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Absite killer plus

What is the source of fever in atelectasis? Alveolar macrophages
What is the first sign of malignant hyperthermia? Increase in end-tidal CO2
What is the treatment for malignant hyperthermia Dantrolene
What is the first muscle to recover from paralytics? Diaphragm
What is the rate-limiting step in cholesterol formation? HMG coA Reductase
Where is angiotensin I converted into angiotensin II? lung
What are the effects of angiotensin II? Vasoconstriction Increases aldosterone (keeps Na, loses K/H in urine)
Describe the anatomy of the vagus innervation of the stomach Left vagus (anterior) gives hepatic branch, Right (posterior) gives celiac branch and "criminal nerve of Grassi"
Which cells produce pepsinogen? Chief cells
Which cells produce intrinsic factor? Parietal cells
What are the main stimuli for H+ production in the stomach? Acetylcholine, gastrin, and histamine
What is the mechanism of omeprazole? Blocks H/K ATPase of parietal cell
What is the most common symptom post-vagotomy? Diarrhea (35%)
What is the cause of early (15-30 min) dumping syndrome? Hyperosmotic load, fluid shift causes neuroendocrine response, peripheral and splanchnic vasodilation
What is the cause of late (2-3 hrs) dumping syndrome? Increased insulin with decreased glucose
What are the 3 actions of CCK? 1) contract gallbladder 2) Relax Sphincter of Oddi 3) Increase pancreatic enzyme secretion
What is the primary stimulus of pancreatic bicarb secretion? secretin
What affects the amount of bicarb in pancreatic secretions? Flow rate: high flow = high bicarb, low Cl. Slow flow allows more HCO3/Cl exchange
Describe the phases of the migratory motor complex Phase I - quiescence; Phase II - acceleration, gallbladder contraction; Phase III - peristalsis; Phase IV - subsiding electric activity; occurs in 90 min cycles
What is the key stimulatory hormone of the MMC? motilin
What drug stimulates motilin receptors? Erythromycin
What is the action of Protein C and Protein S? Protein C degrades active V and VIII. Protein S helps protein C
What is the only clotting factor not made in the liver? Factor VIII (made by reticuloendothelial system)
What is the difference between the three types of Von Willebrand's Disease? Type I and III have low amounts of vWF, respond to ddAVP Type II is qualitatively poor vWF
What is the only inherited coagulopathy with long bleeding time? Von Willebrand's Disease (autosomal dominant)
What is the pathophysiology of Glanzman's thombasthenia? IIb/IIIa receptor deficiency of platelets. Decreased platelet aggregation. Fibrin normally links Gp IIb/IIIa receptors
What is the pathophysiology of Bernard Soulier syndrome? Ib receptor deficiency of platelets. Decreased adherence of exposed collagen. vWF normally links Gp Ib to collagen
What test confirms the presence of von Willebrand Disease? Ristocetin test
What are the three possible treatments for vWD? DDAVP Factor VIII cryoprecipitate
What is the treatment for hemarthrosis in a hemophiliac? Ice, ROM therapy, Factor replacement Do not aspirate
What are the most common inherited thombophilias? Factor V Leiden Prothrombin mutation (GP20210) Hyper-homocysteinemia
What is the treatment for overdose of thrombolytics? Aminocaproic acid (Amikar) - inhibits fibrinolysis
What are the effects of prostacyclin? Decreased platelet aggregation, vasodilatation, bronchial relaxation
What are the effects of thromboxane? Increased platelet aggregation, vasoconstriction, bronchial constriction
What stimulates B cells to become plasma cells? IL-4
Which complements are anaphylatoxins? C3a, C5a
Which complements make up the membrane attack complex? C5-9
What cells are responsible for immunosurveillance against CA? Natural killer cells
What is the source of histamine in blood? Basophils
What is the source of histamine in tissue? Mast cells
What is endotoxin? Where does it come from? Lipopolysaccharide A from gram negative bacteria
What does an elevated mixed venous oxygen saturation (SvO2) indicate? >77% - sepsis or cyandide poisoning
What does a low mixed venous oxygen saturation (SvO2) indicate? <66% - decreased CO
What are the four intraabdominal abscess locations? sub-diaphragmatic sub-hepatic inter-loop pelvic
What two infections can present within hours post-op? B-strep Clostridial (GPR)
What is the mechanism of vancomycin? What is the mechanism of it's resistance? Inhibits cell wall synthesis Altered cell wall (unable to bind)
What is the mechanism of quinolones? DNA gyrase inhibition
What is the mechanism of amphotericin binds sterols to alter fungal cell wall
What antibiotic prolongs neuromuscular blockade? Clindamycin
What are the risks of a blood transfusion? CMV is highest Hep C 1:30-150,000 HIV 1:500,000
What are the vitamin K dependent factors? II, VII, IX, X, protein C + S
Which antibiotics are bacteriocidal, with irreversible binding to 30S ribosome subunit, and resistance due to decreased active transport? Aminoglycosides (gentamicin, neomycin, tobramycin)
What is the only depolarizing neuromuscular blocker used? Succinylcholine
What is an adverse effect of succinylcholine in burn patients? hyperkalemia
What are the effects of reglan (metoclopramide)? Dopamine receptor blocker - Increases LES tone and gastric motility
What is the mechanism of digoxin? inhibits Na/K ATPase to increase calcium in heart
What is the effect of digoxin? Slows AV conduction, inotrope but does not increase O2 consumption
What pressor is most useful in GIB? Vasopressin: reduces splanchnic blood floow, portal flow ~40%. Give with B-blocker to avoid angina
What gastric contents have the highest concentration of K? Saliva (20 meq) > gastric (10 meq) > pancreatic/duodenal (5 meq)
What is the water distribution in a average person? 2/3 is intracellular and 1/3 is extracellular (80% of extracellular fluid is interstitial and 20% is plasma)
