Surgery Case Files

Front 1

Case 40_Blunt Trauma_
What does low GCS indicate?

Back 1

severe head injury - CT scan if pnt stable enough (not indicated in unstable pt)

Front 2

Case 40_Blunt Trauma_
Is chest tube indicated when pneumothorax suspected or confirmed?

Back 2

clinically suspected

Front 3

Case 40_Blunt Trauma_
HypoTN in a polytrauma pt should be presumed to be the result of hemorrhage. What are the five major spaces for blood loss?

Back 3

1. Pleural
2. Intraperitoneal
3. Retroperitoneal
4. Pelvic
5. Soft tissues

Front 4

Case 40_Blunt Trauma_
What does FAST (focused abdominal sonography for trauma) assess? What 4 views?

Back 4

Intraperitoneal beeding (along with DPL diagnostic peritoneal lavage) and Retroperitoneal blood loss assessment. Subxiphoid, R and L upper quadrant, and pelvic views.

Front 5

Case 40_Blunt Trauma_
When is DPL (diagnostic peritoneal lavage) is considered positive?

Back 5

10mL of gross blood, aspirate contains >100000/mL RBC or a WBC count of>500mL

Front 6

Case 40_Blunt Trauma_
When does CT lack sensitivity?

Back 6

For hollow viscus injuries. Fortunately hollow viscus injuries are not typical in blunt trauma.

Front 7

Case 12_Closed Head Injury_
What is the point break for Eye opening, Motor response and Verbal response? Which one is the highest score? Lowest?

Back 7

Motor-highest (6)- obeys comands, localizes pian, withdraws to pain, decorticate (flexion), decerebrate (extension), none; Lowest - eye opening (4)-spontaneous, to speech, to pain, none. Thus, 5 (oriented, confused conversation, inappropriate words, incomprehensible sounds, none) is for verbal response.

Front 8

Case 12_Closed Head Injury_
Why is endotracheal intubation so important in head injury?

Back 8

The injured brain is much more sensitive to hypotension and hypoxia. Mortality is 75%.

Front 9

Case 12_Closed Head Injury_
When do we use manitol. Precautions?

Back 9

A dose of 1g/kg is used to reduce the volume of blood in the brain to decrease edema- ONLY in a STABLE PATIENT. Otherwise hypovolemia and uncompensated shock.

Front 10

Case 12_Closed Head Injury_
What is epidural hematoma?

Back 10

Collection of blood OUTSIDE dura within the skull. Biconvex lense shaped. Middle MENINGEAL artery- most common laceration. Better prognosis.

Front 11

Case 12_Closed Head Injury_
What is subdural hematoma?

Back 11

Blood between the brain and its dura. Damaged bridging veins (less pressure, slow bleed). Worse prognosis than epidural.

Front 12

Case 12_Closed Head Injury_
Classify Mild head injury, Moderate, Severe and Coma.

Back 12

Mild- GCS 13 to15. Moderate- 9 to 12. Severe- 8 to 11. Coma 8 or less

Front 13

Case 12_Closed Head Injury_
What is an early sign of TEMPORAL LOBE herniation? What's its mechanism?

Back 13

Dilation of a pupil with sluggish response to ligh (ipsilateral side mc) The III CN gets compressed against tentorum.

Front 14

Case 12_Closed Head Injury_
When is immediate intubation indicated?

Back 14

During severe closed head injury (GCS<9). Even if the pt is tachypnic. Remember, hypoxic brain is mostly prone to injury, high mortality.

Front 15

Case 26_Short Bowel Syndrome_
What is the most likely location of the clot in Superior Mesenteric Artery (SMA) an what part of intestine is affected?

Back 15

Distal artery-> causes necrosis of R colon, ileum and distal jejunum.

Front 16

Case 26_Short Bowel Syndrome_
What is the etiology of SBS?

Back 16

due to Extensive bowel resection, dfunctional defect (radiation enteritis, severe inflam. bowel dz->diarhea, dehydration, electrolite disturbance, malabsorption, malnutrition.

Front 17

Case 26_Short Bowel Syndrome_
MCC of SBS?

Back 17

Chron's dz and mesenteric infarction - adults; Necrotizing enterocolitis and small bowel volvulus in infants.

Front 18

Case 26_Short Bowel Syndrome_
enteral vs parenteral

Back 18

enteral- economical, promotes entestinal adaptation, but must have sufficient healthy intestines. Parenteral-sufficient nutrition, but $$, liver failure, IV sepsis, poor quality of life.

Front 19

Case 17_RLQ Pain_
What is the imaging modality of choice for a pregnant pt evaluated for an appendicitis?

Back 19

Ultrasound. Especially if pelvic pathology is suspected along side with apdx.

Front 20

Case 17_RLQ Pain_
What is a common condition in children that manifests itself via painful RLQ, lymphadenopathy in sm bowel mesentery?

Back 20

Mesenteric adenitis! Common in children.

Front 21

Case 17_RLQ Pain_
What are the classic S&S of acute apndx?

Back 21

N/V, urge to defecate, pain in periumbilical region that descends to RLQ. Do CBC w/Differential, UA, pregnancy test.

Front 22

If external AC and DC are available to aircraft, what will aircraft choose first?

Back 22

Aircraft will choose external AC power first. If both are connected, and external DC power is selected, and AC is required, select EXT Pwr switch OFF, then cycle back ON to select AC power.

Front 23

Lawrence_Esophagus_
Define Dysphagia, Odynophagia and Globus Hystericus.

Back 23

Dysphagia- difficulty swallowing; Odynophagia- painful swallowing (due to infection, foreign body, injury); Globus Hystericus- "lump in the throat" (possible mass, psych issue?)

Front 24

Lawrence_Esophagus_
Describe anatomy/hystology of esophagus

Back 24

Stratified suqaumous epithelium, upper1/3 skeletal, the rest smooth mouscle

Front 25

Lawrence_Esophagus_
regurgitation vs vomiting

Back 25

R- passive return of ingested material INTO the oropharinx; V- active..

Front 26

Lawrence_Esophagus_
What is another word for hiccup?

Back 26

SINGULTUS - diaphragmatic irritation (diaphragmatic hernia, acute gastric dilation, subendocardial MI)

Front 27

Lawrence_Esophagus_
What Rx will relieve esophageal spasm?

Back 27

Nitroglycerin

Front 28

Lawrence_Esophagus_
Name two types of hiatal hernia and their prevalence.

Back 28

Type I- Sliding and Type II- Rolling, aka paraesophageal ( Rolling is 100x more common)

Front 29

Lawrence_Esophagus_
Sliding hernia significance

Back 29

Significant only when associated with reflux of gastric acid into esophagus. Does not have to be surgically repaired unless symptoms are significant. Unlike Type II aka Rolling aka Paraesophageal - must be repaired, b/c incarceration possible

Front 30

Lawrence_Esophagus_
Chronic reflux may cause this _ condition. What histological change takes place?

Back 30

Barrett's esophagus. Epithelium is transformed to COLUMNAR cells, which in turn may become adenocarcinoma.

Front 31

Lawrence_Esophagus_
What can significant reflux be confused with? What is a good diagnostic study?

Back 31

Type I hiatal hernia (sliding) can have similar symptoms with MI. Similar presentation - substernal pain and tightness that may radiate to jaw. Type II (paraesophageal? the camel) usually Asymptomatic unless herniation is considerable. Barium swallow with fluoroscopy.

Front 32

Lawrence_Esophagus_
What is the most common MOTILITY disorder?

Back 32

Achalasia- "failure to relax."

Front 33

Lawrence_Esophagus_
Mechanism of Achalasia

Back 33

failure of the high-pressure-zone sphincter to relax, NOT contraction of the sphincter. Thus, proximal esophagus dilates. Symptoms- minimal wt loss and regurgitation. Pain is not common. Bird-beak deformity at the hiatus. SURGICAL treatment -HELLER myotomy.

Front 34

Lawrence_Esophagus_
What is the cause of the Second most common esophageal motility disorder?

Back 34

Esophageal DIVERTICULA: outpouchings-> ether TRACTION and PULSION (ZENKER). Putrid breath. Traction -more distal, Zenker(Pulsion)- more proximal.

Front 35

Lawrence_Esophagus_
What is the percentage of esophageal cancers (esophagus has no serosa)? Presentation? What is used for staging and what for diagnosis?

Back 35

Squamous cell carcinoma 85% and Adenocarcinoma 10%. DYSPHAGIA is the most common symptom. CT for staging and Laparoscopy for diagnosis.

Front 36

Lawrence_Esophagus_
Caustic ingestion. Line of treatment.

Back 36

DO NOT induce vomiting. AIRWAY is #1. Used ANTIINFLAMMATORY agents for alkaline or acid burns.

Front 37

Lawrence_Stomach and Duodenum_
Where are the acid-producing eosinophil staining parietal cells found?

Back 37

Fundus and Corpus

Front 38

Lawrence_Stomach and Duodenum_
When performing vagotomy and anterotomy for ulcer treatment, what portion of the stomach is important to be removed?

Back 38

Antrum- the most distal portion of the stomach - G cells produce gastrin (vs parietal in fundus and corpus)). Eosinophil staining gastrin cells

Front 39

Lawrence_Stomach and Duodenum_
What branch of vagus n has to be excised for treatment of ulcers?

Back 39

LARP (L- anterior, R- posterior). Criminal nerve of Gassi - branch of R. With vagal innervation interrupted the parietal cell response to GASTRIN becomes blunted.

Front 40

Lawrence_Stomach and Duodenum_
What is the anatomical landmark where duodenum becomes jejunum?

Back 40

Ligament of Treitz.

Front 41

Lawrence_Stomach and Duodenum_
If duodenal ulcer penetrates through a posterior wall of duodenal bulb, what vessel is at the risk to be damaged?

Back 41

GASTRO DUODENAL artery

Front 42

Lawrence_Stomach and Duodenum_
What are the three main receptors of a parietal cell membrane?

Back 42

CCKb (cholecystokinin B)- gastrin receptor, muscarinic 3 (M3) ACh receptor, and histamine (H2) receptor

Front 43

Lawrence_Stomach and Duodenum_
Name three gastric phases and receptors responsible in each of them?

Back 43

Cephalic- M3. Gastric- CCKb. Intestinal -H2.

Front 44

Lawrence_Stomach and Duodenum_
What part of GI is responsible for Cobalamine B12 absorption?

Back 44

Stomach and duodenum. Must have intrinsic factor IF

Front 45

Lawrence_Stomach and Duodenum_
What is the most common Type of a gastric ulcer? Location?

