TrueLearn

Question 1

longterm outcomes after congenital diaphragmatic hernia repair

Answer 1

chronic pulmonary disease (emphysematous changes, bronchopulmonary dysplasia, reactive airway disease, pulmonary hypertension, pneumonia); usually imporves over the first two years but hypoplastic lungs never reach normal function

developmental delay (lung disease/hypoxemia, postnatal growth failure, prolonged hospitalization)

Question 2

congenital diaphragmatic hernia repair associated with higher recurrence

Answer 2

patch repair or laparoscopic repair of congenital diaphragmatic hernia

Question 3

congenital diaphragmatic hernias on which side (left or right) are associated with better outcomes?

Answer 3

left sided CDH are associated with better outcomes

right sided CDH are more difficult to expose surgically (liver) and require a patch repair more frequently

Question 4

what is the anatomical landmark of the resection plane when performing right and left hepatectomy?

Answer 4

middle hepatic vein; extends from the gallbladder fossa to the IVC

plane between the right and left lobe of the liver is called the midplane of the liver or Cantlie line

Question 5

what is the anatomical landmark between the anterior and posterior segments of the right lobe of the liver?

Answer 5

right portal vein

Question 6

what is the anatomical landmark for the plane between the medial and lateral segment of the left lobe of the liver?

Answer 6

round ligament at the umbilical fissure

Question 7

what is the most common benign neoplasm of the spleen?

Answer 7

hemangioma

most commonly present as an incidental finding
may be solitary or multiple
bluish purple colored lesion
MRI is very sensitive/specific
biopsy is not recommended due to bleeding risk
typically asymptomatic but massive hemangiomas may rupture
splenectomy or partial splenectomy is indicated in cases of massive hemangioma with capsular distention and pain

Question 8

management of pancreatic serous cystic neoplasms

Answer 8

very low risk of malignancy, should be resected if clearly symptomatic or if they cannot be distinguished from malignant cystic neoplasms

Question 9

management of pancreatic mucinous cystic neoplasms

Answer 9

high risk of malignancy, should be resected regardless of size

Question 10

management of main duct or mixed type intraductal papillary mucinous neoplasms (IPMN)

Answer 10

resection is indicated because of high risk of associated malignancy

Question 11

management of branched duct intraductal papillary mucinous neoplasms (IPMN)

Answer 11

determined by size, symptoms, radiographic, and cytological findings
the following should be resected:
- branched duct IPMN >/= 3.0cm
- any symptomatic branched duct IPMN
- any branched duct IPMN associated with radiographic (mural nodules) or cytological findings concerning for malignancy

asymptomatic branch duct IPMN < 3.0cm without radiographic or cytologic findings concerning for malignancy should be followed by cross sectional imaging

Question 12

nodular lymphoid hyperplasia (numerous polyps in the small and large intestine, rarely in the stomach)

Answer 12

enlarged submucosal lymphoid follicles associated with immunosupression (immunocompetent patients usually asymptomatic)

Question 13

is colorectal or small intestine nodular lymphoid hyperplasia associated with increased malignancy?

Answer 13

colorectal nodular lymphoid hyperplasia is not associated with increased malignancy but small intestine nodular lymphoid hyperplasia is associated with increased incidence of lymphoma

Question 14

what is the lymphatic drainage of the cervical esophagus?

Answer 14

internal jugular and upper tracheal lymph nodes

Question 15

what is the lymphatic drainage of the dorsal esophagus?

Answer 15

posterior mediastinal lymph nodes

Question 16

what is the lymphatic drainage of the anterior portion of the thoracic esophagus

Answer 16

tracheal lymph nodes superiorly and subcarinal/paraesophageal lymph nodes inferiorly

Question 17

what is the lymphatic drainage of the abdominal esophagus?

Answer 17

cardiac and celiac lymph nodes which eventually drain into the cisterna chyli or the thoracic duct

Question 18

lymphatic drainage from the upper 2/3 of the esophagus goes in what direction?

Answer 18

cephalad

Question 19

lymphatic drainage from the lower 1/3 of the esophagus goes in what direction?

Answer 19

cephalad and caudad

Question 20

where are insulinomas found?

Answer 20

over 99% are found in the pancreas, rare cases are found in ectopic pancreatic tissue
5% are associated with tumors of the parathyroid glands and pituitary (MEN1)
most insulinomas are <2cm
insulinomas are uniformly distributed throughout the pancreas

Question 21

how is chylothorax diagnosed?

Answer 21

high triglyceride levels in pleural fluid (>110mg/dL)

Question 22

what is the treatment of chylothorax?

Answer 22

depends on cause and severity
postoperative chylothorax: initially conservative; drainage of >500mL/day predicts failure of conservative treatment
thorascopic thoracic duct ligation is the surgical treatment of choice

lymphoma related chylothorax should initially be managed with thoracentesis, conservative measures, and treatment of the underlying cause

other treatment options include thoracoscopic talc pleurodesis, thoracic duct ligation or pleuroperitoneal shunting
transabdominal percutaneous embolization of the thoracic duct is an alternative to surgical ligation (not widely available)

Question 23

what is the most common subtype of melanoma?

Answer 23

superficial spreading melanoma; initially grows in a radial fashion but has the potential for a vertical growth phase if untreated

Question 24

what type of melanoma is most commonly seen in sun-exposed elderly patients?

Answer 24

lentigo maligna melanoma; associated with slow growth and the best overall prognosis

Question 25

what type of melanoma is most commonly seen in the hands and feet of African Americans

Answer 25

acral lentiginous melanoma; associated with delayed diagnosis and poor prognosis

Question 26

what type of melanoma has an early vertical growth phase and has the worst overall prognosis of any subtype?

Answer 26

nodular melanoma

Question 27

what are symptoms of sarcoidosis? how is it diagnosed and treated?

Answer 27

in sarcoidosis abnormal collections of chronic inflammatory cells (noncaseating granulomas) form in multiple organs

dyspnea, dry cough
erythema nodosum, uveitis
hilar adenopathy

diagnosed with biopsy via bronchoscopy or open lung biopsy

treated with steroids

Question 28

where is cholecystokinin produced?

Answer 28

I cells of the duodenum and jejunum

Question 29

what causes release of cholecystokinin?

Answer 29

ingestion of fat, protein and amino acids (enteroendocrine cells)

Question 30

what does cholecystokinin cause?

Answer 30

inhibition of proximal gastric motility
increased antral and pyloric contraction
relaxation of the sphincter of Oddi
stimulation of gallbladder contraction and pancreatic secretion

Question 31

clinical presentation concerning for scaphoid fracture

Answer 31

fall on outstretched hand

pain worse with palpation over the snuffbox

Question 32

diagnosis of scaphoid fractures

Answer 32

immediate post injury XR may not show the fracture

CT or MRI may assist with diagnosis or a thumb spica cast can be applied and XR repeated in 2 weeks

Question 33

management of scaphoid fractures

Answer 33

nondisplaced fractures of distal, midbody, or proximal (but not proximal pole) scaphoid fractures are treated with immobilization for 6, 10, 12 weeks respectively

thumb spica cast (hand to elbow) is required. there is increased incidence of nonunion with short arm splints or wrist casts

serial XR are performed every 2 weeks until radiographic healing has occurred

Question 34

indications for referral to a hand surgeon for scaphoid fracture

Answer 34

fractures of the proximal pole, displacement >1mm, delayed prsentation of acute fractures (>3 weeks), scapholunate ligament rupture, carpal instability

Question 35

management of pancreatic injury without ductal involvement (grade I or II)

Answer 35

external closed-suction drainage
(penrose of sump drains are associated with high rates of intra-abdominal abscess formation and skin breakdown at the exit site)

Question 36

management of proximal pancreatic stump injury

Answer 36

ligation of the duct and oversewing of the parenchyma

Question 37

management of pancreatic injury involving the duct and left of the superior mesenteric vessels

Answer 37

distal pancreatectomy with or without splenectomy with staple or suture ligation of the proximal pancreatic duct

Question 38

management of pancreatic injury to the right of the superior mesenteric vessels in the head of the pancreas with intact duodenum

Answer 38

debridement with wide drainage of the pancreatic head

Question 39

management of massive destruction of the head of the pancreas or combined injury to the pancreas and duodenum

Answer 39

pancreaticoduodenectomy (in stable patients)

Question 40

damage control operations for pancreatic injury

Answer 40

hemorrhage control, external drainage, temporary abdominal closure

Question 41

what is phimosis and how is it treated?

Answer 41

abnormal constriction of the opening in the foreskin that precludes retraction over the glans penis resulting from chronic inflammation, infection (balanitis), and edema of the prepuce

treatment: dilation, dorsal slit circumcision, complete circumcision

forcible retraction of the prepuce can cause paraphimosis (trapping of the prepuce behind the glans penis) which limits the venous and lymphatic outflow while allowing continued arterial inflow (urologic emergency)

phimosis complicates sexual function, voiding, hygiene but is not an emergency; physiologic in neonates

Question 42

what is the goal of treatment of any branchial cleft remnant?

Answer 42

complete surgical resection

Question 43

dissection of second branchial cleft remnant

Answer 43

dissection penetrates platysma and cervical fascia
ascend along carotid sheath to hyoid bone, turn medially between branches of the carotid, continue behind posterior belly of digastric muscle and stylohyoid muscle, in front of hypoglossal nerve, ends before pharynx in tonsillar fossa (identified by putting finger in the mouth and pressing down in the tonsillar fossa

a second stepladder incision may be required to complete the dissection in older patients with a long tract

Question 44

what is included with excision of the third and fourth branchial remnant

Answer 44

thyroid lobectomy or resection of the superior pole as indicated by the extent of the cyst

Question 45

what optimizes the cosmetic result of branchial cleft cyst excision?

Answer 45

transverse cervical incision in a skin crease directly over the cyst

Question 46

excision of first branchial cleft remnant

Answer 46

superficial lobe of the parotid gland may need to be reflected upward to expose the tract or may require excision in cases of chronic infection

Question 47

surgical management of brachial cleft remnants when there is infection

Answer 47

antibiotics and delayed surgery (several weeks) while inflammation resolves
abscesses - limited I&D

if excision is pursued in the presence of inflammation/infection there is a higher risk of recurrence, incomplete excision, nerve injury (facial, hypoglossal)

Question 48

atherosclerotic renal artery lesions - location and management

Answer 48

proximal renal artery

angioplasty and stenting

Question 49

fibromuscular dysplasia of the renal artery - location and management

Answer 49

distal renal artery

angioplasty without stenting

Question 50

indications for renal artery revascualrization

Answer 50

difficult to control hypertension (3+ medications)
decreased renal function
hemodynamically significant stenoses

Question 51

diagnosis of renal artery stenosis

Answer 51

Ultrasound, CTA, MRA
no longer use serologic renin measurement (venous sampling) because it is invasive and has low specificity unless diagnosis is otherwise difficult

Question 52

renal artery stenosis and ratio of the flow velocity in the renal artery and aorta

Answer 52

ratio velocity in renal artery to aorta > 3.5 = stenosis > 60%

renal artery velocity >180cm/sec is abnormal

Question 53

renal artery resistive index (RRI)

Answer 53

RRI = 1 - [(end diastolic velocity/maximal systolic velocity) x100]

renal artery resistive index (RRI) > 0.8 identifies patients in whom the renal angioplasty/stenting did not improve renal function or blood pressure

Question 54

characteristics of the posterior vagal trunk

Answer 54

posterior trunk is larger, normally separated from the posterior esophageal wall (1-2cm) and localized between the 6 and 8 o’clock positions of the esophageal circumference

Question 55

characteristics of the anterior vagal trunk

Answer 55

anterior trunk is normally buried within the fibers of the anterior aspect of the esophageal wall between the 12 and 2 o’clock positions

Question 56

where does the criminal nerve of Grassi originate and where does it run?

Answer 56

the criminal nerve of Grassi originates from the posterior vagus nerve and runs toward the left side of the distal esophagus

Question 57

what is the most common case of recurrent ulceration after truncal vagotomy?

Answer 57

incomplete vagotomy due to failure to identify and divide the posterior vagus nerve

Question 58

treatment of hypocalcemia

Answer 58

patients with clinical, biochemical, or EKG evidence of hypocalcemia should be treated

symptomatic patients with ionized Ca < 3: IV replacement of calcium gluconate or calcium chloride (provides more elemental calcium than calcium gluconate)

oral calcium supplementation for less severe hypocalcemia

Question 59

what is familial hypercalcemic hypocalciuria?

Answer 59

autosomal dominant disease caused by increased calcium resorption in the kidney due to a defective PTH receptor leading to mild hypercalcemia with normal levels of parathyroid hormone; no treatment is required

Question 60

common causes of exudative effusion

Answer 60

pneumonia, malignancy, infection, chylothorax

Question 61

common causes of transudative effusion

Answer 61

congestive heart failure, liver cirrhosis, nephrotic syndrome, renal failure

Question 62

Light’s Criteria

Answer 62

1. pleural fluid to serum protein ratio > 0/5
2. pleural fluid to serum LDH ratio > 0.6
3. pleural fluid LDH concentration > 2/3 the upper limit of the serum reference range

Question 63

presentation of Hirschsprung disease

Answer 63

50 to 90% of children with Hirschsprung disease present during the neonatal period with abdominal distention, bilious vomiting, and feeding intolerance suggestive of distal intestinal obstruction
90% have delayed passage of meconium
delayed presentation in childhood or adulthood with chronic constipation (constipation after weaning in breastfed infants)

Question 64

presentation of jejunal atresia

Answer 64

infants with bilious emesis, abdominal distention, failure to pass meconium
air fluid levels on KUB with absent distal gas
barium enema with small unused colon, useful to exclude multiple atresias (present in 10-15% of caseS)

Question 65

presentation of intestinal malrotation

Answer 65

symptoms related to midgut volvulus, duodenal obstruction, or intermittent/chronic abdominal pain
most develop symptoms in the first month of life
chronic abdominal pain, intermittent episodes of emesis (may be nonbilious), early satiety, weight loss, failure to thrive, malabsorption, diarrhea

Question 66

presentation of duodenal atresia

Answer 66

generally first detected during a prenatal ultrasound evaluation
immediately after birth, KUB shows double bubble sign if obtained before OGT decompression of swallowed air
if distal air is present an upper GI contrast study should be obtained rapidly to confirm diagnosis and exclude midgut volvulus

Question 67

what types of cancers are most likely to metastasize to the adrenals?