What drug can reverse adverse effects of steroids on wound healing? Vitamin A
How many kcal/g are in protein, fat, and carbs? Protein: 4 kcal/g Fat: 9 kcal/g Carbs: 3.4 kcal/g
Describe vitamin D synthesis Vit D made in skin, to liver for (25-OH, calcidiol), then to kidney for (1-OH, calcitriol), then active
What is the respiratory quotient? Ratio of CO2 produced to O2 consumed 0.7 = fat used 1.0 = carb used
What is the preferred fuel of the colon? Short chain fatty acids - butyric acid
Describe fat digestion Long chain: Micelles to enterocytes to chylomicrons to lymphatics (to jxn LIJ/SCV); medium and short chain are directly absorbed into portal system with aa's and carbs
What is the preferred fuel of the small bowel? Glutamine
What is the #1 amino acid in the blood stream? Glutamine
What causes a decrease in glutamine in the blood stream during stress? Glutamine goes to kidney to form ammonium to help acidosis
What vitamin deficiency causes hyperglycemia (relative diabetes) and neuropathy? Chromium
What vitamin deficiency causes perioral rash, hair loss, poor healing, and change in taste? Zinc
What vitamin deficiency causes weakness (respiratory) and encephalopathy? Phosphate (needed for ATP)
What vitamin deficiency causes anemia and neutropenia? Copper
Describe the Cori cycle glucose to lactate, to the liver, to glucose
During starvation, what does the brain use for fuel? ketones from fatty acids (instead of glutamine)
What are the electrolyte concentrations of NS vs LR? Normal saline: 154 meq Na and Cl LR: Na 130, K 4, Ca 2.7, Cl 109, bicarb 28
What two electrolyte abnormalities cause hyperexcitability (increased reflexes, tetany)? Hypocalcemia and hypomagnesemia
How does magnesium affect calcium? Low Mg inhibits PTH, so replace MG if difficulty correcting Ca
What are the phases of the cell cycle? G1 - most variable period; S - DNA replication; G2; M - Mitosis
What phase of the cell cycle is most sensitive to radiation therapy? M - mitosis
What are the recommendations for biopsy of an extremity sarcoma? Excisional if < 4cm, otherwise longitudinal incision (less lymphatic disruption, easier to excise scar if biopsy positive)
What is a complication of bleomycin and busulfan? pulmonary fibrosis
What are the risks of tamoxifen? DVT and Endometrial cancer
Ret proto-oncogene is diagnostic for what? What is the treatment? Medullary thyroid cancer Patient with family history of MEN who has ret proto-oncogene should have total thyroidectomy
What is a side effect of vincristine and cisplatin? Neurotoxicity
What cells provide wound contraction? Myofibroblasts
What cells are responsible for healing by secondary intention? Myofibroblasts
What is the principal collagen late in scar? Type I
What is the principal collagen in a healing wound? III (this is the collagen of granulation tissue)
What type of collage is low in Ehler-Danlos? III
What is the time frame of collagen production in a wound? Begins day 3, max at day 21, then constant amount but more crosslinking, strength
What is the order of cells to a healing wound? Platelets PMNs macrophages (essential) fibroblasts (dominant by day 5)
What are the effects of TGF-B? stimulates fibroblasts and chemotactic for neutrophils (too much/too long can cause fibrosis)
What is the effect of PDGF? Attracts fibroblasts and increases smooth muscle to speed matrix deposition and collagen formation
What is the main source of TNF? Macrophage/monocyte
What cell does TNF recruit and activate? neutrophils
How does TNF cause wasting/cachexia in cancer patients? Anorexia, glycolysis, and lipolysis
What is batson's plexus, and what is it's significance? Valveless vertebral veins that connect to internal vertebral venous plexus They allow direct mets to the spine
What is Poland's syndrome? Amastia, hypoplastic shoulder, no pectoralis
What is Mondor's disease? What is the treatment? thrombophlebitis of superficial vein of breast. Cord like mass laterally. Treat with NSAIDS
Describe the "T" staging of breast cancer T1 = <2cm T2 = 2-5cm T3 = >5cm T4 = skin or chest wall involvement
Describe the "N" staging of breast cancer N1 = ipsilateral lymph nodes (1-3 LN on path) N2 = fixed or matted LN (4-9 LN on path) N3 = infraclavicular, supraclavicular, or internal mammary (>10 LN on path)
Describe the staging of breast cancer according to TNM guidelines Stage I = T1 Stage IIA = T1N1 or T2N0; IIB = T2N1, T3N0 Stage IIIA = T1-3 and N2, or T3N1; IIIB = T4N0-2; IIIC = Any T N3
How does hormone receptor status in breast cancer affect prognosis? ER+PR+ > ER-PR+ > ER+PR- > ER-PR-
What % of DCIS develop invasive cancer? 50%
What % of LCIS develop invasive cancer? 30-40% (in either breast)
What is the difference pathophysiologically in cancer risk between DCIS and LCIS? DCIS is a precursor to cancer LCIS is a marker of risk
What % of Phyllodes tumor are malignant? 10%
What is the treatment for Phyllodes tumor? Wide local excision, rarely mastectomy. No axillary node dissection necessary (spread is hematogenous, not lymphatic)
What type of cancer is BRCA1 and BRCA2 associated with? BRCA1 - ovarian CA (50%) BRCA2 - male breast CA
What are the indication for RT after mastectomy? >4 nodes skin or chest wall involvement +margins
What are absolute contraindications to breast-conserving therapy requiring radiation? Prior radiation to breast/chest wall Radiation therapy during pregnancy Diffuse suspicious or malignant appearing microcalcifications Widespread disease not able to be incorporated by local excision Positive margins
What is the #1 cause of blood nipple discharge? Intraductal papilloma - no risk of CA
What is Stewart-Treves syndrome? Angiosarcoma arising from chronic lymphadema, often as a complication after mastectomy. Presents as a purplish mass on arm ~10 yrs s/p MRM
