QE COPY Flashcards

Question

Cowden's mutation and cancers

Answer 1

Mutation: pten Ca: breast, thyroid ca, hamartomas, endometrial

Answer 2

1. Right- IVC 2. Left- Left renal vein

Answer 3

1. TOTAL thyroidectomy 2. >1 cm or bilobar: bilateral central/level 6 dissection 3. Lateral neck dissection on that side if central+ 4. Start T4 postop. Monitor w/ calcitonin AND CEA - RAI is c/i! (C cell origin)

Answer 4

1. Acute w/ any sx's or severe (<110): hypertonic saline bolus 2. Chronic and asxatic: free water restriction - give hypertonic saline if < 110 3. Hyper or euovolemic: free water restriction 4. Hypovolemic: can give NS or LR (no 3% unless sxs!) **rapid correction leads to CPM - "from low to high your pons will die"

Answer 5

- Marginal: REYGB at GJ anastomosis - Cameron: on lesser curve of large hiatal hernia - Marjolin ulcer: chronic wound - Cushing's ulcer: elevated ICP

Answer 6

1. Dx: aka comlpex sclerosing lesion - Mammo: spiculated mass with central sclerosis (lucency) and surrounding distortion - Histo: fibroelastic core w/ entrapped ducts Gross: white center (central scar) 2. Tx: core bx ➡ excisional bx (to r/o ca)

Answer 7

1. Prealbumin: >15; t1/2 is 1-2 days; good post-op marker 2. Albumin: >3.5; t1/2 is 21 days; good pre-op marker

Answer 8

>2cm- ligation and bypass <2cm- observation; avoid stents

Answer 9

1. Stable ➡ methotrexate or salpingotomy - MTX: absolute c/i if the patient is breast-feeding 2. Unstable, free fluid, ongoing pain/bleeding ➡ salpingectomy

Answer 10

- hyperK: peaked T wave, eventual SINE - hypoK: flat T waves, U waves

Answer 11

1. IgE allergic rxn; anaphylaxis; tx w/ epi 2. Ab rxn; AIHA 3. immune cx; serum sickness, hep's 4. delayed; t-cell; dermatitis, PPD 5. auto-immune

Answer 12

- Well differentiated: surgery post-partum - Postpone until 2T if advanced (MTC, nodes, mets) - Anaplastic requires immediate surgery in any trimester - RAI is c/i (during pregnancy and w/ breastfeeding)

Answer 13

1. Cyclic: OCP/NSAIDS - sxs improve after menses 2. non-cyclic and >30 OR cyclic + mass ➡ mammo

Answer 14

1. Confined to appendix: appe only (no LADN'y) - must have negative margin - scope in 6w to r/o sync lesions 2. Involving base, ruptured, or +margin: R hemi +/- LADN 3. Peritoneal dissemination: perc bx - if appendicitis: remove ruptured segment + directed peritoneal bx - no appendicitis: postpone appe until cytoreductive surgery - no hipec/cancer operation until staged **need post-op scope to r/o synchronous lesions

Answer 15

4- spon 3- to voice 2- to pain 1- none

Answer 16

- "polymorphic ventricular tachycardia" - 2/2 hypoK, hypoCa, hypoMg, macrolides

Answer 17

- CVP 2-6 - WP 4-12 - SVR 700-1500 - CI 2.5-4

Answer 18

- < 72 hours but not until after appropriate fluid resuscitation - Used for deep 2nd-, 3rd-, and some 4th-degree burns - Viability is based on punctate bleeding (#1), color, and texture after removal (use dermatome)

Answer 19

Path- def in ADAMtS13 Px- fever, anemia, TCP purpura, renal dz, neuro sx (FATRN) Tx- plasmapheresis ➡ steroids ➡ splenectomy

Answer 20

AT comes off first and goes lateral TP trunk- PT behind tibia, peroneal behind fibula

Answer 21

- HCC: rapid enhancement. rapid w/out. "hot" on nuclear imaging - Mets: Hypoattenuation - Adenoma: rapid enhancement. rapid w/out. "cold" on nuclear imaging. gado/eovist not retained - Hemangioma: peripheral nodular enhancement. delay: centripetal fill-in (no early washout!) - FNH: Centrifugal enhancing. w/out except for scar enhancement. take up sulfer colloid and gado/eovist

Answer 22

Px: profound AG metabolic acidosis - oxalate stones → renal failure Tx: NaB + fomipazole (ADH inhibitor) - consider iHD

Answer 23

Runs under the vas/uterine arteries Runs over the iliacs

Answer 24

1. ASA lifelong 2. Plavix - BMS: 1 month - DES: 6 months (ideally). Can be 1 month if needed for urgent surgery (cancer)

Answer 25

1. supracondylar humerus- brachial artery 2. DRF- median nerve 3. Mid shaft- radial nerve 4. ant shoulder disloc- ax. nerve 5. post shoulder disloc- ax. artery

Answer 26

R time- FFP K time- cryo a angle- cryo MA- PLTs LY 30- TXA Rule of 6's: R > 6 minutes alpha angle > 60 degrees MA < 60 mm LY30 > 6%

Answer 27

Score: pH <4 , changes in position, duration, # of episodes > 14.7 is positive

Answer 28

1, 2, and 3 SD = 67%, 95%, and 99.7% of the data

Answer 29

Hyperchloremic metabolic acidosis (urine high in Cl is exchanged for bicarb which is excreted)

Answer 30

Dx: usually found in cecum and ascending colon -2nd MC CO gi bleed (vs. div's) - MC CO right colon bleeding - MC CO bleeding > 65 yo Tx: if bleeding or iron deficiency 1. Endoscopic 2. Surgery if refractory

Answer 31

Px: post-mastectomy lymphangiosarcoma (bruises) - 2/2 chronic lymphedema; 10 years from surgery Dx: incisional bx Tx: wide local excision w/ 3-6 cm margin + chemotherapy - often requires arm amputation - don't need to stage nodes (hematog spread)

Answer 32

Stable and healthy- stone removal and take down fistula Unstable, old/frail- stone removal only!

Answer 33

Tyrosine kinase inhibitor Tx of HCC

Answer 34

1. Heineke: <10cm; open long and close transversely 2. Finney: > 10cm; segment folded on itself and common wall created 3. Side2Side isoperistaltic (Michellassi): > 20 cm; overlap stricture/dilated area; 2x enterotomy/sew bowel together **Bleeding is MC complication

Answer 35

Dx: Scintigraphy gastric emptying Tx: - Metoclopramide (Reglan): dopa antagonist - gastric pacemaker or pyloroplasty - feeding tube - TPN

Answer 36

1D: epidermis 2D superficial: pap dermis, painful, hair follicles intact; blanches - don't need grafting 2D deep: retic dermis, decreased sensation; loss of hair follicles, no blanch - need skin grafts 3D burn: subcutaneous fat, leathery 4D: fat/muscle/bone; surg

Answer 37

- TV at 4-6 ml/kg - Permissive hypercapnia - Proven benefit: prone, lung protection, paralyze -P/F < 100 = severe

Answer 38

IL1: fever, wound healing IL2: T cell proliferation IL4: B cell proliferation. abxs allergic rxs IL5: eosinophil growth, asthma, allergic rxns IL 10: anti-inflammatory C5-9: MAC ➡ cell lysis

Answer 39

Loc: distal (a cells) Px: dermatitis, DRH, DM, nec mig erythema - most malignant - no stones (vs. SS'oma) Dx: gluc > 1000 Tx: distal panc + splenectomy + LADN'y + CC'y

Answer 40

ACA: Plasmin inhibitor - Use: DIC, excess tpa Streptokinase/Urokinase/TPA: plasmin activator - bust clot

Answer 41

1. carb: immunosuppression, resp failure 2. lipid: pro inflammatory 3. protein: false neurotransmitters, rise in ammonia/urea - can worsen hepatic encephalopathy (use branched chain AA instead of aromatic AA)

Answer 42

- Dx: red, crusty, weeping lesion - Bx: PARTIAL thickness pleomorphism (full = SqCC in Situ) - Tx: cryotherapy, photodynamics, imiquimod, cautery (no margin)

Answer 43

- Duhamel: agang stump in place/gang colon pulled behind; end-to-side mosis; neo-rectum; lowest stricture rate - Soave: pull-through; “reverse alte”; remove M/SM; pull through within an aganglionic CUFF; least dissection - Swenson: original; aganglionic segment resected to sigmoid colon; pull-through with end-to-end anastomosis- colon x rectum.

Answer 44

- If less than 3 nodes positive on SLN and T1 or T2 disease, BCT is OK - if >70, t1, ER+ and SNLBx neg ➡ can consider no XRT after lumpectomy

Answer 45

shock expanding hematoma pulsatile bleed thrill/bruit absent pulse ischemia If negative ➡ ABI...if positive ➡ CTA (to localize)

Answer 46

1. Submucosal invasion > 1mm 2. Poorly differentiated 3. <1 mm margin 4. LV invasion 5. Tumor budding 6. Taken piecemeal

Answer 47

anemia, glossitis, brittle nails, cardiomegaly

Answer 48

- eso: T2 (MP) - stomach: t2 (MP) - colon: t4b (adjacent organs) - rectal: t3 (through MP) - lung: n2 nodes

Answer 49

1. Interstitial: <4w- acute peripanc collection >4w pseudocyst 2. Necrotic: <4w- acute necrotic collection >4w- walled of necrosis

Answer 50

- SB: glutamine - LB: short-chain fatty acids (acetate, butyrate). Directly absorbed by intestinal epithelium w/out lipolysis

Answer 51

Motilin – released by intestinal cells of gut; acts. on smooth muscle to↑ intestinal motility (erythromycin acts on this smooth muscle receptor)

Answer 52

- Start 8 years after sx onset - 2-4 random bx every 10 cm throughout the colon + suspicious areas Repeat schedule: - normal: q1-3 years - PSC, stricture, or dysplasia w/out colectomy: q1 year Any dysplasia usually gets a colectomy - if resectable can consider endoscopic resection with close surveillance

Answer 53

Px: bloody stools after 1st feed - prematurity is biggest RF tx: - resuscitation, ngt, abx (no surgery) x 7-10 day (50% success) -surgery (50%): resect all non-viable segments. create stoma.

Answer 54

- U/S and TSH: a. Nodule + Low TSH ➡ RAI uptake scan - hot/functioning: toxic adenoma (no cancer) ➡ thionamide, b-block + lobectomy - cold: FNA b. Nodule + Normal/High TSH ➡ FNA

Answer 55

Tx: simple mastectomy w/ SLNBx - BCT usually can’t be done b/c not enough tissue - if ER+: tamoxifen (Her2+ is rare). consider orchiectomy if metastatic. - More likely ER/PR+ than females! - Prognosis similar to W but delay in px - a/w BRCA 2/Chromosome 13. Should BRCA test if family hx

Answer 56

Mano: - high amplitude (> 180 mmHg)/long peristalsis (>6 sec) - normal LES pressure - normal relaxation Tx: (identical to DES) 1. PPI, CCB, TCA 2. Long segment myotomy if refractory

Answer 57

1. Intro-op: - convert to open, intra-op cholangio, repair OR - widely drain and send to specialty center 2. Post-op: - Perc cholangiography to define the anatomy - Control spillage: external drain +/- stent +/- PTC - Repair in 6-8 weeks

Answer 58

1. LGD: ablation OR scope q6-12m - OK for fundoplication 2. HGD: ablation + Q3m scope - fundoplication c/i 3. T1a: ablation 4. t1b (or low risk T2): upfront esophagectomy *Fundoplication does not decrease cancer risk

Answer 59

SE: runs between rectus and posterior rectus sheath; branch of int mammary IE: runs between rectus and transversalis fascia; branch of EI

Answer 60

- hypoxia, hypercarbia, severe upper airway edema - If stable/GCS > 8 and level of injury unknown ➡ ABG ➡ nasoendoscopy/bronchoscopy to visualize cords ➡ intubate for swelling

Answer 61

1. EGD → CTA (if stable) 2. angio embolization (no surgery) - catheterize the celiac artery first ➡ R/L hepatic ➡ SMA

Answer 62

Path: narrowing of SC/Ax vein 2/2 mech compression Px: acute swelling Tx: catheter-directed thrombolysis before anything else (NOT open thrombectomy)

Answer 63

Tx- recombinant at3 or FFP followed by heparin then warfarin

Answer 64

Mech: - hydroxylation of lysine and proline - type 3 collagen cross-linking Def: Scurvy - gingivitis, wound healing, rough skin

Answer 65

1. Neoadjuvant: Stage 2 and above Stage 2: at least t3 (crossing muscularis prop) or any n (stage 3) 2. Adjuvant chemo as well for Stage 3+ (nodes) **XRT either pre or post-op (not both) **Typical course: chemo-XRT ➡ surgery ➡ chemo

Answer 66

Risks: - High risk pt: afib, MHV, recent TE event (3m) - High risk surgery: nsurg, optho, cards Tx: - bridge for high-risk patients - stop warfarin 5 days before surgery if not bridging, resume on day of surgery - Hold Noac 2 days before surgery and resume 1 day after - stop Plavix 5 days before - resume AC within 24h for low risk surgery. 48-72h for high risk surgery.

Answer 67

Adrenal mass Ectopic mass (small cell cancer) **dexa is strongest steroid (hydrocort is weakest)

Answer 68

1. Cl responsive (Ur Cl < 20) - temporary loss, replaceable - vomiting 2. Cl resistant (Ur Cl > 20) - hormonal, continuous loss - conn’s, steroids, hyperaldosterone

Answer 69

6 cm proximal, 2 cm distal - Esophagus: vertical fibers first (outside), then circular (inside)

Answer 70

1. Invasive cancer- no tumor on ink 2. DCIS- 2 mm **if both in specimen, margin is no tumor on ink

Answer 71

1. path: IgG against gp 2b/3a 2. dx: of exclusion- increased megakaryocytes, petechia, TCPenia - smear: normal with low PLTs 3. tx: only if PLT < 30K! steroids → IVIG 2nd line → splenectomy - spleen is source of Ab's

Answer 72

G+/aerobe/clusters coag+ → staph aureus - MC early graft infections coag- → staph epidermidis - MC late graft infection 2/2 biofim

Answer 73

- wait until 6 month old - if no resolution: elective orchiopexy to decrease r/o torsion, infertility, seminoma - risk of ca higher in both testes.

Answer 74

1. differentiation 2. mitotic coun 3. necrosis ** more important than size, nodal/distal mets for prognosis

Answer 75

dx: - CT: displacement of renal parenchyma (vs. Wilm's) - Can also use MIBG and VMA levels (like pheo) - Usually adrenal. Can also be neck, chest, spine - neck can px w/ horner syndrome - tissue bx to get n-myc status tx: 1. S1-2 (low risk) → surg alone 2. S3+ or n-myc+ (high risk) → chemo/XRT then XRT - need bx: chemo regimen determined by n-myc amplification

Answer 76

- MOA: G cells of antrum signal EC cells ➡ Histamine ➡ Parietal cell ➡ H/K exchange (ATP) ➡ HCl (+ intrinsic factor) - Stimulation: ACh, beta ago, AA - Inhibition: acid, SS, secretin, CCK

Answer 77

1. Cervical- inf thyroid 2. Thoracic- aortic branches (bronchial arteries) 3. Abd- left gastric/inferior phrenic

Answer 78

- CBD at 11'. PD at 2’ - Ampulla is between them (they both feed into it) - Blood supply 9' and 3'. - perform sphincterotomy by cutting from 11' to 2'

Answer 79

Grade: 1/2- contusion/stretch ➡ foley 3- part disruption ➡ foley +/- cystostomy/repair 4/5-complete disruption ➡ cystostomy + delayed repair - can try urethral cath with cysto assistance - must get a CTAP to r/o concomitant injuries that would require delayed repair

Answer 80

1. Type C - MC, 85% - Proximal esophageal atresia (blind pouch) and distal TE fistula - dx: AXR ➡ distended, gas-filled stomach, coiling tube - no UGI needed! 2. Type A: second most common, 5% - Esophageal atresia and no fistula - dx: XR: gasless abdomen, coiling tube - no UGI needed! Tx: 1. Resuscitate w/ repogle tube 2. Echo: VACTERL cardiac w/up 3. G-tube placement to decompress and feed 4. Delayed RIGHT extra-pleural thoracotomy 5. Distal ligation of TEF (if gas in abdomen, type C) **long term r/o dysphagia and GERD in almost ALL patients

Answer 81

1. CT or scope to confirm dx. R/o obstruction. 2 supportive, dc narcotics, ng tube, neostigmine 3. if > 10cm ➡ scope decompression and neostigmine 4. failure ➡ OR

Answer 82

Px: bitemporal hemianopsia, galactorrhea, amenorrhea, ED, osteopenia Tx: 1. Bromocriptine or carbegoline (both dopa agonists) - bromo is safe in pregnancy 2. Surgery only if tx failure

Answer 83

- Sevo: rapid induction, less pungent. Good for kids. - Isoflurane: good for neurosurgery; no increase in ICP - Halothane: slow onset/offset, cards depression, hepatitis. - NO: least cardiac depression b/c sympathomimetic. c/i in SBO. Highest MAC.

Answer 84

- competitive inhibitor of ACh at muscarinic receptor - liver metabolism

Answer 85

Dx: string of beads on angiogram Path: fibroplasia, thickened media, collagen formation Tx: angio + balloon (no stent)

Answer 86

MEN1: MENIN gene, TSGene MEN2: RET gene, receptor TK protein, proto-oncogene

Answer 87

0- redo imaging 1- negative, NTD 2- benign, NTD 3- benign, repeat q6m 4- suspicious, bx 5- highly suspicious, bx 6- confirmed, excise **discordance: perform repeat bx w/ surgical excision or core bx (if there was a correctable error)

Answer 88

1. Fluconazole: ergosterol synth inhibitor - Non-systemic candida (yeast infection, c. albicans) - s/e: liver toxic, GI upset 2. Voriconazole: ergosterol synth inhibitor - aspergillosis - s/e: visual changes, psychosis 3. Micafungin: echinocandin; inhibit glucan - invasive/disseminated candidiasis - s/e: TCPenia 4. Amphotericin: binds ergosterol and inhibits cell membrane; lipid soluble (brain access) - invasive mucor, cryptococcal meningitis - s/e: nephrotoxic, electrolytes (hypoK)

Answer 89

- motor: larynx except cricothyroid - sensory: larynx below the cords - injury: hoarseness, airway compromise, permanent ADduction —> bilateral may need a trach Aberrant anatomy: - NR right a/w: arteria lusoria ➡ absent innominate + right SC takes off from left aortic arch - NR left a/w R sided arch - inferior PT is anterior to RLN. Superior PT is posterior to RLN

Answer 90

1. Preop FEV1 and DLCO predicted > 80% ➡ no further testing - >.8L wedge, >1.5L lobe, >2L pneumo - < 80% ➡ lung scan for PPO FEV1, DLCO 2. PPO FEV1, DLCO > 60% ➡ no further testing - < 60% ➡ exercise test 3. VO2 > 10 ml/min/kg ➡ OK for surgery - < 10 ➡ high risk for surgery

Answer 91

- 4th pharyngeal arch releases NCC which form parafollicular C cells

Answer 92

Loc: gastrinoma triangle (CBD, panc neck, 3D) Px: refractory PUD - Mostly malignant Dx: G > 1000 (off PPI) or >200 w/ secretin (off PPI) - SS Scintigraphy (dotatate scan) if can't get off PPI - MRI for regional disease Tx: Screen for MEN1 - <2 cm: enucleate w/ LADN'y - > 2cm: resect w/ LADN'y

Answer 93

1. AMS (<15) 2. RR > 22 3. SBP < 100

Answer 94

1. Benign: Pleomorphic adenoma - Tx: superficial parotidectomy even if asx 2. Malignant: mucoepidermoid carcinoma tx - Tx: total parotidectomy (facial nerve preservation) + MRND + XRT

Answer 95

- Frostnip: rapid moist/pool re-warming - 2d: clear/milky blister- drain - 3d: HMHG blister- leave intact - 4d: bone- prostacyclin/TPA, amputate

Answer 96

1. ASx: NTD 2. Acute abscess: drain only 3. Chronic cyst: offer surgery if effecting QOL - marsupialization and leave open: lower recurrence - primary closure: faster healing. Off midline- less complication (preferred)

Answer 97

<10k if asx <20k if septic, chemo/rads, RF’s <50K if elective surgery

Answer 98

Dx: UGI with double bubble at 2D Tx: - neonates: duo-duo (mobile duo) - adults: duo-jej

Answer 99

TNF-a: produced by PMNs, mphages -cachexia, inflammation IF-gamma: produced by T lymphos - activate PMNs, mphages

