1. Which enzyme is the most potent activator of trypsinogen
  2. Treatment for incidentally found meckels in an adult
    No treatment is required
  3. Treatment for symptomatic meckels diverticulum
    Resection of the meckels and end-to-end anastomosis
  4. 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
  5. What is an esophageal mass lesion that causes dyphagia but has normal mucosa grossly and on microscopy?
    esophageal leiomyoma
  6. What is the treatment for esophageal leiomyoma?
    submucosal enucleation
  7. 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
  8. Most appropriate treatment for incidentally found terminal ileitis during appendectomy
    proceed with appy, but do not resect ileum
  9. Blood supply to the cervical esophagus
    inferior thyroid artery
  10. Where are VIPomas most commonly found?
    pancreatic body and tail
  11. Pancreatic lesion associated with watery diarrhea
  12. What is the cause of intestinal atresias?
    Intrauterine vascular accidents for all atresisas except duodenal which are caused by failure to recannulize
  13. actions of VIP
    • -vasodilator
    • -stimulates pancreatic and intestinal secretion
    • -inhibits gastric acid secretion
  14. symptoms of VIPoma
    • watery diarrhea
    • hypokalemia
    • achlorhydia or hypochlorydia
    • (WDHA)
    • metabolic acidosis
    • flushing
  15. What test can be done to find VIPoma
    octreoscan (somatostatin receptor scintigraphy)
  16. What percentage of VIPomas are malignant
  17. Most common location for VIPomas
    body or tail of the pancreas
  18. Medical treatment for VIPoma
    octreotide therapy
  19. Tumors that secrete VIP
    • GI carcinoids--10% of VIP secreting tumors
    • ganglioneuroblastomas
    • mastocytomas
    • small cell carcinomas of the lung
    • pheochromocytomas
  20. 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
  21. what reduces the deleterious effects of steroids on wound healing?
    vitamin A
  22. 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
  23. First muscles to relax after administration of general anesthesia
    face and neck muscles
  24. last muscles to be paralyzed after the administration of general anesthesia
  25. What is a pancoast tumor
    • apical lung neoplasm
    • causes SVC compression and horner syndrome
  26. What is Horner Syndrome
    compression of the sympathetic chain. causess oculosympathetic palsy: pitosis, meiosis, ipsilateral anhidrosis, enopthalmos
  27. antibiotics likely to cause erythema multiforme or stevens-johnson syndrome
    bactrim (sulfas)
  28. 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
  29. activated T-cells produce which interleukin
  30. Activated macrophages produce which interleukin
  31. function of IL-2
    proliferation of T-cells
  32. Function of IL-1
    • stimulates T-cells
    • activates antigen presenting cells
    • regulates B-cell antibody production
    • promotes hematopoiesis
  33. Function of IL-7
    development of T and B-cell precursors
  34. IL 7 secreted by:
    thymus and bone marrow stromal cells
  35. what contributes to the function of the LES
    • cardiac notch
    • circular muscles of the lower esophagus
  36. most common complication of protamine reversal of heparin

    (protamine is made from fish sperm)
  37. marfan's syndrome inheritance pattern, genes involved
    autosomal dominant

    fibrillin gene (fbn1 or fbn2)
  38. definition of prevalence
    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
  39. treatment for LCIS
    counseling and close follow-up.
  40. sigmoid volvulus: findings on plain film
    dilated loop of colon pointing to the right upper quadrant
  41. treatment for sigmoid volvulus
    no peritoneal signs, stable patient: sigmoidoscopic reduction followed by resection

