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Absite Black Book > Black Book > Flashcards

Black Book Flashcards

1
Q

what is the purpose of cholesterol in the cell membrane?

A

to increase membrane fluidity

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2
Q

what makes cell negative inside?

A

Na/K ATPase, 3Na out for every 2K in

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3
Q

what is the most common intracellular cation?

A

K

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4
Q

what are desmosomes?

A

cell-cell anchor

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5
Q

what are hemidesmosomes?

A

cell-extracellular matrix anchor

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6
Q

what is the most variable part of the cell cycle?

A

G1

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7
Q

what is the largest site of gluconeogenesis?

A

liver

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8
Q

what activates protein kinase C?

A

calcium

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9
Q

what are the initial responses to vascular injury?

A

vasoconstriction by TXA, platelet adhesion, thrombin generation (forms platelet plug)

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10
Q

what is the mechanism of thrombin?

A

converts fibrinogen to fibrin, activates factor 5 & 8, activates platelets

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11
Q

which coagulation factor has the shortest half life?

A

7

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12
Q

which factor is not synthesized in the liver?

A

8

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13
Q

which factors are synthesized in the endothelium?

A

8 and wvf

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14
Q

which factors are vitamin k dependent?

A

2, 7, 9, 10, c, s

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15
Q

how to reverse INR?

A

FFP is immediate and lasts 6 hours, IV vit K takes 6 hours to take effect

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16
Q

what is the mechanism of AT-III?

A

binds and inhibits thrombin, factor 9, 10, 11

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17
Q

what is the mechanism of heparin?

A

binds AT-III to increase its activity 1000x

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18
Q

what is the mechanism of protein C?

A

degrades factor 5 and 8, and fibrinogen

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19
Q

what is the mechanism of TPA?

A

converts plasminogen to plasmin

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20
Q

what is the mechanism of plasmin?

A

degrades factor 5 and 8 and converts fibrinogen to fibrin

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21
Q

which coagulation factors are in extrinsic pathway?

A

2, 5, 7, 10, fibrinogen

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22
Q

which coagulation factors are in intrinsic pathway?

A

8, 9, 11, fibrinogen

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23
Q

which ACT is desirable for routine anticoagulation?

A

150-200

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24
Q

which ACT is desirable for cardiac bypass?

A

> 460

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25
Q

what is the most common congenital hypercoagulable disorder?

A

factor 5 leiden mutation (resistance to activated protein C)

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26
Q

what is the most common acquired hypercoagulable disorder?

A

smoking

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27
Q

what is the key element in development of arterial thromboembolism?

A

endothelial injury

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28
Q

what is virchow’s triad?

A

stasis, endothelial injury, hyercoagulation

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29
Q

which blood product is used if needing AT-III?

A

FFP

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30
Q

why is DVT more common in left leg?

A

iliac artery compresses vein

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31
Q

what anticoagulant should you use if someone has HITT?

A

argatroban

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32
Q

how do you diagnose HITT?

A

platelet drop below 100 or 50% decrease from baseline, ELISA for PF4 ab (if only mildly positive, perform serotonin release assay)

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33
Q

what is the most common congenital bleeding disorder?

A

von willebrand’s disease

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34
Q

what is the most common symptom of von willebrand’s disease?

A

epistaxis

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35
Q

what is the blood test for von willebrands?

A

prolonged bleeding time, aka ristocetin test (PT and PTT are normal)

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36
Q

what is the treatement for von willebrand’s disease?

A

DDAVP (except type 3), or factor VIII-wvf complex, or cryoprecipitate

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37
Q

what are the 3 types of von willebrand disease?

A

1: not enough vwf 2: vwf doesnt work well 3: no vwf

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38
Q

what is hemophelia A and what is dx/tx?

A

factor 8 deficiency; dx by prolonged PTT and normal PT. tx is recombinant factor 8 (other options are DDAVP or cryo). want levels at 100% preop and 50% postop for 3-5 days

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39
Q

what is hemophelia b and what is dx/tx?

A

factor 9 deficiency; dx by prolonged PTT and normal PT; tx is recombinant factor 9 or FFP

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40
Q

what are the rules for plavix after stents?

A

bare metal = 6 weeks, drug eluding = 1 year

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41
Q

what is the antidote for dabigatran?

A

idarucizumab (praxbind)

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42
Q

what is the tx for thrombolitic overdose?

A

aminocaproic acid

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43
Q

what are the contraindications to TPA?

A

absolute: active internal bleeding, recent CVA <2mo ago, crainal pathology; relative: surgery/biopsy within 10 days, ob delivery, major trauma, left heart thrombus, recent GI bleed <90 days ago, uncontrolled HTN; minor: minor surgery, recent CPR, bacterial endocarditis, hemostatic problems such as renal/liver disease, diabetic hemorrhage, retinopathy, pregnancy

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44
Q

what is the half life of heparin?

A

60-90 minutes

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45
Q

what are the side effects of long term heparin?

A

osteoporosis, alopecia

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46
Q

what is the dose of protamine to reverse heparin?

A

1.5mg/100U of heparin

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47
Q

what is the mechanism of warfarin?

A

vitamin K dependent decarboxylation of glutamic residues

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48
Q

how do SCDs work?

A

improve venous return but also induce fibrinolysis with compression by releasing endogenous TPA

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49
Q

how does DDAVP work?

A

stimulates factor 8 and vwf release from endothelium?

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50
Q

how long to hold aspirin?

A

7 days

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51
Q

how long to hold plavix?

A

5-7 days

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52
Q

how long to hold warfarin?

A

7 days

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53
Q

what level do you want platelets at before surgery?

A

50,000

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54
Q

why does calcium decrease with PRBC transfusion?

A

PRBC stored in citrate and citrate binds Ca

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55
Q

when should you transfuse platelets?

A

<10k, <20k with infection or bleeding risk, or <50k if active bleeding or pre-procedure

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56
Q

what should you consider if platelets dont increase after transfusion?

A

allo-immunization, try HBO matched platelets. if still not working, check for HLA antibodies

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57
Q

what is in cryoprecipitate?

A

vwf, factor VIII, fibrinogen, and favor XIII

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58
Q

when to give cryoprecipitate?

A

fibrinogen <100 or bleeding in VWD

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59
Q

what is the most common transfusion reaction? details?

A

febrile non-hemolytic transfusion reaction; fever/rigors after transfusion from preformed recipient abs against donor wbcs. stop transfusion and give tylenol.

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60
Q

what is the most common symptom of blood product allergic reaction?

A

rash; rarely anaphylaxis can occur. MCC is IgA deficiency.

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61
Q

what is the cause of delayed hemolytic transfusion reaction?

A

preformed recipient abs against donor minor RBC antigens (HLA)

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62
Q

what causes TRALI?

A

donor Abs bind recipient WBCs and lodge in lung

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63
Q

what causes acute hemolytic transfusion reaction? s/sx/tx?

A

ABO incompatibility; preformed recipient Abs against donor RBCs. fever, hypotension, tachy, hematuria, renal failure, shock DIC, bleeding. tx with stop transfusion, fluids, diuretics, bicarb, pressors

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64
Q

what is the most common cause of death from a blood transfusion?

A

ABO incompatibility from clerical error.

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65
Q

what is the most common blood product with bacterial contamination, and why?

A

platelets, because they are not refrigerated. MC bug is gram negative rods, usually e. coli

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66
Q

which blood products do NOT have risk of HIV/hepatitis?

A

albumin and immunoglobulins, because they are heat treated

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67
Q

what is the first cell type to arrive in wound healing process?

A

Platelets

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68
Q

what is the dominant/most essential cell type in inflammation/wound healing?

A

macrophages

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69
Q

what are the steps of wound healing?

A

1) inflammation 2) proliferation 3) remodeling

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70
Q

what are the predominant cell type in wound healing from 0-2 days?

A

PMNs

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71
Q

what are the predominant cell type in wound healing from 3-4 days?

A

macrophages

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72
Q

what are the predominant cell type in wound healing from 5+ days?

A

fibroblasts

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73
Q

what is the key growth factor in wound healing?

A

PDGF

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74
Q

where are most cytokines produced?

A

macrophages

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75
Q

why does atelectasis cause fever?

A

alveolar macrophages release IL-1

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76
Q

which interleukin DOWNregulates inflammatory response?

A

IL-10

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77
Q

what is the main cell type in type 1 hypersensitivity reaction?

A

1 is mast cells (as well as basophils)

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78
Q

which cell type responds to intracellular infection?

A

natural killer cells

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79
Q

how long does the inflammation phase of wound healing last?

A

1-10 days

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80
Q

how long does the proliferation phase of wound healing last?

A

5 days to 3 weeks

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81
Q

when does collagen deposition peak in wound healing?

A

3 weeks

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82
Q

how long does maturation/remodeling phase of wound healing last?

A

3 weeks to 1 year

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83
Q

what happens to collagen during wound maturation?

A

type 3 is replaced with type 1

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84
Q

what/when is the most strength a wound ever gets?

A

80%, hits this at 8-12 weeks

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85
Q

how quickly do peripheral nerves regenerate?

A

1mm/day

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86
Q

order of cell arrival in wound?

A

platelet, PMNs, macrophages, fibroblasts, lymphocytes

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87
Q

what is the #1 source for migration of epithelial cells for wound edges?

A

hair follicles

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88
Q

what is the most common collagen type in the body?

A

type 1

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89
Q

what is the most common collagen in cartilage?

A

type 2

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90
Q

what is the collagen of granulation tissue?

A

type 3

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91
Q

what is the primary collagen type in a healing wound?

A

type 1

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92
Q

what is optimal transcutaneous oxygen measurement for wound healing?

A

> 25mmhg

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93
Q

what defines a wound infection?

A

> 10^5/cm^2 bacteria

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94
Q

what vitamin can counteract the effects of steroids on wound healing?

A

Vit A

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95
Q

what is the largest risk factor for wound dehisence?

A

deep wound infection

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96
Q

what determines leak vs fistula?

A

leak if less than 7 days, fistula if 7 or more

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97
Q

what is the major cytokine produced from th1 cells?

A

INF-gamma

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98
Q

what is the main target cell of th1 cells?

A

macrophages

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99
Q

what is the major cytokine produced by th2 cells?

A

IL-4

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100
Q

what is the main target cell of th2 cells?

A

B cells

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101
Q

what type of immune response comes from th1 cells?

A

cell mediated

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102
Q

what type of immune response comes from th2 cells?

A

antibody mediated

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103
Q

what is the most common ab in the spleen?

A

IgM

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104
Q

what is the largest antibody?

A

IgM

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105
Q

what is the primary antibody against A and B antigens on RBCs?

A

IgM

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106
Q

what is the most common antibody overall?

A

IgG

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107
Q

what antibody is responsible for secondary immune response?

A

IgG

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108
Q

which antibody crosses the placenta?

A

IgG

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109
Q

which antibody plays a role in mucosal immunity?

A

IgA

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110
Q

which antibody is involved in type 1 hypersensitivity?

A

IgE

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111
Q

which interleukin is associated with type 1 hypersensitivity?

A

IL-5 (overproduction)

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112
Q

what is a type 2 hypersensitivity?

A

antibody dependent cytotoxicity (acute hemolytic transfusion reaction, hyperacute rejection, ITP)

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113
Q

what is a type 3 hypersensitivity?

A

immune complex deposition (serum sickness, SLE)

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114
Q

what is a type 4 hypersensitivity?

A

delayed type aka t-cell mediated/antibody independent (chronic rejection, PPD, graft vs host disease, contact dermatitis)

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115
Q

what is the most common immune deficiency?

A

malnutrition

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116
Q

what is the main source of histamines in tissues?

A

mast cells

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117
Q

what is the main source of histamines in blood?

A

basophils

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118
Q

what is the most important antigen in donor/recipient matching?

A

HLA-DR

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119
Q

what type of rejection occurs if incompatible ABO?

A

hyperacute

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120
Q

what are some ways to try to decrease the PRA% of a person awaiting transplant?

A

plasmapheresis, IV-IG, or rituximab

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121
Q

when does hyperacute rejection occur?

A

minutes to hours after txp

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122
Q

what causes hyperacute rejection?

A

preformed recipient abs to donor antigens

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123
Q

when does accelerated rejection occur?

A

within 1 week

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124
Q

what causes accelerated rejection?

A

T cell sensitization from previous transfusion, childbirth, previous txp etc

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125
Q

when does acute rejection occur?

A

1 week to 6 months

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126
Q

what causes acute rejection?

A

recipient T cells against donor antigens

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127
Q

what is the main mechanism of chronic rejection after heart transplant?

A

chronic allograft vasculopathy

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128
Q

how to diagnose antibody mediated rejection?

A

HLA serum antibody levels and C4d tissue staining on biopsy

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129
Q

how can you treat antibody mediated rejection?

A

IVIG, plasmapheresis, rituximab, splenectomy

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130
Q

what is cyclosporin and what are its main side effects?

A

calcineurin inhibitor; nephro/hepatotoxic, HUS, tremors, seizures

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131
Q

what is the mechanism of tacrolimus?

A

binds FK binding protein to inhibit IL-2 (similar to cyclosporin but 50x more potent, same side effects) generally less rejection than with cyclosporin

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132
Q

what is the mechanism of sirolimus?

A

mTOR inhibitor that binds FK binding protein to inhibit response to IL-2 (advantage is that it is not nephrotoxic)

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133
Q

what are the side effects of sirolimus?

A

increased triglycerides, impaired wound healing, pancytopenia

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134
Q

what are the side effects of azathioprine?

A

myelosuppression, GI intolerance, pancreatitis, hepatotixic, neoplasia, anemia, pulmonary fibrosis

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135
Q

what are the side effects of mycophenolate (aka Cellcept)?

A

GI upset, pancytopenia

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136
Q

which monoclonal antibody drugs are used for immunosuppression?

A

daclizumab, basilximab (work against IL-2)

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137
Q

what is the mechanism of thymoglobulin?

A

ab directed against antigens on T cells (cytolytic)

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138
Q

what is the most common malignancy following transplant?

A

squamous cell CA of skin

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139
Q

who is at the highest risk of post-transplant lymphoproliferative disorder?

A

children and heart transplants

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140
Q

what causes post-transplant lymphoproliferative disorder?

A

EBV mediated B cell proliferation

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141
Q

what is the most common infection after transplant AFTER 1 month?

A

CMV

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142
Q

what is the most common manifestation of CMV in post transplant patients?

A

febrile mononucleosis (though can present as gastritis, colitis, ophthalmitis)

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143
Q

what is the treatment for CMV?

A

gangciclovir or IVIG

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144
Q

what is the most common cause of ESRD leading to kidney txp?

A

diabetes

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145
Q

what is the most common cause of post-op oliguria after renal transplant?

A

ATN

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146
Q

what is the most common cause of new proteinuria after renal transplant?

A

renal vein thrombosis

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147
Q

what is the most common complication after renal transplant?

A

urine leak

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148
Q

what is the definition of early graft dysfunction in renal transplant?

A

needing HD within the first week of transplant

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149
Q

when is lymphocele most likely to form post renal transplant?

A

3 weeks post op (decreased UOP late)

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150
Q

what does the path for CMV look like?

A

inclusion bodies in leukocytes

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151
Q

what is the most common cause of mortality after kidney transplant?

A

myocardial infarction

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152
Q

what is the workup for a post-transplant patient with increasing Cr and decreasing UOP?

A

duplex US and biopsy

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153
Q

what is the most common complication in living kidney donors?

A

wound infection

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154
Q

what is the most common cause of death in living kidney donors?

A

fatal PE

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155
Q

what is the most common indication for liver transplant?

A

Hep C

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156
Q

what is the most common indication for liver transplant in children?

A

biliary atresia

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157
Q

what is the Milan criteria?

A

defines who with HCC and get a transplant: 1 tumor less than 5cm, or 3 tumors each less than 3cm, or favorable histology. CANNOT have mets, vascular invasion, or cholangiocarcinoma.

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158
Q

what is the best predictor of liver transplant primary non-function?

A

macrosteatosis

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159
Q

what is the utility of the MELD score?

A

if 15 or higher, more likely to benefit from liver transplant; if less than 15, more likely to die from liver transplant than to benefit from it.

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160
Q

what is the most common arterial anomaly in liver transplant?

A

aberrant right hepatic artery coming off SMA

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161
Q

what is the most common complication of liver transplant?

A

biliary leak

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162
Q

how do you treat primary non-function after liver transplant?

A

must re-transplant

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163
Q

what is the most common early vascular complication after liver transplant?

A

hepatic artery thrombosis

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164
Q

what is the difference between early and late hepatic artery thrombosis after liver txp?

A

early leads to fulminant liver failure; late leads to biliary strictures and abscess

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165
Q

what is the most common cause of hepatic abscess after liver txp?

A

hepatic artery thrombosis

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166
Q

how can you tell cholangitis vs rejection on path?

A

cholangitis is JUST PMNs, rejection is mixed endothelitis infiltrate

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167
Q

what does path show in chronic liver rejection?

A

disappearing bile ducts

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168
Q

what is the most common complication of a living liver donor?

A

bile leak

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169
Q

what is the recurrence rate of PBC after txp?

A

20%

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170
Q

what is the recurrence rate of PSC after txp?

A

20%

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171
Q

what is the most common cause of mortality after heart transplant within one year?