Answer 67

lung (most common), GI tract, breast, kidney, pancreas, and skin (melanoma)

Question 68

where does thyroid cancer metastasize?

Answer 68

lung, liver, bones

Question 69

where does ovarian cancer metastasize?

Answer 69

adrenals

Question 70

what is the standard initial operation for treatment of infants with biliary atresia?

Answer 70

Roux-en-Y hepatic portoenterostomy (Kasai Procedure)
1. excision of the entire extrahepatic biliary tree with transection of the fibrous portal plate near the hilum of the liver
2. bilioenteric continuity is reestablished with Roux-en-Y limb
goal is to allow drainage of bile from the liver into the Roux limb via microscopic ductules in the portal plate

liver transplant is used in delayed diagnosis with severe liver failure where a Kasai procedure would be risky and have high failure rate

the use of the appendix as a conduit between the liver and small intestine has been proposed but its use has been limited with some reports of inferior surgical outcome

Question 71

management of neuroblastomas

Answer 71

neuroblastomas are the second most frequent pediatric solid tumor

staging with the International Neuroblastoma Staging System is based on location, extension of the primary tumor, lymph nodes, distant metastases

International Neuroblastoma Risk Group Classification System (low, intermediate, high) based on age, imaging, histology, MYCN amplification, chromosome 11 q aberration, DNA ploidy

low risk (INSS I or II) - surgery alone, goal complete resection
higher stages involve surgery, chemo, radiation

Question 72

where are motilin receptors located?

Answer 72

smooth muscle cells of the GI tract

Question 73

what does motilin do?

Answer 73

initiates the MMC to enhance GI motility

Question 74

where is motilin released from?

Answer 74

small intestine

Question 75

how does erythromycin affect GI motility?

Answer 75

binds to motilin receptors to promote GI motility

Question 76

what do parietal cells secrete?

Answer 76

HCl and intrinsic factor

Question 77

how do enterochromaffin-like cells aid in gastric acid secretion?

Answer 77

histamine release

Question 78

silver sulfadiazine for burn therapy

Answer 78

most common topical burn therapy
low cost, wide range of antimicrobial activity
side effect: transient neutropenia (no treatment required)
contraindicated on areas of new skin grafting and lesions near the eye

Question 79

silver nitrate for burn therapy

Answer 79

comes in soak form

hypotonic solution which has been related to hyponatremia and methemoglobinemia

Question 80

bacitracin with or without neomycin and polymyxin B for burn therapy

Answer 80

superficial partial thickness facial burns

may cause nephrotoxicity

Question 81

mafenide acetate for burn therapy

Answer 81

usually used for small full-thickness injuries

carbonic anhydrase inhibitor, may cause metabolic acidosis

Question 82

borders of the inguinal canal

Answer 82

inferior: inguinal ligament
posterior: conjoint tendon
anterior: aponeurosis of the external oblique
superior: external oblique aponeurosis and musculoaponeurotic extensions of internal oblique and transversalis muscle

Question 83

Lichtenstein repair of an inguinal hernia

Answer 83

the inguinal floor is reconstructed with mesh
the inferior edge of this mesh is sewn to the shelving edge of the inguinal ligament
the medial edge is sewn to the conjoint tendon medially and the internal oblique and transversalis fascia superiorly

do not sew inferior to the shelving edge because of proximity to the external iliac vessels

Question 84

what is Cooper’s ligament?

Answer 84

the extension of the lacunar ligament that extends along the pectineal line of the pubis
inferior to the inguinal ligament

Question 85

fat necrosis of the breast

Answer 85

most common secondary to trauma, average time from trauma to palpable breast mass is 70 weeks

polyarteritis nodosa is a rare cause of fat necrosis

pathology: anucleated adipocytes, lipid laden histiocytes, and multinucleated giant cells, no evidence of malignancy

Question 86

causes of zinc deficiency

Answer 86

reduced absorption or increased gastrointestinal losses (gastric bypass, Crohn disease, chronic liver/renal disease, prolonged TPN)

Question 87

effects of zinc deficiency

Answer 87

failure to thrive, skin rash, impaired wound healing

Question 88

effects of selenium deficiency

Answer 88

cardiomyopathy, hypothyroidism, neurological changes

Question 89

effects of chromium deficiency

Answer 89

hyperglycemia, confusion, peripheral neuropathy

Question 90

effects of copper deficiency

Answer 90

pancytopenia and myelopathy (neuropathy with ataxia)

Question 91

effects of vitamin B12 deficiency

Answer 91

megaloblastic anemia, peripheral neuropathy, beefy tongue, myelopathy

Question 92

type 1 hypersensitivity

Answer 92

anaphylaxis/immediate hypersensitivity reaction

binding of antigens to IgE adn subsequent mast cell and basophil degranulation

systemic vasodilation, itching, urticaria, angioedema, bronchoconstriction, GI symptoms, shock

peanuts, bee stings, medications, C1 esterase deficiency, blood transfusions with IgA deficiency

Question 93

type 2 hypersensitivity

Answer 93

cytotoxic mediated
immunoglobulins attached to a surface antigen with subsequent complement fixation or autoantibodies attached to cell surface receptors
not immediate after exposure to the antigen

Hashimoto thyroiditis, Grave disease

Question 94

type 3 hypersensitivity

Answer 94

circulating antigen-antibody reactions with subsequent complement fixation

deposition of immune complexes into vessels, joints, and kidneys

serum sickness

Question 95

type 4 hypersensitivity

Answer 95

cell mediated immunity

local injury to the area when antigen is present

contact dermatitis

Question 96

what is the most common metastatic tumor to the small bowel via hematogenous spread?

Answer 96

melanoma

Question 97

tumors that metastasize to the small bowel via hematogenous spread

Answer 97

melanoma (most common), lymphoma, breast, lung

Question 98

tumors that metastasize to the small bowl by direct invasion

Answer 98

pancreas, colon cancer

Question 99

tumors that metastasize to the small bowel via peritoneal implants

Answer 99

ovarian, liver, stomach, appendix, colon

Question 100

in which patients is overwhelming post-splenectomy infection most likely?

Answer 100

children undergoing splenectomy for malignancy or hematologic illnesses such as beta thalessemia or sickle cell disease

Question 101

symptoms and diagnosis of condyloma acuminatum

Answer 101

HPV 6 and 11
perianal growth, puritis, discharge, bleeding, odor, anal pain

cauliflower like lesion in radial rows out from the anus

anoscopy and proctosigmoidoscopy because the disease extends internally in >3/4

Question 102

most common location of VIPoma

Answer 102

distal pancreas

Question 103

most common location of gastrinoma

Answer 103

gastrinoma triangle

1. junction of cystic duct and common bile duct
2. junction of second and third parts of duodenum
3. junction of the head and neck of pancreas

Question 104

most common location of somatostatinoma

Answer 104

head of the pancreas

Question 105

VIPoma presentation

Answer 105

intermittent severe watery diarrhea, hypokalemia (lethargy, muscle weakness, nausea), metabolic acidosis (loss of bicarbonate), half have hyperglycemia/hypercalcemia, less than half with cutaneous flushing

Question 106

electrolyte derangement in recurrent vomiting

Answer 106

metabolic alkalosis

hypokalemic, hypochloremic with low urine chloride

Question 107

conditions associated with chloride responsive alkalosis

Answer 107

gastric fluid loss, chloride wasting diarrhea, diuretics

low urine chloride (Cl <10)

Question 108

conditions associated with chloride resistant alkalosis

Answer 108

Conn syndrome, secondary hyperaldosteronism, Cushing syndrome, Liddle syndrome, Bartter syndrome, exogenous corticoids, ongoing diuretics

high urine chloride (Cl >20)

Question 109

Vitamin C deficiency (scurvy)

Answer 109

prevents proline hydroxylation resulting in formation of unstable triple helices secondary to the synthesis of defective pro-alpha chains

gradual loss of preexisting normal collagen leading to fragile blood vessels and loose teeth

Question 110

inflammatory stage of wound healing

Answer 110

characterized by increased vascular permeability, migration of cells into the wound by chemotaxis, secretion of cytokines and growth factors into the wound, and activation of the migrating cells

Question 111

scaffolding stage of wound healing

Answer 111

angiogenesis, fibroplasia, epithelialization

Question 112

proliferative stage of wound healing

Answer 112

formation of granulation tissue

Question 113

what is the most important factor in healing wounds?

Answer 113

tensile strength which depends on collagen deposition and subsequent cross-linking

Question 114

after primary repair of a thoracic esophageal perforation what has been shown to have value in primary healing of the perforation?

Answer 114

pedicled intercostal muscle flap

the parietal pleura is thin and does not make a suitable buttress

Question 115

what molecule leads to the development of cachexia?

Answer 115

tumor necrosis factor alpha
cytokine synthesized by macrophages, monocytes, T cells in response to injury and infection
leads to cachexia by increasing catabolism and insulin resistance

Question 116

what is the effect of granulocyte-macrophage stimulating factor?

Answer 116

stimulates granulocyte and monocyte production from bone marrow stem cells

Question 117

where is interleukin 1 released from and what does it cause?

Answer 117

interleukin 1 is released from the hypothalamus and causes fever

Question 118

what does interleukin 2 promote?

Answer 118

interleukin 2 promotes T cell proliferation and immunoglobulin production

Question 119

what does interleukin 4 stimulate?

Answer 119

Interleukin 4 stimulates T cell differentiation and B cell activation

Question 120

what is the 4:2:1 rule for maintenance fluids?

Answer 120

4mL for the first 10kg
2mL for the second 10kg
1mL for the remaining weight

postoperative fluid replacement should also include the intraoperative fluid deficit and the ongoing loss

Question 121

indication for intervention on asymptomatic carotid disease

Answer 121

> 70% CA stenosis

Question 122

indication for CEA or carotid stenting with symptomatic coronary artery disease

Answer 122

> 90% CA stenosis or contralateral carotid occlusion (theoretical risk for low flow ischemia while on pump for CABG)

Question 123

characteristics and treatment of chronic autoimmune pancreatitis

Answer 123

densely mononuclear cell infiltrate, significant fibrosis, increased autoantibody titer

treated with systemic steroid therapy

Question 124

indications for operative treatment of penetrating facial injury

Answer 124

if the injury is medial to the lateral canthus of the eye then the facial nerve’s ability to recover non-operatively is successful due to arborization

if the injury is lateral to the lateral canthus of the eye then surgical intervention is warranted
- exploration is necessary to repair transected nerve if patient demonstrates facial nerve paraplysis
- if injury is near parotid duct then the parotid duct and gland should be explored
repair should be done within 72 hours of injury before wallerian degeneration prevents identification of the nerve endings of the transected facial nerve

Question 125

what is dermatofibrosarcoma?

Answer 125

low grade sarcoma that is characterized by microscopic lateral extension of tumor cells and high risk of local recurrence

soft tissue tumor that arises from fibroblasts - spindle like CD34 immunohistochemical stain positive

Moh’s procedure is cometimes used to ensure negative margins

predictors of prognosis: grade, size, depth in relation to the fascia, distant or regional metastasis

Question 126

what is the standard treatment of choice for a low simple fistula and some mid-rectovaginal fistulas?

Answer 126

endorectal advancement of an anorectal flap

Question 127

what is the treatment for high fistulas and some mid-rectovaginal fistulas

Answer 127

transabdominal repair

Question 128

what is the management of small and simple rectovaginal fistulas secondary to obstetric trauma?

Answer 128

spontaneous healing occurs in about half of cases; wait 3-6 months until inflammation has subsided before considering surgical repair

Question 129

what is the treatment for popliteal aneurysm >2cm in healthy patients?

Answer 129

bypass and ligation (prevents further embolization in the future as may occur with bypass alone)

popliteal aneurysms < 2.0cm can be observed

Question 130

what branches of the aorta are most commonly injured?

Answer 130

innominate and subclavian

Question 131

what is the most appropriate incision to gain arterial control for an injury to the ascending aorta, aortic arch, innominate, right subclavian, left common carotid?

Answer 131

median sternotomy

Question 132

where is the incision of an emergency room thoracotomy made?

Answer 132

left anterolateral incision in the 5th intercostal space
allows access to the heart
can be extended to a clam shell incision if needed

Question 133

what incision should be made to obtain left subclavian proximal control?

Answer 133

high third interspace anterior thoracotomy

Question 134

what incision should be made to gain control of the descending aorta?

Answer 134

posterolateral thoracotomy

Question 135

what arteries can be accessed via supraclavicular and infraclavicular incisions?

Answer 135

axillary or subclavian arteries

will not allow for control of the innominate artery coming off the aorta

Question 136

what is the most common benign tumor of the lung?

Answer 136

hamartomas
men > women
solitary pulmonary nodule with a slow growth pattern
well circumscribed nodule that may contain popcorn calcification
needle aspiration is frequently diagnostic
indications for resection are proximal location, presence of symptoms caused by endobronchial obstruction or inability to rule out carcinoma

Question 137

management of arrhythmia caused by placing a swan-ganz catheter

Answer 137

1. pull back the catheter into the right atrium

2. lidocaine or other antiarrhythmic

Question 138

which maneuver is indicated for air embolus during swan-ganz catherterization?