    peritoneal signs: ex-lap, sigmoid resection,
  42. signs of abdominal compartment syndrome
    • --abdominal distention
    • --increased peak airway pressure
    • --oliguria-->anuria
    • --decreased cardiac output
    • --hypotension
  43. most common cortisol secreting tumor
    adrenocortical tumor
  44. paget schroetter syndrome
    thoracic outlet syndrome plus effort vein thrombosis
  45. symptoms of paget schroetter
    acute arm pain, swelling, edema, palpaple pulse, neuro intact
  46. most common islet cell tumor in MEN 1
  47. MEN 1 tumors
    • 1. pancreatic islet cell tumors
    • 2. parathyroid adenomas
    • 3. pituitary tumors
  48. gene implicated in MEN1
  49. gastrinoma triangle
    junction of the CBD, cystic duct, and 2nd and 3rd portions of the duodenum, and the neck and body of the pancreas
  50. most common pancreatic islet cell tumors in MEN 1
    • gastrinomas
    • insulinomas
  51. zolinger ellison syndrome
    hypersectretion of gastrin causing excess HCl
  52. most common bacteria seen in the biliary tract
    E. coli
  53. 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
  54. most common liver tumor
  55. most common organism in mastitis
    staph aureus
  56. zenker's diverticulum:
    true diverticulum?
    Where do they occur?
    Associated with what other GI problems?
    Classic symtoms?
    • 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
  57. Brown Sequard syndrome
    ipsilateral motor loss and contralateral sensory loss
  58. Budd-Chiari syndrome
  59. cell type most responsible for hepatic fibrosis
    stellate cells
  60. component of the GCS that is most predictive of outcome
  61. lifetime risk of ovarian cancer in patients with BRCA 1?
    • BRCA-1: 40%
    • BRCA-2: 18%
  62. Risk of breast cancer in patients with BRCA-1? BRCA-2?
    • BRCA-1: 55-85%
    • BRCA-2: 55-85%
  63. cancers associated with BRCA-1? BRCA-2?
    • BRCA-1: breast
    • BRCA-2: male breast cancer, pancreatic ca, melanoma, ovarian ca
  64. indication for CEA
    >80% stenosis-even if asymtomatic,>70% stenosis and symptomatic, <70% stenosis but symptomatic and refractory to medical management,
  65. blood supply to parathyroids
    inferior thyroid artery
  66. antibiotic associated with gallbladder sludge
  67. actions of insulin
    • inhibition of gluconeogenesis,
    • increse glucose absorption by muscle and fat tissue
    • promote protein synthesis
    • promote glycogen synthesis
    • promote fatty acid synthesis
  68. conn's syndrome
    • primary hyperaldosteronism
    • hypertension with hypokalemia
    • hypokalemia causes fatigue, muscle weakness, polyuria, polydypsia, impaired insulin, hyperglycemia
    • caused by adrenal adenoma or bilateral adrenal hyperplasia
  69. testicular tumor(s) associated with increased beta hcg
    germ cell tumor or seminoma
  70. gram negative sepsis with hypotension is due to
    nitrous oxide that is released in response to LPS-A
  71. stewart-treves syndrome
    • lymphangiosarcoma following mastectomy.
    • result of chronic swelling from lymphedema
    • tx: wide local excision with possible xrt
    • poor prognosis
  72. blood oxygen content is determined by:
    • hemoglobin content of blood
    • saturation of hemoglobin
    • very little is contributed by dissolved O2
  73. pancreatic cancer serum markers
    • ca 19-9
    • cea
  74. most important factor affecting survival post-whipple
    margin status (not node status)
  75. nerves at risk during axillary dissection
    • intercostobrachial nerve: causes upper arm numbness
    • thoracodorsal: poor shoulder adduction
    • long thoracic: winged scapula
  76. tumor suppressor genes
    • p53
    • DCC
    • APC
  77. proto oncogenes
    k ras
  78. topical antimicrobial that can cause metabolic acidosis
    mafenide acetate: carbonic anhydrase inhibitor causing hyperchloremic metabolic acidosis
  79. painless, fixed anterior neck mass is most likely
    met from squamous head and neck neoplasms
  80. posterior neck nmasses are most likely
  81. treatment for squamous cell ca of the anal canal
    • nigro protocol: radiation
    • 5-FU
    • mitomycin
  82. most common benign neoplasm of liver
  83. local anesthetic most likely to cause allergic reaction
    ester class: novocain (procain), benzocaine
  84. treatment for hepatocellular carcinoma:

    less than 5cm
    multiple masses less than 3 cm
    greater than 5 cm
    • liver transplant
    • liver transplant
    • excision
  85. child's classification of liver failure is based upon which factors
    • bilirubin
    • albumin
    • PT
    • ascites
    • neuro disorders
  86. brain death criteria
    • lack of brain stem reflexes (doll's eyes, cold calorimetry, corneal, gag, cough)
    • lack of motor response to noxious stimuli
    • lack of pupilary response
    • apnea: no resp drive with pCO2 60mmHg
  87. most common bacterium in colon
    bacteroides (and other anaerobes)
  88. when do you elevate depressed skull fractures and why?
    when depression is greater than 5mm or more than 1 full-thickness width