Answer 100

1. MRI 2. EUS w/ FNA (If unclear): -Pseudocyst: high Am, low CEA -Serous cystadenoma: low Am, low CEA -MCN: low Am, high CEA (>200) -IPMN: high Am, high CEA (>200) ***High CEA > 190

Answer 101

MOA: GABA-A agonist Pros - rapid distribution and on/off - decreases ICP, anti-emetic Cons - s/e: hypotension, resp depression, meta acid - no analgesia - liver metabolism - prop infusion syndrome: metabolic acid + rhabdo

Answer 102

Primary bile salts - cholic acid, cheno-cholic acid (C's) → hepatocytes → conjugated BS: 1. 80% conjugated ➡ active ileum absorbed 2. 20% deconjugated by bacteria ➡ passive colon absorbed 3. 5% out in stool

Answer 103

- Suspect in burn patient with neuro/cards sxs Tx: 1. 100% O2 w/ facemask or intubation (not hi flo) - Hyperbaric O2 if C-Hb > 25% 2. Intubate if comatose, severe acidosis

Answer 104

1. Rigid proctoscopy: w/ in 2cm of anal verge (levators) 2. PE: baseline sphincter dysfxn 3. Recurrent SqCC (s/p Nigro)

Answer 105

- CEA: colon CA - AFP: liver CA - CA 19-9: pancreatic CA - CA 125: ovarian CA - Beta-HCG: testicular CA, choriocarcinoma - PSA: prostate CA - NSE: small cell lung CA, neuroblastoma - BRCA I and II: breast CA - Chromogranin A: carcinoid tumor - Ret oncogene: medullary thyroid CA - KRAS: pancreatic CA (MC genetic mutation)

Answer 106

1. Ivor-Lewis (Trans-thoracic): abdominal + R thoracotomy - anastomosis: thoracic - theoretically more thorough oncologic resection - less overall leak rate - may be better in more fit patients 2. Transhiatal: abdominal + L neck - anastomosis: cervical - theoretically less chance of mediastinal leak, shorter operation BUT more overall leak rate - may be better if old/frail and distal esophagus tumors 3. McKeown: abdominal + L neck - anastomosis: cervical ***Gastric conduit supply- R gastroepiploic (off GDA/CHA)

Answer 107

Loc: head Px: DM, GALLSTONES (> glucagonoma), steatorrhea, block exo/endo pancreas - most malignant Dx: sx's + high fast SS Tx: resect + LADN'y + CC'y

Answer 108

Induction agent Pros- Fewer hemodynamic changes, fast acting, fewest cards s/e Cons- adrenocortical suppression

Answer 109

1. PE 2. Ultrasound 3. AFP, HCG, LDH - Seminoma: no AFP! (most common) - Non-seminoma: high AFP, HCG, LDH 4. Inguinal orchiectomy: any patient with solid testicular mass 5. Based on path/tumor markers decide: - Seminoma: XRT or chemo - Non-seminomatous: retroperitoneal node dissection **ligate cord at level of internal ring so it can later be removed with retroperitoneal node dissection

Answer 110

1. Pyogenic: after cholangitis (MC) or div's (via portal vein); - drain and abx (+mica if fungal) 2. Amoebic: after mexico trip (or aMazon). - dx w/ serology/hemagglutination 1st - metronidazole (no drain) 3. Echinococcal: wall Ca+ and sub-cysts - albendazole and resect/PAIR 4. Fungal: 2/2 chemo/neutropenia - perc drain + micafungin

Answer 111

Proximal landing: > 1.5 cm - diameter < 3cm Common iliac (distal landing): > 1 cm - diameter > 8 mm Neck angulation < 60 degrees External Iliac diameter> 7mm **smoking is stronger RF for AAA **extensive calc is a c/i

Answer 112

1. Sitz bath, fiber 2. topical nifedipine/nitroglycerin - nitro causes headache 3. Surgery (or botox) - Good sphincter tone: LATERAL, INTERNAL sphincterotomy - Poor tone: botox **If 2/2 crohn's dz: optimize medical management

Answer 113

Genes: - MLH1 - MSH2, MSH6 - PMS2 - EPCAM Fxn: DNA MM repair gene causing microsatellite instability

Answer 114

1. acuminatum- HPV (6, 11- warts; 16, 18- Cancer) 2. lata- syphilis

Answer 115

1. Hemangioma: only if sxatic or KM syndrome - enucleate (or resect); angioembo if active bleed 2. FNH: NTD 3. Adenoma: resect if < 4cm w/out OCP response or > 4 cm, male, or growing

Answer 116

-Dx: prenatal dx on US ➡ must confirm with MRI -Tx: 1. intubate (in delivery room) - goal O2 > 60, CO2 < 60 2. NGT +/- ECM 3. delay OR when stable

Answer 117

1. Exudative ➡ drainage or VATS (1-7 days) 2. Fibrinopurulent ➡ VATS (7-21 days) 3. Organizing ➡ thoracotomy (21+) **VATS between days 3-7 - Preferred over 2nd CT placement or fibrinolytic therapy

Answer 118

posterior circulation sxs- dizziness, diplopia, dysphagia, dysarthria, ataxia

Answer 119

1. TOF 2. Transposition of GVs 3. Truncus art 4. Tricuspid atresia 5. TAPVC

Answer 120

Manno: - unorganized peristalisis - normal LES pressure - normal relaxation Tx: 1. CCB (+TCA if chest pain) 2. Botox injection (endoscopic) 3. Last resort: long segment myotomy

Answer 121

1. HDUS: Enter lesser sac through gastrohepatic ligament, divide posterior crus of diaphram 2. Stable: left medial visceral rotation is preferred

Answer 122

px- tender, “cord-like” structure tx- NSAIDs

Answer 123

Bx: stromal overgrowth, atypia, high MI, "leaf-like" - aggressive fibroepithelial lesion - non aggressive is fibroadenoma Tx: WLE w/ 1 cm margin + XRT (if > 5cm) - can spread hematogenous to lung (more than ax nodes)

Answer 124

Right: - SMA (behind pancreas and CBD) - found behind CD during a chole Left: left gastric (in gastrohepatic ligament) - found medial to portal triad - injured during paraeso hernia

Answer 125

Ampicillin/Amoxacillin Vancomycin Zosyn (Resistant to all cephalosporins)

Answer 126

REYGB- 75% SG- 60% Lap band- 50%

Answer 127

HypoCl, HypoK metabolic alk - Mech: Loose HCl and fluid ➡ turn on RAA system Retain Na/Excrete acid (paradoxic acidurea)

Answer 128

Indications for total thyroidectomy: - Tumor > 4cm - Tumor 1-4cm and patient preference - Distant mets or extra-thyroid disease - Nodal disease - Poorly differentiated - Prior radiation *micro-mets do not count as distant disease **if thyroid lobectomy only: tx with thyroid hormone to suppress TSH, get serial U/S to monitor

Answer 129

dx: - < 3cm: excisional bx - > 3 cm: core needle (preferred) or incisional tx: - resect w/ 2 cm marg - neoadj: rhabdomyo, Ewing, high grade, > 10 cm - adj XRT: > 5cm, high grade, recurrence, close marg - adj chemo: never

Answer 130

Infected pancreatic necrosis (WBC + gas on CT) 1. CT with gas 2. Carbapenem 3. FNA + Perc drain OR endo drain (if stomach is close to pancreas) 4. Upsize drain 5. MIS retrop necrosectomy (VARD) 6. Open necrosectomy

Answer 131

- nerve: spinal accessory nerve - location: exit jugular foramen (post triangle) - injury: SCM and trapezius. no shoulder shrug, winged scap!

Answer 132

1. Central cord: loss of pain, temp, motor - motor UE> LE loss (vs. anterior syndrome) - hyperextension in the setting of SS 2. Anterior cord: loss of pain, temp, motor - below the level of the lesion - ASA injury or anterior cord compression

Answer 133

types: af, aflutter, paroxysmal SVT, WPW 1. vagal → adenosine - may unmask afib/flutter 2. HDS: BB, CCB ➡ sync cardioversion 3. HDUS ➡ sync cardioversion

Answer 134

VHL gene - upreg. of VEGF 1. Brain/retinal hemangioblastoma- q2y brain MRI 2. Clear cell RCC- q1y US/MRI of abdomen 3. Pheochromocytoma- yearly metanephrines

Answer 135

1. Punch bx or excisional bx (if < 2cm, non-sensitive area) - MIS- 5mm margin - <1mm- 1cm - 1-2mm- 1-2cm - >2mm- 2cm 2. Clinical positive nodes (stage 3) require FNA for confirmation - negative: SLNBx - positive: completion LN dissection 3. SLNBx: > 1mm (T2) or if .75-1 mm w/ ulceration or mitotic rate > 1 (T1b) 4. If SLNBx+ (stage 3): q4m US surveillance OR completion LN dissection - LN dissection: superficial 1st. Deep if cloquets+, clinically+ positive, >3+ on SLNBx, or CT+ for deep nodes **MOHS can be used for in-situ disease. Need 5 mm margin.

Answer 136

c-spine stabilize → preO2 → fentanyl → etomidate → succinylcholine

Answer 137

PSC: Male; intra/extra hepatic; onion fibrosis; chain of lakes - a/w Ulcerative colitis, cholangioca PBC: Female; intra hepatic; granulomas; +AMA - a/w Sjogren, RA tx: trx, cholesty., UDCA - meds generally don't help

Answer 138

MAP - ICP normal CPP > 60 Normal ICP < 20 - would prefer low MAP with CPP of 60 then higher MAP for brain bleed

Answer 139

1. Perianal, intersphincteric, horseshow, and ischiorectal: through the skin (all are below the levator muscles) 2. Supralevator abscesses need to be drained trans-rectally

Answer 140

Px: bilious emesis Dx: UGI duodenum does not cross midline - should be done in all infants with bilious emesis Tx: urgent OR (risk of malro) 1. resect Ladd’s bands 2. widen the mesentery (resect central bands) 3. counterclockwise rotation 4. place cecum in LLQ (cecopexy), duodenum in RUQ 5. appendectomy

Answer 141

Shape: Biconvex. DOES NOT suture lines Vessel: MMA Px: lucid interval. Ipsilateral blown pupil is early sign - (vs. subarachnoid thunderclap, worst HA)

Answer 142

1- pancreatic (gastrin), pituitary (prolactin), parathyroid (PTH); menin; AD 2a- Parathyroid (PTC), MTC, Pheo (catecholamines); ret; AD 2b- Pheo, MTC, marfanoid/neuroma; ret; AD

Answer 143

Protein intake (grams)/6.25 - (UUN + 4 grams) UUN = grams of nitrogen excreted in the urine over a 24 hour period 4 = stool and insensible losses Recommended protein = 1.5g/kg/day Nitrogen = protein intake/6.25 **muscle is greatest site of protein turnover

Answer 144

stop 5 days before Indications to bridge- mech valve, h/o TE event, afib only if CHAD/VASC 5-6+

Answer 145

1. no RH strain → acoag 2. RH strain → IR catheter 3. RH strain + HDUS → systemic tPA

Answer 146

Px: nitrites, Hurricane spray, fertilizers, g6PD def, serotonergic drugs, benzocaine spray - Fe2+ to Fe3+ impairing O2 binding Dx: blood gas measurement and pulse ox says 85% - MethHb level > 20% Tx: methylene blue or vitamin C (for g6pd or ser)

Answer 147

1. mucosa 2. sub-mucosa (strength layer) 3. muscularis propria 4. serosa

Answer 148

- small: patch plasty - large: contralateral GSV (must maintain venous system b/c deep vein may be injured) - limited time/unstable: shunt

Answer 149

1. unprovoked: malignancy, inherited ➡ indefinite 2. provoked: surgery, travel, preg, OCP, immbility ➡ 3m Special cases: - ileofemoral: cather directed thrombolysis - open thrombectomy ➡ extensive (ileofemoral) DVT OR phlegmasia - Superficial femoral vein is a DVT - Pregnant ➡ use Lovenox. NOAC and Coumadin are c/i

Answer 150

- loop: furosemide - Ca sparing: thiazides (can cause gynecomastia)

Answer 151

Dx: EGD + bx - usually in the stomach - CD20+, lympho infiltration - associated w/ h. Pylori. - non-hogkins (worse prognosis) Tx: - Low grade: triple therapy (eradicate HP) - High grade: chemo and XRT (CHOP) +/- rituximab (CD20)

Answer 152

- <30d: technical error - 1m-2y: intimal hyperplasia, (at the distal anastomosis) - >2y: progressive atherosclerotic disease

Answer 153

Dx: palpable neck mass + Ca > 14 is presumptive dx. Otherwise, dx intra-op based on gross features. - FNA is not recommended - Treat based on intra-operative gross invasion. Frozen section is not helpful. Tx: 1. Control hypercalcemia: usually > 14 - IV fluids 1st! Then bisphosphonates - cinacalcet (sensipar - ca mimetic) 2. Parathyroidectomy w/ hemithyroidectomy (+/- L6/central neck dissection +/- XRT) - no chemo - usually don't perform any node dissection unless palpable nodes

Answer 154

aspirate/gram stain to dx → drainage (internal, external, endoscopic)

Answer 155

Tx: - WLE (1 cm). No SLNBx - APR if sphincter involved, LADN, or > 4mm - No chemo-XRT **5y-S is 20% w/ R0 **WLE = APR

Answer 156

- Case: HSV8 - Px: Violet/brown papules

Answer 157

1. Graves: IgG stimulates TSHr ➡ hyperT - BB, PTU, RAI ➡ thyroidectomy 2. TMN: chronic TSH stimulation ➡ hyperT - BB, PTU, RAI ➡ total/subtotal thyroidectomy 3. Hashimoto's: antiTPO/TG Ab ➡ hypoT - thyroxine ➡ partial thyroidectomy 4. DeQuervains/Subacute: viral URI - path: giant cells, leukocytes - NSAIDS/ASA ➡ steroids 5. Reidels: autoimmune inflammation - steroid, thyroxine ➡ surgery for compression

Answer 158

- cystic: no bx -isoech/hyperech: FNA if > 2cm -hypoech (high sus): FNA if > 1cm

Answer 159

1. 1st line: fiber/bulking, exercises 2. Refractory: endoanal U/S - defect: overlapping sphincteroplasty - no defect or refractory: sacral modulator

Answer 160

- Silver nitrate: electrolytes disturbance (no sulfa) - Silver sulfa: neutropenia, sulfa (covers pseudo) - Mafenide: met acidosis (CA inhibitor), sulfa (covers pseudo and eschar) - Bacitracin: G+; nephrotoxic

Answer 161

PP1 + 2 antibiotics abxs: amoxicillin, metronidazole, tetracycline, clarithromycin for 2 weeks

Answer 162

- chromosome 5 - 1st mutn in adenoma to carcinoma - mc mutation in colon ca - a/w FAP

Answer 163

1. CN 11 2. subclavian artery 3. EJV 4. brachial plexus trunks

Answer 164

1. age 2. age 1st period (earlier is worse) 3. age 1st birth (earlier is better) 4. 1d relative 5. previous bx 6. race

Answer 165

1. post hip disloc’n: sciatic nerve (peroneal branch) 2. post knee disloc’n: popliteal atery 3. DRF: median nerve 4. Supracondylar humerus fx: brachial artery 5. Anterior shoulder disloc'n: axillary nerve

Answer 166

B1 at low dose - inotropy B2 at high dose - vasodilation

Answer 167

1. proximal/distal seal: immediate balloon expansion of distal/proximal attachments + stent - 1a: proximal leak - 1b: distal leak 2. back bleeding: observe. coil embolization if enlarging 3. graft defect (tear or junctional leak): immediate additional graft coverage 4. porosity- reverse anticoagulation

Answer 168

1. Carcinoid- Kulchinsky cells (enterochromaffin-like) tx- < 2cm ➡ appendectomy; > 2cm ➡ R hemi/oncologic resection; chemo if unresectable 2. GIST- cajal cells tx- resection (MC stomach), imantinib 3. Desmoid- spindle cells tx- resect if extra-abdominal. NSAID/estrogen if intra

Answer 169

- Anti-mesenteric border of SB - 2/2 peristant viteline duct - pancreatic and gastric tissue - 2 feet from IC valve

Answer 170

Linezolid, Dapto - Amp if not amp resistant

Answer 171

Milrinine- PD inhibitor, contractility with vasodilation - c/i in renal failure Midodrine- a1 agonist

Answer 172

Px: resistant HTN and hypokalemia 1. AM plasma aldo/renin - A/R < 20: 2nd hyperaldo - A/R > 20: primary hyperaldo ➡ 2. Confirmatory test: salt load suppression test - give salt load ➡ 24h urine aldo remains elevated 3. Discern laterality: CT scan! (>MRI) A. Unilateral: lap adrenal (consider adrenal vein sampling 1st if > 35 to r/o BAH) B. Bilateral or negative ➡ adrenal vein sampling - Lateralization: lap adrenal - No lateralization: idiopathic hyperplasia ➡ tx medically **tx HTN with spironolactone

Answer 173

dx: ↑ascitic PMN ANC > 250 (Se) and - don't require culture (Sp) - e. coli is MC (usually single organism) tx: 1. paracentesis for cx 2. abxs: - <48h/community acquired: 3GC - >48h/hospital acquired: carbapenem + MRSA coverge (dapto) 3. Albumin (survival benefit)

Answer 174

- Tissue typing - Donor organ: carries Ag (on WBC) - Recipient body: carried Ab - Recipient serum with donor wbc

Answer 175

1. Resuscitate, ensure airway 2. Octreotide + antibiotics 3. Endoscopic intervention (ligation/sclerotherapy) 4. Blakemore 5. TIPS (temporized with Blakemore)

Answer 176

1. Elevate HOB 2. Chest CT with IV contrast (can skip CXR) 3. Consider bronch 4. Assess sxs A. Life-threatening sxs: secure airway ➡ consider AC (if thrombus) ➡ venogram ➡ endovascular stenting B. Mild sxs ➡ tissue bx ➡ decide on XRT/chemo - no chemo/XRT unless its 2/2 cancer

Answer 177

Crystalloid: 20cc/kg PRBC: 10cc/kg

Answer 178

- superficial spreading: MC - lentigo: sun exposed, best prog - nodular: worst prog - acral: AA **thickness is most indicative of prognosis

Answer 179

1. Uncomplicated: lap appe 2. Septic/Unstable: immediate lap appe 3. Stable w/ abscess - < 3cm: lap appe - > 3cm: IR drain ➡ interval appe, offer scope 4. Crohn's ileitis - intra-op with normal appendix AND cecum ➡ appe to r/o dx uncertainty

Answer 180

1. urine metanephrine to r/o pheo 1st 2. tx pheo 1st w/ adrenalectomy 3. Address thyroid - 2A: total thyroid + bilateral central neck by 5y - 2B: total thyroid + bilateral central neck by 1y

Answer 181

1. HyperPTH 1st w/ 4-gland resection (hyperplasia not adenoma) + thymectomy (remove ectopics) 2. Asses other lesions

Answer 182

Prognosis: - aggressive, undiff - mort ~ 100%; no tx Tx: XRT improves short-term survival +/- surg - BRAF inhibitor for chemo

Answer 183

Glucagon: alpha cells of pancreas - glycogenolysis, gluconeogenesis Insulin – beta cells of the pancreas - cellular glucose uptake; promotes protein synthesis

Answer 184

1. T0 or T1 (submucosa) 2. < 3 cm 3. < 30% circumference 4. Palpable on DRE (<8cm from anal verge) 5. No high-risk features (poorly diff, LV invasion) **local recurrence rate is higher

Answer 185

Dx: -rare neuroendocrine tumor of the skin -purple raised; looks like BCC w/out rolled edge - CK20+. TTF- (vs. small cell ca of the lung, TTF+) Tx: -Tx: surgical excision + SLNBx! + XRT (very sensitive)

Answer 186

- US aspiration BEFORE I/D if refractory - Bx if > 2 weeks to r/o ca - abxs to cover staph if systemic sxs. Consider MRSA coverage if RFs

Answer 187

1. Resect Ladd’s bands 2. Widen the mesentery 3. Counterclockwise rotation 4. Cecum in LLQ (cecopexy), place duodenum in RUQ 5. Appendectomy

Answer 188

1. CRC: scope q1-2y starting at 20-25 - Surgery if: CRC or endoscopically unresectable lesions - TAC with IRA w/ q1y rectum surveillance 2. Endometrial ca - childbearing: endometrial sampling q1y - after children: TAH-BSO 3. Ovarian ca: annual pelvic exam and TVUS

Answer 189

Dx: U/S or HIDA Tx: 1. fusiform dilation: REY-HJ 2. diverticulum: simple excision 3. choledococele: transduo excision vs. sphincteroplasty 4a. intra + extra dilation: hepatic resection + recon 4b. extra only: excision + recon 5. intra only: transplant

