SURGERY - NMS/Pestana/pretest/lange/uworld

Fluid resusc in burns. How much? Monitor what? when would you give extra fluid? when does rehab start?

4cc per Kg. of body weight per percentage of BSA burned (up to 50%). Give LR. First 1/2 in 8 hrs, second 1/2 in next 16. CVP and hourly urinary output. Keep the former below 15 or 20, aim for 1 cc per Kg body weight per hour for the latter Circumstances where additional fluid is needed (aiming for urinary output of two cc per Kg per hour, instead of one): electrical burns, patients who get escharotomy. day one.

A patient with progressive jaundice which has been present for four weeks is found to have a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated SGOT. The alkaline phosphatase was twice normal value couple of weeks ago, and now is about six times the upper limit of normal.

A "generic" example of obstructive jaundice. Next move? - Sonogram, looking for dilated intrahepatic ducts, possibly dilated extrahepatic ducts as well, and if we get lucky a finding of gallstones.

An 18 year old woman has a 4cm, fluctuant round mass on the side of her neck, just beneath and in front of the sternomastoid. She reports that it has been there at least 10 years, although she thinks that it has become somewhat larger in the last year or two. A CT scan shows the mass to be cystic.

A branchial cleft cyst. Management: Elective surgical removal.

A 23 year old lady describes exquisite pain with defecation and blood streaks on the outside of the stools. Because of the pain she avoids having bowel movements and when she finally does, the stools are hard and even more painful. Physical examination can not be done, as she refuses to allow anyone to even "spread her cheeks" to look at the anus for fear of precipitating the pain.

A classical description of anal fissure. Management: cancer still has to be ruled out. Examination under anesthesia is the correct answer. If you are asked what to do next, the currently favored surgical approach is a lateral internal sphincterotomy.

A 43 year old obese lady, mother of six children, has severe right upper quadrant abdominal pain that began six hours ago. The pain was colicky at first, radiated to the right shoulder and around towards the back, and was accompanied by nausea and vomiting. For the past 2 hours the pain has been constant. She has tenderness to deep palpation, muscle guarding and rebound in the right upper quadrant. Her temperature is 101 and she has a WBC of 16,000. She has had similar episodes of pain in the past, brought about by ingestion of fatty food, but they all had been of brief duration and relented spontaneously or with anticholinergic medications.

Acute cholecystitis. How is the diagnosis made? - Sonogram should be the first choice. If equivocal, an "HIDA" scan (radionuclide excretion scan). Medical management in most cases will "cool down" the process. Surgery will follow.

A 72 year old man has a history of angina and exertional syncopal episodes. He has a harsh midsystolic heart murmur best heard at the second intercostal space and along the left sternal border.

Aortic stenosis. Management: echocardiogram. Surgical valvular replacement is indicated if there is a gradient of more than 50 mm.Hg., or at the first indication of congestive heart failure, angina or syncope.

On the first post-operative day after an open cholecystectomy, a patient has a temperature of 101.

Atelectasis. Management: Listen to the chest, chest X-Ray, encourage deep breathing and coughing.

During a school physical exam, a 12 year old girl is found to have a heart murmur. She is referred for further evaluation. An alert cardiology fellow recognized that she indeed has a pulmonary flow systolic murmur, but he also notices that she has a fixed split second heart sound. A history of frequent colds and upper respiratory infections is elicited.

Atrial septal defect. Management: Echocardiography to establish the diagnosis. Surgical closure of the defect. Closure by way of catheterization is still experimental.

A 54 year old obese man gives a history of burning retrosternal pain and "heartburn" that is brought about by bending over, wearing tight clothing or lying flat in bed at night. He gets symptomatic relief from antiacids, but the disease process seems to be progressing since it started several years ago. Endoscopy shows severe peptic esophagitis and Barrett's esophagus.

Barrett's is premalignant. Surgery would be recommended, probably a Nissen Fundoplication.

An 8 week old baby is brought in because of persistent, progressively increasing jaundice. The bilirubin is significantly elevated and about two thirds of it is conjugated, direct bilirubin. Ultrasound rules out extrahepatic masses, serology is negative for hepatitis and sweat test is normal.

Biliary atresia (narrowing of bile duct). Management: HIDA scan, percutaneous liver biopsy and exploratory laparotomy.

A 56 year old man presents with progressive jaundice which he first noticed six weeks ago. He has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated SGOT. He alkaline phosphatase is about eight times the upper limit of normal. He has lost 20 pounds over the past two months, and has a persistent, nagging mild pain deep into his epigastrium and in the upper back. His sister died at age 44 from a cancer of the pancreas. A sonogram shows dilated intrahepatic ducts, dilated extrahepatic ducts and a very distended, thin walled gallbladder.

Cancer of the had of the pancreas. Terrible prognosis. How do clinch the diagnosis?: CAT scan -which may show the mass in the head of the pancreas; then ERCP -which will probably show obstruction of both common duct and pancreatic duct.

A 72 year old man has lost 40 pounds of weight over a two or three month period. He gives a history of anorexia for several months, and of vague epigastric discomfort for the past 3 weeks.

Cancer of the stomach. How do you diagnose it? - Endoscopy and biopsies.

middle aged lady, multiple episodes of sinusitis. six days ago you started her on decongestants and oral antibiotics for what you diagnoses as frontal and ethmoid sinusitis. Now she tells you over the phone that ever since she woke up this morning, she has been seeing double.

Cavernous sinus thrombosis, or orbital cellulitis. emergency. She needs immediate hospitalization, high dose IV antibiotic treatment and surgical drainage of the paranasal sinuses or the orbit. CT is needed too.

A newborn baby is noted to be tachypneic, cyanotic and grunting. The abdomen is scaphoid and there are bowel sounds heard over the left chest. An X-Ray confirms that there is bowel in the left thorax. Shortly thereafter, the baby develops significant hypoxia and acidosis.

Congenital diaphragmatic hernia. Management: The main problem is the hypoplastic lung. It is better to wait 36 to 48 hours to do surgery to allow transition from fetal circulation to newborn circulation. Meanwhile keep the kid alive with endotracheal intubation, hyperventilation (careful not to blow up the other lung), sedation and NG suction.

An 18 year old lady has a firm, rubbery mass in the left breast that moves easily with palpation.

Fibroadenoma.- often found in teenage girls, and are very movable and firm How is the diagnosis made? - FNA (fine needle aspirate for cytology). If not, core biopsy or if it is the only choice, excisional biopsy. Reassurance alone would not be a good choice! **** Mammogram alone is not the way to go, either. Mammogram is primarily for screening, not for diagnosis. At age 18, mammograms are useless (breast too dense). Sonogram is the only imaging technique suitable for the very young breast.

A 56 year old alcoholic male is admitted with a clinical picture of acute upper abdominal pain. The pain is constant, radiates straight thorugh to the back, and is extremely severe. He has a serum amylase of 800, WBC of 18,000 blood glucose of 150, serum calcium of 6.5 and a hematocrit of 40. He is given IV fluids and kept NPO with NG sution. By the next morning, his hematocrit has dropped to 30 the serum calcium has remained below 7 in spite of calcium administration, his BUN has gone up to 32 and he has developed metabolic acidosis and a low arterial PO2.

He has hemorrhagic pancreatitis. In fact, he is in deep trouble, with at least eight of Ranson's criteria predicting 80 to 100% mortality. What do you do? Very intensive support will be needed, but death commonly occurs from pancreatic abscesses that need to be drained as soon as they appear. Thus serial CT scans will be required.

A 7 year old boy passes a large bloody bowel movement.

In this age group, Meckel's diverticulum leads the list. How is the diagnosis made? - By radioactively labeled technetium scan (not the one that tags reds cells, but the one that identifies gastric mucosa).

A patient involved in a high speed automobile collision has multiple injuries, including rib fractures and abdominal contusions. Insertion of a Foley catheter shows that there is gross hematuria, and retrograde cystogram is normal.

Lower injuries have been ruled out. The blood has to be coming from the kidneys. How is the diagnosis made? - CT scan. Further management: the rule is that traumatic hematuria does not need surgery even if the kidney is smashed. They operate only if the renal pedicle is avulsed or the patient is exsanguinating.

While trying to hook up illegally to cable TV, an unfortunate man comes in contact with a high tension electrical power line. He has an entrance burn wound in the upper outer thigh and an exit burn lower down on the same side.

Management: electrical burns are always much bigger than they appear to be. There is deep tissue destruction. The patient will require extensive surgical debridement, but there is also another item (more likely to be the point of the question): Myoglobinemia, leading to myoglobinuria and to renal failure. Patient needs lots of IV fluids, diuretics (osmotic if given that choice i.e. Mannitol), perhaps alkalinization of the urine.

A 54 year old man has had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate abdominal distention, and has not had a bowel movement or passed any gas for five days. He has high pitched, loud bowel sounds that coincide with colicky pain, and X-Rays that show distended loops of small bowel and air-fluid levels. Five years ago he had an exploratory laparotomy for a gunshot wound of the abdomen.

Mechanical intestinal obstruction, due to adhesions. Management: Nasogastric suction, I.V. fluids and careful observation.

A three day old, full term baby is brought in because of feeding intolerance and bilious vomiting. X-Ray shows multiple dilated loops of small bowel and a "ground glass" appearance in the lower abdomen. The mother has cystic fibrosis.

Meconium ileus. Management: Gastrographin enema my be both diagnostic and therapeutic*, so it is the obvious first choice.

A 35 year old lady has dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, cough and hemoptysis. She has had these progressive symptoms for about 5 years. She looks thin and cachectic, has atrial fibrillation and a low-pitched, rumbling distolic apical heart murmur. At age 15 she had rheumatic fever.

Mitral stenosis. Management: Start with echocardiogram. Eventually surgical mitral valve repair.

A 57 year old alcoholic male is being treated for acute hemorrhagic pancreatitis. He was in the intensive care unit fore one week, required chest tubes for pleural effusion, and was on a respirator for several days, but eventually improved enough to be transferred to the floor. Two weeks after the onset of the disease he begins to spike fever and to demonstrate leukocytosis.

Pancreatic abscess. How do we confirm it? - CT scan. What does he need? - Drainage.

A 33 year old lady is undergoing a diagnostic work-up because she appears to have Cushing's syndrome. Chest X-Ray shows a central, 3 cm. round mass on the right lung. Bronchoscopy and biopsy confirm a diagnosis of small cell carcinoma of the lung.

Radiation and chemotherapy. Small cell lung cancer is not treated with surgery, and thus we have no need to determine FEV1 or nodal status.

A 23 year old lady has had severe hypertension for two years, and she does not respond well to the usual medical treatment for that condition. A bruit can be faintly heard over her upper abdomen.

Renovascular hypertension due to fibromuscular dysplasia. arteriogram then percutaneous angioplasty

A 54 year old right handed laborer notices coldness and tingling in his left hand as well as pain in the forearm when he does strenuous work. What really concerned him, though, is that in the last few episodes he also experienced transitory vertigo, blurred vision and difficulty articulating his speech. Angiogram demonstrates retrograde flow through the vertebral artery.

Subclavian steal syndrome (prox stenosis with supply coming from stolen blood from vertebral arteries). Claudication of the arm with posterior brain neurological symptoms is classical. Management: angiogram -> vasc surg.

A 49 year old has a firm, 2cm. mass in the right breast that has been present for 3 months.

This could be anything. Age is the best determinant for Cancer of the breast. If 72, cancer. At 22, benign. Management: You have to have tissue. Core biopsy is OK, but if negative you don't stop there: only excisional biopsy will rule out cancer.

On the third post-operative day after an open cholecystectomy, a patient develops a temperature of 101.

Urinary tract infection. Management: Urinalysis, Urinary culture, appropriate antibiotics.

A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stable vital signs. No breath sounds on the right. Resonant to percussion.

What is it? - Plain pneumothorax. How is diagnosis verified? There is time to get a chest X-Ray if the option if offered. Treatment: Chest tube to underwater seal and suction. If given option for location, high in the pleural cavity.

A 29 year old migrant worker from Mexico develops fever and leukocytosis, as well as tenderness over the liver when the area is percussed. He has mild jaundice and an elevated alkaline phosphatase. Sonogram of the right upper abdominal area shows a normal biliary tree, and an abscess in the liver.

amebic abscess...very common in Mexico. Management: Alone among abscesses, this one in most cases does not have to be drained, but can be effectively treated with Metronidazole*. Get serology for amebic titers, but don't wait to tx. Don't fall for an option that suggests aspirating the pus and sending it for culture, you can not grow the ameba from the pus.

A 19 year old male is involved in a motorcycle accident. Among many other injuries he has a pelvic fracture. He has blood in the meatus and scrotal hematoma. Retrograde urethrogram shows an anterior urethral injury

anterior urethral injury dx w/ retrograde urethrogram tx: repaired right away.

Half an hour after the first feed, a baby vomits greenish fluid. X-Ray shows a double bubble sign: a large air fluid level in the stomach, and a smaller one in the first portion of the duodenum. There is air in the distal bowel, beyond the duodenum, in loops that are not distended.

incomplete obstruction from duodenal stenosis, annular pancreas, or it could be malrotation. malrotation is an emergency. do contrast enema, if not diagnostic order a water-soluble (gastrographin) upper GI study.

A 60 year old lady has a routine, screening mammogram. The radiologist reports an irregular area of increased density, with fine microcalcifications, that was not present two year ago on a previous mammogram.

malignant radiological image. stereotactic radiologically guided core biopsy. If unsatisfactory, the next move would be needle localized excisional biopsy.

A 64 year old lady presents with progressive jaundice which she first noticed two weeks ago. She has a total bilirubin of 12, with 8 direct and 4 indirect, and minimally elevated SGOT. The alkaline phosphatase is about ten times the upper limit of normal. She is otherwise asymptomatic, but is found to be slightly anemic and to have positive occult blood in the stool. A sonogram shows dilated intrahepatic ducts, dilated extrahepatic ducts and very distended, thin walled gallbladder.

malignant, but also lucky. The coincidence of slowly bleeding into the GI tract at the same time that she develops obstructive jaundice points to an ampullary carcinoma, another malignancy that can be cured with radical surgery. Next move: Endoscopy.

A three week old baby has had "trouble feeding" and is not quite growing well. he now has bilious vomiting and is brought in for evaluation. X-Ray shows a classical "double bubble", along with normal looking gas pattern in the rest of the bowel.

malrotation. can occur anytime. contrast enema to verify, then emergency surgery

A 72 year old man had three large bowel movements that he describes as made up entirely of dark red blood. The last one was two days ago. He is pale, but has normal vital signs. A nasogastric tube returns clear, green fluid without blood

not bleeding now (clear asp). 3/4 of all GI bleeding is upper, and virtually all the causes of lower GI bleeding are diseases of the old: diverticulosis, polyps, cancer and angiodysplasias. How is the diagnosis made? - Angiography is not the first choice for slow bleeding or bleeding that has stopped. The first choice now is endoscopies, both upper and lower.

A newborn baby is found on physical exam to have an imperforate anus.

"VACTER": vertebral, anal, cardiac, TE and renal/radial look for a fistula nearby (to the vagina in little girls, to the perineum in little boys), which will help determine the level of the blind pouch

1. massive hematemesis in a child

1. extrahepatic portal vein obstruction from bacterial infection in infancy (often omphalitis)--> portal hypertension --> variceal bleeding

5% chance of developing colon cancer (mostly after age 50) - shift of freq of cancers from left to right colon 1. risk factors for dev. colon cancer

1. familial syndromes, IBD, eastern european, age>50, high fat diet, low fiber diet, low dietary calcium obesity, diabetes, smoking

diabetes mellitus pre-op 1. gastroparesis 2. hypoglycemic drugs 3. pre-op insulin - also give glucose/dextrose IV drip to maintain glycemic levels during surgery - tight glycemic control dec. morbidity/mortality

1. fast >12 hours + metoclopamide (gastrokinetic) 2. no metformin 24 hours before surgery (lactic acidosis risk), no sulfonyl ureas 2-3 days before surgery 3. 2/3 daily dose of NPH to prevent ketoacidosis

1. complications of SCI

1. hypotension, ileus, renal stones/pyelo, ectopic calcifications, DVT/PE

- lymph node dissection used for assessing prognosis in breast cancer/melanoma 1. sentinal lymph node excision

1. inject technetium 99m tracer into tumor, follow to draining area then identify sentienael node

varicose veins 1.clinical presentation 2. dx 3. tx

1. local pain/edema, dilated superficial veins 2. trendelenburg test- elevate leg put tourniquet around it and then ask patient to stand normally veins refill slowly venous duplex - finds DVT/venous reflux air plesmythography - finds venous hypertension/ 3. asymptomatic - duplex/compression stocking symptomatic - greater saphenous ligation and perforator phlebectomy thermal ablation transilluminated powered phlebectomy

1. risk of perioperative pulmonary edema in patients with past CHF and no signs of CHF vs. clinical/radiographic evidence of CHF 2. when does post-op pulmonary edema occur 3. causes of post-op pulmonary edema

1 .6 vs 16% 2. first hour after surgery 3. volume overload, cessation of positive pressure ventilation, myocardial depression (anesthetic), post-op hypertension

shock treatments 1. hypovolemic 2. cardiogenic 3. neurogenic 4. septic 5, obstructive

1 .aggressive volume adminstration, stop ongoing losses 2. inotropes, dobutamine/dopamine, nitroglycerine to reverse cardiac ischemia 3. volume resuscitation, phenylephrine/NE if unresponsive to voluem 4. volume recsuscitation, dobutamine if adequate volume and SVO2 <70%, NE or DA if MAP <65% and adequate volume 5. volume resuscitation, correction of underlying condition

1. arterial supply to the adrenal glands 2. adrenal portal system

1. 3 sources: phrenic artery, aorta, renal artery 2.glucocorticoids from the cortex activates phenylethanolamine N-methyltransferase to convert NE to EPI

1. follow up after breast cancer treatment

1. 3-6 month clinical exams, yearly mammography

1. treatment of salter harris 3/4 vs 1/2 2. torus (buckle) fracture 3. greenstick fracture 4. spiral fracture

1. 3/4 = open reduction/fixation b/c they are intra articular fractures 1/2 - closed reduction with cast 2. incomplete fractures that occur at metaphysis but dont include growth plate 3. fracture only extends through one side of the bone 4. raises question of child abuse, must do a skeletal survey next

1. superior/inferior parathyroid glands origin 2. cell types of parathyroids 3. hyperPTH symptoms

1. 4th branchial pouch/3rd branchial pouch 2. chief and oxyphil cells 3. hypercalcemia,hypercalciuria, hypophosphatemia, hyperphosphaturia

chiari malformation type 1 chiari malformation type 2 chiari malformation type 3 *other features: elongation of medulla/lower CN, beaked tectum, fused corpora quadrigemina absent corpus callosum, microgyria

1. 4th ventricle above foramen magnum, upper cervical cord displaced caudally 2. low cerebellar tonsils, hydrocephalus (stenosis of aqueduct of sylvius), and spinal dysraphism 3. progressive caudal displacement of vermis, pons and medulla below the foramen magnum

1. % of body weight that is water 2. " intracellular water 3. " extracellular water 4. " interstitial 5. " intravascular water

1. 50-70% ~ 2/3 body weight 2. 65% of TBW (30-40% of weight) 2/3 3. 35% of TBW (20-30% of weight) 1/3 4. 25% of TBW (15-20% of weight) 2/3 of extracellular 5. 10% of TBW (5% of weight) 1/3 extracellular * key compartment for maintaining volume status

hypercoagulability 1. surgical patient prophylaxis 2. genetic hypercoaguable states

1. 5000 units heparin subQ8, or lovenox 30mg subQBID, or 40mg subQQD, IVC filters 2. protein S/C deficiency, factor V leiden mutations, Antithrombin 3 mutation

hepatic failure acute alcoholic hepatitis 1. how long should pre-op abstience be 2. mortality of genreal anesthesia for portal decompression - chronic liver disease tolerate surgery better - decompinsated cirrhosis increases 3. management of portal hypertension

1. 6-12 weeks 2. 50% 3. Beta blockers, octreotide, TIPS

1. when should cleft lip/palate be reparied

1. lip before 3 months, palate 12-18 months (later than this inc. speech impairment)

ruptured AAA 1. risk of rupture if <4.5cm 2. risk factors 3. clinical triad 4. surgical complications

1. 9%/year 2. hypertension and COPD 3. severe pain, pulsatile tender abdominal mass, shock (BP, pulse, syncope) 4. post-op ARF (21%), ischemic colitis, acute leg ischemia, spinal cord ischemia, aortic graft infection (staph aureus/epidermidis), aorticoenteric fistula

1. ATN: urine osm, urine Na, FENa, BUN/SCR 2. Prerenal: urine osm, urine Na, FENa, BUN/SCR

1. <350, >40, >2%, <10 2. >500, <20, <1%, >20

1. lymphedema post axillary node dissection management 2.chest wall recurrence tx 3. distant mets recurrence

1. AVOID ALL TRAUMA, minor skin infections must be treated early with ABX 2. radiation therapy/masectomy (if in breast after rads), systemic therapy 3. hormonal therapy and chemotherapy

cyclosporine 1. dosing 2. SE

1. adjust to reach best possible trough level 2. nephrotoxicity, hypertension, neurotoxicity, hirsutism, gingival hyperplasia, hyperlipidemia

abdominal aortic aneurysm 1. risk factors 2. dx 3. eggshell sign 4. when to treat AAA

1. age, smoking, hypertension, family history 2. incidental CT, *ultrasound* , abd Xray 3. seen on xray calcification of abdominal aorta 4. <5cm - do serial ultrasounds, >5cm do repair, >4mm growth/year, symptomatic

dandy walker syndrome

1. agenesis of foramen magendie and luschka leads to filling of posterior fossa with large cyst and enlargement of lateral/third ventricles

immediate life threatening injuries 1. list them

1. airway obstruction, tension pneumothorax, open pneumothorax, massive hemothorax, cardiac tamponade, flail chest

`1. what markers for prostate and colon cancer 2. what histological finding for lymph nodes 3.c-erb and her2 correlation with breast cancer survivial 4. what gene amplification detected by PCR in pancreatic cnacer

1. PSA for prostate, CEA for colon cancer 2. cytokeratin 3. poorer survival 4. KRAS

hemangioma 1. patho 2. histo 3.dx/ tx

1. benign hepatic tumor, creates sx. by pressing on capsule/adjacent structures 2. vascular lacunae lined with endothelial cells 3. CT with contrast shows enhancement followed by decreased enhancement over 10 minutes (CENTRIPETAL ENHANCEMENT) excision only if symptomatic

cerebellar astrocytoma prognosis 2. clinical pres 3. tx

1. better than supratentorial astrocytoma 2. cerebellar signs, ipsilateral dysmetria, 3. resection and cure

aortic stenosis 1. pathogenesis + pathology 2. sx

1. bicuspid (congneital), acquired progressive calcification of the valves, rheumatic fever (sten/insuf)-->dec. cross sectional area of the valve-->inc. LV pressure load--> concentric hypertrophy 2. ANGINA, SYNCOPE, DYSPNEA -- poor survival after symptoms occur

1. what malignancies cause hypercalcemia 2. what connective tissue diesase causes hypercalcemia

1. breast, prostate, pulmonary, hematologic (MM) 2. sarcoidosis (R/O with CXR)

developmental dysplasia of the hip 1. patho 2. dx

1. breech birth 2. ortolani/barlow positive, assymmetry of gluteal folds/leg lengths, follow up postitive physcal exam with ultrasound 3. pavilik harness

GI bleeds 1. hematemesis 2. hematochezia 3. melena

1. bright red or coffee grounds (hemoglobin+acid-> methemoglobin) -- bleed proximal to ligament of treitz 2. passage of bright red blood by rectum -- not specific to an area of the GI tract 3. dark tarry stools, longer time in GU tract , but not neccessarily from upper GI tract

coagulopathys 1. signs/sx - hx. liver/renal disease 2. what level of platelets necessary for surgery 3. causes of dec. platelet function

1. bruising, petichiae, easy bleeding/nose bleeds, unexplained dental/surgical bleeding 2. >100k 3. uremia, aspirin, clopidogrel, GPIIa/IIIb inhibits, vWF disease, low total count

gastric ulcer disease 1. symptoms 2. dx 3. what is important r/o with gastric ulcer 4. tx 5. indication + surgical tx

1. burning midepigastric pain after eating 2. upper GI radiographs, endoscopy, H.pylori (urea breath test), tissue biopsy 3. gastric cancer that has ulcerated 4. avoid ethanol/tobacco/drugs, H2/PPI, antacids,sucralfate, H.pylori (amox/clarithro/metronidazole), partial gastrectomy (NOT VAGOTOMY) 5. intractability, perforation, obstruction, bleeding

tacrolimus 1. dosing 2. SE

1. by trough levels 2. nephrotoxic, neurotoxicy, diabetes

bronchiectasis 1. patho 2. dx/tx 3. surgical tx

1. chronic illness w/ excessive sputum -- > bronchial dilation of lower lobes 2. high res. CT tx = abx/pulmonary hygene 3. segmental resection

plummer vinson syndrome

1. chronic iron deficiency --> esophageal webs just below the cricopharyngeus muscle, atrophic oral mucosa, spooning of nails, IDA

calcifications: renal stones, fecaliths, 1. pancreatic calcification 2. heavily calcified abdominal vessels 3. malignant masses that calcify

1. chronic pancreatitis 2. mesenteric ischemia 3. teratomas and metastasis

Abdominal exam ddx based on pain 1. RUQ 2. LLQ 3. RLQ 4. mid abdominal 5. LUQ

1. acute cholecystitis, subhepatic, intrahepatic abscess 2. diverticulitis, peridiverticular abscess 3. acute appendicitis, appendiceal abscess 4. pancreatic malig/abscess, pancreatitis, abscess, perforated ulcer, leaking aortic aneurysm 5.gastric/colonic malignancy, subphrenic abscess

pleural empyema 1. patho (3 stages)

1. acute or serous phase (0-7d)- pleural fluid produced transitional/fibropurulent phase (7-21d) - fluid gravitates to dependent areas --> septation/loculation chronic or organized phase (>21d)- fibrin/pleura fuse and thicken --> abscess

1. complications post lung transplant

1. acute rejection, bronchial anastomotic, pneumonia (CMV),

hypervolemia 1. signs 2. causes 3. treatment

1. acute shortness of breath, tachycardia, peripheral edema, pulmonary edema 2. cardiac failure, liver failure 3. diuresis

pancreatic pseudocysts 1. patho 2. clinical pres 3. dx/tx

1. acute/chronic pancreatitis --> lesser sac collection --> *3-5 weeks* -> fibrosis/thickening/arrangement of neighbor organs *NO EPITHELIUM* 2. persistent amylase, low grade fever, inc. WBC, chronic pain , minor bleeding causes dec. in hemoglobin/hematocrit 3. US/CT - shows pseudocyst tx = allow it to mature b/c it may remit by itself (3-5 weeks), TPN, aspiration/internal drainage through ant-wall of stomach, external drainage, excision (if its small and @ tail of pancreas)

cardiogenic shock 1. pathogenesis 2. major distinctive in lab values 3. dx/tx

1. dec. cardiac performance- ususally myocardial ischemia, blunt chest trauma,arrythmia, CHF, valvular disease 2. increased central venous pressures 3. IV fluids inc. PCWP, but do not inc. BP tx = IV fluids bring PCWP up to 15-20mmHg, and inotropes (dopamine/dobutamine) to maintain CO

tumor suppressor genes 1. function 2. p53 3. aflatoxin 4. human papilloma virus mechanism -DNA repair gene mutations also increase mutation rate in other genes leading to more cancer -cancer is multistep process

1. dec. cellular proliferation 2. mutaiton seen in 75% of colon cancers and 90% of HCC 3. mutates p53 gene --> HCC in the liver 4. binds E6/E7 and inhibtis p53

SCFE 1. patho 2. dx/tx

1. endocrinopathy obesity, african descent --> knee pain 2. AP and frog lateral radiographs of the hip tx = external fixation of the joint with pins - stabilization with a screw in the center of the femoral capital epiphysis

malignant small intestine neoplasms carcenoid tumors 1. patho 2. what determines likelyhood of mets

1. enterochromaffin cells - MC location is the small bowel, appendix, ileum, rectum 2. size of the tumor, >2cm = 80% chance of mets

ewings sarcoma 1. patho + clinical pres 2. tx

1. small round cell tumor t (11:22) forms pseudorosettes--> pain and tumefaction sx similar to osteomyelitis, FEVER* occurs in diaphysis/spine/pelvis inc. risk of osteosarcoma in adulthood 2. tx =surgery, radiation, and cehmo sensative

1. distribution of lower extremity atherosclerosis in smokers vs diabetics

1. smokers -superficial femoral artery 2. diabetics - tibioperoneal

RCC 1. risk factors 2. clinical pres 3. paraneoplastic synrdomes

1. smokin, VHL 2. pain, hematuria, flank mass + VARIOUS PARANEOPLASTIC SYNDROMES 3. stouffers syndrome (hepatic dysfunction), hypercalcemia, hypertension, erythrocytosis, fevers from pyrogen production

bronchogenic carcinoma (MCC cause of cancer death in US) 1. patho adenocarinoma of the lung 2. histo 3. mets bronchoalveolar carcinoma (a type of adeno) 4. spread

1. smoking >20 pack years, asbestos, nickel, arsenic, petroleum 2. acinar formations arising from sub-segmental airways 3. vascular mets 4. spreads alng alveolar wall

hamartomas 1. pathology 2. tx

1. solitary pulmonary nodule, benign lesion, adenochondromas, mixed tissue types ex. smooth muscle/cartilage 2. removal during diagnostic thoracotomy

hyperchloremia (>110) 1. causes 2. dx 3. tx

1. surgical administration of IV fluids 2. increased H+ due to excess chloride (dilutional acidosis) 3. 1/2 NS with 1.5 amps NaHCO3-, which has 152 mEq Na nd only 77 chloride

acute pancreatitis 1. ultrasound findings *US cannot be performed with excess bowel gas

1. swelling greater than normal AP thickness, calcification of duct, cysts, abscessses, cholelithiasis

DVT 1. postphlebitic syndrome 2. phlegmasia alba dolens + tx 3. phlegmasia cerulea dolens (blue)

1. swelling, ulceration,brawny induration due to chronic valvular incompetence- tx = compression, unna boot, long term support hose 2. occlusion of iliac/femoral veins leads to arterial spasm tx = thrombolytic/heparin 3. occlusion to outflow in iliac/femoral veins, cyanosis, massive edema, absent pulses, blood loss, ulceration tx = thrombolytic , thrombectomy, IVC filter if hx. of PE, surgical AV fistula

ependymomas - tends to met through CSF pathway 1. clinical pres 2. dx/tx

1. sx of inc. ICP 2. CT/MRI shows well circumscribed mass near ventricles, tx = surgery/radiation

1. fibrosarcoma + tx 2. rhabdomyosarcom + tx for embryonal vs pleomorphic

1. radioresistant, treat with wide resection 2. skeletal muscle derived, typically involves head, neck and GU system. tx = surgery/radio/chemo for embryonal, wide excision for pleomorphic

SDH (subdural hematoma) 1. patho + sx 2. dx

1. rapid accel/decel --> disrupted bridging veins on the dura/cortical surface --> slow accumulation over days--> slow deterioration of mental status/focal deficits (if chronic type) 2. CT scan, tx = craniotomy, or burr hole

GU tuberculosis 1. patho 2. dx

1. reactivation after primary seeding--> calcification/scarring 2. hematuria/pyuria without bacteriuria

nodular (proliferative) fasciitis 1. patho 2. tx

1. reactive non-neoplastic response to injury 2. excision

1. what is the most common complication of lymphedema 2. names for lymphedema in young woman and >35 years of age ***DVT IS NOT A RISK FACTOR FOR CELLULITIS

1. recurrent cellulitis 2. praecox , tarda

An 18 year old boy has epistaxis. The patient denies picking his nose. No source of anterior bleeding can be seen by physical examination.

Either septal perforation from cocaine abuse, or posterior juvenile nasopharyngeal angiofibroma. refer to ENT.

1 what primary tumors met to the brain

lung, breast, prostate, kidney, melanoma

how to avoid intraoperative thyroid storm in graves disease patient

make euthyroid with propranolol and PTU/methimazole

complications of rhinoplasty

nasal obstruction, epistaxis, septal absecess-->perforation

BRCA1/2

autodom inheritance higher in jewish populations: tumor suppressor gene mutation-- inc. risk for breast and ovarian cancers---' 75% lifetime risk of cancer

atrophic gastritis patho + risk for what condition

autoimmune metaplasia --> achlorohydra/parietal cell antibodies --> elevated gastrin/pernicious anemia --> inc. risk for gastric carcinoid/gastric adenocarcinoma

clinical presentation of nasopharyngeal cancer

enlarged posterior cervical nodes, and unilateral serous otitis media

what liver lesion is liver biopsy contraindicated

hepatic adenoma*- because of the risk of bleeding.

what tumors tend to metastasis to the spine

prostate, lung, breast

what is worst possible injury in patient with seatbelt trauma after a car crash (who is hemodynamically stable)

ruptured hollow viscus

which pathogen associated with necrotizing enterocolitis in neonates

staph epidermidis

treatment of hepatic adeoma (non-ruptured)

stop OCP/observe for regression, surgical resection (most recent recommendation)

catamenial pneumothorax

thoracic endometriosis --> recurrent pneumothorax that occurs within 72 hours or menstruation

renal response to hyperventilation

wasting of bicarb and retention of chloride

unique clinical presentation of villous adenoma of the colon

watery diarrhea/hypokalemia

1. lumbar stenosis patho + clinical pres 2. what relieves the pain of spinal stenosis

wear and tear --> osteophytes/hypertrophy -->stenosis/compression of multiple spinal nerve roots bilaterally 2. bending over which opens the spinal canal

obturator fossa hernia patho

weight loss --> loss of fat pad overlying the obturator fossa --> strangulation of bowel loop causing pain down MEDIAL THIGH

when should NG suction NOT be used

when strangulation or hernia is suspected

neck dissections for cancer 1. radical neck dissection 2. modified neck dissection 3. segmental neck dissection

1,. removes cervical lymphatics and removal of SCM, IJV, spinal accessory nerve 2. removes cervical lymphatics, spares SCM, IJV, spinal accessory nerve 3. removal of less than all five nodal groups on one side of neck

causes of post operative fever

1-2 days - wind - pneumonia 3-5 days - water - UTI 4-6 days - walking 5-7 days - wound >7 days - wonder drugs

what rate of hyponatremia correction is safe

1-2 mEq/L/Hr, any faster than this is a risk for pontine myelolinolysis <25mEq/L correction over 48 hours is safe

1. what fraction of patients experience perioperative arrhythmias/fraction that are significant 2. cause of arrythmias

1. 84%, 5% significant, inc. frequency with longer surgeries 2. metabolic -hyoxia, hypercarbia, hypokalemia, hyperkalemaia electrocauthery -- esp. in pts with defibrilators

acoustic neuromas 1. patho + sx 2. dx/tx

1. 8th nerve tumor --> tinnitus, hearing loss, imbalance, vertigo, asymmetrical hearing loss 2. dx = audiogram, MRI with contrast tx = early resection

1. most common posterio fossa tumors

1. acoustic neuromas, epidermoid cysts, meningiomas, hemangioblastomas,medulloblastoma, ependymoma, choroid plexus papillomas (BENIGN), epidermoid tumors

condyloma acuminatum 1. patho 2. clinical pres/sx 3. tx

1. HPV, sexually transmitted HPV16/18 higher risk for cancer 2. cauliflower like masses, pain, anal wetness 3. bichloracetic acid, excision/electrocoagulation, interferon

1. what infectious causes of cancer 2. what kind of cancer causes most death -incidence same as mortality, but breast is highest for women

1. HTLV1, hep B and C EBV, HPV 2. lung, colon, breast

daclizumab, basiliximab 1. mechanisms 2. use. 3. SE

1. IL2 blockers, prevent T cell expansion 2. antirejection prophylaxis 3. anaphylaxis

shock treatment

1. IV volume fluid replaement, blood products if hematocrit <30% or if blood loss has occured, inotrope support, vasoconstrictors (USE CAUTION)

1. diagnostic test of choice for kidney stone 2. managment of cryptorchid testicles

1. IVP 2. chorionic gonadotropin therapy for one month, operative placement of testes into scrotum before age 1, + repair of the obligate inguinal hernia repair

cerebrovascular accidents 1. TIA 2. amaurosis fugax 3. CVA

1. TIAs- rapid onset peaking at 5 minutes, resolving <24 hours; motor, sensory, aphasia symptoms 2. transient monocular blindness caused by a embolus to a retinal vessel**** common in temporal arteritis/interal carotid atherosclersis 3. completed stroke >24 hour duration

vocal polyps 1. patho 2. tx

1. UNILATERAL polyps do not regress with speech therapy 2. careful excision avoiding damage to lamina propria

addisons disease 1. primary 2. secondary 3. clinical presentation

1. autoimmune, bilateral adrenal TB/fungal, bilateral adrenal hemorrhage (septicemia, postpartum, anticoagulants) 2. ACTH suppression by corticosteroids, pituitary pathology 3. anorexia, malaise, weight loss, hypoglycemia, hypotension, hyperpigmentation of skin,

lumbar disc herniation 1. clinical pres 2. physical exam 3. tx

1. back pain after lifting or valsalva that is worsened with lifting / valsalva 2. lumbosacral spasm, straight leg raising sign , radicular signs/symptoms 3. bed rest, analgesics, anti inflammatory, CT scan, disectomy by posterior approach

encephaloceles 1. patho 2. tx

1. congenital brain herniation 2. total removal if they communicate

esophageal cancer 1. risk factors 2. what tumor type 3. tx

1. corrosive esophagitis, alcohol, tobacco, dietary factors 2. adenocarcinoma at the gastroesophageal junction 3. surgical resection, not radiation sensitive

1. acute liver rejection lab values 2. chronic rejection mechanims

1. elevated LFTS 2. vanishing bile duct due to destruction of the small surrounding blood vessels

primary hyperparathyroidism 1. dx

1. elevated serum calcium x3, elevated PTH, <1:33 ratio of phos:calcium, hyperphosphaturia, , inc. urinary cAMP,

1. advantages split thickness skin grafts 2. disadvantages of """"

1. large supply of donor areas, ease of harvesting, rapid donor site reuse, decreased primary contracture, 2. dec. durability, hyper pigmentation, hyper-pigmentation, secondary contracture

1. what is the most likely source of isolated enlarged cervical lymph nodes in the neck

1. metastatic SCC

esophageal disruption 1. patho 2. tx

1. penetrating trauma --> mediastinitis 2. mediastinal drainage and primary closure with tissue reinforcement

1. intracerebral hematoma pathogenesis 2. cerebral contusions pathogenesis 3. layers of the scalp 4. what kind of skull fracture is associated with seizures

1. penetrating trauma or accel/decel injury 2. coup or cotracoup 3. SCALP - skin, subcutaneous tissue, aponeurosis, loose areolar, periosteum 4. depressed skull fracture

Several months after sustaining a crushing injury of his arm, a patient complains bitterly about constant, burning, agonizing pain that does not respond to the usual analgesic medications. The pain is aggravated by the slightest stimulation of the area. The arm is cold, cyanotic and moist.

Causalgia (reflex sympathetic dystrophy) Management: A successful sympathetic block is diagnostic, and surgical sympathectomy will be curative.

A 21 year old college student is found on a routine physical examination to have a single, 2 cm. nodule in the thyroid gland. The young man had radiation to his head and neck when he was thirteen years old because of persistent acne. His thyroid function tests are normal.

Needs FNA. Worrisome b/c male, young, hx of radiation exposure..... would be suspecting papillary carcinoma of the thyroid due to radiation hx

A 72 year old man with multiple manifestations of arteriosclerotic occlusive disease has hypertension of relatively recent onset, and refractory to the usual medical therapy. He has a faint bruit over the upper abdomen.

Renovascular hypertension due to arteriosclerotic plaque (usually bilateral).

acoustic neuromas 1. clinical presentation 2. dx

1. tinnitus, hearing loss, evolving unsteadiness, problems with speech discrimination and then loss of hearing --> late loss of corneal reflex and facial weakness, nystagmus, gait ataxia 2. resection or radiosurgery

crohns disease 1. surgical tx

1. total protocolectomy, NO ILEAL POUCH ANAL ANASTOMOSIS, strictureplasty

aortic regurgitation 1. peripheral pulse features

1. water hammer pulse (corrigan pulse from rapid systolic upstroke), pulsus bisferiens (double systolic hump), wide pulse pressure

1. when to initiate nutritional support -just because patient is obese does not mean they don't need nutritional support 2. """ severely ill

1. when patient loses 10% of body weight 2. early support if prolonged NPO is expected

what imaging study is best for finding BLOOD in the brain

CT without contrast (will show up dark) MRI is good for intracerebral lesions but poor at detecting blood

workup for bone cancer

CT/MRI, technetium 99, biopsy

femoral canal repair

approach femoral sheath through inguinal canal floor- opposing inguinal ligmaent to coopers ligament, or plugging space with mesh

key vascular structure at manubriosternal joint (T4 level)

arch of the aorta (same level of carina) pulmonary trunk/ascending+descending aorta are BELOW this level

bronchial carcinoid tumors

arise in the proximal bronchi rarely produce carcinoid syndrome, slow growing rarely met, 90% survival

medical causes of coagulopathy

aspirin, plavix (clopidogrel) GPIIb/IIIa inhibiotrs, warfarin, heparin, fibrinolytics (tpa/urokinase)

osteoarthritis

degeneration of cartilage, non-inflammatory, normal WBC.

which types of aortoiliac bypass do not require general anesthesia (good for patients with COPD, coronary disease, poor general condition, "hostile abdomen" or anesthesia intolerance)

femorofemoral and axillofemoral bypass * extra-anatomic bypass*

physical exam finding indicating urethral damage

high riding prostate on rectal examination

donovan bodies

histological finding of granuloma inguinale an STD tx = tetracycline

effect of hyperventilation on CVP

hyperventilation increases pH, which increases CVP thus decreasing blood flow **this can help to avoid brain swelling in intracranial injuries **only useful for 8-24 hours because metabolic compensation takes over

paradoxical aciduria

hypokalemic met alk- kidney conserves potassium and secretes protons ex. gastric outlet obstruction

tension pneumothorax clinical signs + tx

hypotension, dec. breath sounds, tracheal deviation--> tx = needle decompression then chest tube PRIOR TO CXR

dieulafoys lesions - patho/sx 2. tx

large tortuous artery in the submucosa that protrudes through a gastric mucosal defect within 6cm of the GE junction - sx - sudden onset massive upper GI bleeding and hypotension 2. therapeutic endoscopy

first test for patient in the ER who has a suspected cervical spine injury

lateral cervical spine x ray

hesselbachs trangle

laterally inferior epigastrics, inferior inguinal ligamnet, medially lateral aspect of rectus sheath

treatment for lung mass in a smoker

lobectomy, biopsy is not necessary, chemotherapy and radiation for stage III and locally advanced lesions

management of blunt renal trauma 2. indications for surgery

non surgical management - bed rest, antibiotics, 2. fever, leukocytosis, evidence of hemorrhage, inc. pain and tenderness in kideny area

fat digestion

. pancreatic lipase, bile emulsification releases monoglycierids/fatty acids at the brush border fo the epithelial cells of the jejunum

postop managment - examination, removal of surgical tubes, ambulation, close monitoring, not excessive pain meds

...

ursodeoxycholic acid

...

page 68 cardiac risk algorithm

... look at it

synovial fluid examination page 542

....

chaps 1-3 questions notes 1. b 2. c 3. b 4. c 5. a-d 6. c 7. d-a ~ clean/clean contaminated can be closed primarily contaminated wounds - use delayed primary closure 8. a 9. a - octreotide decreases pancreatic fistula output 10. c 11. c 12. b-c 13. c- liver dz, hepatobiliary dz, malnourished --> get PT/PTT/platelet Sump drains - decrompress stomach chest tube- for pneumothroax connected to underwater seal so that air/fluid cannot reflux (negative pressure is gen w/ each breath) jackson-pratt drain- abdominal closed suction drain for secretions in the abdomen

.....

look at questions 12/13 in lange for fluid compositions

.....

water moves across cell membranes to equilibrate osmolality--- principle intracellular is K, extracellular Na

.............

predict changes in HR/BP/VP/SVR/CO/PCWP/SVO2/CaO2/VO2c for: hypovolemic shock cardiogenic shock neurogenic shock septic shock obstructie shock

...see page 32 in the book for quizzing

nitrogen balance should be slightly positive in patients with adequate protein intake (0.8-1 gram/day)

/.....

1. what is goal urine output in burn patient 2. parkland formula for 2nd/3rd degree burns

0.5-1ml/kg/hr 2. 4 ml/kg*%area burned-- give half calculated volume in the first 8 hours, then the rest in the next 24 hours

closed drains- connect to a sealed reservoir 1. gravity drainage 2. underwater seal drainage system 3. suction drainage

1 . fluid drains into reservoir 2. prevents prevents air/fluid from re-entering the body by siphoning 3. self explanatory...

parathyroid cysts 1. location/features. 2. clinical presentation tx = surgical excision

1 .solitary mass at either inferior pole of the thyroid gland 2. tracheal deviation with resp. obstruction and hoarseness

rectus sheath hematoma 1. pathogenesis + SX

1 .trauma, sudden muscular exertion, anticoagulation--> hematoma formation --> RLQ or LLQ pain + irritation of peritoneum causes fever, leukocytosis, anorexia, nausea

consumption/dilution coagulopathy 1. cause

1, severe trauma/sepsis/major surgery, hypothermia and acidosis in trauma 2. correct cause, replace factors with FFP

biliary disease diagnostic modalities 1. HIDA scan + what useful to identify 2. HIDA + CCK - what is useful to identify

1. Tc99-lidocaine conjugate emits gamma rays - dx- acute cholecystitis, choledochal cysts, bile leaks, common bile duct obstcution 2. biliary dyskinesia, calculous/acalculous cholecystitis (non-visilizable b/c blocked cystic duct), common duct obstruction (no nucleotide in duodenum

1. treatment of cervical disc syndromes

1. analgesics, NSAIDs, anti inflamm, muscle relaxants, cervical collar removal of disc/decompression, laminectomy/foraminotomy for lateral herniation

undifferentiated large cell carcinoma 1. histo 2. location 3. mets

1. anaplastic large cells with abundant cytoplasm 2. central or peripheral 3. highly malignant, mets early

acute mesenteric vascular disease 1. dx/tx

1. angiography****** , surgical embolectomy, aortomesenteric bypass (if thrombus) vasodilators: paparavine, nitroglycerina (for non-occlusive mesenteric ischemia) *resection of necrotic bowel during "second look laparotomy"

pelvic fractures 1. usual cause 2. tx

1. auto-ped accidents 2. bed rest until hemodynamically stable, + watch for bladder/urethra/colon damage

hashimotos thyroiditis (struma lymphomatosa) 1. patho 2. dx/tx

1. autoimmune thyroid disease --> diffuse goiter/hypothyroidism --> fibrosis 2. decreased uptake on radioiodine scan, thyroid function studies show hypothyroidism, ANTI-THYROID ANTIBODIES tx = thyroxine therapy, surgery if there is a dominant mass

transfusion 1. alternatives 2. acute normovolemic hemodilution 3. hemostatic agents

1. autologous banking, EPO, autotranfusion (recycle lost blood during surgery), 2. remove blood after anesthesia induction 3. FFP, cryoprecipitate, DDAVP, aprotinin, (inhibits plasmin), aminocaproic acid, fibrin glue

pre-op eval 1. how to inc. RBC mass 2. rules for transfusion 3. symptomatic anemia 4. transfusion in critically ill

1. autologous blood donation iorn supplements EPO (pts w. renal failure, AOCD) intraoperative blood salvage 2. hemoglobin > 10 no transfusion 7-10 compensate adequately and require individual assessment <7 benefit from transfusion symptomatic anemia - transfuse 3. tachycardia, oliguria, hypotension, fatigue, syncope, tachypnea, dyspnea, TIA 4. no difference in mortality if conservative (<7) or liberal >10 transfusion

1. what nerve damage is associated with shoulder dislocations 2. what structures are damaged by knee dislocation 3. what patients tend to have quadriceps disruption

1. axillary nerve palsy 2. popliteal artery/vein, peroneal nerve 3. old patient with diabetes proximal o the patella

CAD 1. catheter interventions 2. CABG indications 3. LAD CABG artery graft 90% patent at 10 years, vein grafts 50% patent at 10 years 4. indications for surgical treatment of MI

1. balloon angioplasty, + stent (non-coated or coated with sirolimus) 2. three vessel disease, left main coronary, dec. ventricular function, diabetics with three vessel dz 3. bypass LAD with left internal mammary (lowest occlusion rates) 4. ventricular aneurysm,ruptured ventricle, rupture of interventricular septum, mitral valve papillary muscle dysfunction

pulmonary stenosis 1. tx 2. indication for treatment

1. balloon valvuloplasty, or surgical correction 2. RV/Pulm art gradient >50-80mmHg

1. what cardiac studies should be ordered pre-op 2. what does echocardiography measure

1. baseline CXR, EKG, Echocardiography, PFT 2. ventricular ejection performance, and valvular disease

1. sign of basilar fracture 2. sign of anterior basal fracture 3. sign of petrous ridge fracture

1. battles sign, otorrhea 2. periorbital ecchymosis (Raccoon's eyes), conjunctival hemorrhage, cribriform plate fracture (rhinorrhea), 3. hemotympanum

torus palatinus 1. patho

1. benign bony growth at midline palate,

chondroblastomas 1. patho

1. benign cartilage tumors that occur at the epiphysis of long bones - occasionally undergo malignant degeneration

endochondromas 1.patho 2. radiographic findings 3. tx

1. benign intraosseous tumors of cartilaginous origin--> asymptomatic or pathologic fractures 2. popcorn calcifications with surrounding reactive sclerosis 3. curretage/bone grafting if it causes a pathologic fractures

1. spitz nevi 2. ephelides 3. which nevi must be treated

1. benign juvenille melanomas - smooth round pink-black lesions occur in nests in the dermis 2. freckles - occur in basal/upper dermis 3. junctional and giant pigmented nevi

benign osteoid osteoma 1. patho + clinical pres 2. histo + xray 3.t x

1. benign painful lesion of the femur/tibia, pain is relieved by aspirin 2. disorganized dense calcified osteoid tissue Xray - small lucency surrounded by reactive sclerosis 3. aspirin

osteoblastoma 1. patho 2. tx

1. benign painful lesion similar to osteoid osteoma but >2cm 2. surgical excision + bone grafting

infantile hemangioendothelioma 1. patho/pres 2. tx

1. benign tumor of endothelial cells, potentially malignant -- hepatomegaly and high output cardiac failure 2. excision/hepatic artery ligation

dobutamine 1. effect/use 2. use

1. beta 1/beta 2 agonist-- inc. CO/vasodilation (dec. SVR)--- best drug for improving cardiac function 2. cardiogenic shock

perioperative cardiac risk reduction 1. beta blockers pts/conditions/goal - continue beta blockers 30 days after surgery 2. alpha blockers 3. anesthesia strategy - HMG CoA reductase inhibitors also decrease post-op cardiac complications 4. temperature

1. beta blockers (pts w/ischemic HD, CVD, renal insuf, DB, CAD) - intermed/high risk procedures w/ 1 or more cardiac risk factors -goal HR = 60-70 BPM 2. clonidine/mivazerol, dec. perioperative ischemia/mortality 3. neuraxial safer than general anesthesia 4. maintenance of normothermia helps to minimize post-op ventricular arrythmias

full thickness grafts 1. advantages 2. disadvantages

1. better cosmesis, dec. secondary contractures 2. limited donar sites, inc. primary contracture

1. bening nipple discharges + causes 2. malingant nipple discharge 3. dx

1. bilateral, clear, green, white with stimulation/palpation--- probably fibrocystic changes or papilloma 2. unilateral, bloody fluid, sponataneously ejected 3. cytologic examination of discharge, mammogram

SMA syndrome 1. patho 2. sx 3. tx 4. duodenal diverticula

1. 3rd stage of duodenum obstructed by SMA ~ young thin women, immobilization, pressure (aka CAST SYNDROME) 2. vomiting, post-prandial pain 3. eliminate contributing factors, surgical releasing of ligament of treitz, 4. opposite amulla of vater - severe hemorrhage or perforation but usually asymptomatic

1. calculation of SVR with CO + what is normal 2. calculation of PVR with CO + what is normal

1. SVR = 80 * (MAP - CVP)/ CO -- 800-1200 dynes 2. PVR = 80 * (MPAP - PCWP) / CO-- 20-120 dynes

1. treatment of ERCP induced pancreatitis

1. Somatostatin + other treatments

1. primary hyperparathyroidism localization 2. surgical tx

1. Tc sestamibi, SPECT, US/CT/MRI (most accurate), selective venous sampling (for unsuccessful first surgery) 2. subtotal/total thyroidectomy with intraoperative PTH monitoring

chlangiocarcinoma 1. patho/clinical pres 2. pathology 3. assc 4. tx

1. bile duct epithelium tumor --> RUQ pain, jaundice, hepatomegly, palpable mass 2. hard mass shows adenocarcinoma of biliary epithelium 3. clonorchis sinensis, PSC, thorotrast 4. resection, poor prognosis

1. pyelonephritis 2. cause of uncomplicated UTI 3. sx of UTI 4. dx of UTI

1. flank pain, fever, chills, bacteruria or pyuria 2. usually ascending colonization form the introitus -- fecal flora ecol, gram negative rods, enterococci, staph 3. freq, urg, dysuria, cloudy or foul smelling, 4. pyuria, bacteriuria, nitrate positive (indicates that there is bacteria), leukocyte esterase, urine culture

clinical features of lung cancer 1. symptoms 2. metastatic extrapulmonary symptoms 3. paraneoplastic syndromes

1. cough, dyspnea, cx pain, fever, sputum, or ASYMPTOMATIC 2. weight loss, malaise, CNS sx, bone pain 3. cushings, hypercalcemia, lambert eaton,hypertrophic osteoarthropathies, gynecomastia

colon/rectal surgery infections 1. what bacteria cause the infectiosn 2. elective prophylaxis 3 emergency prophylaxis

1. ecoli, b.fragilis 2. mechanical removal, erythromycin or neomycin (10-22 hours before surgery) 3. IV antibiotics, and dont close abdomnial wound

urologic surgery infections 1. organisms - suprapubic catheters are usually colonized with bacteria, dont have to treat - treat the infection before doing surgery****

1. ecoli, gram neg rods, enterococcus

autoimmune hemolytic anemia 1. patho + sx 2. dx/tx

1. either WARM OR COLD hemolytic antibodies --> splenomegaly, anemia, jaundice 2. coombs positive, reticulocytosis, Cr51 tagged RBCs conc. in spleen tx = steroids, azathioprine, splenectomy

1. treatment of SCC and basal cell carcinoma of the skin 2. treatment of melanoma

1. electrodesiccation, curettage, cryosurgery, excision, mohs micrographic surgery, topical 5FU 2. wide excision, parotidectomy for anterior face melanoma, radiation, dacarbazine, BCG for local disease control,

1. how to evaluate a patient with suspected choledocholelithiasis

1. elevated ALP/T-bili indicates biliary obstruction --> US shows dilation --> ERCP to characterize obstruction --> CT scan to look at head of pancreas

1. dx patient with myocardial contusion 2. ECG findings 3. tx

1. first pass radionuclide angiography - shows degree of myocardial impairment caused by decreased compliance echocardiography (assess vent. wall/CO/EF) cardiac enzymes are not sensitive/specific in detecting myocardial damage 2. new RIGHT BUNDLE BRANCH BLOCK from damage to anterior interventricular septum, ST changes, T wave changes, new Q waves 3. inotropic support

anorectal incontinence 1. mechanical defects 2. neurogenic causes 3. systemic disease - also severe diarrhea, proctatits, encopresis, rectal tumors

1. episiotomy, anal fistulotomies, anorectal trauma 2. pudendal nerve injury from labor/perineal descent, neurologic disease (MS) 3. scleroderma, diabetes

esophageal atresia 1. most common issue 2. VACTERL 3. clinical pres, 4. tx

1. esophageal atresia with distal tracheoesophageal fistula 2. vertebral, anal, cardiac, TE fistula, renal, limb dysplasia 3. excessive drooling, aspiration or cyanosis, tachypnea, scaphoid abdomen, 4. inability to pass a NG tube, radiographs show blind pouch tx = upright position, gastrostomy, stretch proximal pouch to prepare for repair

esophageal reflux 1. indications for surgery 2. surgical procedures

1. esophageal webs, strictures, barrets esophagus (squamous to columnar) 2. nissen fundolication - 360 wrap of stomach around esital esophagus belsey mark 4 operation- 270 degree wrap hill wrap - posterior gastropexy - arcuate ligament used to bring esophagus back intra-abdominal

1. hypersplenism 2. clinical presentation of hypersplenism 3. what CBC/bone marrow finding indicates hypersplenism 4. dx of hypersplenism - spleen filters opsonized bacteria

1. exaggerated destruction of rbc/wbc/platelets 2. either anemia (pallor fatigue dyspnea), leukopenia (inc. susceptibility to infection), thrombocytopenia (bruising epistaxis) 3. increased reticulocytes, bone marrow aspirate shows inc. megakaryocytes 4. ultrasound/CT shows size of spleen, + lab findings

conns syndrome 1, patho 2. how to differentiate primary vs secondary hyperaldo 3. causes of secondary hyperaldo 4. sx hyperaldo

1. excess aldo secretion by adenoma 2. primary renin is low, secondary renin is high 3. RAS, malignant hypertension, CHF/cirrhosis/nephrotic syndrome 4. HTN, weakness, polyuria, polydipsia, fatigue

skin cancer 1. treatment of choise

1. excision for all types***

1. tricuspid regurgitation clinical findings 2. quincke pulse

1. exophthalmos, engorged liver (pulsating) 2. alternate flushing/paling of the nail beds, characteristic of aortic regurg

SCC 1. patho 2. appearance 3. tx 4. site of mets if on the face

1. exposure to sunlight/old scars/arsenicals, nitrates, hydrocarbons --> persistent hyperkeratosis --> epithelial derived cancer, mets via blood/lymphatics 2. lesion with satellite nodules 3. radiation therapy* electrodesiccation, excision with primary closure, mohs surgery 4. ipsilateral submental node

short bowel syndrome 1. patho 2. sx 3. how to feed

1. extensive bowel resection, less than 100cm remaining 2. diarrhea, with loss of fat/protein/vitamins 3. post-op TPN + wean oral: inc. total calories, elemental diet, antiperistaltic, PPI/H2 blockers, vitamin supplmentation, medium chain triglycerides

what patients are not-candidates for breast cancer srugery

1. extensive edema of the breast, satellite nodes of carcinoma, inflammatory carcinoma, parasternal tumor (int. mammary mets), supraclavicular mets, edema of the arm, distant mets

collateral circulation around common atherosclerotic vessels 1. internal carotid 2. aortoiliac disease 3. popliteal artery 4. superficial femoral artery

1. external carotid 2. lumbar arteries and internal mammary arteries 3. deep femoral, geniculate collaterals 4. deep femoral

post cholecystectomy syndrome 1. patho (extrabiliary/biliary)

1. extrabiliary in origin: hiatal hernia, PUD, pancreatitis, irritable bowel, food intolerance biliary in origni: stone in the bile duct, stone in the cystic duct, sphincter of oddi stenosis, biliary stricture

unusual anions higher in intracellular or extracellular 1. bicarb 2. sulfate 3. chloride 4. calcium 5. mg 7. proteins Total = 200meq intracellular 154 extracellular

1. extracellular (30meq/L) 2. intracellular (150meq/L) 3. extracellular (115meq/L) 4. extracellular (5meq/L) 5. intracellular (40meq/L) 6. intracellular 40, extracellular 16

breast cancer eval 1. FNA 2. core needle biopsy 3. incisional biopsy used to dx. what type of breast cancer 4. excisional biopsy

1. extraction of cells can be examined cytologically if atypical do excisional bx 2. evaluate sold leseions 3. inflammatory breast cancer dx 4. completely remove the lesion

intraabdominal abscess 1. causes 2. most common sites 3. signs/sx 4. dx/tx 5. approach for pelvic and subphrenic abscesses

1. extrinsic (penetrating trauma/surg) or intrinsic (perforation of hollow viscus or intra organ abscess) 2. subphrenic,subhepatic, lateral gutters, pelvis, periappendiceal/colonic 3. fever (SPIKING), pain, leukocytosis, tender to palpation, 4. dx= CT/ultrasound, tx= percutaneous unilocular drainage, multilocular surgical 5. pelvic = superior vagina subphrenic = 12th rib approach

clotting cascade 1. PT + use 2. PTT + use 3. thrombin time + use

1. extrinsic cascade - 7, 10, 5, 2, -- all produced by liver, PT = good measure of vitamin K dependent coagulation factors, used to monitor warfarin 2. intrinsic cascade - 12, 11, 9, 8, 10, 5, 2 -- used to monitor heparin 3. measures fibrinogen to fibrin, elevated when fibrinogen is depleted (DIC), or with heparin

vascular tumors 1. pyogenic granuloma 2. spider nevi 3. glomus tumor

1. face/chest/fingers, rapidly grow, bleed very easily 2. telangiectasias -= central arteriole with radiating vessels tx = laser, electrodessication, cryo 3. painful tumor under nail bed, also tumor of the middle ear or jugular bulb

1. epispadias 2. associated condition + tx

1. failure of closure of the dorsal penis surface, 2. exstrophy of the bladder- repaired with closure of bladder defect, or excision/urinary diversion

spina bifida (an ex. of spinal dysraphism) 1. patho 2. meningocele 3. myelomeningocoele

1. failure of fusion of vertebral arches 2. saclike posterior- midline herniation of dura 3. herniation of dura and neural elements

hypercalcemia 1. sx 2. causes 3. treatment

1. fatigue, confusion, n/v, dehydration, anorexia, hyperparathyroidism (assc. renal calculi/ulcer disease) 2. 1' hyperparathyroidism, thyrotoxicosis PTHrP secretion tumors (20-30% of tumors) sarcoidosis, tuberculosis excess calcium, vitamin D, *thiazides*** renal disease, milk alkali, familial hypocalciuric hypocalcemia 3. *isotonic resuscitation*** --> diuresis of calcium**** furosemide (NOT THIAZIDE) bisphosphonates/calcitonin/steroids (3rd line) mithramycin

why do patients who have had their ileum removed get renal stones

1. fatty acids that are not absorbed combine with calcium allowing free oxalate to be reabsorbed by the colon