    to decrease the risk of seizures.
  89. how to treat duodenal atresia
    side to side duodenoduodenostomy with decompressive g-tube
  90. chromosome responsible for MEN-II
    chromosome 10
  91. primary effects of heparin
    stimulates antithrombin III
  92. normal svo2 and what PO2 corresponds to it
    75 (40)
  93. 3 reasons for marginal ulcers
    • incomplete vagotomy
    • incomplete antrectomy
    • Z-E syndrome
  94. objective measure of true compartment syndrome
    compartmental pressure of >30mmHg
  95. zones of the neck
    • I: sternal notch to cricoid
    • II: cricoid to angle of the mandible
    • III: angle of the mandible to base of the skull
  96. milroy's disease
    hereditary lymphedema, onset at infancy (usually) caused by failure of lymphatics to develop properly
  97. what is the target of OKT3
    CD3 receptor
  98. maximum preservation time for
    Small Bowel?
    • kidneys: 48 hrs
    • pancreas: 24 hrs
    • liver: 12 hrs
    • heart, lung, small bowel: 8 hrs
  99. treatment of CMV
  100. phyllodes tumor
    • stromal lesion consisting of epithelial and mesenchymal cells.
    • most (>90%) are benign and related to fibroadenoma
  101. pagets disease of breast
    invasive ductal carcinoma involving nipple aroela complex treated with modified radical mastectomy
  102. what percentage of blood flow to the liver is from the hepatic artery? from the portal vein?
    • 75percent from the portal vein
    • 25 percent from the hepatic artery
  103. most of the blood supply to hepatic mets comes from which vessel
    hepatic artery
  104. what is the landmark for dividing the proper hepatic artery and the common hepatic artery?
  105. which artery provides most of the blood to bile ducts
    hepatic artery
  106. which artery, when mistaken for the cystic artery, is a cause of complication during lap chole
    right hepatic artery
  107. signs of lidocaine toxicity
    tinnitus, restlessness, nystagmus, facial muscle tremors, anxiety, seizure
  108. what to do for patients having a severe reaction to local anesthetic
    • stop injection
    • airway management
    • ventilate
    • evaluate circulation
    • drugs if needed
    • oxygen
  109. mechanism of action of NO
    gas that permeates through cell membranes instead of acting at a signal transduction mechanism
  110. what is the clo test
    rapid urease test of mucosal biopsy specimen
  111. gold standard test for H. pylori? additional tests?
    • histology (confirm clo test)
    • urea breath test
    • culture and sensitivity
  112. resuscitation of children
    • 20ml/kg of LR rapid bolus, repeated once
    • if continued deterioration, 10ml/kg packed cells
  113. goodsall's rule regarding anal fistula in ano
    anterior fistulas connect with rectum in straight line, posterior fistulas curve toward the midline internal opening in the rectum
  114. definition of anal fissures
    • linear tear in the anal mucosa
    • pain and bleeding common
    • most occur in posterior midline
    • look for ibd or hiv with anterior fissures
    • treat with lateral internal sphincerotomy after six wks of med management
    • med management includes botulinum toxin (effective treatment in 95% of patients
  115. half life of albumin? pre-albumin
    • 21 days.
    • 1.9 days
  116. decrease hemoglobin affinity for oxygen (right shift) (O2 unloading)
    • increased CO2
    • increased temperature,
    • increased ATP
    • Increased 2,3 DPG
    • increase hydrogen (decreased pH) (increased acidity)
  117. stimulus for pancreatic water and electrolyte secretion
  118. where are pancreatic digestive enzymes stored? what causes their release?
    • acinar cells
    • released in response to cck and vagal stimulation
  119. what are the pancreatic exocrine enzymes?
    • proteases: trypsin, chymotripsin, carboxypeptidase, elastase,
    • nucleases: ribonuclease, deoxyribonuclease,
    • lipolytic: lipase, colipase, phospholipase
    • amylolytic (starch): amylase, lipase,
  120. activation of trypsinogen to trypsin
  121. lipase breaks down fat into
    glycerol and fatty acids
  122. endocrine function of pancreas
    • islets of langerhans--3 cell types:
    • alpha cells: secrete glucagon
    • beta cells: secrete insulin
    • delta cells: secrete somatostatin
  123. which malignancy is highly associated with H.pylori and first line treatment is eradication of H.pylori
    gastric MALT
  124. how many calories in a gram of:
    • 9
    • 4
    • 4
  125. part of the gi tract where calcium is absorbed
    duodenum and jejunum
  126. actin
    cytoskeleton filament
  127. name the molecular motor proteins
    • myosin
    • kinesin
    • dynein
  128. mmp's bind to _________ and use energy from ________ _________ to generate molecular level movements
    cytoskeletal filaments,