What is the difference between the two types of alveoli? Type I: functional gas exchange Type II: produce surfactant (1% of alveoli)
What is the association between the thymus and myasthenia gravis? 10% of m.g. have thymomas Resecting thymus (even if no thymoma) in m.g. improves 90%
Popcorn lesion on CXR hamartoma
What are the indications for CABG? intractable symptoms >50% left main triple vessel disease 70% LAD + 1 other vessel
What is the treatment for a patent ductus arteriosus Indomethacin - blocks PG production - effective in ~70% Surgery for those that don't close at 6 months of age
What are the effects of IABP? Augments diastolic coronary blood flow and reduces afterload by inflating during diastole (inflates 40msec before T wave, deflates with p wave)
What electrolytes are actively secreted by the colon? K and HCO3
Describe the blood supply of the rectum Superior rectal artery off IMA Middle off internal iliac Inferior off internal pudendal (off internal iliac)
What are the most common genetic mutations in colon cancer? p53 (85%), DCC (70%), ras (50%)
Amsterdam criteria 3 1st generation relatives, over 2 generations, 1 diagnosed before age 50
Gardner's syndrome colon CA and desmoid tumors
Turcot's syndrome colon CA and brain tumors
Peutz Jeghers polyposis and mucocutaneous pigmentation; increased risk of GI, gonadal, breast cancers
What gene is associated with sacroiliitis in IBD? HLA B27
Where are most anal fissures located? posterior midline, 10% are anterior in women
What are the causes of anal fissures which are lateral or recurrent? IBD, TB, or syphilis
What is normal LES tone and length? 15-25 mm Hg, 4cm long, 40cm from incisors
What is the treatment of diffuse esophageal spasm? calcium channel blockers
What is the pathophysiology of achalasia? Decreased ganglion cells in Auerbach's plexus, absence of peristalsis and esophageal dilation. High LES pressures
What is main arterial supply to stomach when used to replace esophagus? right gastroepiploic artery
What is the treatment of esophageal leiomyoma? If symptomatic or >5cm excise by enucleation via thoracotomy (R if middle, L if lower esophagus) Do not biopsy on EGD
What is Killian's triangle? A potentially weak spot where a pharyngoesophageal diverticulum (Zenker's) is more likely to occur. Posterior triangular area in the pharynx between the inferior constrictor and the cricopharyngeus muscle
What is a painless mass on the roof of the mouth? Torus - bony exotosis, midline of palate
Which has a greater risk for cancer, leukoplakia or erythroplakia? Erythroplakia
What is the general treatment for different stages of head and neck SCCa? Stage I+II(up to 4cm, no nodes) Rx with single modality (surgery or RT) Stage III+IV get combined modality
What is the treatment for glottic Ca? If cords not fixed, then RT If cords fixed, need surgery and RT
What is the most common type of lip cancer? Epidermoid carcinoma. Lower > upper due to sun exposure
What is the usually presentation of nasopharyngeal carcinoma? 50% presesnt late (as neck mass). Drain to posterior neck nodes. A/w EBV
What is the treatment of lip cancer? Resect, primary closure if <1/2 of lip, otherwise flaps. Radical neck dissection if node+
What is Plummer-Vinson syndrome? What type of cancer is increased? Triad of dysphagia (due to esophageal webs), glossitis, and iron deficiency anemia. Increased risk of esophageal/tongue Ca
What are the most common malignant salivary gland tumors? #1 - Mucoepidermoid carcinoma #2 - Adenoid cystic carcinoma (#1 of submandibular and minor glands)
What are the most common benign salivary gland tumors? Pleomorphic adenoma (#1 overall), Warthin tumor
What is the treatment for a benign salivary gland tumor? Superficial parotidectomy (spare CNVII). If malignant, take whole parotid. If high grade, need radical neck dissection
What is the difference between a radical neck dissection and a modified radical neck dissection? Radical neck takes CN XI, SCM, IJ. Modified spares some combination of those structures (CN XI is most morbid)
What is the cause of unilateral nasal obstruction and recurrent epistaxis in a teen male? What is the treatment? Juvenile Nasopharyngeal Angiofibroma - benign but locally agressive vascular tumor of nasal cavity. Embolize (internal maxillary artery), then extirpate
What is a replaced right or left hepatic artery? Replaced right - originating off SMA (occurs in 17%) Replaced left - originating off left gastric (occurs in 10%)
What are Kupffer cells? Specialized macrophages in the liver responsible for clearing portal blood and immunosurveillance. Also responsible for early alcohol-induced liver injury.
Describe the anatomical relationship of the Portal triad Portal vein posterior to CBD (on R) and hepatic artery (on L)
What is the #1 cause of benign biliary stricture? Iatrogenic (lap chole)
What are the symptoms and treatment of cholangitis? Fever, RUQ pain, jaundice, +/- hypotension, MS changes. Needs immediate IV Abx, IVF, emergent decompressions/drainage of CBD
What is the treatment of gallbladder adenocarcinoma? Cholecystectomy adequate if confined to mucosa. If grossly visible tumor - regional lymphadenectomy, wedge segment V, skeletonize portal triad
What is the triad of hemobilia? UGIB, RUQ pain, and jaundice - caused by fistula between biliary duct and hepatic arterial system
What is the treatment of hemobilia? workup and treatment with arteriogram
How does the gallbladder concentrate bile? Active absorption of Na, Cl (H20 then follows)
What is the treatment for hepatic adenoma? Hepatic adenoma is an indication for resection 10% rupture/bleed + malignant potential
What is the treatment for hepatic hemangioma? Do nothing unless giant or symptomatic/consumptive
What is Kasabach-Merritt syndrome? Consumptive coagulopathy or CHF due to hemangioma - usually in infants.
