Surgery Shelf

Front 1

Comminuted fracture

Back 1

Results in more than 2 bone fragments (vs. simple fracture)

Front 2

Colles' fracture and cause

Back 2

Distal radius fracture, usually from falling on outstretched handSmith's fracture

Front 3

Smith's fracture

Back 3

Reverse Colles, from falling on dorsum of hand

Front 4

Jones' fracture

Back 4

Fracture at base of 5th metatarsal diaphysis

Front 5

Bennett's fracture

Back 5

Fracture-dislocation of base of 1st metacarpal w/ disruption of carpometacarpal join

Front 6

Boxer's fracture

Back 6

Fracture of metacarpal neck, classically of 5th metacarpal

Front 7

Monteggia fracture

Back 7

Fracture of proximal third of ulna with dislocation of radial head

Front 8

Pott's fracture

Back 8

Fracture of distal fibula

Front 9

Which dislocation needs to be reduced on the xray table, and to prevent what?

Back 9

Hip dislocation, to prevent avascular necrosis

Front 10

What 2 structures are at risk with a humeral fracture?

Back 10

Radial nerve
Brachial artery

Front 11

Chief concern with tibial fractures

Back 11

Associated compartment syndrome

Front 12

Pain in the anatomic snuff box indicates

Back 12

Fracture of scaphoid bone

Front 13

Contracture of the forearm flexors might indicate

Back 13

Wokmann's contracture: final sequela of forearm compartment syndrome as fibrous tissue replaces dead muscle

Front 14

Most common site of compartment syndrome and why

Back 14

Calf: 4 compartments (anterior, lateral, deep posterior, superficial posterior)

Front 15

Pain, paresthesia, paralysis after a fracture

Back 15

Worry about compartment syndrome!

Front 16

Structures at risk with shoulder dislocation (2)

Back 16

Axillary nerve and artery

Front 17

Structures at risk with elbow dislocation (3)

Back 17

Brachial arter, ulnar nerve, median nerve

Front 18

Most common cause of hip dislocation

Back 18

MVA

Front 19

Structures at risk with hip dislocation (2)

Back 19

Sciatic nerve, blood supply to femoral head (--> avascular necrosis)

Front 20

Structures at risk with knee dislocation (5)

Back 20

Popliteal artery and vein, peroneal nerve, ACL, PCL

Front 21

Management of knee dislocation

Back 21

Arteriogram (may need arterial repair) and immediate attempt at relocation (don't want to xray), then ligamentous repair

Front 22

What is McMurray's sign?

Back 22

Medial tenderness of knee w/ flexion and internal rotation of knee: indicates medial meniscus tear

Front 23

Unhappy triad

Back 23

ACL, MCL, and medial meniscus tear

Front 24

Test for intact Achilles tendon

Back 24

Thompson's test: squeeze gastrocnemius; should result in plantar flexion of the foot

Front 25

What is turf toe?

Back 25

Hyperextension of great toe due to tear of tendon of flexor hallucis brevis, seen in football players

Front 26

Another name of exercise-induced anterior compartment syndrome/hypertension

Back 26

Shin splints

Front 27

What is a heel spur?

Back 27

Plantar fasciitis w/ abnormal bone growth in the plantar fascia

Front 28

What is Marjolin's ulcer?

Back 28

Squamous cell carcinoma that arises in a chronic sinus from osteomyelitis

Front 29

DDx of possible bone tumor

Back 29

1) Mets
2) Primary bone tumor
3) Metabolic disorder (e.g. hyperparathyroidism)
4) Infection

Front 30

Sclerotic bone reaction in a tumor often indicates

Back 30

Tumor is benign

Front 31

Bone tumor with sunburst pattern

Back 31

Osteosarcoma

Front 32

Bone tumoor with ground glass lytic lesions

Back 32

Fibrous dysplasia

Front 33

Bone tumor with onion skinning

Back 33

Ewing's sarcoma

Front 34

How can Ewing's sarcoma mimic the appearance of osteomyelitis?

Back 34

Bone cysts

Front 35

Unicameral bone cyst

Back 35

Fluid-filled cyst in proximal humerus of kids

Front 36

Presentation and treatment of unicameral bone cyst

Back 36

Asymptomatic until pathologic fracture

Steroid injections

Front 37

Aneurysmal bone cyst

Back 37

Hemorrhagic lesion, locally destructive by expansile growth but doesn't metastasize

Front 38

Presentation and Rx of aneurysmal bone cyst

Back 38

Pain and swelling

Curettage and bone grafting

Front 39

Bouchard's vs. Heberden's nodes

Back 39

OA

Enlarged PIP vs. DIP joints

Front 40

Rx for degenerative (OA or post-traumatic) arthritis

Back 40

NSAIDs only for acute flares, local

Front 41

Pannus

Back 41

Inflammatory exudate overlying synovial cells inside the joint

Front 42

Charcot's joint

Back 42

Arthritic joint from peripheral neuropathy

Front 43

What does the Salter-Harris classification describe, and what does it indicate risk of?

Back 43

Fractures in children involving physis and how much

Potential growth arrest

Front 44

Rx for congenital hip dislocation

Back 44

Pavlik harness (maintains hip reduction w/ hips flexed)

Front 45

Indications for surgery for scoliosis

Back 45

Respiratory compromise
Rapid progression
Curves >40 degrees
Failure of brace

Front 46

What is Legg-Calve-Perthes disease?

Back 46

Idiopathic avascular necrosis of femoral head in kids

Front 47

What occurs in SCFE?

Back 47

Migration of proximal femoral epiphysis anteriorly on the metaphysis in kids

Front 48

What is Blount's disease?

Back 48

Idiopathic varus bowing of tibia

Front 49

Varus vs. valgus

Back 49

Varus is bow-legged
Valgus is knock-kneed

Front 50

What is Osgood-Schaltter's disease?

Back 50

Apophysitis of tibial tubercle due to repeated powerful contractions of the quads

Front 51

Spinal anesthesia is risky in which pts

Back 51

CAD, low EF, valvular disease, diabetic peripheral neuropathy

Front 52

What are the risks of spinal anesthesia

Back 52

Pts who cannot vasoconstrict peripherally or increase CO appropriately: may become hypotension due to the vasodilation caused by spinal anesthesia

Front 53

How long must aspirin or NSAIDs be d/c prior to surgery

Back 53

ASA 1 wk
NSAIDs 2 days
(due to how long they effect platelets)

Front 54

Common preop tests to consider, depending on risks

Back 54

CBC, chem panel, LFTs, pt/ptt/plts, urinalysis, ECG, CXR

Front 55

Management of pt found to be anemic before surgery

Back 55

Postpone surgery and investigate anemia

Front 56

Fractures with worst prognosis for future growth

Back 56

Those that extend through the growth plate (can form bony bridges that disrupt later growth)

Front 57

Nerve possibly injured by transverse humeral fracture

Back 57

Radial nerve

Front 58

Injury to radial nerve at wrist would cause

Back 58

Sensory deficits (only more proximal would affect motor function)

Front 59

Advantage of open fractures reductions

Back 59

Shorter period of immobilization

Front 60

Disadvantages of open fracture reductions (3)

Back 60

Increased trauma at at fracture site
Infection risk
Delay in bone healing & possible non-union b/c disrupts clots/ hematomas helpful in healing

Front 61

Dislocation of the radial head w/ fracture of proximal third of the ulna

Back 61

Monteggia's deformity

Front 62

Posterior shoulder dislocation may be from

Back 62

Seizure

Front 63

Common fracture from falling on outstretched hand

Back 63

Navicular bone fracture

Front 64

Pain in anatomic snuff box

Back 64

Navicular bone fracture

Front 65

Recovery time for navicular bone fracture

Back 65

Immobilization of wrist for 16wks-6mo

Front 66

Osteitis fibrosa cystica is associated with

Back 66

hyperparathyroidism

Front 67

Increased bone density is seen in

Back 67

Oteopetrosis

Front 68

Another name for Paget's disease

Back 68

Osteitis deformans

Front 69

Most common site of osteosarcoma

Back 69

Distal femur

Front 70

Rx for osteosarcoma

Back 70

Combo chemo + surgical resection

Front 71

Severe bone pain relieved by ASA

Back 71

Osteoid osteoma

Front 72

Round-cell type tumor on diaphysis of long bones

Back 72

Ewing's sarcoma

Front 73

Nasopharyngeal carcinoma is associated with

Back 73

EBV

Front 74

Management of severe facial trauma

Back 74

Stabilize C-spine, intubate or tracheostomy if needed, CT, nasal packing to control hemorrhage, can delay repair if needed

Front 75

Rx for SCC of the nasopharynx

Back 75

Radiation; radial neck dissection if LN mets

Front 76

Rx for SCC of the oropharynx

Back 76

Surgery and/or radiation

Front 77

Rx for SCC of the hypopharynx

Back 77

Surgery (often + radiation) and radial neck dissection

Front 78

Pleomorphic salivary gland adenomas

Back 78

Rubbery, slow growing, potentially malignant, high recurrence, lips/tongue/palate

Front 79

First branchial cleft fistula opens where and dissection may damage which nerve

Back 79

External auditory canal
Facial

Front 80

Second branchial cleft fistula opens where, passes where, and is adjacent to which nerve

Back 80

Posterolateral pharynx (below tonsillar fossa)
Passes btwn carotid bifurcation
Adjacent to hypoglossal nerve

Front 81

Painless nodule along lateral border of SCM

Back 81

Branchial cleft anomaly

Front 82

Rx for branchial cleft anomalies

Back 82

Surgical excision

Front 83

Common complication of tongue cancer (2)

Back 83

Tongue deviation from involvement of hypoglossal nerve

Decreased sensation from involvement of lingual nerve

Front 84

Painless swelling in midline of neck that moves with swallowing or tongue protusion

Back 84

Thryoglossal duct cyst

Front 85

Course of thyroglossal duct cysts

Back 85

Retention of epithelial tract between thyroid and its embryo origin at base of tongue

Front 86

Rx for thryoglossal duct cyst

Back 86

Surgical resection (often includes hyoid bone) due to risk of infection/ progressive enlargement (and recurrence if only excise)

Front 87

When does buccal carcinoma usually present and why?

Back 87

Late (mandibular or amxillary involvement, cervical mets) because of lack of symptoms

Front 88

3 reasons for postponing surgery

Back 88

Glucose >250, active infection (cellulitis, PNA, UTI, etc.) diastolic BP >110

Front 89

Why are beta-blockers not held before surgery?

Back 89

High rate of rebound HTN if they are

Front 90

Abstaining from smoking for how long is required to decrease postoperative respiratory morbidity?

Back 90

6-8wks

Front 91

Laparoscopy is contraindicated in which pts?

Back 91

Poor pulm function/ severe COPD pts (b/c it increases CO2 absorption into the blood which requires increased excretion and therefore increased pulmonary work)

Front 92

5 factors used to predict risk for cardiac complications after vascular surgery

Back 92

Q waves on ECG
Hx of ventricular ectopy that requires Rx
Hx of angina
DM that requires Rx
>70yo

Front 93

Most common cause of death after LE revascularization is?

Back 93

MI

Front 94

What does Child's classification measure?

Back 94

Hepatic reserve/ liver function and therefore likelihood of mortality with surgery

Front 95

What are the 5 parts of Child's classification

Back 95

Bili, albumin, ascites, encephalopathy, nutrition

Front 96

Management of an ulcerated hernia

Back 96

Expedited surgery, as ulcers are often due to pressure necrosis, which increases the risk of rupture and has a mortality rate of 10-40%

Front 97

What is a cause of oozing blood in a pt with CKD undergoing surgery?

Back 97

Uremia --> platelet dysfunction

Front 98

What is the management of platelet dysfunction due to uremia, and what won't help?

Back 98

Transfusing platelets won't help

Desmopressin, FFP, estrogen, postop hemodialysis

Front 99

What types of procedures need Abx prophylaxis for pts with high risk cardiac conditions (e.g. prosthetic heart valves)

Back 99

Dental work, GI or GU surgery, lung surgery

Front 100

What type of Abx prophylaxis is used?

Back 100

Amox for dental/ upper respiratory tract procedures

Amp and gent for GI and GU procedures

Front 101

What complication should be monitored for in pts undergoing a bowel prep?

Back 101

Dehydration

Front 102

Management of a breast lump with negative mammography

Back 102

Still biopsy!

Front 103

Which histological pattern for DCIS is most concerning for malignancy?

Back 103

Comedo: up to 30% contain invasive carcinoma

Front 104

Rx for LCIS

Back 104

Close observation: mammography every 6mo

Front 105

Management of sclerosing adenosis vs. atypical ductal hyperplasia

Back 105

Sclerosing adenosis can usually be observed; ADH should be excised

Front 106

Management of breast lump in a woman <30yo

Back 106

Usually ultrasound first (to determine if cystic), then mammogram

Front 107

Dietary changes for fibrocystic breast disease

Back 107

Decrease caffeine
Vita E supplement

Front 108

What is a phyllodes tumor?

Back 108

Usually a large fibroadenoma (giant cell fibroadenoma) with variable malignant potential and occasional ulceration of overlying skin

Front 109

Management of bilateral clear discharge

Back 109

Observation, usually associated with fibrocystic disease or subareolar duct ectasia

Front 110

Management of unilateral bloody discharge

Back 110

Surgical biopsy; usually due to intraductal papilloma, but small risk of carcinoma

Front 111

Metastatic work-up for breast cancer

Back 111

CXR for lung and bone mets
Liver enzymes

Front 112

Breast cancer histo subtype with worst prognosis

Back 112

Inflammatory carcinoma

Front 113

What is peau d'orange and what does it indicate?

Back 113

Edema of the skin overlying the mass; tumor invasion of local dermal lymphatics (worse prognosis)

Front 114

What does a palpable supraclavicular LN indicate?

Back 114

Stage IV disease with distant mets: unresectable and incurable

Front 115

Why is a crusted nipple lesion concerning?

Back 115

Could be Paget's disease of the breast, 95% of which are asociated with an underlying carcinoma

Front 116

Two arteries that supply the breast

Back 116

Internal mammary
Lateral thoracic

Front 117

What distinguishes a modified radical mastectomy?

Back 117

Spares the pectoralis major

Front 118

What is a sentinel node?

Back 118

Node that first receives lymphatic drainage from the tumor

Front 119

Which patients should not have lumpectomy + radiation?

Back 119

Those who are not candidates for radiation: CT disease or prior radiation to the chest/ breasts

Front 120

Contraindications to breast reconstruction

Back 120

Primary lesions involving the chest wall, extensive local or regional disease, or stage III or IV cancer

Front 121

Which women with breast cancer need adjuvant chemo?

Back 121

Tumor >2cm or >Stage 1, especially if ER negative

Front 122

Which women with breast cancer need neoadjuvant chemo?

Back 122

Stage III (to shrink tumor before surgery); usually not Stage IV since will only get palliative radiation/chemo

Front 123

Likely diagnosis of a nodule in the suture line of a women with a history of breast cancer?

Back 123

Local recurrence

Front 124

Likely diagnosis of a mammographic abnormality in the contralateral breast of a women with a history of breast cancer?

Back 124

New primary cancer

Front 125

Management of elevated LFTs of a women with a history of breast cancer?

Back 125

Contrast CT to evaluate for liver mets

Front 126

Management of pathologic fracture?

Back 126

Orthopedic repair +} postop radiation (controls cancer but doesn't inhibit fracture union)

Front 127

Likely diagnosis of a coma in a women with a history of breast cancer?

Back 127

Hypercalcemia (from bony mets and PTHrp)

Front 128

Likely diagnosis and management of decreased sensation/movement in one leg in a women with a history of breast cancer?

Back 128

Surgical emergency: may be extradural mets to the spine

Steroids, cord decompression, and radiation

Front 129

Rx for mastitis

Back 129

Warm compresses + Abx (staph and strep coverage)

Front 130

Management of gynecomastia in adolescents

Back 130

Usually spontaneously regresses

Front 131

Need to replete every 1ml of EBL with how much isotonic fluid?

Back 131

3ml

Front 132

Why do IVF requirements decrease during the recovery period?

Back 132

Pts begin to mobilize fluid from third space accumulation as they regain GI function

Front 133

Normal urine output

Back 133

0.5-1ml/kg/hr

Front 134

How to distinguish type of postobstructive diuresis (pathologic concentrating defect vs. osmotic diuresis)

Back 134

Low osmolality: concentrating defect
High osmolality: osmotic diuresis

Front 135

Postop fever

Back 135

PNA, URI, UTI, DVT, drug-related, indwelling IVs

Front 136

Most common cause of postop fever

Back 136

Atelectasis

Front 137

Rx for atelectasis

Back 137

Vigorous pulmonary toilet and incentive spirometry (NOT antibiotics)

Front 138

What does a fluctuant postop wound indicate, and what is the management?

Back 138

Fluid collection: remove staples and drain pus; culture fluid and irrigate

Front 139

Drop of pus on skin at venipuncture exit site

Back 139

Suppurative phlebitis (infected thrombus in vein and around indwelling cathether)

Front 140

Rx for suppurative phlebitis

Back 140

Remove catheter and excise the infected vein + IV Abx

Front 141

Intestinal contents draining from wound

Back 141

Small bowel fistula

Front 142

Causes of small bowel fistula

Back 142

Leak at jejunostomy insertion site
Breakdown of small bowel anastomosis
Missed enterotomy

Front 143

Management of small bowel fistula

Back 143

If signs of peritonitis: operative reexploration

If not, CT to r/o intra-abdominal collection (which would need to be drained), and then monitor drainage + NPO

Front 144

Factors associated with failure of fistula to heal

Back 144

Foreign body in wound
Radiation damage to area
Infection or IBD
Epithelialization of fistulous tract
Neoplasm
Distal bowel obstruction

Front 145

Concern with very high postop fever

Back 145

Clostridium infection (gas-forming organism: G+, spore forming)

Front 146

Signs of clostridium infection

Back 146

Discharge with foul odor/color, crepitus (from gas produced by anaerobes), cellulitis (gas gangrene)

Front 147

Rx for clostridium infection

Back 147

High-dose penicillin G + debridement + hyperbaric oxygen therapy + tetanus immunization

Front 148

Ddx for hemoptysis

Back 148

Malignancy, bronchitis, PNA, TB, PE

Front 149

What does "T" indicate on GCS?

Back 149

Intubated

Front 150

Goals for CPP and ICP?

Back 150

<70 and <20

Front 151

GBM is a tumor of what type of cells?

Back 151

Glial cells

Front 152

Which skull fractures require surgery, and when?

Back 152

Depressed (if >1cm inward) or compound (when bone and overlying skin are broken)

Front 153

Management of CSF draining from ears/nose

Back 153

Observe, surgical repair of dura if >14 days

Front 154

Management of xanthrochromia

Back 154

4 vessel cerebral angiogram to assess for cerebral aneurysm + Rx to counteract vasospasm + BP control + anticonvulsant therapy

Front 155

Compression of CNS --> fixed/dilated pupil is usually due to?

Back 155

Herniation

Front 156

Rx of Schwannomas

Back 156

Excision

Front 157

What is a countrecoup lesion?

Back 157

Contusion on opposite side of head from injury (as compared to a coup lesion)

Front 158

Most frequent sites of cerebral contusion

Back 158

Orbital surface of frontal lobes and anterior portion of temporal lobes

Front 159

Rx for substantial contusion

Back 159

Anti-convulsants

Front 160

Rx for meningiomas

Back 160

Usually benign
Resection
10% recurrence

Front 161

Rx for subdural hematoma

Back 161

Drainage of hematoma thru burr hole; formal craniotomy may be required if fluid reaccumulates

Front 162

Significant contusions are usually associated with

Back 162

Loss of consciousness

Front 163

Excruciating headache, stiff neck, photophobia

Back 163

Subarachnoid hemorrhage

Front 164

When is surgery for VSD indicated (3)?

Back 164

CHF, pulmonary vascular resistance, or if still open at 5yo

Front 165

Cause of imperforate anus

Back 165

Failure of descent of urorectal septum

Front 166

How is imperforate anus distinguished as high or low?

Back 166

Based on whether rectum ends below or above level of levator ani complex

Front 167

In females, high imperforate anus often occurs with

Back 167

Persistent cloaca

Front 168

Rx for high vs. low and outcomes

Back 168

Low: perineal operation
High: pull-thru procedure required, lower likelihood of continence

Front 169

Rx for Hirschsprung's

Back 169

Colostomy decompression

Front 170

Cause of jejunoileal atresia

Back 170

Mesenteric vascular accident during intrauterine growth

Front 171

Rx for jejunoileal atresia

Back 171

Resection of primary anastamosis

Front 172

Most common type of intussusception

Back 172

Ileocolic

Front 173

Rx for intussusception

Back 173

Barium enema, unless has bloody mucous or peritonitis or systemic toxicity: then needs surgery

Front 174

Rx for annular pancreas

Back 174

Bypass procedure (duodenoduodenostomy)

Front 175

Presentation similar to acute appendicitis

Back 175

Inflamed Meckel's diverticula

Front 176

When should a Meckel's diverticula be removed?

Back 176

Only if symptomatic (obstructed, etc.)

Front 177

Where is a congenital diaphragmatic hernia and what does it cause?

Back 177

Posterolateral
Respiratory distress from pulmonary hypoplasia

Front 178

Rx for congenital diaphragmatic hernia

Back 178

Stabilize pulmonary HTN crisis medically or with extracorporeal membrane oxygenation prior to attempting repair

Front 179

Initial Rx for hyponatremia

Back 179

Free water restriction, then hypertonic saline (slowly, if needed)

Front 180

2 common causes of postop hyponatremia

Back 180

Stimulation of ADH and excessive water administration in first few days postop

Front 181

Pts with ileal resection are at risk for what type of kidney stones?

Back 181

Calcium oxalate (w/o an ileum, unabsorbed fatty acids reach the colon and combine with calcium, leaving oxalate to be absorbed and excreted in the kidney)

Front 182

Mg deficiency in common in which pts?

Back 182

Malnourished and large GI fluid losses

Front 183

Guidelines for prophylactic Abx for colon resections

Back 183

Single dose <1hr before case (cefazolin), same as always; redose for long cases based on half-life

Bowel prep + oral Abx effective against aerobes and anaerobes as well

Front 184

Preop cardiac workup for pt with risk factors

Back 184

EKG + stress test (exercise or, if can't tolerate it, pharmacological)

Front 185

Hypochloremic, hypokalemic metabolic alkalosis is also known as

Back 185

Contraction alkalosis

Front 186

Rx for contraction alkalosis

Back 186

Volume repletion with NS + K is usually enough to correct the alkalosis

Front 187

Rx for HIT

Back 187

Stop heparin, start lepirudin, transition to warfarin when plts >100,000

Front 188

When do you need a platelet transfusion for HIT?

Back 188

Never: HIT promotes thrombosis, not hemorrhage

Front 189

Significant postop bleeding

Back 189

Presume failed surgical control of blood vessels

Front 190

When do most periop MIs occur?