Answer 138

left lateral decubitus

traps air in the right atrium

Question 139

appearance of blunt thoracic aortia injury most often secondary to acute deceleration on CXR

Answer 139

widened mediastinum, apical cap, displacement of the trachea/left main bronchus/NGT

Question 140

where is blunt thoracic aorta rupture most likely to occur?

Answer 140

at the level of the ligamentum arteriosum secondary to it being relatively fixed at that location

Question 141

what is the imaging of choice to rule our blunt thoracic aortic injury and to make surgical plans for this injury?

Answer 141

CTA

Question 142

how do acute paraesophageal hernias present?

Answer 142

sudden onset of retching, vomiting, chest pain

can progress rapidly to strangulation and gastric ischemia

Question 143

management of acute paraesophgeal hernias

Answer 143

NGT placement to relieve pressure followed by surgical intervention approached via urgent laparotomy or laparoscopy
repair may require mesh

Question 144

in what patients is pneumocystis carinii seen? what do they present with? how is it treated?

Answer 144

immunocompromised patients

weeks of dry cough, fever, sweats, difficulty taking a deep breath, tachypnea, tachycardia, cyanosis, fine crackles on auscultation

CXR reveals diffuse bilateral infiltrates

may be disseminated via lymphatics and hematogenous spread to thyroid, liver, bone marrow, lymph nodes, spleen

prophylaxis with bactrim in transplant patients

Question 145

what is seen on CXR in mycobacterium tuberculosis?

Answer 145

cavitating lesion

Question 146

in what region is histoplasmosis most common?

Answer 146

Ohio River Valley

caves

Question 147

in what region is coccidiomycosis most common?

Answer 147

southwestern US

Question 148

how is a DeMeester score calculated?

Answer 148

DeMeester score is calculated based on percent total time pH<4 while upright, supine, and overall
number and duration of each episode is monitored

Question 149

what is an abnormal DeMeester score?

Answer 149

> 14.72 (95th percentile)

Question 150

what is esophageal impedance?

Answer 150

an adjunct to traditional pH testing using electrical current
low voltage current is applied to multiple electrodes within the probe to determine the presence of liquid, food, or esophageal tissue; the direction of a bolus may also be determined (this allows for detection of nonacid reflux and may be used to determine reflux even with PPIs)

Question 151

where is the pH probe placed in esophageal pH monitoring?

Answer 151

5cm above the LES

Question 152

what electrolyte abnormalities are seen in refeeding syndrome?

Answer 152

hypokalemia, hypophosphatemia, hypomagnesemia

decreased Mg and K lead to arrhythmia and sometimes cardiac arrest
decreased phos leads to decreased ATP generation (weakness, encephalopathy, congestive heart failure, ventilator dependence)

Question 153

what is the management approach of acute diaphragm injury?

Answer 153

acute injuries of the diaphragm are repaired through an abdominal incision via laparotomy or laparoscopy

Question 154

what is the management approach of chronic diaphragm injury?

Answer 154

thoracoscopic

Question 155

blunt trauma is more likely to result in diaphragm injury on which side?

Answer 155

left more common than right because liver diffuses some of the energy on the right side
(75% on the left)

Question 156

what are the characteristics of diaphragmatic injury secondary to blunt trauma?

Answer 156

linear tear in the central tendon

Question 157

what is the most common indication for parotidectomy?

Answer 157

neoplasm

Question 158

genetic abnormality in which electrolyte leads to malignant hyperthermia with certain inhalational anesthetic agents?

Answer 158

calcium
mutation results in altered calcium regulation in skeletal muscle
enhanced efflux of calcium from endoplasmic reticulum

Question 159

what is the mechanism of inheritance in malignant hyperthermia?

Answer 159

autosomal dominant with variable penetrance

Question 160

what is seen in malignant hyperthermia?

Answer 160

rigidity and hypermetabolism
uncontrolled glycolysis, aerobic metabolism, cellular hypoxia, progressive lactic acidosis, hypercapnia, heat, hyperkalemia, myoglobinuria, DIC, CHF, bowel ischemia, compartment syndrome

Question 161

What is seen in vitamin D deficiency?

Answer 161

osteomalacia, pathologic bone fractures, proximal myopathy

Question 162

what is seen in Vitamin E deficiency?

Answer 162

neuronal degeneration, neuropathy, spinocerebellar ataxia

seen in prolonged steatorrhea

Question 163

what are the vitamin K dependent coagulation factors?

Answer 163

II VII IX X

Question 164

what is seen in vitamin A deficiency?

Answer 164

visual disturbances, night blindness, ocular keratitis

Question 165

what are the causes of vitamin K deficiency?

Answer 165

inadequate dietary intake (including TPN without fat emulsions), insufficient adsorption (biliary tract obstruction), loss of storage (hepatic disease)

Question 166

how does fat necrosis of the breast present?

Answer 166

firm, irregular, often nontender mass that may be associated with skin retraction and thickening
on mammography appears as soft tissue with calcified rim, may have spiculated calcifications (often not distinguishable from cancer)

Question 167

what is the presentation of a phyllodes tumor?

Answer 167

rapidly growing smooth, round, breast mass

Question 168

what type of acid base disturbance is seen with high ileostomy output?

Answer 168

nonanion gap metabolic acidosis

Question 169

what are the indications for emergency thoracotomy for hemothorax?

Answer 169

initial chest tube output of 1500mL of blood or persistent drainage of 200-300mL/hr

Question 170

indications for emergency room thoracotomy

Answer 170

1. cardiac arrest (resuscitative thoracotomy)
2. massive hemothorax
3. penetrating injuries of the anterior aspect of the chest with cardiac tamponade
4. large open wounds of the thoracic cage
5. major thoracic vascular injuries in the presence of hemodynamic instability
6. major tracheobronchial injuries
7. evidence of esophageal perforation

Question 171

what medical therapy is used for Crohn disease persistent perianal fistula?

Answer 171

infliximab, a monoclonal chimeric antibody to tumor necrosis factor

Question 172

how do azathioprine and 6MP work?

Answer 172

inhibition of DNA synthesis leads to immunosuppression by suppressing cytotoxic T cell and natural killer cells

Question 173

how does sulfasalazine suppress inflammation?

Answer 173

5-ASA derivative that inhibits cyclooxygenase and lipooxygenase pathways
used in moderately active and quiescent Crohn’s

Question 174

what liver tumors are appropriate for laparoscopic resection?

Answer 174

LLRs are ideal for tumors <5cm located in segments 2, 3, 4, 5, 6

Question 175

what surveillance is indicated following surgery for stage III colorectal cancer?

Answer 175

CEA levels every 3-6 months for 2 years and then every 6 months for 3 years
CT of pelvis annually for 5 years and colonoscopy within 1 year

Question 176

what is the treatment for stage III rectal cancer?

Answer 176

neoadjuvant chemoradiation followed by resection followed by adjuvant chemotherapy

Question 177

which nerve becomes the posterior vagus?

Answer 177

the right vagus

Question 178

which nerve becomes the anterior vagus?

Answer 178

the left vagus

Question 179

where does the criminal nerve of Grassi originate and what does it innervate?

Answer 179

the posterior vagus gives rise to a high branching nerve, the criminal nerve of Grassi, which innervates the cardia of the stomach and continues down the remainder of the stomach to join the celiac plexus
if the vagotomy is performed below the level of the criminal nerve of Grassi, the patient may continues to remain symptomatic

Question 180

where does the hepatic branch of the vagus originate and what does it innervate?

Answer 180

the anterior vagus gives rise to the hepatic branch which innervates the stomach and near the pylorus it branches to the nerve of Latarejet which innervates the pylorus

Question 181

how is a truncal vagotomy performed?

Answer 181

both the anteiror and posterior vagus nerves are transected at the level of the distal esophagus 4cm proximal to the GE junction

Question 182

what is a selective vagotomy?

Answer 182

division of the two vagus nerves just below the posterior celiac branches that innervate the pancreas, small intestine, and hepatic branches

Question 183

what is a highly selective vagotomy?

Answer 183

dissection of the nerves near their terminal ends where the nerves splay out into a characteristic crow’s foot appearance with preservation of the Latarjet’s nerves
a drainage procedure is not necessary

Question 184

why are the excised nerves sent to pathology in vagotomy?

Answer 184

a 1-2cm area of each nerve is sent to pathology to confirm the vagus was excised as intended prior to ending the procedure

Question 185

what is the maximum amount of air a person can expel from the lungs after a maximal inhalation called?

Answer 185

vital capacity

it is equal to the inspiratory reserve volume + tidal volume + expiratory reserve volume

Question 186

amount of air moved in a normal breath

Answer 186

tidal volume

Question 187

amount of air left after maximal exhalation

Answer 187

residual volume

Question 188

amount of air left after exhaling a normal breath

Answer 188

expiratory reserve volume

Question 189

expiratory reserve volume + residual volume

Answer 189

functional residual capacity

Question 190

where is the most likely site for a traction diverticulum to occur in the esophagus?

Answer 190

mid-esophagus

Question 191

what is a traction diverticula of the esophagus?

Answer 191

true diverticula that occurs as a result of inflammatory processes in the nearby lymph nodes that pull on the esophageal wall

Question 192

what is a Zenker diverticulum and where does it occur?

Answer 192

pulsion diverticulum which occurs above the cricopharyngeus muscle
false diverticulum which only contains mucosa and submucosa that herniated through muscular wall

Question 193

what is an epiphrenic diverticulum and where does it occur?

Answer 193

pulsion diverticula which occurs in the distal esophagus

false diverticulum which only contains mucosa and submucosa that herniated through muscular wall

Question 194

what is the most common site for melanoma recurrence?

Answer 194

skin > subcutaneous tissue, distant lymph nodes > visceral sites

Question 195

what are the common visceral sites of metastasis of melanoma?

Answer 195

lung, liver, brain, bone, GI tract

Question 196

what are two common causes of death in metastatic melanoma?

Answer 196

respiratory failure, cerebral complications

Question 197

what is the larges risk factor for postoperative cardiac complications?

Answer 197

active congestive heart failure

Question 198

what is the predominant cellular source of tumor necrosis factor?

Answer 198

macrophages

Question 199

what is the operative treatment of type II choledochal cysts?

Answer 199

excision of the cyst and primary closure of the choledochotomy

Question 200

what is the operative treatment of type III choledochal cysts?

Answer 200

transduodenal approach with either marsupialization or excision of the cyst

Question 201

what is the operative treatment of type I choledochal cysts?

Answer 201

primary cyst excision with Roux-en-Y hepaticojejunostomy reconstruction

Question 202

why are internal drainage procedures not used for choledochal cyst treatment?

Answer 202

higher rates of stricture, stone formation, pancreatitis, and cholangitis

Question 203

when is intramural cyst dissection and removal of the cyst wall epithelium (leaving the posteromedial outer cyst wall adjacent to the portal vein and hepatic artery intact) used for management of choledochal cysts?

Answer 203

severe inflammation and fibrosis resulting in adhesion of the cyst wall to the hepatoduodenal ligament

Question 204

MAP - ICP =

mean arterial pressure minus intracranial pressure

Answer 204

CPP (central perfusion pressure)

Question 205

what is central perfusion pressure?

Answer 205

net pressure gradient causing brain perfusion, should be a minimum of 60mmHg

Question 206

GCS eye criteria/scoring

Answer 206

4. open spontaneously
5. open in response to speech
6. open in response to pain
7. do not open

Question 207

GCS verbal criteria/scoring

Answer 207

5. oriented, appropriate
6. confused speech
7. inappropriate speech
8. incomprehensible speech
9. no speech

Question 208

GCS motor criteria/scoring

Answer 208

6. obeys commands
7. localizes painful stimulus (cross midline)
8. withdraws from painful stimuli
9. flexor response (decorticate)
10. extensor response (decerebrate)
11. no response

Question 209

what are absolute contraindications for liver transplantation?

Answer 209

inability to withstand the operative procedure, recent intracranial hemorrhage, untreated extrahepatic malignancy

Question 210

which type of thyroid cancer results from proliferation of cells derived from neural crest cells?

Answer 210

medullary thyroid cancer

parafollicular C cells produce calcitonin and are derived from neural crest cells

Question 211

what is the primary fuel of neoplastic cells?

Answer 211

glutamine

Question 212

what are the stages of skin graft healing?

Answer 212

imbibition: diffusion of nutrients into the graft without direct blood supply
inosculation: donor and recipient capillary beds align
revascularization: arterial inflow and venous outflow detected

Question 213

what are the precursors of glucose in gluconeogenesis?

Answer 213

lactate, pyruvate, glycerol

Question 214

what is the Cori cycle?

Answer 214

lactate produced from glycolysis in the skeletal muscles and peripheral tissues are shifted to the liver and transformed into glucose
Cori cycle uses 4 ATP molecules to produce a single amino acid, inefficient

Question 215

what is the most common indication for liver transplantation?

Answer 215

end stage liver disease - minimal function and no potential for recovery

Question 216

what is fulminant hepatic failure?

Answer 216

the progression from good health to liver failure with hepatic encephalopathy within 8 weeks
the mortality rate is 75% without transplantation
indication for emergent liver transplantation

Question 217

weakness in the conjoint tendon that forms the posterior wall of the inguinal canal leads to what type of hernia?

Answer 217

direct inguinal hernia (medial to the inferior epigastric vessels)

Question 218

what forms the anterior and medial boundaries of the femoral canal?

Answer 218

iliopubic tract

Question 219

what is diastasis recti?

Answer 219

separation of the rectus muscles at the linea alba resulting in cosmetic defect that generally does not demand surgical attention

Question 220

a sac that resides lateral to the inferior epigastric vessels and is primarily the result of a patent processus vaginalis describes what type of hernia?