What is the treatment of liver amebic abscess? metronidazole, not surgical
What is the treatment of hydatid cysts? Surgical resection with chemotherapy before and after (albendazole or mebendazole)
What is the work-up of hydatid cysts? Casoni skin test + Indirect hemagglutination
What are the main risk factors for hepatocellular carcinoma? Alcoholism, Hep B+C, hemochromatosis, PBC, aflatoxin, alpha-1-antitrypsin deficiency - PBC and Wilson's are not risk factors
What type of HCC has best prognosis? Fibrolamellar
What is the difference between these types of peripheral nerve injuries: neuropraxis, axonotmesis, neurotmesis? Neuropraxis - focal demyelination, improves Axonotmesis - loss of axon continuity (nerve and sheath intact). Regen 1mm/day Neurotmesis - loss of nerve continuity, surgery required for nerve recovery
What triggers ADH release? Produced when high osmolarity is sensed at supraoptic nucleus of hypothalamus
What is Diabetes Insipidus? Alcohol and head injury inhibit ADH release - high UOP, low urine SG, high serum osmolarity/Na
What is SIADH? Increased ADH release most often by head trauma/tumors or SCLC. Oliguria, high urine osmolarity, low serum osmolarity/Na
What is the effect of ADH? Causes increased free water absorption at the distal tubules and collecting ducts and increases peripheral vascular resistance
What is cerebral perfusion pressure? Mean Arterial Pressure (MAP) - Intracranial Pressure (ICP) Keep ~70
What is Cushing's triad? Hypertension, bradycardia, and Kussmaul respirations (slow, irregular) associated with increased ICP
Describe the Glasgow Coma Scale ratings Motor: 6 commands, 5 localizes, 4 withdraw pain, 3 flexion, 2 extension, 1 none Verbal: 5 oriented, 4 confused, 3 inappropriate, 2 incomprehensible, 1 none Eyes: 4 spont, 3 command, 2 pain, 1 none
What are the signs of spinal shock? Hypotension with bradycardia, warm perfused extremities (vasodilation) Cord injury above T5
What are the deficits in anterior spinal artery syndrome? Lose bilateral motor, pain, and temperature. Keep position sense, light touch
What is Brown-Sequard syndrome? Spinal cord hemi-transection Lose ipsilateral motor, contralateral pain and temperature
What is Central Cord Syndrome? Acute cervical spinal cord injury characterized by bilateral loss of upper extremity motor, pain, and temperature; legs relatively spared. Often due to hyperextension
What are the indications to operate on a skull fracture? If open or depressed
What are the effects of L3-L4 disc herniation? L4 root compresson - quadriceps, week knee jerk
What are the effects of L4-L5 disc herniation? L5 root compression - foot drop, possible big toe hyperesthesia
What are the effects of L5-S1 disc herniation? S1 root compression - weakness in plantar flexion (pushing off toes), weak ankle jerk, hyperesthesia lateral foot/calf
What is the terrible triad of O'Donaghue? lateral blow to knee - injury to ACL, MCL, medial meniscus
What does the medial nerve do? thumb apposition, sensation to most of palm, 1st 2 1/2 fingers (carpal tunnel)
What does the ulnar nerve do? intrinsic musculature of hand, finger abduction, wrist flexion, sensation to 2 1/2 fingers/back of hand
What does the radial nerve do? Wrist/finger extension, sensation to back of lateral hand; no motor in hand
What are the benefits of early ORIF in femur fracture? early mobilization decreased fat embolization
What is a Salter-Harris fracture? Which types need open procedures? fracture that involves the epiphyseal plate or growth plate of a bone Types III, IV, V are intra-articular and thus need open repair
What are the signs of hip dislocation? Posterior (90%) - internal rotation, flexed, abducted thigh Anterior - frog leg (external rotation, abduction)
What three fractures are prone to compartment syndrome? Calcaneous, tibia, supracondyle of humerus
What is treatment of knee dislocation? Most texts say arteriogram all posterior, but at least some vascular assessment (ABI/CT angio/duplex US) is necessary to evaluate popliteal injury even in the presence of normal vascular assessment
What nerve is commonly injured in shoulder dislocation? axillary nerve in anterior dislocation (90% of dislocations)
What is a Volkmann's contracture? What is the treatment? Permanent flexion contracture of the hand at the wrist. Caused by supracondylar humerus fx -> compromised anterior interosseous artery -> deep forearm flexor compartment syndrome Needs fasciotomy
What does a tender snuffbox indicate? Navicular fracture - even with negative XR, requires cast up to elbow
What is a Dupuytren's contracture? What is the treatment? Progressive proliferative of palmar fascia causing flexion contracture of fingers of hand, unknown exact cause (trauma, DM, EtOH, epilepsy) Treatment with steroids, physical therapy, but may need fasciotomy
What is a Monteggia fracture? What is the treatment? proximal ulnar fracture with radial head dislocation Treat with ORIF
What is a sunburst pattern on x-ray suggest? Osteogenic sarcoma
What does "onion layering" on x-ray suggest? Ewing sarcoma
What do pseudorosettes on path suggest? Ewing sarcoma
What are the signs of annular pancreas? Treatment? Double bubble on x-ray. Prone to pancreatitis, possible obstruction. Treat obstruction with duodenojejunostomy, do not resect pancreas
What is effective pain relief for non-resectable pancreatic CA? Celiac plexus block (50% EtOH on both sides of aorta near celiac)
What is treatment of pancreatic pseudocyst? Expectant management initally - 85% resolve on their own If persistent and symptomatic - internal drainage by cyst-gastrostomy, -duodenostomy, or -jejunostomy
What are the signs of an insulinoma? Treatment? Whipple's triad (symptoms of hypoglycemia, glucose <45, improvement with glucose) Insulin to glucose ratio >0.4 Increased C-peptide Rx = enucleation (though 90% are benign)
What are the boundaries of the gastrinoma triangle? (1) cystic/CBD junction (2) 3rd part of the duodenum (3) neck of the pancreas
What are the signs of gastrinoma? Severe ulcer disease, diarrhea (lipase destruction by acid, malabsorption, incr secretion)
What test evaluates gastrinoma? Secretin stimulation test - normal patients will decrease gastrin Though a serum gastrin level >1000 is virtually diagnostic
What are the symptoms of a somatostatinoma? gallstones steatorrhea pancreatitis diabetes
What are the symptoms of a glucagonoma? Treatment? diabetes glossitis stomatitis necrolytic migratory erythema (presenting problem in 70%) Rx = streptozocin/doxorubican (selectively destroy alpha cells) and octreotide (inhibits release)
What are the symptoms of VIP-oma? WDHA syndrome = watery diarrhea hypokalemia achlorydia
