MIX 4 QBANK Flashcards
definition volvulus
twisted 180°
x-ray findings of a cecal volvulus
kidney shape
Bird’s beak
what vascular supply does cecal volvulus rotator around
ileocolic
treatment of cecal volvulus
right hemicolectomy with primary ileocolic anastomosis
treatment of advanced ovarian cancer metastatic
resect so no tumor greater than 2 cm left Debulk: multiple bowel resections Radical hysterectomy-entire pelvic tumor mass Bladder Sidewall Cul-de-sac Titanium Rectosigmoid
Approaches extraperitoneal ventral to dorsal technique
Splenectomy
Total omentectomy
Hepatic resection
Diaphragm peritoneal stripping
symptoms of lidocaine toxicity
earlier signs- tingling of the tongue and lips metallic taste Lightheaded tinitus Visual disturbances
progressive signs-
Slurred speech
Disorientation
Seizures
Cardiovascular: Widened PR interval Wide QRS Sinus tachycardia Ultimately cardiovascular collapse
treatment of local anesthetic toxicity
oxygen airway support
If seizure does not terminate spontaneously:
Benzodiazepine (medazepam)
Or
Thiopental
cardiovascular support may be needed
Intralipid for Marcaine/ bupivacaine
workup for insulinoma and CT scan shows multiple lesions and pancreas
portal venous sampling for localization of highest functional tumors
management of zone one injury
Central- Diaphragm to sacrum Renal hilum lateral contained colon Aorta Vena cava Portal vein Proximal renal vessels Anchors Duodenum
Both penetrating and blood injuries with hematoma should be explored surgically
Zone 2 retroperitoneal injury
lateral
Renal hilum
Kidneys
Adrenals
Superior ureters
Blunt injuries and hematoma did not need to be explored
Left associated colon injury, urinoma, expanding hematoma
Stone to penetrating injuries with hematoma are explored
Zone 3 retroperitoneal injury
inferior central - pelvis Iliac vessels Rectum Distal sigmoid Distal ureters
Stable non-expanding hematomas nonoperative
Hematomas from penetrating injury may need exploration
structures at risk with inferior esophageal mobilization for fundoplication
vagus nerve
Left hepatic artery coming from the left gastric can be encountered
Minor salivary gland tumors most common locations
90% malignant
Palate is the most common origin 50%
lip 15%
buccal mucosa 12%
tongue and floor of mouth 5%
minor salivary gland tumor tissue type in presentation
most
adenoid cystic carcinoma
signs of malignancy:
rapid tumor growth
Pain
Ulceration
Treatment of minor salivary gland tumor
surgical resection with adequate margins
Conclusion:
Involved mucosa
Muscle
Bone
postoperative radiation if: high grade positive margins Perineural spread Deep invasion into muscle bone Lymph nodes Metastases
what hormone is responsible for secretion of bicarbonate and stomach passes food into duodenum
secretary and
causes increased bicarbonate decreased chloride
Heineke-Mikulicz Strictureplasty indications and procedure
Crohn’s stricture
strictures up to 5-7 cm long
Longitudinal incision over stricture closed transversely
Finney strictureplasty indications and procedure
strictures up to 10-15 cm long
loop of stricture as doubled and incised and closed as functional side to side
diagnosis and young female on oral birth control pills with 6 cm liver lesion
hepatic adenoma
imaging findings of hepatic adenoma
early phase enhancement
the management of hepatic adenoma
symptomatic resect
Asymptomatic adenomas stopped oral contraception and followup
Resect before planned pregnancy
boundary of the femoral canal
anterior chest inguinal ligament
Posterior pectineal ligament
Medial lacunar ligament
Lateral femoral vein
what invasive maneuver often needs to be performed for management of femoral hernia
division of inguinal ligament to fully reduce the herniated bowel
splenic septated cyst workup and treatment
most common parasitic source:
echinococcus!