A

infection

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172
Q

what is the most common cause of mortality after heart transplant after 5 years (and overall)?

A

chronic allograft vasculopathy (aka accelerated atherosclerosis of small coronary vessels)

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173
Q

what is the most common cause of mortality after lung transplant within one year?

A

reperfusion injury

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174
Q

what is the most common cause of mortality after lung transplant after one year (and overall)?

A

bronchiolitis obliterans (aka chronic rejection)

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175
Q

which complication of diabetes does not improve after pancreatic transplant?

A

vascular disease

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176
Q

what is the most common complication after pancreatic transplant?

A

vessel thrombosis

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177
Q

how does acute rejection of small bowel transplant present?

A

diarrhea

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178
Q

what is the most common organism in surgical site infection?

A

staph aureus

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179
Q

what is the most common organism in vent associated penumonia?

A

staph aureus

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180
Q

what is the mechanism that makes MRSA resistent?

A

altered penicillin binding protein

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181
Q

what is the most common organism in line infection?

A

staph epidermidis

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182
Q

what is enteroccus resistant to?

A

all cephalosporins

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183
Q

what is the mechanism of enterococcus to vanco?

A

mutation of the cell wall binding protein

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184
Q

what is the most common organism in the gut?

A

bacteroides fragillis

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185
Q

what is the most common organism in burn wound infections?

A

pseudomonas

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186
Q

what is the most common aerobic bacteria in the colon?

A

e. coli

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187
Q

what causes the SIRS response in gram negative infections?

A

lipid A (LPS) is potent stimulant of TNF-a

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188
Q

what are ways to prevent SSI during OR?

A

stop tobacco, clippers (not razor), abx within 1 hour before incision, maintain blood glucose, keep O2 high, keep patient warm

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189
Q

what wound class is prepped bowel?

A

clean contaminated

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190
Q

which wound types should theoretically be left open?

A

contaminated and dirty

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191
Q

what is the most common organism in SSI?

A

staph aureus

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192
Q

what defines a surgical site infection (bacteria load)?

A

10^5 bacteria

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193
Q

what is the glucose goal in critically ill patients?

A

120-180

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194
Q

what is the most common organism in ventilator associated pneumonia?

A

staph aureus, but must cover for pseudomonas too

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195
Q

what is mendelson’s syndrome?

A

chemical pneumonitis from aspiration of gastric secretions (ARDS picture)

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196
Q

which central line placement has the lowest risk of infection?

A

subclavian

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197
Q

what is the abx regimen of choice if nec fasc is due to strep pyogenes?

A

high dose IV penicillin and clindamycin

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198
Q

how do you treat lung abscess?

A

usually abx alone, rarely need drainage or surgery

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199
Q

what test is the gold standard for c. diff?

A

stool cytotoxin assay

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200
Q

what test is the rapid check for c. diff?

A

stool ELISA for toxin A or B

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201
Q

what is the best initial treatment if fungemia is suspected?

A

anidulafungin (eraxis)

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202
Q

how do you treat candiduria?

A

remove foley; usually dont need abx

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203
Q

what is the abx tx of choice for actinomyces?

A

IV penicillin

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204
Q

what is the abx of choice for nocardia?

A

bactrim

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205
Q

what are the diagnostic criteria for SBP?

A

WBC >500, PMNs >250, positive cultures

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206
Q

what is the abx ppx for SBP?

A

norfloxacin (be sure to give to those with ascites and variceal bleed)

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207
Q

what is the most common organism in infected peritoneal dialysis catheter?

A

staph aureus

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208
Q

what is the tx of choice for infected peritoneal dialysis catheter?

A

IV/peritoneal vanco and gentamycin; intraperitoneal heparin can help; if not resolving in 4-5 days then remove catheter (though must remove if fungus, pseudomonas, or TB)

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209
Q

best diagnostic test for osteomyelitis?

A

bone biopsy

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210
Q

who should get tetanus toxoid if previously vaccinated?

A

clean/minor wounds if >10 years ago or dirty wounds if >5 years

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211
Q

what happens if you get needle stick from HIV patient?

A

HAART tx within 1 hour and for 4 weeks; ELISA test at time of stick and at 4 weeks

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212
Q

what is the most common condition in HIV requiring laparotomy?

A

CMV colitis (bleeding, perforation)

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213
Q

what is the most common location of lymphoma in HIV?

A

stomach

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214
Q

what is the symptom and tx of brown recluse spider bite?

A

necrosis; PO dapsone

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215
Q

what is the most common organism in human bites?

A

strep pyogenes; though eikenella is ONLY found in human bites

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216
Q

what is the most common organism in SBP?

A

e. coli

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217
Q

what is hoffman elimination?

A

drug is metabolized in blood and does not require organ metabolism (good for liver/renal failure, example is cisatricurium)

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218
Q

mechanism of zofran?

A

blocks serotonin (5 HT) receptor

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219
Q

what is alvimopan?

A

Entereg… mu opiod antagonist for post op ileus

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220
Q

how to treat SVT?

A

adenosine

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221
Q

what is the single best agent to decrease mortality in CHF and after MI?

A

ACE inhibitor

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222
Q

which diuretic can cause hyperkalemia?

A

spironolactone

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223
Q

what is the only agent found to improve survival in severe COPD?

A

home oxygen

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224
Q

what is the mechanism of infliximab (remicade)?

A

antibody to TNF-a

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225
Q

what is the antidote to tylenol overdose?

A

n-acetylcystine

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226
Q

what is the antidote to benzo overdose?

A

flumazenil

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227
Q

what is the antidote to wilson’s disease (copper)?

A

penicillamine

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228
Q

what is the antidote to overproduction/ingestion of iron?

A

deferasirox

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229
Q

what does a small MAC mean in anesthesia?

A

more lipid soluble, more potent, slower onset

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230
Q

what does a high MAC mean in anesthesia?

A

less lipid soluble, less potent, faster onset

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231
Q

what is the notable side effect of halothane?

A

hepatitis

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232
Q

what is the main side effect of etomidate?

A

adrenal insuffiency

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233
Q

what is the best indicator for successful intubation?

A

end tidal CO2

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234
Q

what causes rapid drop in end tidal CO2?

A

disconnected from vent, PE, CO2 embolus

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235
Q

what is the mechanism of dexmedetomidine?

A

CNS alpha 2 agonist

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236
Q

what is benefit of fentanyl over morphine?

A

no histamine release so shouldnt drop BP

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237
Q

what is the last muscle to become paralyzed (and first to recover)?

A

diaphragm

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238
Q

which muscle is the first to go down (and last to recover)?

A

face/neck

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239
Q

what is the first sign of malignant hyperthermia?

A

increase in end tidal CO2

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240
Q

what is the mechanism of dantrolene?

A

inhibits Ca release from muscle

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241
Q

how is rocuronium metabolized?

A

liver

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242
Q

how is pancuronium metabolized?

A

kidney

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243
Q

how is cisatricurium metabolized?

A

hoffman elimination

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244
Q

what is main side effect of cisatricurium?

A

hypotension

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245
Q

how is vecuronium metabolized?

A

heatic-biliary

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246
Q

how do neostigmine and edrophonium work?

A

block acetylcholineesterase

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247
Q

what is the maximum dose of local lidocaine?

A

5mg/kg (7 if with epi), so if 1% lidocaine can use 0.5cc/kg

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248
Q

what is ASA class 1?

A

healthy patient

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249
Q

what is ASA class 2?

A

mild disease without limitation

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250
Q

what is ASA class 3?

A

severe disease

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251
Q

what is ASA class 4?

A

disease is a severe constant threat to life

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252
Q

what is ASA class 5?

A

moribund, impending death

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253
Q

what is ASA class 6?

A

organ donor

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254
Q

when does a person who has had a CABG need pre-op testing?

A

if >5 years since CABG

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255
Q

when does someone who had cardiac stents placed need pre-op testing?

A

if >2 years since stents

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256
Q

how long to wait after MI for elective surgery?

A

6-8 weeks

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257
Q

what is the usual origin and location of replaced right hepatic artery?

A

off of SMA, coursing posterior/lateral to CBD

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258
Q

how long after cardiac stents requires preop cardiac workup?

A

> 2 years

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259
Q

how long after CABG requires preop cardiac workup?

A

> 5 years

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260
Q

what is the blood supply to the thymus?

A

inferior thyroid artery and internal mammary artery

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261
Q

what is pyridostigmine?

A

cholinesterase inhibitor, used for myesthenia gravis

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262
Q

what is the composition of normal saline?

A

154 Na and 154 Cl

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263
Q

what is the composition of LR?

A

130 Na, 4 K, 2.7 Ca, 109 Cl, 28 lactate

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264
Q

what is the equation for plasma osmolarity?

A

(2 x Na) + (glucose/18) + (BUN/2.8)

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265
Q

what is the standard dose of maintenance fluid?

A

4:2:1 rule (by 10kg increments)

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266
Q

what is the best indicator of adequate fluid resuscitation?

A

urine output

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267
Q

what are the benefits of adding dextrose to IVF?

A

stimulates insulin release to increase glucose and amino acid uptake, protein synthesis, and prevent protein catabolism

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268
Q

what metabolic abnormality can be caused by normal saline?

A

non-anion gap metabolic acidosis

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269
Q

what is the maximum does of bupivicaine?

A

2 (or 2.5) mg/kg

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270
Q

what is the pressor of choice if hypotension is due to epidural?

A

phenylephrine

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271
Q

order of rapid sequence intubation?

A

preoxygenate, induction, muscle relaxant/paralytic, intubation

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272
Q

what comorbidities are most associated with post op death?

A

1 renal failure, #2 CHF

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273
Q

what is the proper replacement fluid for sweat?

A

1/2 NS

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274
Q

what electrolyte is concentrated in saliva?

A

K

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275
Q

how much fluid is secreted by the stomach daily?

A

1-2 L

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276
Q

what electrolytes are lost in stomach fluid?

A

H and Cl

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277
Q

what is the proper replacement fluid for stomach losses?

A

D5 1/2 NS with 20K

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278
Q

how much fluid is secreted by the pancreas daily?

A

500cc - 1 L

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279
Q

what is the main electrolyte secreted in pancreatic fluid?

A

bicarb

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280
Q

what is the replacement fluid of choice for pancreatic secretion?

A

LR

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281
Q

what is the replacement fluid for biliary losses?

A

LR

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282
Q

how much fluid is secreted by the biliary system daily?

A

500cc - 1L

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283
Q

what is the main electrolytes lost in small bowel fluid (ie fistula, ileostomy?)

A

bicarb and K

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284
Q

what is the replacement fluid of choice for small bowel losses?

A

LR

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285
Q

what is the main electrolyte lost from the colon?

A

K

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286
Q

what is the replacement fluid of choice for colonic losses?

A

LR

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287
Q

what is the equation for FeNa?

A

((plama Cr x urine Na) / (Urine Cr x plasma Na)) x 100

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288
Q

what causes hypernatremia the majority of the time?

A

dehydration

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289
Q

what is the amount Na can be corrected in hypernatremia?

A

0.7 meq/L/h

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290
Q

how do you calculate free water deficit?

A

0.6 x kg x ((Na/140) - 1)

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291
Q

what is the usual cause of hyponatremia?

A

fluid overload

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292
Q

what is the amount Na can be corrected in hyponatremia?

A

0.5 meq/L/h

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293
Q

what are the most common causes of hypercalcemia?

A

hyperparathyroidism, then malignancy

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294
Q

which cancers cause hypercalcemia?

A

lung and breast

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295
Q

how do you treat hypercalcemic crisis?

A

NS rapid infusion, lasix, dialysis

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296
Q

what is the best treatment of hypercalcemia caused by malignancy?

A

bisphosphonates

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297
Q

what EKG change is seen in hypercalcemia?

A

shortened QT

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298
Q

what EKG change is seen in hypocalcemia?

A

prolonged QT

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299
Q

how to correct Ca for low albumin?

A

add 0.8 for each 1 below 4

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300
Q

what is the best treatment for hypermagnesemia?

A

calcium

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301
Q

what metabolic derangement is seen with excessive gastric loss?

A

hypochloremic hypokalemic metabolic alkalosis with paradoxical aciduria

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302
Q

how many calories are in fat?

A

9 kcal/g

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303
Q

how many calories are in protein?

A

4kcal/g

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304
Q

how many calories are in carbs?

A

4 kcal/g

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305
Q

how many calories are in dextrose?

A

4 kcal/g

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306
Q

how many calories are in alcohol?

A

7 kcal/g

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307
Q

how many calories does the average person need per day?

A

25 kcal/kg/d

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308
Q

how much protein does the average person need per day?

A

1-1.5g/kg/d (about 20% of daily intake)

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309
Q

how much does severe illness/trauma increase caloric need?

A

20-60%

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310
Q

how much does pregnancy increase caloric need?

A

300 kcal/d

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311
Q

how much does lactation increase caloric need?

A

500 kcal/d

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312
Q

how much does burns increase caloric need?

A

add 30 kcal/d x % burned to the standard requirement

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313
Q

how much does burns increase protein requirement?

A

add 3g x % burned to the standard requirement

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314
Q

what factors are included in the harris benedict equation?

A

weight, height, age, gender

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315
Q

how does fever change energy expenditure?

A

basal metabolic rate increases 10% for each degree over 38.0

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316
Q

what is the primary energy source for the brain?

A

glucose

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317
Q

how long does it take for the body’s glycogen stores to be gone?

A

18-24 hours

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318
Q

what activates trypsinogen?

A

enterokinase from duodenum

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319
Q

what is the major fuel source of the stomach?

A

glutamine

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320
Q

what is the main fuel source of small bowel enterocytes?

A

glutamine

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321
Q

what is the main fuel source of the pancreas?

A

glutamine

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322
Q

what is the main fuel source of the spleen?

A

glutamine

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323
Q

what is the major fuel source of the liver?

A

ketones

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324
Q

what is the main fuel source of large bowel colonocytes?

A

short chain fatty acids (butyrate)

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325
Q

what is the main fuel source of the heart?

A

short chain fatty acids

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326
Q

what is the main fuel source of skeletal muscle?

A

glucose

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327
Q

what is the main fuel source of the brain?

A

glucose

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328
Q

what is the main fuel source of kidney?

A

glucose

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329
Q

what is the main fuel source of peripheral nerves?

A

obligate glucose

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330
Q

what is the main fuel source of the adrenal medulla?

A

obligate glucose

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331
Q

what is the main fuel source of RBCs?

A

obligate glucose

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332
Q

what is the main fuel source of PMNs?

A

obligate glucose

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333
Q

what is the main fuel source of lymphocytes and macrophages?

A

glutamine

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334
Q

what is the main fuel source of cancer cells?

A

glutamine

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335
Q

what is the equation for respiratory quotient?

A

CO2 produced / O2 consumed

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336
Q

what respiratory quotient is indicative of overfeeding?

A

> 1

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337
Q

what respiratory quotient is indicative of starvation?

A

<0.7

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338
Q

what respiratory quotient is indicative of pure fat metabolism?

A

0.7

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339
Q

what respiratory quotient is indicative of pure protein metabolism?

A

0.8

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340
Q

what respiratory quotient is indicative of pure carb metabolism?

A

1.0

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341
Q

what respiratory quotient is considered “balanced feeding”?

A

0.825

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342
Q

what is the half life of albumin?

A

20 days

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343
Q

what is the half life of transferrin?

A

8 days

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344
Q

what is the half life of prealbumin?

A

2 days

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345
Q

what is the primary substrate of gluconeogenesis?

A

alanine

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346
Q

what inflammatory marker mediates cachexia?

A

TNF-a

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347
Q

what are the symptoms of chromium deficiency?

A

hyperglycemia, confusion, neuropathy

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348
Q

what are the symptoms of selenium deficiency?

A

cardiomyopathy, hypotheyroidism, neuro changes

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349
Q

what are the symptoms of copper deficiency?

A

pancytopenia, neuropathy/ataxia

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350
Q

what are the symptoms of zinc deficiency?

A

rash, blisters, chronic wounds, wasting

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351
Q

what are the symptoms of thiamine (B1) deficiency?

A

wernicke’s enceophalopathy, gaze palsy, cardiomyopahty, neuropathy

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352
Q

what are the symptoms of pyridoxine (B6) deficiency?

A

seizures, cheilitis, neuropathy

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353
Q

what are the symptoms of cobalmin (B12) deficiency?

A

megaloblastic anemia, beefy tongue, neuropathy

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354
Q

what are the symptoms of folate deficiency?

A

megaloblastic anemia, beefy tongue

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355
Q

what are the symptoms of niacin deficiency?

A

pellagra (diarrhea, dementia, dermatitis)

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356
Q

what are the symptoms of essential fatty acid deficiency?

A

thrombocytopenia, dermatitis, hair loss, poor wound healing

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357
Q

what are the symptoms of vitamin A deficiency?

A

night blindness

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358
Q

what are the symptoms of vitamin D deficiency?

A

rickets, osteomalacia

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359
Q

what are the symptoms of vitamin E deficiency?

A

neuropathy, spinocereballar ataxia

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360
Q

what are the symptoms of vitamin K deficiency?

A

coaguloapthy

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361
Q

where does the majority of the body’s vitamin K come from?

A

produced by bacteria in the intestines

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362
Q

what is the most common cancer in women?

A

breast

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363
Q

what is the most common cause of cancer related death in women?

