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391 Cards in this Set

  • Front
  • Back
Is routine hair removal recommended from incision sites?
No hair removal is preferred. The CDC guidelines for hair removal state that only interfering hair should be removed if necessary. Electric clippers cause less microscopic damage than blade razors.
Which is a longer-acting local anesthetic agent - lidocaine or bupivacaine?
Bupivacaine - 240-480 minutes

Lidocaine - 60-120 minutes
Should incisions be made parallel or perpendicular to natural lines of tension on the skin?
Incisions made parallel to natural lines of tension heal with thinner scars.
What does it mean if a needle is "swaged?"
That the needle has an already attached suture.
When would you use natural gut sutures made from sheep intestines?
For superficial vessels, or closure of tissues that heal rapidly like buccal mucosa. They tend to lose their tensile strength in just 7-10 days.
What are the advantages of closing surgical skin wounds with staples?
It allows for rapid skin closure, minimal wound inflammatory response and near-equivalent cosmetic results as compared with sutures.
Approximately 95% of abdominal aortic aneurysms begin distal to which arteries?
Renal arteries
What is the major cause of abdominal aortic aneurysm?
95% are associated with atherosclerosis. Other causes include trauma, infection, syphilis, and Marfan syndrome
What is the best initial test to diagnose an abdominal aortic aneurysm?
Ultrasound is an accurate, noninvasive way to assess the size of the aneurysm and the presence of a clot within the lumen
What is the best way to manage an abdominal aortic aneurysm smaller than 4cm in diameter?
Medical management with anti-hypertensive medications - preferably beta blockers
Surgery is indicated when an abdominal aortic aneurysm reaches what size?
5cm. 25% of aneurysms over 5cm rupture within 5 years, and surgical repair is recommended
How should asymptomatic vs. symptomatic thoracic aortic aneurysms be managed?
Symptomatic - immediate surgery
Asymptomatic - surgery is indicated if their diameter is over 5cm
When should aortic dissections be managed surgically rather than medically?
Involvement of the ascending aorta always requires surgery. Asymptomatic dissections of the descending aorta should be managed medically with anti-hypertensives and monitored closely.
What is the best technique for screening and diagnosing carotid artery stenosis?
Carotid duplex scanning is both sensitive and specific for carotid disease.
What is the standard therapy for significant carotid stenosis?
Carotid endarterectomy
What are the indications for carotid endarterectomy?
Vessels with over 75% stenosis, or 70% stenosis with symptoms or bilateral disease with symptoms or 50% stenosis with recurrent TIAs despite aspirin therapy
Which two nerves must the surgeon be careful not to damage in the carotid endarterectomy procedure?
Hypoglossal nerve and the spinal accessory nerve
What is the typical presentation for acute mesenteric artery disease?
Abdominal pain that is sudden in onset and severe with diarrhea or vomiting. Also described as pain that is out of proportion to the physical exam findings.
What is the typical presentation of chronic mesenteric ischemia?
A crampy abdominal pain after eating
In which vessels would you suspect atherosclerosis in a patient complaining of buttock claudication? What about in a patient with calf claudication?
Buttock - aortoilliac atherosclerosis
Calf - femoral atherosclerosis
What are the 5 p's of peripheral vascular disease?
Pulselessness
Pallor
Poikilothermia (coolness)
Pain
Paresthesias
What disease should you suspect if a patient has loss of hair, wasting of musculature and thickened nails on the left foot?
Chronic peripheral vascular compromise
What is the recommended therapy for a patient with chronic peripheral vascular disease?
Smoking cessation and other risk factor modification and a good exercise program
What is the most common breast malignancy?
Ductal carcinoma
Name some breast lesions that are not associated with increased risk of breast cancer-
Simple cysts
fibroadenomas
fibrocystic change
papillomas
What is the most common breast tumor in young women?
Fibroadenoma - not associated with malignancy
What is the most common cause of bloody nipple discharge?
Intraductal papilloma - not associated with malignancy
A woman complains of a breast mass that seems to fluctuate with her menstrual cycle. Is this a sign of malignancy?
No, this is more typical of simple cysts, and not malignancy
What are some physical exam findings that are very sensitive for breast malignancy?
Asymmetry, dimpling, retractions, and excoriation or edema of the skin.
What are the two main treatment options for ductal carcinoma in situ (DCIS) of the breast?
1. Local incision with negative margins followed by radiation
2. Mastectomy without radiation
What is the significance of knowing whether a breast malignancy expresses estrogen and progesterone receptors?
Tumors that express the estrogen receptor have a 30% chance of responding to hormone therapy (aromatase inhibitors or tamoxifen) and a 70% chance if they also express the progesterone receptor.
What are the typical complaints of a patient with ulcerative colitis?
Bloody diarrhea, fever, abdominal pain, weight loss.
What are indications for surgery in a patient with ulcerative colitis?
Colonic obstruction, massive blood loss, failure of medical therapy, toxic megacolon, and cancer.
What is the most common cause of lower GI hemorrhage?
Diverticulosis - usually from the right colon
What are diagnostic modalities in patients with active bleeding diverticula?
Mesenteric angiography and radioisotope bleeding scans. Colonoscopy should not be performed during active bleeding or inflammation.
What is the typical presentation for diverticulitis?
Pain that is progressive over a few days and may be associated with diarrhea or constipation.
What are the diagnostic strategies for acute diverticulitis?
WBC usually elevated.
CT may demonstrate pericolic fat stranding, bowel wall thickening or an abcess.
Colonoscopy or barium enema should not be performed, and plain abdominal film is usually normal.
What are the possible complications of diverticulitis?
Stricture formation, perforation, or fistulization
When is surgical intervention indicated in diverticulitis?
In the presence of complications like strictures, fistula, or perforation, or after a second attack because risk of subsequent attacks and complications increases after a second attack.
Which have a higher malignant potential- colonic polyps with a more villous or tubular component?
The higher the villous component, the higher the risk of malignancy.
When should screening for CRC begin and what is the recommended schedule of exams?
Begin at 50yo, or 40 for increased risk patients.
Yearly fecal occult blood test
Sigmoidoscopy every 3-5 years, colonscopy or barium enema every 10 years
According to the Duke classification of CRC staging, at what stage is a tumor that invades through the muscularis propria into the pericolic or perirectal tissues?
T3
Classically, how do tumors or the right colon present compared to tumors of the left colon?
Right colon lesions usually cause bleeding that is more significant whereas lesions in the left colon typically present with obstructive symptoms.
What is the most common site of metastasis for CRC?
Liver - so LFTs should be checked if CRC is found.
During a colectomy, special care must be taken to avoid damaging which structures?
Ureters. A ureteral stent may be placed preoperatively to help identify the location of the ureters during surgery.
In which part of the colon is angiodysplasia most commonly found?
The cecum and right colon
How is colonic angiodysplasia commonly diagnosed?
Arteriography, nuclear scans or colonoscopy
What treatment options should be considered in an elderly patient with significant blood loss due to angiodysplasia?