Answer 190

Vit D: increase Ca and Ph PTH: increase Ca and decrease Ph

Answer 191

(1.34 x Hb x Sa02) + (.003 x PaO2)

Answer 192

Duo atresia: newborn; bilious emesis directly after birth - a/w down syndrome -dx: AXR- double bubble with no gas distally. don't need UGI -tx: duodenoduodenostomy TEF: newborn, spit ups. can't place NG. resp sxs - dx: AXR- gasless (A), gas (C) - tx: right extra-pleural thoracotomy Pyloric stenosis: 1-3 months; NB projectile vomiting -dx: U/S- 4mm thick, 14 mm long. String sign on UGI -tx: pyloromyotomy (1-2 from duo to antrum) Intussusception: 3m-3y; currant jelly stool - dx: U/S w/ bull's eye - tx: air contrast enema Malro: 1y-5y; sudden onset bilious emesis - dx; UGI- no duo sweep (any child w/ bilious emesis) - tx: ladd's procedure

Answer 193

- recycling of lactate and pyruvate to liver for gluconeogenesis and glucose production - requires alanine - provides 40% of glu when starving

Answer 194

1a: LC only - lap chole only - excise to negative CD margin 1b: muscle involved - OPEN chole + seg 4b and 5 + portal LADN - CD margin positive: REY-HJ **high suspicion for GB Ca should also get an open chole (polyp > 2cm)

Answer 195

Epithelium Lamino Propria Muscularis mucosa

Answer 196

3a: 4 to 9 nodes ➡ +/- neoadj 3b: chest wall (not pec wall) or breast skin ➡ +/- neoadj 3c: supra clavicular nodes ➡ neoadj required

Answer 197

1. Flush ➡ glucagon x 2 2. Lap exploration A. Transcystic: stone < 1 cm, <8 stones, no CHD stones B. Lap CBD: stone > 1cm, > 8 stones, CHD or junction stones 3. Open exploration: if lap exploration failed - CBD < 2 cm: trans-duo sphincteroplasty - multiple stones, CBD > 2 cm: biliary-enteric drainage. - Leave T-tube **thin CD can be dilated

Answer 198

1. FNA- hurthle cells (can be seen in other conditions) 2. Lobectomy 1st for diagnosis 3. If malig: total thyroidectomy +/- L6 nodes 4. If palpable nodes: MRND No RAI

Answer 199

Stomach and Right gastroepiploic - if out abort and discuss conduit options at a later time (don't go for colon or jejunum b/c needs to be prepped)

Answer 200

Ca 125- epithelial bHCG- choriocarcinoma AFP- germ cell/endodermal/yolk sac Inhibin- granulosa/sex-cord

Answer 201

1. Excise if > 3cm, sxatic, atypical w/ 4-6 mm margin - otherwse: cryo, curettage, 5-FU, laser 2. Lifetime surveillance even if tx! - Bowen disease = SqCC in situ = high grade AIN - Actinic keratosis is precursor *vs. pagets disease- excision

Answer 202

1. hyper-acute: w/in 1 hour - path: ABO Ab (t2 HS) - px: mottled organ - tx: remove organ 2. acute cellular: days-weeks; change in organ function - path: B or T (t4 HS) - px kidney: lymphocytic infiltration, tubulitis - px liver: endothelitis, portal triad lymphocytosis - tx: increase IS or pulse steroids ➡ IVIG 3. chronic: months-years - path: B or T (t4 HS) - px kidney: interstitial fibrosis, tubular atrophy - px liver: bile duct atrophy - px heart: vasculopathy and atherosclerosis; 1/2 @ 10y - px lung: bronchiolitis obliterans; 1/2 @ 5y - tx: increase IS or re-trx (no good options)

Answer 203

Dx: CXR ➡ CT ➡ diagnostic scope if inconclusive Tx: repair is always recommended - Abdominal approach - Debride devitlized tissue - Repair with non-absorbable suture - If too large can close primarily can use mesh or tissue flap (if contamination)

Answer 204

1. HypoCa: tingling, chvostek/trousseau sign - EKG: qt prolongation 2. HyperCa: stones, bones, groans, overtones, DI - EKG: shortened QT

Answer 205

Parafollicular C cells Inhibits osteoclast resorption Increases Ph excretion

Answer 206

- Azathioprine/6-MP: inhibit DNA synthesis - Sulfasalazine/5-ASA: COX/LOX inhibitor - Infliximab: monoclonal Ab to TNF; moderate Crohns, recurrent perianal fistula!

Answer 207

1. Gastrin - G cells in antrum - ↑ HCl, IF, and pepsinogen 2. Somatostatin – D cells in pancreas - inhibits gastrin, HCl, insulin, glucagon, secretin, CCK, motilin, pancreatic/biliary/stomach output 3. CCK – I cells of duodenum - gallbladder contraction, relaxation of sphincter of Oddi, ↑ pancreatic enzyme secretion (acinar cells) 4. Secretin – S cells of duodenum - ↑ pancreatic/GB bi release (ductal cells), inhibits gastrin release (this is reversed in patients with gastrinoma), and inhibits HCl release 5. VIP – pancreas and gut - ↑ intestinal secretion (water and electrolytes) and motility

Answer 208

Anal canal- from levators to verge Dentate line- w/in the canal; columnar/sq. jxn Anal verge- sqamous/myoc. jxn Anal Margin- 5-6 cm from the anal verge

Answer 209

Px: breast mass that looks like abscess w/ no infectious signs Dx/tx: u/s ➡ aspiration shows milky debris - continue bfeeding - no abxs (unless infected)!

Answer 210

1. imbibition (direct diffusion) 2. inosculation (cap beds meet) 3. revascularization

Answer 211

Bassini: conjoint tendon to inguinal ligament (from pubic tubercle medially to internal ring laterally) - may need relaxing incision in anterior rectus sheath McVay: open the floor to ➡ conjoint tendon to cooper's/pectineal ligament. - transitional stitch from conjoint, cooper's, and femoral sheath at medial aspect of femoral vein - re-approximate the rest of the inguinal floor by suturing the conjoint tendon to the inguinal ligament - may need relaxing incision Lichtenstein: mesh to inguinal ligament and conjoint tenown Shouldice: divide the floor ➡ 4-layer tissue closure

Answer 212

2, 3, 4, 7, 10, 11, 12 - innominate seperates level 3, 4 - 4: carinal - 7: sub-carinal - 10: R/L hilar -n2 nodes: 1-9 -n1 nodes: 10-14 - cannot sample 5, 6 (sub-aortic/AP window) ➡ chamberlain procedure (Parasternal mediastinotomy) - 8 (para-eso), 9 (IPL) ➡ EUS or VATS

Answer 213

1. Hemostasis: PMNs - 24-48h - PMNs: remove necrotic tissue 2. Inflammatory: monocytes/macrophages - 48-96h - mphage: growth factors, angiogenesis, cell proliferation - chronic wounds 3. Proliferative: fibroblasts - 3 days+ - fblasts: collagen production 4. Maturation: fibroblasts -10 days+ - myofibroblasts for wound contraction PMN (24-48h) ➡ MPhages (48-96h) ➡ Fblast (3d) ➡ MFblast

Answer 214

f8 deficiency, SLR MC inherited disorder tx- DDAVP (mild), f8 concentrate (severe)

Answer 215

Px: MC minor salivary gland tumor (Sub-Mand gland @ Palate) - Spread along nerves - Remains quiescent for years then metastasizes Tx: Total parotidectomy w/ facial nerve preservation + MRND + XRT - don't aggressively resect b/c very XRT responsive

Answer 216

Tx: 1. Resectable if: - contralateral hemi-liver with intact HA, PV, and biliary drainage with no tumor - no distant mets or organ invasion 2. Consider location - Upper ⅓ (Klatskin): lobectomy and stenting of contra lobe - Middle ⅓: hepaticojejunostomy - Lower ⅓: Whipple 3. Chemo + transplant if unresectable

Answer 217

1. Alkalis (Liquid Plumr, Drano) produce deeper burns than acid due to liquefaction necrosis 2. Acid burns (battery acid) produce coagulation necrosis - copious water irrigation as soon as possible - cagluc if HF acid

Answer 218

dx: MRI 1st! then EUS/FNA; high CEA, high amylase tx: 1. Branched - resect if >3 cm, sxs, or signs of malig (nodule) - Otherwise surveillance 2. Main duct - resect if > 1 cm or sxs (60% chance of Ca) - 5-9 mm EUS/FNA. Resect if SOMalig - < 5mm, surveillance MRIs

Answer 219

to close- indomethacin to open- PGE1

Answer 220

Anatomy: 1. Elective trach: between 2nd and 3rd trach rings 2. Crich: CT membrane between thyroid cart and cric - Thyroid ➡ cricoid ➡ rings

Answer 221

low: d1/2-ago (renal dose) medium: B-ago (heart) high: A-ago (vaso) **s/e: high UOP. difficult to titrate. tachyarrythmias

Answer 222

- 4 x weight x TBSA - Use 2 for "modified Brooke formula" - 1st 1/2 in 1st 8h - 2nd half next 16 arm = 9, leg = 18, each torso = 18, head = 9, each hand = 1, genitals = 1 UOP: .5-1 cc/hr. 1-2 cc/hr if child < 30 kg

Answer 223

>20 mg of steroids for > 3 weeks Surgery: continue regular dose the day of surgery + 1. Low risk (inguinal hernia): just continue regular dose day of surgery 2. Moderate risk: 50 mg HC pre-proc. Then 25q8 x 3 3. High risk: 100 mg HC pre-proc. Then 50q8 x 3

Answer 224

Path: outpouching SUPERIOR to cricopharyngeous Dx: UGI (don't do EGD) ➡ manometry (r/o dysmotility) Tx: open or scope approach: <2cm : myotomy alone >2cm: multiple options - consider endoscopic stapling +/- myotomy - 2-5 cm: myotomy with suspension or inversion - larger: diverticulectomy with myotomy

Answer 225

Acute – vaptan, demeclocycline Chronic – fluid restriction, diuresis

Answer 226

Spinal- below l1/l2; SA space; fast; n/m block Epidural- any level; epidural space; slow; no block

Answer 227

Loc: distal Px: watery DRH- hypoK, met acid. achlorhydria, inhibits gastrin - DRH ➡ bicarb sexn ➡ met acid - most malignant Dx: high VIP Tx: distal panc + splenectomy + LADN'y + CC'y

Answer 228

- neo-adj chemo for T2+ or N - proximal- total gastrectomy - distal- partial - 5 cm margin; 15 nodes - Can consider endoscopic mucosal resection: if < 2cm, well-differentiated, mucoa only, no LV invasion

Answer 229

- Made in SON of HT. Stored PP - Cause endothelium to release f8 and vWF

Answer 230

indications for trx w/ HCC - Single tumor < 5cm - No more than 3 tumors each < 3 cm **Hepatectomy if compensated cirrhosis (no portal HTN), low MELD, and solitary mass < 3 cm is still preferred **5-year transplant pt survival is 65-90% indications for trx of cholangioca - cant be intrahepatic - must be unresectable, perihilar, < 3cm - no distant mets

Answer 231

Right ➡ Posterior trunk- criminal nerve (post), celiac branch (ant), post laterjet Left ➡ Anterior trunk- Liver (hepatic branch) and ant Laterjet (L's) 1. Truncal vagotomy: transect ant/post @ distal eso - removes lesser curve and pylorus nerve - selective: resect at ant/post Laterjet - need pyloroplasty. high r/o dumping syndrome 2. Highly selective: transect @ crow’s ft, preserve laterjet - removes innervation to lesser curvature - preserves pylorus → no drainage procedure - lowest morbidity

Answer 232

Loc: throughout (B cells) Px: whipple's triad. Most benign. Dx: I/G > .4 and high C-pep - dx w/ fasting test 1st! - endoscopic U/S most sensitive for detection Tx: < 2cm encucleate, >2cm resect. - High carb diet 1st - Diazoxide if can't tolerate surgery - LADN'y if suspect malignancy

Answer 233

1. dx: breast oil cyst w/ Ca+ rim - smooth, circumscribed lesion outlined in white (course, egg-shell calcs) - suspect post-op 2. tx: no trauma- bx trauma- watch

Answer 234

Px: child with chronic pancreatitis episodes Dx: secretin-enhanced MRCP Tx: - Only tx if sxs - ERCP sph’otomy of MINOR papilla (Santorini/Superior) - Refractory: resect HOP (duo preserving)

Answer 235

- high grade t1b or T2 and above OR any nodal involvement - Also get XRT

Answer 236

1. Marfans- Fibrillin-1 defect (elastin); - AD; mitral regurg, aortic root dilation, lens defect, arachnodactyly 2. Ehlers Danlos- t3 collagen defect - hyper elastic skin, hypermobile joints, aortic root dilation **Both need CTA of aorta to r/o aortic root``

Answer 237

px- hematuria in a smoker dx- CT urogram 1st (bladder, kidney, or ureter ca) 1. T1a- no muscle/including LP tx- transuretehral resexn (TURBT) + mitoM + BCG 2. T2a- muscle/beyond LP tx- cystectomy + LND + chemo 3. T3- fat/nodes tx- neoadjuvant

Answer 238

Small ➡ absorbable in 1 LAYER w/ strap buttress - 2 layer leads to tracheal stenosis - primary repair up to 5-6 rings - bilateral injury ➡ bilateral SCM incisions and join ("U" incision) Large and above 3rd ring → tracheostomy through the defect - avoid below 3rd ring (TI fistula) Access: distal 1/3, right main, proximal L main ➡ right postero-lateral thoracotomy

Answer 239

1. Crohn's: - Creeping fat - Skip lesions - Transmural - Cobblestoning - Granulomas - Fistulas 2. UC: - Crypt abscess - Pseudopolyps

Answer 240

Px- 2/2 renal disease. dx- normal coags. elevated BT only. tx- ddavp

Answer 241

- Circumferential deep burns - Neuro-vascular sxs - Problems ventilating torso burns - Go down to fascia but don't divide the fascia **Perform within 4–6 hours **Usually bedside **May need fasciotomy AFTER

Answer 242

Dx- EGD and Bx (Bx needed to r/o ca!) Tx-only tx if refractory to max medical management after 12 weeks. 1. lesser curve/antrum; normal acid ➡ distal gastrectomy w/ bil 2 2. gastric + duo; high acid ➡ antrectomy + vagotomy 3. pre pyloric: high acid ➡ antrectomy + vagotomy 4. GE junction: normal acid ➡ sub-total gastrectomy + REY

Answer 243

Emergent: 1. Steroids +/- abxs 2. Infliximab, Cyclosporine 3. No response, megacolon (> 6 cm), HDUS, or perf ➡ TAC with end-ileostomy - When stabilized can perform proctectomy and IPAA - Don't do proctectomy in emergent situations Elective: - Indications: dysplasia, cancer, refractory disease - PC w/ IPAA ** Surgery reduces: erythema nodosum, arthritis -- no effect on PSC or ank spondy

Answer 244

- hemangioma + thrombocytopenia - usually infants - resect!

Answer 245

Px- intestinal hamartomas (intususpeption), pigmented oral mucosa, polyposis - Cancers: GI tract, breast, pancreatic - AD, STK11 mutation Screening - Scope @ 25y then q2 years b/c high r/o GI/pancreas ca

Answer 246

- 2/2 failure of umbo ring closure - 11th week gut returns to abdominal cavity - normal bowel (protected) - Other congenital defect are more common

Answer 247

- Contents: VWF, f8, fibrinogen - Uses: 1. VWD 2. Fibrinogen def 3. Hemophilia A

Answer 248

1. penetrating: - zone 1-3 --> explore 2. blunt: - zone1 --> explore - zone 2-3 --> do not explore

Answer 249

1. neurogenic PT: PT --> rib resection, scalenectomy, BPlex dissection 2. venous- catheter-directed thrombolysis → surgical decompression 3. arterial- C7/1r resection, subc artery resection/reconstruction

Answer 250

Dx: > 100 adenoma or < 100 w/ fam hx - AD; APC mutation - CA by 40 - desmoid tumors (slow growing abdominal wall mass) Tx: - sigmoidoscopy q1y at 10 (don't need colonoscopy) - EGD @ 20 or when polyps start- SB polyposis - TAC w/ IRA or PC w/ IPAA depending on rectal involvement at about 20 (or once florid polyposis is seen) - q1y EGD post op for duodenal cancer (MC COD after colectomy) - q1y c'scope if TAC - polyposis/high grade dysplasia @ stump → proctectomy +/- pouch - desmoid: resect. Anti-E if intra-abdominal

Answer 251

female breast, ovarian, male breast I (ch17)- 60, 40, 1 II (ch13)- 60, 10, 10 Tx: -pre-meno: offer bilateral mastectomy OR q1 MRI starting @ 25 - @ 30 annual MRI w/ mammo -post meno: bilateral mastectomy + SOO + HRT until 50 (no TAH) **SOO decrease r/o OVARIAN Ca (80%) for BRCA1/2 AND breast Ca for BRCA2 only (50%) **No TAH!

Answer 252

1. all functioning tumors 2. all > 6 cm ➡ open resection 3. if < 6cm with suspicious features - >10HU, <50% @ 10m w/out ➡ open resection **DO NOT biopsy first

Answer 253

1. Adjuvent chemo: tumor > 1cm, nodal dz, triple neg - echo before for cardiotox 2. Tamoxifen/Anastrazole: 5y for HR+ tumors - Tamox for men 3. Trastuzumab- 1y for Her2/neu+ tumors - echo before for cardiotox 4. Olaparib- 1 year for triple negative/BRCA+ tumors - PARP inhibitor **Oncotype recurrence score > 26 requires adjuvant chemotherapy

Answer 254

path- CENTRAL STELLATE SCAR! dx- bright on arterial phase homogenous tx- resect if sxatic. no malignant potential.

