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444 Cards in this Set
- Front
- Back
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What is the source of fever in atelectasis?
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Alveolar macrophages
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What is the first sign of malignant hyperthermia?
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Increase in end-tidal CO2
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What is the treatment for malignant hyperthermia
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Dantrolene
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What is the first muscle to recover from paralytics?
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Diaphragm
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What is the rate-limiting step in cholesterol formation?
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HMG coA Reductase
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Where is angiotensin I converted into angiotensin II?
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lung
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What are the effects of angiotensin II?
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Vasoconstriction Increases aldosterone (keeps Na, loses K/H in urine)
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Describe the anatomy of the vagus innervation of the stomach
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Left vagus (anterior) gives hepatic branch, Right (posterior) gives celiac branch and "criminal nerve of Grassi"
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Which cells produce pepsinogen?
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Chief cells
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Which cells produce intrinsic factor?
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Parietal cells
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What are the main stimuli for H+ production in the stomach?
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Acetylcholine, gastrin, and histamine
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What is the mechanism of omeprazole?
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Blocks H/K ATPase of parietal cell
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What is the most common symptom post-vagotomy?
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Diarrhea (35%)
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What is the cause of early (15-30 min) dumping syndrome?
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Hyperosmotic load, fluid shift causes neuroendocrine response, peripheral and splanchnic vasodilation
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What is the cause of late (2-3 hrs) dumping syndrome?
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Increased insulin with decreased glucose
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What are the 3 actions of CCK?
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1) contract gallbladder 2) Relax Sphincter of Oddi 3) Increase pancreatic enzyme secretion
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What is the primary stimulus of pancreatic bicarb secretion?
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secretin
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What affects the amount of bicarb in pancreatic secretions?
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Flow rate: high flow = high bicarb, low Cl. Slow flow allows more HCO3/Cl exchange
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Describe the phases of the migratory motor complex
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Phase I - quiescence; Phase II - acceleration, gallbladder contraction; Phase III - peristalsis; Phase IV - subsiding electric activity; occurs in 90 min cycles
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What is the key stimulatory hormone of the MMC?
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motilin
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What drug stimulates motilin receptors?
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Erythromycin
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What is the action of Protein C and Protein S?
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Protein C degrades active V and VIII. Protein S helps protein C
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What is the only clotting factor not made in the liver?
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Factor VIII (made by reticuloendothelial system)
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What is the difference between the three types of Von Willebrand's Disease?
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Type I and III have low amounts of vWF, respond to ddAVP Type II is qualitatively poor vWF
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What is the only inherited coagulopathy with long bleeding time?
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Von Willebrand's Disease (autosomal dominant)
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What is the pathophysiology of Glanzman's thombasthenia?
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IIb/IIIa receptor deficiency of platelets. Decreased platelet aggregation. Fibrin normally links Gp IIb/IIIa receptors
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What is the pathophysiology of Bernard Soulier syndrome?
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Ib receptor deficiency of platelets. Decreased adherence of exposed collagen. vWF normally links Gp Ib to collagen
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What test confirms the presence of von Willebrand Disease?
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Ristocetin test
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What are the three possible treatments for vWD?
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DDAVP Factor VIII cryoprecipitate
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What is the treatment for hemarthrosis in a hemophiliac?
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Ice, ROM therapy, Factor replacement Do not aspirate
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What are the most common inherited thombophilias?
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Factor V Leiden Prothrombin mutation (GP20210) Hyper-homocysteinemia
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What is the treatment for overdose of thrombolytics?
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Aminocaproic acid (Amikar) - inhibits fibrinolysis
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What are the effects of prostacyclin?
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Decreased platelet aggregation, vasodilatation, bronchial relaxation
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What are the effects of thromboxane?
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Increased platelet aggregation, vasoconstriction, bronchial constriction
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What stimulates B cells to become plasma cells?
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IL-4
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Which complements are anaphylatoxins?
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C3a, C5a
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Which complements make up the membrane attack complex?
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C5-9
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What cells are responsible for immunosurveillance against CA?
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Natural killer cells
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What is the source of histamine in blood?
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Basophils
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What is the source of histamine in tissue?
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Mast cells
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What is endotoxin? Where does it come from?
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Lipopolysaccharide A from gram negative bacteria
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What does an elevated mixed venous oxygen saturation (SvO2) indicate?
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>77% - sepsis or cyandide poisoning
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What does a low mixed venous oxygen saturation (SvO2) indicate?
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<66% - decreased CO
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What are the four intraabdominal abscess locations?
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sub-diaphragmatic sub-hepatic inter-loop pelvic
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What two infections can present within hours post-op?
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B-strep Clostridial (GPR)
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What is the mechanism of vancomycin? What is the mechanism of it's resistance?
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Inhibits cell wall synthesis Altered cell wall (unable to bind)
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What is the mechanism of quinolones?
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DNA gyrase inhibition
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What is the mechanism of amphotericin
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binds sterols to alter fungal cell wall
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What antibiotic prolongs neuromuscular blockade?
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Clindamycin
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What are the risks of a blood transfusion?
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CMV is highest Hep C 1:30-150,000 HIV 1:500,000
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What are the vitamin K dependent factors?
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II, VII, IX, X, protein C + S
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Which antibiotics are bacteriocidal, with irreversible binding to 30S ribosome subunit, and resistance due to decreased active transport?
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Aminoglycosides (gentamicin, neomycin, tobramycin)
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What is the only depolarizing neuromuscular blocker used?
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Succinylcholine
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What is an adverse effect of succinylcholine in burn patients?
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hyperkalemia
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What are the effects of reglan (metoclopramide)?
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Dopamine receptor blocker - Increases LES tone and gastric motility
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What is the mechanism of digoxin?
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inhibits Na/K ATPase to increase calcium in heart
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What is the effect of digoxin?
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Slows AV conduction, inotrope but does not increase O2 consumption
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What pressor is most useful in GIB?
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Vasopressin: reduces splanchnic blood floow, portal flow ~40%. Give with B-blocker to avoid angina
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What gastric contents have the highest concentration of K?
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Saliva (20 meq) > gastric (10 meq) > pancreatic/duodenal (5 meq)
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What is the water distribution in a average person?
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2/3 is intracellular and 1/3 is extracellular (80% of extracellular fluid is interstitial and 20% is plasma)
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What drug can reverse adverse effects of steroids on wound healing?
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Vitamin A
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How many kcal/g are in protein, fat, and carbs?
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Protein: 4 kcal/g Fat: 9 kcal/g Carbs: 3.4 kcal/g
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Describe vitamin D synthesis
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Vit D made in skin, to liver for (25-OH, calcidiol), then to kidney for (1-OH, calcitriol), then active
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What is the respiratory quotient?
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Ratio of CO2 produced to O2 consumed 0.7 = fat used 1.0 = carb used
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What is the preferred fuel of the colon?
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Short chain fatty acids - butyric acid
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Describe fat digestion
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Long chain: Micelles to enterocytes to chylomicrons to lymphatics (to jxn LIJ/SCV); medium and short chain are directly absorbed into portal system with aa's and carbs
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What is the preferred fuel of the small bowel?