serology
splenectomy
asymptomatic non-parasitic splenic cyst
observed with ultrasound followed
Risk of cyst rupture even with minor trauma when large cyst
Small symptomatic non-parasitic cyst may be excised with a splenic preservation
Cancer most likely to metastasize the spleen
along
primary tumor most likely to be found and spleen
sarcoma
ischemic reperfusion injury after renal transplant
presentation maybe a 36 hours
acute tubular necrosis
treated with fluid resuscitation
may require dialysis
test to confirm vascular occlusion after renal transplant
radioisotope scanning and ultrasound
disseminated intravascular coagulation
causes: Trauma Hemodialysis Obstetric Malignancy Sepsis
thrombin and plasma INCREASE
causes bleeding and clot formation
Antithrombin III and plasminogen levels DECREASE
bacteria associated with emphysematous gallbladder and diabetes
Clostridium perfringens
Paget Von Schroeder syndrome
venous thoracic outlet syndrome
Effort thrombosis
Narrowing of the subclavian AXILLARY vein
At the level of the costoclavicular space
Most medial aspect of thoracic outlet
Sources of compression: First rate Clavicle Subclavius Costal coracoid ligament Anterior scalene Tubercle
If emboli occur: ARTERIAL
described first-degree burn
painful
Erythema
Blanche
Describes second-degree superficial burn
superficial dermis
Painful
Erythema
Blanche
blister
described deep second-degree burn
deep dermis
Painful
Do not blanch
Pale
Mottled
described third-degree burn
subcutaneous fat
heart Left artery Eschar PAINLESS Black, White or RED
tetralogy of fallot findings
overriding aorta
VSD
Right ventricular outflow obstruction
Right ventricular hypertrophy
Management of irreducible inguinal hernia in newborn found to have ischemic bowel-operative approach
Our section can usually be performed through hernia sac!
Most common location and anatomy a hepatic artery And course
and celiac trunk Superior edge of the pancreas Gastroduodenal artery Right gastric artery Courses into portal triad bifurcates into right and left
common variant of left hepatic artery
off of left gastric
localization studies insulinomas
EUS
CT scan - 40%-still done
intraoperative ultrasound most sensitive (careful, gastrinoma not that useful)
Also continues calcium angiography-calcium stimulates increase in tone secretion
criteria to diagnosis primary hyperparathyroidism
increased PTH
Increase calcium
Normal or elevated urine calcium (differentiate from familial hypercalcemic hypocalciuria)
chloride- phosphorus ratio: 33:1
superior vena cava syndrome
diagnosis CT
Bronchoscopy biopsy
Treatment:
Chemoradiation
surgery rarely possible due to great vessel involvement
CMV colitis
immunocompromised
Bloody diarrhea
Endoscopy with biopsy confirms
Treatment ganciclovir
Resection considered only with life-threatening ischemia or uncontrolled bleeding
Or
Peritonitis
Normal right ventricular pressure
appearance on EKG
20-30/0-8
square roots sign
normal pulmonary artery wedge pressure
appearance on EKG
6-15
smooth curves with low amplitude
loss of Dicrotic notch
mechanism of action of heparin
indirect thrombin inhibitor
ACCELERATES antithrombin III activity
aspirin mechanism
irreversible cyclooxygenase inhibitor
electrolyte abnormality seen after full resuscitation of burn
HYPER natremia
even though LR
lactated Ringer’s contains
sodium 130 Chloride 109 Lactate 28 Potassium 4 Calcium 3
normal saline containing
sodium 154
Chloride 154
osmolarity of 308 mOsmol/L
Ascitic! PH 5.5
for epidemiology of trauma what our host, Vector, environment
Host-human
Vector-vehicle
Environment
primary spread of T1 adenocarcinoma esophagus
submucosal
treatment of N1 adenocarcinoma esophagus
en bloc resection
treatment of Merkel cell carcinoma
wide excision
Sentinel node for all
Radiation for all
Innervation of cricothyroid
external branches superior laryngeal nerve
innervation of hypopharynx
glossopharyngeal cranial nerve 9 and vagus nerve cranial nerve 10
course of superior laryngeal nerve
off the vagus and exit skull
This ends internal carotid artery
Divided hilar cartilage into internal and external branches
internal branch of superior laryngeal nerve
lateral thyroid membrane
Sensory after her fibers from the supraglottis and vocal folds
external branch of the superior laryngeal nerve
inferior constrictor anterior medial course
Along with the superior thyroid artery
Into the cricothyroid muscle-motor innervation
Separate from superior thyroid artery 1 cm proximal to arterial entrance of capsule superior pole thyroid
transposition of great vessels
associated:
VSD
Hypoplastic aortic arch
Cyanotic
Treatment FIRST with prostaglandin E. to keep ductus arteriosus OPEN
balloon septostomy can also help
death if untreated
increase risk of ovarian cancer
pain breast with estrogen exposure
including not breast-feeding
Family history of:
Colon
Breast
Endometrial
high-dose ovulation induction
peroneal talc use!