Back 190

3rd post op day when third space fluids return to circulation, increasing preload and O2 demand

Front 191

Management of acute mesenteric ischemia with and without peritoneal signs

Back 191

With: emergent XL
Without: angiography, then celiotomy once diagnosis of arterial occlusion or bowel infarction made

Front 192

Prolonged aPTT likely indicates

Back 192

von Willebrand's disease

Front 193

Diagnostic test for von Willebrand's disease

Back 193

Lack of platelet aggregation with addition of ristocetin

Front 194

Management of pt with vWD who needs surgery

Back 194

Transfusion of cryoprecipitate (which provides vWF and increases F VIII)

Front 195

Management of polycythemia vera pt who needs surgery

Back 195

Emergent: FFP infusion
Elective: delay until hematocrit/ plts are normalized (can use alkylating agents)

Front 196

When large amts of banked blood are transfused, pts become deficient in what clotting factors?

Back 196

V and VIII (as well as platelets)

Front 197

Postop bowel function: timing for return to normal and initiation of enteral feeding

Back 197

Small bowel: within hrs
Stomach: within 24 hrs
Colon: 3-4 days
Can institute enteral feeding w/in 24hrs safely

Front 198

3 electrolyte consequences of refeeding syndrome

Back 198

Hypokalemia, hypomagnesemia, hypophosphatemia (as electrolytes are shifted back intracellularly)

Front 199

3 other complications of TPN

Back 199

Hyperglycemia
Hyperchloremic acidosis
Volume overload --> CHF

Front 200

Fever, hypotension, lethargy, hypoglycemia, hyperkalemia after steroid taper

Back 200

Adrenal insufficiency

Front 201

Rx for adrenal crisis

Back 201

IV steroids (dexamethasone), volume resuscitation

Front 202

When should transfusion with FFP be given?

Back 202

On call to the OR

Front 203

Factors that predispose to fistula formation and may prevent closure

Back 203

Foreign body
Radiation
Inflammation
Epithelialization of the tract
Neoplasm
Distal obstruction
Steroids

Front 204

Fever, chills, hypotension, oliguria, pain at IV site

Back 204

Hemolytic tranfusion reactions (due to reaction of recipient Abs against transfused antigens)

Front 205

Management of pt with hemophilia A who needs surgery

Back 205

If severe disease: e-aminocaproic acid (AMICAR; inhibits fibrinolysis) and desmopressin (DDAVP, increases VIII and vWF)

If mild: DDAVP alone

Front 206

Why can FFP not be used successfully in hemophiliacs?

Back 206

Factor levels are too low; need cryo or recombinant factos

Front 207

NSAIDs can cause ___ dysfunction

Back 207

Platelet

Front 208

Potential vitamin deficiency syndromes from gastrectomy and Bilroth II procedure

Back 208

Megaloblastic anemia (decreased intrinsic factor)
Microcytic anemia (iron deficiency from decreased uptake in duodenum)
Osteoporosis (decreased calcium absorption from duodenum/jejunum)
Steatorrhea (fat malabsorpion)

Front 209

Diagnostic test for suspected ureteral injury (intraop and postop)

Back 209

Intraop: methylene blue administration

Postop: CT to see hydronephrosis or fluid collection (urinoma), then IV pyelogram

Front 210

Tingling sensation and muscle cramps after thyroid surgery

Back 210

Hypocalcemia, likely short-term due to transient ischemia of parathyroid gland

Front 211

Rx for symptomatic hypocalcemia

Back 211

IV calcium infusion (or oral if only mild symptoms); Vitamin D if persistent

Front 212

Massive transfusion is associated with what electrolyte abnormality?

Back 212

Hypocalcemia 2/2 chelation with citrate in banked blood

Front 213

Numbness, Chvostek's sign, and prolonged QT

Back 213

Hypocalcemia

Front 214

Best fluid replacement for enteric losses

Back 214

Ringer's lactate

Front 215

Rx for hyperkalemia

Back 215

Kayexalate (to bind it)
Sodium bicarb, dextrose, insulin (all to shift it intracellularly)
Calcium gluconate (to counteract myocardial effects)

Front 216

Best drainage system and location to minimize wound infections

Back 216

Closed drainage system that exits skin away from surgical incision

Front 217

When epithelialization is delayed beyond 3 wks, the incidence of ? increases

Back 217

Hypertrophic scarring

Front 218

Ex of epidermal burn

Back 218

Sunburn

Front 219

Why are superficial partial thickness burns painful?

Back 219

Exposed superficial nerves

Front 220

What leads to healing of superficial partial thickness burns?

Back 220

Regeneration of epidermis from keratinocytes w/in sweat glands and hair follicles (areas with more will heal more quickly)

Front 221

Rx for superficial partial thickness burns and why?

Back 221

Antimicrobial creams and occlusive dressings (epithelialization is faster in a moist environment)

Front 222

Rx for deep partial thickness wounds

Back 222

Excise to a viable depth and then skin graft, esp if in cosmetic location since healing is slow and associated with contraction

Front 223

Rx for full thickness injuries

Back 223

All should be excised and grafted unless <1cm and no compromise of function, b/c all regenerative elements have been destroyed

Front 224

When is the best time to graft burns?

Back 224

Within 5 days of injury to minimize blood loss

Front 225

Ideal skin covering choice?

Back 225

Split skin autograft from unburnt areas

Front 226

Alopecia, poor wound healing, night blindness, anosmia, neuritis, skin rashes

Back 226

Zinc deficiency

Front 227

Excessive diarrhea may lead to a ___ deficiency

Back 227

Zinc

Front 228

Cardiomyopathy may be due to a ___ deficiency

Back 228

Selenium

Front 229

Pts on long-term TPN may develop this deficiency w/ hyperglycemia, peripheral neuropathy, and encephalopathy

Back 229

Chromium

Front 230

Potential abnormality following administration of large volumes of normal saline

Back 230

Non anion-gap metabolic acidosis (due to increased chloride concentrations)

Front 231

Both LR and NS are both __ (acidic/alkalotic) w/ respect to plasma

Back 231

Acidic
pH of LR is 6.5
pH of NS is 4.5

Front 232

Two good situations for NS and for LR

Back 232

NS: vomiting or significant nasogastric suction losses (b/c pt will have tendency toward metabolic alkalosis)

LR: replacing GI losses and correcting ECF deficits

Front 233

3 indications for a vena caval filter

Back 233

- Anticoagulation contraindication/ failure
- Free-floating venous clot
- Chronic PE complicated by pulm HTN

Front 234

Earliest signs of sepsis

Back 234

Altered mental status, flushed skin, tachypnea --> respiratory alkalosis

Front 235

Body's response to stress causes

Back 235

Increased CO
Hyperglycemia
Peripheral vasodilation
Decreased arteriovenous oxygen difference (from decreased peripheral use of O2)

Front 236

Rx for hemolytic transfusion reaction

Back 236

- Fluid resuscitation
- Foley for diagnosis and monitoring of Rx
- Mannitol to induce diuresis (so can clear hemolyzed red cell membranes and avoid renal damage)
- Alkalinization of urine to prevent Hb clumping

Front 237

Surgery for C. diff colitis

Back 237

Subtotal colectomy with end ileostomy

Front 238

Caloric requirements for 70kg man who is:
Nml
Postop
Septic
Multiple trauma/ventilated
Major burn

Back 238

Nml: 1450
Postop: 1500
Septic: 2000
Multiple trauma/ventilated: 2500
Major burn: 3000

Front 239

Bleeding from trach

Back 239

Bleeding from tracheoinnominate artery fistula

Front 240

Management of tracheoinnominate artery fistula

Back 240

If still bleeding: stop (inflate balloon or compress)

Once bleeding stopped: fiberoptic exploration in the OR

Front 241

Criteria for extubation

Back 241

Negative inspiratory force >-20
Weaned to 5cm H2O PEEP
Minute ventilation <10L/min
RR <20/min
Rapid shallow breathing index btwn 60 and 105

Front 242

What is the rapid shallow breathing index?

Back 242

Ratio of RR to tidal volume

Front 243

Anesthetic not to use in SBO operations and why

Back 243

Nitrous oxide, b/c is less dense than air so may cause distension of air-filled spaces

Front 244

Changes in ARDS

Back 244

Hypoxemia
Decreased compliance
Decreased FRC
Alveolar collapse from leakage of protein-rich fluid

Front 245

Oxygen dissociation curve shifts (right/left) indicate?

Back 245

Right: increased tissue oxygen uptake
Left: decreased tissue oxygen uptake

Front 246

Do the following conditions shift the oxygen dissociation curve R or L?
Acidosis
Increased PaCO2
Increased temp
Increased 2,3-DPG
Chronic lung diseases
Banked blood

Back 246

All right except banked blood (b/c low in 2,3-DPG)

Chronic lung diseases shift it right via an increase in 2,3-DPG due to chronic hypoxia

Front 247

Dopamine at low doses

Back 247

Vasodilation of renal/mesenteric vessels and peripheral vasoconstriction, redirecting blood to kidneys/bowels

Front 248

Dopamine at high doses

Back 248

Increases HR, CO, BP and causes peripheral vasoconstriction

Front 249

Dopamine at all doses

Back 249

Increases diastolic BP and coronary blood flow

Front 250

Best pressor choice for cardiogenic shock

Back 250

Dobutamine (positive inotrope and vasodilates, but minimal chronotropic effect so only mild increase in O2 demand)

Front 251

Reversal of epidural opiates

Back 251

IV (not epidural) maloxone

Front 252

Cardiac index =

Back 252

CO/BSA

Front 253

Rx for acalculous cholecystitis

Back 253

Percutaneous drainage

Front 254

Hemodynamics in postop septic shock (early)

Back 254

Increased CO, decreased SVR, normal central pressures

Front 255

Rx for postop septic shock

Back 255

Fluids, pressors, Abx (against gram negative rods and anaerobes, esp after bowel surgery), laparotomy and drainage of intraabdominal abscess when identified/ if pt stable

Front 256

Indications for cholecystectomy in asymptomatic pts

Back 256

Immunocompromised
Porcelain gallbladder (calcified)
Gallstones >3cm (associated w/ dev't of gallbladder carcinoma)

Front 257

Why is an intraop cholangiogram often performed in cholecystectomies?

Back 257

To r/o common bile duct stones

Front 258

2 major complications of a cholecystectomy

Back 258

Injury to the common duct (--> chronic biliary strictures, infection, and cirrhosis)
Injury to hepatic artery (--> hepatic ischemia or bile duct ischemia and stricture)

Front 259

Most common bacteria in cholecystitis

Back 259

E coli, enterobacter, klebsiella, enterococcus

Front 260

Antibiotics for cholecystitis

Back 260

2nd generation cephalosporin preop and for 24hrs postop

Front 261

When is lap chole indicated in cholecystitis?

Back 261

Within 48-72hrs

Front 262

Symptomatic cholelithiasis + elevated bili or elevated LFTs

Back 262

Suspect common bile duct obstruction

Front 263

When is removal of common duct stones not necessary?

Back 263

If they're smaller than 3mm

Front 264

Management of symptomatic cholelithiasis or gallstone pancreatitis in pregnancy

Back 264

Pain meds and hydration

If needed, cholecystectomy (ideally in 2nd trimester) or ERCP

Front 265

Management of cholecystitis + elevated amylase

Back 265

Cholangiogram (and cholecystectomy) is mandatory with biliary pancreatitis

Front 266

Cholecystitis + severe symptomatic pancreatitis

Back 266

Delay cholecystectomy

Front 267

Ddx for very high fever, gallstones, and hypotensive

Back 267

Acute cholecystitis, cholangitis, empyema of gall bladder, or pericholecystic abscess

Front 268

Management of suppurative cholangitis

Back 268

Emergent ERCP with sphincterotomy, decompression of biliary tree, stone removal

Front 269

What causes a palpable gallbladder?

Back 269

Inflamed gallbladder with omentum attached

Front 270

Management of palpable gallbladder?

Back 270

Emergent cholecystectomy due to high rupture risk

Front 271

What is an emphysematous gallbladder?

Back 271

Air in the wall due to gas-forming organism that has invaded the tissues

Front 272

Management of emphysematous gallbladder

Back 272

Urgent surgery

Front 273

Jaundice, fever, and RUQ pain/tenderness

Back 273

Acute (or ascending) cholangitis

Front 274

Management of acute cholangitis

Back 274

Resuscitation, Abx, US of biliary tree

If obstruction or dilation of CBD seen, then ERCP and biliary decompression

Front 275

Name for a common duct stone occurring w/in 2yrs of a cholecystectomy

Back 275

Retained stone

Front 276

Management of biliary stricture

Back 276

Surgical exploration and bypass of stricture usually w/ choledochojejunostomy

Front 277

What two tests should be done in a pt with fever or pain after a lap chole?

Back 277

Abdominal ultrasound and hepatobiliary nuclide scan (HIDA scan: hepatoiminodiacetic acid) looking for infection or biliary leak

Front 278

How does the gallbladder look on a HIDA scan in a pt with acute cholecystitis?

Back 278

Doesn't visualize

Front 279

Management of postop biliary leak identified on HIDA scan

Back 279

ERCP to define anatomy

If large collection: biliary drainage w/ temporary stent placed during ERCP

Front 280

Tender lymph nodes in the groin

Back 280

Lymphadenitis (or, lower likelihood, malignancy)

Front 281

Tender testicle (acte vs. gradual)

Back 281

Acute: torsion of testis
Gradual: viral ochitis or epididymitis

Front 282

Hernia pt with N/V/abdominal distention

Back 282

Incarcerated/ strangulated hernia

Front 283

Hernia pt w/ fever, leukocytosis, and acidosis

Back 283

Strangulated segment of bowel

Front 284

Most hernia repairs involve attaching which two structures?

Back 284

Transversalis fascia to either inguinal ligament or periosteum of pubic ramus

Front 285

Most common hernia repair type

Back 285

Lichtenstein repair (prosthetic mesh approximates superior abdominal wall structures to inguinal ligament)

Front 286

Advtg of mesh?

Back 286

Avoids creating tension on fascial structures, lessening postop pain and recurrence

Front 287

Nerves at risk of injury in hernia repair

Back 287

Genitofemoral, ilioinguinal, iliohypogastric, lateral femoral cutaneous

Front 288

Pediatric hernias represent a

Back 288

Persistent patent processus vaginalis, NOT an abdominal wall defect/ defect in floor of inguinal canal

Front 289

Sliding hernias may involve which other structures herniating?

Back 289

Bladder, cecum, or sigmoid colon

Front 290

When are ventral hernias difficult to repair?

Back 290

Inadequate tissue strength, insufficient tissue, infection, or poor nutrition

Front 291

Management of a perforated duodenal ulcer

Back 291

Emergent celiotomy and ulcer closure

If no Hx of PUD, can close ulcer w/ omental patch; if long-standing disease, antrectomy w/ truncal vagotom

Front 292

Postop postprandial weakness, sweating, lightheadedness, crampy abdominal pain, diarrhea

Back 292

Dumping syndrome

Front 293

When should dumping syndrome symptoms abate?

Back 293

Within 3mo of surgery

Front 294

Mechanism of omeprazole

Back 294

Irreversabily inhibits H+/K+ ATPase in gastric parietal cells

Front 295

Management of ITP w/:
Plts >30,000
Plts <30,000
Active bleeding
Refractory

Back 295

Observe
Prednisone (+/- IVIG)
Plt transfusion
Splenectomy

Front 296

Management of appendical adenocarcinoma

Back 296

R hemicolectomy

Front 297

Management of achalasia

Back 297

Calcium channel blockers or long-acting nitrates; endoscopic dilation; Botox injection

Front 298

Pts with achalasia are at increased risk of

Back 298

Squamous cell carcinoma

Front 299

Which symptoms improve in UC pts after total proctocolectom?

Back 299

Peripheral arthritis, ankylosing spondylitis

Front 300

Indications for UC surgery

Back 300

Toxic megacolon, fulminant colitis, high grade dysplasia/carcinioma, definitive management of intractable disease (need end ileostom yas well)

Front 301

Pancreatic fluid collection 4-6wks after acute pancreatitis

Back 301

Pancreatic pseudocyst

Front 302

Rx for pancreatic pseudocyst or pancreatic abscess

Back 302

Percutaneous catheter drainage w/ Abx

Front 303

CEA and amylase levels in pancreatic malignancy

Back 303

High and low

Front 304

Conditions associated w/ familial autonomous polyposis

Back 304

Colon cancer
Fundic gland hyperplasia in stomach
Premalignant polyps in duodenum and perampullary region
Extraintestinal malignancies
Retroperitoneal and abdominal wall desmoid tumors
Benign osteomas

Front 305

Most frequent serious complication of end colostomes

Back 305

Parastomal herniation

Front 306

Cause of parastomal herniation

Back 306

Stoma placed lateral to, rather than thru, rectus muscle

Front 307

Management of parastomal herniation

Back 307

If symptomatic, needs operative relocation

Front 308

Prolapse occurs most frequently w/ what type of colostomy?

Back 308

Transverse loop colostomy

Front 309

Management of transverse loop colostomy prolapse

Back 309

Restoration of intestinal continuity or converstion to end colostomy

Front 310

Contraindication for pancreatic cancer excision

Back 310

Involvement of superior mesenteric artery

Front 311

Management of variceal bleed

Back 311

Fluisd, octreotide or vasopressin to decrease splanchnic blood flow, beta-blockers for long term prevention

Front 312

Surgical option for recurrent bleeding varices

Back 312

TIPS (transjugular intrahepatic portosystemic shunt)

Front 313

2 classes and 4 types of ulcers

Back 313

Acid associated (II: body of stomach + duodenum; III: prepyloric)
Not acid associated (I: body or lesser curvature; IV: GE junction)

Front 314

Surgical indications for ulcers

Back 314

Hemorrhage, perforation, refractory to medical Rx, inability to r/o malignancy

Front 315

What surgery is required for ulcers?

Back 315

Billroth I or II, + vagotomy if ulcer is a Type II or III (i.e. acid-associated)

Front 316

Billroth I reconstruction

Back 316

Distal gastrectomy w/ gastroduodenostomy

Front 317

Billroth II reconstruction

Back 317

Distal gastrectom w/ gastrojejunostomy

Front 318

What is a Klatskin tumor?

Back 318

Cholangiocarcinoma

Front 319

DDx of biliary obstruction (5)

Back 319

Pancreatic head cancer, periampullary carcinoma, cholangiocarcinoma, stricture of CBD, CBD stone impacted in ampulla

Front 320

2 types of pts who often get CBD strictures

Back 320

Chronic alcoholics w/ chronic pancreatitis

Pts w/ prior biliary surgery

Front 321

What is a "double duct" sign?

Back 321

Dilated CBD and pancreatic duct due to narrowing of distal CBD

Front 322

Option for surgical palliation in pts w/ unresectable pancreatic cancer, and what it helps avoid

Back 322

Biliary and gastric bypass

Prevents gastric outlet or duodenal obstruction and bile duct obstruction

Front 323

Dilated intrahepatic ducts (intrahepatic obstruction) but no dilation of the CBD (extrahepatic obstruction)

Back 323

Cholangiocarcinoma

Front 324

Where are cholangiocarcinomas located?

Back 324

At the bifurcation of the hepatic ducts

Front 325

ERCP or this alternative test can be used to identify the tumor especially if high in the bile duct

Back 325

Percutaneous transhepatic cholangiography

Front 326

Rx for cholangiocarcinoma

Back 326

If primary tumor only, excision (5 yr survival still only 15%)

If unresectable, palliative stenting (5% 5yr survival)

No role for chemo/radiation

Front 327

Biliary cancer with best cure rate

Back 327

Ampullary adenocarcinoma

Front 328

Resection method for ampullary adenocarcinoma

Back 328

Whipple

Front 329

Why is lap chole not a suitable option for malignant gallbladder adenocarcinoma?

Back 329

Need open to remove hepatic tissue (common direct spread to the liver)

Front 330

Management of calcified (porcelain) gallbladder and why

Back 330

Chole b/c of 50% association with adenocarcinoma

Front 331

What test is necessary to ensure not missing other potential diagnoses in a pt with suspected pancreatitis

Back 331

Obstructive abdominal series (rule out perforated ulcer w/ free air, etc.)

Front 332

Pancreatitis + severe deterioration and hypotension

Back 332

Severe necrotizing pancreatitis

Front 333

Two criteria systems for pancreatitis

Back 333

Ranson criteria or APACHE II

Front 334

Pt recovering from percutaneous pancreatic abscess drainage when suddenly becomes hypotensive and drainage becomes bloody

Back 334

Erosion of cathether or abscess into a major artery (diagnose w/ angiography; control w/ embolization)

Front 335

Management of elderly pt with suspected pancreatitis

Back 335

Abdominal CT b/c of concern for other pathologies (mesenteric ischemia and volvulus)

Front 336

Management of hepatic mets found during colectomy for colon cancer?

Back 336

Wedge resection

Front 337

Hernias are defects in what?

Back 337

Transversalis fascia

Front 338

Air in biliary tract of nonseptic pt?

Back 338

Biliary enteric fistula

Front 339

Complication of biliary enteric fistula

Back 339

Gallstone ileus (stone into duodenum causes SBO at distal ileum)

Front 340

Colonic syndrome w/o malignant potential and why not

Back 340

Peutz-Jeghers (intestinal polyposis and melanin spots on oral mucosa), b/c are hamartomas

Front 341

Management of gallstone ileus

Back 341

Ileotomy, removal of stone, cholecystectomy (or interval chole if too inflamed at time of op)

Front 342

Surgical indications for diverticular disease

Back 342

Hemorrhage, recurrent diverticulitis, intractable to medical Rx, complicated diverticulitis (perforated +/- abscess and fistula)

Front 343

Rx for diverticular abscess

Back 343

Percutaneous drainage then definitive resectional therapy

Front 344

Rx for perforated diverticulitis

Back 344

Hartmann's procedure (sigmoid resection w/ end colostomy and rectal stump) or sigmoid resection, anastomosis, and diverting loop ileostomy

Front 345

Rx for biliary dyskinesia

Back 345

Cholecystectomy

Front 346

Rx for gallbladder polyp

Back 346

<1cm: observe w/ serial US
Suspected carcionma: chole w/ intraop frozen section

Front 347

Management of acalculous cholecystitis

Back 347

Abx and perc chole tubes until inflammation has resolved, then lap chole

Front 348

Appendicitis presentation in the elderly (+anticoag, trauma, or sudden muscular exertion) plus mass on CT

Back 348

Hematoma of rectus sheath: conservative management

Front 349

Acute pancreatitis that won't resolve

Back 349

Pancreatic pseudocyst

Front 350

Diagnostic test and management of pancreatic pseudocyst

Back 350

CT

NPO, TPN, observe; if not improved w/in 6wks, cystogastrostomy to drain fluid into GI tract (+biopsy to r/o cancer)

Front 351

Management of simple hepatic cyst

Back 351

Observe; if persistently symptomatic, aspiration and then sclerosant or excision

Front 352

Multilocular cyst in liver w/ calcifications (and management)

Back 352

Suspect echinoccal cyst from GI parasite: need operative sterilization and excision

Front 353

Hepatic abscess

Back 353

IV antibiotics and CT-guided drainage

Front 354

Amebic hepatic abscess

Back 354

Metronidazole, no surgery

Front 355

DDx for solid liver lesion

Back 355

Hemangioma, focal nodular hyperplasia, hepatic adenoma, mets, HCC

Front 356

Pts with hepatic adenoma usually have a history of?