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Glutamine
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What is the #1 amino acid in the blood stream?
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Glutamine
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What causes a decrease in glutamine in the blood stream during stress?
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Glutamine goes to kidney to form ammonium to help acidosis
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What vitamin deficiency causes hyperglycemia (relative diabetes) and neuropathy?
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Chromium
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What vitamin deficiency causes perioral rash, hair loss, poor healing, and change in taste?
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Zinc
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What vitamin deficiency causes weakness (respiratory) and encephalopathy?
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Phosphate (needed for ATP)
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What vitamin deficiency causes anemia and neutropenia?
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Copper
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Describe the Cori cycle
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glucose to lactate, to the liver, to glucose
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During starvation, what does the brain use for fuel?
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ketones from fatty acids (instead of glutamine)
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What are the electrolyte concentrations of NS vs LR?
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Normal saline: 154 meq Na and Cl LR: Na 130, K 4, Ca 2.7, Cl 109, bicarb 28
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What two electrolyte abnormalities cause hyperexcitability (increased reflexes, tetany)?
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Hypocalcemia and hypomagnesemia
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How does magnesium affect calcium?
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Low Mg inhibits PTH, so replace MG if difficulty correcting Ca
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What are the phases of the cell cycle?
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G1 - most variable period; S - DNA replication; G2; M - Mitosis
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What phase of the cell cycle is most sensitive to radiation therapy?
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M - mitosis
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What are the recommendations for biopsy of an extremity sarcoma?
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Excisional if < 4cm, otherwise longitudinal incision (less lymphatic disruption, easier to excise scar if biopsy positive)
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What is a complication of bleomycin and busulfan?
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pulmonary fibrosis
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What are the risks of tamoxifen?
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DVT and Endometrial cancer
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Ret proto-oncogene is diagnostic for what? What is the treatment?
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Medullary thyroid cancer Patient with family history of MEN who has ret proto-oncogene should have total thyroidectomy
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What is a side effect of vincristine and cisplatin?
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Neurotoxicity
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What cells provide wound contraction?
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Myofibroblasts
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What cells are responsible for healing by secondary intention?
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Myofibroblasts
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What is the principal collagen late in scar?
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Type I
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What is the principal collagen in a healing wound?
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III (this is the collagen of granulation tissue)
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What type of collage is low in Ehler-Danlos?
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III
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What is the time frame of collagen production in a wound?
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Begins day 3, max at day 21, then constant amount but more crosslinking, strength
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What is the order of cells to a healing wound?
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Platelets PMNs macrophages (essential) fibroblasts (dominant by day 5)
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What are the effects of TGF-B?
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stimulates fibroblasts and chemotactic for neutrophils (too much/too long can cause fibrosis)
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What is the effect of PDGF?
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Attracts fibroblasts and increases smooth muscle to speed matric deposition and collagen formation
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What is the main source of TNF?
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Macrophage/monocyte
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What cell does TNF recruit and activate?
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neutrophils
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How does TNF cause wasting/cachexia in cancer patients?
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Anorexia, glycolysis, and lipolysis
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What is batson's plexus, and what is it's significance?
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Valveless vertebral veins that connect to internal vertebral venous plexus They allow direct mets to the spine
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What is Poland's syndrome?
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Amastia, hypoplastic shoulder, no pectoralis
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What is Mondor's disease? What is the treatment?
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thrombophlebitis of superficial vein of breast. Cord like mass laterally. Treat with NSAIDS
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Describe the "T" staging of breast cancer
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T1 = <2cm T2 = 2-5cm T3 = >5cm T4 = skin or chest wall involvement
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Describe the "N" staging of breast cancer
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N1 = ipsilateral lymph nodes (1-3 LN on path) N2 = fixed or matted LN (4-9 LN on path) N3 = infraclavicular, supraclavicular, or internal mammary (>10 LN on path)
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Describe the staging of breast cancer according to TNM guidelines
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Stage I = T1 Stage IIA = T1N1 or T2N0; IIB = T2N1, T3N0 Stage IIIA = T1-3 and N2, or T3N1; IIIB = T4N0-2; IIIC = Any T N3
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How does hormone receptor status in breast cancer affect prognosis?
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ER+PR+ > ER-PR+ > ER+PR- > ER-PR-
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What % of DCIS develop invasive cancer?
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50%
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What % of LCIS develop invasive cancer?
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30-40% (in either breast)
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What is the difference pathophysiologically in cancer risk between DCIS and LCIS?
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DCIS is a precursor to cancer LCIS is a marker of risk
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What % of Phyllodes tumor are malignant?
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10%
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What is the treatment for Phyllodes tumor?
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Wide local excision, rarely mastectomy. No axillary node dissection necessary (spread is hematogenous, not lymphatic)
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What type of cancer is BRCA1 and BRCA2 associated with?
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BRCA1 - ovarian CA (50%) BRCA2 - male breast CA
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What are the indication for RT after mastectomy?
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>4 nodes skin or chest wall involvement +margins
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What are absolute contraindications to breast-conserving therapy requiring radiation?
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Prior radiation to breast/chest wall Radiation therapy during pregnancy Diffuse suspicious or malignant appearing microcalcifications Widespread disease not able to be incorporated by local excision Positive margins
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What is the #1 cause of blood nipple discharge?
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Intraductal papilloma - no risk of CA
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What is Stewart-Treves syndrome?
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Angiosarcoma arising from chronic lymphadema, often as a complication after mastectomy. Presents as a purplish mass on arm ~10 yrs s/p MRM
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What is the difference between the two types of alveoli?
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Type I: functional gas exchange Type II: produce surfactant (1% of alveoli)
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What is the association between the thymus and myasthenia gravis?
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10% of m.g. have thymomas Resecting thymus (even if no thymoma) in m.g. improves 90%
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Popcorn lesion on CXR
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hamartoma
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What are the indications for CABG?
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intractable symptoms >50% left main triple vessel disease 70% LAD + 1 other vessel
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What is the treatment for a patent ductus arteriosus
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Indomethacin - blocks PG production - effective in ~70% Surgery for those that don't close at 6 months of age
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What are the effects of IABP?
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Augments diastolic coronary blood flow and reduces afterload by inflating during diastole (inflates 40msec before T wave, deflates with p wave)
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What electrolytes are actively secreted by the colon?
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K and HCO3
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Describe the blood supply of the rectum
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Superior rectal artery off IMA Middle off internal iliac Inferior off internal pudendal (off internal iliac)
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What are the most common genetic mutations in colon cancer?
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p53 (85%), DCC (70%), ras (50%)
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Amsterdam criteria
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3 1st generation relatives, over 2 generations, 1 diagnosed before age 50
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Gardner's syndrome
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colon CA and desmoid tumors
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Turcot's syndrome
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colon CA and brain tumors
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Peutz Jeghers
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polyposis and mucocutaneous pigmentation; increased risk of GI, gonadal, breast cancers
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What gene is associated with sacroiliitis in IBD?