What is the treatment for a choledochal cyst? Must excise, leaving cyst increases cancer, pancreatitis, and cholangitis risks Transplant if type IV or V
What are the types of choledochal cysts? I - (>90% of cysts) dilatation of CBD (part or whole) II - diverticulum III - choledochocele involving sphincter IV - intra and extrahepatic cysts (Caroli's disease) V - intrahepatic cysts
What is pulmonary sequestration? Treatment? mass of non-functioning primitive tissue in the lung Extralobar - systemic artery and vein - resection not necessary Intralobar (75%) - aorta in and pulmonary vein out - lobectomy for recurrent infections
What is the #1 presentation of pulmonary sequestration? infection
What is the cause of respiratory distress at birth, and massive hyperinflation of a single lobe of the lung? What is the treatment? Congenital lobar emphysema Rx: lobectomy, excellent prognosis
What is the first sign of CHF in children? hepatomegaly
What is the treatment for a strawberry hemangioma observation - most involute by age 7
What is the #1 pediatric malignancy overall? leukemia
What gene is neuroblastoma associated with? N-myc
What is elevated in neuroblastoma? VMA - Vanillyl mandelic acid HVA - homovanillic acid
What is the treatment for biliary atresia? Kasi procedure - hepatoportoenterostomy - before age 3 months
What is the #1 cause of painless GIB in children? Meckel's diverticulum
What is the embryologic origin of a Meckel's diverticulum? Persistent omphalomesenteric duct
What is the treatment of intussusception in children? air/contrast enema (max 120mm Hg) IV glucagon can help (relaxes smooth muscle) OR if free air/peritonitis
What is the cause of intestinal atresia? Intra-uterine vascular events Mother may have polyhydramnios
What is the surgical treatment for malrotation? Ladd's procedure - appendectomy, take down bands, counterclockwise rotation
What is a cystic hygroma? What is the most common location? lymphangioma - left posterior triangle of neck
What is the treatment for a thyroglossal duct cyst? Sistrunk procedure - en bloc excision of cyst (midline) with hyoid bone (there is a risk of malignant degeneration of thyroid tissue in cyst)
What is the #1 complication of cystic hygroma? infection
What is the treatment for a Wilm's tumor? nephrectomy (80% cure)
What is the most common type of tracheo-esophageal fistula? Type C - blind esophagus, distal TE fistula. Spit up feeds, NGT won't pass
What other abnormalities can a patient with a tracheoesophageal fistula have? VACTERL - vertebral, anal atresia, cardiovascular, TEF, esophageal atresia, renal, limb defects - structures derived from embryonic mesoderm
What is the #1 cause of a colon obstruction in a newborn? Hirschsprung disease - no BM in first 24 hrs, diagnose with rectal bx
What is the treatment for a meconium ileus? Gastrograffin enema - diagnostic and therapeutic
How does necrotizing enterocolitis in a newborn present? After initiating feeds in a neonate (premie) in the 2nd or 3rd week of life with blood in the stool OR free air/peritonitis/acidosis Classic triad: abd dist, bloody stools, pneumatosis
What is the treatment for imperforate anus? If low - anoplasty If high (meconium in urine, fistula to bladder, vagina, or urethra) - need colostomy
What are the characteristics of gastroschisis? Congenital abd wall defect, intrauterine rupture of umbilical cord, no associated defects, lateral (right) defect, no sac
What are the characteristics of omphalocele? midline defect, may contain liver or other non-bowel contents, frequent anomalies, has peritoneal sac.
What converts norepinephrine to epinephrine? PNMT - Phenylethanolamine N-methyltransferase
What are the common characteristics of a pheochromocytoma? 10% are: malignant, bilateral, in children, part of MEN, extra-adrenal
What is the most common extra-adrenal location for a pheochromocytoma? Organ of Zuckerkandl at aortic bifurcation
What is the pre-operative management for a pheochromocytoma? alpha-blockers first, then beta-blockers if tachycardic
How is the diagnosis of pheochromocytoma made? screen with urine metanephrines, VMA; MIBG can localize
What is Nelson's syndrome? rapid enlargement of a pituitary adenoma that occurs after bilateral adrenalectomy (10%) - incr ACTH, muscle weakness, pigmentation, vision changes
What is Waterhouse Friderichsen syndrome? adrenal hemorrhage a/w meningococcal sepsis
What is Conn's syndrome? hyperaldosteronism = 80% adenoma, 20% bilateral hyperplasia - HTN, low K, high Na
What is Addison's disease? low aldosterone and glucocorticoids = low Na, high K, hypoglycemia. Crisis presents similar to sepsis with hypoTN, fever; steroids are diagnostic and therapeutic
What is the most common cause of congenital adrenal hyperplasia? 21-hydroxylase deficiency
What is Cushing's disease? Excessive secretion of ACTH from the anterior pituitary, usually from a pituitary adenoma. Causes 70% of non-iatrogenic Cushing's syndrome.
What is the most common cause of Cushing syndrome? iatrogenic
What is Cushing's syndrome? hormone disorder with high levels of cortisol - symptoms include characteristic weight gain (truncal obesity, moon face, buffalo hump), purple striae, hirsutism, polyuria, htn, insulin intolerance
How do you determine the type of Cushing syndrome? Dexamethasone suppresion test: Pituitary - high ACTH, cortisol suppressed with steroids Adrenal - low ACTH, not suppressed Ectopic - high ACTH, not suppressed
What hormones does the anterior pituitary secrete? GH, ACTH, TSH, LH, FSH, Prolactin
What hormones does the posterior pituitary secrete? ADH, Oxytocin
What is the classic vision change with pituitary mass effect? Bitemporal hemianopsia - vision missing in outer half of both right and left visual fields
What is the #1 pituitary adenoma? What are the symptoms? Prolactinoma - galactorrhea, irregular menses
What is Sheehan syndrome? postpartum lack of lactation and persistent amenorrhea caused by necrosis of pituitary from blood loss during/after childbirth
What is the treatment for a prolactinoma? Bromocriptine or transphenoidal resection
What is the pathophysiology of hidradenitis? involves apocrine glands, thus seen after puberty
What are the three steps to the healing of a skin graft? Imbibition, inosculation, revascularization
What is the most common cause of flap necrosis? venous thrombosis
What type of cancer demonstrates "peripheral palisading" of nuclei and "retraction artifact" Basal cell carcinoma
What are the common sites for melanoma? Skin > eyes > rectum #1 skin site for men = back, women = legs Worse prognosis on "BANS" - back arms, neck, scalp
What type of scar extends beyond margins: keloid or hypertrophic? keloid
What is the cause of keloid scar? failure of collagen breakdown and increased collagen production