Answer 220

indirect inguinal hernia

Question 221

what is Petersen’s space?

Answer 221

the space between the Roux limb and transverse colon mesentery

Question 222

what is the jejunojejunostomy mesenteric space?

Answer 222

the space between the Roux limb and biliopancreatic limb mesenteries

Question 223

what is a Petersen hernia?

Answer 223

an internal hernia which occurs in the potential space posterior to a gastrojejunostomy caused by the herniation of intestinal loops through the defect between the small bowel limbs , the transverse mesocolon and the retroperitoneum

Question 224

which maneuver is completed to allow for proper supraceliac aortic exposure?

Answer 224

Mattox maneuver
left medial visceral rotation
the left colon, left kidney, spleen, tail of the pancreas, and fundus of the stomach are moved to the midline to provide extensive exposure to the entire abdominal aorta from the diaphragmatic hiatus to the bifurcation

Question 225

which maneuver allows for access to the retrohepatic inferior vena cava and involves medialization of the right sided abdominal organs?

Answer 225

Cattell-Braasch maneuver

right medial visceral rotation

Question 226

which maneuver is used to mobilize the duodenum?

Answer 226

Kocher maneuver

Question 227

which maneuver involves clamping the portal triad and provides inflow occlusion to the liver?

Answer 227

Pringle maneuver

Question 228

what is the most common secondary cause of death for a patient diagnosed with familial adenomatous polyposis after treatment with an appropriate surgical resection?

Answer 228

duodenal tumor

diligent upper endoscopy screening is recommended in all FAP patients beginning at ager 20-25 or when colonic polyps first appear

brain cancer is also seen with FAP but is rarer

Question 229

what landmarks are used for subclavian vein central line access?

Answer 229

1. deltopectoral groove
2. sternal notch
3. medical third of the clavicle

with the introducer needle angled toward the sternal notch, horizontal to the chest wall, and about 1cm inferior to the bend in the clavicle or medial third of the clavicle the subclavian vein may be aspirated
once attained the Seldinger technique is employed with the assistance of fluoroscopy

Question 230

what is the maximum size of a bleeding vessel that can be safely sealed with minimal thermal spread using bipolar electrosurgery?

Answer 230

7mm

Question 231

benefits of bipolar electrosurgery

Answer 231

1. bipolar electrosurgery uses coagulating mode for hemostasis and division of unsupported vascular tissues =7mm
2. the laparoscopic tool is versatile resulting in fewer instrument exchanges
3. less thermal injury occurs compared to monopolar electrosurgery
4. no capacitive coupling occurs and inadvertent direct coupling is unlikely
5. fewer accessories such as grounding electrodes are required eliminating the possibility of alternate site burns
6. safety of the technology for use in laparoscopy has been established

Question 232

posterior dislocation of the hip (flexed, shortened, internally rotated, adducted LE) may be associated with concomitant injury to which nerve?

Answer 232

sciatic nerve (peroneal division)

Question 233

supracondylar humerus fracture is associated with what other injury?

Answer 233

brachial artery injury (may lead to Volkmann’s ischemic contracture)

Question 234

distal radius fracture is associated with what other injury?

Answer 234

median nerve compression

Question 235

anterior dislocation of the shoulder is associated with what other injury?

Answer 235

axillary nerve injury

Question 236

posterior dislocation of the knee is associated with what other injury?

Answer 236

popliteal artery injury

Question 237

pelvic fractures are associated with what other injuries?

Answer 237

bladder injuries

obturator artery injuries

Question 238

femoral vein injury is associated with what?

Answer 238

penetrating trauma or femur fractures

Question 239

what is the Strasberg classification?

Answer 239

the most commonly used system to classify bile duct injuries following CCY

Question 240

Strasberg type A injury

Answer 240

leakage from the cystic duct stump or duct of Luschka

should be oversewn and a drain should be left in place if discovered intraoperatively
if discovered postoperatively, management depends on the severity of the presentation and amount of output

Question 241

Strasberg type B injury

Answer 241

ligation of an aberrant right hepatic duct

Question 242

Strasberg type C injury

Answer 242

transection of an aberrant right hepatic duct

Question 243

Strasberg type D injury

Answer 243

lateral injury to a major duct

Question 244

Strasberg type E injury

Answer 244

complex injuries often accompanied by a vascular component, occur higher on the biliary system

Question 245

complications of acute pancreatitis

Answer 245

pancreatic abscesses, infected necrosis, acute fluid collections and pseudocysts, pancreatic ascites and fistulas, splenic vein thrombosis, and arterial pseudoaneurysms

Question 246

what is the most common cause of benign bile duct strictures?

Answer 246

iatrogenic injury to the bile ducts during CCY

incidence of stricture is higher after laparoscopic versus open CCY

less common causes include malignancy, chronic pancreatitis, Mirrizi syndrome, choledocholithiasis

Question 247

What is Mirrizi syndrome?

Answer 247

results from chronic inflammation associated with gallstones in either the gallbladder or common bile duct
associated with narrowing at the level of the common hepatic duct caused by a stone impacted in the infundibulum

Question 248

management of inguinal hernias in children

Answer 248

all inguinal hernias in children need to be repaired
if the hernia can be reduced then surgery can be delayed for 24-48 hours to allow edema to resolve, if the hernia cannot be reduced then the hernia is repaired urgently
observation beyond 48 hours increases risk of incarceration/strangulation
operative repair is high ligation of the hernia sac

Question 249

what is a phyllodes tumor?

Answer 249

fibroepithelial tumors composed of an epithelial and cellular stromal component; may be considered benign, boarderline, or malignant depending on histologic features (stromal cellularity, infiltration at tumor’s edge, mitotic activity)
10% are malignant and metastasize hematogenously
management is wide local excision or simple mastectomy

Question 250

incision type for colostomy reversal

Answer 250

peristomal circumferential incision has the lowest morbidity

Question 251

what is used for a sentinel lymph node biopsy in pregnant women?

Answer 251

Tc-99m is safe in pregnancy.
blue dye should not be used for sentinel lymph node biopsy in pregnancy due to limited data on teratogenic effect and low risk of anaphylactic maternal reaction

Question 252

what is the most common complication following pancreatic injury?

Answer 252

postoperative pancreatic fistula

Question 253

which bacteria are commonly isolated from biliary cultures?

Answer 253

E. coli, klebsiella, enterobacter, bacteroides

Question 254

what is the natural history of acute cholecystitis?

Answer 254

the impacted stone initially causes a sterile inflammatory response leading to inflammation of the gallbladder mucosa, distention and eventually ischemia. if untreated, this leads to secondary infection, abscess formation, and occasionally sepsis or perforation.

Question 255

what are the steps that lead to formation of ascites?

Answer 255

1. sinusoidal portal hypertension
2. splanchnic vasodilation results in decreased effective arterial blood volume
3. activation of RAAS, vasopressin, SNS to increased circulating volume
4. renal retention of sodium and water, renal vasoconstriction
5. excess fluid is compartmentalized into the peritoneal space because of portal hypertension
6. further splanchnic vasodilation and renal vasoconstriction
7. refractory ascites and hyponatremia

Question 256

what is a galactocele?

Answer 256

a milk retention cyst of the breast that sometimes occurs in postpartum females when breast feeding is slowed or stopped and milk becomes stagnant in ducts
they are composed of water, protein, fat, lactose
protein debris plugs the duct creating obstruction
usually does not becomes infected because milk within the cyst is sterile
initial treatment is supportive

Question 257

what is the most common cause of iatrogenic splenic injury during abdominal surgery?

Answer 257

forceful retraction of the omentum for exposure causing tearing of the splenic capsule

Question 258

what is the pathophysiology of anorectal abscesses?

Answer 258

small mucin secreting crypts (anal glands at the dentate line) get blocked causing localized inflammation that eventually leads to abscess formation
because these glands are located at the intersphincteric space, that is where abscesses start

Question 259

what is the most common site of perforation during colonoscopy?

Answer 259

sigmoid colon (70% of all perforations)
mechanical perforation by endoscope tip, barotrauma from overinsufflation, and therapeutic procedures

Question 260

in an infant with profound cyanosis, what is the best first step in management?

Answer 260

IV PGE 1

maintain patent ductus arteriosus and provide left to right shunting and improved pulmonary blood flow

Question 261

in rectal prolapse repair, are recurrence rates higher for perineal or abdominal approaches?

Answer 261

recurrence rates are higher in the perineal repair (16-30%)

Question 262

are internal or external rectal prolapses easier to surgically treat?

Answer 262

external rectal prolapse is more amenable to surgical repair

Question 263

is the abdominal or perineal approach to rectal prolapse associated with less postoperative pain, fewer complications and shorter hospital stay?

Answer 263

the perineal approach is associated with less pain, fewer complications, and shorter hospital stay

Question 264

After a TIA, what is the risk of stroke within the first 48 hours?

Answer 264

the risk of stroke in the first 48 hours after TIA is 4-10%. This risk increases with time.

Question 265

vertebrobasilar symptoms

Answer 265

ataxia, dizziness, bilateral weakness and numbness

Question 266

what is a TIA

Answer 266

stoke-like symptoms that last for less than 24 hours but can be a predictor of actual stroke

Question 267

What is Barrett’s esophagus, where does it occur, how does it appear on EGD, and what is the cancer risk?

Answer 267

Barrett’s esophagus occurs in the distal esophagus proximal to the GE junction seconary to chronic reflux.
Cells undergo conformational change from squamous to columnar with Goblet cells.
EGD: salmon colored mucosa with inflammation and erosion
Barrett’s esophagus increases the risk of adenocarcinoma but the overall risk is < 1% per year. Because the mortality of esophageal cancer is high, Barrett’s mandates aggressive treatment.

Question 268

what is the most common site of esophageal perforation during endoscopy?

Answer 268

at the level of the cricopharyngeus muscle- narrow opening leading into the esophagus
risk of perforation increases with the presence of Zenker diverticulum and cervical osteophytes
second most common location of perforation after EGD is proximal to the lower esophageal sphincter

Question 269

what percentage of esophageal perforations are iatrogenic secondary to EGD?

Answer 269

30-75% of esophageal perforations are secondary to EGD

Question 270

where does esophageal perforation due to caustic injury typically occur?

Answer 270

at the sites of anatomical compression of the esophagus near the left mainstem bronchus

Question 271

where do esophageal tears secondary to Boerhaave syndrome occur?

Answer 271

in the distal esophagus on the left side after spontaneous vomiting

Question 272

what are contraindications to the use of ketamine?

Answer 272

elevated intracranial pressure (ketamine increases cerebral blood flow)
open eye injuries (ketamine may cause increased intraocular pressure)
ischemic heart disease (ketamine causes hypertension and tachycardia, should not be used as the sole anesthetic in this case)

Question 273

can ketamine be used intrathecally or in an epidural?

Answer 273

no, chlorobutanol is a preservative used with ketamine and is neurotoxic

Question 274

Name pull-through procedures used to treat Hirschsprung’s disease

Answer 274

Swenson, Duhamel, Soave

Question 275

what are the advantages of the Duhamel procedure over the Swenson or Soave procedures for Hirschsprung’s?

Answer 275

Duhamel is believed to be easier and safer with less pelvic dissection; it has a large anastomosis between the rectal stump and normal colon which decreases the risk of anastomotic stricture; the presence of a reservoir makes it appealing for children with longer aganglionic segments

Question 276

describe the Duhamel procedure (type of pull-through for Hirschsprung’s)

Answer 276

the aganglionic rectal stump is left in place and the ganglionated normal colon is pulled behind the stump
a stapler is inserted through the anus with one arm within the normal ganglionated bowel posteriorly and the other in the aganglionic rectum anteriorly
firing of the stapler results in the formation of a neorectum that empties normally because of the posterior patch of ganglionated bowel

Question 277

what mechanisms contribute to hepatorenal syndrome?

Answer 277

1. activation of the RAAS in response to systemic hypotension
2. activation of the SNS in response to systemic hypotension and increased intrahepatic sinusoidal pressure
3. increased release of arginine vasopressin in response to systemic hypotension
4. reduced hepatic clearance of vascular mediators (endothelin, prostaglandins, endotoxin)

Question 278

what is hepatorenal syndrome?

Answer 278

a life-threatening medical condition that consists of rapid deterioration in kidney function in individuals with cirrhosis or fulminant liver failure due to underlying mechanisms that cause renal vasoconstriction in the setting of systemic vasodilation

Question 279

how is cancer metastatic to the colon treated?

Answer 279

it is treated based on the primary malignancy

breast, ovary, melanoma, stomach, esophagus, renal cancers, prostate

Question 280

what is actinic keratosis and how is it treated?

Answer 280

actinic keratosis is a precursor to squamous cell carcinoma
surgical destruction of the epidermis with cautery, cautery and curettage, and cryotherapy are acceptable approaches to the treatment of AK
AK lesions do not require a margin

nonsurgical management includes topical chemo such as 5FU (no role for systemic chemo), photodynamic therapy, topical immune modulators (Imiquimod), fluorescence

Question 281

what skin layer must be removed when performing excision of perianal condylomas?

Answer 281

epidermis

Question 282

what is condyloma acuminata, how is it transmitted, and how is it treated?

Answer 282

caused by HPV and is transmitted by sexual contact
the virus lives and replicates in the epidermis
treated with fulgration and excision, it is essential to excise the epidermal layer and leave dermis. despite this there is a high recurrence rate (the most common complication)
squamous cell carcinoma of the anal skin is a possible sequelae of untreated disease

Question 283

which gene is responsible for the most common genetic alteration in pancreatic cancer?

Answer 283

K-ras

Question 284

which genes are involved in the pathogenesis of pancreatic cancer?

Answer 284

tumor suppressor genes: p53, p16, DPC4, BRCA2
oncogenes: K-ras
mis-match repair genes

Question 285

what are the antibiotics of choice in spontaneous bacterial peritonitis?