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HLA B27
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Where are most anal fissures located?
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posterior midline, 10% are anterior in women
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What are the causes of anal fissures which are lateral or recurrent?
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IBD, TB, or syphilis
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What is normal LES tone and length?
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15-25 mm Hg, 4cm long, 40cm from incisors
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What is the treatment of diffuse esophageal spasm?
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calcium channel blockers
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What is the pathophysiology of achalasia?
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Decreased ganglion cells in Auerbach's plexus, absence of peristalsis and esophageal dilation. High LES pressures
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What is main arterial supply to stomach when used to replace esophagus?
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right gastroepiploic artery
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What is the treatment of esophageal leiomyoma?
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If symptomatic or >5cm excise by enucleation via thoracotomy (R if middle, L if lower esophagus) Do not biopsy on EGD
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What is Killian's triangle?
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A potentially weak spot where a pharyngoesophageal diverticulum (Zenker's) is more likely to occur. Posterior triangular area in the pharynx between the inferior constrictor and the cricopharyngeus muscle
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What is a painless mass on the roof of the mouth?
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Torus - bony exotosis, midline of palate
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Which has a greater risk for cancer, leukoplakia or erythroplakia?
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Erythroplakia
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What is the general treatment for different stages of head and neck SCCa?
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Stage I+II(up to 4cm, no nodes) Rx with single modality (surgery or RT) Stage III+IV get combined modality
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What is the treatment for glottic Ca?
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If cords not fixed, then RT If cords fixed, need surgery and RT
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What is the most common type of lip cancer?
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Epidermoid carcinoma. Lower > upper due to sun exposure
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What is the usually presentation of nasopharyngeal carcinoma?
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50% presesnt late (as neck mass). Drain to posterior neck nodes. A/w EBV
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What is the treatment of lip cancer?
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Resect, primary closure if <1/2 of lip, otherwise flaps. Radical neck dissection if node+
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What is Plummer-Vinson syndrome? What type of cancer is increased?
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Triad of dysphagia (due to esophageal webs), glossitis, and iron deficiency anemia. Increased risk of esophageal/tongue Ca
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What are the most common malignant salivary gland tumors?
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#1 - Mucoepidermoid carcinoma #2 - Adenoid cystic carcinoma (#1 of submandibular and minor glands)
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What are the most common benign salivary gland tumors?
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Pleomorphic adenoma (#1 overall), Warthin tumor
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What is the treatment for a benign salivary gland tumor?
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Superficial parotidectomy (spare CNVII). If malignant, take whole parotid. If high grade, need radical neck dissection
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What is the difference between a radical neck dissection and a modified radical neck dissection?
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Radical neck takes CN XI, SCM, IJ. Modified spares some combination of those structures (CN XI is most morbid)
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What is the cause of unilateral nasal obstruction and recurrent epistaxis in a teen male? What is the treatment?
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Juvenile Nasopharyngeal Angiofibroma - benign but locally agressive vascular tumor of nasal cavity. Embolize (internal maxillary artery), then extirpate
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What is a replaced right or left hepatic artery?
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Replaced right - originating off SMA (occurs in 17%) Replaced left - originating off left gastric (occurs in 10%)
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What are Kupffer cells?
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Specialized macrophages in the liver responsible for clearing portal blood and immunosurveillance. Also responsible for early alcohol-induced liver injury.
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Describe the anatomical relationship of the Portal triad
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Portal vein posterior to CBD (on R) and hepatic artery (on L)
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What is the #1 cause of benign biliary stricture?
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Iatrogenic (lap chole)
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What are the symptoms and treatment of cholangitis?
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Fever, RUQ pain, jaundice, +/- hypotension, MS changes. Needs immediate IV Abx, IVF, emergent decompressions/drainage of CBD
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What is the treatment of gallbladder adenocarcinoma?
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Cholecystectomy adequate if confined to mucosa. If grossly visible tumor - regional lymphadenectomy, wedge segment V, skeletonize portal triad
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What is the triad of hemobilia?
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UGIB, RUQ pain, and jaundice - caused by fistula between biliary duct and hepatic arterial system
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What is the treatment of hemobilia?
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workup and treatment with arteriogram
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How does the gallbladder concentrate bile?
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Active absorption of Na, Cl (H20 then follows)
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What is the treatment for hepatic adenoma?
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Hepatic adenoma is an indication for resection 10% rupture/bleed + malignant potential
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What is the treatment for hepatic hemangioma?
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Do nothing unless giant or symptomatic/consumptive
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What is Kasabach-Merritt syndrome?
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Consumptive coagulopathy or CHF due to hemangioma - usually in infants.
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What is the treatment of liver amebic abscess?
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metronidazole, not surgical
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What is the treatment of hydatid cysts?
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Surgical resection with chemotherapy before and after (albendazole or mebendazole)
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What is the work-up of hydatid cysts?
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Casoni skin test + Indirect hemagglutination
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What are the main risk factors for hepatocellular carcinoma?
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Alcoholism, Hep B+C, hemochromatosis, PBC, aflatoxin, alpha-1-antitrypsin deficiency - PBC and Wilson's are not risk factors
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What type of HCC has best prognosis?
|
Fibrolamellar
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What is the difference between these types of peripheral nerve injuries: neuropraxis, axonotmesis, neurotmesis?
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Neuropraxis - focal demyelination, improves Axonotmesis - loss of axon continuity (nerve and sheath intact). Regen 1mm/day Neurotmesis - loss of nerve continuity, surgery required for nerve recovery
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What triggers ADH release?
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Produced when high osmolarity is sensed at supraoptic nucleus of hypothalamus
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What is Diabetes Insipidus?
|
Alcohol and head injury inhibit ADH release - high UOP, low urine SG, high serum osmolarity/Na
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What is SIADH?
|
Increased ADH release most often by head trauma/tumors or SCLC. Oliguria, high urine osmolarity, low serum osmolarity/Na
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What is the effect of ADH?
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Causes increased free water absorption at the distal tubules and collecting ducts and increases peripheral vascular resistance
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What is cerebral perfusion pressure?
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Mean Arterial Pressure (MAP) - Intracranial Pressure (ICP) Keep ~70
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What is Cushing's triad?
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Hypertension, bradycardia, and Kussmaul respirations (slow, irregular) associated with increased ICP
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Describe the Glasgow Coma Scale ratings
|
Motor: 6 commands, 5 localizes, 4 withdraw pain, 3 flexion, 2 extension, 1 none Verbal: 5 oriented, 4 confused, 3 inappropriate, 2 incomprehensible, 1 none Eyes: 4 spont, 3 command, 2 pain, 1 none
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What are the signs of spinal shock?
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Hypotension with bradycardia, warm perfused extremities (vasodilation) Cord injury above T5
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What are the deficits in anterior spinal artery syndrome?
|
Lose bilateral motor, pain, and temperature. Keep position sense, light touch
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What is Brown-Sequard syndrome?
