1
Q
Why do steroids increase WBC?
A
Impair neutrophil migration
2
Q
What percent of biliary strictures are iatrogenic?
A
80%
3
Q
Which stage gastric cancer (adenocarcinoma) needs neoadjuvant treatment?
A
T2 muscularis propria (stage 1) or N1 (stage 2)
Etoposide, cisplatin, 5-FU, doxorubicin
4
Q
At what distance from GEJ are tumors treated as esophageal vs gastric?
A
2cm
5
Q
First sign of local bupivacaine toxicity?
A
Dizziness
6
Q
Bupivacaine vs opioid epidural - which causes hypotension?
A
Bupivacaine
7
Q
At what spinal cord level are the cardiac accelerator nerves responsible?
A
T6
8
Q
Neurogenic shock: vasopressor of choice if lesion above T6?
A
Dopamine & Norepi – bc expect bradycardia
(from decreased sympathetic stimulation to the heart)
9
Q
Neurogenic shock: vasopressor of choice if lesion below T6?
A
Phenylephrine – bc don’t see bradycardia
10
Q
Are breast exams recommended annually for all women of average-risk?
A
Q1-3 years for age 25-40yo
Q1 year > 40yo
No longer recommend SELF-exams
11
Q
Why perform off midline pilonidal cyst debridements?
A
Too much moisture and bacteria in cleft
12
Q
MOA: orlistat
A
inhibits gastric and pancreatic lipase
13
Q
Long posterior myocutaneous flap (=Burgess technique) for BKA:
Anterior skin incision location and length?
A
10-12cm distal to tibial tuberosity
Transverse incision. 1/3rd calf circumference (minimizes dog ears)
14
Q
Long posterior myocutaneous flap (=Burgess technique) for BKA:
How much should the vertical incision extend?
A
1.5x the length of the anterior skin incision
allow for thick muscle posterior flap
15
Q
GIST margin
A
Grossly negative to 1cm (nothing more)
(If tumor is <2cm and asx, can be observed)
16
Q
GIST tumors arise from?
Immunohisto staining?
A
Interstitial cells of Cajal
Tyrosine kinase- CD117 (KIT), CD34
17
Q
Positioning in pregnancy for lap surgery?
A
LEFT lateral decubitus to off-load the IVC
18
Q
Platelet life span
A
7-9 days
(same duration affect as plavix)
19
Q
1 and 5-year organ transplant survival of kidney, liver, heart
A
1 year: 95% kidney, 90% liver and 85% heart
5 year: drop to 70-80%
20
Q
1 and 5-year organ transplant survival of pancreas and lung
A
75-85%
then drops to 50s%
21
Q
Parathyroid carcinoma surgery
A
En bloc resection, may include ipsi thyroidectomy
22
Q
When do we use activated clotting time over PTT?
A
High heparin dose boluses in cardiovascular surgery
(both intrinsic pathway)
bedside POCT available
23
Q
Triad of death (trauma)
A
Hypocoagulability
Hypothermia
Acidosis
24
Q
Hypothermia can lead to v fib & death. What EKG change is seen early?
A
J wave
25
preferred vein for AV fistula creation?
cephalic over basilic
26
T1B GB adenocarcinoma surgery
Chole + IVB/V hepatectomy + portal lymphadenectomy
+ CYSTIC DUCT MARGIN (if positive, may need to excise portion of CBD)
27
Colonoscopy screening lower age: sensitivity vs specificity
Higher sensitivity, but then specificity lowers
28
1 month postop, is there more collagen I or III?
Collagen I, this remodeling process begins at 21 days
29
Deep 2nd degree burn:
- dermal layer involved?
- sensation?
- appearance under blister?
Reticular dermis (unlike superficial 2nd -- papillary; retain dermal appendages in superficial -- allows for epitheliazation w/o grafting)
No sensation
White/mottled (vs pink & pink in superficial)
30
Superficial vs deep 2nd degree burn: time to heal?
2 weeks
vs
3 weeks (if not healed or large area, then should debride & graft)
31
PID treatment
CTX (x1 dose)
Doxycycline (x2 weeks)
Flagyl (x2 weeks)
32
Which c diff toxin causes intestinal necrosis?
Toxin A
33
Adrenal adenoma size cut-off for OPEN resection
>6cm or unclear fat planes
(increased risk of malignancy)
34
MC cause of "dysplastic" renal artery occlusive disease?
Medial fibroplasia (85%) - most common in women
(artherosclerotic >>> more common than dysplastic)
35
Hemophilia A and B: what % factor is needed to undergo major surgery?
> 80% Factor 8
60-80% Factor 9
36
Burn medication with good eschar penetrance?
madenide acetate (sulfamylon)
for full thickness burns
37
Burn medication with hyponatremia/methemoglobinemia vs. neutropenia?
Silver nitrate
vs
Silver sulfadiazine
38
Carcinoid SB tumor: 1cm vs larger?
>1cm or local +LN, include lymphadenectomy
39
TI Carcinoid surgery
R hemicolectomy
40
gradually enlarging, flesh-colored mass (often w telangiectasias)
(giant) dermatofibrosarcoma protuberans - spares epidermis
WLE 2-4cm margins (perform incisional biopsy first for surgical planning)
41
Endoscopic alternative to Heller myotomy for achalasia
POEM - per-oral endoscopic myotomy
(unknown if longterm outcomes are equal)
42
MCC organism of mycotic AAA?
(1) STAPH AUREUS
(2) salmonella
43
Maximal length allowed to attempt uretero-ureterostomy
<2-3cm
44
dichotic notch on ECG
pulmonary artery
45
RA wave form order
a - Atrial contraction
c - Closing tricuspid valve
X deSCent - (atrial filling)
v - RA eDP
Y deSCent - opening of tricuspid valve and passive atrial filling
46
RV wave form
sharp rise and fall, coinciding with QRS complex
47
Carbon monoxide o2 dissociation curve (left/right) and does o2 have (higher/lower) affinity
Left
Higher affinity --> decreased delivery to tissues
vs.
Acidosis, increased temp shifts to the Right -> Lower affinity for O2
48
Treatment: Carbon monoxide
100% o2 via NRB or hyperbaric chamber
49
MOA & txt: cyanide poisoning
binds cytochrome c oxidase -> blocks mito transport chain
cyanokit (b12) + sodium thiosulfite or nitrite
50
Treatment: beta blocker OD
glucagon + supportive care
(MOA: increases myocardial contractility)
51
Safest location for paracentesis
3cm medial and 3cm superior to ASIS
(not palmar's for cirrhotics- spleen may be big)
52
Criteria for transanal rectal tumor excision
Size <3m
<30% bowel circumference infolved
No LN or perineural/lymphovascular involvement
Well to moderately differentiated
53
Criteria for neoadjuvant chemoXRT: rectal CA
Stage II (T3, N0, M0)
or
Stage III (T1-T3, N1-2, M0)
54
STITCH trial (Lancet 2015)
2-0 PDS, 0.5cm bites that are 0.5cm apart
(21% vs 13% incisional hernia rates at 1 year)
(14 vs 10 minutes)
No incorporation of fat or muscle
55
Location: recanalized left umbilical vein
Inferior border of falciform; shunts blood via L PV, along ligamentum teres to umbilicus
(occurs in 20% of cirrhotics; ppx ligation of falciform on entry)
56
Early AV access failure 2/2 technical. Late is 2/2
intimal hyperplasia
57
Failure of AV fistula to mature is 2/2 to ...
inadequate venous dilation assoc w/ venous side branches or deep location of the venous outflow tract
58
Pancreas exocrine secretions (3):
Proteases (trypsin/chymotrypsin)
Hydrolytic enzymes to cleave lipids (phospholipase)
Amylase (digest starch)
59
Prehepatic causes of portal HTN (3)
PVT
Splenic vein thrombosis
AV Fistula
60
Posthepatic portal HTN (3)
Budd chiari (hepatic vein)
IVC thrombosis
R heart failure
61
Variceal bleeding treatment
Vasopressin & Nitroglycerin
(to prevent ischemia)
EGD s/p resuscitation
62
Pyloromyotomy: must visualize
Bulging Mucosa
(anteriosuperior aspect of pylorus; 1-2mm proximal to duo)
63
Benign causes of pneumatosis
COPD, asthma
IBD
Collagen vasucular disease
Immunosuppressive txts (eg chronic steroids)
64
Benign vs worrisome pneumatosis air patterns
Cystic- benign
Linear- worrisome
65
Midline laparotomy hernia rates
3-20%
66
Which is more common for lap (vs open) appy: SSI or intraabdominal abscess?
Abscess
(also op time)
67
Type A aortic dissection: antihypertensive of choice
Beta blocker (prevent tachycardia)
68
Surgical emergency: Stanford A or B (and Debakey)?
A! Any part of Ascending Aorta
Debakey:
EMERGENT
I ascending + descending
II ascending
vs.
IIIa descending thoracic
IIIb descending thoracic + abdominal
69
"Pop" sound when placing spinal injection
Through dura
(this is after supraspinous ligament, interspinous ligament, & ligamentum flavum)
70
During spinal anesthesia, confirm needle is in intrathecal location by ...