Answer 285

3rd generation cephalosporin (cefotaxime) or fluoroquinolone

gram negative coverage, penetrate ascitic fluid

Question 286

what is the mortality rate associated with spontaneous bacterial peritonitis?

Answer 286

20-40%

Question 287

which cirrhotic patients get prophylactic antibiotic therapy for spontaneous bacterial peritonitis?

Answer 287

1. cirrhotic patients who have a gastrointestinal hemorrhage
2. cirrhotic patients with low protein ascites (under 15g/L)
3. cirrhotic patients with history of spontaneous bacterial peritonitis

Question 288

what bacteria are the most common cause of spontaneous bacterial peritonitis?

Answer 288

gram negative enteric bacteria (single organism)

Question 289

how does spontaneous bacterial peritonitis present?

Answer 289

abdominal pain and fever in cirrhotic patients

Question 290

what leads to perirectal abscess formation?

Answer 290

the majority have a cryptoglandular etiology- blockage of the anal glands leads to an acute infection

other causes include Crohn’s and trauma

Question 291

how do patients with perirectal abscess present?

Answer 291

severely tender, fluctuant mass in the perirectal space

Question 292

where may a perirectal abscess in the ischiorectal space track?

Answer 292

to the rectum to form what is known as a horseshoe abscess

Question 293

what is the most common location of an anal fissure?

Answer 293

posterior midline

Question 294

how do anal fistulas track to the anal canal?

Answer 294

According to Goodsall’s rule where anterior locations track in a linear fashion

Question 295

what is the most common cause of anal incontinence?

Answer 295

obstetric trauma during spontaneous vaginal delivery

Question 296

what is the most common surgical procedure for anal incontinence?

Answer 296

wrap around sphincteroplasty

Question 297

how is a wrap around sphincteroplasty for anal incontinence performed?

Answer 297

identify the sphincter, mobilize it and reapproximate without tension

Question 298

what is the gracilis muscle transposition with constant low frequency stimulation and what is it used for?

Answer 298

the gracilis is identified and tunneled to the perineum to create a neosphincter
this is used for complex and recurrent cases of anal incontinence

Question 299

what is Phalen sign and what does it indicate?

Answer 299

provocative testing with the wrists firmly pressed in full flexion, positive test indicate carpal tunnel syndrome

Question 300

what is carpal tunnel syndrome?

Answer 300

results from compression of the median nerve at the wrist
symptoms include pain, paresis, paresthesia involving the palmar side of the thumb, second finger, third finger and radial side of the fourth finger
symptoms are usually worse at night
physical findings include hypesthesia and decreased two point discrimination
EMG and nerve conduction studies may be performed

Question 301

what is Tinel sign and what does it indicate?

Answer 301

Tinel sign produces paresthesias in the involved digit with tapping over the carpal tunnel
indicative of carpal tunnel syndrome

Question 302

what is the treatment of carpal tunnel syndrome?

Answer 302

initial treatment is conservative (splinting, antiinflammatory medications, steroid injections, etc.)
if conservative management fails after 2-7 weeks then surgery may be considered
avoidance of repetitive motion is important and may result in symptom resolution
surgical decompression is by section of the transverse carpal ligament

Question 303

what is a GIST and where do they originate?

Answer 303

GISTs are mesenchymal neoplasms of the GI tract and are thought to originate from the interstitial cells of Cajal

Question 304

what mutation is seen in 90% of GISTs?

Answer 304

c-KIT (CD117)

Question 305

what is the most important factor indicating malignant potential and poor prognosis for a GIST?

Answer 305

high mitotic index (>5 per 10 high power field)

other less important prognostic indicators include size of tumor >5cm, presence of necrosis, presence of atypia, and location in the small bowel when compared to gastric GISTs

Question 306

what is the tumor marker for epithelial subtype of ovarian cancer?

Answer 306

CA 125
lacks sensitivity and specificity for ovarian cancer and levels may be elevated in endometriosis, uterine myoma, acute/chronic salpingitis, inflammatory disease

Question 307

what is the tumor marker for embryonal cell carcinomas, ovarian choriocarcinomas, mixed germ cell tumors, and some dysgerminomas

Answer 307

beta-hCG

Question 308

what is the tumor marker for yolk sac tumors, embryonal cell carcinomas, and polyembryoma carcinomas, mixed germ cell tumors, and some immature teratomas

Answer 308

alpha-FP

most dysgerminomas are associated with normal alpha-FP

Question 309

what is the tumor marker for dysgerminoma?

Answer 309

lactate dehydrogenase

Question 310

what is the tumor marker for epithelial stromal tumors such as mucinous and endometroid carcinoma and sex cord stromal tumors like granulosa cell tumors and Sertoli-Leydig cell tumors

Answer 310

Inhibin A

Question 311

what is the tumor marker for colon adenocarcinoma?

Answer 311

carcinoembryonic antigen (CEA)

Question 312

what is the recommended post operative surveillance of patients with FAP who opt for a total abdominal colectomy and ileorectal anastomosis?

Answer 312

annual endoscopy 
(12-29% risk of cancer developing in the rectal stump within 20-25 years; patients with mutation in codon 1309 are at higher risk for developing rectal stump cancer)

Question 313

how is a laparoscopic adjustable gastric band placed?

Answer 313

placement utilizes the pars flaccida technique
the band is placed along a space created posterior to the proximal stomach through the avascular portion of the gastrohepatic ligament; this reduces slippage

Question 314

complications of laparoscopic adjustable gastric bands

Answer 314

gastric herniation, band slippage, band erosion

Question 315

how is erosion of a laparoscopic adjustable gastric band diagnosed and treated?

Answer 315

diagnosis is confirmed by endoscopy visualizing the band within the gastric lumen; treatment is removal of the band and repair of the stomach defect

Question 316

how is herniation of a laparoscopic adjustable band managed?

Answer 316

urgent reoperation to manually reduce and resecure the stomach

Question 317

how does LCIS present?

Answer 317

no palpable lesion or calcifications on mammography, incidental finding on final pathology following core needle biopsy done for other reasons

Question 318

what is lobular carcinoma in situ and how is it managed?

Answer 318

LCIS is a tumor marker for breast cancer but it is not a premalignant lesion
prophylactic bilateral mastectomy is an option however negative margins are not required for excisional biopsies

Question 319

what is the risk of subsequent malignancy in LCIS?

Answer 319

0.5-1.0% per year
approximately 10-20% of patients may have ductal carcinoma in situ or invasive cancer in the surrounding tissue of the biopsy specimen showing LCIS

Question 320

what are risk factors for pseudoaneurysm development after an endovascular procedure?

Answer 320

anticoagulation, obesity, use of a large sheath, poor technique, hypertension, dialysis and heavily calcified vessels

Question 321

what is the presentation of a pseudoaneurysm after endovascular procedure and how is it diagnosed?

Answer 321

pain, tenderness at the puncture site with a pulsatile mass which usually occurs within the first 24-48 hours
bruit may be auscultated
diagnosis is confirmed with arterial duplex

Question 322

what is the treatment of a pseudoaneurysm after endovascular procedure?

Answer 322

initial treatment consists of ultrasound guided compression for 10-20 minutes (success is as high as 88%)
thrombin injection into the sac under ultrasound guidance (successful in 95%, complications include anaphylaxis and thrombosis of the main artery)
surgical intervention

Question 323

what are the indications for surgical intervention on pseudoaneurysm after endovascular procedure?

Answer 323

infection, hemodynamic instability, expanding pulsatile mass (especially with skin necrosis or cellulitis), distal ischemia, neurologic deficit (from femoral nerve compression, size >5cm or wide neck), failure of ultrasound techniques

Question 324

if a pseudoaneurysm following endovascular procedure requires surgical repair, how is it done?

Answer 324

technique involves obtaining proximal and distal control and direct repair of the arteriotomy
if the fascia is closed alone there will likely be recurrence so the artery wall must be included
the hematoma may then be evacuated and wound closed

Question 325

which condition is most commonly implicated in Budd-Chiari syndrome?

Answer 325

myeloproliferative disorders

Question 326

which test should be done if a patient has an elevated 24hr urine free cortisol level and elevated serum ACTH?

Answer 326

high dose dexamethasone suppression test

cortisol will be suppressed with pituitary adenomas and will not be suppressed in patients with ectopic tumors

Question 327

what is bilateral inferior petrosal sinus sampling used for?

Answer 327

a patient who meets biochemical criteria for Cushing’s disease (elevated 24 hr urine free cortisol, elevated ACTH) and suppressed cortisol on dexamethasone suppression test but no evidence of pituitary mass on MRI
demonstration of a central to peripheral ACTH gradient on inferior petrosal sinus sampling is sufficient to diagnose Cushing’s disease

Question 328

how does an intrahepatic carcinoma usually present?

Answer 328

liver mass seen on axial imaging

Question 329

what is a Klatskin tumor?

Answer 329

hilar cholangiocarcinoma

affects the upper part of the bile duct

Question 330

how does extrahepatic lower duct cholangiocarcinoma present?

Answer 330

painless jaundice, obstructive labs, high C19-9
axial imaging reveals dilation of the intrahepatic bile ducts, gallbladder, and extrahepatic bile ducts down to the level of the pancreatic head where the dilation terminates abruptly
MRCP/ERCP shows a focal stricture

Question 331

how do patients with pancreatic endocrine neoplasms present?

Answer 331

1. incidental discovery of a mass on cross sectional imaging
2. symptoms secondary to the mass effect of a lesion in the pancreas
3. as a consequence of associated symptoms of a functional tumor

Question 332

clinical findings in glucagonoma

Answer 332

severe dermatitis, mild diabetes, stomatitis, anemia, weight loss

Question 333

how are glucagonomas diagnosed?

Answer 333

clinical presentation, biopsy of the skin lesions and documentation of high fasting levels of serum glucagon

Question 334

what is secretin stimulation testing used for?

Answer 334

to differentiate between gastrinoma, antral G-cell hyperplasia, or hyperfunction
serum gastrin levels of 200 or more suggest gastrinoma, gastrin levels higher than 1000 in the setting of hyperacidity and ulcer disease are virtually pathognomonic for gastrinoma

Question 335

what is post transplant lymphoproliferative disorder?

Answer 335

B-cell proliferation due to therapeutic immunosuppression after organ transplantation
patients develop infectious mono-like lesions or polycloncal polymorphic B cell hyperplasia
some B cells may undergo mutations which will render them malignant giving rise to lymphoma

Question 336

where are the ports placed in a laparoscopic cholecystectomy?

Answer 336

periumbilical, subxiphoid, and two lateral ports

Question 337

how is an intraoperative cholangiogram performed?

Answer 337

injection of contrast into the infundibulum of the gallbladder

Question 338

what is a contraindication to using meperidine (Demerol)?

Answer 338

significant hepatic or renal impairment
a toxic metabolite (normeperidine) has a longer halflife than meperidine and can accumulate to toxic levels in patients with hepatic or renal dysfunction and cause seizures

Question 339

which rectal cancers are candidates for primary surgical therapy?

Answer 339

most rectal cancers are treated with neoadjuvant chemo
tumors that invade the submucosa or muscularis propria (T1 or T2) lesions without lymphadenopathy (N0) are candidates
T1 lesions can undergo transanal excision or abdominoperineal resection, T2 undergo APR

Question 340

which tumors get APR vs LAR?

Answer 340

tumors located in the superior or mid rectum can undergo LAR and avoid colostomy
tumors in the lower third of the rectum less than 2cm from the anal verge are not candidates for LAR and require APR
any tumors at the dentate line with extramural spread to involve the sphincter complex or direct extension into pelvic structures require APR

Question 341

which enzyme is cleared the fastest in the course of pancreatitis?

Answer 341

amylase is cleared first, in less than 48 hours

lipase and elastase remain elevated for > 96 hours

Question 342

where can the splenic artery be identified for quick ligation?

Answer 342

superior to the pancreas in the lesser sac

Question 343

what is oncologic resection of colon cancer?

Answer 343

margin of at least 2-5 cm with at least 12 negative lymph nodes

Question 344

what operation should be done for a type IV ulcer located on the proximal lesser curvature?

Answer 344

Pauchet gastrectomy

if the ulcer is not amenable to this more limited procedure a subtotal gastrectomy would be appropriate

Question 345

what is the ideal oreation for type III gastric ulcers?

Answer 345

antrectomy, vagotomy, and Billroth I reconstruction

Billroth II and Roux-en-Y reconstruction are also appropriate

Question 346

what is the evolution of a hemangioma and how is it treated?

Answer 346

rapid proliferative phase, quiescence phase, and an involution phase
observation is the treatment of choice however surgical excision is required if they involve a critical structure
medical treatment includes systemic steroids and beta blockers
hemangioma interfering with the visual axis should be excised to avoid visual field obstruction, astigmatism, and amlyopia

Question 347

where are clotting factors produced?

Answer 347

all factors are produced in the liver except for factor VIII which is produced by the endothelium

Question 348

what are the vitamin K dependent factors?

Answer 348

II, VII, IX, X, protein C and S

Question 349

what is a Breslow tape and what needs to be taken into account when using it?

Answer 349

The Breslow tape is used to determine height, weight, and resuscitative equipment sizes for children up to 12 years old and 80lb
the Breslow tape may not be accurate for overweight children

Question 350

what is the most common noniatrogenic cause of esophageal perforation?

Answer 350

Boerhaave syndrome

Question 351

what is the blood supply to the cervical esophagus?

Answer 351

inferior thyroid artery

branch of the subclavian

Question 352

what is the blood supply to the abdominal esophagus?

Answer 352

left gastric artery

Question 353

what is the blood supply to the thoracic esophagus?

