BANK MIX 2014 Flashcards
splenic artery aneurysm treatment
open ligation or transcatheter embolization for:
symptomatic aneurysms,
greater than or equal to 2 cm in size,
women of childbearing years.
Conservative management is indicated for patients over 60 years of age who are asymptomatic and have aneurysms of less than 15 mm in diameter.
Surgery may be recommended for pancreatic mass when
greater than 3 cm,
there is mucin present in the patient’s aspirate,
cyst fluid CEA greater than 200,
and/or there is a presence of abdominal pain.
High-risk factors which would indicate the need for further preoperative cardiac evaluation?
High-risk factors: decompensated CHF, recent MI, high-grade AV block, severe valvular heart disease significant arrhythmia, such as VF or AF with RVR.
Intermediate risk factors:
IDDM,
end-stage renal disease,
old MI, or stable angina
consideration for further testing based on the patient’s exercise tolerance and the surgical risk.
Stage 3A lung cancer could involve
ipsilateral mediastinal lymph nodes.
Contralateral mediastinal lymph node involvement in lung cancer is what stage
would be stage 3B
Indications for liver transplant in patients with cholestatic liver disorders.
(1) Liver transplantation is the only effective treatment for liver failure secondary to primary biliary cirrhosis.
(2) Liver transplantation may occasionally be indicated for uncontrolled pruritus.
(3) Liver transplantation is the only effective treatment for decompensated cirrhosis secondary to primary sclerosing cholangitis.
(4) Patients with primary sclerosing cholangitis and cholangiocarcinoma should be excluded from transplantation unless they are enrolled in a clinical trial of experimental therapy. (5) Because of the high incidence of colon cancer, colonoscopies should be performed both before and after transplantation in patients with inflammatory bowel disease. (6) Liver transplantation is indicated in children with biliary atresia if portoenterostomy is unsuccessful or if intractable portal hypertension or liver failure develops despite successful portoenterostomy. (7) Liver transplantation should be considered for its ability to prolong survival and improve quality of life in syndromic and nonsyndromic forms of intrahepatic cholestasis in children. (8) Children with Alagille syndrome should have preoperative assessment for congenital heart disease. (9) In evaluating patients with cystic fibrosis for liver transplantation, assessment of lung disease should be performed.
In the treatment of T1 and T2 oropharyngeal squamous carcinoma associated with significant metastatic neck disease, which one of the following interventions is most effective?
Conservation surgery is “defined as a surgical procedure which removes all underlying tumor and which aims to affect the same cure as radical surgery but with preservation of both structure and function.
It is usually combined with either radiotherapy or chemoradiation.” It is indicated for respectable primary tumors, has minimal functional deficit, and is devoid of any negative effect on the patient’s quality of life in the immediate aftermath of surgery and up to 4 years thereafter.
Conservation surgery combined with postoperative radiotherapy is indicated for stage III and IV disease
surgical weight loss surgery first choice for adolecences
Roux-en-Y gastric bypass
surgical weight loss surgery not approved for adolecences
The adjustable gastric band (AGB) has not been approved by the FDA for use in adolescents - considered investigational
Sleeve gastrectomy should be considered investigational; existing data are not sufficient to recommend widespread and general use in adolescents
NO Biliopancreatic diversion - substantial risks of protein malnutrition, bone loss, and micronutrient deficiencies. These nutritional risks are of particular concern during pregnancy. I
The TRAM flap
avoids implants
uses the skin of the lower abdominal wall to create a breast elevation with vascular supply through the rectus abdominis muscle from its axial blood supplies, the deep inferior epigastric, and the superior epigastric vessels.
It utilizes the deep inferior epigastric vessels for the flap and the internal mammary vessels or the thoracodorsal vessels nourishing the area as well.
There is no longer any risk of necrosis of the skin or fat.
The best approach to access the proximal left main stem is via
RIGHT right sided thoracotomy.
The arch of the aorta descends over the top of the proximal left mainstem bronchus, making it difficult to access
The distal left main stem is best approached
through a LEFT throacotomy
Primary hyperaldosteronism is usually due to
either a small (0.5 to 2 cm) benign unilateral cortical tumor,
or
bilateral cortical adrenal hyperplasia.