Answer 255

Both released by duo S cells ➡ Secretin- duct cells ➡ bicarb I cells ➡ CCK- acinar cells ➡ enzymes

Answer 256

1. duct > 7mm- Peustow, pancreaticojej (for large duct) 2. duct > 7mm and large head- Frey, pancreasticojej + core out head 3. duct < 7mm and large head- Berger, pancreatic head resection

Answer 257

1. Indications for total thyroidectomy: - Tumor > 4cm - Distant mets or extra-thyroid disease - Poorly differentiated - Prior radiation 2. Nodes dissection: A. Lateral neck dissection: of involved compartments if palpable or bx+ nodes B. Prophylactic neck dissection (level 6): if > 4cm, extra-thyroid invasion, +lateral nodes. - Usually not performed for follicular 3. Radio iodine indications (6w post op, want TSH high) - Only after total thyroidectomy to be effective - For high risk tumors: tumor > 1 cm, extra-thyroidal disease

Answer 258

MOA: Accelerates AT3 activity and INDIRECTLY inhibits thrombin Measurement: - PTT - ACT: better intra-op if high doses of hep given

Answer 259

Mammogram every 2–3 years after age 40 then yearly after 50 High-risk screening - mammogram 10 years before the youngest age of diagnosis of breast CA in first-degree relative

Answer 260

1. Nonop: HDS, <10 mm, <5 mm shift 2. Evacuate: > 10mm, >5mm shift, delta GCS > 2, cx signs of ICP

Answer 261

Mixed venous: from PA Central venous: from SVC only (estimation of mixed)

Answer 262

- BB overdose: fluids/atropine → glucagon - CCB: Ca + Insulin + Atropine + Pressor - Tylenol: NAC - Benzos: flumazenil (.2mg IV) - CN/Nitroprusside: sodium thiosulfate, amyl nitrite - Vecuronium/Rocuronium: sugammadex - Ethylene glycol: femopizole and bicarb OR ethanol; iHD - Methemoglobinemia: methylene blue

Answer 263

Bile duct lateral Hepatic artery medial Portal vein posterior

Answer 264

1. Crypto- CNS sxs in AIDs pt tx- amphotericin 2. Coccidio- pulm sxs in the southwest tx- amphotericin 3. Histo- pulm sxs in ohio river valley tx- itraconazole → ampho B (only if sxs) 4. Mucormycosis- burns/trauma w/ bloody cough tx- emergent debride, ampho

Answer 265

eso- 15/7cm stomach- 15/5cm colon-12/5 cm rectum- 12/5 cm

Answer 266

MOA: ONLY depolarizing. degraded by plasma CE - Short half-life and rapid onset (RSI) - Used for "full stomach" s/e: rhabdo, hyperK, M/H, bradycardia c/i: spinal cord injury, renal failure, large burns tx of M/H: stop drug, dantrolene, Bicarb, cooling, tylenol

Answer 267

- Thoracodorsal (lateral): Lat Dorsi, ADduct/extension/IR - Intercosto-brachial: hypesthesia - Lateral petoral: p major, arm flexion - Medial pectoral: p major/minor, ADduct/extension/IR - Long thoracic (medial): SA, wing scap **Wing scap: LTN or spinal accessory nerve

Answer 268

Cohort: prosepective; exposed vs. non-exposed RR- [a/a+b]/[c/c+d] Case control: retrospective; diseased vs. non-diseased OR- (a/b)/(c/d) - good initial study to show an association

Answer 269

Tx: Rutherford 1: no deficits ➡ hep gtt. imaging. eventual revasc 2a: motor intact ➡ imaging. hep gtt (motor intact, sensation). eventual revasc - if early post-op case skip the imaging 2b: any weakness, rest pain ➡ hep gtt and immediate revasc (don't image if delay in tx) - if present in prior graft perform thrombectomy 3: paralysis ➡ amputation Revasc options: 1. Endovascular: short segment, single lesion 2. Open: long segment, multiple lesions

Answer 270

Px: benign tumor of salivary gland - often BILATERAL and 2/2 smoking - Slow growing Tx: complete resection with uninvolved margins even if ASx

Answer 271

path- PERIPHERAL ENHANCEMENT with continued late filling px- young women tx- if rupture, size change, or KM syndrome

Answer 272

Wirsung- major, lies inferior Santorini- minor, lies superior

Answer 273

lactate , pyruvate, AA (alanine, glutamine)

Answer 274

MOA: mTOR (rapamycin) inhibitor - Less nephrotoxic - Alternative to tacro intolerance s/e: - lymphocele (w/ obstruction) - wound complications/poor wound healing: held or switched to tacro before hernia repairs

Answer 275

- Not past the verge: biofeedback, fiber -Many comorbidities or acute presentation: Altemeir (perineal rectosigmoid'y) -Prolpase < 50cm with comorbidities: Delorme (muscle plication) -Young/healthy and elective: rectopexy +/- resection

Answer 276

- gene: p53 mutation; TSG on Ch17; AD inheritance - mech: cell cycle regulation at G1/S to promote apoptosis in DNA damaged cells - px: breast ca + sarcoma b4 45

Answer 277

1. dx: fluid TG > 110 2. tx: chest tube and NPO - < 1L/day: MCT diet, octreotide, TPN → 7d: thoracic duct lig (Open R chest or IR) - > 1L/day: thoracic duct ligation (Open R chest or IR) **for cancer patients: pleurodesis > ligation

Answer 278

Px: Common 2/2 B cell lymphoma - hyperU, K, Ph w/ hypoCa Path: CaPh crystal ➡ renal failure + hypoCa tx: IV hydration ➡ iHD

Answer 279

t1- SM t2- MP t3- xMP/subserosa t4- invade n1- 1-3, n2- >=4

Answer 280

wait 3-6m low- endorectal advancement flap high- abdominal approach

Answer 281

Path: - Associated with hiatal hernia. 2/2 GERD. - Usually distal eso - Mucosal process. No muscle involved - Protective against Barret's Tx: only if sxatic. 1. Bx first to r/o eosino esoph's - if esosino esoph's: medical therapy first 2. Dilation and PPI 3. Steroids, endoscopic resection

Answer 282

NNT = 1/absolute risk reduction (ARR) - ARR = event rate in intervention group - rate in control group - RR = event rate in intervention / rate in null group - RRR = (rate control - rate experimental) / rate control

Answer 283

- Pyloric stenosis: pyloromyotomy - Intussusception: air contrast enema (air > water) - Duo atresia: DD or DJ - TEF: right extrapleural thoracotomy - Malro: LADDS proc

Answer 284

dx: drain amylase 3x serum amylase at 3 weeks - considered a "biochemical leak" if leakage is cx insignificant - amylase clears faster than lipase tx: - NPO, TPN or N-J feeding x 4-6 wks - octreotide if high output (>200/day). Does not increase healing rate or closure. Does decrease output. - consider ERCP w/ stent after 6 weeks (vs. biloma which can be ERCP/stented early)

Answer 285

lido = 5mg/kg (7 w/ epi) bupiv = 2.5 mg/kg (3 w/ epi) tx- lipid emulsion

Answer 286

Epi: - MC fungal infection in IC patient - Histoplasmosis is MC fungal infection overall (itraconazole) Dx: +gallactomannan Ab/Ag detection, PCR, microscopy, cx or path - can cause pneumonioa, lung abscess, brain abscess Tx: - aspergilloma: resect - aspergillosis: voriconazole (inhibits ergosterol)

Answer 287

1. Dx: MC GI Sarcoma - EGD + FNA: SM smooth EGD mass with normal overlying mucosa and central ulcer. Stomach MC. - Bx: cajal cells. c-KIT+ - don't require bx if high suspicion 2. Tx: wedge resection (gross margin) - can be R0 or R1 resection - Imatinib (TK inhibitor) ➡ 5cm or >5 mitosis/50 hpf - mitosis/hpf is most predictive of prognosis (>mets) - neoadjuvant if need to down-stage for resection - adjuvant for 3 years

Answer 288

MOA: gamma CARBOXYLATION (not decarb) of GLUTAMATE on 2, 7, 9, 10, c, s Px of def: coagulopathy, suspect if obstructive jaundice

Answer 289

1. Arterial supply: - IMA to superior rectal a. - II to middle rectal a - II to internal pudendal a. to inferior rectal a. 2. Venous drainage- - SRV ➡ IMV ➡ PV (portal) - MRV/IRV ➡ internal pudendal ➡ internal iliac (systemic)

Answer 290

1. protein = 4 kcal/g 2. dextrose = 3.4 kcal/g 3. lipid = 9 kcal/g 4. carb = 4 kcal/g total req = 25-30 kcal/kg - use ideal body weight if BMI > 25 - 50% carb, 30% fat, 20% protein

Answer 291

1- pericolic abscess 2- pelvic abscess 3- purulent 4- feculent

Answer 292

- Carotid sheath, anca cervicalis, CN 12 (hypoglossal) - Contents of carotid sheath: CN10 (vagus), CCA, ICA, internal jugular - Facial vein is the gateway

Answer 293

px: diminished femoral pulse, butt claudication, ED - younger than infra-inguinal vascular dz patient tx: aortobifemoral bypass

Answer 294

Core needle returns ➡ - Atypical (25% of malignancy) - DH/LH - LCIS/DCIS - radial scar - papillary lesion - any atypia **lesions generally have a 15-30% chance of carcinoma in situ or invasive cancer

Answer 295

1. minimum 20% if normal liver 2. pre-op chemo/some dysfxn = 30% 3. cirrhosis = 40% -Otherwise should undergo PVE -Overt PH is a c/i to PVE

Answer 296

type 1: false positive - say something is true (reject the null) when it's not - alpha = prob of type 1 error. Set at .05 - minimize by decreasing stat significance type 2: false negative - say something is false (do not reject the null, accept H0) when it's true - beta = prob of type 2 error. Set at .2 - minimize by increasing sample size/power **power = 1 - type 2 **reject the null = "a difference exists"

Answer 297

path- EARLY enhancement on arterial phase w/ rapid washout. well-circumscribed. **vs hemangioma: peripheral enhancement over time tx- stop OCP use. resect immediately if > 5cm, sxatic, male gender risks: 1. rupture MC 2. malig transformation

Answer 298

1. Simple/Total mastectomy: removal of all breast tissue, NAC, most of skin (no nodes) 2. MRM: removal of breast parenchyma, NAC, skin, AND level 1-2 nodes 3. BCT: partial mastectomy + XRT

Answer 299

- Pyoderma: pre-tibial ulcer - Erythema Nodosum: pre-tibial erythematous plauque - both associated w/ IBD - both RESOLVE after resection - tx: steroids

Answer 300

Na - (Cl+Bic) NaCl = non-AG, increased Cl, metabolic acidosis AGMA: Methanol, Uremia, Diabetes, Paraldehyde, Iron/INH, LA, Ethanol/Glycol, Salicylates NAGMA: normal saline, DRH, fistula, ureteral conduit, RTA

Answer 301

- reglan: dopamine antagonist - erythromycin: motlin receptor agonist causing SM contraction

Answer 302

If CT and PET: no distance disease ➡ Endoscopic U/S for T and N: t1a- LP and MM t1b- SM (where it spreads) t2- MP t3- adventitia t4a- resectable structures t4b- unresectable structures n1: 1-2 nodes, n2: 3-6 node, sn3: 7+

Answer 303

Bx: Goblet cells and columnar cells 1. No dysplasia: 4 quad every 2 cm q 3-5y - 1 cm if mucosal irregularities - Ca .1%/y 2. LGD: 4 quad every 1 cm q6m. Consider ablation. - Ca .5%/year 3. HGD: ablation/endoscopic resection. 4 quad every 1 cm q3m - Ca 5%/year *Fundoplication is only c/i in HGD *No screening if asx

Answer 304

HNPCC: fulfill amsterdam criteria - 3+ relatives with Lynch syndrome-associated cancers (CRC, endometrium, small bowel, ureter, renal) - 2 generations - 1 ca dx < 50 yo Lynch syndrome: refers to mutation in DNA MM repair gene (MLH1, MSH2, MSH6, PMS2) or the EPCAM gene. - should test in all with new onset CRC

Answer 305

Osm = 2xNa + Glu/18 + urea/2.8

Answer 306

fxn: motor to cricothyroid injury: trouble w/ high pitch, voice remins clear - cord looks normal on laryngoscopy tx: none **MC nerve injury w/ a total thyroid

Answer 307

6- obeys commands 5- localized 4- w/draws 3- flexion (decort) - 'flex your core' 2- extension (decErebrate) 1- none

Answer 308

I- palate II- nose and palate III- entire face

Answer 309

tx: amox/clavulanate (augmentin) - requires I&D if joint appears septic (pain w/ passive motion) **MC for human bites- eikenella

Answer 310

- HAP/VAP: staph aureus (pseudomonas #2) - central line infection: coag negative staph (staph epi) - SSI: staph aureus - UTI: e. coli - GI infection: c. diff - SBP: e. coli - Cholangitis: e. coli - NSTI: polymicrobial - ICU infection: VAP - Fungal infection: hitsto (asperg if I/C) - Graft infection: staph aureus (early), staph epi (late) - Lymphangitis: strep pyogenes

Answer 311

1st give PGE1 → ballon atrial septostomy

Answer 312

RF: HPV 16/18, STI, HIV - test for cervical ca too Dx: - Anoscopy + FNA/core bx - HIV test all patients Tx: - Nigro protocol: XRT (ing/pelvic nodes) + 5FU + MitoC - Recurrence (10-20%): q6 months to diagnose ➡ APR - Lateral to I/S groove (anal margin): tx like skin cancer

Answer 313

Most common cyanotic defect 1. VSD 2. Pulmonary outflow obstruction 3. Over-riding aorta 4. RVH (2/2 RV outflow obstruction w/ harsh murmur) tx- beta blocker; surgery at 3-6m

Answer 314

1. 6mm ➡ NTD 2. 6-8 mm ➡ q6-12m CT 3. > 8mm - low risk pt- q3m CT - high risk pt- bx or resection

Answer 315

Exudate if: PL protein/serum Pr >.5 PL LDH/serum LDH > .6 PL LDH > 2/3 ULN - Exudate: capillary damage from inflammation, neoplasm, trauma - Transudate: change in oncotic pressure;

Answer 316

1. Start with conservative tx 2. Quantify output: - High output: > 500 cc/day ➡ likely OR. Start with NPO/TPN. - Low output: < 200 cc/day ➡ likely conservative. OK for PO intake. 3. If input increased with PO intake ➡ NPO and TPN 4. OR if failed after about 6 weeks

Answer 317

Bacteroides fragiles (anaerobe)

Answer 318

t1a: muscularis mucosa: endo resection t1b: SM: upfront esophagectomy (or low grade t2) t2: muscularis propria: neoadjuvant - low risk: upfront esophagectomy t3: adventitia: neoadjuvant *no serosa. Ca spread through SM lymphatics

Answer 319

Head: kocherize Body: incise gastrocolic ligament ➡ lesser sac Tail: mobilize spleen Trauma: 1. R medial visceral rotation 2. Kocher 3. Divide GC ligament/enter LS 4. Complete Kattel 5. Mobilize LOT

Answer 320

1. originates at L1-L2 @ c. chyli 2. cross from R to L at T4-5 3. empties into L SC/IJ jxn **Carries chylomicrons and LCFA

Answer 321

1. Stomach ulcer: pain right after meal - 75% H. pylori, 25% NSAIDS/ASA 2. Duo ulcer: pain 2-3h after meal - 90% H. pylori, 10% NSAIDS/ASA **NSAID/ASA: decrease mucosal mucus secretion and bicarb secretion

Answer 322

1. Zosyn 2. 3/4G cephalosporin (ceftriaxone, cefepime) 3. Aminoglycodies (genta, tobra) 4. Flouroquinolones (cipro) 5. Meropenem/Imipenem **Not linezolid (good for G+/MRSA)

Answer 323

- Pseudomonas (< 10^5 organisms – not a burn wound infection) - HSV

Answer 324

1- <25% narrowing ➡ ASA 2- > 25% narrowing ➡ ASA 3- PsA ➡ ASA + IR stent 4- complete occlusion ➡ ASA only 5- transection ➡ OR if accessible. Otherwise IR. *most are not surgically accessible

Answer 325

1. Superior parathyroids: from 4th pouch - usual location: posterior to RLN. - Not found: explore retro-esophogeal and para-esophogeal space ➡ open carotid sheath. - TE groove is MC ectopic location 2. Inferior parathyroids: from 3rd pouch (with thymus) - usual location: anterior to RLN. - Not found: explore thymus and thyroid ➡ consider thymectomy or ipsi thyroidectomy even if no palpable mass - thyrothymic ligament is MC ectopic location - more commonly ectopic b/c longer travel 3. 4 normal appearing galnds - supranumary PT in the thymus **Overall, thymus is MC location or ectopic gland

Answer 326

1. Head - main duct: drain + post-op ERCP + staged resection - no duct: drain 2. Tail - main duct (grade 3+): resect w/ splenectomy (unless CHILD and HDS) - no duct (grade 1-2): drain

Answer 327

Tacro: calcineurin inhibitor; bind fK ➡ calcineurin ➡ block IL2 - 100x more potent than cyclosporine - neuro sxs (tremor), GI sxs - nephrotox, hepatotoxic - DM - alopecia Cyclosporine: calcineurin inhibitor; bind cyclophillin ➡ calcineurin ➡ block IL2 - nephrotox, hepatotox, neuro sxs - gingival hyperplasia, hypertrichosis - cycled in bile, gallstones Sirolimus: bind fK ➡ mTor inhibitor (IL2 inhibitor) - impaired wound healing - interstitial lung disease - lymphocele

Answer 328

palmar- ulnar n, adduct dorsal- ulnar n, abduct lumbricals- median (1-2)/ulnar (3-4)

Answer 329

MOA: competitive E inhibitor in breast; weak agonist in uterus/liver S/e: - dvt/pe - endometrial cancer - cant take with SSRI (CYP inhibitors)

Answer 330

Mammo: clustered calcs Tx: like ca - BCT: lumpectomy (2mm) + XRT +/- boost +/- endocrine - no SLNBx (does not metastesize) - no chemotherapy - if XRT c/i → mastectomy AND SLNBx (b/c 20% have invasive ca)

Answer 331

- does not metastasize - not w/ l’omy unless >4cm, multicentric, palpable, high grade - required w/ mastectomy b/c 20% have invasive ca

Answer 332

low CEA, low Amylase tx- resect if sxs

Answer 333

-2-6m: piecemeal removal -1 year: > 10 adenomas -3 years: 3+ adenomas, HGD, > 1cm, villous elements -5 years: 1-2 tubular adenomas (< 1cm) -10 years: hyperplastic polyps (<20)

Answer 334

-Organism: “Shin” 1. Strep pneumo (MC) 2. Neisseria 3. Haemophilus - Empiric tx: vanc + 3GC

Answer 335

Increased muscle activity (shivering) Increased metabolism (sepsis, fever, malignany hyperT) Increased CO Decreased minute ventilation

Answer 336

dx: suspect if recurrent intususpeption, GI bleeds - Meckel's scan (Tc-99) is best test. Increase Se by giving pentagastrin, glucagon, h2 blocker. Not as Se in adults (atrophic gastric cells) - only detects gastric tissue (not panc) - if negative but high suspicion ➡ repeat scan - if inconclusive then proceed with abdominal exploration (not CT) tx: resection if sxs - base < 2 cm → diverticulectomy - > 2 cm or wide base → seg resection - appendectomy as well if exploratory surgery for presumed appe ended up being meckels - If incidental: resect meckel's in kids, leave in adults.

Answer 337

"PAO in the POST" ADH, Oxytocin 2/2 direct stem from neurosecretory cell

Answer 338

dx - PRSS1 trypsinogen mut'n - AD tx: none - smoking cessation is important **different from AI pancreatitis (IgG+)

Answer 339

MOA- PDi, inhibits PLT aggregation tx for periph claudication - c/i in any degree of HF (PDi)

Answer 340

Proximal eso- L cervical Mid eso/prox thoracic eso- R P/L thoracotomy Distal eso- L thoractomy Cervical trachea: collar incision Carina/Either main-stem bronch: RIGHT P/L thoracotomy Aorta: L thoracotomy **for trauma do A/L thoracotomy b/c decub is not safe in unstable patient and want access to the heart

Answer 341

1. proximal ⅓ (U/P jxn and above) → primary uretero-urostomy. Other options: ileal transposition, nephrostomy 2. middle ⅓ → primary u-u (preferred) - Other options: tran uretero-urosotomy, Boari flap 3. lower ⅓ (distal to iliacs) → re-implanation +/- hitch 1. early: w/in 5 days- stent, explore, or repair - HDUS intra-op: ligate, perc neph, delayed repair (3m) 2. late: > 10 days- perc nephro and delayed repair (3m)

Answer 342

7-DHC + sunlight ➡ d3 liver ➡ 25-d3 kindey ➡ 1,25-d3

Answer 343

Start with lobectomy Indications for total thyroidectomy: - Tumor > 4 cm (1-4 cm, close observation or total) - Extra-thyroidal disease - Multi-centric or bilateral lesions - Previous XRT Consider ppx level 6 for high risk If thyroid lobectomy only: - Tx with thyroid hormone to suppress TSH - Get serial U/S to monitor Indications for MRND - extra thyroid extension Radio iodine indications (6w post op, want TSH high) - Consider for 1-4 cm, definitely > 4cm - Extra-thyroidal disease - Need total thyroidectomy to be effective

Answer 344

1: upper D, stable, non-op 2: base of D, unstable, worst, +/- surg - may require intubation 3: c2 vert, usually no OR

Answer 345

5- normal 4- confused 3- inappropriate words 2- incomprehensible 1- none

Answer 346

Meld: 1. Bili 2. INR 3. Creatinine - designed for mortality over 3 months after TIPS - At least 15 for trx - HCC gets automatic score of 22 CTP: Billirubin, Albumin, INR, Ascites, Encephalopathy

Answer 347

dx: dx mammo 1st ➡ U/S is enough or contrast ductogram - MCCO bloody nipple dc - only use ductogram if all other imaging is equivocal tx: excisional biopsy including the ductal segment - do central duct excision if can't ID the duct

Answer 348

most close by 2 <3cm- primary repair >3cm- mesh repair by 5 Inguinal- repair by 2 weeks if reducible - otherwise, OR then

Answer 349

Px: - GastRoschisis to the Right of midline - rare defects...EXCEPTION- instestinal atResia Tx: - cover bowel after delivery - stabilize and attempt primary closure (80%) - for larger defects, place silo for delayed closure - post op: ICU, TPN, assess for short gut

Answer 350

-Zn: wound heal/skin, night blind -Sel: cardiomyopathy -Chromium: hyperglycemia -Copper: micro anemia -B1 (thiamine): wernicke’s encephalopathy, p. Neuropathy, gap acidosis (lactate) -B3 (niacin): pellagra (DRH, dementia, dermatitis)

Answer 351

UES- cricopharyngeus; higher resting pressure (70) LES- lower resting pressure (15)

Answer 352

Relation to GEJ: 1. 1-5 cm above: eso ca - esophagectomy and prox gastrectomy (Ivor lewis) 2. 1 cm above-2 cm below: eso ca - esophagectomy and prox gastrectomy (Ivor lewis) 3. 2-5 cm below GEJ: gastric ca - total gastrectomy *Require 5 cm eso margin, 4 cm gastric margin, 15 nodes for eso CA

Answer 353

1. HGD, TIS, T1a: endoscopic ablation/resection 2. T1b: upfront esophagectomy or endo ablation (if low risk) 3. T2 or N: neoadjuvant then esophagectomy - Low grade T2 (< 3cm, no L/V invasion, well diff): upfront eso 4. T4b or M: definitive chemo-XRT < 5cm from cricoP: definitive chemo-XRT > 5 cm from cricoP: esophagectomy