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Spinal cord hemi-transection Lose ipsilateral motor, contralateral pain and temperature
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What is Central Cord Syndrome?
|
Acute cervical spinal cord injury characterized by bilateral loss of upper extremity motor, pain, and temperature; legs relatively spared. Often due to hyperextension
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What are the indications to operate on a skull fracture?
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If open or depressed
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What are the effects of L3-L4 disc herniation?
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L4 root compresson - quadriceps, week knee jerk
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What are the effects of L4-L5 disc herniation?
|
L5 root compression - foot drop, possible big toe hyperesthesia
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What are the effects of L5-S1 disc herniation?
|
S1 root compression - weakness in plantar flexion (pushing off toes), weak ankle jerk, hyperesthesia lateral foot/calf
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What is the terrible triad of O'Donaghue?
|
lateral blow to knee - injury to ACL, MCL, medial meniscus
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What does the medial nerve do?
|
thumb apposition, sensation to most of palm, 1st 2 1/2 fingers (carpal tunnel)
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What does the ulnar nerve do?
|
intrinsic musculature of hand, finger abduction, wrist flexion, sensation to 2 1/2 fingers/back of hand
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What does the radial nerve do?
|
Wrist/finger extension, sensation to back of lateral hand; no motor in hand
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What are the benefits of early ORIF in femur fracture?
|
early mobilization decreased fat embolization
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What is a Salter-Harris fracture? Which types need open procedures?
|
fracture that involves the epiphyseal plate or growth plate of a bone Types III, IV, V are intra-articular and thus need open repair
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What are the signs of hip dislocation?
|
Posterior (90%) - internal rotation, flexed, abducted thigh Anterior - frog leg (external rotation, abduction)
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What three fractures are prone to compartment syndrome?
|
Calcaneous, tibia, supracondyle of humerus
|
|
|
What is treatment of knee dislocation?
|
Most texts say arteriogram all posterior, but at least some vascular assessment (ABI/CT angio/duplex US) is necessary to evaluate popliteal injury even in the presence of normal vascular assessment
|
|
|
What nerve is commonly injured in shoulder dislocation?
|
axillary nerve in anterior dislocation (90% of dislocations)
|
|
|
What is a Volkmann's contracture? What is the treatment?
|
Permanent flexion contracture of the hand at the wrist. Caused by supracondylar humerus fx -> compromised anterior interosseous artery -> deep forearm flexor compartment syndrome Needs fasciotomy
|
|
|
What does a tender snuffbox indicate?
|
Navicular fracture - even with negative XR, requires cast up to elbow
|
|
|
What is a Dupuytren's contracture? What is the treatment?
|
Progressive proliferative of palmar fascia causing flexion contracture of fingers of hand, unknown exact cause (trauma, DM, EtOH, epilepsy) Treatment with steroids, physical therapy, but may need fasciotomy
|
|
|
What is a Monteggia fracture? What is the treatment?
|
proximal ulnar fracture with radial head dislocation Treat with ORIF
|
|
|
What is a sunburst pattern on x-ray suggest?
|
Osteogenic sarcoma
|
|
|
What does "onion layering" on x-ray suggest?
|
Ewing sarcoma
|
|
|
What do pseudorosettes on path suggest?
|
Ewing sarcoma
|
|
|
What are the signs of annular pancreas? Treatment?
|
Double bubble on x-ray. Prone to pancreatitis, possible obstruction. Treat obstruction with duodenojejunostomy, do not resect pancreas
|
|
|
What is effective pain relief for non-resectable pancreatic CA?
|
Celiac plexus block (50% EtOH on both sides of aorta near celiac)
|
|
|
What is treatment of pancreatic pseudocyst?
|
Expectant management initally - 85% resolve on their own If persistent and symptomatic - internal drainage by cyst-gastrostomy, -duodenostomy, or -jejunostomy
|
|
|
What are the signs of an insulinoma? Treatment?
|
Whipple's triad (symptoms of hypoglycemia, glucose <45, improvement with glucose) Insulin to glucose ratio >0.4 Increased C-peptide Rx = enucleation (though 90% are benign)
|
|
|
What are the boundaries of the gastrinoma triangle?
|
(1) cystic/CBD junction (2) 3rd part of the duodenum (3) neck of the pancreas
|
|
|
What are the signs of gastrinoma?
|
Severe ulcer disease, diarrhea (lipase destruction by acid, malabsorption, incr secretion)
|
|
|
What test evaluates gastrinoma?
|
Secretin stimulation test - normal patients will decrease gastrin Though a serum gastrin level >1000 is virtually diagnostic
|
|
|
What are the symptoms of a somatostatinoma?
|
gallstones steatorrhea pancreatitis diabetes
|
|
|
What are the symptoms of a glucagonoma? Treatment?
|
diabetes glossitis stomatitis necrolytic migratory erythema (presenting problem in 70%) Rx = streptozocin/doxorubican (selectively destroy alpha cells) and octreotide (inhibits release)
|
|
|
What are the symptoms of VIP-oma?
|
WDHA syndrome = watery diarrhea hypokalemia achlorydia
|
|
|
What is the treatment for a choledochal cyst?
|
Must excise, leaving cyst increases cancer, pancreatitis, and cholangitis risks Transplant if type IV or V
|
|
|
What are the types of choledochal cysts?
|
I - (>90% of cysts) dilatation of CBD (part or whole) II - diverticulum III - choledochocele involving sphincter IV - intra and extrahepatic cysts (Caroli's disease) V - intrahepatic cysts
|
|
|
What is pulmonary sequestration?
|
mass of non-functioning primitive tissue in the lung Extralobar - systemic artery and vein Intralobar (75%) - aorta in and pulmonary vein out
|
|
|
What is the #1 presentation of pulmonary sequestration?
|
infection
|
|
|
What is the cause of respiratory distress at birth, and massive hyperinflation of a single lobe of the lung? What is the treatment?
|
Congenital lobar emphysema Rx: lobectomy, excellent prognosis
|
|
|
What is the first sign of CHF in children?
|
hepatomegaly
|
|
|
What is the treatment for a strawberry hemangioma
|
observation - most involute by age 7
|
|
|
What is the #1 pediatric malignancy overall?
|
leukemia
|
|
|
What gene is neuroblastoma associated with?
|
N-myc
|
|
|
What is elevated in neuroblastoma?
|
VMA - Vanillyl mandelic acid HVA - homovanillic acid
|
|
|
What is the treatment for biliary atresia?
|
Kasi procedure - hepatoportoenterostomy - before age 3 months
|
|
|
What is the #1 cause of painless GIB in children?
|
Meckel's diverticulum
|
|
|
What is the embryologic origin of a Meckel's diverticulum?
|
Persistent omphalomesenteric duct
|
|
|
What is the treatment of intussusception in children?
|
air/contrast enema (max 120mm Hg) IV glucagon can help (relaxes smooth muscle) OR if free air/peritonitis
|
|
|
What is the cause of intestinal atresia?
|
Intra-uterine vascular events Mother may have polyhydramnios
|
|
|
What is the surgical treatment for malrotation?