Endoscopy with laser ablation, electrocoagulation or angiography with vasopressin is often effective, but many require segmental colectomy.
Which parts of the colon are most susceptible to volvulus?
Sigmoid (75%) and cecum (25%) because of their relative redundancy.
What percent of people will develop acute appendicitis over their lifetime?
About 10%
A patient complains of acute epigastric pain that migrated to the lower right quadrant and now presents as generalized abdominal tenderness. This history is suggestive of what pathology?
Appendicitis that may have ruptured.
What is the most common reason for urgent abdominal operation?
Appendicitis
What diagnostic modality is used to differentiate a pituitary microadenoma from a macroadenoma?
MRI
What is the indication for surgery in a patient with a prolactinoma?
When symptoms occur, medical therapy with drugs like bromocriptine or cabergoline should be initiated. If this fails to relieve symptoms, transphenoidal surgery is indicated.
How is growth hormone hypersecretion diagnosed?
Serum GH levels are elevated and not suppressed by insulin challenge.
In which decades of life are pheochromocytomas most prevalent?
3rd and 4th decades
Slight female preponderance
Which MEN syndromes are associated with pheochromocytoma?
MEN IIa and MEN IIb
Nuclear medicine scan with which molecule is an effective way to find extra-adrenal pheochromocytomas?
Metaiodobenzylguanidine
How is diagnosis of pheochromocytoma usually made?
Urine examination for catecholamines and catecholamine metabolites (metanephrine, normetanephrine, vanillylmandelic acid)
What three tumors are common to the MEN I syndrome?
Parathyroid hyperplasia (90%)
Pancreatic islet cell tumor (50%)
Anterior pituitary adenoma (25%)
What three tumors are common to the MEN IIa syndrome?
Medullary Thyroid Carcinoma
Pheochromocytoma
Parathyroid hyperplasia
What three tumors are common to the MEN IIb syndrome?
Medullary Thyroid Carcinoma
Pheochromocytoma
Mucosal neuroma
Is the left or right vagal trunk found on the anterior side of the esophagus?
Left - anterior
Right - posterior
Which form of esophageal cancer is most prevalent in the US? Worldwide?
US - squamous cell carcinoma
Worldwide - Adenocarcinoma
What are common causes of esophageal perforation?
Iatrogenic (instrumentation)
Foreign bodies or trauma
Boerhaave syndrome (vomiting)
What two ducts join together to make the common bile duct?
Cystic duct
Common Hepatic duct
What is the triangle of Calot, and what three structures make up its borders?
The cystic artery courses through the triangle of Calot.
Its borders are the cystic duct, the common hepatic duct, and the edge of the liver.
What are the most common organisms cultured during an episode of acute cholecystitis?
E coli
Klebsiella
enterococci
Bacteroides
Pseudomonas
How are the urine and stool of a patient affected with choledocholithiasis?
Patients may relate episodes of passing dark urine or light-colored stool
What lab values are commonly elevated in...
Acute cholecystitis?
Choledocholithiasis?
Cholangitis?
Cholecystitis - WBC
Choledocholithiasis - Bilirubin and Alk. Phos.
Cholangitis - Bilirubin and Transaminases
What signs on ultrasound indicated acute cholecystitis?
Fluid around the gallbladder, a thickened wall and gallbladder distention.
What diagnostic test best identifies stones in the CBD?
ERCP
Stones are found in the gallbladder of an asymptomatic patient on ultrasound. What is the incidence of symptoms or complications per year?
About 2% chance of symptoms or complications per year
What is the immediate treatment for a patient with acute cholecystitis?
Resuscitation with fluids and treatment with broad spectrum IV antibiotics followed by laparoscopic cholecystectomy if the patient has no contraindications to surgery.
What is the treatment plan for a patient with gallstone pancreatitis?
Fluid resuscitation and observation. Antibiotics only in severe cases. Cholecystectomy once inflammation subsides. ERCP if choledocholithiasis is suspected.
What is the primary intervention for a patient with cholangitis?
IV antibiotics and ERCP with sphincterotomy
What is the usual presentation for a patient with cancer of the gallbladder?
Patients usually present with vague right upper quadrant pain. Weight loss and anorexia may also be present.
In most people, the posterior descending artery arises from which other coronary artery?
RCA in 90% of people.
Which blood vessels are commonly chosen to use as grafts in a CABG?
Internal mammary arteries or saphenous veins
What are the surgical indications (CABG) for patients with coronary artery disease?
Severe disease of the left main artery, proximal LAD, or disease in all three main vessels
What are the indications for aortic valve replacement?
Symptomatic aortic stenosis or regurgitation, or asymptomatic patients with progressive cardiomegaly due to aortic stenosis.
Which valvular disease classically presents with an opening snap?
Mitral stenosis.
The OS is followed by a low rumbling murmur
Which is more common - mitral stenosis or regurgitation?
Mitral regurgitation is more common and has a male predominance
What is the medical therapy for mitral regurgitation, and when is surgery indicated?
Afterload reducing agents - usually ACE inhibitors.
Surgery indicated if symptomatic CHF develops, if LV dialation or pulmonary hypertension develops or if AF develops.
What percent of people in the US will have an inguinal hernia repair during their lifetime?
5%. Half of hernias are indirect inguinal and 1/4 are direct.
What developmental defect predisposes to indirect inguinal hernias?
Failure of the processus vaginalis to obliterate
Where do you expect to see the ureters crossing the iliac arteries?
At the bifurcation of the internal and external iliac arteries
What dietary factors are risk factors for kidney stones?
Low fluid intake
High salt
High intake of animal protein
Low-calcium diets
What would you expect to see on urinary sediment in a patient with kidney stones?
Hematuria
Crystals - depending on the composition of the stones
What drugs should be given to a patient in the acute setting with a kidney stone?
Pain and nausea should be controlled with narcotics and antiemetics
Renal stones up to what diameter can be expected to pass spontaneously?
Stones less than 5mm usually do not require intervention.
What is the usual treatment for a patient with renal cell carcinoma?
Radical nephrectomy is usually the intitial treatment. Chemotherapy is offered to patients with metastatic disease but has disappointing results.
What imaging study is indicated to differentiate a cystic liver mass from a solid tumor?
Ultrasound usually works
What are common risk factors for developing hepatocellular carcinoma?
Cirrhosis - usually caused by hepatitis B or alcohol.
Also aflatoxins, hemochromatosis, smoking, vinyl chloride, oral contraceptives
What are the most common cancers that metastasize to the liver?
1. Lung
2. Colon
3. Pancreas
4. Breast
5. Stomach
When is surgical resection of hepatic metastases indicated?
Only when colon cancer is the metastatic tumor, and only when there are three metastatic sites or less. Resection of all other tumors are not recommended.
Is hepatocellular carcinoma more common in the US, or worldwide?
Hepatocellular carcinoma is one of the most common malignancies worldwide but is rare in the US (2 in 100,000)
Where in the body do you find the coronary vein?
The coronary vein drains the stomach and esophagus and empties into the portal vein. It is through the coronary vein that portal hypertension causes esophageal varicies.
