Which enzyme is the most potent activator of trypsinogen
enterokinase
Treatment for incidentally found meckels in an adult
No treatment is required
Treatment for symptomatic meckels diverticulum
Resection of the meckels and end-to-end anastomosis
What is the initial treatment for frostbite? What are subsequent treatments
First: rewarming for 15-20 minutes until thawing is complete.
Then: debride, elevate, administer antibiotics
What is an esophageal mass lesion that causes dyphagia but has normal mucosa grossly and on microscopy?
esophageal leiomyoma
What is the treatment for esophageal leiomyoma?
submucosal enucleation
Treatment for post-op uroma after transection of the ureter.
Immediate: depends on length of ureteral segments
Delayed: place perc neph tubes, then come back another day to reconnect the ureter
Most appropriate treatment for incidentally found terminal ileitis during appendectomy
proceed with appy, but do not resect ileum
Blood supply to the cervical esophagus
inferior thyroid artery
Where are VIPomas most commonly found?
pancreatic body and tail
Pancreatic lesion associated with watery diarrhea
VIPoma
What is the cause of intestinal atresias?
Intrauterine vascular accidents for all atresisas except duodenal which are caused by failure to recannulize
actions of VIP
-vasodilator
-stimulates pancreatic and intestinal secretion
-inhibits gastric acid secretion
symptoms of VIPoma
watery diarrhea
hypokalemia
achlorhydia or hypochlorydia
(WDHA)
metabolic acidosis
flushing
What test can be done to find VIPoma
octreoscan (somatostatin receptor scintigraphy)
What percentage of VIPomas are malignant
60%
Most common location for VIPomas
body or tail of the pancreas
Medical treatment for VIPoma
octreotide therapy
Tumors that secrete VIP
GI carcinoids--10% of VIP secreting tumors
ganglioneuroblastomas
mastocytomas
small cell carcinomas of the lung
pheochromocytomas
What is the Injury Severity Score (ISS)
takes the 3 worst injured body systems and scores them from 1-6. 6 is an unsurvivable injury. take the square of each score and add them together. >25 is considered severe. any score of 6 automatically assigns the value of 75
what reduces the deleterious effects of steroids on wound healing?
vitamin A
What is the management of a painless testicular mass with an associated elevation of B-HCG?
cxr--if abnormalities are found, proceed to ct chest
abd ct
if resectable: radical inguinal orchiectomy with ligation of the spermatic cord at the internal ring, inguinal approach
First muscles to relax after administration of general anesthesia
face and neck muscles
last muscles to be paralyzed after the administration of general anesthesia
diaphragm
What is a pancoast tumor
apical lung neoplasm
causes SVC compression and horner syndrome
What is Horner Syndrome
compression of the sympathetic chain. causess oculosympathetic palsy: pitosis, meiosis, ipsilateral anhidrosis, enopthalmos
antibiotics likely to cause erythema multiforme or stevens-johnson syndrome
bactrim (sulfas)
effects of PTH on calcium homeostasis
--increases renal absorption of calcium
--increases renal excretion of phospate
--increases gi absorption of both calcium and phospate
--causes the release of calcium by binding to osteoblasts which ultimately causes the activation of osteoclasts which break down bone
activated T-cells produce which interleukin
IL-2
Activated macrophages produce which interleukin
IL-1
function of IL-2
proliferation of T-cells
Function of IL-1
stimulates T-cells
activates antigen presenting cells
regulates B-cell antibody production
promotes hematopoiesis
Function of IL-7
development of T and B-cell precursors
IL 7 secreted by:
thymus and bone marrow stromal cells
what contributes to the function of the LES
cardiac notch
circular muscles of the lower esophagus
most common complication of protamine reversal of heparin
the number of cases (old and new) in a population at a specific moment in time, or--the total number of cases in the population divided by the number of individuals in the population
treatment for LCIS
counseling and close follow-up.