A

lung

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364
Q

what is the most common cancer in men?

A

prostate

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365
Q

what is the most common cause of cancer related death in men?

A

lung

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366
Q

what cancers are caused by EBV?

A

burkitt’s lymphoma, nasopharyngeal CA, and post-transplant lymphoproliferative disorder

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367
Q

what cancers are caused by coal tar?

A

larynx, skin, bronchial

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368
Q

what cancer is caused by beta-naphthylamine?

A

urinary tract

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369
Q

what cancer is caused by benzenes?

A

leukemia

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370
Q

what is the most common cancer in a suspicious axillary lymph node?

A

lymphoma

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371
Q

what is the most common cancer to metastasize to the small bowel?

A

melanoma

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372
Q

what is the most common cancer to metastasize to the spleen?

A

colorectal

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373
Q

what is the most common cancer to metastasize to the brain?

A

lung

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374
Q

what is the most common cancer to metastasize to the adrenal gland?

A

lung

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375
Q

what is the most common cancer to metastasize to the kidney?

A

breast

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376
Q

what are the side effects of cisplatin?

A

nephrotoxic, neurotoxic, ototoxic

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377
Q

what are the side effects of carboplatin?

A

myelosupression

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378
Q

what are the side effects of oxaloplatin?

A

nephrotoxic, neuropathy, ototoxic, cold sensitivity

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379
Q

what is the side effect of busulfan?

A

pulmonary fibrosis

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380
Q

what is the treatment medication for metastatic melanoma?

A

dacarbazine

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381
Q

what is the medication tx for pancreatic islet cell tumors?

A

streptozocin

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382
Q

what are the side effects of methotrexate?

A

renal toxicity, radiation recall

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383
Q

what is the tx of methotrexate toxicity?

A

leucovorin

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384
Q

what is the mechanism of methotrexate?

A

inhibits dihydrofolate reductase to inhibit purine and DNA synthesis

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385
Q

what is the mechanism of 5FU?

A

inhibits thymidylate synthase to inhibit purine and DNA synthesis

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386
Q

what are the side effects of tamoxifen?

A

blood clots, endometrial cancer

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387
Q

what are the side effects of aromatase inhibitors?

A

bone fractures

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388
Q

what cancers are treated with bevacizumab?

A

colorectal and non-small cell lung

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389
Q

what cancer is treated with rituximab?

A

non-hodgkins lymphoma

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390
Q

what cancer is treated with imatinib?

A

GIST tumors

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391
Q

what drug is used to treat metastatic or unresectable adrenal cancer?

A

mitotane

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392
Q

what phase of the cell cycle is most vulnerable to radiation?

A

m phase

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393
Q

tumor marker: ABC-B5

A

melanoma

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394
Q

tumor marker: S-100

A

melanoma

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395
Q

tumor marker: CEA

A

colon cancer

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396
Q

tumor marker: AFP-L3

A

HCC

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397
Q

tumor marker: DCP (des gamma carboxyprothrombin)

A

HCC

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398
Q

tumor marker: CA 19-9

A

pancreatic CA

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399
Q

tumor marker: CA 125

A

ovarian CA, endometrial CA

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400
Q

tumor marker: b-HCG

A

testicular CA, choriocarcinoma

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401
Q

tumor marker: PSA

A

prostate CA

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402
Q

tumor marker: NSE

A

small cell lung CA, neuroblastoma

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403
Q

what is the most important prognostic factor in breast CA?

A

nodal status

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404
Q

what is the most important prognostic factor for sarcomas?

A

tumor grade

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405
Q

what is the main side effect of trastuzumab?

A

cardiomyopathy

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406
Q

how much IVF to give kids in trauma bay?

A

20cc/kg bolus of LR

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407
Q

how much blood to give kids in trauma bay?

A

10cc/kg

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408
Q

where to incise pericardium during ED thoracotomy?

A

longitudinally anterior to phrenic nerve

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409
Q

what maneuver is best for retroperitoneal aorta exposure?

A

mattox

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410
Q

what maneuver is best for retroperitoneal IVC exposure?

A

cattel braasch

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411
Q

what is the supposed indication for DPL?

A

blunt trauma with hypotension

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412
Q

what indicates a positive DPL?

A

> 10cc blood, >100,000 RBCs/cc, food particles, bile, bacteria, >500 WBC/cc

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413
Q

what is the cause of traumatic subdural hematoma?

A

tearing of bridging veins between dura and arachnoid plexus

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414
Q

what are indications for operating on a subdural?

A

midline shift >1cm or significant neuro degeneration

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415
Q

what is the cause of traumatic epidural hematoma?

A

usually middle meningeal artery injury

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416
Q

what are the indications for operating on an epidural hematoma?

A

midline shift >5mm or neuro degeneration

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417
Q

where on the skull do you drill burr holes?

A

5cm anterior and superior to external auditory canal

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418
Q

what is equation for cerebral perfusion pressure?

A

MAP minus ICP (ideal is >60)

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419
Q

what is the treatment for diabetes insipidus?

A

replace with D5, DDAVP

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420
Q

what is the treatment for SIADH?

A

fluid restriction first, diuresis, treat underlying cause, if refractory then 3% hypertonic saline

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421
Q

GCS motor function?

A

6= follows commands, 5= localizes to pain, 4= withdraws from pain, 3= decorticate flexion to pain, 2= decerebrate extension to pain, 1= no response

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422
Q

GCS verbal response?

A

5= oriented x3, 4= confused by responds, 3= inappropriate words, 2= incomprehensible sounds/grunting, 1= no response

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423
Q

GCS eye score?

A

4= spontaneous opening, 3= opens to command, 2= opens to pain, 1= nothing

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424
Q

what is the most important prognostic indicator in GCS?

A

motor score

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425
Q

type 1 dens fracture, and tx?

A

stable through tip of dens, rigid collar

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426
Q

type 2 dens fracture, and tx?

A

unstable through dens base, needs halo for 3 months or internal fixation

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427
Q

type 3 dens fracture, and tx?

A

unstable through vertebral body, halo for 3 months or internal fixation

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428
Q

what is the most common cervical spine fracture?

A

dens

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429
Q

what deems a spine fracture unstable?

A

2 of 3 columns fractured

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430
Q

what is type 1 le fort fracture and tx?

A
  • across maxilla, maxillo mandibular fixation (MMF) +/- miniplates
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431
Q

what is type 2 le fort fracture and tx?

A

/ \ lateral to nasal bone, underneath eyes, down towards maxilla, MMF +- miniplates

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432
Q

what is type 3 le fort fx and tx?

A
    • lateral to orbital wall, MMF and miniplates
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433
Q

timing of nerve repair (ex: facial nerve)?

A

within 3 days; if contaminated then washout and tag ends, repair in 30 days

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434
Q

what is the most common cause of facial nerve injury?

A

temporal bone fracture

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435
Q

tx for refractory nose bleeds?

A

embolization of internal maxillary artery or ethmoidal artery

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436
Q

what is zone 1 of the neck?

A

clavicle to cricoid cartilage

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437
Q

what is zone 2 of the neck?

A

cricoid cartilage to angle of mandible

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438
Q

what is zone 3 of the neck?

A

angle of mandible to base of skull

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439
Q

zone 1 neck injury tx?

A

angio, bronch, EGD, swallow study.

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440
Q

incision for zone 1 neck injury?

A

median sternotomy

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441
Q

zone 2 neck injury tx?

A

explore all if penetrates platysma

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442
Q

incision for zone 2 neck injury?

A

lateral neck incision

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443
Q

zone 3 neck injury tx?

A

angio and laryngoscopy

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444
Q

incision for zone 3 neck injury?

A

jaw subluxation, release of SCM and digastric mm., may need to resect mastoid sinus

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445
Q

diagnosis for esophageal injury?

A

EGD and barium swallow

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446
Q

how to repair esophageal injury?

A

2 layers (absorbable mucosa, nonabsorbable outer layer) with muscle flap covering

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447
Q

tx for carotid dissection?

A

if symptomatic, stent. if asymptomatic, anticoagulate

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448
Q

tx for carotid thrombosis?

A

if still flow, then open repair (primary or graft), if no flow, anticoagulate to prevent propegation

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449
Q

incidence of stroke after ligation of carotid artery?

A

20%

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450
Q

tx for vertebral artery dissection or thrombosis?

A

anticoagulate

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451
Q

tx for vertebral artery bleed?

A

angioembolization

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452
Q

what are the boarders of the “box” in chest trauma?

A

xiphoid, nipples, clavicles

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453
Q

indications for OR thoracotomy after chest tube placement?

A

> 1000-1500 initial output, >250cc/h for 3 hours, unstable pt

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454
Q

what is the cause of respiratory impairment in flail chest?

A

underlying pulmonary contusion

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455
Q

approach to diaphragm repair based on timing?

A

if < 1 week, transabdominal. if >1 week, chest

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456
Q

most common location of tear in aortic transection?

A

ligamentum arteriosum (slightly distal to left subclavian artery)

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457
Q

which injuries should be addressed through a left thoracotomy rather than sternotomy?

A

distal left subclavian, descending thoracic aorta

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458
Q

what is the incision for distal right subclavian injury?

A

right mid-clavicular incision with possible clavicle

resection

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459
Q

what is the most common cause of death after heart contusion?

A

v-fib

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460
Q

what is the most common arrhythmia after heart contusion?

A

black book says SVT, score says PVCs

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461
Q

how to fix CBD injuries with <50% circumference damage?

A

primary repair over a stent

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462
Q

how to fix CBD injuries with >50% circumference damage?

A

choledochojejunostomy

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463
Q

what is the most common cause of hemobilia?

A

hepatic artery to biliary duct fistula, usualy 4 weeks after a trauma

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464
Q

what is the tx of choice for hemobilia from fistula?

A

angioembolization

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465
Q

what immunizations are required after splenectomy?

A

pneumococcus, H. influenza, meningitis

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466
Q

what determines whipple vs distal pancreatectomy in trauma (based on location)?

A

whether proximal or distal to SMV

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467
Q

when is graft required for arteries instead of primary repair?

A

if >2cm

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468
Q

what mediates reperfusion injury?

A

PMNs

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469
Q

what structures are in the anterior compartment of the calf?

A

anterior tibial artery, deep peroneal nerve

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470
Q

what structures are in the lateral compartment of the calf?

A

superficial peroneal nerve

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471
Q

what structures are in the deep posterior compartment of the calf?

A

posterior tibial artery, peroneal artery, tibial nerve

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472
Q

what structures are in the superficial posterior compartment of the calf?

A

sural nerve

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473
Q

how does the trifurcation appear on angio?

A

anterior tibial artery branches off first and goes laterally, peroneal artery is middle, posterior tibial artery is medial

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474
Q

structure most likely damaged with: anterior humerus dislocation?

A

axillary nerve

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475
Q

structure most likely damaged with: posterior humerus dislocation?

A

axillary artery

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476
Q

structure most likely damaged with: proximal humerus fx?

A

axillary nerve

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477
Q

structure most likely damaged with: midshaft humerus fx?

A

radial nerve

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478
Q

structure most likely damaged with: distal (supracondylar) humeral fx?

A

brachial artery

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479
Q

structure most likely damaged with: elbow dislocation?

A

brachial artery

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480
Q

structure most likely damaged with: distal radial fx?

A

median nerve

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481
Q

structure most likely damaged with: anterior hip dislocation?

A

femoral artery

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482
Q

structure most likely damaged with: posterior hip dislocation?

A

sciatic nerve

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483
Q

structure most likely damaged with: distal femur fx?

A

popliteal artery

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484
Q

structure most likely damaged with: posterior knee dislocation?

A

popliteal artery

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485
Q

structure most likely damaged with: fibular neck fracture?

A

common peroneal nerve

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486
Q

median nerve innervation in the hand?

A

sensation 1st 3.5 fingers on palmar side, motor finger flexors and thumb flexion

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487
Q

ulnar nerve innervation in the hand?

A

sensory to 5th and 0.5 of 4th digit, motor to wrist flexion and intrinsic hand muscles

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488
Q

radial nerve innervation in the hand?

A

sensory to 1st 3.5 digits on back of hand, motor to wrist and finger extensors

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489
Q

what nerve innervates the deltoid?

A

axillary

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490
Q

what is deficit with L3 nerve?

A

weak hip flexion

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491
Q

what is deficit with L4 nerve?

A

weak knee extension and weak patellar reflex

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492
Q

what nerve causes foot drop?

A

deep peroneal nerve, (L5 root). check sensation at big toe web.

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493
Q

best initial test for ureteral injury?

A

IV pyelogram

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494
Q

which ureteral injuries can be primarily repaired?

A

<2cm in top 2/3; lower 1/3 still reimplant into bladder

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495
Q

how to repair ureter if >2cm and in top 1/3 or middle?

A

trans-ureteroureterostomy

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496
Q

how to repair ureter if >2cm and in lower 1/3?

A

reimplant into bladder (5-0 PDS), may need psoas hitch to help reach

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497
Q

how to handle partial transection of ureter?

A

repair over stent

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498
Q

where is right renal artery in relation to IVC?

A

posterior to IVC

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499
Q

where is left renal vein in relation to aorta?

A

usually anterior, but beware for posterior location when clamping aorta

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500
Q

which renal vein can be ligated vs must be repaired?

A

left can be ligated due to collaterals via adrenal; right must be repaired

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501
Q

what is the best test for urethral injury?

A

retrograde urethrogram

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502
Q

how to treat significant urethral injury?

A

suprapubic tube for 2-3 months then delayed repair

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503
Q

how to treat small, partial urethral injury?

A

foley across tear for 3 weeks

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504
Q

what is the cutoff for fetus viability in trauma?

A

24 weeks

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505
Q

how to assess fetal maturity in pregnant trauma patient?

A

LS ratio >2:1, positive phosphatidylcholine

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506
Q

what is the most common cause of placental abruption in pregnant trauma patient?

A

shock; 2nd is mechanical disruption

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507
Q

what is the utility of kleihauer betke test?

A

detects fetal blood in maternal circulation to identify placental abruption or hemorrhage in pregnant trauma patient

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508
Q

where is the most common site for uterine rupture?

A

posterior fundus

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509
Q

what temperature in hypothermia qualifies for cardiac bypass?

A

<27 degrees

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510
Q

what is the most common cause of immediate death in electrical injuries?

A

cardiac arrest

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511
Q

what is the most common cause of immediate death in lightening strike?

A

electrical paralysis of brainstem

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512
Q

what is the most common cause of death overall in electrical injuries?

A

infection

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513
Q

what is the difference between AC and DC electricution?

A

AC has same entrance and exit site, more damaging. DC has different entrance and exit sites

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514
Q

which abdominal zone 1 hematomas should be explored?

A

all

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515
Q

which abdominal zone 2 hematomas should be explored?

A

penetrating only

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516
Q

which abdominal zone 3 hematomas should be explored?

A

penetrating only

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517
Q

what landmark differentiates abdominal zone 1 from 2?

A

psoas

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518
Q

what class of shock demonstrates tachycardia?

A

class 2+

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519
Q

what class of shock demonstrates hypotension?

A

class 3+

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520
Q

what is the definition of shock?

A

inadequate tissue oxygenation

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521
Q

what is the body’s first response to hemorrhagic shock?

A

increased diastolic pressure due to vasoconstriction

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522
Q

what is the last vital sign to change in shock with kids?

A

blood pressure

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523
Q

what is the most common organ injured in penetrating abdominal trauma?

A

small bowel

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524
Q

what is the most common organ injured in blunt abdominal trauma?

A

spleen (some say liver)

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525
Q

what is the tx for brown recluse spider bite?

A

dapsone

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526
Q

what is the best way to approach the left mainstem bronchus?

A

right thoracotomy

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527
Q

indications for perimortum c section?

A

fetus >24 weeks, aim for c section within 4 minutes of arrest but is contraindicated after 20 min of CPR

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528
Q

what is normal cardiac output?

A

4-8L/min

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529
Q

what is normal cardiac index?

A

2.5-4L/min

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530
Q

what is normal systemic vascular resistqnce?

A

800-1400 (1100)

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531
Q

what is normal pulmonary capillary wedge pressure?

A

7-11

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532
Q

what is normal CVP?

A

3-7

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533
Q

what is the best pressor for septic shock?

A

norepinephrine

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534
Q

what is the best pressor for cardiogenic shock?

A

dobutamine

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535
Q

what is the initial finding on ECHO in early tamponade?

A

impaired right atrial filling in diastole

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536
Q

what is the best pressor for neurogenic shock?

A

phenylephrine

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537
Q

what is the most common cause of adrenal insuffiency?

A

withdrawal of exogenous steroids

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538
Q

what is waterhouse-friederichsen syndrome?

A

bilateral adrenal hemorrhage leading to adrenal insuffiency

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539
Q

which steroid does not interfere with cosyntropin stim test?

A

dexamethasone

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540
Q

what is the clinical presentation of an intubated patient with acute PE?

A

sudden crease in end tidal CO2 and hypotension

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541
Q

which DVT is most likely to result in PE?

A

iliofemoral

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542
Q

what are the systemic alpha 1 effects?

A

arterial and venous vasoconstriction; gluconeogenesis and glycogenolysis

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543
Q

what are the alpha 2 systemic effects?

A

venous vasoconstriction

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544
Q

what are the beta 1 systemic effects?

A

increased contractility and HR

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545
Q

what are the beta 2 systemic effects?