1. meningiomas male/female, assoc. chromosome 2. grading of astrocytomas 3. cell type that gives rise to meningiomas 4. cells that give rise to medulloblastoma 5. "" pineal tumors 6. """" hemangioblastomas

1. female 4x male, chromosome 22 2. low grade, anaplastic, GBM 3. arachnoid cells 4. neuroectodermal remnants 5. germ cells 6. blood vessels

lower extremity occlusive disease 1. common locations 2. SFA (common site of PVD) collateral 3. which patients have deep femoral disease 4. three causes of popliteal occlusion 5. which patients get tibial artery disease

1. femoral, popliteal, tibial 2. deep femoral 3. diabetic patients 4. atherosclerosis, popliteal entrapment (traped by medial head of gastroc), cystic adventitial disease 5. diabetics

hemorrhoids 1. tx

1. fiber, stool softeners, rubber band ligation, sclerotherapy (phenol or sodium morrhuate), photocoagulation, hemorrhoidectomy (surgical or stapled)

1. desmoid tumors + assc syndorme 2. dermatofibrosarcoma protuberans 3. paraganglioglioma (chemodecotma, carotid body tumor)

1. fibromatosis, assc with gardner's syndrome usually on the shoulder/trunk 2. slow growing nodular tumor with high recurrence rate after excision, cartwheel pattern of fibroblasts 3. painless mass in the neck over the carotid bifurcation, slow growing, dont metastasize

thoracic outlet syndrome 1. pathogenesis 2. dx/tx

1. fibromuscular bands, anterior scalene, first rib, cervical rib--> compression of neurovascular bundle , brachial plexus compression, vascular compression 2.MRI tx. = focused physical therapy to strengthen shoulder girdle, supraclavicular scalenectomy, brachial plexus neurolysis, first rib resection

1. splenic artery aneurysms- patho/tx 2. what patients are at high risk of rupture of splenic artery aneurysms 3. popliteal artery aneurysm + tx

1. fibrous dysplasia*/portal hypertension, multiparity,atherosclerosis, trauma, pancreatitis-->MEDIAL NECROSIS -->aneurysm tx = ligation prox/dist to the aneurysm 2. pregnant women 3. most common peripheral aneurysm caused by atherosclerosis, tends to cause distal thromboembolism*** (NOT rupture) tx = ligation and bypass of aneurysm

1. causes of upper GI bleeding in cirrhotics 2. treatment of upper GI bleeding

1. gastritis, peptic ulcer, esophageal varices 2. initial resuscitation, esophagogastroscopy, endoscopic sclerotherapy, vasopressin, emergency portacaval shunt (if refractory to sclero/vasopress)

cronkhite canada syndrome 1. patho/clinical features 2. complications 3. tx

1. generalized GI hamartomas, alopecia, cutaneous pigmentation, atrophy of finger/toenails--> n/v/d, malabsorption, protein losing enteropathy 2. usually death early 3. intestinal obstruction surgery

metabolism during starvation 1. glycogen 2. after glycogen is exhausted 3. what is brains fuel during prolonged starvation - death occurs when 1/2 protein is gone

1. first 24 hours 2. proteins broken down and converted to glucose in the liver + fat breakdown supplies Acetyl CoA/ketones 3. ketones

Burn infections 1. when do most burns get infected, and with what organisms 2. treatment 3. suppurative thrombophlebitis

1. first 5 days s.aureus, >1 wk pseudomonas 2. penicillin G or synthetic penicillin, topical antibiotics 3. infection of an IV catheter, must be treated by excision of the vein

1.protooncogenes 2. her2-neu gene 3. ras oncogene 4. c-myc

1. genes expressed during cellular proliferation 2. receptor gene that is amplified in breast/ovarian cancer 3. signal transduction protein found in 50% of colon and 20% of solid tumors 4. transcription factor that binds to target genes, seen in solid tumors, burkits lymphoma (c-kit-Ig fusion gene)

1. most common testicular tumors 2. nonseminomas -cryptorchidism increases risk for testicular cancer

1. germ cell tumors - seminomas and nonseminomas 2. embryonal carcinoma, teratoma, chroriocarcinoma, yolk sac tumor, lymphoma (esp in patients >60 yo)

essential fatty acid deficiency (TPN) 1. cause 2. clinical pres 3. lab vales

1. giving soybean oil <2x/wk 2. poor wound healing, eczematous skin changes, thrombocytopenia, lethargy 3. triene to tetrane <0.4

gauchers disease 1. patho 2. tx

1. glucosylceramide lipids deposited throughout reticuloendothelial system--> hepatosplenomegaly/bone pain(erlenmeyer flask femur) 2. splenectomy

necrotizing fasciitis 1. patho

1. group A strep soft tissue infection --> gas production in teh soft tissues

mediastinoscopy 1. procedure 2. use

1. instrument inserted behind sternum at tracheal notch and directed along anterior surface of the trachea in pre-tracheal space 2. biopsy of paratracheal/subcarinal nodes, dx. of sarcoidosis, fungal infections, lymphoma

1. why do gallstones form 2. pure pigment bilirubin stones - assc. condition/composition 3. calcium bilirubinate stones - assc condition/composition

1. insufficient micellar liquid causes the concentration of cholesterol/lecithin to increase and stones precipitate out 2. hemolytic disorders (SSA, or spherocytosis) green or black in color / made of unconjugated heme pigments 3. infection or inflammation - inc. biliary calcium and beta glucuronidase, dec. glucaro 1,4 lactone (inhibits conj to unconj)- stones are made of conjugated bili and are brown in color

squamous cell carcinoma of the lung 1. histo 2. location/tumor characteristics

1. intercellular bridging and CELL KERATINIZATION 2. occurs in central lung fields, bronchial obstruction, central necrosis/cavitation

1. popliteal artery entrapment syndrome 2. dx

1. intermittent claudication due to compression by the medial head of gastrocnemius 2. angiography

hepatic failure 1. best inhalational anesthetic for patients with liver failure

1. isoflurane-- not hepatically metabolized ~~ DO NOT USE HALOGENATED INHALATIONAL ANESTHETIC DUE TO HEPATOTOXICITY

hepatic failure 1. clinical features of hepatic disease 2. laboratory tests to evaluate liver

1. jaundice, hemolytic anemia, ascites, peripheral edema, muscle wasting, testicular atrophy, palmar erythema, spider angiomas, gynecomastia, caput medusae, splenomegaly, encephalopathy, asterixis 2. AST, ALT, bilirubin, alk phos, albumin, PT, platelet count, Hep B/C serologies

bariatric surgery 1. GBP 2. gastric restrictive procedures 3. indications for bariatric surgery

1. jejunoileal bypass 2 . gastric banding, pouch should be <30cc 3. >100lbs over IBW, BMI>35,

1. which types of transplants require cross match compatibility 2. what is a positive cross match 3. high PRA patients 4. HLA antibodies

1. kidney, pancreas, heart 2. preformed anti-donor antibodies in serum of the recipient (NOT A CANDIDATE TO RECEIVE THAT GRAFT) 3. have antibodies against most other humans- puts these patients at high risk of organ rejection 4. HLA A,B,C,DR,DP,DQ

gustillo fracture classifications 1. grade 1 2. grade 2 3. grade 3

1. kin opening <1cm, clean break, inside to outside, no muscle contusion, 2. laceration >1 cm, soft tissue damage, flaps, avulsion, 3. 3a - extensive tissue laceration, adequate bone coverage, segmental fractures, gunshots 3b - extensive soft tissue/periosteal stripping, massive contamination 3c. vascular injury requiring repair

nasopharyngeal carcinoma 1. associations 2. tumor types 3. clinical presentation 4. dx / tx

1. kwan tung province of china, EBV** 2. 80% epithelial from fossa of rosenmuller , 7.5% lymphomas 3. epistaxis, cervical adenopathy, nasal obstruction, headache, diplopia (from CN VI palsy 2/2 cranial extension), ptosis 4. endoscopic biopsy, CT/MRI, EBV titer should be monitored as a rise may indicate a recurrence, nodal biopsy NOT recommended b/c risk of implantation of tumor tx = radiation* + chemotherapy, neck dissection for residual nodes

cellulitis/mastitis 1. patho 2. tx

1. lactation--> staph/strep --> inflammation 2. antibiotics (cephalosporin/dicloxacillin), PATIENT CAN STILL BREAST FEED

1. first radiographic evaluation of possible spinal cord injury 2. other necessary radiographic studies 3. treatment of cervical spine injury 4. indications for treatment

1. lateral cervical xray 2. CT, then MRI 3. immobilization, in hard cervical collar, open reduction/fixation 4. incomplete SCI, and progressive neurologic deterioration with radiographic evidence of external compression

blood supply of the stomach 1. lesser curvature proximal 2. lesser curvature distal 3. greater curvature proximal 4. greater curvature distal 5. fundus / body 6. venous drainage of the stomach

1. left gastric artery 2. right gastric artery 3. left gastroepiploic 4. right gastroepiploic 5. vasa brevia (short gastrics) from splenic 6. right/left gastric veins drain into portal vein, left gastroepiploic drains into splenic vein

VSD conoventricular, muscular, inlet septa, conoseptal 1. flow of blood sx- similar to ASD 2. indications for surgery 3. when should surgery be done

1. left to right 2. same as ASD, pulmonary artery pressure is largest factor, pulmonary pressure >85 mmHg has a 50% mortality 3. between age 4-6*** because half the cases of VSD will close on their own

ASD females>males ostium secundum, sinus venosus, ostium primum, PFO 1. direction of flow 2. long term compliation 3. clinical presentation

1. left to right (non-cyanotic ASD,VSD,PDA) 2. pulmonary vascular obstructive disease with shunt reversal (eisenmenger syndrome) 3. dyspnea and easy fatigue as child, CHF as adult, CVA, TIA

1. benign tumors of the esophagus 2. sx of esophageal tumor 3. dx 4. tx

1. leiomyomas (intramural) mucosal polyps, lipomas, fibrolipomas, myxofibromas (intraluminal) 2. dysphagia, regurgitation, weight loss 3. history of dysphagia, barium swallow, esophagoscopy, NO BIOPSY, ultrasound 4. esophagotomy, endoscopy

neurogenic bladder 1. detrusor areflexia (atonic bladder) pathogenesis 2. tx

1. lesions of the sacral cord, nerve roots, cauda equina --> loss of sacral arc --> inc. capacity/compliance, urinary retention, 2. catheterization

verrucous carcinoma of buccal mucosa* 2. tx

1. less invasive, common in tobacco chewers***, grow along gingivobuccal gutter and invades the bone , looks white and shaggy 2. wide excision, typically node dissection is not needed, NO RADIATION, WILL CAUSE METASTASIS

GBM 1. patho 2. findings on MRI

1. malignant degeneration of an astrocytoma or anaplastic astrocytoma 2. necrotic core, poorly demarcated, surrounding edema - if the lesion is well demarcated it is more likely to be an astrocytoma

location/feature of cysts 1. thyroglossal cysts 2. teratomas 3. cystic hygroma 4. branchial cleft cyst

1. midline, firm non-tender 2. anywhere, firm 3. posterior triangle, diffuse 4. preauricular triangle, firm, non-tender

magnesium 1. hypermagnesimia symptoms 2. hypomagnesemia symptoms

1. neuromuscular depression -->depressed DTR-->flaccid quadriplegia/respiratory arrest/hypotension -->AMS/coma, *EKG changes similar to that seen with hyperkalemia (wide QRS, long QT) 2. neuromuscular hyperexcitability, paresthesia, muscle spasm, tetany, EKG looks like hypercalcemia (long QT**)

hypocalcemia (<8) 1. sx 2. cause 3. tx

1. neuromuscular irritability perioral/extremity numbness, hyperactive DTRs, carpopedal spasm, tetany, PVCs 2. parathyroid damage/removal, lactate, citrate, medications 3. oral supplementation, vitamin D, lower hyperphosphatemia

1. capillary hemangiomas 2. cavernous hemangiomas 3. AV hemangiomas location 4. tx. for hemangiomas and subglottic hemangiomas

1. nevus flammeus - period of growth and regression 2. permanent hemangiomas 3. usually on lips and perioral skin 4. regular hemangiomas just wait and if does not go away use laser and surgery subglottic- control airway, steroids

1. does negative MRI/CT rule out mets 2. PET scanning *PET-FDG > CT for diagnosing/staging of colorectal cancer

1. no it does not because of risk of micro mets 2. cancer cells show increased uptake of radiolabeled 2-fluro-2deoxy-D-glucose

vascular malformations 1. AVM 2. telangiectasias 3. cavernous angiomas 4. venous angioma 5. clinical pres

1. no normal brain found in these areas, usually bleed into the parenchyma but can also present with SAH 2. found in the mons, most frequently , low risk 3. sinusoidal vessels anywhere in the brain 4. extensive network separated by normal brain 5. headache/photophobia.loss of consciousness

1. should pre-operative testing be performed on every patient prior to ambulatory surgery in healthy pop 2. what pre-operative assessments predict risk of complications 3. why does emergency surgery have higher m&m

1. no, just order selectively based on patients history, examination and presenting illness. 2. only ASA risk classes, and surgical risk independently 3. because there are more likely acute metabolic derangements`

non-hodgkins lymphoma 1. favorable type 2. unfavorable type 3. treatment

1. nodular, well differentiated 2. diffuse, poorly differentiated 3. chemotherapy and radiation, surgery does not provide better outcomes

esophageal reflux 1. patho 2. sx 3. dx 4. tx

1. non- intraabdominal LES + loss of LES pressure--> reflux of gastric secretions (acid/pepsin) 2. substernal pain, heartburn, regurgitation, EXACERBATED BY LYING DOWN/BENDING 3. manometry - dec. LES pressure esophagoscopy - shows esophagitis 24 hour pH measurement***** 4. PPI, H2 antagonists, cisapride/metoclopramide (gastrokinetics), antacids, weight reduction, no alcohol/tabacco, elevation of head of bed

relapsing pancreatitis 1. patho 2. dx 3. nardi test

1. non-alcoholic, biliary disease, sphincter spasm 2. US finds biliary calculi, bile microscopy (crystals/WBC indicate surgery) NARDI TEST, US dilation after secretin administration 3. morphine + neostigmine-- measure glutamine-oxaloacetic transaminase, glutaminc pyruvic transaminase, GGT, amylase/lipase- @ 4 hour intervals-- indicates sphincteric disease if pain occurs within 15-20mins, no elevation in liver enzymes indicates intact gallbladder

1. surgical repair liver lacerations 2. acute management of a patient with a liver laceration who is hemodynamically unstable

1. non-anatomic laceration repair with sutures, do not resect segments 2. ex-lap, packing the liver, then pringle maneuver, laceration repair

zollinger ellison syndrome 1. patho 2. clinical presentation 3. dx 4. dx if gastrin > 5000 pg/ml

1. non-beta islet cell tumor of the pancreas D cell or delta cell 2. peptic ulceration, diarrhea(inactivation of pancreatic enzymes), GI hemorrhage, ulcer perforation 3. elevated gastrin/gastrin precursor levels >500 pg/ml *PARADOXICAL rise in serum gastrin after IV secretin or calcium** 12 hour basal acid output > 100 ml, no inc. in acid secretion after stimulation of pentagastrin/betazole (parietal cells already maxed out) 4. malignant gastrinoma

pericardial effusion 1.patho 2. surgical tx

1. noxious stimuli caues pericardium to increase fluid production--> >100ml --> tamponade 2. subxyphoid pericardiocentesis

treatment of arthritis med/surg

1. nsaids, corticosteroids, immunosuppresants, gold/remittive agens, anti-TNF alpha surg = osteotomy, arthrodesis (used for small joints of wrist/hand/foot, arthroplasty (total joint replacement)

1. herniated disk syndrome 1. patho 2. radicular signs 3. C5 syndrome 4. C6 syndrome 5. C7 syndrome 6. C8 syndrome

1. nucleus pulposus herniates through rupture in the capsule typically through posterior longitudinal ligament, causes radiculopathic syndrome if impinges on nerve root 2. radiation of pain to arm or leg , weakness, loss of reflexes 3. lateral arm sensory, shoulder abductors/external rotators, dec. biceps reflex 4. radial forearm sensory, bicep/brachioradialis weakness, dec. biceps/radial reflexes 5. posterior arm/ index finger/long finger sensory loss, weakness in wrist/elbow extensors, dec. triceps reflex 6. ulnar medial forearm sensory loss, ulnar deviation of the hand/ finger flexors weakness, dec finger flexor reflexes

corticosteroids 1. side effects

1. obesity, cushingoid facies, atrophic skin, striae, acne diabetes, hypertension, osteoporosis,

treatment for CNS rhino/otorrhea

1. observation and prophylactic antibiotics to prevent meningitis, >14 days surgical repair

obstructive shock 1. pathogenesis 2. major distinctive in lab values

1. obstruction resulting in dec. CO- tension pneumothorax, cardiac tamponade, pulmonary embolism, venous air embolism, cardiac valvular stenosis 2. elevated central venous pressures (same as cardiogenic shock)

1. indications for tonsillectomy 2. indications for adenoidectomy

1. obstructive hypertrophy - airway obstruction, peritonsillar abscess sleep apnea, cor pulmonale, dysphagia 2. chronic nasal obstruction

ruptured AAA 1. anterior spinal artery syndrome pathogenesis + clinical pres 2. treatment of graft infection

1. occlusion of a low level artery of adamkiewicz, systemic hypotension, clamping of aorta, ligation of intercostal/lumbar arteries--> paraplegia, incontinence, loss of pain, but preserved vibration/proprioception 2. total graft excision, and extra anatomic bypass

1. berry aneurysms 2. inflammatory aneurysms 3. atheroscleroti anuerysms 4. tx

1. occurs at vessels that have strong blood stream - IC/posterior communicating artery, anterior communicating aneurysm, basilar artery aneurysm 2. infection of cerebral artery (ex. mycotic) 3. ectatic or fusiform aneuryusms 4. clipping with metallic clip, coiling, occlusion thrombosis, abx/antifungals

gastric antral vascular ectasia 1. patho + sx 2. tx

1. old age (esp. elderly women), autoimmune disease, portal hypertension --> dilation of vasculature extending from the pylorus to the antrum clinical presentation is - UGI bleeding (uncommon) 2. endoscopic laser

1. where should IV catheters be placed in shock patients 2. initial volume resuscitation

1. one above the diaphragm and one below the diaphragm 2. 2L isotonic saline or ringers lactate, followed by blood transfusion (O positive for males, O negative for females)

immediate life threatening injuries 1. open pneumothorax- patho/tx 2. massive hemothorax

1. open chest wound --> air moves out of lung causing alveolar ventilation defect tx = cover wound and inserting thoracostomy tube, closure of wound 2. rapid blood accumulation in the pleural space which compromises ventilation/hypovolemic shock tx = IV access, then thoracostomy tube1

aorticoiliac disease treatment -indications same as lower extremity occlusive symptoms - PCI indicated for focal short segment aortoiliac stenosis/occlusions 1. aortoiliac endarterectomy 2. bypass procedures 3. extra anatomic bypass 4. femoral-femoral bypass

1. open surgical removal of the plaque 2. USUALLY PROSTHETIC - aortobifemoral bypass - inflow near renal arteries, tunneled retroperitoneally to common femoral arteries 3. uses contralateral common femoral and axillary artery - AVOIDS CROSS CLAMPING AORTA 4. good for unilateral iliac disease - prosthetic conduit tunnelled subQ or space of retzius

omphalocele 1. patho 2. assoc conditions 3.t x

1. opening in abdominal wall @ umbilicus with protrusion of bowel with covering 2. pentalogy of cantrell - diaphragmatic hernia, cleft sternum, absent pericardium, intracardiac defects, omphalocele trisomy 13/18, beckwith wiedemann; cardiac, neurologic, GU malformation 3. emergent repair, or cover with a skin flap and repair later, staged repair non-operative - sac coated with silver sulfadiazine, leads to eschar with granulation tissue covering --> later repair

gastroschisis 1. patho 2. assc conditions 3. tx

1. opening in abdominal wall to the right of the umbilicus protrusion of the GI tract with no covering on abdominal viscera 2. rarely intestinal atresia 3. emergent surgery b/c of heat/fluid loss from uncovered bowel

leukoplakia 1. treament 2. when should it be biopsied

1. oral hygene, alcohol/tobacco cessation 2. when it is thick- suggests CIS

testicular cancer 1. NSGCT treatment

1. orchiectomy, retroperitoneal lymphadenectomy + chemotherapy for 4 cycles

legg calve perthes 1. patho 2. assoc. risk factors 3. clinical pres 4. dx 5. tx

1. osteonecrosis of the proximal femoral epiphysis 2. hypothyroid, clotting abnormalaties 3. knee pain that is referred from the him 4. hip irritation, and limited internal rotation/abduction x rays show collapse of femoral epiphysis 5. restoration of range of motion/containment, surgery

inflammatory bowel disease 1. serologic markers

1. pANCA (higher in UC), anti-saccharomyces cerevisiae (higher in CD)

1. how to manage post-op bradycardia after a heart transplant managed 2. contraindications for heart transplant

1. pacing wires, and isoproterenol 2. pulmonary hypertension, tobacco use within 6 months, poor renal/pulm function

atherosclerosis of lower extremities 1. claudication + clinical pres of SFA claudication 2. claudication clinical implications ***claudication is a warning sign of diffuse atherosclerosis 3. treatment of exertional claudication

1. pain felt in large muscles after exercise SFA --> pain in the lower calf 2. not usually limb threatening (LOW RISK FOR GANGRENE), but 75% survival at 5 years and 38% at 10 years from CAD related death 3. vigorous exercise program ONLY, PDE inhibitors, cilostazol, pentoxifylline

urinary calculi 1. clinical presentation 2. dx 3. emergency surgery indications` 4. tx for non- emergency 5. surgical procedures

1. pain from ureter obstruction, hematuria, N/V, irritative bladder 2 .non-contrast spiral CT, excretory urography, ultrasonography, cystourethrography 3. fever (risk of sepsis), renal insufficiency w/ elevated creatinine 4. pain control, oral liquids 5. percutaneous nephrostomy, ureteroscopic, ESWL

1. clinical presentation of scaphoid fracture 2. tx

1. pain in the anatomical snuff box 2. casting or spica with repeat xray at 10-14 days (may not

anorectal incontinence 1. dx 2. tx

1. physical exam, anal manometry, pudendal nerve terminal motor latency 2. anal sphincter repair, gracilis muscle transposition, artificial anal sphincter, colostomy (for neurogenic or systemic causes)

non-palpable breast cancer dx 1 .needle guided biopsy 2. stereotactic (mammotome biopsy)

1. place a localizing wire into the breast and then do bx 2. deploy core needle into mammographic abnormalities

ICU monitoring 1. arterial cath + thrombus prophylaxis 2. values from arterial cath 3. what does mean arterial pressure indicate

1. placed in radial arteries (or femoral, axillary, brachial), flushed with heparin 2. systolic, diastolic and mean (2/3 diastolic +1/3 systolic) 3. pressure to perfuse the organs

1. how does a plaque progress to occlusion 2. plaque embolism

1. plaque grows and may eventually rupture or slow blood flow to the point that thrombosis occurs 2. loss of fibrous cap and discharge of debris distally

idiopathic thrombocytopenic purpura 1. patho/sx 2. tx

1. platelet agglutinating antibodies destroy transfused platelets--> thrombocytopenia/petichial bleeding o f the gums/skin, NO SPLENIC ENLARGEMENT 2. steroids, splenectomy

salivary cancer 1. cell type + locations 2. growth 3.

1. pleomorphic adenomas- lips, palate, tongue 2. slow growing, rubbery consistency

anterior compartment lesions germ cell tumors 1.sites of mets 2. dx /tx

1. pleural lymph nodes, bone, liver, peritoneum 2. radiographs, B-HCG (choriocarcinoma), AFP (yolk sac tumor) tx = seminomas -surgery + **radiotherapy** non-seminomas -combo chemotherapy

segmental waveform analysis (counterpart to segmental pressure testing) 1. doppler waveforms 2. pulse volume recordings

1. polyphasic = normal, monophasic = diminished blood flow 2. sharp upstroke with dichrotic notch = normal no notch and magnitude of upstroke = diminished flow

felty's syndrome 1. clinical pres 2. tx

1. rheumatoid arthritis, splenomegaly, granulocytopenia, gastric achlorhydria, thrombocytopenia/anemia -> spontaneous infections 2. splenectomy helps to resolve neutropenia

angiodysplasia (aka AVM, angiectasis, vascular ectasia) 1. patho 2. dx/tx

1. right colon- chronic intermittent obstruction of submucosal veins--> incompetent precapillary sphincters --> AVM with bowel wall 2. cherry red spots on colonoscopy, nuclear scan, arteriography tx = endoscopic electrocoagulation, segmental colectomy, total colectomy with ileostomy

hypertensive intracranial hemorrhage 1. patho 2. dx 3. tx

1. rupture of small perforating arterioles --> basal ganglia, temporal/frontal lobes, cerebellum, pons --> headache, neuro deficits 2. CT scan 3. control hypertension/source

1. splenic abscess pathogenesis/sx 2. dx/tx

1. s.aureus or strep by direct spread, or hematogenous seeding--> fever, left upper quadrant fullness 2. CT or tectinium 99 scan tx = broad spectrum abx/splenctomy (percutaneous drainage risks hemorrhage)

vascular surgery infections 1. what kind of organisms + prophylaxis 2. what antibiotic to prevent heart infection when there will be transient bactermia

1. s.aureus, s.epidermidis~ perioperateve prophylactic cephalosporin 2. amoxicillin ~ ex. dental extraction

transitional cell carcinoma of renal pelvis/ureter 1. risk factors 2. sx 3. dx 4. tx

1. same as bladder + balkan nephropathy/analgesic abuse 2. hematuria, flank pain 3. IVP, retrograde cystoscopy, ureteroscopy 4. nephroureterectomy

1. neurilemomas 2. neurofibromas + assc syndrome 3. seborrheic keratosis 4. keloids

1. schwann cell sheath derived 2. nerve/fibrous tissue -- von-recklinghausen's disease 3. light to dark brown raised papular lesions- must differentiate from malignant skin lesions 4. accuulation of fibrous tissue that extends past area of trauma

superficial thrombophlebitis 1. patho/clinical pres 2. tx 3. suppurative thrombophlebitis + tx

1. thrombosis of superficial veins-->tender palpable cord along vein, red, warm, indurated 2. nsaids, rest, compression stockings 3. IV infusions in immmunocomp/urns tx = excision of infected vein

riedel's (fibrous) thyroiditis 1. patho 2. tx

1. thyroid parenchyma replaced with fibrous tisseu--> cough, dyspnea, dysphagia + woody goiter 2. surgical removeal

1.autograft 2. isograph 3. allograft 4. xenograft

1. tissue transfer from same individual 2. tissue transfer from genetically identical individual 3. tissue from a non identical member of same species 4. tissue from a different species

oral cancer 1. associations 2. clinical pres 3. dx 4. tx

1. tobacco, alcohol, syphilis, HSV 1 2. loose teeth, non-healing ulcers, odynophagia, lip involvement 3. mandibular radiographs, nodal mets, 4. excision / radiotherpay, partial mandibulectomy

septic shock 1. pathogenesis 2. major distinctive in lab values

1. toxins cause hypoperfusion and dec. 2. increased HR, dec. SVR

1. right hepatic lobectomy 2. left hepatic lobectomy 3. transegmentectomy 4. wedge resections

1. transects liver thorugh interlobar fissure between the gallbladder fossa and the IVC 2. same 3. right lobe and median segment of left lobe -- leaves only left lateral segment 4. small lesions near liver surface

post thyroidectomy hypocalcemia 1. pathogenesis 2. tx 3. ECG change associated with hypocalcemia

1. transient ischemia to parathyroid glands during the operation --> temporary dec. PTH production 2. IV calcium gluconate, if persistent, switch to oral therapy/vitamin D 3. prolonged QT

1. why is protein broken down in injury/sepsis 2. biochemical medieators of protein breakdown

1. transported to the liver to be synthesized into acute phase reactants - ex. fibrinogen, complement, haptoglobin, ferritin, gluconeogenesis 2. glucagon, epinephrine, cortisol, IL-1, TNF (cachectin) *TNF/IL 1 from macrophages

1. tx cushings syndrome 2. complication of bilateral adrenalectomy 3. treatment of ectopic cushings 4. tx for adrenal cushings 5. palliative chemotherapy

1. transsphenoidal resection, pituitary irradiation (yttrium 90), bilateral adrenalectomy (if refractory to transsphenoidal) 2. nelsons syndrome - ACTH secreting pituitary tumor 3. treat underlying neoplasm 4. laparoscopic adrenalectomy, open adrenalectomy (if >6cm) 5. for unresectable tumors, Inhibit adrenal steroid synth - mitotane, metyrapone, trilostane, aminoglutethimide cyproheptadine(5HT antagonist)/bromocriptine- inhibit CRF release

inguinal canal repair 1. bassini

1. transversalis fascia and conjoint tendon sutured to the reflection of the inguinal ligment (coopers ligament)--shelving edge of pouparts ligament spermatic cord returned to normal anatomic location between rinforced inguinal canal floor and external oblique aponeurosis in women round ligmanet ligated and internal ring closed

inguinal canal repair 1. coopers ligament repair (Mcvay) -big problem is pain and reoccurance

1. transversalis fascia/conjoint tendon sutured to coopers ligament (similar to bassini) anterior rectus sheath incision to reduce tension on coopers ligament

1. what is the most accurate measure of adequate fluid resuscitation in burn victim 2. what is most important for patient with facial burn -abx not indicated- selects for resistant gram negatives -tetanus if not received vaccine within one year

1. urine output 2. airway due to progressive subglottic edema can prevent intubation later

needle biopsy incisional biopsy excisional biopsy 1. staging laparotomy

1. used for hodgkins disease to determine stage

biliary disease diagnostic modalities 1. ERCP 2. PTHC

1. used to dx/tx stones using papillotomy, stenting of strictures, 2. localizes site of obstruction and can place drain catheters in jaundiced patient~ used when ERCP cannot visualize due to complete obstructionq

1. recurrent inguinal hernias 2. pantaloon hernias

1. usually direct, most medial aspect of the repair of the floor of inguinal canal 2.direct and indirect combo hernias

1. splenic cysts patho 2. tx

1. usually from previous trauma , 2. surgery if they cause pain

1. cystic astrocytoma: location and imaging finding

1. usually in the cerebellar hemispheres, forms a large non-enhancing cyst with a tumor nodule on the wall

gunshot to chest 1. when is ex thoracoscopy indicated 2. gunshot below the nipple patient is hemodynamically stable, what is next step

1. usually not indicated unless bleeding > 100ml/h 2. ex. lap because the abdomen can rise up to T4 level

ventilation 1. rate 2. tidal volume -permissive hypercapnea beneficial to avoid barotrauma in disease lungs - typical ventilation 1. SIMV or AC if no work of breathing desired 10-12 RR TV - 5-10mmHg PEEP/CPAP - 5mmHg Fraction of inspired O2 - 0.4

1. usuually 10-12, higher will dec. PCO2 2. normal 5ml/kg, but in ventilated patients 8-10ml/kg ~ dec. compliance ex. ARDS 6ml/kg are beneficial

breast cancer histologic findings 1. pagets disease 2. lymphoplasmacyctic reaction

1. vacuolated cells 2. medullary breast carcinoma

non-invasive breast cancer 1. pagets disease of the breast 2. dx/tx

1. vacuolated paget cells* in epidermis of the nipple + eczematous dermatitis of the nipple- may be associated with invasive cancer (if there is a mass associated) 2. biopsy will show the vacuolated paget cells mastectomy

pancreatic cancer 1. general clinical pres 2. head of pancreas cancer clinical pres 3. tail of the pancreas"""

1. vague epigastric pain, weight loss, backpain, DEPRESSION, migratory thrombophlebitis, rarely palpable upper abdominal mass 2. OBSTRUCTIVE JAUNDICE, +/- pain, courvoisier's gallbladder(huge palpable gallbladder) + general sx 3. more advanced stage at clinical presentation

X-ray findings for 1. jejunal obstruction 2. ileal obstruction 3. colon obstruction

1. valvulae conniventes 2. featureless bowel pattern*** 3. haustra

portal hypertension 1. causes of UGI in cirrhotic pts 2. tx of variceal bleeding 3. TIPS procedure

1. varicies, erosive gastritis, PUD, esophageal tears 2. endoscopic variceal banding, injection sclerotherapy, vasopressin, nitroglycerin (counteracts heart/limb/bowel ischemia from vasopressin), somatostatin (-->splanchnic vasoconstriction), splenectomy, metoclopramide/pentagastrin, balloon tamponade , TIPS 3. shunt between hepatic vein and branch of portal vein relieving portal hypertension

1. how do skin grafts survive 2. can skin be grafted right onto denuded bone or cartilage 3. care fro the donor site

1. vascular tissue beds of recipient sites produce plasma by imbibition , then fibrin is produced then inosculation establishes true circulation 2. no it must have a flap procedure 3. meshed non-adherent gauze and semipermeable membranes

raynauds phenomenon 1. patho 2. associated syndromes 3. med/surg tx - raynauds disease is similar but not assc. with systemic disease

1. vasospasm of the feet/fingers triggered by cold exposure/emotion--> pallor, cyanosis, rubor, numb discomfort --> ulceration/gangrene 2. scleroderma, collagen vascular disease 3. avoid cold/tobacco, nifedipine, phenoxybenzamine, cervical sympathectomy (if digital ulceration present)

nitroglycerine 1. effect/use

1. venodilator, coronary artery dilator, dec. venous preload, dec. diastolic wall tension/inc. diastolic blood flow

intubation 1. two issues of ventilator 2. ventilation controls what blood gas 3. minute ventilation formula 4. how to increase oxygenation 5. causes of ventilator associated lung injury

1. ventilation, oxygenation 2. CO2 3. RR * TV 4. increase FiO2 by increaseing alvolar oxygen pressure ex. PEEP 5. volutrauma, barotrauma, oxygen toxicity (high O2 conc)

ventilation 1. pressure support 2. CPAP/PEEP

1. ventilator circuit to preset level above baseline pressure when patient starts inhaling and maintains pressure until patient stops inhaling--- patient initiates/terminates cycles 2. vent circuit pressurized to specified ATM pressure at all times during inspiration/expiration -- increases alvoli recruitment (usually 5mmHG)

1. primary hyperslenism 2. tx

1. very rare, sequestration of blood elements, may be associated with fevers/infection 2. splenectomy

angiosarcoma (malignant hemangioendothelioma) (higher in men) 1. patho/clinical pres 2. site of mets. 3. tx

1. vinyl chloride/throotrast/arsenicals, organochloride pesticides--> 2. spleen* and lungs 3. resection, poor prognosis

laryngeal papillomas 1. patho + sx 2. tx -recurrence is common

1. viral --> multiple polyps --> hoarseness/obstruction 2. laryngoscopic removal with laser, interferon

subacute thyroiditis (giant cell, dequervains) 1. pathogenesis 2. dx 3. tx

1. viral URI--> sore throat, enlargement of gland, tenderness over gland--> hyperthyroidism (possibly) due to release of thryoid hormone 2. DECREASED UPTAKE of radioiodine 3. self limited, beta blockade, (antithyroid drugs dont work)

vocal nodules 1. patho 2. tx

1. vocal abuse-->bilateral benign masses at the junction of the true vocal folds 3. surgery after failing voice thearpy

hypernatremia 1. hypovolemic 2. hypervolemic 3. sx 4. causes

1. volume defecit, more free water than sodium 2. iatrogenic from over infusion of sodium 3. symptoms of volume depletion, lethargy, confusion, coma from water shifts from intracellular CNS compartment 4. insenseble loss from fever/mechanical ventilation, burns, diarrhea, GI tract renal - osmotic diuresis, from hyperglycemia or mannitol, ATN hihg outpu dilute urine

gastric volvulus 1. organoaxial 2. mesenteriocoaxial volvulus 3. sx 4. tx

1. volvulus around cardio pyloric line, associated with PARAESOPHAGEAL HERNIA 2. line perpendicular to cardio pyloric line 3. BORCHARDT'S TRIAD - abdominal pain, retching without vomitus, inability to pass NG tube 4. surgical reduction of torsion

met acid (<7.35) 1. weak acid causes 2. strong acid causes 3. loss of bicarb causes 4. tx

1. weak acid accumulation (AMUDPILES), renal failure (cannot clear metabolic byproducts), lactic acidosis, DKA, toxins 2. hyperchloremic acidosis - excess chloride causes water to dissociate 3. excess renal excretion (RTA), diarrhea 4. treat underlying cause, ONLY use bicarb if pH is VERY LOW **risk of over correcting primary defect = bicarb loss, treat with bicarb

cardiac resuscitation 1. closed chest cardiac massage 2. indications for ER thoracotomy 3. how to monitor circulating blood volume/resuscitative therapy

1. while fluid is begun if patient is asystolic or shows poor cardiac function 2. hypovolemic cardiac arrest despite fluid/closed chest massage and fibrillation , cardiac arrest with penetrating injury to the chest 3. pulse, skin color, cap refill, HR/BP, urine output, CVP

how many units of blood lost during GI bleed before should consider surgery

4-6

4. gardners syndrome 5. turcot's syndrome

4. FAP + osteomatosis, epidermoids cysts, skin fibromas 5. CNS malignancies + colon + cafe au laits

1. reperfusion syndrome 2. tx

>4-6 hours of ischemia reperfused tissues (ie. after embolectomy) undergo edema/swelling, sudden release of accumulated products of ischemia - potassium, lactate, myoglobin, cellular enzymes ***RISK FOR COMPARTMENT SYNDROME 2. alkalinization of the urine, mannitol diuresis, correction of hyperkalemia

timing of rectovaginal fistula repair

>6 months after the causative operation, to allow inflammation to subside

A 33 year old man vomits a large amount of bright red blood.

Define the territory where the bleeding is taking place: from the tip of the nose to the ligament of Treitz. How is the diagnosis made?: for all upper G.I. bleeding, start with endoscopy.

A two month old baby boy is brought in because of chronic constipation. The kid has abdominal distention, and plain X-Rays show gas in dilated loops of bowel throughout the abdomen. Rectal exam is followed by expulsion of stool and flatus, with remarkable improvement of the distention.

Hirschsprungs's disease (aganglionic megacolon) How do you diagnose it? - Barium enema will define the normal-looking aganglionic distal colon and the abnormal-looking thickness biopsy of the rectal mucosa.

Your distant cousins that you have not seen for years visit you and brag about their beautiful baby with "huge, shiny eyes". They show you a picture that indeed proves their assertion (or the exam booklet will have such a picture).

Huge eyes in babies can be congenital glaucoma. Tearing will indeed make them shine all the time. If undiagnosed, blindness will ensue. tx is surgery.

A 45 year old lady comes to your office for a "regular checkup". On repeated determinations you confirm the fact that she is hypertensive. When she was in your office three years ago, her blood pressure was normal. Laboratory studies at this time show a serum sodium of 144 mEq/L, a serum bicarbonate of 28 mEq/L, and a serum potassium concentration of 2.1 mEq/L. The lady is taking no medications of any kind.

Hyperaldosteronism. Possibly adenoma. How is the diagnosis made? - aldosterone and renin levels. If confirmatory (aldo high, renin low) proceed with determinations lying down and sitting up, to differentiate hyperplasia (not surgical) from adenoma (surgical). Treat the first with aldactone. (hyperplasia will inc aldo levels with standing from sitting.) Pursue the second with imaging studies (CT scan or MRI) and surgery.

A 72 year old chronic smoker with severe COPD is found to have a central, hilar mass on chest X- Ray. Bronchoscopy and biopsy establish a diagnosis of squamous cell carcinoma of the lung. His FEV1 is 1100, and a ventilation/perfusion scan shows that 60% of his pulmonary functions comes from the affected lung.

It takes an FEV1 of at least 800 to survive surgery and not be a pulmonary cripple afterwards. If this fellow got a pneumonectomy (which he would need for a central tumor) he would be left with an FEV1 of 440. No way. Don't do any more tests. He is not a surgical candidate. chemorad

where does the conus medullaris occur in the spinal canal

L2

which ECG rhythm can obscure a myocardial infarction ST elevation

LBBB

A 6 year old boy has insidious development of limping with decreased hip motion. He complains occasionally of knee pain on that side. He walks into the office with an antalgic gait. Passive motion of the hip is guarded.

Legg-Perthes disease (avascular necrosis of the capital femoral epiphysis). Remember that hip pathology can show up with knee pain. Management: AP and lateral X-Rays for diagnosis. Contain the femoral head within the acetabulum by casting and crutches.

A 9 year old boy gives a history of three days of burning on urination, with frequency, low abdominal and perineal pain, left flank pain and fever and chills for the past two days.

Little boys are not supposed to get urinary tact infections. There is more than meets the eye here. A congenital anomaly has to be ruled out. Management: treat the infection of course, but also do sonogram right away to begin the work up.

A 45 year old lady with a history of a recent tooth infection shows up with a huge, hot, red, tender, fluctuant mass occupying the left lower side of her face and upper neck, including the underside of the mouth. The mass pushes up the floor of the mouth on that side. She is febrile.

Ludwigs' Angina. (An abscess of the floor of the mouth), bilateral sublingual/submaxillary cellulitis of anaerobes/strep with poor dentition or oral surgery as the source, can progress to fatal upper airway obstruction Management: Tracheostomy and incision drainage of the abscess.

A 45 year old male gives a history of aching back pain for several months. He has been told that he had muscle spasms, and was given analgesics and muscle relaxants. He comes in now because of the sudden onset of very severe back pain that came on when he tried to lift a heavy object. The pain is "like an electrical shock that shoots down his leg", and it prevents him from ambulating. He keeps the affected leg flexed. Straight leg raising test gives excruciating pain.

Lumbar disk herniation. The peak age incidence is 45, and virtually all of these are either L4- L5 or L5-S1. Management: MRI for diagnosis. Bed rest will take care of most of these. Neurosurgical intervention only if there is progressive weakness or sphincteric deficits.

A 22 year old lady seeks help regarding an enlarged lymph node in her neck. The node is in the jugular chain, measures about 2cm, is firm, not tender, and was discovered by the patient six weeks ago. There is a history of low grade fever and night sweats for the past three weeks. Physical examination reveals enlarged lymph nodes in both axillas and in the left groin.

Lymphoma most likely. Management: Tissue diagnosis will be needed. You can start with FNA of the available nodes, but eventual node biopsy will be needed to establish not only the diagnosis but also the type of lymphoma.

A 55 year old man has progressive, unstable, disabling angina that does not respond to medical management. His father and two older brothers died of heart attacks before the age of 50. The patient stopped smoking 20 years ago, but still has a sedentary life style, is a bit overweight, has type two diabetes mellitus and has high cholesterol.

MI waiting to happen... cardiac catheterization to see if he is suitable candidate for coronary revascularization.

for classic clinical presentation of acute appendicitis what imaging study is needed to confrim

NONE - IT IS A CLINICAL DIAGNOSIS - GO RIGHT TO THE OPERATING ROOM

pneumatosis cystoides intestinalis

NOT NECROTIZING ENTEROCOLITIS - incidental finding, may be caused by other intestinal conditions in newborn - can be caused by inital feeding which causes mucosal damage - adults can be from emphysema or rupture of a pulmonary bulla

A very premature baby develops feeding intolerance, abdominal distention and a rapidly dropping platelet count.. The baby is four days old, and was treated with indomethacin for a paten ductus.

Necrotizing enterocolitis. Management: Stop all feedings, broad spectrum antibiotics, IV fluids/nutrition. Surgical intervention if they develop abdominal wall erythema, air in the biliary tree or pneumoperitoneum.

A 79 year old man complains of leg pain brought about by walking and relieved by rest. On further questioning it is ascertained that he has to sit down or bend over for the pain to go away. Standing at rest will not do it. Furthermore, he can exercise for long periods of time if he is "hunched over", such as riding a bike or pushing a shopping cart. He has normal pulses in his legs.

Neurogenic claudication. Management: Get MRI. Eventually surgical decompression of this cauda equina.

first line hypertension control for african descent vs european descent

african - diuretics european - beat blockers or calcium channel blockers

cardiac risk factors in non-cardiac surgical patients

age>70, infarction within 6 months, functional impairment (ex. dyspnea on exertion), mitral regurg, more than 5 PVCs/min, tortuous calcified aorta

bezoars 1. patho 2. sx 3. tx

agglutinated masses of hair (tricho)/vegetable matter(phyto) most commonly in young neurotic women 2. N/V, weight loss, abdominal pain 3. endoscopic or surgical removal (after ingesting meat tenderizer)

treatment for myeloid metaplasia

alkylating agents

most common cause of GI bleeding in neonate

allergic colitis to milk or soy protein #2 = anal fissure

common complications of cardiac grafts

atherosclerosis infection is the most common cause of death

subclavian steal syndrome 2. tx

atherosclerotic occlusion proximal to vertebral exercise --> reversal of flow through the vertebral artery with decreased blood flow to the brain (vertigo, dizziness, LOC) + claudication of the upper extremity 2. carotid subclavian bypass, axillo axillary bypass, angioplasty, subclavian artery transposition

treatment of acute unexpected blood loss ex. emergent aortic rupture, trauma laparotomy

autotransfusion, or transfusion

effort thrombosis (paget von schroetter syndrome) + tx

axillary-subclavian vein thrombosis 2/2 injury or compression, disabling in young athletes tx = thrombolytic therapy

HNPCC

defects in DNA mismatch repair --> acceleration of the mutation cascade

burn managment

early excision of devitalized tissue EXCEPT deep wounds of palms, soles, genetalia Deep partial thickness/full thickness excision should be done 3-7 days after injury topical antimicrobials skin grafts - must have intact vascular bed

manifestations of venous valvular incompetence in the lower limbs

edema, stasis dermatitis, venous ulceration, most often on the medial leg superior to medial malleolus

breast cancer poor prognostic features

edema/ulceration around skin, tumor fixed to chest wall, peau d orange, coopers ligament dimpling, capsular invasion, extranodal spread, arm edema

treatment of chronic venous insufficiency/venous stasis ulceration

elastic stocking support, leg elevation, avoidance of sitting, unna boots

pseudohyperparathyroidism

elevated PTH that is much higher than normal from extra parathyroid source- PTHrP from APUD system tumor

which type of gonadal tumor should be treated with retroperitoneal lymph node dissection

embryonal cell carcinoma

complications of hemothorax

empyema, fibrothorax requiring thoracotomy/decortication

treatment for iatrogenic stricture of the CBD post abdominal surgery

end to side choledochojejunostomy (roux en y)

coarctation of the aorta 5. surgical tx

end-end anastomosis, prosthetic patch graft, subclavian flap procedure (subclavian flap used to enlarge the aorta)

A 72, hypertensive male, on aspirin for arthritis, has a copious nosebleed. His blood pressure is 220/150 when seen in the E.R. He says he began swallowing blood before it began to come out through the front of his nose.

epistaxis secondary to hypertension (most likely to be in the posterior nasal septum vs. anterior nasal septum (kiesselbach's triangle) in children) Management: angiography with embolization These are serious problems that can end up with death. Medical Rx. Call ENT.

best radiological study to evaluate for intestinal obstruction + initial treatment

erect abdominal photographs tx = NG suction, IV fluids, resuscitation

indication for anti-reflux surgery

esophageal strictures (peptic strictures) ~ severe dysplasia treated with esophagectomy

what type of local anesthetics have the most hypersensitivity

ester type - procaine/tetracaine

A 31 year old lady smashes her car against a wall. Hollow viscera will spill their contents. Often they both happen, but one can exist without the other. Here there is not evidence of blood loss, but plenty of clues to suggest that "evil fluid" is loose in the belly. what will she need?

ex lap, repair of injuries

hip osteoarthritis vs trochanteric bursitis clinical presentation

hip osteo - deep pain, referred to inguinal area or knee, internal rotation worsens pain trochanteric bursitis - superficial hip pain exacerbated by external pressure on the lateral thigh

why are patients on TPN at high risk for hypoglycemia + how to adjust TPN for surgery

hyperglycemic glucose solutions cause islet hyperplasia when stop TPN get rebound hypoglycemia change TPN to 50ml/hr during surgery, if keep at 125ml/hr risk of HNKC, if stop entirely, can get severe hypoglycemia

early sepsis changes to the body

hypermetabolic state, release of catecholamines, cortisol, stress hormones, AMS, tachypnea, flushed skin, inc CO, dec. SVR, dec. AV oxygen difference

when should a patient with a wound get tetanus immunoglobulin

if the wound is dirty and has had <3 doses of the vaccine

why is maintaining enteral nutrition important

if there is no enteral stimulation the mucosa atrophies and allows bacteria/toxins to enter the bloodstream

1. what nerves are at risk for damage during an inguinal hernia repair 2. clinical presentation of lateral cutaneous nerve of the thigh injury

ilioinguinal, genitofemoral, iliohypogastric, lateral femoral cutaneous nerves (most commonly injured) 2. burning pain and paresthesia that extends into the thigh

treatment for perforation of the esophagus

left thoracotomy, right throactomy with mediastinal cleanout/esophagectomy/esophagogastrostomy

what features of an intraparenchymal bleed suggest neoplasm

mass effect surrounding edema (indicates that the lesion has been there for a while)

treatment for breast cancer in pregnancy

mastectomy, non-MTX chemotherapy regimes

anatomical feature of GIST

may be submucosal in the GI tract, thus difficult to detect on endoscopy

physical exam findings for mechanical obstruction vs ileus

mechanical obstruction = high pitched tinkling sounds ileus = no sounds

causes of delayed gastric emptying

mechanical obstruction, vagotomy diabetes, myxedema, hypokalemia, anticholinergics, opiate drugs *overcome with a drainage procedure if it is chronic 2/2 vagotomy

indications for ECMO

meconium aspiration sepsis pneumonia congenital diaphragmatic hernia

direct inguinal hernia

medial to internal epigastrics through hesselbachs triangle -- hernia protrudes into the floor of inguinal canal --- related to physical activity, increases with age

what tumor types is IL2 useful for

melanoma and RCC, hematologic malignancies

associated conditions in a child with PDA

mental retardation, cataracts

autoimmune diseases associated with the thymus

myasthenia gravis, SLE, erythroid agenesis, hypogammaglobulinemia, RA, dermatomyositis

thymoma assc. conditions

myasthenia gravis, agammaglobulinemia, red cell aplasia *these tumors typically occur in the anterior mediastinum

hodgkins disease assc conditions

mycotic infections and tuberculosis (due to impaired cell mediated immunity)

prehn sign

negative in testicular torsion positive in epididymitis ~ elevation of the testicle relieves pain

A 44 year old lady shows up in the Emergency Room because she is "bleeding from the breast". Physical exam shows a huge, fungating, ulcerated mass occupying the entire right breast, and firmly attached to the chest wall. The patient maintains that the mass has been present for only "a few weeks", but a relative indicates that it has been there at least two years, maybe longer.

neglect and denial. Obviously a far advanced cancer of the breast. Management: the tissue diagnosis is still needed, and either a core or an incisional biopsy is in order Next? inoperable, and incurable as well...but palliation can be offered. Chemotherapy is the first line of treatment. In many cases the tumor will shrink enough to become operable.

most common primary mediastinal mass

neurogenic tumors (not thymoma....)

droperidol + SE

neuroleptic used for sedation and anti-emetic postoperatively (neuroleptic anesthesia) SE = torsades/QT prolongation, alpha blockade/hypotension

complications of hemodialysis

neuropathy, bone disease, anemia, hypertension

A patient presents to the ER complaining of moderate but persistent pain in his leg under a long leg plaster cast that was applied six hours earlier for an ankle fracture.

never give pain medication and do nothing else for pain under a cast. remove the cast. could be too tight, causing ischemia.

nitroprusside vs nitroglycerin

nitroprusside causes both arterial and venous dilation (use for EMERGENCY HYPERTENSION) nitroglycerine has less effects on arterial circulation (causes venous pooling)

should cardiac meds be stopped prior to surgery

no, risk rebound hypertension

incidentalomas

non functioning masses <3cm are usually never malignant, just repeat imaging after 3-6 months

contraindications for PCI/surgery for PVD

non-ambulatory, non-reconstructable vessels, extensive tissue loss, prohibitive medical comorbidities

what two lesions can show up as a hypofunctioning nodule on thyroid scan

non-functioning follicular adenoma, or carcinoma

bronchopulmonary sequestration

non-functioning lung tissue*** that is separate from the rest of the lung with a distinct blood supply

treatment for a small non-expanding, closed hemothorax

non-surgical, most likely 2/2 fractured ribs. just give analgesics and observe

A 66 year old lady has a modified radical mastectomy for infiltrating ductal carcinoma of the breast. The pathologist reports that tumor measures 4 cm. in diameter and that 7 out of 22 axillary node are positive for metastasis. The tumor is estrogen and progesterone receptor positive.

hormonal therapy with tamoxifen or raloxifene.

treatment for sickle crisis

hydration and analgesia

auditory change noted if VII lesioned proximal to the stapes muscle chorda tympany lesion defecit

hyperacusis loss of taste to anterior 2/3 of tongue

A young mother is visiting your office for routine medical care. She happens to have her 18 month old baby with her, and you happen to notice that one of the pupils of the baby is white, while the other one is black.

ophthalmological and potentially life-and-death emergency. A white pupil (leukocoria) at this age can be retinoblastoma. See ophtho today.

behcets disease

oral/genital/ocular lesions, erythema nodosum appearing rash on skin, thrombophlebitis, autoimmune in etiology treated with corticosteroids

A 32 year old lady presents in the E.R. with swollen, red, hot, tender eyelids on the left eye. She has fever and leukocytosis. When prying the eyelids open, you can ascertain that her pupil is dilated and fixed and that she has very limited motion of that left eye.

orbital cellulitis ophtho emergency. CT scan to assess extent. surgical drainage.

A 25 year old man is found on a pre-employment chest X-Ray to have what appears to be a pulmonary metastasis from an unknown primary tumor. Subsequent physical examination discloses a hard testicular mass, and the patient indicates that for the past six months he has been losing weight for no obvious reason.

orchiectomy and chemo. testicular cancer responds so well to chemotherapy, that treatment is undertaken regardless of the extent of the disease when first diagnosed. Manage exactly as the previous case.

best airway technique for patient with potential cervical spine injury

orotracheal intubation with inline stabilization of the neck followed by cricothyroidotomy if this is unsuccsesful

A young man involved in a motorcycle accident has an obvious open fracture of his right thigh. The femur is sticking out through a jagged skin laceration.

ortho emergency. to OR to clean and get reduced w/in 6 hours.

most common complication of end colostomies

parastomal herniation (avoid this by putting the ostomy though the rectus muscle and to lateral to the rectus muscle

gastrin effects

parietal cells secrete acid chief cells secrete pepsinogen

treatment for partial SBO vs complete SBO

partial can just use NG tube, IV fluids, observation complete SBO (look for peritoneal signs and acidosis) - needs surgical correction

obturator hernia

pass thoguh obturator foramen, causes mid-anterior thigh pain - howship romberg sign

indirect inguinal hernia ~ assc. with bilateral patent processus vaginalis in 10% of patients

pass through the inguinal canal (up to 5% of men in their lifetime) indirect>direct, typically does NOT strangulate

miller abbot tube/cantor tube (long intestinal tubes)

pass through the nose into the small intestine, useful for reliving small bowel obstruction

A 66 year old lady picks up a bag of groceries and her arm snaps broken.

pathologic fracture (i.e: for trivial reasons) means bone tumor. most are metastatic. xrays, whole body bone scan. in women, often breast primary; men have prostate. smokers, lung.

causes of high output renal failure

patient has good urine output, but rising BUN/Cr, and perhaps some electrolyte abnormalities and met acid (cannot get rid of protons) ATN - ischemia, contrast, heme pigments, aminoglycosides

what patients is a brief hypotensive episode most dangerous

patient with coronary artery disease or cerebral vascular disease

classic radial nerve vignette damage

patient with crutches gets wrist drop

A patient involved in a high speed automobile collision has multiple injuries, including a pelvic fracture. On physical exam there is blood in the meatus.

pelvic fracture plus blood in the meatus means either bladder or urethral injury. Evaluation starts with a retrograde urethrogram because urethral injury would be compounded by insertion of a Foley catheter.

cardiac tamponade patho + sx

penetrating/blunt trauma --> fluid accumulation in the pericardium results in impaired venous return to right atrium sx = becks triad - hypotension, muffled heart sounds,JVD

what is the indication for air under the diaphragm

perforated viscus IMMEDIATE EX-LAP

when to do abdominal exploratory procedure with SBO

peritoneal signs, leukocytosis, fever, failure to resolve

sliding inguinal hernia

peritoneum slides with the hernia as it passes through inguinal canal. The viscera becomes part of the the hernia sac.

ePTFE sutures adv/disadv

permenant poroous monofilmanet- can harbor bacteria, slippery, requires multiple throws, soft, inconspicious knots

sequence of diagnosis for lower GI bleed

proctoscopy, mesenteric angiography (technetium sulfur colloid scan), colonoscopy

management for barrett's esophagus patients with severe dysplasia

prophylactic esophagectomy if patient just has barrett's can simply observe

misoprostol (prostaglandin E) use and side effects

prophylaxis against NSAID ulcers, SE = diarrhea

shoulder hand syndrome

reflex autonomic dystrophy 2/2 shoulder injury causes immobilization of ipsilateral extremity tx = corticosteroids, NSAIDs, stellate ganglion block

highly selective (PARIETAL CELL) vagotomy

removes innervation to the parietal cell mass (nerve of GRASSI), but preserves ANT/POS NERVES OF LATARJET SUPPLYING THE PYLORUS --> **NO DRAINAGE PROCEDURE NECESSARY**

A 70 year old man is referred for evaluation because of a triad hematuria, flank pain and a flank mass. He also has hypercalcemia, erythrocytosis and elevated liver enzymes.

renal cell carcinoma. IVP first, then CT scan.

what should recent onset varicocele lead to investigation for

renal tumor due to obstruction of venous outflow to the left renal vein

treatment for patient with gross fecal contamination of the abdomen 2/2 to GSW abdomen

resection of necrotic bowel proximal end ileostomy distal mucous fistula

A man is rescued by firemen from a burning building. On admission it is noted that he has burns around the mouth and nose, and the inside of his mouth and throat look like the inside of a chimney.

respiratory burns, i.e.: smoke inhalation producing a chemical burn of the tracheobronchial tree. --> Diagnosis is made with bronchoscopy. Management revolves around respiratory support. - thermal injury --> swelling/obstruction of the supraglottic airway **should have low threshold for intubation

what are the side effects of epidural narcotics

respiratory depression, generalized itching, reduced GI activity tx = naloxone

fat embolism clinical presentation

respiratory distress, altered mental status, petechial hemorrhage

A patient consults you because he "can not sleep". On questioning it turns out that he has pain in the right calf, which keeps him from falling asleep. He relates that the pain goes away if he sits by the side of the bed and dangles the leg. His wife adds that she has watched him do that, and she has noticed that the leg which was very pale when he was lying down becomes deep purple several minutes after he is sitting up. On physical exam the skin of that leg is shiny, there is no hair and there are no palpable peripheral pulses.

rest pain. Definitively he needs the studies to see if vascular surgery could help him. ABIs, arteriogram, bypass.

indirect inguinal hernia repair

return hernia to peritoneal cavity, divide/ligate base of hernia sac at level of peritoneal cavity, sac is always anteromedial to the cord tightening the internal ring/repair of abdominal wall defect

what causes perioperative MI

return of third spaced fluid to the systemic circuit, increasing preload/CO and increasing caridac demand

management heparin hematoma in a patient who has previously had a pulmonary embolis

reverse with protamine place IVC filter (because this patient has already had an embolis and can have another)

how many bronchopulmonary segments on the left vs right

right has 10, left has 8

what is inside the inguinal canal in women vs men

round ligament = women spermatic cord = men

management of patient with fibrocystic mastopathy

routine screening with mammography or MRI, and ultrasound (if mammography negative)

A 68 year old man is brought to the ER with excruciating back pain that began suddenly 45 minutes ago. He is diaphoretic and has a systolic blood pressure of 90. There is an 8 cm., pulsatile mass palpable deep in his abdomen, between the xiphoid and the umbilicus.

ruptured AAA. emergency surg.

A 69 year old man who smokes and drinks and has rotten teeth has unilateral ear ache that has not gone away in 6 weeks. Physical examination shows serious otitis media on that side, but not on the other.

squamous cell cancer. do triple endoscopy to find and biopsy the primary tumor and to look for synchronous second primaries.

central venous catheter use + complication

thin tube into internal jugular or subclavian vein into SVC- used to administer fluids, TPN, pressors comp = INFECTION

boundaries of the mediastinum

thoracic inlet, diaphragm, vertebral column, sternum three compartments - anterior superior, middle (pericardial sac), posterior superior

treatment of recurrent or persistent pneumothorax

thoracoscopy, resection of bullae, pleurodesis

treatment for malignant pleural effusions

thoracoscopy/removal of fluid, pleurodesis (mechanical or talc)

what patients get prolapse of mucosa over the vocal cords + tx

those who routinely elevate pressure in the chest (singers etc) tx = laryngoscopy and excision of the overlying mucosa

treatment for iliofemoral thrombosis

thrombolytic infusion

when to operate in SBO

total obstruction, acidosis (2/2 strangulation/ischemia)

treatment for gastric aspiration

tracheal suctioning, oxygen and positive pressure ventialtion

post BKA stump prognosis modalities

transcutaneous oxygen monitoring ** Doppler does NOT work at the level of the transection*

todds phenomenon

transient focal weakness or paralysis that results after a seizure

1. surgical treatment for BPH 2. medical treatment for BPH + SE

transurethral prostatectomy, transurethral incision, open prostatectomy, enucleation, laser ablation, microwave therapy, intraprostatic stents 2. alpha 1 blockers (prazosin, tamsulosin) reduce outlet resistance (orthostasis, asthenia) ,5 alpha reductase inhibitors (finasteride reduce PSA by 50%) reduce prostatic size

what vascular complication associated with femoral artery access for cardiac catheterization + tx

traumatic AV fistula Tx = angiography followed by surgical repair of the aneurysm

weak voice after blunt chest trauma/decel

traumatic rupture of the aorta with compression of the recurrent laryngeal nerve

how to test if a patient will respond to splenectomy

treat them with steroids, if their platelet count rises they will likely respond

pringle maneuver

treatment of liver laceration-- occlusion of porta hepatis

1. cholecystitis treatment in the critically ill patient

tube cholecystectomy under LOCAL ANESTHESIA --- general anesthesia carries too high of a risk

A 32 year old man complains of progressive, severe generalized headaches, that began three months ago, are worse in the mornings and lately have been accompanied by projectile vomiting. He has lost his upper gaze and he exhibits the physical finding known as "sunset eyes".

tumor in pineal gland (Parinaud's syndrome.) What do you do?: MRI to start. The neurosurgeons will take care of the rest.