sigmoid volvulus: findings on plain film
dilated loop of colon pointing to the right upper quadrant
treatment for sigmoid volvulus
no peritoneal signs, stable patient: sigmoidoscopic reduction followed by resection
peritoneal signs: ex-lap, sigmoid resection,
signs of abdominal compartment syndrome
--abdominal distention
--increased peak airway pressure
--oliguria-->anuria
--decreased cardiac output
--hypotension
most common cortisol secreting tumor
adrenocortical tumor
paget schroetter syndrome
thoracic outlet syndrome plus effort vein thrombosis
symptoms of paget schroetter
acute arm pain, swelling, edema, palpaple pulse, neuro intact
most common islet cell tumor in MEN 1
gastrinoma
MEN 1 tumors
1. pancreatic islet cell tumors
2. parathyroid adenomas
3. pituitary tumors
gene implicated in MEN1
menin
gastrinoma triangle
junction of the CBD, cystic duct, and 2nd and 3rd portions of the duodenum, and the neck and body of the pancreas
most common pancreatic islet cell tumors in MEN 1
gastrinomas
insulinomas
zolinger ellison syndrome
hypersectretion of gastrin causing excess HCl
most common bacteria seen in the biliary tract
E. coli
everything i need to know about gastrin
produced by g-cells in antrum of the stomach
stimulates gastric production
release from g-cells stimulated by histamine
most common liver tumor
hemangioma
most common organism in mastitis
staph aureus
zenker's diverticulum:
true diverticulum?
Where do they occur?
Associated with what other GI problems?
Classic symtoms?
Treatment?
not a true diverticulum.
occur at Killian's triangle: weakness in the posterior pharyngeal constrictor muscle, above the cricopharyngeus muscle between oblique and horizontal fibers
associated with hiatal hernia and GERD
treat with diverticulectomy and cricopharyngeal myotomy
Brown Sequard syndrome
ipsilateral motor loss and contralateral sensory loss
Budd-Chiari syndrome
cell type most responsible for hepatic fibrosis
stellate cells
component of the GCS that is most predictive of outcome
motor
lifetime risk of ovarian cancer in patients with BRCA 1?
BRCA-2?
BRCA-1: 40%
BRCA-2: 18%
Risk of breast cancer in patients with BRCA-1? BRCA-2?
BRCA-1: 55-85%
BRCA-2: 55-85%
cancers associated with BRCA-1? BRCA-2?
BRCA-1: breast
BRCA-2: male breast cancer, pancreatic ca, melanoma, ovarian ca
indication for CEA
>80% stenosis-even if asymtomatic,>70% stenosis and symptomatic, <70% stenosis but symptomatic and refractory to medical management,
blood supply to parathyroids
inferior thyroid artery
antibiotic associated with gallbladder sludge
ceftriaxone
actions of insulin
inhibition of gluconeogenesis,
increse glucose absorption by muscle and fat tissue
which malignancy is highly associated with H.pylori and first line treatment is eradication of H.pylori
gastric MALT
how many calories in a gram of:
protien
carbohydrate
fat
9
4
4
part of the gi tract where calcium is absorbed
duodenum and jejunum
actin
cytoskeleton filament
name the molecular motor proteins
myosin
kinesin
dynein
mmp's bind to _________ and use energy from ________ _________ to generate molecular level movements
cytoskeletal filaments,
atp hydrolysis
myosin
conventional MMP that uses atp hydrolysis to walk toward the plus ends of actin filaments
kinesin
binds with microtubules-has feet that walk along the microtubule toward the plus end in an antegrate fashion
dynein
retrograde transport (toward the minus end of the microtubule).
cytoplasmic: responsible for vesicle trafficing and localization of the golgi within the cell
axonemal dyneins form heterodimers and trimers--fast movement of microtubules in beating of cilia and flagella
misfolded proteins get __________ and degrated in a _____________
ubiquitylated; proteosome
upp pathway
major way by which a cell is able to dispose of damaged protiens. nonlysosomal
protein degradation pathways
rER: degrades misassembled proteins from the ER (not cytoplasm)
lysosomal: autophagy of senescent organelles
UPP: ubiquitin activating enzymes tag protiens with ubiquitin molecules, targeting them for proteosomes
wound healing: max net collagen content in wound will be achieved by which day
day 42
when does collagen secretion by ___________ occur?
fibroblasts secrete collagen, begins 10-72 hours after injury
tensile strength of healing wound at
3 wks?