A

vasodilation, bronchodilation, increased glucagon and renin

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546
Q

what are the systemic effects of dopamine?

A

renal blood vessel relaxation, sphlanchnic smooth muscle relaxation

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547
Q

what are the effects of V1 receptors?

A

vascular smooth muscle constriction

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548
Q

what are the effects of V2 receptors?

A

water resorption from the collecting ducts

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549
Q

what are the effects of V3 receptors?

A

VIII and vWF release from endothelium

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550
Q

what is the mechanism of milrinone?

A

inhibits cAMP phosphodiesterase

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551
Q

dopamine action based on dose?

A

low: DA receptors, medium: contractility and increase HR; high: alpha 1

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552
Q

what receptors does dobutamine act on?

A

mostly B1, some B2 at high doses

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553
Q

what receptors does phenylephrine act on?

A

just alpha 1

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554
Q

what receptors does norepinephrine act on?

A

mostly alpha 1 and 2, some beta 1

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555
Q

what receptors does epinephrine act on?

A

low: beta 1 and 2, high: alpha 1 and 2

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556
Q

what receptors does vasopressin act on?

A

V1

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557
Q

what is the tx of nipride toxicity?

A

amyl nitrite first then sodium nitrite

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558
Q

what is the most common cause of delayed discharge after cardiac surgery?

A

a-fib

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559
Q

what is the most renally protective measure when someone with CKD needs contrast study?

A

pre-hydration

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560
Q

what is the most common cause of post-op ATN?

A

intraoperative hypotension

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561
Q

why does atelectasis cause fever?

A

IL-1 released from macrophages

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562
Q

what NIF is suitable for extubation?

A

> 20

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563
Q

what RSBI is suitable for extubation?

A

<105

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564
Q

what is the most common cause of ARDS?

A

pneumonia

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565
Q

what is considered a positive apnea test for brain death?

A

increase of CO2 to >60 or increase by 20; negative if BP drops below 60 or pt desaturates

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566
Q

what reflex can remain present in brain death?

A

deep tendon reflexes

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567
Q

what bladder pressure indicates abdominal compartment syndrome?

A

> 20

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568
Q

what complication can topical benzocaine cause during EGD?

A

methemoglobinemia

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569
Q

how does harmonic scalpel cause coagulation?

A

disrupts the protein hydrogen bonds

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570
Q

how does dabigatran affect coags?

A

prolonged PTT

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571
Q

which burns need grafting?

A

deep 2nd degree and above

572
Q

how do 1st and superficial 2nd degree burns heal?

A

epithelialization from hair follicles

573
Q

what is the parkland formula for burns?

A

4cc x kg x % burn (besides 1st degree). give 1/2 in first 8 hours and the rest in the remaining 16h of 24h period, if total is >20%

574
Q

what topical burn tx should be put over cartilage?

A

sulfamylon

575
Q

when is a burn considered infected?

A

> 10^5 bacteria on culture OR if the cx shows any B hemolytic strep

576
Q

what are the benefits of STSG?

A

more likely to survive, can cover larger area

577
Q

what are the benefits of FTSG?

A

less wound contraction, better color match

578
Q

how do skin grafts survive depending on time frame?

A

imbibition 0-3 days, neovascularization day 3+

579
Q

what is the most common cause of skin graft loss?

A

seroma/hematoma under graft

580
Q

what nutrient do burn wounds need?

A

obligatory glucose user

581
Q

what is the most common infection in significant burn patients?

582
Q

what is the most common organism in burn wound infection?

A

pseudomonas

583
Q

most common viral infection in burn wound?

584
Q

what is the best tx for an infected burn wound?

A

excision with allograft and systemic antibiotics

585
Q

which topical burn tx is good for eschar?

A

sulfamylon (mafenide sodium)

586
Q

what are the side effects of silvadene (silver sulfadiazine)?

A

neutropenia and thrombocytopenia

587
Q

what are the side effects of silver nitrate?

A

electrolyte imbalances and methemoglobinemia

588
Q

which topical burn tx is good for pseudomonoas?

A

sulfamylon

589
Q

what are the side effects of sulfamylon?

A

metabolic acidosis due to carbonic anhydrase inhibition, hypersensitivity reactions

590
Q

what is a normal carbon monoxide (carboxyhemoglobin) level?

A

10% in normal people and 20% in smokers

591
Q

what is the tx for carbon monoxide poisoning?

A

100% O2 and consider hyperbarics

592
Q

what are the clinical suspicions for cyanide poisoning?

A

lactic acidosis and elevated O2 on ABG

593
Q

what is the tx for cyanide poisoning?

A

methylene blue and 100% O2

594
Q

what is the tx for corneal abrasion/eye burn?

A

topical fluoroquinolone ointment

595
Q

what is a marjolin ulcer?

A

squamous cell carcinoma in an old burn/chronic wound

596
Q

what kind of necrosis occurs with alkaline materials?

A

liquefaction necrosis

597
Q

what kind of necrosis occurs with acidic materials?

A

coagulation necrosis

598
Q

how do you treat hydrofluoric acid burns?

A

topical calcium to neutralize

599
Q

what is the difference between TEN and SJS?

A

TEN is >30%, SJS is <10%; though both are detachment of epidermis from dermis

600
Q

what are the borders of the anterior neck traingle?

A

anterior border of SCM, sternal notch, inferior border of digastric, and trachea

601
Q

what structures are in the anterior neck triangle?

A

carotid, IJ, an vagus

602
Q

what are the borders of the posterior neck triangle?

A

posterior border of SCM, trapezius, clavicle

603
Q

what structures are in the posterior neck triangle?

A

spinal accessory nerve and brachial plexus

604
Q

what is frey’s syndrome?

A

gustatory sweating from injury to auriculotemporal nerve that crosses with sympathetic nerve fibers

605
Q

what are the branches of the thyrocervical trunk?

A

“STAT”: supracervical artery, transverse cervical artery, ascending cervical artery, inferior thyroid artery

606
Q

what is the first branch of the external carotid artery?

A

superior thyroid artery

607
Q

what is the blood supply to a trapezius muscle flap?

A

tranasverse cervical artery

608
Q

what is the blood supply to a pectoralis major muscle flap?

A

thoracoacromial artery

609
Q

what is the most common CA in a metastatc cervical lymph node?

A

squamous cell CA

610
Q

what is the most common site of oral cavity cancer?

A

lower lip (usually squamous)

611
Q

what is the tx for nasopharyngeal SCC?

A

chemo + radiation

612
Q

what margin is needed for oral cavity cancers?

A

1cm except for tongue needs 2cm

613
Q

what is the chemo regimen. of choice for oral cancers?

A

5fu and cisplatin

614
Q

what is commando procedure?

A

removal of tongue ca with partial mandible resection

615
Q

what is the most common benign tumor of the nasopharynx and larynx?

616
Q

what is the most common tumor of the nasopharynx in kids?

617
Q

what is the tx for nasopharyngeal angiofibroma?

A

angioembolization (usually internal maxillary artery) then resection

618
Q

what is the most common benign parotid tumor?

A

pleomorphic adenoma

619
Q

what is the most common malignant tumor of the salivary glands?

A

mucoepidermoid CA

620
Q

what is the most commonly injured nerve in parotid surgery?

A

greater auricular nerve

621
Q

what is the most common malignant tumor of minor salivary glands?

A

adenoid cystic CA

622
Q

what is a modified radical neck dissection?

A

resection of omohyoid, submandibular gland, sensory nerves C2-C5, cervical branch of facial nerve, and cervical chain LNs. attempt to spare 1 or 2 of spinal accessory nerve, IJ, or SCM. radical neck dissection takes all of these, rarely done.

623
Q

what is the origin of thyroglossal duct cyst?

A

foramen cecum

624
Q

where are 1st bronchial cleft cysts located?

A

angle of mandible

625
Q

where are 2nd bronchial cleft cysts located?

A

anterior to SCM (goes through carotid bifurcation and into tonsillar pillar

626
Q

where are 3rd bronchial cleft cysts located?

A

deep in SCM, emerge from pyriform sinus

627
Q

where are cystic hygromas found?

A

posterior neck triangle, often on the left

628
Q

what is the most common organism in suppurative parotitis?

629
Q

what is the most common organism in ludwig’s angina?

A

actinomyces

630
Q

what is the most common benign head and neck tumor in adults?

A

hemangioma

631
Q

what is the most common organism of mastoiditis?

A

strep pneumo

632
Q

what organism causes epiglottitis?

633
Q

what is secreted by the adrenal glomerulosa?

A

aldosterone

634
Q

what is secreted by the adrenal fasiculata?

A

glucocorticoids

635
Q

what is secreted by the adrenal reticularis?

A

androgens and estrogens

636
Q

what is the role of tyrosine hydroxylase?

A

converts tyrosine to dopa

637
Q

what is the role of PNMT?

A

converts norepi to epi

638
Q

what is the most common extra-adrenal site of neural crest tissue?

A

organ of zuckerkandl

639
Q

what is the most common cause of congential adrenal hyperplasia?

A

21 hydroxylase deficiency

640
Q

what is the most common casue of malignant incidental adrenal mass?

A

mets from lung cancer

641
Q

what size indicates need for resection in incidental adrenal tumor?

642
Q

what CT features are suspicious for malignancy in adrenal tumor?

A

> 10 houndsfield units, washout takes more than 10 minutes, irregular bordersheterogenous, dense, hemorrhagic areas

643
Q

what drug is used for medical treatment of adrenal tumor?

644
Q

what is the best test for diagnosis of pheochromocytoma?

A

24h urine collection

645
Q

what do you ligate first when resecting pheochromocytoma?

A

adrenal vein, to prevent cathecholamine spillage

646
Q

what is the surgery of choice for adrenal cancer?

A

OPEN not MIS

647
Q

what hormones are secreted by the posterior pituitary?

A

ADH and oxytocin

648
Q

what is the most common pituitary tumor?

A

prolactinoma

649
Q

where is the thyroid derived from?

A

1st and 2nd pharyngeal pouch

650
Q

where is the ligament of berry?

A

posterior, medial

651
Q

where is the tubercle of zukerkandl?

A

posterior, lateral

652
Q

what gives rise to the superior thyroid artery?

A

first branch of external carotid

653
Q

what does the inferior thyroid artery supply?

A

both inferior and superior parathyroids

654
Q

where does the thyroid ima artery come from?

A

aorta or inominate

655
Q

where do superior and middle thyroid veins drain to?

656
Q

where does inferior thyroid vein drain to?

A

innominate

657
Q

what does the recurrent laryngeal nerve innervate?

A

motor to all of larynx except cricothyroid mm.

658
Q

what innervates the cricothyoid muscle?

A

superior laryngeal nerve (external branch)

659
Q

where is the recurrent laryngeal nerve found at the thyroid area?

A

posterior in the tracheoesophageal groove, can track with the inferior thyroid artery

660
Q

what is non-recurrent laryngeal nerve associated with?

A

right aberrant subclavian artery off the descending thoracic aorta

661
Q

where is the superior laryngeal nerve found?

A

superior and lateral to thyroid lobes; runs with superior thyroid artery

662
Q

what is the ratio of T4:T3 in serum?

663
Q

where does most T3 come from?

A

produced in the periphery from T4 by deiodinases

664
Q

which is more potent, T3 or T4?

A

T3 is 4x more potent

665
Q

what test is the most sensitive for thyroid gland function?

666
Q

what is the best initial test for thyroid nodule?

A

FNA via US

667
Q

what tests help predict prognosis of thyroid lymphoma?

A

LDH and b-2 microglublin, worse prognosis

668
Q

what is the treatment for thyroid lymphoma?

A

chemo and radiation

669
Q

what is linked to causing thyroid lymphoma?

A

hashimotos

670
Q

what is the most common type of thyroid cancer?

A

papilary (PTC)

671
Q

what is the problem with FNA if it shows follicular cells?

A

cant differentiate adenoma vs cancer

672
Q

what US features are concerning for malignancy in thyroid nodule?

A

hypoechoic, irregular margins, hypervascular, microcalcifications, taller than wide

673
Q

how to treat thyroid adenoma?

A

must do lobectomy to prove it isnt cancer

674
Q

what is bethesda 1 in thyroid nodule?

A

non-diagnostic, unsatisfactory requiring repeat FNA

675
Q

what is bethesda 2 in thyroid nodule?

A

benign, clinical f/u

676
Q

what is bethesda 3 in thyroid nodule?

A

atypia, repeat FNA, cllnical follow up, maybe lobectomy

677
Q

what is bethesda 4 in thyroid nodule?

A

follicular neoplasm, requires lobectomy

678
Q

what is bethesda 5 in thyroid nodule?

A

suspicious for CA, requires lobectomy with frozen section and if + then proceed with CA operation

679
Q

what is bethesda 6 in thyroid nodule?

A

malignant, requires CA operation

680
Q

what are the pathologic hallmarks of papillary thyroid carcinoma?

A

psammoma bodies, orphan annie nuclei

681
Q

how does papillary thyroid carcinoma spread?

A

lymphatics, often to lung

682
Q

what is the most common cause of death in papillary thyroid carcinoma?

A

local invasion (predicts prognosis)

683
Q

what are the indications for total thyroidectomy in Papillary and follicular thyroid CA?

A

> 1cm, extrathyroidal disease (capsular invasion, positive nodes, mets), multicentric or bilateral, previous XRT

684
Q

when is radiation indicated for thyroid carcinoma?

A

unresectable not responsive to radioactive iodine

685
Q

what lab test can be followed after surgery to eval for recurrence of thyroid cancer?

A

thyroglobulin

686
Q

what if you have an enlarged neck lymph node that shows thyroid tissue on biopsy?

A

this is papillary thyroid cancer with lymphatic spread

687
Q

how does follicular thyroid cancer spread?

A

hematogenous, goes to bone (50% have mets at time of diagnosis)

688
Q

what are the risk factors for mets/recurrence in thyroid cancer?

A

grade, age <20 or >50, mets, male gender, extrathyroidal disease, size >1cm (GAMES)

689
Q

what calcitonin level is concerning for metastatic medullary thyroid CA?

A

> 400 preop; do staging imaging

690
Q

what MEN syndrome has worst prognosis for medullary thyroid CA?

691
Q

what are the symptoms of medullary thyroid CA?

A

diarrhea, flushing

692
Q

what is the pathologic evaluation of medullary thyroid cancer?

A

neural crest cells, from parafollicular C cells that secrete calcitonin; gastrin causes increased calcitonin; amyloid seen on path

693
Q

what is the treatment for medullary thyroid CA?

A

total thyroid with central LN dissection and MRND on side of tumor

694
Q

when should prophylactic thyroidectomy be done in MEN2a?

A

6 years old (include central node dissection)

695
Q

when should prophylactic thyroidectomy be done in MEN2b?

A

at 2 years old (include central node dissection)

696
Q

what lab can be tracked for recurrence of medullary thyroid CA?

A

calcitonin

697
Q

what is the path of hurthle cell carcinoma of the thyroid?

A

ashkenazi cells, must do lobectomy to confirm benign

698
Q

which thyroid cancers are responsive to radioactive iodine?

A

papillary and follicular

699
Q

who can not get radioactive iodine?

A

kids, pregnant women, breast feeding women

700
Q

what is the most common cause of hyperthyroidism?

A

grave’s disease

701
Q

what causes grave’s disease?

A

IgG antibodies that stimulate thyroid

702
Q

what are the side effects of PTU and methimazole?

A

aplastic anemia and agranulocytosis (also methimazole is toxic to baby in pregnancy)

703
Q

which anti-thyroid medication can be used in hyperthyroidism in pregnancy?

704
Q

what is the most common casue fo death in thyroid storm?

A

high output cardiac failure

705
Q

what is the most common casue of hypothyroidism in adults?

A

hashimoto’s

706
Q

where are the superior parathyroids?

A

posterior, lateral to RLN

707
Q

what is the embryologic origin of the superior parathyroids?

A

4th pharyngeal pouch

708
Q

where are the inferior parathyroids?

A

anterior, medial to RLN

709
Q

what is the embryologic origin of the inferior parathyroids?

A

3rd pharyngeal pouch

710
Q

what is the most common cause of hypoparathyroidism?

A

previous thyroid surgery

711
Q

what electrolyte changes are seen in hyperparathyroidism?

A

increased calcium, decreased phosphorus; Cl to Phos >33:1

712
Q

which cancer has the highest risk of causing hypercalcemia?

A

squamous cell lung CA

713
Q

what gene increased risk of parathyroid adenoma?

A

PRAD-1 oncogene

714
Q

what are indications for parathyroidectomy in ASYMPTOMATIC people?

A

Ca >13, (or >1 of higher than normal), Cr clearance decreased >30%, osteoporosic aka t score -2.5, urinary calcium >400mg in 24h, age <50, patient preference

715
Q

when should you operative. on parathyroid cancer in pregnant woman?

A

2nd trimester, dont wait until baby is born

716
Q

how to interpret intraop PTH level?

A

should drop >50% in 10 minutes

717
Q

what is the most common ectopic location of parathyroid tissue?

718
Q

what is the surgery of choice for parathyoid in MEN syndrome?

A

remove all 4 and reimplant one into forearm

719
Q

what is the most common cause of secondary hyperparathyroidism?

A

chronic renal failure

720
Q

what are the electolyte findings in secondary hyperparathyroidism?