AKA - left gastric vein
Name some physical exam findings of patients with portal hypertension-
Ascites, jaundice, spider angiomas, testicular atrophy, gynecomastia, palmar erythema
What two blood vessels are connected by a transjugular intrahepatic portosystemic shunt?
Hepatic vein and portal vein
What percentage of patients with a carcinoid tumor present with carcinoid syndrome?
Only 3%. The tumor must metastasize to the liver to produce the syndrome.
Which is more common - small cell or non-small cell carcinoma of the lung?
Small cell (20-25%)
Non-small cell (75-80%)

NSCLC is further divided into squamous cell (30%), adenocarcinoma (35%) and large cell (10%)
What invasive tests are usually required for definitive diagnosis of lung cancer?
Flexible bronchoscopy with biopsy or BAL,
Transthoracic CT-guided fine-needle biopsy,
Mediastinoscopy with LN biopsy
What is the usual treatment for small cell lung cancer?
SCLC is usually widely disseminated at the time of diagnosis, so surgery is rarely indicated. Chemotherapy (cisplatin and etoposide) and radiotherapy is usually indicated
If patients have favorable responses to small cell lung cancer chemotherapy, what step is recommended to decrease the chance of cerebral metastasis?
Prophylactic whole-brain radiation. 50% of untreated patients will develop brain metastasis.
What is the standard care for patients with non-metastatic non-small cell lung cancer?
Surgery (lobectomy) followed by chemotherapy
What is the approximate 5-year survival rate for lung cancer?
Just over 10%
From what tissue is mesothelioma most commonly derived?
Visceral pleura
When is a chest tube indicated for a simple pneumothorax?
When it is greater than 20% or if it increases in size during observation.
What is the immediate intervention for a tension pneumothorax? What is the more definitive treatment?
Immediate - Needle thoracostomy in midclavicular line 2nd intercostal space
More definitive - tube thoracostomy 5th intercostal space anterior axillary line.
How is empyema usually treated?
Tube thoracostomy and antibiotics
What lab findings suggest empyema when fluid is aspirated from the pleural space?
High WBC count, mostly neutrophils
Low pH
Low glucose
High LDH
Which area of the prostate undergoes cellular hyperplasia in BPH?
The transitional zone, or periurethral area of the prostate.
What are possible complications to watch for after a diagnosis of BPH?
UTIs
Formation of bladder calculi
Hydronephrosis
Renal failure
What is the next diagnostic step if a patient has an abnormal rectal prostate examination or elevated PSA level?
Transrectal ultrasonography
What medications are used to treat BPH?
Alpha blockers to relax smooth muscles
5-alpha reductase inhibitors to block the conversion of testosterone to DHT
What are indications for surgery in a patient with BPH?
Postvoid residual volume over 100mL, chronic urinary retention with overflow dribbling, gross hematuria on multiple occasions, recurrent UTIs
From which cells of the prostate does most prostate cancer arise?
95% of prostate cancer is adenocarcinoma, and tumors arise from gladular epithelium in the peripheral zone of the prostate.
How does metastatic prostate cancer usually present?
Bony pain or ureteric obstruction
What pathology is evaluated by the Gleason score?
Prostate cancer staging. A 2-10 scale with well differentiated tumors getting low scores and poorly differentiated tumors getting high scores.
What is the treatment for metastatic prostate cancer?
Hormonal ablation, since most cancers are hormonally sensitive. This can be achieved by pharmacology or bilateral orchiectomy
What are the treatment options for localized prostate cancer?
Radical prostatectomy, external-beam radiotherapy, interstital irradiation with implants
Which testicular tumors are generally more malignant - seminomas or non seminomatous germ cell tumors (NSGCTs)?
Non seminomatous germ cell tumors exhibit greater malignant behavior and metastasize earlier.
Do seminomas usually produce b-HCG, AFP, both, or neither?
Neither b-HCG nor AFP
What is the developmental defect usually present that leads to torsion of the testicle?
An abnormally high attachment of the tunica vaginalis around the distal end of the spermatic cord
What are the two diagnoses that should be considered when a patient presents with an acutely swollen, tender testicle?
Torsion of the spermatic cord and advanced epididymitis
When clinically suspected, how is diagnosis of testicular torsion usually confirmed?
Testicular torsion is evaluated by Doppler ultrasound to differentiate from epididymitis
From what cell is glioblastoma multiforme derived?
Astrocyte
Where are most intracranial tumors seen in children?
Infratentorial posteror fossa tumors - cerebellum
What are the five most common tumors that metastasize to the brain?
Lung, breast, skin (melanoma), kidney, colon
What tumors are known as butterfly gliomas?
Glioblastoma multiforme tumors because they can track across the corpus callosum.
What type of hemorrhage is typically described as "the worst headache of my life?"
Subarachnoid hemorrhage - usually caused by intracranial aneurysm
What is an alternative diagnostic method in a patient highly suspected to have a subarachnoid hemorrhage whose CT is negative?
Lumbar puncture. Four vessel cerebral angiography is then performed to define the aneurysm neck
What is the immediate treatment of patients with subarachnoid hemorrhage?
Control of hypertension with IV medications and administration of phenytoin as prophylactic treatment for seizures.
Where are intracranial aneurysms most commonly found?
At the arterial branch points within the circle of Willis
Which intracranial bleeds classically appear as lens shaped on CT?
Epidural hematoma
Why are patients with epidural hematomas at risk for respiratory failure?
Brainstem herniation impairs the respiratory centers.
What signs on physical exam suggest that there is danger of respiratory failure in patients with epidural hematoma?
GCS score <8
Unilateral dilated pupil indicates brainstem herniation
Bilateral fixed dialated pupils signal impending respiratory failure and death
Which surgical procedure is performed in an emergency if an epidural hematoma must be stopped?
Emergency decompresssion. A burr hole is drilled over the site of hematoma. The middle meningeal artery bleeding is controlled.
Bleeding from which vessels cause subdural hematomas?
Bridging veins that drain blood from the brain into the superior sagittal sinus
What are signs of cauda equina syndrome?
Urinary retention or overflow incontinence, bilateral sciatica, perineal numbness and tingling.
What three classes of immunosuppressive drugs are commonly used during organ transplantation procedures?
Calcineurin inhibitors (tacrolimus or cyclosporine)
Steroids
Antimetabolites (mycophenolate mofetil)
What is the half-life of a cadaver kidney vs one from a live donor?
Cadaver - 10 years
Live - 30 years
On which side of the body is it easier to place a renal transplant?
On the right side as the right iliac vein is more accessible than the left for anastomosis.
What is the major complication of anular pancreas?
Duodenal obstruction
What nerves are responsible for transmitting pain of pancreatic origin and can be cut to relieve pain?
Sympathetic innervation is responsible for transmitting pain of pancreatic origin. In patients with intractable pain from chronic pancreatitis, sympathectomy can be performed.
What are the two major cell types of the exocrine pancreas and what substances do they produce?