What are the four major types of melanoma? superficial spreading (most common), nodular, lentigo maligna, acral lentiginous
What is the Breslow classification of melanoma? <0.75 mm (90% cure) 0.75-1.5mm 1.5-4mm >4mm (80% distant mets)
What type of melanoma has the best prognosis? worst prognosis? best = lentigo maligna; worst = nodular
What are the surgical margins for resection of a melanoma? in situ = 0.5-1 cm margin <1mm depth = 1 cm margin 1-2mm depth = 1-2 cm margin (with SNL) >2mm depth = 2 cm margin
What is MALT a precursor to? gastric lymphoma - regresses with H. pylori treatment
What are the types of gastric ulcers? Type I - lesser curve/body Type II - 2 ulcers (lesser curve and duodenum) Type III - prepyloric (w/i 3 cm) Type IV - high lesser curve/proximal Type V - anywhere a/w NSAIDS
What is the association between gastric ulcers and blood type? Type I = blood type A; Others = type O
What margins are necessary for gastric cancer resection? 5-6cm due to intramural microscopic spread and extensive lymphatics around stomach
What are the effects of a terminal ileum resection? Decreased bile salt absorption -> less colonic H20 absorption -> diarrhea; Decreased B12/intrinsic factor absorption; Decreased binding of oxalate -> oxalate absorbed in colon -> more oxalate stones
What are the symptoms of carcinoid syndrome? flushing, diarrhea, asthma, R sided heart valve dz
What is the test for carcinoid syndrome? urinalysis for 5-HTP (secreted by foregut), 5-HIAA, and serotonin
What factors prevent a fistula from healing? FRIENDS - foreign body, radiation, IBD, epithelization, neoplasm, distal obstruction, sepsis/infection
What chemotherapy agents are used for carcinoid tumors? Steptozocin, doxorubicin, 5 FU
What is the surgical treatment for a crohn's patient with multiple strictures? Do not do resection (to avoid short gut) do stricturoplasties
What % of patients with carcinoid tumors get carcinoid syndrome? 9% - mostly those with extensive mets to the liver
What cells produce calcitonin? parafollicular C cells - derived from neural crest cells
What is the effect of propylthiouracil (PTU)? Peripherally and centrally blocks conversion of T4 to T3
What are side effects of PTU? crosses placenta - cretinism, agranulocytosis, and liver damage
What drugs peripherally block conversion of T4 to T3? PTU, Propanolol, Prednisone (& other steroids) and methimazole
What is the Wolk Chaikoff effect? Reduction in thyroid hormone levels after a large ingestion of iodine - useful in thyroid storm
What is the main limitation of FNA in a solitary thyroid nodule? Differentiation of benign vs malignant follicular and Hurthle cell neoplasms
What do Psammoma bodies bodies on the pathology of an FNA of a thyroid suggest? Papillary thyroid cancer
What is the most common type of thyroid cancer? Papillary
What % of papillary cancer present with positive nodes? 20% of adults, 80% of children
What is the population distribution of papillary thyroid cancer? F:M ratio is 3:1 1/2 are before age 40
What does amyloid on FNA of a thyroid suggest? Medullary thyroid cancer
What gene is associated with medullary thyroid cancer? ret proto-oncogene
What % of patients with medullary thyroid cancer have MEN2? 20% (tend to be bilateral, younger, worse prognosis)
What is the first step in work-up of thyroid nodule after H&P? FNA
What are the limitations of treatment of thyroid cancer during pregnancy? No radioactive iodine during pregnancy or breast-feeding; Operate in second trimester if possible
What does the superior laryngeal nerve innervate? motor to cricothyroid muscle (projection and high pitch), sensory to supraglottis
What does the recurrent laryngeal nerve innervate? All muscle of larynx except cricothyroid
What is the embryologic origin of the parathyroids? Superior from 4th pharngeal pouch, inferior from 3rd; both receive blood supply from inferior thyroid artery
What electrolyte abnormalities are present in primary hyperparathyroidism? Elevated calcium, low phosphate
What disease is associated with osteitis fibrosa cystica? hyperparathyroidism
What % of patients with hyperparathyroidism have a single gland adenoma? 85%
What is MEN I? Wermer's syndrome - parathyroid, pancreas, pituitary (prolactinoma most common)
What is MEN IIa? Sipple syndrome - Parathyroid, adrenal (pheochromocytoma), and thyroid
What is MEN IIb? Thyroid, adrenal, mucosal neuromas/marfan
What type of cell mediates graft vs host disease? T cells
What causes hyperacute rejection? pre-formed antibodies
What test can identify patients who will develop hyperacute rejection? Crossmatch
What causes acute rejection? Foreign MHC antigens of graft cells
During what timeframe is acute rejection at highest risk to occur? 1 week to 3 months
What is the mechanism of chronic rejection? Fibrosis of blood vessels of transplanted tissue - loss of blood supply
What is the mechanism of acute rejection? Due to HLA mismatch, lymphocytic activation by foreign MHC antigens of graft cells
Which risk is higher in patients on immunosupression: viral or bacterial infection? Viral > bacterial because immunosuppression is largely cellular and not humoral
What is the #1 viral infection post transplant? CMV
What is the mechanism of azathioprine (Imuran)? 6MP derivative, purine analog that acts as an antimetabolite, decreases DNA synthesis
What is the mechanism of cyclosporine? Calcineurin inhibitor - inhibits mRNA encoding of IL-2
What is the mechanism of mycophenolate (cellcept)? blocks purine synthesis to decrease T and B cell proliferation
What is the mechanism of tacrolimus (FK506)? Calcineurin inhibitor - blocks IL-2 expressions/production from T cells - more potent than cyclosporine
What is the mechanism of immunosuppression of prednisone? blocks IL-1 from macrophages
What is the mechanism of sirolimus (Rapamune)? mTOR inhibitor - inhibits the response of IL-2 thereby blocking the activation of T and B cells
What is the most common cause of biliary complications post liver transplant? ischemia - check hepatic arterial flow
What is the #1 cause of oliguria s/p renal transplant? ATN
What are the zones of the neck? I - cricoid to sternum (thoracic inlet) II - angle of mandible to cricoid III - base of skull to angle of mandible
What is a positive DPL? gross blood, or identification of food particles, bacteria, bile, >100K RBC/mm, or 500 WBC/mm
What are the indications for thoracotomy after chest tube placement? >1500 cc blood out initially or >200 cc/hr x3 hours
What is the cause of petechiae, hypoxia, and confusion/agitation after a femur fracture? How is the diagnosis made? Fat emboli; Sudan urine stain for fat
What are traumatic diaphragm injuries usually located? 8:1 on the left