Back 356

OCP use

Front 357

How to diagnose a hemangioma?

Back 357

Labeled RBC scan

Front 358

Indications for surgical removal of benign liver mass

Back 358

Symptomatic, risk of spontaneous rupture, uncertainty of diagnosis

Front 359

Why is biopsy not performed when hemangioma or hepatadenoma are suspected but uncertain diagnoses?

Back 359

High risk of bleeding

Front 360

Management of hepatic adenoma?

Back 360

Stop OCPs

Front 361

Why must persistent or large hepatic adenomas be resected?

Back 361

Risk of rupture or of development into HCC

Front 362

When do hepatic adenomas have the highest risk of rupture?

Back 362

During pregnancy

Front 363

What is Bowen's disease?

Back 363

Squamous cell carcinoma in situ

Front 364

Melanoma location with worst prognosis

Back 364

Face or trunk

Front 365

Additional primary melanomas occur in what percentage of pts?

Back 365

5%

Front 366

Which melanoma pts need adjuvant therapy, and what does it consist of?

Back 366

Stage III and IV
Interferon or dacarbazine
Possibly radiation

Front 367

Management of large macular brown lesion on cheek

Back 367

Lentigo maligna (Hutchinson freckle): monitor closely, remove if changing b/c is a precursor to lentigo malignant melanoma

Front 368

Management of subungal melanoma

Back 368

Biopsy requires excision of portion of nail in continuity w/ lesion; reexcision following diagnosis involves amputation at DIP

Front 369

Prognosis for anal melanoma

Back 369

As with other mucosal melanomas, mortality is near 100% at 5 years

Front 370

Firm, painless mass that is larger than most benign tumors

Back 370

Sarcoma

Front 371

Fibrosarcoma and lymphangiosarcoma are associated w/ what two exposures?

Back 371

Fibrosarcoma: therapeutic radiation

Lymphangiosarcoma: axillary lympadenectomy

Front 372

Management of suspected sarcoma

Back 372

Excision biopsy if <3cm
Incisional biopsy if >3cm
NO FNA

Front 373

Poor prognostic indicators in sarcoma

Back 373

Mitoses, degree of necrosis, >15cm, symptomatic

Front 374

Which pts need met workup, what does it consist of, and most common locations for mets

Back 374

All! (22% have mets at presentation)
CT, MRI, CXR
Liver, lung, bone, brain

Front 375

Surgical option for sarcoma

Back 375

Extensive: often total resection of tissue compartment or amputation of extremity

Front 376

Best adjuvant therapy for sarcoma

Back 376

Radiation

Front 377

Management of sarcoma recurrence in the lung

Back 377

Thoracic wedge resection (one of the whom tumors in which excision of pulmonary mets can result in long-term disease-free survival)

Same with liver mets

Front 378

7 factors that slow wound healing

Back 378

Malnutrition
Diabetes
Jaundice
Uremia
Steroids
Chemo
Smoking

Front 379

Why can pts not do heavy lifting for 6wks postop?

Back 379

Collagen production and cross-linking are still occurring, so not yet at full tensile strength, prone to injury/disruption

Front 380

Hard knot-like structure underneath surgical wound

Back 380

Likely a suture knot: should resolve if was absorbable suture, otherwise can be removed under local anesthesia once wound is fully healed

Front 381

What is healing by third intention?

Back 381

Delayed primary closure

Front 382

Erythema and some pus drainage around wound 3mo postop

Back 382

Stitch abscess

Front 383

Management of a stitch abscess

Back 383

Explore opening w/ hemostat and remove suture under local anesthesia

Front 384

Management of postop ventral hernia thru wound

Back 384

Surgery

Front 385

How long should a wound be observed for before considering revision for its appearance?

Back 385

6mo

Front 386

Management of hypertrophic scar

Back 386

Steroid injections and local pressure dressings

Revision usually not appropriate as are likely to recur

Front 387

Raised hypertrophic scar that is spreading outside immediate area of incision

Back 387

Keloid (same as treatment for hypertrophic)

Front 388

Management of wound infection

Back 388

Drainage and debridement; usually don't require Abx (only if cellulitis spreading despite drainage)

Front 389

2 types of wounds that heal by secondary intention

Back 389

Wounds that are intentionally left open

Wounds that become infected and require opening in immediate postop period

Front 390

What is the process of a graft revascularizing from granulation tissue called?

Back 390

Inosculation

Front 391

What is the advantage of split thickness skin grafts for wounds?

Back 391

Reduce wound contraction by 60%

Front 392

Disadvantage of skin grafts

Back 392

More susceptible to trauma than normal skin

Front 393

What is required for the skin graft to attach successfully?

Back 393

Bacterial count on granulation bed must be <10^5 bacteria/gram of tissue

Front 394

Four categories of wounds

Back 394

Clean, clean-contaminated, contaminated, infected

Front 395

Management of contaminated wound

Back 395

Leave open to heal by secondary infection, treat with saline-soaked gauze

Front 396

Definition of a clean wound

Back 396

No entry made into GI, respiratory, or GU tracts and no active infection

Front 397

Definition of clean-contaminated wound

Back 397

There is entry into GI, resp, or GU tract but it is prepared both mechanically and antibacterially (e.g. bowel prep before surgery)

Front 398

Need for prophylactic Abx for clean, clean-contaminated, and contaminated

Back 398

Clean: none
Clean-contaminated: single preop and postop dose

Front 399

4 situations in which prophy Abx are indicated

Back 399

Exposure to bacteria
Prosthetic material
Immunosuppression
Poor bloody supply

Front 400

When should prophy Abx be given?

Back 400

1 hr preop
Postop: multiply half-life of drug by 1-2.5

Front 401

Prophy Abx of choice

Back 401

Amox (or amp if IV)
Pen-allergic: clinda or cephalexin (or cefazolin if IV)

Front 402

Rx for amebic liver abscess

Back 402

Metronidazole

Front 403

Rx for pyogenic liver abscess

Back 403

Perc drainage + Abx against G- and anaerobes

Front 404

Best diagnostic test to determine treatment for sliding hiatal hernia?

Back 404

Flexible endoscopy to look for esophagitis

Front 405

1st test when extrahepatic biliary obstruction is suspected?

Back 405

EUS

Front 406

Increased SGOT and SGPT indicate

Back 406

Hepatocellular disease

Front 407

Increased alk phos indicates

Back 407

Biliary obstruction

Front 408

Obese/hirsute man with painful fluctuant mass btwn gluteal clefts

Back 408

Infected pilonidal cyst

Front 409

Hematochezia, fever, abd pain

Back 409

Ischemic colitis

Front 410

Management of ischemic colitis vs. acute mesenteric ischemia

Back 410

Expectant (IVF, bowel rest, supportive) vs. surgery

Front 411

Pts who undergo major colon resections undergo what change in their bowel habits?

Back 411

None, usually; lots of reserve capacity for water absorption

Front 412

Pts who undergo major colon resections undergo what change in their bowel habits?

Back 412

None, usually; lots of reserve capacity for water absorption

Front 413

Work-up of rectal cancer

Back 413

Rigid proctoscopy (to assess distance of lesion from anal verge); barium enema or colonoscopy to r/o other lesions; CT abd/pelvis for mets; MRI for extent of local invasion; endorectal US for depth of invasion

Front 414

Where are most dietary carbs absorbed?

Back 414

Duodenum (even in short gut syndrome is in residual jejunum)

All of milk except fat absorbed in duodenum

Front 415

Rx for hepatic adenomas <4cm vs. >4cm

Back 415

OCP cessation vs. surgical resection b/c of risk of rupture/hemorrhage

Front 416

Management of acute hemorrhage from L-sided portal HTN (gastric varices + splenic or portal vein thrombosis w/o cirrhosis)

Back 416

Splenectomy

Front 417

Management of hepatic focal nodular hyperplasia

Back 417

Nothing

Front 418

Acute appendicitis presentation but w/ terminal ileum edema/fibrinopurulent exudate in OR

Back 418

Regional enteritis; in kids, just do appy

Front 419

Management of iatrogenic injury of CBD --> biliary stricture

Back 419

End-to-side choledochojejunostomy (Roux-en-Y) performed over a stent

Front 420

Acute intestinal radiation injury is manifested by

Back 420

Diarrhea or GI bleeding

Front 421

Chronic intestinal radiation injury causes ___ and can lead to these clinical problems

Back 421

Progressive vasculitis and fibrosis

Malabsorption, ulceration, fistulization, or perforation

Front 422

4 things that inhibit intestinal motility

Back 422

Sympathetics: drugs, hormones, emotions (fear)
Gastrin

Front 423

Factor that stimulates intestinal motility

Back 423

Parasyms: acetylcholine

Front 424

Best test for diagnosis of gastrinoma

Back 424

Secretin stimulation test

Front 425

Another name for gastrinoma

Back 425

Zollinger-Ellison syndrome

Front 426

Most common location of a gastrinoma

Back 426

"Gastrinoma triangle" : duodenum, junction of neck/body and pancreas, and junction of cystic and common bile duct

Front 427

Expected fluid/electrolyte status in SBO

Back 427

Dehydration from vomiting and poor oral intake

Contraction alkalosis with hypokalemia (due to loss of H+, Na+, and Cl-)

Front 428

Concern with SBO and heme-positive stool in rectum

Back 428

Obstructing tumor or ischemic bowel

Front 429

Management of SBO due to inguinal hernia

Back 429

Urgent repair and relief of bowel obstruction due to risk of strangulation

Front 430

Most common tumor that metastasizes to the intestine

Back 430

Melanoma

Front 431

Indications for surgical exploration with SBO

Back 431

Localized abdominal tenderness, fever, tachy, leukocytosis, metabolic acidosis (high risk for strangulation)

Front 432

2 operative management choices for pt with SBO with uncertain bowel viability

Back 432

Resect and anastamose
OR
Second look operation 24hrs later

Front 433

Greatest risk associated w/ enterotomy

Back 433

Postop leak and development of small bowel fistula

Front 434

3 causes of abdominal distention other than SBO

Back 434

Ileus, air swallowing, constipation

Front 435

Diagnostic tests for suspected ischemic bowel

Back 435

Sigmoidoscopy
Mesenteric angiogram (to determine whether candidate for surgical revascularization)

Front 436

Long-term medical Rx after surgical revascularization

Back 436

ASA

Front 437

Management if full-thickness necrosis found on sigmoidoscopy

Back 437

Exploration and resection (vs. mucosal ischemia only, can observe closely)

Front 438

Long-term management of pt with necrosis from ligament of Treitz to transverse colon

Back 438

Can resect, esp in younger pt, but will have short bowel syndrome and need chronic TPN/ small bowel transplant

Front 439

Most common location for Crohn's

Back 439

Ileocolic

Front 440

Thickened bowel wall with fibrous strictures and deep fissures

Back 440

Crohn's

Front 441

Epithelial ulceration and crypt abscesses

Back 441

UC

Front 442

Noncaseating granulomas or mesenteric lmphadenopathy can both indicate this type of IBD

Back 442

Crohn's

Front 443

Focal aphthous ulcers can indicate this type of IBD

Back 443

Crohn's (whereas general ulceration is usually UC)

Front 444

What is the "string sign" and what does it indicate?

Back 444

Narrowing of terminal ileum from edema: Crohn's

Front 445

Rx for acute disease vs. prevention in UC

Back 445

Steroids for acute
5-aminosalicylic acid for prevention of relapse

Front 446

Drug for perianal Crohn's

Back 446

Metronidazole

Front 447

Problems associated w/ resection of the terminal ileum

Back 447

Poor reabsorption of bile acids and vita B12 --> diarrhea, malabsorption, oxalate stones, B12 deficiency

Front 448

Rx for Crohn's disease of the rectum

Back 448

Can use 5-acetylsalicylic acid

Front 449

Screening recommendations for UC of pancolitis vs. L-colon only

Back 449

Colonoscopy every 1-2yrs beginning after 8yrs of disease vs. after 10yrs of disease

Front 450

Why are random biopsies during colonoscopy necessary in UC?

Back 450

Colon cancer of UC doesn't always follow sequence of polyp --> cancer

Front 451

Fever, blood-tinged diarrhea, and pain on defecation after a total proctocolectomy w/ ileal pouch- anal anastamosis

Back 451

Pouchitis

Front 452

Rx for pouchitis

Back 452

Metronidazole

Front 453

Pt with UC, abdominal pain, distention, fever, and bloody diarrhea

Back 453

Worry about toxic megacolon

Front 454

Diagnostic test for toxic megacolon

Back 454

Abdominal series (v. dilated colon w/ mucosal edema and w/o signs of abscess or perforation); often also a CT to r/o abscess or perf

Front 455

Rx for toxic megacolon

Back 455

If stable: NGT, NPO, TPN, IVF, broad spectrum Abx, high-dose IV steroids

Front 456

Suspected toxic megacolon + free air on upright CXR

Back 456

Perforation! Immediate OR

Front 457

Air in wall of colon on XR

Back 457

Impending perforation, likely OR!

Front 458

PEX manuever that must always be done when appendicitis is suspected?

Back 458

Rectal exam to detect pain in the right pelvis from retrocecal appendicitis

Front 459

Appendicitis like presentation + dysuria/urinary WBCs

Back 459

Possibly uncomplicated UTI, but also possibly appendiceal abscess in continuity w/ bladder

Front 460

Abd pain + urinary RBCs too numerous to count

Back 460

Severe UTI or kidney stone

Front 461

Pregnant woman with RUQ pain

Back 461

Worry about appendicits (appendix has been shifted)

Front 462

Surgical management of perforated appendicitis w/ localized abscess

Back 462

Appy + incise, drain, and irrigaet abscess; leave closed drain in abscess draining to outside; close muscle but leave skin open

Front 463

Suspected appendicitis with small yellow firm mass at TIP of appendix

Back 463

Carcinoid tumor (if not spread, just needs routine appy)

Front 464

Suspected appendicitis with larger yellow firm mass at BASE of appendix

Back 464

Needs excision; if >2cm or at base, suggestive of malignancy and indication for R colectomy

Front 465

Diagnostic tests needed after carcinoid tumor diagnosed on path

Back 465

Baseline urinary 5-hydroxyindoleacetic acid (5-HIAA) and serum serotonin level (carcinoid determinants of malignancy involve mostly biological behavior of tumor)

Front 466

Management of postop pelvic abscess

Back 466

Drain w/ perc catheter if possible, other open surgical drainage (or transrectal/ transvaginal drainage)

Front 467

Colonoscopy screening for pts with first degree relative w/ CRC or adenomatous polyp?

Back 467

Starts at 40yo (or 10yrs prior to relative's diagnosis?)

Front 468

Colonoscopy screening for pts with FH of FAP?

Back 468

Genetic counseling, yearly flex sig

Colectomy once polyps discovered

Front 469

Colonoscopy screening for pts with FH of HNPCC?

Back 469

Genetic testing and colonoscopy every 1-2yrs beginning at age 20yo, yearly beginning at 40yo

Front 470

Colonoscopy screening for pts w/ Hx of large or multiple adenomatous polyps that were remoevd?

Back 470

Colonoscopy 3yrs after removal

Front 471

Colonoscopy screening for pts with Hx of CRC

Back 471

Colonoscopy 1yr after initial op, screening at 3yrs and then 5yr intervals

Front 472

CEA measurement indications after CRC

Back 472

Every 2-3mo for 2yrs (detects 80% of recurernces)

Front 473

Surgical management for external vs. internal hemorrhoids

Back 473

External: excision
Internal: excision or banding

Front 474

Any hemorrhoids w/ bleeding need what?

Back 474

Colonoscopy to r/o colon cancer

Front 475

2 types of polyps

Back 475

Pedunculated (on a stalk)
Sessile (flush w/ mucosa)

Front 476

F/u after polypectomy

Back 476

Repeat colonoscopy after 3-6mo to ensure sucessful removal and then surveillance colonoscopy every 3yrs

Front 477

Management of carcinoma in head sv. stalk of pedunculated polyp

Back 477

Head: polypectomy only
Stalk (esp if margin <2cm, poorly differentiated, or vascular/lymphatic invasion): may require bowel resection in addition to polypectomy

Front 478

Staging studies for colon cancer

Back 478

CXR
CEA
LFTs

Front 479

Most common presenting symptoms of R or L-sided colon cancer

Back 479

Pain/mass

Front 480

Most common presenting symptoms of sigmoid colon cancer

Back 480

Pain or bowel complaints

Front 481

Most common presenting symptoms of rectal cancer

Back 481

Bowel complaints or bleeding

Front 482

Prep before bowel surgery (3 parts)

Back 482

- Bowel prep (polyethylene glycol or mag citrate)
- Oral nonabsorbed Abx (to decrease colonic bacteria)
- Single preop dose of 2nd generation cephalosporin (to decrease wound infections)

Front 483

Specific places to explore for colon cancer mets

Back 483

Small bowel mesentery, peritoneal surface, diaphragm, liver

Front 484

Postop management after colon cancer surgery

Back 484

NPO w/ IVF until bowel function returns; d/c when tolerating food

Front 485

Colon cancer prognosis worse for these types of tumors (4)

Back 485

Mucus-producing
Signet ring cell tumors
Tumors p/w bowel perf
Tumors w/ venous or perineural invasion

Front 486

What types of adjuvant chemo are used in colon cancer pts and for what stage?

Back 486

Stage III
5-FU and leucovorin or levamisole

Front 487

Screening f/u after colon cancer

Back 487

Repeat colonoscopy at 6mo then 12mo intervals + frequent monitoring of CXR, CEA, and LFTs

Front 488

Management of colon cancer + large liver lesion

Back 488

Large liver lesions shouldn't be resected at tmie of surgery

Front 489

Feculent vomiting postop from colectomy ddx (2)

Back 489

Leakaeg from anastomosis --> persistent ileus

Mechanical obstruction

Front 490

Cause of feculent material draining from inferior wound

Back 490

Anastomotic leak that is spontaneously draining to skin; should close with NPO and IVF; need CT scan to determine if there is undrained collection

Front 491

Diagnosis and management of distended colon

Back 491

Likely sigmoid or cecal volvulus

Proctosigmoidoscopy first to eval for/hopefully treat sigmoid volvulus; if negative, emergent celiotomy for presumed cecal volvulus (risk of rupture in 1-2hrs)

Front 492

Common additional site of liver cysts

Back 492

Lung

Front 493

2 equivalent management options for echinococcal liver infections

Back 493

Surgical drainage

Albendazole/mebendazole + perc drainage

Front 494

2 causes of feculent vomiting after colectomy

Back 494

- Leakage from anastomosis --> persistent ileus
- Mechanical obstruction due to adhesions, hernia, or obstructed anastamosis

Front 495

Management of feculent material draining from inferior aspect of colostomy wound

Back 495

Likely due to anastomotic leak

NPO, IVF, usually will self-close

Front 496

Pt 6mo s/p colostomy for colon cancer returning w abd pain, constipation, small stools

Back 496

Concern for anastomotic recurrence of cancer or stricture at anastomosis

Front 497

Rectal carcinomas spread to which lymphatic nodes?

Back 497

Internal iliac
Sacral
Inferior mesenteric
Inguinal (if <5cm from anal verge)

Front 498

Type of resection necessary for rectal cancer >5cm above anal verge vs. <5cm

Back 498

>5cm, can do anterior resection

<5cm, need abdominoperineal resection due to margins including sphincter

Front 499

Which rectal cancers require postop chemo?

Back 499

Stage III (regional LNs) or high-risk stage II

Front 500

Which rectal cancer pts receive preop radiation?

Back 500

Those with large/bulky tumors

Front 501

2 alternatives to colostomy for rectal carcinoma

Back 501

Sphincter-preserving proctectomy or local resection

Front 502

Pelvic pain after rectal cancer

Back 502

Early postop: operative nerve injury or infection

Later: need to r/o local recurrence w/ CT pelvis

Front 503

Which hepatic mets are unresectable?

Back 503

Multiple lesiosn in both lobes, lesions intimate w/ vascular structures or invading local structures, or lesions in cirrhotic livers

Front 504

Most common cause of anal cancer and presenting symptoms

Back 504

SCC
Bleeding, drainage, pain, pruritis

Front 505

Where does anal cancer metastasize to?

Back 505

Inguinal LNs (also superior rectal LNs)

Front 506

Staging w/u for anal cancer

Back 506

CT and transrectal US

Front 507

3 treatment regimens for anal cancer depending on location of lesion:
- Superficial, small, mobile
- Large w/o extension or LNs
- + LNs

Back 507

- Local excision alone
- Nigro protocol: chemo (5-FU, mitomycin C) and radiation, then resection only if there's biopsy-proven residual cancer
- Chemoradiation, then radical resection

Front 508

Pain med to be avoided in diverticulitis

Back 508

Morphine (b/c increases intracolonic pressure)

Front 509

Management of 2nd episode of diverticulitis

Back 509

Elective resection 4-6wks after inflammation has resolved (b/c risk of significant complication (perf, abscess) increases w/ each recurrence)

Front 510

What is required before surgery for diverticulitis?

Back 510

Preop or intraop colonoscopy to identify region w/ diverticula

Front 511

Diverticulitis w/ patient deteriorating

Back 511

Free perforation or intra-abdominal abscess

Front 512

Eval for suspected perf/abscess from diverticulitis

Back 512

CT

Front 513

Management of diverticulitis abscess

Back 513

CT-guided needle insertion of catheter in collection

Front 514

What is Ogilvie syndrome?

Back 514

Pseudo-obstruction: massive cecal and colonic dilation in absence of mechanical obstruction

Front 515

Management of Ogilvie syndrome?

Back 515

D/c narcotics/ anticholinergics; endoscopic colonic decompression if dilation >10cm; surgery if perforation or ischemia suspected

Front 516

Cause of Zenker's diverticulum

Back 516

Premature contraction of cricopharyngeal muscle on swallowing --> partial obstruction

Front 517

Symptoms of Zenker's

Back 517

Dysphagia, regurgitation, recurrent aspiration PNA

Front 518

Diagnosis and treatment of Zenker's

Back 518

Barium swallow
Diverticulectomy w/ cricopharyngeal myotomy

Front 519

RUQ pain, jaundice, GI bleeding

Back 519

Quincke triad for hemobilia

Front 520

Causes of hemobilia

Back 520

Iatrogenic (from percutaneous liver procedures), anticoagulation, gallstones, parasitic infection, neoplasm

Front 521

Diagnosis and treatment of hemobilia

Back 521

Angiography/ endoscopy
Angiographic embolization if intrahepatic
Surgery if bleeding from extrahepatic bile ducts or gallbladder

Front 522

Noncaseating granulomas are associated with this type of IBD

Back 522

Crohn's

Front 523

IBD w/ crypt abscess

Back 523

UC

Front 524

Sensation of voided air with urination

Back 524

Pneumaturia, e.g. from colovesical fistula

Front 525

Most common type of fistula due to diverticulitis

Back 525

Colovesical fistula

Front 526

Most common cause of rapid lower GI bleeding

Back 526

Bleeding diverticula and vascular ectasias

Front 527

Rx for vascular ectasia

Back 527

Coagulation w/ monopolar current

Front 528

Why are diverticula associated w/ bleeding?