Ductal cells - a clear basic-pH solution of water and electrolytes
Acinar cells - pancreatic digestive enzymes
Which pancreatic enzymes are secreted in active form, and which are secreted as inactive precursors?
Active - amylase and lipase
Inactive - proteases
Where do you find the duct of Wirsung and the duct of Santorini?
Pancreas. The duct of Wirsung drains the mature pancreas to the ampulla of Vater. Occasionally, a duct of Santorini drains through a separate minor papilla.
Alcoholism and gallstones cause 80-90% of acute pancreatitis. What are other less common etiologies?
Hyperlipidemia, hypercalcemia, trauma, infection, ischemia, ERCP.
And Scorpions!
What other causes of acute epigastric pain may be confused with acute pancreatitis?
Peptic ulcer disease, acute biliary tract disease, acute intestinal obstruction, acute mesenteric thrombosis, leaking abdominal aortic aneurysm
Which is more sensitive for acute pancreatitis - elevated lipase or amylase?
Elevated lipase levels are specific
Besides elevated amylase and lipase, what lab values indicate acute pancreatitis?
Leukocytosis >10,000
Hyperglycemia
Hypocalcemia
What evidence of acute pancreatitis may be present on a chest X ray?
Routine chest x-ray may reveal a left pleural effusion known as a sympathetic effusion secondary to peripancreatic inflammation.
What is the most sensitive radiologic study for confirming the diagnosis of acute pancreatitis?
CT. Patients show evidence of either parenchymal or peripancreatic edema and inflammation.
What are the five Ranson criteria for acute pancreatitis on admission?
Age>55
WBC>16,000
Serum glucose>200
Serum LDH>350
SGOT>250
What are important early treatments of acute pancreatitis?
IV fluids and NPO
When is acute pancreatitis treated surgically?
Only complications such as chronic pseudocyst, abscess, necrosis or hemorrhage
What is the clinical picture of chronic pancreatitis?
Recurring or persistent upper abdominal pain with evidence of malabsorption, steatorrhea, and diabetes
What is the most accurate means of diagnosing chronic pancreatitis?
ERCP because it clearly defines the pathologic changes of the ductal system and biliary tree. US and CT are useful initial imaging procedures
What is the surgical treatment of choice for a patient with "chain of lakes" appearing pancreatic duct caused by ductal scarring and dialation in chronic pancreatitis?
A longitudinal pancreaticojejunostomy - pancreatic duct is sutured longitudinally to the proximal jejunum.
What is the indication for a Whipple procedure and briefly describe the technique-
Used for carcinoma of the head of the pancreas.
1. Head of pancreas removed
2. Tail of pancreas and CBD sutured to duodenum
3. Antrum of stomach sutured closed and the body is sutured to the proximal jejunum.
What are typical complaints of a patient with pancreatic cancer?
Obstructive jaundice
Weight loss
Constant deep abdominal pain
What are the modalities of choice for evaluating cancer of the pancreas?
CT and ERCP
CT reveals the location and extent of invasion
ERCP defines the ductal anatomy
What is the 5-yr survival rate of pancreatic cancer with and without a Whipple procedure?
Without Whipple - 3%
With Whipple - 10-20%
What is the Courvoisier sign and what pathology does it indicate?
Jaundice and a nontender palpable gallbladder, indicating tumor obstruction of the distal common bile duct
Are presenting bilirubin levels higher in malignant biliary obstruction or obstruction due to gallstones?
Much higher in malignant biliary obstruction
Do patients have better survival with tumors of the pancreatic head or tail?
Head, because obstructive symptoms cause it to be diagnosed at an earlier stage. Cancer of the tail is invariably fatal.
What is the arterial supply to the four parathyroid glands?
Inferior thyroid artery supplies them all
Describe the pathophysiology of secondary hyperparathyroidism-
Usually seen in patients with renal disease. Hyperphosphatemia causes depression of serum ionized calcium and hypocalcemia causes excess PTH.
Which MEN syndromes are associated with hyperparathyroidism?
MEN I and MEN IIa
What two risk factors predispose a person to hyperparathyroidism?
Childhood radiation exposure and family history of MEN syndromes
What is the most common overall cause of hypercalcemia?
Osseous metastatic disease
What is the initial treatment for a patient who presents in a hypercalcemic crisis (coma, delirium, anorexia, vomiting, abdominal pain)?
Vigorous IV hydration and calciuresis with furosemide
What are the preferred methods of localizing a parathyroid tumor?
Technetium(Tc)-sestamibi scanning
Which is the most common form of skin cancer? Which is the most malignant?
Basal Cell Carcinoma - most common
Melanoma - most malignant
What histological factor is most predictive of survival in patients with melanoma?
Tumor thickness is inversely related to survival and is the single most important prognostic indicator
What are the most common sites of metastasis for melanoma?
Lung, brain, bone, and GI tract
What are the ABC's (and D,E) of identifying melanoma?
The five signs of melanoma are
Asymmetric shape
Borders irregular
Color mottled
Diameter
Evolution of lesion, or enlargement
What are some risk factors for developing squamous cell carcinoma besides sunlight exposure?
Tobacco use, HPV, Old burns or sites of chronic infection
What are the two most common causes of small bowel obstruction?
Adhesions and hernias
Classically, what condition is described as sudden, intense abdominal pain out of proportion to physical exam findings?
Ischemic bowel - a clear indication for urgent surgical exploration
What is the typical radiographic finding of small bowel obstruction?
Distended loops of small bowel with multiple air-fluid interfaces
What should the initial treatment be for small bowel obstruction
Nasograstric decompression and fluid resuscitation to restore fluid lost from vomiting
What are some complications of Crohn's disease that may be an indication for surgery?
Fistula
Abscess
Perforation
Bleeding
What are some extraintestinal manifestations of Crohn's disease?
Erythema nodosum
Pyoderma gangrenosum
Anklyosing spondylitis
Uveitis
What method of closing incisions in the bowel reduces the chance of strictures?
Making longitudinal incisions and closing them transversely.
What is the most common cause of rectal bleeding under the age of 2?
Meckel diverticulum
What complications should be considered in a patient with a Meckel diverticulum?
Bleeding
Obstruction - due to intussusception or volvulus
What is a good diagnostic procedure for Meckel diverticulum?
Technetium 99 scan for diverticula with heterotrophic gastric mucosa.
Barium-contrast studies for diverticula without gastric tissue.
Should an asymptomatic Meckel diverticulum be prophylactically removed?
No, if they are found incidentally, they should be left alone
What are the two main ways that Carcinoid tumor can present?
As small bowel obstruction by the primary tumor, or carcinoid syndrome (flushing, diarrhea, sweating, wheezing) if it metastasizes to the liver
What are surgical and non-surgical therapies for carcinoid tumor?
Surgical - Resection of the primary tumor is always indicated
Carcinoid syndrome can be symptomatically relieved by somatostatin analogues (octreotide)
What structure defines the boundary between the duodenum and jejunum?
Ligament of Treitz
Into which portion of the duodenum does bile usually enter through the papilla of Vater.
Second part of the duodenum (descending)
Under which conditions are peptic ulcers treated surgically?