6 months?
15-30%
85-90%
phases of wound maturation
phase I: inflammation
phase II: proliferation
phase III: maturation
orders of cells migrating to wound during healing
1. platelets
2. neutrophils
3. lymphocytes
4. fibroblasts
what happens during phase I wound healing?
inflammation phase
occurs during first 72 hours
injury to skin cause cell migration
macrophages clean and release chemotaxants
provisional ECM with fibronectin promotes cell migration
cell migration halted by contact inhibition.
epithelialization
cellular proliferation continues
epidermis reconstructed
phase II wound healing
proliferation phase
appearance of fibroblasts
collagen releases
turnover of ECM
granulation tissue formation
angiogenesis stimulated by lactate, acidic environment, low O2
wound contaction (begins at day 4-5) due to myofibroblasts
phase III wound healing
maturation phase
remodeling phase
fibroblasts and macrophages disappear
wound collagen content stabilizes
old collagen broken down, new collagen synthesized
cross link numbers increase significantly
type III collagen replaced by type I
medical management of intermittent claudication
smoking cessation
pletal or plavix therapy
assessment of cardiovascular risk factors
exercise regimen
percentage of patients with intermittent claudication who will respond to medical management
60%
pneumobilia, small bowel obstruction in elderly female: what is the most likely diagnosis
gall stone ileus
most comon infections agent transmitted by blood transfusion
CMV
long thoracic nerve:
what does it branch off of?
innervate?
injury causes?
brachial plexux
serratus anterior
winged scapula
risk factors for endometrial cancer
nulliparitiy
late first pregnancy
obesity
tamoxifen
unopposed estrogen
how to calculate calories in tpn
Percent dextrose in 1 liter= # of grams of dextrose
percent protein in 1 liter= # of grams of protien
fat calories=grams of fat x 8
ovarian cancer limited to both ovaries with no other foci of disease: what stage is this?
stage 1b
treatment for lost pulses in the setting of extremity fracture
reduce the fracture. if not resolved, arteriography
treatment of gall bladder ca that has extended into muscular layer
extended resection with liver segments, then chemo or radiation
mechanism of action for protein S
cofactor for protein C
treatment for ascites leak from umbilical hernia
bedrest
diuresis
IV abx
diuresis
herniorrhaphy before discharge
causes of anion gap metabolic acidosis
Methanol
Uremia
DKA
Polyethylene glycol
Isoniazid
Lactic acidosis
Ethanol
Salycilates
cynide
causes of non-anion gap acidosis
FUSEDCARS
Fistula (pancreatic)
Ureteroenteric conduits
Saline
Endocrine (hyperparathyroidism)
Diarrhea
Carbonic anhydrase inhibitors
Ammonium chloride
Renal tubular acidosis
Spironolactone
elevated INR in pancreatic cancer with liver mets and biliary obstruction
biliary obstruction causes elevated INR due to decreased absorption of fat soluble vitamins (ADEK). lack of Vit K leads to decreased clotting factors (2,7, 9, 10)
treatment for appendiceal carcinoid
if less than 2cm and no cecal, vasculator, or mesoappendiceal involvement, appy is enough
if greater than 2 cm, right hemicolectomy
tumor marker associated with ovarian ca
CA 125
CA 125
elevated in some forms of ovarian ca.
approved to follow response to therapy and prognosis after treatment
useful for detecting recurrence
does not detect early cancers
is not a screening test
standard treatment for DVT
IV heparin for 5-7 days while bridging to coumadin--anticoagulatin for 3 months
indications for IVC filter
brain bleed, multi trauma, gi bleed, cor pulmonale from PE's,
how to treat squamous cell anal ca if nigro protocol fails or radiation contraindicated
APR
pre-op tx for hemophilia A
factor VIII
enterokinase:
secreted from where?
action?
duodenum
converts trypsinogen to trypsin which activates lots of proteolytic enzymes
pre-op treatment for von willebrand's disease
cryoprecipitate or desmopressin
von willebrand's disease:
what is it?
what effects on coag tests?
what type of inheritance?