Back 45

Type I. Lesser curvature. Transition zone b/w antrum and cardia.

Front 46

Lawrence_Stomach and Duodenum_
Billroth I and II

Back 46

I- reconstruction of duodenum and remaining stomach. II- remaining stomach and loop of jejunum.

Front 47

Lawrence_Stomach and Duodenum_
What hypertrophic gastric dz is a risk factor for developing adenocarcinoma of the stomach?

Back 47

Menetrie's disease- hypertropic rugae.Overexpression of tumor necrosis factor Beta (TNF beta). S&S:epigastric pain, N/V, diarrhea, anorexia, occult hemorrhage.

Front 48

Lawrence_Stomach and Duodenum_
Upper GI hemorrhage secondary to linear tearing at GE junction

Back 48

Mallory-Weiss Syndrome

Front 49

Lawrence_Stomach and Duodenum_
Gastric polyps in autosomal DOMINANT dz

Back 49

Peutz-Jeghers syndrome

Front 50

Lawrence_Stomach and Duodenum_
Gastric outlet obstruction in children and inmates of mental institution. Cause?

Back 50

Trichobezoar.

Front 51

Lawrence_Stomach and Duodenum_
What signs suggest lymphatic spread of Gastric Adenocarcinoma?

Back 51

Sister Mary Joseph's node (palpable umbilical node). Enlarged L supraCLAVICULAR lymph node (Virchow's node).

Front 52

Lawrence_Stomach and Duodenum_
Definition of Linitis Plastica

Back 52

Complete infiltration of the stomach with CA. Particularly poor prognosis.

Front 53

Lawrence_Stomach and Duodenum_
What is an important aspect of staging of the Adenocarcinoma of the stomach?

Back 53

Endoscopic ultrasound - to determine depth of invasion.

Front 54

Lawrence_Stomach and Duodenum_
What is the name of the metastatic spread of Adenocarcinoma of the stomach to ovaries?

Back 54

Krukenberg's tumor. Do CBC, LFT, Creatinine level, electrolytes

Front 55

Lawrence_Stomach and Duodenum_
Stomach and Lymphoma. Nota bene.

Back 55

Stomach is the primary source of almost 2/3 of ALL GI lymphomas. Non-Hodgkin's variant predominates.

Front 56

Lawrence_Stomach and Duodenum_
GIST- Gastrointestinal Stromal TUmor, formerly as leiomyoma and leiomyosarcoma. Definition

Back 56

Often asymptomatic, but similar to other gastric tumors: bleeding and obstruction. Submucosal mass. Biopsy usu non-diagnostic. 10 of mitotic figures per 50 fields -malignancy.

Front 57

Lawrence_Stomach and Duodenum_
What type of ulcers harbor malignancy?

Back 57

Peptic Ulcers. DUODENAL-high acidity->offensive factors, pain at night that wakes pt up, lower malignancy risk->no biopsy necessary (vs gastric-low acidity, no pain relief w/eating-higher malignancy than duodenal ulcers. Biopsy gastric!)- PUD. Typically in DUODENAL bulb. H.pylori and NSAID's are important ulcerogenic agents.

Front 58

Lawrence_Stomach and Duodenum_
S&S of PUD (vs gastric ulcers). What is unique?

Back 58

Pain is GNAWING in character. Weight gain may be observed b/c food may relief pain. Pain may be present 1-3 hrs post prandial. Over the counter acid suppressants usu help. H.pylori, NSAIDs, tobacco use -pay attention.

Front 59

Lawrence_Stomach and Duodenum_
What diagnostic studies can be used for PUD?

Back 59

Mostly empirical, i.e. H.pylori tests. But Barium swallowing and xray series performed. Also, gastric acid analysis may be used, however it is mostly used for Zollinger-Ellison syndrome.

Front 60

Lawrence_Stomach and Duodenum_
What is the current regimen of H.pylori treatment?

Back 60

acid suppressant, bismuth, tetracycline, metronidazole for 7-14 days.

Front 61

Lawrence_Stomach and Duodenum_
Complications of PUD

Back 61

Tachycardia and rigid abdomen- diffuse chemical peritonitis, pneumoperitoneum (air outlining liver or diaphragm - diagnostic)

Front 62

Lawrence_Stomach and Duodenum_
A perforated peptic ulcer is a sx emergency. What kind of procedure is done to treat the perforation?

Back 62

if perforation is less than 6 hrs old, Graham patch- plication is buttressed with a patch of omentum. Make sure NG tube is in to decompress if perforation is over 12 hrs old, NPO, volume resuscitation, abd xrays.

Front 63

Lawrence_Stomach and Duodenum_
What are the ATLS (American Trauma Life Support) guidelines for upper GI hemorrhage?

Back 63

2 L of crystalloid, followed by whole blood. NG tube to decompress stomach, high dose PPI, correction of coagulation abnormalities.

Front 64

Lawrence_Stomach and Duodenum_
What is distal gastrectomy? vs proximal

Back 64

Added to truncal vagotomy (proximal vagotomy). Removal the bulk to gastrin producing G cells of the antrum.

Front 65

Lawrence_Stomach and Duodenum_
What is proximal gastric vagotomy? vs distal

Back 65

Resection of vagal n.

Front 66

Lawrence_Stomach and Duodenum_
Duodenal polyps- inherited disorder (autosomal DOMINANT). Tnx?

Back 66

Multiple adenomatous poylps may progress to VILLOUS adenoma. Excision is required for prophylaxis.

Front 67

Lawrence_Stomach and Duodenum_
What syndrome is the direct result of the most-well known endocrine tumor, GASTRINOMA?

Back 67

ZOLLinger-ELLison syndrome! Measuring pH of 2.5 or less- positive diagnosis

Front 68

Lawrence_Stomach and Duodenum_
What is th emost common site of amedocarcinoma in the small bowel?

Back 68

DUODENUM

Front 69

Lawrence_Stomach and Duodenum_
Classification of obesety. When do we start Rx and when Sx?

Back 69

BMI <18.5 underwt
18.5-24.9 nL
25.0-29.9 overwt
30.0-39.9 OBESE
40.0 and up Severely obese
at BMI= 27 -Rx...... at 35.0 Sx

Front 70

Lawrence_Stomach and Duodenum_
Complications of bariatric operations/wt loss

Back 70

DVD, PE. Stricture, so "food gets stuck." Nutritional disturbance. Gallbladder dz (Rx Ursodeoxycolic acid). Gastric prolapse due to Adjustable Gastric Band- reflux symptoms, N/V, pain.

Front 71

Lawrence_Breast_
What age group of women demonstrates the most diagnostic problems?

Back 71

30 to 50 yo

Front 72

Lawrence_Breast_
Hormone Replacement Therapy- HRT. Indications and risk

Back 72

Per recent studies, the only benefit is menopausal symptoms control. No benefit in bone fracture prevention or heart disease. Thus, HRT is not recommended for most women.

Front 73

Lawrence_Breast_
Standard in brst CA screening?

Back 73

Most effective is self-exam. monthly. For =>40yo mammography and physical exams. Re: negative mammogram is NO GUARANTEE that CA is not present- 10% neg test.

Front 74

Lawrence_Breast_
What pattern of calcifications is not associated with brst CA?

Back 74

LARGE ROUND microcalcifications are NOT associated. Pleomorphic, linear, branching -are associated with malignancy.

Front 75

Lawrence_Breast_
What age group benefits the most from Ultrasound?

Back 75

under 30 yo for palpable lesions, b/c incidence of CA is low. Has no adverse SE as a study method.

Front 76

Lawrence_Breast_
What benign tumor is seen in late teens to early 30s?

Back 76

Fibroadenoma. If <2.5cm - no intervention just a F/U q6mo for 18mo. If larger- core needle biopsy.

Front 77

Lawrence_Breast_
What benign condition is common for 4th-5th decades?

Back 77

A breast CYST. Ultrasound. If large, aspirate- straw colored or greenish- nL and no cytologic analysis is required.

Front 78

Lawrence_Breast_
What are the Level I and II lymph nodes that are required for dissection in breast CA?

Back 78

Level I- axilary fat pad. Level II- below pectoralis major and behind pectoralis minor.

Front 79

Lawrence_Breast_
Chemo agents for breast CA

Back 79

Cyclophosphamide, doxorubicine and 5-fluorouracil given over 9 to 10 weeks at 3 week intervals.

Front 80

Lawrence_Breast_
What chemo agent is used to treat estrogen-receptor positive tumors, particularly in postmenopausal women?

Back 80

Tamoxiphen. Anastrazole is superior, but SE include osteoporosis.

Front 81

Case 43_Anorectal Disease_
Intense pain with defecation is the most common symptom of what abnormality?

Back 81

Anal fissure. Bleeding is also possible as a symptom. Constipated patients often have this problem.

Front 82

Case 43_Anorectal Disease_
Treatment of choice for anal fissure

Back 82

Sitz baths, bulking agents, stool softeners, nitroglycerine ointment (lowers pressure of Internal Anal Sphincter, vasodilator->bld flow to ischemic tissue).If IAS pressure cannot be eased, botulinum toxin can be injected or incision into the sphincter.

Front 83

Case 43_Anorectal Disease_
What other differential should be considered with anal fissue s&s?

Back 83

Malignancy and Inflammatory Bowel Dz IBD (UC and Crohn's) - strong consideration; hemorrhoids (bleed or itch), fistula-in-ano (drainage, pus, mucus on undergarments), abscess (perianal mass or ulcer)

Front 84

Case 45_Hernia_
S&S?

Back 84

intermittent groin pain or "heaviness" especially with standing or during physical activity.

Front 85

Case 45_Hernia_
Diagnostic studies for hernia?

Back 85

Mostly based on clinical presentation. US or CT may be helpful.

Front 86

Case 45_Hernia_
When is hernia repair becomes urgent?

Back 86

When pain is acute. Suggestive of incarceration/strangulation-> ischemia.

Front 87

Case 45_Hernia_
What type of hernia that manifests with swelling of scrotum or labial majora?

Back 87

Indirect (through indirect inguinal ring, through processus vaginalis, follows sprematic cord)

Front 88

Case 45_Hernia_
What is the medial border of a INDIRECT inguinal hernia?

Back 88

Inferior epigastric vessels (through the Hesselbach triangle)

Front 89

Case 45_Hernia_
What are the boundaries of Femoral hernia?

Back 89

medially-pyriformis and pubic ramus; laterally- femoral vein; superiorly- inguinal ligament.

Front 90

Case 45_Hernia_
What type of hernia is palpable through medial thigh?

Back 90

obturator hernia

Front 91

Case 45_Hernia_
What is the anatomical divide line between inguinal and femoral hernia?