Perforations, massive bleeding, gastric outlet obstruction.
What is the most common histologic type of cancer in the stomach and in which part of the stomach is it most commonly located?
Adenocarcinoma, most likely located in the antral prepyloric region
What are physical exam findings suggestive of metastatic gastric cancer?
Virchow's supraclavicular node
Sister Mary Joseph umbilical node
Blumer shelf on rectal exam
What is the next step if a gastric ulcer is seen on endoscopy?
At least four biopsies should be taken from each quadrant of the lesion
If biopsy of a gastric ulcer comes back positive for adenocarcinoma, what should the next step be?
CT for staging
Which is the preferred surgery for gastric cancer in the distal stomach- Billroth I or Billroth II? What is the difference?
Billroth II.
Billroth I resects the antrum and anastamoses it to the duodenum.
Billroth II resects the antrum and anastamoses it to the jejunum
What are the typical surgical procedures of choice for gastric cancer of the proximal stomach vs. distal stomach?
Proximal - Total gastrectomy with Rou-en-Y esophagojejunostomy
Distal - Billroth II surgery
What is the most common indication for splenectomy?
Hemorrhage secondary to trauma
What are the treatment options for Immune Thrombocytopenic Purpura?
Most patients do not respond to steroid treatment alone and splenectomy is typically indicated
What are the typical pathogens that cause Postsplenectomy sepsis?
Encapsulated bacteria like S pneumonia, H influenza, N meningitidis
What structure does the right recurrent laryngeal nerve loop around? What about the left?
Right - right subclavian artery
Left - arch of the aorta
Name three treatment options for Graves disease-
Antithyroid medication - PTU
Radioiodine ablation
Surgical excision
Which patients with Graves disease is surgical resection most appropriate for?
Patients with contraindications to radioactive iodine therapy or unable to tolerate or respond to PTU. Children and young adults are the majority of such patients
What are significant complications of thyroid surgery?
Recurrent laryngeal nerve damage with vocal cord paralysis
Permanent hypothyroidism
Surgical hypoparathyroidism
What is the incision line during a thyroidectomy?
Curvilinear necklace incision extending to the sternocleidomastoid muscles bilaterally
What is the typical presentation of thyroid cancer?
Asymptomatic painless thyroid nodule on routine physical examination
What are the appropriate steps to workup a painless thyroid nodule?
Thyroid function tests
FNA (most important)
Ultrasound to evaluate whether the nodule is solid or cystic
What are the four types of thyroid cancer? Which is the most malignant?
Papillary (least malignant)
Follicular
Medullary
Anaplastic (most malignant)
What physical findings suggest tension pneumothorax?
Hypotension
Tachycardia
Tracheal deviation
Neck vein distension
Diminished unilateral breath sounds
What is the method for definitive treatment of tension pneumothorax?
Chest tube insertion into the fifth intercostal space at the anterior axillary line (just lateral to the nipple)
How can the fluid status of a patient be evaluated by physical exam?
Assess hemodynamics - hypotension, tachycardia
Level of consciousness
Color of Skin
Character of pulse - thready
What three standard radiographs need to be ordered for all blunt trauma patients?
Cervical spine
AP chest
AP pelvis
What is the initial treatment for a patient with a chemical burn in the eye?
Copious irrigation with any available water source for at least 15-20 minutes
What is delayed primary closure?
Sutures are left untied between the wound edges and left untied for several days. This method is chosen if the wound is contaminated or requires a brief period of debridement
Which cruciate ligament is likely damaged if there is an anterior drawer sign on knee examination?
ACL
Which is the best diagnostic imaging test for evaluating a rotator cuff injury?
MRI is most sensitive and specific
How do patients with ankylosing spondylitis typically describe their back pain?
It is usually worse in the morning and improves with exercise
What is the imaging test of choice for establishing spinal disk prolapse?
MRI
What are indications for surgical treatment of a spinal disk prolapse?
Indications for surgery include muscle weakness, bowel or bladder dysfunction, incapacitating pain
What is the 1 year mortality after a hip fracture?
50%
Which complications of surgery are reduced by early mobilization after surgery?
Venous thromboembolism
Pneumonia
Speed the return of bowel function
Besides infection, what are other post-operative sources of fever?
Atelectasis, DVT, transfusion reaction, drug reaction, tumor, PE
What is the best way to evaluate adequate fluid administration in a patient after surgery?
Urine output should be at least 30cc per hour
How long after ingesting food can the stomach be considered empty of contents?
Patients with normal gastric motility require more than four hours to empty the stomach of solid matter
What are the steps of rapid-sequence intubation
1. Administration of 100% O2
2. IV anesthetic agent
3. IV succinylcholine
4. Cricoid pressure
5. Tracheal intubation
How should anesthesia be achieved in patients with a history of malignant hyperthermia?
Total IV anesthesia and regional anesthesia
How should a patient on metformin have their glucose managed during surgery?
Metformin should be discontinued 12-24 hours before surgery because it increases the risk of lactic acidosis. Glucose levels should be controlled with insulin
What is IV PCA?
Patient controlled analgesia
A device attached to the patients IV line that allows administration of opioids to be controlled by the patient
Which anesthetic agents should be avoided in patients with known pseudocholinesterase deficiency?
Succinylcholine
Mivacurium (neuromusclar relaxant)
Ester anesthetics (cocaine, procaine, tetracaine)
Which common medical problems or conditions adversely affect wound healing?
DM
Cardiovascular disease
Immunocompromised states
Used of immunosuppressants
What are the four classic stages of wound healing?
Hemostasis
Inflammatory
Proliferation
Remodeling
What are the four types of lower extremity ulcers?
Arterial
Venous
Diabetic
Pressure
What is the appropriate management for diabetic ulcers?
Debridement of devitalized tissue
Tissue cultures and treatment of infection
Assessment for underlying osteomyelitis
Accommodative footwear that promote healing
How does negative pressure wound therapy accelerate wound healing?
The absorbent system removes exudate and increases perfusion to the wound by opening the capillary bed. Interstitial edema is also removed
What are common mammographic signs of malignancy?
Stellate or dominant masses
Skin thickening or retraction
Microcalcifications
What is the next step if abnormalities are seen on mammography?
Ultrasound and biopsy (stereotactic core biopsy (SCB) or needle localized breast biopsy (NLB))
What percentage of DCIS progresses to ductal invasive carcinoma if left untreated?
20-30%
What are the two options for a patient diagnosed with DCIS?
Total mastectomy or
Lumpectomy with radiation
Which nerves are at risk for damage during axillary lymph node dissection?
Intercostal brachial nerve
Long thoracic nerve
Thoracodorsal nerve
What is the most aggressive form of breast cancer?
Inflammatory cancer of the breast. Multiagent adjuvant chemotherapy is indicated before surgery (this modality has reduced 5yr survival from 5% to 50%)
What is the most specific and sensitive test for diagnosing GERD?
24-hr pH monitoring. pH electrode is placed 5cm above the LES. A normal study rules out GERD
What foods should be removed from the diet of a patient with GERD?