decrease risk of ovarian cancer
oral birth control
Tubal ligation
minimal alveolar concentration
alveolar concentration of inhaled anesthetic required to prevent movement and 50% of patients to noxious stimuli
initial trauma fluid bolus pediatric
20 mL per kilogram x2
then blood
inotropic agent used for pediatric sepsis that’s different then adults
epinephrine more commonly used and kids
stage IV sarcoma of the extremity
with regional node involvement!
any metastases
what lab finding is seen with 21 hydroxylase deficiency
incr 17-OH progesterone
(careful, don’t confused with 17-hydroxylse deficiency)
21 hydroxylase def salt wasting
most common at risk structure with posterior shoulder dislocation
axillary artery
signs of posterior shoulder dislocation
fixed internal rotation
X-ray findings may be so because humeral head directly posterior on AP view
CT scan most helpful
Treatment of posterior shoulder dislocation
immobilization and external rotation
Rate presentation requires open reduction
Structure at risk with anterior shoulder dislocation
axillary nerve
transanal excision of rectal cancer criteria
Local excision of a rectal cancer may be appropriate for a small cancer in the distal rectum that has not penetrated into the muscularis.
mobile tumors smaller than 4 cm in diameter, that involve less than 40% of the rectal wall circumference, and that are located within 6 cm of the anal verge. These tumors should be stage T1 (limited to the submucosa) or T2 (limited to the muscularis propria), well or moderately differentiated histologically, and with no vascular or lymphatic invasion.
sphincter relationship required for LAR
tumor greater than 2 cm from the sphincter muscle
the sphincter involved:
APR
rectal cancer approach that lower stent and postoperative complications
total mesorectal excision
criteria to transfuse platelets for ITP Undergoing surgery
only for significant bleeding
Alternative:
platelets less than 20 -
IV immunoglobulin x2 days
common cause of bleeding after Whipple- was treated in
gastroduodenal stump blowout - often caused by gastrointestinal anastomosis leak
embolization via hepatic artery
fetal circulation
oxygenated blood from placenta was into SINGLE umbilical vein
And 2 IVC
From right atrium to left atrium through the foramen ovale
and from right ventricle to pulmonary artery shunted through ductus arteriosus to aorta
de and oxygenated blood return to consent to be 2 umbilical arteries that come off internal iliac
contraindications to using nitrous oxide
small bowel obstruction
most common complication of renal stone And how can just be related to bowel resection
calcium phosphate
terminal ileum resection causes increased resorption of oxalate in the colon that is excreted in the urine
initial blood pressure management in the ascending thoracic aortic dissection
beta blocker
labetalol or propranolol
pressure remained above 100 pigmentation add nitroprusside
what is contraindicated in spinal cord injury
succinyl choline
hyperkalemia
also avoided in turn
cardiac findings with hyperkalemia
PVCs
Wide complex tachycardia
Torsade de pointes
Cardiac arrest
half life of insulin
7-10 minutes
Insulin response to oral glucose versus IV
or glucose much greater response increase of insulin
pleomorphic adenoma presentation and treatment
most common benign tumor of the salivary glands
90% of the parotid gland
superficial facial nerve
superficial parotidectomy
most common site of aspiration in the lung
right
treatment of one aspiration
most commonly antibiotics
If not cleared in 8 weeks surgery
Surgery indications:
Large cavities over 4-6 cm
Hemoptysis
Need to rule out malignancy
physiologic functions of parathyroid hormone
Inhibits calcium excretion distal convoluted tubules the kidney
Inhibits phosphate reabsorption
inhibits bicarbonate reabsorption
stimulates vitamin D production and kidneys
stimulated vitamin D conversion to active form
operative approach for open treatment of the Zenker’s diverticulum
LEFT neck
when is a myotomy alone sufficient to treat Zenker’s
