DECJ Flashcards
Tx of SIADH
fluid restrictiondemeclocycline or vaptans (adh inhibitor)
Portal vein thrombosis tx
Control HMHG with variceal ligationAnticoagulate once bleeding controlledConsider distal spleno-renal shunt
MRSA tx
vancomycinif vanc resistant then linezolid
VWF
binds GP1b on PLTs and attaches them to endothelium
Margin for invasives cancer vs. dcis
invasive cancer- gross negativedcis- 1 to 2 mm
Interleukins 1, 2, 4
IL1: feverIL2: T cell prolif and Ig productionIL4: T/B cell maturation
Ovarian tumor markers:AFPCEAHCGLDHCa 125Inhibin
AFP: yolk sac tumor, endodermal sinusCEA: mucinous ovarian tumorHCG: ovarian choriocarcinoma, embryonal carcinomaLDH: dysgerminomaCa 125: epithelial ovarian tumorsInhibin: granulosa cell tumor
Hormones that increase LES pressure
GastrinMotilin
Origin of med thyroid cancer
4th pharyngeal arch NCC –> parafollicular C cells
Gardner syndrome
epidermal cysts, GI polyposis, osteomas
Indidcations for operative treatment of eso perf
early postemetic perforation hemodynamic instability intra-abdominal perforation extravasations of contrast into adjacent body cavities presence of underlying malignancy, obstruction or strictureplace jejunostomy tube for feeding after. don’t place gastric tube (conduit)
Uremic PLT dysfunction
2/2 renal diseasereversible dysfunctiontx- ddavp
B12 def
megalo anemia, neuropathy
Traction vs. Pulsion Diverticulum
traction- inflammation; all 3 layers; mid esopulsion- pressure; 2 layers; above circoph.
Positioning for indirect laryngoscopy
sitting upright with a straight back, leaning slightly toward you with chin pointing upward (“sniffing position”)
Kcal per macronutrient
protein = 4 kcal/gdextrose = 3 kcal/glipid = 9kcal/gcarb = 4 kcal/g
p53
TSG on Ch17cell cycle regulation and apoptosis
Rule of 9s
Each arm 9Each leg 18Ant belly 18, Post belly 18Each hand 1Ant face 4.5, Post face 4.5Genitals 1
EBV associated with
B cell lymphome (Burkitt)n/ph cancer
FRC
Volume of the lung after normal tidal expiration
Cisatracurium
non-depolarizingcleared by Hoffman degradationuse in pts w/ renal and hepatic disease
tacro
MOA: calcineurin inhibitor (binds fK)s/e- nephrotoxic, p. neuropathy, allopecia
SD
1, 2, and 3 SD = 67%, 95%, and 99.7% of the data
Intraductal papilloma
MCCO bloody nipple d/ctx w/ duct excisionno increased r/o ca
Blood supply to esophagus
Upper 3rd- inferior thryoid arteryMiddle 3rd- thoracic aortaLower 3rd- left gastric
Pleomorphic adenoma
MC benign H/N tumormiddle aged womanslow growing; t2 brightTx: superficial parotidectomy even if asx
Rule of 6s
flow > 600/mindiameter > 6mm (after placement)depth of 6mm
Comparing pressors
Norepi: alpha1 >alpha2,beta1Epi: beta1, alpha1 > beta2, alpha2Phenylephrine: alpha1 > alpha2(no beta)
MCCO of spontaneous bacterial peritonitis
E. Coli
Max dose of lido and bupiv
lido = 5mg/kg (7 w/ epi)bupiv = 2.5 mg/kgtx- lipid emulsion
Lamivudine
rTranscriptase inhibitorTx for hep B at low doses; HIV at high doses
Wound healing order of entry
plts → PMNs → macrophages → fibroblast → keratinocytes
5Ts of cyanosis
TOF Transposition of GVs Truncus art Tricuspid atresia TAPVC
Pain after inguinal hernia repair
Ilioinguinal nerveInjured at external ring. Lies anterior to cordtx- local injection
Staging adrenal cancer
s1- <5cms2- >5cms3- n1 or t3s4- mets
location of vagus nerve
LARPleft anterior, right posterior to esophagus
Dopamine dosing
low- d1/2 ago (renal dose)medium- B agohigh- A ago
LIPID A
Gram negative bacteria (Klebsiella)lipopolysaccharide layerendotoxin → septic shock
<p><span>Beta lactamase inhibitors</span></p>
<span>Sulbactam/Tazobactam</span><span>Clavulanic acid</span>
Contents of ant triangle
Carotid sheath, anca cervicalis, CN 12 (hypoglossal)Contents of carotid sheath: CN10 (vagus), CCA, ICA, internal jugular facial vein is the gateway
BRCA risks
female breast, ovarian, male breastI- 60, 40, 1II- 60, 10, 10Women withBRCAbreast CA have the same prognosis stage for stage as non-BRCAbreast CA
Kasabach-Merritt Syndrome:
hemangioma + thrombocytopeniausually infantsresect!