Mint, chocolate, coffee, alcohol

Diet should be low in fat, and patients should stop smoking
Should all patients with Barrett's esophagus have an esophagectomy?
No, only those with high grade dysplasia on histological examination
What are the two most common symptoms of esophageal cancer?
Dysphagia and weight loss
Once esophageal cancer is diagnosed, what is the role of CT scan and endoscopic ultrasound?
CT - can identify distant metastases
EUS - stages the tumor by visualizing the layers of the esophagus and the surrounding lymph nodes
Which layer of the GI tract is missing in the esophagus?
The serosa.
The esophagus is composed of the inner epithelial layer and muscular layer but no outer serosa
What is most commonly used to replace the esophagus during esophagectomy?
Most commonly the stomach is reconstructed and moved up into the thorax. A colonic conduit (usually the left colon) can also be used.
What three imaging studies should be performed when evaluating a patient for esophageal cancer?
Esophagoscopy with biopsy
EUS for staging
CT for distant metastases
What is the differential diagnosis for epigastric pain?
PUD, gastritis, pancreatitis, pancreatic cancer, abdominal aortic aneurysm, early appendicitis, gastroenteritis, ischemic heart disease
What is the recommended surgical procedure for a bleeding peptic ulcer?
Oversewing the bleeding ulcer followed by vagotomy and pyloroplasty
What is the recommended procedure for a perforated duodenal ulcer?
Closed with an omental patch (or Graham patch)
What are the major complications of the vagotomy with pyloroplasty procedure?
Dumping syndrome due to lack of pyloric regulation
Alkaline reflux gastritis of alkaline bile into the stomach
Maybe postvagotomy diarrhea
Why do endoscopic biopsies often fail to detect gastric lymphoma?
Because lymphomas are submucosal
What are the three most common types of cancer found in the stomach?
Adenocarcinomas
GIST
Primary gastric lymphoma
What is Blumer's shelf?
An extraluminal mass palpable during a rectal or pelvic exam resulting from peritoneal metastases from a GI malignancy to the pelvic cul-de-sac
What artery does the left gastric artery arise from?
Right gastric?
Left gastric - celiac trunk
Right gastric - hepatic artery
Which arteries supply the greater curvature of the stomach?
The right and left gastroepiploic arteries
What is the role of chemotherapy and radiation in gastric cancer?
Routine use of adjuvant chemotherapy has not proven beneficial. It is also a relatively radioresistant tumor and radiation offers no proven benefit
What is the recommended diet for a patient with dumping syndrome?
Small, frequent low-carbohydrate, high-protein meals
Why were the diet pills phentermine and phenformin pulled off the market?
They were associated with a high incidence of cardiac valvular disease and pulmonary hypertension
What is currently the gold standard procedure for obesity surgery?
Roux-en-Y Gastric bypass
What are the noteworthy complications of gastric bypass?
Hernias (16%)
Marginal ulcers (13%)
Stomal stenosis (15%)
Wound infections (4%)
Anastamotic leak (1.2%)
What BMI qualifies as a clinical indication for obesity surgery?
>35kg/m2 with a severe obesity related comorbidity
or >40kg/m2
Besides hernia and adhesions, what are other causes of small bowel obstruction?
IBD, diverticulitis, gallstone illeus, bezoars
Why should you test for rectal bleeding in a patient with suspected small bowel obstruction?
It is an early indication of ischemic bowel - the mucosal layer is most susceptible to ischemia and may bleed before total thickness injury occurs
Are bowel sounds hyperactive or hypoactive in small bowel obstruction?
In early obstruction, bowel sounds are hyperactive, but as the bowel distends, there is inhibition of bowel motility and a quieting of bowel sounds.
What are the first treatments for small bowel obstruction?
NG tube decompression
Aggressive IV fluid resuscitation
How can complete bowel obstruction be differentiated from partial bowel obstruction?
In partial obstruction, there's passage of flatus and radiographic evidence of gas and stool in the colon
What acid - base disturbance is expected in a patient with a nasogastric tube?
Metabolic alkalosis
What is the lifetime rate of bowel obstruction due to adhesions after a laporotomy?
About 5%
What gynecologic problems can mimic the pain of acute appendicitis?
PID, ectopic pregnancy, ovarian cyst rupture, Mittelschmerz (midcycle pain), ovarian torsion, ovarian vein thrombosis
What non-gynecologic problems can mimic the pain of acute appendicitis?
Crohn disease, right colon diverticulitis, cholecystitis, perforated ulcer, renal or uretral stone
What clinical features distinguish PID from appendicitis?
PID: longer duration of symptoms, accompanied by nausea and vomiting
Cervical motion tenderness (chandelier sign)
Where is McBurney's point?
1/3 the distance between the anterior spinous process of the ilium to the umbilicus
When should radiographic imaging be employed in the diagnosis of appendicitis?
When the presentation is atypical. If the presentation is typical, CT or ultrasound should be bypassed for emergent surgery.
In children, what two conditions most commonly mimic appendicitis?
Gastroenteritis
Mesenteric lymphadenitis
Why is atelectasis a common complication after surgery?
Pain inhibits deep inspiration that opens up alveoli. The atelectasis is MICROatelectasis and cannot be seen on CXR
Is FNA required after diagnosing a hot thyroid nodule, cold thyroid nodule, both or neither?
Cold lesions have malignant potential and must be analyzed by FNA. Hot lesions do not need to be.
Which malignant thyroid cancers can be diagnosed with FNA and which cannot?
Papillary, medullary and anaplastic can be
Follicular cannot - you need to visualize vascular or capsular invasion on tissue biopsy
Which thyroid cancer contains concentric layers of calcium called Psammoma bodies?
Papillary cancer of the thyroid
How are anaplastic cancers of the thyroid treated?
This is a very aggressive malignant tumor. Thyroidectomy does not improve prognosis and only relieves airway compression. Chemotherapy and radiation may offer palliation.
When is surgery indicated for Hashimoto's thyroiditis?
If the goiter is compressing important structures, if there is suspicion of malignancy, or for cosmetic reasons.
When is surgery indicated for treatment of Graves disease?
Often in young patients with severe disease and large goiters, or other patients who are not responding to radioiodine or medical therapy.
Which two conditions account for 90% of hypercalcemia?
Primary hyperparathyroidism and malignancy
What medications can cause hypercalcemia?
Lithium
Thiazide diuretics
Excess Vitamin D
Vitamin A intoxication
What are the indications for surgery in primary hyperparathyroidism?
Any symptomatic presentation of the disease including renal stones, bone disease, renal insufficiency, GI complications, neuromuscular disease or symptomatic hypercalcemia
From which embyrologic structures are the superior and inferior parathyroid glands derived?
Superior: Fourth branchial pouch
Inferior: Third branchial pouch
Circumoral numbness, weakness, headaches, extremity paresthesia, muscle cramps and convulsions may be presenting symptoms of which electrolyte imbalance?
Hypocalcemia
What is secondary hyperparathyroidism secondary to?
Renal failure - low calcium due to renal loss
What is the pathophysiology of tertiary hyperparathyroidism?