diverticulum less than 2 cm
pexy of the diverticulum not needed
criteria for endoscopic Zenker’s
2-5 cm diverticula
though can be performed less than 3 cm - the surgery is better when less than 3 cm in size
Most common source of metastasis found in the small bowel
melanoma
pulmonary artery occlusion pressure the indicates achieved blood volume expansion
stabilization between 15-20
Purpose of using vasopressin and shock
treatment vasodilatory shock refractory to the infusion of alpha adrenergic agents alone
Central cord injury
upper extremity weaker than lower extremity
patchy sensation
loss of reflexes
Mid to low cervical spine
history of spinal stenosis
Hyperextension
anterior cord injury
infarction
Complete paralysis below injury
Preserved sensory from posterior column
posterior cord injury
complete paralysis and loss of proprioception
loss of vibration
intact pain temperature and light touch
Brown-Séquard syndrome
ipsilateral motor loss
Contralateral pain loss
Contralateral temperature loss
imaging findings of hemangioma
most common benign tumors of the liver
(careful common not adenoma)
peripheral enhancement on arterial phase
‘out grows blood supply’
asymptomatic managed conservatively
imaging findings of adenoma the liver
well circumscribed
heterogeneous
early enhancement an arterial phase
where is greatest risk of placing tacks with laparoscopic inguinal hernia repair
inferior to inguinal ligament
Lateral to epigastrics
risk: Femoral branch of general femoral nerve Lateral femoral cutaneous nerve Spermatic vessels Vas deferens
first line treatment of endometriosis
oral birth control pills
Estrogen inhibitor such as danazol
definitive treatment hysterectomy
action of CCK
gallbladder activity
released from duodenum stimulated by: Fat Needle acid Ascitic environment
Contracts gallbladder
RELAXES the sphincter of Odie
Courvoisier’s sign
enlarged palpable gallbladder in patients with obstructive jaundice caused by tumors of biliary tree or pancreatic head tumors
what size umbilical hernia as expected to close spontaneously in children
less than 2 cm
type of immune response with hypersensitivity
type I
Anaphylaxis
type II immune reaction
and a body IgG IgM
Hemolytic anemia
type III immune reaction
antibody antigen complex
Serum sickness
type 4 immune reaction
peak response 24-72 hours
Contact dermatitis
PPD
CCK is released by work cells and where
I cells duodenum
treatment for parathyroid cancer
en bloc resection
Total parathyroidectomy
ipsilateral thyroidectomy
workup for refractory hypertension
working diagnosis of primary hyperaldosteronism:
Plasma aldosterone to plasma renin ratio 30
Absolute aldosterone 15
24 hour urine aldosterone
CT scan
CT scan unsuccessful:
Adrenal sampling-to not necessary in patient’s older than 40 with solitary adrenal mass greater than 1 cm and normal contralateral gland
adrenal sampling positive
for times greater aldosterone to cortisol level on one side
most common site of cervical cancer node metastases
internal iliac nodes
most common site of endometrial lymphatic drainage
this is different from cervical drainage
Retroperitoneum:
Para-aortic nodes
next best step in management for effort induced thrombosis
catheter directed thrombolysis
which has a high rate of restoring luminal patency
( careful, initial treatment used to be anticoagulation alone)
after pain patency reestablished catheter directed thrombolysis then do first rib possibly and same hospitalization
Most important criteria to predict tolerating the pulmonary lobectomy
FEV1 greater than 0.8
other criteria:
PCO2 not greater than 45-50
DLCO Diffusion capacity not less than 40%
VO2 exercise tolerance not less than 10-12 mL/minute / of kilogram
the FEV1 borderline with his next test to predict tolerating the pulmonary lobectomy
VQ scan
shows distribution of ventilation blood flow to each lobe
CT finding of epidural hematoma
biconvex bordered by cranial suture lines
lenticular
location between skull and dura
Arterial injury
Lucid interval
Acute subdural hematoma findings compared to chronic