A

^PTH, decreased Ca and ^ phos, ^ urine Ca cus kidney cant reabsorb it

721
Q

how do you diagnose calciphylaxis?

A

skin biopsy

722
Q

what causes death in parathyroid cancer?

A

the hypercalcemia

723
Q

what lab values are elevated in parathyroid CA?

A

PTH, Ca, and alk phos

724
Q

what is the most common site of mets in parathyroid CA?

725
Q

what is the surgical tx of parathyroid cancer?

A

parathyroidectomy, ipsilateral thyroidectomy, probably/usually central neck dissection

726
Q

how does parathyroid CA differ clinically from adenoma?

A

usually Ca level is higher and the mass is palpable

727
Q

what is the most common malignant cause of hypercalcemic crisis?

728
Q

what is the initial tx of hypercalcemic crisis?

A

IVF (not LR cus there is calcium in it) then lasix (not thiazide cus it absorbs calcium)

729
Q

what gene is associated with MEN1?

730
Q

what are the findings in MEN1?

A

pituitary tumors, parathyroid hyperplasia, pancreatic tumors

731
Q

what is the most common pancreatic tumor in MEN1?

A

gastrinoma

732
Q

what is the most common pituitary tumor in MEN1?

A

prolactinoma

733
Q

what is the most common cause of death in MEN1?

A

the pancreatic tumor

734
Q

if simultaneous tumors in MEN1, which do you operate on first?

A

hyperparathyroidism

735
Q

what gene is associated with MEN 2a/b?

A

RET proto-oncogene

736
Q

what are the findings in MEN2a?

A

parathyroid hyperplasia, pheochromocytoma, medullary thyroid CA

737
Q

what is the most common symptom of medullary thyroid CA?

738
Q

what is the most common cause of death in MEN2a?

A

medullary thyroid CA

739
Q

if simultaneous tumors in MEN2a, which do you operate on first?

A

pheochromocytoma

740
Q

when do you operate on the thyroid in MEN2a?

A

6 years old

741
Q

what are the findings in MEN2b?

A

mucosal ganglioneuromas and pheochromocytoma; also medullary thyroid CA and marfanoid habitus

742
Q

what is the most common cause of death in MEN2b?

A

medullary thyroid CA

743
Q

when to operate on thyroid in MEN2b?

A

2 years old (more aggressive than 2a)

744
Q

if simultaneous tumors in MEN2b, which do you operate on first?

A

pheochromocytoma

745
Q

are the pheochromocytomas of MEN2 usually malignant or benign?

746
Q

what does the long thoracic nerve innervate?

A

serratus anterior

747
Q

what is the resultant deficit from long thoracic nerve injury?

A

winged scapula

748
Q

what artery supplies the serratus anterior?

A

lateral thoracic artery

749
Q

what does the thoracodorsal nerve innervate?

A

latissimus dorsi

750
Q

what does the medial pectoral nerve innervate?

A

pec major and minor

751
Q

what does the lateral pectoral nerve innervate?

752
Q

what is the most commonly injured nerve with mastectomy or axillary dissection?

A

intercostobrachial nerve

753
Q

where is the intercostobrachial nerve encountered?

A

just below the axillary vein in the axilla

754
Q

what cancers an spread via batson’s plexus?

A

rectal, prostate, and breast

755
Q

what is the most common cause of malignant axillary adenopathy?

756
Q

what is the most common organism in mastitis?

A

staph aureus

757
Q

what is poland’s syndrome?

A

hypoplasia of chest wall with amastia and no pec muscle, hypoplatic shoulder, and webbing of fingers

758
Q

what is mondor’s disease? tx?

A

sclerosing superficial vein thrombophlebitis. of breast; NSAIDS

759
Q

what is the most common breast lesion in adolescents and young women?

A

fibroadenoma

760
Q

what breast lesion has “popcorn lesions” on mammography?

A

fibroadenoma

761
Q

how to work up a mass suspected to be fiboadenoma?

A

if <30, US with FNA, and must feel clinically benign. if >30 mammogram, US, and excisional biopsy

762
Q

what is the path description of a fibroadenoma?

A

prominent fibrous tissue compressing epithelial cells

763
Q

what is the most common cause of bloody nipple discharge?

A

intraductal papilloma

764
Q

which type of fibrocystic breast disease has cancer risk?

A

atypical ductal or lobular hyperplasia

765
Q

how to treat atypical ductal hyperplasia?

A

resect suspicious area (do not need negative margins)

766
Q

what is the cancer risk of LCIS?

A

30% in BOTH breasts; usually DUCTAL carcinoma that develops

767
Q

how to treat LCIS?

A

resect suspicious area but do not need negative margins; then either close follow up or add tamoxifen/raloxifene (50% cancer reduction with these meds)

768
Q

how is LCIS usually diagnosed?

A

generally not palpable or seen on mammogram does not have calcifications is incidentally found on bx for something else

769
Q

how is DCIS usually diagnosed?

A

cluster of calcifications on mammogram

770
Q

what is the cancer risk of DCIS?

A

50% in same breast

771
Q

what are the variants of DCIS?

A

solid, cribiform, papillary, and comedo

772
Q

what is the worst form of DCIS?

773
Q

what is the required margin for DCIS?

774
Q

what are the tx options for DCIS?

A

lumpectomy and radiation OR simple mastectomy and consider tamoxifen

775
Q

what is the role of radiation. in DCIS?

A

decreases recurrence but does not change overall survivial

776
Q

which DCIS need mastectomy instead of lumpectomy?

A

COMEDO, multi-focal or multi-centric, diffuse, re-resected and still + margins, cant get more XRT, high grade, recurrence, or male pt

777
Q

what is the best way to diagnose intraductal papilloma?

778
Q

what is the cancer risk of diffuse papillomatosis?

A

40%, must excise

779
Q

what factors are included in the GAIL risk assessment for breast cancer?

A

age, race, age at menarche, age of 1st live birth, number of 1st degree relatives with breast CA, and number of previous bx ; if >10% then do BRCA testing

780
Q

which BRCA mutation has higher risk of ovarian CA?

A

BRCA 1 (40% compared to 10%)

781
Q

which BRCA has higher risk of male breast CA?

A

BRCA 2 (10% compared to 1%)

782
Q

what screening is required for someone with BRCA?

A

yearly mammogram and MRI starting at age 25, yearly pelvic with US and CA-125 starting at age 25

783
Q

what is BIRADS 1?

A

normal mammogram, routine F/U

784
Q

what is BIRADS 2?

A

benign finding, routine f/u

785
Q

what is BIRADS 3?

A

probably benign, 6 month f/u imaging

786
Q

what is BIRADS 4?

A

suspicious, rec core needle bx (will also end up resected)

787
Q

what is BIRADS 5?

A

very highly suspicious, rec excisional bx

788
Q

what is BIRADS 6?

A

biopsy proven cancer

789
Q

what is a T1 breast mass?

790
Q

what is a T2 breast mass?

791
Q

what is a T3 breast mass?

792
Q

what is a T4a breast mass?

A

chest wall involvement (not include pec muscle)

793
Q

what is a T4b breast mass?

A

involves skin, peau d’orange

794
Q

what is T4c breast mass?

A

both T4a and b combined

795
Q

what is T4d breast mass?

A

inflammatory breast CA (erythema)

796
Q

what is N1 breast lesion?

A

ipsilateral movable axillary nodes or 1-3 nodes

797
Q

what is N2a breast CA?

A

fixed ipsilateral axillary nodes (N2 includes 4-9 nodes)

798
Q

what its N2b breast CA?

A

clinically positive internal mammary nodes without axillary nodes

799
Q

what is N3a breast CA?

A

ipsilateral infraclavicular nodes (N3 includes 10 or more nodes)

800
Q

what its N3b breast CA?

A

ipsilateral axillary AND internal mammary nodes

801
Q

what is N3c breast CA?

A

ipsilateral supraclavicular nodes (considered non-operable)

802
Q

what is the most important prognostic factor in breast CA?

A

node status

803
Q

how do the breast cancer receptors predict prognosis?

A

PR best, ER good, HER2/neu bad

804
Q

what is the most common site of breast cancer mets?

805
Q

what is the most common type of breast cancer?

A

ductal carcinoma

806
Q

what is stage 1 breast CA?

807
Q

what is stage 2a breast CA?

A

T0-1, N1, M0 or T2, N0, M0

808
Q

what is stage 2b breast CA?

A

T2N1M0 or T3N0M0

809
Q

what is stage 3a breast CA?

A

T0-3, N2, M0 or T3N1M0

810
Q

what is stage 3b breast CA?

A

T4 N0-2 M0

811
Q

what is stage 3c breast CA?

812
Q

what is stage 4 breast CA?

813
Q

what is the required margin for breast CA?

A

negative is negative

814
Q

when is SLND indicated?

A

malignant tumor >1cm or DCIS undergoing total mastectomy

815
Q

when is SLND contraindicated?

A

pregnancy, multicentric disease, neoadjuvant therapy, palpable nodes, advanced disease, previous ax dissection, tumor >5cm

816
Q

what are the borders for axillary dissection?

A

axillary vein superior, chest wall medial, skin lateral, pec minor anterior, latissimus posterior

817
Q

what are the lymph node levels 1-3 in breast surgery?

A

1- lateral to pec minor, 2- beneath pec minor, 3- medial to pec minior

818
Q

what are rotters nodes?

A

nodes between pec major and minor

819
Q

when is level 3 LND required?

A

only if grossly involved in breast CA, always for melanoma

820
Q

what risk is increased with level 3 LND for breast CA?

A

lymphedema

821
Q

what is included in a modified radical mastectomy?

A

all breast tissue, fascia of the muscle, nipple-areolar complex, and level 1-2 ax dissection

822
Q

what is included in radical mastectomy in addition to the MRM?

A

pec major and minor and level 3

823
Q

how are stage 1, 2, and 3a/3c breast CA treated?

A

surgery first, then radiation, and adjucant chemo if >1cm, +nodes, or ER/PR negative; consider trastuzumab if HER2 1cm or +nodes, give tamoxifen or aromatase inhibitor for ER/PR+

824
Q

what is the treatment for stage 3b breast CA?

A

neoadjuvant chemo then surgery then chemo-XRT and consider hormonals

825
Q

which breast cancers are non-operable?

A

stage 3c and 4

826
Q

how to treat non-operable breast CA?

A

hormonal therapy and chemo

827
Q

what is the standard chemo regimen for breast CA?

A

TAC (taxane aka paclitaxel, adriamycin, cyclophosphamide)

828
Q

what is the main side effect of paclitaxel?

A

neuropathy

829
Q

what is the main side effect of adriamycin?

A

cardiomyopathy

830
Q

what is the main side effect of cyclophosphamide?

A

hemorrhagic cystitis

831
Q

what is the main side effect. of trastuzumab?

A

cardiac disease (contraindicated if previous cardiac dz)

832
Q

how does trastuzumab work?

A

blocks HER2/neu receptor tyrosine kinase

833
Q

which hormonal is given pre-menopause in breast CA?

834
Q

which hormonal is given post-menopause in breast CA?

A

aromatase inhibitor (anastrozole)

835
Q

what are the main side effects of tamoxifen?

A

blood clots and endometrial CA

836
Q

what is the main side effect of aromatase inhibitor?

837
Q

who still needs radiation after MRM?

A

skin or chest wall involvement, positive margins, tumor >5cm, inflammatory CA, 4 or more nodes +, extracapsular invasion, N2 or 3

838
Q

what are contraindications to radiation in breast CA?

A

scleroderma, collagen vascular disease, previous XRT, pregnancy, lupus, active RA

839
Q

what is the standard follow up surveillance after breast CA tx?

A

annual mammogram and breast exam

840
Q

what are the subtypes of ductal CA of breast?

A

medullary, tubular, mucinous, scirrhotic

841
Q

which subtype of ductal breast CA has worst prognosis?

A

scirrhotic

842
Q

what designates worse prognosis in lobular breast cancer?

A

signet ring cells

843
Q

what deems a cystosarcoma phyllodes malignant?

A

> 5-10 mitoses per high power field

844
Q

how does cystosarcoma phyllodes spread?

A

hematogenous; not via lymph nodes

845
Q

what is the tx for cystosarcoma phyllodes?

A

WLE with 1cm margin, NO NODE DISSECTION

846
Q

what does pathology show for cystosarcoma phyllodes?

A

stromal and epithelial elements, mesenchymal tissue

847
Q

what are risk factors for male breast CA?

A

BRCA, steroids, previous XRT, family history, klinefelters syndrome

848
Q

what is tx for male breast CA?

A

MRM and tamoxifen and systemic tx if indicated

849
Q

what is tx of Pagets of breast?

A

MRM if CA, mastectomy if DCIS (cant do breast conservation because must take nipple)

850
Q

what is stewart treves syndrome?

A

lymphangiosarcoma from chronic lymphedema after axillary dissection (dark purple nodule or lesion on arm 5-10 years after surgery)

851
Q

what is the best indicator of TRAM flap survival?

A

good peri-umbilical muscle perforators

852
Q

what are contraindications to a TRAM flap?

A

smoking, transverse laparotomy incision, ipsilateral CABG that used the IMA

853
Q

how to treat DCIS diagnosed. in pregnancy?

A

lumpectomy under local, then wait til post-partum to do XRT

854
Q

what. is BIRADS 0?

A

insufficient test, repeat

855
Q

what is the significance of the Z11 trial?

A

women with breast CA <5cm and < 3 (+) sentinel nodes do not need axillary dissection, can get radiation instead with equivalent outcomes

856
Q

what can be used for sentinel node localization in pregnancy?

A

radiotracer; can NOT use methylene blue

857
Q

what is the preferred breast reconstruction option if radiation is done?

858
Q

what is the preferred breast reconstruction option if radiation is required but pt wants immediate recon?

A

tissue expander

859
Q

What is one key pathologic finding that distinguishes lobular carcinomas from ductal carcinomas?

A

key pathologic feature of lobular carcinoma is lack of epithelial cadherin expression

860
Q

what hormone tx do men get after breast cancer surgery?

861
Q

what surgery is done for inflammatory breast CA?

A

MRM after chemo

862
Q

what surgery is done for male breast CA?

A

always mastectomy; never lumpectomy

863
Q

what is the single most important predictor of difficult intubation?

A

chest xray

864
Q

what is the blood supply to the trachea?

A

upper 2/3 = inferior thyroid arteries, lower 1/3 = bronchial arteries

865
Q

what is the blood supply to the lung parenchyma?

A

bronchial arteries

866
Q

where does the thoracic duct cross midline?

867
Q

what is the role of type 1 pneumocytes?

A

gas exchange

868
Q

what is the role of type 2 pneumocytes?

A

surfactant production

869
Q

what predicted post-op FEV1 is needed before lung resection?

A

> 0.8 L (>40% predicted); if close then get split function V/Q scan

870
Q

what is the single best predictor of being able to be weaned off ventilator after lung resection?

871
Q

what is the most common complication following lung resection?

A

atelectasis

872
Q

what is the most common cause of empyema?

A

pneumonia with subsequent infection of parapneumonic effusion

873
Q

what are the 3 stages of empyema?

A

exudative, fibrinopurulent, and organizing (chronic)

874
Q

what is the most common benign lung tumor in adults?

875
Q

how to hamartomas of lung appear on CT?

A

popcorn lesion calcifications

876
Q

what is the tx of lung hamartoma?

877
Q

what is the most common benign upper airway tumor in kids?

A

hemangioma

878
Q

what is the most common malignant upper airway tumor in kids?

879
Q

what is the most common benign upper airway tumor in adults?

880
Q

what is the most common malignant upper airway tumor in adults?

881
Q

what do you do FIRST if suspected bleed of tracheoinnominate fistula?

A

overinflate balloon

882
Q

tx of tracheoinnominate fistula?

A

sternotomy and ligation of innominate artery; place strap muscle in between. do not use grafts

883
Q

what is the proper location of tracheostomy?

A

between 2nd and 3rd rings

884
Q

what is the most common cause of lung abscess?

A

aspiration pneumonia

885
Q

what is the most common organism in lung abscess?

A

staph aureus

886
Q

what is the tx of lung abscess?

A

usually just abx, rarely will need CT guided drainage or surgery if not resolving with abx

887
Q

what defines an exudative effusion?

A

lights criteria: fluid to serum LDH >0.6, fluid to serum protein >0.5, or fluid LDH >2/3 of serum

888
Q

how does pleurodesis differ for effusion if benign vs malignant?

A

benign: mechanical, malignant: talc

889
Q

what defines a solitary pulmonary nodule?

A

single, <3cm, surrounded by normal lung tissue without adenopathy or effusion

890
Q

what is the most common cause of lung mets?

891
Q

what is the #1 predictor of survivability in lung CA?

A

nodal involvement

892
Q

what is the biggest risk factor for lung CA?

A

of pack years

893
Q

where is lung cancer most likely to mets to?

894
Q

which nodes can not be assessed via mediastinoscopy?

A

AP window; must do chamberlin procedure (2nd rib) or VATS

895
Q

what is a T1 lung tumor?

896
Q

what is a T2 lung tumor?

A

> 3cm, or invading visceral pleura, or main bronchus tumor >2cm away from carina

897
Q

what is a T3 lung tumor?

A

direct invasion of chest wall, mediastinal pleura, or pericardium; or main bronchus within 2cm of carina

898
Q

what is a T4 lung tumor?