A 42 year old right handed man has a history of progressive speech difficulties and right hemiparesis for five months. He has had progressively severe headaches for the last two months. At the time of admission he is confused, vomiting, has blurred vision, papilledema and diplopia. Shortly thereafter his blood pressure goes up to 190 over 110, and he develops bradychardia.

tumor with localizing signs (left hemisphere, parietal and temporal area) and he manifests the Cushing's reflux of extremely high intracraneal pressure. MRI to dx, then mannitol, hyperventilation, and high dose steroids (decadron) while waiting for surgery. emergent.

inguinal hernia in infants implications

usually congenital and BILATERAL,should explore bilateral inguinal canals during incarceration repair

surgical treatment of ulcers

vagotomy with antrectomy, vagotomy with drainage (includes pyloroplasty, gastrojejunostomy) parietal cell vagotomy (only gastric branches of the vagus are divided, maintains innervation to the pyloris )

treatment of bleeding duodenal ulcer in an elderly patient

vagotomy with pyloroplasty

structures in the spermatic cord

vas deferens processus vaginalis testicular/cremesteric artery pampiniform plexus ilioinguinal and genitofemoral nerves external to cremesteric fascia

what is the risk of circumferential burns + tx

vascular compromise and compartment syndrome (or respiratory compromise) monitor blood flow with doppler ultrasound tx = escharotomy

what kind of repair is used for a patient with large venous laceration ex. IVC or renal vein

vascular repair (compare to interposition graft of the carotids)

spinal anesthesia systemic effects

venous vasodilation/respiratory changes due to ***sympathetic blockade****, can lead to respiratory distress due to dec. CO

A 44 year old man shows up in the E.R. at 11 PM with exquisite perianal pain. He can not sit down, reports that bowel movements are very painful, and has been having chills and fever. Physical examination shows a hot, tender, red, fluctuant mass between the anus and the ischial tuberosity.

very common problem: ischiorectal abscess. Management: The treatment for all abscesses is drainage. This one is no exception. But as always, cancer has to be ruled out. Thus the best option would be an answer that would offer examination under anesthesia and incision and drainage.

A 57 year old man seeks help for "dizziness". On further questioning he explains that he gets light headed and work-up in that direction.

vestibular apparatus problem. either symptomatic treatment (meclizine, phenergan, diazepam), or an ENT workup.

A 57 year old man seeks help for "dizziness". On further questioning, he explains that the room spins around him.

vestibular apparatus problem. either symptomatic treatment (meclizine, phenergan, diazepam), or an ENT workup.

A 72 year old man has 4 cm. hard mass in the left supraclavicular area. The mass is movable, non tender and has been present for three months. The patient has had a 20 pound weight loss in the past two months, but is otherwise asymptomatic.

virchow's node. look for thoracic/abdominal cancers.

1. physical diagnosis of inguinal hernia 2. ddx

vissible mass, ask patietn to stand and lie supine to look for changes in the mass, tender mass to palpation, direct = forward bulge in canal indirect - touches the tip of examining finger +/- reducible with gentle pressure 2. hydrocele, varix, inflamed lymph node, lipoma of spermatic cord, undesceded testicle, abscess or tumor

factors that promote wound healing 1. vitamin A 2. hyperbaric oxygen

vitamin A - promotes inflammation/collagen formation in the wound Hyperbaric oxygen

what patients have enhanced warfarin effects

vitamin K deficiency impaired liver function thyrotoxicosis clofibrate, D-thyroxine

aldosterone deficiency clinical findings

volume depletion, hyponatremia, hyperkalemia, azotemia, acidosis

acute gastric dilation during anesthesia potential consequences

vomiting, aspiration, hypoxia, bleeding, stress gastritis.

A 22-year-old gang member arrives in the E.R. with a single gun shot wound to the precordial area. He is diaphoretic, cold, shivering, anxious, asking for a blanket and a drink of water. His blood pressure is 60 over 40. His pule rate is 150, barely perceptible. He has big distended veins in his neck and forehead. He is breathing OK, has bilateral breath sounds and no tracheal deviation.

when the location of the wound strongly suggests pericardial tamponade, emergency thoracotomy might be done right away without prior pericardial window.

when is sentinel node biopsy contraindicated

when there is palpable axillary lymph nodes in patients with breast cancer

treatment of intracerebral hematoma

wide craniotomy and evacuation of the hematoma/debridement of necrotic tissue

mainstay of treatment for gas gangrene

wide debridement until stable

radiographic findings for traumatic aortic rupture

widened mediastinum/left sided hemothorax in contained aortic ruptures

cushing's triad of increased icp

widened pulse pressure, bradycardia, hypertension

hepatojugular reflex in CHF patients

will cause a rise in CVP >1 mmHg

sodium chloride effect on acid base + which acid base situation is isotonic saline most useful

worsens a metabolic acidosis, it is most useful for met. alk such as NG suction or vomiting because it will decrease the pH

complications that occur around second week post-op abdominal surgery

wound dehiscence, intestinal anastomotic breakdown, intraperitoneal abscess

A 24 year old lady develops moderate, generalized abdominal pain of sudden onset, and shortly thereafter faints. At the time of evaluation in the ER he is pale, tachycardic, and hypotensive. The abdomen is mildly distended and tender, and she has a hemogoblin of 7. There is no history of trauma. On inquiring as to whether she might be pregnant, she denies the possibility because she has been on birth control pills since she was 14, and has never misses taking them.

Bleeding from a ruptured hepatic adenoma, secondary to birth control pills. Management: It's pretty clear that she is bleeding into the belly, but a CAT scan will confirm it and probably show the liver adenoma as well. Surgery will follow.

A 10 year old girl has epistaxis. Her mother says that she picks her nose all the time.

Bleeding from the anterior part of the septum. (IN ELDERLY ITS THE POSTERIOR SEPTUM) Management: Phenylephrine spray and local pressure.

A 24 year old man spends the night cruising bars and drinking heavily. In the wee hours of the morning he is quite drunk and starts vomiting repeatedly. Eventually he has a particularly violent episode of vomiting and he feels a very severe, wrenching epigastric and low sternal pain of sudden onset. On arrival at the E.R. one hour later he still has the pain, he is diaphoretic, has fever and leukocytosis and looks quite ill.

Boerhave's syndrome. How do you confirm the diagnosis? - Gastrographin swallow Treatment: Emergency surgical repair. Prognosis depends on time elapsed between perforation and treatment.

A 23 year old man develops severe headache, seizures and projectile vomiting over a period of two weeks. He has low grade fever, and was recently treated for acute otitis media and mastoiditis.

Brain abscess. Signs and symptoms suggestive of brain tumor that develop in a couple of weeks with fever and an obvious source on infection, spell out abscess. Management: CT to see it. Then the abscess has to be resected by the neurosurgeons.

A 42 year old man has been fired from his job because of inappropriate behavior. For the past two months he has gradually developed very severe, "explosive" headaches that are located on the right side, above the eye. Neurologic exam shows optic nerve atrophy on the right, papilledema on the left and anosmia.

Brain tumor in the right frontal lobe. A little knowledge of neuroanatomy can help localize tumors. The frontal lobe has to do with behavior and social graces, and is near the optic nerve and the olphactory nerve. If you want the fancy name, this is the Foster-Kennedy syndrome. MRI and surg.

A 31 year old nursing student developed persistent headaches that began approximately 4 months ago, have been gradually increasing in intensity and are worse in the mornings. For the past three weeks, she has been having projectile vomiting. Thinking that she may need new glasses, she seeks help from her optometrist, who discovers that she has bilateral papilledema.

Brain tumor. signs of inc ICP over months imply tumor. Morning headaches are typical. If the tumor is in a "silent" area of the brain, there may be no other neurological deficits. Management: MRI. If not offered, settle for CT scan. Measures to decrease intracraneal pressure while awaiting surgery include mannitol, hyperventilation, and high dose steroids (decadron).

postvagotomy diarrhea

common, usually mild, improves 1 year after surgery

what type of skull fractures require exploration

compound skull fractures - fracture site communicates with the exterior

cecal diverticula

congenital "true diverticulum" usually single, presents similar to acute pancreatitis

management of non-bleeding varicies

conservative management with beta blockers

A frantic mother reaches you on the phone, reporting that her 10 year old boy accidentally splashed Drano on his face and is screaming in pain complaining that his right eye hurts terribly.

copious irrigation. pry the eye open under the cold water tap at home, and irrigate for about 1/2 hour before she brings the kid to the hospital. You will do more irrigation at the ER, remove solid matter, and eventually re-check pH before discharge.

treatment of unresectable brain cancer

corticosteroids reduce swelling fractionated radiation to the entire brain

treatment for zenkers diverticulum

cricopharyngeal myomectomy

airway management for patient with massive midface injury

cricothyroidotomy

indications for massive bowel resection

crohns, volvulus, trauma, ischemia

most common cause of death in tetralogy of fallot

cyanosis --> polycythemia --> CEREBROVASCULAR EVENTS***

most common cause of bronchiectasis in young adults

cystic fibrosis

most common causes of lower GI bleeding in children

juvenile polyp (#1), meckels diverticulum (#2)

pseudotumor cerebri

elevated ICP causes headache, damage to optic nerve, peripheral vision loss, and blindness

1. assessment of breathing after intubation

1. auscultate for bilateral breath sounds, and pulse oximetry

warthin's tumor

2nd most common tumor of the parotid gland papillary cystadenoma lymphomatosum, epithelial/lymphoid tissue with germinal centers that occurs in the parotid gland

best treatment for impacted cerumen

3% hydrogen peroxide or other detergent, NOT WATER BECAUSE IT WILL INCREASE INFLAMMATION

aortic stenosis 3. auscultation/pulses 4. EKG 5. surgical tx -CXR may show calcification, -Echo used to determine degree insufficiency/LVH function -cardiac cath to determine co-existing CAD

3. CRESCENDO DECRESCENDO @ right 2nd ICS radiates to the carotids NARROWED pulse pressure w/ pulsus parvus et tardus 4. LVH 5. excision and replacement with prosthetic valve if valve gradient is >50mmHg

aortic insufficiency 3. auscultation/pulses 4. CXR 5. surgical tx - also do echo to determine LV performance - also do cardiac cath to detect CAD

3. LSB diastolic murmur that radiates to the axilla short intense peripheral pulses (water hammer pulses) 4. LVH 5. aortic valve replacement (EF <50%, dilation >75mm)

treatment of abdominal compartment syndrome

laparotomy to relieve the pressure inside the abdomen

drainage of the testicles

para aortic and intra aortic lymph noes

1. what type of cancer is common in male breast cancer

1. ductal cancer

1. median nerve fuction

1. flexors of the hand, sensory to the hand, thenar muscles, pronator muscles of forearm

primary osteoarthitirs 1. clinical finding

1. heberden's nodes, asymmetric hip/knee

SE of tamoxifen

1. inc. risk for endometrial cancer, vaginal bleeding, hot flashes, thromboembolic events,

indications for amputation

1. intractable rest pain, sepsis

1. symptoms of vertebrobasilar TIA or stroke

1. loss of vision, diplopia, ataxia, gait disturbance

1. clubfoot tx

1. manipulation and casting, but if persistent >1 year must undergo surgery

1. treatment of post head trauma seizure

1. phenytoin

1. how much protein required for ill patient

1. up to 2x normal (1 --> 2 g/kg/day)

what is the best diagnostic test for pancreatic ductal injury

ERCP

Cardiac index

CO/BSA

sirolimus 1. mechanism 2. SE

1. same as tacrolimus FK506 calcineurin inhibitor 2. thrombocytopenia/hyperlipidemia, synergistic with cyclosporine

toxic thyroid adenoma 1. clincal presentation

1. single noduel produces excess T4 2. radioiodine scan shows hot nodule, tx = lobectomy

what is the result of excessive suction on a tissue

can cause necrosis

treatment of frost bite

immersion in 40C water, abx, debridment, tetanus vaccine

gastrostomy tubes

inserted between stomach and skin used for feeding or gastric decompression

what hormones are increased in response to injury

insulin (Acute), than ADH, aldosterone, glucagon

what does parietal cell vagotomy spare

nerves of lateget that innervate the pyloris

direct inguinal hernia repair

reinforcing the inguinal canal floor

free water deficit calculation

(0.6*body weight) * (current Na/140 - 1) - 1/2 of the deficit should be replaced in the first 8 hours - 2/2 of the deficit should be replaced in the next 16 hours

ideal calorie:protein ratio

1. 150:1

1. treatment of hep B post transplant

1. lamivudine

1. what structures are usually damaged during splenectomy

1. gastric wall and tail of the pancreas

1. hiradenitis suppurativa

1. infection of apocrine sweat gland in axilla or groin, appears to look like a tumor,

1. does pheos in the mediastinum have endocrine activity``

1. nope not usually

proliferative myositis 1. patho 2. tx

1. post traumatic 2. excision

what kind of hernia more common in the elderly

direct inguinal hernia

complications of of juvenille polyps

intussuception, GI bleeding

rectal tubes

relives colonic ileus, used to treat sigmoid volvulus.

what is the earliest sign of hypovolemia

tachycardia

1. when in brain injury is CPP monitoring indicated

1. GCS less than 8, or if posturing is decerebrate or decorticate, hypotension or hypoxia, CT evidence of cerebral swellign

revised trauma score components 2. Injury severity score

1. GCS, systolic BP, RR range is 1-8, >40 = 60% survival 2. sum of the squares of 3 highest AIS scores

oligodendrogliomas 1. clinical pres

1. SEIZURES, focal neuro deficits, 2. CALCIFIED AREAS within mass on CT/MRI tx = surgery , radiation

1. fluid resuscitation by BSA burned 2. required urine output in adults 3. when should burn patient get NG tube

1. % BSA burned * kg * 2-4ml electrolyte- give half the volume over first 8 hours and remaining over second 16 hours 2. 30-50ml/hour--- adjust fluids accordingly 3. burns >25%, BSA or if patient has N/V

TNM staging 1. T 2. N 3. M 4. stage 0 5. stage 1 6. stage 2 7. stage 3 8.stage 4

1. 0 = no tumor, IS= limited to mucosa, 1= limited to mucosa, 2-limited to serosa, 3=through serosa but not adjacent organs, 4= into adjacent organs 2. 0= no mets/nodes, 1= perigastric within 3cm of primary , 2=only regional >3cm from tumor 3= other intraabdominal nodes 3. 0=no mets, 1-distant mets 4. Tis, N0, M0 5. T1, N0, M0 6. T2/T3, N0, M0 7. T1-T3, N1 or N2, M0 8. T4, T3, N3, M1

choledochal cysts 1. type 1-4 2. dx/tx 3. complicatiosn

1. 1 = fusiform dilation of common bile duct 2 = diverticulum of CBD 3. = choledochochocele of intraduodenal CBD 4= carolis disease ~ cystic involvement of intrahepatic ducts --> intermittent jaundice*** triad of pain/jaundice/abdominal mass in only 30% 2. ultrasound, ERCP, radionuclide scanning tx = cyst excision, 3. cholangiocarcinoma

ion maintenance 1. sodium 2. potassium

1. 1-2 mEq/kg/day 2. 0.5-1 mEq/kg/day

tx duration for 1. uncomplicated cystitis 2. complicated UTI 3. acute prostatitis 4. pyelonephritis

1. 1-3 days 2. 7-14 days 3. 14-28 days 4. 14-21 days

post operative fever 1. pulmonary 2. UTI 3. wound 4. venous 5. drugs - postpericardiotomy, bowel leakage, parotitis, sinusitis, cholecystitis, pancreatitis, pseudomembranous colitis

1. 1-3 days post op- atelectasis, pneumonia, pulmonary problems (narcotic cough, incision pain, abdominal distention) - tx = removal of secretions with nasotracheal suction/bronchoscopy 2. 3-5 days postop due to bladder cath 3. 5-8 days - (strep/claustridium present earlier) 4. DVT (phlebitis), PE, IV cath infections (peripheral IV, suppurative thrombophlebitis), central catheters, subclavian or internal jugular vein catheters 5. any drug especially empiric abx

expected compensation 1. resp acid 2. resp alk 3. met acid 4. met alk

1. 1-4 mEq/L for each 10mm Hg rise in PCO2 2. 2-5 mEq/L for each 10mmHg PCO2 drop 3. PCO2 expect = 1.5(HCO3-) + 8 4. PCO2 expect = 0.7 * (HCO3-) + 20

neurogenic bladder 1. detrusor sphincter dyssynergia pathogenesis 2. tx

1. 1. contraction of the external sphincter during bladder contraction causing functional outlet obstruction 2. catheterization, anticholinergics/intermittent catheterization

1. what TPN substrate is best to increase calories with peripheral IV access

1. 10% soybean or safflower oil (>10% requires central administration due to phlebitis)

mEq Na in 1. normal saline 2. 1/2 normal saline 3. 3% saline - ringers lactate - - plasmalyte -

1. 154 2. 77 3. 513

TPN 1. baseline protein requirements: normal, stress/surgery, polytrauma 2. non-protein cal/g of nitrogen 3. glucose infusion rate

1. 1g/kg/d, 1.5 g/kg/d, 2g/kg/d 2. 100kcal/g nitrogen, 150 if starving 3. 4-5mg/kg/min, any excess increases the production of CO2 due to high RQ

biliary disease diagnostic modalities 1. ultrasound 2. oral cholecystography 3. cholecystokinin stimulation

1. 1st line: 95% accurate to dx calculi, biliary ductal ligation, gallbladder wall thickening 2. oral iopanoic acid tablets --- can identify stones, rarely used today 3. normal OCG --> CCK stim helps to identify gallbladder disease (<40% contraction @ 20mins) + reproducibility of pain

bacterial hepatic abscess 1. pathogenesis 2. clinical presentation 3. txd

1. 2' to infection in abdomen - cholangitis, appendicitis, diverticulitis --> ecoli, bacteroides, enterococcus 2. elevated LFT (alk phos), leukocytosis, fever/chills, RUQ pain, liver tenderness, sepsis, hemobilia 3. percutaneous CTor US guided drainage or surgical drainage/abx

dumping syndrome 1. early 2. late 3. tx

1. 20-30 minutes after eating more common with billroth 2, hypertonic fluid bolus causes fluid shift into intestines 2. 2-3 hours after meal, large carbohydrate causes hyperinsulinemia/hypoglycemia, which leads to catecholamine release from adrenals--> tachycardia, diarrhea, tremulousness + osmotic pressure of massive influx of food 3. dietary modification, octreotide reconstructive surgery

1. fecal occult blood detection 2. false positives on fecal occult blood 3. false negatives

1. 20mL/day of blood, hemoglobin turns peroxide developer blue 2. red meat, turnips, radishes, tomatoes, aspirin, NSAIDs, irron, 3. vitamin C

congenital adrenal hyperplasia 1. pathogenesis 2. clinical pres 3. tx

1. 21 alpha hydroxylase deficiency --> inc. ACTH --> inc androgens 2. virilization, salt wasting pseudohermaphroditism/macrogenitosomia precox 3. steroid replacement`

liver 1. arterial supply 2. variations in blood supply to the liver 3. venous return

1. 25% celiac trunk --> common hepatic artery --> porta hepatis + gastroduodenal --> hepatic artery --> left/right hepatic arteries --> cystic artery (off right hepatic) 2. 20% of population left hepatic off the left gastric 20% the right hepatic off SMA 3. portal vein 75% of blood flow to liver

1. how to calculate how many calories per day for TPN

1. 25-35 kcal/kg/day or use harris benedict equation

1. hormone sensitivity of breast cancer in pregnant women 2. tx of breast cancer in pregnant women

1. ER -, PR- (similar to post-menopausal women) 2. general anesthesia and modified radical masectomy, chemotherapy in 2nd or 3rd trimester

1. radiation treatment of breast cancer 2. chemotherapy treatment candidates 3. SE of chemotherapy 4. neoadjuvant therapy indications 5. hormonal therapies

1. 4500 rad for whole breast + 2000 extra for tumor site 2. node positive, tumor >1 cm, ER/PR negative 3. cyclophosphamide, MTX, 5FU, adriamycin (CMF/CAF/AC/AC + taxol) 4. myelosuppression, alopecia, cardiomyopathy (adriamycin) 5. for large fixed tumors, fixed nodal disease 6. tamoxifen, raloxifene, anastrozole, (for 5 years) +/- tamoxiefen

1. how long does it take for sutured wounds to heal 2. open wounds with necrotic debris dressing 3. clean open wound dressing 4. large open dermal wounds

1. 48 hours for epithelium to migrate 2. wet to dry dressing- thin piece of gauze moistened onto wound, drys and then takes necrotic debris with it 3. wet to wet dressing, gauze is not allowed to dry enhancing wound healing 4. non-adhering petroleum impregnated gauze allows for scab to form under gauze

transfusion 1. when to transfuse

1. 7mg/dL, trauma, class 3 hemorrhagic shock (>1500cc+signs of hypotension), ICU patients if needed, general patients when symptomatic (tachycardia/tachypnea/acidosis)

patient pre-op coronary risk stratification + pre-op assessment 1.low risk 2. intermediate risk 3. high risk

1. <70 years of age, no angina, CHF, MI, diabetes, ventricular ectopy 2. 1-2 risk factors in low risk catagory or sedentary- should do non-invasive assessment ~ proceed with surgery if no ischemia present 3. 3 or more risk factors in low risk category or have stable/unstable angina, or recent MI ~ cardiac cath to define coronary anatomy +/- revascularization, invasive intraoperative cardiac monitoring, parenteral antianginal

1. GCS definition of coma 2. hyper/iso/hypodense hematomas

1. <8 2. hemoglobin >8, 8, <8

intubation - orotracheal, nasotracheal, tracheostomy 1. respiratory rate to intubate 2. respiratory effort to intubate 3. tidal volume "" 4. hypoxia ""

1. >40 RPM, watch 20-30 closely 2. increased respiratory effort 3. <5 liters (look for hypercapnea) 4. <92% should be considered for supp o2 or intubation

pupil changes with brain lesions 1. cortical lesions 2. basal ganglia 3. midbrain 4. pons

1. >6mm, and wandering/roving eye movements 2. 2-3mm, deviated downward/inward 3. 4-5mm, convergent nystagmous, or nystagmus retractorius 4. 1mm pinpoint pupils, ocular bobbing 5. 2mm, downbeat nystagmus

perioperative patients with lung disease 1. what labs to order to evaluate lung disease' 2. what patients need lab evaluation for lung diseases 3. COPD pre-operative preparation 4. asthma pre-operative preparation

1. ABG, CBC (look for secondary polycythemia), PFTs ( 2. cough/dyspnea, >20 pack year smoking, abnormal chest radiograph, morbid obesity 3. antibiotics, B2 agonists, mucolytics (acetylcystine), bronchodilators, steroids 4. B2 agonists, d-tubocurare (has anti-muscarinic activity), propofol (relaxes airway)

cushings disease 1. pituitary cushings disease 2. ectopic cushing syndrome 3. ACTH independent cushings syndrome

1. ACTH overproduction in the pituitary due to adenomas or pituitary corticotroph hyperplasia (hypersecretion of CRH) 2. ACTH is produced by extra adrenal, extrapituitary neoplasm -- common in small cell lung cancer, bronchial carcinoids, thymomas, liver, and pancreas cancer 3. excess of cortisol produce dby adrenal cortex - adenoma, carcinoma,

skin healing 1. factors released by platelets 2. "" macrophages 3. factors that stimulate fibroblast prolif 4. factors that stimulate collagen synthesis

1. ADP, TXA2, TGF, PDGF (~within one hour) 2. 2-3 days, IL-1, FGF, TNF, PDGF 3. TNF, IL-1, FGF, TFGF, EGF, PAI 4. IL1, TNF, TGF

1. kaposi sarcoma + tx 2. lymphangiosarcoma

1. AIDS related, malignant lesion of vascular origin, bluish - red macule that forms multiple nodules + tx = excision, radiotherapy 2. patients with postmastectomy edema-->red/blue/purple nodules with satellite lesions very poor prognosis

chronic pancreatitis 1. pathogenesis/pathology 2. clinical presentation 3. dx

1. ALCOHOL/congenital --> early plugging/ eosinophilia -> fibrosis/calcification thought the gland --> ductal dilatation (chain of lakes)--> CBD obstruction 2, unrelenting pain, impaired glucose tolerance/diabetes, malabsorbtion/steatorrhea, upper GI bleeding (from splenic vein thrombosis) 3. calcifications of the ductal system, splenic vein

1. effect of inhalational anesthetics on myocardial function + compensation 2. halothane hypotension mechanism

1. ALL ARE MYOCARDIAL DEPRESSANTS - countered by reflex sympathetic vasoconstriction 2. peripheral vasodilator and myocardial depression * exaggerated in a patient taking a vasodilator

Gorlin syndrome 1. patho 2. clinical pres

1. AUTOSOMAL DOMINANT 2. multiple basal cell carcinomas, skin ribbing on palms/soles, epithelial jaw line cysts, rib abnormalities, dural calcifications, MALIGNANCY OF BASAL CELL CARCINOMA AFTER PUBERTY****

HNPCC 1. patho/clinical features 2. screening

1. AUTOSOMAL DOMINANT - DNA mismatch repair gene mutation-->microsatellite instability proximal colon cancers,inc. risk of poorly differentiated carcinomas 2. yearly colonoscopy starting at age 20

cowdens syndromes 1. patho/clinical features 2. tx

1. AUTOSOMAL DOMINANT - hamartomas of GI tract, mucocutaneous abnormalities (oral papules, keratotic growths), breast, thyroid, uterine cancer 2. not usually required

peutz jeghers 1. patho/clinical features 2. complictions 3. tx

1. AUTOSOMAL DOMINANT - hyper pigmented spots on the lips, buccal mucosa, and digits, HAMARTOMAS of the GI tract (NOT USUALLY MALIGNANT) 2. GI bleeding, intussusception, malignancy 3. symptomatic polyp removal

von recklinghausen (NF1) 1. patho 2. clinical pres

1. AUTOSOMAL DOMINANT 17q11.2 NGF mutation (neurofibromin) --> centripetal neurofibromas 2. cafe au lait, vitiligo, optic gliomas, axillary freckling lisch nodules, meningitis, spina bifida, syndactyly,

central neurofibromatosis (NF2) 1. patho 2. clinical pres

1. AUTOSOMAL DOMINANT 22q11 schwannomin 2. BILATERAL ACOUSTIC NEUROMAS, NEUROFIBROMAS, cafe au laits, gliomas, juvenille lenticular opacity,

arytenoid dislocation 1. patho + clincal presentation 2. tx

1. ET intubation or external trauma + SOFT BREATHY VOICE AFTER INTUBATION 2. prompt reduction

familial adenomatous polyposis 1. patho/clinical features + extraintestinal 2. complications 3. screening 4. tx (surg+ pharm)

1. AUTOSOMAL DOMINANT APC gene chromo 5, 1/3 spontaneous----- 100s of polyps by puberty/young adult, cancer by mid 30s extraintestinal = epidermoid cysts, osteomas, cutaneous fibromas, desmoid tumors of abdomen, GI polys, retinal pigmentation, periampullary carcinoma, thyroid carcinoma 2. bleeding, intussusception 3. APC gene, yearly endoscopy if cannot undergo genetic screening. 4. total proctocolectomy w or w/o continent ileostomy, colectomy with ileorectal anastomosis, total protocolectomy with ileal pouch anal anastomosis (f/u with proctoscopy q 6mo) + celecoxib

diffuse juvenile polyposis 1. patho/clinical features 2. complictions 3. tx

1. AUTOSOMAL DOMINANT- hamartomas and adenomas 2. intussusception, diarrhea, protein loss, 10% risk of cancer 3. subtotal colectomy/ileorectal anastomosis, if diffuse do a total-proctocolectomy 3.

cystinuria 1. patho 2. prevention of stone formation 3. tx

1. AUTOSOMAL RECESSIVE - defect in reabsorption of cystine , ornithine, arginine, lysine 2. hydration, and alkalinization of urine, D-penicillamine, alpha mercaptopropionylglycine 3. percutaneous procedures, extracorporeal shock wave lithotripsy, dissolution therapy (n-acetylcysteine), bicarbonate

ranson's criteria 1. at admission 2. at 48 hours

1. Age in years > 55 years White blood cell count > 16000 cells/mm3 Blood glucose > 10 mmol/L (> 200 mg/dL) Serum AST > 250 IU/L Serum LDH > 350 IU/L 2. Serum calcium < 2.0 mmol/L (< 8.0 mg/dL) Hematocrit fall > 10% Oxygen (hypoxemia PO2 < 60 mmHg) BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration Base deficit (negative base excess) > 4 mEq/L Sequestration of fluids > 6 L

1. tumor markers for testicular cancer 2. "" prostate cancer 3. "" ovarian cancer 4. p53 oncogenes assc with which tumors

1. B-HCG, AFP, LDH 2. PSA 3. CA125 4. assc with osteogenic sarcomas/colon cancers

bladder cancer 1. treatment for CIS 2. tx for muscle invasive localized disease 3. tx for metastatic disease

1. BCG 2. radiation therapy, radical cystectomy/prostatectomy (+pelvic lymphadenectomy with prostatectomy, urethrectomy), anterior pelvic exenteration for women conduits, continent diversion, neobladder formation 3. MTX, vinblastine, adriamycin, cisplatin

surgical tx. for PVD - primary patency, assisted primary patency, secondary patency

1. BYPASS - inflow and outflow vessel bypass using a greater saphenous/lesser saphenous veins or prosthetic conduits

GIST (10-30% malignant) 1. patho 2. dx 3. tx - other benign tumors are lipomas, hemangiomas, fibromas, neurofibromas

1. CD117+ interstitial cells of cajal in the ileum 2. CD117+, size >10cm, >10 mitotic figures/high powered field, *** GASTRIC MUCOSA MAY BE INTACT ON UGI ENDOSCOPY**** DOUGHNUT SIGN ON BARIUM STUDY AS GROWS FROM SUBMUCOSA TO LUMEN necrosis, mets 3. wide surgical resection, IMATINIB MESYLATE (c-kit tyrosine kinase inhibitor)

post transplant infection 1. infectious diseases 2. CMV organ system effects

1. CMV, EBV, HSV, VZV 2. pneumonitis, ulceration/hemorrhage of the stomach, duodenum, colon, hepatitis, esophagitis, retinitis, encephalitis, pancreatitis

1. most common tumor of young people 2. locations of brain tumors in children 3. common pediatric brain tumors 4. common adult brain tumor (~age 60)

1. CNS tumors 2. posterior fossa 50%, supratentorial 50% 3./ medulloblastroma, cerebellar astrocytoma, craniopharyngioma, brain stem glioma, 4. metastatic carcinoma, malignatn glioma, meningioma, pituitary adenoma

spontaneous pneumothorax 1. patho 2. dx/tx 3. surgery indication/tx

1. COPD/young age, thin body --> subpleural bleb ruptures into pleural space 2. physical examination/CXR tx = chest tube drainage 3. recurrent pneumo, persistent air leaks (>7-10 days), incomplete expansion, hemopneumothorax* tx = stapling apical pleural blebs/abrasions(via videothoracoscopy)

1. what important imaging study before rectal cancer surgery 2. what treatment is often done before surgery for rectal cancer

1. CT of the upper abdomen to search for liver mets 2. radiation and or neoadjuvant chemotherapy

1. localization of pituitary cushing's 2. localization of ectopic cushings 3. localization of adrenal cushing

1. CT, MRI, polytomography of sella 2. chest film, CT, MRI 3. CT/MRI, NP59 radioisotope scanning, retrograde adrenal venography, venacavography

pheochromocytoma 1. localization 2. tx

1. CT/MRI, arteriography after alpha blockade, scintigraphy with radiolabeled m-iodobenzylguanidine (similar to NE) 2. phenoxybenzamine, propranolol 2 weeks before surgery bilateral adrenalectomy if patient has MEN

lung cancer 1. dx 2. surgical tx 3. CI to thoracotomy 4. adjuvant

1. CXR (nodule, infiltrate, atelectasis) CT scan PET scan - find mets/nodes/primary tumor mediastinoscopy percutaneous needle biopsy 2. pulmonary resection (wedgectomy, or lobectomy) 3.N2/N3, malig effusion, SVC syndrome, laryngeal nerve extension, phrenic nerve paralysis, poor pulmonary function 4. chemo/radio, and pre-op chemotherapy

1. neck mass diagnostic evaluation

1. CXR, barium swallow, CT of neck, panendoscopy, biopsies

vWF disease 1. tx

1. DDAVP prior to surgery, FFP in emergencies

hidradenitis suppurativa 1. patho 2. sx

1. DOES NOT INVOLVE CRYPTOGLANDULAR ANAL CANAL - apocrine gland infection, forms subQ sinus tracts that can spread to perineum, scrotum, labia 2. multiple complicated fistulas around anal canal 3. excision with contracture healing

prostate cancer 1. dx 2. extra modalities needed for staging 3. tx 4. tx for distant metastatic disease + SE

1. DRA shows NODULE, PSA levels, free PSA (low is high risk), TRUS, biopsy 2. CT of abdomen/pelvis, MRI of prostate, radionuclide bone scan, pelvic node dissection 3. radiation, radical prostatectomy, 4. distal metastatic disease- LHRH agonist (leuprolide)**, bilateral scrotal orchiectomy SE = impotence, breast enlargement, fatigue, osteoporosis, weight gain

1. what viral infections cause splenomegaly/hypersplenism 2. """ parasitic infections 3. """ fungal

1. EBV, HIV, hepatitis 2. echinococcus, malaria, leishmaniasis, trypanosomiasis 3. histoplasmosis

1. treatment for rib fractures

1. FAST exam or peritoneal lavage to assess for splenic trauma--- then nerve blocks/pulmonary physiotherapy, surgery is not needed ***DO NOT BIND THE CHEST

1. what patients need an early intubation 2. oral tracheal intubation 3. nasotracheal intubation 4. surgical airways

1. GCS<8, major head/face/neck injury, impaired ventilation 2. PREOXYGENATE, cervical stabilization, rapid sequence induction, with cricoid pressure 3. should not be done if patient has basilar skull fracture, and should only be done in patient who is breathing spontaneously 4. if unable to perform standard intubation- jet ventilation, cricothyroidotomy, tracheostomy

1. sliding hiatal hernia pathogensis 2. sx

1. GE junction herniates through the esophageal hiatus ~~ much less dangerous than para-esophageal hernia (note- in para-esophageal hernia - the GE junction remains below the diaphragm) 2. postprandial fullness, heart burn

1. what GFR to start dialysis + complications 2. treatment of hyperkalemia 3. treatment of post-op bleeding in patient with renal failure -dialyze 24 hours before surgery and 24 hours after surgery because the processes requires heparin 4. when should dialysis be used emergently

1. GFR <5%(<3ml/min), Cr >15 peritoneal = peritonitis hemodialysis = blood borne infections (staph), heparin exacerbates coagulopathy 2. IV calcium (protects heart), sodium bicarb, insulin, glucose (shifts K into intracellular compartment), exchange resins, dialysis 3. DDAVP, FFP 4. hyperkalemia, metabolic acidosis (but cant give bicarb), severe volume overload, signs of uremia (pericarditis, mental status change,

stapling devices 1. use

1. GI, vascular, pulmonary surgeries, non-reactive permanent

1. what type of immune reaction common in BMT

1. GVHD - graft has donor type lymphoid cells that respond to the host as foreign *also occurs in liver transplant

zollinger ellison syndrome tx

1. H2 blockers + highly selective vagotomy, localization (gastrinoma triangle) removal of the tumor (often on pancreas), H2 blockers, PPIs ****THIS DISEASE IS OFTEN METASTATIC AT PRESENTATION

1. sx of increased ICP. 2. how to measure ICP

1. HA, N/V, clouding of mentation, papilledema, upward gaze (parinaud's), 6th nerve palsy, bulging fontanelles 2. ventriculostomy (also gives option to remove CSF), intraparenchymal monitoring, subarachnoid bolt, lumbar puncture (estimate)

1. patient is hypotensive and had head trauma, what should do next 2. what should be done to lower ICP IMMEDIATELY - assume cervical spine injury in every patient thats unconscious, has face/head contusions, vertebral tenderness, dec. mentation

1. HEAD TRAUMA IS NOT CAUSING HYPOTENSION --LOOK FOR ANOTHER SOURCE OF HYPOTENSION 2. mannitol, and intubation with hyperventilation (causes cerebral vasoconstriction)

diverticulitis 1. patho + complications 2. sx 3. dx

1. HEMORRHAGE, perf of a diverticulum results in pericolic infection, pericolic phlegmon, abscess, peritonitis, fistula (w/ bladder, vagina, skin_ 2. LLQ pain radiates to back/pubic/groin , fever, leukocytosis, pelvic mass (phlegmon/abscess), ileus, pneumaturia, pyuria, fecaluria (if fistula forms) 3. *CT scan*, leukocytes, after stable: colonoscopy to r/o cancer, cystoscopy to find fistula` (NO CONTRAST ENEMA CAN GET CONTRAST IN PERITONEUM)

verrucae vulgaris 1. patho 2. tx of persistent warts

1. HPV virus invades stratum spinosum --> warts 2. curretage/electrodissection, cryotherapy, chemotherapy

diverticulitis 1. tx for phlegmon 2. tx for abscess 3. tx for feculent peritonitis/recurrent diverticulitis/fistulas *all muscular colon should be removed*

1. IVF, NPO, IV abx 2. IVF NPO, IV abx, PERCUTANEOUS CT guided drainage of abscess followed by resection after acute phase is resolved 3. IVF/Abx, resection of diseased bowel, hartmann's operation (colostomy from rectal stump) re-anastomosed after 10 weeks

urological trauma 1. evaluation tests 2. evaluation of blood in the urethra 3. what are the complications of renal trauma

1. IVP or CT 2. retrourethrogram 3. post traumatic hypertension (ischemic tissue continues to make renin

how to calculate sodium defecit 1. formula

1. Kg * X * (140-Na) X = 0.6 for males 0.5 for females

1. what does PCWP measure 2. what CV abnormalitiy will perterb the relationship between PCWP and LAP/LVEDP

1. LAP and LVEDP 2. pulmonary vasoocclusive disease, mitral stenosis

1. detection of liver mets *1/3 of all cancers spread to the liver*** most common organ site of mets 2. imaging screening 3. tx

1. LFTs only 50-65% detection, CEA has good sensitivity, but poor specificity 2. ultrasound, MRI, CT 3. surgical resection (for unilobular only) 5FU, hepatic arterial floxuridine, radiation (palliative), hepatic artery ligation (transient reduction in tumor size), cryoablation (palliative)

1. change of PMI with LVH/RVH

1. LVH displaced laterally, RVH parasternal

1. clark melanoma levels

1. Level 1 - superficial to basement membrane Level 2 - papillary dermis Level 3 - between papillary and reticular dermis Level 4 - reticular layer Level 5 - subcutaneous fat

Abdominal exam -fever, tachypnea/tachycardia, hypotension -jaundice, dehydration, mental disorientation 1. inspection 2. rebound tenderness 3. spasm

1. Look for: distention = obstruction guarding scaphoid abdomen = abdominal hernia hernias more visible when patient is standing 2. occurs when examining hand is quickly removed from abdominal wall- acute peritoneal irritation 3. voluntary (tensing in response to pain) or involuntary (taut due to inflammation)

SVC syndrome 1. causes 2. clinical pres

1. MCC = bronchogenic carcinoma*** invades vena cava, lymphoma rarely- thoracic aortic aneurysm, 2. upper body edema, cyanosis, dilated subQ collateral vessels of chest, headache 3. palliative care- diuretics, radiation

cardiac tumors 1. cardiac myxomas 2. which tumor types frequently metastasize to the heart 3. clinical presentation of cardiac tumors

1. MCC benign cardiac tumors of the left atrium 2. melanoma, lymphoma, leukemia 3. pericardial effusion/tamponade***, CHF, arrhythmias, peripheral embolization

ventilation 1. when is the patient able to be extubated

1. SIMV <4, PS <10, FiO2 0.4 with good sats, PEEP <8mmHg, good LOC, RR<30 TV >5ml/kg, rapid shallow breathing indec (RR/TV) <100 VC >20ml/kg (normal 60-80) NIF- >20mmHg (normal 60-80 below ATM) ABG - >90% O2 sat, 35-45 PCO2

nasal cavity/paranasal sinus cancer 1. pathogenesis- + differentiation of maxillary vs ethmoid/posterior tumors 2. what is an inverted papilloma associated with 3. clinical presentation 4. dx

1. MCC location is maxillary sinuses, 80% SCC well differentiated if maxillary, poorly differentiated if from posterior nasal cavity/ethmoids 2. malignancy in adjacent tissue (it itself is BENIGN) 3. nasal obstruction, epistaxis, localized pain, CN deficits, face mass, proptosis, trismus 4. CT, MRI, biopsy

medullary carcinoma 1. associated condition 2. histo features. and markers 3. pathogenesis

1. MEN type II 2. C cells of the thyroid, producing thyrocalcitonin, *amyloid/collagen* deposition 3. lymphatogenous and hematogneous

1. in a patient with neurologic defects and a negative CT what is the next step 2. how to assess neck for fractures

1. MRI 2. C1-T1 levels, to rule out ligamentous injury, do flexion/extension films

MEN2B (mucosal neuroma syndrome) 1. features 2. dx -aggressive tx important

1. MTC Pheochromocytoma multiple neuromatous mucosal nodules marfanoid body habitus 2. marfanoid habitus, and mucosal neuromas

1. what is a carotid bruit predictive of -carotid bruits are not good indicators of carotid artery disease 2. work up of cerebrovascular disease 3. medical tx 4. surgical tx - check back pressure and EEG, if see ischemic changes use a shunt while the carotid is clamped

1. MYOCARDIAL INFARCTION, NOT STROKE 2. duplex doppler imaging, CT/MRI, EKG/holter, cerebral angiography 3. warfarin (for heart origin), aspirin, ticlopidine 4. carotid endarterectomy (fro symp and asymp) carotid angioplasty/stents - for high bifurcation of carotids/recurrent stenosis

MEN 2A (Sipple's syndrome) 1. features 2. dx 3.tx

1. Medullary thyroid carcinoma - elevated serum calcitonin pheochromocytoma - usually bilateral hyperparathyroidism- more mild than MEN1 2. elevated calcitonin 3. thyroidectomy for MTC, pheo tx,

measuring caloric requirements 1. indirect calorimetry 2. ficks equation 3. harris benedict equations

1. O2 inhaled - O2 exhaled ~ 1ml O2/min = 7kcal/day 2. CO * AV oxygen difference 3. REE calculate dfrom gender, height, weight, and age variable * stress factor ~~~ usually 25 kcal/kg/day * stress factor

hepatocellular adenoma 1. assc 2. presentation 3. pathology 4. dx/tx

1. OCP use in women, diabetes anabolic steroids, pregnancy 2. palpable mass/pain, spontaneous rupture/hemorrhage (9% mortality)**** 3. hepatocytes only (NO BILE DUCT EPITHELIUM), soft tumors 4. ultrasound, MRI with gadolinium, LFTs normal, biopsy tx= excision (avoid bleeding), resect prior to preg if large, resuscitation/hepatic artery ligation if hemorrhage, resection/angiographic embolization if severe bleeding

testicular cancer 1. symptoms 2. dx 3. tx

1. PAINLESS swelling/enlargement of testicles, persistent epididymitis, excessive pain from minimal trauma mets - back pain, abdominal mass, anorexia, weight loss, gynecomastia, abdominal mass, 2. testicular swelling, gynecomastia, abdominal mass, AFP, BHCG, 3. orchiectomy, radiotherapy to para aortic nodes, retro petal radiation, cisplatin/etoposide/bleomycin (x4)

esophageal webs 1. patho 2. schatzki's rings 3. tx

1. PART OF PLUMMER-VINSON SYNDROME - atrophic oral mucosa, anemia, dysphagia 2. thin lower esophageal webs (scars) common in patients with reflux - tx is acid control/endoscopic dilation 3. esophageal dilation/antireflux procedures

1. rubella assc. congenital heart condition 2. downs syndrome assc. congenital heart condition 3. top 5 MCC congenital heart defects 4. symptoms of congenital heart defects

1. PDA 2. endocardial cushion defects 3. VSD, transposition, ToF, hypoplastic left heart, ASD 4. easy fatigability, exercise intolerance, poor feeding habits/weight gain, frequent pulm infections

coarctation of the aorta 1. other assc cardiac defects 2. sx 3. dx + CXR 4. echo

1. PDA, VSD, bicuspid aortic valve 2. headaches, epistaxis, lower extremity weakness, dizziness 3. upper extremity HTN, dec. lower extremity pulses, systolic murmur, RIB NOTCHING ON CXR (from dilated collateral intercostal vessels***) 4. degree of flow limitation

tumors of small intestine hamartomas 1. patho (assc condition)

1. PEUTZ JEGHERS SYNDROME - (mucocutaenous pigmentation + intestinal polyposis)- LOW MALIG POTENTIAL

acute abdomen gynecologic pain 1. cervical or parauterine tenderness 2. uterine/ovarian/pelvic mass ddx

1. PID 2. intrauterine pregnancy, ectopic pregnancy, pelvic/ovarian/tubal inflmmatory disease +/- abscess, pelvic or gynecologic malignancy

cholangiocarcinoma 1. patho/clinical presentation 2. dx/tx - death due to biliary cirrhosis/inadequate drainage, intrahepatic infection/abscess, sepsis

1. PSC/parasitic infection/gallstones/thorotrast/ cysts-->adenocarcinoma--> severe jaundice, pruritus, anorexia, weight loss, aching RUQ pain 2. ERCP, percutaneous transhepatic cholangiography tx= pancreaticoduodenectomy with biliary/gastrointestinal reconstruction, rigid stenting palliates biliary obstructive symptoms

1. what should be monitored after liver transplant

1. PT/INR, metabolism of citrate from blood products, uptake of K by hepatocytes, LFTs

renal artery stenosis 1. surgical tx 2. medical tx

1. PTA, renal artery endarterectomy aortorenal artery bypass, nephrectomy 2. antihypertensives

tricuspid stenosis/insuff 1. t. stenosis pathogenesis/pathology 2. t. insuff pathogenesis/pathology 3. tricuspid stenosis cardiac/systemic effects

1. RHEUMATIC FEVER assoc w/mitral dz 2. mitral insufficiency, right vent dilation/pulmonary HTN/RV failure, carcinoid syndrome, bacterial endocarditis (drug addicts) 3. inc RA pres, peripheral edema, JVD, hepatomegaly, ascites

Mitral stenosis 1. pathogenesis/pathology 2. symptoms 3. right heart progression

1. RHEUMATIC FEVER--> 10-25 years--> thickening of the leaflets/shortening of chordae --> narrowing of opening-->inc. LA pres, pulm HTN, Afib, dec. CO, inc. PVR 2. dyspnea*, orthopnea, cough, hemoptysis, SYSTEMIC ARTERIAL EMBOLIZATION 3. inc. right heart pressure--> tricuspid regurg

1. quincke traid of hemobilia 2. causes of hemobilia 3. dx/tx

1. RUQ pain, jaundice, GI bleeding 2. anticoagulation, gallstones,parasites, neoplasms, 3. angiography, and angiographic embolization

1. anterior triangle of the neck boundaries 2. posterior triangle of the neck boundaries

1. SCM, mandible, midline of neck 2. SCM, trapezius, clavicle

imperforate anus -infralevator, supralevator 1. associated anomalies 2. dx + XRAY 3. electrolyte imbalance

1. VACTERL, hpospadias, epispadias, bladder exstrophy, vagianl atresia, sacral agenesis, spina bifida 2. search fore fistulous tract, meconium in the urine for males, urinary tract infections XRay = infracolonic air, air against the bladder 3. hyperchloremic acidosis

1. what what nerves effected by tumors of the cerebellopontine angel

1. VI, VII, VIII

renal dysfunction 1. clinical findings 2. pre-op labs 3. lab findings of renal failure - also proteinuria - depleted nitrogen stores - anorexia -inc. UTI - impaired immune function - impaired hp B elimination

1. VOLUME OVERLAOD - rales, JVD, hypertension peripheral edema, signs of coagulopathy, altered CNS function, pericardial/pleural rubs/effusions 2. electrolytes, BUN, creatinine (calc. GFR/FENa), hematocrit, urinalysis (glucose/protein), chest radiograph 3. salt retention high FENa, hyperkalemia, hyponatremia, hypertension, met. acid, anemia, coagulopathy (due to altered platelet aggregation), secondary hyperparathyroidism

insulinoma (nesidioblastosis) 1. clinical presentation 2. dx 3. tx

1. WHIPPLES TRIAD: fasting intolerance, fasting hypoglycemia <60, relieve of sx by administering glucose hypoglycemia, bizarre behavior, palpitations, nervousness 2. fasting insulin/glucose levels, >20% proinsulin, glucagon causes inc. insulin release, calcium induced insulin release SOMATOSTATIN (OCTREOTIDE) NUCLEAR SCAN***** 3. surgical resection after identification by careful palpation + ultrasound

fibrocystic breast change (chronic cystic mastitis) 1. fibroadenoma + histo 2. cystosarcoma phyllodes tumor + tx 3. sclerosing adenosis 4. atypical hyperplasia 5. what treatment causes fat necrosis of the breast

1. YOUNGER WOMEN, firm well demarcated, movable, fibrous stroma tissue with epithelial component, has WHORL LIKE PATTERN 2. giant fibroadenomas large polygonal cells with abundant cytoplasm/lymphoid infiltration - more cellular in appearance - tx = wide local excision 3. prolif of acini in nodules 4. increases the risk of breast cancer 5. radiation therapy and trauma

maintenance water calculations 1. urine estimate 2. body weight ~100-125 ml/hour is standard order rate

1. [(0.5 ml/kg/hr * BW)*24] + 750 2. 100 ml/kg/day (4cc/kg/hr) first 10 kg 50ml/kg/day (2cc/kg/hr) second 10 kg 20ml/kg/day (1cc/kg/hr) each kg over 20kg

1. monro kellie hypothesis 2. rate of volume change and effect on brain 3. what is the upper limit of ICP

1. a change in one component must be offset by compensatory change of the other (blood, CSF, brain mass) 2. fast rate causes more profound change 3. 15mmHg

1. what is a flap (put down before a skin graft) 2. fasciocutaneous flap 3. when are skin flaps indicated

1. a segment of tissue including a segmental artery, cutaneous arterial supply, 2. skin transfer including a anatomically distinct artery 3. wound closure in areas of poor vascularity, facial reconstruction, areas over bone where padding is needed*

acute pancreatitis 1. clinical presentation 2. classic hx 3. dx 4. barium study findings

1. abdominal tenderness, epigastric guarding, rebouding, retroperitoneal hemorrhage w/ third spacing, hypovolemia, hypotension, tachycardia, shock, TURNERS SIGN, CULLEN'S SIGN 2. heavy meal + alcohol --> pain 1-4 hours after + pain is relieved by leaning forward 3. Dynamic CT scan (*shows necrosis)***, amylase:creatinine >5, serum amylase (>1000 gallstone, 200-500 alcoholic), serum lipase, upper abdomen films, barium study, US. 4. pad sign - smoothing or obliteration of duodenal mucosal folds by edematous pancreas

ventral hernia 1. define 2. incisional hernia + tx

1. abdominal wall hernia in areas other than inguinal region 2. poor wound healing after surgical incision tx = closure with non-absorbable suterues and propylene or ePTFE prosthetic mesh

traumatic neuromas 1. patho 2. tx

1. abnormal regeneration of nerve after traumatic injury leads to oval shaped encapsulated nerve fibers that ARE PAINFUL 2. excision

examination methods flexible sigmoidoscopy colonoscopy barium enema (not good to detect small tumors, risk of peritonitis) water soluble contrast enema (if barium is CI) CT scan - MRI- defecography 1. indications for colonoscopy

1. abnormalities on barium enema, IBD, diverticular disease, polyps, GI symptoms unjustified by contrast studes, lower GI bleeding, sigmoid volvulus

1. aortoiliac occlusive disease segmental pressure/waveform findings

1. abnormalities starting at thigh level

hirschsprung disease 1. patho 2. clinical pres 3. dx 4. tx

1. absence of parasympathetic ganglia cells 2. non passage of meconium, constipation, obstipation, DRE causes release of watery stool, bouts of diarrhea/vomiting 3. abdominal radiographs show air fluid levels, barium enema shows transition zone with dilated proximal gut and constricted distal gut , biopsy shows absence of auerbach's plexus, stain for acetylcholinesterase 4. initial treatment = colostomy swenson,duhamel, soave procedures,

pneumothorax 1. dx 2. tx

1. absent breath sounds, tracheal deviation away from affected side, hypotension 2. needle decompression, chest tube

1. what kind of suture for biliary/urinary + advantage 2. disadvantages of braided sutures

1. absorbable ~ decreased infection risk b/c no foreign body 2. infection risk, inc. drag on tissue

anesthesia in patients with renal failure 1. benzos 2. succinylcholine 3. what is the best NMJ blocker for patients with renal failure 4. effect of inhalational anesthesia agents on GFR

1. accumulate and lead to prolonged sedation 2. inc. potassium CI in hyperkalemic patients 3. atracurium - undergoes enzymatic degradation independent of renal function 4. dec. GFR, and dec FENa

epidural hematoma 1. patho + pres. 2. dx/tx

1. accumulation of blood between bone and dura--> knocked out--> lucid interval--> slow loss of consciousness 2. lenticular high density formation on CT tx = small manage conservatively, large must evacuate and ligate the blood vessel

1. vagus effect on gastric secretions 2. L/R vagus orientation with respect to esophagus + what does each side supply - vagus nerves become ant/pos nerves of laterjet that terminate at the pylous as a crows foot

1. acetylcholine released by vagus --> stimulates parietal cell secretion, gastrin release, gastric motility 2. left anterior - supplies anterior stomach/liver/gallbladder/biliary tree right posterior - posterior stomach/celiac branch to the pancreas/small bowel/right colon

duodenal ulcers 1. patho 2. pyloric channel ulcers 3. sx 4. dx 5. tx

1. acid hypersecretion (2/2 inc. parietal mass), H.pylori--> ulcer in the first stage of the duodenum 2. refractory to medical treatment, 3cm near the pylorous 3. epigastric pain radiating to the back RELIEVED BY FOOD, pain wakes patients up at night 4. esophagoduodenoscopy***, UGI radiographs, gastric pH analysis, serum gastrin levels, urease breath test 5. medical first, then vagotomy+gastroenterostomy (drainage procedure = pyloroplasty or gastroenterostomy or antrectomy - overcomes the vagotomy stasis)

1. thyroid hormone function 2. what is produced by the parafollicular C cells of the thyroid

1. activation of energy producing processes, increasing metabolic rate/oxygen consumption enhanced metabolic, circulatory and somatic effects of catecholamines (inc. CO/pulse/blood flow) 2. thyrocalcitonin

cerebral edema 1. what is worse for brain injury, acute or chronic brain edema 2. cytotoxic edema + what causes it 3. vasogenic edema + what causes it

1. acute 2. depletion of neuronal glucose/oxygen-- seen in cerebral infarction, and reyes syndrome 3. breakdown of BBB and leakage of plasma into extracellular spaces-- trauma, brain tumor, infection, surgery, hypertonicity, mannitol

gastric tumors 1. types 2. location 2. risk factors 4. symptoms 5. extra-gastric sites

1. adeno (95%), squamous, carcinoid, GIST, lymphoma 2. more proximally located in the stomach 3. age>70, diet high in salt/smoked food, low protein, h.pylori, low A and C vitamins, gastritis, pernicious anemia, blood group A, male, adenomatous polyps 4. epigastric pain, fatigue, anorexia, vomiting, weight loss, dysphagia, SISTER MARY JOSEPH NODES, VIRCHOWS NODES 5. KRUKENBERG TUMOR, BLUMER SHELF TUMOR, spleen, diaphragm, omentum, colon, liver, lungs

prostate cancer 1. most common cell type 2. prostatic intraepithelial neoplasia 3. gleason scale 4. most common site of metastasis

1. adenocarcinoma 2. precursor to prostate cancer 3. most common + second most common grades of tumor seen 4. BONE - osteoblastic on xray + elevated ALP

1. primary homeostasis 2. secondary hemostasis

1. adherence adherence to injured vessel GP1b-vWF activation - TXA2 + GPIIB/IIIA + fibrinogen forms the platelet plug 2. tissue factor - VII from vessel starts clotting cascade --> extrinsic/intrinsic paths ~~ activate factor X --> activates thrombin with V --> fibrinogen to fibrin + XIII cross links

SBO 1. patho (causes) 2. sx 3. dx 4. tx

1. adhesions (post-op), hernias (esp. femoral), adenocarcinoma/lymphoma, gallstone ileus (ileocecal valve gallstone obstruction, crohn's intussusception/volvulus 2. crampy abd pain, n/v, distention, dec. flatus/bowel movements 3. DILATED LOOPS OF BOWEL, AIR FLUID LEVEL, AIR IN COLON (for early or incomplete) 4. Conservative: resuscitation with IV fluids, NG decompression, urinary catheter to monitor urine output Surgery: laparotomy to identify the cause of obstruction

acute abdomen 1. how can recent surgery lead to abdominal obstruction 2. peritonitis characteristic maneuver 3. cholelithiasis characteristic maneuver 4. acute peptic ulcer vs cholecystitis/pancreatitis effect of food

1. adhesions, reoccurance of malignancy, 2. lieing very still 3. eat antiacids 4. acute peptic ulcer, food helps, pancreatitis/cholecystitis food exacerbates

1. ABCDE 2. AMPLE 3. GCS

1. airway - establish patent airway breathing, - ensure both lungs are ventilated circulation - restore circulating volume, compress ext. bleeding sites disability- check for neuro deficit exposure/environment - fully expose the patient and cover with warm blankets 2. allergies, medications, previous illness, last meal, events surrounding injury 3.

nasal polyps 1. patho 2. clinical pres 3. tx

1. allergic response, aspirin reaction, ASSC. WITH CYSTIC FIBROSIS 2. BILATERAL (COMPARE TO PAPILLOMAS) 3. excision in if they obstruct the nasal passageway

phenylephriene 1. effect/use 2. why should it not be used in low CO hypothension

1. alpha agonist that causes pure arterial constriction --- use for situations with HIGH CO, LOW SVR ex. SIRS/sepsis 2. this will dec. blood flow to the tissues even more

epinephrine 1. effect/use 2. what limits dose of epinephrine

1. alpha agonist, some beta agonist activity- causes vasoconstriction and incraesing CO 2. more tachycardia compared to NE

lung abscess 1. patho 2. tx 3. surgery indications

1. alt. sensorium, alcoholics, drug overdose, elderly, debilitated--> aspiration--> pos seg of upper lobe/sup. segment of lower lobe--> mixed organism abscess 2. IV abx (PENICILLIN), transbronchial drainage w/ bronchoscope 3. failure to respond to abx hemorrhage >6cm in diameter rupture + empyema- may require open drainage/decortication

cancer cells metastasis mechanisms 1 billion cell tumor = 1cm size

1. altered expression of adhesion molecules 2. ability to produce ECM 3. ability to produce cytoskeletal proteins for motility 4. angiogenic factors

ARDS 1. physiologic alterations 2. causes 3. what test is most important to diagnose ARDS 4. TX

1. alveolar collapse from protein rich fluid in interstitium --> hypoxemia unresponsive to elevations of inspired O2 dec. compliance dec. FRC, PaO2/FiO2 <200, no cardiac cause (normal PCWP) (WITHIN 24-48 HOURS AFTER EVENT) 2. sepsis syndrome, aspiration, multiple transfusion, soft tissue injury/trauma, near drowning, fat embolism, DIC, pancreatitis 3. ABGs (shows hypoxemia), CXR, PCWP may be normal... 4. PEEP on ventilator

crohns disease 1. treatment 2. complications 50% of people who require surgery will need it again in 5 years

1. aminosalicylates, prednisone, sulfasalazine, metronidazole, TPN, infliximab (TNF-alpha monoclonal) - conservative surgical resection 2. obstruction (strictures), abscesses/fistulas (to the urethra, bladder, vagina), perianal disease

1. what drugs for bacterial endocarditis prophylaxis for GI/GU procedures

1. amp/gent vanc/gent - if allergic to amp/amox amox/amp vanc - if allergic to amp/amox`

1. tx of uncomplicated cystitis 2. tx of complicated UTI 3. complications of UTI 4. what patients tend to get renal papillary necrosis

1. ampicillin, amoxicillin, first gen cephalo, fluoroquinolones, nitrofurantoin, TMP SMX 2. fluoroquinolones, cefepime 3. renal papillary necrosis, perinephric abscess - ascending infection reaches the kidney pyonephrosis (infected hydronephrosis - casued by obstruction of ureter by stone) 4. diabetics --- sloughing of renal papillae causes ureteral obstruction/hydronephrosis

bladder cancer 1. risk factors 2. clinical pres 3. dx 4. cell types

1. aniline dyes, aromatic amines, B-naphthylamine CIGARETTES, phenacetin (analgesic), chronic inflammation (catheters etc), schistosoma haematobium, cyclophosphamide, irradiation 2. painless hematuria, frequency, urgency 3. urinalysis, intravenous urogram, cystourethroscopy, BTA/NMO22 molecular tests 4. transitional cell***, CIS, squamous cell (schistosoma), adenocarcinoma

1. what test detects anal sphincter term 2. which disease does not have a rectosphincteric reflex 3. what does pudendal EMG detect 4. what is endorectal ultrasound used for

1. anorectal manometery - detects tone, rectosphincteric reflex 2. hirschprungs disease 3. pudendal nerve injury that supplys anal sphincter 4. rectal cancer invasion depth, anal sphincter injury, complicated anal fistulas

cardiac arrest 1. causes 2. tx 3. what drugs used in cardiac arrest

1. anoxia, coronary thrombosis, electrolyte, myocardial depressants, conduction, vagotonic maneuvers 2. A (ET) B (Ambu-bag or vent) C - cardiac massage, defibrillation, drug therapy 3. epi, calcium, sodium bicarb (for acidosis), vasopressors, atropine

cardiac trauma 1. most commonly affected chamber 2. pericardial tamponade clinical presentation

1. ant- right ventricle 2. distended neck veins, hypotension, pulsus paradoxus, distant heart sounds