    atp hydrolysis
  129. myosin
    conventional MMP that uses atp hydrolysis to walk toward the plus ends of actin filaments
  130. kinesin
    binds with microtubules-has feet that walk along the microtubule toward the plus end in an antegrate fashion
  131. 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
  132. misfolded proteins get __________ and degrated in a _____________
    ubiquitylated; proteosome
  133. upp pathway
    major way by which a cell is able to dispose of damaged protiens. nonlysosomal
  134. 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
  135. wound healing: max net collagen content in wound will be achieved by which day
    day 42
  136. when does collagen secretion by ___________ occur?
    fibroblasts secrete collagen, begins 10-72 hours after injury
  137. tensile strength of healing wound at
    3 wks?
    6 months?
    • 15-30%
    • 85-90%
  138. phases of wound maturation
    • phase I: inflammation
    • phase II: proliferation
    • phase III: maturation
  139. orders of cells migrating to wound during healing
    • 1. platelets
    • 2. neutrophils
    • 3. lymphocytes
    • 4. fibroblasts
  140. 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
  141. 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
  142. 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
  143. medical management of intermittent claudication
    • smoking cessation
    • pletal or plavix therapy
    • assessment of cardiovascular risk factors
    • exercise regimen
  144. percentage of patients with intermittent claudication who will respond to medical management
  145. pneumobilia, small bowel obstruction in elderly female: what is the most likely diagnosis
    gall stone ileus
  146. most comon infections agent transmitted by blood transfusion
  147. long thoracic nerve:
    what does it branch off of?
    injury causes?
    • brachial plexux
    • serratus anterior
    • winged scapula
  148. risk factors for endometrial cancer
    • nulliparitiy
    • late first pregnancy
    • obesity
    • tamoxifen
    • unopposed estrogen
  149. 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
  150. ovarian cancer limited to both ovaries with no other foci of disease: what stage is this?
    stage 1b
  151. treatment for lost pulses in the setting of extremity fracture
    reduce the fracture. if not resolved, arteriography
  152. treatment of gall bladder ca that has extended into muscular layer
    extended resection with liver segments, then chemo or radiation
  153. mechanism of action for protein S
    cofactor for protein C
  154. treatment for ascites leak from umbilical hernia
    • bedrest
    • diuresis
    • IV abx
    • diuresis
    • herniorrhaphy before discharge
  155. causes of anion gap metabolic acidosis
    • Methanol
    • Uremia
    • DKA
    • Polyethylene glycol
    • Isoniazid
    • Lactic acidosis
    • Ethanol
    • Salycilates
    • cynide
  156. causes of non-anion gap acidosis
    • Fistula (pancreatic)
    • Ureteroenteric conduits
    • Saline
    • Endocrine (hyperparathyroidism)
    • Diarrhea
    • Carbonic anhydrase inhibitors
    • Ammonium chloride
    • Renal tubular acidosis
    • Spironolactone
  157. 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)
  158. 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
  159. tumor marker associated with ovarian ca
    CA 125
  160. 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
  161. standard treatment for DVT
    IV heparin for 5-7 days while bridging to coumadin--anticoagulatin for 3 months
  162. indications for IVC filter
    brain bleed, multi trauma, gi bleed, cor pulmonale from PE's,
  163. how to treat squamous cell anal ca if nigro protocol fails or radiation contraindicated
  164. pre-op tx for hemophilia A
    factor VIII
  165. enterokinase:
    secreted from where?
    • duodenum
    • converts trypsinogen to trypsin which activates lots of proteolytic enzymes
  166. pre-op treatment for von willebrand's disease
    cryoprecipitate or desmopressin
  167. 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
  168. 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
  169. 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
  170. principal stimulants for secretion of exocrine pancreas
    CCK and vagal stimulation (acetylcholine)
  171. 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
  172. hemophilia
    what is it?
    inheritance pattern?
  173. leupradine prevents what after liver transplantation?
    hepatitis B
  174. isoproterenol
    • beta adrenergic synpathomimetic
    • potent chronotrope and inotrope
    • periperal vasodilation
    • bronchodilation
    • increased O2 demand (due to chronotropic and inotropic effects)
  175. toxic activity of GN bacterial endotoxin
    • LPS tail (Lipid A portion)
    • triggers release of TNF alpha from macrophages
    • activates compliment
    • activates clotting cascade
  176. MEN IIA
    • parathyroid HYPERPLASIA
    • pheochromocytoma
    • medullary thyroid ca
  177. MEN IIB
    • pheochromocytoma
    • medullary thyroid ca
    • mucosal neuromas
    • musculoskeletal abnormalities (marfans)
  178. MEN I
    • 3 p's
    • parathyroid hyperplasia
    • pancreatic islet cell tumors (gastrinoma)
    • pituitary adenoma (prolactinoma)
  179. 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
  180. genes associated with MEN I and II
    • I: MENIN gene
    • II: RET protooncogene
  181. 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
  182. 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
  183. somatostatinoma
    • rare
    • sx: DM, gallstones, steatorrhea, hypochlohydria
    • most are malignant
    • most are located in head of panc
    • perform chole with resection
  184. glucagonoma
    • sx: DM, stomatitis, dermatitis, wt loss
    • dx with fasting glucagon level
    • most are malignant
    • most are found in tail of pancreas
  185. VIP oma
    • WDHA
    • dx: exclusion, increased VIP
    • most are malignant
    • most are in distal panc
  186. neurosensory transmitter for the colon
    substance P and calcitonin gene-related peptide
  187. dramatic increase in collagen content of wound at which days
    begins at day 3 and is max by day 21
  188. antibody responsible for HIT
    platelet factor 4
  189. 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
  190. nodal staging in breast ca:
    • N1: ipsilateral axillary
    • N2: fixed ipsilateral axillary
    • N3: ipslilateral internal mammary
  191. ludwig's angina
    pain associated with life-threatening cellulitis of the floor of the mouth in setting of dental infection
  192. virchow's node
    stomach ca met to supraclavicular node
  193. parotiditits
    pain at angle of mandible, infection of parotid usually staph
  194. warthins tumor
    • 2nd most frequent benign salivary gland tumor
    • more often occurs in males
    • 10% are bilateral
    • painless mass
  195. 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
  196. 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
  197. predictive value of ranson's criteria
    • 0-2: 2% mortality
    • 3-4: 15% mortality
    • 5-6: 40% mortality
    • 7-8: 100% mortality
  198. ghrelin
    enzyme that stimulates hunger. produced in stomach. one of the reasons that gastric bypass works to suppress appetite
  199. left shift on oxygen/hemoglobin association curve
    • increased affinity for O2, impaired unloading
    • alkalosis
    • decreased 2,3 dpg
    • decreased temperature
  200. right shift in oxygen, hemoglobin dissociation curve
    • increased unloading, decreased affinity of oxygen for hemoglobin
    • acidosis
    • increased temperature
    • increased 2,3 dpg
  201. sites of breast ca mets
    • bone--50%
    • lung--20%
    • pleura--15%
    • soft tissue--10%
    • liver--10%
  202. cell origin of most ovarian cancers
  203. cell type responsible for fever during atelectasis
    alveolar macrophages via IL-1
  204. type 1 and 2 pneunocytes
    • 1: functional gas exchange
    • 2: surfactant
  205. most common causes of pyogenic liver abscesses
    • 1. cholangitis
    • 2. diverticulitis
    • 3. appendicitis
  206. FAP:
    inheritance pattern?
    gene involved?
    increased risk for what other cancers?
    • autosomal dominant
    • APC on chromosome 5
    • periampullary cancer (duodenal)
  207. 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
  208. how is resistance to penicillin acquired by bacteria?
    enzymatic degradation: acquire plasmids with genes for beta-lactamase
  209. how do bacteria acquire resistance to vancomycin?
    change in cell wall protein
  210. bacterioSTATIC antibiotics
    • tetracyclines
    • chloramphenicol
    • clindamycin
    • lincomycin
    • sulfonamides
    • TMP
    • dapsone
    • INH
    • macrolides
  211. bacterioCIDAL antibiotics
    • rifampin
    • quinolones
    • aminoglycosides
    • penicillins
  212. MCC of bloody nipple discharge
    intraductal papilloma
  213. size of non-function adrenal mass at which surgery should be performed
  214. Lynch syndromes
    • I: colorectal cancer by age 44, proximal colon
    • II: associated with extracolonic cancers: endometrial, ovarian, gastric, small intestine, pancreatic, ureteral
  215. most common parotid tumor
    pleomorphic adenoma: mixture of epithelial and myoepithelial elements in variable background stroma that can be mucoid, myxoid, cartilaginous, or hyaline
  216. size of splenic artery aneurysm for which surgical repair should be recommended for pregnant women.
  217. boundaries of complete axillary lymph node dissection
    • axillary vein superiorly
    • latissimus dorsi laterally
    • upper outer breast tissue inferiorly
    • lateral border of pecs medially
  218. non-depolarizing neuromuscular blockade
    • pancuronium
    • vecuronium
    • atracurium
  219. depolarizing paralytics
  220. most common side effect of pancuronium and other non-depolarizing paralytics
    tachycardia, increased cardiac output, hypertension
  221. most common side effect of depolarizing paralytics
    succinylcholine: bradycardia
  222. steps in RSI
    • lidocaine: 1.5mg/kg IVP (for increased ICP or pts with reactive airway
    • atropine: 0.5mg IVP for bradycardia
    • Etomidate: 0.3mg/kg IV (max 40mg)
    • succinylcholine: 1.5mg/kg IV (max 150mg) (will cause fasciculations)
  223. side effects of succinylcholine
    • fasciculations
    • hyperkalemia
    • bradycardia
    • prolonged neuromuscular blockade
    • malignant hyperthermia
  224. reversal agent for succinylcholine if patient does not lose paralysis
    neostigmine 0.5 to 2mg IV
  225. sequence of pre-op preparation for removal of pheochromocytoma
    • phenoxybenzamine (alpha blockade) FIRST
    • then propranolol
    • salt load
    • steriods
  226. most commonly injured structure during lower extremity fasciotomy
    common peroneal nerve
  227. arimidex
    • aromatase inhibitor: blocks synthesis of estrogen
    • used for ER positive tumors in post-menopausal women
    • reduces local recurrence and mortality
    • reduced risk of DVT
    • reduced risk of endometrial ca
  228. for patients with liver or renal disease, which is the best paralytic to use in RSI
    cis-atracurium due to hoffman degradation in plasma rather than metabolism by liver or kidneys
  229. fibromuscular dysplasia
    • autosomal dominant
    • frequently affects renal arteries
    • thickening of the intima, media, or adventitia
    • responds well to angioplasty
    • most common sites in order: renal arteries, carotids, abdominal visceral arteries
  230. characteristics of HER-2/neu positive tumors
    • more aggressive breast cancer
    • herceptin is used to provide survival benefit
    • more frequently ER negative
    • more likely metastatic
  231. blood supply to the pancreas
    • head: superior pancreaticoduodenal from GDA (branch of hepatic artery from celiac trunk) and inferior pancraticoduodenal from SMA
    • body and tail: variable. dorsal pancreatic from the splenic or from branches of gastroepiploic
    • venous drainage: all ends up in portal vein
  232. production of bilirubin
    • macrophages break down RBC's and break heme down to biliverdin
    • biliverdin reduces to unconjugated bilirubin
  233. haptoglobin
    binds to free circulating hemoglobin. hapto/hemo compound is removed from circulation in the spleen
  234. stercobilin
    breakdown product of bilirubin excreted in feces. give brown color
  235. cushing's syndrome: symptoms
    • central obesity
    • glucose intolerance
    • hypertension
    • plethora
    • hirsutism
    • osteoporosis
    • nephrolithiasis
    • mentrual problems
    • muscle weakness
    • depression
  236. cushing's syndrome: most common causes
    • #1: iatrogenic (corticosteriod administration)
    • #2: cushing disease--ACTH secreting pituitary adenoma
    • #3: adrenal adenoma (10%)
    • #4: ectopic CRH syndrome (<1%)
  237. side effects of cyclophosphamide
    • alopecia
    • nausea/vomiting
    • hemorrhagic systisis
    • intestinal toxicity
  238. chemotherapeutic agent with major side effect of cardiotoxicity
  239. 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
  240. 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
  241. major complications of a Nissen
    • dysphagia (wrap too tight)
    • perforation