Back 91

Inguinal ligament

Front 92

Case 45_Hernia_
describe the boundaries of the Hesselbach's trianle.

Back 92

Edge of rectus medially; inguinal ligament inferolaterally; inferior epigastric vessels superolaterally

Front 93

Case 45_Hernia_
What type of hernia is lateral to inferior epigastric vessels and through INTERNAL (layer wise is deeper) ring (vs external ring-more medial and superficial as spermatic cord exits it)?

Back 93

INDIRECT hernia. Often follows spermatic cord and into the scrotum. The MOST common type!

Front 94

Case 45_Hernia_
Howship-Romberg sign. What is it diagnostic of?

Back 94

Obturator hernia (mc in thin elderly women). Hip is extended, aDDucted and medially rotated - pain.

Front 95

Case 9_Upper GI bleed_
Main considerations?

Back 95

Resuscitation, diagnosis, treatment! Monitor response via monitoring urine output, clinical appearance, BP, HR, Hgb and Hct serial levels, central venous pressure monitoring.

Front 96

Case 9_Upper GI bleed_
In massive upper GI bleed, how is the need for visualization approached?

Back 96

Endotracheal intubation before endoscopy

Front 97

Case 9_Upper GI bleed_
When do you order platelets and when plasma?

Back 97

Platelets for thrombocytopenia and plasma for coagulopathy.

Front 98

Case 9_Upper GI bleed_
What type of bleeding is related with portal hypertension?

Back 98

Esophageal variceal bleeding

Front 99

Case 9_Upper GI bleed_
What is a Mallory-Weiss tear?

Back 99

A proximal gastric mucosa tearing due to coughing, retching, or vomiting. Usu self-limiting, mild. Supportive care, ENDOSCOPY.

Front 100

Case 9_Upper GI bleed_
What othertypes of GI bleeds are known, other than Mallory-Weiss and Esophageal variceal bleeding?

Back 100

Esophagitis and AV-arteriovenous malformation. Self-limiting.

Front 101

Case 9_Upper GI bleed_
What is the most common nonvariceal bleeding source?

Back 101

Duodenal ulcers and Gastric erosions - 25% and 25%. Gastric ulcers-20%. Mallory-Weiss tears-7%. Neoplasms, AV malformations and Dieulafoy erosions are rare.

Front 102

Case 9_Upper GI bleed_
What increases pt mortality with acute upper GI bleeding?

Back 102

RE-bleeding, increased age, development of bleeding in the hospital.

Front 103

Case 9_Upper GI bleed_
Significance of NSAIDS in ulcers.

Back 103

10% of pts who take NSAIDS develop ulcers!

Front 104

Case 9_Upper GI bleed_
What condition has the highest chance of re-bleeding?

Back 104

Esophageal varices -60%
Gastric cancer- 50%
Gastric ulcer- 25%
Duodenal ulcer- 24%

Front 105

Case 9_Upper GI bleed_
What is the endoscopic therapy to stop nonvareceail bleeding?

Back 105

Epinephrine injections followed by thermal therapy. Next step is antihistamine H2 or PPI. Stop NSAIDs or add misoprostol (prostaglandin analog-> interaction with platelets), selective COX2 inhibitors

Front 106

Case 9_Upper GI bleed_
What is most common cause of chronic accult bld loss, i.e. no acute episodes until late in the dz?

Back 106

Cancer

Front 107

Case 9_Upper GI bleed_
What's the next step after IV fluids and NG tube placement to stop esophageal varices?

Back 107

Endoscopic sclerotherapy

Front 108

Case 9_Upper GI bleed_
What is the mcc of pediatric upper GI hemorhage?

Back 108

extrahepatic portal venous obstruction

Front 109

Case 29_AAA abd aortic aneurysm_
Most common cause and location?

Back 109

95% as a result of atherosclerosis and 90% are INFRArenal in location. (In the stem pt is taking ASA)

Front 110

Case 29_AAA abd aortic aneurysm_
What is the law that's dealing with the wall tension, square of radius and inverse to the thickness ofthe wall?

Back 110

The Law of Laplace

Front 111

Case 29_AAA abd aortic aneurysm_
What is the risk of rupture if AAA reaches 5 cm in diameter?

Back 111

25% over 5 years. At 5 cm repair is recommended. Up o 60% pts do not make it to the emergency rood alive with ruptured AAA

Front 112

Case 29_AAA abd aortic aneurysm_
What is the most common cause of preoperative morbidity and mortality?

Back 112

Cardiac complications

Front 113

Case 32_Nipple Discharge_
What is the mcc of bloody nipple discharge?

Back 113

Intraductal papilloma (mostly unilateral and benign)

Front 114

Case 32_Nipple Discharge_
Diagnostic study of choice for fibrocystic change and duct ectasia?

Back 114

Ultrasound. Mammography for women older than 40 years of age. Mammography provides both screening and diagnostic opportunities.

Front 115

Case 32_Nipple Discharge_
What are common nipple diseases?

Back 115

Paget's disease- ductal carcinoma (flaky or scaly skin on the nipple, straw-colored or bloody nipple discharge, skin and nipple changes in only one breast or the flattened nipples) and Bowen's disease- squamous carcinoma in situ (gradually enlarging, well demarcated erythematous plaque with an irregular border and surface crusting or scaling, after 60 ya)

Front 116

Case 32_Nipple Discharge_
The most common reason for nipple discharge in a woman of a reproductive age?

Back 116

Pregnancy! Do a pregnancy test

Front 117

Case 32_Nipple Discharge_
Pregnancy test is neg. Prolactin level is 100ng/mL. What's the diagnosis for the discharge?

Back 117

Gallactorrhea secondary to pituatary adenoma.

Front 118

Case 32_Nipple Discharge_
What Rx's can cause galactorrhea as a SE?

Back 118

Reserpine (antipsychotic and antihypertensive), TCA (Amitriptyline, Clomipramine, Doxepin, Imipramine, Trimipramine, Nortiptyline, Desipramine), phenothiazides, metoclopramide (antiemetic and gastroprokinetic), oral contraceptives

Front 119

Case 32_Nipple Discharge_
What is a study of choice for pt with continuous discharge from a duct?

Back 119

A ductogram

Front 120

Case 32_Nipple Discharge_
MCC of serosanguineous nipple discharge?

Back 120

Intraductal papilloma (consider ductogram or biopsy)

Front 121

Case 12_Thermal injury_
Fluids for burn victims

Back 121

2 to 4 mL/kg/% burn of Lactated Ringer's

Front 122

Case 12_Thermal injury_
In a burn pt twhat is one of the instances when the intubation is likely necessary?

Back 122

When the oropharynx is dry, red, or blistered

Front 123

Case 12_Thermal injury_
What is one of the must-do lab test inburn pts?

Back 123

COHgb levels (carboxyhemoglobin). Greater than 30%-> likely CNS d

Front 124

Case 12_Thermal injury_
Post-burn: What mediators are released to cause local edema, capillary permeability increase, perfusion decrease and end organ dysfunction?

Back 124

thromboxane A2, PROSTOGALNDINS, reactive oxygen radicals are released from injured tissue. Must give IV fluids.

Front 125

Case 12_Thermal injury_
What is the fluid resuscitation guidelines for a burn victim? What is the formula called?

Back 125

PARKLAND formula: 3-4 mL/kg/% area burnt. Give half in the first 8 hours. Then other half in the next 16 hrs. ISOTONIC - Lactated Ringer's. nL saline will cause hyperCl metabolic acidosis

Front 126

Case 12_Thermal injury_
For what Total Burn Skin Area percentage ORAL rehydration is appropriate?

Back 126

for up to 15%

Front 127

Case 12_Thermal injury_
What TYPE of fluid should be given during fluid resuscitation?

Back 127

Lactated Ringer's b/c it is isotonic. Large volumes of nL saline will cause hyperchloremic metabolic acidosis.

Front 128

Case 12_Thermal injury_
When do you give colloids (albumin)?

Back 128

Because of large capillary permeability colloids are avoided during first 12-18 hrs.

Front 129

Case 12_Thermal injury_
How do you assess the adequacy of fluid resuscitation?

Back 129

Urine Output. Adults should produce 0.5 mL/kg/hour (0.5-1 kids, 1-2 infants). Averaged over 2-3 hours to assess the adequacy of resuscitation.

Front 130

Case 12_Thermal injury_
What is the Rule of Nines?

Back 130

Used in calculating the burn area %: Front/Back leg-9 and 9
Front/Back arm-4.5 and 4.5 Front/Back head and neck-4.5 and 4.5
Front/Back torso-18 and 18

Front 131

Case 12_Thermal injury_
What not to use on a burn victim?

Back 131

Nota bene: do not use steroids b/c pt's immune system is going to be compromised as it will be (if >10%TBSA), do not use IV abics b/c selection for resistant organisms.

Front 132

Case 12_Thermal injury_
Silver nitrate vs Sulfamylon (Mafenide) vs Silver sulfadiazine (SS). Pigskin.

Back 132

All resist colonization. SS does not penetrate infected wounds. Mafenide-painful on application and inhibits carbonic anhydrase (causing severe metabolic acidosis), yet PENETRATES eschar & is useful for infected wounds. Silver nitrate-turns area black, causes leaching Cl and Na->hypoCl/Na as SE. Does not penetrate. Pigskin's growth factors allow to stimulate epithelial growth in PARTIAL skin burns (if there is a capacity for epithelialization_

Front 133

Case 12_Thermal injury_
70 kg man with 40% burn. What is the fluid resuscitation plan?

Back 133

70X3X40=8400 mL. Half=4200 given w/in first 8 hrs (525mL/hr), the other 4200mL w/in 16hrs to follow (263mL/hr)

Front 134

Case 12_Thermal injury_
If COHgb in ICU after 1 hr on 100%O2 is 15%, what was the % of COHgb at the fire (what was the pt exposed to?)? Important to understand potential CNS damage.

Back 134

Half life of COHgb is 60 min. Within 1 hr on O2 pt decreased 50% of initial COHgb. I.e. on exposure COHgb was ~30%- possible CNS dysfunction, permanent is a possibility. 60%-coma. eg: 3 min at moderately smoky fire->30% COHgb!!!

Front 135

Case 12_Thermal injury_
Burn complications per system:

Back 135

Neuro-delirium
Pulm-respir. failure
GI-Stomach and Duodenal ulcers (decerased splanchnic bld flow). Acalculous cholecystitis, pancreatitis, hepatic dysfunction
Renal-Acute Tubular Necrosis (myoglobinuria)

Front 136

Case 44_Adrenal Incidentaloma_
As incedentaloma is found what hornomes are we looking for on evaluation?