biconcave crescent-shaped crossing over lateral suture but does not cross midline ( because of presence of falx)
tearing or bridging veins
Location between arachnoid dura mater
careful, chronic subdural fade to the density of the CSF
lab findings of primary hyperparathyroidism
increase calcium
Decrease phosphorus
Increased PTH
Normal or INCREASED urine calcium
diagnosis with diabetes associated with dermatitis-migratory
GLUCOGONoma
necrolytic migratory erythema
location of VIPomas
body and tail
location of gastrinoma in pancreas
body and tail
same as VIPoma
diagnosis and treatment of glucagonoma
serum glucagon levels usually greater than 500
preoperative colon
Controlled diabetes, octreotide
Debulking
treatment of abscess superior to dentate line
most common type of fistula
No external opening-Mae tract to rectal wall
We tracked to lower rectum
Passes within in the intersphincteric space
treatment:
Must find crypt or abscess originated-
Endoscopy, probing, sigmoidoscopy that’s rule out Crohn’s
The internal opening found-drained or fistulotomy
Approach may require incising mucosa and longitudinal internal sphincter muscle of rectal wall
Antibiotics none needed once drained
cancer associated with vinyl chloride exposure
hepatic ANGIOSARCOMA
colovesical fistulas more common in men or wome with diverticulitis
man because uterus acts as barrier
pathophysiology of developing gastroischesis
associated with normal involution of the second umbilical vein
anesthesia agents associated with malignant hyperthermia
inhaled volatile
depolarizing muscle relaxant
earliest sign of malignant hyperthermia
tachypnea
Tachycardia
Hypertension
Increased end tidal CO2
other findings:
Hyperkalemia
Acidosis
mechanisms dantrolene
muscle relaxant
Blocks excitation contraction coupling of muscle cells
Cantile’s line
IVC and gallbladder
segments of left liver
2
3
4
most lateral segments of the left liver
2 and 3
most posterior segments of right liver
6 and 7
right shift of oxygen saturation curve
the decrease his oxygen affinity
with increase release to tissue
” right his right”
increased temperature increase pCO2 increased to 2,3-DPG - helps unload o2 DECREASED pH (increase acid) hypoxia carbon monoxide decreases P50 of hemoglobin
left shift of oxygen saturation curve
more tightly bound worse for tissue
decrease temperature
Decreased pCO2
Decrease 2,3 DPG
INCREASED pH (decreased acid)
fetal hemoglobin
presentation and CT findings of pancreatic lymphoma
bulky mass
Surrounding lymphadenopathy
- increased LDH
normal bilirubin
absence:
Weight loss
Extrahepatic biliary obstruction
elevated bilirubin
EUS biopsy confirms
NO surgery for lymphoma
Treatment:
chemotherapy
criteria for resection for cure of pancreatic adenocarcinoma
Resectable tumors are defined as localized to the pancreas, with no evidence of SMV or portal vein involvement (i.e., no abutment, distortion, thrombus, or encasement) and a preserved fat plane surrounding the SMA and celiac artery branches, including the hepatic artery. Patients with imaging consistent with resectable disease should proceed with operative resection.
only regional lymph nodes are still considered operative management
field of resection, ascites, or vascular involvement beyond the borderline 180 dgr incasement
pancreatic adenocarcinoma defines borderline resectable as tumors that exhibit one of the following characteristics:
(1) severe unilateral or bilateral SMV-portal impingement; (2) less than 180-degree tumor abutment on the SMA; (3) abutment or encasement of hepatic artery, if reconstructible; and (4) SMV occlusion, if of a short segment, and reconstructible
Adjuvant chemo for pancreatic adenocarcinoma
Current NCCN guidelines continue to recommend gemcitabine or 5-FU alone, or in combination with 5-FU– based chemoradiation, as adjuvant treatment following resection for PDAC
neoadjuvant chemoradiation pancreatic adenocarcinoma
no studies have shown an improvement in overall survival for patients who receive neoadjuvant chemotherapy and radiation.