Answer 353

branches directly off the thoracic aorta

Question 354

management of Barrett’s esophagus

Answer 354

low or moderate grade dysplasia - repeat endoscopies every 3-6 months
high grade dysplasia - endoscopic ablation (previously esophagectomy)

Question 355

describe laparoscopic esophagomyotomy (Heller myotomy)

Answer 355

standard surgical treatment of achalasia
dissection of the gastroesophageal junction with preservation of the anterior vagus nerve
myotomy should extend 5-6cm on the esophagus and 2cm on the stomach below the gastroesophageal junction
a partial fundal wrap should be performed to avoid reflux associated with Heller alone (not Nissen, higher rate of post operative dysphagia)

Question 356

how are anal melanomas diagnosed and managed?

Answer 356

women > men, average age 63
suspect in a deeply pigmented hemorrhoid causing symptoms, may not be pigmented
EUA and excisional biopsy for diagnosis
anal canal melanomas do not respond to chemo, radiation, immunotherapy
surgery is rarely curative but is the best option. abdominoperineal resection confers no survival benefit over wide local excision (if involves destroying anal sphincter then needs diverting colostomy)

Question 357

how do anal canal melanomas spread?

Answer 357

submucosally into the rectum, rarely invade adjacent organs
lymphatic spread to mesenteric nodes is seen in 1/3 at the time of diagnosis, spread to inguinal nodes is less common
wide hematogenous spread especially to the liver and lung is common accounting for most deaths

Question 358

What are the diagnostic criteria for spontaneous bacterial peritonitis?

Answer 358

elevated ascitic fluid absolute PMN count of at least 250 and a positive ascitic fluid bacterial culture without an obvious intra-abdominal source of infection

Question 359

what adjunctive treatment is recommended to decrease in hospital mortality for SBP?

Answer 359

IV albumin

Question 360

what is the mechanism for the ionotropic effect of amrinone?

Answer 360

inhibition of the breakdown of cAMP
phosphodiesterase inhibitor that blocks cAMP breakdown and facilitates an increase in calcium uptake by the sarcoplasmic reticulum of the heart increasing contractility
amrinone also acts as a vasodilator by causing relaxation of vascular smooth muscle cells

Question 361

what is the management of toxic megacolon secondary to C.diff colitis?

Answer 361

total abdominal colectomy with end ileostomy

Question 362

what is the first step in management of an open pneumothorax?

Answer 362

occlusive dressing on three sides followed by a tube thoracostomy at a site distant rom the wound

Question 363

what injury should be expected with persistent pneumothorax despite a well-placed chest tube and a continuous air leak throughout the entire respiratory cycle?

Answer 363

tracheobronchial disruption

clinical signs: subcutaneous emphysema, continuous large airleaks, hemoptysis
fallen lung sign on CT (lung falls away from the hilum)

Question 364

which test is used to confirm carcinoid syndrome in a symptomatic patient?

Answer 364

24 hour urine 5-HIAA measurement
sensitivity 73% specificity 100%
can be falsely elevated with serotonin rich foods and certain medications

Question 365

what is chromogranin A a marker of?

Answer 365

chromogranin A is a sensitive serum marker but is nonspecific; elevated in multiple types of neuroendocrine tumors

Question 366

what is somatostatin receptor scintigraphy scan used for?

Answer 366

somatostatin scintigraphy should be used after the diagnosis of carcinoid syndrome has been confirmed to identify occult metastasis in patients being considered for curative resection and to determine if the patient is likely to respond to octreotide

Question 367

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

Answer 367

cirrhosis

Question 368

what is the most common complication of cirrhosis?

Answer 368

ascites

Question 369

what is the first step in managing ascites?

Answer 369

dietary sodium restriction

Question 370

what is the most common adult small bowel lymphoma?

Answer 370

Non-Hodgkin B cell type

Question 371

is small bowel lymphoma associated with systemic symptoms?

Answer 371

No fevers, night sweats, etc.

Question 372

what is the most common site of small bowel lymphoma?

Answer 372

terminal ileum

Question 373

diseases linked to small bowel lymphoma

Answer 373

Wegener disease, lupus, Crohn disease, celiac sprue

Question 374

what is the most common cause of urinary retention after hemorrhoidectomy?

Answer 374

pelvic floor muscle spasms

Question 375

what is the first line therapy for T2 anal cancer?

Answer 375

chemoradiation with 5FU and mitomycin C based regimens

abdominoperineal resection is indicated with evidence of disease 6 months after initiation of treatment or with local recurrence

Question 376

what electrolyte abnormalities are seen in tumor lysis syndrome?

Answer 376

hypocalcemia, hyperuricemia, hyperkalemia, hyperphosphatemia, increased creatinine

Question 377

during ex-lap for acute mesenteric ischemia what is done after seeing signs of patchy segmental bowel ischemia from jejunum to ascending colon?

Answer 377

palpate the SMA at the level of the ligament of Treitz
if blood supply is compromised a transverse arteriotomy with embolectomy via Fogarty balloon is performed (allows for easy closure without narrowing the lumen)
frankly necrotic bowel is resected at the initial operation while all questionable bowel is left for a second look operation in 24-48 hours

Question 378

consequences of hypokalemia and the potassium levels at which they occur

Answer 378

hypokalemia = K less than 3.5
fatigue, ileus, arrhythmia
EKG changes (U wave, flat/inverted T wave) with K < 3
rhabdomyolysis can occur when K < 2.5
flaccid paralysis when K < 2
weakness K < 2.5

hypokalemia is usually asymptomatic until potassium concentration falls below 3

Question 379

what is the most common location of GIST?

Answer 379

stomach (60-70%)
small bowel (20-25%)
colorectum (5%)
esophagus (5%)

Question 380

which GISTs have a better prognosis, those in the small bowel or stomach?

Answer 380

gastric GIST have a better prognosis than small bowel GIST

Question 381

is preoperative biopsy required for resectable lesions which are consistent with GIST on imaging?

Answer 381

no but biopsy may be considered if treatment with imatinib is considered in the setting of large tumors o there is evidence of metastatic disease
if done biopsy should be endoscopic

Question 382

what is GIST prognosis based on?

Answer 382

tumor size and mitotic index

Question 383

how is refeeding syndrome managed?

Answer 383

electrolyte abnormalities should be corrected early
feeding should be started at a lower rate and increased over a week
patients with refeeding symptoms can continue to receive nutrition but the rate should be slowed

Question 384

what characterizes the proliferative phase of wound healing?

Answer 384

neovascularization and collagen synthesis

begins with formation of a provisional matrix of fibrin and fibronectin as part of initial clot formation

macrophages are present initially but fibroblasts appear by day 3 in the fibronectin-fibrin framework and initiate collagen synthesis

neovascularization is driven in part by tissue hypoxia (hypoxia inducible factor- 1)

Question 385

what is ferritin?

Answer 385

ferritin is an iron storage protein and acute phase reactant
extracellular serum level correlates with total body iron stores
low in iron deficiency anemia, high in anemia of chronic disease

Question 386

which pancreatic neuroendocrine tumor is associated with diarrhea and refractory peptic ulcer disease?

Answer 386

gastrinoma

Question 387

which pancreatic neuroendocrine tumor is associated with fasting hypoglycemia, symptoms of hypoglycemia, and symptom relief with glucose?

Answer 387

insulinoma

Question 388

which pancreatic neuroendocrine tumor is associated with watery diarrhea, hypokalemia, and achlorihydria?

Answer 388

VIPoma

Question 389

which pancreatic neuroendocrine tumor is associated with anemia, weight loss, stomatitis, dermatitis, and diabetes?

Answer 389

glucagonoma

Question 390

which pancreatic neuroendocrine tumor is associated with steatorrhea, diabetes, and cholelithiasis?

Answer 390

somatostatinoma

Question 391

what is the surgical approach for acute mesenteric ischemia?

Answer 391

xiphoid to pubis midline incision
examine the small bowel, resect gangrenous or perforated bowel
self retaining retractor
lift omentum and transverse colon cephalad to evaluate the SMA
retract small bowel to the right and pack sigmoid to the left
divide ligament of Treitz, mobilize duodenum to the right
palpate the SMA at the base of the transverse colon mesentery

Question 392

what organ is exposed by opening the lesser sac?

Answer 392

pancreas

Question 393

what vessel is exposed with the right medial visceral rotation?

Answer 393

IVC

Question 394

what vessels are exposed with the left medial visceral rotation?

Answer 394

aorta including take off of the celiac trunk and SMA

Question 395

what organs are exposed with the Kocher maneuver?

Answer 395

first/second portion of the duodenum and the pancreatic head

Question 396

what are the borders for the posterior triangle of the neck?

Answer 396

sternocleidomastoid
trapezius
clavicle

Question 397

where is Zone 1 of the neck and what structures may be injured?

Answer 397

clavicle to cricoid

lung apex, trachea, brachiocephalic/subclavian artery and veins, nerve roots, esophagus

Question 398

where is Zone 2 of the neck and what structures may be injured?

Answer 398

cricoid to angle of the mandible

carotid/vertebral arteries, jugular veins, esophagus, trachea

Question 399

where is Zone 3 of the neck and what structures may be injured?

Answer 399

angle of the mandible to the skull base

external or internal carotids, jugular veins, cranial nerve, hypopharyneal nerve

Question 400

indications for operative interventions for neck trauma

Answer 400

hemodynamic instability (regardless of zone)

signs of tracheal injury (subcutaneous air, bubbling from the wound)

hard signs of vascular injury (bruit, thrill, expanding or pulsatile hematoma)

Question 401

what may be included in work up for neck injury?

Answer 401

CXR to evaluate for hemothorax or pneumothorax, retropharyngeal air, apical capping

four vessel CTA, color flow Doppler to evaluate for vascular injuries

esophagography with barium or esophagoscopy to evaluate for esophageal injury

laryngotracheobronchoscopy may also be performed

Question 402

what are complications of therapeutic hypothermia following cardiac arrest?

Answer 402

coagulopathy, cardiac dysrrhythmia, increased infection risk, hyperglycemia, cold diuresis

should be stopped immediately if significant bleeding develops

Question 403

what is afferent loop syndrome following Billroth II gastrojejunostomy and how is it managed?

Answer 403

obstruction of the afferent limb secondary to excessive length of the afferent limb (more common than efferent limb obstruction)
abdominal pain, cramping, vomiting
surgical management is required - conversion to Billroth I or Roux-en-Y or creation of an enteroenterostomy (afferent to efferent; Braun anastomosis)

Question 404

what is efferent loop syndrome following Billroth II gastrojejunostomy and how is it managed?

Answer 404

gastric outlet obstruction caused by kinking of the efferent jejunal limb often because of herniation of the limb posterior to the anastomosis

nausea, bilious emesis, abdominal pain

uncommon, usually occurs in the first postoperative month

corrected surgically by reducing the efferent loop if it has herniated posterior to the anastomosis, then closing the retroanastomotic space to prevent recurrence

Question 405

resuscitation in septic shock

Answer 405

IVF to achieve MAP >/= 65
if not achieved with fluids, start pressors starting with norepinephrine and then vasopressin

dopamine is indicated if there is low risk for arrhythmia and absolute or relative bradycardia

dobutamine is an inotrope that can be considered as an adjunct if there are signs of cardiac dysfunction (high cardiac filling pressures or low cardiac output)

Question 406

when is phenylephrine used in septic shock?

Answer 406

phenylephrine should not be used in septic shock unless 1. norepinephrine is associated with serious arrhythmia 2. cardiac output is high and the blood pressure is persistently low 3. salvage therapy when combined with vasopressors and MAP is not >=/ 65

Question 407

what is pseudomyxoma peritonei and what treatment has the best outcomes?

Answer 407

chronic progressive mucinous malignancy characterized by copious mucin production
occurs most commonly as a result of a ruptured cystadenocarcinoma, usually appendiceal origin
best outcomes involve surgicla debulking with excision of the entire parietal peritoneum, ovaries, uterus, and fallopian tubes, with administration of hyperthermic intraperitoneal chemotherapy (HIPEC) intra-operatively

Question 408

what is the most common late postoperative complication of restorative proctocolectomy with ileal-pouch anal anastomosis for ulcerative colitis?

Answer 408

pouchitis, a nonspecific inflammation of the ileal pouch
occurs in up to 50%
presents with increased stool frequency, urgency, incontinence, abdominal pain, bleeding

other complications: SBP, anastomotic leak (leading to sepsis, abscess, fistula), stricture

Question 409

what are the mechanisms by which radiation therapy causes changes?

Answer 409

direct damage to DNA and production of oxygen free radicals

Question 410

what cells are most affected by radiation colitis?

Answer 410

rapidly dividing crypt cells are most sensitive to radiation damage
atrophy of the villi causing degeneration of the mucosal lining

Question 411

when does chronic radiation injury appear and what does it involve?

Answer 411

6-12 months after radiation
secondary to progressive fibrosis of the microvasculature causing endothelial thickening which leads to nonhealing ulcers and telangiectasias of the bowel wall, fistulas, and sepsis

Question 412

what do all types of LeForte fracture have in common?

Answer 412

ptrygoid plate fracture

Question 413

LeForte type 1

Answer 413

horizontal fracture through the maxilla superior to the maxillary dentition

Question 414

LeForte type 2

Answer 414

pyramidal type fracture outlining the nose, fracture through the maxilla and orbit

Question 415

LeForte type 3

Answer 415

complete craniofacial separation, fracture of facial bones from the skull

Question 416

what are the histologic types of small bowel adenomas and where are they most commonly found?

Answer 416

tubular, tubulovillous, villous
predominantly found in the duodenum, majority in the periampullary region
25% of villous and tubulovillous adenomas harbor malignancy, must be resected
screen for colorectal cancers in patients with duodenal adenomas

Question 417

what does a soap bubble or paint brush sign on contrast series indicate?