Back 136

Excess catecholamines, aldosterone, cortisol and androgens. Find out: HR, BP, Hx HA, palpitations, profuse sweating, abd pain, features suggestive of Cushing's

Front 137

Case 44_Adrenal Incidentaloma_
What is the functional assessment of incidentaloma?

Back 137

24-hour urine collection

Front 138

Case 44_Adrenal Incidentaloma_
What to look for in 24-hr urine collection for pheochromocytoma

Back 138

Vanillyl-Mandelic Acid (VMA), metanephrine and normetanephrine

Front 139

Case 44_Adrenal Incidentaloma_
What to look for in 24-hr urine collection for aldesterone-producing adenoma

Back 139

aldosterone and plasma renin

Front 140

Case 44_Adrenal Incidentaloma_
What is the test to evaluate for hypercortisolism?

Back 140

overnight 1-mg dexamethasone (is an exogenous steroid that provides negative feedback to the pituitary to suppress the secretion of ACTH) suppression test

Front 141

Case 44_Adrenal Incidentaloma_
When is Sx recommended?

Back 141

for ALL FUNCTIONING tumors and non-functioning that are >/=4cm. Also tumors that are enlarging, suggestive of carcinoma, solitary adrenal mets

Front 142

Case 44_Adrenal Incidentaloma_
What type of cells is pheochromocytoma arises from? What does "a 10% tumor" mean relative to pheochromocytoma?

Back 142

CHROMAFFIN cells of adrenal gland.
10% are bilateral, extra-adrenal, multiple, malignant, familial

Front 143

Case 44_Adrenal Incidentaloma_
What test other than 24-hr urine collection can also be used for the purposes of evaluation of metanephrine?

Back 143

measurement of PLASMA free metanephrine levels - more sensitive than 24-hr urine test

Front 144

Case 44_Adrenal Incidentaloma_
What imaging scan has the highest specificity for imaging of pheochromocytoma?

Back 144

An iodine-131 metaiodobenzylguanidine MIBG (scan

Front 145

Case 44_Adrenal Incidentaloma_
When is Sx recommended?

Back 145

for ALL FUNCTIONING tumors and non-functioning that are >/=4cm. Also tumors that are enlarging, suggestive of carcinoma, solitary adrenal mets

Front 146

Case 44_Adrenal Incidentaloma_
What is the mot common tumor metastasizings to the adrenal gland?

Back 146

lung carcinoma

Front 147

Case 44_Adrenal Incidentaloma_
What type of cells is pheochromocytoma arises from? What does "a 10% tumor" mean relative to pheochromocytoma?

Back 147

CHROMAFFIN cells of adrenal gland.
10% are bilateral, extra-adrenal, multiple, malignant, familial

Front 148

Case 44_Adrenal Incidentaloma_
What test other than 24-hr urine collection can also be used for the purposes of evaluation of metanephrine?

Back 148

measurement of PLASMA free metanephrine levels - more sensitive than 24-hr urine test

Front 149

Case 44_Adrenal Incidentaloma_
What imaging scan has the highest specificity for imaging of pheochromocytoma?

Back 149

An iodine-131 metaiodobenzylguanidine MIBG (scan

Front 150

Case 44_Adrenal Incidentaloma_
What is the pharma protocol for sx pheochromocytoma removal?

Back 150

Alfa-blockers first (eg phenoxybenzamine. An alfa-Methyl-p-tyrosine can be added in combination with phenoxybenzamine as the former blocks tyrosine hydroxylase-rate limiting enzyme) to control vasoconstriction 1-2 wks before surgery, then add Beta-blockers (eg. esmolol) to oppose reflex tachycardia.

Front 151

Case 44_Adrenal Incidentaloma_
What agent can be used during pheochromocytoma removal sx if hypotension is refractory to fluid replacement?

Back 151

Neo-Synephrine

Front 152

Case 5_Benign prostate hypertrophy_
What is the function of prostate and a unique fact about the glad itself?

Back 152

To produce ejaculate. HUMAN prostate is the only mammalian glad that has a capsule

Front 153

Case 5_Benign prostate hypertrophy_
What are the SYMPTOMS of BPH called?

Back 153

Prostatism -frequent slow urination of small amounts, incomplete voiding, hesitancy

Front 154

Case 5_Benign prostate hypertrophy_
Tests to perform in the eval of prostate hypertrophy

Back 154

DRE, PSA levels and dynamics, biopsy. UA- to exclude UTI and hematuria (possible bladder CA)

Front 155

Case 5_Benign prostate hypertrophy_
Etiologies of bladder outlet obstruction

Back 155

BPH or ureTHral stricture

Front 156

Case 5_Benign prostate hypertrophy_
Pharm management of BPH

Back 156

Alfa1-blockers to relax the prostate's smooth muscle. BLockers of metabolites of testosterone (causes involution of prostate glandular tissue and shrinkage overall)

Front 157

Case 5_Benign prostate hypertrophy_
If pt is dizzy and has syncope episodes. What Rx can the pt be taking?

Back 157

Alfa1-ANTOgonist/Blockers (SilodoSIN, prozoSIN, tamsuloSIN, alfuzoSIN, doxazoSIN)

Front 158

Case 33_CaROTID Artery Disease_
What kind of symptoms arise from Carotid artery disease?

Back 158

Almost ALWAYS NEUROLOGIC (i.e. not dizziness, syncope, one neuro-confusion), i.e. unilateral weakness w/out speech impediment.

Front 159

Case 33_CaROTID Artery Disease_
Physical findings of the dz and confirmation study

Back 159

Bruit- turbulent blood flow in a narrow artery. Audible. Do a Duplex Ultrasound study

Front 160

Case 33_CaROTID Artery Disease_
What is the most common cause of cerebral ischemic event related to carotid artery disease? What are the two most common severe complications following Carotid Endarterectomy?

Back 160

Embolization.
Perioperative stroke and Acute MI.

Front 161

Case 33_CaROTID Artery Disease_
What to do if stenosis is found?

Back 161

If symptomatic- operate. Sx outcome is operator dependent. If no symptoms- prophylaxis with ASA

Front 162

Case 14_Claudification Syndrome_
Most likely reason for claudification.

Back 162

Superficial femoral artery occlusion (angiorgam) . PE: pain, pallor and pulselessness. Femoral occlusion is confirmed by the absence of a femoral pulse.

Front 163

Case 14_Claudification Syndrome_
What sx procedure is done to resolve femoral artery occlusion?

Back 163

Arterial bypass: with saphenous vein or prosthetic material

Front 164

Case 19_Colorectal CA & Polyps_
S&S of Colorectal CA

Back 164

Non-specific: ANEMIA (most common) microcytic while no ASA or other NSAIDs taken, distention, Hx of polyp removal.

Front 165

Case 19_Colorectal CA & Polyps_
How do you differentiate R vs L colon CA?

Back 165

If initial stages: L-sided is pencil thin stool & diarrhea, more obstruction than R-sided.

Front 166

Case 19_Colorectal CA & Polyps_
What type of CA is leading in lethality in the USA?

Back 166

#1-Lung. #2-Colon (Rectum and R-side most common sites)

Front 167

Case 19_Colorectal CA & Polyps_
TNM staging highlights: T3 and T4; N1 N2 N3; M1

Back 167

Stage 2~ T3-T4- thru muscularis propria-into peritoneum; Stage 3-N1 N2 N3; Stage 4- M1 systemic mets

Front 168

Case 19_Colorectal CA & Polyps_
Invasive AdenoCA treatment

Back 168

Systemic resection (i.e. a part of colon from either side of the lesion)

Front 169

Case 19_Colorectal CA & Polyps_
S&S of Colorectal CA

Back 169

Non-specific: ANEMIA (most common) microcytic while no ASA or other NSAIDs taken, distention, Hx of polyp removal.

Front 170

Case 19_Colorectal CA & Polyps_
How do you differentiate R vs L colon CA?

Back 170

If initial stages: L-sided is pencil thin stool & diarrhea, more obstruction than R-sided.

Front 171

Case 19_Colorectal CA & Polyps_
What type of CA is leading in lethality in the USA?

Back 171

#1-Lung. #2-Colon (Rectum and R-side most common sites)

Front 172

Case 19_Colorectal CA & Polyps_
TNM staging highlights: T3 and T4; N1 N2 N3; M1

Back 172

Stage 2~ T3-T4- thru muscularis propria-into peritoneum; Stage 3-N1 N2 N3; Stage 4- M1 systemic mets

Front 173

Case 19_Colorectal CA & Polyps_
Invasive AdenoCA treatment

Back 173

Systemic resection (i.e. a part of colon from either side of the lesion). CXR, CT abd and pelvis to follow right away.

Front 174

Case 19_Colorectal CA & Polyps_
Anatomical position of the RECTUM and what's its significance?

Back 174

final 15 cm of the GI tract. Close to surrounding structures-> mets and local tumor recurrence

Front 175

Case 19_Colorectal CA & Polyps_
What is the highest risk group for colorectal CA- nearly 100%?

Back 175

FAP!!!!! Family adenomatous polyposis (FAP) syndrome---- Must undergo FLEXIBLE sigmoidoscopy q1-2 years beginning age 10-12.

Front 176

Case 19_Colorectal CA & Polyps_
BRCA1 vs BRCA2

Back 176

BRCA2 confers an increased risk of colon CA. BRCA1-not

Front 177

Case 19_Colorectal CA & Polyps_
If colonic polyp was removed. What is the F/U recommendations?

Back 177

Colonoscopy after 3 years of the removal. If nothing found, colonoscopy every 5 years past the last colonoscopy.

Front 178

Case 19_Colorectal CA & Polyps_
Treatment of Stage 3 colon CA

Back 178

hemicolECTOMY with adjuvant chemo (FOLFOX4, i.e. 5-FU, Leuvocorin, and Oxaliplatin)

Front 179

Case 19_Colorectal CA & Polyps_
F/U if strong famHx of colorectal CA (not FAP)?

Back 179

Start colonoscopy at 40 years of age or 10 years prior to the age of the diagnosed family member, whichever is first.

Front 180

Case 19_Colorectal CA & Polyps_
Colonoscopy guidelines for an individual without a risk

Back 180

Start screening at 50 years of age and every 10 years.

Front 181

Case 50_Crohn's Disease_
What are the two imaging tests used in Crohn's assessment?

Back 181

CT and Small Bowel FollowThrough (SBFT) radiography - location and presence of intra-abdominal abscesses.

Front 182

Case 50_Crohn's Disease_
When to go surgical and when medical route?

