

Radioactive iodine ___ Graves ophthalmopathy

A

worsens

446
Q

In which patient popul will digoxin side effects be more apparent?

A

Hypokalemic

Compete at the Na/K pump

447
Q

Repair for PROXIMAL destructive CBD injury?

DISTAL CBD?

A

proximal: roux en y HJ
distal: roux en y choledochoJ

448
Q

What does a PPI inhibit?

A

H+/K+ pump of parietal cell

449
Q

What can you give someone with antithrombin III deficiency when you want to tx them with heparin?

A

FFP

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