1. spinal cord blood supply

1. anterior spinal arteries (-->anterior sulcal artery) and posterior spinal arteries, segmental radicular arteries

gastric ulcer complications perforations 1. location + sx 2. tx

1. anterior surface of the duodenum - sudden onset severe abdominal pain RADIATING TO THE SHOULDER, N/V, board like abdomen, shock 2. observation, operative closer with patch of omentum

branchial cleft anomalies 1. anatomic location 2. first branchial cleft location and fistula tract 3. second cleft location and fistula location - tend to occur after a URTI

1. anterior to the SCM, or deep to it 2. superior to hyoid bone, fistula courses superiorly to external auditory canal 3. 2/3 the way down the SCM anteriorly, fistula extends between int/ext carotids to tonsillar fossa, adjacent to XII

1. which drug causes iatrogenic colon perforation 2. why should barium sulfate not be used in patients who may be at risk for colon perforation 3. how should patient with acute abdomen and no clear diagnosis be managed

1. anti-inflmmatory, immunosuppresives (esp. corticosteroids 2. fecal materail and barium mixes and will adhere to the peritoneal cavity. ***use diatrizoate meglumine 3. they should be managed by continued observation and repeated CBC/ABG/amylase/electrolytes

azathioprine 1. mechanism 2. SE

1. antimetabolite, inhibit rapidly dividing cells 2. leukopenia

*crohns disease (granulomatous ileitis) 1. distribution 2. sx 3. signs (ie. other assc. syndromes) 4. gross appearance 5. pathological apperance

1. any area of the GI tract, but most common is terminal ileum 2. abdominal pain, diarrhea, lethargy, fever, weight loss ***anorectal disease ~ fistulas, ulcers, perirectla abscess*** 3. uveitis/iritis, joint arthralgias, arthritis, erythema nodosum, pyoderma gangrenosum, primary sclerosing cholangitis 4. thickened shortened mesentery, grayish discolored bowel with circumfirential fat wrapping 5. mucosal ulceration and granulomas

tetanus prophylaxis 1. who should get prophylaxis - perviously immunized gets booster if has not had one in 10 years 2. what should be done for patient who has never been immunized - debridement + prophylactic penicillin

1. any person with penetrating injury, 2. TETANUS 3 initial doses then 2 doses at 4-6 weeks and 2 doses 6-12 weeks

crohns disease 1. location and lesion depth 2. histology 3. extraintestinal manifestations 4. clinical presentation

1. anywhere anus to mouth with rectal sparing, terminal ileum, transmural inflammation 2. granulomas, linear ulcers 3. same, but less sclerosing cholangitis 4. diarrhea, cramping, RLQ pain, malaise fever, weight loss, fistulas, *anal abscess/fistula fulminant colitis

1. what are the sites of injury from accel-decel injury 2. do all projectiles need to be removed from the person

1. aortic arch @ lig. arteriosus small bowel/mesentery creates bucket handle tear avulsion of spleen at the hilus renal pedicle avulsion 2. no unless they are near a vital structure-- just debride the tract

perioperative valvular heart disease 1. which conditions associated 2. aortic/mitral regurg what is most important factor 3. mitral stenosis effect of hypotension (such as that caused by inhalational anesthetics)

1. aortic stenosis, aortic/mitral regurg, mitral stenosis 2. degree of left ventricular function 3. hypotension causes inc. HR/dec. diastolic filling time --> pulmonary edema

1. most common indication of laparotomy in pregnancy

1. appendicitis

nitroprusside 1. effect/use 2. SE

1. arterial AND venous vasodilator 2. cyanide toxicity, reflex tachycardia, acidosis

1. stent restenosis prophylaxis - in emergency if patient has not completed anti-platelet therapy, utilize platelet therpy if bleeding occurs

1. aspirin and clopidogrel-- 4 months after sirolimus eluting stent, and 6 months after a paclotaxel eluting stent

pancreatitis 1. acute pancreatitis 2. acute relapsing 3. chronic relapsing 4. chronic

1. asymptomatic patient that gets attack which then subsides with treatment 2. recurrent episodes that resolve 3. chronic inflammation that fluctuates in intensity without resolution 4. unrelenting symptoms due to inflamm/fibrosis of the pancreas

pulmonary complications of surgery 1. #1/#2 2. gastric aspiration treatmnet - also bronchospasm, pulmonary edema, pneumothorax, PE, ARDS

1. atelectasis/pulmonary infection 2. H2/PPIs, bronchoscopy, NO STEROIDS, NG tube for gastric decompression

renal artery stenosis 1. photo/clinical pres 2. dx

1. atherosclerosis and fibromuscular dysplasia --> renin/angiotensin/aldosterone--> multidrug failure, abdominal/flank bruits, age <35, >55, worsening HTN in previously well controlled 2. catopril renal scan, duplex scanning (shows inc. velocity) renal/systemic renin index (renal vein* renin-infra renal vena caval renin/systemic renin) selective rnal arteriography CTA/MRA

1. which staph infect the skin also - anaerobes, gram negatives 2. tx. of an abscess

1. aureus, and epidermidis , 2. gramstain + drainage/irrigation/debridement/excision choose erythro/cephalo/fluroquin

gastric ulcer disease 1. casues 2. gastrin/ acid levels in gastric ulcer disease duodenal ulcers 2x>gastric ulcers 3. type1-5 ulcers + tx for each - duodenal ulcers/cancers are MCC pyloric obstruction

1. bile reflux, NSAIDs, steroids, ethanol, smoking, H.PYLORI (NOT ACID HYPERSECRETION) 2. gastrin 2x higher, acid lower than normal**** 3. type 1 = body of stomach/incisor angle (tx : antrectomy or proximal vagotomy) type 2 = body of stomach + duodenal ***type 3 = pyloric channel (tx: antrectomy with vagotomy) vagotomy + gastroduodenostomy if severely inflamed pyloric channel) type 4 = high in stomach adjacent to esophagus type 5 = NSAID/aspirin, throughout the stomach

1. MELD score for liver transplantation 2. indications for liver transplant

1. bilirubin, creatinine, INR (range 6j-40) 2. chronic liver disease (hep C, alcohol cirrhosis, hep B, PBC, PSC)--> ascites, encephalopathy, esophageal variceal hemorrhage in children biliary atresia is very common

1. polycythemia vera intra/post operative complication 2. how to avoid complication

1. bleeding due to qualitative deficiency in platelets 2. antineoplastics prior to surgery busulfan or chlorambucil, or phlebectomy prior to an operation if emergency

1. complications of urinary calculi removal 2. contraindications to surgical calculi removal

1. bleeding, perinephric hematoma, steinstrasse, hypertension 2. coagulopathy, anti-platelet,

calcineurin inhibitors 1. general mechanism

1. block transcription of cytokine genes (IL2) that activate helper T cells

GI surgery infections 1. what situations need prophylactic antibiotics (cephalo/fluroquin) 2. what patients get bile duct infections + prophylaxis/treatment 3. what organism in bile duct infections

1. blood or obstruction in GI tract, H2/proton pump inhibitrs 2. calculous cholecystitis, comon duct obstruction + cephalosproin/penicillin combo 3. ecoli , step faecalis (enterococcus), c.perfringins

ulcerative colitis 1. clincial presentation 2. toxic megacolon 3. dx

1. bloody diarrhea, mucus and pus, abdominal pain, malaise, fever, weight loss, TOXIC MEGACOLON 2. dilation of transverse colon, abdominal pain/distension, fever, leukocytosis, hypoalbuminemia, perforation 3. proctoscopy (inflam starts @ dentate line), abdominal radiographs (r/o toxic megacolon) stool samples (f/o parasites/pathogens) serologic markers (pANCA) colonoscopy small bowel contrast (r/o crohns)

duodenal hematomas 1. patho + clinical pres 2. tx

1. blunt abdominal trauma, high obstructive signs 2. coiled spiral sign on CXR (stack of coins) tx = non-surgical, evacuation of hematoma

mediastinal tamponade 1. cause 2. clinical pres

1. blunt or penetrating trauma 2. hypotension, dyspnea, cyanosis, decreased pulse pressure, swelling of the upper extremities

pulmonary contusion 1. patho 2. dx/tx

1. blunt trauma --> capillary disruption --> intraalveolar hemorrhage/edema --> small airway obstruction WITHIN FIRST 24 HOURS (COMPARE TO ARDS) 2. CXR (PATCHY ALVEOLAR INFILTRATES) ABG, respiratory distress sx tx = fluid restriction, supplemental oxygen, chest physiotherapy, chest tube drainage

diaphragmatic disruption 1. patho 2. dx/tx

1. blunt trauma***** to cx/abd produces radial tear starting at esophageal hiatus (tends to be on left more than right) 2. chest radiograph showing trauma +/- abdominal organs in the thoracic cavity tx = NG tube(to prevent gastric dilation/resp distress), transabdominal diaphragm repair

traumatic myositis ossificans 1. patho 2. tx 3. myositis ossificans progressiva

1. bony deposits in muscle post trauma 1-4 wks after trauma 2. persistent painful masses excised 3. progressive systemic illness that begins early and results in conversion of muscle into bone

scoliosis 1. tx

1. brace if curve is <20 degrees, >20 use rod fixation surgery

anterior compartment lesions thymoma 1. patho 2. dx/tx

1. branchial cleft pouch --> all three tissue types 2. smooth walled cystic lesions with smooth lobulated with calcifications 3. total surgical excision

1. primary tumors that met to bone 2. dx of metastatic bone cancer 3. tx"""

1. breast, lung, prostate, thyroid, kidney 2. lytic lesions, and bone scans 3. radiation therapy

clostridial myositis 1. define + risk factors 2. pres/sx 3. lab findings 4. xray findings

1. c.perfringens gas gangrene, seen in wounds with extensive tissue destruction, contaminated, delayed treatment, corticosteroids, 2. severe pain, pulse increase, pale, weakness, crepitus, tender to the touch, 3. falling hematocrit, rising bilirubin (hemolysis), gram positive bacilli with spores**** 4. air in soft tissues (cause of the crepitus)

1. what complication is higher in cadaver vs living donor kidney transplant 2. treatment of acute rejection

1. cadaver transplants have higher frequency rate of delayed graft function/ATN 2. prednisone, cyclosporine, azathioprine, +/- anti-IL2 or replace AZA with mycophenolate mofetil

list 5 sites of compartment syndrome

1. calf (tibia fracture) forearm (supracondylar fracture) foot (calcaneous fracture) thigh (crush injury) hand (crush injury)

esophagitis 1. MCC infectious esophagtiis 2 .sx

1. candida - usually in immunosuppressed, abx, malignancy. less commonly TB/herpes 2. odynophagia,

1. what is the complications of breast implants

1. capsular contracture around the implant, hematoma, infection

1. what type of alcoholic complication excludes patient from liver transplant 2. when can acetaminophen overdose exclude from liver transplant - primary HCC with <5cm tumor is a candidate

1. cardiomyopathy and cerebral atrophy 2. multiple suicide attempts

1. halothane major side effect 2. enflurane major side effect 3. methoxyflurane

1. cardiovascular suppression, hepatitis 2. epilepsy like EEG changes 3. nephrotox

congenital tracheomalacia 1. pathogenesis + sx 2. dx/tx

1. cartilage softening from compression by vascular rings (aortic arch anomalies) --> wheezing/stridor, feeding problems, infections 2. air tracheography, bronchoscopy, angiography tx = endoscopic web removal, tracheostomy , aortopexy for chondromalacia

1. prepubertal male gynecomastia patho 2. pubertal male gynecomastia 3. senescent gynecomastia 4. drug causes of gynecomastia 5. disease that causes gynecomastia

1. caused by adrenal or testicular carcinoma 2. common and will regress spontaneously 3. 40% of aging men with dec. testosterone, and inc. estradiol/LH 4. thiazides, digoxin, theophylline, anti-depressants, alcohol/marijuana 5. cirrhosis, renal failure, malnutrition

blood transfusions in: 1. hypertonic solutions ex. 5%dextrose 2. ringrers lactate

1. causes hemolysis of RBC 2. clotting --> PE risk

1. cause of very large distended colon in RUQ on abdominal x ray ddx 2. first diagnostic test + subsequent actions

1. cecal or sigmoid volvulus**** tumor, foreign body, colitis 2. sigmoidoscopy b/c it can be reduced if it is the sigmoid then follow with celiotomy

post-operative cecal volvulus 1. patho 2. tx

1. cecum twists on its mesentery 2. right hemicolectomy -- decompression presents risk of infection, colonoscopy risks perforation or rupture

1. SMA colon blood supply 2. IMA colon blood supply 3. IMV drainage 4. SMV drainage

1. cecum, ascending colon, proximal transverse colon 2. distal transverse, descending, sigmoid colon 3. left colon to splenic vein 4. right colon to splenic/portal vein

giant cell granuloma 1. two types 2. tx

1. central within the jaw, and peripheral on the gums or alveolar mucosa 2. excision/curetage

transforamen magnum herniation

1. cerebellar tonsils herniate through foramen magnum causing a cushings response (hypertension, bradycardia, apnea)

1. treatment for non-limb threatening PVD (ex. claudication)

1. cessation of tabacco/tx. HTN/DM/, pentoxifylline - reduces blood viscosity and platelet aggregation exercise programs

1. chemodectomas 2. carotid body tumors 3. glomus jugulare/ 4 glomus tympanicum - other random tumors- esthesioneuroblastoma, osteogenic sarcoma, ewings sarcoma ameloblastoma, rhabdomyosarcoma, chordroma

1. chemoreceptor derived, found in the jugular bulb, carotid body, aortic arch, ganglion nodosum, ear and larynx 2. may secrete catecholamines, form from cells that normally detect pO2, rarely met. 3. originate in jugular bulb 4. originate along tympanic nerve

tuberculosis 1. tx 2. indications for surgery

1. chemotherapeutics, surgical resection rarely 2. bronchopleural fistula with empyema, destroyed lobe or lung persistent open cavities bronchial stenosis pulmonary hemorrhage carcinoma aspergilloma bronchiectasis

1. pneumothorax/hemothorax drain type 2. obstructed/nonfunctional GI tube drain type 3. drain type for masectomies or skin flaps with large raw surfaces - use drain to treat absecess

1. chest tube 2. sump drain ~ most likley NG tube 3. suction drainage

1. risk factors that thyroid nodule is malignant 2. features of malignant nodule 3. which thyroid malig assc. with inc. thyrocalcitonin, what genetic test shoudl be done on these patients

1. children, inc. age >40, women, FH of medullary carcinoma , radiation exposure 2. firm, infiltrating surrounding tissues, solitary nodules, rapid growth, ipsilateral lymph node enlargement, ipsilateral vocal cord paralysis, non-thyroid hormone producing, cold nodules 3. Medullary carcinoma of the thyroid, RET protooncogene

which ion is high in: ~ ie. which ion should be replaced if significant losses from this location 1. stomach secretions 2. duodenum 3. ileum 4. colon 5. gallbladder 6. pancreas

1. chloride* and sodium 2. sodium 3. sodium and chloride 4. sodium* and bicarb 5. sodium and chloride 6. chloride and bicarb -- inverse relationship depending on if pancreas stimulated, also sodium is high

complications of cholecystitis/cholelithiasis 1. biliary enteric fistula/gallstone ileus sx 2. tx

1. cholecystitis (any cause)--> adhesions, perf, fistula formation--> stone passage into bowel (usually duodenum) --> terminal ileum/peritoneal cavity --> obstruction--> +/- sx of cholecystitis--> SBO sx N/V, obstipation, distention 2. emergency laparotomy , proximal enterotomy with stone extraction, closure of fistula and cholecystectomy

choledocholithiasis 1. treatment for recurrent common bile duct stones (ie. after cholecystectomy)

1. choledochoduodenostomy, or choledochojejunostomy, transduodenal sphincteroplasty, endoscopic sphincterotomy

type of urinary dysfunction assc with 1. treatment of bladder voiding dysfucntion

1. cholinergic modulators , alpha modulators for sphincter tone, catheterization, urinary diversion, bladder augmentation

1. which tumors have elevated BHCG 2. :""" AFP

1. choriocarcinoma, and seminomas 2. yolk sac tumors, embryonal carcinoma, teratomas

1. what is the difference diagnostically between acute and chronic prostatitis

1. chronic does not have systemic signs

radiographic findings around the pancreas 1. calcification of the lesser sac 2. gas collection in lesser sac 3. blurred psoas shadows 4. displacement of organs in the lesser sac 5. "cutoff" sign 6. inverted 3 sign 7. pad sign (barium study)

1. chronic pancreatitis (alcoholism) 2. abscess formation in/around pancreas 3. pancreatic necrosis/fluid in retroperitoneum 4. edema in the lesser sac 5. colonic spasm adjacent to inflamed pancreas causes transverse colon gas to end abruptly 6. focal duodenal and jejunal ileus 7. smoothing or obliteration of duodenal mucosal folds by edematous pancreas

secondary hyperparathyroidism 1. pathogenesis 2. tx (med/surg)

1. chronic renal failure--> inability to synthesize active vitamin D, inability to excrete phosphate leads to hyperphosphatemia--> elevated PTH--> bone demineralization, vascular calcification, skin ulcerations 2. dialysis, phosphate binding antiacids, active vitamin D supp, calcium supplements, CALCIUM MIMETICS surg= parathyroidectomy with autotransplantation

\regional enteritis 1. clinilcal pres 2. associated extraintestinal symptoms - presentation like acute appendicitis is a positive prognostic factor- will not progress to fulminant disease

1. chronic slowly progressive with symptom free periods ~ anorexia, abd pain, diarrhea, fever, weight loss 2. ank spondy, polyarthritis, erythema nodosum, pyoderma gangrenosum, gallstones, NASH, biliary fibrosis

1. evaluation of urethral injury 2. what is the risk of an unsplinted fracture

1. retrograde urethrography , DON'T PUT IN A FOLEY ***** 2. fat embolization syndrome

1. actinic keratosis + tx 2. bowens disease + tx 3. keratoacanthoma

1. chronic sun exposure - causes scaly epidermal lesions , occurs in 3rd/4th decade of life tx = local excision w/ free margins on frozen section,cryotherapy, 5FU 2. arsenic/viruses -->intraepidermal SCC or CIS of the skin - erythematous plaque with yellow crust tx = same as actinic keratosis 3. locally destructive lesion found on head, NOT MALIGNANT, w/ spontaneous resolution tx = excision/biopsy

1. chemotherapies used for head/neck squamous cancers 2. use of chemotherapy in head/neck cancers

1. cisplatin + 5FU/paclitaxel, methotrexate for palliation 2. make tumors more susceptible to surgery/radiation, inc. response rates, adjuvant to reduce recurrence, unresectable tumors or distant mets

1. primary intention 2. secondary intention 3. delayed primary intention

1. clean wounds, ALL LAYERS CLOSED cosmetic scar, bacteria in subQ layer can cause infection 2. DEEP LAYERS CLOSED, 1-3 dressing changes daily, subQ left OPEN--> open qubQ granulates and heals with broad scar- no infection b/c skin is not closed 3. deep layers closed, subQ open and packed, inspected post op day 4-5, if subQ is clean, suture skin closed. IF purulent, leave opne to heal by secondary intention

benign liver cyst 1. patho 2. dx

1. clear watery fluid filled cysts usually in the right lobe 2. US shows anechoic* area on liver ultrasound, drainage shows colorless fluid

pseudomembranous colitis 1. what abx associated 2. gross findings 3. dx 4. tx

1. clindamycin/ampicillin 2. yellow plaques over teh mucosa, pseudomembranes made of fibrin/cellular debris 3. proctoscopy/colonoscopy*, c.diff toxin titers, stool culture grows c.diff 4. metronidazole, oral vancomycin (resistant cases), cholestyramine binds toxin (but also inhibits abx...)

1. management of aortoenteric fistula

1. closure of fistula, ligation of infrarenal aorta and extra anatomic bypass

small cell anaplastic (oat cell) carcinoma of the lung 1. histo 2. electron micro 3. location/tumor characteristics 4. mets 5. tx

1. clusters, nests of small round oval or spindle shaped cells with little cytoplasm 2. neurosecretory granules 3. centrally located 4. mets by lymphatic/vascular routes 5. COMBINATION CHEMOTHERAPY, NOT THORACOTOMY/LOBECTOMY***

1. what tumors cause elevated CEA 2. what is CEA useful to detect

1. colon* (50%), pancreatic, gastric, lung, breast 2. predicts likelihood of recurrence after colon resection, and sensitive for recurrence

anterior compartment lesions lymphoma 1. patho + sx

1. common site of lymphoma is anterior mediastinum--> cough, chest pain, fever, weight loss, hoarseness 2. CXR, lymph node biopsy (via mediastinoscopy or anterior mediastinotomy) tx = non-surgical

acute limb ischemia 1. complications of revascularization surgery (after surgery patient cannot move his feet)

1. compartment syndrome (tx = immediate fasciotomies) myoglobinuria --> ATN

non-invasive breast cancer 1. ductal CIS 2. ductal CIS dx/tx 3. lobular CIS + risk of recurrence

1. confined to ductal cells, no invasion of basement membrane 2. excision with clear margins,, 25% of recurrence excision with clear margins + radiation 8% recurrence, or simple mastectomy 3. 15-20% bilateral recurrence after excision

acute pancreatitis 1. indications for surgery 2. surgical tx 3. complication of peritoneal lavage

1. confirm refractory cases, relieve biliary/pancreatic duct obstruction (use caution inc. mortality), 2. cholecystostomy, CBD drainage, peritoneal lavage, lesser sac drainage (only if patient is septic), GALLSTONE PANCREATITIS- cholecystectomy AFTER resolution of symptoms on same hospital visit*** pancreatic resection INCREASES MORTALITY 3. deterioration of pulmonary function from abdominal distension

laryngeal webs 1. patho + sx 2. tx

1. congenital , or vocal fold trauma--> stridor, weak phonation, feeding problems 2. excision/division

cecal volvulus women <40 years old 1. patho 2. sx/signs 3. dx (abdominal xray/barium enema) 4. tx

1. congenital anatomic anomaly w/ incomplete fixation of right colon, also: cancer of right colon, midgut non-rotation, adhesions, CW turn -->obstruction/ischemia 2. similar to sigmoid volvulus 3. abdominal x ray shows large cecum, barium shows birds beak 4. right colectomy with ileo transverse colonic anastomosis, colonic decompression, cecopexy

lymphedema 1. milroy's disease 2. lymphedema praecox 3. lymphedema tarda 4. secondary lymphedema 5. where does lymphedema usually start compared to venous disease 6. tx

1. congenital lymphatic insufficiency (ie. in an infant) 2. primary lymphedema <30 years of age (Meigs disease) 3. primary lymphedema >30 years of age 4. 2/2 post surgical lymphedema, wuchereria bancrofti, postphlebitic syndrome, 5. starts in the dorsum of the foot 6. compression, pneumatic compression boots, treat infection

reiters disease 1. clinical pres 2. assc HLA

1. conjunctivitis, urethritis, arthralgias AND myocarditis, aortitis, pericarditis 2. HLA B27 (also ank-spondy, aortic regurg, pericarditis)

myeloid metaplasia 1. pathogenesis 2. tx

1. connective tissue proliferation in the bone marrow, liver, spleen --> proliferation of hematopoietic tissue in liver, spleen, bones 2. alkylating agents, male hormones stijulate bone marrow, splenectomy

gastric polyps 1. hyperplastic polyps + tx 2. adenomatous polyps

1. consequence of chronic atrophic gastritis, tx = brush cytology and polypectomy 2. 20% risk of malig, tx = polypectomy

ulcerative colitis 1. location and lesion depth 2. histological findings` 3. extraintestinal findings

1. continous, always includes rectum, NO ANAL OR PERIANAL DISEASE, mucosally restricted, 2. crypt abscesses, psudopolyps 3. ank spondy, sacroileitis, peripheral arthritis, erythema nodosum, pyoderma gangernosum, iritis, episcleritis, scleroising cholangitis

pancreas transplantation 1. post op immunosuppression 2. monitoring rejection in panreas transplant

1. corticosteroids, calcineurin inhibitor, mycophenolate mofetil 2. urinary amylase with bladder drainage, enteric drained pancreas monitored with plasma amylase/lipase and periodic pancreas biopsies , ELEVATED BLOOD GLUCOSE

MEN syndromes 1. what screening labs for MEN1 2. """ MEN2A/2B

1. gastrin, insulin, glucagon, somatostatin 2. serum gastrin, calcitonin (after pentagastrin or provocative calcium infusion test), urine VMA, serum calcium (hyperparathyroidism)

hyperkalemia (>6mEq/L) 1. sx + ECG 2. causes 3. medical disease 4. tx*

1. cramping, diarrhea, nervousness, flaccid paralysis, weakness ECG - peaked T, wide QRS--> VFib 2. rhabdo, tissue necrosis, metabolic acidosis, hyperglycemia 3. addisons disease 4. IV calcium- 1gram Ca2+ gluconate (stabilizes cardiac myocyte), D50 + 10 units of insulin (shifts K+ into cell), bicarbonate (shifts intracellularly) ion exchange resin (kayexalate) furosemide dialysis

brain stem glimoas 1. patho 2. dx/tx

1. cranal nerve palsy, gait unsteadyness 2. hydrocephalus, poor enhancing intraaxial brain stem lesion tx= radiation

prefered airway maintenance in patient with severe facial fractures

1. cricothyroidotomy because this will protect the cervical spine

1.furuncles 2. carbuncles + what patients get these more often 3. hiradenitis suppurativa*

1. cutaneous staph abscesses seen with acne and other skin disorders*** 2. cutaneous abscesses that spread through the dermis into subQ region (COMMON IN DIABETES) 3. infection of apocrine sweat glands of axillary, inguinal, perineal regions --- CHRONIC - requires complete excision of the apocrine glands***

1. what is most common middle mediastinal mass 2. most common posterior mediastinal mass 3. most common anterior mediastinal masses

1. cysts (bronchogenic, pericardial, enteric) 2. neurogenic tumors 3. substernal extension of benign substernal goiter, thymomas, lymphomas, germ cell tumors

cerebral injury 1. mechanisms of cerebral concussion 2. uncal herniation 3. pupillary dilation 4. reduction of ICP

1. damage to the reticular formation of the brainstem leads to altered LOC (earliest sign) 2. inc. ICP causes uncal processes of temporal lobe to herniate through tentorium cerebri 3. compression of ipsi oculomotor nerve and parasympathetics 4. hyperventilation (fastest), mannitol , dexamethasone

1. junctional nevi 2. compound nevi 3. intradermal nevi 4. giant pigmented nevi

1. dark, flat, smooth lesions, that are hair and develop in basal epidermis, often on palms/soles 2. well circumscribed elevated 3. light colored, well circumsribed 4. irregular nodular surface >1sqft of body surface area

when post-op does third space fluid become mobilized + what patients is this dangerous for + what happens

1. day 3-4, increases intravascular volume excreted--- hypervolemia occurs in patients with cardiac/renal impairment --> CHF/pulm congestion

change in REE 1. prolonged starvation 2. skeletal trauma 3. sepsis 4. 3rd degree burns >20% of BSA

1. dec. 10-30% 2. inc. 10-30% 3. inc. 30-60% 4. inc. 50-100%

1.what causes death in a tension pneumothorax 2. tx

1. dec. CO, hypoxemia, ventricular arrhythmias 2. needle decompression, followed by chest tube DO NOT DELAY THIS SEQUENCE WITH AN X RAY

hypophosphatemia 1. patho 2. consequences

1. dec. phosphate--> low ATP 2. rhabdomyolysis, CHF, arrhythmias, hemolysis, weakening of respiration

aortic disruption 1. pathogenesis 2. CXR 3. dx/tx

1. deceleration injury (ascending aorta moves forward while descending aorta is fixed)--> tear in the aorta just distal to left subclavian usually leaves adventitia intact 2. widened mediastinum, indistinct aortic knowb, depressed left mainstem bronchus, right deviated trachea, left pleural effusion, hoarse voice from damage to recurrent laryngeal 3. aortogram, interposition graft with or without distal perfusion

epigastric hernias- epiploceles 1. define 2. repair

1. defect in linea alba above umbilicus 2. simple suturing

cervical spondylosis 1. patho

1. degenerative arthritic changes to the spine, neural foramen impinge on nerve root --> radicular symptoms 2. osteophytectomy and disectomy cervical laminectomy

hypochloremia (<90) 1. causes 2. urine change 3. tx

1. dehydration or vomitting (associated with hypokalemia) + build up of bicarbonate (met alk) 2. met alk leads to increased K+ / H+ in the urine b/c inc. aldosterone 3. replace chloride and volume deficit, replace K+

1. inflammatory aneurysm 2. mycotic AAAs

1. dense fibrotic reaction of ant/lat walls of the aneurysm leading to adherent organs 2. salmonella infection in the infrarenal aorta

anal canal cancers (above dentate) 1. adenocarcinoma 2. melanoma

1. derived from anal glands/ducts- may present as anal fistula tx = similar for rectal cancer 3. 3rd most common site, tx = resection, poor survival

type of urinary dysfunction assc with 1. lumbar disk disease 2. diabetic cystopathy

1. detrusor acontractility, decreased urinary sphincter activity -->obstructive symptoms predominate 2. dec. bladder sensation, inc. capacity, dec. contractility, elevated post-void residual volume

neuroblastoma 1. patho 2. dx/tx 3. site of mets

1. develops along sympathetic chain** - abdominal mass is most common, horner's syndrome, acute cerebellar ataxia, opsoclonus, 2. bone marrow aspiration, urinalysis (VMA and HVA), CT, CXR tx = surgery, radiation, chemotherapy (cyclophos, vin, adria, dacarba), autologous bone marro wtransplant 3. liver, lung, skin, bone

blind loop syndrome 1. patho + sx

1. diabetes, scleroderma, small bowel resection, diverticular disease, carcinoma --> slowed peristalsis --> bacteria proliferation --> MACROCYTIC ANEMIA (B12/folate), steatorrhea, malabsorbtion

1. what type of injury from compression type abdominal injury 2. what type of injury from deceleration type injury

1. diaphragmatic hernia - will see deviation of mediastinum and respiratory distress, xray will show hemidiaphragm elevation 2. avulsion of renal vascular pedicle, SMA, splenic pedicle

complications of radiation treatment on the bowel

1. diarrhea, GI bleeding, vasculitis/fibrosis, malabsorption, ulceration ,fistulization, perforation

abdominal exam auscultation 1. silent abdomen 2. causes of ileus 3. intermittent peristaltic rushes

1. diffuse peritonitits with absence of peristalsis~ occurs with intestinal ischemia/gangrene, prolonged mechanical obstruction, ileus 2. pneumonia, renal stones**, trauma, hypokalemia, hypophosphatemia, hypomagnesemia 3. intestinal obstruction, episodic abdominal pain, gastroenteritis

laryngocele 1. patho 2. laryngopyelocoele 3. internal laryngocele clinical pres 4. external laryngocele clinical pres 5. tx

1. dilation of laryngeal saccule creating air sac that communicates with laryngeal ventricle 2.infected laryngocele -- potentially fatal from asphyxia if aspirated 3. protrudes into larynx/aryepiglottic folds - causes hoarseness, breathlessness, stridor 4. protrudes from the neck increases with cough/valsalva 5. surgical excision

hyponatremia 1. hyperosmolar 2. normosomolar (pseudo) 3. hypoosmolar 4. hypovolemic hypoosmolar 5. hypervolemic hypoosmolar 6. euvolemic

1. dilutional hypernatremia - ex. hyperglycemia, mannitol, osmotically active particles 2. hyperglycemia, hyperlipidemia, hyperproteinemia mess up Na measurement 3. true hyponatremia 4. hypovolemia --> ADH + thirst ~~ ADH conserves free water, and thirst adds to hyponatremia w/ *low total body sodium* 5. low cardiac output/hypoalbuminemic, --> volume overload , *high total body sodium* 6. seen perioperativly and SIADH (stress response to trauma/surgery - causes retained free water)

1. how to control hemorrhage

1. direct pressure on bleeding wounds, prox/distal compression of bleeding vessels, pressure vessels, pneumatic splints, anti-shock trousers

cardiac contusion 1. patho 2. dx/tx

1. direct sternal impact causes range of depth of injury --> arrhythmias, myocardial rupture, ventricular septal rupture, LVF 2. EKG, isoenzymes, 2D electrocardiogram tx = cardiac/hemodynamic monitoring, arrhythmia management, inotropic support for cardiogenic shock

1. what kind of fractures are most commonly associted with vascular injury

1. dislocation fractures ex. knee dislocations, supracondylar humerus fracture

pancreatitis 1. radiologic signs 2. causes of acute pancreatitis

1. displacement of duodenum/stomach anteriorly, downward displacement of transverse colon, dilated pancreatic duct, smooth tapering of CBD on angiogram 2. alcohol, gallstones, hyperlipidemia (assc. w/ low amylase), recent ERCP* hypocalcemia, hypokalemia, thiazide, lasix, sulfonamides, pancreatic divisum

herniation 1. subfalcine + sx 2. transtentorial + sx 3. kernohan's notch phenomenon

1. displacement of supratentorial brain mass to the other side of the falx --> motor to leg loss, and bladder control loss 2. medial temporal lobe is forced over edge of tentorium --> deterioration of consciousness, ipsilateral pupillary dilation (CNIII), contralateral hemiparesis 3. contra mydriasis, ipsi hemiparesis

1. sites of limb threatening fractures 2. what diagnostic tools to diagnose vascular insufficiency after a bone fracture 3. signs of major arterial injury in a limb

1. distal femur, proximal tibia, supracondylar humerus, knee dislocations 2. ankle brachial index <0.9, duplex doppler, angiography 3. weak pulse, distal cyanosis, expanding hematoma, pulsatile bleeding, cold extremities, distal paralysis/paresthesias, bleeding not controlled with pressure

portal hypertension tx selective portosystemic shunts - distal 1. splenorenal shunt 2. paraesophageal devascularization with esophageal transection and reanastomosis 3. when is splenetomy indicated

1. distal splenorenal shunt (warren) - distal splenic vein is anastomosed to left renal vein -- this only decompresses the gastroesophageal venous system 2. transthoracic esophageal devascularization, transabdominal gastric devascularization, splenectomy, selective vagotomy, pyloroplasty 3. splenic vein thrombosis* (from pancreatitis/neoplasm) - cures gastric varices in these cases

hydatid cysts of liver 1. patho 2. complications 3. sx 4. dx/tx

1. dog feces --> echinococcus granulosus --> humans --> liver/other places in body 2. rupture and seeding, extrahepatic cysts (lungs) 3. liver enlargement, RUQ pain, history of travel 4. EOSINOPHILIA, ultrasound/CT US- shows internal echos usually in right lobe of liver tx =perioperative albendazole + surgical removal of cyst material followed by 0.5 silver nitrate solution **DO NOT SPILL THE CONTENTS INTO THE PERITONEAL CAVITY (-->ANAPHYLAXIS)

transfusion complications 1. cause of febrile/allergic transfusion reactions + tx 2. electrolyte disturbances 3. coagulopathy 4. ABO

1. donar cytokines, donar leukocytes, contaminants -- tx = leukodepletion, antipyretics 2. hyper kalemia, hypocalcemia (from citrate in blood that binds calcium) 3. transfused blood has no platelets or factors

1. sump drains 2. open drains

1. double lumen catheters that allow air ro irrigation enter one lumen and suction on the other ex. NG tube 2. not sealed, allow bacteria/material s to move ex. penrose drain

1. hypospadias pathogenesis

1. downward (ventral) curvature of the penis caused by fibrous tissue (chordee) --> opening of the penis on ventral surface

1. ring halo sign 2. post traumatic rhinorrhea + tx 3. post traumatic otorrhea 4. tx of 3 and 4

1. drops of CSF mixed with blood forms a halo around a central bloody area 2. from fracture of the cribriform plate, tx = lumbar drain if persistent 3. from fracture of mastoid air cells 4. put bed at 45 deg, lumbar CSF drain promotes fistula healing, craniotomy with closure of dural defect NO ABX B/C IT SELECTS FOR ORGANISMS

1. what congenital/hereditary causes of pancreatitis 2. what iatrogenic causes of pancreatitis

1. duct strictures, pancreas divisium, cystic fibrosis, 2. instrumentation (ERCP) and drugs

1. stress incontinence 2. urge incontinence 3. urethral diverticlum

1. due to anatomic defect in bladder neck, inc. intra abdominal pressure causes loss of urine 2. detrusor instability (parkinson's, urethral syndrome, interstitial cystitis) 3. TRIAD - dysuria, dyspareunia, dribbling

duodenal atresia 1. patho + sx 2. assoc conditions 3. dx/tx

1. duodenum fails to recanalize in development--> bilious vomiting 2. trisomy 21, cardiac/VACTERL components, annular pancreas 3. double bubble sign involving air in the stomach 4. gastric decompression, abx, duodenoduodenostomy, do not divide an annular pancreas

arteriography for PVD 1. complications with contrast 2. arterial complications 3. pseudoaneurysm + tx

1. dye induced nephrotoxicity--> ATN w/ high output renal failure 1-2 days post-op dye allergy 2. arterial thrombosis, atheroembolism due to disruption of a thrombus ( BLUE TOES***) 3. @ puncture site - as a result of improper hemostasis tx = US guided compression to produces thrombosis in the false cavity

1. how to lower intracranial pressure 2. consumptive coagulopathy in brian injury pathy 3. lab values of consumptive coagulopathy + tx

1. elevation of the patients head, hyperventilation (causes vasoconstriction from low PCO2), mannitol (inc. serum osmolarity), albumin + loop diuretics, sodium pentobarbital (dec. cerebral blood flow, should have swan ganz placed), hypothermia 2. causes release of thromboplastin, which activates extrinsic path leading to DIC 3. elevated PT/PTT, low fibrinogen, elevated fibrin split products/d dimers, dec. platelets tx = cryoprecipiate for fibrinogen, platelet for <100k, FFP for PT/PTT

cerebrovascular accidents 1. causes 2. pathogenesis

1. embolization (cardiac or carotid) primary vessel occlusion intracerebral hemorrhage subarachnoid hemorrhage 2. atherosclerosis of carotids --> embolization of fibrotic debris or stenosis proceeds to thrombosis

peptic ulcers 1. treatment for simple perforated peptic ulcer 2. treatment for long standing ulcer disease

1. emergency celiotomy + omental patch 2. highly selective vagotomy (disects the parietal cell mass, but preserves ANT/POS NERVES OF LATERJET), antrectomy/truncal vagotomy, pyloroplasty and truncal vagotomy

1. high coronary risk procedures 2. intermediate "" 3. low """

1. emergency operations, aortic/major vascular, peipheral vascular, long procedures with blood loss/fluid shiftr 2. carotid endarterectomy, head/neck, intraperitoneal/intrathoracic, orthopaedic, prostate 3. endoscopic, superficial, cataract, breast

1. indications for lung transplant 2. what approach for lung transplant

1. emphysema, COPD, alpha 1 antitrypsin, PPH, cystic fibrosis 2. lateral throacotomy

schwannomas 1. patho 2. clinical pres

1. encapsulated tumors surrounded by nerve or attached to nerve- NON MALIGNANT* 2. presents as a painless mass

portal hypertension 1. clinical presentation

1. encephalopathy (ammonia/hepatic insufficiency) GI hemorrhage malnutrition (alcoholics) ascites (hypoalbuminemia, hyperaldo, sinusoid HTN) venous collateral development (caput/hemorrhoids) splenomegaly (hypersplenism)

portal hypertension 1. emergency surgery for acute massive bleeding

1. end - side portacaval shunting or porta caval shunt, ligation of varices, high rate of re-bleeding

traumatic arterial injury 1. management

1. end to end anastomosis if there will be no tension (ie. <5cm) >5 cm of destroyed artery, use saphenous vein graft

abdominal aortic aneurysm 1. tx

1. endoaneurysmamorrhaphy, endovascular repair (requires infrarenal neck and one adequate common iliac)

pancreatic tumors 1. APUD cells + common features 2. specific types of tumors

1. endocrine cells of gut - amine precursor uptake and decarboxylation 2, inuslinomas, gastrinomas, glucagonomas, VIPomas, somatostatinomas

bladder cancer 1. staging tests 2. what does muscle invading disease indicate + what should be done 3. treatment for bladder cancer that does not enter the muscle

1. endoscopic resection (look for muscle invasive disease), bimanual examination 2. invasive metastatic disease CXR, and chest CT scan, BONE SCAN , serum alk phos (helps ID bony mets) 3. INTRAVESICULAR thiotepa, mitomycin C, doxorubicin, BCG (stimulates immune response for tx CIS), alpha interferon

gastric ulcer complications hemorrhage 1. treatment

1. endoscopy, thermal closure of vessel, injection of sclerosing/vasoconstrictive agents surgery if massive hemorrhage (>1500cc of blood), truncal vagotomy, pyloroplasty, vagotomy with antrectomy

hemorrhoids 1. patho - first degree - bleed but don't prolapse -second degree- bleed and prolapse and reduce spontaneously -third degree - bleed/prolpase, and must be manually reduced -fourth degree cannot be manually reduced 2. external hemorrhoids 3. sx

1. engorgement of the anal cushions (highly vascular) from prolonged straining and increased abdominal pressure 2. lie below anal verge 3. bleeding, mucous, prolapse, pruritus-- only painful if incarcerated or or prolapsed

head and neck lymphoma 1. clinical presentation 2. hodgkins extranodal sites 3. clinical presentation 4. dx/tx

1. enlarged cervical node , firm and rubbery 2. waldeyer's tonsillar ring, nasal cavity, orbit, salivary glands 3. fever, sweats, weight loss, malaise 4. dx = endoscopy/excisional biopsy , CXR, CT scan, bone marrow tx = MOPP/radiotherapy for hodgkin's disease non-hodgkins tx = chemotherapy (CHOP) + irradiation

fibrous dysplasia of the jaw 1. patho 2. dx

1. enlargement of the bone of the jaw (maxilla>mandible) 2. radiograph shows sclerosis, lytic lesions, unilocular lesions

BPH 1. patho 2. histo 3. clinical pres 4. dx 5.

1. enlargement of the prostate that occurs in aging men - testosterone dependent process 2. stromal/epithelial hyperplasiain the periurethral zonethat compresses the urethra 3. LUTS - weak stream, hesitancy, incomplete emptying, double voiding, frequency, urgency, nocturia, dyusura 4. DRE, bladder palpation, hematuria, PSA*, ultrasound residual volume, urometrics, trans rectal ultrasound,

amebic hepatic abscess 1. patho 2. clinical pres 3.dx/ tx

1. entamoeba histolytica travels from GI tract to portal vein--> right lobe --> anchovy paste pus / painful and tender enlarged liver 2. fever, leukocytosis, hepatomegaly RUQ pain 3. dx = indirect hemagglutination test, stool sample/micro metronidazole surgical drainage not necessary

1 epidermal inclusion cysts 2. sebaceous cyst 3. dermoid cyst .

1. epiddermal cells are trapped in subQ tissue 2. blockage of a sweat gland --> accumulation of a cyst 3. congenital lesions that can have intracranial communication (if glabellar or nasal location)

1. first degree burns 2. second degree burns 3. third degree burns 4. when to hospitalize patients for burns

1. epidermis 2. superficial involves papillary dermis, deep involves reticular dermis 3. involves entire dermis 4. 3rd degree >2% of BSA, partial thickness >10%, or 2nd/third degree on face, hands, feet, genetalia, or major flexion cresases

giant cell tumors of bone 1. patho 2. radiographic findings

1. epiphyseal-metaphyseal region of femur, tibia and distal radius 2. circumscribed lytic lesion

resp alk 1. causes 2. tx

1. increased breathing- anxiety, pain, shock, sepsis, salicylates, CNS dysfunction, pulmonary embolus (hypoxia/intrapulmonary shunts) 2. decreasing minute ventilation

1. indications for perioperative invasive hemodynamic monitoring 2. what patients need bacterial endocarditis prophylaxis 3. what cardiac disease patients do not need prophylaxis

1. fluid shifts in patients with LV dysfunction, or fixed CO, major vascular surgery in patient with LV dysfunction 2 .prosthetic heart valves, rheumatic valve damage, MVP/MVR, congenital heart defects, systemic/pulmonary shunts, HCM, prior hx bacterial endocarditis 3. isolated secundum ASD, 6 months post ASD/VSD/PDA repair, post CABG, MVP w/o regurg, innocent murmurs, previous kawasaki/rheumatic w/o valvular dysfucntions, pacemakers/defibriliators

- trauma, inflammation (ex. crohns), malignancy, radiation damage can all cause fistulas 1. complications of fistulas 2. when is operation neccessary

1. fluid/electrolyte imbalanc (ex. pancreatic fistula leaking bicarb--> met acid) sepsis skin excoriation - intestinal secretions drain onto skin malnutrition - hemorrhage ex. mesenteric vessel erosion 2.foreign body at the fistula, radiation injury, injured bowel or inflammatory bowel disease at fistual epithelialization of fistula tract neoplasia at fistula distal obstruction beyond fistula

carcinoid syndrome 1. sx 2. dx 3. tx - prog - 70% if no liver mets, 20% if there are liver mets

1. flushing, diarrhea, bronchoconstriction, tricuspid/pulmonary valve disease caused by serotonin/other vasoactive substances released by the tumor 2. elevated 5-hydroxyindoleacetic acid (breakdown of seratonin) 3. resection/debulk, chemotherapy, chemoembolization

1. which kind of thyroid cancer mets hematogenously 2. which thyroid cancers have local invasion 3. what is most useful diagnostic test to determine if nodule is malignant

1. follicular carcinoma 2. follicular, medullary, anaplastic 3. needle biopsy (except for follicular neoplasms)

1. wide local resection 2. radical local resection 3. radical resection with en-bloc excision of lymphatic drainage 4. super radical resection

1. for low grade tumors that dont met/spread lymphatically, ex. basal cell carcinoma, mixed tumor of the parotid gland 2. neoplasms that deeply invade surroundign tissue ex. extremity sarcoma -- includes entire muscle compartment where the tumor lies. 3. used for tumors taht first met to regional nodes ex. colon cancer - take colon segmetn + mesentery/lymphatics 4. large portions of the body localy extensive disease with low likelihood of mets ex. pelvic exenteration.

cholecystostomy 1. procedure

1. for patients with cholecystitis and too much inflammation or too ill to undergo cholecystectomy -- place external tube for drainage

1. flaps 2. rotation flap 3. free flap

1. for wounds with vascular loss, transfer tissue with blood supply 2. flap retains blood supply, but mobilized to different site 3. tissue removed from normal blood supply to another area must reanastomose~ ex. great toe to hand

congenital diaphragmatic hernias 1. patho 2. dx + CXR 3. tx

1. foramen of bochdalek posterolateral diaphragmatic defect (-->resp distress/PPH in infants) foramen of morgagni anterior diaphragmatic defect (detected in adulthood as low ant- mediastinal mass on CXR) 2. tachypnea, dyspnea, accessory muscles, breath sounds that are decreased/absent on affected side, shifted heart sounds, scaphoid abdomen CXR - gas pattern in hemithorax 3. routine ventilation, ECMO/repair

achalasia 1. tx 2. associated complications

1. forced pneumatic dilation esophagomyotomy, modified Heller procedure= laparoscopic myotomy and partial fundoplication Medical- nitrates/CCBs, botulinum toxin injections 2. 7x greater risk of SCC compared to general population

1. clinical pres of prostatitis/chronic pelvic pain syndrome 2. acute bacterial prostatitis + dx/tx 3. chronic bacterial prostatitis + tx tx 4. non bacterial prostatitis + tx 5. prostodynia

1. frequency, urgency, perineal pain, fullness, dysuria 2. bacterial infection of the prostate + fever dx =urinalysis, expressed prostatic secretions tx = TMP SMX or fluoroquinolone x 30 days, or amp+gent, or vanc 3. NO FEVER****** TMPSMX x 6 weeks, fluroquinolone x 6 weeks 4. doxy x 6 weeks, 5. antibiotics, alpha antagonists, TCA, gabapentin, diazepam, biofeedback, stress reduction, saw palmetto, pyegeum extracts

1. pectus excavatum (most common cx wall def) 2. pectus carinatum 3. polands syndrome

1. funnel chest 2. pigeon breast overly prominent sternum 3. unilateral absence of costal cartilages, pectoralis muscle and breast

1. enzyme deficiency hemolytic anemias 2. RBC membrane abnormalities that cause hemolytic anemia 3. thalassemias patho + tx 4. congenital erythropoietic porphyria + tx

1. g6pd, pyruvate kinase 2. spherocytosis, elliptocytosis 3. defect in hemoglobin chains leads to anemia/splenomegaly, thalassemia major is assoc with early death/splenomegaly/anemia/jaundice tx = splenectomy/transfusions 4. AUTOSOMAL RECESSIVE pyrrole metabolism defect --> porphyrin deposition in the skin --> photosensitivity, bullous dermatitis, hemolytic anemia tx = splenectomy

1. post transplant prophylaxis against CMV (from a seropositive donar) 2. what kind of cancers higher post transplant

1. ganciclovir 2. skin cancer SCC, PTLD (EBV associated B cell lymphoproliferative disease tx = acyclovir)

achalasia 1. patho ~ similar to chagas 2. sx 3. dx

1. ganglionic dysfunction --> high LES pressure, failure of LES to relax when swallowing--> dilation of the esophagus + 10x inc. freq of esophagus cancer*** 2. dysphagia to liquids>solids, regurg, weight loss, aspiration related respiratory symptoms*** 3. X Ray* shows dilated proximal esophagus with bird beak LES, esophageal manometry* shows high LES pressure at rest* and absent peristalsis

complications of cholecystitis/cholelithiasis 1. emphysematous cholecystitis 2. dx/tx 3. gangrenous cholecystitis 4. perforated cholecystitis

1. gangrenous cholecystitis with invasion of gas forming organisms, rapid progressive sepsis 2. gall bladder is filled with gas radiologically tx = urgent cholecystectomy + abx 3. cystic artery thrombosis--> extensive inflammation/necrosis of gallbladder 4. necrosis and leakage of bile into peritoneal cavity-->subhepatic abscess

1. paraesophageal hernia patho 2. tx

1. gastric cardia/fundus/viscera herniates through the esophageal hiatus into thorax within a true peritoneal sac--> causes strangulation/obstruction of the esophagus (DANGEROUS) 2. repair the diaphragmatic hernia, reduce the volvulus if present

met alk (>7.45),HCO3- >26mEq/L 1. cause

1. gastric content loss* --> Aldosterone--> reabsorb Na, secrete H+, over administration of alkali, acetate in TPN,

malrotation of the intestine 1. normal dev 2. malrotation anatomy 3. patho + sx 4. dx 5. tx

1. gut develops extraabdominally then undergoes 270 degree rotation and comes back into the abdomen 2. cecum not in RLQ (found in right upper quadrant with ladds bands), duodenum not behind SMA 3. malrotation --> obstruction or volvulus --> bilious vomitting, bloody stool late with ischemia/necrosis 4. ABD XR - double bubble sign with gas in the stomach/duodenum, upper GI shows displaced ligament of treitz 5. ladd procedure- break ladds bands, put cecum in correct position/appendectomy,

pilonidial disease 1. patho 2. tx

1. hair from the skin of post sacral superior gluteal cleft ingrows and causes foreign body reaction 2. I&D, or excision with secondary intention

SIADH 1. patho 2. lab findings

1. head injury, neoplasms, pulmonary disease, drugs, postoperative 2. high urine osmolarity, hyponatremia (--> brain swelling --> CNS sx), high FENa, high urine sodium

basal cell carcinoma 1. location 2. features 3. ttx

1. head/neck 2. slow growing, translucent edges, erythematous/pigmented, telangiectatic, may ulcerate 3. curettage/electrodesiccation, radiation therapy, excision with primary closure, mohs micrographic surgery, cryotherapy,

pituitary tumors 1. clinical pres 2. dx/tx

1. headaches, bitemporal hemanopsia --> cushings, acromegaly, hyperprolactinemaia, or hypopituitarism 2. radioimmunoassays, CT/MRI looking at sella, angiography, tx = bromocriptine for prolactioma, surgical resection for non-prolactinomas (transphenoidal), radiation

1. VHL clinical pres

1. hemangioblastmas of cerebellum* and retina and congenitla cysts of kidneys, pancreas, liver and RCC, and ERYTHROCYTOSIS (from EPO)

septic arthritis 1. pathogenesis 2. dx

1. hematogenous spread of organisms to the joint space 2. aspiration of the joint showing WBC>50k w/ PMN predominence

thyroiditis 1. patho 2. dx/tx

1. hematogenous spread of organisms to thyroid gland --> pain, tenderness swelling over both lobes of thyroid gland 2. needle aspiration/bacteriologic studies tx = local resection or open drainage, antibiotics

osteomyelitis 1. patho 2. dx/tx

1. hematogenous spread of staph/strep to bone 1. ESR, CBC, needle aspiration of bone tx = antibiotics/surgical drainage, abx impregnanted beads

transfusion complications 1. symptoms of ABO incompatibility 2. delayed hemolytic reaction 3. diseases transmitted 4. hemolytic transfusion reaction lab findings **don't forget, blood transfusions cause immunosuppression - morbidity/infections, inc. cancer recurrence, inc. mortality

1. hemoglobinuria, DIC*** fever, chills, coagulopathy (BLEEDING), renal failure, circulatory collapse 2. 3-7 days =- fever, malaise, hyperbilirubinemia -- Rh system or other minor antibody system 3. HIV, hep C, hep B, HTLV 1/2, west nile, CJD 4. elevated PT/PTT/bleeding time, elevated D-dimers/FSP, elevated free hemoglobin, low hepatoglobin, hemoglobinuria

pituitary apoplexy

1. hemorrhage into the pituitary- similar in pres to ruptured berry aneurysm, headache, impaired vision, extraocular dysfunction, stiff neck

hepatocellular carcinoma (MCC liver malig) more malignant in men 1. assc 2. environmental assc

1. hep B/hep C, cirrhosis (esp. macronodular), hemochromatosis, schistosomiasis 2. polychlorinated biphenyls, chlorinated hydrocarbons, CCL4, nitrosamines, vinyl chloride, organochlorine pesticides aflatoxin, throtrast

1. what is the most common vascular complication of liver transplant 2. what is the most common vascular complication of renal transplant 3. lymphatic complication of kidney transplant - ureter-bladder anastomosis leak also occurs

1. hepatic artery thrombosis 2. renal artery stenosis, or thrombosis and renal vein thrombosis 3. perinephric lymphocele

acute abdominal pain 1. tenderness to percussion over liver/kidney 2. iliopsoas sign 3. obturator sign 4. murphys sign 5. rovsing's sign

1. hepatitis, pyelonephritis 2. appendicitis, perinephric abscess, flex ipsilateral hip while lying down/pain with flexion + resistance of hip 3. pain when thigh is flexed and int/ext rotated - inflammatory processes of obturator muscle ex. obturator hernia 4. RUQ palpation during inspiration, - acute cholecystitis 5. palpation on the LLQ causes RLQ pain

hepatocellular carcinoma 1. clinical presentation 2. dx 3. mets 4. tx

1. hepatomegaly, RUQ pain, malaise, fever, jaundice, weight loss, abdominal mass, 10% acute hemorrhage, paraneoplastic syndromes (ex. cushings) 2. ELEVATED AFP***, hepatic ultrasound/CT/MRI. 3. invasion into diaphragm, lung (most common) 4. resection/transplantation, AFP monitoring, palliative chemoembolization

hepatic failure - avoid hypotension in patient with liver failure b/c it can cause ischemic damage 1. what kind of heart failure in cirrhosis patients 2. what electrolyte abnormalities in chronic alcoholism 3. cirrhosis coagulopathy

1. high output cardiac failure 2. hypokalemia, hypomagnesemia, hypophosphatemia, met. acid, lactic acidosis 3. vitamin K deficiency, factor synthesis deficiency

1. pattern of electrical burn injuries 2. tx

1. high resistance structures sustain the worst damage (ex. tendon/bone etc) while superficially it may appear mild 2. aggressive rehydration with strong fluid output (prevent renal damage from myoglobinuria), fasciotomy(deep myonecrosis), skin grafting, amputation, high dose penicillin to prophylax for clostridium, mafenide acetate

neurogenic shock 1. pathogenesis 2. major distinctive in lab values 3. TX

1. high spinal cord injury--> loss of sympathetic tone ~ vasovagal response, cervicothoracic spinal cord injury, spinal anesthesia. hypotension/vasodilation (WARM SKIN***), bradycardia (compare to septic shock) 2. dec. SVR with normal or decreased HR 3. fluid resuscitation, vasoconstrictors (phenylephrine)

diverticular disease 1. hemorrhage clinical presentation 2. dx 3. tx

1. high volume bright red blood/shock 2. crystalloid, transfusion, NG tube ( r/o upper GI hemorrhage), proctoscopy (r/o hemorrhoids), coagulation study, mesenteric arteriogram (+vasopressin infusion @ site*) 3. mesenteric arteriogram vasopressin, segmental colectomy. total abdominal colectomy with ileostomy

radiation therapy 1. more effective for highly oxygenated or oxygen deficiency cells 2. what phase of cell cycle most effective 3. what cell proliferative rate most effective

1. highly oxygenated 2. M phase 3. rapidly proliferating cells (Ex. bone marrow/GI mucosa)

orthopedic urgencies 1. hip dislocation 2. open fractures + tx 3. penetrating joint injuies tx

1. hip dislocations (>12 hours --> AVN) 2. open fractures - debridement, splinting, first gen cephalo (or vanc in penicillin allergic), aminoglycoside/penicillin for patients with soil contamination tetanus irrigation and debridement 3. irrigation adn debridement by arthorscopy (ex. knee dash strike),

CAD 1. dx 2. medical tx 3. how to determine degree of CAD

1. history, EKG usually NORMAL, exercise stress test ***, radio thallium scan (finds ischemic/infarcts) 2. nitrates, aspirin, beta blockers (reduces post-op mortality), digitalis, CCB 3. cardiac cath, coronary angiography -- >50% narrowed = significant (@70% get angina)

laryngeal cancer 1. clinical presentation 2. dx 3. tx

1. hoarseness, stridor, cough, dysphagia, aspiration 2. laryngoscopy 3. local excision for CIS, radiation, surgical removal

mitral insufficiency 1. auscultation 2. most important diagnostic test -cardiac cath to detect CAD 3. surgical tx 4. indications for surgery

1. holosystolic blowing murmur that radiates to the axilla + accentuated apical impulse 2. echocardiography + color doppler - to determine the degree of regurg and anatomic abnormalities 3. mitral valve repair (quadrangular resection of pos leaflet), annuloplasty ring 4. EF <60%, ventricular dilation >45mm dias, Afib, pulm hypertension

coronary artery disease 1. risk factors 2. effect on myocardium

1. htn, smoking, hypercholesterolemia, FH, DM, obesity 2. dec. compliance, dec. contractility, necrosis

1. white bile 2. what causes physiologic release of bile

1. hydrops of the gallbladder- accumulation of mucus in cystic duct obstruction 2. CCK, and vagal/splanchnic nerves

thyroid storm 1. clinical presentation 2. when is recurrent laryngeal nerve injury dangerous

1. hyper metabolism, hyperpyrexia, tachyarrhythmias, hemorrhage, hypoparathyroidism, recurrent laryngeal nerve injury 2. when the damage is bilateral, airway obstruction occurs

mesenteric venous thrombosis 1. patho/sx 2. dx

1. hypercoagulable --> progressive abdominal pain and distension, 2. CT scan shows contrast concentration in mesenteric vein 3. heparin, celiotomy if there is peritonitis

diabetes mellitus 1. DKA 2. adjusted Na 3. how to correct ketoacidosis

1. hyperglycemia, ketosis, acidosis, massive dehydration (osmotic diuresis) 2. measured Na is 1.7 lower for every 100mg/dl glucose elevation 3. administration of IV fluids, insulin, bicarbonate, potassium

MEN1 (Wermer's syndrome) 1. features 2. dx 3. tx

1. hyperparathyroid, non-beta pancreatic tumors (ex. zollinger ellison pituitary tumors (acromegaly, galactorrhea, amenorrhea, cushings syndrome) 2. suspect in patients with symptoms of peptic ulceration, elevated calcium 3. parathyroidectomy with arm reimplantation, removal of gastrinomas, pituitary tumors treated iwth bromocriptine

tertiary hyperparathyroidism 1. pathogenesis 2. tx

1. hyperparathyroidism after successful renal transplant from parathyroid hyperplasia 2. surg= parathyroidectomy with autotransplantation

galactorrhea 1. causes

1. hyperprolactinemia, hypothyroidism, OCP, phenothiazines, antihypertensives, chest trauma,

type of urinary dysfunction assc with 1. spinal cord injury 2. cerebrovascular accidents 3. parkinsonism 4. myelodysplasia + tx

1. hyperreflexia with DSD sacral spinal lesions cause areflexia 2. detrusor hyperreflexia, NO***DSD, sphincter control intact 3. detrusor hyperreflexia, failure to relax external sphincter 4. ex. myelomeningocoele, detrusor hyperreflexia/high intravesicular pressure, tx = anticholinergic agents dec. bladder pressure********

1. clinical presentation of cushings syndrome (clinical manifestations of glucocorticoid excess) 2. diagnosis of cushing's disease 3. how to differentiate ectopic from pituitary cushing's

1. hypertension, DM, hypokalemia, osteoporosis, central fat redis, muscle wasting, striae, easy bruising 2. total plasma cortisol, overnight dex suppression test >30ug.dl @8am 24 hour urinary free cortisol 3. dex suppression test - will be suppressed in pituitary cushing's, will not be suppressed in ectopic/adrenal cushings CRH stimulation test - increased in pituitary, baseline in ectopic/adrenal LPH level - higher in ectopic cushings

pyloric stensosis 1. patho + sx 2. electrolyte 3. dx

1. hypertrophy of the pylorus --> gradual onset of projectile vomiting 2. hypocholremic, hypokalemic met alk 3. physical examination palpable mid epigastric mass, succussion**, ultrasound, upper GI xray series, visible peristalsis tx = nasogastric decompression, pyloromyotomy

1. hyperaldosteronism lab values 2. what must be repleted before accurate aldo can be measured 3. postural aldosterone response in adenoma vs hyperplasia 4. dx of aldo secreting adenomas 5. tx

1. hypokalemia, hypernatremia, met.alk 2. potassium - hypokalemia inhibits aldosterone secretion 3. hyperplasia inc. aldo, adenoma no change/decrease 4. adrenal venous blood sampling, CT/MRI, iodocholesterol scintigraphy 5. laparoscopic adrenalectomy, spironolactone, mitotane, ketoconazole

pulse abnormalities 1. rapid faint pulse 2. slow full pulse 3. earliest BP sign of hypotension 4. patient with major trauma has stable vital signs