Back 182

Obstruction from subacute inflammation-can be resolved with anti-inflammatory and immunomodulatory therapies. Fibrotic strictures- surgical only. Do Small Bowel FollowThrough (SBFT) radiography

Front 183

Case 50_Crohn's Disease_
What are the Patterns of Crohn's?

Back 183

intra-abdominal (stricture, inflammation or perforation) and perianal (anal strictures, fistulas-in-ano, and abscesses)

Front 184

Case 50_Crohn's Disease_
Describe Stricturoplasty for Crohn's

Back 184

Only when strictures are suspected. The strictured segment of sm bowel divided longitudinally then reapproximated transversely->increase in diameter of that segment. SE: after repetitive resections->short bowel syndrome->permanent Total PareNternal (TPN) therapy (1% occurrence)

Front 185

Case 50_Crohn's Disease_
What can lead to re-occurrence of Crohn's?

Back 185

Tobacco smoking and repeated NSAID use

Front 186

Case 50_Crohn's Disease_
What are 5-Aminosalicylate derivatives that are used in mild to moderate Crohn's?

Back 186

Sulfasalazine, Asacol, Pentasa (SE: sperm abnormalities, folate malabsorption, HA)

Front 187

Case 50_Crohn's Disease_
Crohn's Rx therapy- Metronidazole (for mild to moderate dz)

Back 187

SE: peripheral neuropathy, METALIC taste, disulferam-like rxn (blocking the enzyme acetaldehyde dehydrogenase-flushing, clammy hands, tachycardia, poor perfusion-like symptoms.)

Front 188

Case 50_Crohn's Disease_
immunomodulators: AZT and 6-mercaptopurine for moderate to sever Crohn's

Back 188

SE: nausea, rash, hepatitis, pancreatitis, B-cell lymphoma, bone marrow suppression.

Front 189

Case 50_Crohn's Disease_
Immunomodulator- INFLIXIMAB to tnx Crohn's

Back 189

Effective in refractory to all cases. SE: opportunistic infections and B-cell lymphoma

Front 190

Case 28_Diverticulitis_
What are the findings on CT of abdomen in case of Diverticulitis?

Back 190

sigmoid (Western countries, vs R colon in Asian populations) diverticula, Mesenteric fat STRANDING, abscess formation

Front 191

Case 28_Diverticulitis_
What are complications of Diverticulitis?

Back 191

Perforation, obstruction, FISTULA (mc colon-to-bladder) formation, ABSCESS formation

Front 192

Case 28_Diverticulitis_
When to use barium enema?

Back 192

Use barium enema only AFTER the resolution of acute diverticulitis. Otherwise there is a danger of perforation and barium leakage into peritoneum

Front 193

Case 28_Diverticulitis_
Difference of treatment of MESENTERIC vs PELVIC abscess

Back 193

Antibiotics for mesenteric. Percutaneous drainage for pelvic!

Front 194

Case 24_Fascial Dehiscence_
What are the complications of FD?

Back 194

Abdominal evisceration, enterocutaneous fistulas (direct communication b/w sm bowel lumen and a skin opening), incisional hernias

Front 195

Case 24_Fascial Dehiscence_
What are the WOUND HEALING phases?

Back 195

1.INFLAMMATORY phase- immediately- till 7 days. Inflammtory cells sterilize the wound, secrete growth factors stimulating fibroblasts and keratinocytes.
2.PROLIFERATION phase-3rd-21st days, deposition of fibrin-fibrinogen MATRIX and collagen
3.REMODELING phase- 21st day-years, capillary regression->less vascularized wound, collagen cross-linking, tensile strength increasing.

Front 196

Case 24_Fascial Dehiscence_
When do we re-open?

Back 196

1.pending or present Evisceration. 2.Concern for entero(sm bowel)-cutaneous fistula formation 3.Intra-abdominal infection

Front 197

Case 24_Fascial Dehiscence_
Suture not to use to avoid FD

Back 197

Braided (debris within suture material) or Non-absorbable suture - should be avoided!

Front 198

Case 2_GERD aka Heartburn_
Definition of the heartburn

Back 198

Acid flow from the stomach to distal esophagus

Front 199

Case 2_GERD aka Heartburn_
What are potential complications of continuous GERD?

Back 199

1.Stricture formation.
2.Barrett's esophagus.

Front 200

Case 2_GERD aka Heartburn_
Barrett's esophagus complication

Back 200

Replacement of nL squamous epithelium of the esophagus with COLUMNAR and intestinal METAPLASIA -> esophagial ADENOcarcinoma risk

Front 201

Case 2_GERD aka Heartburn_
When is Sx indicated?

Back 201

When dz is refractory to PPI (omePRAZOLE, lansoPRAZOLE, dexlansoPRAZOLE, pantoPRAZOLE, rabePRAZOLE). When PPI cannot be taken. When pt does not wish to take PPI lifelong.

Front 202

Case 2_GERD aka Heartburn_
What is the most reliable OBJECTIVE indicator of GERD?

Back 202

24 hour pH monitoring

Front 203

Case 42_Testicular Cancer_
What is the most common manifestation?

Back 203

Heaviness WITHOUT tenderness in the scrotal area. I.e. the tumor is painLESS!

Front 204

Case 42_Testicular Cancer_
Diagnostic modality for the CA?

Back 204

Ultrasound. Once a solid mass in confirmed-> Resect (radical inguinal orchiectomy)!

Front 205

Case 42_Testicular Cancer_
What are the markers for the CA?

Back 205

Alfa Fetal Protein (AFP), beta hCG, lactic dehydrogenase (LDH).

Front 206

Case 42_Testicular Cancer_
What tumor cell types are representative of the CA?

Back 206

Seminoma (90%) and nonseminomatous germ cell types

Front 207

Case 42_Testicular Cancer_
How does the tumor spread?

Back 207

Along the spermatic cord to the RETROPERITONEUM around vena cava and aorta. (Impossible to dissect if radiotherapy is performed before the resection)

Front 208

Case 42_Testicular Cancer_
What is a Virchow node?

Back 208

A hard mass over LEFT clavicle. A sign of a mets within lymph nodes.

Front 209

Case 42_Testicular Cancer_
What abnormal finding at birth predisposes for the CA?

Back 209

Cryptorchidism- significant risk of a germ cell tumor.

Front 210

Case 41_Thymoma and Myasthenia Gravis_
What is a common physical finding for the condition?

Back 210

ANTERIOR mediastinal mass with ptosis, diplopia, dysarthria, dysphagia, respiratory problems.

Front 211

Case 41_Thymoma and Myasthenia Gravis_
Pathophys of MG?

Back 211

Disorder at neuromuscular junction from autoimmune damage of nicotinic cholinergic receptors->weakness that's worse with exercise.

Front 212

Case 41_Thymoma and Myasthenia Gravis_
What is the confirmatory test for MG?

Back 212

The Edrophonium-Tensilon test. Differentiates cholinergic crisis from MG. Provides more Ach to improve MG, but worsens cholinergic crisis (muscles stop responding to bombardment with Ach) by overly stimulating.

Front 213

Case 41_Thymoma and Myasthenia Gravis_
Primary treatment of thymoma

Back 213

MediAN sternotomy of ANTERIOR (Thymoma) mediastinal mass

Front 214

Case 41_Thymoma and Myasthenia Gravis_
Location of neurogenic tumors vs thymomas (and germ cell tumors: seminomatous and nonseminomatous, eg. teratoma)

Back 214

Posterior mediastinum vs ANTERIOR mediastinum

Front 215

Case 51_Ulcerative Colitis_
Define toxic megacolon

Back 215

Abd pain, fever, sepsis AND radiographic findings of colonic distension >6cm

Front 216

Case 51_Ulcerative Colitis_
UC histology vs Crohn's

Back 216

UC-mucosa ONLY vs Crohn's-transmural. Thus, UC has greater risk for cancer associated with dysplastic changes (eg sessile pseudopolyp->must perform colorectal RESECTION)

Front 217

Case 51_Ulcerative Colitis_
define PANcolitis

Back 217

UC that involves entire colon and rectum

Front 218

Case 51_Ulcerative Colitis_
define ileal J-pouch

Back 218

creation of NEORECTUM via reconstructing ileus with a terminal J and anastamosing it with anus (ileal pouch anal anastomosis)

Front 219

Case 51_Ulcerative Colitis_
Where does UC usually begin and in what direction does it progress?

Back 219

Starts in rectum and progresses to proximal colon (mucosal involvement only, thus CA hyperplastic changes risk vs Crohn's-transmural)

Front 220

Case 51_Ulcerative Colitis_
name extraintestinal manifestations associated with UC

Back 220

uveitis, coagulopathy, ankylosing spondilitis, scleroderma, sclerosing cholangitis (bile ducts inside and outside liver), arthritis, dermatomyositis (inflammation of muscle and skin)

Front 221

Case 51_Ulcerative Colitis_
SE of long use of steroids

Back 221

immunosuppression, accelerated bone loss, hirsuitism, masculinization, osteoporosis, loss of muscle mass, glucose intolerance (DM)

Front 222

Case 51_Ulcerative Colitis_
What if rectum is not involved in a pt with UC. What's the treatment?

Back 222

If rectum is not involved then consider diagnosis of Crohn's for which treatment is different: i.e. do colonoscopy and biopsy for Crohn's. Total proctocolectomy is a contraindication.

Front 223

Case 1_Breast CA_
What is the initial workup for brst CA?

Back 223

Bilateral mammography and core needle or excisional biopsy

Front 224

Case 1_Breast CA_
If CA is confirmed what additional workup is necessary?

Back 224

LFTs, CBC, CXR to assess possible mets - staging for level I and II. Stage III-add bone scan, abd and brain CT/MRI

Front 225

Case 1_Breast CA_
Fine needle aspiration (FNA). What is its peculiarity?

Back 225

It can determine the presence of CA but cannot ID if the CA is invasive or not. The question remains: is this CA invasive? F/U with additional workup: CBC, CXR, LFTs

Front 226

Case 1_Breast CA_
What muscle become an anatomical landmark for the level of axillary node involvement?

Back 226

Pectoralis MINOR. Start counting 1,2,3 from the axilla (1-lateral to the muscle, 2-beneath it, 3-medial to it)

Front 227

Case 1_Breast CA_
Neoadjuvant chemotherapy in brst CA. What's its significance?

Back 227

Purely cosmetic benefits. There is no difference b/w survival rates of neoadjuvant and adjuvant therapy pts

Front 228

Case 1_Breast CA_
What is the most commonly used antiestrogen agent or SERM (selective-estrogen receptor modulator)?