|
Ladd's procedure - appendectomy, take down bands, counterclockwise rotation
|
|
|
What is a cystic hygroma? What is the most common location?
|
lymphangioma - left posterior triangle of neck
|
|
|
What is the treatment for a thyroglossal duct cyst?
|
Sistrunk procedure - en bloc excision of cyst (midline) with hyoid bone
|
|
|
What is the #1 complication of cystic hygroma?
|
infection
|
|
|
What is the treatment for a Wilm's tumor?
|
nephrectomy (80% cure)
|
|
|
What is the most common type of tracheo-esophageal fistula?
|
Type C - blind esophagus, distal TE fistula. Spit up feeds, NGT won't pass
|
|
|
What other abnormalities can a patient with a tracheoesophageal fistula have?
|
VACTERL - vertebral, anal atresia, cardiovascular, TEF, esophageal atresia, renal, limb defects - structures derived from embryonic mesoderm
|
|
|
What is the #1 cause of a colon obstruction in a newborn?
|
Hirschsprung disease - no BM in first 24 hrs, diagnose with rectal bx
|
|
|
What is the treatment for a meconium ileus?
|
Gastrograffin enema - diagnostic and therapeutic
|
|
|
How does necrotizing enterocolitis in a newborn present?
|
After initiating feeds in a neonate (premie) in the 2nd or 3rd week of life with blood in the stool OR free air/peritonitis/acidosis Classic triad: abd dist, bloody stools, pneumatosis
|
|
|
What is the treatment for imperforate anus?
|
If low - anoplasty If high (meconium in urine, fistula to bladder, vagina, or urethra) - need colostomy
|
|
|
What are the characteristics of gastroschisis?
|
Congenital abd wall defect, intrauterine rupture of umbilical cord, no associated defects, lateral (right) defect, no sac
|
|
|
What are the characteristics of omphalocele?
|
midline defect, may contain liver or other non-bowel contents, frequent anomalies, has peritoneal sac.
|
|
|
What converts norepinephrine to epinephrine?
|
PNMT - Phenylethanolamine N-methyltransferase
|
|
|
What are the common characteristics of a pheochromocytoma?
|
10% are: malignant, bilateral, in children, part of MEN, extra-adrenal
|
|
|
What is the most common extra-adrenal location for a pheochromocytoma?
|
Organ of Zuckerkandl at aortic bifurcation
|
|
|
What is the pre-operative management for a pheochromocytoma?
|
alpha-blockers first, then beta-blockers if tachycardic
|
|
|
How is the diagnosis of pheochromocytoma made?
|
screen with urine metanephrines, VMA; MIBG can localize
|
|
|
What is Nelson's syndrome?
|
rapid enlargement of a pituitary adenoma that occurs after bilateral adrenalectomy (10%) - incr ACTH, muscle weakness, pigmentation, vision changes
|
|
|
What is Waterhouse Friderichsen syndrome?
|
adrenal hemorrhage a/w meningococcal sepsis
|
|
|
What is Conn's syndrome?
|
hyperaldosteronism = 80% adenoma, 20% bilateral hyperplasia - HTN, low K, high Na
|
|
|
What is Addison's disease?
|
low aldosterone and glucocorticoids = low Na, high K, hypoglycemia. Crisis presents similar to sepsis with hypoTN, fever; steroids are diagnostic and therapeutic
|
|
|
What is the most common cause of congenital adrenal hyperplasia?
|
21-hydroxylase deficiency
|
|
|
What is Cushing's disease?
|
Excessive secretion of ACTH from the anterior pituitary, usually from a pituitary adenoma. Causes 70% of non-iatrogenic Cushing's syndrome.
|
|
|
What is the most common cause of Cushing syndrome?
|
iatrogenic
|
|
|
What is Cushing's syndrome?
|
hormone disorder with high levels of cortisol - symptoms include characteristic weight gain (truncal obesity, moon face, buffalo hump), purple striae, hirsutism, polyuria, htn, insulin intolerance
|
|
|
How do you determine the type of Cushing syndrome?
|
Dexamethasone suppresion test: Pituitary - high ACTH, cortisol suppressed with steroids Adrenal - low ACTH, not suppressed Ectopic - high ACTH, not suppressed
|
|
|
What hormones does the anterior pituitary secrete?
|
GH, ACTH, TSH, LH, FSH, Prolactin
|
|
|
What hormones does the posterior pituitary secrete?
|
ADH, Oxytocin
|
|
|
What is the classic vision change with pituitary mass effect?
|
Bitemporal hemianopsia - vision missing in outer half of both right and left visual fields
|
|
|
What is the #1 pituitary adenoma? What are the symptoms?
|
Prolactinoma - galactorrhea, irregular menses
|
|
|
What is Sheehan syndrome?
|
postpartum lack of lactation and persistent amenorrhea caused by necrosis of pituitary from blood loss during/after childbirth
|
|
|
What is the treatment for a prolactinoma?
|
Bromocriptine or transphenoidal resection
|
|
|
What is the pathophysiology of hidradenitis?
|
involves apocrine glands, thus seen after puberty
|
|
|
What are the three steps to the healing of a skin graft?
|
Imbibition, inosculation, revascularization
|
|
|
What is the most common cause of flap necrosis?
|
venous thrombosis
|
|
|
What type of cancer demonstrates "peripheral palisading" of nuclei and "retraction artifact"
|
Basal cell carcinoma
|
|
|
What are the common sites for melanoma?
|
Skin > eyes > rectum #1 skin site for men = back, women = legs Worse prognosis on "BANS" - back arms, neck, scalp
|
|
|
What type of scar extends beyond margins: keloid or hypertrophic?
|
keloid
|
|
|
What is the cause of keloid scar?
|
failure of collagen breakdown and increased collagen production
|
|
|
What are the four major types of melanoma?
|
superficial spreading (most common), nodular, lentigo maligna, acral lentiginous
|
|
|
What is the Breslow classification of melanoma?
|
<0.75 mm (90% cure) 0.75-1.5mm 1.5-4mm >4mm (80% distant mets)
|
|
|
What type of melanoma has the best prognosis? worst prognosis?
|
best = lentigo maligna; worst = nodular
|
|
|
What are the surgical margins for resection of a melanoma?
|
in situ = 0.5-1 cm margin <1mm depth = 1 cm margin 1-2mm depth = 1-2 cm margin (with SNL) >2mm depth = 2 cm margin
|
|
|
What is MALT a precursor to?
|
gastric lymphoma - regresses with H. pylori treatment
|
|
|
What are the types of gastric ulcers?
|
Type I - lesser curve/body Type II - 2 ulcers (lesser curve and duodenum) Type III - prepyloric (w/i 3 cm) Type IV - high lesser curve/proximal Type V - anywhere a/w NSAIDS
|
|
|
What is the association between gastric ulcers and blood type?
|
Type I = blood type A; Others = type O
|
|
|
What margins are necessary for gastric cancer resection?
|
5-6cm due to intramural microscopic spread and extensive lymphatics around stomach
|
|
|
What are the effects of a terminal ileum resection?
