Jeopardy Flashcards
Critical maneuver in the surgical treatment of Zenker’s diverticulum
Zenker’s diverticulum = esophageal diverticulum, sac-like outpouching thru a weakness in the muscle
Critical maneuver = cricomyectomy/cricopharyngeal myotomy = cutting of the cricopharyngeal muscle
Most common cause of lower GI bleed
Diverticular disease
2nd = AVM
Most common nerve injured during an inguinal hernia repair
Ilioinguinal nerve
62 yo M w/ hematuria, flank pain, and right renal mass
(a) Dx
(b) Tx
(a) renal cell carcinoma until proven otherwise
(b) remove kidney
Most cause of portal HTN in the US
Alcoholic cirrhosis
Makeup of NS
Normal saline has Na and Cl: 154 of both
Margins for a 3mm thick melanoma
2 cm
-all melanomes of 2 mm or more depth get 2cm margins
If pt w/ APC mutation of chromosome 5 gets colon removed at age 20, what further maintenance is required
APC mutation on chromosome 5 = FAP (familal adenomatous polyposis)
After prophylactic complete colectomy at 20, still need yearly EGD to screen for duodenal carcinoma
3 buckets of etiologies for mesenteric ischemia
- Arterial embolism/thrombosis- if have an emboli or clot that blocks the splanchnic blood supply
- ex: cardiac embolism, atherosclerotic disease, thrombosed mesenteric aneurysm, aortic/mesenteric dissection - Venous thrombosis- hypercoagulable state, malignancy, prior abdominal surgery
- Nonocclusive mesenteric ischemia- from splanchnic hypoperfusion and vasoconstriction (ex: hypovolemic shock)
- most commonly affects watershed areas of the colon that have limited collateralization
Type of IBD w/ transmural involvement
Chron’s
Beck’s triad
(a) What does it indicate?
(b) Name the three parts
Beck’s triad = cardiac tamponade
(b) Distended neck veins, hypotension, muffled heart sounds
Tx for hydrogen fluoride burn
Calcium gluconate
2 genetic syndromes that carry organ removal early on in life for cancer prophylaxis
MEN2- prophylactic thyroid removal due to 100% risk of medullary thyroid cancer
FAP (APC mutation)- ppx colon removal at age 20
Immediate actions to prevent rhabdo
Tons of IV fluids
-alkalinize urine
First line in mgmt of anal fissures
Physical exam: if posterior and midline w/o perianal skin tags, can start first line tx of
- constipation relief: fiber, stool softener
- topical analgesia
- topical nifedipine or topical nitroglycerin
If Not midline, presence of perianal skin tags- must work up for Chron’s
Peritoneal-lined abdominal wall defect
Omphalocele
-50% cardiac defects
While without peritoneal lined = gastrochiesis
Most common valvular abnormality secondary to an MI
Mitral valve prolapse
Vitamin that reverses effect of steroids on wound healing
Steroids hinder wound healing, thought that vitamin A reverses that effect
Which has a better prognosis: gastrochiesis or omphalocele?
Gastrochesis has better outcome b/c omphalocele (peritoneal lined) has almost 50% chance of concomitant cardiac defect
What is Eisgenmenger’s syndrome?
When a congenital left to right shunt causes pulmonary HTN and eventual reversal of the shunt into a cyanotic right to left shunt
Pulsatile right groin mass 4 hrs s/p cardiac cath
Dx
Pseudoaneurysm of femoral vein
-from blood collection when catheter removed too gradually from femoral vein
Tx = inject thrombin
Workup when suspecting mesenteric ischemia
Patient HDS? Yes- Abdominal CT, if suspicious for mesenteric ischemia do mesenteric arteriogram
If HDUS, resuscitate w/ IVF, empiric abx, get plain abdominal film to look for free air/signs of advanced ischemia
What UV ray is associated w/ melanoma
UV B
Treatment plan for rectal cancer 1cm above the dentate line
APR = abdominal peritoneal resection w/ neoadjuvant chemo
Which anorectal entity can be treated w/ botox
Anal fissure- if fails conservative medical management (topical analgesia and nifedipine, relief of constipation), can turn to surgery or botulinum toxin
-botulinum toxin over surgery in pts at high risk for incontinence (multiparous F and older pts)
First branch of the abdominal aorta
Phrenic artery
General goal of fluid resuscitation in burn victim used over Parkland formula
Usually give fluids until urine output is about 1-1.5cc per ml of fluid (LR) given
Shortcut for maintenance fluids
Just add 40 to wt if pt is over 20 kg
Ex: maintenance fluids for 70 kg pt = 110 cc/hr
What is priaprism?