Answer 417

small bowel villous adenoma

Question 418

what is the most common type of collagen found in a scar?

Answer 418

type I

Question 419

what is the most common type of collagen in the body?

Answer 419

type I

Question 420

what is the most common type of collagen in cartilage?

Answer 420

type II

Question 421

what is the most common type of collagen in blood vessels, fetal skin, and the uterus?

Answer 421

type III

Question 422

what is the most common type of collagen in the basement membrane?

Answer 422

type IV

Question 423

what is the most common type of collagen in the cornea?

Answer 423

type V

Question 424

what are the effects of increasing PEEP?

Answer 424

improved oxygenation (takes hours to have effect)
keep alveoli open at the end of expiration
reduces venous return and cardiac output

Question 425

what does increasing tidal volume or respiratory rate do?

Answer 425

increases ventilation

Question 426

what is the fastest way to increase oxygenation?

Answer 426

increasing the inspired concentration of oxygen

Question 427

what are the anatomic changes in Tetralogy of Fallot?

Answer 427

pulmonary stenosis
ventricular septal defect, overriding aorta with deviation of the origin to the right side and concentric right ventricular hypertrophy

Question 428

what type of heart murmur is seen in Tetralogy of Fallot?

Answer 428

crescendo-decrescendo harsh systolic ejection murmur that radiates posteriorly due to right ventricular outflow obstruction (not the VSD)

Question 429

what structures are preserved in a highly selective vagotomy?

Answer 429

Latarjet’s nerves which provide motor function to the pylorus
posterior branches of the vagus that innervate the pancreas and small intesting
anterior branches of the vagus that innervate the liver and the gallbladder

Question 430

what is the primary fuel source of the small bowel enterocyte in times of stress?

Answer 430

glutamine

Question 431

what is the primary course of fuel for colonocytes?

Answer 431

short chain fatty acids

Question 432

what two structures are connected by the epididymis?

Answer 432

testis and vas deferens

it is responsible for semen transport and is the site of sperm maturation

Question 433

compare split and full thickness skin grafts

Answer 433

split thickness skin grafts have less primary contraction, more secondary contraction, better graft survival, ability to cover larger surface area

Question 434

what is pharmacokinetics?

Answer 434

pharmacokinetics = what happens to a drug in the body

dissolution, absorption, distribution, metabolism, excretion

Question 435

what is pharmacodynamics?

Answer 435

pharmacodynamics = what the drug does to the body

cell membrane disruption, ligand binding, cytotoxicity

Question 436

what is the most appropriate position for indirect laryngoscopy?

Answer 436

upright with atlanto-occipital extension

Question 437

what is the optimal position for colonoscopy?

Answer 437

left lateral decubitus

turn to supine or apply pressure to left lower quadrant if there is difficulty advancing the scope to the cecum

Question 438

what is the bicaval technique for recipient hepatectomy in liver transplantation?

Answer 438

excision of the recipient liver en bloc with the retrohepatic inferior vena cava after caval clamps have been placed in a suprahepatic and infrahepatic position
disadvanage: requires dissection posterior to the vena cava possibly leading to bleeding

Question 439

what is the piggyback technique for recipient hepatectomy in liver transplantation?

Answer 439

leaving the vena in continuity, the hepatic veins are divided within the substance of the liver
advantage: one single caval anastomosis required limiting warm ischemic time

Question 440

what is the cavocavostomy technique for recipient hepatectomy in liver transplantation?

Answer 440

side to side caval technique
clamps are placed on the right, left, and middle hepatic veins
the liver is then excised, the venous stumps are oversewn and the clamps are removed
advantages: shorter vena cava clamping time, minimal or no changes in the recipient’s hemodynamics (vena cava clamp is placed longitudinally, only occluding the anterior third of the vena cava), lower incidence of caval stenosis (cavostomy performed), lover risk for hepatic vein outflow complications (longer anastomosis)

Question 441

where are level 2 mediastinal lymph nodes located?

Answer 441

superior to the innominate artery

Question 442

where are level 4 mediastinal lymph nodes located?

Answer 442

inferior to the innominate artery

Question 443

Which mediastinal lymph nodes are visualized with EBUS?

Answer 443

superior and inferior mediastinal lymph nodes at stations 2R/2L, 4R/4L, 7, 10, 11, 12

level 5 subaortic lymph nodes (aortopulmonary window) are lateral to the ligamentum arteriosum and are usually not usually accessible by EBUS

Question 444

what is a Chamberlain procedure (anterior mediastinostomy)?

Answer 444

incision is made to the left of the sternum on the 2nd or 3rd intercostal space (not to the right)
levels 5 and 6 are sampled

Question 445

why has VATS largely replaced anterior mediastinostomy (Chamberlain procedure)?

Answer 445

superior visualization
less surgical time
more information about the extent of local disease

Question 446

how is soft tissue sarcoma of the extremities treated?

Answer 446

surgical resection with 1-2 cm margins
adjuvant radiation decreases the risk of recurrence but does not affect survival and is associated with higher risk of fibrosis ands stiffening joints (reserved for high risk patients, >5cm in size and high grade or recurrent tumors not previously treated with radiation)
adjuvant chemo has not been shown to be beneficial
neoadjuvant chemo is important in patients with rhabdomyosarcoma, Ewing sarcoma, high grade tumors >10cm in size, and tumors 5-10cm with chemosensitive histology

Question 447

where is pain felt due to appendicitis and why?

Answer 447

early in appendicitis, distension of the lumen causes vague abdominal pain due to visceral nerve fibers that course through the SMA ganglia (periumbilical pain)

inflammation of the parietal peritoneum later produces a localizing effect

somatic pain fibers from T7-T12
thinly myelinated and fast conducting

muscle rigidity is an involuntary spasm of abdominal muscles in response to peritoneal inflammation

Question 448

what are mesenteric cysts?

Answer 448

rare, benign lesions
seen on US, CT, MRI
typically unilocular without a solid component
presentation ranges from incidental finding to acute abdominal pain. nonspecific complaints of nausea, vomiting, anorexia or weight loss are common
most common location for mesenteric cysts is small bowel mesentery (terminal ileum most common)
treated with enucleation which may require resection of associated bowel if blood supply to the adjacent bowel is compromised
simply unroofing the cysts results in a high rate of recurrence

Question 449

aggressive thyroid cancer, few survive 6 mo past presentation
most common in patients 60-70 years old
women >men
long standing neck mass that rapidly enlarges and is then associated with pain, dysphonia, dysphagia, dyspnea
large mass fixed to the tracheolaryngeal framework resulting in vocal cord paralysis and tracheal compression
more than 80% have jugular LN involvement and more than 50% have systemic metastases at the time of presentation
most patients die of vena cava syndrome, asphyxiation, or exsanguination

Answer 449

anaplastic thyroid cancer

Question 450

what is the most important prognostic indicator with colorectal carcinoid tumors?

Answer 450

tumor size

Question 451

Brooke Formula
Parkland Formula
for burn resuscitation

Answer 451

patients >15% total body surface area

modified Brooke = 2mL/kg/TBSA leads to less over-resuscitation than Parkland = 4mL/kg/TBSA

to calculate the 24 hour fluid requirements with one half given over the first 8 hours and the remainder given over the next 16 hours

common to guide titration according to goal urine output 0.5-1mL/kg/hr

Question 452

rule of nines for calculating TBSA of burns

Answer 452

second or third degree burns

4.5% for each side of each arm (9% total each arm)
18% front torso, 18% back torso
9% of each side of each leg (18% total each leg)
9% head
1% genitals

Question 453

what structure is used to guide the dissection of the elevator ani muscles from the perineum into the pelvis?

Answer 453

coccyx

Question 454

Describe APR

Answer 454

abdominal portion - rectum is dissected into the pelvis including wide mesenteric excision
perineal dissection - close the anus with purse string, vertically oriented elliptical incision around the anus, tip anus upwards to sever attachment to the coccyx
insert finger into presacral space and sweep finger laterally to identify the elevator muscles
expose the levator muscle on one side, divide between the clamps lateral to rectum to avoid compromising the circumferential margin

Question 455

therapeutic strategy in rectal cancer

Answer 455

surgery - stage I (Tis, T1, T2 and no nodal involvement)

neoadjuvant chemotherapy followed by surgery - stage II and above (>/=T3 +/- nodes)

Question 456

type of surgery for cancer in the upper rectum

Answer 456

left hemicolectomy

Question 457

type of surgery for cancer in the middle and lower rectum

Answer 457

low anterior resection

Question 458

type of surgery for cancer close to the anal sphincters or lower rectum with no oncological clearance possible

Answer 458

abdominoperineal resection

Question 459

type of surgery for T1 rectal cancers within 8cm of the anal verge, <3 cm in size, well-differentiated, <30% circumference involvement, and mobile, non-fixed

Answer 459

transanal local excision

Question 460

what structure is used to guide dividing the peritoneum on the right side of the rectosigmoid in APR?

Answer 460

sacral promontory

Question 461

what level of fibrinogen is associated with increased risk of bleeding?

Answer 461

< 150 mg/dL

normal circulating levels of fibrinogen are 200-400

Question 462

causes of spontaneous rectus sheath hematomas

Answer 462

vigorous abdominal wall contraction (coughing, sneezing, exercise)
especially in older patients and those on anticoagulation

Question 463

traumatic rectus sheath hematomas

Answer 463

blunt or penetrating trauma

iatrogenic injury during laparoscopy

Question 464

management of rectus sheath hematomas

Answer 464

non-expanding: observation

large/expanding, anticoagulation: angiography and/or surgery

Question 465

abdominal mass that does not cross the midline and does not move with rectus muscle flexion, seen in rectus sheath hematoma

Answer 465

Fothergill’s sign

Question 466

gold standard surgery for young UC patients with intact sphincter

Answer 466

total proctocoloectomy with ill pouch anal anastomosis

avoids ostomy and creates reserved for improved continence and decreased frequency

Question 467

technique used to decrease tension at the ileoanal anastomosis

Answer 467

division of the ileum flush with the cecum, complete mobilization of the small bowel mesentery to the third portion of the duodenum and the pancreatic body, full adhesiolysis off necessary and step-ladder relaxing incisions on the front and back of the mesentery over tension lines along the superior mesenteric vessels

Question 468

location of the right renal artery in relation to the IVC and renal calyx

Answer 468

right renal artery is posterior to the IVC and anterior to the renal calyx

Question 469

where does the spinal accessory nerve (CN XI) exit the skull?

Answer 469

exits skull at the jugular foramen

Question 470

what does CN XI innervate?

Answer 470

sternocleidomastoid, trapezius

Question 471

BI-RADS 0 interpretation and management

Answer 471

incomplete assessment

additional studies needed

Question 472

BI-RADS 1 interpretation and management

Answer 472

negative

routine screening

Question 473

BI-RADS 2 interpretation and management

Answer 473

benign

routine screening

Question 474

BI-RADS 3 interpretation and management

Answer 474

probably benign

6 month follow-up

Question 475

BI-RADS 4 interpretation and management

Answer 475

suspicious

core needle biopsy

Question 476

BI-RADS 5 interpretation and management

Answer 476

highly suggestive of malignancy

core needle biopsy

Question 477

BI-RADS 6 interpretation and management

Answer 477

biopsy-proven malignancy

appropriate care

Question 478

in which patients are pure fungal abscess most often seen?

Answer 478

hematologic malignancies recovering from chemotherapy induced neutropenia

Candida is most common followed by Aspergillus and Cryptococcus; first line treatment is drainage and caspofungin or micafungin

Question 479

what are the most common causes of pyogenic liver abscesses?

Answer 479

hepatobiliary malignancy and biliary tree instrumentation

Question 480

which factors does PT measure?

Answer 480

extrinsic pathway - I, II, V, VII, X

Question 481

which factors does PTT measure?

Answer 481

intrinsic pathway - I, II, V, VIII, IX, X, XI, XII

Question 482

describe the Beger procedure

Answer 482

resection of the pancreatic head with Roux-en-Y jejunal loop as side-to-end and side-to-side pancreaticojejunostomy

reserved for patients with a large inflammatory mass in the head of the pancreas with no evidence of distal ductal dilation

Question 483

describe to Puestos procedure

Answer 483

longitudinal pancreaticojeunostomy

reserved for chronic pancreatitis with dilation of the pancreatic duct > 7mm

Question 484

describe the Frey procedure

Answer 484

coring out the head of the pancreas with a longitudinal dissection of the pancreatic duct toward the tail
reconstruction with Roux-en-Y pancreaticojejunostomy

reserved for smaller inflammatory masses of the head of the pancreas and dilated pancreatic ducts

Question 485

describe the Whipple procedure

Answer 485

pancreaticoduodenectomy
resection of the head, duodenum, and distal 1/3 of the stomach
reconstruction with GJ, PJ, HJ

reserved for neoplasms of the head of the pancreas, used in chronic pancreatitis if malignancy cannot be excluded

Question 486

describe the Bern procedure

Answer 486

modification of the Beger procedure that involves resection of the pancreatic head
pancreas is not transected at the level of the portal vein as in the Beger which is advantageous in extensive inflammation
reconstruction requires a single anastomosis with a Roux-en-Y jejunal loop to the pancreas
no significant difference in outcomes between Beger and Bern

Question 487

what are bronchopulmonary sequestrations

Answer 487

non-functional pulmonary tissue fed by anomalous systemic arterial supply and have no connection to bronchial tree

intralobar - increased risk of bleeding
extralobar - usually asymptomatic with low risk of infection

Question 488

describe congenital lobal emphysema

Answer 488

caused by failure in development of bronchus cartilage resulting in air trapping with expiration
90%+ of cases involve either left upper or middle lobes
presents between first few days and first 6 months after birth
CXR with overinflation of the involved lobe

Question 489

what is a Morgagni hernia?