|
Decreased bile salt absorption -> less colonic H20 absorption -> diarrhea; Decreased B12/intrinsic factor absorption; Decreased binding of oxalate -> oxalate absorbed in colon -> more oxalate stones
|
|
|
What are the symptoms of carcinoid syndrome?
|
flushing, diarrhea, asthma, R sided heart valve dz
|
|
|
What is the test for carcinoid syndrome?
|
urinalysis for 5-HTP (secreted by foregut), 5-HIAA, and serotonin
|
|
|
What factors prevent a fistula from healing?
|
FRIENDS - foreign body, radiation, IBD, epithelization, neoplasm, distal obstruction, sepsis/infection
|
|
|
What chemotherapy agents are used for carcinoid tumors?
|
Steptozocin, doxorubicin, 5 FU
|
|
|
What is the surgical treatment for a crohn's patient with multiple strictures?
|
Do not do resection (to avoid short gut) do stricturoplasties
|
|
|
What % of patients with carcinoid tumors get carcinoid syndrome?
|
9% - mostly those with extensive mets to the liver
|
|
|
What cells produce calcitonin?
|
parafollicular C cells - derived from neural crest cells
|
|
|
What is the effect of propylthiouracil (PTU)?
|
Peripherally and centrally blocks conversion of T4 to T3
|
|
|
What are side effects of PTU?
|
crosses placenta - cretinism, agranulocytosis, and liver damage
|
|
|
What drugs peripherally block conversion of T4 to T3?
|
PTU, Propanolol, Prednisone (& other steroids) and methimazole
|
|
|
What is the Wolk Chaikoff effect?
|
Reduction in thyroid hormone levels after a large ingestion of iodine - useful in thyroid storm
|
|
|
What is the main limitation of FNA in a solitary thyroid nodule?
|
Differentiation of benign vs malignant follicular and Hurthle cell neoplasms
|
|
|
What do Psammoma bodies bodies on the pathology of an FNA of a thyroid suggest?
|
Papillary thyroid cancer
|
|
|
What is the most common type of thyroid cancer?
|
Papillary
|
|
|
What % of papillary cancer present with positive nodes?
|
20% of adults, 80% of children
|
|
|
What is the population distribution of papillary thyroid cancer?
|
F:M ratio is 3:1 1/2 are before age 40
|
|
|
What does amyloid on FNA of a thyroid suggest?
|
Medullary thyroid cancer
|
|
|
What gene is associated with medullary thyroid cancer?
|
ret proto-oncogene
|
|
|
What % of patients with medullary thyroid cancer have MEN2?
|
20% (tend to be bilateral, younger, worse prognosis)
|
|
|
What is the first step in work-up of thyroid nodule after H&P?
|
FNA
|
|
|
What are the limitations of treatment of thyroid cancer during pregnancy?
|
No radioactive iodine during pregnancy or breast-feeding; Operate in second trimester if possible
|
|
|
What does the superior laryngeal nerve innervate?
|
motor to cricothyroid muscle (projection and high pitch), sensory to supraglottis
|
|
|
What does the recurrent laryngeal nerve innervate?
|
All muscle of larynx except cricothyroid
|
|
|
What is the embryologic origin of the parathyroids?
|
Superior from 4th pharngeal pouch, inferior from 3rd; both receive blood supply from inferior thyroid artery
|
|
|
What electrolyte abnormalities are present in primary hyperparathyroidism?
|
Elevated calcium, low phosphate
|
|
|
What disease is associated with osteitis fibrosa cystica?
|
hyperparathyroidism
|
|
|
What % of patients with hyperparathyroidism have a single gland adenoma?
|
85%
|
|
|
What is MEN I?
|
Wermer's syndrome - parathyroid, pancreas, pituitary (prolactinoma most common)
|
|
|
What is MEN IIa?
|
Sipple syndrome - Parathyroid, adrenal (pheochromocytoma), and thyroid
|
|
|
What is MEN IIb?
|
Thyroid, adrenal, mucosal neuromas/marfan
|
|
|
What type of cell mediates graft vs host disease?
|
T cells
|
|
|
What causes hyperacute rejection?
|
pre-formed antibodies
|
|
|
What test can identify patients who will develop hyperacute rejection?
|
Crossmatch
|
|
|
What causes acute rejection?
|
Foreign MHC antigens of graft cells
|
|
|
During what timeframe is acute rejection at highest risk to occur?
|
1 week to 3 months
|
|
|
What is the mechanism of chronic rejection?
|
Fibrosis of blood vessels of transplanted tissue - loss of blood supply
|
|
|
What is the mechanism of acute rejection?
|
Due to HLA mismatch, lymphocytic activation by foreign MHC antigens of graft cells
|
|
|
Which risk is higher in patients on immunosupression: viral or bacterial infection?
|
Viral > bacterial because immunosuppression is largely cellular and not humoral
|
|
|
What is the #1 viral infection post transplant?
|
CMV
|
|
|
What is the mechanism of azathioprine (Imuran)?
|
6MP derivative, purine analog that acts as an antimetabolite, decreases DNA synthesis
|
|
|
What is the mechanism of cyclosporine?
|
Calcineurin inhibitor - inhibits mRNA encoding of IL-2
|
|
|
What is the mechanism of mycophenolate (cellcept)?
|
blocks purine synthesis to decrease T and B cell proliferation
|
|
|
What is the mechanism of tacrolimus (FK506)?
|
Calcineurin inhibitor - blocks IL-2 expressions/production from T cells - more potent than cyclosporine
|
|
|
What is the mechanism of immunosuppression of prednisone?
|
blocks IL-1 from macrophages
|
|
|
What is the mechanism of sirolimus (Rapamune)?
|
mTOR inhibitor - inhibits the response of IL-2 thereby blocking the activation of T and B cells
|
|
|
What is the most common cause of biliary complications post liver transplant?
|
ischemia - check hepatic arterial flow
|
|
|
What is the #1 cause of oliguria s/p renal transplant?
|
ATN
|
|
|
What are the zones of the neck?
|
I - cricoid to sternum (thoracic inlet) II - angle of mandible to cricoid III - base of skull to angle of mandible
|
|
|
What is a positive DPL?
|
gross blood, or identification of food particles, bacteria, bile, >100K RBC/mm, or 500 WBC/mm
|
|
|
What are the indications for thoracotomy after chest tube placement?
|
>1500 cc blood out initially or >200 cc/hr x3 hours
|
|
|
What is the cause of petechiae, hypoxia, and confusion/agitation after a femur fracture? How is the diagnosis made?
|
Fat emboli; Sudan urine stain for fat
|
|
|
What are traumatic diaphragm injuries usually located?
|
8:1 on the left
|
|
|
What are the effects of splenectomy on the immune system?
|
decreased tuftsin, properidin, and fibronectin (non-specific opsonins), decreased IgM production - susceptible to encapsulated organisms
|
|
|
What % of patients does splenectomy improve: hereditary spherocytosis? ITP?
