Truelearn Questions Flashcards
Incision for an injury to the left subclavian, left ventricle, descending aorta, left pulm artery, distal esophagus
Left posterolateral incision
If you cannot identify cystic duct, what do you do next
IOC through the infundibulum of the gallbladder
Vascular Injuries
- -Anterior tibial ligation can occur if needed
- -Brachial artery must be repaired to prevent hand ischemia
- -Primary repair or interposition graft should be done when possible
- -Injuries to both tibial arteries must be repaired to ensure there is at least a single vessel run off to the foot
- radial artery injuries can be safely lighted in pts with good ulnar flow
Pancreatic Leak
When fluid amylase levels are more than 3x higher than serum amylase levels
Embolectomy Size
Aortic Embolectomy- 6 or 7 french
Iliacs- 5 french
Femoropopliteal- 4 french
Tibial - 3 french
Reasons for Diagnostic Laparoscopsy
Gynecological evaluation
Oncalogic staging
Chronic abdominal pain
Hiatal Hernias
Type 1: most common, GE junction lies above the diaphragm (sliding hernia)
–can be treated non op with proton pump inhibitors
Type 2: paraesophageal hernia
- -ge junction is fixed and there is a true hernia sac in which the fundus of the stomach rises upward into the chest
- -should be electively repaired
Type 3: 2nd most common
Mixed hernia
GE junction lies above the diaphragm
Enlargement of the hernia allow the stomach and other organs to protrude through the hernia sac
Antidotes
Ethylene Glycol: fomepizole
Opioids: naloxone
Benzos: flumezanil
Methemoglobin: methalene blue
Hepatoblastoma
Tx with neoadjuvant chemo followed by surgrery
Gastroschesis
Abdominal wall defect located over the area where normal involution of the right umbilical vein occurs
True cause of gastroschesis is unknown
If intestine fails to return - protrusion through the umbilical ring- omphalocele
Omphalocele
By the 11th week of gestation, the midgut returns back into the abdominal cavity and undergoes normal rotation and fixation, along with closure of the umbilical ring. If the intestine fails to return, the infant is born with abdominal contents protruding directly through the umbilical ring, termed an omphalocele
Most common composition of nephrolithiasis?
Calcium Oxalate
Which of the following is the MOST common cause of this syndrome in Asia
Budd-Chiari syndrome
- venous obstruction
- at the level of the inferior vena cava, the hepatic veins, or the central veins within the liver.
The etiology of this syndrome has a geographical variation.
In the West, acute or chronic thrombosis and malignancy is the most common etiology.
In Asia, membranous webs are the major cause of obstruction of the vena cava and hepatic veins.
The most common causes of Budd-Chiari syndrome in the WEST are hypercoagulable conditions associated with polycythemia vera, paroxysmal nocturnal hemoglobinuria, myeloproliferative disorders and conditions associated with high estrogen levels such as pregnancy and use of contraceptive pills.
Bottom Line: In Asia, membranous webs are the major cause of obstruction of the vena cava and hepatic veins in patients with Budd-Chiari syndrome.
TNM staging for thyroid cancer
T1, <2 cm; T2, 2-4 cm, >4 cm; T3, >4 cm; T4a, extrathyroidal extension; T4b, invades prevertebral fascia or encases carotid artery or mediastinal vessels.
N0, no nodal involvement; N1, regional nodal metastases; N1a, metastasis to level 6 lymph nodes; N1b, metastasis to unilateral, bilateral, or contralateral cervical or superior mediastinal lymph nodes;
M0, no distant metastases; M1, distant metastases
Therefore, the patient in this scenario is T2, N1a, and M1. However, Age is the most important component of the TNM staging for well-differentiated thyroid cancer. For patients younger than 45 years, all patients are classified to either stage I or stage II regardless of the tumor size and lymph nodes involvement. Thus, this patient has stage II thyroid cancer despite the distant metastasis.
Posterior laparoscopic retroperitoneal adrenalectomy
Posterior retroperitoneal laparoscopic approach is most ideal for patients with previous abdominal surgeries and bilateral adrenal lesions.