Answer 489

anteriomedial congenital diaphragmatic hernia

5% of CDH

Question 490

what is a Bochdalek hernia?

Answer 490

posterolateral congenital diaphragmatic hernia

most common type of CDH

Question 491

proposed cause of congenital diaphragmatic hernia

Answer 491

failure of closure the pleuroperitoneal canal

Question 492

treatment of inflammatory breast cancer

Answer 492

induction chemotherapy followed by surgical resection once inflammatory skin changes have subsided
radiation to reduce locoregional recurrence
there is no role for breast-conserving therapy in inflammatory breast cancer

Question 493

which of the following blood products is safe when considering the risk of transmitting hepatitis?

Answer 493

albumin is heat treated prior to packaging, which eradicates any circulating viruses

Question 494

describe dermatofibrosarcoma

Answer 494

rare (<1%) form of sarcoma that usually presents as a flesh-colored ass over the back and can be mistaken for keloid or hypertrophic scars

microscopic tentacles that extend laterally from the lesion - careful en bloc excision with a wide margin (2cm) to prevent recurrence or Mohs surgery

immune reactivity to CD34
usually low grade
commonly diagnosed between 30 and 50

Question 495

gut absorption of calcium is decreased in deficiency of which vitamin?

Answer 495

vitamin D

Question 496

what is a common cause of outflow failure in peritoneal dialysis?

Answer 496

omental wrapping

treated with omentopexy or omentectomy if needed

Question 497

is prior abdominal surgery a contraindication to peritoneal dialysis?

Answer 497

not id LOA can be safely and effectively performed

Question 498

how are hernias developed during peritoneal dialysis managed?

Answer 498

repair hernias electively without removal of the peritoneal dialysis catheter

Question 499

patients with polycystic kidney disease undergoing peritoneal dialysis are at increased risk of what complication?

Answer 499

abdominal wall hernias

Question 500

what is the most likely reason for non healing anal fissure after sphincterotomy?

Answer 500

inadequate division of the sphincter complex resulting in persistent tension

Question 501

risk factors for stress gastritis

Answer 501

critical illness, multi-organ system failure
ventilator dependency
massive resuscitation
extensive trauma
burns
hemorrhage

acid production has a secondary role (prophylactic PPI can aid in prevention)

Question 502

what mammography finding is pathognomonic for fat necrosis?

Answer 502

oil cyst - circumscribed mass of mixed soft tissue density and fat with a calcified rim

Question 503

when is short term follow-up and no biopsy ok for management of fat necrosis?

Answer 503

with a clear history of trauma and radiographic findings consistent with fat necrosis

Question 504

factors associated with increased postoperative morbidity and mortality?

Answer 504

performing = 4 mets
frailty score >/= 2
ASA class >/= 2
created albumin level

Question 505

management of brown recluse spider bite

Answer 505

initial management with cold compresses and elevation to decrease of spread of venom
frank areas of necrosis will need to be derided but early surgical intervention can result in unnecessary removal of tissue

Question 506

symptoms of hypophosphatemia

Answer 506

diplopia, dysphagia, confusion, respiratory muscle weakness

Question 507

symptoms of hypokalemia

Answer 507

constipation, fatigue, arrhythmia

Question 508

symptoms of hyponatremia

Answer 508

dizziness, lethargy, headache

Question 509

symptoms of hypernatremia

Answer 509

thirst, altered level of consciousness, tachycardia

Question 510

where are Delphian lymph nodes found?

Answer 510

within the anterior suspensory ligament, small group of midline prelaryngeal nodes

Question 511

where are level VI lymph nodes found?

Answer 511

the central compartment

Question 512

where are level II lymph nodes found?

Answer 512

upper jugular

Question 513

where are level III lymph nodes found?

Answer 513

mid jugular

Question 514

where are level IV lymph nodes found?

Answer 514

lower jugular

Question 515

where are level V lymph nodes found?

Answer 515

posterior triangle

Question 516

where are level I lymph nodes found?

Answer 516

submental

Question 517

where are level VII lymph nodes found?

Answer 517

superior mediastinal

Question 518

which lymph nodes does thyroid cancer tend to involve?

Answer 518

level VI before II, III, IV

I and VII are most common

Question 519

where are Rotter’s lymph nodes found?

Answer 519

between the pectorals major and minor muscles

Question 520

what are the most common endoscopic findings in eosinophilic esophagitis?

Answer 520

edema, rings, exudates, furrows, and strictures

Question 521

what is the mechanism of action of magnesium sulfate when used to treat premature labor?

Answer 521

competitive inhibition of calcium influx

magnesium sulfate causes tocolysis by inhibiting calcium at motor end plates and cell membrane calcium influx

Question 522

what is the management of periampullary tumors?

Answer 522

standard management is surgical resection with a Whipple but with small tumor, benign path, and patient preference a trans duodenal tumor resection is reasonable

Question 523

what is the appropriate management of medullary thyroid cancer?

Answer 523

total thyroidectomy with bilateral level VI central lymph node dissection
if there is evidence of metastasis to the lateral lymph nodes, a lateral neck dissection should be done

Question 524

in MEN IIA and IIB what prophylactic surgery is required?

Answer 524

total thyroidectomy before one year of age for MEN IIB and before age five for MEN IIA

Question 525

mechanism, metabolism, and side effects of tacrolimus

Answer 525

calcineurin inhibitor that acts by binding FK-binding protein
inhibition of IL2
metabolized by cytochrome P450 system
side effects: headache, seizures, tremors, nephrotoxicity, hypertension, alopecia, hyperkalemia, hypomagnesemia, GI symptoms, increased infections

Question 526

adverse effects of corticosteroids

Answer 526

adverse effects include acne, increased appetite and associated weight gain, mood changes, diabetes, hypertension, and impaired wound healing.

Question 527

adverse effects of azathioprine

Answer 527

the most significant and commonly dose-related, is bone marrow suppression. This leukopenia is often reversible with dose reduction or temporary cessation of the drug. Other significant side effects include hepatotoxicity, pancreatitis, neoplasia, anemia, and pulmonary fibrosis.

Question 528

adverse effects of mycophenolate mofetil

Answer 528

The most common side effects of mycophenolate mofetil are gastrointestinal in nature, most commonly diarrhea, nausea, dyspepsia, and bloating. Other important side effects are leukopenia, anemia, and thrombocytopenia.

Question 529

adverse effects of sirolimus

Answer 529

Sirolimus is a substrate of CYP3A/4 and has many significant drug interactions. Side effects of sirolimus include hypertriglyceridemia, impaired wound healing, thrombocytopenia, leukopenia, and anemia.

Question 530

when is surgery indicated for electrical injury?

Answer 530

vascular compromise with progressive neurologic dysfunction

Question 531

how are renal complications from electrical injury prevented?

Answer 531

fluid resuscitation titrated to 2mL/kg/hr
IV sodium bicarb
mannitol

Question 532

what medication should be avoided in burn patients 48 hours after injury

Answer 532

succinylcholine due to exaggerated hyperkalemic response which may result in cardiac arrest

Question 533

for how long should electrical burns patients be on a cardiac monitor if they have indications?

Answer 533

at least 24 hours
indications for monitoring:
arrhythmia on initial EKG
evidence of cardiac ischemia on initial EKG
history of cardiac arrest or loss of consciousness at time of injury

Question 534

how do bronchopleural fistulas present?

Answer 534

persistent air leaks from chest tubes

Question 535

what is lobar torsion and how does it present?

Answer 535

occurs when the bronchus and adjacent vascular structures twist upon themselves
typically occurs in the immediate post operative period following right upper lobectomy
mucus plugging of airways can cause white out of the affected lobes on CXR
presents with fevers, tachycardia, decreased breath sounds
if discovered early - detorsion, if not will need lobectomy

Question 536

what is the calculation for nitrogen balance?

Answer 536

nitrogen balance (grams) = protein intake / 6.25 - (UUN + 4)

UUN = urinary excretion of nitrogen in a 24 hours period
6.25g of protein has 1g of nitrogen

Question 537

describe discrete data

Answer 537

nominal, binary, or ordinal
no implied order
describe the quality of what is being studied and provide qualitative rather than quantitative observations

chi squared test is used for binary data

Question 538

describe continuous data

Answer 538

composed of number that can be broken down into many increment such as age, height, weight, blood pressure
measures of central tendency to describe the chief feature of the data set
they are comparable to the population mean using tests of significance such as Student T test

Question 539

how is catheter associated thrombosis managed?

Answer 539

therapeutic anticoagulation in the absence of contraindication (in which case IVC filter should be placed)
the catheter may be left in place if it remains functional

Question 540

how much of the liver’s blood supply comes from the hepatic artery and portal vein?

Answer 540

75% from the portal vein
25% from the hepatic artery

however they each supply 50% of the liver’s oxygen

Question 541

etiologies of chylous ascites

Answer 541

malignant obstruction of lymphatic vessels at the base of the mesentery or the cisterns chyli
congenital lymphangiectasia
thoracic duct obstruction
lymph peritoneal fistula

Question 542

what does cetuximab work on and which cancers does it treat?

Answer 542

cetuximab works against EGFR and is used in colon and head and neck cancer, not useful in KRAS+

Question 543

what is trastuzumab used for?

Answer 543

HER2 breast cancer

Question 544

what is rituximab used against and what cancers does it treat?

Answer 544

rituximab is used against CD20 in the treatment of lymphoma and CLL

Question 545

what is the mechanism of imatinib, and what is it used against?

Answer 545

imatinib is a tyrosin kinase inhibitor used against c-kit and ABL in the treatment of GIST and CML

Question 546

Diagnosis:

Cortisol level suppresses with low dose dexamethasone

ACTH level low (ACTH appropriately suppressed)

Answer 546

primary hypercortisolism; adrenal adenoma

Question 547

Diagnosis:

cortisol level suppresses with high-dose dexamethasone

ACTH normal to slightly high (ACTH inappropriately normal to elevated)

Answer 547

Cushing disease; pituitary adenoma

Question 548

Diagnosis:

cortisol does not suppress

ACTH very high (in the hundreds); ACTH is responsible

Answer 548

ectopic ACTH syndrome; small cell lung cancer

Question 549

is NSAID induced mucosal ulceration more common in the stomach or duodenum?

Answer 549

stomach

Question 550

how many patients with H. pylori develop peptic ulcer disease?

Answer 550

20%

Question 551

H pylori infection is present in what percentage of patients with duodenal ulcers and gastric ulcers?

Answer 551

H pylori is present in almost all patients with duodenal ulcers and about 70% of patients with gastric ulcers

Question 552

what are the three different patterns of inflammation associated with H pylori infection?

Answer 552

diffuse, astral, and stomach body related inflammation

Question 553

what is the most common cause of portal been thrombosis in children?

Answer 553

umbilical vein infection

Question 554

causes of portal vein thrombosis

Answer 554

umbilical vein infection, hepatic malignancy, myeloproliferative disorders, coagulopathies (protein C and antithrombin III deficiency), inflammatory bowel disease, trauma, pancreatitis, previous splenorenal shunt

most cases in adults are idiopathic
most common cause in children is umbilical vein infection

Question 555

what is the triad of symptoms seen in pheochromocytoma?

Answer 555

headache
diaphoresis
palpitations

most patients do not present with all three symptoms and they are often paroxysmal in nature
most common symptom is 90%

Question 556

how is pheochromocytoma diagnosed?

Answer 556

24 hour urine metanephrines and catecholamines

Question 557

which familial disorders are associated with pheochromocytoma?

Answer 557

von Hippel-Lindau syndrome
MEN2
neurofibromatosis type 1

Question 558

what is the pheochromocytoma rule of 10s?

Answer 558

10% malignant
10% bilateral
10% extra adrenal
10% familial (likely more)

Question 559

indications for central venous catheter

Answer 559

chemotherapeutic agents
TPN (10 or 20% dextrose preparation)
vasopressors
3% hypertonic saline
inability to place peripheral venous catheters

Question 560

causes of abdominal compartment syndrome

Answer 560

post traumatic hemorrhage
intraperitoneal bleeding
retroperitoneal bleeding
aggressive fluid resuscitation causing visceral edema

Question 561

effects of abdominal compartment syndrome

Answer 561

decreased cardiac output from decreased venous return
increased peak inspiratory pressures and pulmonary failure
decreased portal flow to the liver
decreased urine output from decreased flow to the kidneys
decreased blood flow to the intestines

Question 562

diagnosis: tense abdomen, ventilator insufficiency (increased peak inspiratory pressure) progressing to oliguria and cardiac collapse

Answer 562

abdominal compartment syndrome

Question 563

diagnosis of abdominal compartment syndrome

Answer 563

bladder pressure >20mmHg

new onset organ failure

Question 564

presentation of chronic mesenteric ischemia

Answer 564

severe sharp abdominal pain that develops 30-60 minutes after a meal and is associated with gradual weight loss from developing food fear

Question 565

treatment of acute mesenteric ischemia

Answer 565

exploratory laparotomy, assessment of bowel integrity, retraction cephalic of the transverse colon and tracing of the middle colic artery to the root of the mesentery to locate the SMA
transverse arrteriotomy, removing clot with Fogarty catheter both proximally and distally, closing the arteriotomy site

Question 566

treatment of severe class II purulent peritonitis or Hinchey Class IV fecal peritonitis from acute sigmoid diverticulitis

Answer 566

ex-lap, sigmoid resection, rectal stump creation, end colostomy

Question 567

differential diagnosis for acute onset of severe, sharp and diffuse abdominal pain

Answer 567

biliary colic, ureteral colic, perforated ulcer, ruptured abdominal aortic aneurysm, acute mesenteric ischemia

Question 568

patient safety events that result in patient death, permanent harm, severe temporary harm, or risk thereof

Answer 568

sentinel events