For individuals with significant SMV–portal vein involvement (>180 degrees or short-segment encasement), or hepatic arterial or SMA abutment (<180 degrees) who have been traditionally considered unresectable, neoadjuvant therapy may play an important role in identifying the subset of patients most likely to derive benefit from aggressive multimodality therapy, including surgical resection with vascular reconstruction.[51] This type of aggressive treatment should be undertaken only by an experienced multidisciplinary team in the setting of a clinical trial
ASA classification
one-normal healthy
2 - mild systemic disease
3-severe systemic disease
4-severe systemic disease that is consistent with threat to life (unstable angina)
5-morbnd patient does not expected to survive without intervention
6-brain-dead
lack of any adjustment and intubation difficulty
lab findings of hemophilia A.
prolonged PTT
Normal PT and bleeding time
Intraoperative choices to administer and bleeding hemophilia A in order of preference
cryoprecipitate:
factor 8 and fibrinogen
Reed-Sternberg cells
associated with lymphoma
HeinZ bodies
the nature to hemoglobin
target cells
immature cells the increasing number
pappenheimer bodies
iron granules seen increasing after splenectomy
cell mediated immunity
T. cell mediated response
initiate CD4 and CD8 lymphocyte
pathogens targeted: Virus Fungus protozoans INTRAcellular bacteria
but not good old fashion bacteria like a Haemophilus influenza
indications for emergency discectomy of vertebrae
cauda equina syndrome only indication for urgent
condition of ovarian torsion
initial venous and lymphatic obstruction
Cyanotic edematous ovary
Progresses to low-grade fever and leukocytosis with adnexal necrosis
Doppler
Primary common duct stones
most common primary bile duct stone composition is calcium bilirubinate
pigmented in colon
Block-excess bilirubin due to hemolysis
Brown-de congregation of bilirubin by bacteria, Escherichia coli precipitates and calcium bilirubinate
most common nerve injured and laparoscopic hernia repair
Genital femoral
Lateral femoral cutaneous
most common nerve injury with open inguinal hernia repair
ilioinguinal
Genital branch of general femoral ( careful, most common in laparoscopy is genital femoral)
Iliohypogastric
testicular tumor consistent with AFP or beta hCG and LDH elevation
nonseminomatous germ cell tumor
testicular tumor consistent with beta hCG elevated only
10-20% seminoma
careful, AFP never elevated with seminoma
management of lower moderate grade dysplasia of Barrett’s
endoscopy every 3-6 months
rollover fundoplication when Barrett’s is diagnosed
if low or moderate:
Fundoplication can stop progression but will not reverse Barrett’s
presentation of nasopharyngeal carcinoma
ear infections in Caucasian elderly male
with tobacco history
Nasal obstruction
Conductive hearing loss
Indications for urgent surgical intervention gunshot wound of the kidney
renal pedicle avulsion - life-saving nephrectomy
expanding hematoma
un contained retroperitoneal hematoma
shock
relative indication:
Large amount of devitalized renal parenchyma
does not mandate surgical repair:
Urine extravasation!
most lacerations are to minor calyces and stopped spontaneously
workup for urine extravasation-
Serial CT scan
diagnosis of nutcracker esophagus
manometry amplitude greater than 180
contraction greater than 6 seconds
normal progressive contraction on esophagram
hyperperistalsis on EGD
esophageal pathology with corkscrew esophagus
diffuse esophageal spasm
careful, amplitude normal on manometry
contraindications ketamine
myocardial disease
brain lesion
(Downs ok)
Increase myocardial oxygen consumption
Increased intracranial pressure
advantage full-thickness skin graft
less contracture
poor take rate
advantage split thickness skin graft
left vulnerable to shear force
To be placed directly over muscle flap
ct finding of pyogenic absces
rim enhancing and gas bubbles
Uncal herniation early signs
cranial nerve III which causes early findings of anisocoria, ptosis, impaired extraocular movements, and sluggish pupillary light reflex on the ipsilateral side of the lesion. Initially
Cervical cancer with nodal spread tx
Stage IIIB lesion with a poor prognosi
(Advanced stage tumors are defined as IIB-IVA)
Radiation therapy and chemotherapy, not surgery, are the primary treatment modality for advanced cervical cancer.
physiologic leukocytosis of pregnancy, which may be as high as
16,000 cells/mm3.