GIST
Submucosal mass C-kit positive Spreads hematogenouslyi Lymph node dissection not indicated Just negative margins Form from interstitial cell of cajal Imatinib--tyrosine kinase inhibitor
even for complete resection, NCCN and Europeans still recommend postoperative gleevag in high risk patients (tumor bigger than 10 cm or more than 10 mitotic count per HPF
Yethere’s overall survival and recurrence-free survival benefits and they recommend at least 36 months
CAGB
Internal mammary is the best conduit
Brown recluse spider bite in children
Treat with cold compress and elevation
Whipple’s triad
Dx of insulinoma
1) neuroglycopenic symptoms
2) low blood glucose
3) relief of symptoms with glucose administration
Li-Fraumeni Syndrome
Soft tissue sarcoma (before 45)
Breast and brain neoplasms
*****p53 **
Aortoenteric fistula
First do an EGD to rule out an upper GI bleed as a cause of the bleeding
PEEP
Results in increased dead space ventilation and hypotension because of decreased preload
Magnesium
In icu pts you want magnesium to be >2
Hypomagnesemia: neuromuscular and CNS irritability, impairs parathyroid hormone excretion
appendiceal tumor:
1% of the time
Carcinoid most common
If <1cm–treat with appendectomy alone
If found to have appendiceal adenocarcinoma
–should then receivce right hemicolectomy and cytoredcuctive surgery of implants
Liver anatomy
The right and left liver are separated by the IVC and gallbladder II III IV are left liver II III are most lateral V through VIII are right liver VI and VII are more posterior Caudate is segment 1
Rectus sheath hematoma
Caused by forceful contraction of anterior abdominal wall while coughing
Roux-en-Y
Most common short term and most common overall metabolic complication is dehydration
Ovarian Torsion
Ultrasound is dx
Acute, severe, unilateral, lower abdominal pain
Intermittent
FAP
Increased risk for duodenal and periampullary polyps that harbor carcinoma
Duodenal adenocarcinoma is the leading cause of death after colorectal cancer in pts with FAP
High risk pts with multiple polyps, large polyps, villous architecture , known displasia should undergo a whipple
Entamoeba histolytica
Fecal-oral transmission
7-10 times more common in men
Spreads to the liver through portal vein
Fatty Acids
Short and medium chain fatty acids are absorbed by simple diffusion and long chain fatty acids enter a Michelle for absorption
Oral glucose challenge does what
insulin release increases and therefore insulin promotes uptake of glucose in all cells except B cells, hepatocytes and CNS cells
Glucose inhibits glycogenolysis and fatty acid breakdown
Blind loop syndrome
result after a chronic obstruction to a portion of the intestines. This causes bacterial overgrowth due to stasis within the obstructed limb. The bacteria bind with vitamin B12 and decrease its absorption into the body. Deficiencies in vitamin B12 lead to megaloblastic anemia and peripheral neuropathy.
Left hepatic artery variant
Common variant is from the left gastric artery
Common variant of common hepatic artery is from the SMA
Lymphedema
The risk of developing lymphedema one year after sentinel node biopsy and axillary dissection is 13%. The risk of developing lymphedema is 2% in sentinel node biopsy alone
Phalen’s test
Tines’ sign
Phalen’s test is a provocative test which reproduces the patient’s symptoms with the wrists firmly pressed in full flexion.
Tinel’s sign produces paresthesias in the involved digit with tapping over the carpal tunnel.
Roux Syndrome
affects a small subset of patients undergoing distal gastrectomy and roux-en-Y reconstruction. It is characterized by delayed gastric emptying in the absence of mechanical obstruction. The patient presents with epigastric pain, vomiting, and weight loss. An upper GI is often the initial test of choice but a gastric emptying study can confirm the suspicion. The test can often show delayed gastric emptying and reversed motility of the roux limb moving digested food toward instead of away from the stomach. The initial treatment of choice is a promotility agent. If that is unsuccessful, surgical intervention to reduce the size of the gastric pouch is indicated. For severe complications total gastrectomy and resection of the roux limb can be performed.
Septic Thrombophlebitis
Septic thrombophlebitis most commonly results from the insertion of intravenous catheters and needles or intravenous drug abuse. However, venous thrombi can become secondarily infected during bacteremia or if contiguous to areas of infection.
Post renal failure
Post-renal acute renal failure (ARF) is more common in the outpatient setting. Causes of post-renal ARF include prostatic hypertrophy, ureteric calculi, retroperitoneal fibrosis, pelvic tumors or papillary necrosis.
Infantile Hemangiomas (how do you handle complicated ones)
For complicated cases, peri-orbital, disfiguring, ulcerated, or involving the airway should be treated with Propranolol as a first line agent.
Lymphatic Drainage of the Thyroid Gland
What are Delphine lymph nodes
thyroid gland has intracapsular lymphatic channels that provide communication between the two lobes across the isthmus.
Within the anterior suspensory ligament is a small group of midline prelaryngeal lymph nodes known as the Delphian nodes.
The central compartment lymph nodes are classified as level VI.
The upper jugular, midjugular, and lower jugular are classified as level II, III, and IV; respectively,
whereas the posterior triangle lymph nodes are level V.
Thyroid cancers tend to involve level VI lymph node metastases before involving levels II, III, IV.
Submental (level I) and superior mediastinal (level VII) involvement is less common but can occur.
Lidocaine Toxicity
Cardiovascular Disturbances:
Widened PR, widened QRS, sinus tachy
earliest signs of an overdose or inadvertent intravascular injection are numbness or tingling of the tongue or lips, a metallic taste, light-headedness, tinnitus, or visual disturbances.
Signs of toxicity can progress to slurred speech, disorientation, and seizures
abdominal cysts
Mesenteric Cyst: cystic structure without solid components present in the small bowel mesentery unattached to the small bowel is most consistent with a mesenteric cyst.
Intestinal Duplication Cyst: Intestinal duplication may appear as a cystic structure on ultrasound but it is by definition attached to and communicates with the adjacent bowel.
Benign Liver Tumors
Hepatic Hemangioma:
- most common liver tumor
- congenital vascular malformations
- observe if asymmptomatic
Hepatic Adenomas: Hepatic adenomas are most frequently seen in women of childbearing age and are associated with oral contraceptives
- risk of bleeding
- if greater than 4 cm, should undergo resection
Focal Nodular Hyperplasia: most commonly diagnosed in female patient
- no associated with oral contraceptive use
- central scar
- no risk of malignancy, no risk of rupture, no risk of bleeding
Bariatric Surgery Weight Loss
50-60% weight loss at 2 years