Back 528

Underlying vasa recta artery penetrating thru bowel wall

Front 529

How to diagnose an ongoing GI bleed w/ negative upper and lower scopes

Back 529

Technetium-labeled RBC scan or mesenteric angiography

Front 530

When to use angiography vs.RCN scanning

Back 530

Angiography in less stable pts
RBC scanning in more stable pts, can detect slower bleeds

Front 531

2 treatment options for bleeding discovered during angiography

Back 531

Vasopressin into the vessel
Embolization

Front 532

Typical pt/ causes of sigmoid volvulus

Back 532

Debilitated pts from nursing homes due to chronic laxative use, chronic illness, or dementia

Front 533

Type of obstruction in sigmoid volvulus

Back 533

Closed loop obstruction

Front 534

Rx for sigmoid volvulus

Back 534

Rigid proctosigmoidoscopy and placement of rectal tube

Front 535

Definitive Rx for sigmoid volvulus

Back 535

Sigmoid colectomy w/ colostomy or anastomosis

Front 536

Rx for cecal volvulus

Back 536

Urgent surgical treatment w/ detorsion alone, cecopexy, or right colectomy

Front 537

3 treatment options for Ogilvie's syndrome w/ colon diameter >11-12cm (otherwise conservative Rx)

Back 537

1) Endoscopic decompression
2) Neostigmine (increases colonic tone and counteracts dilation)
3) Surgical decompression

Front 538

Rx for rectal prolapse

Back 538

Internal: high fiber diet
External w/ bleeding: surgery

Front 539

3 surgical options for prolapse

Back 539

1) Rectopexy (no removal)
2) Transabdominal rectosigmoid resection
3) Perineal approach w/ removal and anastamosis

Front 540

Rx for anal fissures (conservative vs. more invasive)

Back 540

Bulk agents/ softeners, sitz baths

If deep and chronic, lateral sphincterotomy +/- biopsy if suspicious for cancer

Front 541

What are anal fissures and what causes them?

Back 541

Tears in the anoderm (--> painful BM, tenderness on palpation, blood on TP) due to repeated trauma from hard stools or IBD

Front 542

Pain and drainage in sacrococcygeal area

Back 542

Pilonidal abscess (infection in hair-containing sinus in sacrococcyx)

Front 543

Rx for pilonidal abscesses

Back 543

Unroof, remove all hair, leave open to heal by secondary intention

Front 544

Most common complications of stomas

Back 544

#1: leakage around the bag
Also parastomal herniation, bowel obstruction abscess, fistula formation

Front 545

What is a Hartmann pouch?

Back 545

If distal bowel is closed and not brought to abdominal wall but rather dropped back into pelvis

Front 546

Common indication for Hartmann pouch

Back 546

Diverticulitis when bowel can't be safeul reconnected

Front 547

Small intestine bleeding in a pt under 30

Back 547

Meckel's diverticulum

Front 548

Work-up for suspected Meckel's?

Back 548

99m-Tc pertechnate scan

Front 549

What type of tumor is a carcinoid tumor?

Back 549

Apudoma

Front 550

Congenital cystic dilation of the extrahepatic biliary duct?

Back 550

Choledochal cyst

Front 551

Management of choledochal cyst?

Back 551

Complete resection of cyst (due to risk of malignant changes) and roux-en-y choledochojejunostomy

Front 552

What is stress ulceration?

Back 552

Acute gastric or duodenal erosive lesions following shock, sepsis, major surgery, trauma, or burns

Front 553

Cause of stress ulceration?

Back 553

NOT increased acid; may be ischemic damage to mucosa; often ulcers are in multiple places

Front 554

Treatment of pancreatic pseudocyst?

Back 554

Wait 6wks to allow for spontaneous resolution; then excise, externally drain, or internally drain into GI tract

Front 555

Do pancreatic pseudocysts have malignant potential?

Back 555

No, b/c have no epithelial lining

Front 556

Complications of pseudocysts

Back 556

Gastric outlet and extrahepatic biliary obstruction

Spontaneous rupture and hemorrhage

Front 557

What is a Diuelafoy's lesion?

Back 557

Abnormally large submucosal artery that protrudes thru small, solitary mucosal defect 6cm distal to GEJ --> spontaneous bleeding

Front 558

Rx for Diuelafoy's lesion?

Back 558

Endoscopic

Front 559

When is hemicolectomy needed for appendiceal carcinoid tumors?

Back 559

If >2cm

Front 560

Asthma, right heart valvular disease, flushing, hepatomegaly, diarrhea

Back 560

Carcinoid syndrome

Front 561

Indication for resection of a gallbladder polypoid lesion?

Back 561

Clinical symptoms

Front 562

Electrolyte abnormalities after pancreatectomy

Back 562

Hypocalcemia
Hypophosphatemia
Iron deficiency
Pernicious anemia

Front 563

Characteristics of cecal diverticula?

Back 563

Congenital
Solitary
True diverticula (involve all layers of bowel wall)

Front 564

Management of liver hemangiomas?

Back 564

Can usually observe; affected by hormones, but usually only hemorrhage iatrogenically (from attempted biopsy)

Front 565

CEA is elevated in these pts w/o cancer

Back 565

Smokers

Front 566

High CEA indicates?

Back 566

High likelihood liver involvement/ peritoneal spread

Front 567

Management of Mallory Weiss tear?

Back 567

If bleeding stopped: expectant
To control bleeding: balloon tamponade, endoscopic control, gastrostomy/oversewing, or vasopressin (but not in CAD pts)

Front 568

Types of gastric ulcers and which are acid-associated?

Back 568

I (lesser curvature)
II (gastric and duodenal)
III (pyloric)
IV (juxtracardial)
II and III are acid associated

Front 569

Rx for Type I ulcer

Back 569

Antrectomy (+/- vagotomy)

Front 570

Surgical Rx for type III ulcer?

Back 570

Vagotomy and antrectomy

Front 571

Surgical Rx for toxic megacolon?

Back 571

Subtotal colectomy with end ileostomy

Front 572

Rx for SCC of the anus refractory to Nigro protocol (chemo and XRT)?

Back 572

Abdominal-perineal resection w/ permanent end colostomy

Front 573

Rx for proximal and midrectal cancers?

Back 573

Low anterior resection

Front 574

Radiolucency under right hemidiaphragm indicates?

Back 574

Pneumoperitoneum

Front 575

Causes of pneumoperitoneum

Back 575

Perforated diverticulum, perforated gastric ulcer, perforated transverse colon carcinoma, or strangulated hernia w/ necrotic bowel

Front 576

Intestines in upside down U

Back 576

Sigmoid volvulus

Front 577

How does PEEP improve oxygenation?

Back 577

Increasing FRC b ykeeping alveoli open at end of expiration

Front 578

Potential negative effects of increased PEEP (3)

Back 578

- Alveolar overdistention --> pneumothoraces
- Decreased venous return/CO
- Increased minute ventilation requirements due to increased dead space ventilation

Front 579

Systemic hypotension, JVD, distant heart sounds

Back 579

Beck's triad for cardiac tamponade

Front 580

What is pulsus paradoxus?

Back 580

Decrease in SBP by >10 at end of inspiration

Front 581

Risk factors for eriop MI

Back 581

Previous infarction, esp w/in 6mo
DOE
Age >70
MR
> 5 PVCs/min
Tortuous or calcified aorta

Front 582

When should you not use epi w/ lidocaine?

Back 582

Tissues supplied by end arteries (fingers/ toes, ears, nose, penis)

Front 583

What can interfere with measurement of wedge pressure w/ Swan Ganz catheter?

Back 583

PEEP or CPAP

Front 584

Increased risk of periop stroke with?

Back 584

History of stroke

Front 585

What is the mortality from periop stroke?

Back 585

High

Front 586

PaCO2 levels are a reliable indicator of?

Back 586

Adequacy of alveolar ventilation

Front 587

Respiratory acidosis from hypercarbia

Back 587

Alveolar hypoventilation

Front 588

Hypoxemia with increased PCO2 is NOT

Back 588

PE, pulmonary edema, PNA, or atelectasis (b/c those pts should be hyperventilating (decreased CO2) to improve oxygenation

Front 589

Benefits of albumin vs. transferrin/acute phase reactants to eval nutritional status

Back 589

Long life life (3 wks) vs. short (hrs), but not affected by intravascular volume

Front 590

The physiologic goal of shivering is to ___, which causes ___

Back 590

Generate heat to maintain core temp

Increases metabolism by 3-5x, which increases O2 consumption/ CO2 production, which is usually counterproductive in critically ill pts

Front 591

What should be administered preop in a pt with vWD?

Back 591

Cryoprecipitate (provides both FVIII and vWF)

Front 592

Best choice for stress ulcer prophylaxis

Back 592

Sucralfate (better than antacids, which cause loss of acidic protection and G- overgrowth)

Front 593

Procedure for tracheostomy

Back 593

Skin incision below cricoid cartilage, strap muscles spared and retracted, thyroid isthmus divided if necessary, trachea entered at second tracheal ring

Front 594

Rx for malignant hyperthermia
(3)

Back 594

Cessation of anesthesia, hyperventilation w/ 100% O2, IV dantrolene

Front 595

Effect of PE on CVP

Back 595

Increases by causing RV overload and increasing RAP

Front 596

Renal failure with eosinophilia

Back 596

Cholesterol atheroembolism

Front 597

Hyperkalemia, hyponatremia, hypoglycemia, fever, weight loss, dehydration

Back 597

Adrenocortical insufficiency (e.g. Addison's disease)

Front 598

Why are antacids given before emergency intubation?

Back 598

Risk of intubation, esp if don't know gastric contents

Front 599

Rx for necrotizing fasciitis

Back 599

Wide debridement

Front 600

Passive rewarming is appropriate for which pts?

Back 600

Mild hypothermia (between 34 and 36C)

Front 601

Smoke inhalational injuries: cause, which lab value is elevated, mortality

Back 601

Epithelial injury from chemical irritation

Carboxyhemoglobin

Low in absence of cutaneous burns

Front 602

Which anesthetic can cause seizures?

Back 602

Enflurane

Front 603

Adjunct anesthetic that can cause hypotension if given in bolus

Back 603

Morphine

Front 604

Anesthetic with nephrotoxicity

Back 604

Methoxyflurane

Front 605

Complications of halothane

Back 605

Hypotension, decreased CO

Front 606

Anesthetic that can cause increased distension if used in a pt with bowel obstruction

Back 606

Nitrous oxide

Front 607

Hypertensive pt after carotid endarterectomy is at risk for ___, so needs this treatment and monitoring

Back 607

- Hemorrhagic stroke
- Aggressive BP management with nitroglycerin or nitroprusside
- Arterial cath for beat to beat monitoring of BP

Front 608

Indications for intracranial pressure monitoring (5)

Back 608

Subarachnoid hemorrhage, hydrocephalus, postcraniotomy status, Reye's syndrome, blunt head trauma w/ repeated surgeries

Front 609

A thrombin time measures the function of what?

Back 609

Fibrinogen

Front 610

Which nerve innervates the majority of the intrinsic hand muscles?

Back 610

Ulnar nerve

Front 611

Which nerve innervates the extensor muscle (and one other function)?

Back 611

Radial nerve (also does forearm supination w/ musculocutaneous nerve)

Front 612

Which inflammatory mediator is key to wound healing?

Back 612

Monocytes (phagocystose + secrete GFs)

Front 613

When in healing to fibroblasts appear?

Back 613

Day 3

Front 614

Which type of collagen predominates during proliferative phase of wound healing, and what is it replaced with?

Back 614

Type III
Type I

Front 615

Lympangitic inflammatory streaking along extremities indicates infection with what type of bacteria, and what Abx are indicated?

Back 615

Strep
Penicillin

Front 616

Cutaneous ulcers associated with IBD?

Back 616

Pyoderma gangrenosum

Front 617

Rx for pyoderma gangrenosum

Back 617

Systemic steroids and immunosuppressants (e.g. cyclosporine)

Front 618

Rx for frostbite (initial rewarming and overall)

Back 618

Rapid warming in hot water (40-44C)

Elevation, Abx, tetanus toxoid, debridement of necrotic skin

Front 619

What are clean surgical wounds?

Back 619

No part of respiratory, GI, or GU tract entered

Front 620

3 causes of squamous cell carcinoma

Back 620

Sun exposure, chronic ulcers or sinus tracts (draining osteomyelitis), history of radiation or thermal injury

Front 621

Advantage/disadvantage of Mohs surgery

Back 621

Improved cosmetic result, but longer time required (small increments with immediate frozen section analysis); no difference in outcomes

Front 622

Where do the superficial and deep finger flexors insert and which has a common muscle belly?

Back 622

Superficial: middle phalanx
Deep: distal phalanx; common muscle belly (so only superficial flexors can move finger when others are immobilized)

Front 623

Healing a tendon injury requries formation of a ___, requiring a balance between ____?

Back 623

Tenoma, which tends to become adherent to surrounding sheath; need balance btwn avoiding adhesions w/ early mobilization and risk of rupturing unhealed tendon

Front 624

Tendon repair of the hand is most difficult in which area?

Back 624

Fibroosseous tunnels

Front 625

When should devitalized tissue be excised in cases of severe burns?

Back 625

Early, except w/ deep wounds of palms, soles, genitals, and face

Staged excision of deep partial-thickness or full thickness burns btwn 3 and 7 days after injury

Front 626

Topical therapy used for burns to delay colonization?

Back 626

Silver sulfadiazine

Front 627

Why can skin autograft not be placed over eschar?

Back 627

Requires a vascular bed

Front 628

When should longitudinal escharotomy be performed?

Back 628

First sign of vascular compromise

Front 629

Rare complication of silver nitrate

Back 629

Methemoglobinemia

Front 630

More common complication of silver nitrate

Back 630

Hyponatremia and other electrolyte imbalances

Front 631

Main complication with silver sulfadiazine

Back 631

Neutropenia

Front 632

Main complication with mafenide acetate

Back 632

Metabolic acidosis 2/2 inhibition of carbonic anhydrase

Front 633

Where is SCC of the lip usually found?

Back 633

Lower lip (b/c of sun exposure)

Front 634

When are early carpal tunnel syndromes often noticed?

Back 634

Nocturnally

Front 635

When does carpal tunnel often present in women?

Back 635

During pregnancy, w/ recurrent symptoms during PMS in subsequent periods

Front 636

What is responsible for wound contracture?

Back 636

Fibroblasts with actin microfilaments

Front 637

Initial Rx for leukoplakia

Back 637

Oral hygiene, avoidance of alcohol/tobacco, avoidance of chronic irritation (e.g. ensuring dentures fit properly)

Front 638

When does leukoplakia need biopsy?

Back 638

Thick lesions

Front 639

When are cleft lips/palates repaired?

Back 639

Lip in first 3mo of life
Palate at 12-18mo

Front 640

What is a Marjolin's ulcer?

Back 640

SCC that develops in a chronic wound such as a previous burn scar or sinus tract 2/2 osteo

Front 641

Rx for Marjolin's ulcer

Back 641

Surgical excision or amputation

Front 642

What is the cause of compartment syndrome for burn pts?

Back 642

Increased pressure 2/2 tissue edema and lack of elasticity of burnt skin (eschar)

Front 643

Rx for compartment syndrome due to burns

Back 643

Escharotomies of affected extremity

Front 644

Which wounds should not be closed?

Back 644

- Dirty or contaminated (e.g. animal bites)
- Trauma by puncture/gunshot or crush injury)
- Older than 6hrs

Front 645

What prophylactic Abx should be used for bowel cases?

Back 645

3rd generation cephalosporin (for G- coverage)

Clinda or metronidazole for anaerobic coverage

Front 646

Ulcer over medial malleolus, painless, and associated w/ brawny induration

Back 646

Venous stasis ulcer

Front 647

Most common location for diabetic ulcers

Back 647

Plantar surface of foot

Front 648

Most common location for ischemic ulcers

Back 648

Dorsum of foot or 1st/5th toe

Front 649

Rx for acute diaphragmatic rupture

Back 649

Emergent ex lap

Front 650

What is a seatbelt sign and how is it managed?

Back 650

Abdominal wall ecchymosis from seatbelt

Observe for signs of enteric or mesenteric injury even if pt stables/tests negative

Front 651

When should you tape the chest for rib fracture and why?

Back 651

Never! (compounds problem of inadequate ventilation)

Front 652

Management for lower rib fractures

Back 652

Imaging to assess for associated abd injuries, pain control, admit if respiratory probelms, will heal spontaneously

Front 653

Organ most likely to be daamged in blunt abd trauma

Back 653

Spleen

Front 654

Rx for venous injury in hemodynamically unstable pts

Back 654

Ligation, not repair (only repair if HDS, is a proximal vein, and there is also an arterial injury)

Front 655

Rx for signs of arterial insufficiency w/ signs of neuro compromise in extremity (Ps)

Back 655

Immediate op and repair

Front 656

Eval for penetrating trauma below nipples

Back 656

Diagnostic peritoneal lavage

Front 657

Why is local wound exploration contraindicated in penetrating trauma to the chest?

Back 657

Risk of creating pneumothorax

Front 658

Insulin secretion in trauma pts is?

Back 658

Increased

Front 659

Rx for complete common bile duct transection

Back 659

T-tube
W/ loss of tissue, choledochojejunostomy or cholecystojejunostomy

Front 660

Abd trauma w/ pain, RUQ mass, obstructive symptoms, and coiled spring appearance of duodenum

Back 660

Duodenal hematoma

Front 661

Rx for duodenal hematoma

Back 661

NGT and observe

Front 662

Rx for closed radial nerve palsy

Back 662

Fracture reduction and observation, 90% will self resolve

Front 663

First sign of increased ICP

Back 663

Change in level of consciousness

Front 664

Initial Rx for increased ICP w/ hypotension

Back 664

Hyperventilation (mannitol or head elevation may exacerbation hypotension)

Front 665

What is flail chest?

Back 665

Paradoxical respiratory movement due to at least 2 fractures in each of 3 adjacent ribs

Front 666

Rx for flail chest

Back 666

Analgesia, chest physiotherapy

Mechanical ventilation only if respiratory compromise develops

Front 667

High carboxyhemoglobin levels indicate

Back 667

Carbon monoxide poisoning

Front 668

Rx for carbon monoxide poisoning (mild vs. severe) and for how long?

Back 668

Mild: 100% O2
Severe (coma, respiratory failure): Hyperbaric chamber

Either should last until carboxyhemoglobin levels are <10%

Front 669

Rx for single pelvic fracture in pelvic ring

Back 669

Bed rest until HDS, then gentle ambulation

Front 670

How does fluid resuscitation for electrical injury compare to that for thermal injury?

Back 670

Can't use BSA b/c often deep tissue damage is worse than superficial; need massive amts of fluid

Front 671

Electrical pts require f/u with what specialists?

Back 671

Ophthalmologists (b/c of risk of cataract development)

Front 672

Highest rate of vascular injury comes with this MSK injury

Back 672

Knee dislocations (due to extreme force required to dislocate the joint)

Front 673

Indications for thoracotomy after chest tube placement?

Back 673

1500ml of blood on initial chest tube placement
OR
Persistent bleeding at 200mL/hr for 4hrs or 100 mL/hr for 8hrs

Front 674

With subQ emphysema in the extremities, worry about

Back 674

Necrotizing fasciitis

Front 675

Rx for suspected clostridium infection

Back 675

High dose penicillin G

Front 676

Rx for myocardial contusion with normal ECG

Back 676

Tele for 24hrs, no need for ICU, low risk of complications

Front 677

Cellular changes during injury/sepsis (4)

Back 677

- Gluconeogenesis
- Acute phase protein synthesis (fibrinogen, completement, haptoglobin, ferritin)
- Decreased glutamine (is consumed)
- Increased urinary nitrogen loss and peripheral release of aas (from accelerated protein breakdown)

Front 678

Diagnostic test for suspected penetrating injury to rectum

Back 678

Sigmoidoscopy

Front 679

Why is barium contraindicated in suspected penetrating injury to colon, and what should be used instead?

Back 679

Spillage of barium mixed with feces into peritoneal cavity would increase likelihood of intraabdominal abscess

Water-soluble medium

Front 680

Rx for postop bile leak

Back 680

ERCP with sphincterotomy and/or tenting

Front 681

When is a bile leak a biliary fistula?

Back 681

If drains >50cc/day for over 2 wks

Front 682

When is a bile leak major, and what mangement does that warrant?

Back 682

Early biliary drainage >300cc/day

Re-laparotomy and hepatico-jejunostomy

Front 683

What cannot be excluded following vascular trauma w/ ischemic changes despite palpable pulses?

Back 683

Arterial injury

Front 684

When do blowout orbital fractures require immediate operative intervention (4)?

Back 684

- Extraocular muscle entrapment (e.g. inability to move eye in particular direction)
- Fracture >50% of orbital floor
- Diplopia
- Enophthalmos >2mm

Front 685

Management of blunt renal trauma?

Back 685

Nonsurgical:
- Bedrest to decrease likelihood of secondary hemorrhage
- Abx to reduce likelihood of infection w/in hematoma

Front 686

If urethral injury is suspected, what should be done prior to placing a Foley?

Back 686

Retrograde urethrogram

Front 687

Management of pt with urethral injury who cannot receive a Foley cath?

Back 687

Suprapubic cath

Front 688

3 complications of pancreatic injury

Back 688

Fistula, pseudocyst, abscess

Front 689

Most common cause of death in pts with pancreatic injury

Back 689

Exsanguination from associated injury to major vascular structures

Front 690

Management of penetrating pancreatic injur

Back 690

Most just need simple drainage

Front 691

How does a pneumatic antishock garment work?

Back 691

Elevates BP by increasing peripheral vascular resistance

Front 692

How should a pneumatic antishock garment be discontinued?

Back 692

Very slowly to prevent sudden irreversible hypotension

Front 693

Indications for ER thoracotomy

Back 693

- Release cardiac tamponade in pts deteriorating radpily
- Cross-clamping of descending in aorta if can't maintain BP otherwise
- Internal cardiac massage for pts w/ faint pulses/distant heart sounds and other resuscitation unsuccessful

Front 694

Rx for enterocutaneous fistulas

Back 694

Bowel rest, TPN, correct electrolyte abnormalities

Front 695

Complications of enterocutaneous fistulas

Back 695

Fluid and electrolyte depletion, skin necrosis, malnutrition

Front 696

Imaging study for pt with enterocutaneous fistula

Back 696

Small-bowel follow through to determine location, relation to other organs, and whether there is distal obstruction

Front 697

Which enterocutaneous fistulas are least likely to close?