A

organ or great vessel invasion

899
Q

which lung cancer N stage is considered resectable?

900
Q

what is N1 in lung cancer?

A

ipsilateral peribronchial or perihilar

901
Q

what is N2 in lung cancer?

A

ipsilateral mediastinal or bronchial, AP window, esophageal, periaortic

902
Q

what is N3 in lung cancer?

A

contralateral nodes or supraclavicular/scalene nodes

903
Q

what is stage 1 lung CA?

A

1a: T1N0M0; 1b: T2N0M0

904
Q

what is stage 2 lung CA?

A

2a: T1N1M0; 2b: T2N1M0 or T3N0M0

905
Q

what is stage 3 lung CA?

A

3a: T3N1M0 or T1-3N2M0, 3b: any T4 or any N3

906
Q

what is stage 4 lung CA?

A

any M (which includes malignant effusion)

907
Q

at what lung cancer stage does neoadjuvant tx come before resection?

908
Q

what is the most common cause of SVC syndrome?

A

non-small cell lung CA

909
Q

what is the tx for SVC syndrome?

A

emergent radiation

910
Q

what is the most common paraneoplastic syndrome?

A

small cell ACTH release

911
Q

what is the most common mediastinal tumor in adults and children?

A

neurogenic (usually in posterior mediastinum)

912
Q

what is the most common tumor in the anterior mediastinum in adults?

913
Q

what is the most common anterior mediastinal tumor in kids?

A

germ cell (most common teratoma, but. if malignant than seminoma)

914
Q

what is the most common tumor in the middle mediastinum (kids and adults)?

915
Q

what is the most common cause of mediastinal lymphadenopathy?

916
Q

how to differentiate seminoma from non-seminoma?

A

non have HCG and AFP positive

917
Q

what lab value is prognostic for germ cell tumors of lung?

918
Q

how is chylothorax diagnosed?

A

sudan red stain, TAGs>110

919
Q

what is the tx for chylothorax?

A

1-3 weeks of NPO, TPN, chest tube, and octreotide. if doesnt work then ligate it low in R chest

920
Q

where does the phrenic nerve run in the neck?

A

anterior to anterior scalene

921
Q

where does the long thoracic nerve run in the neck?

A

posterior to middle scalene

922
Q

what is the most common cause of bronchiectasis?

A

cystic fibrosis

923
Q

what is the current lung cancer screening recommendation for smokers?

A

annual CT aged 55 to 80 with at least a 30 pack-year smoking history who either currently smoke or have quit in the past 15 years

924
Q

which node levels are in the AP window?

925
Q

what is the most common congenital heart lesion?

926
Q

what are the components. of tetralogy of fallot?

A

VSD, pulmonary stenosis, overriding aorta, R ventricular hypertrophy

927
Q

what is the most common cause of death in the US?

A

coronary artery disease

928
Q

what defines right dominant circulation of the heart?

A

posterior descending artery comes off of R coronary artery (most common)

929
Q

what defines left dominant circulation of the heart?

A

posterior descending artery comes off of circumflex coronary artery

930
Q

what are the branches of the left coronary artery?

A

LAD and circumflex

931
Q

how long do CABG vessels last, based on the vessel chosen?

A

IMA- 90% at 20 years, saphenous 80% at 5 years

932
Q

what phase does the heart freeze in during cardiac surgery?

933
Q

what volume of pleural effusion is detectable on CXR?

934
Q

which things are causes of exudative effusion?

A 
Malignancy
Pneumonia/infection
Tuberculosis
Pancreatitis
Pulmonary embolism
Chylothorax
935
Q

what is the best topical tx for MRSA in a burn wound?

A

mupirocen (bactroban)

936
Q

what are the indications for aortic stenosis valve replacement?

A

symptomatic and severe (<1 sq cm) or asymtomatic and <0.6cm

937
Q

what is the most common organism overall in endocarditis?

A

strep bovis

938
Q

what is the most common organism in acute endocarditis?

939
Q

what is the most common organism in endocarditis that. is from IVDA?

A

pseudomonas

940
Q

which layer of the aorta is a dissection in?

941
Q

what is standford type a vs b aortic dissection?

A

A= ascending included, B-= no ascending (boundary is proximal innominate artery)

942
Q

what is the debakey classification of aortic dissection?

A

1= both ascending and descending, 2= ascending only, 3= descending only

943
Q

where should the a line go in an aortic dissection patient?

A

right radial, because dissection may make the left side inaccurate

944
Q

which aortic dissections need to be repaired?

A

all type As, any B that has complications (rupture, expansion, limb/organ ischemia, etc)

945
Q

what is the most common cause of ascending aortic aneurysm?

A

cystic medial necrosis

946
Q

which ascending aortic aneurysms should be repaired?

A

symptomatic, rapid increase in size (>0.5cm/y), or >5.5cm

947
Q

what is the most common cause of descending aortic aneurysm?

A

atherosclerosis

948
Q

where is the majority of foci of afib?

A

pulmonary vein

949
Q

what is the first sign of cardiac tamponade on ECHO?

A

right atrial diastolic compression

950
Q

wha is the most common cardiac tumor?

A

myxoma; usually in left atrium

951
Q

what is the most common primary malignant tumor of the heart?

A

angiosarcoma

952
Q

what is the most common metastatic tumor to the heart?

953
Q

what is the most common primary pediatric heart tumor?

A

rhabdomyoma

954
Q

what is the treatmetn for post CABG pericarditis?

A

NSAIDs, steroids

955
Q

should carotid or CABG be done first if pt needs both?

A

carotid; then CABG 4 weeks later

956
Q

what is the best preventative agent for atherosclerosis?

957
Q

what is the most important risk factor for CVA?

958
Q

what is the first branch of internal carotid?

A

ophthalmic artery

959
Q

what is the first branch of external carotid?

A

superior thyroid

960
Q

what is amaurosis fugax?

A

transient occlusion of opthalmic artery

961
Q

what is the best treatment for vertebral artery stenosis?

A

PTA with stent

962
Q

what is the criteria for shunting during CEA?

A

if stump pressure <40 do a shunt

963
Q

what is the most commonly injured nerve during CEA?

964
Q

which nerve gets injured from retracting at the angle of the jaw during carotid?

A

marginal mandibular branch of facial nerve

965
Q

what causes severe post op HTN after carotid?

A

injury to carotid body

966
Q

what velocity on US is considered indication for CEA?

A

> 230 cm/s

967
Q

what is the most common cause of mortality after CEA?

968
Q

what is the triad of Leriche syndrome?

A

buttock claudication, lack of femoral pulses, impotence

969
Q

what structures are in the anterior compartment of the leg?

A

deep peroneal nerve and anterior tibial artery

970
Q

what structure are in the lateral compartment of the leg?

A

superficial peroneal nerve

971
Q

what structures are in the deep posterior compartment of the leg?

A

posterior tibial artery, peroneal artery, tibial nerve

972
Q

what structures are in the superficial posterior compartment of the leg?

A

sural nerve

973
Q

what is the first symptom of compartment syndrome?

A

pain with passive movement

974
Q

what is the treatment of popliteal entrapment syndrome?

A

resection of medial head of gastrocnemius

975
Q

what bug is most common cause of early vascular graft infection (<1 month)?

A

staph aureus

976
Q

what bug is the most common cause of late (and overall) vascular graft infection?

A

staph epidermidis

977
Q

what is the most sensitive test for diagnosing vascular graft infection?

A

tagged WBC scan

978
Q

what is the most common cause of AAA?

A

atherosclerosis causes degeneration of medial layer

979
Q

what size criteria deems need for fixing a AAA?

A

> 5.5 cm or growing >0.5cm/year

980
Q

what is the most common cause of death after AAA repair?

A

early: MI, late: renal failure

981
Q

what vessel is at risk when cross clamping aorta for AAA repair?

A

retroaortic L renal vein

982
Q

how do you precent an aortoenteric fistula?

A

cover proximal suture line with aneruysm sac

983
Q

what is the anticoagulant of choice in pregnancy?

984
Q

what are the size criteria for EVAR?

A

proximal and distal neck must be at least 1-3cm (no more, no less), diameter at landing zone at least 3.2cm, angle must be <60, iliac must be >7mm

985
Q

what is a type 1 endoleak?

A

leak at proximal or distal graft attachments

986
Q

what is a type 2 endoleak?

A

retrograde flow from collateral branches, such as lumbar arteries

987
Q

what is a type 3 endoleak?

A

leaking from different parts of the graft

988
Q

what is a type 4 endoleak?

A

leaking through graft wall (endotension)

989
Q

what is a type 5 endoleak?

A

cant identify the cause

990
Q

which types of endoleaks need immediate repair?

A

type 1 and 3

991
Q

what are the common complications of vessel aneurysms?

A

above inguinal ligament rupture, below inguinal ligament thrombose/embolize

992
Q

what is the criteria for fixing iliac aneurysms?

A

symptomatic, >3cm, or infected

993
Q

what is the criteria for fixing femoral aneurysms?

A

symptomatic, >2.5cm, or infected

994
Q

what is the criteria for fixing popliteal aneurysms?

A

symptomatic, >2cm, or infected

995
Q

how likely is someone with a popliteal aneurysm to have another one somewhere else?

A

50% bilateral, 50% elsewhere

996
Q

how to treat arterial pseudoaneurysm?

A

if from percutaneous procedure, try thrombin injection first. if at graft site, repair surgically

997
Q

what is the criteria for fixing visceral aneurysms?

A

> 2cm (1.5 for renal)

998
Q

what is the most common visceral artery aneursym?

999
Q

which splenic artery aneurysms should be fixed?

A

symptomatic, pregnant, plan to become pregnant, or >3-4cm

1000
Q

what is the most common cause of arterial emboli?

1001
Q

what is the most common site of arterial emboli to get stuck?

A

common femoral artery

1002
Q

when to consider EKOS instead of embolectomy?

A

if clot is at trifurcation (more distal than femoral) in an acute embolus, or if chronic progressive atherosclerotic disease in any part of the leg

1003
Q

why might a person with kawasaki’s need a CABG?

A

coronary artery aneurysms are common

1004
Q

what is the most common cause of AV graft failure?

A

intimal hyperplasia

1005
Q

what is the most common organism in suppurative thrombophlebitis?

A

staph aureus

1006
Q

what is the usual tx of fibromuscular dysplasia of the renal arteries?

A

angioplasty

1007
Q

what is the minimal vein size for AVF?

1008
Q

what is the Rutherford classification of acute limb ischemia?

A

Stage I: viable limb that is not immediately threatened (intact motor/sensory with +pulses)
Stage IIa: marginally threatened/salvageable limb (intact motor but lost sensory)
Stage IIb: immediately threatened limb that is salvageable only with immediate revascularization (mild to moderate motor loss with significant sensory loss)
Stage III: Irreversibly damaged limb with major tissue loss or permanent nerve damage (profound motor and sensory loss, generally with paralysis)

1009
Q

where is gastrin produced?

A

g cells in antrum and duodenum

1010
Q

what cells does gastrin target?

A

parietal and chief cells

1011
Q

what are the responses of gastrin?

A

secretion of HCl, IF, and pepsinogen

1012
Q

what is released from parietal cells?

A

HCl and IF

1013
Q

what is released from chief cells?

A

pepsinogen

1014
Q

where is somatostatin produced?

A

d cells in antrum

1015
Q

what stimulates somatostatin release?

A

acid in the duodenum

1016
Q

what does somatostatin do?

A

inhibits everything

1017
Q

what is octreotide?

A

somatostatin analog

1018
Q

where is GIP produced?

A

k cells in duodenum

1019
Q

what stimulates GIP?

A

glucose in the stomach

1020
Q

what is the target and reaction of GIP?

A

insulin released by pancreatic beta cells

1021
Q

where does CCK come from?

A

I cells in duodenum and jejunum

1022
Q

what stimulates CCK?

A

protein and fat in duodenum

1023
Q

what are the effects of CCK?

A

gallbladder contraction, relaxation of oddi sphincter, increased pancreatic enzyme secreation, increased intestinal motility, hepatic bile synthesis, satiety

1024
Q

where does secretin come from?

A

S cells in duodenum

1025
Q

what stimulates secretin?

A

acidity (pH <4), fat, bile

1026
Q

what inhibits secretin?

A

pH >4, gastrin

1027
Q

what are the responses to secretin?

A

inhibits gastrin and HCl, increases pancreatic bicarb release, increases bile flow, increases bicarb from brunners glands in duodenum

1028
Q

what stimulates VIP release?

A

fat, acetylcholine

1029
Q

where does VIP come from?

A

cells in gut and pancreas

1030
Q

what are the responses to VIP?

A

increased gut motility, decreased gastrin release, and increased intestinal secretion of water/lytes

1031
Q

where does glucagon come from?

A

alpha cells in pancreas (a little from stomach and intestine too)

1032
Q

what stimulates glucagon secretion?

A

decreased serum glucose, increased amino acids, cagal acetylcholine, GRP, cathecholamines

1033
Q

what are the responses to glucagon?

A

gluconeogenesis, glycogenolysis, lipolysis, ketogenesis, proteolysis, decreases gastric acid, pancreatic secretion, intestinal/stomach motility, and MMC

1034
Q

where does insulin come from?

A

beta cells of pancreas

1035
Q

what stimulates insulin release?

A

serum, glucose, glucagon, CCK, protein ingestion

1036
Q

what is the response to insulin?

A

cellular glucose uptake, synthesis of protein, glycogen, and triglycerides

1037
Q

where does pancreatic polypeptide come from?

A

islet cells in pancreas

1038
Q

what stimulates pancreatic polypeptide secretion?

A

fasting, exercise, and hypoglycemia

1039
Q

what does pancreatic polypeptide do?

A

decrease pancreatic function

1040
Q

where does peptide YY come from?

A

terminal ileum and colon

1041
Q

what is the response to peptide YY?

A

decreased gastric emptying and acid secretion, pancreatic function, and GB contraction; suppresses appetite and increases water/lyte absorption from colon

1042
Q

where does gastrin-releasing peptide come from?

A

post-ganglionic fibers of vagus nerve

1043
Q

what are the responses to gastrin-releasing peptide?

A

increased gastric acid secretion, intestinal motor activity, and pancreatic enzyme secretion

1044
Q

where does motilin come from?

A

M cells in duodenum

1045
Q

where are motilin receptors present?

A

antrum, duodenum, colon

1046
Q

what stimulates motilin secretion?

A

duodenal acid and vagus input

1047
Q

what inhibits motilin secretion?

A

somatostatin, secretin, pancreatic polypeptide, and duodenal fat

1048
Q

what is the main response of motilin?

A

increased antrum and duodenal motility

1049
Q

what hormones are involved in anorexia?

A

CCK and peptide YY

1050
Q

what are the layers of the esophagus?

A

mucosa, submucosa, muscularis propria, NO SEROSA

1051
Q

what is the blood supply to the esophagus?

A

cervical- inferior thyroid a, thoracic-directly off aorta, abdominal- mainly left gastric and some inferior phrenic

1052
Q

where does the criminal nerve of grassi come from?

A

right vagus

1053
Q

what part of vagus heads toward liver/biliary tree?

A

left vagus

1054
Q

what is normal pharyngeal contraction pressure with food bolus?

A

70-120mmHg

1055
Q

what is normal upper esophageal sphincter pressure?

A

60 at rest and 15 with food

1056
Q

what is normal LES pressure?

A

15 at rest and 0 with food

1057
Q

what is normal esophageal contraction pressure with food?

A

30-120mmHg; <10 is “burned out”

1058
Q

what are the anatomic distances of the esophagus?

A

from incisors: 15cm to cricopharyngeus, 25cm to aortic arch, 45cm to diaphragm hiatus

1059
Q

what makes the upper esophageal sphinter?

A

cricopharyngeus muscle

1060
Q

what is the most common site of esophageal perforation?

A

cricopharyngeus

1061
Q

where are the surgical approaches to the esophagus based on location?

A

neck = left, upper 2/3 thoracic = right thoracotomy, lower 1/3 thoracic = left thoracotomy

1062
Q

what is the best initial test for dysphagia?

A

esophagogram

1063
Q

what is the best test for diagnosis of achalasia?

A

manometry (will see high LES pressure and lack of peristalsis)

1064
Q

why do patients with achalasia need an EGD?

A

rule out cancer

1065
Q

what is the standard length for myotomy in heller?

A

7cm onto esophagus and 2cm onto stomach below GEJ

1066
Q

what is seen on esophogram with diffuse esophageal spasm?

A

corkscrew esophagus

1067
Q

what is seen on manometry with diffuse esophageal spasm?

A

high amplitude, repetitive, non-peristaltic contractions with normal LES relaxation

1068
Q

what is the tx of diffuse esophageal spasm?

A

calcium channel blocker, trazadone, psych exam

1069
Q

what is seen on manometry for achalasia?

A

LES does not relax, loss of peristalsis

1070
Q

what is the tx of achalasia?

A

CCB, balloon dilation, surgery is myotomy and fundoplication

1071
Q

what is seen on manometry in nutcracker esophagus?

A

normal LES with high amplitude peristalsis

1072
Q

what is seen on manometry with scleroderma?

A

aperistalsis, weak contractions, low/absent LES tone

1073
Q

what is the most common cause of epiphrenic diverticulum?