Removing stylet and looking for CSF
If doesn't come back, can try rotating needle 90 degrees
If still none, remove needle
71
ICP monitoring criteria if:
- CT abnormal: ***
- CT normal: ***
CT abnormal: and GCS < 8
CT normal (if 2 of 3 met):
- age >40
- hypotension
- abnormal posturing
72
BRCA: autosomal *** tumor supressor gene -> lifetime risk breast CA is 70%
dominant
73
BRCA 1 and 2 chromosomes
BRCA 1: 17
BRCA 2: 13
74
Higher risk of ovarian CA: BRCA 1 or 2?
BRCA 1 (40%) vs 15%
75
Low Mg can lead to low K because of ...
Low Mg can lead to low Ca because of ...
Renal potassium wasting
Inhibits parathyroid hormone secretion
76
SSI risk: Class III vs class IV wound
Contaminated (intraop spillage): 13%
Dirty/infected (spillage preop or pus): 40%
77
Indication for cholecystectomy: asx polyp (size)
Polyp >10mm
Polyp >6mm + high risk features (native american, sessile, sx, gallstones, age >50)
(>18mm then concerned for gallbladder CA)
78
GB adenocarcinoma: T1b _ layer
Muscular layer or beyond
79
HIT tests (2)
Serotonin release assay
Anti PLT factor 4 IgG assay
80
Warfarin: pro and anti-coagulative properties first?
PRO-thrombotic, depletes protein C
81
Barrett's esophagus: screening if dysplasia
4-quadrant q-1cm every 3-6 months until nondysplastic
Then every 3 to 5 years (for no dysplasia)
82
Lung protective Tidal volume
4-6mL/kg
83
Right ovarian torsion more common than left (why? 2 reasons)
Longer utero-ovarian ligament
Sigmoid not present (may prevent)
84
Highly selective vagotomy affects the ...
Lesser curve only (pylorus-sparing)
85
At GE juntion, left vagus is ... (posterior/anterior), while right vagus is ... (posterior/anterior)
LARP
Left - anterior
Right - posterior
86
Half lives of heparin vs lovenox?
Heparin 60-90 minutes
SQ Lovenox 4 to 7 hours
(generally active for ~4-5 half lives, <3%)
87
What kind of SB tumor is treated with antibiotics?
B cell MALToma
88
Tryptophan (AA) is a precursor to niacin and serotonin, so carcinoid syndrome can lead to (3)
Dementia
Dermatitis
Diarrhea
(Niacin B3 deficiency)
89
B1 deficiency
Beriberi (peripheral neuropathy & HF)
Wernicke
(Thiamine)
90
B2 deficiency
Stomatitis, glossitis, normocytic anemia
(Riboflavin)
91
Vitamin E deficiency
Peripheral neuropathy
Spinocerebellar ataxia
Hemolytic anemia
92
B6 deficiency
Microcytic anemia
Beefy tongue
Peripheral neuropathy
(Pyroxidine)
93
Penicillin-allergic abx ppx for colon operation
Aminoglycoside/Fluoroquinolone + Clinda/Flagyl
Aztreonam & Clinda also OK
94
Horseshoe abscesses extend from the postanal space to bilateral _
Ischiorectal space
95
Modified Hanley procedure incisions
Small incision btw tip of the coccyx and anal verge
(then using hemostat gently separate external muscle fibers, drain abscess, place seton)
Two lateral counter incisions (also with setons)
96
Hinchey 1a vs 1b
1a: confined phlegmon
1b: pericolic abscess
97
Normal aortic valve size
Severe aortic stenosis valve size
Normal: 3-4 cm2
Severe AS: <1.0 cm2
(need replacement of sx or <1.0 cm2)
98
"beads on a string" or "chain of lakes" MRCP
PSC (intra and extrahepatic ducts involved)
99
Screening in PSC patients
q6month to 1 year MRCP / RUQ US
annual CA 19-9
q1-2y colonoscopy (with or without UC)
*colon, GB, and cholangio risks
100
Treatment: large desmoid tumors of ant abdominal wall
Wide local excision with frozens (need negative margin or else 80% recurrence)
+/- adj chemo, adj XRT (if R1/R2 resection)
*spindle-cells*
No need for CT because not metastatic
101
Adrenal tumor c/f carcinoma (2)
Size > 4-6cm irregular mass with peripheral enhancement
Central (non-enhanced) necrosis
102
What may contribute to anastomotic leaks in the first 24 hours?
Breakdown of collage by metalloproteinases
103
At postoperative day 3-4, anastomotic scaring has ***% of its strength
60%
104
What makes the submucosal layer the strength layer of an anastomosis?
High content of collagen fibers
105
#1 cause of acute pancreatitis in the US
Gallstones (not etoh), 70-80% of cases
106
Antibody in autoimmune pancreatitis
IgG4
107
What's a more useful and sensitive biomarker in asx NET, chromogranin A or 5-HIAA?
Chromogranin A
- monitor dz progression and recurrence
(5-HIAA is only helpful in serotonin syndrome)
108
LR and K-sparing diuretics should NOT be used in ...
Hypercalcemic crisis
(Ca > 14)
(K-sparing prevent Ca excretion; LR has 2.7 meq Ca)
109
GISTs are most common in the ...
stomach (60-70%)
then SB jejunum (20-25%)
(high risk if >5cm, mit index >5)
110
Popliteal aneurysms (>2cm) should be excluded and bypassed with ***
saphenous vein ideally
(can use graft if needed)
111
Three landmarks for subclavian vein
deltopectoral groove
sternal notch
medial third of the clavicle
112
Gastric varices likely 2/2
SVT (splenic vein thrombosis), often pancreatitis induced
(instead, spleen is drained by collateral short and posterior gastric veins)
113
MC nosocomial PNA and GI bugs:
Staph a
C diff
114
septic cholangitis abx choice
zosyn for pseudomonal coverage (20%)
MC bug: e coli
115
MCC end stage renal disease that leads to transplant
DIABETES (not htn)
116
When are cirrhotics started on treatment for varices?
Large >5cm, or red spot/red wale markings (or prior hx bleeding, ie "secondary prophylaxis")
Non-selective beta blocker or banding
Otherwise surveil in 1-2 years
117
Antibiotic prophylaxis for bleeding varices
Fluoroquinolones or ctx
118
3rd vs 4th degree skin grafting plan?
Split-thickness for 3rd degree
Full-thickness for 4th degree
119
Full thickness skin grafts have more primary or secondary contracture?
Primary
(and require a well-vascularized wound bed)
120
S/p gastric bypass, steatorrhea, fatigue: test to diagnose
Carbohydrate breath test
Detects hydrogen or methane
For blind loop syndrome/bacterial overgrowth
(stagnant loop)
121
Early vs late dumping syndrome symptoms
Early- abd pn diarrhea (30 min)
Late- diaphoresis (2-3 hrs)
122
Cutting mode electrocautery: *** (continuous/intermittent) low voltage energy, over a small area
Continuous
123
Blend is used on *** setting to include ***
Cutting in combo with coagulation waveform for hemostasis
124
Angioplasty patency is favorable for *** (short/long) segment and *** (proximal/distal)
Short, proximal
125
PCC: time to reverse INR
< 1 hour
(vs FFP > 2 hours; Vit K 12 hours)
126
Lateral internal sphincterotomy incontinence rate
15%
(only 5% recurrence vs botox 40% and meds up to 60%)
(controlled dilation 2-15%; fissurectomy with flap 7-12%)
127
Most drugs follow first order kinetics, meaning the elimination rate is based on ***
concentration in the blood
128
TXA should be given within *** hours
3 hours
129
Cause of hereditary spherocytosis
Deficiency in spectrin
(RBCs are more fragile as they enter the spleen)
130
Hereditary spherocytosis: perform splenectomy (after 5 yo) & ***
cholecystectomy
(2/2 chronic hemolysis)
131
Pancreatic cyst:
High CEA, high amylase
Low CEA, high amylase
High CEA - IPMN
Low CEA - pseudocyst
High amylase = ductal communication
132
Pancreatic cyst:
Low CEA, low amylase vs
High CEA, low amylase
High CEA - mucinous ("ovarian-like stroma")
Low CEA - serous ("honeycomb")
(muCin and IPmucinN - have high Cea bc they have mucin)
133
Pancreatic cysts (2):
Mucinous and high viscosity
Mucinous cystadenoma
IPMN
(and both have KRAS mutations)
134
Hormone released when calcium is high
Calcitonin (from thyroid)
135
TIPS connects the *** to ***
Hepatic vein to portal vein
136
Immunosuppressive agent with neurotoxic affects
(headache, confusion, tremors)
Tacrolimus
(calcineurin inhibitor, IL-2)
137
Immunosuppressive agent with hypertriglyceridemia & impaired wound healing
Sirolimus
138
Gallbladder adenocarcinoma treatment: T3 or T4
T3 (invading serosa & beyond) - add en bloc resection
T4 (PV, HA, or 2+ extra-hepatic organs)- unresectable
139
Gallbladder adenocarcinoma stage for just cholecystectomy
T1a LAMINA PROPRIA
140
Killian's triangle borders
Superiorly: inferior pharyngeal constrictors
Inferiorly: cricopharyngeus m.
141
In Boerhaave's, typically where is the perforation?
Distal, on the left
142
Nerve most typically injured in small saphenous procedures (and distribution)
Sural n.
(lateral posterior, lower 1/3rd of the leg)
Vs saphenous n. which runs with greater saphenous vein
143
In addition to DDAVP, what can be given in a bleeding ESRD uremic patient?