inherited disease of either deficiency or malfunctioning vWF causing inability of platelets to adhere to subendothelial collagen. can also cause low factor VIII
prolonged bleeding time
autosomal dominant
treatment for iatrogenic CBD injury
if found early?
if found late?
immediate reconstruction with roux en y hepaticojejunostomy
PTC tube, followed by reconstruction 6 weeks later
management of
intraperitoneal bladder rupture?
extraperitoneal bladder rupture?
immediate repair by transabdominal approach and closure in 3 layers. suprapubic cystostomy may be necessary, otherwise foley
foley catheter for 10 to 14 days
principal stimulants for secretion of exocrine pancreas
CCK and vagal stimulation (acetylcholine)
physiological changes in pregnancy
increased WBC to 10-15
increased blood volume by 40-50%
high cardiac output
hemodilutional anemia
gi motility decreases--GERD and constipation
increased GFR
increased fibrinogen
decreased protien S causing hypercoagulable state
hemophilia
what is it?
inheritance pattern?
leupradine prevents what after liver transplantation?
hepatitis B
isoproterenol
beta adrenergic synpathomimetic
potent chronotrope and inotrope
periperal vasodilation
bronchodilation
increased O2 demand (due to chronotropic and inotropic effects)
toxic activity of GN bacterial endotoxin
LPS tail (Lipid A portion)
triggers release of TNF alpha from macrophages
activates compliment
activates clotting cascade
MEN IIA
parathyroid HYPERPLASIA
pheochromocytoma
medullary thyroid ca
MEN IIB
pheochromocytoma
medullary thyroid ca
mucosal neuromas
musculoskeletal abnormalities (marfans)
MEN I
3 p's
parathyroid hyperplasia
pancreatic islet cell tumors (gastrinoma)
pituitary adenoma (prolactinoma)
treatment considerations for different MEN syndromes
MEN I: need to correct hyperparathyroidism first--4 gland resection with autotransplantation, then PPI for ZES if present, may need resection
MEN IIA: medullary thyroid ca number 1 cause of death. need prophylactic total thyroidectomy. threat pheo first
MEN IIB: treat pheo first
genes associated with MEN I and II
I: MENIN gene
II: RET protooncogene
Insulinoma
most common islet cell tumor of panc
whipples triad: fasting hypoglycemia, hypoglycemic symptoms, releif with glucose
85-95 percent benign
treat mets with streptozocin, octrotide, 5FU
Gastrinoma
ZE sydrome
most common panc tumor in MEN I patients
50% malignant and multiple
75% spontaneous
25% assoc with MEN I
gastrinoma triangle
refractory ulcer dz, diarrhea
serum gastrin > 200, >1000 diagnostic
tx: enucleate if <2cm, resect if >2cm
find inside duodenum
use somatostant receptor scintography to locate tumor
somatostatinoma
rare
sx: DM, gallstones, steatorrhea, hypochlohydria
most are malignant
most are located in head of panc
perform chole with resection
glucagonoma
sx: DM, stomatitis, dermatitis, wt loss
dx with fasting glucagon level
most are malignant
most are found in tail of pancreas
VIP oma
WDHA
dx: exclusion, increased VIP
most are malignant
most are in distal panc
neurosensory transmitter for the colon
substance P and calcitonin gene-related peptide
dramatic increase in collagen content of wound at which days
begins at day 3 and is max by day 21
antibody responsible for HIT
platelet factor 4
staging of breast ca
I: <2cm, N0
IIa: <2cm, N1, or 2-5cm, N0
IIb: 2-5cm, N1 or <2cm, N0
IIIa: T0-3, N2 or T3, N1-2
IIIb: T4 (chest wall, skin, inflammatory) or N3
IV: any M
nodal staging in breast ca:
N1: ipsilateral axillary
N2: fixed ipsilateral axillary
N3: ipslilateral internal mammary
ludwig's angina
pain associated with life-threatening cellulitis of the floor of the mouth in setting of dental infection
virchow's node
stomach ca met to supraclavicular node
parotiditits
pain at angle of mandible, infection of parotid usually staph
warthins tumor
2nd most frequent benign salivary gland tumor
more often occurs in males
10% are bilateral
painless mass
ranson's criteria
24 hours after admission
predicts mortality in pt's with acute pancreatitis
age>55
glucose>200
wbc>16
LDH>350
AST(SGOT)>250
ranson's criteria
48 hours after admission