Back 697

Proximal small bowel fistulas (up to mi-ileum) w/ high output of fluid

Front 698

Choice for repair of artery

Back 698

End-to-end anastamosis if possible
If too much lost, use a vein graft

Front 699

Contraindications for nonoperative management of a splenic injury (2)

Back 699

Indication of associated injury requiring operation (e.g. peritonitis)

Hemodynamically unstable pt or deteriorating

Front 700

4 criteria through which DPL can be positive (diagnostic peritoneal lavage)

Back 700

>10cc gross blood initially
>100,000 RBC/ uL
> 500 WBC / uL
Elevated amylase, bili, or alk phos

Front 701

CXR indications of thoracic aortic injury

Back 701

Widening of mediastinum
Loss of aortic knob
Sternal or scapular fracture
Multiple L rib fractures
Massive L hemothorax

Front 702

PEX difference in pts in neurogenic vs. hypovolemic shock

Back 702

Neurogenic: pts are warm and pink and usually bradycardic
Hypovolemic: pts are cold and clammy and usually tachycardic

Front 703

Abdominal compartment syndrome causes (5)

Back 703

- Increased ICP/ decreased CPP (Due to decreased venous return)
- Decreased venous return/CO
- Increased SVR
- Increased peak airway pressures
- Decreased RBF/GFR and liver function

Front 704

Rx for laryngeal obstruction

Back 704

Cricothyroidotomy

Front 705

Rx for pericardial tamponade

Back 705

Subxiphoid, supradiaphragmatic incision and creation of pericardial window

Front 706

Rx for an open pneumothorax

Back 706

Occlusive dressing over defect; later thoracostomy tube (preferably thru separate incision) and formal closure of chest wall

Front 707

Which cells produce TNF?

Back 707

Monocytes/macrophages (present in G-shock and sepsis)

Front 708

Paucity of bile ducts on liver bipsy years after transplant indicate

Back 708

Chronic rejection

Front 709

Rx for chronic liver rejection

Back 709

Retransplantation

Front 710

Rx for portal venous thrombosis early after transplant

Back 710

XL and thrombectomy

Front 711

Sequela of hepatic arterial thrombosis

Back 711

Biliary strictures 2/2 ischemia

Front 712

What is combined in a transplant cross match?

Back 712

Donor lymphocytes w/ recipient serum

Front 713

What is a cross match searching for, and why would those things be present?

Back 713

Recipient Abs against donor HLA antigens

Not naturally present but acquired from pregnancy, blood transfusion, or prior transplant

Front 714

What does a positive cross match predict?

Back 714

Transplantation will cause a hyperacute rejection

Front 715

Shortly after receiving chemo, pt becomes febrile w/ hyperkalemia, hyperphosphatemia, and hypocalcemia

Back 715

Tumor lysis syndrome

Front 716

Which cells mediate tumor lysis syndrome?

Back 716

Cytotoxic T cells

Front 717

How does cyclosporine work?

Back 717

Inhibits IL-2 production, so there is no expansion of cytotoxic T cells or production of antibodies

Front 718

Conservative measures for renal failure pts not yet in need of emergent dialysis

Back 718

<60g of protein/day
Limit fluids
Kayexylate for hyperkalemia

Front 719

Best transplant matches

Back 719

Living relative with 6 HLA matches > living relative with 0 HLA matches > cadaveric transplant

Front 720

Most common cause of death within 1yr of cardiac transplant

Back 720

Infection

Front 721

Most common cause of death after 1yr of cardiac transplant

Back 721

Accelerated graft arteriosclerosis

Front 722

Presentation of hyperacute renal rejection

Back 722

Swollen bluish oliguria

Front 723

Histology of hyperacute renal rejection

Back 723

Fibrin; platelet thrombosis; necrosis of glomerular tufts, renal arterioles, and small arteries

Front 724

Rx for hyperacute renal rejection

Back 724

Plasmapheresis and cyclophosphamide decrease antibody load, but no definitive treatment available

Front 725

Main toxicity of cyclosporine

Back 725

Nephrotoxicity

Front 726

Matching criteria for cardiac transplants

Back 726

Size and ABO compatability (cannot tissue-type like with renal transplants, b/c can only be protected by hypothermia for 4hr)

Front 727

Increased Cr, decreased UOP, fever, tenderness 2mo after renal transplant

Back 727

Acute rejection (1wk-3mo posttransplant)

Front 728

Rx for acute renal rejection

Back 728

Biopsy to confirm diagnosis, high dose steroids, anti-T-cell antibody (e.g. OKT3)

Front 729

4 most common post-transplant viruses

Back 729

CMV, EBV, VZV, Herpes viruses

Front 730

CMV infection can cause

Back 730

Ulceration and hemorrhage in GI tract
Pneumonitis, retinitis, encephalitis, pancreatitis

Front 731

Best and worst survival rate after liver transplant is for which pts?

Back 731

Best: cholestatic liver disease
Worst: fulminant hepatic failure

Front 732

Rx for GVHD

Back 732

More aggressive immunosuppression

Front 733

Glucose and end-organ outcomes after pancreas transplant for T1DM

Back 733

Normal serum glocuse and normal GTT

No reversal of diabetic retinopathy or reduction in ulcers/amputations

Can prevent recurrence of nephropathy if combo w/ kidney transplant

Front 734

How long should presence of an extrahepatic malignancy defer liver transplant for?

Back 734

2yrs after curative therapy

Front 735

Contraindication to liver transplant

Back 735

Alcohol use w/in 3mo

Front 736

What is OKT3?

Back 736

Monoclonal Ab against CD3 antigen complex on mature T cells

Front 737

Severe complications of OKT3 (4)

Back 737

Noncardiogenic pulmonary edema
Encephalopathy
Aseptic meningitis
Nephrotoxicity

Front 738

What is OKT3 used for (3)?

Back 738

Rejection prophylaxis, acute rejection, induction therapy

Front 739

Diagnostic test for enlarged cervical LNs

Back 739

FNA (or open biopsy if lymphoma is suggested)

Front 740

When should adjuvant chemo be started?

Back 740

10-14 days after surgery, to allow for wound healing (unless there are compelling clinical indications for more urgent treatment)

Front 741

Extravasation of chemo agents during IV administration may cause what?

Back 741

Severe ulceration and sloughing

Front 742

What can normalize wound healing when given with methotrexate?

Back 742

Folinic acid

Front 743

For which 4 tumor types is histologic grade closely correlated with stage/ prognosis?

Back 743

Soft tissue sarcoma, transitional cell cancer of the bladder, astrocytoma, chondrosarcoma

Front 744

Wilms tumor is associated with what 4 conditions and how often?

Back 744

Aniridia, cryptorchidism, hemihypertrophy, hypospadias
10%

Front 745

Most common presentation of Wilms tumor

Back 745

Asymptomatic mass (hematuria in less than half, hypertensive in just over half)

Front 746

MEN 1 tumors

Back 746

Pituitary, pancreatic, parathyroid

Front 747

MEN 2A tumors

Back 747

Hyperparathyroidism, pheochromocytoma, medullary thryoid cancer

Front 748

MEN 2B tumors

Back 748

Pheochromocytoma and mucosal neuromas, medullary thyroid cancer, gangliomas

Front 749

Most common GI site for non Hodgkin's lymphoma?

Back 749

Stomach

Front 750

What are interferons?

Back 750

Glycoproteins; products of virus-infected cells that inhibit viral replication

Front 751

3 diseases that interferons are very effective in

Back 751

Burkitt's lymphoma
Hairy cell leukemias (and other hematologic malignancies)
Hep B and C

Front 752

Typical procedure for parotid carcinoma

Back 752

Superficial parotidectomy w/ facial nerve preservation (may need deeper/loss of nerve if tumor is more involved) + regional node dissection (50% rate of occult mets)

Front 753

Most common operative complication of chemotherapy?

Back 753

Perirectal abscess

Front 754

This condition carries an increased risk of testicular cancer

Back 754

Cryptorchidism (even after surgical correction)

Front 755

Procedure for testicular cancer

Back 755

Inguinal orchiectomy + LN dissection if embryonal or teratoma

Front 756

Why don't seminomas need LN dissection?

Back 756

Very radiosensitive

Front 757

Why don't choriocarcinomas need LN dissection

Back 757

Very chemosensitive, often w/ pulm mets

Front 758

Pheos are associated with these 4 syndromes

Back 758

MEN 2A, MEN 2B, VHL, NF-1

Front 759

What causes tissue death from radiation?

Back 759

Both direct effect of xrays and indirect effect mediated by free radicals

Front 760

Which cells are resistant to radiation?

Back 760

Those deficient in oxygen

Front 761

Cells in which phase of the cell cycle are most sensitive to radiation?

Back 761

M phase

Front 762

IL-2 is an effective drug for pts with which two metastatic diseases?

Back 762

Metastatic melanoma and metastatic RCC

Front 763

Complications of IL-2 treatment

Back 763

Lymphocytosis, eosinophilia, fluid retention, fever, decrease in peripheral vascular resistance (is like septic shock)

Front 764

Nitrates and nitrosamides are associated with what kind of cancer?

Back 764

Stomach cancer

Front 765

Excessive amts of dietary fat and fiber deficiency is associated with what kind of cancer?

Back 765

Colorectal cancer (and pancreas, prostate, and uterine)

Front 766

3 elements of the mainstay of immunosuppression for cardiac and renal transplants

Back 766

Steroids
Calcineurin inhibitors (FK506 or cyclosporine)
Antimitotic agents (azthioprine or mycophenylate mofetil)

Front 767

Should needles be capped or uncapped for HIV pts?

Back 767

Always uncapped! Capping procedures are more dangerous

Front 768

RET protooncogene is associated w?

Back 768

MEN 2

Front 769

PTEN tumor suppressor gene is associated w/?

Back 769

Cowden disease (multiple harmartoma syndrome)

Front 770

p16 tumor suppressor gene is associated w/?

Back 770

Malignant melanoma

Front 771

Which tumors are more likly to be ER+, BRCA1 associated or BRCA2?

Back 771

BRCA 2

Front 772

Which other cancers are associated with BRCA1?

Back 772

Colon and prostate

Front 773

Which other cancers are associated with BRCA2?

Back 773

Gallbladder, bile duct, pancreatic, gastric, melanoma, prostate

Front 774

Toxicity associated w/ cyclophosphamide

Back 774

Hemorrhagic cystitis

Front 775

Toxicity associated w/ bleomycin

Back 775

Pulmonary fibrosis

Front 776

Toxicity associated w/ vincristine

Back 776

Peripheral and central neurotoxicity

Front 777

Toxicity associated w/ cisplatin

Back 777

Oto/neuro/nephrotoxicity

Front 778

Toxicity associated w/ 5-FU

Back 778

Mucositis, dermatitis, cerebellar dysfunction

Front 779

4 posttransplant malignancy and the viruses associated with them?

Back 779

Posttransplant lymphoproliferative disorder (enlarged LNs): EBV
HCC: HBV or HCV
Kaposi's sarcoma: HHV8
Cervical cancer: HPV

Front 780

Rx for posttransplant lymphoproliferative disorder

Back 780

Withdraw immunosuppression, antivirals, chemo, or monoclonal Abs

Front 781

What is tertiary hyperparathyroidism?

Back 781

Persistent hypercalcemia 2/2 autonomous parathyroid function after renal transplant (high calcium pre and posttransplant)

Front 782

What is a Dukes C colon cancer?

Back 782

AKA Stage III, indicates involves adjacent LNs

Front 783

Mild increase in creatinine shortly after renal transplant likely indicates?

Back 783

Nephrotoxicity from cyclosporine, hold it

Front 784

Low WBC count after renal transplant likely indicates?

Back 784

Bone marrow toxicity from azathioprine, hold it

Front 785

Rx for renal transplant pt with CMV

Back 785

High dose gancyclovir

Front 786

Elevated Cr 3-6mo after transplant with vs. without fever and graft tenderness and Rx

Back 786

With: likely rejection, start steroid burst and/or OKT3
Without: likely cyclosporine toxicity, hold it

Front 787

Rx for adrenal insufficiency

Back 787

Exogenous steroids

Front 788

Preop Rx for Addison's disease

Back 788

Exogenous steroids

Front 789

Best test for adrenal insufficiency?

Back 789

ACTH stimulation test

Front 790

Difference between adenoma and carcinoma on thyroid scan

Back 790

High uptake (hot) for adenoma
Low uptake (cold) for carcinoma

Front 791

Swelling under incision, stridor, difficulty breathing after thyroidectomy and Rx

Back 791

Wound hematoma: intubation, explore wound, evacuate hematoma, control bleeding

Front 792

True or false: previous history of therapeutic radiation to breast is an absolutely contraindication to lumpectomy with XRT

Back 792

True

Front 793

Rx for inflammatory breast cancer

Back 793

Surgery, chemo, and XRT

Front 794

3 Rx options for prolactinomas

Back 794

Asymptomatic: observe
Symptomatic: dopamine agents (e.g. bromocriptine)
Refractory symptoms: surgery

Front 795

What is sestamibi scanning for?

Back 795

Parathyroid problems

Front 796

Labs in primary hyperparathyroidism (2 most imp for diagnosis)

Back 796

Increased PTH with increased serum calcium

Front 797

Hypercalcemia with low urinary calcium

Back 797

Familial hypocalciuric hypercalcemia (vs. in primary hyperparathyroidism, urinary calcium should be high or nml)

Front 798

Usual Rx for glucagonoma

Back 798

Distal pancreatectomy

Front 799

Rx for hyperglycemia in unresectable glucagonoma pts

Back 799

Octreotide

Front 800

When do adrenal adenomas need to be resected?

Back 800

If they are functioning, nonfunctioning but >6m, or carcinoma suspected

Front 801

Rx after adrenal surgery

Back 801

Steroid replacement for 6-12mo postop, even if contralateral adrenal is normal

Front 802

Radiation-induced thyroid cancer is usually what histo type?

Back 802

Papillary

Front 803

Rx for radiation-induced thyroid cancer

Back 803

Near total or total thyroidectomy due to high incidence of bilateralityand more effective use of radioactive iodine postop

Front 804

What % of pts with radiation history and thyroid nodule have cancer?

Back 804

40%

Front 805

Risk of invasive breast cancer after LCIS: what type, what location, and for how long?

Back 805

Most commonly ductal carcinoma

Risk equivalent in both breasts, last indefinitely, not correlated to amt of LCIS

Front 806

Whorled pattern in breast mass on young girl?

Back 806

Fibroadenoma

Front 807

Work up for incidentally identified adrenal tumor (e.g. small incidentaloma) (4 things and what each is ruling out)

Back 807

- Dexamethasone suppression test (to r/o Cushing's)
- 24hr urine collection to r/o pheo
- Serum lytes and plasma renin/aldosterone to r/o aldosteronoma
- MRI to r/o malignancy

Front 808

First therapy for hypercalcemia

Back 808

Vigorous hydration to restore intrasvascular volume --> renal perfusion and increased urinary calcium excretion

Front 809

What diuretics should be used in hypercalcemia?

Back 809

Loop diurectics (Lasix); thiazides are contraindicated b/c cause pts to become hypercalcemic

Front 810

Indications for surgery for asymptomatic primary hyperparathyroidism

Back 810

<45yo
Markedly increased urine Ca
Kidney stones
Decreased Cr clearance
Marked hypercalcemia
Decreased bone mass

Front 811

Two causes of fat necrosis in the breast

Back 811

Trauma
Prolonged pressure

Front 812

Fat necrosis is often confused with?

Back 812

Breast cancer (although it doesn't increase the risk of carcinoma)

Front 813

Diagnosis and treatment of fat necrosis

Back 813

Excisional biopsy, once confirmed, then excision

Front 814

45yo woman with HTN, hair development, and 7cm suprarenal

Back 814

Functional adrenocortical tumor (functional indicates can secrete cortisol, androgens, estrogen, aldosterone, or multiple hormones)

Front 815

What is Cushing's disease?

Back 815

Pituitary tumor --> hypercortisolism --> bilateral adrenal hyperplasia

Front 816

Rx for functional adrenocortical tumor

Back 816

Resection

Front 817

Adjuvant therapy for unresectable functional adrenocortical tumor

Back 817

Mitotane

Front 818

Preop treatment for pheo

Back 818

Alpha blockade 1-3wks in advance (+ volume expansion)
Then add beta blockade (not alone b/c of risk of CV collapse)

Front 819

True or false: chemotherapy is contraindicated during pregnancy

Back 819

False; only during first trimester, is generally safe during second and third trimesters

Front 820

Nipple erosion and eczema

Back 820

Paget's disease of the breast

Front 821

Paget's disease with a mass

Back 821

Likely an infiltrating ductal carcinoma

Front 822

Rx for Paget's disease

Back 822

Modified radical mastectomy (possibly less if no associated mass?)

Front 823

Paradoxical rise in serum gastrin and IV secretin is diagnostic of what syndrome?

Back 823

Zollinger Ellison syndrome

Front 824

Rx for Zolllinger-Ellison syndrome

Back 824

Distal pancreatectomy (where the gastrinoma mass usually is)

Front 825

Which drugs are useful in Zollinger Ellison syndrome?

Back 825

H2 blockers

Front 826

Preop treatment before thyroidectomy for Graves disease to prevent postop thyroid storm

Back 826

Medicate to euthyroid
10 days of Lugol's iodide solution, propylthiouracil, or methimazole

Front 827

Rx for thyroid storm

Back 827

Beta blockade (e.g. propanolol)

Front 828

Rx for primary hyperparathyroidism

Back 828

Resection of usually solitary adenoma

Front 829

Rx for parathyroid hyperplasia

Back 829

Resection of 3 1/2 parathyroid glands; leave the rest and can reexplore if needed
Calcium and possibly Vita D supplementation afterward

Front 830

Rx for cystosarcoma phyllodes

Back 830

Wde excision with adequate margins

Front 831

What is Hurtle cell cancer and how does it usually behave?

Back 831

Type of follicular thyroid cancer; often multifocal and bilateral, more likely to metastasize, higher mortality

Front 832

Rx for Hurthle cell lesions?

Back 832

Lobectomy if unilateral adenoma
Total thyroidectomy for carcinoma

Front 833

What test is not useful for Hurthle cell cancer and why?

Back 833

FNA, b/c can't determine invasion

Front 834

Amyloid deposits in the stroma of a thyroid tumor indicate?

Back 834

Medullary carcinoma

Front 835

Rx for follicular thyroid mass

Back 835

Adenoma: lobectomy
Carcinoma or >4cm: total thyroidectomy

Front 836

12 signs of Cushing's syndrome

Back 836

Truncal obesity
HTN
Hirsutism
Moon facies
Proximal muscle wasting
Ecchymoses
Skin striae
Osteoporosis
DM
Amenorrhea
Growth retardation
Immunosuppression

Front 837

What percent of gastrinomas/insulinomas are malignant?

Back 837

50%/10%

Front 838

What antibiotic is useful in unresectable malignant insulinoma?

Back 838

Streptozotocin (controls symptoms by selectively destroying islet cells)

Front 839

How do the characteristics of positive lymph nodes change the staging of breast cancer

Back 839

Palpable lodes are only Stage II unless they are fixed or matted, then Stage III

Front 840

What is desmoplasia/ a desmoplastic reaction?

Back 840

Growth of fibrous or connective tissue, secondary to another insult (e.g. scar formation around a neoplasm or adhesions after abdominal surgery)

Front 841

Rx for sclerosing adenosis

Back 841

Nothing: is a benign lesion

Front 842

Rx for LCIS

Back 842

Twice yearly exams and yearly mammography; is not a precancerous lesion in itself, just predicts future risk of cancer but equal in both breasts

Front 843

Which subtype of DCIS has the highest recurrence?

Back 843

Comedo

Front 844

Rx for stress urinary incontinence

Back 844

Estrogen, pelvic floor exercises, timed voiding, or urethral sling surgery

Front 845

Rx for urge incontinence

Back 845

Anticholinergics, biofeedback, timed voiding

Front 846

Cause of overflow incontinence

Back 846

Bladder outlet obstruction

Front 847

Cause and Rx for total incontinence (continuous leakage of urine)

Back 847

Fistula
Surgery

Front 848

Hypospadias in the scrotal area is associated with these 2 other problems

Back 848

Bilateral undescended testes
Infertility

Front 849

Where is hypospadias most commonly

Back 849

Corona

Front 850

Hypospadias in the corona is often associated with a?

Back 850

Chordee (ventral curvature of penis)

Front 851

Why would a pt not have hematuria with a kidney stone?

Back 851

If completely occluding lumen of ureter

Front 852

What % of kidney stones recur

Back 852

50% within 5-10yrs

Front 853

Initial Rx for kidney stones

Back 853

Hydration and analgesics

Front 854

Pathophys of testicular torsion

Back 854

Abnormally narrowed testicular mesentery w/ tunica vaginalis surrounding testis and epididymis in bell clapper deformity

Front 855

Testicular pain decreased w/ elevation

Back 855

Prehn sign for epididymitis

Front 856

Rx for testicular torsion

Back 856

Bilateral orchiopexy

Front 857

Which renal tumor can only be diagnosed on patho?

Back 857

Oncocytoma

Front 858

3 types of benign kidney lesions

Back 858

Simple cysts, angiomyolipomas, oncocytomas

Front 859

Rx for RCCs based on size

Back 859

<4cm: partial nephrectomy
>4cm: radial nephrectomy (includes ipsilateral adernal gland and perirenal fat)

Front 860

How does prostate cancer spread?

Back 860

Direct extension, lymphatics, blood vessels

Front 861

Most common site of distant mets from prostate cancer?

Back 861

Axial skeleton with osteoblastic bony lesions

Front 862

Rx for prostate cancer with T1 masses in men >65yo?

Back 862

Expectant management

Front 863

Where in the gland does prostate cancer usually initiate?

Back 863

Periphery

Front 864

Risk factors for prostate cancer

Back 864

FH, African American, diet

Front 865

Surgical indications for BPH

Back 865

Urinary retention refractory to medical Rx, upper tract dilation, renal insufficiency 2/2 outflow obstruction, bladder stones, recurrent UTIs

Front 866

Rx for BPH

Back 866

TURP

Front 867

Postop problem with TURP

Back 867

Hyponatremia due to hemodilution 2/2 absorption of irrigation fluid

Front 868

Management of suspected ruptured urethra

Back 868

Retrograde urethrogram
If complete disruption: suprapubic cath, delay repair 4-6mo (after which hematoma will be resolved)

Front 869

Rx for ureteral injury

Back 869

Reconstruction (primary anastamosis vs. ureteroplasty)

Front 870

Rx for ureteral injury if can't do immediate repair

Back 870

Placement of stent w/ catheter into proximal ureteral stump and delayed reconstruction

Front 871

Which kidney stones require further workup?

Back 871

>1cm (if <.5cm, likely to pass spontaneous): IV pyelogram

If high-grade obstruction, need nephrostomy or passage of ureteral stent

Front 872

Rx for cryptoorchidism

Back 872

Inguinal orchiopexy before 1yo

Front 873

To which LNs do seminomas usually metastasize?

Back 873

Along regional lymhatic drainage pathways to iliac, aortic, and renal LNs

Front 874

Rx for seminoma

Back 874

Removal of affected testis
Sample LN (usually external iliacs) for mets; if present, radiation

Front 875

Best postop assessment of sigmoid viability?

Back 875

Sigmoidoscopy

Front 876

Repeated cellulitis in pt with unilateral LE swelling is due to?