Approximately 50% of the cases are due to unilateral adrenal tumors (range 33% to 67%).
Primary hyperaldosteronism Patients characteristically present with
hypertension, hypokalemia, and weakness,
but it is now recognized that many patients are normokalemic on presentation.
A patient presents with agitation, thirst, lethargy, decreased blood pressure, and hyperthermia. Which one of the following conditions is most likely
HYPERnatriemia
HYPERnatriemia ssx
An increased extracellular sodium concentration may result from loss of water, inadequate water intake, excessive sodium intake, or ADH insufficiency. Patients with diabetes insipidus produce large volumes of urine due to a deficiency in ADH. Deficiency of vasopressin is known as central diabetes insipidus. Impairment of the tubular function of the kidney results in nephrogenic diabetes insipidus. Hypotension may be the result of hypovolemia. The most common signs are lethargy, mental status change, and thirst.
Diabetes, dermatitis, deep venous thrombosis, and depression are symptoms of
glucagonoma
characterized by mild diabetes, gallstones, and diarrhea with or without steatorrhea
somatostatinoma
watery diarrhea, hypokalemia, and hypochlorhydria, characteristic of Verner-Morrison syndrome occurs with what tumor
VIPoma
Which one of the following is the most common operative technique in the surgical repair of indirect inguinal hernias in children?
High ligation and excision of the patent sac with anatomic closure
Caroli’s disease is characterized by
hepatic fibrosis with multiple dilations of the intrahepatic biliary tree.
associated with malignancy.
anesthetic with minimal effects on hemodynamics,
Nitrous oxide
all other agents result in hypotension due to cardiac depression or a decrease in systemic vascular resistance.
pt with INR of 5 for afib what is best preop reversal - give time frames
Vitamin K administered IV INR will fall to 1.5 to 2.0 in 24 hours
Oral vitamin K is a good option if the surgery is over 24 hours away.
fresh frozen plasma within 12 hours
intervention for mesenteric ischemia from portal vein thrombosis
anticoagulation
Digoxin should be considered for the outpatient treatment of all patients who have
persistent symptoms of heart failure (class II-IV) due to systolic dysfunction despite conventional pharmacologic therapy
Digoxin cannot be administered to patients who have
significant sinus or atrioventricular block unless it has been treated with a permanent pacemaker, nor is it a primary therapy for the stabilization of patients with acutely decompensated heart failure. A low dose of 0.125 mg daily is recommended for patients over 70 years of age, those with impaired renal function, or those with a low lean body mass. In the absence of a direct correlation between serum digoxin concentration and the drug’s therapeutic effects, serial assessment of serum digoxin levels is not required in most patients.
most frequent surgical procedure for pyloric-prepyloric ulcers
Selective vagotomy with antrectomy or pyloroplasty (in order to prevent an unopposed absence of vagal tone)
most frequent surgical procedure for bleeding juxtapyloric ulcer that is refractory to endoscopic techniques.
Truncal vagotomy with pyloroplasty and stitching of the bleeding ulcer =| three stich
most frequent surgical procedure for for duodenal ulcer
Proximal gastric vagotomy
most appropriate for patients presenting with a long fibrous stenosis of the postpyloric region after several courses of short-term medical treatment for duodenal ulcer.
Truncal vagotomy with a gastroenterostomy,
Dragstedt’s classical operation is
volatile agents effects on respiration
increased respiratory rate
decreased tidal volume.
increase the apneic threshold for CO2.
bronchodilating properties
attenuate the bronchial reactivity to airway manipulation.
attenuate hypoxic pulmonary vasoconstriction.
volatile anesthetics physiologic effects
increase blood flow to the brain, muscle and skin,
increase respiratory rate, decrease tidal volume and have bronchodilatory properties.
decrease blood flow to the kidney, liver and intestines
decrease the urine output and GFR.
While placing a suture in the diaphragmatic crus during a Fundoplication, bright red blood is noted to be emitting from the mediastinum, below the crus. what is the blood vessel that has been hit
the aorta
elevated arm stress test (EAST)
EAST asks the patient to hold their arms up with 90 degree shoulder abduction and external rotation (“surrender position”) for 3 minutes. Patients with neurogenic TOS develop symptoms of pain and paresthesias within 60 seconds.