Traumatic renal artery thrombosis
Unilateral- anticoagulationBilateral- OR or IR stent
Adenoid cystic carcinoma
MC minor salivary gland tumor (SM gland)propensity for perineural invasionRemains quiescent for years then metastasizes aggressively
SLNBx for melanoma
< .75 mm none> .75 to 1 mm w/ ulceration, mitosis, invasion
Hernia repairs:BassiniMcVayLichtenstein
Bassini: CT to ILMcVay: CT to cooper’sLichtenstein: mesh
Casues of increased ETCO2
Increased muscle activity (shivering)Increased metabolism (sepsis, fever, malignany hyperT)Increased CODecreased minute ventilation
Acute cellular rejection
T cell mediatedpath: portal cellular infiltrate + endotheliitistx: pulse steroids → consider thymo
Phyllodes tumor
“sarcoma of the breast”tx- en bloc resectionhematog spread- chemo/LN dissection unnneccesary
Birads 0
More imaging: mammogram or targeted US
Mediastinal tumors
Anterior: lymphoma MC in children, thymoma MC in adultsMiddle: lymphoma MCPosterior: neurologic MC
Vitamin C
hydroxylation of lysine and prolinetype 3 collagen cross-linking
Staph virulence factors
protein A: binds Fc component of IgG, forcing variable region to face away from bacterium Enterotoxins: intestines Toxic shock syndrome toxin-1 (TSST-1): superantigen. binds MHC II and T-cell receptor Coagulase: converts fibrinogen to fibrin clot Exfolatins: skin-exfoliating toxins
CN11
spinal accessory nerveexit jugulars forameninnervates SCM and trapezius goes along post triangle
Tx of SVC syndrome
Angio stenting and steroidsfor sxatic reliefUrgent chemo/rads therapy
Silvadene, mafenide, silver nitrate s/e
Silvadene: s/e- neutropenia, hypersensitivity, kernicterus (avoid in preg)Mafenide: psuedomonas coverages/e- met acidosisSilver Nitrate: s/e- hypoNatremia
Indications for radioiodine thereapy
2-4 cm massvascular invasionanti-Tg AbTG < 5
Hemophilia A
f8 DEFICIENCY SLRMC inherited disordertx- DESMOPRESSIN (mild), f8 concentrate (severe)
Strongest layer of bowel
SM
Contents of post triangle
CN 11 subclavian arteryEJVbrachial plexus trunks
Paget-Schroetter syndrome
Exercise induced thrombosis of subclavian/axillary VEINTx- catheter directed thrombolysis
NEC
Bloody stools after 1st feeddx- pneumatosistx- resuscitation, abx; OR if free air, clinical deterioration
Fibroadenoma
cyclical paindx- US guided core bxonly excise if discordance with biopsy!