    both complications occur about 1% of the time
  242. 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
  243. signs of malignant hyperthermia
    • first: increased end tidal CO2
    • very high temperature
    • tachycardia
    • tachypnea
    • increased O2 consumption
    • rigors
    • rhabdomyolysis
    • circulatory collapse
  244. what to do if perforated esophagus during endoscopy for achalasia
    immediate thoracotomy and repair.
  245. which clotting factor is not synthesized in the liver
    factor VIII
  246. 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
  247. 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
  248. gold standard for diagnosing amoebic vs. pyogenic liver abscesses
    serology: positive flourescent antibody for E histolytica is diagnostic for patients with suspected amebiasis
  249. 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
  250. 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
  251. treatment of gallstone pancreatitis
    • supportive care
    • bowel rest
    • iv fluids
    • nutrition support
    • NG tube
    • ERCP
    • lap chole with IOC after resolution of pancreatitis
  252. most common cause of bacteremia in hospitalized patients
    central line sepsis
  253. what can activate trypsinogen to trypsin
    • enterokinase
    • acidic environment
  254. 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
  255. most common tumor in women younger than 35
    fibroadenomas of breast
  256. renal vein, artery, pelvis: order encountered anterior to posterior
    vein, artery, then pelvis
  257. treat homocystinuria with which vitamin
    vitamin B6 (pyridoxine)
  258. 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
  259. left gonadal vein drains into?
    right gonadal vein drains into?
    • left renal vein
    • inferior vena cava
  260. most common symptom in pt's presenting with pituitary adenoma
    bitemporal hemianopsia
  261. tumor marker in colon cancer
  262. treatment of non-displaced iscial rami fracture
    non-weight bearing for 2 weeks
  263. treatment for displaced pelvic and longbone fractures
    external fixation
  264. surgical treatment for open book pelvic fractures
    dcp plate
  265. 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
  266. topical agent associated with metabolic acidosis in burn patients
    sulfamylon--carbonic anhydrase inhibitor
  267. how does pancreatic necrosis look on CT
    lack of contrast enhancement of pancreatic parenchyma
  268. characteristic CT scan findings for:
    focal nodular hyperplasia
    simple cysts
    • peripheral nodular enhancement and progressive centripetal filling
    • kupffer cells allow uptake of sulfa-colloid, enhancement on technetium scan
    • fluid filled structures with thin walls, no septations
    • hypervascular lesion with early filling
  269. HNPCC:
    inheritance pattern
    genes involved and type of gene
    tumor location
    associated cancers
    medical management
    • autosomal dominant
    • hMSH2 or hMLH1, DNA repair genes
    • proximal
    • endometrial, ovarian, renal and urinary tract
    • sulindac and celebrex reduce the size and number of polyps
  270. characteristics at endoscopy that predict high risk of rebleeding from a gastric ulcer
    • active pulsatile bleeding
    • visible vessel
  271. bowens disease
    • intraepidermal SCC of anal margin
    • treated with WLE
  272. paget's disease of anal margin
    • intraepidermal adenocarcinoma
    • treated with WLE
  273. tx for basal cell carcinoma of anal margin
  274. Treatment of SCC of
    anal CANAL?
    anal MARGIN?

