Criteria & Algorithms

Question 1

Criteria for the diagnosis of Infective endocarditis

Answer 1

Duke Criteria: 2 major, 1 major & 3 minor, or 5 minor

Major:
Typical organism on 2 blood cx: viridans strep, aureus, HACEK, S. Bovis, or community acquired enterococci.
Echo showing: intracardiac mass, abscess, partial dehiscence of prosthetic valve, or new regurg

Minor:
Previous IE, IVDA, protshesis, or cardiac lesion.
Fever > 38 ° C.
Vascular phenomena: emboli, mycotic aneurisms, Janeway lesions, conjunctival hemorrhage.
Immunologic phenomena: Glomerulonephritis, Osler nodes, Roth spots.
Microbiological findings not meeting any major criteria.

Question 2

Types of Klatskin tumors

Answer 2

Type I: limited to common hepatic duct
Type II: involve the bifurcation of the L & R hepatic ducts
Type IIIa: enter secondary right
Type IIIb: or secondary left intrahepatic ducts

Question 3

Rules or clinical clearance of the cervical

spine

Answer 3

NEXUS criteria: the 
patient is alert and not intoxicated; no 
posterior midline C-spine tenderness; 
no neurologic de cit; and no pain ul 
distracting injuries.

Question 4

Determination if pt needs ankle imaging

Answer 4

Ottawa ankle rules.
X-rays indicated if:
Tenderness over the distal 6cm of tib/fib.
Tenderness over either malleolus
Inability to bear weight over 4 steps
Tenderness over base of the 5th metatarsal
Tenderness over the navicular bone

Question 5

Clinical criteria for predicting the mortality risk of acute pancreatitis

Answer 5

Ranson criteria:

At admission:

Age in years > 55 years
WBC count > 16000 cells/mm3
Blood glucose > 11 mmol/L (> 200 mg/dL)
Serum AST > 250 IU/L
Serum LDH > 350 IU/L

Within 48 hours:
Serum calcium < 2.0 mmol/L (< 8.0 mg/dL)
Hematocrit fall > 10%
Oxygen (hypoxemia PaO2 < 60 mmHg)
BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration
Base deficit (negative base excess) > 4 mEq/L
Sequestration of fluids > 6 L

Question 6

How much rapid acting insulin should you add for coverage of intermittent hyperglycemia?

Answer 6

2 units for every 50 glucose above 100

Question 7

Bismuth Corlette classification of cholangiocarcinomas

Answer 7

Type I: occurs below the confluence of the L & R hepatic duct
Type II: occurs at the juncture of the L & R hepatic ducts
Type III: involves either the L or R hepatic duct
Type IV: involves secondary extensions of either the L or R hepatic ducts

Question 8

Gharbi types for classifying hyatid cyst

Answer 8

(Gharbi types): 
a simple cyst (type
I), a cyst with free-floating hyperechogenic material called hydatid sand (type II), a cyst with a
rosette appearance suggesting a daughter cyst (type III), and a cyst with a diffuse hyperechoic
solid pattern (type IV)

Question 9

Bedside Index for Severity in Acute Pancreatitis (BISAP) score

Answer 9

The parameters for BISAP include blood urea nitrogen (BUN) level
greater than 25 mg/dL, impaired mentation, 2 or more systemic inflammatory response syndrome (SIRS) criteria, age greater than 65 years, and the presence of pleural effusion.

Question 10

Criteria used for evaluation of intraoperative chemical cure during parathyroidectomy

Answer 10

Miami criteria:

PTH has a half life of 3 min. 10 min after resection of single adenoma, there should be an ≥ 50% drop in serum PTH. This can be repeated at 20 min if initial response is incomplete.

Chemical response is not affected by age, renal fxn, or BMI according to recent JAMA surgery study

Question 11

Fluid recussitation in a burn patient

Answer 11

Parkland formula:

Question 12

Grading system for a blunt carotid injury

Answer 12

grade I: luminal irregularity or dissection with less than 25% luminal narrowing; grade II: dissection or intramural hematoma with greater than or equal 25% luminal narrowing; grade III: pseudoaneurysm; grade IV: occlusion; grade V: transection

Question 13

DVT triad

Answer 13

Virchow triad

Stasis, endothelial injury, hypercoagulability

Question 14

Harris-Benedict equations

Answer 14

Basal energy expenditure is calculated based on height, weight, age.

Total energy expenditure = Basal energy expenditure * (activity factor) * (stress factor)

Pt on vent * 1.1
Pt on bed rest * 1.5
Normal ambulation * 1.25
Manual worker *1.5-2.0
Trauma + infection * 1.5
Major burn *2.0

Question 15

Criteria for diagnosing HNPCC

Answer 15

Amsterdam criteria:

(1) a family with at least three relatives having proven colorectal cancer and one individual being a primary relative of the other two, (2) at least two generations being affected, and (3) one individual being diagnosed before age 50. Broader sets of criteria include the Bethesda and Modified Bethesda criteria, which may more accurately define the syndrome.

3 individuals
2 generations
1 <40yo

Question 16

Diagnostic criteria for necrotizing soft tissue infxn

Answer 16

LINREC (Laboratory Risk Indicator for Necrotizing Fasciitis) Score

CRP (mg/L)	
<150	  0
≥150	+4
WBC per mm³	
<15	         0
15-25	+1
>25	       +2
Hemoglobin (g/dL)	
>13.5	  0
11-13.5	+1
<11	       +2
Sodium	
≥135	  0
<135	+2
Creatinine	
≤ 1.6 mg/dL / 141 µmol/L	      0
>1.6 mg/dL / 141 µmol/L	    +2
Glucose
≤180 mg/dL / 10 mmol/L	      0
>180 mg/dL / 10 mmol/L	    +1

LRINEC score ≥ 6 had a sensitivity of approximately 90% and a specificity of approximately 95%, PPV 92% and NPV 95%. However, this cut-off still missed 10% of patients with necrotizing fasciitis.

Question 17

Criteria for peds HCT in trauma

Answer 17

Pediatric Emergency Care Applied Research Network (PECARN) Criteria

Age (>/

Question 18

Classification for choledochal cysts

Answer 18

Todani classification

Ia. Cystic dilatation of EHD
Ib. Cystic dilatation of CBD
Ic. Fusiform dilatation of CBD
II. CBD Diverticulum
III. Choledochocele at the confluence of the CBD and PD
IVa. Multiple dilated areas & strictures in CBD and intrahepatic ducts
IVb. Multiple dilated areas & strictures in CBD
V. Carol do, multiple intrahepatic dilatations

Question 19

Classification of severity of acutecholecystitis

Answer 19

Tokyo guidelines

Grade III
Cholecystitis w/ end organ dysfunction
5.4% 30-day mortality

Grade II (≥1 of the following conditions):
Elevated WBC count (>18,000/mm3)
Palpable tender mass in the right upper abdominal quadrant
Duration of complaints >72 hours
Marked local inflammation (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis, emphysematous cholecystitis)
0.8% 30-day mortality

Grade I
Acute cholecystitis does not meet the above criteria
1.1% 30-day mortality

Question 20

Classification of Hidradenitis Suppuritiva

Answer 20

Hurley stage I disease involves localized abscesses without sinus tracts or scarring.
Hurley stage II involves multiple abscesses, scarring, and sinus tracts in the axilla that are separated by normal-appearing skin.
Hurley stage III disease involves diffuse disease with multiple interconnected sinus tracts and abscesses involving an entire anatomic area with scarring. Often draining, no healthy skin between