Erection lasting 8 or more hours
Where is the blood coming from if: Pringle maneuver being performed but the pt is still bleeding from the liver
Pringle maneuver = compression of the portal triad = compressing portal vein, hepatic artery, and CBD
So if still bleeding blood is coming from the hepatic vein (only one not compressed)
Why does TPN have to be administered thru a central line?
B/c it’s hyperosmolar- if put directly into small veins in the arm it would cause direct sclerosis
-central line or PICC line
Most common type of breast cancer
Invasive ductal carcinoma
Cause of pneumaturia in pt w/ acute sigmoid diverticulitis
Vesical fistula = fistula btwn bladder and colon
-pneumaturia = air in the urine
Most common endocrine tumor of the pancreas
Insulinoma = most common
If gastrinoma, suspect MEN1 (much less common)
What is the urachus?
Urachus = fibrous remnant of the allantois, connection btwn bladder and umbilicus
Pt w/ hematemesis morning after binge drinking
Mallory-Weiss tear 2/2 repetitive wretching during vomiting
Calf pain and associated ABIs, what happens under the following ABC (ankle brachial index)
under .9
under .5
under .3
Under .9 = intermittent clauddication
Under .5 = rest pain
Under .3 = ulcers/skin break down
Features of MEN2B
- Medullary thyroid cancer
- Pheochromocytoma
- Marfanoid habitus
- Mucosal neuromas in 100%
Features of MEN1
3 P’s: pancreatic, parathyroid, pituitary
- Pancreatic tumor- gastinoma
- Parathyroid gland hyperplasia
- Pituitary tumor = prolactinoma
When to suspect hemobilia
Hemobilia = bleeding into biliary tree (GI bleed) b/c of fistula btwn artery and bile duct
-suspect it when pt presents w/ jaundice, GI bleed w/ recent liver injury or instrumentation (ex: TIPs, biopsy, trauma)
Gene associated strongly w/ male breast cancer
BRCA2
BRCA2- 10% risk of breast cancer in male
Cardiac chamber most commonly injured by penetrating trauma
Right ventricle
-sits the most anteriorly
What artery is involved if a duodenal ulcer is bleeding?
Gastroduodenal artery
-from the common hepatic artery of the celiac trunk
72 yo F w/ loop of bowel medial to the femoral vein on CT
Dx?
Femoral hernia
Mneumonic for lateral to medial is NAVAL: nerve, artery, vein, ___ (space where hernia goes), lymphatics
Mgmt of 83 yo M w/ sigmoid volvulus
Immediately: flexible sigmoidoscopy to reduce it, then definitive surgery to prevent recurrence
-sigmoidectomy (removal of sigmoid colon) a few days after once stabilized, or immediately if can’t reduce w/ sigmoidoscopy
32 yo M in MVA
HR 40, BP 80/38
What type of shock is he in?
Neurogenic shock
- hypovolemic/septic would have tachycardia if BP was so low
- low HR shows spinal cord injury
In Budd-Chiari, what part of the liver can continue to drain into the IVC
Budd-Chiari = hepatic vein thrombosis
-caudate lobe is basically it’s own separate lobe, it has it’s own vein draining into the IVC, so it will maintain drainage in Budd-Chiari
Mediastinal tumor associated w/ myasthenia gravis
Thymoma
83 yo M w/ LBO and dilated U-shaped area of colon
Dx?
Sigmoid volvulus
‘coffee-bean’ shape on abdominal plain film
Most common form of anal cancer
Squamous cell
Most common site of lower extremity atherosclerotic occlusion
Superficial femoral artery
Hemorrhoids
(a) Which causes pain
(b) Which causes BRB per rectum
Hemorrhoids
(a) Only external hemhorroids are painful (unless internal prolapse) b/c internal are above the dentate/pectinate line
(b) Internal hemorrhoids bleed
Name for transient monocular blindness
Amaurosis fugax
Most common organ injured in blunt trauma
Spleen
Embryonic malformation causing midgut volvulus
Malrotation
Acute left shoulder pain upon passive elevation of legs
Dx
= Kher’s sign- sign of blood or air in peritoneal cavity
-classically a sign of splenic rupture
Which brachial plexus do the parathyroid glands come from
Inferior parathyroids come from the third brachial plexus
Superior parathyroids come from the fourth brachial plexus
Vitamin needed for collagen cross linking
Vitamin C
Clinical significance of PCWP
Pulmonary capillary wedge pressure- measured by Swan Ganz catheter into pulmonary arteries, is used as an indirect measure of left atrial pressure
- diagnostic for LV failure, MS, cause of acute pulmonary edema
ex: acute pulmonary edema w/ normal PCWP = ARDS
Features of MEN2A
- Medullary thyroid cancer (100%)
- ppx remove thyroid at 6 mo - Pheochromocytoma
- Parathyoid hyperplasia
- 4 gland hyperplasia
Predominant type of collagen present 6 weeks after surgery
Type I collagen
75 yo F w/ symptomatic 79% ICA stenosis
Next step?