Venous TOS presentation and treatment
arm edema due to subclavian vein stenosis or thrombosis.
Initial management of venous TOS consists of thrombolysis or anti-coagulation followed by 1st rib resection.
Arterial TOS presentation and treatment
arm fatigue with exertion
or
evidence of digital ischemia or emboli.
Arterial TOS has the strongest association with an anomalous cervical rib.
There is no acceptable non-interventional therapy for arterial TOS.
Treatment may involve thrombectomy, embolectomy, subclavian artery aneurysm resection, and anomalous cervical rib resection.
direct thrombin inhibitors
argatroban, bivalirudin, or lepirudin i
respiratory alkalosis defined as is
a pH greater than 7.45 with a PaCO2 less than 35 mm Hg.
is.
percentage of neck masses malignant in adults
(80%) malignant!
Most of these malignancies are metastatic head and neck squamous cell carcinoma (HNSCC) from the nasopharynx, oropharynx, or hypopharynx.
malignant lymph nodes, neuromas or neurofibromas, carotid body tumors, brachial cleft cysts, lipomas, sebaceous cysts, parathyroid cysts, or soft tissue tumors.
the optimal treatment for pediatric Graves’ disease
thyroidectomy!?
Whereas most adult patients undergo a trial of antithyroid drug therapy, there is a high failure rate with this treatment and alternative therapies become important. Although the remission rates are similar for high-dose RAI and surgery with virtually all patients requiring thyroid hormone supplementation, the small but increased risk of death, nonthyroid neoplasms, hyperparathyroidism, and potential increase in thyroid malignancy make surgery a more appealing option than high-dose RAI, especially in children.
cell of origin of papillary Thyroid cancer
The follicular cell
also is the cell of origin of follicular, and Hürthle cell cancer,
produce thyroglobulin as a tumor marker.
The Hürthle cell is an inflamed follicular cell. The chief and oxyphil cells are found in parathyroid tissue.
cell origin Medullary thyroid cancer
parafollicular or C cells.
CEA and calcitonin are both tumor markers for medullary thyroid cancer.
T staging of oropharyngeal cancer
T1 = tumors less than or equal to 2 cm T2 = tumors greater than 2 cm and less than 4 cm T3 = tumors greater than 4 cm T4 = tumors with local tissue invasion.
how do diagnose the difference between cystosarcoma phyllodes and phyllodes tumor from fibroadenoma
core needle biopsy
Cystosarcoma phyllodes
also called phyllodes tumour
very rare but locally aggressive fibroepithelial tumour in its malignant form, and accounts for 0.3 to 1% of all breast neoplasias.
A core needle biopsy with results favoring fibroadenoma should allow the breast physician to treat the lesion as a fibroadenoma, with observation and close follow-up or with enucleation.
Core needle histologic examination of phyllodes tumor allows the physician to preoperatively plan the definitive management at one surgical procedure, reducing the need for reoperations.
Open excisional breast biopsy for smaller lesions or incisional biopsy for large lesions is the definitive approach in diagnosing cystosarcoma phyllodes, whereas mammography and ultrasonography are unreliable in differentiating benign cystosarcoma phyllodes (CSP) from the malignant form of the condition or from fibroadenomas.
Also, no specific hematologic tumor markers or other blood tests are available and fine-needle aspiration for cytologic examination usually is inadequate.
In high-risk cancer patients undergoing surgery, VTE prophylaxis regimens include
pneumatic compression ± gradient elastic stockings
plus— unfractionated heparin 5,000 2 hours preoperatively,
then unfractionated heparin 5000 units every 8 hours
For extended prophylaxis:
enoxaparin 40 mg or dalteparin 5,000 IU daily, (in selected high-risk patients):
A patient with a RUL 5cm NSCLC with chest wall invasion and positive mediastinal lymph nodes. Treatment includes which one of the following treatment options
Neoadjuvant chemoradiotherapy
followed by right upper lobectomy with chest wall resection
what cancer occurs most frequently in the duodenum and is also the most common small-bowel cancer
Adenocarcinoma is the most common small-bowel cancer (33%)
followed by carcinoid tumors (29%),
GI lymphomas (19%),
GI sarcomas (19%).