1. hypovolemia 2. neurologic injury with inc. intracranial pressure and hypercarbia 3. narrowed pulse pressure with diastolic hypertension 4. STILL RESSUSCITATE, YOUNG HEALTHY PEOPLE CAN COMPENSATE FOR A WHILE BUT THEN THEY WILL CRASH and drop BP/lose consciousness

immediate life threatening injuries 1. airway obstruction- patho/tx 2. tension pneumothorax patho/tx

1. hypoxia, hypercapneia, acidosis-->cardiac arrest tx = clear secretions/foreign bodies, and establish airway 2. air escapes from visceral plerua lung and cannot be released--> mediastinal shift/compression of vena cava-->hypotension tx = needle decompression and underwater seal/suction

esophageal perforation 1. causes 2. rupture of the esophagus complications 3.sx 4. dx 5. tx

1. iatrogenic, trauma, boerhaave 2. acute mediastinitis--> almost always fatal 3. severe chest pain 4. crepitation in the neck, hammans sign (heart crunch sound), septic shock, CX radiograph shows air in mediastinum or air under diaphragm, barium swallow, CT 5. primary repair with tissue butress, esophageal resection + gastrotomy tube

cecostomy tubes

large caliber tubes surgically inserted into distended cecum used for colonic ileus ~ helps prevent rupture of cecum >12cm,

hypokalemia (K+<3.5, <3 = severe) - cardiac pateints keep K+ >4 1. sx + ECG 2. causes: renal, extrarenal 3. intracellular shifts 4. what medical diseases (2) 5. tx

1. ileus, weakness, T wave flattening, ST depression, U waves, long QT, --> Vtach 2. renal = diuretics, vomitting (aldosterone), RTA extra-renal: diarrhea, burns 3. insulin, alkalosis 4. hyperaldosteronism, cushings syndrome 5. 20mEq/hour or 40 (monitored) 10mEq --> 0.1mEq/L change in conc.

diffuse axonal injury 1. patho 2. clinical pres 3. dx

1. impact, sharp accel/decel --> shear forces /shock waves to the brain and damage to deep axonal tracts @ gray/white junction 2. marked neurological dysfunction 3. CT scan shows punctate hemorrhages

acute cholecystitis 1. patho/clinical pres 2. ddx

1. impacted stone in the cystic duct/gallbladder neck--> direct pressure with ischemic, ulceration, edema, impaired venous return--> bacterial infection--> fever, nausea, vomiting, RUQ tenderness, murphy's sign, 2. perforated/penetrating ulcer, MI, pancreatitis, hiatal hernia, RLL pneumonia, appendicitis, hepatitis, HZV

aortoiliac disease 1. claudication sx 2. leriche syndrome 3. distal thromboembolism clinical pres 4. aortoiliac disease physical exam findings

1. in buttocks/thighs/calves 2. aortoiliac occlusive disease of distal aorta - buttock/thigh claudication, absent femoral pulses, impotence 3. presents with blue toes 4. absent femoral/distal pulses, bruits of the pelvis

diabetes mellitus 1. hyperosmolar non-ketotic state + tx 2. effect of uncontrolled DM on operative infections, healing -operative mortality in DM - 2%~ mostly CV and sepsis (staph) complciations

1. in resoponse to stress - non-ketotic, hyperglycemic hyperosmolar coma, not associated with acidosis tx = IV fluids, insulin, K+ 2. inc. infections, interferes with wound healing

1. where are fractures likely to happen in young patients/skeletally mature but young/old

1. in the growth plates ligaments metaphyseal portions of long bones

Jejunal/ileal/colonic atresias 1. patho + pres 2. associated conditions 3. dx /tx

1. in utero vascular accidents --> ischemia of bowel segment --> atresia/stenosis usually ileum --> bilious vomiting 2. cystic fibrosis 3. air fluid levels and distended bowel on xray, contrast studies tx = end to end intestinal anastomosis, NG tube to prevent aspiration

atherosclerosis of lower extremities 1. gangrene 2. wet "" 3. dry ""

1. inaddequate blood flow to tissue --> ULCER-->tissue necrosis 2. infection with non-viable tissue 3.

hypovolmeic shock 1. define 2. hypovolemic shock 3. physiological response

1. inadequate tissue perfusions to maintain normal metabolism 2. major burns, blood loss, third spacing + loss of RBCs--> dec. CO/O2 delivery 3. peripheral vasoconstriction to maintain perfusion to vital organs

meningiomas 1. clinical pres 2. dx/tx

1. inc ICP,seizures, focal deficits, 2. well defined border, adjacent to the dura, intense enhancement, well demarcated border, SPINAL TAP - shows increased pressure, elevated protein, positive cytology tx= excision, radiation, chemo

PDA 1. ductus arteriosus closure mechanism 2. clinical pres 3. dx

1. inc blood/oxygen causes breakdown of PGE1/2 leading to closure of the ductus 2. dyspnea, fatigue, palpitations, CHF sx 3. machine like murmur, widened pulse pressure, bounding peripheral pulses, echocardiography 4. ligation of the ductus >2-3 years of age, or premature infants indomethacin (prostaglandin inhbiotor)

dopamine 1. low dose effects 1-3ug/kg/min 2. mid dose "" 3-10ug/kg/min 3. high dose >10 ug/kg/min 4. effect of dopamine on coronary flow at all concentrations****

1. inc. blood flow to the kidneys/intestines 2. beta receptor agonist inc. CO/cardiac contractility 3. alpha agonist 4. diastolic blood pressure rises, and thus increases pressure at the coronary ostia

compartment syndrome 1. patho + sx 2. dx/tx

1. inc. in interstitial fluid pressure within an osteofascial compartment --> necrosis of the muscle and dysfunction of nerves in the compartment--> pain out of proportion, pain with passive stretch, pain and tenseness on palpation, pain on palpation paresthesias - burning or tingling 2. dx = >30mmhg pressure, tx = surgical fascial release

1. wound healing steps 2. considering wound healing when administering anti-neoplastics 3. how to normalize wound healing in patient on methotrexate

1. inc. inflamm/vascular permeability--> fibrin/PMNs/monocytes/platelets macrophages 4th day - proliferative phase - fibroblasts produce mucopolysaccharides/collage 20th day - maturation phase - cross linking of collagen fibers 2. wait >14 days after surgery/injury to resume anti-neoplastics 3. folinic acid

umbilical hernias - present in EVERY child at birth 10x >in women usually spontaneously closes by 2 years of age 1. clinical associations 2. repair

1. inc. intraabdominal pressure - ascites/preg 2. simple transverse repair of fascial defect, at age 3-5yo, or >1-2cm defect (many of these close spontaneously before this age)

hemangioma 1. pathogenesis 2. tx (+ when is it indicated)

1. inc. mast cells --> elevated, red, soft lesion that grows rapidly then spontaneously regresses 2. only treat if functional impairment or platelet consumption

portal hypertension 1. patho of portal hypertension 2. MCC 3. patho of cirrhosis

1. inc. portal venous pressure --> venous collaterals--> dilated veins/varices that can rupture/hemorrhage 2. cirrhosis- alcohol/hepC (MCC), schistosomiasis, wilsons, hepatic fibrosis, hemochromatosis 3. narrowing of sinusoidal/post-sinusoidal vessels as centrilobular collagen deposits

1. preoperative interventions to reduce pulm complications of surgery

1. incentive spirometry, deep breathing, CPAP, postural drainage of respiratory secretions

wounds 1. clean 2. clean contaminated 3. contaminated 4. dirty/infected

1. incisions under sterile conditiosn that doesnt involve bowel/tracheobronchial/GU/oropharynx < 2% infection 2. bowel/tracheobronchial/GU/oropharynx involved, minimal contamination and *no* signs of active infection- cholecystectomy, colon resection, appendectomy, bladder surgery 3-4% infection 3. major contamination of wound - ex. gross spillage of colon, infection of biliary tract,, resp or GU system, fresh trauma, ex .pus in gallbladder with spillage, bowel obstruction with enterotomy 7-10% infection 4. infection present before wound is made - ex. abscess, trauma wound with necrotic tissue, perforated viscus 30-40% infection

hepatic failure 1. why does obstructive jaundice increase the risk for infection 2. cholangitis treatment 3. obstructive jaundice coagulopathy -also associated with post-op renal failure (correlates w/ bilirubin level), gastrointestinal hemorrhage, delayed wound healing/infection 4. risk factors for post-op complications in patients with obstructive jaundice

1. increased intestinal absorption of enteric endotoxin w/o luminal bile salts 2.endoscopic retrograde cholangiopancreatography with sphincterotomy and biliary stenting or transhepatic cholangicography with drainage 3. 2/2 vitamin K malabsorbtion, DIC if there is biliary sepsis 4. hematocrit <30%, bili >11, malignancy, hypoalbuminemia, cholangitis, azotemia

diverticular disease 1. patho 2. location

1. increased intraluminal pressure associated with low fiber diet --> outpouching and muscular hypertrophy 2. MC is sigmoid colon (b/c has the smallest radius)

1. CABG/PTCA risk of perioperative coronary disease -saphenous grafts 10-20% occluded by 1year - PTCA restenosis 6 monts = 25-35% 2. when do most post-op MIs occur

1. increased risk 2. 1-2 days post op

acute abdomen <8 hours onset 1. gradual periumbilical pain 2. severe explosive pain 3. progressive severe pain 4. localized pain that recurs as generalized pain 5. crampy pain (crescendo/decrescendo) + lack of flatus 1-2 days 6.crampy pain that becomes constant and severe

1. indicates visceral peritoneal irritation- appendicitis, diverticulitis ~ may progress to more local 2. immediate soiling of the peritoneaum - ex. viscus perforation 3. worsening intraabdominal condition - ex ischemic necrosis of the bowel 4. inflammed organ has perforated- ex. ruptured acute appendicitis 5. obstruction in the GI tract ex. bowel obstruction 6. involved bowel segment is not ischemic/gangrenous

1. cadaver organ donors 2. dx of brain death

1. individuals with irreversible brain death 2. neurological examination, absent reflexes from brainstem/higher, normothermic, no depressant drugs,apnea test negative, EEG and cerebral blood flow

1. three types of immunosuppression needed for organ transplant 2. anti-rejection regiments 3. mainetnence thearpy

1. induction, anti-rejection, maintenance therapy 2. high dose steroids, cyclosporine or tacrolimus, and a third drug to prevent acute rejection 3. long term suppression cyclosporine or tacrolimus combined with corticosteroids

abdominal Xray 1. lost psoas muscle shadows/peritoneal fat lines 2. shifting organ margins 3. what is diagnosed with intravenous pyelogram 4. boerhaave syndrome + what study should be ordered

1. infections, hematomas, abscesses 2. abnormal masses 3.pyelonephritis, perinephric abscess, renal infarct, appendicitis, 4. esophageal rupture/left pleural effusion after violent vomitting (from INC. INTRABD PRESSURE)-- barium swallow study

1. most common type of shoulder dislocation 2. mechanism of anterior dislocation

1. inferior 2. abduction and external rotation

1. clinical pres of mycobacterial infection of the neck

1. inflamed mass or draining sinus in the head/neck associated with the submandibular/parotid glands

chronic cholecystitis 1. patho/clinical pres 2. dx/tx

1. inflammation of the gallbladder--> RUQ/epigastric pain, vomiting, radiation to back/right scapula*, ASSC with eating fatty foods 2. OCG (shows filling defect/fails to appear), ultrasound shows stones tx = cholecystectomy, or oral bile salts, lithotripsy

percutaneous intervention for PVD 1. PTA 2. stents 3. complications of PCI for PVD

1. inflatable balloon catheter fractures the plaque in the artery- larger proximal vessels have better results than smaller distal vessels (fem/pop/tib) 2. helps prevent recoil of angioplasty 3. atheroembolism - blue toes - no tx, large vessels treated surgically or TPA intimal hyperplasia thrombosis rupture

caustic esophageal strictures 1. patho 2. dx 3. tx

1. ingestion of lye/drain/oven cleaner, history of reflux/dysphagia 2. history and endoscopy (NOT PAST PROXIMAL BORDER OF DAMAGE- RISK OF PERF**) 3. antibiotics, radiographs,dilation fo the esophagus, dilation of the esophagus, anti-reflux operation

thrombotic thrombocytopenic purpura 1. patho 2. dx

1. inhibition of ADAMTS13, cannot convert precursor vWF to mature vWF--> fever, thrombocytopenic purpura, hemolytic anemia, neurologic disturbances 2. biopsy shows occlusion of arterioles/capillaries w/ hyaline membrane*** tx = splenectomy, steroids

fibrinolysis 1. tissue factor pathway inhibitor 2. protein s/c 3. antithrombin III 4. tPA/urokinase

1. inhibits TF-VII complex 2. inhibits V and VIII 3. inhibits Xa complex 4. converts plasminogen to plasmin -->cleaves fibrin

factors negatively effecting wound healing + management 1. diabetes 2. jaundice + when to operate 3. uremia 4. immunosuppresant + which immunosuppressant is good for surgerical patients

1. inhibits inflamm response and immune system, increases susceptibility, and dec. wound strength 2. inhibits normal wound healilng-- only operate if LFT is good, or if operation will solve jaundice 3. dialyze prior to operation 4. steroids + azathioprine inhibit wound healing, cyclosporine does not inhibit healing of wounds

1. bladder trauma management 2. penis fracture

1. initially pass a catheter into the bladder, retrograde urethrogram, laceration repair 2. blunt trauma bends the tunica albunginia --> eccymosis, swelling, deviation of the penis.

wound healing 1. coagulation phase 2. inflammatory phase 3. proliferative phase 4. remodeling - whole process mediatd by TGF, PDGF (inc. fibroblasts), chemokines/cytokines, MMPs

1. injured tissue/blood vessels release local mediators to stop bleeding + prim/secondary hemostasis + vasoconstriction 2. a. cellular - inc. vascular perm allows PMNs to migrate and clear necrotic debris/microbes, macrophages remodel ECM b. vascular - hypoxia stimulates angiogenesis, inflamm vasodilation creates edema/fluid influx 3. fibroblasts have invaded and produce collagen, myofibroblasts contract the wound, 4. initial collagen degraded, new collagen synth along stress lines

1. two layers of esophagus 2. two types of muscle in esophagus *esophagus has NO SEROSAL COVERING 3. inervation

1. inner circular, outer longitudinal 2. striated upper 1/3, smooth lower 2/3 3. symp/psymp from pharyngeal plexus, vagus, upper/lower cervical, splanchnic

chronic graft rejection

1. insidious onset, multifactorial, chronic rejection, involves both the cell mediated and humoral arms of immune system -- manifests as vascular rejection of the graft/atherosclerosis

1. anterior brain circulation and what regions are supplied by this 2. posterior circulation and what regions are supplied by this

1. internal carotids, give rise to the middle cerebral, and anterior cerebral--> frontal, temporal, parietal lobes, and deep gray 2. two vertebral arteries --> basilar artery--> pons, cerebellum, thalamus, occipital lobes (posterior cerebral arteries)

1. blood supply to the breast 2. venous drainage of the breast 3. lymphatics of the breast

1. internal mammary and lateral thoracic arteries 2. axillary vein, intercostal veins, internal mammary veins 3. axillary chain***, level one nodes (lat to pec minor), level 2 nodes (behind pec minor), level 3 nodes (medial to pec minor), rotters nodes (interpectoral nodal tissue lie between pec major/minor), internal mammary chain

penis 1. arterial supply 2. venous drainage 3. innervation of the penis 4. mechanism of an erection

1. internal pudendal artery from internal iliac 2. deep dorsal vein and superficial dorsal vein 3. sympathetic from superior hypogastric plexus --> hypogastric nerve --> pelvic plexus parasympathetic --> S2-S4 --> pelvic nerve --> pelvic plexus somatic in pudendal nerve S2-S4** 4. PS NS --< NO from nonadrenergic, noncholinergic neurons and endothelium

anorectal abscess and fistula 1. pathogenesis 2. sx 3. tx 4. anorectal fistula 5. goodsall's rule 6. fistula tx

1. intersphincteric anal gland origin (CRYPTOGLANDULAR)--> abscess--> fistula 2. anorectal pain, swelling, drainage of pus/blood, fever/leukocytosis 3. incision and drainage, NO ABX unless immunocomp 4. communication between anal crypt (usually posterior) and perianal area 5. ext. opening posterior to transverse line connects with pos. crypt and vice versa UNLESS anterior opening >3cm then it connects to pos. 6. identify both openings, and fistulotomy

gastric sarcomas 1. GIST cells + histo dx 2. sx 3. tx 5 year survival 50%

1. interstitial cells of cajal, CD117 positive 2. obstruction, pain, bleeding 3. surgical removal, gleevec (imatinib - c-Kit kinase inhibitor)

gastric adenocarcinoma 1. classifcation (2 types) 2. tx 3. important prognostic factor`` 10-20% 5 year survival

1. intestinal type - distal stomach well differentiated (forms glandular structures) diffuse type (small infiltrating tumor) proximal stomach - leather bottle stomach (linitis plastica/signet ring cells) 2. resection with wide margins (subtotal gastrectomy), removal of nodes/omentum, 5 FU, leucovorin, radiation 3. penetrance through the serosa, if does not penetrate, 5 year survival = 70%

1. what organs displaced from decel injury 2. midline bullet to the abdomen most likely hit what structures

1. intestines, kidneys, aorta *PEDICLED ORGANS 2. small intestine, transverse colon, aorta, vena cava, aorta

1. recurrent stenosis after vascular endarterectomy pathogenesis 2. tx recurrent stenosis 3. when to treat asymptomatic carotid artery stenosis

1. intimal hyperplasia if within first 2 years, if >2 years, it is progressive atherosclerotic disease 2. aspirin and clopidogrel, angiogram/angioplasty if symptomatic 3. >70% occlusion of the carotid artery

1. locations of spinal cord tumors 2. ependymomas characteristic 3. location of schwannomas + clinical pres 4. clinical presentation of neurofibromas 5. lipomas of the spinal cord

1. intramedullary, extramedullary, intradural extramedullary 2. assc. with syrinx, or filum terminale of lumbo sacral region 3. protrude from neural foramen, present with radiculopathy 4. same as schwannomas - radiculopathy 5. intra/extradural tethering of the spinal cord in the filum terminale

chylothorax 1. causes 2. tx

1. intrathroacic surgery, trauma, malignant invasion 2. low fat diet, repeated thoracostomy if does not resolve after several days surgical sub-diaphragmatic approach and re-ligation of the thoracic duct

1. three ways to measure intracranial pressure

1. intraventricular catheter (can also drain), subarachnoid bolts, intraparenchymal probes

hydrocephalus (obstructive and communicating) 1. causes 2. clinical pres

1. intraventricular hemorrhage, aqueductal stenosis, masses, chiari malformations 2. bulging fontanelles, scalp vein dilation, upward gaze palsy (parinauds sydnrome) paipilledema,lethargy, irritability, nausea, ataxia, vomitting 3. CT/MRI tx= ventriculoperitoneal shunt, ventriculoatrial shunt (for infants)

follicular carcinoma 1. associated condition 2/ pathogenesis 3. histo features - radioresistant hurthle cell variant

1. iodine deficient goiter 2. hematogenous spread to distant sites, lungs (vs papillary spreads through lymphatics) 3. hurthle cells

1. lymphatic drainage of the thyroid 2. course of the recurrent laryngeal nerves 3. path of spread of thyroid cancer to larynx

1. ipsilateral cervical lymph nodes 2. right recurrent around right subclavian, left recurrent around ligamentum arteriosum --> both ascend to the larynx in tracheoesophageal groove posterior medial aspect of the thyroid gland 3. uses nodes of the tracheoesophageal groove***

small bowel transplantation 1. indications 2. post-op complications 3. histologic appearance of rejection

1. irreversible bowel failure on TPN, congenital atresias, volvulus, necrotizing enterocolitis, gastroschisis, crohns, trauma, SMA occlusion 2. sepsis, stomal complicaitons, GVHD 3. blunting of microvilli, mononuclear invasion of the wall

acute gastritis 1. patho 2. complications 3. tx

1. irritating agents, alcohol/ethanol 2. massive hemorrhage 3. remove inciting agent, and antacid therapy usually results in prompt healing

stress hemorrhage gastritis (stress ulceration aka erosive gastritis) 1. patho 2. curling vs cushing 3. dx/tx

1. ischemia (dec. splanchnic flow*) to gastric mucosa 2/2 inciting event--> shallow mucosal ulcer that starts in the fundus, often multiple sites in the stomach 2. sepsis, multi organ failure, severe trauma, 3. curling - ulcer in burn patients cushing ulcer in patients with head trauma 4. dx = upper endoscopy by ICU team (too shallow for CT/UGI tx = correct underlying problems, PPI/H2, radiographic embolization

how does edema damage neurons/axons

1. ischemia, dec. oxygen diffusion, lipid peroxidation

1. lower extremity changes suggestive of vascular disease

1. ischemic ulcerations, elevation pallor/dependent rubor, trophic changes (shiny appearance of the skin, diminished hair growth),

teratomas 1. epidermoid cysts 2. dermoid cysts 3. teratoid cysts 4. clinical pres of cervical teratoma

1. lined with squamous epithelium 2. epithelium lined, containing skin appendages, occur along lines of fusion of embryological dermatomes usually above the thyroid cartilage 3. lined with epithelium contain cheezy keratinous material 4. stridor, apnea, cyanosis due to compression

1. which cancers in the mouth tend to be squamous cell 2. """" adenocarcinoma

1. lip, tongue, esophagus, larynx 2. hard palate minor salivary glands, salivary glands

acute alcoholic hepatitis 1. clinical presentation 2. pathological findings 3. dx * should not perform portal hypertension procedure in the presence of alcoholic hepatitis

1. liver failure and tender liver 2. hepatocyte necrosis and hyaline bodies (mallory bodies) 3. hx, elevated LFTs,

graves disease 1. patho 2. symptoms 3. dx 4. tx - surgical is subtotal/total thyroidectomy

1. long acting thyroid stimulator is produced (anti-TSHR) increases T3/T4 production --> 2. palpitations, sweating, intol to heat, irritability, insomnia, tremors, abnormal deposition of mucopolysaccharide --> exophthalmos, edema of eyelids, pretibial edema 3. elevated total serum T4, diffuse increased radioiodine uptake, thyroid scan shows enlarged thyroid, low cholesterol, blood sugar and alk phos increased 4. radioiodine (dont use during preg), PTU blocks T4-T3 conversion, methimazole inhibit peroxidase, high dose iodine, propranolol, lugols iodine prior to surgery

1. DVT prophylaxis

1. low dose heparin, pneumatic compression stockings

1. primary closure 2. secondary intention 3. delayed primary clsoure

1. low infection risk, skin edges approximated and closed 2. high infection risk - leave wound open and allow to heal, epithelialization starts at skin edges and progresses to grnaulation bed +/- skin graft 3. heavily contaminated - leave wound open, and then close 3-5 days later - ex. perf. appendicitis

acute abdominal pain 1. how does leukocytoisis in elderly/diabetic differ from normal person who is septic 2. lymphocytic leukopenia (suggests what) 3. causes of elevated serum amylase also order: ABG serum electrolytes, creatinine, coagulation profile, LFT, B-HCG 4. imaging studies

1. lower level of WBC in septic state 2. viral illness 3. acute pancreatitis, mesenteric thrombosis, perforated ulcer, perforated peptic ulcer, gangrenous cholecystitis, small bowel strangulation, chronic renal failure 4. upright chest (r/o cx dx) and flat/upright abdominal, CT scan (better for free air + extra dx. info)

1. treatment for stage 1 breast cancer 2. treatment for lobular CIS 3 "" ductal CIS treatment 4. ""locally advanced breast cancer with invasion to pec. major 5. "" sclerosing adenitis - infiltrating lobular caner - has linear "indian file" arrangement *assoc with BILATERAL disease

1. lumpectomy + axillary nodes and adjuvant radiation, or modified radical mastectomy 2. just CLOSE observation, it is a marker for future risk**** INCREASED RISK FOR BILATERAL BREAST CANCER 3. wide excision,+/- radiation, or modified radical mastectomy with in continuity axillary node dissection 4. radical mastectomy 5. just observation

breast cancer treatment 1. surgery tx 2. which nerve is at risk during mastectomy 3.modified radical mastectomy 4. skin sparing mastectomy 5. radical mastectomy

1. lumpectomy with negative margins +/- radiation, with axillary sampling/sentinel node biopsy 2. long thoracic nerve (WINGED SCAPULA) 3. includes axillary node dissection ,sentinel node biopsy 4. non-areolar breast skin reserved with immediate reconstruction 5. radical mastectomy - includes the pectoralis major muscle

tongue cancer (MCC malignant oral cavity tumor) 1. site of mets 2. tx -advanced lesions have a poor prognosis

1. lymph nodes/lymph glands 2. surgery and radiation equal

vascular malformations (capillary, venous, lymphatic, AV) 1. lymphatic + tx 2. AV + tx

1. lymphangioma/cystic hygroma - hypertrophy of soft tissues tx = excision 2. remains stable, then expands tx = excision

1. clinical finding of strep skin infections

1. lymphangitic inflammatory streaking, tx = penicillin

hodgkins lymphoma 1. favorable type 2. unfavorable type

1. lymphocyte predominance 2. mixed cellular, lymphocyte depleting

1. common primary tumors of the spleen 2. is mets common to spleen 3. is laparotomy indicated for any stage hodgkin's/non-hodgkins disease 4. is splenectomy indicated for CLL/CML

1. lymphoma, sarcoma, hemangioma, hamartomas 2. nope-- alot of immune cells here 3. no chemotherapy only for the most part now 4. yes it is

unicameral bone cysts 1. patho + cclinical pres 2.tx

1. lytic expansile lesions of the metaphyseal that extends to the growth plate--> pathologic fracture tx - intralesional steroid injection

chondromyxoid fibroma 1. patho

1. lytic lesion with sclerotic rim that occurs in the metaphysis juxtaposed to the growth plate

acute limb ischemia 1. where do macro vs micro emboli lodge 2. sources of emboli 3. atheroembolization 4. where else can mural thrombi occur aside from heart

1. macro in femoral bifurcation, micro in the distal tibial/digital arteries 2. a.fib, myxoma, mural thrombi, rheumatic heart dz, PFO (PARADOXICAL EMBOLISM) 3. atherosclerotic plaques are nidus for thrombus formation 4. infrarenal AAA, and poplitieal aneurysm,

DVT 1. risk factors 2. pathogenesis 3. clinical pres 4. dx/tx *POSTOP PROPHYLACTIC HEPARIN PREVENTS DVT*********

1. major abdominal surgery, prostate surgery, orthopedic surgery* 2. lower venous system in calf area--> pulmonary emboli 3. calf/thigh pain, edema, HOMANS SIGN, PE symptoms 4. duplex ultrasound* venography, magnetic resonance venography (for pelvic DVT) tx = heparin 5-10d-->warfarin 3-6mo, thrombolytic with urokinase/tPA, IVC filter (if heparin CI or PE) leg elevation, compression stocking/unna boot intermittent calf compressions w/ pneumatic cuff

hepatic abscess/cysts 1. clinical presentation 2. dx

1. major systemic symptoms (fever/fatigue/sepsis/anemia), few localizing effects 2. same as liver tumor

1. blood in the stool ddx 2. palpable rectal mass ddx 3. acute prostatitis rectal exam findin

1. malignancy, diverticulitis, angiodysplasia, polyps hemorrhoids, ulcer, colitis, diverticulitis, 2. pelvic abscess 2/2 perf viscous, PID, metastatic malignancy, rectal cancer 3. tender, warm prostate gland

osteosarcoma 1. patho + pres 2. histo 3. dx/tx

1. malignant tumor of bone most commonly in distal femur (codmans triangle) --> pain and tumefaction (pain often worse at night) 2. fibrogenic, chondrogenic, osteogenic , malignant osteoid***, dx= Xray - shows sunburst type appearance* and osteolysis with new bone formation, ESR is normal, elevated ALP 3. RADIATION SENSITIVE, resection, neoadjuvant, adjuvant

chondrosarcoma 1. patho 2. radiographic findings

1. malignant tumor of cartilage --> pain and tumefaction 2. lytic lesions with stippled calcification, cortical thickening, 3. surgical tx with 2 cm tumor free margins

medulloblastomas 1. patho + clinical pres 2. dx/tx 3. pattern of metastasis 4. tx of mets

1. malignant tumors of vermis*/4th ventricle causes symptoms of increased ICP 2. non--hemogenous mass adjacent to /in 4th ventricle tx = resection + radiotherapy 3. "drop" metastasis - shedding of viable tumor cells into the CSF causes spinal cord dysfunction or other CNS symptoms (detect with MRI) 4. complete craniospinal irradiation with local boosts, procarbazine, lomustine, vincristine

breast cancer 1. staging diagnostic tests 2. T 3. N 4. M 5. sites of mets for breast cancer poor prognostic features

1. mammogram, CXR, CT scan (supraclavicular/mediastinal), LFTs, US of liver, bone scan (if patient has bone pain/positive nodes) 2. Tis = CIS, T1 <2cm, T2 >2 <5, T3, >5, T4 ext. to breast wall 3. N0= no mets, N1 = mets to movable axillary nodes, N2 = mets to fixed axillary nodes, N3= mets to ipsi internal mammary nodes 4. M0 no mets, M1 distant mets/supraclavicular nodes 5. lung, liver, adrenals, bone, brain

1. how does CNS tumors cause impariment

1. mass effect, seizures, steal phenomenon, metabolic impairments,

malignant breast disease 1. symptoms 2. risk factors 3. what must be ruled out in a patient with axillary node disease

1. masses, rarely pain, axillary node enlargement 2. BRCA1/2, first degree relatives effected, nulliparous, high socioeconomic status, exogenous estrogen 3. lung cancer, hodgkins disease, pancreatic cancer, squamous cancer of the skin

ogilvie syndrome 1. definition 2. dx 3. tx

1. massive cecal/colonic dilation in the absence of mechanical obstruction --> ischemia/perforation if untreated 2. must exclude mechanical obstruction with colonoscopy or contrast enema 3. d/c narcotics/anticholinergics, endoscopic decompression, rectal tube placement, surgical treatment if others fail

tracheobronchial disruption 1. clinical pres 2. dx/tx

1. massive progressive subcutaneous emphysema 2. collapsed lung fails to expand after placing thoracostomy tube, tx= primary repair

acute abdominal pain 1. cough tenderness 2. flank/periumbilical region eccymosis 3. subQ, sub fascial, pelvic crepitus

1. max tenderness when patient coughs/sudden jarring movements 2. retroperitoneal hemorrhage- trauma, hemorrhagic pancreatitis, abdominal aneurysm, intestinal gangrene 3. rapid gas forming infection-- *urgent dx/exploration neccessary

acute abdomen 1. n/v/anorexia 2. bloody diarrhea 3. symptoms of sepsis 4. how does sepsis symptoms differ in cholangitis/choledocholithiasis

1. may be acute inflammatory/non-surgical or surgical 2. colitis, salmonella, or colonic ischemia 3. fevers/chilss 4. FEVER ACCOMPANIED WITH SHAKING CHILLS

laboratory evaluation for peripheral vascular disease 1. segmental arterial blood pressures 2. what finding on SABP indicates arterial obstruction within underlying segment 3. ankle brachial index 4. exercise testing

1. measure at aortoiliac, femoral popliteal, tibial, distal --reference against brachial pulse 2. > 20 mmHg difference between brachial pulse and lower extremity pulse 3. ankle pressure compared with brachial artery pressure --0.5-0.9 = claudication, 0.2-0.49 - ischemic rest pain, <0.20 is impending tissue loss 4. do brachial:ankle pulse comparison after exercise, >0.20 difference in the ratio is PVD

tissue/mechanical valve replacement 1. which type requires lifelong anticoag 2. which type requires reoperation 3. what is risk of stroke assc. with mechanical valves 4.which valve type assc with endocarditis

1. mechanical 2. tissue 3. 1-2%/year 4. BOTH BOTH BOTH

carpal tunnel syndrome 1. nerve involved 2. associated conditions 3. symptoms 4. dx

1. median nerve which passes through carpal tunnel, compressed by a thickened flexor retinaculum 2. pregnancy, rheumatoid arthritis 3. numbness/painful paresthesia in distribution of median nerve, thenar muscle atrophy 4. nerve conduction study shows dec. conduction of median nerve and preserved function of ulnar nerve

1. which procedure to see the anterior mediastinum 2. """ lung, esophagus and posterior mediastinum 3. rapid thoracic exposure in trauma 4. anterior parasternal mediatinotomy

1. median sternotomy 2. posterolateral thoracotomy 3. anterolateral thoracotomy 4. aka chamberlain - 2-3 cm parasternal incision allowing insertion of of mediastinoscope

colon cancer 1. right sided sx 2. left sided sx 3. dx 4. lab dx

1. melanotic stool, IDA, right sided mass, guaiac positive stool 2. red blood per rectum, cramping abdominal pain (obstruction), changed bowel habits 3. DRE, rigid proctosigmoidoscopy, endorectal ultrasound (depth of invasion), colonoscopy, barium enema (if cant reach cecum), CT scan (mets) 4. CEA, liver enzymes hemoglobin, hematocrit

hepatic failure 1. which narcotic accumulates 2. treatment of hepatic encephalopathy 3. treatment of ascites

1. meperidine 2. protein restriction, intestinal antibiotics (neomycin), lactulose, sodium phenylacetate, sodium benzoate 3. diuresis, water restriction, paracentesis

jejunoileal atresia 1. patho 2. tx 3. in an infant with obstruction what is the most important first diagnostic test

1. mesenteric vascular accident during development 2. end to end anastomosis 3. gastrografin enema - will help to differentiate volvlulus vs meconium ileus, vs atresia

wilms tumor 1. patho 2. WAGR dx = CT, ultrasound 3. tx

1. mesodermal, mesonephric, metanephric in origin --> asymptomatic flank mass, abdominal pain, hematuria, anorexia 2. wilms tumor, aniridia, hemihypertrophy, GU malformations, renal defects , 3. surgery, dactinomycin, adriamycin, vincristine, radiotherpay (assc. w/ many complications)

multiple masses on CXR 1. ddx 2. risk of pulm AV fistulas 3. treatment of pulm AV fistulas

1. mets, granulomatous infection, sarcoid, RA, AV malformation, pulmonary AV fistula 2. paradoxical emboli, brain abscesses, hemothorax 3. fistula embolization***

mitral insufficiency 1. pathogenesis/pathology 2. clinical pres 3. major comp

1. mitral valve dz, vent. dilation, infective endocarditis, rheumatic fever***, myxomatous degeneration***-->mitral valves rise >2mm above the annulus on echo--> mitral prolapse--> mitral regurg --> inc. LA pressure, inc PVR, inc LV SV 2. dyspnea on exertion, fatigue, palpitation, Afib 3. AFIB --> SYSTEMIC THROMBOEMBOLI

supracondylar fractures 1. treatment 2. tx 3.repair of simple femur fracture for a patient <10 and >10 4. volkmanns contracture

1. monitor for compression or entrapment of the brachial artery with careful neurovascular exam 2. <10 closed reduction/immobilization, >10 intramedullary rod and open plating or external fixation 3. muscles has been replaced by fibrous tissue 2/2 compartment syndrome

bronchial adenoma (malignant) adenoid cystic carcinoma 1. location 2. tx - less favorable prognosis than carcinoid tumors

1. more centrally near trachea/carina area 2. en bloc excision of the tumor including peribronchial tissue + radiation

VIPoma (WDHA) 1. clinical pres 2. tx

1. more than 5L/day watery diarrhea, rich in potassium appears like watery tea metabolic acidosis hypokalemia diarrhea continues in the absence of eating (compare to ZES) 2. octreotide, excision of pancreatic tumor

radiation injury to the small bowel 1. acute phase 2. chronic phase

1. mucosal injury, N/V, diarrhea, bleeding/perforation (rare) 2. obliterative vasculitis, abdominal pain, malabsorption, bowel obstruction, abscess, fistula, hemorrhage

biliary atresia 1. patho 2. dx 3. tx - earlier treatment is best

1. multifactorial--> failure of development of intra/extrahepatic ducts--> jaundice at birth (conjugated) 2. r/o TORCH, electrophoresis for A1A, ultrasound (shows fibrotic ducts), technetium 99 labeled iminodiacetic acid derivatives, percutaneous liver biopsy 3. roux en y jejunum for correctable biliary atresia kasai procedure for uncorrectable, liver transplant

anaplastic carcinoma 1. histo 2. pathogenesis

1. multiple cell morphology 2. local invasion and hematogenous

plummers disease 1. patho 2. dx/tx

1. multiple hyperfunctioning nodules leads to hyeprthyroid state usually in patients with pre-existing non-toxic goiter 2. similar to graves-- only diff is radioiodine is less effective, and high dose iodides will worsen plummers disease

antilymphocyte sera 1. two types used 2. SE 3. mechanism

1. muromonab CD3 (OKT3), anti thymocyte globulin 2. first dose reaction, chills, bronchospasm 3. depletes T cells

head trauma 1 patient has head trauma signs of ICP, but won't respond to fluid resuscitation

1. must have another bleed somewhere else because brain can not bleed enough to cause hypotension

thymomas 1. associated paraneoplastic 2. symptoms of invasive thymoma 3. dx 4. tx

1. myasthenia gravis 2. chest pain, dyspnea, SVC syndrome 3. CXR, CT, MRI - shows anterior mediastinal mass 4. median sternotomy and removal of tumor iphosphatmide, etoposide, cisplatinum, paclitaxel

diffuse esophageal spasm 1. treatment

1. myotomy followed by manometry along the length of the spasm

aortic insufficiency 1. pathogenesis/pathology 2. sx

1. myxomatous degen, aortic dissection, bacterial endocarditis, rheumatic fever, aortic root aneurysms--> LV VOLUME LOAD --> dilated cardiomyopathy 2. early palpitations/dyspnea on exertion--> CHF/death

transposition of the great vessels cyanotic heart disease 1. obligate defect 2. dx 3. surgical tx

1. need left/right heart communication --- usually ASD, or PDA or VSD 2. echocardiogram shows pulmonary trunk from left ventricle 3. prostaglandin E1, balloon atrial septostomy then arterial switch

1. four categories of coin lesions 2. person with no other malig has a coin lesion is this malig? 3. radiographic features of benign coin lesion 4. radiographic features of a malignant coin lesion ***MUST DO A TISSUE BIOPSY*** <40 yo, >2/3 likelihood to be benign

1. neoplastic disease, or granulomatous, or vascular, or infection (fungus or TB) 2. nope 3. concentric/laminated calcification is present, popcorn like, well circumscribed, has not grown in size, has been present for a long time 4. fleck like calcification, indistinct margins

RCC 1. dx 2. ddx for renal mass 3. tx

1. nephrotomography, ultrasound, CT scan with contrast, MRI, aspiration/biopsy 2. renal cell carcinoma, renal oncocytoma, angiomyolipoma (tuberous sclerosis), fibroma, renal adenoma 3. radical nephrectomy, lymph adenectomy (*paraaortic/paracaval), metastatic RCC, interferon, interleukin, lymphokine activated killer cells, tumor infiltrating lymphocytes

anesthesia in patients with renal failure - correct volume status pre-op - avoid intraoperative hypotension -maintain diuresis 1. which drugs should be avoided

1. nephrotoxic drugs- aminoglycosides, vancomycin, IV contrast, ACE

pheochromocytoma 1. patho 2. locations of the tumors 3. clinical presentation 4. dx

1. neural crest chromaffin cell malignancy --> production of NE/EPI 2. adrenal medulla, organs of zuckerkandl, extra adrenal paraganglia, urinary bladder, mediastinum 3. paroxysms of hypertension, headaches, sweating, palpitations, tremor, chest pain, 4. elevated urinary metanephrine and VMA, catecholamine levels

paravertebral sulcus lesions 1. neurogenic tumors types 2. neuroblastoma sites of met

1. neurilemomas (schwann cells) neurofibromas/sarcomas, ganglioneuromas (symp ganglion), neuroblastomas 2. bone, liver, regional lymph nodes

carcinoid tumors 1. patho 2. locations 3. carcinoid syndrome - >2cm probably metastatic

1. neuroectodermal cell derived, store 5-hydroxytryptophan and decarboxylate to make biogenic amines 2. appendix, ileum, rectum, stomach, colon 3. liver mets of carcinoid tumors allow biogenic amines to enter systemic circulation********

1. what effect on systemic vascular tone in patients with cervical spine injury 2. pharmacologic tx of SCI. 3. central cord syndrome 4. anterior SCI 5. brown sequard

1. neurogenic shock due to disruption of sympathetic pathways, hypotension and bradycardia (unopposed vagus) 2. methylprednisolone within 8 hours 3. sensory > motor function deficit at the level of the lesion, 2/2 hyperextension 4. ASA damage --> weakness, and lack of pain sensation, INTACT DORSAL COLUMN FUNCTION 5. ipsi loss of motor / light touch, vibration contra loss of pain

neck abscess 1. clinical pres 2. bezold abscess 3. ludwig's angina 4. parapharyngeal space abscesses 5. retropharyngeal abscess 6. peritonsillar abscess

1. painful fluctuant mass, with dysphagia, dyspnea, leukocytosis, fever 2. from infection of the middle ear/mastoid 3. dental source abscess that occupies sublingual space - RISK FOR AIRWAY OBSTRUCTION 4. arise from tonsils/posterior teeth--> mediastinitis/carotid blowout 5. infected retropharyngeal nodes --> obstruction/mediastinitis 6. 2/2 acute tonsillitis, ipsilateral palata edema, deviation of the uvula, hot potato voice, trismus, dysphagia

osteochondromas 1. patho 2. tx

1. palpable tumors of bone --> possible malignant degeneration presents with pain 2. excision if symptoms warrent

splenic vein thrombosis 1. patho 2. tx

1. pancraetitis --> splenic vein thormbosis --> significant bleedintg from esophageal/gastric varicies 2. splenectomy

glucagonomas 1. patho 2. clinical presentation

1. pancreatic alpha 2 islet cell tumors 2. diabetes, weight loss, dermatitis, anemia, stomatitis that cause inc. secretion of glucagon`

duodenal tumors - adeno*, carcinoids, GIST, gastrinomas, parcomas, hamartomas, adenomas 1. tx

1. pancreaticoduodenectomy

thromboangitis obliterans 1. patho 2. symptoms 3. tx

1. panvasculitis of artery/vein/nerve, associated with HEAVY SMOKING 2. migratory superficial phlebitis of extremities 3. cessation of smoking, not surgery

1. what type of thyroid cancer associated with radiation 2. metastasis pattern of this type of cancer

1. papillary type 2. cervical lymph nodes, distant mets uncommon

acute abdominal pain gas patterns on xray 1. evenly distributed air in the small/large intestines 2. localized to a specific area ex. sentinel loop 3. dilated gastric bubble + tx 4. distended air/fluid filled bowel loops 5. both ends of a loop obstructed

1. paralytic ileus 2. acute pancreatitis, localized duodenal ileus 3. acute gastric dilation (risk of vasovagal hypotension + tx = NG tube 4. mechanical obstruction - high risk for ischemia necrosis 5. volvulus - closed loop obstruction - HIGH RISK FOR RUPTURE

malignant neoplasms of the parotid 1. mucoepidermoid carcinoma 2. squamous cell carcinoma 3. tx

1. parotid duct origin, low grade is soft and preserves facial nerve, high grade is aggressive and does not spare facial nerve 2. hard on palpation and assc. with pain and nerve paralysis 3. total parotidectomy

pre-op eval 1. volume status 2. electrolyte abnormalities 3. RBC mass

1. past/current weight, skin turgor/mucous membrane, JVD/rales, vitals, BP, HR, orthostatic pressure changes, urine output 2. n/v, anorexia, bowel obstruction 3. acute blood loss, chronic anemia, sickle cell anemia,

1. two morphologic forms of colonic polyps 2. 3 types of benign colonic polyps

1. pedunculated and sessile 2. hyperplastic (MCC, thickened mucosa), hamartomatous (abnml mix of issues, incl. juvenile), inflammatory (pseuodpolyps in UC and lymphoid)

papillomas 1. squamous papillomas of the oral cavity 2. location/appearance of nasal papillomas - malignant degeneration in 2% of patients

1. pedunculated, squamous in appearance, tx with excision 2. UNILATERAL lateral wall of the nasal cavity, appear red, or gray

pneumopericardium 1. causes 2. tx

1. penetrating/blunt chest trauma, anaerobic bacteria, iatrogenic, direct extension from adjacent organs (ex. from perf. gastric ulcer) 2. surgical emergency, must open the pericardial sac

pancreatic cancer 1. dx 2. surgical tx for head of the pancreas 3. surgical tx for midbody/tail of pancreas - total pancreatectomy - helps avoid missing multicentric tumor, and anastomotic leaks

1. percutaneous FNA, ERCP w/ contrast/xray, percutaneous transhepatic cholangiography (needle into hepatic duct and contrast injected *elevated CA 19-9 2. pancreaticoduodenectomy for adenoma of the head (no mets outside abdomen, no tumor in port hepatis/SMA, no mets to liver/other organs) 3. distal pancreatectomy

acute abdominal pain gas patters on xray 1. free air in peritoneal cavity 2. gas in the wall of the colon 3. air stippling in soft tissue structures 4. air fluid level outside the intestinal tract (or hemidiaphragm elevation) 5. air in the biliary tree

1. perforation of viscus (more common with gastroduodenal vs colonic perforations), peritoneal dialysis, 1 wk post laparotomy 2. pneumatosis intestinalis - isolated intestinal perforation, necrotizing enterocolitis 3. dissection of air into tissues, or gas forming infection 4. subphrenic or subhepatic abscess 5. choledochoduodenostomy, cholangitis, large gall stones (erode into duodenum)

diverticular disease of the small bowel 1. location/effect of duodenal diverticula 2. consequences of jejunoileal diverticula

1. periampullary--> cholangitis, pancreatitis, common duct stones 2. intususception, bleeding, perforation, malabsorbtion (due to bacterial overgrowht)

perioperative cardiac risk 1. hypertension risk (dias >110) 2. change in blood pressure >50% at any time or >33% for >10mins risk 3. class 1 or 2 angina 4. class 3 angina + management

1. perioperative hypotension or hypertension exacerbation 2. perioperative MI 3. NOT RISK FACTOR FOR PERIO 4. walking up a flight of stairs or 2 blocks- same risk of MI as previous 6 mo before surgery 5. angina on exertion - 2x risk compared to class 3 angina-- MUST GIVE ANTI-ANGINAL THERAPY IN PERIOPERATIVE PERIOD

1. most common surgical complication of systemic chemotherapy 2. SE assoc with L-asparaginase 3. what is interferon alpha used to treat 4. most common GI site for non-hodgkins lymphoma

1. perirectal abscess, also GI bleeding, thrombocytopenia 2. pancreatitis 3. hep B and C 4. stomach (then SI/colon)

1. diagnostic test for occult intraperitoneal injury with abdominal trauma 2. diagnostic test for retroperitoneal or visceral bleeding 3. diagnostic test for damaged abdominal viscera and subcapsular hemorrhage

1. peritoneal lavage 2. angiography 3. CT scan

oropharyngeal cancer 1. clinical presentation 2. dx/tx

1. persistent sore throat, ipsilateral otalgia, , restriction of tongue motion 2. dx = CT/MRI, endoscopy, tx = radiation/surgery and composite resection - radical neck dissection, partial mandibulectomy and excision of tumor

mondor's disease 1. patho 2. tx

1. phlebitis of thoracoepigastric vein --> palpable visible tender cord along upper quadrants of breast 2. anti inflammatory drugs and warm compresses

anal margin cancers (below dentate) 1. squamous cell presentation/tx 2. basal cell presentation/tx 3. bowens disease "" 4. perianal pagets ""

1. polypoid fungating or ulcerated abdominal mass- excision and radiation, resection 2. central ulceration with raised edges- excision, mohs micrographic surgery, radiation for advanced lesions 3. carcinoma in situ itching, burning, bleeding-->squamous cell - wide local excision 4. erythematous eczematous rash, intractable pruritus- wide local excision

acute supporative parotitis 1. patho 2.

1. poor dentition, dehydration (post op)-> STAPH infection --> inflammatory reaction in the gland 2. hydration, antibiotics, surgical drainage if progressive,

1. how to estimate coronary risk for non-cardiac surgery

1. poor exercise tolerance, (cannot reach MET-4) recent MI poor/moderate functional capacity post MI stress test without ischemia lowers risk coronary revascularization lowers risk for cardiac complications`

1. when does asymptomatic cholelithiasis require treatment

1. porcelain gallbladder because there is a 25% chance of malignancy

vascular malformations (capillary, venous, lymphoatic, AV) 1. capillary + tx 2. capillary VM assc. syndromes 3. venous

1. port wine stain- grows with the patient, no spntaneous regression tx = laser 2. sturge weber, klippel trenaunay weber 3. cavernous - mature vessels in subQ tissue, including muscle, may sequester platelets tx= wide excision, or sclerosant injection

1. most common cause of hypersplenism - usually clinically insignificant hypersplenism

1. portal hypertension (2/2 hypertension, cirrhosis, budd chiari, congestive heart failure)

portal hypertension 1. pre-hepatic causes 2. post-hepatic causes (4)

1. portal vein thrombosis, congenital atresia, extrinsic compression (2' tumors) 2. budd chiari (idiopathic or hypercoagulable states ie. malig, OCP, trauma, post BMT) constrictive pericarditis (inc. IVC pressure) splenic shunts/fistulas inc. portal flow splenic vein thrombosis (--> varices of only the gastric fundus)

breathing patterns 1. lesions to the forebrain 2. lesions to the cerebral hemisphere+basal ganglia 3. lesion to midbrain 4. lesions to the medulla 5. acidosis

1. post hyperventilation apnea - no resuming breathing after hyperventilation 2. cheyne stokes - hypnea alternative with apnea crescendo/decrescendo pattern 3. central neurogenic hyperventilation- 4. cluster breathing, ataxic breathing (periodic breathing with apneic periods punctuated by abnormal breaths) 5. kussmaul respirations - deep rapid breathing

1. what post-operative pulmonary issue is more frequent in obese patients` 2. which surgeries are assc. with highest change in post-op FRC

1. post-op atelectasis + restrictive pulmonary pattern 2 .thoracotomy and upper abdominal surgery-- due to altered cx wall/diaphram mechanics, post op pain, impaired cough,

cholangitis 1. patho/sx 2. tx

1. post-op strictures/common bile duct stones/neoplasms/PSC/contrast studies--> obstruction and infection with ECOLI --> CHARCOTS TRIAD*** - fever, jaundice, RIQ pain** 2. abx, resuscitation, relief of obstruction

acute abdominal pain gas patters on xray 1. three most common causes of bowel obstruction 2. air in non-anatomic location 3. isolated distended loop of bowel with bird beak margins 4. thumbprinting mucosal edema on dilated colon 5. isolated distention of colon with air

1. post-operative adhesions, carcinomas of colon, 2. ex. below the inguinal ligament = hernia 3. volvulus 4. ischemic or gangrenous bowel 5. distal colonic obstruction (malig, constipation, stricture, volvulus), toxic megacolon (acute colitis), colonic ileus (cecum enlargement)

cystic hygromas 1. location 2. tx

1. posterior triangle, axilla, mediastinum, groin, reach up to the parotid region, transilluminate 2. surgery, but typically recur

1. fibrous dysplasia of the rib 2. chondroma 3. osteochondroma malignant tumors = fibrosarcoma, chondrosarcoma, osteogenic sarcoma, myeloma, ewings sarcoma

1. posterior/lateral portion of rib, non-painful, part of albrights syndrome 2. MCC benign tumor of cx wall, occurs at costochondral junction 3. occurs anywhere on rib

post gastrectomy syndromes 1. alkaline reflux gastritis- patho, dx/tx 2. afferent loop syndrome\ 3. nutrient deficiency assc.

1. postgastrectomy - epigastric pain/n/v, weight loss, dx =free reflux of bile tx = conversion of billroth 1/2 to roux en y 2. intermittent mechanical obstruction by gastrojejunostomy - postprandial distention, pain, nausea, bilious emesis, tx - conversion of afferent loop to roux en-y 3. loss of acidic environment causes loss of iron in food--> IDA

1. causes of post operative hyponatremia 2. tx 3. what to do if the patient starts having hyponatremic seizure (Na ~ 115)

1. postoperative ADH (part of stress response) + excessive free-water (oral or IV) in the postoperative days 2. withholding free water. 3. give hypertonic saline injections

pre-op eval 1. infection + how to time abx prophylaxis POOR PRE-OPERATIVE RISK FACTORS FOR MORTALITY: serum albumin, ASA, cancer, emergency, age, BUN, SGOT>40, weight loss, WBC>11k =

1. postpone elective surgery until infection is controlled prophylactic antibiotics - dose so that concentrations are bactericidal before skin incision

chronic mesenteric ischemia 1. clinical presentation 2. pathogenesis 3. dx/surgical tx

1. postprandial pain, food fear, weight loss 2. stenosis/occlusion of CA/SMA/IMA by atherosclerosis at the origin of the vessels 3. duplex scanning shows inc. velocity of blood arteriography*, CT abdomen tx = aortomesenteric bypass (from supraceliac aorta, or infrarenal aorta) transaortic mesenteric endarterectomy

diabetes melitus 1. consequences of neuropathy 2. labs 3. cause of acidosis in diabetes 4. why should these patients not get radioopaque dye studies

1. postural hypotension, urinary retention, impaired motility, gastroparesis, impotence, cardiac autonomic dysfunction, stocking/glove sensory loss-->infections 2. HbA1C, volume/electrolytes, serum glucose, anion gap 3. lactic acidosis, DKA, retained organic acids phos/sulf (2/2 renal failure) 4. can cause acute renal failure in patients >40 yo, and creatinine >2

imperforate anus 1. infralevator tx 2. supralevator tx

1. potts anal transfer - by dilation of the fistula denis browne cutback - if mucosa is close to the fistula 2. colostomy

gastric ulcer complications gastric outlet obstruction 1. patho 2. sx 3. dx/tx

1. pre-pyloric ulcers, chronic scarring of pyloric channel --> pyloric stenosis 2. crampy abdominal pain, early satiety, weight loss, dilated stomach, vomiting partially digested food, hypokalemia, met alk, 3. dx = abdominal distention, succussion splash, tx = NG suction, vagotomy w/antrectomy, vagotomy with drainage

reflux etiology 1. inc. intrabdominal pressure causes 2. lower LES tone 3. raise LES tone

1. pregnancy, obesity, gastric dilation 2. atropine, glucagon, secretin 3. alkalinization, gastrin, epinephrine, cholinergics, alpha agonists,

macnatriers disease (hypertrophic gastritis) 1. patho 2. tx

1. premalignant hypertrophic gastric mucosa - giant rugae, mucous cells, gastric hypersecretion, excessive protein loss (very low serum albumin, hypochlorhydria 2. anticholinergics, acid suppression, octreotide, H.pylori.

zenkers diverticulum 1. pathogenesis 2. common assciations 3. sx 4. dx 5. tx - diverticulum starts near the bifurcation of the common carotid

1. premature cricopharyngeal constriction--> incoordination between UES and contraction of pharynx --> mucosa that herniates between the cricopharyngeal muscles (false diverticulum) 2. hiatal hernia, GERD 3. dysphagia* halitosis, regurg, nocturnal aspiration, aspiration pneumonia*** 4. barium swallow, ENDOSCOPY CONTRAINDICATED HIGH RISK OF PERFORATION 5. cricopharyngeal myotomy

necrotizing enterocolitis 1. patho + sx 2. dx 3. tx -birth weight is major factor determining survival -compilation include short bowel syndrome - other comorbidities include intraventricular cerebral hemorrhage, chronic pulmonary insuficeincy

1. premature infant + ischemic injury to immature intestine + bacteria b/c immature immune system--> mucosal sloughing -->abdominal distension, blood stools, feeding intolerance 2. leukopenia, thrombocytopenia, hyponatremia, met acid, pneumatosis intestinalis, distended edematous bowels 3. GI decompression, parenteral abx, fluids, -if abdomen is perforated/peritonitis/unstable/palpable mass resect the involved intestine

1. rule of 7s of benign neck masses 2. diagnostic tests which should be ordered for neck mass

1. present > 7 days, >7 months is malignant, >7 years is congenital 2. CBC, CXR, TB test, heterophil titer, thyroid function, VDRL/RPR,

ventilation 1. synchronized intermittent mandatory ventilation 2. assist or volume control

1. preset rate/tidal volume, varies automatically based on the patients respiratory effort - patient shares effort and increases minute ventilation - good for weaning patients off ventilator 2. NO WORK OF BREATHING - preset tidal volume on ventilator and additional breaths are assisted by ventilator to provide full preset tidal volume. -- minute ventilation is preset tidal volume*vent+pts rate

1. treatment for colon injuries 2. diagnosis of colon/rectum injuries

1. primary repair + abx for common civilian injuries, colostomy if gross contamination, or shock 2. immediate sigmoid/colonoscopy, if inconclusive use gastrografin contrast study (NOT BARIUM INC. RISK OF ABSCESS)

malignant mesothelioma 1. patho 2. surgical tx

1. prior asbestos exposure --> pleural effusion presentation 2. thoracoscopy, talc sclerosis

desmoid tumors 1. patho

1. prior trauma --> fascia mass that invades locally 2. complete excision

rectal prolapse (not mucosal prolapse) 1. patho + sx 2. tx

1. prolonged internal intussusception, hysterectomy, elderly --> mucosal lined bowel protruding from the anus and incontinence/pain/bleeding 2. low anterior resection with rectopexy, ripsteins procedure, perineal proctectomy with low colorectal anastomosis, anal encircling procedures, hartmanns procedure

mallory weiss syndrome 1. patho 2. dx 3. tx *more common in cirrhotics

1. prolonged severe vomiting/retching--> partial thickness tear in lower esophagus (near GE junc), extends to greater curvature of cardia 2. endoscopy 3. blood volume replacement, balloon tamponade, endoscopic control, gastrotomy w/ oversewing antacids,gastric lavage, suture of tear by laparotomy if bleeding persists

1. how to calculate nitrogen balance 2. which protein should be measured to determine protein nutrition 3. is weight gain a good method of protein nutritional support

1. protein intake / 6.25 = nitrogen input grams nitrogen output grams = urine urea nitrogen +2 -4 g of nitrogen in stool 2. pre-albumin 3. NO WORST BECAUSE ILL PATIENTS OFTEN RETAIN WATER ~ but may still be catabolic

what increases LES pressure what decreases LES pressure

1. protein meal, alkalinization of stomach, gastrin, vasopressin, cholinergic drugs 2. secretin, nitroglycerine, glucagon, chocholate, fatty meals, gastric acidification

struvite calculi 1. patho 2. radiographic findings

1. proteus, providencia, pseudomonas, klebsiella --> alkaline urine --> precipitation of Mg/phos 2. RADIOPAQUE

1. spiegelian hernias

1. protrude through abdominal wall along semilunar line at semicircular line or douglas where transversus abdominus and internal oblique aponeuroses change to pass anteriorly to rectus muscle

bronchial adenoma (malignant) Carcinoid tumors (MCC) 1. location 2. patho 3. sx 4. dx/tx

1. proximal bronchi 2. basal bronchial stem cells --> neuroendocrine development--> bronchial obstruction--> METS ONLY IN ATYPICAL TYPE (10%) 3. cough, infection, hemoptysis, wheezing, asymptomatic 4. chest radiograph shows nodule/atelectasis- tx = surgical resection (lobectomy, wedge, segment,

1. common locations for atherosclerosis 2. fatty streaks 3. fibrous plaques 4. complex plaques

1. proximal internal carotid, and infrarenal aorta-- typically at arterial bifurcations 2. subintimal lesions made of cholesterol laden macrophages and SMC 3. advanced streaks with ECM 4. included intimal ulceration and intraplaque hemorrhage

myasthenia gravis 1. clinical presentation 2. pathogenesis 3. tx

1. ptosis, double vision, dysarthria, dysphagia, weakness 2. antibodies against N-Ach-R reduces muscle contraction 3. neostigmine, pyridostigmine, thymectomy***

1. what data can be learned from right heart catheterization 2. what data can be learned from left heart catheterization

1. pulm artery pressure, CO, PCWP, L-R shunts 2. coronary angiography, ventriculography (EF)

ToF 1. features 2. blood flow 3. clinical presentation 4. auscultation - cardiac cath shows degree of stenosis. 5. surgical tx

1. pulmonary stenosis, VSD, RVH, overriding aorta 2. right to left -- cyanotic heart disease 3. cyanosis, dyspnea on exertion, squatting inc. SVR decreasing R-L shunting, clubbing 4. harsh systolic murmur 5. systemic to pulmonary shunt (blalock taussig)

1. aortic stenosis pulse finding 2. aortic insufficiency pulse finding 3. jugular venous distension causes

1. pulsus parvus et tardus 2. wide pulse pressure +water hammer pulse 3. cardiac tamponade, tricuspid regurg, right heart fialure

mycophenolate mofetil 1. mech 2. SE

1. purine metabolism inhibitor, more lympho specific compared to azathioprine 2. bone marrow suppression and GI SE

acute abdominal pain gas patters on xray 1. air within the portal vein

1. pylephlebitis (gas forminng infection in teh portal system) necrotic tissue derived from small intestine, appendix/colon

1. signs of a base of the skull fracture 2. cardiac tamponade dx/tx

1. raccoon sign, battles sign, CNS otorrhea, CNS rhinorrhea (CSF fluid can enter mastoid air cells and middle ear/eustachian tube to nasopharynx) 2. echocardiography**** , tx = pericardial window, pericardiocentesis

papillary carcinoma of the thyroid 1. associated exposure 2. pathogenesis 3. tumor markers and histo features

1. radiation 2. slow growth invading directly into local lymphatics 3. thyroglobulin, orphan annie eyes***, psammoma bodies***

1. treatment of epidermoid cancers of the anal canal

1. radiation and chemotherapy (fluorouracil/mitomycin)------ surgery has been shown to not be very effective

immediate life threatening injuries 1. cardiac tamponade patho/tx 2. flail chest patho/tx

1. rapid accum of blood in pericardial sac--> compression of cardiac chambers--> dec. diastolic filling--> tx = pericardial decompression by pericardiocentesis or median sternotomy or left anterior thoracotomy 2. blunt chest trauma with multiple rib fractures --> paradox chest movements--> alveolar hypoventilation tx = pain control, *mechanical ventilation*

necrotizing 1. define 2. signs/symptoms/xray 3. organisms 4. tx

1. rapidly progressing bacterial infection causes vascular thrombosis/necrosis as it progresses **UNDERLYING SKIN MAY APPEAR NORMAL** 2. hemorrhagic bullae/crepitus, redness, fever/tachycardia, foul smelling discharge xray- shows air in the soft tissues 3. milleri group strep, staph, gram neg aerobes, anaerobes 4. surgical debridement, antibiotics, LIFE THREATENING