Back 876

Unilateral primary lymphedema

Front 877

Pt s/p AAA repair now w/ severe L flank pain and bloody mucus per rectum

Back 877

Ischemic colitis due to damage to IMA

Front 878

Smokers often have isolated atherosclerosis in which LE artery?

Back 878

Superficial femoral

Front 879

Diabetics often have isolated atherosclerosis in which LE artery?

Back 879

Tibioperoneal

Front 880

Inability to dorsiflex toes may indicate

Back 880

Anterior compartment syndrome

Front 881

Acute arterial occlusion w/o collaterla inflow and rapid reperfusion of ischemic muscle may cause

Back 881

Anterior compartment syndrome

Front 882

Rx for claudication

Back 882

Smoking cessation, weight loss, exercise; vasodilators don't help

Front 883

How long is aspirin's antiplatelet effect?

Back 883

7-10days

Front 884

Mechanism of aspirin

Back 884

Inhibits synthesis of thromboxane A2 and subsequent production of prostaglandins

Front 885

Pt with angina and claudication who is now light-headed on exertion especially when working with his arms may have?

Back 885

Subclavian steal syndrome

Front 886

What is the subclavian steal syndrome?

Back 886

Atherosclerotic occlusion of subclavian artery proximal to vertebral artery so that when involved arm (usually left) exercises, becomes relatively ischemia, causing reversal of flow thru the vertebral artery --> diminished flow to the brain

Front 887

Rx for subclavian steal syndrome

Back 887

Carotid-subclavian bypass or subclavian-carotid transposition (or dilation/stenting of artery)

Front 888

Aortoiliac atherosclerotic occlusive disease causes what symptom?

Back 888

Claudication of buttock and thigh

Front 889

Bilateral stenosis or occlusion of what arteries can cause sexual impotence?

Back 889

Hypogastric (internal iliac) arteries

Front 890

Best predictor of periop ischemic cardiac eevnts for peripheral vascular surgery

Back 890

Dipyridamole-thallium imaging (pts often can't undergo stress test)

Front 891

Management of acute graft occlusion is with what med?

Back 891

Urokinase (fewer allergic rxns than streptokinase)

Front 892

% effectiveness of urokinase and reocclusion rate %

Back 892

75% effective
20% reoccluded w/in 1yr (even if angioplasty or anastamotic revision performed; 50% w/o surgical revision)

Front 893

Rx for symptomatic popliteal aneurysm

Back 893

Exclusion (ligation) and surgical bypass; can also terat asymptomatic pts if good surgical candidates

Front 894

Cause of popliteal aneurysms and what else to look for

Back 894

Atherosclerosis
Often bilateral and/or associated with extrapopliteal aneurysms

Front 895

Abdominal pain out of proportion to PEX?

Back 895

Intestinal ischemia

Front 896

Increased serum lactate may be associated with what arterial pathology?

Back 896

Mesenteric ischemic

Front 897

Management of pt with AAA and horshoe kidney

Back 897

Preop arteriogram to define the likely unusual vascular anatomy

Retroperitoneal dissection and implantation of all renal arteries

Front 898

Immunocompromised pt with new murmur, fever, back pain, and enlarged saccular abdominal aorta below renal arteries

Back 898

Mycotic aortic aneurysm

Front 899

What is the cause of mycotic aortic aneurysms?

Back 899

Infection w/ staph or salmonella

Front 900

Rx for infrarenal mycotic aortic aneurysm

Back 900

Axillofemoral bypass, excision of invovled aorta, grafting, Abx for 3-6mo

Front 901

Best surgical option for rest claudication in otherwise healthy patient

Back 901

Aortoefmoral bypass

Front 902

Best surgical option for rest claudication in pt with many comorbidities

Back 902

Extraanatomic bypass (femorofemoral or axillofemoral bypass)

Front 903

Contraindication to femorofemoral bypass?

Back 903

Bilateral iliac artery disease

Front 904

Rx for empyema

Back 904

Thoracotomy with decortication (to allow lung to reexpand) and antibiotics

Front 905

Facial swelling and cyanosis on bending over

Back 905

Superior vena cava syndrome

Front 906

Top 2 causes of SVC syndrome

Back 906

Bronchogenic carcinoma
Lymphoma

Front 907

Rx for SVC syndrome

Back 907

Diuresis
Radiation and chemo for malignancy

Front 908

Rx for perforation of esophagus during endoscopy for pts w/ and w/o underlying esophageal problem

Back 908

Without: thoracotomy w/ primary repair and drainage of mediastinum

With: thoracotomy with esophagectomy

Front 909

Rx for lung abscess

Back 909

Prolonged Abx; if fails, percutaneous or surgical drainage

Front 910

Rx for descending aortic dissection

Back 910

Reduction in change in BP over change in time (dP/dT): beta blockade, then nitroprusside

Front 911

Indications for operative intervention for descending aortic disection

Back 911

End-organ failure, inadequate pain relief despite medical Rx, rupture, signs of impending rupture (increasing diameter or periaortic fluid)

Front 912

Unilateral hip pain on outer surface of thigh, more painful with pressure (e.g. when sleeping)

Back 912

Trochanteric bursitis

Front 913

What is Paget's disease of the bone and what are pts predisposed to?

Back 913

Osteitis deformans: accelerated bone turnover in localized areas --> focal bony hypertrophy

Bone is weak and prone to pathologic fractures

Front 914

How to distinguish trochanteric bursitis pain from that of hip OA?

Back 914

Trochanteric: superficial
Hip OA: pain is deep within the joint, may be referred to inguinal area/ knee

Front 915

Which manuevers worsen trochanteric bursitis vs. hip OA?

Back 915

TB: external rotation or resisted abduction

OA: internal rotation

Front 916

Peritoneal abdomen, bloody stool, N/V

Back 916

Bowel infarction

Front 917

Acute abdominal or back pain followed by syncope and eventually hypovolemic shock

Back 917

AAA rupture

Front 918

Where does the pain in acute renal colic start/ radiate to?

Back 918

Unilateral flank pain, radiates to groin

Front 919

Differentiate the swelling in a ligamentous knee injury vs. meniscal

Back 919

Ligamentous: rapid from hemarthrosis

Meniscal: over 12-24hrs

Front 920

"Popping" sensation in knee likely indicates

Back 920

Meniscal injury

Front 921

Tenderness over medial knee in athlete or obese older woman w/out popping sensation

Back 921

Anserine bursitis

Front 922

2 most common complications from rhinoplasty

Back 922

Nasal obstruction
Epistaxis

Front 923

Whistling noise after nasal surgery, and why pts are at risk for this complication

Back 923

Nasal septal perforation (at risk b/c of poor blood supply: is cartilage)

Front 924

Which pts are predisposed to nasal polyps

Back 924

Asthma/ allergic disorders (due to chronic inflammation)

Front 925

Symptom of nasal polyp and management

Back 925

Chronic nasal obstruction
If symptomatic: surgical removal

Front 926

Pain, tenderness, and erythema within the nose

Back 926

Nasal furuncuolosis 9from staphylococcal folliculitis)

Front 927

Predisposing factors for nasal furunculosis

Back 927

Nose picking or nasal hair plucking

Front 928

Why is nasal furuncolosis life threatening?

Back 928

Can spread to cavernous sinus

Front 929

What are the two most common causes of postop nasal septal perforation?

Back 929

Septal hematoma
Septal abscess (much less common)

Front 930

Most common iatrogenic cause of tension pnuemo

Back 930

Subclavian central venous catheter placement

Front 931

Malignant vs. benign breast calcifications

Back 931

Malignant: microcalcs
Benign: coarse calcs

Front 932

Breast biopsy with fat globules and foamy histiocytes

Back 932

Fat necrosis

Front 933

One week after abdominal injury w/ negative CT pt has fever, shaking chills, and deep abdominal pain

Back 933

Retroperitoneal abscess from pancreatic injury (wouldn't necessarily be diagnosed on initial CT, unlike many other injuries)

Front 934

Trauma pt with gross hematuria

Back 934

Suspect bladder injury

Front 935

Diagnostic test for suspected bladder injury

Back 935

Retrograde cystogram w/ post void films

Front 936

First step in management of a pt with new-onset oliguria with a Foley

Back 936

Change Foley to ensure not clogged (then fluids)

Front 937

Pts with Crohn's are predisposed to what GU abnormality and why?

Back 937

Nephrolithiasis
Fat malabsorption --> hyperoxaluria

Front 938

Struvite stones are often due to persistent infection by what bacteria?

Back 938

Proteus

Front 939

What are staghorn calculi?

Back 939

Struvite stones that fill the entire renal pelvis

Front 940

N/V, abd pain, hypoglycemia, and hypotension after stressful event (e.g. surgery)

Back 940

Adrenal insufficiency

Front 941

Which pts are particularly predisposed to this type of postop adrenal insufficiency?

Back 941

Steroid-dependent pts

Front 942

What is the cause of postop obstructive atelectasis?

Back 942

Airway blockage --> retained air distal to occlusion (which is eventually reabsorbed); affected airway becomes airless and collapses

Front 943

Compensation for hypoxemia due to postop atelectasis

Back 943

Respiratory alkalosis (hyperventilation)

Front 944

How far in advance of surgery is preop smoking cessation beneficial?

Back 944

>8wks prior to surgery
If closer, actually have increased risk of postop pulm complications

Front 945

Unilateral bloody nipple discharge in perimenopausal woman with no other findings on PEX/imaging

Back 945

Intraductal papilloma

Front 946

Why are intraductal papillomas often not palpated/ visualized on imaging?

Back 946

Small size (US can only detect >1cm) and beneath areola so difficult to palpate

Front 947

Rx for unresponsive trauma pt who is still hypotensive after fluids

Back 947

Emergent ex lap (suspect continued bleeding)

Front 948

What is Legg-Calve-Perthes isease?

Back 948

Avascular necrosis of femoral capital epiphysis

Front 949

Radiologic difference between SCFE and Legg-Calve-Perthes

Back 949

SCFE: femoral epiphysis is structurally intact w/in acetabulum, just misaligned

LCP: severe abnormalities of epiphysis/ avascular degeneration

Front 950

Hip pain w/ limp in young boy

Back 950

With limp, most likely Legg-Calve-Perthes (I think?)

Front 951

Child w/ limp and normal XRs

Back 951

Transient synovitis of hip

Front 952

Bowel sounds in ileus vs. SBO

Back 952

Ileus: hypoactive/ absent
SBO: hyperactive ("tinkling")

Front 953

Cause of ileus after trauma

Back 953

Retroperitoneal hemorrhage associated w/ vertebral fractures

Front 954

High-riding prostate, scrotal hematoma, and inability to urinate is most likely due to what kind of urethral injury?

Back 954

Posterior urethra (pelvic hematoma causes the high-riding prostate)

Front 955

Which type of urethral injury is commonly associated w/ pelvic fracture

Back 955

Posterior urethra

Front 956

2 most common causes of anterior urethra injury

Back 956

Blunt trauma to perineum (straddle injury)

Instrumentation of urethra

Front 957

How does intraperitoneal bladder rupture present?

Back 957

Peritoneal signs on PEX

Front 958

Multiple bony lesions with elevated alk phos

Back 958

Paget's disease of the bone (osteitis deformans)

Front 959

Paget's disease of the bone is associated with these three other conditions in the head

Back 959

Increased head/hat size
CN palsies
Hearing loss

Front 960

3 vaccines needed after splenectomy

Back 960

S. pneumoniae, N. meninigitidis, H. influenzae

Front 961

Common ortho injury after seizures and typical presentation

Back 961

Posterior dislocation of shoulder
Pt holding arm adducted and internally rotated

Front 962

When is surgery indicated for GERD?

Back 962

10-15% of pts with GERD refractory to medical therapy

Front 963

Preop requirements for GERD surgery

Back 963

EGD with biopsy and esophageal manometry (to demonstrate intact esophageal peristalsis)

Front 964

Surgery of choice for GERD

Back 964

Nissen fundoplication (restores GEJ and LES to normal intra-abdominal position and wraps stomach around distal esophagus to augment LES tone while preserving LES relaxation)

Front 965

Surveillance for Barrett esophagus

Back 965

Endoscopy and biopsies ever 18-24mo to determine if it has progressed to dysplasia

Front 966

Rx for Barretts with severe dysplasia

Back 966

Esophageal resection (high risk of occult adenocarcinoma)

Front 967

4 types of hiatal hernia

Back 967

Type I: GEJ above diaphragam
Type II: paraesophageal (stomach herniates into chest but GEJ in nml location)
Type III: mixed, i.e. stomach herniates into chest + GEJ in chest
Type IV: other abd contents in chest

Front 968

Why is a Type II hernia dangerous?

Back 968

Risk for a gastric volvulus

Front 969

Indications for surgery for H. pylori

Back 969

Persistent ulcer after adequate treatment (8-12 wks of medical Rx with EGD showing persistent ulcer)

Front 970

3 surgical options for H. pylori

Back 970

1) Highly selective vagotomy (procedure of choice, despite recurrence risk)
2) Truncal vagotomy and pyloroplasty
3) Vagotomy and antrectomy (highest complication rate)

Front 971

What should always be done in cases of persistent ulcer?

Back 971

Measure serum gastrin levels

Front 972

Which types of ulcer are associated with low vs. high acid?

Back 972

Types I and IV: low acid
Types II and III: high acid

Front 973

Where are the 4 types of gastric ulcers located?

Back 973

Type I: lesser curvature
Type II: simultaneous duodenal ulcer
Type III: prepyloric
Type IV: gastric cardia/GEJ

Front 974

All gastric ulcers require this diagnostic test

Back 974

Biopsy to rule out malignancy

Front 975

Surgical options for gastric ulcers, based on type

Back 975

Antrectomy
Add truncal vagotomy if type II or III (acid producing)

Front 976

How to stage gastric cancer

Back 976

Abdominal explroation

Front 977

Early gastric cancer surgical treatment

Back 977

Distal subtotal gastrectomy

Front 978

Which subtype of gastric carcinoma has teh best prognosis?

Back 978

Intestinal

Front 979

Resection of infiltrating gastric carcinoma includes?

Back 979

Stomach, omentum, and perigastric LNs

Front 980

What is linitis plastica?

Back 980

Diffusely infiltratnig gastric carcinoma; involves all layers of stomach wall with marked desmoplastic reaction

Front 981

Rx for linitis plastica

Back 981

Total gastrectomy with splenectomy, though cure is rare

Front 982

How does linitis plastica appear on biopsy?

Back 982

Wall of stomach appears fixed and rigid

Front 983

Cancer at the GEJ/proximal stomach has a better/worse prognosis than those in the antrum?

Back 983

Worse

Front 984

Surgical Rx for perforated ulcer

Back 984

Close ulceration with Graham patch

If pt had previous ulcer symptoms/ treatment, should also do vagotomy and pyloroplasty

Front 985

Management of perfed ulcer that appears >12hrs ago

Back 985

Quick closure and then monitor in ICU for sepsis with fluids, IV Abx, and omeprazole

Front 986

Two drugs with gastric mucosal protective properties

Back 986

Misoprostol (PGE1 analog)
Sucralfate (topical cytoprotective)

Front 987

What does an ulcer with a white base indicate?

Back 987

How not bled recently, can observe

Front 988

Management of ulcer visualized on endoscopy with clot and/or visible artery?

Back 988

Endoscopic hemostasis
With visible artery and recent bleed, may need surgical intervention

Front 989

How does the endoscopic management of gastric vs. duodenal ulcers differ?

Back 989

All gastric ulcers require biopsy!

Front 990

3 management options for gastric varices

Back 990

More recalcitrant than esophageal:
- Cyanoccrylate glue
- TIPS
- Splenectomy

Front 991

Gastritis and gastric varices in pt w/ history of chronic pancreatitis: diagnosis and management

Back 991

May be due to splenic vein thrombosis --> left sided portal HTN

Splenectomy if bleeding is persistent

Front 992

Rx for esophageal varices

Back 992

- FFP and Vita K
- Vasopressin or octreotide to lower portal pressure
- Sclerotherapy/band ligation

Front 993

Multiple linear erosions in the gastric mucosa at the GEJ

Back 993

Mallory Weiss Syndrome

Front 994

Rx for persistent bleeding from Mallory Weiss Syndrome

Back 994

Injection or electrocautery

Front 995

Three heart infections associated with Reiter's syndrome (reactive arthritis)

Back 995

Myocarditis, aortitis, pericarditis

Front 996

4 conditions associated with HLA-B27

Back 996

Reactive arthritis
Aortic regurg
Pericarditis
Ankylosing spondylitis

Front 997

Coughing up hair may indicate

Back 997

Teratoma in connection with tracheobronchial tree

Front 998

Which receptors do the following drugs act on, causing what effects?
Epi

Back 998

B1 and B2

Front 999

Which receptors do the following drugs act on, causing what effects?
Norepi

Back 999

B1 and B2, at nerve synapses

Front 1000

Which receptors do the following drugs act on, causing what effects?
Isoproterenol

Back 1000

Beta agonist --> vasodilator and chronotropic

Front 1001

Which receptors do the following drugs act on, causing what effects?
Dopamine

Back 1001

Alpha-1 and dopamine receptors --> vasodilation

Front 1002

Which receptors do the following drugs act on, causing what effects?
Dobutamine

Back 1002

Similar to dopamine as strong inotrope but minimal chronotropic action

Front 1003

Which receptors do the following drugs act on, causing what effects?
Milirinone/amrinone

Back 1003

Vasodilation and inotropy via inhibition of phosphodiesterase

Front 1004

Which receptors do the following drugs act on, causing what effects?
Digitalis

Back 1004

Inhibiits NaKATPase --> positive inotrope

Front 1005

Which receptors do the following drugs act on, causing what effects?
Nitroprusside vs. nitroglycerin

Back 1005

Both are vasodilators

Nitroprusside: balanced arterial and venous dilation

Nitroglycerian: more venous effects --> venous pooling

Front 1006

Octreotide vs. vasopressin for bleeding esophageal varices

Back 1006

Octreotide is better b/c vasopressin has side effect of coronary vasoconstriction

Front 1007

Management for persistent esophageal variceal bleeding despite medical therapy (3)

Back 1007

Portosystemic shunt (high mortality)Balloon tamponade
TIPS procedure

Front 1008

Long-term prevention of bleeding of esophageal varices

Back 1008

Beta blockers

Front 1009

Pt with fever, chills, night sweels, weight loss, and epigastric upset

Back 1009

Gastric lymphoma (constitutional symptoms + epigastric upset)

Front 1010

Rx for pts with mucosa-associated lymphoid tissue lymphoma in the stomach

Back 1010

H pylori eradication only; surgery if fail to respond (more advanced gastric lymphomas reuire surgery)

Front 1011

8 complications from central venous catheter placement

Back 1011

Arterial puncture
Pneumothorax
Hemothorax
Thrombosis
Air embolism
Sepsis
Vascular perf
Myocardial perf --> tamponade

Front 1012

Where should a central venous catheter be on CXR?

Back 1012

Ideally in the SBC, but at least proximal to cardiac silhouette

Front 1013

First step in hip fractures from a fall in the elderly, once stabilized with pain control and DVT prophy

Back 1013

Determine the cause of the fall/ operative risk

Front 1014

Signs and symptoms of transtentorial herniation of the uncus

Back 1014

Ipsilateral hemiparesis
Ipsilateral mydriasis and strabismus
Contralateral hemianopsia
Altered mental status

Front 1015

Pain in forefoot/ btwn 3rd and 4th toes and a clicking sensation when palpating while squeezing the metatarsal joints

Back 1015

Morton's neuroma (positive Mulder sign)

Front 1016

Rx for Morton neuroma

Back 1016

Metatarsal support w/ bar or padded shoe inserts (on both sides so even!) to decrease pressure on metatarsal head; surgery if fails conservative Rx

Front 1017

What is Boerhaave syndrome?

Back 1017

Esophageal perforation due to recurrent retching alone

Front 1018

Best test for diagnosing an esophageal perf

Back 1018

Water-soluble esophagram

Front 1019

Rx for esophageal perf

Back 1019

Primary closure and drainage of mediastinum w/in 6hrs to prevent mediastinitis

Front 1020

Rx for Legg-Calve-Perthes disease (idiopathic osteonecrosis of the femoral head)

Back 1020

Maintaining placement of femoral head w/in acetabulum so heals in proper shape/position (w/ splints or surgery)

Front 1021

Tachypnea, tachycardia, hypoxia, unilateral decreased breath sounds w/in 24hrs (or even minutes) of rib fracture

Back 1021

Pulmonary contusion

Front 1022

How to distinguish pulmonary contusion from ARDS?

Back 1022

ARDS takes 24-48 hrs to develop and is bilateral

Front 1023

Appendicitis like presentation, but 5 days duration and stable pt: diagnosis and management

Back 1023

Likely contained abscess

IVF, Abx, bowel rest, perc drainage if possible, appendectomy in 6-8wks

Front 1024

Flexion of right hip against resistance elicits severe pain

Back 1024

Psoas sign: indicative of psoas abscess associated w/ appendicitis

Front 1025

Rx for apnea in pt with cervical spine injury

Back 1025

Orotracheal intubation w/ rapid sequence intubation (requires 4 people)

Front 1026

Why is needle cricothyroidotomy not useful in adults?

Back 1026

Risk of carbon dioxide retention

Front 1027

Congenital adhesions in children

Back 1027

Ladd's bands

Front 1028

Fever, urticaria, arthritis, nephritis

Back 1028

Serum sickness (immune complex reaction against heterologous proteins)

Front 1029

Burn pt with hyperglycemia, leukocytosis, tachypnea, and tachy

Back 1029

Sepsis (bronchopneumonia or bound wound infection)

Front 1030

Which wound pts need tetanus vaccine?

Back 1030

Dirty wound w/ last dose >5yrs ago
Clean wound w/ last dose >10yrs ago

Front 1031

Most common form of thyroid cancer following radiation

Back 1031

Papillary carcinoma

Front 1032

Management of pt with neck nodule with history of neck radiation

Back 1032

Proceed directly to thyroidectomy

Front 1033

Medullary thyroid cancer is associated with a mutation in which gene

Back 1033

RET

Front 1034

5 H&P findings that indicate that a neck nodule may be malignant

Back 1034

Hoarseness
Dyspnea
Dysphagia
Cervical LN enlargement
Vocal cord paralysis

Front 1035

Work-up of neck nodule

Back 1035

FNA

Front 1036

When should neck cysts be removed?

Back 1036

Large (>4cm) or recurs (to eliminate risk of malignancy)

Front 1037

Rx for a colloid nodule in the neck

Back 1037

Benign: medical thyroid suppression and f/u

Front 1038

Psammoma bodies indicate this type of thyroid cancer

Back 1038

Papillary

Front 1039

Amyloid deposits and calcitonin staining indicate this type of thyroid cancer

Back 1039

Medullary

Front 1040

Undifferentiated cells indicate this type of thyroid cancer, with this management

Back 1040

Anaplastic
Chemo and radiation

Front 1041

Hurthle cells indicate this type of thyroid cancer, with this management

Back 1041

Adenoma or low-grade
Lobectomy

Front 1042

Follicular cells indicate what diagnosis/management?