Cryoprecipitate (vwf)
(need to improve plt adhesion w/ vwf)
144
Max dose 1% lido w epi
7 mg/kg = 0.7mL/kg
vs 4mg/kg wo epi
1% lido is 10 mg/mL
145
Bupivacaine wo epi (0.25%)- max dose
0.8-1.0 mL/kg for 0.25%
(=2-2.5mg/kg)
146
Bupivacaine w epi- max dose
w epi 2.5-3.0 mg/kg
(1.0-1.2 mL/kg)
147
When do you excise LCIS?
(1) If nonclassical (pleomorphic or florid)
(2) imaging-pathologic discordance
148
Umbilical hernia: congenital or acquired incomplete growth or impaired embryological development leading to weakness at the ***
Umbilical ring
It circumferentially contract after birth and is normally reinforced by the paired lateral umbilical ligaments, singular round ligament, urachal remnant, and Transv fascia
149
Paired lateral umbilical ligaments = obliterated ***
Singular ligamentum teres = obliterated ***
Urachal remnant
Transversalis fascia
Umbilical arteries
Umbilical veins
150
MOA: Ketamine
NMDA ANTAgonist
Can be an adjunct to reduce opioid use
151
MOA: Flumazenil
GABA r antagonist
152
Treatment: Merkel cell carcinoma (clinically neg nodes)
WLE + SLNB + Radiation therapy
Regional +LN 12-15%
(Neuroendocrine, deeply blue cells)
153
Esophageal CA: N2
3-6 nodes
154
Malignant phyllodes: MC metastasis
Liver
155
Malignant phyllodes: margins and LN?
1cm
No axillary staging (hematogenous spread; similar to fibroadenoma)
Like a sarcoma- +vimentin, +actin
156
Radiofrequency or endovenous laser ablation is for *** small or large veins?
Large
Sclerotherapy is for smaller
157
% resolution of DM vs HTN after bariatric surgery
Type II DM - 75%
HTN - 60%
158
Pringle maneuver should be limited *** intervals
15-20 minutes
159
Rate of hyponatremia correction
4-6 mEq/L/hr
6-12mEq/L in first 24 hours
(less than <18 mEq/L in 48 hours)
160
Treatment: lympangitis
Antibiotics (eg Clindamycin)
161
Major benefit of trach
Improved comfort
Can help wean sedation and extubate sooner if possible
162
Mann Whitney U (Wilcoxin rank-sum) test indication
Continuous, non-parametric
163
Wilcoxin signed rank test indication
Continuous, non parametric, PAIRED
164
Marfan syndrome defect in ***
Fibrillin
165
Size for intervention of femoral aneurysm
2.5cm
166
Hepatic adenoma > *** cm -- OR for resection
5cm
Don't try stopping OCPs first unless <5cm
167
Howship Romberg sign
Obturator hernia- increased pain/ hyperanesthesia from inguinal crease towards the medial thigh, with EXtension ADduction & INTernal rotation
168
Where do you incise the obturator membrane if needed to free up hernia?
Medially and downward to avoid vessels
169
What's the benefit of obtaining a CTA neck before carotid endarterectomy?
Because if very proximal, may need to stent instead
170
ICA peak systolic velocity (PSV) when stenosis is 50-70%
125-230 cm/s
>70% is >230
171
What percent of sphincter involvement should you consider a sphincter-preserving fistula surgery?
>30%
(eg endoanal advancement flap or LIFT ligation of intersphincteric fistula tract)
172
Cholangiocarcinoma: Most common, most favorable, and least favorable morphology/histology?
Most common AND least favorable- sclerosing
Most favorable- papillary
Nodular is also unfavorable
173
ITP: when do you transfuse platelets intraop?
After splenic ARTERY ligation
174
PLT transfusion cutoff for major surgery, neuro surgery, in general?
Neuro: 100,000
Major surgery: 50,000
In general: 10,0000
175
Diverticular bleeding is caused by an arterial rupture of
Submucosal branch or vasa recta
176
Diverticula (colon) layers included
Mucosa and submucosa poke through weakening in muscularis propria
177
MOA: TPA
Tissue plasminogen activator: converts plasminogen to active plasmin -> fibrinolysis
178
Fibrinogen level at risk of bleeding
<150
(normal: 200--400)
179
SAAG cutoff
1.1
(> 1.1 is high serum albumin, so cause is hydrostatic
vs.
<1.1 is low serum albumin, so cause is oncotic)
180
Etiologies of high SAAG
Etiologies of low SAAG
High SAAG: ANYTHING with portal HTN, normal cirrhosis also has low total ascites protein
High SAAG (total ascites protein <2.5g):
Pre & intra-hepatic (cirrhosis, PVT, late budd chiari)
- If PMN >250 -> SBP
High SAAG (high ascites protein >2.5g)
Post-hepatic
Early budd chiari syndrome
IVC obstruction
Heart failure
Pericarditis
Low SAAG (SAAG <1.1)
Peritoneal carcinomatosis
Nephrotic syndrome
Severe malnutrition
181
Duration of c tube until elective chole vs c tube study
6-8 wks
182
Most common ectopic location of superior vs inferior parathyroid gland:
Superior- TE groove
Inferior- thymus
*most commonly missed is still normal location
183
Wound contraction is reduced in area where skin is ***
Tighter bc bringing the skin together makes the open wound smaller
184
Do square or circle wounds repair faster?
Square
Forces of circular cancel each other; a reason why stoma reversals keep circular incisions (limit stenosis)
185
2.5cm sessile polyp- EMR or endoscopic submucosal?
Too big for EMR
*procedure: inject solution into submucosa to elevate lesion
186
What is cardiac index?
CO / body surface area
187
MC salivary malignancy
Mucoepidermoid adenoma
188
*** salivary gland has an insidious onset & late distant metastasis (w affinity for nerve)
Adenoid cystic carcinoma
189
Typical peripheral axon regenerates at ***/ day
1-2mm/day
(or 1 inch per month)
190
Body and tail of pancreas are fed by the *** artery
Splenic
191
Superior and inferior pancreaticoduodenal arteries arise from...
Superior- GDA
Inferior- SMA
192
Calcitonin decreases *** levels
Can it be used for hypercalcemic crisis?
Calcium AND phos
Yes is can be helpful in hypercalcemic crisis
193
Calculation for prevalence =
TP + FN
194
Sensitivity =
TP / (TP+FN)
195
Specificity =
TN / (TN + FP)
196
Acute thrombi (DVT) are echolucent or echogenic?
Lucent
(ie hypoechoic)
197
intervention for radial scar? pre-malignant?
Excise bc 8-17% + for malignancy
Not definitively deemed pre-malignant
198
Spiculated mass with central lucency
Radial scar
199
Cutoff for rapid shallow breathing index
<105
RR/TV (L)
200
Stop dabigatran *** days before surgery
2 days - just like the other DOACs
(except if low CrCl -> then 4 days, unlike other DOACs)
201
Which DOAC is excreted by the kidneys?
Dabigatran
thus should be renally dosed
202
Pancoast tumor txt:
Chemo XRT THEN surgery
(non-small lung CA typically)
203
Position of slipped fundoplication?
Above GE (at least partially)
Migrated fundoplication is fully above
204
Neoadj chemo is needed for this minimum esophageal T stage
T2
And T3 - into adventitia
205
MELD score of *** is assigned to HCC
22
206
RCRI (Revised Cardiac Risk Index) Factors
What if you have 1+ factor?
IDDM
CHF
Cr>2.0
Cerebrovascular dz
Ischemic heart dz
If have 1 of the following factors and undergoing intermediate+ risk surgery, obtain EKG
207
Geriatric patients are prone to overdose from opioids because of
Increased sensitivity to CNS depressants
(altered receptor density, diminished neurotransmitter reserve, impaired homeostatic mechanisms)
208
What is a small pancreatic duct size for a whipple?
<5mm
209
TRALI is caused by
Antibodies in donor plasma
210
MC electrolyte derangement after burn resuscitation
HyperK
211
Peripheral groin block
2cm medial to ASIS
(ilioinguinal and iliohypogastric)
212
Forest class I peptic ulcer disease
Actively bleeding
Ia- pulsatile
Ib- oozing
213
Most common GB polypoid lesion
Cholesterolosis- cholesterol-laiden macrophages in the lamina propria
214
MC site of perf during EGD for caustic ingestion
Distal esophagus
vs typical iatrogenic injury- killian triangle
215
Warfarin skin necrosis txt
Stop coumadin
Give vitamin K
Start heparin gtt
216
Stage 3 decubitus ulcer: what layer of tissue is exposed?
Subcutaneous tissue
vs
1- non-blanching erythema
2- dermis
4- bone
217
Sacral wound with eschar: stage?
Unstagable
(need to debride)
218
Post-angio pseudoaneurysm: indication for conservative management
Size < 2-3cm
Otherwise if 3-5cm, try US-guided compression and thrombin
If complicated (>5cm, wide neck, neuro changes, HDS unstable), etc -> surgery for repair
219
Ophthalmic artery is a branch of the ...
Internal carotid artery
(Ipsi amaurosis fugax)
220
Typical power level =
0.8
1-beta = power
typical beta = 0.2
221
In addition to sample size, power is dependent on ***
Standard error of the mean
(lower SE -> higher power)
222
Melanoma T staging:
Depth
T1: < 1mm
T2: 1.01-2.0mm
T3: 2.01-4.0mm
T4: >4.01mm
T a vs b (no ulceration vs ulceration)
223
Melanoma N2 Staging
2-3 LN
224
Why is it not helpful to inject local into the abscess cavity?