1074
Q

what is the tx of zenkers?

A

cricopharyngeal myotomy via left neck

1075
Q

what is the best test for esophageal perforation?

A

gastrograffin esophogram

1076
Q

what is the most common location and cause of esophageal perforation?

A

EGD at cricopharyngeus

1077
Q

which esophageal perfs need esophagectomy instead of primary repair?

A

> 48 hours, septic, or gross contamination

1078
Q

what is the #1 cause of non-iatrogenic esophageal perforation? #2?

A

boerhaaves; then foreign body

1079
Q

what is the workup of caustic esophageal injury?

A

first EGD, then swallow study

1080
Q

what is the best test for GERD?

1081
Q

what demester score indicates surgery?

1082
Q

what is the histology of barretts?

A

squamous to columnar metaplasia with goblet cells

1083
Q

what is the surveillence stndard for Barretts?

A

4 quadrant bx at 1cm intervals annually

1084
Q

what is the tx of choice. for high grade dysplasia in setting of barretts?

1085
Q

how much free esophagus do you need when doing fundoplication?

A

5cm in mediatinum, 2cm in abdomen

1086
Q

what is a type 1 hiatal hernia?

A

GE junction above diaphragm

1087
Q

what is a type 2 hiatal hernia?

A

paraesophageal, GEJ in normal position

1088
Q

what is type 3 hiatal hernia?

A

type 1 and 2 combined

1089
Q

what is type 4 hiatal hernia?

A

includes another organ besides the stomach

1090
Q

what is borchardts triad?

A

chest pain, retching without vomit, inability to pass NGT

1091
Q

what is the most common form of rotation for gastric volvulus?

A

organoaxial

1092
Q

what is the most common benign tumor of the esophagus?

1093
Q

what layer of the esophagus forms leiomyoma?

A

muscularis propria (submucosal)

1094
Q

what is the best test to diagnose an esophageal leiomyoma?

A

barium swallow followed by EGD with EUS (do not biopsy though)

1095
Q

what are the indications for surgery in an esophageal leiomyoma?

A

> 5cm, symptomatic, intraluminal, pedunculated, or mobile

1096
Q

what surgery do you do for an esophageal leiomyoma?

A

thoracotomy and enucleation (but can try endoscopic removal if <5cm)

1097
Q

what surgery do you do for a leiomyosarcoma?

A

esophagectomy

1098
Q

what is the diagnostic test for fibrovascular polyp of esophagus?

A

barium swallow; dont do EGD because it is intraluminal and can obstruct airway

1099
Q

what is tylosis?

A

combo of hyperkeratosis of hands/feet and esophageal cancer

1100
Q

what is the best test for T stage of esophageal CA?

1101
Q

what is the best test for determining overall resectability of esophageal CA?

1102
Q

what is the most important prognostic factor fo esophageal CA?

A

nodal spread

1103
Q

what is the worst tumor marker for prognosis of esophageal CA?

1104
Q

what is the most common esophageal cancer?

A

adenocarcinoma; linked to barretts and spreads to liver

1105
Q

where does esophageal squamous cell CA mets to?

1106
Q

what is the neoadjuvent regimen for esophageal CA?

A

cisplatin and 5fu and radiation

1107
Q

what margin is required for esophagectomy in CA?

1108
Q

what artery supplies blood to the gastric conduit after esophagectomy?

A

right gastroepiploic

1109
Q

what is the benefit of ivor lewis esophagectomy?

A

anastomosis in chest has lower leak rate

1110
Q

what is the most common colon segment used for esophageal reconstruction?

A

left colon based off left colic artery

1111
Q

which esophageal cancers can be treated with EMR/ablation?

A

T1a only if favorable grade, the rest need esophagectomy

1112
Q

which esophageal cancers get neoadjuvant?

A

all T2 and greater, some T1b depending on details/grade of the tumor. or any positive nodes

1113
Q

which esophageal cancer can get esophagectomy without neoadjuvant tx?

A

T1b if favorable grade

1114
Q

what is T1a esophageal CA?

A

invades lamina propria/muscularis mucosa

1115
Q

what is T1b esophgeal CA?

A

invades the submucosa, thus reaches the lymphatics

1116
Q

what is T2 esophageal CA?

A

invades the muscularis propria

1117
Q

what is T3 esophageal CA?

A

invades the adventitia (there is no serosa)

1118
Q

what is T4 esophageal CA?

A

invades adjacent structures (a: resectable structures, b: unresectable structures)

1119
Q

what is the N staging of esophageal cancer?

A

1: 1-2 nodes, 2: 3-6 nodes, 3: 7 or more nodes

1120
Q

where does the left gastroepiploic artery come from?

1121
Q

where does the right gastroepiploic artery come from?

1122
Q

where. does the right gastric artery come from?

A

common hepatic

1123
Q

what cells are in the fundus/body of stomach?

A

chief cells, parietal cells

1124
Q

where is b12 absorbed?

A

terminal ileum

1125
Q

what is pernicious anemia?

A

loss of parietal cells, thus no IF so cant absorb B12

1126
Q

what cells are in the antrum?

A

g cells, d cells, mucus and bicarb secreting glands

1127
Q

what is the role of brunners glands?

A

(found only in duodenum) secrete pepsinogen and alkaline mucus to protect the duodenum from acid

1128
Q

what is a billroth 1?

A

antrectomy with gastroduodenal anastomosis

1129
Q

what is a billroth 2?

A

antrectomy with gastrojejunal anastomosis

1130
Q

which gastric ulcers have normal acid?

A

1 & 4 (and 5 due to nsaids)

1131
Q

which gastric ulcers have increased acid production?

1132
Q

what is the best test for h pylori?

A

biopsy of antrum

1133
Q

what is type 1 gastric ulcer?

A

on lesser curve in body of stomach

1134
Q

what is type 2 gastric ulcer?

A

2 ulcers, lesser curve and duodenum

1135
Q

what is type 3 gastric ulcer?

A

pre-pyloric

1136
Q

what is type 4 gastric ulcer?

A

lesser curve high along cardia

1137
Q

what is type 5 gastric ulcer?

A

anywhere, due to NSAIDs

1138
Q

which stomach ulcers are associated with Type A blood?

1139
Q

which stomach ulcers are associated with type O blood?

1140
Q

are duodenal ulcers more likely anterior or posterior?

1141
Q

what is the most common complication of duodenal ulcers?

1142
Q

what is standard triple therapy for H pylori?

A

PPI, clarithromycin, and amoxicillin for 14 days

1143
Q

what is quadruple therapy for h pylori?

A

PPI, flagyl, tetracycline, and bismuth salts

1144
Q

which tests are used to confirm h pylori eradication?

A

urea breath test or stool antigen (not ELISA serology because it stays positive)

1145
Q

which arteries are ligated when oversewing a bleeding duodenal ulcer?

A

GDA and pancreaticoduodenal artery

1146
Q

what is the main side effect of TIPS?

A

encephalopathy

1147
Q

what are the advantages of roux en y over billroths?

A

no bile reflux and decreased dumping syndrome

1148
Q

what is the most common complication after vagotomy or gastrectomy?

A

diarrhea, from non-conjugated bile salts in colon

1149
Q

what causes dumping syndrome?

A

rapid entrance of carbs into jejunum (phase 1 is hyperosmotic load causing fluid shifts = hypotension; phase 2 is delayed from reactive increase in insulin leading to hypoglycemia)

1150
Q

what is the best test for dumping syndrome?

A

gastric emptying study

1151
Q

what is the tx for dumping syndrome?

A

small, high protein/low carb/low fat meals, can give octreotide before meals; if refractory can convert to roux en y

1152
Q

what are the symptoms of alkaline reflux gastritis?

A

n/v, post-prandial pain not relieved by vomiting

1153
Q

what is the best test for alkaline reflux gastritis?

1154
Q

what is the tx for alkaline reflux gastritis?

A

PPI, cholestyramine, reglan; convert to roux en y if refractory

1155
Q

what is afferent loop syndrome?

A

obstruction of biliary limb in B2 or roux en y

1156
Q

what are the symptoms of afferent loop syndrome?

A

non-bilious vomiting and pain, relieved with bilious emesis

1157
Q

what is the best test for afferent loop syndrome?

A

CT, PO contrast does not fill the limb

1158
Q

what is the tx of afferent loop syndrome?

A

can try balloon dilation, otherwise OR for re-anastomosis with shorter limb and tx of the problem causing the obstruction (ex: adhesions)

1159
Q

what is blind loop syndrome?

A

stasis in biliary limb leading to bacterial overgrowth

1160
Q

what are the symptoms of blind loop syndrome?

A

pain, malabsorption, B12 deficiency from bacteria using it all up, steatorhea

1161
Q

what is the best test to dx blind loop syndrome?

A

EGD with aspiration/culture

1162
Q

what is the tx of blind loop syndrome?

A

tetracycline and flagyl, with reglan or erythromycin; can do sx to make limb shorter

1163
Q

how is the emptying of the stomach altered by a vagotomy?

A

relaxation is impaired; increased liquid emptying but decreased solid emptying (thus need to do pyloroplasty)

1164
Q

what is the most common cause of recurrent peptic ulcer disease after surgery?

A

incomplete vagotomy (such as criminal nerve of grassi, or poorly performed HSV)

1165
Q

what is the cause of isolated gastric varices? tx?

A

splenic vein thrombosis from pancreatitis, tx is splenectomy

1166
Q

what BMI is criteria for gastric bypass surgerry?

A

> 40 or >35 with comorbidities such as HTN, DM, OSA

1167
Q

how long should the roux limb be in RNYGB?

1168
Q

how long should the y (biliary) limb be in RNYGB?

1169
Q

why isn’t jejunoileal bypass performed anymore?

A

liver cirrhosis, kidney problems, and osteoporosis (if encountered, convert to RNYGB)

1170
Q

what is the most common cause of leak after RNYGB?

A

ischemia (though if early leak, this is technical error)

1171
Q

how much excess weight loss % is lost with each type of bypass surgery?

A

lap band: 40-55%, sleeve 54-69%, RNYGB 61%, duodenal switch 70%

1172
Q

what is the most common benign gastric neoplasm?

A

GIST tumor

1173
Q

what is the best test for GIST?

A

EGD with biopsy, send for c-kit staining

1174
Q

what is the path seen with GIST tumor?

A

spindle cells, interstitial cells of cajal, autonomic pacemaker cells

1175
Q

where is the most common location of GIST?

A

stomach (70%)

1176
Q

where is the most common site of mets for GIST?

1177
Q

what makes a GIST malignant?

A

> 5-10 mitoses / 50 HPFs or size >5cm

1178
Q

what is the surgical tx of GIST?

A

wedge resection with 1cm margin, NO nodal dissection

1179
Q

which GIST need chemo?

A

all malignant (imatinib)

1180
Q

what is mALT lymphoma?

A

low grade B cell NHL from h pylori

1181
Q

what is the most common organ involved in extra-nodal lymphoma?

1182
Q

what is the dx modality for gastric lymphoma?

A

EUS with bx

1183
Q

which gastric lymphomas get surgery?

A

only stage 1 (submucosal) the rest get chemo +/- XRT

1184
Q

what is the most common location of gastric cancer?

1185
Q

what is the best test for gastric CA?

A

EGD with bx

1186
Q

what are the two types of gastric cancer?

A

intestinal (adenocarcinoma) and diffuse (linitis plastica)

1187
Q

which type of gastric cancer shows glands on path?

A

intestinal

1188
Q

what margin is required for gastric cancer?

1189
Q

how do you treat GE junction gastric cancer?

A

like esophageal cancer; esophagectomy and 5cm stomach margin

1190
Q

how do you treat gastric cancer in upper 1/3 of stomach?

A

total gastrectomy and esophagojejunal anastomosis

1191
Q

how. doyou treat middle or lower 1/3 gastric cancers?

A

distal gastrectomy and gastrojejunostomy

1192
Q

how do you treat diffuse gastric cancer?

A

total gastrectomy and esophagojejunal anastomosis

1193
Q

what is the chemo regimen for gastric cancer?

A

5FU, doxorubicin, and mitomycin

1194
Q

which gastric cancers need chemo?

A

anything stage 2 or higher get adjuvant chemo

1195
Q

what is the T stage of gastric CA?

A

T1: lamina propria or submucosa, T2: muscularis propria or subserosa T3: into serosa T4: adjacent structures

1196
Q

what is the N stage of gastric CA?

A

N1: 1-6 nodes, N2: 7-15 nodes, N3: >15 nodes

1197
Q

how many nodes are needed when resecting gastric CA?

1198
Q

what is D1 resection in gastric CA?

A

perigastric nodes

1199
Q

what is D2 resection in gastric CA?

A

D1 plus celiac nodes

1200
Q

what is D3 resection in gastric CA?

A

D2 plus hepatoduodenal nodes

1201
Q

what is D4 resection in gastric CA?

A

D3 plus periaortic and pericolic nodes

1202
Q

what gastrin level is pathoneumonic for ZE?

1203
Q

what protoncogene is associated with GIST/ckit?

1204
Q

what is the most common hepatic artery variant?

A

R hepatic off SMA

1205
Q

where is replaced R hepatic artery found?

A

behind neck of pancreas posterior/lateral to CBD

1206
Q

where is replaced left hepatic artery found?

A

gastrohepatic ligament, off of L gastric

1207
Q

what veins form the portal vein?

A

SMV and splenic

1208
Q

What is the orientation of the structures in the hepatoduodenal ligament?

A

CBD lateral, proper hepatic artery medial, and portal vein posterior

1209
Q

Where does the falciform divide the liver?

A

Between medial and lateral left lobe

1210
Q

What is inside the falciform ligament?

A

Remnant umbilical vein

1211
Q

What is the orientation of the structures in the hepatoduodenal ligament?

A

CBD lateral, proper hepatic artery medial, and portal vein posterior

1212
Q

Where does the falciform divide the liver?

A

Between medial and lateral left lobe

1213
Q

What is inside the falciform ligament?

A

Remnant umbilical vein

1214
Q

what separates the right and left lobes of the liver?

A

cantile’s line: line through the GB fossa to IVC

1215
Q

which coagulation factor is not made in the liver?

1216
Q

what is the only water soluble vitamin stored in the liver?

1217
Q

what are kupffer cells?

A

macrophages in the liver

1218
Q

what are the most common complications in hepatic resection?

A

bleeding and bile leak

1219
Q

which hepatocytes are most sensitive to ischemia?

A

centra lobar (zone 3)

1220
Q

where does urobilinogen come from?

A

breakdown of bilirubin by bacteria in terminal ileum

1221
Q

what is the rate limiting step for cholesterol synthesis?

A

HMG CoA reductase

1222
Q

what causes gallstones in obese patients?

A

overactive HMG CoA reductase

1223
Q

what causes gallstones in thin people?

A

underactive 7-alpha-hydroxylase

1224
Q

what is the most common cause of jaundice?

A

Gilbert’s disease (abnormal conjugation)

1225
Q

what is the best indicator of synthetic function of the liver with cirrhosis?

1226
Q

what is normal portal vein pressure?

1227
Q

what factors are included in Child Pugh score?

A

ascites, encephalopathy, INR, bilirubin, albumin

1228
Q

what factors are included in MELD score? significance?

A

bilirubin, INR, Cr; >15 likely to benefit from txp, <15 likely to die of liver txp before liver disease

1229
Q

what is the milan criteria for liver txp?

A

HCC with 1 lesion <5cm or 3 lesions <3cm

1230
Q

what medication is used for bleeding prophylaxis in someone with varices?

A

propanolol

1231
Q

what are the benefits of TIPS?

A

decreases ascites, variceal bleeding, increases txp free survival, and improves Cr clearance

1232
Q

what is a denver shunt?

A

peritoneal-venous shunt to R IJ

1233
Q

what is the unique complication of denver shunt?

1234
Q

what is the benefit and complication of splenorenal shunt? (aka warren shunt)

A

good for varices, but makes ascites worse

1235
Q

how can you increase hepatic reserve prior to liver resection?

A

portal vein embolization

1236
Q

how does hepatic vein thrombosis happen after pregnancy? tx?

A

ovarian vein thrombosis propagates to IVC then hepatic veins; heparin and abx

1237
Q

what is the most common casue of portal vein thrombosis in children?

A

umbilical vein infection

1238
Q

what is the most common cause of massive hematemesis in children?

A

portal vein thrombosis

1239
Q

what is budd chiari syndrome? most common cause?

A

hepatic vein thrombosis; polycythemia vera

1240
Q

what is the most common symptom of budd chiari syndrome?

1241
Q

what is the diagnosis and tx of budd chiari?

A

retrograde hepatic vein angiogram (diagnostic and therapeutic)

1242
Q

what is seen on liver bx with budd chiari?

A

sinusoidal dilatation and hepatic centrilobular congestoin

1243
Q

what liver disease is associated with ulcerative colitis?

A

PSC (DOES NOT GET BETTER WITH COLECTOMY)

1244
Q

what is the best test to diagnose PSC?

1245
Q

what is the main risk of having PSC?

A

cholangiocarcinoma

1246
Q

what is the treatment for PSC?

A

transplant; though 20% will recur

1247
Q

what lab tests are diagnostic of PBC?

A

increased anti-mitochondrial abs (m2IgG most sensitive) and LFTs (diagnostic enough to not need biopsy)

1248
Q

does PBC have increased cancer risk?