Back 228

TAMOXIFEN. Also aromatase inhibitors are gaining popularity in treatment due to beneficial effects. Must determine receptor sensitivity studies before starting Tamoxifen.

Front 229

Case 1_Breast CA_
What are the side effects of treatment with Tamoxifen (SERM or anti-estrogen)?

Back 229

Impotency in males. Clots. Strokes. Cataracts.

Front 230

Case 1_Breast CA_
Definition of a sentinel lymph node.

Back 230

The first lymph node in the lymph node basin draining a tumor. Allows to avoid radical axillary lymph node excision.

Front 231

Case 1_Breast CA_
Risk factors

Back 231

Increased Exposure to estrogen=early menarche (late menopause, nulliparity).

Front 232

Case 1_Breast CA_
Staging of brst CA

Back 232

Stage I- <2cm tumor size
Stage II- 2-5 cm
Stage III-axillary nodes involved
Stage IV-distant mets

Front 233

Case 1_Breast CA_
Hod do you treat a hormone receptor positive pt vs estrogen receptor negative pt?

Back 233

All hormone pos-TAMOXIFEN. Estrogen Receptor neg-chemo

Front 234

Case 1_Breast CA_
What if the CA expresses HER2/neu receptors? What Rx is treatment?

Back 234

TRAS-TU-ZU-MAB

Front 235

Case 1_Breast CA_
Name tumor markers for recurrent brst CA

Back 235

CEA and CA 15-3 or CA 27-29

Front 236

Case 3_Esophageal perforation_
S&S of Boerhaave syndrome

Back 236

acute chest pain after vomiting, midepigastric pain, shoulder pain

Front 237

Case 3_Esophageal perforation_
What is a common presentation that suggests disruption of the mediastinal pleura?

Back 237

pleural effusion (fluid b/w lungs and chest cavity)-sharp chest pain with cough or deep breaths. Left pleural effusion is most common when distal 1/3 esophagus is involved.

Front 238

Case 3_Esophageal perforation_
What is the best diagnostic test?

Back 238

Gastrographin (i.e. water soluble) esophagogram

Front 239

Case 3_Esophageal perforation_
What is the most common iatrogenic (hospital) cause of the perforation?

Back 239

Endoscopy

Front 240

Case 4_Malignant Melanoma_
Where does melanoma begin histologically?

Back 240

Basal layer of epidermis, because that's where melanocytes are.

Front 241

Case 4_Malignant Melanoma_
What type of Melanoma has a rapid vertical growth phase?

Back 241

Nodular type (ulceration and hemorrhage).

Front 242

Case 4_Malignant Melanoma_
What type begins on hands and feet? Who is more susceptible?

Back 242

Acral type-pigmented patch. Mostly in African Americans, Asians and Latinos.

Front 243

Case 4_Malignant Melanoma_
What is an early sign of Malignant Melanoma?

Back 243

Pruritis. Re: ABCDs of melanoma.

Front 244

Case 4_Malignant Melanoma_
What is the most common type?

Back 244

Superficial.

Front 245

Case 4_Malignant Melanoma_
If tumor depth is 1.5mm to 4mm, what is an adequate margin for excision?

Back 245

2cm. Mainstay therapy. Use Breslow (from the granular layer to the layer of deepest penetration) system of staging-more accurate than Clark system.

Front 246

Case 6_Small Bowel Obstruction_
Usual steps in management of uncomplicated SBO

Back 246

NG tube to decompress the stomach, fluid resuscitation, Foley cath to measure urine output.

Front 247

Case 6_Small Bowel Obstruction_
Complications of SBO

Back 247

Intravascular fluid loss to the third space (fluid levels in bowel) and due to vomiting, may further lead to azotemia and renal insufficiency. After IV fluids ex lap may be needed (i.e.Sx)

Front 248

Case 6_Small Bowel Obstruction_
Mechanical SBO

Back 248

Venous stasis and decreased perfusion->ischemia->CRAMPLIKE pain, N/bilious vomiting (peristalsis) (thus distal tract contents can have stool passed: clinically false thinking of stool passing. Yet obstruction is present)

Front 249

Case 6_Small Bowel Obstruction_
Define ILEUS

Back 249

distension of SB and/or colon from nonobstructive causes (metabolic derangements, recent abd sx, Rx SE)

Front 250

Case 6_Small Bowel Obstruction_
What is elevated serum AMYLASE suggestive of?

Back 250

Usu acute pancreatitis, but may also develop in complicated SBO.

Front 251

Case 6_Small Bowel Obstruction_
Metabolic derangements due to ischemia:

Back 251

anion gap acidosis (Na- (Cl + bicarb)). nL is 8-15. Change in bicarb is inversely proportional to change in AG. Less bicarb (nL20-29)suggests presence of lactic acid, which suggest ischemia! Important to calculate in elderly, b/c elderly pt is not always feverish-which can be mistakenly interpreted). But WBCs should be elevated regardless of the presence of fever.

Front 252

Case 6_Small Bowel Obstruction_
What is the time-frame for post-Sx SBO?

Back 252

within 30 days. Often treated with IV fluids and NG tube, i.e. decompression and supportive. Resolves thereafter.

Front 253

Case 6_Small Bowel Obstruction_
What are the causes of Lactic acidosis (low bicarb(nL20-29))?
Lactic acidosis = high Anion Gap (>15)

Back 253

high anion gap (AG nL8-15) means:
-shock (septic, cardiogenic, hypovolemic)
-low tissue perfusion (decreased oxygen delivery to tissues)
-excessive expenditure of energy (eg.seizures)

Front 254

Case 7_Carpal Tunnel Syndrome_
What other conditions is it associated with?

Back 254

Endocrine- DM, myxedema (HYPOthyroidism), hyperthyroidism, acromegaly and pregnancy.

Front 255

Case 7_Carpal Tunnel Syndrome_
Tests for the syndrome

Back 255

Phalen maneuver (flex) and Tinel's sign (tap). Electrophysiologic studies

Front 256

Case 7_Carpal Tunnel Syndrome_
Treatment of median n. compression (can be anywhere in the brachial plexus)

Back 256

NSAID's and splint for nighttime.

Front 257

Case 8_Gallstone Disease_
CHarco'ts triad

Back 257

RUQ pain, fever, jaundice- CHolangitis, i.e. infection within bile ducts. Tnx ANTIBIOTICS for cholangITIS and decompression of the bile duct by ERCP or surgery

Front 258

Case 8_Gallstone Disease_
How is biliary colic different from other disease just from looking at the lab values?

Back 258

Normal LFT's, No wall thickening, No dilation of Common Bile Duct

Front 259

Case 8_Gallstone Disease_
Pathophysiology of biliary colic

Back 259

Gallbladder contractions are stimulated by CCK (cholecystokinin) after food ingestion.

Front 260

Case 8_Gallstone Disease_
What is presence of air in the biliary tree significant of?

Back 260

Acute Cholangitis! Common in ELDERLY. Lifethreatening, Urgent Sx/ERCP and broad spectrum ANTIBIOTICS

Front 261

Case 8_Gallstone Disease_
Charcot's triad equals what condition?

Back 261

Cholangitis (abx) : fever, jaundice, RUQ pain

Front 262

Case 10_Lower GI Hemorrhage_
Define three age groups and prevalence of GI bleed causes in each of those groups

Back 262

1)Kids and adolescents: Meckel's diverticulum (dz of 2's), IBD inflammatory bowel dz, polyps;
2)Adults: diverticulosis, IBD, cancer;
3)Elderly (over 60yo): diverticulosis, cancer, angiodysplasia (degenerative vascular lesion in the GI mucosa)

Front 263

Case 10_Lower GI Hemorrhage_
Anatomical landmarks of GI

Back 263

Upper ends and Lower GI begins at the ligament of Trietz that support duodenum

Front 264

Case 10_Lower GI Hemorrhage_
Utility of RIGID proctosigmoscopy

Back 264

the most distal 25cm of lower GI (to r/o colorectal bleeds, if angiodysplasia epi can be injected or coagulation)

Front 265

Case 10_Lower GI Hemorrhage_
With Hx of previous abdominal vascular reconstruction what is a possibility when bleeding persists?

Back 265

AortoEnteric fistula may have been formed

Front 266

Case 10_Lower GI Hemorrhage_
What is MELENA (black blood in stool or tarry stool) associated with?

Back 266

Lower GI bleed (streaks of frank flood- rectal bleeding)

Front 267

Case 10_Lower GI Hemorrhage_
Define three age groups and prevalence of GI bleed causes in each of those groups

Back 267

1)Kids and adolescents: Meckel's diverticulum (dz of 2's), IBD inflammatory bowel dz, polyps;
2)Adults: diverticulosis, IBD, cancer;
3)Elderly (over 60yo): diverticulosis, cancer, angiodysplasia (degenerative vascular lesion in the GI mucosa)

Front 268

Case 10_Lower GI Hemorrhage_
Anatomical landmarks of GI

Back 268

Upper ends and Lower GI begins at the ligament of Trietz that supports duodenum

Front 269

Case 10_Lower GI Hemorrhage_
Utility of RIGID proctosigmoscopy

Back 269

the most distal 25cm of lower GI (to r/o colorectal bleeds, if angiodysplasia epi can be injected or coagulation)

Front 270

Case 10_Lower GI Hemorrhage_
With Hx of previous abdominal vascular reconstruction what is a possibility when bleeding persists?

Back 270

AortoEnteric fistula may have been formed

Front 271

Case 10_Lower GI Hemorrhage_
What is MELENA (black blood in stool or tarry stool) associated with?

Back 271

Lower GI bleed (streaks of frank flood- rectal bleeding)

Front 272

Case 10_Breast CA risk and surveillance_
Tamoxifen chemoprevention "must knows"

Back 272

must be weighed against the risk of thromboembolic complications, endometreal CA.

Front 273

Case 10_Breast CA risk and surveillance_
Risk developing the CA

Back 273

mother or sister-1.8 fold
premenopausal age-3 fold
bilateral- 4-5 fold is postmenopausal
9 fold if postmenopausal

Front 274

Case 10_Breast CA risk and surveillance_
Surveillance guidelines for a high-risk pt

Back 274

Annual mammography (detection of nonpalpable masses) from 35 years of age

Front 275

Case 15_Penetrating Abdominal Trauma_
What are indicators of shock?

Back 275

cool skin and >2sec capillary refill

Front 276

Case 15_Penetrating Abdominal Trauma_
What are the indications for celiotomy (incision into abdomen)?