Back 1042

Nondiagnostic, but doesn't exclude cancer, so thyroid lobectomy indicated

Front 1043

Lymphocytic infiltrate indicates what diagnosis/ management

Back 1043

Lymphoma (Rx: radiation) or chronic lymphocytic thryoiditis (Rx: thyroid hormone replacement)

Front 1044

2 most common complications of thyroid surgery

Back 1044

Injury to recurrent laryngeal or external branch of superior laryngeal

Injury to parathyroid --> hypocalcemia

Front 1045

Management of papillary cancer (2 subgroups of pts)

Back 1045

Previous H&N radiation: total thyroidectomy

No radiation Hx: limited thyroid lobectomy and isthmusectomy (or total thyroid if >1.5cm)

Front 1046

Management of follicular thyroid cancer

Back 1046

Microinvasive: formal lobectomy and isthmusectomy

>4cm or clear cancer: total thyroidectomy

Front 1047

What areas have a higher incidence of follicular thyroid cancer?

Back 1047

Iodine deficient areas

Front 1048

Primary means of spread of follicular cancer

Back 1048

Vascular

Front 1049

Management of medullary thyroid cancer

Back 1049

Total thyroidectomy

Front 1050

Histologic feature of medullary thyroid cancers

Back 1050

Hyperplasia of C cells (parafollicular) with amyloid

Front 1051

Which thyroid cancers utilize postop iodine-131 ablation

Back 1051

Follicular (always) and papillary (sometimes, + thyroid suppression w/ thyroid hormone)

Front 1052

Why does medullary cancer not require I-131/thyroid suppression postop?

Back 1052

Tumor arises from C cells

Front 1053

Postop monitoring of medullary cancer uses these two serum levels

Back 1053

Calcitonin
CEA

Front 1054

Rx for parathyroid adenoma

Back 1054

Resection of involved gland; identification of other glands and biopsy of one to ensure normalcy

Front 1055

Rx for parathyroid carcinoma

Back 1055

Resection of all four glands

Front 1056

What is a sestamibi scan used for?

Back 1056

Preop demonstration of enlarged parathyroid glands to identify adenoma w/o need for idenftification of remaining glands (minimally invasive)

Front 1057

Most common site for "missing" parathyroid gland on exploration

Back 1057

Thymus

Front 1058

Common postop risk in parathyroidectomy pts

Back 1058

Tetany (from hypocalcemia)

Front 1059

What is Chvostek's sign?

Back 1059

Tap on facial nerve adjacent to ear --> spasm of orbicularis oris

Front 1060

When should asymptomatic hypercalcemia be explored

Back 1060

>11

Front 1061

Initial treatment for acute hypercalcemia (5 agents, in order)

Back 1061

1) Rehydration w/ normal saline
2) Furosemide
3) Mithramycin, calcitonin, glucocorticoids

Front 1062

Why do pts with chronic frenal failure develop secondary hyperparathyroidism

Back 1062

Retain phosphate from decreased GFR; hyperphosphatemia --> hypocalcemia --> elevated PTH

Front 1063

Indications for surgical management of secondary hyperphosphatemia

Back 1063

Bone pain, intractable pruritus, ectopic calcifications in the soft tissues

Front 1064

What is calcium tachyphylaxis?

Back 1064

Ectopic calcifications in the soft tissues

Front 1065

Surgical management of secondary hyperphosphatemia

Back 1065

Removal of all but 50mg of parathyroid (possible transplant it to forearm)

Front 1066

Pt with hyperparathyroidism who suddenly develops uncontrollable HTN

Back 1066

Undiagnosed pheochromocytoma

Front 1067

Rx for uncontrolled HTN from pheo

Back 1067

Combo alpha and beta blockage

Front 1068

What is the 10% rule with pheos?

Back 1068

10% malignant
10% extraadrenal
10% produce epi
10% bilateral

Front 1069

2 important principles in pheo resection

Back 1069

Minimize release of catecholamines with:
- Minimal manipulation of tumor
- Ligation of all venous drainage before tumor manipulation

Front 1070

Swollen tender thyroid gland

Back 1070

De Quervain's thyroiditis

Front 1071

Classically elevated lab test in thyroiditis

Back 1071

ESR

Front 1072

Histology of de Quervain's thyroiditis

Back 1072

Giant cell granulomas around degenerating thyroid follicles

Front 1073

Rx for de Quervain's thyroidits

Back 1073

Analgesics and aspirin; steroids in resistant cases

Front 1074

Rx for Hashimoto's thyroidits

Back 1074

Thyroid replacement and biopsy of all suspicious lesions (due to higher incidence of malignancy)

Front 1075

Zollinger-Ellison syndrome is associated with what familial syndrome?

Back 1075

MEN-1 (pancreatic endocrine tumor)

Front 1076

Typical localization of gastrinoma

Back 1076

Duodenum and head of pancreas (gastrinoma triangle)

Front 1077

Primary chemo agent used for tumor control of gastrinoma

Back 1077

Streptozocin

Front 1078

What is the Whipple triad and what tumor does it indicate?

Back 1078

Fasting hypoglycemia, symptomatic hypoglycemia, relief w/ glucose admin

Insulinoma

Front 1079

Rx for unresectable insulinoma

Back 1079

Diazoxide (inhibitor of insulin release)

Front 1080

Rx for incidentally identified adrenal mass

Back 1080

>5cm: surgical excision (high likelihood of adrenal cortical carcinoma)
<5cm: observation (if normal catecholamines, cortisol, and K+)

Front 1081

Most likely diagnosis with CXR appearance of:
popcorn

Back 1081

Hamartoma

Front 1082

Most likely diagnosis with CXR appearance of:
bulls eye configuration

Back 1082

Benign

Front 1083

Most likely diagnosis with CXR appearance of:
calcium-containing

Back 1083

Granuloma (not malignant)

Front 1084

Diagnostic tests for CXR mass

Back 1084

CT and then needle biopsy

Front 1085

Main risk of needle biopsy

Back 1085

Pneumothorax

Front 1086

What doubling time favors malignant nodule?

Back 1086

5wks to 280 days

Front 1087

What does a low CT density number (<100) indicate

Back 1087

Favors malignant status

Front 1088

3 common cancers that metastasize to the lugn

Back 1088

Colorectal
Breast
Renal

Front 1089

Lung nodule associated w/ a dental abscess and with chest wall involvement

Back 1089

Actinomycosis

Front 1090

Lung nodule associated w/ chronic skin ulcers

Back 1090

Blastomycosis

Front 1091

Preop eval for pneumonectomy

Back 1091

Cardiac: EKG and echo (for EF and wall motion)
Lungs: PFTs, V/Q scan

Front 1092

2 causes of a widened mediastinum

Back 1092

Aortic aneurysm
Hilar LAD

Front 1093

What is the hilum and what does it contain

Back 1093

Pedicle that attaches lung to medistinal structuers

Pulm artery, pulm vein, main bronchus (bilaterally)

Front 1094

What stage is lung fcancer with positive ipsilateral hilar LNs?

Back 1094

Stage II

Front 1095

What stage is lung fcancer with positive mediastinal LNs?

Back 1095

Stage III

Front 1096

Where is a Pancoast tumor located and what vessel produces that space?

Back 1096

Apex of the lung in the groove (superior sulcus) produced by the subclavian artery

Front 1097

Workup of lung nodule identified on CXR (4 pts)

Back 1097

CT
Possibly bronchoscopy and mediastinoscopy
Needle biopsy

Front 1098

Rx for Pancoast tumor

Back 1098

Irradiation for 6wks
Then surgical resection of involved chest wall and lung

Front 1099

Hemoptysis in healthy young non-smoker

Back 1099

Most likely from bronchial adenoma (also consider TB)

Front 1100

Why do bronchial adenomas cause hemoptysis?

Back 1100

Vascular and arise within bronchi, often obstructing them (--> atelectasis)

Front 1101

2 types of bronchial adenomas

Back 1101

Carcinoid tumors
Adenocystic carcinomas

Front 1102

Rx for bronchial adenoma

Back 1102

Lovectomy

Front 1103

Pleural effusion in 70yo

Back 1103

Cancer until proven otherwise, though most likely heart failure

Front 1104

Diagnostic test for pleural effusion not related to CHF

Back 1104

Thoracentesis and pleural biopsy

Front 1105

What is pleural fluid cultured for (in addition to looking for malignant cells)?

Back 1105

Bacteria, TB

Front 1106

Rx and likely prognosis for mesothelioma

Back 1106

Extrapleural pneumonectomy is the only potential cure; high mortality E

Front 1107

Etiology of spontaneous pneumo

Back 1107

Rupture of apical blebs

Front 1108

Two causes of rupture of apical blebs

Back 1108

Spontaneous
Strenuous activity

Front 1109

What two signs indicate that a spontaneous pneumo is a tension pneumo?

Back 1109

Total lung collapse
Mediastinal shift

Front 1110

How does a water seal for a chest tube function?

Back 1110

Maintains a negative pressure in pleural space and chest tube so that air and fluids may escape from the chest, and creates a one-way valve to prevent air and fluids from reentering the cavity

Front 1111

Rx for recurrent pneumothorax

Back 1111

Thoracoscopic excision of blebs and pleural abrasion (pleurodesis), which causes irritation --> adhesions

Front 1112

Which wound pts need tetanus IG?

Back 1112

<3 doses of tetanus vaccine or dirty wound with unknown immunization status

Front 1113

Management of pt with hypotension and possible aortic aneurysm

Back 1113

Explore in OR (+/- ultrasound for diagnosis, but no time for CT)

Front 1114

Unstable trauma pt with CXR showing widened mediastinum, large left hemothorax

Back 1114

Aortic injury

Front 1115

Causes of a psoas abscess

Back 1115

Not just appendicitis; also contiguous spread from nearby bone or bowel, or hematogenous spread from furuncles or other infection

Front 1116

Which part of the bone is associated osteosarcoma vs. Ewing's sarcoma?

Back 1116

Osteosarcoma: metaphyses (rapid bone growth)

Ewing's: diaphyses

Front 1117

Osteolytic lesion with onion skin appearance

Back 1117

Ewing's sarcoma

Front 1118

"Sunburst" pattern or periosteal new bone formation w/ elevation (Codman's triangle)

Back 1118

Osteosarcoma

Front 1119

In which malignant bone tumor is alk phos elevated?

Back 1119

Osteosarcoma

Front 1120

Which malignant bone tumor has bone pain worse at night, often precipitated by trauma?

Back 1120

Osteosarcoma

Front 1121

Which malignant bone tumor is associated with systemic symptoms (fever, malaise, weight loss)?

Back 1121

Ewing's sarcoma

Front 1122

Soap bubble appearance of bone (due to osteolysis)

Back 1122

Osteoclastoma (giant cell tumor of bone)

Front 1123

DRE with tender, fluctuant mass palpable only w/ tip of finger

Back 1123

Pelvic abscess (in rectovesical pouch)

Front 1124

Presentation of pelvic abscess

Back 1124

Fever, leukocytosis, painful defecation, diarrhea (from bowel irritation)

Front 1125

Most common cause of pelvic abscess in men vs. women

Back 1125

Men: appendicitis
Women: gyne infection

Front 1126

Rx for pelvic abscess

Back 1126

Drainage

Front 1127

Flaccid paralysis after vascular surgery

Back 1127

Spinal cord ischemia

Front 1128

Which part of the spinal cord is most vulnerable to infarction

Back 1128

Thoracic

Front 1129

Diagnostic test and Rx for postop spinal cord ischemia

Back 1129

MRI

Lumbar drains to reduce spinal pressure

Front 1130

Fat embolism is often secondary to?

Back 1130

Long bone fracture

Front 1131

Few days after trauma w/ dyspnea, tachypnea, chest pain, hypoxemia worsened by fluids, and patchy alveolar infiltrates on CXR

Back 1131

Pulmonary contusion

Front 1132

Hx of PNA now with pleural effusion

Back 1132

Empyema

Front 1133

Why are empyemas often culture negative?

Back 1133

Previous treatment

Front 1134

When to suspect G- with empyema

Back 1134

Alcoholic, unconscious, recent op, pulmonary aspiration

Front 1135

Management of empyema (3)

Back 1135

Abx
Evacuate pus
Reexpand lung
(chest tube for last 2)

Front 1136

Rx for loculated empyema

Back 1136

Thoracotomy and decortication

Front 1137

Three vessel disease indicates blockages in what three arteries?

Back 1137

Right main
LAD
Circumflex

Front 1138

Most common conduits used to bypass obstructed coronaries (2)

Back 1138

Greater saphenous vein grafts
Internal thoracic (mammary) artery (best patency)

Front 1139

2 important components of cardiopulmonary bypass

Back 1139

Cardioplegia solution (enough potassium to stop heart)

Hypothermia

Front 1140

Average mortality for CABG surgery

Back 1140

3%

Front 1141

Repair options for mitral valve stenosis

Back 1141

Commissurotomy (splitting commissures and reconstituting lumen w/ dilation)

Front 1142

Repair options for mitral regurg

Back 1142

Excising insufficent/redundant portions of leaflets and narrowing/reinforcing mitral annulus w/ annuloplasty ring

Front 1143

Option for mitral valve disease if repair isn't feasible

Back 1143

Prosthetic valve

Front 1144

Work-up of newly diagnosed aortic stenosis

Back 1144

Cardiac cath to determine status of coronary circulation (better outcomes of valve replacement if intact)

Carotid Doppler to r/o internal carotid obstruction

Front 1145

Difference btwn mechnical (metal/plastic) and tissue valves

Back 1145

Mechanical require anticoagulation

Tissue deteriorate, require replacement at ~7yrs

Front 1146

What causes a Zenker (pulsion/pharygneal) diverticulum

Back 1146

Abnormal uncoordinated constriction of cricopharygneal muscle during swallowing, which increases the pressure in this area of pharynx and forces out a pouch of mucosa covered by pharygneal muscle

Front 1147

What is another type of esophageal diverticulum and where is it?

Back 1147

Epiphrenic (near distal GEJ)

Front 1148

Etiology of achalasia

Back 1148

Loss of smooth muscle ganglionic cells of Auerbach's plexus and neuronal degeneration

Front 1149

Rx for achalasia (2)

Back 1149

Disruption of lower-esophageal high-pressure zone w/ dilation:
- Heller myotomy
- Endoscopically w/ transesophageal pneumatic dilation (only 60% successful, vs 100% for Heller)

Front 1150

Fever, dysphagia, odynophagia, drooling, and submandibular swelling w/ crepitus

Back 1150

Ludwig angina (rapidly progressive bilateral cellulitis of submandibular and sublingual spaces)

Front 1151

Cause of Ludwig angina and involved bugs

Back 1151

Infected mandibular molar

Strep and anerobes (--> crepitus)

Front 1152

Management of Ludwig angina (3)

Back 1152

Abx, removal of infected tooth
Monitor for respiratory difficulty and intubate if necessary (asphyxiation is most common cause of death)

Front 1153

Why is traumatic rupture of the diaphragm more common on the left?

Back 1153

Liver is protective on the right

Front 1154

Diagnostic tests for ruptured diaphragm

Back 1154

CXR raises suspicion
Barium swallow or CT w/ oral contrast are diagnostic

Front 1155

Needle shaped crystals on UA

Back 1155

Uric acid stones

Front 1156

Why do uric acid stones need to be evaluated by CT or IV pyelography?

Back 1156

Radiolucent

Front 1157

Three components of GCS and their max points

Back 1157

MVE: Motor Response (6), Verbal Response (5), Eye Opening (4)

Front 1158

Rx for clot in the superficial femoral vein

Back 1158

Still heparin! Is actually a deep vein, is just the distal part of the femoral vein

Front 1159

Management of trauma pt with splenic injury on US (2 diff scenarios)

Back 1159

Unstable: emergent XL
Stable: CT to determine splenic injury and need for operative repair

Front 1160

What is the final sequel of compartment syndrome

Back 1160

Volkmann's ischemic contracture (dead muscle has been replaced with fibrous tissue)

Front 1161

4 possible complications of diverticulitis

Back 1161

Abscess
Perforation
Obstruction
Fistula formation

Front 1162

Rx for fluid collection/abscess formation after diverticulitis (dependent on size)

Back 1162

<3cm: IV Abx and observation
>3cm or worsening symptoms: CT-guided drainage; if unsuccessful, surgery for drainage and debridement

Front 1163

Rx for diverticulitis w/ fistula, perforation, or obstruction

Back 1163

Sigmoid resection

Front 1164

Tenderness over a bony surface that is worse with palpation

Back 1164

Stress fracture

Front 1165

Burning, numbness, and aching of the distal plantar surface of the foot/ toes

Back 1165

Tarsal tunnel syndrome

Front 1166

Pain and tenderness particularly w/ flexion/extension of hand/wrist after a bite or puncture wounds

Back 1166

Tenosynovitis

Front 1167

Most common tumor of posterior mediastinum

Back 1167

Neurogenic tumors

Front 1168

Diagnostic test for neurogenic tumor, and what are you looking for?

Back 1168

CT scan
Determine whether tumor is present in spinal canal

Front 1169

Management for neurogenic tumor in posterior mediastinum/spinal canal

Back 1169

Combined thoracic and neurosurg approach

Front 1170

2 most common tumors of the middle mediastinum

Back 1170

Lymphatic tumors
Various cysts

Front 1171

Two most common type of middle mediastinal cysts

Back 1171

Bronchogenic
Pericardial (water bottle appearance)

Front 1172

Management of mediastinal cysts

Back 1172

Removal due to potential inflammatory complications, i.e. fistula formation

Front 1173

Most likely histopath of esophageal cancer by location

Back 1173

Upper and middle third: squamous cell
Lower third: adeno

Front 1174

Staging workup for esophageal cancer

Back 1174

EUS (for wall penetration and LNs), CT C/A for celiac LNs

Front 1175

Rx for cancer of the cervical and upper third of the esophagus

Back 1175

Irradiation (chemoradiation)

Front 1176

Rx for cancer in the middle third of esophagus

Back 1176

Neoadj rads/chemo hopefully to allow surgical resection

Front 1177

2 esophagectomy options

Back 1177

Transhiatal esophagectomy
Formal esophagectomy utilizing a neck anastamosis (gastroesophageal)

Front 1178

Advt of a neck anastamosis

Back 1178

Can manage anastamosis leak easily, which is a common postop complication (10%)

Front 1179

Rx for cancer in the distal third of the esophagus

Back 1179

Esophagectomy and proximal gastrectomy

Front 1180

How can an esophageal carcinoma cause constant cough?

Back 1180

Chronic aspiration from tracheoesophageal fistula due to tumor erosion into the trachea

Front 1181

Rx for advanced esophageal cancer

Back 1181

Palliation with gastrostomy, esophageal stents, radiation, or palliative resection

Front 1182

Recurrence rate of TIA without treatment

Back 1182

40%

Front 1183

Periop stroke risk during carotid endarterectomy

Back 1183

1-3%

Front 1184

3 nerves at risk during carotid endarterectomy

Back 1184

Hypoglossal, vagus, marginal branch of facial

Front 1185

Med to send pts home on after carotid endarterectomy

Back 1185

ASA

Front 1186

Cause of amaurosis fugax

Back 1186

Emboli from carotid bifurcation --> internal carotid --> ophthalmic artery (first branch of ICA)

Front 1187

What is a Hollenhorst plaque

Back 1187

Portion of embolus seen on retinal exam as bright shiny spot in retinal artery

Front 1188

One extremity w/ absence of distal extremity pulses, cool and cyanotic, decreased sensation, weakness

Back 1188

Acute arterial embolus

Front 1189

Rx for acute arterial embolus

Back 1189

Heparin and immediate OR (better recovery with quicker revascularization)

Front 1190

Procedure used to treat acute arterial embolus

Back 1190

Balloon catheter embolectomy

Front 1191

Procedure done during embolectomy to ensure adequacy of procedure

Back 1191

Intraop arteriogram

Front 1192

Inability to dorsiflex foot + calf tenderness after embolectomy

Back 1192

Compartment syndrome

Front 1193

Cause of postop compartment syndrome

Back 1193

Ischemia-reperfusion injury (edema after reperfusion)

Front 1194

Long-term therapy after embolectomy

Back 1194

Chronic anticoagulation with warfarin

Front 1195

Hairless leg, loss of sensation, thin/shiny skin

Back 1195

Suggestive of chronic ischemia from peripheral vascular disease

Front 1196

Where is claudication pain most commonly located?

Back 1196

Calf

Front 1197

ABIs for normal, mild claudication, severe (multilevel occlusion), and rest pain/tissue loss

Back 1197

Normal: >0.9
Mild: 0.6-0.8
Severe: <0.5
Rest pain: <0.3

Front 1198

How does the Doppler wave form change with occlusive disease

Back 1198

Normal triphasic --> biphasic with moderate stenosis (less compliance) --> monophasic with severe stenosis

Front 1199

Unilateral absence of femoral pulse

Back 1199

Aortoiliac occlusive disease

Front 1200

Management of aortoiliac occlusive disease

Back 1200

Often surgery, as is generally more progressive than more peripheral occlusive disease

Front 1201

Surgical treatment for aortoiliac occlusive disease

Back 1201

Balloon dilation and/or stent placement or surgical revascularization

Front 1202

What is important to evaluate in a diabetic with peripheral vascular disease and a foot ulcer?

Back 1202

Whether bloody supply is sufficient to allow ulcer to heal; if not, will require revascularization

Front 1203

Arteriogram may demonstrate two patterns of occlusive disease

Back 1203

Inflow disease: inadequate blood blow into femoral artery (E.g. aortoiliac disease)

Outflow disease: single or multiple occlusions of leg arteries, esp superficial femoral or popliteal

Front 1204

F/u and long-term management after vascular bypass surgery

Back 1204

Frequent duplex exams of graft
ASA, lipid control, foot care

Front 1205

Impotence, calf/thigh pain on exertion and relieved by rest, smoker, absence LE pulses

Back 1205

Aortoiliac disease 2/2 atherosclerosis

Front 1206

What is Leriche syndrome?

Back 1206

Aortoiliac disease 2/2 atherosclerosis

Front 1207

When should arteriograms be performed for aortoiliac disease/ low extremity disease?

Back 1207

Not until a decision to proceed with surgery has been made

Front 1208

3 treatment options for aortoiliac disease

Back 1208

Lifestyle modification, percutaneous transluminal angioplasty, aortobifemoral bypass

Front 1209

Percutaneous transluminal angioplasty vs. aortobifemoral bypass

Back 1209

PTA best for signle, short-segment iliac stenosis

Bypass best for bilateral loss of pulses/ occlusion of entire system

Front 1210

Alternative to aortobifemoral bypass for high risk pt

Back 1210

Axillofemoral bypass graft

Front 1211

Painful, cyanotic big toe after revascularization

Back 1211

"Trash foot": atheroembolization of fibrin, platelets, or disloged atherosclerotic debris that has blocked small pedal or digital arteries during unclamping

Front 1212

Rx for trash foot

Back 1212

Heparinization followed by long-term antiplatelet therapy

Front 1213

Likelihood of a cardiac event during vascular surgery

Back 1213

Up to 10% for MI, arrhythmia, or heart failure in major vascular reconstruction

Front 1214

Method used to assess cardiac risk in pts w/ various backgrounds (3 categories)

Back 1214

Class III/IV CHF or EF <20%: coronary angiography

Asymptomatic: straight to surgery

History of MI/moderate angina: DT scan

Front 1215

How long should a vascular procedure be delayed after MI

Back 1215

At least 3mo

Front 1216

Eagle's criteria in prediction of periop cardiac morbidity (6)

Back 1216

>70yo
DM
Angina
Ventricular arrhythmia
Q waves on preop EKG
DT scan redistribution

Front 1217

How fast, on average, do AAAs grow?