Does not work in the acidic environment
225
Location of petersen's defect
Between the small bowel loops, transverse colon, and the retroperitoneum
At the level of the J-J
(occurs after any G-J)
226
What is sutured closed for petersen's defect?
Mesentery between the roux limb and transverse colon
227
Treatment: type III choledochal cyst
Endoscopic sphincterotomy
(ie cholodochocele, distal intra-ampullary CBD)
228
Most common type of cholodochal cyst
Type I (fusiform dilitation of CBD)
229
Which choledochal cysts have the highest risk of malignant transformation?
I and IV
I txt: excision, cholecystectomy, & biliary enteric anastomosis
230
Treatment: type II choledochal cyst
Diverticulectomy
(true diverticula)
231
Type IV-A vs IV-B choledochal cyst treatment?
IV-A hepatic resection (intra & extrahepatic)
IV-B excision (extra-hepatic)
vs
V caroli dz- biliary drainage procedure +/- hepatic resection; transplant
232
Most common organism involved in OPSI
Streptococcus pneumoniae
233
What is responsible for gram negative sepsis?
Lipid A endotoxin (component of LPS outer membrane)
Lipopolysaccharide (outer cell membrane) = Lipid A + O-saccharide
234
Dermatofibrosarcoma margins
2-4cm
Lesions have lateral extension
235
Pulm artery pressure > ___ is a contraindication to transplant
35 mmhg
236
___ (cytokine) is associated with cachexia
TNF-alpha
(IL1- fever, IL2- T cells & Ig production, IL4- T &B cells)
237
_lay mesh is retro-rectus, anterior to the posterior sheath/peritoneum
Sublay
IPOM is also not-intuitively called the intraperitoneal sublay or onlay
238
Annual incidence of acute presentation of hernia while monitoring ventral hernias
2.6% (range 0-20%)
239
Who should get a component separation?
Hernia > 10cm, loss of domain
240
Smoking or pregnancy- automatically ASA __
2
241
EtOH, ESRD, COPD, poorly controlled DM - ASA __
3
242
Who is ASA 4?
Stroke / MI within 3 months
Low EF, ongoing cardiac or valvular dz
DIC
243
Thrombotic thrombocytopenia purpura is caused by ___
Deficiency of ADAMTS13
Cleaves vwf into multimers
244
Treatment: TTP
Plasmapheresis & steroids (decrease autoantibodies to ADAMTS13)
245
Bethesda IV: lobectomy vs total thyroidectomy?
Lobectomy IF
<4cm
No micro-calcifications
No extrathyroidal extension
246
Gallstone pancreatitis: risk of recurrence within 30 days
25%
247
__ branch of the superior laryngeal nerve innervates the cricothyroid muscle which affects voice pitch
External
248
Weakness and numbness s/p AFV creation with otherwise normal exam
Ischemic monomelic neuropathy (=nerve ischemia)
(txt: immediate ligation)
249
Goal CPP
60-70 mmHg
250
Which artery is more medial - peroneal and posterior tibial?
Posterior tibial
(Both are posterior)
251
Anterior vagal trunk is divided into:
Hepatic division and Anterior gastric n. (gives rise to Nerve of latarjet)
252
Posterior vagal trunk gives rise to the __ division
Celiac and Posterior gastric n. divisions (gives rise to Criminal n. of Grassi -- which may SOMETIMES arise above the celiac division)
253
Syndrome name: Post-polypectomy (during colonoscopy) pt with transmural burn without perforation
Post-polypectomy electrocoagulation syndrome
254
Size polyp that often requires hot (rather than cold) snare
>10mm
255
Contraindication to preserve pylorus in whipple
Obvious encroachment of first portion of the duodenum
256
Cowden's- in addition to hamartomatous polyps, pts also get __
Fibromas
257
Most effective APC
Dendritic cell
258
Oral abx with MRSA coverage
Bactrim, doxycycline, clindamycin
259
Low frequency transducers are used for the FAST exam to optimize __ at the cost of __
Tissue penetrance, at the cost of image quality
260
Thin area of gastrohepatic ligament that is incised during fundoplication
Pars flaccida
Located just above caudate lobe of liver, near the GE junction
(area to enter lesser sac)
261
Amount of intra-abdominal esophagus in hiatal hernia repair
3-5cm
262
Goal plateau pressures in ARDS
Lung protective TVs
<30 cm h2o
4-6cc/kg
263
Conjugated bile acids are absorbed in the TI (80%) while deconjugated by gut bacteria are absorbed in the
Colon
Or excreted in stool (5%)
264
Bariatric diets are __ protein (g/day) and __ carb (g/serving)
High protein - 60-80 g / day
Low carb - <10 g / serving
265
Intra-aortic balloon decreases __ and improves ___
Decreases afterload
Improves coronary artery filling during diastole
266
Stress dose steroids are indicated if you take *** mg of prednisone (or *** mg hydrocortisone) daily for 3 wks
>20mg prednisone
or
>80mg hydrocortisone
If, intermediate dosing, then consider HPA axis testing
5mg prednisone
20mg hydrocortisone
If <5mg, no stress dose needed
267
What dosing is needed for stress dose steroids for low vs intermediate vs high-risk surgery?
Low: none
Intermediate: AM dose + intraop 50mg hydrocortisone -> then 25 q8
High: AM dose + 100mg -> intraop 50mg q8 -> 25mg q8 ...
268
Criteria for q3 year colonoscopy
3-10 adenomas
1 adenoma > 1cm
adenoma with villous features
high-grade dysplasia
sessile polyp >1cm
*3-5 years is for 3-4 adenomas <1cm or for hyperplastic >1cm
269
Criteria for q1 year colonoscopy
> 10 adenomas
270
Criteria for q6 month colonoscopy
>20mm removed in PIECEMEAL
271
MCC acute liver failure in the US
Tylenol OD
272
% excess weight loss for RYGB and SG (and DM remission?)
RYGB: 70%
SG: 50-60%
Similar! 70-80% and 50%
DS w BPD is similar to RYGB
273
Treatment for central vs nephrogenic DI?
Central: desmopressin
Nephrogenic: thiazide
274
Most common colon bacteria
Bacteroides (fragilis)
275
Indications for radioactive iodine s/p total thyroidectomy (papillary)
Tumor size > 4cm
Extrathyroidal extension
Bulky lymphadenopathy
>5 positive LNs
276
Typical synthroid starting dose?
2 micrograms / kg body weight
277
Cushing pattern
Parallel, full thickness
Side to side dolphin -- like lembert but different direction
Interveted tissue edges, more leak resistant
Often the first layer of bowel anastomosis
278
Lembert sutures
Partial thickness (seromuscular), perpindicular
Serosal to serosal apposition
Often second layer of bowel anastomosis
279
Connell sutures
Full thickness, perpindicular
Into the bar, out of the bar, across the stress...
280
Who needs neoadj chemo in esophageal CA?
T2- muscularis propria
or any N+
T1a- endsocopic resection (lamina propria/muscularis mucosa)
T1b- upfront resection (submucosa)
281
Measure surveillance thyroglobulin for *** cancers
Papillary and follicular
282
Thoracic outlet
Subclavian v.
Phrenic n.
ANTERIOR scalene
Subclavian a.
Brachial plexus
MIDDLE scalene
283
Melanoma margins:
Depth <1mm -> 1 cm margin
Depth 1mm+ -> 2 cm margin (max)
284
Who needs SLNB for melanoma?
>0.8mm depth or ulcerated, and NO clinically + nodes
285
MC site of NET
Rectum (2/2 colonoscopy screening)
Followed by ileum
286
Most important prognostic factor for pancreatic adenocarcinoma
T staging
5 year survival
Node negative - 30%
Stage IV - 1%
287
Treatment of sx or severe (>14) hypercalcemia
NS 0.9%
-> followed by calcitonin and IV bisphosphonates (and sometimes denosumab, RANK-L antibody)
288
Superior thyroid and inferior thyroid artery are branches of ***
Superior thyroid artery - 1st branch off external carotid
Inferior thyroid artery - off thyrocervical trunk (same as parathyroids)
289
Superior and middle thyroid veins come off ***
Internal jugular vein
290
Inferior thyroid vein comes off the ***
Innominate vein
291
Ima artery comes off the ***
Innominate or aorta
To isthmus
Only occurs in 1% of people
292
Most common location of RLN injury
Ligament of berry
293
Differentiated thyroid CA staging: < 55yo
Stage 1- no mets
Stage 2- distant mets
294
Differentiated thyroid CA staging: > 55yo
Stage 1- <4cm
Stage 2- >4cm or N or strap m. involvement
Stage 3- larynx, trachea, esophagus, RLN
Stage 4- pre-vertebral fascia, major vessel encasement; distant mets
295
Medullary thyroid CA histology
Amyloid deposition
296
Txt: medullary thyroid CA
Total thyroid + central neck dissection level IV (bilateral) + possible ipsi lateral dissection
Prophylactic thyroidectomy age 1-10; usually age 5. Age 1 if level D codon
297
Hurthle cell prognosis
Good, usually benign
Path: lots of pink cytoplasm
298
Delphian nodes
Level VI "pre laryngeal" central nodes; first location of thyroid CA spread
- adjacent to pyramidal lobe of thyroid
Anterior suspensory ligament
299
Pharyngeal pouches: thyroid, parathyroids
Thyroid: 1-2
Sup parathyroid: 4 (assoc w thyroid complex)
Inf parathyroid: 3 (assoc w thymus); more often ectopic, most commonly tail of thymus
300
Treatment: parathyroid CA
parathyroidectomy
ipsi thyroidectomy
central neck dissection
301
PTH kidney activity
Absorb Ca
Excrete bicarb and phosphate
302
MC sx medullary thyroid CA
Diarrhea, from elev calcitonin
303
Papillary vs follicular CA- lymph vs hematogenous spread?