hct drop>10%
bun increase
Ca <8
arterial pO2 < 60
base deficit >4
fluid needs greater than 6L
predictive value of ranson's criteria
0-2: 2% mortality
3-4: 15% mortality
5-6: 40% mortality
7-8: 100% mortality
ghrelin
enzyme that stimulates hunger. produced in stomach. one of the reasons that gastric bypass works to suppress appetite
left shift on oxygen/hemoglobin association curve
increased affinity for O2, impaired unloading
alkalosis
decreased 2,3 dpg
decreased temperature
right shift in oxygen, hemoglobin dissociation curve
increased unloading, decreased affinity of oxygen for hemoglobin
acidosis
increased temperature
increased 2,3 dpg
sites of breast ca mets
bone--50%
lung--20%
pleura--15%
soft tissue--10%
liver--10%
cell origin of most ovarian cancers
epithelial
cell type responsible for fever during atelectasis
alveolar macrophages via IL-1
type 1 and 2 pneunocytes
1: functional gas exchange
2: surfactant
most common causes of pyogenic liver abscesses
1. cholangitis
2. diverticulitis
3. appendicitis
FAP:
inheritance pattern?
gene involved?
increased risk for what other cancers?
autosomal dominant
APC on chromosome 5
periampullary cancer (duodenal)
treatment of pancreatic necrosis
pancreatic necrosis with signs of sepsis-->aspirate
if infected (organisms found)-->broad spectrum abx and drainage or pancreatic necrosectomy
laparotomy with debridement and wide sump drainage, or...
laparotomy with debridement, open packing and repacking
how is resistance to penicillin acquired by bacteria?
enzymatic degradation: acquire plasmids with genes for beta-lactamase
how do bacteria acquire resistance to vancomycin?
change in cell wall protein
bacterioSTATIC antibiotics
tetracyclines
chloramphenicol
clindamycin
lincomycin
sulfonamides
TMP
dapsone
INH
macrolides
bacterioCIDAL antibiotics
rifampin
quinolones
aminoglycosides
penicillins
MCC of bloody nipple discharge
intraductal papilloma
size of non-function adrenal mass at which surgery should be performed
>6cm
Lynch syndromes
I: colorectal cancer by age 44, proximal colon
II: associated with extracolonic cancers: endometrial, ovarian, gastric, small intestine, pancreatic, ureteral
most common parotid tumor
pleomorphic adenoma: mixture of epithelial and myoepithelial elements in variable background stroma that can be mucoid, myxoid, cartilaginous, or hyaline
size of splenic artery aneurysm for which surgical repair should be recommended for pregnant women.
>2cm
boundaries of complete axillary lymph node dissection
axillary vein superiorly
latissimus dorsi laterally
upper outer breast tissue inferiorly
lateral border of pecs medially
non-depolarizing neuromuscular blockade
pancuronium
vecuronium
atracurium
depolarizing paralytics
succinylcholine
most common side effect of pancuronium and other non-depolarizing paralytics
chemotherapeutic agent with major side effect of cardiotoxicity
adriamycin
rule of 5's when placing swan-ganz catheter
40 cm from right IJ to PA
45 cm form right subclavian to PA
50 cm from left IJ to PA
55cm from left subclavian to PA
pulmonary sequestrations:
what are they?
what is the vascular abnormality?
how are they treated?
congenital lesions also known as cystic lung disease. piece of lung tissue is not attached to pulmonary blood supply and does not communicate with other lung tissue
arterial supply is always systemic, drainage is either systemic or pulmonary
treatment is thoracotomy and resection
major complications of a Nissen
dysphagia (wrap too tight)
perforation
both complications occur about 1% of the time
branching of hepatic artery
common hepatic artery is branch of celiac trunk
GDA is branch of common hepatic
right gastric is branch of common hepatic
proper hepatic distal to common hepatic
proper branches into right and left hepatic
cystic artery is branch of right hepatic
signs of malignant hyperthermia
first: increased end tidal CO2
very high temperature
tachycardia
tachypnea
increased O2 consumption
rigors
rhabdomyolysis
circulatory collapse
what to do if perforated esophagus during endoscopy for achalasia
immediate thoracotomy and repair.