Answer 354

Indications: 1. Extra-eso complications: cough, aspiration, CP 2. Persistant sxs 3. C/I to antireflux meds 4. Barrett's w/out HGD 5. Strictures 6. Esophagitis C/I: 1. Cancer 2. Barrett's w/ HGD

Answer 355

Classic sxs: heart burn + regurg Alarm: 1. dysphagia (not regurgitation) 2. odynophagia (pain) 3. bleeding 4. weight loss 5. anemia *Require EGD

Answer 356

1. sxs or > 4cm- enucleate 2. < 4cm- observe 3. >8cm or circumferential- esophagectomy Approach: Cervical- L Mid eso- R Distal eso- L

Answer 357

1. CT of chest, abdomen- M 2. Whole-body PET scan- M 3. EUS- T and N stage

Answer 358

0. Avoid NGT. No neutralizing agents 1. CT scan if stable 2. Early endoscopy (AFTER CT) 3. OR if unstable. Otherwise, restart orals in 48h. *alkali- liquefaction necrosis. worse outcome *acid- coagulation necrosis

Answer 359

1. Divide G-H ligament 2. ID R crus and posterior vagus 3. ID L crus and anterior vagus 4. Divid short gastric vessels 5. Expose GEJ (excise eso fat pad) 6. Myotomy (6 eso, 2 stomach) - outer long 1st - inner circular 2nd 7. Partial wrap

Answer 360

1. Divide G-H ligament 2. Transect the L gastric. Keep the R gastric. ---- Lesser Curve Mobilized---- 3. Transect gastro-colic until prox duo. Avoid R gastro-epiploic! 4. Extend gastro-colic to take the L gastro-epiploic, short gastric vessels, and gastrophrenic vessels ---- Grater Curve Mobilized ---- To gain extra length: 1. Kocher maneuver 2. Divide the R gastric artery Greater omentum = gastro-colic + gastroc-splenic + gastro-phrenic ligaments

Answer 361

Loc: distal eso. R > L. Pulsion Tx: only if sxs. - L diverticulectomy w/ contra myotomy

Answer 362

Dx: XR then contrast esophogography (GG then Ba) - EGD if UGI is negative but still high suspicious - don't require CT Tx- 1. abxs (fungus) 2. Cervical: open neck and place drains 3. Thoracic: L thoracotomy, extended myotomy, cover w/ 2 layers - if achalsia: contra myotomy 4. Buttress with IC muscle NG, chest tube 5. Very unstable: exclusion and diversion Selective non-op: 1. Contained perf w/ minimal signs of sepsis OR 2. Very poor operative candidate Stenting: contained perf or minimal extrav after EGD

Answer 363

(U Na/S Na) / (U Cr / S Cr) * 100 <1% = Pre-renal >1% = Intrinsic >4% = Post-renal

Answer 364

- Mech: fat to carb metabolism ➡ resumption of ATP production and Insulin surg ➡ Ph influx into cells ➡ hypoPh - Px: HypoMg, Ph, K; paresthesia, confusions, RD - COD is cardiac failure

Answer 365

10 mmHg increase in pCO2 = .08 decrease in pH

Answer 366

1. Central- DDAVP 2. Peripheral- tx underlying causes (stop Li), amiloride, HCTZ

Answer 367

W/up: Post-meno w/ bleeding ➡ TVUS ➡ endo bx Tx: Hysterectomy, bilateral SO, peritoneal w/out, LN sampling - Required for Tx AND staging! - XRT if high risk - Chemo if mets

Answer 368

Left lateral decubitus position Entry port: - take into account fundal height (6cm above) - P/S @ 12 wks, half-way @ 16 weeks, umbo @ 20 weeks - 2T-3T: supra-umbo if possible otherwise LUQ or RUQ

Answer 369

Px: Sudden pain + adnexal mass w/out bleeding - prior similar episdoes Dx: pelvic US with doppler Tx: - Lap detorsion - Oopherectomy only if- necrosis, cancer, recurrent

Answer 370

Fibrinogen level (<100 = r/o bleeding) Reverse: a-CA

Answer 371

Cause: protein C def (not S!) Tx: Stop Coumadin Give vitamin K Start hep gtt or argatroban

Answer 372

Intrinsic: 8, 9, 11, 12 Extrinsic: 7 (shortest t 1/2), Tissue factor Common: 1, 2, 5, 10

Answer 373

Apixaban: andexanet Rivoroxaban: andexanet Dabigatran: idarucizumab (+iHD)

Answer 374

dx: normal PLTs. Abnormal BT, PTT - ristocetin test or measure vWF level tx: 1. type 1: not enough; ddavp ➡ cryo - MC congenital bleeding disorder 2. type 2: qualitative; VWF/f8 concentrate, cryo - DDAVP for some subtypes 3. type 3: VWF/f8 concentrate, cryo **only type 1 (and some type 2 subtypes) can use DDAVP

Answer 375

0. Correct precipitating cause 1. Lactulose (goal 2-3 stools/day) 2. Rifaximin 3. Neomycin

Answer 376

1. HIV: 4wks of anti-retroviral combo 2. HBV: HBIG + Vaccine 3. HCV: No recommendations.

Answer 377

7 - 8 - 4a - 2 6 - 5 - 4b - 3

Answer 378

Dx: doppler (usually 2/2 to p. vera) Tx: 1. Lifelong AC 2. < 4 weeks: thrombolytics 3. > 4 weeks: angioplasty/stenting 4. Refractory: TIPS, transplant, surgical shunt

Answer 379

2/2 chronic pancreatitis induced splenic vein thrombosis tx- Splenectomy

Answer 380

Increase preload initially, then decrease Increase afterload. Decrease CO Increased PCO2. Decrease FRC Decrease renal function

Answer 381

Head- Superior PD (Off GDA, off CHA, off CeT) and Inferior PD (off SMA) Body/Tail- Branches of the splenic artery Head- right of SMA (SMV is right of SMA also) Uncinate- hugs the SMV and SMA Neck- over the SMA Body/tail- left of SMA

Answer 382

1. Bili > 4 2. CBD stone on U/S 3. CBD > 6 mm and Billi > 2 4. Ascending cholangitis

Answer 383

Px: pancreatitis w/ normal Lipase and LFTs Dx: IgG+, biopsy to prove. - CT: dilated w/ no Calcs. "sausage" appearance. - Brush biliary tree if concern for malignancy - different from hereditary pancreatitis (PRSS1 mut'n) Tx: 0. Bx first! 1. ERCP if stricutre: r/o ca, relieve obstruction 2. Steroids

Answer 384

1. Pancreatic protocol CT 2. EUS: if questionable LN or vessel involvement 3. ERCP: if jaundice or dx uncertainty - 90% sensitive for dx 4. PET/CT: selectively if suspicion for malignancy. 5. Staging scope: if suspect disseminated dz - > 3cm, high Ca 19-9, tail tumor, high weight loss/malnutrition 6. Bx: Not if resectable. Only if neo-adj chemo

Answer 385

Thrombotic: at origin of SMA; prox. jejunum to transverse colon - smokers Embolic: distal SMA; jejunal sparring - embolism (usually from left atrial appendage) 1. IVF, abxs, AC 2. Emergent revascularization - peritonitis: ex lap to evaluate bowel, open embolectomy - consider endovascular if specialized center, no peritonitis, and low suspicioun for necrotic bowel

Answer 386

- Dx: 1. duplex (Celiac > 200, SMA > 275) is 1st line for screening 2. CTA (>70%) for definitive dx (best test) - Tx: Sxs + stenosis of > 70% 1. Endovascular plasty/stent is 1st line. 1V SMA stenting is enough even if both celiac/SMA are inovlved 2. Open surgery: if can't tolerate endovascular - aorto-mesenteric/celiac bypass graft vs. endarterectomy vs. mesenteric re-implantation

Answer 387

1. BB 2. ACEi: unless 1 kidney or bilateral dz - efferent dil'n can worsen kidney dz 2. PTA: perc trans-luminal angio +/- stent (or open revascularization) - only if refractory to meds! 3. Nephrectomy **CORAL trial: PTA is not better than maximum medical therapy

Answer 388

1. Lift transverse mesocolon 2. Trace MCA. Palpate the SMA at root of mesentery along inferior margin of pancreas 3. Incise peritoneum and dissect down to the artery (left of the SMV) 4. Therapeutic heparinize 5. Proximal and distal control 6. Transverse arteriotomy PROXIMAL to middle colic origin 7. 2 or 3 Fogarty balloon passed proximal and distal 8. Close arteriotomy with interrupted proline

Answer 389

1. LEFT lateral decubitus and Trendelenburg (trap air in the RV) 2. Aspirate central line

Answer 390

1. Non-disabling stroke or TIA: 2d-2w 2. Big stroke: no consensus

Answer 391

6+ hours of warm ischemia Steps: - lateral incision: between tibia and fibula ➡ open anterior and lateral compartment - medial incision: 1 finger posterior to tibia ➡ open fascia over the gastric ➡ peel soleus off of the tibia ➡ open deep posterior fascia

Answer 392

- Longitudinal incision over the groin - Expose femoral common, SFA, and profunda - Control with vessel loops - Ensure ACT > 250 - 4-5F fogarty proximal, then distal to SFA and profunda (2x clean pass for each) - Infuse hep saline - Close arteriotomy w/ interuppted prolene

Answer 393

1. Femoral: vertical incision over the artery from inguinal ligament 2. AK Pop: frog-leg position. 10 cm MEDIAL incision along groove between Sartorius and vastus lateralis. I 3. BK Pop: frog-leg position. MEDIAL incision below the tibia (along the GSV). Dissect to the deep compartment. 4, TP trunk: MEDIAL incision below the tibia. Divide soleus origin of the tibia

Answer 394

Location: 1. Rad/Ceph 2. Rad/Bas 3. Bra/Ceph 4. Bra/Bas 5. Prosthetic peripheral 6. Prosthetic ax-brachial 7. Prosthetic femoral **Upper extremity preferred to LE Rule of 6's: - flow > 600/min - diameter > 3mm before placement. > 6mm after placement - depth of 6mm **artery at least 2 mm

Answer 395

Path- Prox SC stenosis. Reversal of flow through ipsilateral vertebral to SC Tx: if V/B sxs (diplopia, vertigo, dysphagia, ataxia) 1. PTA w/ stent to SC artery 2. Carotid to SC bypass

Answer 396

1. Uncomplicated: b-blocker for impulse control, elective repair - Surveillance q3, 6, 12m. TEVAR if progression 2. Complicated: impending rupture, propagation, expansion, malperfusion of aortic branch, refractory pain, refractory HTN ➡ TEVAR - Need at least 2 cm landing zone distal to L SC

Answer 397

1. > 2cm, sxatic, or fertile age female - embolize distal AND proximal (back bleeding from short gastric) - trauma/rupture situation may require splenectomy 2. Otherwise, monitor

Answer 398

- splenic: > 2cm or sxs ➡ embolize - iliac: > 3 cm ➡ covered stent - femoral: > 2.5 cm ➡ covered stent - pop: > 2 cm ➡ exclusion and bypass

Answer 399

tx: < 2cm observe > 2cm: - skinny neck: thrombin injection - wide neck: operative intervention Surgery for complicated disease: - infxn (cellulitis) - skin necrosis, skin changes - neuro deficit, AMS - HDUS, pulsatile,

Answer 400

- Recurrent laryngeal: MC cranial nerve; 2/2 clamping; hoarseness - Marginal mandibular: excessive retraction and angle of jaw; Ipsilateral lip palsy - Hypoglossal nerve: ipsilateral tongue deviation - G/Ph nerve: from high dissection; difficult swallowing - Superior laryngeal: high-pitch - Accessory: failure to shrug shoulders

Answer 401

- Treat with immediate surgery - Put patient on bypass - Median sternotomy

Answer 402

Iliofermoal dvt 2/2 R iliac artery compressions L iliac vein against lumbar spine tx- venogram, thrombolysis and stenting

Answer 403

1. NGT+ ➡ EGD w/in 24h- clips, coags, banding, sclerose 2. NGT-: - HDUS: IR angio (must be brisk) - HDS- C'scope/consider RBC scan, surgery

Answer 404

Elective indications: - refractory to medical management - suspicion of a malignancy within an ulcer Acute indications: HDS, minimal contamination AND: 1. PUD w/ unknown h. pylori status (if known can just be tx medically) OR 2. Unable to stop NSAID therapy (NSAID ulcer)

Answer 405

Indications: bleeding, perforation, obstruction 1. Bleeding: EGD ➡ EGD ➡ duodenotomy/gastrotomy w/ over-sewing of ulcer bed - can tie off the GDA if continues to bleed - no vagotomy 2. Perforation: get h pylori status! ➡ omental patch w/ post op h. pylori treatment (90% H.pylori related) - If close to pylorus: pyloroplasty (+/- truncal vagotomy) - If giant ulcer (> 2 cm): controlled duodenostomy, jejunal or omental graft/patch, partial gastrectomy 3. Obstruction: NGT, resuscitation, anti-secretory ➡ EGD w/ balloon dilation ➡ antrectomy - Only do acid surgery acutely (vagotomy/drainage) if: 1. HDS, minimal contamination AND 2. PUD w /h. pylori status negative, unknown, refractory OR unable to stop NSAID therapy (NSAID ulcer) **EGD does not require bx for duodenal ulcers

Answer 406

Indications for surgery: bleeding, perforation, refractory - 8-12w of PPI + H. pylori eradication - must bx at 8 spots Approach: 1. GC, antrum, body: wedge resection 2. Lesser curve: distal gastrectomy w/ bili 3. GEJ: - bleeding: anterior gastrotomy, over-sew, send biopsy - perf: sub-total gastrectomy w/ REY reconstruction **Can't wedge lesser curve b/c prominent L gastric arcade and deformed stomach

Answer 407

1. Afferent limb obstruction: prevent with afferent limb < 20 cm - acute: convert Bil 1 or REY (STAT!) - chronic: Bacterial overgrowth: try abxs 1st (Rifaximin) . convert to REY 2. Dumping syndrome: small meals, no sugar ➡ octreotide 3. Alkaline reflux gastritis: prevent w/ roux limb > 40 cm. - pro-kinetics, bile-acid binding ➡ convert to REY with long roux 4. Post vagotomy DRH: cholestyramine (dx of exclusion) ➡ reversed jejunal segment

Answer 408

4-weeks after triple therapy: 1. Urea breath test: preferred 1st line 2. EGD + Bx: preferred if known gastric ulcer (r/o CA) 3. Fecal Ag test **Gram-, spiral-shaped

Answer 409

1. 1st 4 hours: exogenous glucose 2. 4h-1d: Liver glycogen 3. 1d-1w: gluconeogenesis phase (alanine from muscle) 4. 1w+: protein-sparing phase - FA/Ketones are used everywhere - RBCs use glucose only

Answer 410

Dx- mass unchanged with contraction Tx- CTA if HDS. OR if unstable: 1. Observation- no active bleed 2. IR- if active bleeding or T3 (pre-vesicle space) 3. OR- if HDUS or skin necrosis **can also consider IR if HDUS

Answer 411

1. Remain in place for 3-6 weeks for tract to form 2. Cholangiogram to assess CD patency 3. Clamp tube or elective chole if surgical candidate

Answer 412

1. Linoleic acid- omega-6 (Cis, Unsturated) - inflammatory 2. α-linolenic acid- omega-3 (Cis, Unsturated) - anti-inflammatory Deficiency: waxy skin, dermatitis, hair loss, TCP

Answer 413

CO2/O2 < .7 = underfeeding/starving .7 = pure fat .8 = pure protein .8-.9 = desired 1 = pure carb >1 = overfeeding

Answer 414

BSC: most common malignancy in USA; pearly, rolled borders, peripheral palisading; MC upper lip ca SqCC : scaly patch; keratin pearls, parakeratosis, full-thickness pleomorphism (partial = AK); MC lower lip ca - MC ca after trx Tx: - 4 mm for unaggressive: well differentiated and < 2 cm - 8 mm for aggressive: poorly differentiated, > 2cm, or Marjolin - 1 mm for MOHS - MOHS for aggressive subtypes - LADN'y for clinical positive nodes - Can consider SLNBx for high risk SqCC - Limited role for chemo/XRT

Answer 415

Dx: - LRINEC score: Na. glucose, WBC, CRP, Hb, Cr; >8 = 95% PPV - CT: gas, thick fascia Bacteria profile: - MC polymicrobial -if monomicrobial, MC GAS/strep pyogenes: M protein virulence Tx: - abxs: carbapenem OR broad spectrum w/ clinda (anti-toxin effect) and MRSA coverage - surgery

Answer 416

Dx: - Perc bx: usually sqcc - Mediastinoscopy (or EBUS) Tx: - Induction chemo-XRT - surgical evaluation - c/i to surgery: extra-thoracic mets, n2 disease, brachial plexus above T1, >50% vertebral body, eso/trachea involvement - vascular involvement is not c/i

Answer 417

1- High Ca/Low Ph: over-secretion 2- Low Ca/High Ph: CKD or VitD def (physiologic) 3- High Ca/High Ph: hyperplasia 2/2 kidney transplant **VitD def: compensatory hyperPTH 2/2 to low Ca and Ph

Answer 418

Dx: "onion skin" in diaphysis - pelvis is MC location Tx: chemotherapy (1st line) + surgery or XRT

Answer 419

No bronchial commmunication 1. Intra-lobar: MC; blood from aorta; pulmonary veins 2. Extra-lobar: systemic arteries and veins Tx- lobectomy or segmentectomy

Answer 420

Right: - oblique/major fissure: separates lower from middle/upper - horizontal/minor: separates middle from upper - main bronchus 90-degrees; 2 bronchi Left: - oblique/major fissure; 1 bronchus

Answer 421

RF- trach below 4th ring OR, high pressure cuff, high innominate cross 1. Over-inflate the cuff 2. Intubate from above 3. Compress against the sternum 4. Median sternotomy 5. Ligation AND division of innominate artery 6. Buttress tracheal hole w/ muscle **aorto-enteric fistula should also be treated aggressively with operative takedown and extra-anatomic bypass

Answer 422

- Air Leak > 5 days - Recurrent (even if contra-side) - High risk occupation (scuba, pilot)

Answer 423

Px: sudden decrease in UOP weeks after trx -2/2 lymphatic leak from iliac dissection -Sirolimus is a RF Dx: US Tx: perc drain (if sxs) ➡ peritoneal window

Answer 424

1. Thrombosis: sudden cessation of UOP immediately post op -Dx: U/S -Tx: nephrectomy unless small branch 2. Stenosis: refractory HTN and elevated Cr - Dx: US (vel > 180, 70%) - Tx: perc angio/stent **No pain with arterial issue (pain = venous issue)

Answer 425

w/up: 1. doppler U/S: check vasc/urteter mosis, bladder outlet obstruction 2. empiric fluid bolus Causes 1. Immediate: arterial thrombosis- nephrectomy 2. Weeks: lymphocele- open/lap peritoneal window 3. Months: polymovirus (BK)- nephrostomy + reconstruction

Answer 426

1. Inflow: iliac vessels (kidney- left, pancreas- right) --donor SMA and splenic artery are connected with donor iliac artery Y graft to be plugged into the right iliiac 2. Outflow: iliac vessels --donor SMV/splenic vein are already connected. Plugged into R iliac vein (or SMV/PV) **Duo can be connected to SB or bladder

Answer 427

1. Elevated Cr. Low UOP. 2. US: high RI is a non-specific finding - Vascular abnormality ➡ angio, stent, or surg - Lymphocele/Urinoma ➡ perc drain ➡ perit window - Negative: graft dysfunction ➡ Core needle bx

Answer 428

1. HA thrombosis: MC - Early: FHF ➡ thrombectomy OR re-trx - Late (months): abscess, strictures ➡ temporize, re-trx - Stenosis: angio and stent 2. PV thrombosis: rare - Early: FHF ➡ thrombectomy or re-trx - Late (months): encephalopathy, varices ➡ AC - Stenosis: angio and stent

Answer 429

-Px: hepatitis, dermitis, GI sxs after stem-cell/marrow trx -Path: DONOR T cells morph into Th cells; target host -Dx: bx -Tx: steroids + IS

Answer 430

1. Surgical de-torsion of involved testes - If doubtful viability: <10 keep, >10yo orchiectomy 2. Exploration and fixation of uninvolved testis as well! **don't delay OR for U/S if suspicion is high

Answer 431

Dx: triple phase CT (don't need tissue bx unless mets) - do cystoscopy after CT Tx: Upfront Radical nephrectomy + LND +/- chemo +/- XRT - TK inhibitor is 1st line chemo - Simultaneous thrombectomy if IVC thrombus

Answer 432

1. Communicating: children. 2/2 patent processus - <2yo: conservative, observe - >2yo: surgical excision of processus 2. Non-communicating: adults. 2/2 secretions not connected to peritoneum - dont tx if asx. tx w/ excision **can dx on PE (transillumination). DO NOT need U/S

Answer 433

Dx - usually incidental/bilateral - pre-menopausal white women. mammo negative -R/o breast ca is .5% per year Tx - Lumpectomy/Excisional bx (10-20% chance of DCIS/CA) - Don't need negative margins - No SLNBx - Can use tamoxifen to prevent hormone+ cancers (even if you don't know hormone status) PPx options - Surgery - Hormonal therapy - Surveillance w/ MRI or mammo q6m

Answer 434

Dx: clinical diagnosis - rapid erythema with paeu de orange < 6 months - mammo/US first!: must have path of invasive cancer - bx: dermal lymphatic invasion is suggestive but not required Tx: 1. Neo-adjuvant - can give trastuzumab if HER2+ 2. MRM 3. XRT 4. Endocrine tx

Answer 435

Px: painful/larger w/ periods or pregnancy Dx: - imaging: well-circumcribed, coarse ca+ - bx: fibro-epithileal lesions ("aggressive" = phyllodes) Tx: - obesrve if: mobile, concordant imaging/bx - resect if: > 3cm, sxs, growth, anxiety, discordance, lesions "not further defined"

Answer 436

Dx: mammo + U/S + bx - mammo is safe Tx: 1T (13w): mastectomy + SLNBx (radioactive sulfer) +/- chemo at 2T 2-3T: lumpectomy + SLNBx (radioactive sulfer) +/- chemo + post delivery XRT - chemo is safe in 2nd/3rd trimesters. XRT is not - XRT is c/i throughout preg **No blue dye!