Papillary- lymphatic (histo: orphan annie eyes - CLEAR cystoplasm... psammoma bodies)
Follicular- hematogenous
304
Sarcoma margins
1-2cm
305
Does DCIS require postop radiation in BCT?
Yes
But not necessarily SLNB unless multicentric, area involved >4cm, HER2+, high-grade, comedonecrosis
306
What are indications for neoadj chemo for sarcoma?
>10cm high grade
or
>5cm high grade liposarcoma or synovial sarcoma
307
Who should get adj chemoXRT after rectal CA resection?
T3-T4
Nodal disease
Metastatic dz
308
MC location of Mallory Weiss tear?
GEJ
309
At what hour intraop should ancef be readministered?
4 hours
310
Indication for sx: Esophageal leiomyoma
>5cm or sx
311
Etiology: Traction vs epiphrenic diverticulum
Traction- granulomatous dz (mid esophagus)
Epiphrenic- dysmotility (distal esophagus)
Txt: if symptomatic (excise + c/l myotomy)
312
Which esophageal diverticulum is a true diverticulum?
Traction
313
Patients on steroids have *** times increased risk of anastomotic leak
3.5
314
Typical osmolality
280-295
Significance- true hyponatremia (low osmo) vs pseudohyponatremia (normal osmo)
315
*** execution error that occurs when there is a failure in memory or attention
Lapse
316
A slip vs fumble mistake
Slip- incorrectly performed (eg cut wrong thing structure), lapse in concentration
Fumble- clumsy (eg inadvertent enterotomy)
317
Needle decompression site for peds vs adults
Peds- 2nd mid-clavicular
Adult- 5th mid-axillary
318
Incision for large horseshoe abscess
Posterior incision (from anal verge towards coccyx)
2x counter incisions over ischiorectal fossas
319
Inguinal hernia annual incarceration risk
0.18% per year
320
Stress ulcers are *** (shape) and *** (location)
Linear erosions in gastric body/fundus
321
Location of type I vs IV gastric ulcers
I- lower lesser curve
IV- higher lesser curve
"You go low, I go highh"
322
Most common minor salivary gland tumor
Adenoid cystic carcinoma
(The palate is the most common site of origin)
323
SLNB for subungual melanoma?
If depth >1mm
324
When can you try to spare the digit for subungual melanomas?
<0.8mm depth
325
Emancipated minors includes (2):
Military
Married
326
Treatment: glucagonoma
Distal pancreatectomy and splenectomy (high risk of malignancy)
(most often body & tail of pancreas)
327
Treatment: gastrinomas vs insulinomas
Both enucleation (IF <3cm)
Formal resection if:
- <2mm from main duct
- abutting duo or >3cm
328
Type of graft preferred for joint?
Full thickness
Limited contraction would inhibit mobility if split thickness were used
329
Desired respiratory quotient
0.8-0.9
<0.7 starving
0.8 fat
0.9 protein
1.0 carbs
330
NEC babies are at risk of *** later
Colon strictures (not SB)
331
Revised cardiac risk index factors and risks
332
Marjolin ulcer margins vs typical basal cell carcinoma vs cutaneous SCC
1cm
4mm
4-6mm
333
Calcineurin vs mTOR inhibitors
Calcineurin- tacrolimus, cyclosporine
mTOR- sirolimus, everolimus
334
What kind of stomach ulcers are associated with hiatal hernias?
Cameron ulcers
(linear impressions from diaphragm)
--
Curling ulcer- on duo
Dieulafoy lesion- large submucosal arteries w erosion of overlying mucosa
335
ADH 3 functions:
1) reabsorb H2o collecting tubule
2) vasoconstriction
3) release of vWF and factor VIII
336
Acid base disturbance in pancreatic transplant and why?
Non-gap MA
Anastomose new pancreas to recipient bladder (via duo). Vessels to recipient iliac vessels => loss of bicab from pancreatic juices
337
Indications to resect a meckels:
MALE Adults <50 yo
Children <18 yo
Length >2cm
Broad base, palpable abnormality, fibrous bands
338
Why does DDAVP help uremic platelets?
What blood test is abnormal?
Bc uremia also impacts factor VIII function (in addition to PLT)- both of which are helped with DDAVP
Just bleeding time
339
Surveillance for adenomas <4cm?
Yes!
Rpt CTAP in 3-6 months
Rpt bloodwork in 1 year
340
High CO2, Low Bicarb VBG - acidic or basic pH?
Low pH
341
What part of intussusception is more prone to perforation?
Intussuscipiens (recipient bowel), eg colon in I-C intussuception
- (Colon is what becomes congested, ischemic, and causes Currant jelly stools)
vs. intussusceptum is the ileum which invaginates into colon
- looks like a septum
342
VIPoma acid base status
Hypokalemic, NG metabolic acidosis
343
CT cystogram- volume of contrast and method (syringe vs gravity)
350cc via gravity
344
Cutaneous squamous cell carcinoma margins
4-6mm
345
MC bug in pyogenic liver abscess?
- in setting of colon CA?
E coli & Klebsiella
Klebsiella esp in CRC
40% have an underlying malignancy
346
Primary source of bilirubin
Senescent red blood cells
(aged or active hemolysis)
347
Shortcut for EKG rate
300-150-100-75-60
348
Medial and posterior borders of femoral hernia
Pectineus inferiorly/posteriorly
Lacunar ligament medially
349
IHR mesh vs primary repair recurrence rates?
5% vs 20%
350
MC malignancy of childhood
Leukemia
351
Umbilical hernias < ***cm often close on their own by 5 yo
1.5cm
Can repair before 5yo if >2cm or symptomatic
352
Bladder pressure > *** is assoc w compartment syndrome
20 mmHg
353
Borders of central neck dissection (levels VI and VII)
Superiorly - hyoid bone
Inferiorly - innominate artery
Laterally - carotid arteries
354
Why does fluid overload cause a fib in postrop thoracic cases?
Atrial distention
Risk increases with the more lung that is taken
Ranges from <5% (wedge) to >15% (pneumonectomy)
355
Pancreatic duct size cutoff for Frey vs Beger?
Frey - dilated duct > 7mm
Beger - non-dilated duct
Both involve enlarged pancreatic head
356
Frey vs Begger surgery
Frey- lateral pancreatojejunistomy with local pancreatic head resection
Beger- duodenal sparing pancreatic head resection
Frey = Beger + Puestow (kind of)
357
Indication and surgery for Puestow
Pancreatic duct >7mm (normal is <3.5mm)
No head enlargement
Lateral or longitudinal pancreatojejunostomy
358
Normal pancreatic duct sizes
4-3-2
Head- 4mm
Body- 3mm
Tail- 2mm
Abnormal dilation is >=7mm
359
Two main CDH strategies:
Permissive hypercapnia
Low inspiratory pressures
360
Normal peak inspiratory pressures on ventilator
35-40 cmH2O
361
Goal UOP for burn patient
Same as everyone else - 0.5-1.0cc/kg/h
362
What has replaced the Parkland formula for burn resuscitation?
Brooke - 2 x cc/kg/TBSA over 24hrs (1/2 over first 8hrs)
Rule of 10s - 10 x TBSA = initial hourly rate
363
NET Rectal cancer: size cutoff for T1 cancer -> LAR/APR
>2cm then surgery
If <1cm with neg margins -> endoscopic
364
What size CBD stones can be flushed out?
<3-4mm
(ideally 4 minutes after 1mg glucagon)
365
Cause: Febrile hemolytic vs non-hemolytic rxn
Hemolytic- ABO incompatibility (host antibodies vs donor PRBCs)
Non-hemolytic- (cytokines from) donor leukocytes or just rxn to donor leukocytes
366
Treatment: Febrile hemolytic vs non-hemolytic rxn
STOP transfusion
Hemolytic - fluids
Non-hemolytic- antihistamines, epi, steroids
367
Thoracoabdominal area
Superiorly: nipples or tip of scapula
Inferiorly: to costal margins:
368
Pressor in cardiogenic shock with low MAPs
Norepi
369
Reversal for argatroban vs dabigatran
Argatroban- PCC (II, VII, IX, X)
Dabigatran- idarucizumab
370
Heparin vs lvnx half life
Heparin- 1 hour
Lovenox- 5 hours
371
For stage I or II non-small lung CA, do you need to do a mediastinal dissection?
Yes, high rate of upstage
Stage III - gets neoadjuvant
372
For lung CA, do you ever perform a wedge resection?
Only if very poor pulm reserve
373
Nonseminomatous vs seminoma tumor marker
Nonseminomatous- AFP, beta hcg, LDH
Seminoma- rarely beta hcg, never AFP
374
SMA syndrome from embolus: typical distribution
Jejunal sparing AND T-colon sparing (distal to middle colic)
375
Most common graft sites for full thickness grafts
Eyelids
Skin or postauricular, supraclavicular, antecubital, inguinal, genital areas
376
Treatment: somatostatinoma
Resection, NOT enucleation
Usually malignant
377
Borders of submental triangle?