Back 276

hollow viscus injuries (s&s: rigidity, guarding, tenderness distant from the stab wound). Laparoscopy lack sensitivity in detecting hollow viscus injuries and is a Sx procedure.

Front 277

Case 15_Penetrating Abdominal Trauma_
Laparoscopy as a Sx procedure

Back 277

Accurate in dnz diaphragm injuries and can be used to repair some injuries. Lacks sensitivity to determine hollow viscus injuries

Front 278

Case 16_Blunt Chest Trauma_
What will a CXR show in case of a ruptured thoracic aorta?

Back 278

Apical CAP (often left lung apex), obliteration of the aortic KNOB, and hemomediastinum, WIDENED mediastinum

Front 279

Case 16_Blunt Chest Trauma_
What is the test of choice for TRA traumatic rupture of aorta?

Back 279

Aortogram -involves placement of a catheter in the aorta and injection of contrast material while taking x-rays of the aorta.

Front 280

Case 18_Venous Thromboembolic Disease_
PO vs IV anticoagulants

Back 280

Warfarin vs Heparin

Front 281

Case 18_Venous Thromboembolic Disease_
What marker is elevated in DVT/PE?

Back 281

d-Dimer (also in Sx and trauma)-> nonspecific

Front 282

Case 18_Venous Thromboembolic Disease_
Pregnancy and Heparin

Back 282

Heparin is not contraindicated in pregnancy. Closed head injury 14 days post- heparin is ok. Contrainducation in HIT.

Front 283

Case 18_Venous Thromboembolic Disease_
What has the highest risk of PE?

Back 283

Subclavian vein thrombosis (vs DVT)

Front 284

Case 18_Venous Thromboembolic Disease_
Differentiate lymphadenopathy vs lymphedema

Back 284

Lymphedema- obstruction;
Lymphadenopathy- dz of lymphatics ->swelling

Front 285

Case 20_Soft Tissue Sarcoma_
Firm and NONTENDER mass post traumatic even, which brought attention to the mass rather than caused it (non-tender)

Back 285

Soft Tissue Sarcoma (STS)

Front 286

Case 20_Soft Tissue Sarcoma_
treatment of choice for Soft Tissue Sarcoma. What NOT to do.

Back 286

Excisional biopsy is absolutely contraindicated, b/c adequate resection margins cannot be achieved and definitive care will be compromised. Sx resection is the treatment of choice.

Front 287

Case 20_Soft Tissue Sarcoma_
What is the most likely site of mets?

Back 287

Lungs! Must do CXR every 3-6 months post resection for life

Front 288

Case 20_Soft Tissue Sarcoma_
What are genetic predispositions associated with STS?

Back 288

Neurofibromatosis (xsome 17, von Reckinghausen, cafe-au-lait)
Li-Fraumeni syndrome
Retinoblastoma
Familial polyposis coli

Front 289

Case 20_Soft Tissue Sarcoma_
What location if treated makes failure most likely post sx resection?

Back 289

Retroperitoneal. Local and regional recurrence is the most likely to take place.

Front 290

Case 21_Thyroid Mass_
What are the dzs of MEN2 syndrome?

Back 290

Medullary thyroid carcinoma, Pheochromocytoma and parathyroid hyperplasia. Autosomal dominant

Front 291

Case 21_Thyroid Mass_
When is Sx indicated?

Back 291

When COMPRESSIVE symptoms are present. Or when I-123 Thyroid Scintiscan test showed COLD nodule, i.e. risk of carcinoma

Front 292

Case 21_Thyroid Mass_
What associated with thyroid mass sign points towards malignancy?

Back 292

cervical lymphadenopathy

Front 293

Case 22_Spontaneous Pneumothorax_
Causes of primary dz (thin tall younger men and in smokers)

Back 293

Rupture of subpleural blebs

Front 294

Case 22_Spontaneous Pneumothorax_
Causes of secondary dz (mostly in pt with COPD, over 50yo)

Back 294

Bullous emphysematous dz, cystic fibrosis (CF), 1' and 2' cancers, necrotizing infections (eg by Pneumocystis carini)

Front 295

Case 22_Spontaneous Pneumothorax_
Differentiate pneumothorax from tension pneumo from open pneumo

Back 295

pneumo- air entered and prevents expansion of lung vs flap that let air in and traps it, vs air sucked directly through chest wall (a hole)

Front 296

Case 22_Spontaneous Pneumothorax_
What is necessary to evacuate blood, air, fluid from chest cavity?

Back 296

Tube thoracostomy

Front 297

Case 23_PostOp Acute Respiratory Insufficiency_
How would you differentiate an Acute Lung Injury (eg contusion) from PE if the pt is postsurgical.

Back 297

Time frame (it takes time for PE, while ALI is sooner in onset). CXR- PE is nL, ALI- bL nonsegmental infiltrates

Front 298

Case 23_PostOp Acute Respiratory Insufficiency_
How is aspiration dangerous?

Back 298

Spillage of gastric contents into bronchial tree->chemical burn or pneumonitis (inflammation)

Front 299

Case 23_PostOp Acute Respiratory Insufficiency_
What increases the risk for PE?

Back 299

Trauma, bed rest and cancer

Front 300

Case 23_PostOp Acute Respiratory Insufficiency_
ARDS. Describe the mechanism in light of trauma to the lungs

Back 300

Trauma->Inflammation->endothelial injury and destruction of type II pneumocytes->surfactant deficit; Intra-alveolar hemorrhage (V/Q mismatch)->hyaline membrane deposition and fibrosis

Front 301

Case 23_PostOp Acute Respiratory Insufficiency_
Ventilation is reflected by the Pco2. Hypercapnia (high CO2) and physical signs

Back 301

It is not associated with agitation or anxiety. Thus, in someone with altered consciousness measure end tidal CO2 (by capnography) or have Pco2 by ABG.

Front 302

Case 23_PostOp Acute Respiratory Insufficiency_
When are diagnostic bronchoscopy and bronchoalveolar lavage indicated?

Back 302

In an immunocompromised with a new onset of fever and bilateral pulmonary infiltrates (eg an AIDS pt with those s&s)

Front 303

Case 23_PostOp Acute Respiratory Insufficiency_
Pulmonary Capillary Wedge Pressure (PCWP). Examples of Low-nL and High.

Back 303

Capillary leak (ARDS) vs hydrostatic mechanism of cardiogenic pulmonary edema.

Front 304

Case 25_PostOp Fever_
What is the imaging modality? Labs?

Back 304

CT scan. UA, CBC and bld cultures.

Front 305

Case 25_PostOp Fever_
A febrile (>100.4 F) post-abd Sx pt

Back 305

intra-abd infection until proven otherwise

Front 306

Case 25_PostOp Fever_
Tertiary microbial peritonitis and its agents

Back 306

In immunodeficient pt- low virulence or opportunistic agents: Staph epidermidis, Enterococcus faecalis and Candida. FYI: secondary peritonitis-most common (perforation or necrosis of hollow organ). Primary peritonitis- mcc is liver dz ascites.

Front 307

Case 25_PostOp Fever_
Pathophysiology of intra-abdominal infections

Back 307

macrophages and PMN leukocytes recruited. Ileus - to contain localization and FIBROpurulent peritonitis to localize spillage

Front 308

Case 25_PostOp Fever_
What is secondary peritonitis and what are the goals of fighting it?

Back 308

spillage of endogenous microbes into the peritoneal cavity following visceral perforation. Must localize the source and initiate an early ABX therapy

Front 309

Case 25_PostOp Fever_
What is a STANDARD dual-agent therapy for intra-abd infections?

Back 309

Amonoglycoside (Amikacin, Neomycin, Streptomycin, Tobramycin, Gentamycin) plus Metronidazole or CLINDAMYCIN (anaerobic, malaria, acne, MRSA, SE: C.dif diarrhea-pseudomembranous colitis)

Front 310

Case 25_PostOp Fever_
Clindamycin use and SE

Back 310

Tnx: ANAerobes, Malaria, Acne, MRSA
SE: C.Dif colitis- Pseudomembranous colitis

Front 311

Case 25_PostOp Fever_
What is the NON-STANDARD dual agent therapy for intra-abdominal infections?

Back 311

A second or a third generation cephalosporin (cefotetan, cefotoxin, ceftriaxone, cefotaxime, cefepime), plus Metronidazole or Clindamycin

Front 312

Case 25_PostOp Fever_
What is the NON_STANDARD dual agent therapy for intra-abdominal infections?

Back 312

A Fluoroquinalone (Ciprofloxacin, Levofloxacin, Gatifloxacin), plus Metronidazole or Clindamycin

Front 313

Case 25_PostOp Fever_
Fluoroquinalone

Back 313

Aromatic substitution @ C7 position. SE: highest risk for Pseudomembranous colitis (often but not always C.diff infection) and MRSA.

Front 314

Case 25_PostOp Fever_
Treatment of severe infections or infections in immunocompromised hosts

Back 314

Imipenem-cilastatin, Piperacillin-tazobactam (Zosyn), Ticaracillin-culvulanate

Front 315

Case 25_PostOp Fever_
Aminoglycosides. How are they used?

Back 315

Rarely used as a first-line therapy against gram negative due to availability of many other agents.

Front 316

Case 25_PostOp Fever_
What is the most common cause of fever within the first 24 hours postOp?

Back 316

ATELECTASIS post-surgical atelectasis, characterized by splinting, restricted breathing after abdominal surgery. Incentive spirometry is prophylaxis

Front 317

Case 30_Hypotensive Patient_
How do we assess/monitor ventricular function or cardiac output in a hypotensive pt?

Back 317

Place echo/pulmonary artery (PA) catheter

Front 318

Case 30_Hypotensive Patient_
How do we continuously monitor BP in a hypotensive pt?

Back 318

Central venous monitor (CVP) and arterial catheter

Front 319

Case 30_Hypotensive Patient_
When is pulmonary capillary wedge pressure decreased?

Back 319

Only during HYPOvolemic shock state (dehydration, hemorrhage)

Front 320

Case 30_Hypotensive Patient_
When is systemic vascular resistance decreased?

Back 320

Only in DISTRIBUTIVE shock (sepsis, neurogenic, anaphylaxis) due to decrease in vascular tone

Front 321

Case 30_Hypotensive Patient_
In hypovolemic type of shock what happens to preload?

Back 321

it is decreased

Front 322

Case 30_Hypotensive Patient_
If pt has lost 500 mL of blood, how much crystalloid solution needs to be infused?

Back 322

x3. For every mL lost 3 mL of crystalloids should be infused (0.9% or Ringer's lactate, i.e. isotonic solution).

Front 323

Case 30_Hypotensive Patient_
What is the initial therapy for a hypotensive pt?