Back 1217

4mm/yr

Front 1218

Cause of erectile dysfunction after AAA repair

Back 1218

Interupption of hypogastric circulation or autonomic nerves on aorta

Front 1219

Rx for hypotensive pt with ruptured AAA

Back 1219

Straight to OR; no IVF first b/c could convert contained rupture into free intraperitoneal rupture

Front 1220

HDS patient with AAA and history of syncope/abdominal pain

Back 1220

CT scan; if AAA present, esp w/ nearby hematoma, to OR

Front 1221

Pt with postop ischemic colitis, sigmoidoscopy demonstrates limited to mucosa

Back 1221

Bowel rest, GI decompression, ABx, frequent rescoping

Front 1222

Pt with postop ischemic colitis, sigmoidoscopy demonstrates full thickness involvement

Back 1222

Resection of nonviable bowel and end colostomy

Front 1223

2mo after AAA repair pt is febrile with inflamed femoral incision

Back 1223

Vascular graft infection, usualyl from skin flora

Front 1224

Diagnostic test for suspected vascular graft infection

Back 1224

CT

Front 1225

Rx for vascular graft infection

Back 1225

Complete removal of graft, debridement of all infected tissues, revascularization by extra-anatomic bypass, long-term Abx

Front 1226

Pt with history of aortic surgery/vascular graft and new onset upper GI bleeding

Back 1226

Eval for aortoenteric fistula

Front 1227

Diagnostic test for aortoenteric fistula

Back 1227

CT abd or angiography

Front 1228

Rx for aortoenteric fistula

Back 1228

Removal of graft, repair of GI tract, extra-anatomic bypass

Front 1229

Abd pain, weight loss, intermittent diarrhea, multiple abdominal bruits

Back 1229

Chronic mesenteric ischemia

Front 1230

Diagnostic test for chronic mesenteric ischemia

Back 1230

Mesenteric arteriogram

Front 1231

Rx for chronic mesenteric ischemia

Back 1231

Revascularization using bypass graft from aorta

Front 1232

Tearing chest/back pain, diaphoresis, HTN

Back 1232

Aortic dissection

Front 1233

Rx for aortic dissection

Back 1233

Beta blockers unless invovl;es ascending aorta (requires surgery)

Front 1234

Why can warfarin be hypercoagulable early on?

Back 1234

Protein C deficiency

Front 1235

DVT pt with chronic, marked edema; skin ulceration around ankles; venous claudication

Back 1235

Postthrombotic syndrome due to chronic venous HTN in lower leg

Front 1236

Rx for postthrombotic syndrome

Back 1236

Chronic use of support hose (good prevention as well)

Front 1237

When do pts with a mild to moderate TBI need neuroimaging? (4 symptoms)

Back 1237

Brief LOC
Vomiting
Headache
Disorientation

Front 1238

Difference btwn tibial stress fracture and medial tibial stress syndrome on exam

Back 1238

Latter (shin splints) have no tibial tenderness on palpation

Front 1239

What is the respiratory quotient (RQ)?

Back 1239

Ratio of CO2 produced to O2 consumed; assessment of metabolism

Front 1240

Causes of RQ of 0.8, 1.0, 1.05

Back 1240

0.8: high protein diet or sepsis
1.0: Largely carbohydrate diet
1.05: Mechanically ventilated pt

Front 1241

Why is RQ imp in intubated pts?

Back 1241

High RQ can indicated overfeeding w/ carbs that --> excessive CO2 production which will make weaning more challenging, esp in pts with preexisting lung disease

Front 1242

Abd pain, bloody diarrhea, fever, and leukocytosis after AAA repair

Back 1242

Bowel ischemia

Front 1243

Acute rectal bleeding with blood that fills the toilet

Back 1243

Diverticulosis is most likely

Front 1244

Time line of development of postop infections

Back 1244

PNA (<2 days), UTI, DVT, wound infection, drug fever (>7 days)

Front 1245

2 most common causes of drug fever

Back 1245

Anticonvulsants
Bactrim

Front 1246

How to differentiate pneumothorax from cardiac tamponade in pt with hypotension and JVD

Back 1246

Decreased breath sounds and mediastinal deviation in pneumothorax

Front 1247

Where to perform needle thoracostomy

Back 1247

2nd intercostal space in midclavicular line

Front 1248

Pneumomediastinum, subQ emphysema, and persistent pneumo despite chest tube placement

Back 1248

Bronchial rupture

Front 1249

Pt who cannot lower arm smoothly (drops rapidly from 90 degree position)

Back 1249

Rotator cuff tear

Front 1250

Hypotension and back pain after cardiac cath

Back 1250

Retroperitoneal bleeding

Front 1251

Chronic immobile hard mass on hard palate

Back 1251

Torus palatinus: congenital benign exostosis (bony growth)

Front 1252

When does torus palatinus need surgical correction?

Back 1252

Symptoms, interferes w/ speech or eating, or problems with fitting dentures

Front 1253

Pt with claudication signs but normal ABI

Back 1253

Exercise testing with repeat ABI

Front 1254

ABI <0.9 indicates how severe of an occlusion?

Back 1254

>50% in a major vessel

Front 1255

Which pts need a Td booster even if their last shot was within 10 yrs?

Back 1255

Dirty wound if shot >5yrs ago

Front 1256

Which patients need Td booster?

Back 1256

Last dose >10yrs ago
OR
Severe or dirty wounds and last dose >5yrs ago

Front 1257

Which pts need tetanus immunoglobin?

Back 1257

Unimmunized (or unknown)
OR
Last Td >10yrs ago and dirty wound

Front 1258

4 strategies for control of tetanus symptoms

Back 1258

Abx (metronidazole and penicillin)
Removal of unbound tetanospasmin (with TIG)
Control muscle spasms
Airway protection

Front 1259

Causes of esophageal ulceration (6)

Back 1259

Instrumentation
High pressures from persistent vomiting
Pill esophagitis
Barrett's --> ulcer
Infectious esophageal ulcer (Candida)
Ingestion of caustic substance

Front 1260

Diagnostic test and surgical option for suspected meniscal tear

Back 1260

MRI
Arthroscopy (or open surgery)

Front 1261

Why are fractures of the 2nd, 3rd, and 4th metatarsals managed conservatively?

Back 1261

Surrounding metatarsals act as splints and nonunion is uncommon

Front 1262

Hypotension and tachycardia, but with a high PCWP that increases further with fluids

Back 1262

Cardiac shock, e.g. myocardial contusion

Front 1263

Abd pain radiating to groin, N/V, and soft abdomen

Back 1263

Renal colic from obstructed kidney stone

Front 1264

6 signs of necrotizing surgical infection

Back 1264

1) Intense pain in wound
2) Sepsis
3) Decreased sensitivity at wound edges
4) Cloudy gray discharge
5) Tense edema outside skin
6) SubQ gas w/ crepitus

Front 1265

Which type of pts often get necrotizing infections postop?

Back 1265

Diabetics

Front 1266

Rx for postop necrotizing wound infection

Back 1266

Surgical exploration and debridement

Front 1267

Possible cause of cardiac arrest immediately after intubation in trauma pt

Back 1267

If pt is hypovolemic, the increase in intrathoracic pressure decreases venous return + venous dilation from sedatives --> cardiac arrest

Front 1268

How to prevent postop bacterial parotitis

Back 1268

Adequate hydration and oral hygiene

Front 1269

What is an abdominal succussion splash, and what does it indicate?

Back 1269

Auscultate upper abdomen and rock pt back and forth at hips; retained gastric material >3hrs --> splash sound

Indicates gastric outlet obstruction

Front 1270

Causes of gastric outlet obstruction

Back 1270

Malignancy, PUD, Crohn's, strictures (2/2 ingestion of caustic agents), gastric bezoars

Front 1271

Pathophys of biliary colic

Back 1271

Ingestion of fatty meal --> gallbladder contraction --> gallstone pushed against cystic duct (stone falls back when GB relaxes)

Front 1272

Cause of abdominal pain referred to the shoulder

Back 1272

Peritonitis --> irritation of diaphragm

Front 1273

Region of the bladder most susceptible to injury, and region that is covered by peritoneum (thru which urine can leak into peritoneum)

Back 1273

Bladder dome

Front 1274

Most common site of extraperitoneal bladder rupture

Back 1274

Bladder neck

Front 1275

Management of suspected SBO with acidosis

Back 1275

Laparotomy

Front 1276

Management of duodenal obstruction 2/2 hematoma

Back 1276

NGT with parenteral nutrition until hematoma resolves (1-2wks)

Front 1277

Burning pain and paralysis in upper extremities only

Back 1277

Central cord syndrome

Front 1278

Which pts often develop central cord syndrome and from what injury?

Back 1278

Elderly pts 2/2 forced hyperextension of neck

Front 1279

Ipsilateral motor and proprioception loss and contralateral pain loss below level of lesion

Back 1279

Brown Sequard syndrome (hemisection of cord)

Front 1280

Loss of motor function below lesion level w/ loss of pain and temp on both sides below lesion (but maintain proprioception)

Back 1280

Anterior cord syndrome

Front 1281

Common cause of anterior cord syndrome and best diagnostic test for extent of neurologic damage

Back 1281

Burst fracture of vertebra

MRI

Front 1282

Paraplegia, variable sensory loss, urinary and fecal incontinence

Back 1282

Cauda equine syndrome

Front 1283

Dose for prophylactic low dose heparin?

Back 1283

5000U SQH preop and q8-12postop

Front 1284

Most common ABG abnormality in PE

Back 1284

Decreased PCO2 due to hyperventilation

Front 1285

Management of a PE while on heparin therapy

Back 1285

Failure of anticoagulation --> IVC filter

Front 1286

Pt being anticoagulated w/ heparin for DVT who vomits 100ml of blood but is HDS

Back 1286

D/c systemic anticoagulation immediaetly; provide IVC filter

Front 1287

Woman with cervical cancer extending into pelvic wall w/ acute edematous, cyanotic, painful left leg

Back 1287

Phlegmasia cerulea dolens (inflammatory, cyanotic, painful): acute interruption of venous outflow from obstruction 2/2 pelvic malignancy (extreme ileocaval DVT)

Front 1288

Possible complication of phlegmasia cerulea dolens

Back 1288

Sensory and motor loss and possibly venous gangrene

Front 1289

Rx for phlegmasia cerulea dolens

Back 1289

Anticoagulation and leg elevation; monitor viability of tissue, rarely may require venous thrombectomy

Front 1290

Management of lack of gag reflex in trauma pt

Back 1290

Inspect airway digitally for foreign bodies

Front 1291

Blunt trauma to neck + hoarseness, change in voice, or stridor (most likely diagnosis + management)

Back 1291

Suspect laryngeal edema; need intubation befoer airway obstruction occurs

Front 1292

What GCS score is an indication for intubation?

Back 1292

8 (or less)

Front 1293

Common cause of simple pneumothorax in trauma pt

Back 1293

Rib fracture that lacerates visceral pleura and underlying lung parenchyma

Front 1294

When can a chest tube be removed?

Back 1294

Lung is fully inflated (on repeat CXR) and no further air leak is apparent

Front 1295

After insertion of chest tube, large amt of air leaks over next 6hrs and lung remains only partially inflated

Back 1295

Major airway injury (disruption of bronchus or trachea): requires thoracotomy and lung resection to repair injury

Front 1296

When can a pneumothorax be observed?

Back 1296

Small, not enlarging, no free fluid in pleural space, no other injuries, AND asymptomatic pt

Front 1297

Typical cause of tension pneumo

Back 1297

Lung lac that acts like one way valve (allows air to enter pelural space but prevents it from escaping --> increased positive pressure)

Front 1298

When do pneumothorax pts need needle thoracostomy before chest tube placement?

Back 1298

Tension pneumo (hypotensive)

Front 1299

Management of cardiac tamponade (initial and subsequent)

Back 1299

Subxiphoid pericardiodentesis (or pericardial US) or needle aspiration

To OR for pericardial window and to stop bleeding source

Front 1300

How much blood loss is necessary before see tachycardia; how much before hypotension?

Back 1300

15% (750-1500ml)

30% (1500-2000ml)

Front 1301

After how much blood loss do pts usually require transfusion?

Back 1301

30% (1500-2000ml)

Front 1302

Should you insert a central catheter on the same side or opposite side as a pneumothorax?

Back 1302

Same side; otherwise could develop one on opposite side as complication of insertion

Front 1303

Why doesn't a head injury usually cause hypotension?

Back 1303

Cushing reflex: maintains BP + pt becomes bradycardic

Front 1304

Concern with intubation of pt with possible cervical spine injury

Back 1304

Cannot tilt the head; need in-line traction to maintain cord alignment, or nasotracheal intubation

Front 1305

Trauma pt with priapism

Back 1305

Suspect spinal cord injury

Front 1306

5 signs of spinal cord injury in trauma pt (other than loss of motor function in extremities)

Back 1306

Priapism
Loss of anal sphincter tone
Loss of vasomotor tone
Bradycardia
Intestinal ileus

Front 1307

2 indications for thoracotomy based on chest tube output

Back 1307

>1500ml initially
>200ml/hr for 3 hrs

Front 1308

Concern with stab wound below clavicle + hypotension (and management)

Back 1308

Subclavian arterial or venous injury

Perform angiogram if pt stable; surgical exploration if not

Front 1309

Difference in management of gunshot wound vs. stab wound

Back 1309

Unpredictable bullet path, so often need abdominal exploration if wound near abdomen

Front 1310

Why is a portable CXR unrelaible for diagnosing thoracic aortic transection

Back 1310

Tends to magnify mediastinum

Front 1311

Diagnostic test for suspected aortic injury

Back 1311

Aortic angiography (or CT of chest)

Front 1312

When is a diagnostic peritoneal lavage most useful?

Back 1312

Unclear diagnosis of abdominal injury and pt is hemodynamically unstable (is an alternative to FAST scan)

Front 1313

Indications for surgical exploration on diagnostic peritoneal lavage?

Back 1313

>10ml of blood on opening, >100,000 RBCs on lavage fluid
Vegetable matter
Bile

Front 1314

Diagnostic test for suspected pelvic bleed

Back 1314

Pelvic angiogram

Front 1315

Most likely source of pelvic bleed and management

Back 1315

Branch of internal iliac artery
Embolization

Front 1316

What is essential before removing a damaged kidney?

Back 1316

Document presence of two kidsneys with IV pyelogram

Front 1317

Management of a flank hematoma

Back 1317

Often 2/2 renal parenchymal injury; can be observed in stable pts

Front 1318

Management of blood on opening the peritoneum

Back 1318

Pack all 4 quadrants with gauze to stop bleeding; attempt hemostasis one at a time

Front 1319

Post cardiac surgery w/ fever, leukocytosis, tachy, chest pain, and sternal wound drainage

Back 1319

Mediastinitis

Front 1320

Rx for postop mediastinitis

Back 1320

Drainage, surgical debridement, and prolonged Abx

Front 1321

Unilateral LE edema that worsens while at work (e.g. when legs are dependent)

Back 1321

Venous valve incompetence

Front 1322

Damage to facial nerve causes what symptom

Back 1322

Facial droop

Front 1323

Anterior shoulder dislocation can damage which nerve?

Back 1323

Axillary nerve

Front 1324

Weakness worse in upper extremities

Back 1324

Central cord syndrome

Front 1325

Bilateral loss of vibratory and proprioceptive sensation

Back 1325

Posterior cord syndrome

Front 1326

Bilateral spastic motor paresis

Back 1326

Anterior cord syndrome

Front 1327

Anterior cord syndrome is due to occlusion of what artery?

Back 1327

Vertebral artery

Front 1328

Abx for mastitis

Back 1328

Dicloxacillin or cephalosporins

Front 1329

Tenderness in anatomic snuffbox likely indicates

Back 1329

Scaphoid fracture

Front 1330

Rx for scaphoid fracture

Back 1330

Wrist immobilization for 6-10wks (if nondisplaced) due to risk of nonunion

Front 1331

Lack of pain and temp sensation in upper extremities

Back 1331

Syringomyelia

Front 1332

Cause of syringomyelia

Back 1332

Disruption of CSF drainage from central cord of spinal cord --> fluid filled cavity compressing neural tissue

Front 1333

Pulsatile groin mass below inguinal ligament

Back 1333

Femoral artery aneurysm

Front 1334

Why do femoral artery aneurysms cause anterior thigh pain

Back 1334

Compression of femoral nerve, which runs lateral to the artery

Front 1335

Management of traumatic amputation in the field

Back 1335

Limb/digit wrapped in sterile gauze, moistenized with sterile saline, placed in plastic bag on ice while transported to ED

Front 1336

Confusion, wheezes, seizure post smoke inhalation

Back 1336

Suspect CO poisoning

Front 1337

Rx for suspected CO toxicity

Back 1337

100% oxygen via nonrebreather facemask (hyperbaric oxygen if unresponsive)

Front 1338

3 types of retroperitoneal hematoma and management of each

Back 1338

Zone 1- central hematoma (abdominal exploration)
Zone 2- kidney (observe unless unstable)
Zone 3- pelvic hematoma (explore only if from penetrating trauma to exclude vascular injury)

Front 1339

Blood behind tympanic membrane or ecchymosis in mastoid region/ around eyes

Back 1339

Indicates basal skull fracture

Front 1340

CSF leaking from ear or nose

Back 1340

Indicates basal skull fracture

Front 1341

Why does hypothermia lead to poor outcomes in trauma pts

Back 1341

Coagulopathy from platelet dysfunction and prolongation of PT and PTT

Front 1342

Pt with ongoing intraabdominal bleeding who has oliguria, abd distension, and difficulty respirating

Back 1342

Worry about abdominal compartment syndrome

Front 1343

If pt doesn't respond to fluid challenge, 2 ways to see if they are truly volume depleted

Back 1343

CVP
PCWP if place Swan-Ganz cathether

Both indicate hypovolemia if low

Front 1344

Previous stab injury now with SOB, tachy, murmur, JVD

Back 1344

Traumatic arteriovenous fistula --> high output cardiac failure

Front 1345

What is Branhma's sign?

Back 1345

Occlusion of fistula --> drop of 10bpm in HR

Front 1346

Management of flail chest

Back 1346

Adequate ventilation (may need intubation), administration of O2, careful fluid balance to avoid pulmonary edema

Front 1347

Management of hematoma after stab wound to the neck

Back 1347

Surgical exploration

Front 1348

When is a preop angiogram useful in pts with neck injuries?

Back 1348

Wound in Zone 1 or 3 (below or avoid cricoid) and HDS pt

Front 1349

Management of asymptomatic carotid injury or thrombosis

Back 1349

Anticoagulation

Front 1350

Parkland formula

Back 1350

Volume of LR = %BSA burned x weight x 4ml/kg

Give 1/2 that volume over first 8hrs, second half over next 16hrs

Front 1351

When are topical Abx needed for burns, and what is commonly used?

Back 1351

Deep wounds
Silver sulfadiazine

Front 1352

Burn pt with hematuria

Back 1352

If RBCs seen in urine, pt has myoglobulinuria, at risk for ATN

Front 1353

Management of myoglobulinuria

Back 1353

Fluids, alkalinization of urine, osmotic diuresis

Front 1354

Burn pt with chocolate brown blood, central cyanosis of trunk, or even seizures/coma

Back 1354

Methemoglobinemia (iron in ferric (Fe3+) form, which can't bind O2)

Front 1355

Management of methemoglobinemia

Back 1355

IV methylene blue (hyperbaric oxygen in extreme cases)

Front 1356

Work-up of electrical burn

Back 1356

Potential interior damage, so: EKG, cardiac enzymes, maintain high urine ouput, alkalinize urine

Front 1357

What should a patient on TPN's nitrogren balance be?

Back 1357

Positive (esp if amlnourished or in severely catabolic state)

Front 1358

Type of coma seen in TPN (3 descriptive words) and its cause

Back 1358

Hyperglycemia, hyperosmolar, nonketotic 2/2 dehydration following excessive diuresis due to hyperglycemia

Front 1359

Which organ is often damaged by TPN?

Back 1359

Liver (fatty liver or structural damage; even cirrhosis over years)

Front 1360

Asian immigrant with mass in posterior nasal cavity

Back 1360

Nasopharyngeal carcinoma

Front 1361

3 common presentations of nasopharyngeal cancer

Back 1361

Recurrent otitis media
Recurrent epistaxis
Nasal obstruction

Front 1362

Nasopharyngeal cancer is associated with these 3 risk factors

Back 1362

EBV infection
Smoking
Nitrosamine consumption

Front 1363

Best option to control bleeding in massive hemoptysis

Back 1363

Intubation, place bleeding lung in dependent position, fluids, and:
Bronchoscopy

Front 1364

Definition of massive hemoptysis

Back 1364

>100ml blood / 24hrs

Front 1365

LUQ pain, hypotension, and left shoulder pain

Back 1365

Splenic lac (shoulder pain is from splenic hemorrhage irritating the phrenic nerve and diaphragm: Kehr sign)

Front 1366

Test for meniscus tear vs. MCL/LCL tear

Back 1366

McMurray's for meniscus
Valgus/varus for ligaments

Front 1367

Injury from torsion of knee with foot planted; popping sound and severe pain at time of injury; slow swelling; locking during terminal extension

Back 1367

Medial meniscus tear

Front 1368

Management of suspected scaphoid fracture with normal imaging

Back 1368

Thumb spica cast and reimage in 7 days

Front 1369

Best diagnostic test for development dysplasia of the hip (2 groups)

Back 1369

<4mo: ultrasound
>4mo: xray

Front 1370

Treatment options for resistant dumping syndrome (2)

Back 1370

Octreotide or reconstructive surgery

Front 1371

Dropping of contralateral pelvis when pt stands on one foot

Back 1371

Trendelenburg sign

Front 1372

Cause of Trendelenburg sign

Back 1372

Weakness of gluteus medius and minimus (innervated by superior gluteal nerve)

Front 1373

How to rapidly normalize INR

Back 1373

FFP

Front 1374

Which pts get acalculous cholecystitis?

Back 1374

Chronically ill pts in ICU (multiorgan injury, trauma, severe burns, sepsis, TPN)

Front 1375

Rx for critically ill pt with acalculous cholecystitis

Back 1375

Percutaneous drainage and Abx

Front 1376

Management of very classic appy presentation

Back 1376

Emergent surgery (don't wait for CT)

Front 1377

Management of SCFE

Back 1377

Surgical pinning of the femoral head

Front 1378

Where is the fluid collection in a hydrocele?

Back 1378

Tunica vaginalis due to patent processus vaginalis

Front 1379

When is surgical repair for a hydrocele indicated

Back 1379

After 12mo due to risk of inguinal hernia