1. how much fluid does the colon recieve/reabsorb daily - Na reabsorbed actively, K reabsorbed passivly 2. bacterial fermentation in the colon 3. what bacteria infeces (1/3 of feces mass) - colonic gas = nitrogen, oxygen , co2, H2, methane

1. recieves 900-1500ml/day, reabsorbs 90% of this 2. undigested carbohydratte--> short chain fatty acids which power sodium transport 3. bacteroides, and ecoli

cellulitis 1. clinical presentation 2. organism + treatment 3. what is most likely if does not resolve with penicillin

1. redness, tenderness, edema, fever/leukocytosis, lymphangitis 2. streptococcus, penicillin 3. probably an underlying deep abscess

1. effect of general anesthesia on pulmonary function - spinal/regional lower pulmonary risks 2. parameters/process for extubation

1. reduces FRC up to 1-2 weeks post op, bronchospasm (ETT), impaired mucociliary function (mechanical vent), pneumothorax (barotrauma) 2. assess for oxygenation, asses for ventilation, wean, 30 minute spontaneous breathing trial*** (no pressure support or intermittent mandatory ventilation)

mastalgia 1. cyclic type 2. non-cyclic tx - dont forget to investigate for breast cancer

1. related to menstrual cycle 2. restrict caffeine, wear bra, NSAIDS, vitamin e, primrose oil, severe tx - tamoxifen or danazol

ER thoracotomy 1. indications 2. contraindcations

1. release cardiac tamponade in patient deteriorating rapidly allow aorta clamping for intra abdominal bleeding that is not responding to other treatments allow cardiac massage for patients for cardiac patients with weak or absent pulses who are not responding to other resuscitative measures 2. no vital signs (pulse/pupil/respiration) in the field blunt trauma to multiple organ systems and no vitals on arrival to ER

pancreatic cancer 1. palliative procedures 2. medical tx

1. relieve biliary obstruction, relieve gastric outlet obstruction, gastrojejunosotmy/choledochojejunostomy, trans hepatic biliary stents 2. 5FU, gemcitabine +/- radiation

craniopharyngioma 1. patho 2. clinical pres

1. remnants of rathke's pouch --> cystic tumors with areas of calcification--> compression of the pituitary, optic tracts, third ventricle 2. visual field defects, weight gain, diabetes insipidus

chordomas 1. patho

1. remnants of the notochord --> tumors in the clival region and sacrococcygeal region

1. ddx for calcium stone 2. medical treatment for urinary calculi 3. how to detect uric acid calculi 4. treatment of uric acid stones

1. renal hypercalciuria, absorptive hypercalciuria, hyperparathyroidism, normocalcemia, RTA (sarcoid, hypercalcemia, vitamin D intox, immobilization syndrome) 2. hydration, thiazides, orthophosphates, citrate, low calcium diet 3. dense white on CT, BUT RADIOTRANSLUCENT ON KUB 4. alkalinization of urine, citrate, bicarb,

leukoplakia/keratosis 1. patho 2. dx 3. tx

1. repeated trauma in the mouth 2. bx to rule out carcinoma in smokers /drinkers/persistent lesions 3. just observe

tumors metastatic to the lung 1. tx - common primaries- colorectal, breast, melanoma, renal

1. resection in patients with less than 3-5 nodules

resp acid (<7.35) 1. causes 2. what nutrient incrases CO2 production 3. tx

1. resp depression (drugs/alcohol/sedation+analgesia/anesthetics), stroke, trauma, iatrogenic (vent), ARDS, COPD, myasthenia gravis, spinal cord injury 2. carbohydrates 3. inc. alveolar ventilation +/- mechanical vent

1. resting energy expenditure (REE) 2. TEE - in starvation, BMR decreases to preserve body mass

1. resting energy expenditure utilized by NON-fasting individual at rest (1.2*BMR or ~ 25kcal/kg/day) 2. REE * stress factor (ex. surgery, trauma, sepsis) 10% rise for every degree centegrade over normal

colon cancer 1. surgical tx 2. adjuvant tx 3. post-op monitoring 4. what to do with postive CEA post-op

1. segmental resection, low anterior resection (for upper 1/3 of colon), miles procedure, pull through operation 2. 5 FU, leucovorin, oxaliplatin, + pre-op radiation (post op radiation not done because margins are clear) 3. CEA monitoring***= most sensitive colonoscopy post op 1 year, then every 3-5 years if negative. 4. chest radiography, abdominal CT - to detect pulm/hepatic mets

astrocytoma 1. clinical pres 2. dx/tx

1. seizures, headache, inc. ICP, focal deficits 2. CT/MRI shows irregular enhancement with zone of edema around tumor tx = surgical resection, radiation, chemotherapy

neurogenic bladder 1. conservative management 2. surgical management

1. self cath, manual void, bethanechol chloride 2. bladder augmentation, bladder neck resection, supravesical ureteral diversion

1. which type of testicular tumor is extremely radiosensative 2. choriocarcinoma pattern of spread

1. seminoma 2. 80% goes the lungs, hematogenous spread

lumbar disc herniation syndromes 1. L2 2. L3 3. L4 4. L5 5. S1 6. S2-S3

1. sensory loss of anterior thigh/inguinal ligament, hip flexion/abduction motor weakness 2. anterior thigh sensory, hip abduction and knee extension 3. anterior thigh, medial leg to medial malleolus sensory, knee extension, foot inversion dec. knee jerk 4. lateral leg, dorsum of foot, foot and toe extension 5. lateral leg, foot to small toe, sole of foot, foot and toe flexion, dec. ankle jerk 6. buttocks, perneal, genitalia, intrinsic luslces of the foot, sphincteric dysfunction

1. external branch of recurrent laryngeal nerve 2. internal branch of recurrent laryngeal nerve 3. what nerve is damaged during mobilization of the upper pole of the thyroid

1. sensory to the larynx, motor to the cricothyroid muscle (INCREASES PITCH BY TENSING THE VOCAL CORDS) 2. sensory to the larynx intrinsic muscles of the larynx, 3. superior laryngeal nerve--> hoarseness and weakness

acalculous cholecystitis 1 .patho/clinical pres 2. dx 3. tx

1. sepsis/burns/multiorgan failure/ critically ill --> no stones kinking/fibrosis, cystic artery thrombosis, sphincter spasm, prolonged fasting, dehydration, generalized sepsis/multiorgan failure --> fever, nausea, vomiting, RUQ tenderness, murphy's sign 2. cholecystintigram fails to visualize the gallbladder, no stones are seen, ultrasound shows no stones, pericholecystic fluid, gallbladder distension, thickening of gallbladder wall 3. percutaneous drainage under CT guidance for ICU or URGENT cholecystectomy

cardiac trauma 1. workup for patient that has sustained blunt trauma to chest 2. lung changes with blunt trauma - rupture of valves should undergo replacement or repair

1. serial EKG and cardiac enzymes, 2. intraalveolar hemorrhage/edema, dec. pulm elasticity, lung/chest wall dec. compliance, inc. PCO2/A-a grad/shunt fractions

crohns disease 1. dx 2. medical tx 3. indications for surgery 4. post-surgical reccurance

1. serologic, proctoscopy (to r/o UC), barium studies, colonoscopy, CT scan (for abscess) 2. 6MP, AZA, MTX, cyclosporine, infliximab, TPN bowel rest (more effective in CD than UC). metronidazole/ciprofloxacin for anal disease 3. obstruction, abscess, fistulas, abscesses (CT guided drainage), debilitating disease, fulminant colitis, hemorrhage, cancer 4. at site of anastomosis

1. four layers of the stomach wall 2. cardiac glands 3. fundus cells 4. pyloroantral mucosa

1. serosa, muscularis, muscularis mucosa, mucosa 2. produce mostly mucus 3. mucus cells, chief cells (pepsinogen), parietal cells (HCL and intrinsic factor) 4. G cells (gastrin)

1. hyperacute graft rejection 2. acute graft rejection 3. tx acute graft rejection

1. serum of recipient has preformed antibodies that kill endothelium of graft, and form fibrin/platelet thrombi, killing the graft within 24 hours (avoid with negative crossmatch) ***avoid with cross matching 2. cell-mediated response mediated by helper T cells that clonally expand -- occurs within 6th post op day 3. high dose immunosuppressives

erectile dysfunction 1. dx 2. tx

1. serum testosterone, anemia, nocturnal penile tumescence, intracorporeal injection of vasoactive substances (r/o venous leak), duplex sonography (high venous outflow is problem) , cavernosography, pudendal arteriography 2. counseling, cGMP PDE inhibitors, vacuum devices, intracorporeal injections, penile implants

acute mesenteric vascular disease 1. acute mesenteric ischemia clinical presentation 2. pathogenesis

1. severe abdominal pain out of proportion of physical findings (no evidence of peritonitis), 2. embolization, thromboiss on pre-existing atheroscleortic lesions, non-occlusive (ex. cardiogenic shock, high dose vasoconstrictors)

atherosclerosis of lower extremities 1. ischemic rest pain 2. sx ischemic rest pain 3. "" clinical implications

1. severe arterial flow restriction where collateral flow is insufficient at rest (compare to claudication) 2. intense pain in distal foot and arch exacerbated by elevation 3. LIMB THREATENING 85% amputation at 5 years

temporal arteritis 1. clinical pres 2. dx/tx

1. severe throbbing unilateral headache, visual changes, jaw pain, malaise 2. dx = temporal artery biopsy, ESR tx =prednisone followed by temporal artery bx/ resection

phases of digestion 1. cephalic phase 2. gastric phase 3. intestinal phase 4. negative feedback

1. sight/smell/thought of food - vagal stimulates parietal cells to release acid + release of gastrin** 2. mechanical distention of the antrum leads to inc. gastrin release 3. cholycystokinin and other factors modulate acid production 4. decline of vagal stimulation, inc. acid--> duodenal negative feedback via secretin (inhibits gastrin)

mesenteric adenitis 1. clinical pres

1. similar to appendicitis, but when resection is attempted, the appendix appears normal and there are enlarged lymph nodes and boggy appearance of the cecum

bronchial adenoma (malignant) mucoepidermoid carcinoma 1. location - tx similar to carcinoid ....

1. similar to carcinoid distribution

pancreatic injury 1. usual treatment for penetrating pancreatic injury 2. treamtent of distal pancreatic duct damage in the region of the head of pancreas 3. complications of pancreatic injury

1. simple percutaneous drainage of hematoma 2. roux en y 3. fistula, pseudocyst, abscess, MASSIVE HEMORRHAGE

internal intussusception 1. patho + sx 2. tx 3. indications for surgery + - recurrence is very rare

1. single rectal ulcer + colitis cystica profunda(glandular tissue below the mucosa)*, peyers patch hyperplasia (post viral), tumors --> distal bowel telescoping into itself causing obstruction --> urgency, rectal fullness, pelvic pain, currant jelly stools 2. inc. fiber, stool softeners, glycerine suppositories, enemas 3. debilitating sx, anal incontinence, chronic bleeding, -- tx = low anterior resection of sigmoid/proximal rectom with colorectal anastomosis/fixation

1. what kind of pacemaker for bradyarrythmias 2. what kind of device for patients with MI, CHF, dec. EF, PVCs

1. single/dual chamber pacemakers 2. internal cardiac defibrillator

`1. what is the risk of not removing skull fragments in a compound fracture

1. skull abscess

1. mixed tumor of parotid + tx 2. papillary adenocystoma also.... bening lymphoepithelial tumor, oxyphil addenomahemangiomas, lymphangioimas

1. slow growing benign, tx = surgery only 2. epithelioid/lymphoid, soft to touch, contains mucoid material

metastasis of seminomas

1. slow mets, radiosensitive, tends to met to the iliac, aortic, renal lymph nodes

primary hyperparathyroidism 1. pathogenesis 2. clinical presentation

1. solitary adenoma (MCC)** MEN, familial hyperparathyroidism, ectopic or pseudohypoparathyroidism, PTHrp 2. stones, bones (osteitis fibrosa cystica- hemorrhagic brown lesions), moans (psych), groans (PUD, hypergastrinemia, cholelithiasis, pancreatitis), also weakness and fatigue, constipation

anus - surrounded by puborectalis - anorectal ring 1. anoderm 2. anal verge - columns of morgagani/anal crypts - anal glands/anal ducts -->anal crypts 3. muscular sphincter (2)

1. specialized epithelium devoid of hair follicles /sebaceous glands 2. junction between anoderm and perianal skin at dentate line 3. internal sphincter (involuntary control) external sphincter - (voluntary control) ~ striated muscle

1. common sites of fractures in older patients with osteoporois

1. spine, hip, proximal humerus, distal radius

1. indications for splenectomy

1. splenic cyst, varicies, spherocytosis, splenic abscess, echinococcal cyst, spleen tumors,

ischemic colitis 1. patho. 2. three phases 3. tx 4. radiologic findings of ischemic colitis 5. dx

1. splenic flexure/mid-sigmoid colon have communication between collaterals--- post-surgical w/ligation of the IMA, atherosclerosis, vasculitis, CVD, polycythemia, CHF, digitalis, OCP, anti-hypertensives, MI/sepsis (low flow states) 2. transient ischemia - mild abdominal pain and maroon stool, thumb printing on barium enema, hemorrhagic mucosa on colonoscopy partial thickness ischemia w/ stricture - severe abdominal pain, fever, leukocytosis gangrenous ischemia - acute abdomen sx, abdominal pain, 3. hospitalization, observation, IV fluids, abs, resection of strictures, emergency resection/colostomy of gangrenous ischemia 4. thumb sign early, intramural air later 5. *****barium enema*****

1. skin graft 2. adv/disadv of thick vs thin

1. split portion of skin containing epidermis and part of the dermis 2. thick = less contraction, but more scarring from graft site

SAH 1. patho 2. clinical pres 3. neurologic findings for pos communicating* aneurysm 4. neurologic findings for internal carotid communicating 5. dx/tx

1. spontaneous (berry aneurysm or AVM), or trauma. 2. n/v, stiff neck, photophobia, dec. mentation, 3. 3rd nerve palsy 4. monocular visual field cut 5. CT if positive follow by angiogram

boerhaave syndrome 1. patho/clinical pres 2. dx/tx

1. spontaneous esophageal perforation (compare to mallory weiss) after inc. intra abdominal pressure (ex. vomiting)--> retrosternal or left chest/shoulder pain , pneumomediastinum, hydropneumothroax 2. gastrografin swallow and clinical hx, tx= left thoracotomy*** with repair of the tear

1. most common primary head and neck tumor 2. most common environmental exposure in head/neck cancers 3. symptoms that suggest neck cancer

1. squamous cell carcinoma 80% 2. smoking in 85% 3. sore throat >3 weeks, dysphagia, dyspnea, non-healing ulcers, hemoptysis, neck mass

tracheal neoplasms 1. cell type 2. what tumors met to the trachea 3. dx/tx

1. squamous cell carcinomas = MCC, also adeno 2. lung, esophagus, thyroid 3. CXR, tracheal tomography, fluoroscopy, bronchoscopy (right before surgery), PFT tx = pre-op abx, tracheal resection w/ end to end anastomosis - cervical incision for the upper half of trachea - posterolateral thoracotomy for the lower trachea

anal canal cancers (above dentate) 1. epidermoid types 2. presentation 3. dx/tx

1. squamous, basaoid, cloacogenic, mucoepidermoid 2. bleeding, pain, anal mass 3. physical exam, anoscopy, endorectal ultrasound, CT of pelvis/liver, chest radiograph tx = resection, external beam radiation,5FU, mitomycin C, external beam radiation

pericarditis 1. patho 2. surgical tx

1. staph/strep, viral, uremia, trauma, malignancy, CT disorders 2. underlying cause, open drainage, usually self resolving 3.

1. prosthetic infections organisms + tx -important to prophylax during surgery against organisms based on which part of the body surgery is taking place

1. staphylococcus (epidermidis) tx = removal of prosthesis

- self breast examinations should be done month 1. mammogram schedule 2. ultrasound use 3. MRI use

1. start at age 40 and yearly thereafter, or 5 years earlier than the youngest person with breast cancer 2. TARGETED examination, not for screning 3. very sensitive, but not specific, useful to use after a negative mammogram

hypomagnesemia 1. causes 2. clinical presentation **HYPOMAGNESEMIA CAN OCCUR WITH NORMAL SERUM MAGNESIUM

1. starvation, malabsorption, acute pancreatitis, chronic alcoholism 2. CNS hyperactivity, muscle tremors, inc. DTR, tetany, positive Chvostek sign

1. indication for carotid endarterectomy in asymptomatic healthy patient

1. stenosis >60% reduces risk of ipsilateral stroke

hypopharynx and cervical esophagus cancer 1. clinical presentation 2. dx/tx

1. throat pain, otalgia, dysphagia, hoarseness, airway obstruction 2. barium swallow and endoscopy with biopsy tx= laryngopharyngectomy, radical neck dissection, and radiotherapy

primary sclerosing cholangitis 1. patho/sx 2. dx/tx

1. stenosis/obstruction/fibrosis --> RUQ pain, painless jaundice, w/o fever/chills, pruritus, fatigue, nausea --> cirrhosis/hepatic failure 2. ERCP/transhepatic cholangiogram shows thickening/stenosis of the biliary duct system, no evidence of primary liver disease tx = hepaticoenteric or choledoenteric anastomosis,T tube, percutaneous stent, cholecystectomy

spine injury 1. treatment

1. steroid protocol (30 mg/kg then 5.4mg/kg/hr) started within 8 hours of injury - urgent decompression, spinal stabilization

corrosive ingestions 1. management

1. steroids and antibiotics reduces the formation of strictures DO NOT INDUCE VOMITING DO NOT TRY TO NEUTRALIZE THE SUBSTANCE

ulcerative colitis 1. medical tx 2. surgical tx indications 3. surgical tx

1. steroids, sulfasalazine, 5-ASA, immunosuppressants (6MP, AZA, MTX, cyclosporine), abx. 2. hemorrhage, fulminant colitis, toxic megacolon, colonic stricture/dysplasia >10 year duration 3. total proctocolectomy with permanent ileostomy ***proctocolectomy with anal sphincter preservation and ileoanal anastomosis (this cannot be done in CD b/c or recurrent disease in ileal pouch) abdominal colectomy with closure of rectal stump ileostomy with blowhole colostomy

chronic constrictive pericarditis 1. patho + sx 2. surgical tx

1. stiffening/calcification of the pericardium --> dyspnea, easy fatigability, JVD, ascites, hepatomegaly, peripheral edema 2. pericardiectomy

1. patient with deep wound to the leg still has palpable pulses, what should be next step of management

1. still do exploration to assess for vascular trauma because there could be partial transection ,or an expanding hematoma

gastric lymphoma 1. most common site for gastric lymphoma 2. sx 3. dx 4. tx 5 year survival >95% if no nodes, 75% if nodes involved

1. stomach 2. vague abdominal pain, early satiety , fatigue 3. endoscopy w/ biopsy, bone marrow biopsy, CT chest/abdomen, tehst for H.pylori 4. CHOP + radiation, surgical for complications of advanced disease

1. gallstone pancreatitis patho 2. alcoholic pancreatitis patho

1. stone in the common duct/impacted papilla --> reflux of bile into pancreatic duct 2. direct damage to acinar cells and inc. concentration of enzymes --> formation of stones --> multifocal duct obstruction/inc. intraductal pressure--> inflamm/fibrosis

calculous sialadenitis 1. patho 2. dx

1. stones in the salivary duct, 2. radiographs, sialogram, 3. transoral removal if near duct, external excision if it is deep in the gland

choledocholithiasis 1. patho/clinical pres 2. dx/tx

1. stones pass from gallbladder to the duct or primary in the duct--> RUQ pain that radiates to the back/shoulder, intermittent obstructive jaundice*, acholic stools, bilirubinuria 2. non-palpable gallbladder, US, ERCP, transhepatic cholangiography/radionucleotide scan, ELEVATED ALP*** tx = cholecystectomy, choledochotomy, stone removal, T-tube placement, percutaneous drainage during septic phase, operative cholangiography*, common bile duct exploration (if cholangiogram shows filling defect) tx = chemical dissolution (methyl-ter-butyl ether, or mono-octanoin), fluoroscopic guided mechanical extraction

1. primary fibrinolysis 2. tx for primary fibrinolysis

1. strepto/urokinase therapy, surgery of the prostate, liver failure 2. aminocaproic acid - inhibits plasminogen to plasmin *DO NOT GIVE TO PATIENTS WITH DIC BECAUSE IT WILL CAUSE INTRAVASCULAR CLOTTING****

norepinephrine 1. effect/use 2. what limits dose of NE

1. strong alpha agonist causes vasoconstriction beta agonist increases contractility of heart 2. tachycardia (from beta agonist activity

1. migrating motor complex 2. where is most water absorbed in the small intestine 3. where is potassium absorbed 4. how is sodium/chloride absorbed 5. how is calcium absorbed 6. where is iron absrobed

1. strong contraction in the duodenum every 23 hours removes residual food 2. jejunum (passive) 3. jejunum (passive) 4. active sodium, chloride follows passively 5. active transport enhanced by PTH and vitamin D 6. duodenum 7. jejunum

diffuse esophageal spasm 1. patho 2. sx 3. tx

1. strong non-peristaltic contractions w/ normal spincteric relaxation 2. cx pain that radiates to the head/neck (MIMICS MI), CXR may show corkscrew esophagus 3. esophagomyomectomy from aorta to above LES, CCB, nitrates (smooth muscle relaxers)

aorticoiliac disease treatment 1. axillobifemoral bypass

1. subQ conduit from axillary artery also used as tx. for aortic graft infection

pulmonary artery catheter 1. anatomy 2. what is measured 3. what does SVO2 <70% indicate SVO2 <60% deprives organs of oxygen 4. risks of insertion of PAC

1. subclavian --> RA-->RV --> pulmonary artery- 2. pulmonary capillary wedge pressure = left atrial pressure = LV preload~~ use this info to alter fluid therapy to maximize CO CO = using hemodilution SVO2 - saturation of venous blood (normal = 70%) - SVR/PVR 3. inc. o2 consumption or dec. o2 delivery 4. pneumothorax, transient V.fib, RBBB, cardiac perforation

TPN 1. administration 2. PPN administration 3. complications

1. subclavian line, PICC, internal juglar vein~~ tip in SVC--- start at half goal rate for 12 hours, and then advance 2. less hyperosmolar, less phlebitis, can be administered by peripheral vein 3. hemothorax, pneumothorax, infections, hyperglycemia, hepatic dysfunciton

diffuse multinodular goiter 1. patho + clinical pres 2. dx / tx 3. finding of a cold nodule

1. suboptimal thyroid hormone production with elevated TSH --> adenomatous hyperplasia--> asymptomatic, or obstructive symptoms/dysphagia 2. thyroid function studies NORMAL, radioiodine shows nodular uptake, tx = thyroxine, if symptomatic thyroidectomy 3. should be followed up w/ biopsy to r/o malig

angina pectoris 1. stable angina 2. unstable angina - also angina at rest, and post infarction angina

1. substernal cx pain lasting 5-10 mins caused by stress or exercise, relieved by resting 2. recent change from previous pattern

maxillary sinus cancer 1. stage T1/T2 treatment 2. stage T3/T4 treatment

1. subtotal or radical maxillectomy + radiation 2. radiation, then surgery and chemotherapy

1. what is the major hemostatic disorder associated with blood transfusion 2. What factors deficient in banked blood

1. thrombocytopenia *transfuse platelets if >6-8U of blood are transfused 2. V and VIII (replace with FFP)

melanoma 1. risk factors + most common locations 2. dx 3. tx

1. sun exposure, back and legs, congenital nevocellular nevus 2. histo, clarks classification, breslow's 3. total excision, sentinel node biopsy, end lymph node dissection (assume it has spread to the nodes), regional hyperthermic perfusions (isolate blood supply of limb and deliver high dose chemotherapy), dacarbazine, carmustine, lomustine, IL2, radiotherapy

1. drainage of the cerebral cortex 2. deep brain venous drainage

1. superficial cerebral veins 2. internal cerebral, basal veins --> great vein of galen, --> straight sinus --> internal jugular veins

neck 1. fascial planes 150 lymph nodes in the neck

1. superficial fascia envelops the platysma deep fascia- superficial invests SCM/trapezius, pretracheal, prevertebral

1. mondors disease 2. zuskas disease

1. superficial thrombophlebitis caused by surgery, infection, or trauma, typically self limiting 2. mammary fistula - dilated lactiferous ducts that become chronically inflamed and have periareolar draining sinuses-- tx = complete excision and removal of the terminal duct

1. what artery can be lacerated by a fracture of the greater sciatic notch 2 tx pelvic fractures

1. superior gluteal artery 2. AP radiograph, pelvic instability with pressure over iliac crests tx = fluid resuscitation, emergent stabilization with external pelvic fixation,

ARDS 1. treatment

1. supportive (tracheobronchial toilet), maintain oxygenation, maintain PO2 >60 with conservative use of PEEP and FiO2 STEROIDS DO NOT HELP TOO MUCH PEEP/FIO2 CAN DAMAGE THE LUNGS

1. treatment of glottic thyroid 2. dx. of ectopic thyroid 3. substernal goiter tx 4. thyroglossal duct cyst

1. suppression of TSH with thyroxine, removal if there are obstructive symptoms 2. radioiodine uptake scan 3. surgery only, they dont respond to thyroxine supplementation 4. midline painless masses that are connected to the base of the tongue, passes through the hyoid bone

neurogenic bladder 1. detrusor hyperreflexia (hypertonic bladder) pathogenesis 2. tx

1. suprasacral lesions decrease capacity/compliance, uninhibited contractions 2. anticholinergics, bladder catheterization, surgical bladder augmentation

pulmonary embolism 1. risk factors 2. sx 3. dx 4. tx

1. surgery, pregnancy, estrogen, heart disease, obesity, malignancy, trauma varicose veins, age 2. tachycardia*, tachypnea*, arrhythmias, right ventricular strain, pleuritic chest pain, westermark's sign hemoptysis, friction rub, gallop 3. pulmonary arteriogram, perfusion/ventilation lung scan using radioisotope - shows VQ mismatch CT scan with contrast, inc. end tidal CO2, inc. dead space, hypoxemia, normal PaCO2 due to hyperventilation 4. heparin, cardiovascular support (O2/shock tx), thrombolytics, pulmonary embolectomy, warfarin long term

pleural effusions 1. transudative patho 2. exudative patho 3. tx

1. systemic disorders taht alter hydrostatic/oncotic pressure leading protein poor filtrate to enter pleural space 2. altered permiability --> protein rich filtrate into pleural space 3. throracoscopy, thoracotomy

surger/radiation - used for primary/regional nodes chemotherapy/immunotherapy - used to treat areas of distant spread 1. adjuvant therapy

1. systemic therapy for patients with local control at high risk for microscopic disease---- used to destroy distant microfoci of cancer

ASD 1. dx + CXR -echo shows direction of shunting 2. cardiac cath finding 3. indications for surgery + surgical tx

1. systolic murmur in left 2nd/3rd ICS, CXR show RV enlargement and prominent pulmonary vasculature, RAD (secundum), LAD (primum), mitral regurg from cleft mitral valve 2. inc. oxygenation in the RA 3. 1.5-2x pulmonary blood flow - closure of ASD by percutaneous approach

esophageal carcinoma 1. risk factors 2. types 3. mets 4. dx 5. tx

1. tabacco, alcohol ingestion, nitrosamines, poor dentition,hot beverages 2. squamous (MCC), adeno (assc. barrets), muceoepidermoid carcinoma, adenoid cystic carcinoma 3. liver, bone, brain 4. dysphagia/weight loss, contrast, CT chest, esophagoscopy, bronchoscopy 5. transhiatal esophagectomy, ivor lewis esophagectomy, radiotherapy/chemotherapy (platinum, cisplatin, radiotherapy

hypovolemia 1. signs - correct acute loss quickly 2. correction of chronic hypovolemia 3. correction of hypernatremia with hypovomeia

1. tachycardia, hypotension, decreased urine output, loss of skin turgor, thirst, change in mental status 2. replace first half over 8 hours, second half in 24-48 hours 3. do not allow it to drop more than 0.5-1 mEq/hour

anal fissures 1. patho + sx 2. physical findings 3. tx

1. tear in anoderm (posterior to midline) caused by constipation/diarrhea--> tension on internal anal sphincter--> ischemia of muscle --> anal pain/bleeding with defecation 2. sentinel skin tag, hypertrophied anal papilla, spasm of internal sphincter 3. stool softeners/fiber, nitroglycerine ointment, botulinum toxin, internal sphincterotomy, anal sphincter stretch

1. why is acute parotitis so painful 2. parotid gland saliva drainage 3. which nerve pierces the parotid gland 4. what are the branches of the facial nerve

1. the parotid gland has a tight sheath around it 2. stensen's duct through buccinator muscle opposite the second molar 3. facial nerve 4. temporal, zygomatic, buccal, mandibular, cervical

1. thymus embryological origin 2. histo 3. what other organ is the thymus associated with occasionally

1. third branchial pouch 2. multilobulated: each lobule has cortex (lymphocytes) and medulla (hassals corpuscles) 3. ectopic inferior parathyroid glands

thymic cysts 1. patho 2. location 3. complications tx = surg

1. third pharyngeal pouch origin, attachment remains in the neck 2. anterior triangle, firm non tender mass 3. pain, dysphagia, hyperplasia,

1. diagnostic test for achilles tendon rupture

1. thompson test - squeezing calf and observing plantar flexion (which is absent)

pleural empyema 2. dx/tx

1. thoracocentesis, pH <7.4, organism culture, cloudy, foul smelling tx = CT guided catheters + TPA lytic therapy, aspiration/drainage (Acute), thoracotomy, debridement, decortication, continuous drainage (chronic/organized)

inguinal canal repair 1. shouldice repair 2. prosthetic mesh repairs 3. truss

1. transverslis fascia divided longitudinaly and imbricated on itself in two layers internal oblique and conjoint tendon sutured to the reflection of inguinal ligament (shelving edge of pouparts) 2. repair inguinal floor by using mesh to close the space suturing it to trasnversalis fascia/conjoint tendon 3. external compression in patients which cannot have safe hernia repair

enterocutaneous fistulas .1 MCC 2. dx 3. what determines likelihood of spontaneous closure 4. management

1. trauma during surgery 2. barium swallow 3. proximal high flow unlikely, distal slow flow likely 4. percutaneous intubation of fistula with a catheter TPN to maintain nutritional balance during the healing process (4-6 wks)

laryngeal granuloma 1. patho 2. tx

1. trauma from ET tube/reflux laryngitis --> granuloma occur over arytenoid cartilage 2. antireflux therapy, speech therapy, excision, botulinum toxin

osteomyeliotis 1. patho 2. what organisms in young children 3. older children 4. immunosuppressed 5. sickle cell

1. trauma to the knee causes capillary venous sludging under the growth plate and allows minor bacteremic conditions to initiate an infection/elevated periosteum --> sequestrum -->involucrum 2. staph, haemophilus, strep 3. staph 4. pseudomonas 5. salmonella

fat necrosis of the breast 1. patho 2. dx/tx

1. trauma, prolonged pressure etc --> liquefaction of breast tissue and formation of cystic/calcified mass **may be suspicious for breast cancer 2. excisional biopsy shows calcified/cystic mass with foamy macrophages and fat globules that has no correlation with cancer tx= surgical removal

arachnoid cysts 1. patho

1. trauma--> CSF filled cysts when arachnoid fuses forming CSF pouches.

1. causes of splenic rupture 2. splenosis 3. most common complications after splenectomy

1. traumatic rupture, or iatrogenic, or spontaneous due to splenomegaly 2. distribution of splenic fragments through abdominal cavity to help preserve spleen immune function 3. atelectasis***, also damage to stomach/tail of pancreas, subphrenic abscess + left pleural effusion, thrombocytosis

1. 3 histological types of neoplastic polyps - colon cancer has an adenoma--> carcinoma sequence -familial adenomatous polyposis 2. factors that predict malignancy of polyp 3. tx 4. criteria for endoscopic polypectomy

1. tubular (MCC), villous, tubulovillous 2. villous> tubulovillous >tubular, inc. size (>2cm), more atypia 3. endoscopic polypectomy, transanal polypectomy, segmental colectomy (sessile polyps) 4. pedunculated, cancer confined to stalk, no venous/lymphatic invasion, moderate-well differentiation

invasive breast cancer 1. favorable histologic types 2. unfavorable histologic types a. medullary b. invasive lubular

1. tubular (grade 1 intraductal), colloid/mucinous, papillary 2. ----------------------------------------- a. medullary cancer (lymphoplasmacytic** infiltration/well circumscribed lesion), b. invasive lobular cancer (small cell infiltrates around benign ducts)

tumors of small intestine adenomas 1. types of adeomas 2. clinical presentation 3. tx

1. tubular, villous (malig), brunners 2. bleeding, obstruction, intussusception 3. endoscopic/surgical resection

malignant small intestine neoplasms adenocarcinoma 1. patho 2. sx 3. tx without nodes - 80% 5 year survival with nodes = 10-15% 5 year survival

1. tumor of glandular nature - in the duodenum/proximal jejunum 2. often very late in the disease 3. segmental resection + mesentery

hepatoblastoma (MCC primary liver tumor in childrne) 1. patho/clincal pres 2. tx

1. tumor of nests of primitive cells --> abdominal distention, FTT, liver failure sx 2. surgical excision

multiple myeloma 1. patho/clinical pres 2. dx

1. tumor of plasma cells --> overproduction of bence jones proteins (monoclonal Ig), lytic lesions of spine/long bones--> pathologic fractures, anemia, ESR, elevated serum calcium 2. urine electrophoresis, shows M protein spike, bone marrow biopsy shows plasma cells replacing marrow, Xray shows punched out lytic lesions,

meningiocarcinomatosis 1. patho + clincal pres 2. associated conditions 3. tx

1. tumor that spreads through the subarachnoid space present with meningismus, ventricular obstruction --> CN III/VII/VIII deficits 2. lymphoma, leukemia, breast cancer 3. radiation and intrathecal

pancreas transplantation 1. indications for pancreas transplant 2. contraindications for pancreas transplant 3. what is the advantage of PAK

1. type 1 diabetes 2. periperal vascular diase, CAD, obesity, type 2 diabetes 3. can see if the patient had a good response to the kidney before giving them pancreas

acute cholecystitis 1. dx/tx

1. ultrasound* (thick walled gallbladder with stones, pericholecystic fluid, wall thickening) HIDA, CBC, amylase, LFT, ECG, CXR tx = cholecystectomy (immediate/delayed) + perioperative abx

1. what is important to know about the patient prior to surgery 2. standard pre-op labs

1. underlying medical conditions, allergies, current medications/supplements, difficulty with procedures/anesthetics, family bleeding disorders 2. CBC, electrolytes, glucose, creatinine LFTs PT/PTT/platelet count urinalysis - if urinary tract instrumentation is needed ECG - cardiac disease, hypertension chest radiograph - intrathoracic procedures

carcinoma of the gallbladder 1. patho **very poor prognosis

1. unknown/cholelithiasis/porcelain gallbladder--> adenocarcinoma -->lymphatic spread or direct spread to the liver--> RUQ pain, N/V,

neurogenic bladder 1. upper vs lower motor neuron damage effect on bladder tone 2. sx/assc 3. dx

1. upper = inc. tone, lower = dec. tone 2. freq, urg, nocturia, incontinence, vertebral disease, pelvic surgery, meds 3. bulbocavernosus reflex, urodynamic studies P/V curves - filling phase- high compliance is normal -voiding phase (flow rate, contractility) EMG - show if appropriate relaxation occurs with voiding

1. what stones form in acidic urine 2. what stones form in alkaline urine 3. what substances inhibit stone formation 4. what is the most common urinary stone 5. which urinary stone is translucent

1. uric acid** and cysteine 2. struvite stones (mg/phos) 3. high weight glycoproteins, citrate, magnesium, phosphate, zinc 4. calcium oxalate 5. URIC ACID

1. histology of spleen 2. which diseases involve abnormal splenic sequestration 3. what does the spleen clear from the blood 4. what kind of immunoglobulins are produced by the spleen

1. white pulp - lymphocytes, macrophages, plasma cells red pulp - cords of reticular cells 2. autoimmune hemolytic anemia, idiopathic thrombocytopenic purpura 3. clears cells that have IgG on their surface, and aged/abnormal RBCs 4. IgM in teh white pulp

liposarcoma 1. tx 2. location 3. fibrosarcoma 1. pahto

1. wide excision, 2,. any area including retroperitoneum

blunt aortic tears/great vessel injury 1. CXR 2. dx/tx

1. widened mediastinum, deviated NG tube, depressed left mainstem bronchus, blurring of aortic knob 2. CXR, transesophageal echocardiography, angiography

ECMO 1. pathophys

1. widespread inflammation of the coagulation cascade/fibrinolytic/complement/kallikrein system + release of epi/nepi/histamine/bradykinin , diffuse edema

1. prosthetic heart valve patients perioperative management *caged disk prosthetic mitral valves have high risk of thrombosis *LVOT obstruction worsens in patients with HCM during perioperative period (due to catecholamine release)

1. withhold warfarin for 3 days before surgery, start heparin until 12 hours before surgery and 2-3 days after surgery when oral intake resumes

focal nodular hyperplasia 1. assc 2. clinical pres 3. pathology 4. histo

1. women / OCP use 2. incidental finding, less likely to rupture then hepatocellular adenoma 3. single or multiple lesions with nodular appearance, central STELLATE scar, radiating septa (looks like regenerating nodules of cirrhosis) 4. hyperplastic hepatocytes and kupffer cells (inflamm), prominent bile duct epithelium***

abdominal trauma assessment 1. diagnostic peritoneal lavage - also do ultrasound, CT,

1.1L of saline into the abdominal cavity, positive if >100k RBCs, and >500 wbcs

enteral nutrtion (NG, nasoduodenal, nasojejunal), gastrotomy, jejunostomy 1. rate 50-65% carbs, 10-20% proteins 1-1.2 kcal/ml 2. complications 3. avoidance of complications

1.20ml/hour, inc. by 20ml/hour every 6-12 hours until caloric needs are met, maintain residual less than 200 or 4x the rate of feeding 2. aspiration of gastric content, bloating, mesenteric ischemia 3. post pyloric placement, maintain head of bed @ 45

hereditary spherocytosis 1. patho 2. sx 3. dx /tx

1.AUTOSOMAL DOMINANT mutation in ankyrin leads to sphere shaped cells more likely to lyse. and more rigid which causes them to be held in splenic pulp where they lyse from lack of glucose/ATP 2. gallstones, malaise, jaundice*, anemia*, splenomegaly* 3. inc. osmotic fragility, elevated retic, chromium 51 tagged cells concentrate in the spleen tx = splenectomy

sigmoid volvulus -men >60yo 1. patho 2. sx/signs 3. abdominal x ray, barium enema 4. tx

1.RF old age/chronic constipation, long freely movable colon, ample mesentery --> CCW turn around mesentery--> obstruction 2. n/v, abdominal distention, discomfort, obstipation, tympany/distention on exam, 3.dx = sigmoidoscopy/contrast barium studies x ray- massively distended bowel bow near the diaphragm*** (bent inner tube sign "looks like upside down U")- as sigmoid enlarges it moves to RUQ enema - obstructing twist - bird beak deformity 4. sigmoidoscopic decompression** (if tube reduction fails), sigmoidectomy with colostomy (hartmanns) sigmoidectomy with colorectal anastomosis

1. what drugs for bacterial endocarditis prophylaxis for dental/oral/respiratory/esophageal

1.amox (oral), amp (IV), clinda (o/iv)/cephalexin/cefazolin (iv) azithro/clarithro (allergic to penicillin)

defecation obstruction 1. anal stenosis cause + tx 2. non-relaxation of puborectalis sx, dx, tx

1.hemorrhoidectomy, trauma, radiation - tx = repeated dilation or advancing of pedicles of skin into anal canal 2. sx - digital maneuvers to remove stool, pelvic pain, incomplete evacuation dx - normal colon transit time, defecography (shows failure to relax), inability to expel air filled balloon tx - biofeedback (non-surgical)

ascites 1. pathogenesis 2. which portosystemic shunts will not worsen ascites 3. tx 4.peritoneal jugular shunt complication

1.hypoalbuminemia, hyperaldosteronism (dec. hepatic breakdown) 2. side to side and mesocaval 3. salt/water restriction, aldosterone antagonists, peritoneal jugular shunting (tube from peritoneal cavity to jugular vein, TIPS 4.bleeding because they can cause DIC

small bowel lymphomas 1. patho 2. sx + complications 3. tx

1.i mmunosuppression, inflammatory diseases (ex. crohns) --> usually non-hodgkins B cell lymphoma 2. -abdominal pain, fatigue, weight loss, diffuse adenopathy -perforation, intussusception, obstruction 3. wide local resection, chemotherapy, radiation

pancreatic cholera 1. pathogenesis 2. clinical features 3. tx *very poor prognosis, often malignant

1.inc VIP from pancreatic tumor --> severe diarrhea assc. with hypersecretion of pancreatic - non-beta islet cell tumor 2. watery diarrhea, hypokalemia (causes muscle weakness), achlorhydria 3. surgical exision , usually found in tail of pancreas

acute myocardial infarction 1. TC99m scan 2. TC201 scan

1.must be done within 18 hours after onset, will show hot spot in infarcted area 2. will show cold spot due to hypoperfusion (give after exercise or dipyrimadole)

pancoast tumor 1. treatment 2. cause - extremity sarcoma - pre-op radiation, radical local resection, post-operative adjuvant radiation/chemotherapy

1.pre-operative radiation, for brachial plexus spread and this also makes tumor surgically resectable 2. bronchogenic sarcoma that effects C8-T1 nerve roots, sympathetic trunks (horners)

risk factors for perioperative cardiovascular risk 1. major 2. intermediate 3. minor

1.recent MI, unstable/severe angina, significant arrythmias: AV block, ventricular arrythmias, supraventricular arrythmais with uncontrolled ventricular rate, valvular diesase 2. angina pectoris, prior MI by history or Q waves, prior CHF, Diabetes 3. age > 70, abnormal ECG, rhythum other than sinus, low functional capacity, stroke hx, uncontrolled hypertension

visceral compartment lesions (middle mediastium) 1. pericardial cysts 2. bronchogenic cyst 3. ascending aortic aneurysms

1.smooth walled cysts that occur at cardiodiaphragmatic angle 2. thin bronchial epithelial walled mucus containing mucus arise posterior to the carina, can cause pulmonary compression, can rupture and cause hemoptysis 3. great vessels dilate in middle mediastinum

mortality of patient coding after ruptured AAA vs ruptured vs non-ruptured

100% vs 60% vs 3%

treatment for hemolytic transfusion reaction

100ml 20% mannitol to protect the kidneys, discontinue the blood products HCO3- to alkalinize the urine

epiphrenic hernia clinical associations

10cm before the esophagocardiac junction, assc with hiatal hernia, diffuse esophageal spasm, and achalasia

2. post splenectomy sepsis clinical pres 3. what age has highest risk for post-splenectomy sepsis 4. what organisms cause post splenectomy sepsis 5. prevention of """

2. influenza symtoms, high fever, shock, death 3. age 2-5 in those with reticuloendothelial dieseae 4. s. pneumo, neisseria, h.flu 5. pneumococcal vaccine, n.meningitidis/h.flu vaccine, prophylactic penicillin

bolus fluids for patient in shock

20ml/kg of blood or saline solution

chronic pancreatitis 4. medical tx 5. surgical tx for dilated ducts 6. surgical tx for non-dilated fibrotic ducts

4. analgesia, insulin/glucagon, pancreatic enzymes (viokase/pancrease/pancreozymin) 5. puestow operation - look up picture its pretty awesome distal pancreatectomy duval operation- similar to puestow but tail of pancrease is amputated and proximal duct anastomosed roux-en-y 6. child operation- 95% pancreatectomy splanchnicectomy (relieves the pain only) duodenum sparing pancreatic head resection

mitral stenosis 4. auscultation 5. CXR 6. EKG 7. surgical tx - use Echo to eval CO/EF - cardiac cath to calculate mitral cross sectional area/CAD

4. apical diastolic rumble, OS, loud S1 (inc. pulm pressure) 5. prom pulm vasculature, inc. density of right heart, LA enlargement 6. RVH, RAD, P wave changes 7. commissurotomy or balloon mitral valvuloplasty, mitral valve replacement (if chordae/papillary muscles diseased)

relapsing pancreatitis 4. tx of biliary cause 5. tx of sphincteric cause - negative provocative test --> ERCP/r/o alcohol abuse

4. cholecystectomy, CBD exploration, biliary manometry, spin 5. cholecystectomy, wide sphincteroplasty

focal nodular hyperplasia 4. dx/tx

4. sulfur scan (kupfer cells uptake it) to differentiation between hepatocellular adenoma and FNH tx = excision/hepatic artery ligation

4. tricuspid insufficiency murmor 5. tricuspid stenosis 6. CXR - also echo and cardiac cath 7. surgical tx

4. systolic murmur at lower sternal border 5. diastolic murmur at lower sternal border 6. inc. right heart size 7. insufficiency - tricuspid repair, tricuspid replacement

treatment of rabid animal bite (suspected rabies)

5 day course of vaccine, single dose of HRIG with some applied around the wound

how long should uncomplicated otitis media be treated and how long should it take for the tympanic membrane to look normal again

5 days (10 days in recurrent or chronic) 3 months to look completely normal

how long should noncardiac surgery be delayed in a patient with MI or CHF and what intraoperative drugs should be used

6 months after MI digitalis/diuretics to prevent volume overload -- TWO MAJOR FACTORS ARE MI WITHIN 6 MONTHS, AND HX OF CHF

fibrocystic breast change (chronic cystic mastitis) 6. mammary duct ectasia 7. which type of breast cysts are benign vs possibly malignant + tx . 8. intraductal papilloma

6. dilation of subareolar ducts, retroareolar mass, nipple discharge, retraction of nipple 7. milk and simple cysts are benign, bloody cysts may show atypia or malignancy tx = excise as breast mass if doesn't resolve on its own 8. polyp of the breast duct common in perimenopausal women, causes bloody nipple discharge, treatment is excision

Maintainence IV calculation for 70kg male

70 kg male = 110 cc/hr by weight calculation 77mEq/L sodium 20mEq/L K -

how long does it take for a simple peptic ulcer to heal with pharmacologic treatment, what should be done if the ulcer doesnt heal

8-12 weeks, if doesnt heal should do upper GI endoscopy with biopsy to detect adenocarcinoma

A 44 year old lady has a palpable mass in her thyroid gland. She also describes losing weight in spite of a ravenous appetite, palpitations and heat intolerance. She is a thin lady, fidgety and constantly moving, with moist skin and a pulse rate of 105.

A "hot" adenoma. Management: confirm hyperthyroidism by measuring free T4. Confirm source of the excessive hormone with radioactive iodine scan. Do surgery after Beta blocking.

A 54 year old lady has a severe ureteral colic. IVP shows a 7mm ureteral stone at the ureteropelvic junction.

A 3mm stone has a 70% chance of passing. a 7mm stone only has a 5% probability of doing so. This one will have to be smashed and retrieved. Best option among answers offered would be shock-wave-lithrotripsy.

A mother brings her 6-year-old girl to you because " she has failed miserably to get proper toilet training". On questioning you find out that the little girl perceives normally the sensation of having to void, voids normally and at appropriate intervals, but also happens to be wet with urine all the time.

A classic vignette: low implantation of one ureter. In little boys there would be no symptoms, because low implantation in boys is still above the sphincter, but in little girls the low ureter empties into the vagina and has no sphincter. The other ureter is normally implanted and accounts for her normal voiding patter. Management: PE looking for abnormal ureteral opening. Often physical exam does not reveal the anomaly, and imaging studies would be required (start with IVP). Surgical repair will follow.

A 42 year old lady hits her breast with a broom handle while doing her housework. She noticed a lump in that area at the time, and one week later the lump is still there. She has a 3 cm. hard mass deep inside the affected breast, and some superficial ecchymosis over the area.

A classical trap for the unwary. It is cancer until proven otherwise. Trauma often brings the area to the attention of the patient...but is not cause of the lump.

A 44 year old man has unequivocal signs of multiple liver metastasis, but no primary tumor has been identified by multiple diagnostic studies of the abdomen and chest. The only abnormality in the physical exam is a missing toe, which he says was removed at the age of 18 for a black tumor under the toenail.

A classical vignette for malignant melanoma (the alternate version has a glass eye, and history of enucleation for a tumor). No self-respecting malignant tumor would have this time interval, but melanoma will.

Two weeks after an open cholecystectomy a patient develops fever and leukocytosis. The wound is healing well and does not appear to be infected.

A deep abscess. Two locations are prime suspects: subphrenic or subhepatic. Had the operation been an appendectomy, pelvic abscess would be the first pick. Management: CT scan to find the abscess and to guide the radiologist for the percutaneous drainage.

A 62 year old man complains of perianal discomfort, and reports that there are streaks of fecal soiling in his underwear. Four months ago he had a perirectal abscess drained surgically. Physical exam shows a perianal opening in the skin, and a cord-liked tract can be palpated going from the opening towards the inside of the anal canal. Browninsh purulent discharge can be expressed from the tract.

A pretty good description of a fistula in ano. Management: First rule out cancer with proctosigmoidoscopy. Then schedule elective fistulotomy.

A 62 year old man is found on physical exam to have a 6 cm. pulsatile mass deep in the abdomen, between the xiphoid and the umbilicus.

AAA elective surgery

what is early treatment of spinal cord injury

ABCs and high dose steroids*** CT to assess bone MRI to assess cord and soft tissues

leg claudication with walking. dx/tx

ABIs, then arteriogram, then bypass surg.

what should be an important first lab to check in a patient with generalized prurutus

ALP, not bilirubin because bilirubin is not always elevated in obstructive jaundice

acute adrenal insufficiency clinical pres + tx

AMS, N/V, hypotension, hyperthermia, hypoglycemia, hyperkalmeia tx = 100 mg hydrocortisone IV bolus then 200-400mg hydrocortisone/24h

best imaging test to rule out cervical spine injury

AP, lateral and odontoid views of the spine plain lateral radiographs in flexion/extension helps to rule out ligamentous injury/instability

steps of colon carcinogenesis

APC--> polyp --> DCC (allows progression), --> kras (allows polyp to enlarge)--> p53 (allows initiation of malig)

pancreatitis pulmonary complication

ATELECTASIS 2/2 factor that alters pulmonary surfactant

A 79 year old man with atrial fibrillation develops and acute abdomen. He has a silent abdomen, with diffuse tenderness and mild rebound. There is a trace of blood in the rectal exam. He has acidosis and looks quite sick. X-Rays show distended small bowel and distended colon up to the middle of the transverse colon.

Acute abdomen in the elderly who has atrial fibrillation, brings to mind embolic occlusion of the mesenteric vessels. Acidosis frequently ensues, and blood in the stool is often seen. unfortunately not much can be done, as the bowel is usually dead.

A 43 year old man develops excruciating abdominal pain at 8:18 PM. When seen in the E.R. at 8:50 PM, he has a rigid abdomen, lies motionless in the examining table, has no bowel sounds and is obviously in great pain, which he describes as constant. X-Ray shows free air under the diaphragms.

Acute abdomen plus perforated viscus equals perforated duodenal ulcer in most cases. What needs to be done? - Emergency exploratory laparotomy.

A 59 year old man arrives in the E.R. at 2 AM, accompanied by his wife who is wearing curlers on her hair and a robe over her nightgown. He has abdominal pain that began about one hour ago, and is now generalized, constant and extremely severe. He lies motionless in the stretcher, is diaphoretic and has shallow, rapid breathing. His abdomen is rigid, very tender to deep palpation, and has guarding and rebound tenderness in all quadrants.

Acute abdomen. He has generalized acute peritonitis. Management: The acute abdomen does not need a precise diagnosis to proceed with surgical exploration. Lower lobe pneumonia and myocardial infarction to have to be ruled out with chest X-Ray and EKG, and it would be nice to have a normal amylase...but the best answer is prompt ex lap.

A 26 year old drug-addicted man develops congestive heart failure over a short period of a few days. He has a loud, diastolic murmur at the right, second intercostal space. A physical exam done a few weeks ago, when he had attempted to enroll in a detoxification program was completely normal.

Acute aortic insufficiency due to endocarditis. Management: Emergency valve replacement, and antibiotics for a long time.

A 43 year old obese lady, mother of six children, has severe right upper quadrant abdominal pain that began three days ago. The pain was colicky at first, but has been constant for the past two and a half days. She has tenderness to deep palpation, muscle guarding and rebound in the right upper quadrant. She has temperature spikes to 104 and 105, with chills. Her WBC is 22, 000, with a shift to the left. Her bilirubin is 5 and she has an alkaline phosphatase of 2,000 (about 20 times normal). She has had episodes of colicky pain in the past, brought about by ingestion of fatty food, but they all had been of brief duration and relented spontaneously or with anticholinergic medications.

Acute ascending cholangitis. Further test?: The diagnosis is already clear. Sonogram might confirm dilated ducts. Management: This is an emergency decompression of the biliary tract. To achieve the latter ERCP is the first choice, but PTC (percutaneous transhepatic cholangiogram) is another option.

A 62 year old male presents with chills, fever, dysuria, urinary frequency, diffuse low back pain and an exquisitely tender prostate on rectal exam.

Acute bacterial prostatitis. Management: I.V. antibiotics... NO further rectal exams or any vigorous prostatic massage. Doing so could lead to septic shock.

A 59 year old lady has a history of three prior episodes of left lower quadrant abdominal pain for which she was briefly hospitalized and treated with antibiotics. Now she has left lower quadrant pain, tenderness, and a vaguely palpable mass. She has fever and leukocytosis.

Acute diverticulitis. How is the diagnosis made? - CT scan. Treatment is medical for the acute attack (antibiotics, NPO, bowe rest) but elective sigmoid resection is advisable for recurrent disease (like this lady is having). Emergency surgery (resection or colostomy) may be needed if she gets worse or does not respond to treatment.

A 24 year old man presents in the emergency room with very severe pain of recent onset in his right scrotal contents. There is fever of 103 ° and pyuria. The testis is in the normal position, and it appears to be swollen and exquisitely painful. The cord is also very tender.

Acute epididimitis. antibiotics. maybe US to rule out torsion, which is an emergency.

A 4 year old child is brought by his mother to the emergency room because "she is sure that he must have swallowed a marble". The kid was indeed playing with marbles and apparently completely healthy when he was put to bed, but four hours later he had developed inspiratory stridor, a fever of 103 and obvious respiratory distress. The kid is sitting up, leaning forward, drooling at the mouth and looking very sick indeed.

Acute epiglotitis. confirm w/ lateral xray of neck. get nasotracheal intubation. IV abx for H flu.

A child with a febrile illness but no history of trauma has persistent, severe localized pain in a bone.

Acute hematogenous osteomyelitis Management: don't fall for the X-Ray option. X-Ray will not show anything for two weeks. Do bone scan.

A 44 year old alcoholic male presents with severe epigastric pain that began shortly after a heavy bout of alcoholic intake, and reached maximum intensity over a period of two hours. The pain is constant, radiates straight through to the back and is accompanied by nausea, vomiting and retching. He had a similar episode two years ago, for which he required hospitalization.

Acute pancreatitis. How is it diagnosed? - Serum and urinary amylase and lipase determinations. CT scan if the diagnosis is unclear, or in a day or two if there is no improvement. Management: NPO, NG suction, IV fluids.

A 60 year old man shows up in the ER because he has not been able to void for the past 12 hours. He wants to, but can not. On physical exam his bladder is palpable half way between the pubis and the umbilicus, and he has a big, boggy prostate gland without nodules. He gives a history that for several years now, he has been getting up four or five times a night to urinate. Because of a cold, two days ago he began taking anthistamines, using "nasal drops", and drinking plenty of fluids.

Acute urinary retention, with underlying benign prostatic hypertrophy. Management: Indwelling bladder catheter, to be left in for at least 3 days. Long term therapy includes many options, best are probably long-term alpha-blockers for symptomatic relief, or some form of prostatic resection.

An 82 year old gentleman who has congestive heart failure and chronic obstructive pulmonary disease is told by his primary care physician that his level of prostatic specific antigen (PSA) is abnormally high. The gentleman has seen ads in the paper for sonographic examinations of the prostate, and he has one done. The examination reveals a prostatic nodule, which on trans-rectal biopsy is proven to be carcinoma of the prostate. The man is completely asymptomatic as far as this cancer is concerned. He has not evidence of metastasis either.

After a certain age, most men get prostatic cancer...but die of something else. As a rule, asymptomatic prostatic cancer is not treated after age 75.

A 55 year old lady presents with vague upper abdominal discomfort, early satiety and a large but ill-defined epigastric mass. Five weeks ago she was involved in an automobile accident where she hit the upper abdomen against the steering wheel.

Again pancreatic pseudocyst, in this case secondary to trauma rather than as a sequela of pancreatitis. You could diagnose it on the cheap with a sonogram, but CT scan is probably the best choice. It will need to be drained, and the radiologist will do it with CT guidance. An older option was to operate and anastomose the pseudocyst to the GI tract.

A man who fell from a second floor window has clinical evidence of fracture of his femur. The vignette gives you a choice of X-Rays to order.

Always get X-Rays at 90° to each other (for instance, AP and lateral), always include the joints above and below, and if appropriate (this case is) check the other bones that might be in the same line of force (here the lumbar spine).

A 62 year old man has vague, poorly described epigastric and upper back discomfort. He has been found on physical exam to have a 6 cm. pulsatile mass deep in the abdomen, between the xiphoid and the umbilicus. The mass is tender to palpation.

An abdominal aortic aneurysm that is beginning to leak. Management: Get a consultation with the vascular surgeons today.

A 72 year old lady has a red, swollen breast. The skin over the area looks like orange peel. She is not particularly tender, and it is debatable whether the area is hot or not. She has no fever or leukocytosis.

Another classic for cancer of the breast. Management: get that tissue diagnosis (here a punch biopsy of the skin is an option. It probably is permeated with cancer).

A 28 year old male is brought to the office by his mother. Beginning four months ago he has had three operations, done elsewhere, for a perianal fistula, but after each one the area has not healed, but actually the surgical wounds have become bigger. He now has multiple unhealing ulcers, fissures all around the anus, with purulent discharge. There are no palpable masses.

Another classic. The perianal area has fantastic blood supply and heals beautifully even though feces bathe the wounds. When it does not, you immediately think of Crohn's disease. Management: You still have to rule out malignancy. A proper examination with biopsies is needed. The biopsies should diagnose Crohn's.

A 61 year old man presents with a one year history of episodes of vertigo, diplopia, blurred vision, dysarthria and instability of gait. The episodes last several minutes, have no associated headache and leave not neurological sequela.

Another version of transient ischemic attacks, but now the vertebrals may be involved. Management: choose an arteriogram that examines all the arteries going to the brain: i.e. an aortic arch study. Vascular surgery will follow.

A patient involved in a car accident sustains a burst fracture of the vertebral bodies. He develops loss of motor function and loss of pain and temperature sensation on both sides distal to the injury, while showing preservation of vibratory sense and position sense.

Anterior cord syndrome.

A 55 year old lady falls in the shower and hurts her right shoulder. She shows up in the ER with her arm held close to her body, but rotated outwards as if she were going to shake hands. She is in pain and will not move the arm from that position. There is numbness in a small area of her shoulder, over the deltoid muscle.

Anterior dislocation of the shoulder, with axillary nerve damage. Management: Get AP and lateral X-Rays for diagnosis. Reduce.

A patient involved in a high speed automobile collision has multiple injuries, including rib fractures and abdominal contusions. Insertion of a Foley catheter shows that there is hematuria, and retrograde cystogram is normal. CT scan shows renal injuries that do not require surgery. Six weeks later the patient develops acute shortness of breath and a frank bruit.

Anytime there is injury and then a bruit forms followed by heart failure, it's a fistula. I think there was an aortoenteric fistula on my shelf as well.

A 29 year old lady calls your office at 10 AM with the history that she woke up that morning with one side of her face paralyzed.

Bell's palsy. Management: The latest trend is to start these patients right away on anti-viral medication (against herpes symplex virus). idiopathic and resolves spontaneously in most cases, tho.

for patient with cardiovascular risk factors which perioperative drug reduces mortality

BETA BLOCKERS (metoprolol)

patient has symptoms typical of gallbladder disease, but no findings of cholelithiaiss or choledocholethiasis, or no relief after choelecystectomy

BILIARY DYSKINESIA

A 71 year old West Texas farmer of Irish ancestry has a non-healing, indolent, punched out, clean looking 2 cm. ulcer over the left temple, that has been slowly becoming larger over the past three years. There are no enlarged lymph nodes in the head and neck.

Basal cell carcinoma. How is it diagnosed? - Full thickness biopsy at the edge of the lesion (punch or knife). Treatment: Surgical excision with clear margins, but conservative width.

A 12 year old boy is short for his age, has bitemporal hemianopsia and has a calcified lesion above the sella in X-Rays of the head.

Craniopharyngioma. Get MRI to dx then do pituitary surgery.

treatment for biliary dyskinesia

CCBs endoscopic sphincterotomy

most common site of arterial thromboembolism

COMMON FEMORAL ARTERY *90% SOURCE IS THE HEART (EX. AFIB OR MURAL THROMBUS)

1. distinguishing feature of colonic histology 2. tenia coli 3. haustra

CRYPTS OF LIEBERKUHN 2. incomplete outer longitudinal muscle forms three distinct bands 3. outpouchings of colonic wall between tenia coli

diverticulitis with perforation/abscess treatment (without diffuse peritonitis)

CT guided percutaneous drainage NOT COLONOSCOPY**** SURGICAL DRAINAGE ONLY IF PERCUTANEOUS FAILS

initial diagnostic study for diverticulitis

CT scan initially colonoscopy to rule out cancer

first step in evaluation of a suspected pelvic fracture

CT with contrast

A 56 year old man has bloody bowel movements. The blood coats the outside of the stool. He has been constipated, and his stools have become of narrow caliber.

Cancer of the distal, left side of the colon. How is it diagnosed? - Colonoscopy and biopsies. If given choices start with flexible sigmoidoscopy.