which clotting factor is not synthesized in the liver
factor VIII
after biopsy of GE junction tumor shows adenocarcinoma, what is the next step in staging
endoscopic ultrasound to asses depth of invasion and presence of periesophageal lymph nodes
then CT C/A/P to evaluate for metastatic dz
bronch if proximal lesion
FAP
inheritance pattern
gene involved (and type of gene)
tumor location
other associated cancers/tumors
autosomal dominant, 100% penetrance by 35yo
APC-- a tumor suppressor gene
left sided tumors
desmoid tumors, periampullary ca, hepatobiliary tumors
gold standard for diagnosing amoebic vs. pyogenic liver abscesses
serology: positive flourescent antibody for E histolytica is diagnostic for patients with suspected amebiasis
skin lesion seen with coumadin therapy
patches erythema and dark necrosis seen over the posterior thighs and buttocks which occurs in patients with protein C deficiency
what is vital capacity
maximum amount of air a person can exhale after maximum inspiration.
IRV plus TV (inspiratory capacity ) plus experitory reserve volume
normal vital capacity 3-5 liters
treatment of gallstone pancreatitis
supportive care
bowel rest
iv fluids
nutrition support
NG tube
ERCP
lap chole with IOC after resolution of pancreatitis
most common cause of bacteremia in hospitalized patients
central line sepsis
what can activate trypsinogen to trypsin
enterokinase
acidic environment
cowdens disease
hereditary hamartomatous polyposis syndrome
hamartomas of colon and stomach
associated mucocutaneous lesions
thyroid adenomas/goiter
fibroadenoma/fibrocystic disease of breasts
uterine leiomyomas
macrocephaly
10% risk of thyroid ca
50% risk of breast ca
no increased risk of colon ca
most common tumor in women younger than 35
fibroadenomas of breast
renal vein, artery, pelvis: order encountered anterior to posterior
vein, artery, then pelvis
treat homocystinuria with which vitamin
vitamin B6 (pyridoxine)
internal mammary:
what does it branch from?
what is its course
what are its branches
first branch of subclavian artery
descends behind cartilages of upper 6 ribs medially
gives of pericardiophrenic, mediastinal, pericardial, sternal, anterior intercostal and perforators.
terminal branches: musculophrenic and superior epigastric
left gonadal vein drains into?
right gonadal vein drains into?
left renal vein
inferior vena cava
most common symptom in pt's presenting with pituitary adenoma
bitemporal hemianopsia
tumor marker in colon cancer
CEA
treatment of non-displaced iscial rami fracture
non-weight bearing for 2 weeks
treatment for displaced pelvic and longbone fractures
external fixation
surgical treatment for open book pelvic fractures
dcp plate
typhilitis
neutropenic enterocolitis
seen in immunocompromised patients
on CT--dilated cecum and pericolic stranding
treat with conservative therapy (bowel rest, NG tube, abx)
surgical treatment: cecal tube, resection
topical agent associated with metabolic acidosis in burn patients
sulfamylon--carbonic anhydrase inhibitor
how does pancreatic necrosis look on CT
lack of contrast enhancement of pancreatic parenchyma
if surgery is indicated, ethmoidectomy and removal of a portion of lamina papyracea
potts puffy tumor
soft tissue swelling due to subperiosteal abscess over the frontal sinus
staph aureus
treatment of sialadenitis
IV abx against staph aureus
heat application to parotid
IV hydration
lemon drops
surgical drainage of any abscess
contents of foramen ovale
V3
accesory meningeal artery
petrosal nerve
emissary vein
most common cause of epiglottitis
H. influenza
study used to monitor response to therapy for malignant otitis externa
gallium-67 scan (gallium gets incorporated into macrophages and RES cells as gallium-lactoferrin complex). reverts to normal once resolution of infection progresses
location of most branchial cleft cysts
second branchial cleft system
small pit in skin just anterior to the lower third of the sternocleidomastoid muscle