  275. metabolic derangement in infant with pyloric stenosis
    • HYPOchloremic
    • HYPOkalemic
    • metabolic ALKALOSIS
  276. most common malignant tumor of parotid?
    most common overall tumor of parotid?
    mucoepidermoid carcinoma

    pleomorphic adenoma (benign mixed tumor)
  277. histological findings of cardiac myxoma
    • spindle cells
    • primitive connective tissue
  278. cystic hygroma:
    embryonic origin?
    histological characteristics?
    sequestered lymphatic sacs that fail to communicate with lymphatic channels.

    unilocular or multilocular, cystic structure with a thick or thin wall, proteinaceous fluid inside
  279. lymphangiomas:
    typical location
    neck (70-80%) in posterior cervical triangle
  280. preferred source of nutrition for cancer cells
  281. preferred nutrition source for colonocytes
    short chain fatty acids like butyric acid
  282. primary nutrition for small bowel
  283. ASA classification
    • 1: healthy
    • 2: mild systemic disease (HTN, DM)
    • 3: severe systemic disease (prev. MI, angina)
    • 4: severe systemic disease that is a threat to life (renal or liver failure, unstable angina, severe COPD)
    • 5: Not expected to live 24 hours
    • 6: Organ donor
  284. white clot syndrome
    • aka HITT
    • IgG mediated
    • acrocyanosis of digits, extremity gangrene, stroke, MI, PE
    • occurs in 2-3% of patients treated with unfractionated heparin
    • can be caused by LMWH
    • warfarin worsens
  285. afferent loop syndrome:
    roux en y
  286. BIRADS classifications
    • 0: incomplete study
    • 1: negative study
    • 2: benign findings
    • 3: probably benign, follow up closely
    • 4: suspicious abnormality should biopsy
    • 5: highly suggestive of malignancy
  287. keloids
    • overgrowth of scar beyond boundaries of wound
    • excess of disorganized collagen
    • treat with excision, steriods, compression, and rads
  288. BRCA 1
    • located on chromosome 17q
    • autosomal dominant
    • 85% of patients with mutation will get breast cancer by 70yo
    • 45% lifetime risk of ovarian cancer
  289. blood supply to head of the pancreas
    anterior and posterior pancreaticodudenal arteries which arise from the SMA and branches of celiac axis
  290. blood supply to distal body and tail of pancreas
    splenic and gastroepiploic arteries
  291. risk factors for cecal volvulus
    • prior hx of abdominal surgery
    • pregnancy
  292. contraindications for lumpectomy and XRT
    • 1st and 2nd trimester pregnancy
    • some autoimmune disorders (lupus, scleroderma)
    • previous tx with lumpectomy and xrt
    • multicentricity
  293. dosing of lidocaine:
    with epi
    without epi
    • 7mg/kg
    • 4-5 mg/kg