Hyoid
Anterior belly of digastric
Symphysis menti
378
If not clostridium, MCC nec fasc
GAS
(group A strep)
379
Childs pugh class- % M&M by class?
A- 10%
B- 30%
C- 75-80%
380
Cell cycle phases most susceptible to radiation
G2 and M phases - when dividing
381
When are protons vs electrons used in radiation?
Protons- penetrate deeper
- deposit energy at END of their paths. Minimal effect on tissue passed through
Electrons- more superficial/skin cancers
382
Curvilinear vs radial echoendoscope purposes?
Curvilinear- for biopsies (parallel plane)
Radial- luminal imaging of GI tract (perpindicular plane)
383
IPMN high risk features
Main pancreatic duct >1cm
Enhancing mural nodule =>5mm
CBD obstruction / jaundice
Also s/p FNA:
-intraductal mucin
-thick wall
-mural nodules
-cytology suspicious for malignancy
384
Obstruction in insufflation tubing: *** (high/low) flow and pressure?
Low flow
High pressure
vs leak would be
High flow
Low pressure
385
Penicillin allergy: ***% chance of cross-reactivity with cephalosporins
10%
386
Size of gastric pouch?
Where do you enter lesser sac?
10-30mL
~5cm in length
Enter lesser sac 3-4cm below GEJ
387
For colon surgery, can 2nd gen cephalosporins be given alone or with flagyl?
Alone - cefoxitin and cefotetan
- has anaerobic coverage
388
Boari flap vs psoas hitch: mid vs lower ureteral injury?
Boari flap- mid
Psoas hitch- lower
389
Who needs to have their warfarin bridged vs stopped?
High CHADS2 >5-6
(or high CHA2DS2 VASc)
390
Corticotrophin stimulation test - administer *** then measure cortisol at ***
ACTH
at 30 and 60 minutes
391
Best stricturoplasty for 5-7cm long stricture
Heineke–Mikulicz strictureplasty
- cut longitudinally; close transversely
392
Best stricturoplasty for 10-20cm long stricture
Finney
- longitudinal incision along stricture, then sew posterior wall and anterior wall
(side to side)
393
If bile reflux gastritis after BII, then convert to a roux en y with roux length of ___
40-60cm
394
MCC Nipple discharge
Intraductal papilloma
395
What stage melanoma patients need careful surveillance (q6-12 month exams)?
Stage IIA +
=T2b, >1mm + ulceration
or
T3a, >2mm w/o ulceration
396
Everolimus: MOA and indication
Oral mTOR inhibitor
Well-differentiated metastatic PNETs
397
Delorme vs Altemeier layers
Delorme- strip mucosa, plicate muscle
Altemeier- full thickness resection
398
Stages of graft wound healing (3)
Imbibition (0-48hrs)- plasma fluid for nourishment
Inosculation (48-72hrs)- connect donor & host blood supply
Revascularization (>72hrs)
399
Resection for hepatic flexure colon CA
Extended Right Hemi (ileocolic and middle colic)
(same as prox/mid Transverse colon)
400
Left Hemi vs Extended Left Hemi vascular ligation
IMA vs. IMA + L branch of Middle colic
401
How many cm of esophgaus should be intraabdominal in fundoplication?
3cm
402
Do you repair anterior or posterior crura in fundoplication?
Posterior, use permanent sutures
403
Law of Laplace
Tension = Pressure*(Radius/Wall thickness)
404
Paget Schroetter first step of treatment
Thrombolysis, then anticoagulation for 3 months
Then anatomic surgery if needed
405
Critical limb ischemia concern for ABI < ___
0.5
406
Congenital adrenal hyperplasia pneumonic
CAT
Aldosterone / Testosterone
11- both
17- hyperaldo
21- hypertestosteron
407
High grade vulvar intraepithelial neoplasia txt
WLE, 5mm margin
408
Looking at ampula via endoscope, CBD is at the ___ o'clock position and pancreatic duct is at the ___ o'clock position
CBD- 11 o'clock
Pancreas- 1 to 3 o'clock
ampulla of vater is at 12 o'clock
409
Minor papilla is more distal or proximal? Easier or more difficult to cannulate?
More proximal
Smaller, more difficult to cannulate
410
Copper deficiency sx (2)
Pancytopenia
Neuropathy w/ Ataxia
411
Chromium deficiency
Diabetes-like
412
Selenium deficiency
Keshan disease -- cardiomyopathy, impaired growth, pain, weakness, hypothyroid
413
Zinc deficiency
Growth failure
Delayed sexual maturity
Decreased immunity
Wound healing
Rash
414
Per Day Equivalents
PO Oxy
PO Morphine
PO Dilaudid
IV Morphine
IV Dilaudid
Per Day Equivalents:
PO Oxy: 15mg
PO Morphine: 25mg
PO Dilaudid: 6.25mg
IV Morphine: 8.5mg
IV Dilaudid: 1.25mg
Methadone: around 1:4 for lower doses but 1:10, ie more potent at higher doses... methadone 5mg=morphine 20mg
Think typical dose
Oxy 5mg
PO morphine 7.5mg
PO Dilaudid 2mg
IV Morphine ~3-4mg
IV dilaudid 0.4mg
415
MHC II are found on __ cells. MHC I are found on ___ cells
MHC II- only on APCs
MHC I- on all cells
416
BIRADS 4: description and % malignancy
Suspicious for malignancy
2-95%
(BIRADS3- probably benign; BIRADS5- highly suggestive of malignancy)
417
Txt: Barretts
Low grade dysplasia - ablation
High grade dysplasia or T1a cancer - endoscopic mucosal resection
418
Nerve responsible for thumb vs rest of hand muscles
Thumb - median n.
Hand - ulnar n.
except lumbricals: median & ulnar n.
419
Pancreas divisum- minor papilla is the __ (ventral/dorsal) and __ (santorini/wirsing)
Minor papilla (more proximal): Dorsal, santoirini
420
Class of shock- narrow pulse pressure
Class II
Increased diastolic BP from vasoconstriction
421
SMA syndrome is caused by SMA compression on the ___
3rd portion of duo
Txt: D-J anastomosis for bypass
422
Why do gallstones form after weight loss surgery? (2)
(1) Liver secretes increased cholesterol into bile & bile salt secretion decreases
-> supersaturated with cholesterol
(2) GB hypomotility
423
How quickly can G-J ulcers form after gastric bypass?
4-6 wks -> can then lead to stenosis
424
Most important prognostic factor for thyroid CA (papillary/follicular)
AGE! If <40, even better than no LN disease
425
Which spreads to LNs? Papillary and/or follicular CA
Just papillary; follicular spreads hematogenously
(thus slightly more aggressive)
426
Concern for breast malignancy: branching vs non-branching calcifications?
Branching, pleomorphic
427
Timeline for etoh withdrawal-induced seizures
6-48 hours
428
Cardiac index can usually compensate in ___ shock
Septic
429
After total gastrectomy, what technique can be used to help prevent a duo stump leak?
(besides oversewing, buttressing etc)
Double-tract reconstruction
Ie extra D-J anastomosis
430
Why do full thickness skin grafts have more primary contracture?
More elastin in wound since they have all the dermis
431
Higher risk of hematoma/seroma: full or split thickness?
Full - lack the interstices of FTSG
432
Height of collis gastroplasty
3cm
Indication: if <2cm of esophagus is intra-abdominal
433
50% of mesenteric cyst masses are __
Mesenteric cyst lymphangiomas
434
MC location of IPMN vs serous neoplasm?
IPMN - head
Serous - tail
The rest all of over
435
Do IPMNs have capsules?
No
436
What makes pseudocysts "pseudo"?
Non-epithelialized wall
437
Location of Bochdalek vs Morgagni hernias?
Bochdalek - posterior lateral (more common). often left but not always
Morgagni - anterior near sternu (often incidental)
438
Vent settings for ARDS
Low TV, low PEEP
APRV (airway pressure release ventilation) - rescue mode of ventilation
Just continuous pressure with brief pauses for expiration
- settings are high and low Pressure, high and low Time at that pressure
439
What vent settings for patient to extubate?
SIMV- synchronized intermittent mandatory ventilation
- pt can initiate their own breaths in addition to set RR
440
How do you measure bladder pressure?
Instill 25cc of saline into empty bladder via foley. Measure pressure at end expiration
441
Plateau pressures: high vs low in lung vs airway issue?
what about ACS?
High plateau- lung & ACS
Low plateau- airway
442
How do you calculate hepatic venous pressure gradient?
What is normal? What suggests clinically significant portal HTN?
Wedge pressure MINUS free hepatic v. pressure
Normal <5 mmHg
Portal HTN >10-12 mmHg
443
In what cases of liver disease will HV wedge pressure be normal?
Pre-sinusoidal
Catheter inserted into IVC -> HVs. Won't see earlier backup pressure
444
After reducing immunosuppression, what is first-line therapy for PTLD?