What are the effects of splenectomy on the immune system? decreased tuftsin, properidin, and fibronectin (non-specific opsonins), decreased IgM production - susceptible to encapsulated organisms
What % of patients does splenectomy improve: hereditary spherocytosis? ITP? 100% spherocytosis 80% ITP
What is the treatment for TTP? plasmapheresis, not splenectomy
What are the physiological effects of ARDS? decreased pulmonary compliance
How does aging affect PFTs? reduces FEV1 and FRC
What equation describes oxygen delivery? CO x O2 content = CO x Hgb x 1.3 x SpO2
What equation describes oxygen use? CO x (CaO2 - CvO2)
What are the effects of PEEP on the lungs? Increased FRC, increased compliance
What is functional residual capacity (FRC)? air in lungs after normal exhalation
What is inspiratory capacity? maximum amount of air able to be inhaled (TV + inspiratory reserve volume IRV)
What is vital capacity? greatest volume that can be exhaled (IRV + TV + ERV)
What causes an increase in oxygen dissociation from hemoglobin ("right shift")? increased temperature, CO2, H+, 2,3DPG (high altitude, babies)
What is the treatment of carbon monoxide poisoning? 100% O2 - reduces CO half-life from 5 hrs to 1 hr
What are the characteristics of silvadene? good activity against candida/pseudomonas, poor eschar penetration. risk of neutropenia
What are the characteristics of mafenide acetate (sulfamylon)? painful, can cause acidosis due to carbonic anhydrase inhibition
What are the characteristics of silver nitrate? Can cause hyponatremia and hypochloremia due to leeching of NaCl
What is the #1 infection in burn patients? pneumonia
What is a Marjolin's ulcer? SCCA that develops in a chronic burn wound
What is the effect of EDRF (endothelium derived relaxing factor) vasodilation via cGMP, increased in sepsis; nitric oxide is most common example
What are markers for non-seminomatous testicular cancer? AFP and B-HCG
What is the surgical approach to biopsy a testicular mass? Orchiectomy via inguinal incision. Never trans-scrotal
What stage seminomas get RT? Chemotherapy? All stages - very radiosensitive Node + get platinum-based chemo
What are the long term effects of cryptorchidism? increased testicular cancer, orchiopexy can increase fertility but not decrease cancer risk
What is the treatment of testicular torsion? Bilateral orchiopexy
How is a urethral injury diagnosed? retrograde urethrogram (RUG), do not place foley - needs suprapubic catheter
What is the treatment for a traumatic bladder injury? Extraperitonal - a/w pelvic fx, foley only for drainage Intraperitoneal - no pelvic fx, usually dome rupture - laparotomy with multi-layer closure and foley
What are the most common type of kidney stones? oxalate - especially after small bowel resection
What type of kidney stones are associated with proteus infection? struvite stones, "staghorn" - proteus produces urease
What is the classic triad of renal cell carcinoma? abd pain (capsule stretching), mass, hematuria
Where is erythropoetin made? What stimulates its production? 95% made in kidney, stimulated by hypoxia, (decreased production in ESRD)
What causes fever and hypertension in a renal cell carcinoma patient? Increased erythropoetin - erythrocytosis
What is the #1 peripheral aneurysm? popliteal
What are popliteal aneurysms associated with? 50% bilateral, 1/3 have AAA
When do you treat a splenic aneurysm? If >2 cm, child bearing age, planning pregnancy, or symptomatic then resect, otherwise can just monitor
Bloody diarrhea POD#2 after AAA repair - what is the next step? sigmoidoscopy to eval for ischemia (due to loss of IMA) - if necrosis then take to OR
What is the initial treatment of claudication? smoking cessation, excercise, trental - not surgery
What is the #1 CN injury during CEA? vagus nerve (clamp application) - hoarseness
What are the long-term effects of PID? Increased risk of infertility and ectopic pregnancy
What is a Krukenberg tumor? colon or stomach CA met to ovary - see signet cells on path
What is Meig's syndrome? pelvic tumor -> ascites, hydrothorax
Rectal bleeding, irregular menses, pelvic pain, and bluish mass on proctoscopy in a female - what is the diagnosis? Endometriosis involving the rectum
What is the treatment of endometriosis? hormonal therapy
What is the staging of ovarian cancer? I - limited to ovary II - in pelvis III - throughout abdomen IV - distant mets
What is a Howship Romberg sign? inner thigh pain with internal rotation - indicates obturator hernia
What does the ileoinguinal nerve innervate? sensation to inner thigh and scotum
What does the genitofemoral nerve innervate? travels along spermatic cord to innervate cremaster muscle and scrotal skin
What is a spigelian hernia? Hernia inferior to linea semicircularis through linea semilunaris - deep to ext oblique
What is a Petit's hernia? Hernia through lumbar triangle (iliac crest, ext oblique, latissimus dorsi)
Describe the innervation to the pectoralis muscles Medial pectoral nerve to pec major and minor; lateral pectoral nerve to pec major only
What biopsy finding in fibrocystic disease of the breast has an increased cancer risk? Atypical ductal or lobular hyperplasia
What is the FEV1 required for a: wedge resection? lobectomy? pneumonectomy? 0.6L; 1L; 2L
What ABG values increase the risk of a lung resection? pCO2 >45 or pO2 <50 at rest
What marks the transition between the anal canal and the rectum? Levator ani
What is primary, secondary, and tertiary peristalsis? Primary - CNS initiates swallow, occurs with food bolus; Secondary - occurs with esophageal distention (propagating waves); Tertiary - non-propagating/dysfunctional
What is the most common site of esophageal perforation? Cricopharyngeal muscle (usually by EGD)
What is Mirizzi syndrome? Compression and/or inflammation of common hepatic duct by a stone in the infundibulum of the gallbladder causing stricture and hepatic duct obstruction
What is the normal half-life of: RBCs? PMNs? platelets? RBC - 120 days; PMNs - 1-2 days; platelets - 7 days
What is the mechanism and effect of Amrinone? Phosphodiesterase inhibitor - inotrope, increases CO and decreases SVR
What is a side effect of carbapenems? Seizures
What are side effects of aminoglycosides? Reversible nephrotoxicity, irreversible ototoxicity
What is the mechanism of rifampin? RNA polymerase inhibitor
Which antibiotic can affect platelets? PCNs and cephalosporins - can bind platelets and increase bleeding times
What triggers renin release? Macula densa senses low Na/Cl
What is the mechanism of malignant hyperthermia? Ca release from sarcoplasmic reticulum
What does antithrombin III do? binds to and inhibits thrombin; inhibits factors IX, X, XI. Heparin binds this