1249
Q

what is the suspected diagnosis if a liver cyst has “frong like projections”?

A

cystadenoma/cystadenocarcinoma

1250
Q

which side of the liver is more likely to have ecchinococal cyst?

A

right side

1251
Q

how do you diagnose an ecchinococcal cyst?

A

ELISA for IgG antibodies

1252
Q

how do humans get echinococcal cyst?

A

dogs that are infected by sheep

1253
Q

how does echinococcal cyst appear on CT?

A

calcified with double cyst wall and daughter cysts

1254
Q

how do you treat echinococcal cyst?

A

first consider ERCP to r/o duct communication, do not aspirate cyst! (risk of anaphylaxis); pre-op albendazole for 2 weeks then either PAIR or resection with hypertonic saline packs and ETOH injection

1255
Q

what is the most common organism in liver abscess?

1256
Q

what is the most common cause of liver abscess?

A

biliary tract disease

1257
Q

what is the treatment for liver abscess?

A

percutaneous drain and abx

1258
Q

how does entomeoba hstolytica reach the liver?

A

from colon via portal vein

1259
Q

what lab test can prove entomeoba histolytica?

A

agglutinin and immunoeletrophoresis antibody test

1260
Q

what is the treatment for liver abscess caused by entomeoba histolytica?

A

flagyl for 10 days (usually dont need drainage)

1261
Q

what are the signs/symptoms of schistosomiasis liver abscess?

A

maculopapular rash, variceal bleeding, travel to middle east, RUQ pain

1262
Q

what lab test can prove schistosomiasis?

A

agglutinin and immunoeletrophoresis antibody test, eosinophils, stool and urine O+P

1263
Q

what is the treatment for schistosomiasis?

A

praziquantel (usually dont need drainage)

1264
Q

what are the risk factors for hepatic adenoma?

A

women on OCPs, steroids, autoimmune disease

1265
Q

what will sulfer colliod scan show in hepatic adenoma?

A

negative because no kupffer cells in adenoma

1266
Q

which hepatic adenomas should be resected?

A

> 4cm, dont go away with d/c of OCPs/steroids, increasing in size, worsening symptoms, not on OCPs/steroids

1267
Q

how does FNH appear on CT?

A

hypervascular, homogenous, fills in arterial phase, central stellate scar

1268
Q

which liver mass has positive sulfur colloid scan?

1269
Q

what is tx of FNH?

A

not surgery; d/c OCPs/steroids and monitor

1270
Q

what is the most common benign liver tumor?

A

hemangioma

1271
Q

what is seen on CT with liver hemangioma?

A

peripheral to central enhancement

1272
Q

which liver mass has positive tagged RBC scan?

A

hemangioma

1273
Q

what is the tx for liver hemangioma?

A

no resection, conservative unless symptomatic (then youd resect it and pre-op embolization. if kid or unresectable, do steroids/XRT

1274
Q

how does HCC appear on CT?

A

vascular in arterial phase and washes out in portal venous phase, heterogeneous with necrotic areas

1275
Q

what lab tests can help diagnose HCC?

A

AFP and DCP (des-gamma carboxyprothrombin)

1276
Q

which type of HCC has the worst prognosis?

A

diffuse nodular

1277
Q

how much liver remnant is needed with normal liver function?

1278
Q

how much liver remnant is needed with an degree of liver dysfunction?

1279
Q

how much liver remnant is needed with cirrhosis?

1280
Q

what margin is required for liver resection?

1281
Q

what drug is used for unresectable liver cancer?

1282
Q

what is the best diagnostic study for liver mets?

A

intraop ultrasound

1283
Q

how do primary liver tumors vs mets differ on imaging?

A

primary are hypervascular, mets are hypovascular

1284
Q

what fascia forms the inguinal ligament?

A

external oblique

1285
Q

what layer forms the roof of the inguinal canal?

A

external oblique

1286
Q

what is the floor of the inguinal canal?

A

internal oblique fascia combined with transversalis fascia

1287
Q

what forms the conjoined tendon?

A

internal oblique fascia combined with ransversalis facia

1288
Q

what layer forms the cremasteric muscles?

A

internal oblique

1289
Q

what is the inguinal ligament attached to?

A

ASIS and pubis

1290
Q

what forms the inferior portion of the inguinal canal?

A

inguinal ligament

1291
Q

what is the lacunar ligament?

A

where the inguinal ligament splays onto pubis, connects the inguinal and pectineal ligaments

1292
Q

what is the pectineal ligament?

A

aka cooper’s ligament, periosteum of superior pubic ramus and transversalis fascia

1293
Q

what are the boundaries of hesselbach’s triangle?

A

rectus, inferior inguinal ligament, inferior epigastric vessels

1294
Q

what is the most common type of hernia?

A

indirect inguinal

1295
Q

which are more likely to recur: direct or indirect hernia?

1296
Q

what causes indirect hernia?

A

patent processus vaginalis

1297
Q

what causes direct hernia?

A

weakness in abdominal wall

1298
Q

how to treat a sliding hernia with ovary in it?

A

ligate round ligament to return ovary into abdomen

1299
Q

where is the vas deferens in the cord?

1300
Q

what is a bassini hernia repair?

A

conjoined tendon and transversalis fascia approximated to inguinal ligament

1301
Q

what is a mcvay hernia repair?

A

conjoined tendon and transversalis fascia approximated to cooper’s

1302
Q

what is a Lichtenstein hernia repair?

A

mesh reforms floor and between conjoined tendon and inguinal ligament

1303
Q

what is the treatment of ostitis after hernia repair?

1304
Q

where do you make the relaxing incision for a hernia repair?

A

1cm above pubic tubercle at lateral border of rectus

1305
Q

whre do hernias usually recur?

A

medial to mesh

1306
Q

how to treat hernias you cant reduce during operation?

A

divide the inguinal ligament

1307
Q

what is the most common EARLY complication after hernia repair?

A

urinary retention

1308
Q

what causes testicular atrophy after hernia repair?

A

injury to spermatic veins

1309
Q

what is the most common cause of pain after inguinal hernia repair?

A

compression of ilioinguinal nerve

1310
Q

where is the ilioinguinal nerve encountered during inguinal hernia repair?

A

anterior to cord structures

1311
Q

what are the symptoms of ilioinguinal nerve injury?

A

loss of cremasteric reflex, numbness of ipsilateral penis, scortum, and medial thigh

1312
Q

where is the genital branch of the genitofemoral nerve encountered?

A

posterior and inferior to cord

1313
Q

what does the genital branch of geniteofemoral nerve innervate?

A

motor to cremasters and sensory to scrotum

1314
Q

what does the femoral branch of the genitofemoral nerve innervate?

A

sensory to lateral thigh

1315
Q

where does the femoral branch of the genitofemoral nerve run?

A

lateral to iliac vessels

1316
Q

how do you repair femoral hernia?

A

open = mcvay, or can do laparoscopic

1317
Q

when should you repair an umbilical hernia in children?

A

5 years old (before starting school)

1318
Q

what hernia has inner thigh pain with internal rotation of thigh?

1319
Q

what is a petit hernia?

A

inferior lumbar triangle: external abdominal oblique, lumbodorsal aponeurosis or lattisimus dorsi, and iliac crest

1320
Q

what is a grynfelt-lesshaft hernia?

A

superior lumbar triangle: internal abdominal oblique, lumbodorsal aponeurosis, and 12th rib

1321
Q

what is fothergills sign?

A

rectus sheath hematoma mass gets more prominent with rectus muscle flexion

1322
Q

where is the triangle of doom?

A

inferior, lateral

1323
Q

what is unique about the layers of the gallbaldder wall?

A

no submucosa

1324
Q

why does a person get gallstones after terminal ileum resection?

A

poor absorption of bile acids, so more unconjugated bilirubin is aborsbed

1325
Q

what disorders cause black gallstones?

A

sickle cell, spherocytosis, hemolytic anemia, TPN, terminal ileum resection

1326
Q

why does e. coli cause brown gallstones?

A

produces beta glucoronidase, which deconjugates bilirubin leading to formation of calcium bilirubinate

1327
Q

what is the most common organism in cholecystitis?

1328
Q

what is the most sensitive test for cholecystitis?

1329
Q

what is the most common kind of gallbladder polyp?

A

cholesterol

1330
Q

what are the indications for cholecystectomy in gallbladder polyps?

A

> 1cm, stones also present, sessile, malignant looking, have PSC

1331
Q

what is the most common cause of CBD injury during cholecystectomy?

A

excess cephalad retraction

1332
Q

what is the surgery for upper 1/3 bile duct CA?

A

hepatic resection

1333
Q

what is the surgery for middle 1/3 bile duct CA?

A

hepaticojejunostomy

1334
Q

what is the surgery for lower 1/3 bile duct CA?

1335
Q

what is the tx for stage T1a gallbladder CA?

A

open chole (mucosa/lamina propria only)

1336
Q

what is the tx for T1b gallbladder CA?

A

GB and wedge resection of segments 4-5 with 2-3cm margin (invades muscularis) and stripping of nodes

1337
Q

what is the tx for any gallbladder CA beyond the muscularis (T12and greater) ?

A

formal 4b and 5 liver resection in addition to nodes/GB

1338
Q

what is the first branch off the SMA?

A

inferior pancreaticoduodenal

1339
Q

where are the superior mesenteric vessels (vein vs artery)?

A

vein is to right of artery

1340
Q

what causes annular pancreas?

A

failure of clockwise rotation. ofthe ventral pancreatic bud

1341
Q

what is seen on imaging with annular pancreas?

A

double bubble sign, stenosis on UGI

1342
Q

what is the tx of choice for annular pancreas?

A

duodeno-jejunostomy (can also do duodenoduodenostomy)

1343
Q

what is the tx of choice for symptomatic pancreatic divisum?

A

ERCP/sphincterotomy

1344
Q

what is the most common location of heterotopic pancreas?

1345
Q

what is the tx of hemorrhagic pancreatitis?

A

angioembolization

1346
Q

what is peustow procedure?

A

longitudinal pancreaticojejunostomy when duct is dilated (8mm or more)

1347
Q

what is beger procedure?

A

pancreatic head resection

1348
Q

what is Frey procedure?

A

combo of peustow and beger

1349
Q

what is the cytology findings of pancreatic pseudocyst?

A

no glycogen, no mucin, high amylase

1350
Q

what is the cytology seen with serous cystadenoma of pancreas?

A

high glycogen, low mucin

1351
Q

what is the cytology seen with mucinous cystadenoma?

A

high mucin (premalignant, must resect)

1352
Q

what is the #1 risk factor for pancreatic adenocarcinoma?

1353
Q

what tumor markers are seen in pancreatic cancer?

A

CA 19-9, K-ras, p53, CDKN2A, and SMAD4

1354
Q

what is the most common complication after whipple?

A

delayed gastric emptying

1355
Q

which pancreatic neuroendocrine tumors can not be found with octreotide scan?

A

insulinoma

1356
Q

which pancreatic neuroendocrine tumors do not respond to octreotide?

A

somatostatinoma

1357
Q

where to pancreatic neuroendocrine tumors spread to ?

1358
Q

what is the most common functional neuroendocrine pancreatic tumor?

A

insulinoma

1359
Q

where are insulinomas found? are they malignant?

A

evenly throughout pancreas, 90% benign

1360
Q

what is whipple’s triad?

A

classic presentation of insulinoma: fasting hypoglycemia, sx of hypoglycemia, relief with glucose

1361
Q

what is the surgical tx of insulinoma?

A

if <2cm enucleate, if >2cm formal resection

1362
Q

what is the most common pancreatic neuroendocrine tumor in MEN1?

A

gastrinoma

1363
Q

where are gastrinomas found? are they malignant?

A

gastrinoma triangle; 50% malignant

1364
Q

what is the gastrinoma triangle?

A

CBD, neck of pancreas, 3rd portion of duodenum

1365
Q

what are the symptoms of gastrinoma?

A

complicated ulcer disease, diarrhea improved with PPI

1366
Q

how do you diagnose gastrinoma?

A

fasting serum gastrin (>200 suspicious, >1000 diagnostic), basal acid output >15, secretin stimulation test shows increased gastrin level, CT, octreotide scan

1367
Q

where are somatostatinomas found? are they malignant?

A

head of pancreas, most are malignant (worst prognosis of all pancreatic neuroendocrine tumors)

1368
Q

what are the symptoms of somatostatinoma?

A

DM, gallstones, steatorrhea

1369
Q

where are glucagonomas found? are they malignant?

A

distal pancreas, most are malignant

1370
Q

what are the symptoms of glucagonoma?

A

diabetes, dermatitis (necrolytic migratory erythema), weight loss, stomatitis

1371
Q

where are VIPomas usually found? are they malignant?

A

distal pancreas, most. are malignant

1372
Q

what are they symptoms of VIPoma?

A

watery diarrhea not improved with PPI, hypokalemia, achlorhydria

1373
Q

what size of pancreatic duct is considered dilated?

1374
Q

where is the splenic vein in relation to splenic artery?

A

posterior and inferior

1375
Q

what are the ligaments to the spleen?

A

gastrosplenic, splenocolic, splenonephric, and splenophrenic

1376
Q

what are howell jolly bodies?

A

nuclear remnants

1377
Q

what are heinz bodies?

A

hemoglobin (siderocytes)

1378
Q

what are pappenheimer bodies?

1379
Q

what is the most common immunoglobulin in spleen?

A

IgM; largest producer of IgM in body

1380
Q

where is the. mostcommon site of accessory spleen?

A

splenic hilum

1381
Q

what is the most common condition, aside from trauma, requiring splenectomy?

1382
Q

what is the most common splenic tumor?

A

hemangioma

1383
Q

what is the most common malignant splenic tumor?

1384
Q

which splenic cysts should be removed?

A

> 10cm becomes cancer risk

1385
Q

what size is the spleen in ITP?

1386
Q

what is the treatment for ITP?

A

steroids first, then IVIg, anti-rh abs, splenectomy if fials medical management

1387
Q

when do you give platelets if needed during splenectomy?

A

after ligation of splenic artery

1388
Q

what organism is most likely to cause infection after splenectomy?

A

strep pneumoniae

1389
Q

who should get prophylactic augmentin after splenectomy?

A

children <10yo

1390
Q

what causes TTP?

A

deficiency of enzyme ADAMTS13

1391
Q

what is the tx for TTP?

A

plasmapheresis, usually NOT splenectomy

1392
Q

which causes of splenectomy are most susceptible to OPSI?

A

non-trauma, thalassemia high and trauma least. Wiskott-Aldrich is most

1393
Q

how often does pneumococcal and meningitis vaccine need to be boostered after splenectomy?

A

pneumo: every 3 years, meningitis: every 5 years

1394
Q

what is the most common cause of chylous ascites?

1395
Q

what is the most common congenital reason for splenectomy?

A

hereditary spherocytosis

1396
Q

what is the tx for hereditary spherocytosis?

A

splenectomy and cholecystectomy

1397
Q

what is felty syndrome?

A

RA, neutropenia, splenomegaly

1398
Q

what is the most common splenic cyst? tx?

A

echinococcal, splenectomy

1399
Q

what is the most common organism in splenic abscess?

A

streptococcus

1400
Q

what do goblet cells secrete?

1401
Q

what is the serology test for celiac?

A

anti-transglutamase abs

1402
Q

what is the most common symptom of crohns?

A

anal disease

1403
Q

what is the best test for diagnosing crohns?

A

colonoscopy with biopsies

1404
Q

what kind of kidney stones are seen in crohns disease?

A

calcium oxalate

1405
Q

what is the best test for finding a carcinoid tumor?

A

octreotide scan

1406
Q

what tests should be checked with suspected carcinoid?

A

urine 5HIAA and chromogranin A

1407
Q

what kind of cells are found in carcinoid tumor?

A

kulchitsky cells (APUD, neuroendocrine)

1408
Q

what is the most common site of carcinoid tumor?

A

appendix; then ileum, then rectum

1409
Q

what are the chemo options for carcinoid?

A

octreotide, interferon, streptozocin, 5fu

1410
Q

what is the most common small bowel tumor?

A

leiomyoma, usually extra-luminal

1411
Q

what is the most common cancer with puetz jegher?

1412
Q

what is the most common cause of intussuception in adults?

A

cecal adenocarcinoma

1413
Q

what is the most common casue of stomal infection?

1414
Q

what. isthe most common casue of acute abdominal pain in first trimester?

A

appendicitis

1415
Q

when is appendicitis most likely to occur in pregnancy?

A

2nd trimester

1416
Q

what is the tx for benign appendix mucocele?

1417
Q

what is the tx for malignant appendix mucocele?

1418
Q

which part of the colon does not have serosa?

1419
Q

where does middle rectal artery come from?

A

internal iliac

1420
Q

where does inferior rectal artery come from?

A

internal pudendal

1421
Q

which muscle forms external anal sphincter?

A

puborectalis

1422
Q

what nerves innervate the external anal sphincter?

A

internal pudendal (sympathetic) and perineal branch of S4

1423
Q

what is the nerve supply to internal anal sphincter?

A

pelvic splanchnics (s2-s4 parasympathetic)

1424
Q

what layer makes up internal anal sphincter?

A

muscularis propria

1425
Q

what is the treatment for disuse pouchitis compared to infectious pouchitis?

A

disuse: SCFA enema; infectious = cipro/flagyl

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