Answer 437

1. > 5cm (T3+) 2. 4+ nodes (N2) 3. + margin 4. skin involvement 5. inflammatory BC **if prefer recon must be delayed or used a tissue expander for immediate recon

Answer 438

Fluid: 20cc/kg Blood: 10cc/kg

Answer 439

Access usually with Mattox maneuver If < 50% closure primary with polypropylene suture If > 50% perform a PTFE patch

Answer 440

1. Serosal tear: interrupted, non-absorbable 2. <50%: 1 or 2 layer closure 3. >50%: resection and anastaoisis 4. Multiple short segments: resection and anastamoisis

Answer 441

Zone 1: thoracic inlet to cric ➡ median sternotomy with left neck incision Zone 2: cric to angle of mand ➡ left neck incision Zone 3: angle of mand to skull base ➡ IR

Answer 442

2,3 DPG Elevated temp Higher paCO2 Acidosis

Answer 443

1. No VS changes 2. Tachycardia 3. Hypotension and combative 4. No UOP and obtunded

Answer 444

MOA: NMDA glutamate ANTAgonist, s/e: tachycardia, hallucinations c/i: - MI (b/c SNS activity/cardiac demand) - Space occupying brain lesion

Answer 445

1. abx 1h prior to incision (for approrpaite pts) - include G negative coverage for GI procedures 2. abx dc w/in 24h 3. appropriate hair removal 4. controlled 6am glucose in cards pts 5. dc foley on POD1-2 6. normothermia

Answer 446

On morning of surgery: - Don't take oral hypo-glycemics - Don't take short-acting insulin - Take 1/2 of long-acting insulin **Insulin pump should be converted to insulin gtt for emergency surgery

Answer 447

- Gustatory sweating - 2/2 auriculotemporal nerve - Suspect after parotidectomy for H/N tumor - tx with anti-persiperant

Answer 448

1. TG duct: midline through hytoid bone; sistrunk procedure - if infected tx w/ abxs first 2. Brachial cleft: anterior SCM; resection - 2nd cleft cyst MC (mid/lower neck) 3. Cystic hygroma: posterior triangle; resection (avoid infection)

Answer 449

5 mm bites every 5 mm

Answer 450

1. ASx- can observe 2. Sxs- sugarbaker is preferred - keyhole is alternative - do not relocate - Only repair for obstruction or strangulation - LB herniates more than SB

Answer 451

Type 1- asx: NTD; sxatic: PPI; Surgery if refractory Type 2-4: surgery even if asx

Answer 452

dx- venous congestions from damage to pamp plexus after open hernia repair. POD 2-5 tx- NSAID and pain meds. Orchiectomy is last resort.

Answer 453

1. Exogenous steroids 2. ACTH pituitary adenoma (Cushing disease) 3. Cortisol secreting adrenal adenoma 4. ACC

Answer 454

Cause- AI attack of adrenal cx Labs- hypoNa, hyperK Dx: cosyntropin stim test - cortisol remains low - deceased cortisol and aldo with high ACTH Tx- steroids

Answer 455

px: moon facies, striae 1. Initial tests: choose 1-2 - 24h urine free cortisol (most se) - late night salivary cortisol (when cortisol is lowest) - overnight 1 mg dexa suppression 2. ACT Level A. ACTH normal/high - high dose dexa suppresion - no suppression: small cell lung ca - suppressed: pituitary adenoma (Cushing's disease) (MC endogenous) B. ACTH low - CT positive: adrenal mass - CT negative: exogenous (most common)

Answer 456

Dx: neuroendocrine tumor - 24H urine HIAA - chromoA for progression (not specific, false + on PPI) - Octreotide scan if can't locate Path: +chormogranin. desmoplastic mesentery. - grade ~ Ki67 index Px: - Rectum > SI (ileum) > Appendix (MC tumor of appendix) - GI tract > pulm > GU. Rectum MC - Carcinoid Syndrome: 2/2 liver mets or large GI tumor Tx: - SS analogues (lanreotide) for sxs - < 2 cm: local excision (transanal, appendectomy, segmental) ➡ no further w/up. - > 2 cm: staging CT. formal cancer resection. - all lung carcinoids get formal resection with MLND - c/scope post-op b/c 15% have synch lesions

Answer 457

1. AC 2. Surgery if peritonitis or failure to improve - can also consider endovascular thrombolytics 3. 2nd look operation 24-48 hours

Answer 458

1. Beta blocker 2. Methimazole. PTU if preggo 3. RAI once euthyroid: worsens opthalmopathy and c/i in pregnancy/breast-feeding 4. Surgery if refractory, opthalmotaphy, compressive sxs, RAI and methimazole/PTU c/i - consider lugol's solution pre-op (only for Grave's) **Preggo: beta blocker, PTU. Avoid RAI. Surgery if can't tolerate PTU

Answer 459

1. FNA- r/o ca 2. Bloodwork- antiTPO/TG Ab 3. Tx- thyroxine ➡ partial thyroid **MCCO hypoT and goiter in the US

Answer 460

1. Full immunized (>= 3 toxoid doses) - clean/minor: toxoid vaccine if dose >= 10 years - dirty or > 1cm: toxoid vaccine if dose >= 5 years 2. Unknown or not fully immunized - clean/minor: toxoid vaccine - dirty or > 1 cm: toxoid vaccine + Ig

Answer 461

Px: colitis, retinitis, hepatitis (can effect any organ system) Dx: - usual CD4 < 50 - PCR is unreliable b/c does not prove end-organ disease (can be falsely negative) - must scope and bx: Cowdry bodies, punched out ulcers Tx: gancylovir (valgan is oral form) - initiate HAART - opthalmic exam to r/o retinitis

Answer 462

1. PET/CT 2. PFTs 3. Bronchoscopy (can be intra-op) 4. Mediastinal eval- EBUS or mediastinoscopy

Answer 463

MCCO long term lung trx failure 2/2 bronchiole inflammation Px- serial decline in PFTs. Normal tacro. CT- ILD Dx- of exclusion Tx- steroids (inhibit COX2), IS, reTrx (very poor outcomes)

Answer 464

1. Above T6: nor-epi (b/c HoTN and brady) 2. Below T6: Phenylephrine (may worsen brady above T6) **don't normally get neuorgenic shock below T6

Answer 465

- wound healing especially in steroid patients - def: night blindness, dry eyes

Answer 466

PPV = of those who test + how many have the dz NPV = of those who test - how many do not have the dz Increasing prevalence = increase PPV and decrease NPV Increasing survival = increasing prevalence

Answer 467

Correlation coeff between -1 and 1 1 = very strong positive (direct proportion) > .7 = strong positive 0 = no correlation - .7 = strong negative Do not determine causation

Answer 468

1. Safety in a small group of humans 2. Effectiveness and side effects 3. RCT compared to standard of care 4. Long term safety and monitoring

Answer 469

1. Median sternotomy: right 2. Left Anterolateral thoracotomy: left subclavian - trap door supraclav incision for distal access

Answer 470

Compensated cirrhosis, no portal HTN, low MELD, and solitary mass < 3 cm - hepatectomy is preferred to transplant if they are Childs A

Answer 471

Embolus- lodges after the middle colic. Jejunal sparring Thrombus- at ostium; pan-bowel

Answer 472

A/w: - FAP (after surgery, 2nd MCCO death), Gardner syndrome Path: non calcified, fibrotic, low mit index, spindle cells Tx: - WLE for extra-abd; NSAID, anti-Estrogen (tamoxifen) if intra! - XRT if sensitive area

Answer 473

1. Dexa suppression (cortisol) 2. Urine androgens (sex hormones) 3. Plasma metanephrines (pheo) 4. aldo/rennin ratio > 30 (salts)

Answer 474

Px- cyclic pain, pain with sex Dx- dx laparoscopy Tx- 1. Medical therapy 2. Surgery if unresponsive. Ablation if young.

Answer 475

1. Idiopathic bilateral adrenal hyperplasia (60%)- medical 2. Adrenal adenoma (Conn's syndrome)- lap adrenal 3. Adrenal adenoca- open adrenal + mitotane * Can use adrenal vein sampling to distinguish

Answer 476

Triple phase CT: 1. Unresectable- distant met, >180 SMA/celiac, any aorta/IVC, unreconstructable PV/SMV - EUS/FNA for tissue dx for neoadjuvant 2. Borderline- <180 SMA/celiac, reconstructable PV/SMV - EUS/FNA for tissue dx for neoadjuvant 3. Resectable - dx lap (to confirm resectability) + whipple

Answer 477

Hanley procedure: - Midline drainage incision of deep posterior space (through ano-coccygeal ligament) - Bilateral lateral counter-incisions for ischiorectal space **all external drainage

Answer 478

<30% sphincter- fistulotomy or cutting seton >30% sphincter- draining setons THEN ARAF or LIFT **Crohns patient: px w/ multiple fistulas - avoid fistolotomy. - draining setons. Can try infliximab if active infection has resolved.

Answer 479

G1- bleeding, G2- spontaneous reduce, G3- manual reduce: 1st line: sitz, stool softener, bowel reg, fiber, fluids 2nd line (office): band, sclerotherapy, coagulation - band is most effective - sclerotherapy if on blood thinners G4- can't reduce - surgical HMHD'ectomy (stapled has higher recurrence)

Answer 480

1st line: sitz, stool softener, bowel reg, fiber, fluids 2nd line: surgical HMHD'ectomy Thrombosed: incise or excision if w/in 48h

Answer 481

Px: intractable pruritis, eczematoid rash Tx: scope (r/o malignancy) - dc topical agents - perianal punch bx + WLE

Answer 482

Criteria - bilateral HA or PV - unilateral HA with extensive contra duct Tx - no extrahepatic dz ➡ neoadj chemo-XRT + liver trx - extrahepatic dz ➡ chemo-XRT

Answer 483

For hilar cholangioca. Only t4 unresectable. 1: CH duct- REYHJ + LADN +/- lobectomy 2: bifurcation- REYHJ + LADN +/- lobectomy 3: R or L HD- REYHJ + LADN + lobectomy 4: Both ducts- chemo-XRT + liver trx

Answer 484

1. Dissect CD to the level of the duo 2. Cholodochotomy distal to the CD/CBD junction 3. Fush, basket, or fogarty balloon the stone out 4. Close primarily, over a T-tube, or over a stent

Answer 485

Dx: fever, RUQ, and jaundice - stones > malignancy > stricture Tx: - signs of sepsis: resuscitate/abx then urgent ERCP - no sick: US/MRCP

Answer 486

Px: Biliary pain with normal RUQ U/S after years lap chole Dx: mannometry (no MRCP or CT 1st) Tx: endoscopic sphincterotomy at 11' (CCB usually ineffective) - CBD at 11', PD at 1-3' - h/o REY: open transduo sphincterotomy

Answer 487

Low bile salts Low lecithin High cholestersol

Answer 488

px- GB neck/CD stone compresses CHD types: 1: no fistula- cholecystectomy 2: < 1/3 circ- CC'ectomy + CBD repair w/ T-T 3: < 2/3 circ- CC'ectomy + REY-HJ 4: full circ- CC'ectomy+ REY-HJ

Answer 489

1. Cholesterolosis: MC; CE mphages in LP; benign 2. Adenomyomatosis: benign 3. Adenoma: malignant; >1cm is RF for CA (resect)

Answer 490

1. Intra-op - <50%, not cautery: primary repair - >50%, or cautery: REY-HJ 2. Late phase - Place drain - Define anatomy w/ ERCP, PTC, or MRCP - Place PTC tube - CTA to assess for R/L HA injury - Delayed reconstruction 6-8 weeks once optimized

Answer 491

1. Sx: cc'ectomy 2. For asx: - > 18 mm: tx as GB cancer - > 10 mm: CC'y - 6-10 mm: q6m U/S for 1 year. cc'ectomy if PSC

Answer 492

1. Cholangioca and HCC: US/MRI/MRCP q6-12m. Annual CA 19-9 2. GB CA: US q6-12m 3. CRC: colonscopy q1-2 years (regardless of UC)

Answer 493

1. CT w/ oral/rectal (no IV b/c will obscure bladder) (not cystoscopy, colonoscopy, or Ba enema) 2. Colonoscopy to r/o malignancy 3. Cystoscopy if suspect cancer. Retrograde cysto if CT is equivocal or operative planning Tx- resect sigmoid even if asx; Don't need to repair the bladder, just drain

Answer 494

1. R hemi- IC, RC, RBMC - cecum/asc colon 2. Extended R- IC, RC, MC - hepatic flex/prox t colon 3. L hemi- LBMC, LC - Distal TV, splenic flex, prox descending 4. Extended L- LBMC, origin of IMA - splenic flex 5. Sigmoid- IMA (hi- b4 LC, low- after LC) - dist desc/sig

Answer 495

1. Exam and CEA q3-6m x 3 years 2. Colonoscopy @ q1, 3, and 5 years - No prior scopes: q3-6m (intra-op scope is difficult in un-prepped bowel) 4. CT CAP q1y x 3 years - At 2 years: recurrence local or hepatic - after 2 years: hepatic more often

Answer 496

1. TRUS (avoid if > t2) or MRI- T/N stage - suspicious nodes on MRI count as clinical stage N (neo-adj) 2. CT CAP- M stage 3. C'Scope- for initial dx and sync lesion. not for T stage 4. Rigid Sig'Scope- for distance from anal verge (required! even. if c'scope done)

Answer 497

1. Segmental colitis- partial colectomy 2. Rectal sparing pan-colitis- TAC w/ IRA 3. Pan-colitis w/ rectum- PC w/ end ileostomy - IPAA whether w/ or w/out loop should NOT be done on Crohn's b/c r/o pouchitis

Answer 498

Stable- R hemi and primary mosis (no pexy) Unstable- R hemi with end ileostomy

Answer 499

Dx: 5+ polyps or any polyps w/ family hx - SMAD4+ Non-adenomatous polyps ~ hamartomas

Answer 500

1. CRC: MC - q1y C-scope @ 20-25 - TAC w/ IRA or TPC w/ IPAA if CA or unresectable adenoma - q1y scope post op 2. Endometrial: 2nd MC - q1y endometrial sampling @ 30-35 - ppx TAH-BSO after children 3. Ovarian: - q1y TVUS and Ca-125 @ 30-35 - ppx TAH-BSO after children 4. Stomach: - EGD/Bx q2-3y @ 30-35 5. Renal: transitional cell ca - q1y UA and US @ 30-35

Answer 501

Tumors that require APR: 1. < 5cm for anal verge 2. Tumor at dentate line w/ sphincter involved 3. Tumor that can't get a 1 cm distal margin w/out sphincter 4. Poor pre-surgical anorectal function (history of DRH) 5. Locally recurrent low-lying cancer **Generally follows pre-chemo location of tumor unless COMPLETE tumor response. If tumor initially involved the sphincter complex and now does not ➡ still require APR

Answer 502

-Muir-Torre: MLH/MSH; sebaceous gland tumor -Gardner: APC; desmoid tumors, osteomas, epidermal cysts/lipomas -Turcot: APC; Malignant CNS tumors -P/J: STK; myocutameous pigmentation -Cowden: PTEN; Hamartoma polyps, endometrial/breast/thyroid CA -JuP: SMAD4; epistaxis, AVM, telangiectasia

Answer 503

1. Bridge to surgery in acute obstruction (usually with metastatic cancer) 2. Palliative measure * Usually for L-sided lesions

Answer 504

Gram: G+ bacillus, anaerobic Tx: 1. Primary: oral fidox - oral vanc is 2nd line now 2. Fulminant: oral vanco w/ IV flagyl; +vanc enema if ileus - no fidox 3. Recurrence: PO fidox or vanco 4. Multiple recurrence: tapered fidox or vanco - consider fecal transplant 5. Sepsis/Megacolon: total colectomy (colon > 6 cm, cecum > 10 cm) Virulence: - Toxin A: intestinal necrosis - Toxin B: cytotoxin

Answer 505

Dx- CT first to rule out non-ischemic colitis or infarction; C'scope to confirm - suspect in low flow state, HoTN - CTA can't dx b/c its a microvascular disease Tx- usually supportive; OR if perf, sepsis

Answer 506

**All require bichemical testing before imaging! 1. Glucagonoma: glucagon > 1k; NME, DM, DVT (no stones vs. SS'oma) 2. Inuslinoma: fasting I/G > .4 and high C-pep; whipple triad 3. Gastrinoma: G > 1k or increase G w/ sec; refractory PUD, HyperCa 2/2 MEN1 4. VIPoma: high fasting VIP (exclude other causes); DRH, Achlorhydria, hypoK (2/2 DRH) 5. SSoma: High fasting SS; DM, STONES, steatorrhea *Do not perform imaging or go to the OR until biochemical diagnosis!

Answer 507

-W/up: MRI/MRCP or PP CT ➡ >1.5 cm, sxs, dilated main duct, solid component, fam hx ➡ EUS/FNA 1. Serous cystadenoma: low M/CEA, low Am; resect if sxs 2. MCN: high M/CEA, low Am; resect 3. IPMN: high M/CEA, high Am; resect if main duct or > 3 cm 4. Pseudocyst: low M/CEA, high Am; observe x 6w; if sxs or > 6cm cystgastrostomy

Answer 508

1. Glucagonoma: distal panc w/ splenectomy + cc'y 2. Inuslinoma: enucleate 3. Gastrinoma: enucleate if < 2 cm; >2 cm, whipple 4. VIPoma: distal panc w/ splenectomy + cc'y 5. SSoma: resect w/ cc'y 6. Non functional: < 2cm observe or enucleate. > 2cm resect

Answer 509

No only if low malig risk- insulinoma, non function < 2cm, gastrinoma < 2cm

Answer 510

1. CHA: gives off GDA then R gastric - GDA gives of SPDA and R gastroepi 2. Splenic: gives off short gastrics and L gastroepi

Answer 511

Sinus tach is MC S1Q3T3 pattern w/ TWI

Answer 512

MC primary lung tumor in children Dx- air/fluid filled cystic lesions. Looks like pneumo. Tx- Surgical resection +/- chemo-XRT

Answer 513

Lead-time bias is due to early detection. Remember the "d" in lead is for early detection. Length-time bias is due to slow cases being detected more often simply because they are slowly progressing/indolent. Remember the "g" in length is for slowly progressing.