Renal calcium loss causes a compensatory increase in PTH by the parathyroid tissues, but then the hypertrophied glands continue to inappropriately secrete PTH in the face of high calcium
What should the first test be when diagnosing a palpable thyroid nodule?
Ultrasonography to distinguish between a cystic and solid mass
What is the appropriate initial therapy for Crohn's disease?
Medical therapy is the first line- corticosteroids have a beneficial effect on acute CD. Sulfasalazine has a limited role in CD. Anti-TNF therapies have shown benefit.
What is the medical therapy for Ulcerative colitis?
Steroid therapy to control the disease initially, followed by sulfasalazine to prevent relapse
What are the indications for surgery in Crohn's disease?
Complications like recurrent obstruction, abscess formation, severe colitis, anal destruction, malignancy, profuse blood loss, perforation.
How does a high fiber diet prevent diverticulosis?
Fiber increases stool weight, decreases whole gut transit time and lowers colonic intraluminal pressure.
What percentage of people with diverticulosis will develop diverticulitis?
15-30%
What is Saint's triad?
The constellation of cholelithiasis, hiatal hernia, and diverticulosis
What is the classic position in which you might find a patient with peritonitis resting?
Lying very still with knees flexed
If a patient has left lower quadrant pain and peritonitis, and radiography suggests a perforated diverticulum, what other entity must you consider?
Sigmoid colon cancer causing perforation
What operation is indicated for a patient with a perforated sigmoid diverticulum and generalized peritonitis?
A Hartman operation - resection of the diseased sigmoid colon with a left-sided colostomy and closure of the distal rectal stump (anastamosis is not indicated in a highly contaminated field)
How long after a Hartman procedure should the patient wait before reanastomosis is completed?
4-6 months after the initial procedure
What diagnostic techniques are indicated for locating a significant active bleed suspected to be somewhere in the large bowel?
Nuclear scintigraphy, angiography, or both should be performed
What are the indications for surgical resection of bowel in a patient with an acute attack of diverticulitis?
If there is evidence of multiple abscesses or perforation, an emergency laporotomy should be performed.
If it is the second mild or moderate attack, prophylactic removal is indicated once the acute event subsides
In a patient who is anemic due to blood loss, what does the MCV tell you about the blood loss?
It it's low, its probably a chronic blood loss, while if it's normal, it is probably acute.
What is the screening protocol for colorectal cancer in average risk adults?
Anual fecal occult blood test plus sigmoidoscopy every five years and colonoscopy every ten years.
How large should the surgical margins be when resecting a colorectal tumor?
At least 2cm both proximal and distal to the tumor
What is the most accurate method for staging rectal cancer?
ERUS - endorectal ultrasound
Demonstrates the depth of invasion and involvment of local lymph nodes
When is adjuvant chemotherapy or radiation recommended for patients with CRC?
Only in stage III disease, and stage II patients with bowel obstruction or vascular/lymphatic invasion
6 months of 5-FU plus leucovorin
From which structures do peri-rectal abscesses typically originate?
Infections of the anal glands and crypts
What is the procedure of choice for diagnosing internal hemorrhoids?
Anoscopy
How is severity of internal hemorrhoids classified?
1st degree - no protrusion
2nd degree - protrudes but reduces spontaneously
3rd degree - reduces with manual pressure
4th degree - does not reduce - prone to strangulation
What is effective therapy for bleeding 1st or 2nd degree internal hemorrhoids?
Band ligation, infrared photocoagulation and sclerotherapy.
What are the indications for surgical treatment of internal hemorrhoids?
3rd or 4th degree hemorrhoids - ones that protrude from the anus on physical exam. They are at risk of strangulation
What percent of patients with gallstones develop symptoms each year?
2%
Is asymptomatic cholelithiasis an indication for prophylactic cholecystectomy?
No
What are the two reasons there might be an air bubble in the gall bladder on a plain radiograph?
Infection with gas producing organisms
Fistula between gall bladder and intestine
Which organisms are most commonly found in the bile of patients with acute cholangitis?
E coli
Klebsiella
Enterococcus
What lab values are characteristic in patients with acute cholangitis?
Elevated bilirubin / direct
Elevated Alk Phos
Elevated GOT and GPT
What is Reynold's pentad for cholangitis?
Fever
Jaundice
Right upper quadrant pain (Charcot)
Plus mental status deterioration
and severe shock
What are the three possible theraputic techniques for emergency biliary duct decompression?
Percutaneous Transhepatic Cholangiography (PTC)
ERCP
Surgical decompression
How effective is US for differentiating obstructive from nonobstructive lesions of the bile ducts?
99% accuracy by visualizing bile duct dilation
What medical therapy is recommended for patients with acute variceal bleeding?
Octreotide is preferred to vasopressin because it has fewer side effects (less coronary vasoconstriction). It causes arterial vasoconstriction and reduces portal hypertension
What are the five criteria for placing cirrhotic patients in Child-Pugh classification categories?
Bilirubin levels
Albumin levels
Ascites
Encephalopathy
Nutritional status
What is the most common cause of portal hypertension in the US? Worldwide?
US - alcoholic liver disease
Worldwide - schistosomiasis
If medical and endoscopic therapy fail to control acute variceal bleeding, what is the next step to definitively control the bleeding?
A Sengstaken Blakemore tube placed in the esophagus and stomach is a definitive but temporary control of bleeding with serious risk of complications
What radiographic signs of pancreatitis may be present on a plain abdominal film?
Pancreatic calcification if the patient has chronic pancreatitis. Possibly some dilated loops of small bowel or a sentinal loop.
What signs of pancreatitis might be found on US?
An edematous pancreas or more importantly, stones in the gall bladder or a dilated common bile duct
What symptoms raise the suspicion of pseudocyst after acute pancreatitis resolves?
Early satiety, abdominal distention, or an abdominal mass
When should a pancreatic pseudocyst be drained or resected surgically?
If it is >5cm or if it is unresolved after 6 weeks
Why might the INR of a patient with pancreatic cancer be elevated?
There may be biliary obstruction which may cause decreased absorption of vitamin K. INR can be corrected by giving parenteral vitamin K
What are some symptoms of pancreatic cancer?
Abdominal pain, weight loss, jaundice, fatigue, back pain, anorexia, nausea, vomiting
What is the best modality for staging pancreatic cancer?
Abdominal CT - identifies pancreatic masses, determines operability and identifies masses
What is the 5 year survival rate of pancreatic cancer after a Whipple resection?
About 15%
What three conditions account for over 80% of causes of small bowel obstruction?
Adhesions, groin hernias, and small bowel tumors
What conditions increase intraabdominal pressure and may contribute to the development of abdominal wall hernias?
Obesity, ascites, constipation, COPD, urinary retention, pregnancy
What is a pantaloon type hernia?
When there is both a direct and indirect hernia present
How can you clinically differentiate between a direct and indirect hernia?
Reliable differentiation can only be done at surgery depending on the relation of the hernia to the epigastric vessels
How is the management of an incarcerated abdominal hernia different from a reducible hernia?