How do you calculate nitrogen balance? N balance = N in - N out = Protein/6.25 - (24 hr urine N + 4g)
What converts natural killer cells to lymphokine activated killer cells? IL-2
What is the mechanism of metronidazole? produces oxygen radicals that breakup DNA
What are the effects of ketamine? increases cardiac work, O2 use, secretions, and BP; no respiratory distress; hallucinations possible
What are side effects of vancomycin? Redman syndrome (histamine release), nephrotoxicity, ototoxicity
What are side effects of metronidazole? Disulfiram-like reaction, peripheral neuropathy
What are 3 laboratory indications of low volume, "pre-renal" FeNa <1, Urine Na <20, BUN/Cr >30
What is the function of peptide YY? Where is it secreted? inhibits acid secretion, "ileal break"; released from terminal ileum
How does prostate surgery affect clotting? Can release urokinase -> activates plasminogen -> thrombolysis
How do sequential compression devices work? Improve venous return and release tPA -> induce fibronolysis
What are the side effects of halothane? renal and liver toxicity
What fractures are associated with non-union? clavicle, 5th metatarsal fracture
Which organisms are carbapenems least effective against? MEPP: MRSA, enterococcus, proteus, pseudomonas
What are indications for radiation to an extremity sarcoma? high grade, close margins, or tumor >5 cm
What genes are associated with breast cancer? p53, bcl-2, c-myc, c-myb, her2neu
What is the mechanism of ulcer formation with chronic NSAID use? Inhibits prostaglandin synthesis, causing decreased mucus and bicarb secretion and increased acid production
What are the types of wounds and their respective wound infection rates? Clean (hernia) - 2%; Clean-contaminated (prepped colon resection) - 3-5%; Contaminated (GSW to colon with repair) - 5-10%; Gross contamination (abscess) - 30%
What are common causes of GIB in HIV? Lower > Upper; Upper - Kaposi sarcoma, lymphoma; Lower - CMV, bacterial, HSV
What is Comedo breast cancer? What is the treatment? Most aggressive subtype of DCIS, has necrotic areas, high risk of microinvasion and recurrence; Rx - mastectomy
What is Paget's disease of the breast? Treatment? Scaly skin lesion on nipple, suggesting underlying DCIS or ductal CA; Rx - MRM if cancer present, simple mastectomy if not
What are the indications for chemotherapy in breast cancer? >1 cm tumor or positive nodes (except postmenopausal women with positive estrogen receptors -> tamoxifen)
Describe the relevant anatomy of the diaphragm T8 - vena cava; T10 - esophagus + vagus; T12 - aorta + thoracic duct
When do you resect a thymoma? All require resection, 50% are malignant
What do you suspect with a pansystolic murmur 2-7 days after an MI? Post-MI VSD
What is the anatomy of the thoracic duct? Enters chest on right with aorta at T12, crosses to left at T4, then joins left subclavian at junction with IJV
What are the types and treatment of aortic dissections? Stanford: A = involves ascending, always needs surgery; B = does not involve ascending, medical management unless persistent pain or end-organ ischemia
What is the most common congenital heart defect? Ventricular septal defect
Which hormones are involved in paraneoplastic syndromes of: squamous cell lung CA? small cell lung CA? Squamous cell - PTH-related peptide; Small cell - ACTH (most common), ADH
What is a catamenial pneumothorax? PTX occurring in temporal relation to menstruation, caused by endometrial implants in visceral lung pleura
What are the most common types of anal canal tumors? Squamous cell (AKA epidermal, basaloid, cloacogenic, transitional), Adenocarcinoma, and melanoma
What is the treatment for a low T2 rectal carcinoma? APR or LAR (need 2cm margin from levator muscles for LAR)
What is pyoderma gangrenosum? What is the treatment? Painful raised pustules on skin with necrotic center which progress to spreading ulceration - a/w IBD; Rx - local wound care, steroids, dapsone
Which extraintestinal manisfestations of UC do not improve after colectomy? Primary sclerosing cholangitis and ankylosing spondylitis
What does manometry showing normal LES tone but strong unorganized contractions suggest? What is the treatment? Diffuse esophageal spasm; Rx - Ca channel blockers and nitrates
What does manometry showing increased LES pressure, incomplete relaxation, and no peristalsis suggest? What is the treatment? Achalasia; Rx - Ca channel blockers and LES dilation first (60% effective), if fail - Heller myotomy (LES circular muscle transection) + Nissen
What is the most commonly injured nerve with parotid surgery? Greater auricular nerve - numbness over lower portion of auricle
How does clopidogrel (Plavix) affect platelets? ADP receptor antagonist
What is the most common cause of a spontaneous intestinal fistula? crohn's disease
What is the most common site of GI lymphoma? stomach
Which segment of the liver drains directly into IVC? Segment I - caudate lobe
What is the initial treatment of GI bleeding in Mallory-Weiss syndrome? Observation - most cases stop with nonoperative management
For what condition is the risk of overwhelming postsplenectomy sepsis highest? Thalassemia
What is the most common cause of hypercalcemic crisis? malignancy
What does the sudden onset of glucose intolerance in a patient receiving TPN indicate? sepsis
What vitamin deficiency causes dermatitis, diarrhea and dementia? Niacin - this syndrome is called Pellegra
What can enhance immune function in critical illness? arginine
What is an effect of stored blood? Decreased 2,3-DPG - leftward shift of oxygen disassociation curve
What is the pathophysiology of ITP? Antiplatelet IgG originating in the spleen
What hematologic disease has the highest morbidity after splenectomy? Myeloid dysplasia
What vitamin deficiency causes dermatitis, hair loss, and thrombocytopenia? Essential fatty acid deficiency
What is the most common complication of heparin reversal with protamine? Hypotension
What is the optimal treatment for bleeding gastric varices in chronic pancreatitis? Splenectomy
What does a RQ >1 indicate? What does a RQ <0.7 indicate? >1 = lipogenesis (overfeeding); <0.7 = ketosis and fat oxidation (starving)
What is fetal wound healing characterized by? increased hyaluronic acid synthesis
What is the most common cause of hypercalcemia in breast cancer? Parathyroid Hormone Related Peptide (PTHrP
Which nerve injury results in foot drop? Which nerve injury results in decreased foot eversion? Foot drop = deep peroneal nerve Foot eversion = superficial peroneal nerve
Lateral neck mass in infancy with rotation of the head Treatment? congenital torticollis Treatment = physical therapy, rarely surgical resection of muscle
Created by: jclanton82
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