Adenocarcinomas were located most frequently in the duodenum
most common locations of adenocarcinoma and small bowel
duodenum jejunum and ileum,
most common location of carcinoid tumors in the small bowel
predominantly in the ileum
most common location of Sarcomas and the small bowel
jejunum
most common location of lymphomas and the small bowel
occurred almost equally in the jejunum and ileum. the
Chloride-responsive metabolic alkalosis would his urine versus blood chloride level and what is extracellular fluid volume status; example of cause
involves urine chloride levels of less than 10 mEq/L and is characterized by decreased ECF volume and low serum chloride levels,
as occurs with vomiting.
Chloride-resistant metabolic alkalosis
(e.g., primary aldosteronism)
involves urine chloride levels of more than 20 mEq/L a
increased ECF volume.
how is elevated anion gap metabolic acidosis created
inorganic acid (e.g., phosphate or sulfate),
organic acid(e.g., ketoacids or lactate)
exogenous acid(e.g., salicylate) acids
incompletely neutralized by bicarbonate
a normal anion gap metabolic acidosis results from
an excessive loss of bicarbonate from the gastrointestinal tract or kidneys
or
when hydrogen ions cannot be secreted because of renal failure.
Normal portal pressure is
hepato- venous pressure gradient 5 to 8 mmHg,
clinically significant portal hypertension is defined as
hepato-venous pressure gradient HVPG of at least 10 mmHg, and diagnosis is conformed at a level greater than 12 mmHg.
Portal hypertension sinusoidal
(e.g., cirrhosis),
portal hypertension pre-sinusoidal
(e.g., portal vein thrombosis),
portal hypertension post-sinusoidal
(e.g., hepatic venoocclusive disease; drugs).
The duct of Wirsung
is the main pancreatic duct.
It drains the entire pancreas from tail to head,
it lies mid-gland more posterior than anterior,
it joins the common bile duct and terminates at the ampulla of Vater.
The duct of Santorini
is the minor pancreatic duct.
It drains the anterosuperior portion of the pancreatic head
it may empty into the duct of Wirsung
or
terminate in the duodenum via the minor papilla.
Which one of the following lipid-lowering therapies requires monitoring of serum creatinine kinase (CK) in patients complaining of muscle pain, or who are at high risk of developing myopathy or rhabdomyolysis
cholesterol absorption inhibitors and statins
can cause erroneous reading of the dual-wavelength pulse oximeter. a
methemoglobin
injection of dyes such as indocyanine green and methylene blue,
certain colors of nail polish
Fetal hemoglobin has the similar absorption spectrum, as adult hemoglobin and will not affect significantly the readings.
Bilirubin does not affect the accuracy of the dual-wavelength pulse oximeter.
stage I lung cancer defined by tumor finding on CT scan the lung.
T1a (tumor is 2 cm or less)
or
T1b (tumor is greater than 2cm and 3cm or less).
Diaphragmatic pacing indicated for what patient’s
high cervical spine lesions
central alveolar hypoventilation.
limited success with intractable hiccups and COPD
in the United States The peak age of HCC is
greater than 65 in the United States
United States, HCC rates are highest in which ethnicity
Asians, followed by African Americans and whites.
Males are two to fourfold more likely to develop HCC
Liver transplantation Living donor transplantation may be offered for HCC if the waiting time is
long enough to allow tumor progression leading to exclusion from the waiting list.
The major causes of hypercalcemia include
primary hyperparathyroidism,
vitamin D intoxication,
diseases associated with high bone turnover and solid tumor metastases, otherwise known as the humoral hypercalcemia of malignancy.
Signs and symptoms of hypercalcemia develop when calcium levels reach what and may include
15 mg/100m mL
mental status changes, vomiting, PROXIMAL muscle weakness, renal dysfunction, cardiac conduction problem
A 24-year-old woman with asthma requires postoperative intravenous analgesia. Which one of the following medications should be avoided
Morphine and Meperidine has significant histamine release which can contribute to asthma exacerbation and should be avoided in asthma patients.