Answer 514

Ipsi loss of motor Contra loss of pain/temp

Answer 515

Suspect if GB w/ normal US and EGD Dx- HIDA scan w/ EF < 35% (c/i in pregnancy) Good responders if classic sxs (n/v, RUQ pain, w/ fatty meals)

Answer 516

1. Try ETT placement with a miller blade 2. Needle cric is preferred over open if < 12 yo - use cuffed tubes for everyone except newborns

Answer 517

1. Serial dilations 2. PPI 3. Consider stenting - Surgery is last resort (in contrast to achalasia)

Answer 518

Carina or either mainsteim: RIGHT thoracotomy (aorta in the way on the left)

Answer 519

- Carotid stenting has higher incidence of stroke - CEA has high incidence of MI - Composite end-point of stroke, death, MI was the same

Answer 520

- px: 2/2 bill2 or REYGB - watery stools, bloating, b12 deficiency - dx: d-Xylose (carb test breath test) - tx: abxs (Rifaximin) ➡ surg 2nd line

Answer 521

1. Ilioinguinal: under to EO, anterior to cord - sensation to medial thigh 2. Ilio-hypogastric: supero/medial to the ilio-inguinal. Between EO and IO - sensation to lower abdomen 3. GB of GF: runs within the spermatic cord, posterior to the cord structures - sensation to scrotum MC injuries: - Open repair: II, GB of GF - Lap repair: lateral femoral cutaneous, GF **Iliac vein inured when sewing mesh to shelving edge

Answer 522

Path: liver failure ➡ sinusoidal portal HTN ➡ increase CO and splanchnic dilation (compensatory)➡ HoTN ➡ turn on RAA system ➡ renal constriction Px: - albumin + vasoconstrictive agents (terlipressin) - TIPS - transplant

Answer 523

1. No N2 disease (stage 1-2) ➡ up-front surgery - lobectomy + MLNDx. Can consider segmentectomy. - can wedge if 2:1 margin ratio 2. N2 disease or T4 ➡ chemo-XRT first n1- ipsi bronchial/hilar nodes n2- ipsi mediatinal/subcarinal (2-9) t1- <3cm t2- >3cm t3- >5cm OR invading pleura, chest wall, phrenic n, pericardium OR nodule in same lobe t4- >7cm OR invading DPGM, mediastinum, heart, great vessels, trachea, RLN, esophagus, vert body, carina. OR different lobe

Answer 524

1. < 8mm ➡ surveillance 2. > 8 mm ➡ PET-CT - FDG- ➡ surveillance 3. FDG+ ➡ tissue dx (either intra-op frozen or CT-guided, bronchoscopy) - nodal disease --> EBUS 4. No N2 dz --> Segmentectomy or lobectomy - n2 disease --> chemo

Answer 525

1. Complete dissection of hernia sac from mediastinum - look for replaced L hepatic and hepatic branch of vagus near pars flaccida - avoid vagus nerve - divide short gastrics to aid in mobilization 2. At least 3 cm of esophagus into the abdomen! -- Colis gastroplasty if insufficient 3. Close the hiatus with sutures or mesh (posterior and inferior) -- mesh has better short term outcomes only -- RELAXING incision if can't reapproximate

Answer 526

1. Aldosteronoma: Spironolactone + ACEi/ARB +/- CCB +/- K sparing diuretic 2. Pheo: phenoxybenzamine then BB Intra-op: - HTN crisis: Nitro gtt - Tachy arrythmia: Esmolol gtt

Answer 527

1. Solitary nodule, confided to the liver, < 5 cm (not strict), child A, no portal HTN, and adequate liver remnant - Consider portal vein embolization if remnant is insufficient - Consider pre-op TACE to as an adjunct 2. Un-resectable disease: child B+, > 5cm (not strict), portal HTN, inadequate liver remnant - Transplant if candidate: UNOS criteria - Otherwise: loco-regional therapy or systemic therapy

Answer 528

1. Back-pressure < 40 2. Previous colon surgery 3. SMA stenosis 4. Inadequate left colon flow

Answer 529

1. FAP- chromosomal; APC - > 100 polyps, including small bowel (duodenum) - Surveillance: start at 10 2. HNPCC (Lynch)- microsatalite; MSH, MLH, PMS, EPCAM - <10 polyps in the colon - Surveillance: start at 20

Answer 530

1. Papillary/Follicular: lobectomy +/- total + consider ppx L6 for high risk 2. MTC: total + bilateral L6 (usually) + T3 post op - RAI is c/i 3. Hurthle: lobectomy then total + bilateral L6 4. Anaplastic: chemo-XRT +/- total if operable + central and lateral nodes 5. PT: hemi-thyroid +/- L6 (usually not) **MRND if L6 is positive

Answer 531

1. Neuro exam: - absent brain stem reflexes - no response to stimuli 2. Apnea test: CO2 > 60 after 10 minutes - if test aborted OR CO < 60 ➡ - can't perform test if confounding factors: unstable, hypercarbia, intoxication, paralytics (unable to wean), c-spine injury 3. Confirmatory test: CTA, MRA or nuclear scan

Answer 532

1. Open: sewing mesh onto EO --> femoral vein 2. TEP: tacking mesh medially --> corona mortis (obturator branch)

Answer 533

1. Mucoepidermoid: MC malignant - total parotid + ppx MRND + XRT 2. Adenoid cystic: malignant - total parotid + ppx MRND + XRT 3. Pleomorphic adenoma: MC benign - superficial parotidectomy 4. Warthin/Papillary cystadenoma - superficial parotidectomy **Use modified Blair incision for these tumors

Answer 534

1. Boerhave: XR suggestive ➡ UGI (CT controversial) 2. Traumatic esophogeal perf: Trauma CT ➡ EGD or UGI 2. UGI bleed: +/- NGT ➡ EGD

Answer 535

1. Cellular: - mild: steroids (inhibit COX2) - severe: TG 2. Ab: - Plasmaphoresis (clear Ab) - IVIG (so body thinks there are still ab) - Rituximab (CD20 Ab)

Answer 536

Induction: choose 1 1. Thymoglobulin - polyclonal Ab (potent) 2. Basiliximab - IL2 inhibitor (mild) Maintenance 1. Tacrolimus 2. MMF 3. Prednisone 4. Sirolimus

Answer 537

1. Bactrim- PCP, toxo gondi, listeria, nocardia 2. Diflucan- antifungal 3. Valganciclovir- CMV

Answer 538

1. ABO Incompatibility - A, B, O Ab 2. Cross-match: recipient serum X donor lymphocytes - preformed HLA Ab (A, B, DR). DR is most important. **Livers don't need a cross-match **Can give A2 donors to O recipients **Donor: Ags are important (WBC) **Recipient: Abs are important

Answer 539

MAC = minimum alveolar [] to prevent movement in 50% of people Low MAC = lipid soluble High MAC = water soluble - NO has highest MAC Factors that decrease MAC: older age, met acidosis, hypothermia, anemia, pregnancy - require less anesthesia

Answer 540

High r/o gastric ca ppx gastrectomy by age 40

Answer 541

px- failure to pass meconium dx- sweat chloride test, "soap bubble sign" on XR tx- GG then NAC enemas - surgery: ostomy for antegrade enema **Cystic fibrosis is 2nd MCCO pancreatic insufficiency (after chronic pancreatitis)

Answer 542

1. Pulm sequestration: infection w/ abnormal CXR - tx: resection 2. Cystic adenoid malformation: similar to sequestrion but communications w/ TB tree - tx: lobectomy 3. Congenital lobar emphysema: XR looks like tension PTX - tx: lobectomy 4. CDH: Bochdalek- back/left, MC; Morgagni- rare, anterior - a/w pulm HTN, NTD, malrotation - tx: intubate +/- ECMO. Delayed repair.

Answer 543

1. IgG (small, y-shape) 2. IgA (two y's with joined tails) 3. IgM (pentad)

Answer 544

Nutritional requirements for average healthy adult male (70 kg) 1. 20% protein calories: 1 g protein/kg/day - burn: 1g/kg/day + 3 g/day x % BURN...(usually 2-2.5g/kg/day) 2. 30% fat calories 3. 50% carbohydrate calories

Answer 545

Compare PAIRED ordinal variables between two groups when normal distribution cannot be assumed - ex: patient satisfaction before and after an intervention (1-5)

Answer 546

Like a regression model but for survival analysis Allow you to control for different factors

Answer 547

- Increased HR, increased SV - Decreased SVR, Decreased BP - Dilutional anemia. More PRBC but also more water. Requires more blood loss for HoTN

Answer 548

1. Cause: affarent limb is too long from LOTz 2. Px: acute or chronic - Acute: complete obstruction requiring emergent OR - Chronic: partial obstruction w/ bacterial overgrowth - steatorrhea, B12 deficiency. MC w/ antecolic Bili2 3. Dx: - Acute: abdominal pain with dilated afferent limb in early post op - Chronic: d-xylose breath test 4. Tx - stat OR for REY revision - Chronic: abxs --> REY/shorten the limb

Answer 549

- Pd1 inhibitors: pembrozilumab, nivolumab - CTLA inhibitors: ipilmumab - If Braf+: braf inhibitor remains 2nd line

Answer 550

Adults - benign: hamartoma (popcorn calcification) - malignant: sqcc Children - benign: hemangioma - malignant: carcinoid

Answer 551

MC soft tissue tumor in children tx: surgery + SLNBx - consider neo-adjuvent if unresectable - post-op chemo-XRT (very radiosensitive)

Answer 552

1. Aberrant or Dominant left vertebral a. 2. Previous CABG using LIMA (cardiac ischemia) 3. LUE AVF

Answer 553

px- asbestos exposure (shipyard) dx- CT then tissue dx tx- surgery, XRT, systemic chemotherapy, HIPEC

Answer 554

S/p REY GB On the jejunal side Dx- EGD Tx- PPI + sucralfate + stop smoking + avoid NSAID +/- tx H. pylori (if present)

Answer 555

1. Appendix (75%) 2. Mesothelioma (45%) **c/i: extra-peritoneal dz

Answer 556

1. Condyloma in low risk patient: simple anoscopy (internal extent defined) and ablate 2. High risk pt: homosexual, HIV, women w/ +pap ➡ anal cytology/anal pap ➡ high resolution anoscopy, - Condyloma: ablate - AIN1: observe/annual screen - High grade: AIN2, AIN3 ➡ ablate - All patients: give HPV vaccine - LSIL/HSIL ➡ high resolution anoscopy

Answer 557

<1 cm - endoscopic removal 1-2 cm- full thickness excision > 2cm- LAR or APR **Invasion into muscularis/LN involvement- require TME

Answer 558

1. Poor differentiation 2. Vascular/Lymphatic invasion 3. Invasion below the SM 4. < 2mm of surgical margin 5. Base involvement (Haggit 4)

Answer 559

1. CRC- q1-2y c'scope starting at 10 2. Duo/Stomach ca- EGD at 20 or when polyps occur 3. Pap thyroid ca- thyroid U/S q2-5y at 18 4. Desmoid fibromatosis- CTAP if famhx, palpable mass, or sxs

Answer 560

Staging: -Stage 1-2: Don't need staging CT CAP - Stage 3+: Consider CT CAP or PET/CT - Stage 4: MRI brain + PET/CT MC Mets: 1. Lungs 2. Small bowel! - suspect if multiple isolated small bowel masses 3. Colon

Answer 561

Primary anastomosis with DLI (DIVERTI trial) or without DLI (LADIES trial) is safe except if: - HDUS - Acidosis - Acute/Chronic organ failure - I/S - Very old - Poor pre-op sphincter function

Answer 562

- Killian's triangle - Inferior to pharyngeal constrictor (thyropharygneous) - Superior to cricopharyngeous

Answer 563

Lifetime PPI DO NOT convert to a Nissen b/c baseline achalasia

Answer 564

1. Criciopharyngeous 2. AA/Left mainstem bronchus 3. Hiatus

Answer 565

- Gastroparesis - Delayed gastric emptying - Reflux - DRH - normal UGI!

Answer 566

1. EGD- r/o ca 2. 24h pH- prove reflux 3. Esophagram- r/o motility disorder (DES, eso web) 4. Manometry- r/o other motility disorders

Answer 567

A- xeropthalmia D- hypoca, hypoPh E- hemolytic anemia K- elevated INR **suspect with any fat malabsorption

Answer 568

NAD - "no denominator" (140 - current Na) * TBW TBW = .6 or .5 x (weight in kg) .9NS = 154 mEq per liter 3%NS = 514 mEq per liter replete 6 mEq/24 hours

Answer 569

Squamous cell- PTHrP Adenoca- hypertrophic osteodystrophy Small cell- SIADH

Answer 570

HyperCa, hypocalcuria HyperMg Elevated PTH, normal Ph **gastric bypass can elevate Li levels

Answer 571

Main storage protein of Iron Low in iron def anemia High in anemia of chronic dz (acute phase rxn)

Answer 572

Hypopituitarism (anterior pit) 2/2 gland necrosis from HoTN Usually px w/ hypoNa

Answer 573

1. Chlamydia: doxy 2. Gonorrhea: CTX 3. Trich/BV: flagyl

Answer 574

path: IgG to PF4 dx: 50% PLT fall ➡ Ser release assay tx: stop SQH. start fondaparinox, argatroban - use bivalirudin is liver/cirhotic patients

Answer 575

- CCK: I cell, SI - Gastrin: G cells, antrum and duo - Glucagon: alpha cells, pancreas - Histamine: ECL cells, stomach - Insulin: beta cells, pancreas - Motilin: Mo cells, SI - Secretin: S cells, SI - SS: delta cells, pancreas

Answer 576

1. Mobilize ligaments 2. CC'y and cannulate CD 3. Isolate vessels 4. Ligate HA ➡ PV ➡ HV 5. Divide parenchyma

Answer 577

1. Trx: tumor < 5cm or 3+ tumors < 3cm 2. Resection: early stage, preserved liver function 3. RFA: early-stage BUT poor OR candidate 4. TACE: intermediate stage disease 5. Sorafenib: advanced/Unresectable

Answer 578

2-3 paracentesis/month despite Na restriction and diuretics s/e: - increase r/o encephalopathy - no change in overall survival

Answer 579

kwashiorkor - moderate calorie intake; inadequate protein - large belly. normal weight. marasmus - insufficient calorie and protein - simian face. low weight.

Answer 580

glucose: Na-dependent secondary active transport galactose: Na-dependent secondary active transport fructose: Na-independent facilitated diffusion

Answer 581

- Dx: EUS/FNA ➡ high CEA, low amylase - Location: body/tail - Spleen Preserving Distal Pancreatectomy (usually can be spleen preserving) - No follow-up is needed (no increase r/o recurrence)

Answer 582

- Hypotension, Bradycardia - Administer slowly: 1 mg per 100 units of insulin - Has partial reversal on lovenox - No renal/liver adjustment required

Answer 583

px: flesh-colored sarcoma resembling a keloid - inovles dermis and subcutaenous tissue. No epidermis. dx: - excisional bx if < 3 cm - core/incision if > 3 cm - histo: spindle cells, +cd34, +Vimentin tx: - imatinib to down-stage if needed - en block resection w/ 2-4 cm margin`

Answer 584

Lesions > 2cm from primary but not beyond regional tumor basin - immunotherapy or BRAF inhibitor - only excise if feasible (few lesions)

Answer 585

1- non-blanching erythema 2- dermis 3- full-thickness subcutaenous 4- muscle, bone fascia

Answer 586

H-J bodies and Target cells - If absent: accessory spleen (usually in hilum or tail of the pancreas) - HJ bodies: nuclear remnant (purple spot in cytoplasm) - Target cells (codocyte): deformed RBC with excess membrane ID accessory spleen: peripheral smear ➡ radionucleotide tech sulfur colloid scan

Answer 587

Px- weight gain, reflux years after a bypass Dx- UGI or CT with oral contrast Tx- observation, resection of the involved segment

Answer 588

1. Laparoscopic-assisted ERCP or ERCP through a gastrostomy 2. Double balloon endoscopy

Answer 589

dx: neurogenic- schwannoma, neurofibroma - CT then MRI. Bx not needed tx: all require resection (even if asx) **lymphoma if middle **thymoma if anterior

Answer 590

- carina/contra trachea involvement is still resectable ➡ sleeve pneumonectomy - SVC involvement can still be resectable - c/i: N3 disease ➡ contralateral mediastinal LN involvement

Answer 591

- 1st branch off the subcalvien - supplies anterior chest wall, breast - bifurcates to form superior epigastric and m/phrenic - gold standard for LAD bypass - can ID during clambshell thoracotomy

Answer 592

1. Abxs 1st. No drain if < 4 cm 2. Cath drainage: > 4 cm or failure of abxs - perc (peripheral) or bronch (central) 3. Surgical resections Indications for surgery: - failed medical tx - BP fistula - hemoptysis - suspect cancer - empyema

Answer 593

Px- asx or abnormal PSA Dx: - Transrectal U/S guided bx - 12 samples - Gleason score 1-5

Answer 594

"salt and sex" 21: most common; sex - dx: high 17 levels 17: salt 11: salt and sex

Answer 595

amide- two "i's"; plasma cholinesterase metab; ester- one "i"; liver metab; PABA analogue --> allergic reactions

Answer 596

px: AD; ryanodine receptor type 1 mech: huge increase in INTRAcell Ca tx: stop drug, dantrolene, Bicarb, cooling, tylenol - dantrolene: ryanodine rec antagonist

Answer 597

1. Early morning salivary or serum cortisol (screen when cortisol is highest) - vs. cushing's which requires PM cortisol (when cortisol is lowest) 2. High dose cosyntropin (ACTH) stim: give 250 ug and measure serum cortisol (positive if < 18) Tx- Resuscitation. IV dex 4 q24 or HC 100 q8 **dexa is strongest steroid (hydrocort is weakest)

Answer 598

1. Tamoxifen: ER partial agonist - for ER/PR positive and < 70 - 5 years - s/e: dvt, endometrial ca 2. Anastrazole: reversible aromatase inhibitor - for ER/PR positive and > 70 - 5 years - s/e: MSK fractures 3. Trastuzumab: monoclonal Ab to Her2/Neu rec - for HER2 positive - 2 years - s/e: cardiotoxic

Answer 599

px: scaly, ulcerated crust of the areola dx: nipple punch bx with epidermal cells w/ clear cytoplasm and oval nuclei tx: total mastectomy (including NAC) and SLNBx - don't need ax dissection - no breast conservation - total mastectomy even if small underlying lesion

Answer 600

- Symptomatic sinus bradycarias - Mobitz II (2nd degree) AV block - 3rd degree AV block - New L or R BBB **If transcutaneous is unsuccessful ➡ transvenous

Answer 601

- 1d- PR > 200 ➡ no tx if asx - 2d Mobitz 1- progressive PR prolongation, then dropped beat ➡ no tx if asx - 2nd Mobitz 2- random dropped beat. normal PR ➡ atropine and pacing - 3rd degree- A and V pump independently ➡ atropine and pacing

Answer 602

MOA: inhibits N/K ATPase. Stimulated PSNS - increased contractility (Ca rushes in) - slows AV node conduction S/e: - fatal arrythmia (especially in the setting of hypoK) - beware of patients with n/v (hypoK met alk) - keep K > 4

Answer 603

- Within 4 minutes of CPR for cardiac arrest - Fetus must be at least 24 weeks - Give O, Rh negative blood if needed - usually 2/2 abruption (vaginal bleeding)

Answer 604

- LAD is MC - Primary repair is preferred - If too much loss of length then CABG - Do not ligate

Answer 605

1. EKG +/- trop - negative: can dc - positive: admit to tele (Sinus tach is abnormal) 2. Persistant arrhythmia or HoTN ➡ echo

Answer 606

Dx: CT w/ rectal contrast is best Tx: 1. Intraperitoneal ➡ colonic injury 2. Extraperitoneal ➡ primary repair w/ loop sig colostomy - if inaccessible just leave open and divert - avoid presacral drainage or distal washout

Answer 607

- mobilize to see extent of injury - most commonly primary repair - if large along the greater curve can wedge staple - if very extensive can resect and reconstruct w/ REY or Billroth

Answer 608

Right: median sternotomy Left: - anterior thoracotomy: proximal control - supraclavicular incision: distal control - can connect with sternotomy for "trap door"

Answer 609

1. Central: disrupted ADH synthesis ➡ responds to DDAVP 2. Peripheral: genetic or Li induced defective ADH receptor ➡ low salt diet, amiloride

Answer 610

1. Steal: pain, diminished pulse, cold hand - Tx: DRIL (distal revasc interval ligation) - Ligate immediately distal to AVF. Bypass distal to the ligation site. - 2/2 to impaired compensatory mechanisms 2. IMN: pain, normal pulse, warm hand - Tx: immediate ligation - 2/2 nerve ischemia

Answer 611

Thrombus is in GSV, SSV 1. AND w/in 3 cm of Saph-fem jxn or saph-pop jxn ➡ therapeutic AC for 3-6 months 2. No near the jxns ➡ prophylactic AC for 45 days 3. Otherwise: surveillance **Superficial femoral vein is a DEEP vein **EHIT: heat induced thrombus after RFA - tx with AC until resolution if it involves femoral jxn and > 50% occlusion - < 50%: compress, NSAID, surveillance

Answer 612

- RFA or EVLA are 1st line - Indications for surgery instead: high ligation and vein stripping: 1. proximal/dilated and tortuous GSV 2. previous thrombophlebitis 3. vein too large (RFA > 15mm, EVLA > 8 mm) - lower extremity telangiectasias, reticular veins, and small varicose veins ➡ sclerotherapy recommended

Answer 613

- Dosal: superfial peroneal n. - 1st webspace: deep peroneal n. (is deeper) - Medial: saphenous n. - Lateral: sural n.