Rituximab
(CD-20 monoclonal antibody)
445
MC SBP bugs:
#1 E coli
Klebsiella
Pneumococcus
txt: cefotaxime or other 3rd gen cephalosporin
446
Ranson's criteria:
Pre:
Age>55
WBC>16
Glucose>200
LDH>350
AST>250
Post (>48 hours):
(mostly fluid status)
BUN increase > 5 mg/dL
Base deficit > 4 mEq/L
Fluid requirement > 6L
PaO2 < 60 mmHg
Calcium < 8 mEq/L
Presence of 3+ means severe acute pancreatitis
447
CCK- in addition to GB & sphincter of oddi stimulation, what other organs does it act on?
Pancreas- potent stimulator
Stomach- inhibits gastric emptying
448
CCK is produced by __ cells of the ___
I cells of the duodenum & jejunum
449
Duodenal switch anastomoses
Proximal SB transection (250cm total) to ileum 100cm from cecum
Bring up roux limb to transected proximal duodenum
450
Sx: hypomagnesemia
Tetany muscle spasms
(opposite of absent DTRs)
451
Sx: hypoK
flattened T waves
452
Sx: Hypophosphatemia
Respiratory distress
Weakness
453
MALTOMA B cell markers
CD19, CD20, CD22
454
What if MALTOMA is h pylori cytogenetic + t(11;18)?
H pylori abx
+ radiation (or rituximab if radiation contrainidicated)
455
Txt: non-hodgkin large b cell lymphoma
R-CHOP
Rituximab
Cyclophosphamide
Doxorubicin
Vincristine
Prednisone
+/- radiation
+/- resection
Gastric lymphoma- also uses CHOP / R
456
Intraop BP control for pheochromyctoma
Nitroprusside
457
What toxicity can arise from nitroprusside and whats the treatment?
Cyanide poisoning
(releases nitric oxide- potent vasodilator)
Txt: B12 and sodium thiosulfate
458
Management of high vs moderate vs low fistula output?
High > 500 cc/day
Moderate: 200-500 cc/day
Low < 200 cc/day
Low- OK to give regular diet
High- NPO, TPN
459
What % of ECF will close spontaneously on their own?
1/3 in 4-6wks postop
460
Rovsing vs Psoas vs Obturator
Rovsing- press of LLQ -> pain in RLQ
Psoas- extend R thigh posteriorly (laying on L side) -> pain in RLQ
Obturator- flex knee and internal rotation -> pain in RLQ
461
Dysphagia to solids vs liquids: mechanical obx (eg tumor) vs achalasia?
Achalasia- both
Mechanical- initially solid, progresses to liquid
462
Mortality of elective EVAR vs open AAA repair?
1-2%
(if survive surgery, 25% if rupture)
vs
5%
(if survive surgery, 50% if rupture)
463
Mirizzi syndromes results in compression on the ___
Common hepatic duct
464
Lentigo maligna- favorable or unfavorable?
Non-aggressive, slow growing
In elderly people, sun-exposed areas
Vs. nodular aggressive
vs. superficial spreading- MC
465
Peaked T wavs vs U waves
T waves- hyperK
U waves- hypoK
466
Is GB cancer with mets to liver resectable?
No
467
HS abx choices for stage I vs III dz
tetracycline like doxycycline
clinda & rifampicin
468
Anion gap will be falsely low in cases of ___ albumin.
Low albumin
469
Non-gap MA occurs because
Loss of bicarb (ECF, diarrhea or renal) is accompanied by gain of Cl -> hyperchloremic state
470
Anion gap occurs because there is an increased amount of
Fixed acid
471
Earliest manifestation of AG
Increased minute ventilation / TV
472
Non-cyanotic heart dz include
VSD
ASD
Coarctation of aorta
473
Typical abx for human vs dog/cat bites
Cefoxitin 2nd gen (Eikenela - resistant to 1st gen cephs)
Augmentin
474
Normal SVO2 level?
What does it mean if it's high vs low?
>75%
High: Tissues are not able to extract O2 readily (most types of shock)
Low: Tissues are extracting more oxygen (seen in SEPTIC shock)
475
Where is the incisura?
Angle at edge of lesser curve
(where antrum begins)
476
Criminal n. of grassi vs latarjet are branches of L or R vagus?
GRassi- Right (celiac plexus)
Latarjet- Left (also hepatic branch)
477
Difference in truncal vs selective?
Above or below posterior branches of celiac plexus
478
Latarjet innervates the ___?
Is this preserved in highly selective vagotomy?
Pylorus
Yes- why you don't need a drainage procedure
479
Criminal n. of grassi innervates the __?
Cardia
A high posterior right branch
- if vagotomy performed below the level of this nerve, pt will remain symptomatic
480
Median n. injury can occur with __ fx's
Distal radius fx
First 3 fingers
May need decompression of carpal tunnel
481
Bern procedure for pancreas is like ___
Beger
Bern procedure has same indication, but only 1 anastomosis (NOT longitudinal)
481
Beger: how many anastomoses involving pancreas?
2
482
Duodenal injury grade with >50% involvement
Grade III
Grade IV is >75% of D2
483
Zone II of the neck
Cricoid cartilage to angle of the mandible
484
MC sites of metastasis of melanoma:
LN (75%)
Lung
Liver
Brain
Bone
Adrenal
SB (35%)
485
Adalimumab
ie Humira
TNF-alpha inhibitor
HS, IBD
486
Confused combative stage of shock?
Grade III
Also elev HR and dec BP
487
Gold standard test to diagnose gastroparesis
(eg as a result of vagotomy)
Nuclear medicine gastric emptying study
488
Location of organ of zuckerlandl
Anterolateral to distal abdominal aorta btw takeoff of IMA and aortic bifurcation
(catecholamine-producing cells for fetus's but usually regresses)
489
Mild and moderate hypothermia temps
<95 F
<90 F
490
Blunt zone II hematoma: explore?
If non-expanding -> OK not to explore
491
For cattell braasch, you medialize the right colon, cecum and SB to have access to ___?
IVC
Aorta
Duo
492
Oral potassium repletion typical dosing
40-100 mEq/day in 2-4 divided doses
If IV, only 10 mEq / hr in peripheral IV
493
Fetal distress is heart tones less than ___
120/min
494
BRCA1 vs BRCA2: higher risk of ovarian CA vs male breast CA
BRCA1- breast CA; ovarian CA; triple-negative breast CA
BRCA2- male breast CA; more likely ER/PR+. more prostate and pancreatic CA
495
FAST is unreliable for < ____cc of blood
300-600cc
496
Medication for HRS
Terlipressin- vasopressin analogue
497
Pembrolizumab
PD1 recepetor (programmed death 1)
vs CTLA-4 Ipilimumab (for melanoma also)
498
Cetuximab
Bevacizumab
Monoclonal antibodies against:
Epidermal growth factor receptors
VEG-F vascular endothelial growth factors
Both for CRC
499
UC colonoscopy screening
q1-2 years, 8-10 yrs after initial diagnosis
500
Mattox maneuver- mobilized ___ organs for exposure of L retroperitoneum
Pancreas, spleen, and colon medially
501
Kocher maneuver exposes
Duo and head of pancreas
502
Synthetic absorbable mesh vs biologic mesh
BioA, Phasix
Acellular collagen matrix
503
Dx: patchy thickening of the basement membrane with infiltration of lymphocytes in the lamina propria of the transverse colon
microscopic colitis
504
MC injured ventricle in penetrating trauma
RV (more anterior)
505
Txt: traumatic long-segment partial circumference injuries (< 50%)
Patch angioplasty
- either with an autologous vein patch or synthetic patch (ie, bovine pericardium)
If > 50% circumference -> interposition graft
506
Umbo hernia repair in pregnancy?
Wait until 6-12 months after
507
__ can enhance biliary excretion of conjugated bilirubin in patients with patent extrahepatic ducts
Phenobarbital
Helpful to differentiate neonatal jaundice from biliary atresia
508
What vein comes in front/across the aorta?
L renal vein
Nutcracker occurs when SMA compresses L renal vein -> gonadal vein reflux
509
Does AFP decrease with HCC treatment?
Yes
510
Housefield units: fat, water, blood?
Fat- -100
Water- 0
Blood- +30-45
511
Malignant thymoma: what precludes surgical resection?
Stage III (invade neighboring structures) -require induction chemotherapy prior to resection.
Stage IV tumors - unresectable but can potentially be managed with surgical debulking and chemoradiation
512
% time with pH < 4 during 24-hour pH monitoring
abnormal > 6%
normal < 4%
513
Do DCIS +Her2Neu get trastuzumab?
No - only if invasive CA
But DCIS ER/PR+ get hormone therapy
514
Considerations before getting access in LE endovascular procedure?
Avoid calcifications
Stay above femoral head
515
What's a lower risk procedure -- aorto-bifem or axillo-bifem bypass?
Aortobifemoral bypass
516
For SMA embolectomy, what technique can be used for closure if it's a small vessel or longitudinal arteriotomy?
Patch angioplasty
517
Air embolism position (while doing central line) and why?
Left Lat Decubitus
Prevent air from traveling from RV to PA
518
MCC AV graft fails to mature
Poor outflow -> perform fistulogram of outflow tract
519
Early graft failure is 2/2 technical error. Intermediate and late is 2/2
intimal hyperplasia (<2 years)
progression of atherosclerotic disease (>2 years)
520
PE with R heart strain, large clot burden, hemodynamic instability: thrombolytics vs thrombectomy
Thrombolytics -- unless c/i like recent surgery, hemorrhagic stroke, bleeding risk
521
Who gets a heimlich valve?