|
100% spherocytosis 80% ITP
|
|
|
What is the treatment for TTP?
|
plasmapheresis, not splenectomy
|
|
|
What are the physiological effects of ARDS?
|
decreased pulmonary compliance
|
|
|
How does aging affect PFTs?
|
reduces FEV1 and FRC
|
|
|
What equation describes oxygen delivery?
|
CO x O2 content = CO x Hgb x 1.3 x SpO2
|
|
|
What equation describes oxygen use?
|
CO x (CaO2 - CvO2)
|
|
|
What are the effects of PEEP on the lungs?
|
Increased FRC, increased compliance
|
|
|
What is functional residual capacity (FRC)?
|
air in lungs after normal exhalation
|
|
|
What is inspiratory capacity?
|
maximum amount of air able to be inhaled (TV + inspiratory reserve volume IRV)
|
|
|
What is vital capacity?
|
greatest volume that can be exhaled (IRV + TV + ERV)
|
|
|
What causes an increase in oxygen dissociation from hemoglobin ("right shift")?
|
increased temperature, CO2, H+, 2,3DPG (high altitude, babies)
|
|
|
What is the treatment of carbon monoxide poisoning?
|
100% O2 - reduces CO half-life from 5 hrs to 1 hr
|
|
|
What are the characteristics of silvadene?
|
good activity against candida/pseudomonas, poor eschar penetration. risk of neutropenia
|
|
|
What are the characteristics of mafenide acetate (sulfamylon)?
|
painful, can cause acidosis due to carbonic anhydrase inhibition
|
|
|
What are the characteristics of silver nitrate?
|
Can cause hyponatremia and hypochloremia due to leeching of NaCl
|
|
|
What is the #1 infection in burn patients?
|
pneumonia
|
|
|
What is a Marjolin's ulcer?
|
SCCA that develops in a chronic burn wound
|
|
|
What is the effect of EDRF (endothelium derived relaxing factor)
|
vasodilation via cGMP, increased in sepsis; nitric oxide is most common example
|
|
|
What are markers for non-seminomatous testicular cancer?
|
AFP and B-HCG
|
|
|
What is the surgical approach to biopsy a testicular mass?
|
Orchiectomy via inguinal incision. Never trans-scrotal
|
|
|
What stage seminomas get RT? Chemotherapy?
|
All stages - very radiosensitive Node + get platinum-based chemo
|
|
|
What are the long term effects of cryptorchidism?
|
increased testicular cancer, orchiopexy can increase fertility but not decrease cancer risk
|
|
|
What is the treatment of testicular torsion?
|
Bilateral orchiopexy
|
|
|
How is a urethral injury diagnosed?
|
retrograde urethrogram (RUG), do not place foley - needs suprapubic catheter
|
|
|
What is the treatment for a traumatic bladder injury?
|
Extraperitonal - a/w pelvic fx, foley only for drainage Intraperitoneal - no pelvic fx, usually dome rupture - laparotomy with multi-layer closure and foley
|
|
|
What are the most common type of kidney stones?
|
oxalate - especially after small bowel resection
|
|
|
What type of kidney stones are associated with proteus infection?
|
struvite stones, "staghorn" - proteus produces urease
|
|
|
What is the classic triad of renal cell carcinoma?
|
abd pain (capsule stretching), mass, hematuria
|
|
|
Where is erythropoetin made? What stimulates its production?
|
95% made in kidney, stimulated by hypoxia, (decreased production in ESRD)
|
|
|
What causes fever and hypertension in a renal cell carcinoma patient?
|
Increased erythropoetin - erythrocytosis
|
|
|
What is the #1 peripheral aneurysm?
|
popliteal
|
|
|
What are popliteal aneurysms associated with?
|
50% bilateral, 1/3 have AAA
|
|
|
When do you treat a splenic aneurysm?
|
If >2 cm, child bearing age, planning pregnancy, or symptomatic then resect, otherwise can just monitor
|
|
|
Bloody diarrhea POD#2 after AAA repair - what is the next step?
|
sigmoidoscopy to eval for ischemia (due to loss of IMA) - if necrosis then take to OR
|
|
|
What is the initial treatment of claudication?
|
smoking cessation, excercise, trental - not surgery
|
|
|
What is the #1 CN injury during CEA?
|
vagus nerve (clamp application) - hoarseness
|
|
|
What are the long-term effects of PID?
|
Increased risk of infertility and ectopic pregnancy
|
|
|
What is a Krukenberg tumor?
|
colon or stomach CA met to ovary - see signet cells on path
|
|
|
What is Meig's syndrome?
|
pelvic tumor -> ascites, hydrothorax
|
|
|
Rectal bleeding, irregular menses, pelvic pain, and bluish mass on proctoscopy in a female - what is the diagnosis?
|
Endometriosis involving the rectum
|
|
|
What is the treatment of endometriosis?
|
hormonal therapy
|
|
|
What is the staging of ovarian cancer?
|
I - limited to ovary II - in pelvis III - throughout abdomen IV - distant mets
|
|
|
What is a Howship Romberg sign?
|
inner thigh pain with internal rotation - indicates obturator hernia
|
|
|
What does the ileoinguinal nerve innervate?
|
sensation to inner thigh and scotum
|
|
|
What does the genitofemoral nerve innervate?
|
travels along spermatic cord to innervate cremaster muscle and scrotal skin
|
|
|
What is a spigelian hernia?
|
Hernia inferior to linea semicircularis through linea semilunaris - deep to ext oblique
|
|
|
What is a Petit's hernia?
|
Hernia through lumbar triangle (iliac crest, ext oblique, latissimus dorsi)
|
|
|
Describe the innervation to the pectoralis muscles
|
Medial pectoral nerve to pec major and minor; lateral pectoral nerve to pec major only
|
|
|
What biopsy finding in fibrocystic disease of the breast has an increased cancer risk?
|
Atypical ductal or lobular hyperplasia
|
|
|
What is the FEV1 required for a: wedge resection? lobectomy? pneumonectomy?
|
0.6L; 1L; 2L
|
|
|
What ABG values increase the risk of a lung resection?
|
pCO2 >45 or pO2 <50 at rest
|
|
|
What marks the transition between the anal canal and the rectum?
|
Levator ani
|
|
|
What is primary, secondary, and tertiary peristalsis?
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Primary - CNS initiates swallow, occurs with food bolus; Secondary - occurs with esophageal distention (propagating waves); Tertiary - non-propagating/dysfunctional
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What is the most common site of esophageal perforation?
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Cricopharyngeal muscle (usually by EGD)
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What is Mirizzi syndrome?
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Compression and/or inflammation of common hepatic duct by a stone in the infundibulum of the gallbladder causing stricture and hepatic duct obstruction
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What is the normal half-life of: RBCs? PMNs? platelets?
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RBC - 120 days; PMNs - 1-2 days; platelets - 7 days
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What is the mechanism and effect of Amrinone?
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Phosphodiesterase inhibitor - inotrope, increases CO and decreases SVR
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What is a side effect of carbapenems?