what his more common in the small bowel primary tumor or metastatic tumor
metastatic
Most common met melanoma
list cancer that metastasized to small bowel
melanoma #1 extra-abdominal source
intra-abdominal sources more common overall: Cervix Ovaries Kidneys Stomach Colon Pancreas
mechanism of amiodarone
in addition of the breakdown of cyclic AMP
phosphodiesterase inhibitor
INCREASE his calcium uptake-increased contractility
also vasodilator
most common cause of bleeding from pelvic fracture and zone 3 hematoma
sacroiliac joint associated arterial bleeding
Usually branch of the internal iliac artery
embolized for pelvic bleed with fracture
The incidence of arterial hemorrhage amenable to embolization is approximately 10%. In these cases, arteriography with embolization can be lifesaving.
disruption of the sacroiliac (SI) joint, female gender, and duration of hypotension were all predictors of a positive angiogram
T. stage colon cancer
1 invasive submucosa 2 today's muscularis propria 3 through muscularis propria and into pericolic rectal tissue 4a to surface of visceral peritoneum the 4b invades visceroperitoneum
n-stage colorectal adenocarcinoma
N1 1-3 regional nodes
N1a one regional node N1b 2-3 regional nodes N1c without regional nodes: but with: deposits in the subserosa, mesentery, non-peritonealized pericolic or perirectal tissue
N2a 4-6 nodes
N2b 7 or greater
pancreatic divisum
failure of fusion of the ventral and dorsal pancreatic ducts
usually asymptomatic
treated with ERCP and sphincteroplasty with sten
duct of Wirsung still drained via major papilla:
drains uncinate process and part of pancreas head
Duct of Santorini:
still draining to be a lesser papilla
drains head, body, tail
diagnoses ERCP
primary pulmonary hypertension
idiopathic
Aggressive and often fatal
duodenal atresia
double bubble
Down’s syndrome, maternal polyhydramnios, malrotation, annular pancreas, biliary atresia, cardiac, esophageal, renal, anorectal
VACTRL
distal to anterior levator-biliary emesis
Its distal areas still seen after double bubble need upper GI contrast exclude midgut volvulus
treatment:
Duodenal duodenostomy
either side to side or transverse to distal longitudinal diamond-shaped
went blood work findings are seen with complete asplenia
Howell-Jolly bodies - no more spleen to filter is out
work up for accessory spleen postsplenectomy
Howell-Jolly bodies - no more spleen to filter is out
radionucleotide image 2 located accessory spleen
best test for pheochromocytoma
For pheochromocytoma, the most sensitive markers are serum metanephrines and normetanephrines, which are the breakdown products of circulating catecholamines. If the serum metanephrines are twice the normal level or higher, the patient has a pheochromocytoma;
Do not make the mistake of ordering serum catecholamines, as their rapid fluctuations render them useless. If the result of the serum metanephrines leaves the diagnosis in doubt, a 24 hour urine collection for metanephrines, catecholamines, and vanillylmandelic acid should be ordered. While the sensitivity of this test remains above 95%, it also has better than 95% specificity.
choledochocyst type I
fusiform dilation common bile duct
Most common
Cholecystectomy and hepatico J.
choledochocyst type II
EXTRA hepatic
diverticular cyst
Cholecystectomy and hepatico J.
choledochocyst type III
Distal to common bile duct - Junction with duodenum
cholecystectomy
Resection
Choledochoduodenostomy
choledochocyst type IV
BOTH intrahepatic and extrahepatic
May require liver resection of involved segment
choledochocyst type V
INTRA-hepatic
May be to liver failure - In which case transplant is treatment
refractory hypertension 6 months post renal transplant
transplant renal artery stenosis
workup may include:
Color Doppler ultrasound
MR angiography ( Better than CT)
spiral CT
treatment:
Percutaneous transluminal angioplasty
most common type of hip dislocation
Posterior dislocations compose 70-80% of all hip dislocations and 90% of all sports-related hip dislocations.
most common type of shoulder dislocation
ANTERIOR
he clinical presentation of anterior hip dislocation is characterized by abduction and external rotation. Anterior dislocation of the hip, although less common, is more frequently associated with fracture of the femoral head or indentation deformation. Large femoral head fractures and those associated with acetabular or femoral neck fractures have a high incidence of avascular necrosis and hip arthritis
Posterior dislocations compose 70-80% of all hip dislocations and 90% of all sports-related hip dislocations.