An incarcerated hernia is a surgical emergency and should be operated immediately. Reducible hernias can be scheduled for elective repair.
What is the difference between a CVA and a TIA?
TIAs present with reversible neurologic deficits that lasts less than 24 hours. The deficits in an acute CVA last longer than 24 hours
After auscultating a carotid bruit, what is the next diagnostic step?
Duplex ultrasound is the primary diagnostic modality to evaluate carotid stenosis
What causes amaurosis fugax?
Focal emboli to the ophthalmic artery causing a transient loss of vision
If a patient presents to the ER with an acute neurological deficit, like loss of vision or facial paralysis, what should the first diagnostic test be?
A CT scan of the head to rule out an intracranial hemorrhage or mass
Which patients presenting with an acute CVA are candidates for thrombolysis?
If the duration of symptoms is less than 3 hours and a CT has ruled out intracranial hemorrhage
What structures are found in the carotid sheath?
Carotid artery
Internal jugular artery
Vagus nerve
Should asymptomatic carotid stenosis be treated with carotid endarterectomy?
Yes, definitely if the stenosis is over 80% and selectively if it is between 60-80%
What drug therapy should a patient be on if they are diagnosed with carotid stenosis over 50%?
Antiplatelet therapy - aspirin
Maybe other medications to control blood pressure, and lipids.
How large is a normal abdominal aorta? How large does an aneurysm need to be before you consider elective operation?
Normal aorta are 1.5-2.0 cm

Aneurysms over 5.5cm should be electively repaired
What is the most common situation in which abdominal aortic aneurysm is diagnosed?
Incidentally on imaging studies for other reasons
What neoadjuvant therapy is used before resecting a pheochromocytoma?
Alpha blockers - phenoxybenzamine or prazosin over a number of weeks before surgery
What are the indications for removing an adrenal mass found on CT scan?
If there is evidence of excess hormonal secretion
or if the mass is over 3cm
What is the difference in management between STEMI and NSTEMI?
STEMI requires immediate reperfusion strategies while NSTEMI can be treated with antiplatelet drugs and thrombin inhibitors until the patient is stablized.
Are coronary artery stenoses that are less than 50% physiologically significant?
Yes, the vast majority of MIs occur due to plaque rupture in vessels with less than 50% luminal stenosis
What is the ideal vessel to use during a CABG?
The internal mammary artery
What are the three most common causes of aortic stenosis?
Degenerative calcification
Congenital bicuspid valve
Rheumatic aortic stenosis
What are the three cardinal symptoms of aortic stenosis?
Angina
Syncope
CHF
What is the major advantage and major disadvantage of bioprostheses for cardiac valves compared with mechanical valves?
Advantage: no longterm anticoagulation required
Disadvantage: Limited lifespan of 15 to 17 years (may be an OK choice in older patients)
What is the course of anticoagulation after a bioprosthetic heart valve replacement?
Anticoagulation with coumadin for 3 months and then aspirin therapy thereafter.
What is the classic symptom of mitral stenosis?
Dyspnea
It may also present as thromboembolic events, like stroke.
What medical therapy may improve symptoms (and amount) of mitral regurgitation?
Diuretics can reduce the degree of mitral regurgitation
What are the most common sites of metastasis in lung cancer?
Lymph nodes
Contralateral lung
Adrenal glands
Liver
Brain
Bones
When should surgical resection be considered in small cell lung cancer?
If it is a peripheral lesion
What is the standard surgical procedure if correction of spontaneous pneumothorax is indicated?
Apical bullectomy with a pleurectomy or pleural abrasion
In a patient with COPD, why does lung volume resection improve the disease? What are the goals of surgery?
Lung reduction improves the elastic recoil of the lung, corrects the chest wall mechanics and resects the part of the lung with the highest V/Q mismatch
Which diseases are the most common indications for lung transplant?
COPD, infections, Cystic fibrosis, Interstitial lung diseases
Where are the most common sites of melanoma on men vs. women?
Men: Back and chest
Women: Arms and legs
When should an incisional vs. excisional vs. shave biopsy be used to diagnose melanoma
Excisional: almost always
Incisional: maybe on the face or scalp
Shave: never
Is there any effective adjuvant chemotherapy available for melanoma?
Recombinant interferon has been shown to improve the survival of node-positive stage III patients
What superficialy differentiates a first degree burn from a second degree burn?
Second degree burns tend to blister
How are second degree burns managed compared to third degree burns?
Second degree burns heal spontaneously, while third degree burns won't and require debridement and closure by secondary intention or skin grafting
What is the best way to manage a patient with carbon monoxide poisoning?
Give high concentrations of oxygen
What is important to remember about the nutrition that should be provided to severely burned patients?
Enteral feeding should begin as soon as possible, and there are high caloric demands. High protein diets should be given and hyperglycemia avoided as it promotes infection
Should antibiotics be given to a severely burned patient to prevent infection?
No, prophylactic antibiotics do not reduce infection rates and only foster the proliferation of resistant pathogens
Why is Ringer's Lactate fluid preferred to normal saline in major trauma patients?
The high chloride concentration of normal saline can lead to lactic acidosis if given in large quantities
What does the 'D' step consist of in the ABC(DE)'s of assessing trauma patients?
Assessing baseline neurologic status including Glasgow Coma Scale and pupillary response
Below what Glasgow Coma Scale level should a patient have a definitive airway placed?
Any patient with a GCS of 8 or less should have a definitive airway
What is the most common radiographic indicator of aortic rupture?
Widened mediastinum
Is a patient in shock likely to have a widened or narrowed pulse pressure?
Narrowed
A patient continues to be in hypovolemic shock despite aggressive fluid resuscitation. There is no external bleeding, or expanding hematomas, or evidence of hemothorax on CXR. Where is the most likely site of bleeding and how should it be evaluated in the ER?
The process of elimination points to abdominal bleeding. Focused Abdominal Sonagraphic evaluation for Trauma (FAST) should be performed to identify blood in the abdomen.
What is normal urine output for a patient with a urinary catheter?
Should be greater than 0.5mL/kg/hr
What is the most common cause of fever in the early postoperative period?
Atelectasis
How long after surgery do abdominal wound infections most commonly occur?
5-7 days postoperatively
What is the primary treatment for an infected surgical wound?
Wide opening of the infected subcutaneous layer and removal of infected material. The incision is then treated as an open wound. Antibiotics are a secondary component of treatment
What is the pathophysiologic basis for groin hernias in children?
A patent processus vaginalis leading to an indirect hernia
How is a communicating hydrocele treated differently from a noncommunicating hydrocele?
A noncommunicating hydrocele should resorb spontaneously.
A communicating hydrocele needs to be repaired like an indirect hernia
What percentage of patients with lower extremity claudication will require surgery to preserve their limb?
75-80% have diminished claudication with conservative treatment.
About 20% require invasive intervention for limb salvage
What is the most likely site of occlusion in the arterial system of the lower extremity
The distal superficial femoral artery (SFA) as it passes through the adductor canal