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Seizures
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What are side effects of aminoglycosides?
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Reversible nephrotoxicity, irreversible ototoxicity
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What is the mechanism of rifampin?
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RNA polymerase inhibitor
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Which antibiotic can affect platelets?
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PCNs and cephalosporins - can bind platelets and increase bleeding times
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What triggers renin release?
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Macula densa senses low Na/Cl
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What is the mechanism of malignant hyperthermia?
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Ca release from sarcoplasmic reticulum
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What does antithrombin III do?
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binds to and inhibits thrombin; inhibits factors IX, X, XI. Heparin binds this
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How do you calculate nitrogen balance?
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N balance = N in - N out = Protein/6.25 - (24 hr urine N + 4g)
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What converts natural killer cells to lymphokine activated killer cells?
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IL-2
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What is the mechanism of metronidazole?
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produces oxygen radicals that breakup DNA
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What are the effects of ketamine?
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increases cardiac work, O2 use, secretions, and BP; no respiratory distress; hallucinations possible
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What are side effects of vancomycin?
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Redman syndrome (histamine release), nephrotoxicity, ototoxicity
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What are side effects of metronidazole?
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Disulfiram-like reaction, peripheral neuropathy
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What are 3 laboratory indications of low volume, "pre-renal"
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FeNa <1, Urine Na <20, BUN/Cr >30
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What is the function of peptide YY? Where is it secreted?
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inhibits acid secretion, "ileal break"; released from terminal ileum
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How does prostate surgery affect clotting?
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Can release urokinase -> activates plasminogen -> thrombolysis
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How do sequential compression devices work?
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Improve venous return and release tPA -> induce fibronolysis
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What are the side effects of halothane?
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renal and liver toxicity
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What fractures are associated with non-union?
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clavicle, 5th metatarsal fracture
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Which organisms are carbapenems least effective against?
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MEPP: MRSA, enterococcus, proteus, pseudomonas
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What are indications for radiation to an extremity sarcoma?
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high grade, close margins, or tumor >5 cm
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What genes are associated with breast cancer?
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p53, bcl-2, c-myc, c-myb, her2neu
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What is the mechanism of ulcer formation with chronic NSAID use?
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Inhibits prostaglandin synthesis, causing decreased mucus and bicarb secretion and increased acid production
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What are the types of wounds and their respective wound infection rates?
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Clean (hernia) - 2%; Clean-contaminated (prepped colon resection) - 3-5%; Contaminated (GSW to colon with repair) - 5-10%; Gross contamination (abscess) - 30%
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What are common causes of GIB in HIV?
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Lower > Upper; Upper - Kaposi sarcoma, lymphoma; Lower - CMV, bacterial, HSV
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What is Comedo breast cancer? What is the treatment?
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Most aggressive subtype of DCIS, has necrotic areas, high risk of microinvasion and recurrence; Rx - mastectomy
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What is Paget's disease of the breast? Treatment?
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Scaly skin lesion on nipple, suggesting underlying DCIS or ductal CA; Rx - MRM if cancer present, simple mastectomy if not
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What are the indications for chemotherapy in breast cancer?
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>1 cm tumor or positive nodes (except postmenopausal women with positive estrogen receptors -> tamoxifen)
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Describe the relevant anatomy of the diaphragm
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T8 - vena cava; T10 - esophagus + vagus; T12 - aorta + thoracic duct
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When do you resect a thymoma?
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All require resection, 50% are malignant
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What do you suspect with a pansystolic murmur 2-7 days after an MI?
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Post-MI VSD
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What is the anatomy of the thoracic duct?
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Enters chest on right with aorta at T12, crosses to left at T4, then joins left subclavian at junction with IJV
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What are the types and treatment of aortic dissections?
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Stanford: A = involves ascending, always needs surgery; B = does not involve ascending, medical management unless persistent pain or end-organ ischemia
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What is the most common congenital heart defect?
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Ventricular septal defect
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Which hormones are involved in paraneoplastic syndromes of: squamous cell lung CA? small cell lung CA?
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Squamous cell - PTH-related peptide; Small cell - ACTH (most common), ADH
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What is a catamenial pneumothorax?
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PTX occurring in temporal relation to menstruation, caused by endometrial implants in visceral lung pleura
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What are the most common types of anal canal tumors?
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Squamous cell (AKA epidermal, basaloid, cloacogenic, transitional), Adenocarcinoma, and melanoma
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What is the treatment for a low T2 rectal carcinoma?
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APR or LAR (need 2cm margin from levator muscles for LAR)
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What is pyoderma gangrenosum? What is the treatment?
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Painful raised pustules on skin with necrotic center which progress to spreading ulceration - a/w IBD; Rx - local wound care, steroids, dapsone
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Which extraintestinal manisfestations of UC do not improve after colectomy?
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Primary sclerosing cholangitis and ankylosing spondylitis
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What does manometry showing normal LES tone but strong unorganized contractions suggest? What is the treatment?
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Diffuse esophageal spasm; Rx - Ca channel blockers and nitrates
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What does manometry showing increased LES pressure, incomplete relaxation, and no peristalsis suggest? What is the treatment?
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Achalasia; Rx - Ca channel blockers and LES dilation first (60% effective), if fail - Heller myotomy (LES circular muscle transection) + Nissen
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What is the most commonly injured nerve with parotid surgery?
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Greater auricular nerve - numbness over lower portion of auricle
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How does clopidogrel (Plavix) affect platelets?
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ADP receptor antagonist
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What is the most common cause of a spontaneous intestinal fistula?
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crohn's disease
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What is the most common site of GI lymphoma?
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stomach
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Which segment of the liver drains directly into IVC?
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Segment I - caudate lobe
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What is the initial treatment of GI bleeding in Mallory-Weiss syndrome?
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Observation - most cases stop with nonoperative management
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For what condition is the risk of overwhelming postsplenectomy sepsis highest?
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Thalassemia
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What is the most common cause of hypercalcemic crisis?
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malignancy
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What does the sudden onset of glucose intolerance in a patient receiving TPN indicate?
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sepsis
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What vitamin deficiency causes dermatitis, diarrhea and dementia?
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Niacin - this syndrome is called Pellegra
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What can enhance immune function in critical illness?
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arginine
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What is an effect of stored blood?
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Decreased 2,3-DPG - leftward shift of oxygen disassociation curve
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What is the pathophysiology of ITP?
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Antiplatelet IgG originating in the spleen
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What hematologic disease has the highest morbidity after splenectomy?
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Myeloid dysplasia
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What vitamin deficiency causes dermatitis, hair loss, and thrombocytopenia?
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Essential fatty acid deficiency
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What is the most common complication of heparin reversal with protamine?
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Hypotension
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What is the optimal treatment for bleeding gastric varices in chronic pancreatitis?
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Splenectomy
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What does a RQ >1 indicate? What does a RQ <0.7 indicate?
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>1 = lipogenesis (overfeeding); <0.7 = ketosis and fat oxidation (starving)
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What is fetal wound healing characterized by?
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increased hyaluronic acid synthesis
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