    there are 10mg's of lidocaine in 1 ml of 1% lidocaine
  294. chemo for GIST
  295. hurthle cell carcinoma
    • subtype of follicular thyroid carcinoma
    • if < 2cm and within one thyroid lobe, can do lobectomy or isthmusectomy
    • if 2-4cm, total thyroidectomy if has risk factors
    • if >4cm, total thyroidectomy
  296. pathophysiology of AAA
    • proteolytic activity in the media and collagen scaffold of the adventitia
    • increased MMP 9 and 1
    • IL1 beta and TNF alpha are elevated
    • protease inhibitors decreased
    • decreased type III collagen
  297. composition of LR
    • Na: 130
    • Cl: 109
    • Ca: 3
    • K: 4
    • Lactate: 28
  298. gene mutation associated with medullary thyroid ca
    RET proto-oncogene (codes for tyrosine kinase receptor)
  299. management of mid rectal penetrating injury
    retroperitoneal rectal injury:

    diverting colostomy, washout of distal rectal stump, wide presacral drainage
  300. specificity
    true negative / true negatives plus false positives
  301. indications for removal of ASYMPTOMATIC meckles
    • if base is narrow compared to length
    • if thick (possible ectopic tissue)
  302. melanoma treatment
    • <1mm: 1cm margin
    • 1-4mm: 2cm margin
    • >4mm: >2cm margin
  303. blood supply to esophagus:
    • inferior thyroid
    • aorta and branches of right and left bronchial arteries
    • left gastric artery and paired inferior phrenic arteries
  304. blood supply to parathyroids most commonly from
    inferior thyroid artery
  305. diagnostic work-up of testicular mass
    • physical exam
    • ultrasound
    • serum tumor markers: AFP, B-HCG, LDH
    • radical inguinal orchiectomy with ligation of spermatic cord at the internal ring
  306. cell: interleukin produced
    bone marrow
    • t-cells: IL2
    • macrophages: IL1
    • thymus: IL7
    • bone marrow stromal cells: IL7
  307. antibiotic associated with biliary sludge
  308. most common location for VIPomas
    pancreatic body and tail
  309. functions of insulin
    • glucose absorption by muscle and adipose tissue
    • promotes protein synthesis
    • INHIBITS gluconeogenesis
    • PROMOTES glycogen synthesis
    • PROMOTES fatty acid synthesis
  310. treat homocystinuria with
    • vit b6 (pyridoxine)
    • vit b12
    • folate
  311. tumor markers associated with various testicular tumors:
    • B-hcg: associated with NSGCT and seminoma
    • AFP: associated with NSGCT
    • LDH: prognostic value
  312. branches of the GDA
    • right gastroepiploic
    • anterior superior pancreaticoduodenal artery
    • posterior superior pancreaticoduodenal artery
    • retroduodenal artery
  313. work-up of VIPoma
    • rule out all other causes of watery diarrhea
    • VIP levels (multiple)
    • Once diagnosed, CT abd with PO and IV contrast
    • Octreoscan (somatostatin receptor scintigraphy) to detect exptrapancreatic site of tumor
    • evaluate retroperitoneum and adrenals because they are the next likely site after the pancreas
  314. isoproterenol
    beta agonist, increases heart rate and contractility
  315. most common cause of cushing's syndrome
    • iatrogenic is #1,
    • then pituitary adenoma is #2
    • then adrenal adenoma is #3
  316. serum tumor marker associated with ovarian ca
    ca 125
  317. venous drainage of the pancreas
    all ends in portal vein which starts at the union of the splenic vein and superior mesenteric vein
  318. gastric varices can be caused by compression or obstruction of which structure
    obstruction of the splenic vein
  319. true or false: Lynch 1 is associated with extracolonic cancers
    false. Lynch II is associated with endometrial, ovarian, gastric, small intestinal, and pancreatic cancers
  320. structures of lateral neck from anterior to posterior
    • subclavian vein
    • phrenic nerve
    • anterior scalene
    • subclavian artery
    • brachial plexus
    • middle scalene
    • long thoracic nerve
    • posterior scalene
  321. aminoglycoside class of antibiotics
    • amikacin
    • gentamycin
    • kanamycin
    • neomycin
    • streptomycin
    • tobramycin
  322. macrolide antibiotics
    • azithromycin
    • clarithromycin
    • erythromycin
  323. inhibits cell wall synthesis by inhibiting peptidoglycan synthesis
  324. topical antimicrobial that can cause metabolic acidosis
    mafenide (sulfamylon)
  325. T and N classifications of colon ca
    • T: depth of invasion
    • T1: through muscularis mucosa into submucosa
    • T2: through submucosa into muscularis propria
    • T3: through muscularis propria into outer most layers of colon but not through them, no other organ involvement
    • T4a: through the serosa, but not to nearby organs
    • T4b: invades nearby organs
    • N1a: 1 lymph node
    • N1b: 2-3 lymph nodes
    • N1c: mesenteric, but not in nodes
    • N2a: 4-6 nearby nodes
    • N2b: 7+nearby nodes
  326. staging of colon cancer
    • stage I: T1-2, N0, M0
    • stage IIa: T3, N0, M0
    • stage IIb: T4a, N0, M0
    • stage IIc: T4b, N0, M0
    • stage IIIa: T1-2, N1, M0 or T1, N2a, M0
    • stage IIIb: T3-4a, N1, M0 or T2-3, N2a, M0 or T1-2, N2b, M0
  327. pts with colon cancer and resectable liver mets--what is their survival
    25% 5 year survival
  328. serum markers for pancreatic ca
    CEA and CA 19-9
  329. most influential factor in survival regarding pancreatic cancer
    disease free margins
  330. which has worse prognosis:
    pancreatic head cancer
    pancreatic body or tail cancer
    body or tail
  331. retroperitoneal portions of large intestine
    ascending, descending and distal third of rectum
  332. extraperitoneal structures
    • Suprarenal glands
    • Aorta/IVC
    • Duodenum (2nd and 3rd or 4th portions)
    • Pancrease (head and body, not tail)
    • Ureters and bladder
    • Colon (ascending, descending)
    • Kidneys
    • Esophagus
    • Rectum (distal 1 or 2 thirds, depending on text)
  333. trick for remembering Ghrelin
    • think "Growlin"
    • produced by the stomach (stomachs growl)
    • stimulates appetite (stomachs growl when hungry)
  334. reverse heparin with
    protamine sulfate
  335. lifetime risk of ovarian cancer in BRCA mutations
    • BRCA1: increased risk of breast and ovarian, breast cancer risk is 55-85%, ovarian is 20-40%
    • BRCA2: increased risk of breast and ovarian, breast cancer risk is 55-85%, ovarian is 10-20%
    • BRCA2 also associated with male breast cancer, pancreatic cancer, melanoma
  336. neurotransmitter for colon
    substance p
  337. derangements seen with Conn's syndrome
    • hypertension with hypokalemia, hypernatremia
    • primary aldosterone producing adrenal adenoma or
    • bilateral adrenal hyperplasia
  338. used to prevent hep b transmission following liver transplant
  339. functions of vagus
    • enhanced gut motility
    • reduce HR
    • regulates inflammation: inhibit cytokine active, stimulate release TNF
  340. categories of hormones with examples
    • polypeptide: (cytokines, glucagon, insulin)
    • amino acides: (epinephrine, serotonin,histamine)
    • fatty acids: (glucocorticoids, prostaglandins, leukotrienes)
  341. best way to indirectly estimate oxygen debt
    base deficit and lactate levels
  342. omega 3 fatty acids:
    how do they affect inflammatory response?
    anti-inflammatory: inhibit TNF and NF-B and leukocyte adhesion, migration