Back 323

Fluid resuscitation, not pressors!

Front 324

Case 31_Pancreatitis (Acute)_
What is peculiar about pancreatitis?

Back 324

Severe dz is associated increased fluid permeability->large volume losses of intravascular fluid to the tissues->decreased perfusion of kidneys, lungs. IV fluids!!!- a must

Front 325

Case 31_Pancreatitis (Acute)_
When to use abx?

Back 325

Necrosis can set in later (confirm with CT)-> IMIPENEM/CILASTATIN is the best agent to penetrate the pancreatic tissue

Front 326

Case 31_Pancreatitis (Acute)_
Amylase and Lipase levels in pancreatitis

Back 326

useful in diagnosis but correlate poorly with disease severity

Front 327

Case 34_Pulmonary Nodule_
How does PET scan work?

Back 327

It detects the increase in glucose metabolism. Some tumors commonly have such increase

Front 328

Case 34_Pulmonary Nodule_
What are the common sites of lung CA metastasis?

Back 328

Liver and adrenals

Front 329

Case 34_Pulmonary Nodule_
What is the presence of calcified lesions significant of?

Back 329

BENIGN process. But all calcified lesions require further investigation

Front 330

Case 34_Pulmonary Nodule_
What other sites of lung CA mets are important to keep in mind besides liver and adrenals?

Back 330

Brain, bone and ipsilateral lung

Front 331

Case 34_Pulmonary Nodule_
What is the primary purpose of the CT imaging in chest masses?

Back 331

To determine ANATOMIC location, not whether it is benign or malignant

Front 332

Case 34_Pulmonary Nodule_
What is the initial presenting symptom in 75% of lung CA?

Back 332

cough

Front 333

Case 35_Periampulary Tymor_
If pt presents with painless obstructive jaundice, wt loss, recent onset of DM, what imaging test should be done first?

Back 333

Ultrasound. To rule out/in biliary stones as the source of obstruction and to ***** the anatomic location of the biliary obstruction

Front 334

Case 35_Periampulary Tymor_
What does DIRECT bilirubinemia suggest?

Back 334

Liver is conjugating, then biliary obstruction is the reason

Front 335

Case 35_Periampulary Tymor_
Courvoisier's sign

Back 335

painless jaundice with palpable gallbladder

Front 336

Case 35_Periampulary Tymor_
When is periampulary tumor considered unresectable, icluding a contrainducation to pancreaticoduodenectomy (PD)?

Back 336

When it invades the superior mesenteric artery (SMA).

Front 337

Case 35_Periampulary Tymor_
What is pancreaticoduodenectomy (PD) aka WHIPPLE resection?

Back 337

A procedure involving resection of the duodenum, the head of the pancreas, the common bile duct, and often the distant stomach

Front 338

Case 35_Periampulary Tymor_
What is a chemoagent that prolongs the survival of pt with pancreatic CA?

Back 338

GEM-CITA-BINE

Front 339

Case 35_Periampulary Tymor_
What is the most common type of periampulary CA?

Back 339

Pancreatic CA. The worst prognosis

Front 340

Case 37_Mesenteric Ischemia_
What are the s&s?

Back 340

Intense abd pain after meals. Hx of HTN, diminished peripheral pulses(atherosclerotic dz)

Front 341

Case 37_Mesenteric Ischemia_
Hallmark of chronic mesenteric ischemia?

Back 341

Food fear

Front 342

Case 37_Mesenteric Ischemia_
What does a superior mesenteric artery supply?

Back 342

Small bowel and ascending and transverse colon

Front 343

Case 37_Mesenteric Ischemia_
How is the Superior Mesenteric Artery embolectomy done?

Back 343

Via the root of the small bowel mesentery

Front 344

Case 38_Preoperative Risk Assessment and Optimization_
How is the risk of perioperative cardiac death ot MI assessed?

Back 344

Extremely low if pt completed sx coronary revasculization within 5 years or had angioplasty from 6 mo to 5 years prior.

Front 345

Case 38_Preoperative Risk Assessment and Optimization_
Peculiarity of serum Cr (vs urine Cr) in an elderly pt?

Back 345

Serum Cr may not be accurate in an elderly pt due to decreased muscle mass

Front 346

Case 39_Peptic Ulcer Disease_
S&S?

Back 346

eating food generally improves burning pain. H2 antagonist have always relieved the symptoms.

Front 347

Case 39_Peptic Ulcer Disease_
What is type 3 ulcers?

Back 347

gastric ulcers that are located 2 cm within the pylorus and associated with excessive acid secretion. Hemorrhage and perforation is frequent.

Front 348

Case 39_Peptic Ulcer Disease_
What is type 5 ulcers?

Back 348

Can occur anywhere in the stomach and are associated with NSAIDs and aspirin ingestion.

Front 349

Case 39_Peptic Ulcer Disease_
What strong association is found with peptic ulcer disease?

Back 349

H.pylori infection

Front 350

Case 39_Peptic Ulcer Disease_
What triple regimens are currently available for H.pylori eradication?

Back 350

OMC, OAC, OAM (O-omeprazole, a PPI, M-metronidazole, C-clarithromycin, A-amoxicillin) for 1-2 weeks

Front 351

Case 39_Peptic Ulcer Disease_
Since type 3 peptic ulcers are related to increased acid production, what type of therapy is performed in their treatment?

Back 351

Vagotomy and antrectomy

Front 352

Case 39_Peptic Ulcer Disease_
What strong association is found with peptic ulcer disease?

Back 352

H.pylori infection

Front 353

Case 39_Peptic Ulcer Disease_
What triple regimens are currently available for H.pylori eradication?

Back 353

OMC, OAC, OAM (O-omeprazole, a PPI, M-metronidazole, C-clarithromycin, A-amoxicillin) for 1-2 weeks

Front 354

Case 39_Peptic Ulcer Disease_
Since type 3 peptic ulcers are related to increased acid production, what type of therapy is performed in their treatment?

Back 354

Vagotomy and antrectomy

Front 355

Case 46_Necrotizing Soft Tussue Infections (NSTI)_
Why does subcu tissue separate easily in NSTI?

Back 355

Microvascular thrombosis and necrosis

Front 356

Case 46_Necrotizing Soft Tussue Infections (NSTI)_
Initial abx treatment regimen

Back 356

Broad spectrum: gram pos, neg and anaerobic bacteria

Front 357

Case 46_Necrotizing Soft Tussue Infections (NSTI)_
What is one of the leading factors contributing to delays i nthe recognition of NSTI?

Back 357

Because of skin's rich bloo dsupply, skin necrosis takes longer time to develop->delays in recognition of the problem

Front 358

Case 46_Necrotizing Soft Tussue Infections (NSTI)_
What are some of the early manifestations of NSTI?

Back 358

Extension of edema beyond the spread of erythema and severe pain

Front 359

Case 46_Necrotizing Soft Tussue Infections (NSTI)_
Imaging studies for NSTI

Back 359

MRI and CT.

Front 360

Case 46_Necrotizing Soft Tussue Infections (NSTI)_
What is the likely organizm of NSTI when Hx suggests contact with fish or seawater?

Back 360

Vibrio species. Treat with cefTAZidime (fish=taz)

Front 361

Case 46_Necrotizing Soft Tussue Infections (NSTI)_
What is the "lay press" for "flesh eating bacteria"'s etiology?

Back 361

GABS Group A beta-hemolytic Streptococcus (common in alcoholics, DM, immunocompromised pts)

Front 362

Case 46_Necrotizing Soft Tussue Infections (NSTI)_
What abx for NSTI by GABS?

Back 362

Clindamycin with penicillin

Front 363

Case 46_Necrotizing Soft Tussue Infections (NSTI)_
What is the causative agent of Toxic shock Syndrome (mental obtundation is common)?

Back 363

pyogenic toxin superantigens of Staph and Group A beta-hemolytic Strep: Major Histocompatibility Complex class III leads to T-cell clonal expansion and massive release of proinflammatory cytokines by macrophages and T-cells

Front 364

Case 46_Necrotizing Soft Tussue Infections (NSTI)_
What is the most important treatment for NSTI?

Back 364

Rapid, agresive surgical debridement. Lack of improvement->inadequate debridement

Front 365

Case 47_Wilm's Tumor (Pediatric Abd Mass)
What is frequently seen with this condition?

Back 365

Hematuria

Front 366

Case 47_Wilm's Tumor (Pediatric Abd Mass)
What may be the first sign of a neonatal bowel obstruction that may appear as an abdominal mass?

Back 366

Maternal polyhydramnios

Front 367

Case 47_Wilm's Tumor (Pediatric Abd Mass)
What is a classic sign of a severe presentation of intussusception?

Back 367

The child draws its legs up to its abdomen.

Front 368

Case 47_Wilm's Tumor (Pediatric Abd Mass)
Differentiate neuroblastoma and Wilms' Tumor

Back 368

Failure to thrive (and fine calcifications on radiographs) vs normal development. Neoadjuvant chemo prior to tumor rescection vs nothing prior to the rescection.

Front 369

Case 47_Wilm's Tumor (Pediatric Abd Mass)
What is the most common type of retroperitoneal mass in a child older that 1 year?

Back 369

Neuroblastoma- CBC, Urine for catecholamines.
Chemo.
1p36 or 11q23 chromosomes.

Front 370

Case 49_Immune Thrombocytopenia Purpura (Splenic Dz)_
What is it associated with?

Back 370

Splenic production of IgG against platelets

Front 371

Case 49_Immune Thrombocytopenia Purpura (Splenic Dz)_
What is the initial txn of ITP?

Back 371

Corticosteroids. For long term->splenectomy.

Front 372

Case 49_Immune Thrombocytopenia Purpura (Splenic Dz)_
What is required for dnx?

Back 372

Bone Marrow aspirate: Normal to hypercellular megakaryocutes count in the bone marrow (in response to the increased peripheral destruction)

Front 373

Case 49_Immune Thrombocytopenia Purpura (Splenic Dz)_
What to do if platelet count is increased inspite of steroid therapy.

Back 373

It is the best indication for splenectomy to work and be of lasting effect.

Front 374

Case 49_Immune Thrombocytopenia Purpura (Splenic Dz)_
What is a rare but serious condition that can occure postsplenectomy, especially if the procedure was done to imporve hematologic dz?

Back 374

OPSS overwhelming postsplenectomy sepsis

Front 375

Case 49_Immune Thrombocytopenia Purpura (Splenic Dz)_
When is overwhelming postsplenectomy sepsis is less common?

Back 375

When splenectomy is performed due to trauma and not to improve hemotologic disease.