Epiphrenic diverticula
present with Dysphagia and regurgitation
result of distal esophageal dysmotility - result of a hypertensive distal esophageal muscle
Usually a right thoracotomy is used with exclusion of the diverticulum and a distal myotomy across the lower esophageal sphincter onto the stomach.
indications for Whipple with trauma
Pancreaticoduodenectomy is indicated for
massive, uncontrollable retropancreatic hemorrhage arising from vascular injuries to the:
portal vein to
superior mesenteric artery
superior mesenteric vein
obvious irreversible injury to the head of the pancreas involving the:
main pancreatic duct
intrapancreatic portion of distal common bile duct
portions of the duodenum
list order most frequent occurrence of anal cancer types
80% are squamous cell cancers, 16% are adenocarcinomas,
4% other .
The most common symptoms of anal cancer presentation
anal bleeding (45%) mass sensation (30%)
Anal cancer has been associated with
human papillomavirus infection, history of receptive anal intercourse, HIV infection, history of sexually transmitted diseases, history of cervical cancer, and use of immunosuppressive medication after solid organ transplantation.
Standardized techniques for intra-abdominal pressure measurement
transduction at the midaxillary line at the iliac crest
installation 25 cc or less
Long-term bile obstruction is thought to lead to liver cirrhosis, which can be associated with which one of the following disorders
autoimmune disorders such as celiac disease, hypothyroidism, Raynaud’s phenomenon, and/or Sicca syndrome (dry eyes or mouth).
and
Primary biliary cirrhosis
treatment relative effectiveness for meconium ileus
SURGERY-Regardless of the surgical technique, there is an improved survival for MI with surgery.
Bishop-Koop ileostomy is effective and time-tested.
toIn appropriate clinical cases, primary resection and anastomosis may have a lower surgical morbidity. the
treatment of transmediastinal lung lesions: right lobe adenocarcinoma left upper lobe bronchoalveolar carcinoma
treated as synchronous primaries and should be individually treated as such.
A bronchoalveolar carcinoma is treated with either a wedge resection or a lobectomy.
In this instance, it is a small lesion and is amenable to wedge resection.
adenocarcinoma-is an invasive lung cancer is treated with lobectomy.
most common tumor types can originate from the nasopharynx
Nasopharyngeal carcinoma is the most common
Nasopharyngeal carcinoma is strongly correlated to
ethnicity (Asian), Epstein-Barré virus infection, and dietary habits.
Symptoms vary depending on exact location but may include ear, nasal, and throat symptoms as well as cranial nerve palsies.
usual treatment of nasopharyngeal carcinoma
Radiation and chemotherapy is the usual treatment
preferred treatment for symptomatic patients with duodenal cancer
Whipple procedure
best test to evaluate diaphragm function
The sniff test
fluoroscopic exam where the patient is asked to “sniff” while the motion of the diaphragm is observed.
It is the best test to demonstrate functional abnormalities of the diaphragm.
Anterior mediastinal tumors
four T’s: thymoma, teratoma, thyroid cancer, terrible lymphoma.
Posterior or paravertebral mediastinal tumors are likely to be of what tissue source given example
neurogenic, such as neurofibroma.
The differential diagnosis of esophageal varices/hemorrhage includes
anything that Leads to portal hypertension:
schistosomiasis, severe congestive heart failure, hemochromatosis, Wilson's disease, autoimmune hepatitis, portal/splenic vein thrombosis, sarcoidosis, Budd-Chiari syndrome, chronic pancreatitis, hepatitis B, hepatitis C, alcoholic cirrhosis, primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC).
the workup for head and neck masses.