Posterior hip dislocations
Posterior hip dislocations are much more common than anterior dislocations
classically present with an adducted, flexed, and internally rotated extremity (choice A).
stimulate the LES
Alpha-adrenergic neurotransmitters or beta-blockers stimulate the LES,
gastrin and motilin
stimulants decrease in pressure of LES
alpha blockers and beta stimulants decrease its pressure.
cholecystokinin, estrogen, glucagon, progesterone, somatostatin, and secretin decrease LES pressure
when vecuronium elim decreased
renal or hepatic dysfunction
what effects Cisatracurium elim
Hoggman elimination
also seen with atracurium
good choices if the patient has hepatic or renal failure
requirements for endovascular aneurysm repair
aortic neck length greater than 1.5 cm
Neck angulation less than 60°
landing zone greater than 1 cm
type I endoleak
around graft at proximal or distal attachment
Type II endoleak
Retrograde collateral branch
Lumbar, testicular, inferior mesenteric
Type III endoleak
Between different parts of components
Type IV endoleak
2 graft wall
Type V endoleak
Unknown origin
Breslow stage
this is the pure depth in millimeters stage
stronger predictor of outcome and Clark’s
Products probability of lymph node involvement and five-year survival
treatment of stage III colon adenocarcinoma
Stage III colon cancers benefit from adjuvant chemotherapy. Following resection, the recommended chemotherapy regimen is with 5-FU, Leucovorin, and Oxaliplatin. This is known as the FOLFOX therapy, and has shown to increase survival in patients with Stage III colon cancer.
chest tube output and hemothorax that mandates operative intervention
greater than 1500 mL Initial
Persistent drainage of 200-100 mL per hour for 4 hours after initial drainage
what is the plasma carrier of cholesterol
LDL
diagnosis of solitary lung mass with popcorn calcification
hamartoma
Benign
Workup for suspected hemobilia
first endoscopy - Rules out other sources
angioma and embolectomy definitive
most minor hemobilia is managed conservatively
what is most potent hormone to stimulates pancreatic enzyme secretion
CCK
stimulated by a release of fatty acid and polypeptide and duodenum
normal location for anal fissure
posterior
lateral need workup for Crohn’s or STI
diseases that splenectomy cure
hereditary cytosis
NON-Hodgkin’s lymphoma
CLL with symptomatic splenomegaly
C-peptide finding with insulinoma
high
C-peptide is endogenous
mechanism of aldosterone
increase sodium retention and distal tubule
stimulated by angiotensin II the
mechanism of angiotensin II
convert angiotensin I to angiotensin II didn’t stimulate release of aldosterone
mechanism of Renin
convert angiotensin edge and angiotensin I
stimulated by low-sodium and distal convoluted tubule, hyperkalemia, hypovolemia
diagnosis during laparoscopy sudden decrease in end-tidal CO2 and hypotension
CO2 embolus
management of familial hypercalcemia hypocalciuria
no treatment indicated
hypercalcemia usually mild
defects associated with maternal polyhydramnios
tracheoesophageal fistula
Duodenal atresia
mechanism of jejunal atresia
intrauterine mesenteric vascular accident
mechanism of gastroischesis
failed obliteration of umbilical vein
medications contraindicated in obstructive hypertrophy cardiomyopathy
dopamine #1 no no
inotrope causes further decreasing cardiac filling and worsens ventricular outflow tract obstruction
medications for obstructive hypertrophy cardiomyopathy
beta blocker - metoprolol first line
calcium channel blocker
slow down and relax heart to improve filling
amiodarone helps decrease arrhythmia potential
risk factors a squamous cell carcinoma head and neck
Tobacco
Alcohol
HPV
Epstein-Barr virus
immune functions IgA
intestinal tract
Produced by plasma cell
Findings antigen Negative bacteria Prevent colonization Neutralize his toxin Works against virus
DOES NOT work with optimization