Continued air leak, not surgical candidate or doesnt want surgery
522
Does PPI reversibly or irreversibly bind H/K?
Irreversibly
523
MC intestinal blunt injury in pediatrics?
Injury to jejunum or ileum
524
MCC mortality after blood transfusion?
TRALI
transfusion related acute lung injury
525
No LINX for (5)
Large or paraesophageal hernia
Obesity
Esophageal dysmotility
Severe or baretts esophagitis
Prior GI tract surgery
526
Is non-sponteaneous or spontaneous nipple discharge pathologic?
spontaneous
527
VIPOMA: alkalosis or acidosis?
NG met ACIDOSIS
HypoK HypoCl
528
Colon CA screening if first-degree relative with hx?
40 yo or 10yrs before diagnosis if earlier
529
Treatment: pelvic congestion syndrome (pelvic varicose veins)
Progesterone
If hormones, fail -> coil embolization
530
PD-L1 tumor marker
Gastric CA and liver CA
531
GIST markers (2)
C-kit
CD117
532
A cystic duct can be dilated up to *** mm to accomodate a choledochoscope
4-6mm
533
Rectal CA: T3 definition and management
T3- invading thru muscularis propria INTO MESORECTUM
"Total" neoadjuvant: FOLFOX + long-course XRT -> Re-stage
534
Chronic venous insufficiency is confirmed with reflux > *** (time) of deep veins
> 1.0 second
535
Hypoechoic vs hyperechoic clot on US
Hypo- acute
Hyper- chronic
536
In children with incarcerated inguinal hernia, when do you operate after you reduce?
Wait 24-48 hours to allow bowel edema to go down
537
Is succinylcholine depolarizing or non-depolarizing?
Depolarizing
538
Why can't you use succinylcholine in burn or spinal injury patients?
Have more receptors at synapse -> at risk of HyperKalemia
539
Lower leg compartment most at risk of ACS
Anterior
(fibrous and osseous attachments more rigid)
540
Clinical situations in which bladder pressures are less reliable
Neurogenic bladder
Massive ascites
Obesity
Pelvic hematoma
(obtain at end-expiration)
541
Which yields a higher risk of central venous stenosis -- IJ or subclavian line?
Subclavian
542
What kind of error is a missed medication when patient goes to OR 2/2 EMR?
Latent error - hidden process or design that goes missed
543
Error of commission vs omission
comission- something done to patient (eg giving a medication their allergic to)
omission- something missed (failure to provide treatment)
vs slip- lapse in concentration
544
Do pseudocysts usually regress on their own?
40% within 6-12 wks
(can monitor if asx for 3-6 months)
545
New adjunct for recurrent c diff episodes
Bezlotuximab
(IV med, given once, neutralize toxin before attaching to host cells)
546
Spigelian hernia contents usually protrude ***
Laterally and inferiorly, posterior to EO
Couldn't go medially bc of intact rectus sheath/muscle
547
What chemo agent is most commonly used in HIPEC?
Mitomycin
548
MOA: Taxol
Microtubule STABILIZATION (to arrest disassembly); arrest the cell in metaphase
549
Pheochromocytoma adrenalectomy: ligate vein or artery first?
Vein, to avoid catecholamine spillage
(traditional thinking)
550
Nephrogenic vs cerebral SIADH treatment?
Loop diuretic
vs
Vaptan (vasopressor receptor antagonist)
551
MC variant of renal arterial anatomy?
Supernumerary arteries off aorta
552
Peripheral pallisaiding of nuclei - skin cancer type
Basal cell carcinoma
553
Should zone III retroperitoneal hematomas being explored?
For penetrating, but NOT blunt
554
Does cellulitis count as an SSI?
No
555
MELD 90-day mortality for 17-19 vs. 32+?
3%
vs
66%
556
First muscle to paralyze and first to come back
First to paralyze: small fascial muscles
(Last to paralyze) & First to return: diaphragm
557
What's more medial -- the common femoral artery or vein?
Vein
558
In whom do you resect incidental Meckel's vs. not?
Incidental:
- children < 18 yo
- men < 50
Resect if >2cm, assoc w fibrous band, or palpable abnormality:
- women < 50
Only if palpable abnormality:
- adults > 50
559
At 20 weeks, the uterus is palpable at the ***
umbilicus
560
Segment of colon: greatest absorptive capacity
Ascending
561
Advanced, unresectable HCC
Bevacizumab (VEGF) with atezolizumab (PDL-1)
562
MELD < *** do not have a survival benefit from transplant
15
563
Purulence means a *** wound (clean/clean-cont/cont/dirty)
Dirty/infected
564
Who gets intra-lesional steroids vs adalimumab in HS?
Stage 1 (no tracts): clinda, tetracyclines & metformin; intra-lesional steroids
Stage 2/3 (recurrent w tracts): if you fail PO abx (eg tetracycline) -> adalimumab (anti-TNF alpha)
+ surgical txt
565
Mammogram: "coarse, egg shell calcifications"
Fat necrosis
566
SAAG > 1.1 differential?
ANYTHING that causes portal HTN
Low total ascites protein:
- Pre & intra-hepatic (cirrhosis, PVT, late budd chiari)
- DON'T FORGET: If WBC >500 or PMN >250 cells/mm^3 -> SBP
High total ascites protein: post-hepatic, cardiac
567
SAAG < 1.1 differential?
High serum albumin:
- nephrotic syndrome
- peritoneal carcinomatosis
- TB
- biliary leak
- pancreatic ascites
568
Gestational age for which mom should receive steroids if going to deliver?
Less than or equal to 34 wks
(no surfactant)
569
Dose of hypertonic saline in acute hyponatremia
100cc of 3% NaCl up to 3 times
570
Risk of SSI in clean-contaminated vs dirty wound?
Clean-contaminated: 7-10%
Dirty: 50-60%
571
Surveillance interval for >10 adnomas
1 year
572
Thoracoabdominal compartment syndrome incisions
Anterior axillary line: clavicles to costal margins
(transverse portion can be included)
Down to but not including fascia
573
Wound healing: fibroblasts peak on day ***
Day 5
(Lymphocytes peak at day 7 but there are still more fibroblasts)
574
Wound healing: collagen type III replaced by collagen type I timeline
Day 4 to 21
(by day 7, type III as nearly disappeared; type I>III usually by about day 4)
"Proliferation" phase
575
Wound healing: neutrophils peak at ***
24-48 hours
576
QT > ___ ms is a risk of torsades
500ms
577
FEV1 > ___ is necessary in c/l lung for pneumonectomy
> 800mL
(so total FEV1 > 1.6L)
VO2 max must exceed 75% on CPET
578
Length vs lead-time bias
Screening test gets a lead -- discovering cancer earlier even tho survival is no different
vs
Length-time bias -- more indolent cancers being diagnosed (eg PSA, prostate CA)
579
Corrected total calcium
Serum calcium + (0.8*(4-albumin)
Ionized calcium is less dependent on albumin
Also don't forget to correct Mg
580
Severe hypocalcemia is < *** (corrected)
7.5
or ionized < 3.0
581
Nerve involved in issue with plantar flexion
Tibial nerve
(Posterior compartment)
582
Nerve involved in issue with DORSI flexion
DEEP peroneal nerve (ANTERIOR compartment)
vs. SUPERFICIAL - eversion (LATERAL compartment)
583
Nerve most at risk during fasciotomy
SUPERFICIAL peroneal nerve - eversion (LATERAL compartment)
584
When do you refer a CKD patient for AVF?
CrCl <25 mL/min
585
Smokers vs ESRD: location of LE PAD?
Heavy smokers- SFA
ESRD & DM- infra-popliteal
586
Timeline s/p CAD w angioplasty and stent to go for surgery
Only Angioplasty: 14 days
Bare metal stent: 30 days
DES: 6 months
There is also mixed data on stopping ASA, in favor of continuing it for high-risk candidates unless bleeding risk
587
HIT 1 vs 2
1- more mild, acute onset. May continue hep
2- more severe, 5-14 days. Stop hep
588
ESRD patients can have dabigatran or argatroban?
Argatroban
589
Berkson bias
inpatients are not as healthy as general population
590
Pygmalion bias
Researcher expects a new therapy to be better
591
Somatostatinoma clinical signs
DM
Gallstones
Steatorrhea
592
Current max acceptable cost to gain one additional QALY ("willingness-to-pay") threshold = $____ per QALY.
$100,000-$150,000
593
Six Sigma
Error reduction and quality improvement via:
-Define
-Measure
-Analyze
-Improve
-Control
Lean is focused on waste reduction with value stream mapping
594
Role of LDL? Why is it atherogenic?
Transfers cholesterol from liver to peripheral tissues
Very low density is converted to intermediate low density (by Lipoprotein lipase); which is converted to LDL in the liver
595
How do non-gap MAs avoid an anion gap?
Loss of bicarb -> gain of Cl- to make up for it
Vs anion gap: caused by increase in fixed amount of acid
596
Anion gap will be falsely ___ in patients with low albumin
LOW
597
Teduglutide (a ___ analogue) helps with short gut by helping mantain
GLP-2
Intestinal epithelium
598
Primary substrate of hepatic gluconeogenesis day 5-7 of NPO
Alanine
(Cori cycle)
vs Ketone bodies fuel the brain
599
HCC vs adenoma imaging
Both rapid filling
HCC- rapid washout
Adenoma- isotense on delayed filling
600
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