A 65 year old man present with a 4 cm. hard mass in front of the left ear, which has been present for six months. The mass is deep to the skin and it is fixed. He has constant pain in the area, and for the past two months has had gradual progression of left facial nerve paralysis. He has rock-hard lymph nodes in the left neck.

Cancer of the parotid gland. FNA is appropriate, but parotid masses are never biopsied in the office or under local anesthesia. Refer to ENT.

A 59 year old black man has a rock-hard, discrete, 1.5 cm. nodule felt in his prostate during a routine physical examination.

Cancer of the prostate. Management: Trans-rectal needle biopsy. Eventually surgical resection after the extent of the disease has been established.

A 59 year old is referred for evaluation because he has been fainting at his job where he operates heavy machinery. He is pale and gaunt, but otherwise his physical exam is remarkable only 4+ occult blood in the stool. Lab studies show a hemogoblin of 5.

Cancer of the right colon. How is it diagnosed? - Colonoscopy and biopsies. Treatment: Blood transfusions and eventually right hemicolectomy.

A 55 year old lady is being evaluated for protracted diarrhea. On further questioning she gives a bizarre history of episodes of flushing of the face, with expiratory wheezing. A prominent jugular venous pulse is noted on her neck.

Carcinoid syndrome. How do you diagnose it? - Serum determinations of 5-hydroxy-indoleacetic acid (serotonin)

A 35 year old blond, blue eyed man left his native Minnesota at age 18, and has been living an idyllic life as a crew member for a sailing yacht charter operation in the Caribbean. He has multiple nevi all over his body, but one of them has changed recently...

Change in a pigmented lesion is the other tip off to melanoma. It may be growth, or bleeding, or ulceration, or change in color...whatever. Management: full thickness biopsy at the edge of the lesion, margin free local excision if superficial melanoma (Clarks' levels one or two, or under 0.75 mm), wide local excision with 2 or 3 cm. margin if deep melanoma.

A 72 year old man has been known for years to have a wide pulse pressure and a blowing, high- pitched, diastolic heart murmur best heard at the second intercostal space and along the left lower sternal border with the patient in full expiration. He has had periodic echocardiograms, and in the most recent one there is evidence of beginning left ventricular dilatation.

Chronic aortic insufficiency. Management: Aortic valve replacement.

A disheveled, malnourished individual shows up in the emergency room requesting medication for pain. He smells of alcohol and complains bitterly of constant epigastric pain, radiating straight through to the back that he says he has had for several years. He has diabetes, steatorrhea and calcifications in the upper abdomen in a plain X-Ray.

Chronic pancreatitis. if forced to go further diagnostic test, pick ERCP.

A 69 year old lady has a 4 cm. hard mass in the right breast, with ill defined borders, movable from the chest wall but not movable within the breast. The skin overlying the mass is retracted an has an "orange peel" appearance...or the nipple became retracted six months ago.

Classical cancer of the breast. What do you do? - You have to have tissue. Core biopsy is OK, but if negative you don't stop there: only excisional biopsy will rule out cancer.

A 17 year old man is found to have a blood pressure of 190/115. This is checked repeatedly in both arms and it is always found to be elevated, but when checked in the legs it is found to be normal.

Coarctation of the aorta. Further testing; start with a chest X-Ray, looking for scalloping of the ribs. Eventually aortogram and ultimately surgery.

A middle aged homeless man is brought to the ER because of very severe pain in his forearm. The history is that he passes out after drinking a bottle of cheap wine and he slept on a park bench for an indeterminate time, probably more than 12 hours. There are no signs of trauma, but the muscles in his forearm are very firm and tender to palpation, and passive motion of his fingers and wrist elicit excruciating pain. Pulses at the wrist are normal.

Compartment syndrome. Management: Emergency fasciotomy.

A 15 year old girl has gained weight and become "ugly". She shows a picture of herself a year ago, where she was a lovely young lady. Now she has a hairy, red, round face full of pimples; her neck has a posterior hump and her supraclavicular areas are round and convex. She has a fat trunk and thin extremities. She has mild diabetes and hypertension.

Cushing's. AM and PM cortisol levels, dexamethasone suppression test, MRI of the sella and eventually trans-sphenoidal pituitary surgery.

A 32 year old woman is admitted to the psychiatry unit because of wild mood swings. She is found to be hypertensive and diabetic and to have osteoporosis. (she had not been aware of such diagnosis beforehand). It is also ascertained that she has been amenorrheic and shaving for the past couple of years. She has gross centripetal obesity, with moon fascies and Buffalo hump, and thin, bruised extremities. A picture from 3 years ago shows a person of very different, more normal appearance.

Cushings. How is the diagnosis made? - Start with AM and PM cortisol determinations. Later she will get dexamethasone suppression tests and MRI of the head looking for the pituitary microadenoma, which will eventually be removed by the trans-nasal, trans-sphenoidal route.

A 6 year old boy is brought to the U.S. by his new adoptive parents, from an orphanage in Eastern Europe. The kid is small for his age, and has a bluish hue in the lips and tips of his fingers. He has clubbing and spells of cyanosis relieved with squatting. He has a systolic ejection murmur in the left third intercostal space. Chest X-Ray shows a small heart, and diminished pulmonary vascular markings. EKG shows right ventricular hypertrophy.

Cyanotic kids could have any of the 5 conditions that begin with the latter "T": -Transportation of the great vessels -Truncus arteriosus -Total anomalous pulmonary venous connection -Tricuspid atresia, which are rare -Tetralogy of Falot (PROVe = pulm stenosis, RVH, overriding aorta (over the VSD), and VSD) Blue from the moment of birth, bet on transposition. Found later to be cyanotic, bet on tetralogy. Start with an echo.

MCC bronchiectasis

Cystic fibrosis

A 6 year old child has a mushy, fluid filled mass at the base of the neck, that has been noted for several years. The mass is about 6 cm. in diameter, occupies most of the supraclavicular area and seems by physical exam to go deeper into the neck and chest.

Cystic hygroma. Management: Get a CT scan to see how deep this thing goes. They can extend down into the chest and mediastinum. Surgical removal will eventually be done.

A 27 year old immigrant from Mexico has a 12 x 10 x 7 cm. mass in her left breast. It has been present for seven years, and slowly growing to it's present size. The mass is firm, rubbery, completely movable, is not attached to chest wall or to overlying skin. There are no palpable axillary nodes.

Cystosarcoma Phyllodes (has leaf like projections). Large, bulky masses/cysts Management: Tissue diagnosis is needed (some of these become outright malignant sarcomas), given the size best done with core or incisional biopsy. Margin-free resection will follow.

On the fourth post-operative day after an open cholecystectomy, a patient develops a temperature of 101. There is tenderness to deep palpation in the calf, particularly when the foot is dorsiflexed.

Deep venous thrombosis. Management: Duplex ultrasound (Doppler flow plus real time B-mode) to confirm diagnosis. Anticoagulation to prevent thrombus propagation.

risk factors for PVD

DM, tobacco, hyperlipidemia, family history, HTN

what is the choice agent for cardiogenic shock

DOBUTAMINE B1 agonist increases CO/dec. PVR, but is not chronotropic therefore it will not increase myocardial O2 demand much

which part of the GU tract is most likely to damage due to blunt pelvic/abdominal trauma

DOME of the bladder (near developmental hiatus of the bladder) causes abdominal peritonitis

In the newborn nursery it is noted that a child has uneven gluteal folds. Physical exam of the hips reveals that one of them can be easily dislocated posteriorly with a jerk and a "click", and returned to normal position with a "snapping".

Developmental dysplasia of the hip Management: Abduction splinting. (Don't order X-Rays in a newborn. Calcification is still incomplete and you will not see anything. US if <4 mo.)

A 74 year old man has sudden onset of extremely severe, tearing chest pain that radiates to the back and migrates down shortly after it's onset. His blood pressure is 220/100, he has unequal pulses in the upper extremities and he has a wide mediastinum on chest X-Ray. Electrocardiogram and cardiac enzymes show that he does not have a myocardial infarction.

Dissecting aneurysm of the thoracic aorta. Management: Arteriogram first, but the forces that dissected the vessel plus the force of the dye injection could further shear the aorta, thus study is done with beta blockers or IV nitrates to lower blood pressure. If the aneurysm is in the ascending aorta, emergency surgery will be done. If it is in the descending, intensive therapy (in the ICU) for HTN.

what finding on contrast CT increases likelihood malignancy

ENHANCEMENT

port

EQUIVALENT TO CENTRAL VENOUS CATHETER AND PERIPHERALLY INSERTED CENTRAL CATHETER, BUT NO EXTERNAL EXTENSION USED FOR LONGER TERM

A 77 year old man suddenly loses sight from the right eye. He calls you on the phone 10 minutes after the onset of the problem. He reports no other neurological symptoms.

Embolic occlusion of the retinal artery. Management: ophtho emergency, little can be done for the problem. He has to get the ER instantly and it might help for him to breathe into a paper bag on route, and have someone press hard on his eye and release repeatedly.

A 45 year old man shows up in the ER with a pale, cold, pulseless, paresthetic, painful and paralytic lower extremity. The process began suddenly two hours ago. Physical exam shows no pulses anywhere in that lower extremity. Pulse at the wrist is 95 per minute, grossly irregular.

Embolization by the broken-off tail of a clot from the left atrium. Emergency surgery with use of Fogarty catheters to retrieve the clot.

A second year medical student is hospitalized for a neurological work-up for a seizure disorder of recent onset. During one of his convulsions it is determined that his blood sugar is extremely low. Further work-up shows that he has high levels of insulin in the blood with low levels of C-peptide.

Exogenous administration of insulin. If the C-peptide had been high along with the insulin level, the diagnosis would have been insulinoma. Management: In this case, psychiatric evaluation and counseling (He is faking the disease to avoid taking the USMLE). If it had been insulinoma, CT scan or MRI looking for the tumor in the pancreas, to be subsequently removed surgically.

A newborn is noted to have a moist medallion of mucosae occupying the lower abdominal wall, above the pubis and below the umbilicus. It is clear that urine is constantly bathing this congential anomaly.

Exstrophy of the urinary bladder. rare, needs to be fixed in 48 hours.

A 60 year old man known to have hemorrhoids complains of anal itching and discomfort, particularly towards the end of the day. He has perianal pain when sitting down and finds himself sitting sideways to avoid the discomfort. He is afebrile.

External hemorrhoids. proctosigmoidoscopic examination to rule out cancer.

causes of pulmonary insufficiency in trauma

FAT EMBOLISM #1 aspiration, atelectasis, pulmonary contusion, pneumonia, pneumothorax, pulmonary edema, pulmonary thromboembolism

A 56 year old man develops slow, progressive paralysis of the facial nerve on one side. It took several weeks for the full blown paralysis to become obvious, and it has been present now for three months. It affects both the forehead as well as the lower face.

Gradual, unilateral nerve paralysis suggests a neoplastic process. Work-up: Gadolinium enhanced MRI.

A 62 year old chronic smoker has an episode of hemoptysis. Chest X-ray shows a central hilar mass. Bronchoscopy and biopsy establish a diagnosis of squamous cell carcinoma of the lung. His FEV1 is 2200, and a ventilation/perfusion scan shows that 30% of his pulmonary function comes from the affected lung.

FEV1 of at least 800 to survive surgery. Afterwards, his will be >800 still, so good candidate. CT scan and mediastinoscopy are in order, to ascertain if surgery has a decent chance to cure him.

A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stable vital signs. No breath sounds at the base on the right chest, faint distant breath sounds at the apex. Dull to percussion. A chest tube placed at the right pleural base recovers 120 cc of blood, drains another 20 c in the next hour.

Further treatment: The point of this one is that most hemothoraxes do not need exploratory surgery. Bleeding is from lung parenchyma (low pressure), stops by itself. Chest tube is all that is needed. Key clue: little blood retrieved, even less afterwards.

A 25-year-old man is stabbed in the right chest. He is moderately short of breath, his blood pressure is 95 over 70, pulse rate of 100. No breath sounds on at the base on the right chest, faint distant breath sounds at the apex. Dull to percussion. A chest tube placed at the right pleural base recovers 1250 cc of blood...(or it could be only 450 cc at the outset, but followed by another 420 cc in the next hour and so on).

Further treatment: The rare exception who is bleeding from a systemic vessel (almost invariably intercostal) will need thoracotomy to ligate the vessel, unlike most hemothorax pts, whose bleeding resolves on its own.

A 54 year old obese man gives a history of burning retrosternal pain and "heartburn" that is brought about by bending over, wearing tight clothing or lying flat in bed at night. He gets symptomatic relief from antiacids, but the disease process seems to be progressing since it started several years ago.

GERD. maybe biopsies/endoscopy to assess extent.

SE pentoxifylline

GI upset

braided absorbable sutures used for what kind of surgery

GI/visceral and general closures

what sites are most common for initiating sepsis Mortality rate

GU and respiratory tracts, biliary tract 40-50%

A healthy 24 year old man steps on a rusty nail. Three days later he is brought to the ER moribund, with a swollen, dusky foot, in which one can feel gas crepitation.

Gas gangrene. What to do? - Tons of IV penicillin and immediate surgical debridement of dead tissue, followed by a trip to the nearest hyperbaric chamber for hyperbaric O2 treatment.

A 28 year old lady has virulent peptic ulcer disease. Extensive medical management including eradication of H.Pylori fails to heal her ulcers. She has several duodenal ulcers in the first and second portions of the duodenum. She has watery diarrhea.

Gastrinoma (Zollinger-Ellison). How is the diagnosis made? - Start by measuring serum gastrin. Later CT scans (or MRI) of the pancreas looking for the tumor, and surgery to remove it.

A 48 year old lady has had severe, migratory necrolytic dermatitis for several years, unresponsive to all kinds of "herbs and unguents". She is thin, has mild stomatitis and mild diabetes mellitus.

Glucagonoma. How is the diagnosis made? - Determine glucagon levels. Eventually CT scan or MRI looking for the tumor in the pancreas. Surgery will follow. If inoperable, somatostatin* can help symptomatically and streptozocin* is the indicated chemotherapeutic agent.

A 55 year old, obese man suddenly develops swelling, redness and exquisite pain at the first metatarsal-phalangeal joint.

Gout. Management: Diagnosis by serum uric acid determination and identification of uric acid crystals in fluid from the joint. Rx. with colchicine (anti neutrophil), allopurinol or probenicid (inc. renal excretion of urate).

A 35 year old male is about to be discharged from the hospital where he was under observation for multiple blunt trauma sustained in a car wreck. It is then discovered that he has microscopic hematuria.

Gross traumatic hematuria in the adult always has to be investigated.

54 year old man has had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate abdominal distention, and has not had a bowel movement or passed any gas for five days. He has high pitched, loud bowel sounds that coincide with the colicky pain, and X- Rays that show distended loops of small bowel and air-fluid levels. Five years ago he had an exploratory laparotomy for a gunshot wound of the abdomen. Six hours after being hospitalized and placed on nasogastric suction and I.V. fluids, he develops fever, leukocytosis, abdominal tenderness and rebound tenderness.

He has strangulated obstruction: i.e., a loop of bowel is dying -or dead- from compression of the mesenteric blood supply. What does he need? - Emergency surgery.

A 7 year old child falls off a jungle gym and has minor abrasions and contusions. When checked by his pediatrician, a urinalysis shows microhematuria.

Hematuria from the trivial trauma in kids means congenital anomaly of some sort. Management: start with sonogram. IVP may be needed later.

A 19 year old college student returns from a trip to Cancun, and two weeks later develops malaise, weakness and anorexia. A week later he notices jaundice. When he presents for evaluation his total bilirubin is 12, with 7 indirect and 5 direct. His alkaline phosphatase is mildly elevated, while the SGOT and SGPT (transaminases) are very high.

Hepatocellular jaundice. Management: Get serologies to confirm diagnosis and type of hepatitis.

A 3 week old first-born, full term baby boy began to vomit three days ago. The vomiting is projectile, has no bile in it, follows each feeding and the baby is hungry and eager to eat again after he vomits. He looks somewhat dehydrated and has visible gastric peristaltic waves and a palpable "olive size" mass in the right upper quadrant.

Hypertrophic pyloric stenosis. Management: Check electrolytes: hypokalemic, hypochloremic metabolic alkalosis may have developed. Correct it, rehydrate and do Ramsted Pyloromyotomy.

A bunch of newborn boys are lined up in the nursery for you to do circumcisions. You notice that one of them has the urethral opening in the ventral side of his penis, about mid-way down the shaft.

Hypospadia. Don't do the circ b/c foreskin might be needed later for reconstruction.

treatment for perirectal abscess

I&D (curative in 50%), develop an fistula later, but dont worry about it now due to risk of damage to sphincter muscles

MCC cushings syndrome

IATROGENIC

what mineral deficiency occurs after subtotal gastrectomy and billroth 2

IDA because loose acidic environment of the stomach, cannot release ferric ion from foot so that is available to small intestine

treatment for suspected ruptured AAA (hx mid abdominal pain, pulsatile abdominal mass, now vascular collapse)

IMMEDIATE EX-LAP, no imaging etc

diagnostic algorithm for patient with traumatic hematuria who is hemodynamically stable

IVP then arteriography

mechanisms to decrease post operative pneumonia

Incentive spirometry *** CPAP, deep breathing, intermittent postive pressure breathing

A 55 year old man has an upper G.I. endoscopy done as an outpatient to check on the progress of medical therapy for gastric ulcer. Six hours after the procedure, he returns complaining of severe, constant, retrosternal pain that began shortly after he went home. He looks prostrate, very ill, is diaphoretic, has a temperature of 104 and respiratory rate of 30.

Instrumental perforation of the esophagus. How do you confirm the diagnosis? - Gastrographin swallow Treatment: Emergency surgical repair. Prognosis depends on time elapsed between perforation and treatment.

A newborn baby has repeated green vomiting during the first day of life, and does not pass any meconium. Except for abdominal distention, the baby is otherwise normal. X-Ray shows multiple air fluid levels and distended loops of bowel.

Intestinal atresia. Management: This one is due to a vascular accident in uteru, thus there are no other congenital anomalies to look for, but there may be multiple points of atresia.

A 9 month old, chubby, healthy looking little boy has episodes of colicky abdominal pain that make him double up and squat. The pain lasts for about one minute, and the kid looks perfectly happy and normal until he gets another colick. Physical exam shows a vague mass on the right side of the abdomen, an "empty" right lower quadrant and currant jelly stools.

Intussusception. Management: Barium enema is both diagnostic and therapeutic in most cases. ex lap w/ manual reduction if that doesn't work.

A 67 year old smoker with high cholesterol and coronary disease has an indolent, unhealing ulcer at the tip of his toe. The toe is blue, and he has no peripheral pulses in that extremity.

Ischemic ulcers are at the farthest away point from where the blood comes. Management: Doppler studies looking for pressure gradient, arteriogram. Revascularization may be possible, and then the ulcer may heal.

A 16 year old boy complains of low grade but constant pain in his distal femur present for several months. He has local tenderness in the area, but is otherwise asymptomatic. X-Rays show a large bone tumor, with "sunburst" pattern and periosteal "onion skinning".

Malignant bone tumor. Either osteogenic sarcoma or Ewing's sarcoma. Management: Do not attempt biopsy. Referral is needed, not just to an orthopedic surgeon, but to a specialist on bone tumors.

A 66 year old man presents with progressive jaundice which he first noticed six weeks ago. He has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated SGOT. The alkaline phosphatase is about six times the upper limit of normal. He is otherwise asymptomatic. A sonogram shows dilated intrahepatic ducts, dilated extrahepatic ducts and a very distended, thin walled gallbladder. Except for the dilated ducts, CT scan is unremarkable. ERCP shows a narrow area in the distal common duct, and a normal pancreatic duct.

Malignant, but lucky: probably cholangiocarcinoma at the lower end of the common duct. He could be cured with a pancreatoduodenectomy (Whipple operation). Next move: get brushings of the common duct for cytological diagnosis.

A 66 year old man presents with progressive jaundice which he first noticed six week ago. He has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated SGOT. The alkaline phosphatase is about six times the upper limit of normal. He has lost 10 pounds over the past two months, but is otherwise asymptomatic. A sonogram shows dilated intrahepatic ducts, dilated extrahepatic ducts and a very distended, thin walled gallbladder.

Malignant, silent, obstructive jaundice. A distended gallbladder is an ominous sign: when stones are the source of the problem, the gallbladder is thick-walled, non-pliable. What do you do next? - You already have the sonogram. Next move is CAT scan and ERCP.

A 24 year old man spends the night cruising bars and drinking heavily. In the wee hours of the morning he is quite drunk and he starts vomiting repeatedly. He initially brings up gastric contents only, but eventually he vomits bright red blood.

Mallory Weiss tear of the esophagogastric junction. Management: Endoscopy to ascertain the diagnosis. Bleeding is typically arterial and brisk, but self- limiting. Photocoagulation may be used if needed.

A 19 year old gang member is shot in the abdomen with a 38 caliber revolver. The entry wound is in the epigastrium, to the left of the midline. The bullet is lodged in the psoas muscle on the right. He is hemodynamically stable, the abdomen is moderately tender.

Management: No diagnostic tests are needed. A penetrating wound of the abdomen gets exploratory laparotomy every time. Only hidden trap you might get in the question relates to preparations prior to surgery: an indwelling bladder catheter, a big bore venous line for fluid administration and a dose of broad spectrum antibiotics.

You get a phone call from a frantic mother. Her 7 year old girl spilled Drano all over her arms and legs. You can hear the girl screaming in pain in the background.

Management: The point of this question is that chemical injuries - particularly alkalis-need copious, immediate, profuse irrigation. Instruct the mother to do so right at home with tap water, for at least 30 minutes before rushing the girl to the E.R.

A 54 year old man has had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate abdominal distention, and has not had a bowel movement or passes any gas for five days. He has high pitched, loud bowel sounds that coincide with the colicky pain, and X- Rays that show distended loops of small bowel and air-fluid levels. Five years ago he had an exploratory laparotomy for a gunshot wound of the abdomen.

Mechanical intestinal obstruction, due to adhesions. Management; Nasogastric suction, I.V. fluids and careful observation.

A 54 year old man has had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate abdominal distention, and has not had a bowel movement or passed any gas for five days. He has high pitched, loud bowel sounds that coincide with the colicky pain, and X- Rays that show distended loops of small bowel and air-fluid levels. On physical exam a groin mass is noted, and he explains that he used to be able to "push it back" at will, but for the past 5 days has been unable to do so.

Mechanical intestinal obstruction, due to an incarcerated (potentially strangulated) hernia. Management: After suitable fluid replacement needs urgent surgical intervention.

A 7 year old boy passes a large bloody bowel movement.

Meckel's diverticulum. Do a radioisotope scan looking for gastric mucosa in the lower abdomen.

A 53 year old man develops vague right upper quadrant abdominal discomfort and a 20 pound weight loss. Physical exam shows a palpable liver with nodularity. Two years ago he had a right hemicolectomy for cancer of the ascending colon. His carcinoembryogenic antigen (CEA) had been within normal limits right after his hemicolectomy, is now ten times normal.

Metastasis to the liver from colon cancer. Next move? - CT scan to ascertain extent. If mets are confined to one lobe, resection may be done. Otherwise, chemotherapy if he has not had it.

diagnostic sutdies for lower GI bleed

NG tube (to rule out UGI bleed) mesenteric angiography, radionuclide scan endoscopy (absolute r/o UGI) colonoscopy - anoscopy

A 69 year old man who smokes and drinks and has rotten teeth has a hard, fixed, 4 cm. mass in his neck. The mass is just medial and in front of the sternomastoid muscle, at the level of the upper notch of the Thyroid cartilage. It has been there for at least six months, and it is growing.

Metastatic squamous cell carcinoma to a jugular chain node, from a primary in the mucosa of the head and neck (oro-pharyngeal-laryngeal territory). Management: Don't biopsy the node! FNA is OK, but the best answer is to do a triple endoscopy (examination under anesthesia of the mouth, pharynx, larynx, esophagus and tracheobronchial tree).

A 4 year old falls from his tricycle. In the ensuing evaluation he is found to have microscopic hematuria.

Microhematuria in kids needs to be investigated, as it often signifies congenital anomalies...particularly if the magnitude of the trauma does not justify the bleeding. Start with sonogram.

A 55 year old lady has been known for years to have mitral valve prolapse. She now has developed exertional dyspnea, orthopnea and atrial fibrillation. She has an apical, high pitched, holosystolic heart murmur that radiates to the axilla and back.

Mitral regurgitation. Management: Start with the echocardiogram, eventually surgical repair of the valve (annuloplasty), or possibly valve replacement.

A 55 year old chronic smoker reports three instances in the past two weeks when he has had painless, gross, total hematuria. In the past two months he has been treated twice for irritative voiding symptoms, but has not been febrile and urinary cultures have been negative.

Most likely bladder cancer. Management: With this very complete presentation some urologist would go for the cystoscopy first, but the standard sequence of IVP first and cystoscopy next is the only correct answer for an exam.

A 37 year old lady has a lumpectomy and axillary dissection for a 3 cm. infiltrating ductal carcinoma. The pathologist reports clear surgical margins and metastatic cancer in four out of 17 axillary nodes.

Next - More extensive tumors need adjuvant systemic therapy, and the rule is that premenopausal women get chemotherapy and postmenopausal women get hormonal therapy. This is one clear one for chemotherapy.

A 31 year old lady smashes her car against a wall. She has multiple injuries including upper and lower extremity fractures. Her blood pressure is 75 over 55, with a pulse rate of 110. On physical exam she has a tender abdomen, with guarding and rebound on all quadrants.

No tests needed. Ex lap.

Burn patient was well resuscitated, had good hemodynamic parameters but required a lot of fluid. On the third day he starts to pee out a storm. What does that mean?

Nothing. Expected b/c fluid from burn edema is coming out.

treatment for patient with BOTH aortoiliac and femoropopliteal occlusive disease

ONLY aortofemoral bypass because the distal occlusive *only do combined procedures for severe life threatening ischemia

acute pancreatitits 1. ranson's criteria 2. tx

On admission: age, WBC, glucose, LDH, SGOT initial 48 hours: HCT, BUN, Ca, PaO2, HCO3- deficit, fluid estimate 2. NG suction, IV fluids (crystalloid), burn unit monitoring, foley output measure, PaO2 monitoring/chest radiograph - (resp distress/pleural effusions common) antibiotics (esp. IMIPENEM/CILISTATIN protect against cholangitis) NPO ~ NO ERCP ****

what will inc. CVP

PE, hypervolemia, PEEP ventilation, pneumothorax, ....sepsis dec. CVP from systemic vasodilation

why is PEEP dangerous in patients with hypovolemic shock

PEEP decreases ventricular preload, and can result in

what coagulation component decreases mortality in septic shock

PROTEIN C

liver disease coagulation lab findings+ tx

PT inc --- tx = FFP, cryoprecipitate

what paraneoplastic syndrome is associated with a localized SCC

PTHrP hypercalcemia tx = aggressive hydration, resection/radiotherapy

paraneoplastic syndrome associated with small cell carcinoma

PTHrP hypercalcemia (pseudohypoparathyroidism)

what blood gas value is an indication of alveolar ventilation

PaCO2

what is best indicator of alvoelar ventilation

PaCO2

criteria to wean ventilator

PaO2 >70 w/ FiO2<0.35 Aa gradient <350 PaO2/FiO2 ratio >300 PaCO2 >30/<55 VC >10-15ml/kg rapid shallow breathing index <105 max negative inspiratory force > -20cm H2O Minute ventilation <10L/min tidal volume >5ml/kg RR <30 b/min

A 49 year old alcoholic male presents with ill-defined upper abdominal discomfort and early satiety. On physical exam he has a large epigastric mass that is deep within the abdomen, and actually hard to define. He was discharged from the hospital 5 weeks ago, after successful treatment for acute pancreatitis.

Pancreatic pseudocyst. Management: You could diagnose it on the cheap with a sonogram, but CT scan is probably the best choice. It will need to be drained, and the radiologist will do it with CT guidance. An older option was to operate and anastomose the pseudocyst to the GI tract.

An automated blood chemistry panel done during the course of a routine medical examination indicates that an asymptomatic patient has a serum calcium of 12.1 in a lab where the upper limit of normal is 9.5. Repeated determinations are consistently between 10.5 and 12.6. Serum phosphorus is low.

Parathyroid adenoma. Your next move here is PTH determination and sistimibi scan to localize the adenoma. Surgery will follow.

A three day old premature baby has trouble feeding and pulmonary congestion. Physical exam shows bounding peripheral pulses and a continuous, machinery-like heart murmur.

Patent ductus arteriosus. Management: Echocardiography and surgical closure or indomethacin.

A 62 year old man with cirrhosis of the liver and ascites, presents with generalized abdominal pain that started 12 hours ago. He now has moderate tenderness over the entire abdomen, with some guarding and equivocal rebound. He has mild fever and leukocytosis.

Peritonitis in the cirrhotic with ascites, or the child with nephrosis and ascites, could be primary peritonitis - which does not need surgery - rather than the garden-variety acute peritonitis secondary to an intra-abdominal catastrophe that requires emergency operation. How is the diagnosis made? - Cultures of the ascitic fluid will yield a single organism. Treatment will be with the appropriate antibiotics.

A 45 year old man presents with a 2 cm. firm mass in front of the left ear, which has been present for four months. The mass is deep to the skin and it is painless. The patient has normal function of the facial nerve.

Pleomorphic adenoma (mixed tumor) of the parotid gland. (most common tumor of parotid, #2 = papillary cystadeoma (aka warthins tumor) How is it diagnoses? - FNA is appropriate, but the point of the question will be to bring out the fact that parotid masses are never biopsied in the office or under local anesthesia. Look for the option that offers referral to a head and neck surgeon for formal superficial parotidectomy.

A 72 year old man consults you with a history that for the past several days he has noticed that bubbles of air come out along with the urine when he urinates. He also gives symptoms suggestive of mild cystitis.

Pneumaturia due to a fistula between the bowel and the bladder. Most commonly from sigmoid colon to dome of the bladder, due to diverticulitis. Cancer is the second possibility. Management: NOT cystoscopy or sigmoidoscopy; they seldom show anything. CT scan is the way to go. sigmoidoscopic exam would be done at some point to r/o cancer, but not as the first test. Eventually surgery will be needed.

A 45-year-old man is involved in a high-speed automobile collision. He arrives at the ER in coma, with fixed dilated pupils. He has multiple other injuries (extremities, etc). His blood pressure is 70 over 50, with a feeble pulse at a rate of 130. What is the reason for the low BP and high pulse rate?

Point of the question: It is not from neurological injury. (Not enough room in the head for enough blood loss to cause shock). Look for answer of significant blood loss to the outside (could be scalp laceration), or inside (abdomen, pelvic fractures).

After a grand mal seizure, a 32 year old epileptic notices pain in her right shoulder and she can not move it. She goes to the near-by "Doc in a Box", where she has X-Rays and is diagnosed as having a sprain and given pain medication. The next day she still has the same pain and inability to move the arm. She comes to the ER with the arm held close to her body, in a "normal" (i.e., not externally rotated, but internally rotated) position.

Posterior dislocation of the shoulder. Very easy to miss on regular X-Rays. (PIN and AEX) Management: Get X-Rays again but order axillary view or scapular lateral.

You receive a call from a patient at 3:00 AM. His regular urologist retired five years ago, and he has not sought a replacement. At about 11:00 PM last night, the patient injected himself with papaverine directly into the corpora, as he had been instructed to do for his chronic, organic impotence. He achieved a satisfactory erection and had intercourse, but the erection has not gone away and he still has it at this time.

Priapism is another urological emergency. Management: Continued erection beyond four hours begins to damage the corpora. He needs emergency injection of an alpha agonist (phenylephrine, epinephrine or terbutaline) into the corpora. Once the crisis is over, the patient has to be switched from papaverine to Prostaglandin E1, which is now the agent of choice to achieve erection because it is less likely to produce priapism.

A 60 year old man known to have hemorrhoids reports bright red blood in the toilet paper after evacuation.

Probably bleeding from internal hemorrhoids. Management: It is not reassurance and hemorrhoid remedies prescribed by telephone. In all these cases, cancer of the rectum has to be ruled out. The correct answer is proctosigmoidoscopic examination.

A 23 year old nun presents with a history of amenorrhea and galactorrhea of six months duration. She is very concerned that other may think that she is pregnant, and she vehemently denies such a possibility.

Prolactinoma. measure prolactin level, get MRI to prepare for surg. bromocriptine if can't do surg.

best adjuvant for ER+ breast cancer in post-menopausal vs pre menopausal

aromatase inhibitors (anastrozole) for post menopausal, SERMS for pre menopausal (tamoxifen etc)

A 27 year man is recovering from an appendectomy for gangrenous acute appendicitis with perforation and periappendicular abscess. He has been receiving Clindamycin and tobramycin for seven days. Eight hours ago he developed watery diarrhea, crampy abdominal pain fever and leukocytosis.

Pseudomembranous colitis from overgrowth of Clostridium Difficile. How do you diagnose it? - Eventually with stool cultures, but proctosigmoidoscopy can show a typical picture before the cultures are back. Stop the clindamycin, give either Vancomycin or Metronidazole, and avoid lomotil.

Criteria for right bundle branch block (RBBB) on EKG

QRS >0,12 sec Slurred S wave in lead I and V6 RSR'-pattern in V1 where R' > R ~ myocardial contusion can cause this

A 61 year old man presents with a history of hematuria. Intravenous pyelogram shows a renal mass, and sonogram shows it to be solid rather than cystic. CT scan shows a heterogenic, solid tumor.

RCC

A 77 year old man falls in the nursing home and hurts his hip. X-Rays show that he has a displaced femoral neck fracture.

REQUIRES OPEN PRIMARY ARTHROPLASTY DUE TO RISK OF AVASCULAR NECROSIS blood supply to the femoral head is compromised in this setting and the patient is better off with a metal prosthesis put in, rather than an attempt at fixing the bone. With intertrochanteric fractures on the other hand, the broken bones can be pinned together and expected to heal.

treatment for ankle sprains

RICE, functional moblization with stirrup brace

free bleeding in the peritoneal cavity referred pain

RIGHT SUPRACLAVICULAR AREA DUE TO DIAPHRAGMATIC IRRITATION (example was ectopic pregnancy)

Indications for mechanical ventilation

RR>35/min Vc <15mL/kg (A-a)DO2 >350Kpa after 15min 100%O2 VD/Vt>0.6 PaO2<60 PaCO2>60

A 59 year old, myopic gentleman reports "seeing flashes of light" at night, when his eyes are closed. Further questioning reveals that he also sees "floaters" during the day, that they number ten or twenty, and that he also sees a cloud at the top of his visual field.

Retinal detachment. One or two floaters would not mean that. More than a dozen is an ominous sign, and that "cloud" at the top of the visual field is hemorrhage settling at the bottom of the eye. Management: Another ophthalmological emergency. The retina specialist will use laser treatment to "spot weld" the retina back in place.

classic block dissection o f the neck

SCM, external/internal jugular veins, spinal accessory nerve, submandibular gland, lymphatic tissue

which non-infectious cause of inflammatory arthritis

SLE, rheumatic fever, erythema nodosum, ank spondy, reiters, inflammatory bowel disease, gout/pseudogout

A white, fat, female, aged 40 and mother of five children gives a history of repeated episodes of right upper quadrant abdominal pain brougth about by the ingestions of fatty foods, and relieved by the administration of anticholinergic medications. The pain is colicky, radiates to the right shoulder and around to the back, and is accompanied by nausea and occasional vomiting. This time she had a shaking chill with the colicky pain, and the pain lasted longer than usual. She has mild tenderness to palpation in the epigastrium and right upper quadrant. Laboratory determinations show a bilirubin of 3.5, an alkaline phosphatase 5 times normal and a serum amylase 3 times normal value.

She passed a common duct stone and had a transient episode of cholangitis (the shaking chill, the high phosphatase) and a bit of biliary pancreatitis (the high amylase). US to confirm gallstones. Cholecystectomy after she is better. if she deteriorates, stone may be impacted at ampulla of Vater and need ERCP.

A 58 year old lady has a soft tissue tumor in her thigh. It has been growing steadily for six months, it is located deep into the thigh, is firm, fixed to surrounding structures and measures about 8 cm. in diameter.

Soft tissue sarcoma is the concern. Diagnosis: start with MRI. Leave biopsy and further management to the experts.

A 47 year old lady describes difficulty swallowing which she has had for many years. She says that liquids are more difficult to swallow than solids, and she has learned to sit up straight and wait for the fluids to "make it through". Occasionally she regurgitates large amounts of undigested food.

Sounds like achalasia (incomplete LES relaxation, increased LES tone, and lack of peristalsis of the esophagus) How do you make the diagnosis? - Manometry studies.

A 26 year old lactating mother has cracks in the nipple and develops a fluctuating, red, hot, tender mass in the breast, along with fever and leukocytosis.

Sounds like an abscess...and in this setting it is. However, only lactating breasts are "entitled" to develop abscesses. On anybody else, a breast abscess is a cancer until proven otherwise. Management: Incision and drainage is the Rx. For all abscesses, this one included. But, if an option includes drainage with biopsy of the abscess wall, go for that one.

A 55-year old, HIV positive man, has a fungating mass growing out of the anus, and rock hard, enlarged lymph nodes on both groins. He has lost a lot of weight, and looks emaciated and ill.

Squamous cell carcinoma of the anus. How to diagnose it? - Biopsies of the fungating mass. Eventual treatment: Nigro protocol of pre-operative chemotherapy and radiation.

A young recruit complains of localized pain in his tibia after a forced march at boot camp. He is tender to palpation over a very specific point on the bone, but X-Rays are normal.

Stress fracture. will not show up radiologically until 2 weeks later. Treat the guy as if he had a fracture (cast) and repeat the X-Ray in 2 weeks.

A 42 year old lady consults you for urinary incontinence. She is the mother of five children and ever since the birth of the last one, seven years ago, she leaks a small amount of urine whenever she sneezes, laughs, gets out of a chair or lifts any heavy objects. She relates that she can hold her urine all through the night without any leaking whatsoever.

Stress incontinence. Management: Well planned kegal pelvic floor muscle exercises, Surgical repair of the pelvic floor.

types of non-selective shunts for portal hypertension (4)

TIPS end to side- does not allow for future transplant mesocaval - still allows for transplant in the future side to side - used for budd chiari

which cytokine responsible for gram negative shock*****

TNF--> PMN activation, inc. vascular permeability, inc. IL1/2/6, microvascular thrombosis

long term complication of TPN

TPN induced liver failure

1. meigs syndrome 2. brenners tumor 3. dysgerminoma

TRIAD: ascites, RIGHT SIDED pleural effusion, benign ovarian tumor 2. benign fibroepithelial tumor 3. germ cell tumor with lymphocytes

H. pylori ulcer treatment

TRIPLE THERAPY - colloidal bismuth, amox/amp, metronidazole, QUADRUPE - add PPI

A 25 year old man presents with a painless, hard testicular mass.

Testicular cancer. Management: radical orchiectomy by the inguinal route. That irreversible, drastic step is justified because testicular tumors are almost never benign. Beware of the option to do a trans-scrotal biopsy: that is a definitive no-no. lymph node dissection in some cases (too complicated a decision for you to know about) and platinum-based chemotherapy. Serum markers are useful for follow up: AFP and beta-HCG, and they have to be drawn before the orchiectomy

A 14 year old boy presents in the Emergency Room with very severe pain of sudden onset in his right testicle. There is no fever, pyuria or history of recent mumps. The testis is swollen, exquisitely painful, "high riding", and with a "horizontal lie". The cord is not tender.

Testicular torsion, a urological emergency. Management: Emergency surgery to save the testicle.

A 55 year old man is diagnosed with type two diabetes mellitus. On questioning about eye symptoms he reports that sometimes after a heavy dinner the television becomes blurry and he has to squint to see it clearly.

The blurry T.V. is no big deal: the lens swells and shrinks in response to swings in blood sugar...the important point is that he needs to start getting regular ophthalmological follow up for retinal complications. It takes 10 or 20 years for those to develop, but type 2 diabetes may have been present that long before it was diagnosed

A red headed 23 year old lady who worships the sun, and who happens to be full of freckles, consults you for a skin lesion on her shoulder that concerns her. She has a pigmented lesion that is assymetrical, with irregular borders, of different colors within the lesion, and measuring 1.8 cms.

The classical ABCD that alerts you to melanoma or a forerunner (dysplastic nevus). Management: full thickness biopsy at the edge of the lesion, margin free local excision if superficial melanoma (Clarks' levels one or two, or under 0.75 mm), wide local excision with 2 or 3 cm. margin if deep melanoma.

A 22 year old gang leader comes to the E.R. with a small, 1 cm. deep sharp cut over the knuckle of the right middle finger. He says he cut himself with a screwdriver while fixing his car.

The description is classical for a human bite. he did it by punching someone in the mouth... human bites are bacteriologically the dirtiest that one can get. Rabies shots will not be needed, but surgical exploration by an orthopedic surgeon will be required.

A 77 year old man has a colonoscopy because of rectal bleeding. A villous adenoma is found in the rectum and several adenomatous polyps are identified in the sigmoid and descending colon.

The issue with polyps is which ones are pre-malignant, and thus need to be excised, and which ones are benign and can be left alone. Premalignant include, in descending order of malignant conversion: familial polyposis, Gardner's, villous adenoma and adenomatous polyps. Benign include juvenile, Peutz-Jeghers, inflammatory and hyperplastic.

A 33 year old man has had three large bowel movements that he describes as made up entirely of dark red blood. The last one was 20 minutes ago. He is diaphoretic, pale, has a blood pressure of 90 over 70 and a pulse rate of 110.

The point of the vignette is that something needs to be done to define the area from which he is bleeding. With the available information it could be from anywhere in the G.I. tract. The first diagnostic move here is to place a nasogastric tube.

A 62 year old man describes severe epigastric and substernal pain that he can not characterize well. There is a history suggestive of gastroesophageal reflux, and EKG and cardiac enzymes have been repeatedly negative.

The question here is whether retrosternal pain is due to acid reflux or not. The test that you do is an acid perfusion (Bernstein) test, that reproduces the pain when the lower esophagus is irrigated with an acid solution.

A 22 year old male has a 2 cm. round firm mass in the lateral aspect of his neck, which has been present for four months. Clinically this is assumed to be an enlarged jugular lymph node and it is eventually removed surgically. The pathologist reports that the tissue removed is normal thyroid tissue.

There is no such thing as "lateral aberrant thyroid". This is metastatic follicular carcinoma from an occult primary in the thyroid gland. Management: Look for the primary with a thyroid scan. Eventually surgery.

A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stable vital signs. No breath sounds on the right. Resonant to percussion at the apex of the right chest, dull at the base. Chest X-Ray shows one single, large air-fluid level.

What is it? - Hemo-pneumothorax. Chest tube, surgery only if bleeding a lot.

A 15 year old girl has a round, 1 cm. cystic mass in the midline of her neck at the level of the hyoid bone. When the mass is palpated at the same time that the tongue is pulled, there seems to be a connection between the two. The mass has been present for at least 10 years, but only recently bothered the patient because it got infected and drained some pus.

Thyroglossal duct cyst. Management: - Sistrunk operation* (removal of the mass and the track to the base of the tongue, along with the medial segment of the hyoid bone).

A 60 year old man complains of extremely severe, sharp, shooting, "like a bolt of lighting", pain in his face which is brought about by touching a specific area, and which lasts about 60 seconds. His neurological exam is normal, but it is noted that part of his face is unshaven, because he fears to touch that area.

Tic doloreaux (trigeminal neuralgia). Management: Rule out organic lesions with MRI. Treat with anticonvulsants (carbamazepine****** is first line).

A 42 year old man has suffered from chronic ulcerative colitis for 20 years. For the past 12 hours he has had severe abdominal pain, temperature of 104 and leukocytosis. He looks ill, and "toxic". His abdomen is tender particularly in the epigastric area, and he has muscle guarding and rebound. X-Rays show a massively distended transverse colon, and there is gas within the wall of the colon.

Toxic megacolon. Management: Emergency surgery for the toxic megacolon, but other indications for surgery include: chronic malnutrition, "intractability" and risk of developing cancer. The involved colon has to be removed, and that always includes the rectum.

Within eight hours after birth, it is noted that a baby has excessive salivation. A small, soft nasogastric tube is inserted and the baby is taken to X-Ray to have a "babygram" done. The film shows the tube coiled back upon itself in the upper chest. There is air in the gastrointestinal tract.

Tracheo-esophageal fistula, the most common type (type C) with proximal blind esophageal pouch and distal TE fistula. first, rule out the associated anomalies ("VACTER": vertebral, anal, cardiac, TE and renal/radial). The vertebral and radial will be seen in the same X-ray you already took, you need echo for the heart, sonogram for the kidneys and physical exam for the anus. Then off to surgery.

A 62 year old right handed man has transient episodes of weakness in the right hand, blurred vision, and difficulty expressing himself. There is not associated headache, the episodes last about 5 or 10 minutes at the most, and they resolve spontaneously. Funduscopic examination reveals highly refractile crystals in the left retinal artery.

Transient ischemic attacks in the territory of the left carotid artery (probably an ulcerated plaque at the left carotid bifurcation). How is the diagnosis confirmed? - In spite of a constant search for a non-invasive alternative, the gold standard is still angiogram. Treatment: Carotid endarterectomy.

A patient with multiple trauma from a car accident is being attended to in the emergency room. As multiple invasive things are done to him, he repeatedly grimaces with pain. The next day it is noted that he has a facial nerve paralysis on one side.

Trauma to the temporal bone can certainly transect the facial nerve, but when that happens the nerve is paralyzed right there and then. Paralysis appearing late is from edema. The point of the vignette is that nothing needs to be done.

A six year old boy has been stumbling around the house and complaining of severe morning headaches for the past several months. While waiting in the office to be seen, he assumes the knee-chest position as he holds his head. Neurological exam demonstrates truncal ataxia.

Tumor of the posterior fosa. Most brain tumors in children are located there, and cerebellar function is affected. Management: MRI, neurosurgery.

complications associated with continuous aterio-venous hemofiltration for ARF

arterial thrombosis, aneurysm, fistula, infection

A 67 year old diabetic has an indolent, unhealing ulcer at the heel of the foot.

Ulcer at a pressure point in a diabetic is due to neuropathy, but once it has happened it is unlikely to heal because the microcirculation is poor also. Management: control the diabetes, keep the ulcer clean, keep the leg elevated.. may end up amputating the foot.

A two year old has unilateral wheezing and the lung on that side looks darker on X-Rays (more air) than the other side.

Unilateral in toddlers suggest foreign body. Appropriate X-Rays, physical examination or endoscopies and extraction -typically under anesthesia.

A 52 year old man complains of hearing loss. When tested he is found to have unilateral sensory hearing lose on one side only. He does not engage in any activity (such as sport shooting) that would subject that ear to noise that spares the other side.

Unilateral versions of common ENT problems in the adult suggest malignancy. In this case, acoustic nerve neuroma. If the hearing loss had been conductive, a cerumen plug would be the obvious first diagnosis. How is it diagnosed? MRI looking for the tumor.

A two year old has unilateral foul smelling purulent rhinorrhea.

Unilateral versions of common bilateral ENT conditions in toddlers suggest foreign body. Appropriate X-Rays, physical examination or endoscopies and extraction -typically under anesthesia.

A 16 year old boy sneaks out with his older brother's friends, and goes on a beer-drinking binge for the first time in his life. He shortly thereafter develops colicky flank pain.

Ureteropelvic junction obstruction. Management: Start with ultrasound (sonogram). Repair will follow.

A 33-year-old lady is involved in a high-speed automobile collision. She arrives at the E.R. gasping for breath, cyanotic at the lips, with flaring nostrils. There are bruises over both sides of the chest, and tenderness suggestive of multiple fractured ribs. Blood pressure is 60 over 45.

What is it? - A variation on an old theme: classic picture for tension pneumothorax...but Where is the penetrating trauma? : The fractured rubs can act as a penetrating weapon. Management: chest tube to the left right away! Do not fall for the option of getting X-Rays first, but you need them later to rule out wide mediastinum (aortic rupture).

portal vein thrombosis causes

ascending umbilical infection in the neonate chronic pancreatitis, pancreatic carcinoma, iatrogenic

what clotting factors become deficient in a patient who is transfused large ammounts of blood

V and VIII also thrombocytopenia

foramen ovale

V3 mandibular branch of trigeminal lesser petrosal of CNIX

cryoprecipitate contents

VIII, fibrinogen, XIII, vWF`

A 44 year old, obese woman has an indolent, unhealing ulcer above her right malleolus. The skin around it is thick and hyperpigmented. She has frequent episodes of cellulitis, and has varicose veins.

Venous stasis ulcer (2/2 chronic venous insufficiency). Management: Unna boot. Support stocking. Varicose vein surgery.

A three month old boy is hospitalized for 'failure to thrive". He has a loud, pansystolic heart murmur best heard at the left sternal border. Chest X-Ray shows increased pulmonary vascular markings.

Ventricular septal defect. Management: Echocardiography and surgical correction.

An 82 year old man develops severe abdominal distension, nausea, vomiting and colicky abdominal pain. He has not passed any gas or stool for the past 12 hours. He has a tympanitic abdomen with hyperactive bowel sounds. X-Ray shows distended loops of small and large bowel, and a very large gas shadow that is located in the right upper quadrant and tapers towards the left lower quadrant with the shape of a parrot's beak.

Volvulus of the sigmoid. Management: Proctosigmoidoscopy should relieve the obstruction. Rectal tube is another option. Eventually surgery to prevent recurrences could be considered.

when can TPA be used in acute MI

WITHIN 6 HOURS AFTER ONSET OF MI

A 41 year old male presents to the E.R. reporting that he slipped in the shower and injured his penis. Exam reveals a large penile shaft hematoma with normal appearing glans.

What is it? - A classical description of fracture of the tunica albuginea...including the usual cover story given by the patient. These always happen during sexual intercourse with woman on top...but patient will not say so. Management: this is one of the few urological emergencies. Surgical repair is needed.

A motorcycle daredevil attempts to jump over the 12 fountains in front of Caesar's Palace Hotel in Las Vegas. As he leaves the ramp at very high speed his motorcycle turns sideways and he hits the retaining wall at the other end, literally like a rag doll. At the Er. he is found to be remarkably stable, although he has multiple extremity fractures. A chest X-Ray shows fracture of the left first rib and widened mediastinum.

What is it? - Actually a real case. Classical for traumatic rupture of the aorta: King size trauma, fracture of a hard-to-break bone (it could first rib, scapula or sternum) and the tell-tale hint of widened mediastinum How is the diagnosis made? - Arteriogram (aortogram). Treatment: Emergency surgical repair.

A 14-year-old boy is hit over the right side of the head with a baseball bat. He loses consciousness for a few minutes, but recovers promptly and continues to play. One hour later he is found unconscious in the locker room. His right pupil is fixed and dilated.

What is it? - Acute epidural hematoma (probably right side) How is it diagnosed? - CT scan showing lens shaped hemorrhage (crescent is subdural) Treatment? - Emergency surgical decompression (craniotomy). Good prognosis if treated, fatal within hours if it is not.

On the second post-operative day after surgery for repair of bilateral inguinal hernias, the patient reports that he "can not hold his urine". Further questioning reveals that every few minutes he urinates a few cc's of urine. On physical examination there is a large palpable mass arising from the pelvis and reaching almost to the umbilicus.

What is it? - Acute urinary retention with overflow incontinence. Management: Indwelling bladder catheter.

A 62 year old lady has an eczematoid lesion in the areola. It has been present for 3 months and it looks to her like "some kind of skin condition" that has not improved or gone away with a variety of lotions and ointments.

What is it? - Another sneaky way for cancer of the breast to show up. If you get this one in an extended matching set, the answer is Paget's disease of the breast-which is a cancer under the areola. Management: A full thickness punch biopsy of the skin would be OK, but core biopsy or incisional biopsy of the tissue underneath would be OK also.

A 65 year old West Texas farmer of Swedish ancestry has an indolent, raised, waxy, 1.2 cm skin mass over the bridge of the nose that has been slowly growing over the past three years. There are no enlarged lymph nodes in the head and neck.

What is it? - Basal cell carcinoma. How is it diagnosed? - Full thickness biopsy at the edge of the lesion (punch or knife). Treatment: Surgical excision with clear margins, but conservative width.

A car hits a pedestrian. He arrives in the ER in coma. He has...(raccoon eyes... or clear fluid dripping from the nose...or clear fluid dripping from the ear...or ecchymosis behind the ear)...

What is it? - Base of the skull fracture. How is it diagnosed? - CT scan. Needs cervical spine X-Rays. Implications for therapy: needs neurosurgical consult, needs antibiotics.

A 77-year-old man becomes "senile" over a period of three or four weeks. He used to be active and managed all of his financial affairs. Now he stares at the wall, barely talks and sleeps most of the day. His daughter recalls that he fell from a horse about a week before the mental changes began.

What is it? - Chronic subdural hematoma. (venous bleeding, size 7 brain in size 8 skull) How is diagnosis made? - CT scan. Treatment: Surgical decompression (craniotomy). Spectacular improvement expected.

A 53-year-old man is involved in a high-speed automobile collision. He has moderate respiratory distress. Physical exam shows no breath sounds over the entire left chest. Percussion is unremarkable. Chest X-Ray shows air fluid levels in the left chest.

What is it? - Classical for traumatic diaphragmatic rupture. It is always on the left. CXR will also show mediastinal shift in addition to air fluid levels Further test? Not really needed. A nasogastric tube curling up into the left chest might be an added tid bit. could also do a barium swallow (according to uworld..) Management: Surgical repair.

A 54-year-old lady crashes her car against a telephone pole at high speed. On arrival at the E.R. she is in moderate respiratory distress. She has multiple bruises over the chest, and multiple site of point tenderness over the ribs. X-Rays show multiple rib fractures on both sides. On closer observation it is noted that a segment of the chest wall on the left side caves in when she inhales, and bulges out when she exhales.

What is it? - Classical physical diagnosis finding of paradoxical breathing, leading to classical diagnosis of flail chest. She is at high risk for other injuries. Management: tube thoracocentesis followed by early endotracheal intubation and pain management Rule out other injuries (aortic rupture, abdominal injuries) The real problem is flail chest is the underlying pulmonary-contusion, for which the treatment is controversial, including fluid restriction, diuretics, use of colloid rather than crystalloid fluids when needed, and respiratory support. The probable wrong alternatives will revolve around various ways of mechanically stabilizing the part of the chest wall that moves the wrong way...because that used to be what was believed in the past. Further management: if other injuries require that she go to the OR, prophylactic bilateral chest tubes because she is at high risk to develop tension pneumothorax when under the positive pressure breathing of the anesthetic.

A 32-year-old male is involved in a head-on, high-speed automobile collision. He is unconscious at the site, regains consciousness briefly during the ambulance ride and arrives at the E.R. in deep coma, with a fixed, dilated right pupil.

What is it? - Could be acute epidural hematoma, but acute subdural is better bet. Diagnosis? - CT scan. Also need to check cervical spine! Treatment? - Emergency craniotomy, poor prognosis because of brain injury.

A 35 year old lady has a ten year history of tenderness in both breasts, related to menstrual cycle, with multiple lumps on both breasts that seem to "come and go" at different times in the menstrual cycle. Now has a firm, round, 2 cm. mass that has not gone away for 6 weeks.

What is it? - Fibrocystic disease (cystic mastitis, mammary dysplasia), with a palpable cyst. Management: tissue diagnosis (i.e: biopsy) becomes impractical when there are lumps every month. *Aspiration of the cyst and re-examination in 6 weeks is the answer here*. If the mass goes away and the fluid aspirated is clear, that's all. -if bloody it goes to cytology. -if does not go away, or recurs she needs biopsy. Answers that offer mammogram or sonogram in addition to the aspiration would be OK, but not as the only choice.

what daily prophylactic drug will reduce cardiac complications assc with CAD

aspirin 325mg every other day

A 22-year-old gang member arrives in the E.R. with multiple guns shot wounds to the abdomen. He is diaphoretic, pale, cold, shivering, anxious, asking for a blanket and a drink of water. His blood pressure is 60 over 40. His pulse rate is 150, barely perceptible.

What is it? - Hypovolemic shock Management: Several things at one: Big bore IV lines, Foley catheter and I.V. antibiotics. Ideally exploratory lap immediately for control of bleeding, and then fluid and blood administration. If O.R. not available, fluid resuscitation while waiting for it.

A 22-year-old gang member arrives in the E.R. with multiple gun shot wounds to the chest and abdomen. He is diaphoretic, pale, cold, shivering, anxious, asking for a blanket and a drink of water. His blood pressure is 60 over 40. His pulse rate is 150, barely perceptible.

What is it? - Hypovolemic shock still the best bet, but the inclusion of chest wounds raises possibility of pericardial tamponade or tension pneumothorax. As a rule if significant findings are not included in the vignette, they are not present. Thus, as given this is still a vignette of hypovolemic shock, but you may be offered in the answers the option of looking for the missing clinical signs: distended neck veins (or a high measured CVP) would be common to both tamponade and tension pneumo; and respiratory distress, tracheal deviation and absent breath sounds on a hemithorax that is resonant to percussion would specifically identify tension pneumothorax

A 41 year old man has been in the intensive care unit for two weeks, being treated for idiopathic hemorrhagic pancreatitis. He has had several percutaneous drainage procedures for pancreatic abscesses, chest tubes for pleural effusions, and bronchoscopies for atelectasis. He has been in and out of septic shock and respiratory failure several times. Ten minutes ago he vomited a large amount of bright red blood, and as you approach him he vomits again what looks like another pint of blood.

What is it? - In this setting, it has to be stress ulcer. Management: It should have been prevented by keeping the pH of the stomach above 4 with H2 blockers, antacids or both; but once the bleeding takes place the diagnosis is made as usual with endoscopy. Treatment may require angiographic embolization of the left gastric artery.

A 34 year old lady has been having bloody discharge from the right nipple, on and off for several months. There are no palpable masses.

What is it? - Intraductal papilloma. What is to be done? - the way to detect cancer that is not palpable is with a mammogram. That should be the first choice. If negative, one may still wish to find and resect the intraductal papilloma to provide symptomatic relief. Resection can be guided by galactogram, or done as a retroareolar exploration.

A 54-year-old lady crashes her car against a telephone pole at high speed. On arrival at the E.R. she is breathing well. She has multiple bruises over the chest, and is exquisitely tender over the sternum at a point where there is a crunching feeling of crepitation elicited by palpation.

What is it? - Obviously a sternal fracture...but the point is that she is at high risk for myocardial contusion and for traumatic rupture of the aorta. Further tests: as you would do for a MI : EKG, cardiac enzymes, but the real important ones would be CT scan, transesophageal echo or arteriogram looking for aortic rupture.

A 26-year-old lady has been involved in a car wreck. She has fractures in upper extremities, facial lacerations and no other obvious injuries. Chest X-Ray is normal. Shortly thereafter she develops hypotension, tachycardia and dropping hematocrit. Her CVP is low.

What is it? - Obviously blood loss, and it has to be in the abdomen. To go into hypovolemic shock one has to lose 25 to 30% of blood volume, which in the average size adult will be nearly a liter and a half (25 to 30% of 4.5 to 5 liters). In the absence of external hemorrhage (scalp lacerations can't bleed that much), the bleeding has to be internal. That much blood can not fit inside the head, and would not go un-noticed in the neck (huge hematoma) or chest (X-Rays can spot anything above 150 cc). Only massive pelvic fractures, multiple femur fractures or intra-abdominal bleeding can accommodate that much blood. The first two would be obvious in physical exam and X-Rays. The belly can be silent. Thus the belly is invariably the place to look for that hidden blood. How is it diagnosed? - invasive way was the diagnostic peritoneal lavage. The newer, non-invasive ways are the CAT scan or sonogram. CT scan is best, but it can not be done in the patient who is "crashing". (the X-Ray department is a never-never land where patients die unattended). Try to gage from the question whether the patient is stable - do CT scan, or literally dying on your hands, in which case diagnostic peritoneal lavage or sonogram is done in the E.R. Eventual therapy: most likely finding will be ruptured spleen. If stable, observation with serial CT scans will follow. If not, exploratory laparotomy.

A 22-year-old gang member arrives in the E.R. with multiple guns shot wounds to the chest and abdomen. He is diaphoretic, cold, shivering, anxious, asking for a blanket and a drink of water. His blood pressure is 60 over 40. His pule rate is 150, barely perceptible. He has big distended veins in his neck and forehead. He is breathing OK, has bilateral breath sounds and no tracheal deviation.

What is it? - Pericardial tamponade Management: No X-Rays needed, this is a clinical diagnosis!. Do Pericardial window. If positive, follow with thoracotomy, and then exploratory lap.

A patient involved in a high speed automobile collision has multiple injuries, including a pelvic fracture. Insertion of a Foley catheter shows that there is gross hematuria.

What is it? - Presumably there was no blood in the meatus to warn against the insertion of an indwelling catheter, and since the latter was accomplished without problem, the urethra must be intact. That leaves us with bladder injury. Assessment will require retrograde cystogram.

A 54-year-old lady crashes her car against a telephone pole at high speed. On arrival at the E.R. she is breathing well. She has multiple bruises over the chest and multiple sites of point tenderness over the ribs. X-Rays show multiple rib fractures on both sides, but the lung parenchyma is clear and both lungs are expanded. Two days later her lungs "white out" on X- Rays and she is in respiratory distress.

What is it? - Pulmonary contusion. It does not always show up right away, may become evident one or two days after the trauma. Management: Fluid restriction (using colloid), diuretics, respiratory support. The latter is key, with intubation, mechanical ventilation and PEEP if needed.

A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stable vital signs. No breath sounds at the base on the right chest, faint distant breath sounds at the apex. Dull to percussion.

What is it? - Sounds more like hemothorax. How do we find out? - Chest X-Ray If confirmed, treatment is chest tube on the right, at the base of the pleural cavity.

A blond, blue eyed, 69 year old sailor has a non-healing, indolent 1.5 cm. ulcer n the lower lip, that has been present, and slowly enlarging for the past 8 months. He is a pipe smoker, and he has no other lesions or physical findings.

What is it? - Squamous cell carcinoma. How is the diagnosis made? - Biopsy, as described before. Treatment: he will need surgical resection with wider (about 1 cm.) clear margins. Local radiation therapy is another option.

A 22-year-old gang member arrives in the E.R. with multiple gun shot wounds to the chest and abdomen. He has labored breathing and is cyanotic, diaphoretic, cold and shivering. His blood pressure is 60 over 40. His pulse rate is 150, barely perceptible. He is in respiratory distress, has big distended veins in his neck and forehead, his trachea is deviated to the left, and the right side of his chest is tympantic, with no breath sounds.