Answer 614

- HDS: perform a cancer resection - HDUS: resect and divert - Scope in 3-6 months to r/o synch lesion **Divert if unstable, contaminated, poor nutrition, etc.

Answer 615

- Cremasterics (vessels, muscle, lymphatics) - GB of GF - Testicular artery and veins - Vas deferens - Processus vaginalis **round ligament in women

Answer 616

1- RCT or SR of RCT 2- Cohort study or SR of cohort studies 3- Case-control or SR of case-control 4- Case series 5- Expert opinion

Answer 617

1. neoadjuvant 1st unless pure fetal histology and low mitotix index 2. resection 3. transplant if 4+ section involved/unresectable after chemo Good prog: < 5 yo, AFP > 100

Answer 618

Vertebral Anal Cardiac TE fistula Renal, Radial bone Limb defects

Answer 619

px: infant with bilirubinemia dx: 0. Rule out TORCH infections/neonatal hepatitis 1. HIDA with no contrast in the duo 2. Cholangiogram: look at what segments are strictured 3. perc bx (tissue dx) tx: REY-HJ vs. REY-portoenterostomy (Kasai) ➡ transplant if unsuccessful

Answer 620

Tyrosine ➡ L-dopa ➡ dopamine ➡ NE ➡ adrenal PNMT ➡ Epi

Answer 621

rf's- high IS, pulse steroids px- hematuria, nephritis after kidney trx tx- decrease IS, cysto/possible stent

Answer 622

- stop smoking 4-6 weeks b4 surgery - mechanical and abx prep before elective colectomy - perioperative glucose < 200 - clippers > razors - abxs 1h b4 incision; 2h for vanc or FQ - normothermia - closing tray for colorectal cases

Answer 623

MOA- inhibit 30s; bacteriocidal Coverage- GNRS, pseudomonas s/e- nephrotoxic, ototoxic

Answer 624

1. PTU or methimazole 2. Steroids **No alpha/beta blockade

Answer 625

- MutY: 10 R sided adenomas ➡ MUTYH - FAP: 100s of adenomas + desmoid ➡ APC - Peutz-Jeghers: hamartomas + skin lesions ➡ STK11 - Juvenile polyposis: hamartomoas + telangiectasias ➡ SMAD4 - Lynch/HNPCC: L sided adenomas ➡ MLH1, MSH2, MSH6, PMS2 - Cowden: hamartomas + breast/thyroid ➡ PTEN

Answer 626

- Screening scopes 8 years after onset. Scope q1-3 years thereafter. - Invisible HGD: confirm w/ high-def endoscopy q3-6m ➡ total proctocolectomy w/ IPAA - Visible HGD: 1. Resectable: endoscopic resection + serial scopes 2. Not-resectable: TC w/ IPAA - for Crohn’s can do segmental resection

Answer 627

Indications for surgery of brain bleeds: 1. Epidural: > 1.5 cm or > 5 mm shift 2. SDH: > 1 cm or > 5 mm shift 3. Intra-parenchymal: > 5mm shift

Answer 628

- cant be intrahepatic (prognosis is too poor) - must be unresectable, perihilar, < 3cm - no distant mets

Answer 629

- Adults risk starts at < 180 cm - Infants risk starts at < 75 cm - Feeds with elemental nutrition

Answer 630

- suspect when colon > 6cm - TAC w/ end ileostomy - Keep the ileocolic intact for future J pouch - Keep the SRA intact for good staple line flow - Divide rectum above the posterior peritoneal reflection at level of sacral promontory

Answer 631

A- CD stump leak: - Intraop: clip/ligate and leave drain - Postop: perc drain + ERCP plasty/stent B- Aberrant right hepatic ligation: - Only if sxs ➡ REYHJ C- Transect aberrant right hepatic: - Only if sxs ➡ REYHJ D- Lateral injury to CHD/CBD: - No devascularization and small: 1' T-tube closure - Devascularized: REY-HJ E- full transection of CHD/CBD - < 1cm or distal w/out tension: 1' T-tube closure - > 1cm OR proximal injury: REY-HJ e1- > 2cm, below confluence e2- <2cm, below confluence e3- at confluence (confluence intact) e4- at confluence (confluence separated) e5- aberrant RH duct injury w/ CBD stricture

Answer 632

1. Prior radiation 2. Radiation therapy contraindicated by pregnancy 3. Inflammatory breast cancer 4. Diffuse suspicious or malignant-appearing microcalcifications 5. Widespread disease that is multicentric 6. A positive pathologic margin after repeat re-excision MRM = removal of breast parenchyma, NAC, skin, AND level 1-2 nodes

Answer 633

CRAP GPs spend all day on SICKFACES.com. Inducers: Rifampicin Alcohol Phenytoin Sulphonylureas Inhibitors: Sodium valproate Isoniazid Fluconazole Grapefruit juice Sulfonamides Ciprofloxacin Omeprazole Metronidazole

Answer 634

dx: CT and histopathology - mc at the appendix tx: - ex lap in acute setting to resolve obstruction - cytoreductive surgery + HIPEC - don't do palliative feeding tube without tissue dx/staging

Answer 635

1. Imiquimod, Podophyllotoxin, Sinecatechins 2. Cryo, acetic acid, surgery, laser 3. Podophylin, 5-FU

Answer 636

1. Px: painless jaundice. 2. W/up: - Ca 19-9 - CT/MRI - Tissue: 1. ERCP w/ stent: brushings + in 50% (preferred if obstuctive) 2. EUS/FNA: negative bx does NOT rule out

Answer 637

- PSC - UC - Choledochal cyst - Biliary tract infection

Answer 638

1.Mild: 90-94; mild MS change 2. Moderate: 84-89; afib, HoTN 3. Severe: 84-70; Osborne waves, coma 4. Profound: <70; no vitals

Answer 639

- If patient is hypotensive - TAC w/ end ileostomy - If stabilized- prep 1st with 4-6L of PEG. Scope w/in 24h.

Answer 640

Stage: extent of submucosal invasion! 0- superficial to MM (no SM) 1- invasion into head 2- invasion into neck 3- invasion into stalk 4- in SM. superficial to MP. **all superficial. toMP Mx: - all sessile are 4 by definition - 4 is an indication for resection - < 4 cancer without high risk features ➡ polypectomy alone w/ follow-up scope in 3 months

Answer 641

Path- bulging of rectum into vagina Dx- bimanual exam reveal large bulge in posterior vagina Tx- transvaginal plication of vaginal muscularis +/- mesh

Answer 642

1. CLD 2h preop 2. Preop gabapentin and tylenol 3. Thoracic epidural or TAP block 4. Pre-op entereg + 7 days post-op 5. Scope patch 6. Non-opiate 7. Normothermia, good O2, glycemic control, skin preop 8. Net zero fluids 9. Avoid draina nd prolonged foley 10. Dc w/in 3 days

Answer 643

Dx: nuclear study or radio-opaque marker Tx: 1. Medical management 2. TAC with IRA is most effective - pelvic floor dysfunction must be addressed prior to surgery

Answer 644

1. Foreign body 2. Radiation 3. Inflammation/Infection 4. Epithelialization 5. Neoplasia 6. Distal obstruction

Answer 645

- average risk: start at 45. Screen q 10 years. -1d relative: start at 40 OR 10y b4. Screen q5 years even if normal.

Answer 646

1. Colonoscopic detorsion 2. Sigmoid resection DURING the admission

Answer 647

- Colon: has taenia/above reflection - Rectum: no taenia/below reflection

Answer 648

dx: gg swallow then thin barium tx: - NPO, IV abxs - consider stenting - generally don't need IR drain - includes cervical and thoracic

Answer 649

1. PPI or H2 block daily x 8 weeks - BID if severe sxs, HGD, or esophagitis 2. Work-up for anti-reflux surgery - dysplasia should be eradicated prior to surgery 3. Continue surveillance - no dysplasia: q5y - LGD: q6m. ablation. - HGD: q3m. ablation or endoscopic resection.

Answer 650

1. Abxs first - unless rupture or HDUS 2. Drainage/Surgery if failure

Answer 651

- type 1: most abundant. scar tissue. predominate after 8 weeks of wound healing. - type 3: 1st 2-3 weeks of wounds healing. weaker. **Collagen deposition peaks at 3 weeks. Degradation starts then

Answer 652

1. > 5mm or < 5mm w/ red spots - Tx: beta blocker or banding ➡ TIPS 2. < 5 mm: repeat scope in 1-2 years **bleed rate 10%/year w/ 20% mortality

Answer 653

- leucine, isoleucine, valine - metabolized by the muscle instead of liver - use to feed liver impaired patients

Answer 654

1. Superficial: inability to evert. numbness at dorsum (except 1st web space) 2. Deep: foot drop. numbness of first web space

Answer 655

Px- pancreatic head mass with LADN. Normal Ca 19-9. Constitutional sxs Tx- chemo only

Answer 656

- Cancers: SqCC, BSC, melanoma in-situ Location: face, genitalia, hand/foot - Size: > 6mm on high-risk area - High risk subtype: morphaeform, dibrosing, sclerosing, infiltrating, micronodular - High risk features: Ill defined borders, peri-neural invasion, prior radiation, immunosuppression

Answer 657

1. > 4 nodes on superficial dissection 2. Positive cloquet's node 3. Enlarged ileo-obturator nodes on CT 4. Clinically palpable femoral nodes

Answer 658

- IF secreted by parietal cells - improves absorption of b12 in the TI - post gastrectomy can get megaloblastic anemia

Answer 659

Surgical resection with complete LADN - usually lobectomy

Answer 660

- PD-1: pembrolizumab; melanoma (1st line); NSC lung ca, - EGFR: cetuximab; KRAS NEGATIVE colon ca - CTLA4: ipilimumab; melanoma (2nd option) - RET: selpercatinib; MTC (MEN) - Aromatase: anastrazole; ER+ breast ca - HER2: trastuzumab; HER2+ breast ca

Answer 661

Px: pulm sxs in ohio river valley - MC mycosis in the overall - SVC syndrome if fibrosis CT: fibrosing mediastinitis Bx: oval budding yeasts Tx: only if sxs - itraconazole → ampho B - stent if fibrosis

Answer 662

MMF: purine (T cell) inhibitor - GI sxs, myelosuppression, anemia Basilixamab: il2 inhibitor - GI sxs Azathioprine: purine (T cell) inhibitor - myelosuppression, marrow suppression, pulm fibrosis

Answer 663

MOA: mu agonist s/e: seizures - 2/2 to metabolite normeperadine - worse with renal impariment

Answer 664

Bupivocaine: HoTN Morphine: respiratory depression

Answer 665

1. Pregnancy 2. Diffuse micro-calcs 3. Positive pathologic margin 4. Multi-quadrant disease

Answer 666

Stage 1: pitting edema, no fibrosis - compression garment Stage 2: fibrosis - complete decongestive therapy Stage 3: severe fibrosis, elephantiasis - pneumatic compression **venous insufficiency does NOT cause lymphedema

Answer 667

Pedicled: - TRAM: superior epigastric. use rectus. - Lat dorsi: thoracodorsal Free: - DIEP flap: deep IE vessels. lower abdominal skin. Rectus spared. **delayed autologous flap is preferred over implant if XRT is expected

Answer 668

- NE: alpha1 > beta1 - Epi: beta1 > alpha 1, some beta 2 - Phenyl: all alpha1 - V1 stimualtor

Answer 669

- constrict the efferent arteriole to promoted blood to kidney - increase ADH secretion - JG cells sense low Na and release renin - absorb water/na and excrete K/H

Answer 670

medial-to-lateral: 1. GB of GF 2. FB of GF 3. Femoral 4. Anterior femoral cutaneous 5. Lateral femoral cutaneous (MC injured)

Answer 671

G1: longest. self regulation. go to G0 if irregular. - p53 regulated G1/S transition S: DNA replication G2: 2nd check-point M: mitosis/cell division - most XRT sensitive

Answer 672

Chrom: deletion of short arm of chrome 11 Px: Wilm's tumor Aniridia- absent iris GU anomalies- cryptorchidism, hypospadia, streak ovary Retardation

Answer 673

Dx: U/S, current jelly stools, abdominal mass Tx: 1. Air contrast enema (75% effective) - surgery if unstable, perforation, mass, or completely unsuccessful on repeat U/S 2. Repeat enema 3. Observe for 4 hours if success - only 5% recur

Answer 674

1. 1-2 cm: simple closure 2. 2+ cm: graham patch repair 3. >4 cm: resection and reconstruction - thal patch, pyloric exclusion, G-J 4. >4 cm unstable: controlled fistula via drain through defect, pyloric exclusion, G-J with REY or Billroth 2 - consider drainage procedure if HDS and unlikely. to comply with PPI or developed ulcer on PPI

Answer 675

Tx: bx all SB lesions - excision of adenomas or all sx'atic tumors - < 3 cm: endoscopic resection - > 3cm: surgical resection (trans-duodenal polypectomy, segmental resection). Whipple if peri-ampullary and worrisome features. - routine surveillance for recurrence

Answer 676

- diffuse uptake ➡ Grave's: BB, PTU, RAI ➡ total/subtotal thyroidectomy if refractory (consider lugol's solution before surgery) - focal uptake ➡ toxic adenoma: BB, PTU and lobectomy - multiple areas of increased uptake ➡ TMN ➡ RAI and/or PTU ➡ total/subtotal thyroidectomy if refractory

Answer 677

1. FAST+, HDS ➡ OR for pericardial window ➡ extend to median sternotomy if blood found 2. FAST+, HDUS ➡ immediate median sternotomy (preferred) or ED thoracotomy (left anterolateral) - Finger compression - If failure ➡ pledgeted repair (avoid balloon/staples if possible). Horizontal mattress, permanent (prolene)

Answer 678

1. Widened mediastinum 2. Apical cap 3. Displacement of trachea 4. Depression of L mainstem bronchus *suggest injury at ligamentum arteriosum

Answer 679

- HTN - Hepatic cysts - Head (Intracranial) aneurysms

Answer 680

Thrombophlebitis: 1. Superficial veins: dc the IV, warm compress, NSAIDS - abxs if you suspect infection - surgery if failure of abxs or septic 2. Deep veins: abxs + AC x 2-3 weeks ➡ thrombectomy and vein excision only if refractory (high morbidity) Catheter-related DVT: - anticoagulation - catheter can remain in place if functional, needed, and not infected

Answer 681

1. GFR < 6 and asx 2. GFR < 15 with sxs - absolute: uremic pericarditis, pleuritis, encephalopathy - relative: AEIOU

Answer 682

MOA of abxs: - cell wall: PCN, cephalsporin, vanc - protein 30s: AG (gent), tetracyclines (doxy) - protein 50s: macrolide (azithro), clinda, linezolid - dna synthesis: quinolones (gyrase), bactrim (folate), flagyl (free radicals)

Answer 683

- ancef, cefoxitin, or cefotetan + flagyl - unasyn - pen allergic: clinda or vanc + gent, cipro, levo, aztrenoam

Answer 684

- make albumin > 3.5 - stop smoking 4-6 weeks pre op - mechanical and PO prep before colectomy - glucose 110-200 - use clipper over blade - give abxs w/in 1h (2h for vanc/FQ) - closing tray for colons - keep patient warm

Answer 685

QI strategies: - six sigma: improve quality by covering all variables to measurable parameters - teamSTEPPS: optimize teamwork through leadership, communication, mutual support, situation monitoring - SBAR: communication tool for team safety. situation, background, assessment, recommendation - re-AIM: strategy to reach targeted population of evidence-based practice. reach, effectiveness, adoption, implementation, maintain - PDSA: test a change. plan, do study, act.

Answer 686

Cirrhotic w/: 1. GI bleed 2. Low protein ascites 3. Hx of SBP 4. Cr > 1.2 5. Billi > 3, C/P > 9 6. Na < 130

Answer 687

1. >2cm or at base: R hemi 2. high risk (high MI, KI > 2%, mixed histology, LV invasion meso invasion): R hemi 3. Otherwise: appe only **require c'scope post-op b/c 15% have synch lesions

Answer 688

1. US: tylenol 2. Worldwide: viral hepatitis (Hep B)

Answer 689

A- mucosal breaks <5 mm B- mucosal breaks >5 mm C- mucosal breaks spanning 2 folds, <75% circ D- mucosal breaks >75% circumference

Answer 690

- absent peristalsis - normal/low LES pressure **contrast to achalasia: aperistalsis and high LES pressure

Answer 691

1. arginine 2. omega-3 FA - a/w less infections, shorter LOS

Answer 692

- Renals come off just under the SMA at L2 - SMA hugs the left renal vein - Renal arteries run behind the veins and the IVC

Answer 693

- Thoracic approach with anterior 270-degree wrap - Bailout after failed abdominal approaches

Answer 694

1. Anterior to SCM. Divide platysma 2. Divide omohyoid, strap muscles 3. Retract carotid structures laterally 4. Ligate middle thyroid vein and inferior thyroid artery

Answer 695

- response to neoadjuvant chemo - not size. or node status (its already disseminated)

Answer 696

Ileum (has most lymphoid tissue)

Answer 697

1. Anteior: base of transverse mesocolom 2. Lateral: mobilize 4D and LOTz

Answer 698

- megaloblastic anemia - fat malabsorption/ADEK def - cholesterol stones (EH circulation) - oxalate stones (ca binds fat instead of Ox)

Answer 699

1. BPD/DS: prevent marginal ulcers and dumping syndrome (keep pylorus) - sleeve - resect TI 100 cm from ICV - roux limb end-to-end to duo 2. BPD: good for weight loss but high ulcer/dumping syndrome - resect stomach - ileum to stomach (250 cm from ICV) - more distal ileum to BP limb (100 cm from ICV)

Answer 700

1. Vit D- bone dz, hypoCa 2. Vit A- night blind 3. Folate- skin changes 4. Iron- anemia 5. Thiamine- encephalopathy

Answer 701

1. Measure lactate 2. Blood cx b4 abxs 3. Abxs after cx 4. 30 ml/cc bolus if HoTN, LA 5. Pressors for MAP >65

Answer 702

1. arginine 2. omega-3 FA - a/w less infections, shorter LOS

Answer 703

1. Pulmonary dysfunction: tx w/ steroids 2. Thyroid dysfunction: tx w/ steroids or thionamides

Answer 704

G+: exotoxins G-: endotoxins (lipid A)

Answer 705

- Get diagnostic mammo - Then excisional bx (15-30% of cancer) - Like LCIS you do not need a negative margin - Finally chemo-ppx with tamoxifen **ALH and LCIS if low risk and concordant

Answer 706

medial- pec minor lateral- lat dorsi superior- ax vein posterior- subscap

Answer 707

- Pale cytoplasm - Prominent nucleoli (orphan annie) - Psammoma bodies - Large/crowded nuclei

Answer 708

Artery: R and L the same - Superior a: from inf phrenic - Middle a: from aorta - Inferior a: from renal a Vein - L adrenal vein: into L renal v - R adrenal vein: into IVC

Answer 709

-7 degrees of freedom

Answer 710

Celiac- ligate SMA- shunt or repair IMA- ligate

Answer 711

- Band should be at 45-degree angle - Too much contrast past the band means its underfilled - Fundus above means slipped band - Band melding with lumen of the stomach: erosion

Answer 712

> 1mm < 1mm w/ ulceration or > 1 mm2 mitoses

Answer 713

1. venous branches (doesn't fill enough) 2. fistula is too deep (can't pop out)

Answer 714

- take out plaque between media and adventitia - pull out plaque transversely - acute deficit post op: get an U/S 1. thrombus/initimal flap: re-explore 2. normal U/S ➡ cerebral angio

Answer 715

Fistula takedown, prior graft revmoval (if s/p evar) and extra-anatomic bypass

Answer 716

1. Unclear boundary of solid component 2. Irregular shape 3. Calcs 4. Hypoechoic

Answer 717

1. GCS <=8 with abnormal head CT 2. GCS <=8 with normal head CT and 2 of the following: - age > 40 - abnormal posturing - hx of HoTN

Answer 718

Boundaries: - Anterior bellies of digastric - Hyoid bone - Symphysis menti - Mylohyoid is floor Contents: - Contents: mylohyoid nerve, anterior jugular veins

Answer 719

5 IV morphine = - .7 IV HM - .05 IV fentanyl 15 PO morphine = - 3 PO HM - 10 POD Oxy

Answer 720

FRC = RV + ERV - TV not included - Increases with age - Decrease with obesity, pneumoperitoneum

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