Panendoscopy
directed biopsies
mucosal site sampling under general anesthesia should include the nasal cavity, nasopharynx, oropharynx, hypopharynx, and larynx. Bronchoscopy, esophagoscopy, and ipsilateral tonsillectomy to
the course of a replaced left hepatic artery
The replaced left hepatic artery originates off the left gastric artery and courses to the right through the lesser sac, through the fissure for the ligamentum venosum, and into the umbilical fissure to perfuse the left hepatic lobe
management of chylous ascites and being treated with chemotherapy for small bowel lymphoma
Treatment includes treatment of the lymphoma with chemotherapy, a low fat medium chain triglyceride diet and diuresis
Chylous ascites presents in patients with lymphoma and retroperitoneal lymph node involvement.
use of succinylcholine in renal failure
In renal failure, succinylcholine is not contraindicated if the potassium level is normal, since it does not cause excessive release of potassium
cisatracurium metabolism
metabolized via Hoffman elimination and ester hydrolysis and is the best muscle relaxant to use with patient in renal failure
contraindications a halothane
halothane causes hepatitis
avoided in liver failure;
cranial pressure and is a good choice for induction
contraindication of vecuronium
vecuronium undergoes in part metabolism and excretion in the liver and may have prolonged action.
age is most commonly responsible trigger malignant hyperthermia
Succinylcholine and halogenated anesthetic agents can trigger malignant hyperthermia and should not be used;
alternative agent to use for malignant hyperthermia
nitrous oxide and intravenous anesthetic agents can be used safely.
best agency used for asthma intubation
Ketamine is a bronchodilator and is a good anesthetic choice in asthma; hydromorphone and fentanyl.
NO morphine causes histamine release
contraindications for ketamine
head injury
Ketamine increases the cerebral blood flow and intracranial pressure and should be avoided in the setting of intracranial hypertension
best agent for head injury induction
propofol decreases the cerebral metabolic rate, blood flow and intracranial pressure and is a good choice for induction.
The major causes of hypokalemia
excessive renal loss,
gastrointestinal losses due to vomiting and diarrhea.
When potassium levels are in the range of 2 to 2.5 mEq/L symptoms are likely to include
muscular weakness, ST changes, T wave depression, and U wave elevation on EKG
the superior pubic ligament shares the same tissue plane and is derived from the same tissue origin as the
transversus aponeurosis and the transversalis fascia,
McVay and Anson use what structure for reconstructing the posterior wall of an inguinal hernia.
the superior pubic ligament
It is used in large and difficult hernia repairs, including incisional hernias.
In Halsted operation
the external oblique aponeurosis is closed under the spermatic cord,
involves a 4-layer repair of the canal’s posterior wall.
The Bassini repair
apposition of the inguinal ligament to the:
transversus abdominis,
transversalis fascia,
lateral rectus sheath
In Modified Bassini, the posterior wall is not opened while the sutures placed between the transversus arch and the inguinal ligament creates tension on the tissues involved.
The Shouldice repair
imbricated posterior wall closure with continuous monofilament suture;
it warrants close patient follow-up
This alloimmune response is predominantly driven by what cell and reduction of organ transplant
T cell recognition of foreign major histocompatibility complexes (MHC).
the reason for T-cell inhibiting drugs
This alloimmune response is predominantly driven by
symptoms of hyponatremia
headache, nausea, vomiting, muscle cramps, lethargy, restlessness, disorientation, and depressed reflexes. In serious cases, seizures, coma, permanent brain damage, respiratory arrest, brain stem herniation, and death occur.
Atracurium can cause
histamine release in higher dose and after rapid administration and can contribute to hypotension on induction; cisatracurium in clinical doses does not have such an effect.
A 55-year-old male undergoes a screening EGD for GERD. He is found to have Barrett’s Esophagus without dysplasia. His next EGD should be done at which one of the following time frames
Barrett’s esophagus should be followed up with EGD every 6 months until 2 EGD’s demonstrate no dysplasia. At that point screening can go to every year.
present as a swelling or tract anterior to the sternocleidomastoid muscle
95% of branchial cleft abnormalities originate from the second arch.
surgical excision is the treatment.
Thyroglossal duct cysts present
in childhood as a midline mass.
Internal hernia leading to bowel obstruction most common site and cause after lap roux en y
jejunojejunal anastomosis, at the passage in the transverse mesocolon allowing the retrocolic Roux limb, and behind the Roux limb (Petersen hernia)
but decreased when the Roux limb is in an antecolic position.