What is it? - Tension pneumothorax. Management: Immediate big bore IV catheter placed into the right pleural space, followed by chest tube to the right side, right away! Watch out for trap that offers chest X-Ray as an option. This is a clinical diagnosis, and patient needs that chest tube now. He will die if sent to X-Ray. Exploratory lap will follow.

A 14 year old boy slides down a banister,not realizing that there is a big knob at the end of it. He smashes the scrotum and comes in to the E.R. with a scrotal hematoma the size of a grapefruit.

What is it? - The issue in scrotal hematomas is whether the testicle is ruptured or not. How is the diagnosis made? - Sonogram will tell. Management: If ruptured, surgery will be needed. If intact, only symptomatic treatment.

A 19 year old gang member is shot once with a 38 caliber revolver. The entry wound is in the left mid-clavicular line, two inches below the nipple. The bullet is lodged in the left paraspinal muscles. He is hemodynamically stable, but he is drunk and combative and physical exam Is difficult to do.

What is it? - The point here is to remind you of the boundaries of the abdomen: although this sounds like a chest wound, it is also abdominal. The belly begins at the nipple line. The chest does not end at the nipple line, though. Belly and chest are not stacked up like pancakes: they are separated by a dome. This fellow needs all the stuff for a penetrating chest wound (chest X-Ray, chest tube if needed), plus the exploratory lap.

A 27 year old intoxicated man smashes his car against a tree. He is tender over the left lower chest wall. Chest X-Ray shows fractures of the 8th, 9th and 10th ribs on the left. He has a blood pressure of 85 over 68 and a pulse rate of 128.

What is it? - This one is a classic: ruptured spleen. In the absence of other clues, clinically significant hidden intra-abdominal bleeding comes from a ruptured spleen. This case is actually full of other clues that point to the spleen. First negotiate the diagnostic dilemma: if he responds promptly to fluid administration, and does not require blood, go for the CT scan. Further management in that case may well be continued observation with serial CT scans. If he is "crashing", he will need the peritoneal lavage or sonogram followed by exploratory laparotomy.

A 34-year-old lady suffers severe blunt trauma in a car accident. She has multiple injuries to her extremities, has head trauma and has a pneumothorax on the left. Shortly after initial examination it is noted that she is developing progressive subcutaneous emphysema all over her upper chest and lower neck.

What is it? - Traumatic rupture of the trachea or major bronchus. Additional findings: Chest X-Ray would confirm the presence of air in the tissues. Management: Fiberoptic bronchoscopy to confirm diagnosis and level of injury and to secure an airway. Surgical repair after that.

A 17 year old girl is stung by a swarm of bees...or a man of whatever age breaks out with hives after a penicillin injection...or a patient undergoing surgery under spinal anesthetic...eventually develop BP of 75 over 25, pulse rate of 150, but they look warm and flush rather than pale and cold. CVP is low.

What is it? - Vasomotor shock (massive vasodilation, loss of vascular tone) Management: Vasoconstrictors. Volume replacement would not hurt.

A 72 year old man who lives alone calls 911 saying that he has severe chest pain. He cannot give a coherent history when picked up by the EMT, and on arrival at the ER he is cold and diaphoretic and his blood pressure is 80 over 65. He has an irregular, feeble pulse at a rate of 130. His neck and forehead veins are distended and he is short of breath.

What is it? - cardiogenic shock, from massive MI. Management: verify high CVP. EKG, enzymes, coronary care unit etc. Do not drown him with enthusiastic fluid "resuscitation", but use thrombolytic therapy if offered.

A patient has suffered third degree burns to both of his arms when his shirt caught on fire while lighting the back yard barbecue. The burned areas are dry, white, leatherly anesthetic, and circumferential all around arms and forearms.

What is it? - circumferential burns: The leathery eschar will not expand, while the are under the burn will develop massive edema, thus circulation will be cut off. (Or in the case of circumferential burns of the chest, breathing will be compromised). Management: Compulsive monitoring of peripheral pulses and capillary filling. Escharotomies at the bedside at the first sign of compromised circulation.

A 19 year old male is involved in a severe automobile accident. Among many other injuries he has a pelvic fracture. He has blood in the meatus, scrotal hematoma and the sensation that he wants to urinate but can not do it. Rectal exam shows a "high riding prostate".

What is it? - posterior urethral injury. prostate is displaced from expanding hematoma How is the diagnosis made? - retrograde urethrogram Management: They will not ask you, but these get a suprapubic catheter, and the repair is delayed 6 months.

A 27 year old intoxicated man smashes his car against a tree. He is tender over the left lower chest wall. Chest X-Ray shows fractures of the 8th, 9th and 10th ribs on the left. He has a blood pressure of 85 over 68 and a pulse rate of 128, which do not respond satisfactorily to fluid and blood administration. He has a positive peritoneal lavage and at exploratory laparotomy a ruptured spleen is found.

What is the issue here? - When dealing with a ruptured spleen an effort will be made to repair it rather than remove it. In children the effort will be even greater. But if the vignette says that the spleen had to come out, then further management includes administration of pneumovax and some would also immunize for hemophilus influenza B and Meningococcus.

potential indirect hernia

assc. with undescended testis, testis in inguinal canal, hydrocele

dates for mammography and DRE and pap smear

mammograpy after age 35-40 DRE annually after age 50 pap smear every 3 years after age 30 with 2 negative tests

A 42 year old lady drops her hot iron on her lap while doing the laundry. She comes in with the shape of the iron clearly delineated on her upper thigh. The area is white, dry, leatherly, anesthetic.

What is the issue? - less extensive burns can be taken to the O.R., excised and grafted on day one, saving tons of money. the vignette is a classical one where the decision is easy: very small and clearly third degree. Answer: Early excision and grafting.

when should heparin be started in a surgical patient

before the surgical procedure

On the fifth post-operative day after a right hemicolectomy for cancer, the dressings covering the midline abdominal incision are found to be soaked with a clear, pinkish, salmon-colored fluid.

Wound dehiscence. Keep the patient in bed, tape his belly together and schedule surgery for re-closure.. look out for evisceration from getting up or sneezing, in which case keep the bowel covered and moist with sterile dressings, and rush the patient to the OR for re-closure.

Seven days after an inguinal hernia repair, a patient returns to the clinic because of fever. The wound is red, hot and tender.

Wound infection. Management: Open the wound, drain the pus, pack it open.

A 55 year old lady is involved in a minor traffic accident where her car was hit sideways by another car that she "did not see" at an intersection. When she is tested further it is recognized that she has bitemporal hemianopsia. Ten years ago she had bilateral adrenalectomies for Cushing's disease.

Years ago, before imaging studies could identify pituitary microadenomas, patients with Cushing's were treated with bilateral adrenalectomy instead of pituitary surgery. In some of those patients the pituitary microadenoma kept on growing and eventually gave pressure symptoms. That is Nelson's syndrome.

clinical presentation of renal colic (2/2 renal stones)

abdominal pain radiates to the groin, n/v patient writhes in pain because this pain is retroperitoneal in origin (compare to peritonitis)

kehr sign

abdominal pain that refers to the shoulder from peritonitis that irritates the diaphragm (C3/C4/C5) is carried by the phrenic nerve and referred to the shoulder

myxomatous degeneration

abnormal accumulation of proteoglycans and alterations in collagen

what can lead to error in segmental arterial BP measurements

abnormal cuff width, noncompressible arteries (calcified, common in tibial artery of diabetics)

A 44 year old man is referred for treatment of hypertension. His physical appearance is impressive: he has big, fat, sweaty hands; large jaw and thick lips, large tongue and huge feet. He is also found to have a touch of diabetes. In further questioning he admits to headaches and he produces pictures of himself taken several years ago, where he looks strikingly different.

acromegaly. GH levels, MRI, pituitary surg.

A 22 year old man develops vague periumbilical pain that several hours later becomes sharp, severe, constant and well localized to the right lower quadrant of the abdomen. On physical examination he has abdominal tenderness, guarding and rebound to the right and below the umbilicus. He has a temperature of 99.6 and a WBC of 12,500, with neutrophilia and immature forms.

acute appendicitis ex lap

tympany in the left upper quadrant + complication

acute gastric dilation, reflex hypothension (vagal)

A 53 year old lady is in the ER complaining of extremely severe frontal headache. The pain started about one hour ago, shortly after she left the movies where she watched a double feature. On further questioning, she reports seeing halos around the lights in the parking lot when leaving the theater. On physical exam the pupils are mid-dilated, do not react to light, the corneas are cloudy and with a greenish hue, and the eyes feel "hard as a rock".

acute glaucoma. get to ophtho. diamox (acetazolamide), pilocarpine drops, or mannitol.

most common tumor of the epididymis

adenomatoid

top 3 most common causes of obstruction

adhesions, hernias, intestinal tumors

monofilament suture 1. advantages/disadvantages] 2. what kind of surgery used for

adv - less drag, disadv- stiffer, requires more throws, kinking weakens strand 2. cardiovascular surgery, hernias and fascial surgery

1. femoral hernia 2. common associations

along femoral sheath in femoral canal - posterior to inguinal ligament, anterior to pubic ramus, lateral to the pubic tubercle medial to the femoral vein*** (commonly damaged) 2. pregnancy, female, prior inguinal hernia repair

treatment for paroxysmal tachycardia

alternating pressure on the left and right carotids verapamil electrocardioversion if severe

neonatal inguinal hernia

always indirect, high risk of incarceration, more common on the right/bilateral, patient must undergo repair and exploration and exploration of BOTH SIDES

what antibiotics for patients with heart valves undergoing GI surgery

ampicillin/gentamycin

management for multiple rib fractures

analgesics, AVOID INTUBATION, aggressive bronchial toilette

why is primary anastomosis of the CBD not prefered treatment for complete transection

anastomosis leads to bile duct stricture instead it is better to anastomose CBD to the small bowel

treatment for a patient presenting with peripheral vessel trauma (ex. no palpable pulses)

angiography to plan the operative approach if stable immediate OR if unstable

treatment of intractable traumatic epistaxis

angiography with embolization

ddx lower GI bleeding

anorectal disease, diverticular, angiodysplasia, polyps, malignancy, IBD, ischemic colitis meckel's, intussusception

anterior vs posterior shoulder dislocation clinical presentaiton

anterior - arm held ABducted and externally rotated posterior - arm held ADducted and internally rotated

which vein is most likely to be damaged during tracheostomy

anterior jugular vein

treament of cholangitis

antibiotics, ERCP and sphincterectomy

what drugs are associated with drug fever

anticonvulsants, TMP/SMX + others

what conditions cause a bounding pulse (widened pulse pressure)

aortic incompetence, PDA hyperthyroidism, peripheral AV fistula, anemia

mammography detected lesions

breast calcifications <2mm, punctate, microlinear or branching and clustered along ducts or clusters greater than 5 calcifications /cm, stellate shaped lesions, solitary dominant masses

A 13 year old boy complains of pain in the groin ( it could be the knee) and is noted by the family to be limping. He sits in the office with the foot on the affected side rotated towards the other foot. Physical examination is normal for the knee, but shows limited hip motion. As the hip is flexed, the leg goes into external rotation and it can not be rotated internally.

bad hip in this age group is slipped capital femoral epiphysis, an orthopedic emergency. Management: AP and lateral X-Rays for diagnosis. The orthopedic surgeons will pin the femoral head in place.

why should cholecystectomy be performed within 2-3 days after acute cholecystitis

because early inflammatory response creates a plane of dissection, and if performed too late there will be adhesions forming

calcification patterns of a coin lesion that is suggestive of a benign or malignant lesion

benign - concentric rings of calcification malignant - flecks of calcification

juvenille (retention polyps)

benign hamartomas of the small intestine/rectum autoamputate, benign

ameloblastoma + tx

benign odontogenic tumor with cystic degeneration that occurs at the junction of the ramus and body of the mandible tx = resection with 1-2 cm clear margins

true epithelial lined cysts of the pancreas

benign or malignant cystadenoma of the pancreas

central cord syndrome (ex. syringomyelia after cervical trauma)

bilateral loss of motor and pain/temp sensation with preservation of fine touch/proprioception at the level of the lesion, common after hyperextension injuries

how to treat an episode of acute renal graft rejection

biopsy to grade the rejection high dose steroids, antilymphocyte globulin

treatment of breast cancer bone metastasis

bisphosphonates - inhibit bone demineralization

A 33 year old man has had three large bowel movements that he describes as made up entirely of dark red blood. The last one was 20 minutes ago. He is diaphoretic, pale, has a blood pressure of 90 over 70 and a pulse rate of 110. A nasogastric tube returns copious amounts of bright red blood.

bleeding between the tip of the nose to the ligament of Treitz. How is the diagnosis made?: for all upper G.I. bleeding, start with endoscopy.

pulmonary emboism

blocks blood flow through pulmonary artery, causes obstructive shock and hypoxia

currant jelly stool

blood + stool, 2/2 intussusception, or meckels diverticulum

A 62 year old male known to have normal renal function reports an episode of gross, painless hematuria. Further questioning determines that the patient has total hematuria rather than initial or terminal hematuria.

blood coming anywhere from kidneys to bladder, cancer is main worry (RCC or trans cell cancer in bladder). "gold standard-first study" is IVP (aka excretory urogram). It's main contraindication is poor renal function. Next step is cystoscopy. CT scan is superb for renal pathology, but is still not the first step in most cases.

which blood type assc with duodenal ulcers

blood group O***, non-secretors (no excess antigen in blood )

what substances can be returned from a peritoneal lavage

blood, bile, amylase, urine, stool

most common site for breast cancer mets

bone is most common but lung, liver, bone, brain,

A 39 year old lady completed her last course of postoperative adjuvant chemotherapy for breast cancer six months ago. She comes to the clinic complaining of constant back pain for about 3 weeks. She is tender to palpation over two well circumscribed areas in the thoracic and lumbar spine.

bone mets do bone scan. if positive, xrays are needed to rule out benign reasons for it to light up.

what radiologic imaging modality is more sensitive for stress fractures

bone scan

other things to consider for cervical distribution pain

brachial plexopathy, thoracic outlet syndrome

what must be considered in patients with clavicular fractures

brachial plexus injury (do neurological exam), and subclavian artery (check pulses + auscultate)

1. somatostatin effects

dec. growth hormone, insulin, glucagon, secretin, gastrin, VIP, PP, gastric acid, pepsin, pancreatic enzymes, TSH, renin, calcitonin, intestinal/biliary/gastric motility

lymphoepithelioma

cancer of the posterior 1/3 of the tongue, has a poor prognosis

what is achlorohydria in the setting of stomach ulcer suggestive of

cancer, atrophic gastritis,

treatment for perforated diverticulum with diffuse peritonitis

cannot do end to end due to the peritonitis so do resection with end colostomy with oversewing of the distal segment - should not do end to end anastomosis in the setting of peritonitis

A 44 year old black man describes progressive dysphagia that began 3 months ago with difficulty swallowing meat, progressed to soft foods and is now evident for liquids as well. he locates the place where food "sticks" at the lower end of the sternum. He has lost 30 pounds of weight.

carcinoma of the esophagus. What do you do? - Barium swallow first, then endoscopy and biopsies. CT scan next.

tracheal stenosis cause + treatment

cause: malig, ET intubation + many others resection of the affected region of the trachea

An elderly man is involved in a rear end automobile collision where he hyperextends his neck. He develops paralysis and burning pain of both upper extremities while maintaining good motor function in his legs.

central cord syndrome. high dose corticosteroids soon after a spinal cord injury may help minimize the permanent damage

symptoms of cnacer

change in bowel or bladder, persistent sore, cough/hoarseness, thrombophlebitis, cachexia, weight loss, enlarged nodes, neurological symtpsom

what causes lung injury/death in patients with smoke inhalation injury 2. what labs to order

chemical damage to the respiratory tree--> edema and pneumonitis 2. order carboxyhemoglobin

A one year old baby is referred to the University Hospital for treatment of a subdural hematoma. In the admission examination it is noted that the baby has retinal hemorrhages.

child abuse.

A three year old girl is brought in for treatment of a fractured humerus. The mother relates that the girl fell from her crib. X-Rays show evidence of other older fractures at various stages of healing in different bones.

child abuse.

how to deterimine operative risk of shunting procedure for portal hypertension

childs classification - bilirubin, albumin, ascites, encephalopathy, malnutrition

pre-op treatment for patients with polycythemia vera

chlorambucil - suppresses the bone marrow

what stimulates chief cells - gastrin stimulates - parietal cells

cholinergic impulse, gastrin, secretin

which cofactors required for insulin responsiveness

chromium, manganese

mikulicz disease

chronic inflammation and swelling of the salivary glands - benign/painless

kasai procedure complications

cirrhosis, portal hypertension, need for hepatic transplantation later in life, anastomotic leakage

budd chiari causes

cirrhosis, trauma, OCP

A toddler is brought to the E.R. with burns on both of his buttocks. The areas are moist, have blisters and are exquisitely painful to touch. The story is that the kid accidentally pulled a pot of boiling water over himself.

classical for second degree. (Note that in kids third degree is deep bright red, rather than white leatherly as in the adult). Management for the burn is silvadene (silver sulphadiazine) cream. Management for the kid may require reporting to authorities for child abuse.

1. preparation for colon procedure

clear fluid diet, no solid food for 24-48 hours pre-op cathartics/laxatives - mannitol, 4 liters of polyethylene glycol, castor oil, magnesium citrate, bisacodyl, enemas~ saline/phosphasoda *antibiotics - neomycin/erythromycin-- achieve high intraluminal concnetrations in the colon

A 55 year old man has progressive, unstable, disabling angina that does not respond to medical management. His father and two older brother died of heart attacks before the age of 50. The patient stopped smoking 20 years ago, but still has a sedentary life style, is a bit overweight, has type two diabetes mellitus and has high cholesterol. Cardiac catheterization demonstrates 70% occlusion of three coronary arteries, with good distal vessels. His left ventricular ejection fraction is 65%.

clearly needs coronary bypass, and with 3 vessel disease there should be no argument for angioplasty instead of surgery.

treatment for midshaft femur fracture

closed reduction and intramedullary fixation

treatment of a stab wound to the chest

closure of the wound and insertion of a chest tube to prevent PTX

what will exacerbate urinary retention with BPH

cold temp, alcohol, narcotics, antihistamines, anticholinergics,

what can cause elevated CEA

colon cancer, lung cancer, pancreatic cancer, gynecologic malignancies, cirrhosis, pancreatitis, renal failure, IBD, smoking

what is pre-operative evaluation for a patient with a suspected hernia (non-strangulated)

colonoscopy or barium enema

repair of the common carotid in comatose patient vs non-comatose

comatose - ligation of the carotid, do not attempt reconstruction on non-comatose - proximal/distal control and interposition grafting

why does hyperkalemia occur during shock

dec. renal perfusion, inc. tissue releases, anaerobic metabolism

aspirin, probenecid effect on MTX exrection

decrease MTX excretion from the kidneys

which chemotherapeutic agents cause multidrug resistance how to avoid MDR

dactinomycin anthracycline vinca alkaloids doxorubicin * via glycoprotein transmitter from MD1 gene cyclosporine and verapamin

trendelenberg gait

damage to the superior gluteal nerve (2/2 trauma or SCFE) leading to weakness of the gluteus medius/minimus muscles --> weakness of hip extension, and effected pelvis side tips downwards

complications of herniorrhaphy what patients get recurrent disease

damage to vas deferens, damage to vascular structures, iatrogenic cryptorchidism patients with connective tissue disorders- ehlers danlos, hunters syndrome, or inc. intra abdominal pressure

what diabetic complication is prevented with pancreas transplant for type 1

diabetic nephropathy

acid base disturbance associated with isotonic saline

dilutional acidosis- because isotonic saline overloads the kidneys ability to excrete chloride

first step in management of a hypotensive patient who is in hypovolemic shock

displace the uterus to the left off the IVC to increase venous return

How to avoid implantation of tumor cells during surgery How to avoid vascular dissemination of tumor cells during resection

dissection through uninvolved tissue with wide margins avoiding the tumor dont manipulate teh tumor, and ligate vascular pedicle early

what is most common cause of late vascular graft failure

distal atherosclerotic disease

findings that indicate a pancreatic cancer is unresectable

distant mets, invasion of the SMA, invasion of the portal vein,

meconium ileus xray findings

distended bowel with soap bubble appearance

cross match

donor lymphocytes with recipient serum/complement - detects DSA~~~ indicates risk for hyperacute reaction

diagnostic test of choice for DVT

doppler analysis and B-mode ultrasonography

two most common vascular rings that cause compressive symptoms of the trachea/esophagus

double aortic arch left aorta with right ligamentum arteriosum

varicocele clinical pres

dragging or heaviness in the scrotum, bag of worms feeling, does not transilluminate, increases in size with valsalva

MCC pyloric obstruction in adults

duodenal ulcer, gastric carcinoma

1. ddx upper GI hemorrhage 2. what is best diagnostic tests for GI bleeding 3. treatment of GI bleeding

duodenal ulcer, gastric ulcer, erosive gastritis, esophageal/gastric varices, mallory-weiss tear, gastric carcinoma, AVM 2. fiberoptic endoscopy* (need stable vitals), upper GI series, passage of NG tube, angiography 3. NG tube, FFP/platelets/vitamin K , H2 antagonists, PPI, antacids, vasopressin(powerful vasoconstrictor), endoscopy sclerosis of varicies, angiography administered vasopressin/embolization of vessels balloon tamponade

etiology difference between gastric and duodenal ulcers

duodenal ulcers 2/2 acid hypersecretion gastric ulcers 2/2 breakdown of mucosal defenses (*ALWAYS BIOPSY GASTRIC ULCER)

treatment of symptomatic annular pancreas

duodenojejunostomy -is better than gastrojejunostomy because this procedure requires vagotomy to prevent marginal ulceration

initial evaluation of suspected DVT initial treatment of suspected DVT

duplex ultrasound if negative, do pelvic CT IV bolus heparin

1. clostridial myonecrosis dx/tx

dx = gas gangrene with crepitus, boxcar shaped gram positive bacilli tx = wide debridement, high dose penicillin G (20 million units/day)

ddx of lower GI bleeding in a 2 year old

juvenile polyp meckel diverticulum intussusception - assoc w/ pain/ colicky episodes, currant jelly stools

A 54 year old man with a 40 pack/year history of smoking gets a chest X-Ray because of persistent cough. A peripheral, 2 cm. "coin lesion" is found in the right lung. A chest X-Ray taken two years ago had been normal. CT scan shows no calcifications in the mass and no enlarged peribronchial or peritracheal lymph nodes. Bronchoscopy and percutaneous needle biopsy have not been able to establish a diagnosis. The man has good pulmonary function and is otherwise in good health.

example of a man who could stand lung resection (peripheral lesion, good function) and who stands a good chance for cure (no node mets). Diagnosis steps should be pushed to the limit. Start with bronchoscopy***(or high res CT) and washings, if unrewarding go to percutaneous needle biopsy, and if still unsuccessful go to open biopsy, i.e.: thoracotomy and wedge resection.

cardiac myxoma treatment

excision of the myxoma and bypass

when should patients with GI bleed be sent for surgery

exsanguinating hemorrhage/uncontrollable hemorrhage, profuse bleeding with hypotension, >4 U of blood/>1U/8hr

1. which factors are deficient in stored plasma 2. which coagulation factors are not synthesized by the liver

factor V and VIII 2. thromboplastin, calcium, VIII,

Familial adenomatous polyposis

familial APC gene mutation leads to early onset colon cancer

key features of history suggesting disorder of the colon bleeding, pain, anal or perianal mass, change in bowel habits, incontinence, history of cancer, polyps

fasdfadsf

biliary colic clinical presentation

fatty meals causes RUQ/epigastric pain and N/V that resolves completely and on its own NO LEUKOCYTOSIS, FEVER, OR JAUNDICE

acute febrile nonhemolytic transfusion reaction

fever several hours after transfusion Tx= antipyretics/stop blood products

most common complication of chronic pancreatitis

fibrosis of the head of the pancreas with CBD obstruction (appears as smooth tapering on radiograph)

pleural effusion 2/2 necrotizing pneumonia tx

first thoracocentesis for diagnosis (transudate vs exudate) then closed chest tube drainage thoracotomy and decortication only if empyema not adequately drained

complications of thyroglossal cysts tx

fistulas and sinuses tx = sistrunk procedure - whole cyst, whole fistula, middle third of hyoid bone

sequence of interventions for hemodynamically unstable patient who hemoperitoneum is suspected

fluid resuscitation abdominal ultrasound/peritoneal lavage (if patient is obese) exploratory laparotomy if hemoperitoneum is confirmed

management of patient who is having a hemolytic transfusion reaction

fluids and mannitol, to protect the kidneys from the hemoglobinuria which can lead to ATN NOT STEROIDS

diagnostic test of choice for CNS aneurysms/AVMs

four vessel angiography, CT angio is second

spondylolisthesis

fracture of pars intra-articularis of L5 --> anterior displacement of L5 relative to S1

monteggia's deformity

fracture of proximal third of ulna with dislocation of the radial head

long term risk of partial gastrectomy

gastric cancer of the remnant due to reflux of bile and relatively low acid

when to use barium vs gastrographin to evaluate esophageal injury

gastrografin - if worried about perforation/mediastinitis barium - if worried about aspiration

At the time of birth it is noted that a child has a large abdominal wall defect to the right of the umbilicus. There is a normal cord, but protruding from the defect there is a matted mass of angry looking, edematous bowel loops.

gastroschisis (defect in the anterior abdominal wall through which the abdominal contents freely protrude). don't confuse with omphalocele (abdominal wall defect in organs remain outside of the abdomen IN A SAC because of a defect in the development of the muscles of the abdominal wall). in gastroschisis the umbilical cord is not involved and the lesion is usually to the right of midline. there is also no sac. tx is surgery.

germ cell vs non-germ cell tumors

germ cell - seminoma, non seminoma (embryonal, choriocarcinoma, teratoma, teratocarcinoma, yolk sac) non-germ cell = leydig, sertoli

On a routine pre-employment physical examination, a chest X-Ray is done on a 45 year old chronic smoker. A "coin lesion" is found in the upper lobe of the right lung.

get old CXR. if there, prob not cancer, follow w/ periodic CXRs. if not there, work up.

in acute massive blood loss, when is blood needed/when is crystalloid sufficient

give blood if >1500cc is lost if hemodynamically unstable after 2L of crystalloid

ITP patient perioperative platelet managment

give platelets right before surgery

what is the risk of excess glucose/protein/fat in TPN

glucose -hepatic steatosis - also excess glucose causes excess CO2 and difficulty weaning patients from ventilator protein - hyperuricemia fat - immune suppression

what is major fuel source for the gut/lymphocytes/macrophages/ fibroblasts + what cells synthesize it

glutamine, synthesized by skeletal muscle, lung, liver

intramedullary tumors clinical presentation

gradual evolving myelopathy, partial brown sequard syndrome vs extramedullary that present initially with radiculopathy and then cord compression

sarcoma botryoides

grape like polyploid mass in vagina of young girls causing vaginal bleeding

1. sympathetic innervation of the stomach 2. pain sensation of the stomach 3. lymphatic drainage of the stomach

greater splanchnic nerves T5-T10--> celiac ganglion --> gastric arteries--> stomach 2. afferent sympathetics of greater splanchnic nerves 3. superior gastric nodes - upper lesser curvature and cardia pancreaticolineal nodes - upper great curvature and splenic nodes suprapyloric nodes - antra stomach inferior gastric/subpyloric nodes - right gastroepiploic vessels

Half an hour after the first feed, a baby vomits greenish fluid. The mother had polyhydramnious and the baby has Down's syndrome. X-Ray shows a "double bubble sign": a large air fluid level in the stomach, and smaller one in the first portion of the duodenum. There is no gas in the rest of the bowel.

green vomit in a newborn => duodenal atresia or annular pancreas. surgery, look for other anomalies.

thalassemia blood smear findings

heinz bodies, nucleated RBCs, target cells

type 1 ulcer treatment type 2/3 "" type 4 type 5

hemigastrectomy - bilroth 1 (vagatomy/antrectomy) or bilroth 2 vagatomy with antrectomy antrectomy with extension to include ulcer, antrectomy with wedge excision of ulcer omental patch if bleeding

treatment for ESRD with creatinine >15

hemodialysis

what is the most important indication for splenectomy

hemodynamic instability

hemotologic side effect of unfractionated heparin

heparin in duced thrombocytopenia - heparin antibodies seen 5-10 days after begin therapy, switch to lepirudin or argatroban

how does hepatic blood supply differ anatomically between arteries and veins

hepatic veins run between segments, hepatic arteries run into segments

spigelian hernia

hernia along lateral border of the rectus abdominis muscle

what is the risk of general anesthesia in children <50 weeks gestation age, or <2.5kg

immature reticular activating systems leads to apneic episodes following general anesthesia use cutoff <60 weeks for premature infants

treatment for patient with pelvic fracture in shock

immediate external fixation selective angiography with embolization

hyponatremia symptoms progression

inc ICP from intracellular swelling--> muscle twitching/inc. DTR convulsions, loss of reflexes, hypertension

illness effect on metabolism

inc. BMR, dec. use of fats/ketones, inc. depedence on glucose derived from catabolism of protein

pagets disease of bone

inc. weak woven bone deposition labs show inc. Alk phos, but normal serum calcium

Indications for PCI/surgery for PVD

incapacitating claudication, rest pain tissue loss

spermatic cord hydrocele

incompletely obliterated processus vaginalis causes hydrocele formation, transilluminates on scrotal examination *EXACTLY THE SAME AS AN INGUINAL HERNIA, BUT NO BOWEL CONTENTS!!!!

IABP

increases coronary perfusion during diastole by increasing afterload on the heart forcing blood into coronary vasculature- useful for patients with myocardial ischemia

septic shock

infection related SIRS that is refractory to fluid resuscitaiton and vasopressors

rectum blood supply/ drainage/lymph - rectum has complete muscular rings - valves of houston project into the lumen of the rectum -

inferior mesenteric --> superior rectal (supplies upper/middle) internal iliac --> middle/inferior rectal upper/middle rectum --> superior rectal veins --> IMV-->portal vein lower rectum/anal canal--> middle rectal veins--> internal iliac--> IVC inferior mesenteric nodes

blood supply to the trachea

inferior thyroid artery, subclavian artery, superior intercostal artery, internal mammary artery, innominate artery, bronchial circulation

chemotherapy effect on post surgical healing + how to avoid negative effects

inhibits early phase of wound healing, should restart agents 7-10 days post op

uremia coagulopathy lab findings + tx

inhibits platelet aggregation (interferes with platelet factor III, VIII/vWF interaction) --- tx = DDAVP/cryoprecipitate increases vWF or FFP

jejunostomy tubes

inserted into jejunum as surgical procedure, used for feeding

tenckhoff peritoneal dialysis catheter

inserted into the peritoneal cavity for long term dialysis or ascites management --

peptide producing tumors of the pancreas

insulinomas, zollinger ellison tumors (gastrinomas)

disruption of which nerve in the neck causes dysphagia and aspiration

internal branch of superior laryngeal nerve which causes loss of sensory in the larynx

anatomy of inguinal canal 1. int/external rings 2. anterior wall 3. inferior wall 4. roof 5., posterior wall

internal inguinal ring in transversalis fascia lateral to inferior epigastric vessels ---> external inguinal ring in oblique aponeurosis.... 2. external oblique aponeurosis 3. pouparts ligamnet 4. conjoint tendon (derived from internal oblique, transversus abdominus 5. transversalis fascia

inflammatory breast cancer

intradermal lymphatic spread* of breast cancer, very aggressive, skin appears red. dx= skin biopsy to assess dermal lymphatics

A 32 year old gentleman had a Clark's level 5, 3.4 mm. Deep, melanoma removed from the middle of his back three years ago. He now has...(a tumor in a weird place, like his left ventricle, his duodenum, his ischiorectal area...anywhere!).

invasive melanoma (it has to be deep) metastasizes to all the usual places (lymph nodes plus liver-lung-brain-bone) but it is also the all-time-champion in going to weird places where few other tumors dare to go.

which drug improves pulmonary function in COPD

ipratropium bromide

treatment for a patient with both atresia and meconium ileus

irrigation with acetylcysteine to relieve any potential obstructions

how does methanol cause anion gap acidosis

it causes lactic acid production

what is low SVR a sign of what is high SVR a sign of

it is a sign of sepsis or systemic inflammation sign of inadequate cardiac output

1. blood supply to the small intestine 2. compare arcades/vasa recta of jejunum/ileum 3. layers of the small intestine - plicae circularis more common in the proximal small intestine, peyers patches in the ileum

jejunal and ileal branches of SMA (duodenum also gets SPDA from gastroduodenal 2. jejunum - only 1-2 arcades with long vasa recta ileum - multiple arcades that are closer to the bowel with short vasa-recta 3. mucosa (columnar + goblets), submucosa- (meissner's plexus, peyer's patches, blood vessels, elastic/fibrous tissue), muscularis mucosa- (outer longitudinal/inner circular, auerbach's plexus) serosa

abdominalobstructions: simple, strangulating, closed, intussusception, perforating

just a list yo

what is the difference in clinical presenation between a meniscal tear and ligamentous injury to the knee

ligamentous injury presents with immediate hemarthrosis/swelling, immediate inability to bear weight + ant/pos drawers/lachmann's onset of swelling is 12-24 hours with meniscal tears +McMurray

treatment of hyperkeratosis of the lip

lip stripping and resurfacing with mucosal advancement

1. lymphatic drainage of the gallbladder 2. motor innervation/sensory innervation valves of heister (useless structures in cystic duct) 3. how much bile/day and what stimulates bile production 4.good replacement fluid for biliary losses

liver and hilar nodes 2. vagal fibers from celiac ganglia T8/T9 sympathetic fibers to celiac plexus T8/T9 3. 600ml/day- vagal/splanchnic stimulation, secretin, theophylline, phenobarbital, steroids 4. lactated ringers

what causes increased PT

liver failure, vitamin K deficiency, consumption of factors

medial meniscus tear clinical features

locking, swelling, effusion, joint tenderness, locking of the knee in extension + Mcmurray test

baker jejunostomy tubes

long intestinal tube passed through abdominal wall into proximal jejunum and then to to the cecum, used to splint the bowel or decompress distended bowel in surgery

what is the effect of banked blood on oxygen dissociation curve

low 2,3 DPG shifts curve to the left, higher oxygen affinity

DIC lab findings + tx

low fibrinogen + elevated PT/PTT tx underlying cause, anticoagulant therpy

life threatening causes of abdominal pain

lower lobe pneumonia acute MI* DKA acute hepatitis abdominal aortic aneurysm

aortoiliac atherosclerosis collateral network

lumbar branches of the aorta to retroperitoneal branches of the gluteal arteries to the profunda femoris arteries of the legs

neurogenic claudication

lumbar spinal stenosis--> nerve irritation --> burning electric type pain with numbness and paresthesias of the lower extremities

A 62 year old gentleman had a radical prostatectomy for cancer of the prostate three years ago. He now presents with widespread bony pain. Bone scans show metastasis throughout the entire skeleton, including several that are very large and very impressive.

luteinizing hormone-releasing hormone agonists ***(leuprolide)***, and another option is antiandrogens (flutamide).

what operation has a high rate of causing intestinal fistulas

lysis of adhesions

cuffed central venous catheter (hickman type)

maintains access to veins for prolonged time periods--- catheter has cuff of dacron felt that allows granulation tissue to form and secure it for long term - LASTS FOR YEARS - USED FOR CHEMOTHERAPY, HEMODIALYSIS, HYPERALIMENTATION

CMV infection in immunosuppressed clinical pres

malaise, arthralgia, leukopenia, myalgia ulceration of the GI tract, hepatitis, esophagitis, retinitis

marjolin's ulcers

malignant degeneration to SCC arising from a chronic wound often seen in burn scars

1. how is cerebral blood flow regulated 2. CPP calculation 3. cushings response 4. what is hypotension an indication of in neurosurgical patient

metabolic control autoregulation 2. CPP = MAP-ICP-- usually between 50 and 100 mmHg 3. compression of the medullary centers --> hypertension, bradycardia, short/shallow respirations, -- indicates irreversible damage 4. loss of sympathetic control: hypothalamus, medullary, or SCI

1. foot deformities in children 2. what neuromuscular sisorders can cause foot deformities 3. what other bone condition associtated with foot deformities

metatarsus adductus , talipes equinovalgus, planovalgus 2. polio, cerebral palsy, myelomeningocele, diastematomyelia, CMT 3. deveolpmental dislocation of thehip

what are the dyes used for sentinel node biopsies, and which is assc. with anaphylaxis

methylene blue and isosulfan blue isosulfan blue is associated with anaphylaxis

how does presence of metastasis to lymph nodes change treatment for lung cancer

mets to nodes make the patient not a surgical candidate, must do chemotherapy and radiation

A 52 year old lady has constant, severe back pain for two weeks. While working on her yard, she suddenly falls and can not get up again. When brought to the hospital she is paralyzed below the waist. Two years ago she had a mastectomy for cancer of the breast.

mets. most cord mets are extradural. MRI.

ADEK absorption B12 Vitamin C/thiamine/folate

micelles through mucosa B12 - complexed with intrinsic factor vitamin C, thiamine, folate are actively transported

copper deficiency clinical presentation

microcytic hypochromic anemia

squamous cell carcinoma of the esophagus location

middle 1/3 of the esophagus

bronchogenic cysts

midline suprasternal notch cyst present at birth, behind the carina, treat with surgical excision, may present with hemoptysis, may become infected

salicylates metabolic disturbance

mixed resp alk, met acid

A 62 year old lady has a 4 cm. hard mass under the nipple and areola of her rather smallish left breast. A core biopsy has established a diagnosis of infiltrating ductal carcinoma. There are no palpable axillary nodes.

modified radical mastectomy is the choice here. Why go after the axillary nodes when they are not palpable?: Because palpation is notoriously inaccurate in determining the presence or absence of axillary metastasis. radical mastectomy = breast, underlying chest muscle (including pectoralis major and pectoralis minor), and lymph nodes of the axilla are removed

meckels diverticulm 1. features 2. sx 3. indications for surgery 4. dx

most common diverticulum (2% of the population), 2 ft from ileocecal valve, 2:1 ration M:F, made of gastric and pancreatic tissue 2. bleeding (due to gastric mucosa), bowel obstruction, diverticulitis 3. age <40, >2 cm in length, fibrous banding around appendix, diverticulum, mesentery 4. Tc 99m pertechnetate scan will bind to gastric tissue of the diverticulum

atraumatic massive hemoptysis - patho, dx, tx

most commonly caused by m.tuberculosis will show opacity on CXR associated with TB lesion - also AVMs tx = bronchoscopy to localize and control bleeding - angiography and embolization if vascular lesion

A 62 year old lady has a dominant, 2 cm. mass on the left lobe of her thyroid as well as two smaller masses on the right lobe. It is visible during swallowing. They are all soft and she has no palpable lymph nodes in the neck.

most thyroid nodules are benign. FNA is best for this case. Bad if: young, male, single nodule, history of radiation to the neck, solid mass on sonogram and cold nodule on scan.

complications of radiation therapy for head/neck cancers

mucositis, xerostomia, loss of taste, dermal/soft tissue fibrosis, dental caries, bone/soft tissue necrosis

treatment of multiple vs single brain mets

multiple = whole brain radiotherapy single = segmental resection `

postoperative patient with resp acidosis and hypoxemia and hypercarbia

must be alveolar hypoventilation because PE/pulmonary edema/atelectasis CO2 partial pressures will be normal

treatment for an intimal flap in a patient with traumatic neck injury

must be explored and repaired due to risk of stroke or occlusion later

ear pinna hematoma treatment

must needle drain with incision and packing not treating --> avascular necrosis with shriveling of the pinna and calcification of the hematoma

hydrocele in a newborn

observe for first 12 months because most resolves spontaneously

most common complication of Meckels diverticulum in adults most common complication of Meckels diverticulum in children

obstruction 2/2 volvulus, band obstruction, intussusception bleeding (LGI bleeding), inflammation

A 72 year old man is being observed with a ureteral stone that is expected to pass spontaneously. He develops chills, a temperature spike to 104 and flank pain.

obstruction and infection, a urological emergency. Management: Massive intravenous antibiotic therapy, but the obstruction must also be relieved right now. In a septic patient stone extraction would be hazardous, thus the option in addition to antibiotics would be decompression by ureteral stent or percutaneous nephrostomy.

You are called to the nursery to see an otherwise healthy looking newborn boy because he has not urinated in the first 24 hours of life. Physical exam shows a big distended urinary bladder.

obstruction. (kids die in utero w/o kidneys.) First look at the meatus, it could be simple meatal stenosis. If it is not, posterior urethral valves is the best bet. Management: Drain the bladder with a catheter (it will pass through the valves). Voiding cystourethrogram for diagnosis, endoscopic fulguration or resection for treatment.

A 40 year old, obese mother of five children presents with progressive jaundice which she first noticed four weeks ago. She has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated SGOT. The alkaline phosphatase is about six times the upper limit of normal. She gives a history of multiple episodes of colicky right upper quadrant abdominal pain, brought about by ingestion of fatty food.

obstructive jaundice, with a good chance of being due to stones. What do you do next? - Start with the sonogram. If you need more tests after that, ERCP is the next move, which could also be used to remove the stones from the common duct. Cholecystectomy will eventually have to be done.

lumbar hernias

occur on flanks seen in superior grynfeltts and inferior petits triangles

spasmodic dysphonia (vocal cord spasm) + tx

occurs in people who strain their voices --> fluctuation in normal voice tx = botulinum toxin injections

refeeding syndrome

occurs in severely malnourished patients after full nutritional support --> hypophosphatemia --> drop in ATP --> respiratory failure****

what physical exam finding for posterior communicating artery aneurysm

oculomotor palsy

A newborn baby is noted to have a shiny, thin, membranous sac at the base of the umbilical cord. Inside the sac one can see part of the liver, and loops of normal looking bowel.

omphalocele. (abdominal wall defect in organs remain outside of the abdomen IN A SAC because of a defect in the development of the muscles of the abdominal wall). more congenital defects in these kids. surgery to fix. in gastroschisis the umbilical cord is not involved and the lesion is usually to the right of midline. there is also no sac. don't confuse with gastroschisis (defect in the anterior abdominal wall through which the abdominal contents freely protrude).

tension pneumonthrax + tx

one way valve in the lung that allows air in. Inc. unilateral pleural pressure causing mediastinal structures to be displaced to contralateral side with compression of IVC and decreased return to right heart tx = placement of chest tube

richters hernia

only a portion of the circumferential wall in the hernia tends to necrosis/infarct/perforate

initial treatment for a post thyroidectomy hemorrage (expanding hematoma at site of surgery)

open wound and evacuate the hematoma

tx for thyroid carcinoma

operative removal, lifetime treatment with exogenous thyroid hormone

consequences of pelvic radiation on the colon

proctitis with inflammation and ulceration +/- fistulization

A front seat passenger in a car that had a head-on collision relates that he hit the dashboard with his knees, and complains of pain in the right hip. He lies in the stretcher in the ER with the right extremity shortened, adducted, and internally rotated.

orthopedic emergency: posterior dislocation of the hip. The blood supply of the femoral head is tenuous, and delay in reduction could lead to avascular necrosis. Management: X-Rays and emergency reduction.

A little toddler has had the flu for several days, but he was walking around fine until about two days ago. He now absolutely refuses to move one of his legs. He is in pain, holds the leg with the hip flexed, in slight abduction and external rotation and you can not examine that hip he will not let you move it. He has elevated sedimentation rate.

orthopedic emergency: septic hip. Management: Under general anesthesia the hip is aspirated to confirm the diagnosis, and open arthrotomy is done for drainage.

lumbar spondylysis

osteoarthritis of the lumbar spine that causes aching pain exacerbated by walking or standing, relieved by sitting, radiation to buttocks or legs tx = rest/analgesics, surgical decompression with laminectomy

what is likely to be incarcerated in a young woman with a non-reducible labial mass with no GI symptoms

ovary -- travels through a patent inguinal canal as a indirect inguinal hernia

best way to determine protein nutrition adequacy

overall condition nitrogen balance weekly visceral proteins (prealbumin 2x weekly)

splenectomy complications

overwhelming postsplenectomy sepsis - sepsis, pneumonia, meningitis **prevent with post-splenectomy vaccines, and prophylactic antibiotics

acute limb ischemia 1 . 5 Ps of ischemic lower extremity syndrome 2. evaluation 3. tx (initial therapy and surgical tx)

pain (acute), pallor (coolness/mottling), paralysis, paresthesias (neural), pulselessness 2. doppler, arteriography 3. heparin, hydration/mannitol diuresis, --> embolectomy, or bypass, TPA, urokinase

necrotizing surgical infection - clinical presentation and treatment

pain, fever, tachycardia, cloudy gray discharge from incision site inc. risk in diabetic patients tx = surgical exploration of the wound

5Ps of arterial injury

pallor, pulselessness, paresthesias, pain, paralysis

how to determine level of amputation - digital, ray, transmetatarsal, below the knee, above the knee - below/above the knee amputations inc. energy expenditure of ambulation

palpable pulse at lease one level above amputation site good skin temp/cap refill pulse > 50 mmHg at level of amputation

what drugs decreases fractures in multiple myeloma

pamidronate, calcium bisphosphonate

two layers of the dermis

papillary layer - fine collagen fibers, capillaries reticular layers - dense collagen, dermal appendages

most common thyroid tumor of children

papillary thyroid carcinoma

absent bowel sounds with gaseous distension of small/large bowel

paralytic ileus occurs post surgery, post trauma, retroperitoneal hemorrhage, vertebral fracture

causes of functional obstruction

paralytic/adynamic ileus (post op, or direct irritation such as peritonitis), retroperitoneal hematoma, nerve root compression, nephrectomy

A thin, hyperactive 38 year old lady is frustrated by the inability of her physicians to help her. She has episodes of severe pounding headache, with palpitations, profuse perspiration and pallor, but by the time she gets to her doctor's office she checks out normal in every respect.

pheochromocytoma. How to diagnose it? - Start with 24 hr. urinary determination of metanephrine and VMA (Vanillylmandelic acid). Follow with CT scan of adrenal glands. Surgery will eventually be done, with careful pharmacological preparation with alpha-blockers.

A 27 year old lady presents with a six month history of headaches, visual loss and amenorrhea. The day of admission to the hospital she developed a severe headache, marked deterioration of remaining vision and stupor. Besides the stupor, physical exam is remarkable because her blood pressure is 75/45. Funduscopic examination reveals bilateral pallor of the optic nerves.

pituitary adenoma.

peripherally inserted central catheter

placed in antecubital vein and threaded proximally into intrathoracic vein ~ used as central catheter in outpatients

vWF disease: ristocetin test finding + factor deficiency

platelets dont aggregate in response to ristocetin in 70% of patients also there will be a factor VIII deficiency, but not as extreme as with hemophilia

A one year old child is suspected of having strabismus. You verify that indeed the corneal reflection from a bright light in your examining room comes from different places from each of his eyes.

point is to remember that the brain can choose to ignore visual input from one eye. tx: surgery

A two year old has a huge, pedunculated lipoma hanging out from his right upper eyelid, and obstructing his vision on that eye.

point is to remember that the brain can choose to ignore visual input from one eye. tx: surgery

widening of the carina on bronchoscopy

poor prognostic sign for lung tumor

clamping of the portal vein in the case of uncontrollable bleeding from the liver effect on hemodynamics

portal outflow obstruction causes splenic hypervolemia and systemic hypovolemia tx = overtransfusion of blood DO NOT USE VASOPRESSORS FOR HYPOVOLEMIA

what does a RIGHT varicocele indicated

possible malignancy (varicocele usually occurs on the left)

what knee injury causes popliteal thrombosis

posterior dislocation of the knee 2/2 trauma

A football player is hit straight on his right leg and he suffers a posterior dislocation of his knee.

posterior dislocation of the knee can nail the popliteal artery. Attention to integrity of pulses, arteriogram and prompt reduction are the key issues.

most common complication after a patient has adequately treated DVT

postphlebitic syndrome - aching/cramping, swelling, varicose veins, skin discoloration, brown or red skin discoloration, ulceration

what ion is wasted with hypomagnesemia

potassium and calcium (b/c it causes functional hypoparathyroidism)

A 58 year old lady discovers a mass in her right axilla. She has a discreet, hard, movable, 2 cm. mass. Examination of her breast is negative, and she has no enlarged lymph nodes elsewhere.

potential presentation for cancer of the breast. In a younger patient you would think lymphoma. It could still be lymphoma on her. She needs a mammogram (we are now looking for an occult primary), and the node will eventually have to be biopsied.

which groups are at risk for dissecting aortic anuerysm

pregnant, marfan's, bicuspid aortic valve, coarctation

antibiotic regimen for colon surgery

preoperative oral abx 1-2 days before, parenteral abx in the operating room, and postoperative abx 2-4 days

caues of hypercalcemia

primary/secondary/tertiary hyperparathyroidism, metastatic bone disease, myeloma, sarcoidosis, thiazides, milk alkali syndrome, thyrotoxicosis

ostium primum vs ostium secundum ASD clinical pres

primum presents in teens, secundum presents later in life.

RQ for protein/fat/carbs

protein = 0.8 fat = 0.7 carbs = 1.0

radiographic findings of hyperparathyroidism

proximal ends of long bone show reabsorption and brown bone tumors (osteitis fibrosa cystica), tufts of terminal phalanges, subperiosteal absorption on radial site of middle phalanges

clinical signs of aortic disruption

pseudocoarctation weak voice widened mediastinum left sided pleural effusion

which organism is 3rd generation cephalosporins ineffective against

pseudomonas

A 32 year old man has sudden onset of impotence. One month ago he was unexpectedly unable to perform with his wife after an evening of heavy eating and heavier drinking. Ever since then he has not been able to achieve an erection when attempting to have intercourse with his wife, but he still gets nocturnal erections and can masturbate normally.

psychogenic.

A patient known to have a congenital heart defect requires extensive dental work.

pt is to remember that these patients need antibiotic prophylaxis for subacute bacterial endocarditis.

isoproterenol

pure beta 1/2 agonist --> vasodilator and chronotropic

An adult female relates that five days ago she began to notice frequent, painful urination, with small volumes of cloudy and malodorous urine. For the first three days she had no fever, but for the past two days she has been having chills, high fever, nausea and vomiting. Also in the past two days she has had pain in the right flank. She has had no treatment whatsoever up to this time.

pyelo. hospitalization, IV antibiotics and at least a sonogram to make sure that there is no concomitant obstruction.

A 44 year old lady is recovering from an episode of acute ascending cholangitis secondary to choledocholithiasis. She develops fever and leukocytosis and some tenderness in the right upper quadrant. A sonogram reveals a liver abscess.

pyogenic abscess, it needs to be drained (the radiologists will do it percutaneously) and give antibiotics **will show same symptoms as cholangitis (charcots triad), except on xray may reveal elevation of the right hemidiaphragm

penile/vulvar cancer treatment

radical resection and bilateral groin dissection removing deep and superficial nodes

how to identify accessory spleens

radioactive technetium scans 99mTc

management of acute hemorrhage 2/2 ruptuered hepatic adenoma

radiologic embolization (least invasive), or hepatic artery ligation**, followed by elective resection of the associated segment after bleeding resolves

easiest way to inc. FRC post-operatively

raise the head of the bed

juvenile nasopharyngeal hemangiofibroma

rare - non-malignant tumors containing fibrous/vascular tissue occurs almost exclusively in males, it may progress to destroy surrounding bone

ectopic pancreas`

rare- stomach, duodenum, jejunum

clinical presentation of strangulated inguinal hernia + tx

recent onset swelling in the groin that is NOT REDUCIBLE tx = fluid resuscitation and immediate emergency surgery

A 22 year old lady notices an enlarged lymph node in her neck. The node is in the jugular can, measures about 1.5 cm, is not tender, and was discovered by the patient yesterday. The rest of the history and physical exam are unremarkable.

recheck in 3 weeks. if still there, investigate further.

how to treat hemophiliacs wiht VIII/IX antibodies

recombinant VII --

which nerve is most likely damaged in thyroid surgery

recurrent laryngeal nerve

what is most likely injured in someone who has a been physically choked

recurrent laryngeal nerve from compression of the cricothyroid joint

carbohydrate digestion

salivary/pancreatic amylase reduces sugars to galactose/glucose and absorbed by active transport (except fructose which is passive)

schilling test

saturate patient with IM B12, then give radiolabeled oral B12 and measure urine B12 levels. <3% of radiolabeled B12 in urine = PERNICIOUS ANEMIA

A 12 year old girl is referred by the school nurse because of potential scoliosis. The thoracic spine is curved toward the right, and when the girl bends forward a "hump" is noted over her right thorax. The patient has not yet started to menstruate.

scoliosis may progress until skeletal maturity is reached. Baseline X-Rays are needed to monitor progression. At the onset of menses skeletal maturity is about 80%, so bracing may be needed. Pulmonary function could be limited if there is large deformity.

secretin vs cholecystokinin effects

secretin - fluid/electrolyte release cholecystokinin/vagal stim - enzymatic release

post vagotomy syndromes

seen more commonly with truncal vagotomy- includes: diarrhea delayed gastric emptying dumping syndrome (early or late) recurrent ulcers diarrhea anemia alkaline reflux gastritis

manuever to prevent aspiration during intubation

sellick maneuver, external pressure on the cricoid cartilage

which gonadal tumor very sensitive to radiation

seminomas/dysgerminomas non-seminomas are radioresistant

falciform ligament intralobar fissure

separates the lateral and middle segments of the left lobe along the segmental fissure imaginary line between gall bladder fossa anterior and IVC posterior

1. best way to monitor for postoperative sigmoid ischemic colitis 2/2 abdominal aortic aneurysm repair***

serial post-operative sigmoidoscopy

best indicator of nutritional adequacy

serum albumin

A 44 year old lady complains bitterly of severe headaches that have been present for several weeks and have not responded to the usual over-the-counter headache remedies. She is two years post-op. from modified radical mastectomy for T3, N2, M0 cancer of the breast, and she had several courses of post- op chemotherapy which she eventually discontinued because of the side effects.

severe headaches in someone who a few years ago had extensive cancer of the breast means brain mets until proven otherwise. do CT of brain

A 69 year old man who smokes and drinks and has rotten teeth has hoarseness that has persisted for six weeks in spite of antibiotic therapy.

squamous cell cancer do triple endoscopy to find and biopsy the primary tumor and to look for synchronous second primaries.

tracheobronchial rupture clinical presentation

significant air leak and persistent pneumothorax *****despite chest tube placement*****, will also see pneumomediastinum and subcutaneous emphysema*******

source of sepsis in patient with NG tube

sinusitis from irritation/infection of the nasal mucosa --> sepsis

zinc deficiency clinical presentation

skin lesions, enterohepatic acrodermatitis, hypogonadism, poor wound healing, immunodeficiency

nicoladoni branham sign

slowing of heart rate when AV fistula is compressed

ringers lactate is similar to which body fluid

small intestine

A 72 year old man who in previous years has passed a total of three urinary stones is now again having symptoms of ureteral colic. He has relatively mild pain that began six hours ago, and does not have much in the way of nausea and vomiting. X-Rays show a 3mm. Ureteral stone just proximal to the ureterovesical junction.

small stone, almost at the bladder. Give him time, medication for pain, and plenty of fluids, and he will probably pass it.

what is absorbed by the gall bladder mucosa

sodium chloride and water, which helps to concentrate bile pigments/salts

A 33 year old man has had three large bowel movements that he describes as made up entirely of dark red blood. The last one was 20 minutes ago. He is diaphoretic, pale, has a blood pressure of 90 over 70 and a pulse rate of 110. A nasogastric tube returns clear, green fluid without blood.

somewhere distal to the ligament of Treitz. lower endoscopy is notoriously difficult and unrewarding in massive bleeding. If he is bleeding at more than 2 cc per minute, emergency angiogram is the way to go.

An 18 year old street fighter gets stabbed in the back, just to the right of the midline. He has paralysis and loss of proprioception distal to the injury on the right side, and loss of pain perception distal to the injury on the left side.

spinal cord hemisection, better known as Brown-Sequard's.

bladder autonomic dysreflexia

spinal cord lesions T6 and above --> excessive sympathetic activity --> hypertension, diaphoresis, headache tx = chlorproamzine, nifedipine

cantiles line

splits the liver into right/left lobes, runs from the IVC to the gallbladder

A 69 year old man who smokes and drinks and has rotten teeth has a painless ulcer in the floor of the mouth that has been present for 6 weeks and has not healed.

squamous cell cancer do triple endoscopy to find and biopsy the primary tumor and to look for synchronous second primaries.

A 44 year old lady has a 2 cm. palpable mass in the upper outer quadrant of her right breast. A core biopsy shows infiltrating ductal carcinoma. The mass is freely movable and her breast is of normal, rather generous size. She has no palpable axillary nodes.

standard option here is segemental resection (lumpectomy), to be followed by radiation therapy to the remaining breast, as well as axillary node dissection to help determine the need for adjuvant systemic therapy.

treatment for knee trauma in the setting of acute traumatic injury with head/abdominal injury

steinmann pinn insertion/traction, patient can undergo operative reduction at a later date

protein digestion

stomach (pepsin), pancreatic proteases, brush border peptidases, active transport

stomach vs small bowel vs colon time to recovery of function post operativly

stomach - 24 hours small bowel - 4 hours colon - 3-4 days

A 60 year old diabetic male presents with abrupt onset of right third nerve paralysis and contralateral hemiparesis. There was no associated headache. The patient is alert, but has the neurological deficits mentioned.

stroke. Vascular surgery in the neck is designed to prevent strokes, not to treat them once they happen. This fellow will get a CT scan to assess the extent of the infarct, and supportive treatment with eventual emphasis on rehabilitation.

A 64 year old black man complains of a very severe headache of sudden onset and then lapses into a coma. Past medical history reveals untreated hypertension and examination reveals a stuporous man with profound weakness in the left extremities.

stroke. supportive with eventual rehabilitation efforts if he survives. CT scan is the universal first choice to see blood inside the head.

what is the most common source of tumors in the neck

structures above the clavicle (80%) ex. occult piriform fossa tumor

A 39 year old lady presents to the ER with a history of a severe headache of sudden onset that she says is different and worse than any headache she has ever had before. She is given pain medication and sent home. She improves over the next few days, but ten days after the initial visit she again gets a sudden, severe and singular diffuse headache and she returns to the ER. This time she has some nuchal rigidity on physical exam.

subarachnoid bleeding from an intracranial aneurysm. The "sentinel bleed" that is not identified for what it is is a common feature. The "sudden, severe and singular" nature of the pain, are classics. And the nuchal rigidity betrays the presence of blood in the subarachnoid space. Diagnosis: We are looking for blood inside the head, thus start with CT. Angiograms will eventually follow, in preparation for surgery to clip the aneurysm.

what hip fractures present with external rotation

subcapital and intertrochanteric fractures with external rotation of the lower extremity ex. SCFE

pt under general anesthesia having hemolytic transfusion reaction what to look for

sudden onset hypotension and bleeding (DIC) -- in concious patient will see dark urine, fever, back pain, chills

arterial supply to the duodenum venous drainage of the pancreas

superior pancreaticoduodenal - branch of gastroduodenal inferior pancreaticoduodenal - branch of SMA A/P pancreaticoduodenal venous arcades into portal/SM veins

fothergills sign

supine to seated will increase abdominal wall tenseness and DECREASE the ability of an INTRAABDOMINAL MASS to be palpated *an abdominal wall mass will show no change with this manuever

why are surgical patients on TPN at higher risk for hyperosmotic non-ketotic coma + what signs/labs to look for + tx

surgery causes an insulin resistant state (combo with sepsis/steroids/inadequate insulin) look for: excess post-op diuresis, BUN/Cr >20, tx = DC TPN (if present), insulin, replete potassium

treatment for renal cysts

surgical removal b/c malig cannot be ruled out

what is major feature of intracerebral neoplasm that helps distinguish it from AVM/coagulopathy/hemorrhage

surrounding edema

normal pressure hydrocephalus

symmetrical enlargement of the ventricular system clinical presentation = dementia, ataxia, urinary incontinence

when a patient has a hiatal hernia what indicates need for surgery

symptomatic esophagitis, objectively measured with pH/manometric studies

synchronous vs metachronous malignant lesions

synchronous - lesions found at the time of surgery, or within 6 months after surgery metachronous - detected >6 months after surgery

hetastarch + what lab value changes

synthetic colloid - similar in osmotic pressure as 5% albumin large volumes cause dilutional coagulopathy and dec. platelet function, will see HYPERAMYLASEMIA (it prevents excretion of amylase)

SIRS

systemic inflammatory response syndrome >2 of the following fever or hypothermia tachypnea tachycardia leukocytemia, leukopenia, bandemia

clinical presentation of malignant hyperthermia + managment

tachycardia, inc. O2 consumption, inc. CO2 production, hyperkalemia, myoglobinuria, rhabdomyolysis, acidosis end case ASAP, hyperventilation with 100% O2, IV dantrolene, alkalinization of urine to protect kidneys

three braod causes of hypotensive shock

tamponade, blood loss, pneumothorax

endometriosis clinical sign

tender uterosacral ligaments palpated on physical exam

ddx for crohns disease

ulcerative colitis, lymphoma, infectious- TB, amebiasis, yersinia, campylobacter, salmonella

transfusion reaction clinical presentation

unexplained fever, apprehension, headache, falling hemoglobin/hematocrit, heat at infusion site, hypotension, oliguria, respiratory distress, abnormal bleeding***

diagnostic test for acute stress gastritis

upper endoscopy

compilications of ESRD 2. treatment of patient with uremic hyperkalemic emergency

uremic complications: peripheral neruopathy, severe hypertension, pericarditis, bleeding, severe anemia, severe hyperkalemia 2. limit protein, insulin/glucose, kayexalate enemas, peritoneal dialysis

A 52 year old man has right flank colicky pain of sudden onset, that radiates to the inner thigh and scrotum. There is microscopic hematuria.

ureteral colic. CT abdomen/pelvis followed by an IVP or US.

A 33 year old man has urgency, frequency, and burning pain with urination. The urine is cloudy and malodorous. He has mild fever. On physical exam the prostate is not warm, boggy or tender.

urinary cultures and start antibiotics...but also start a urological work-up. Do not start with cystoscopy (do not instrument an infected bladder b/c it can --> septic shock). Start with either IVP (always a traditional way to begin a urological work-up), or sonogram (which is also a pretty safe thing to do on anybody under any circumstances).

gastroesophageal balloon tamponade tubes (sengstaken blakemore/minnesota tubes)

used to compress and tamponade bleeding varicies