Pancuronium
non-depoleliminated by kidney and liver
Location ofsuperior sympathetic block
3 to 5 cm in length on the longus capitus muscle anterior to the transverse process of the second, third, and rarely the fourth cervical vertebrae
Order of contents in thoracic outlet
vein (SC)phrenicmuscle (scalene)artery (SC)nerve (br plexus)
Insulinoma
Loc: throughoutPx: whipple’s triadtx- < 2cm encucleate, >2cm resect
GCS verbal
5- normal4- confused3- inappropriate words2- incomprehensible1- none
<p><span>Plasmin</span></p>
<p><span>Degrades f5, 8, fibrinogen, and fibrin</span></p>
TXA2
vasoconstrictorsreleased by PLTs
Pseudocyst
encapsulatedlack epithelial lining>5cm requires drainage
<p><span>Sevoflurane</span></p>
fast, less laryngospasm, less pungentgood for mask induction
<p><span>Fibrin</span></p>
<p><span>Links Gp2b/3a to form PLT plug</span></p>
NOAC reversak
Dabigatran (pradaxa)- Idarucizumab, iHDApixaban- PCC (partial)Rivoroxaban- PCC (partial)
Indications for post op radio-iodine
2-4 cmvascular invasionanti-Tg AbTG<5
PEAK and TROUGH
PEAK- amountTROUGH- frequency
Desmoid tumor
Locally aggressive with no portential for metsTx with resection and chemo
MC vitamind def after REY GB
B12
Ulcers:MarginalCameronMarjolin ulcerCushing’s ulcer
Marginal- REYGB at GJ anastomosisCameron- on lesser curve of large hiatal herniaMarjolin ulcer- chronic woundCushing’s ulcer- elevated ICP
Products of posterior pituitary
“PAO in the POST”ADH, Oxytocin2/2 direct stem from neurosecretory cell
Stage 3 breast cancer and tx
3a- 4 to 9 nodes –> consider neoadj for BCT3b- chest wall (not pec wall) or breast skin –> neoadj required3c- supra clavicular nodes –> neoadj required
Tx of GIST
Resection w/ gross marginNo LN dissectionAdd imatinib (TK inhibitor) if >5m/50HPF
Non-cyanotic heart defects
ASDVSDcoarctation
Bevacizumab
recombinant humanizedmonoclonal antibodythat blocks angiogenesis by inhibitingVEGF-A
c/i to BCT
multicentricinflammatory cac/i to radiation
<p><span>AT3 Functions</span></p>
<p><span>Inhibits thrombin2. Inhibits f9, 10, 11</span></p>
Ranson’s criteria on admission
“GA Law” Glu > 200 age > 55 LDH > 350 AST > 250 WBC > 16
Cholangiocarcinoma types
1- below confluence2- at confluence3- R or L hep duct4- R and L hep duct5- multicentric
Glycogen
stores depleted after 24-48h of starvationMOST found in skeletal muscle, rest in the liver
Types of esophogectomy
Transhiatal- laparotomy and cervical incision/anastIvor Lewis- thoracic incisions/anast
type 3 choledochocal cyst
choledochoceletx- transduodenal marsupialization or excision
Treatment of colo-cutaenous fistula
Start with conservative tx High output: > 500 cc/day –> likely OR Low Output: < 200 cc/dayt –> likely conservative OR if failed after about 6 weeks
CPP
MAP - ICPnormal CPP > 60Normal ICP < 20hyperventilation to 35 decreases CO2 causing vascoconstriction and decreasing ICP
Accessible nodal stations w/ EBUS
2, 3, 4, 7, 10, 11, 12
tx of Meckels
tx- resection if sxs. if appendicits leave Meckel’s alone If no appendicitis take out the Meckel’sOnly consider taking out incidentally found asx Meckel’s in young/healthy ptif bleeding, inflamed or tumor at base –> segmental resection
Hypocalcemia
tinglingchvostek/trousseau signEKG- qt prolongation
Angiodysplasia of the colon
2nd MC CO gi bleed (vs. div’s)Usually found in cecum and ascending colon
<p><span>Effective for enteroccous</span></p>
Ampicillin/AmoxacillinVancomycinTimentin/Zosyn(Resistant to all cephalosporins)
Lateral to medial femoral anatomy
Femoral nerveFemoral arteryFemoral veinEmpty space (hernia)Lacunar ligamentSuperficial ring
Gastrin
G cells of antrum signal EC cells –> His –> Parietal cell –> HClStimulated by ACh, beta ago, AA
Tx for gallstone ileus
Stable and healthy- stone removal and take down fistulaUnstable- stone removal only!
septic shock
high CI, low SVR, +/- wedge
Normal SBP in a neonate
60-90
How to reach D2 during EGD
right rotation and manipulate the up/down control knob
S/e of tamoxifen
dvt/peuterine cancer
Best test for resectability and staging of eso cancer
Resectability- ctStaging- US
Specific to UC
Crypt abscessPsuedopolyps
LeFort fxs
I- palateII- nose and palateIII- entire face
Epoteitn
stimulated by HYPOXIA produced by kidney fibroblastsLiver is major producer of EPO in fetus
Cutoff for low risk lung nodules not requiring follow-up
6mm
Best opioid to use for AKI
methadone and fentanyl/sufentanil hydromorphone or oxycodone are used with cautionmorphine and codeine are avoided
<p><span>Anti-staph Penicillins</span></p>
OxacillinMethicillinNafcillin
Bile concentration
Sodium chloride channels actively transport salt across the epithelium efficientlyand water follows passively in response to the resultant osmotic force
Warthin tumor/Papillary cystadenoma
benign tumor of salivary glandoften BILATERAL and 2/2 smokingTx- complete resection with uninvolved margins even if ASx
Hurthle cell
Usually benignMUST do lobectomy to diagnosetx- total thyroid if malignant. XRT effective.