Carotid endarterectomy
-for anything above 70% stenosis and below 99% (already fully occluded at 99%…)
Maintenance fluids for a 60 kg pt
60 kg pt- 100 cc/hr of maintenance fluids
4-2-1 rule, or shortcut of just adding 40 to wt
Cell type
(a) First to the scene for wound healing
(b) Most important for wound healing
(c) Deposits collagein
Cell type
(a) Platelets are first on the scene
(b) Macrophages are the most important for wound synthesis
(c) Fibroblasts deposit collagen
Name the 2 watershed areas of the colon
Splenic flexure and rectosigmoid junction
-have minimal collateral blood supply => fastest to be affected by splanchnic hypoperfusion
Most common source of emboli to the lower extremity
The hearttttt
Treatment for squamous cell anal cancer
Nigro protocop = pre-operative use of chemotherapy and medical radiation for squamous cell carcinoma of the anus
-tx NOT excision
2 weeks s/p liver trauma pt presents w/ jaundice and hematemesis
Dx?
Hemobilia = bleeding into the biliary tree b/c of fistula btwn splanchnic vessel and a bile duct
- consider after liver injury or instrumentation
- artery anastamoses to bile duct => bleeding into the duodenum
- jaundice 2/2 hemolysis
Tonicity of fluids for the first 24 hrs post-op
Isotonic
Liver tumor in 25 yo F w/ RUQ pain and intraabdominal hemorrhage
Hepatic adenoma
-RF = OCP use
Where does the thoracic duct drain into?
Left subclavian vein
An isolated lower extremity crush injury puts what organ system at risk of failure?
Kidneys
Nephrotoxicity from rhabdo: all blood gets crushed in the trapped limb => hemolysis => rhabdo
-damage to kidneys from myoglobin
Pt presents w/ Charcot’s triad
(a) First line
(b) Next step if don’t improve w/ first line therapy
Charcot’s triad = fever, RUQ pain, jaundice = presentation of cholangitis
(a) Give abx and fluids, then if pt improves schedule elective choley
(b) If pt doesn’t improve w/ abx and fluids, assumption that stone is in CBD => do ERCP to remove stone in the common bile duct
What is the definitive tx for anal sphincters
Lateral sphincter removal (lateral internal sphincterectomy)
-only once medical management has been failed and endoscopy has ruled out Chron’s
G-cells
(a) Location
(b) Function
G-cells
(a) antrum of the stomach
(b) Secrete gastrin to stimulate secretion of HCl
What solution is used for fluid resuscitation in burn victims?
Use LR (not NS!!!!) -NS in super high volumes can cause hyperchloremic metabolic acidosis (b/c has 154 Cl)
52 yo M w/ epigastric pain and free air in the abdomen on plain film
Ruptured gastric ulcer
Most common bladder cancer
Transitional cell carcinoma- arising from transitional epithelium
-most common cancer of the GU system, second most common cancer of the kidney
62 yo M p/w severe epigastric pain, diaphoresis, dyspnea, and rales
Dx?
Acute MI
Percent of body surface burned if both arms are affected
18%
-each arm is 9% in an adult
32 yo F w/ cecal volvulus
Treatment
Cecal volvulus = rotation/torsion of a mobile cecum and ascending colon, which can progress to ischemia, necrosis, perforation
Tx for cecal volvulus = right hemicolectomy
Most common solid tumor in children
(a) Under 2 yo
(b) Over 2 yo
Solid tumors in children
a) Under 2 yo = neuroblastoma
(b) Over 2 yo = nephroblastoma (Wilm’s
Treatment for testicular torsion
Untwist and hope it reperfuses…
If you go to the OR to untwist, do bilateral untorsion and fixation b/c other side is at high risk
Pancreatic tumor associated w/ necrotizing skin process
Glucagonoma
- necrolytic migratory erythema strongly associated w/ glucagonoma
- red patches commonly affecting limbs and skin around the mouth
Procedure for resolved gallstone pancreatitis
Lap choley
-40% cases of pancreatitis caused by gallstones, so once acute phase is calmed down, tx w/ lap choley
Keloid vs. hypertrophic scar
(a) Biggest differentiator
(b) Prognosis
Keloid = tissue extends beyond the border of the original wound, while they don’t extend in hypertrophic scar
Hypertrophic scars may spontaneously resolve, while keloids are unlikely to
64 yo M w/ postprandial abdominal pain w/ bloody diarrhea
Mesenteric ischemia- classically have pain out of proportion to physical exam