Neostigmine
reversal of non-depol muscle relaxantsAChE inhibitor
Imaging associated with benign adrenal mass
< 10HURapid washout< 4cm
ITP
px- petechiae and megakaryotcytestx-steroids (IVIG 2nd line) do not tx unless PLT < 30k or 20k in low risk
Paired vs. unparied t test
Paired- compares study subjects at 2 different times (paired observations of the same subject)Unparied-compares two different subjects
Respiratory quotient
CO2 produced / O2 consumed>1 → carb is major nutrient.7 → lipids major nutrient
Absolute c/i to spinal anesthesia
Infection at the siteHypovolemiaAllergyIncreased ICP
Parkland formula
4 x weight x TBSA 1st 1/2 in 1st 8h2nd half next 16
Steps of rapid sequence intubation
c-spine stabilize → preO2 → fentanyl → etomidate → succinylcholine
Where to find superior and inferior PD during a whipple
Superior:pancreatic headInferior: uncinate process
Tx of Barrett’s
low grade dysplasia: repeat scope/bx in 6mhigh grade dysplasia: endoscopic mucosal resection
cyclosporine
MOA: calcineurin inhibitors/e- 100x less potent then tacro, nephrotoxic, hypertrichosis, gum hyperplasia
Effective for VRE
SynercidLinezolid
Kaposi’s sarcoma
HSV8Violet/brown papules
T and N staging eso cancer
t1a- LP and MM t1b- SM t2- MP t3- adventitia t4a- resectable structures t4b- unresectable structuresn1: 1-2 nodesn2: 3-6 nodesn3: 7+
CRC T and N
t1- SMt2- MPt3- xMP/subserosat4- invaden1- 1-3, n2- >=4
Triple therapy
PP1 + 2 antibioticsabxs: amoxicillin, metronidazole, tetracycline, clarithromycin
Chole docho in REY bypass pt
w/ GB –> lap chole with CBD exploration –> ERCP through remnantstomachw/out GB –> ERCP with double balloon endoscopt –> ERCP throught remnant stomach
bile salt circulation
conjugate in hepatocytes into gly/taurine secreted into bile 80% reabsorbed in ileuim ACTIVELY 20% DECONJUGATED by bacteria deconjugated salts absorbed in colon PASSIVELY 6. 5% is excreted
Howship-Romburg Sign
Pain in medial thigh with internal rotation and extensionSuggests an obtruator hernia
MS vs. ED
MS- Fibrillin defect (elastin); AD, tall, aortic root dilation, lens defect, arachnodactylyED- t1, t3 , t5 collagen defect; hyper elastic skin, hypermobile joints
Most abundant bacteria in the colon
Bacteroides fragiles
Liver lesions on arterial phase: HCC Mets Adenoma Hemangioma FNH
HCC- Homogeneous enhancement Mets- Hypoattenuation Adenoma- Heterogeneous enhancement Hemangioma- Periph enhancing FNH- Centrifugal enhancing
Number of lung segments
R-10L-8
confounding
a variable that influences both thedependent variable and independent variablecausing a spurious association
Epidural hematoma
BiconvexMMADOES NOT suture lines
Bethesda criteria for thyroid
10 mm is cutoff to get an FNA Non-diagnostic → repeat FNA Benign → follow-up Undetermined significance → repeat FNA Suspicious for follicular neoplasm → lobectomy, repeat FNA, or genetic testing (no core needle) Suspicious for malignancy → lobectomy vs. thyroidectomy Malignant → thyroidectomy
<p><span>Effective for P/A/S</span></p>
Ticarcillin (+ticarcillin), Piperacillin (+Zosyn)3/4G cephalosporin (ceftriaxone, cefepime)Aminoglycodies (genta, tobra)FlouroquinolonesMeropenem/Imipenem
HNPCC and criteria
HNPCC pts who fulfill Amsterdam clinical criteria for Lynch syndromeCriteria: 3 relatives (one 1st deg)w/ Lynch syndrome-associated cancer (CRC, endometrial, small bowel, ureter/renal) 2 successive generations 1 < 50 yo
MALT lymphoma
associated w/ h. Pylori.Tx: Low grade: triple therapy High grade: chemo and XRT (CHOP) +/- rituximab
MCCO chylous ascites
malignancy
Gastroschisis
GastRoschisis to the Right of midlinerare defects…EXCEPTION- instestinal atResia
Tx of AT3 def
Heparin does not work!Tx- recombinant at3 or FFP followed by heparin then warfarin
Indications to tx ICA stenosis
if Asx, only tx if > 60if sx, tx if > 50sxs- contralateral motor/sensory sxs, ipsi vision sxs
STSG vs. FTSG
STSG- epi + part dermis; worse cosmesis; more contracture! (don’t use over joints)FTSG- epi + dermis; lower survival; more resistant; hypertrophic scar formation; more sensation
ASA
irreversible inhibitor of PG metabolism in PLTs2/2 cox acetylation7-days of PLT dysfunction
Tx for beta blocker overdose
glucagon
Products of anterior pituitary
TSH, ACTH, FSH/LH, GH, Proneurosecretory cell stimulates hypothalamus which lets go of releasing hormone
Rapid coumadin reversal
PCC
Pyoderma gangrenosum
associated w/ IBDRESOLVES after resectionpre-tibialtx- steroids
Central cord syndrome
loss of pain, temp, motormotor UE> LE loss (vs. anterior syndrome)
Scope schedule after Crohn’s dx
10 years after dx then every year to r/o dysplasia
TNFa
produced by macrophagescauses cachexia
Beckwith Wiedmann Syndrome
3m-2yAssociated with hepatoblastoma and wilm’s tumor
type 1 choledochocal cyst
fusiform dilationtx- excision w/ REY H-J
<p><span>Cryo</span></p>
<p><span>vWF, f8, fibrinogen</span></p>
Breslow depth
t1: < 1mm → .5-1 cm margint2: 1-2 mm → 1-2 cm margint3: > 2 mm → 2 cm margin
Best test to dx gastroparesis
Scintigraphic gastric emptying
Atlanta classification pancreatits
- Interstitial: <4w- acute peripanc collection, >4w psuedocyst2. Necrotic: <4w- acute necrotic collection >4w- walled of necrosis
<p><span>FFP</span></p>
<p><span>All factors, Protein C and S, AT3</span></p>
Child’s Pugh Score
Billirubin, Albumin, INR, Ascites, Encephalopathy
ARDS ratio
P/F mild- 200 to 300 moderate 100-200 severe < 100
Orientation of portal triad
Bile duct lateralHepatic artery medialPortal vein posterior
Schiatzki’s Ring
Associated with hiatal herniaTx- only if sxatic. dilation and PPI; do not resect
MOA reglan and erythromcyin
reglan: dopamine antagonisterythromycin: motlin receptor agonist causing SM contraction
indications to bx a neck mass
confirm FNA or core needle with excisional biopsy! >1.5 cm enlarged node withoutsigns of infection persistence after trial of antibiotics and observation >2-4 wks increasing size of mass
Peri-op anti-PLT agents
Clopidogrel (plavix): hold 5-7 days before elective surgeryASA: continue through the surgery
neurogenic shock
high CI, low SVR, low wedge
Indications for iHD
GFR 10-15 for sxaticGFR < 5 for asymptomaticSxs = AEIOU (acid, lytes, intox, olverload, uremia)
Breast Cancer in pregnancy
1T- MRM. Chemo is not OK.2T/3T- consider BCT. Modfied radio-isotope. Chemo is OK. Post delivery radiation.
Who needs stress dose steroids
> 20 mg of steroids for > 3 weeks
Frey syndrome
gustatory sweating s/p parotidectomy
Layers of colon/rectum
- mucosa2. sub-mucosa3. muscularis propria4. serosa
FNH
path- CENTRAL STELLATE SCAR!; bright on arterial phase homogenoustx- resect if sxatic. no malignant potential.
TOF
Most common cyanotic defectVSD, PS, OA, RVHtx- beta blocker; surgery at 3-6m
Omphalocele
2/2 failure of umbo ring closure 11th week gut returns to abdominal cavitynormal bowel (protected)Other congenital defect are more common
Hard signs of vascular injury
shockexpanding hematomapulsatile bleedthrill/bruitabsent pulseischemia
Primary lymphoid organ vs. secondary
Primary: generate cells i.e. liver, bone, thymusSecondary: maintain cells i.e. nodes, spleen, MALT