    good for post op patients
  343. effects of prostacyclin during systemic inflammation
    inhibition of platelet aggregation
  344. lab findings in adrenal insufficiency
    • hypoglycemia (decreased gluconeogenesis)
    • hyponatremiea (decreased renal tubular sodium resorption due to decreased aldosterone)
    • hyperkalemia due to decreased renal excretion of K
    • calcium is normal
  345. eicosanoids
    what causes their formation
    name some
    produced from the oxidation of the membrane phospholipid arachidonic acid (omega 6 fatty acid ) or omega 3 fatty acid

    throboxane, prostaglandins, prostacyclines, HETE's and leukotrienes
  346. new onset glucose intolerance in TPN patient can be due to defficiency of what?
  347. deficiency of which trace mineral results in eczematoid rash
  348. deficiency of what trace mineral linked to microcytic anemia (hint: not iron)
  349. effects of ADH during hypovolemic shock
    • increase water permeability at distal tubules
    • decrease renal water and salt losses
    • potent mesenteric vasoconstrictor
    • increases hepatic gluconeogenesis
    • increases hepatic glycolysis
  350. what are toll-like receptors
    • receptors upregulated during cellular stress/damage.
    • receptors for intracellular products (DAMP's)
    • cause upregulaton of immune response
  351. pro-inflammatory cytokines
    • IL 1a and b
    • IL 2
    • IL 6
    • IL 8
    • Interferon
    • TNF
    • PAF
  352. anti-inflammatory cytokines
    • IL 4
    • IL 10
    • IL 13
    • PGE2
    • TGF beta
  353. cytokine released immediately after injury
    • TNF alpha
    • released from macrophages, monocytes, and t cells
    • increased in trauma patients, but greatly increased in septic patients
  354. percent of blood volume normally in splanchnic circulation
  355. name the parts of the oral cavity
    • vermillion border of the lips
    • circumvallate papillae
    • buccal mucosa
    • anterior 2/3 tongue
    • upper and lower alveolar ridges
    • hard palate
    • retromolar trigone
    • floor of the mouth
    • soft palate
    • gingivae
    • retromolar trigone
  356. nerve injured after resection of parapharyngeal tumor
    • prestyloid: mandibular branch of facial,
    • poststyloid: cranial nerves IX-XII, sympathetic chain
  357. clothesline injury:
    • tracheostomy under local anesthesia
    • c-spine films
    • endoscopy to eval for tears
    • exploration and repair
    • antibiotics
    • steriods

    cautions: do not nasally or endotracheally intubate--can worsen tears
  358. most common severe complication of acute sinusitis
    • preseptal cellulitis: (extraocular muscles not involved) treat aggressively with abx agains strep pneumo and h. influenza
    • orbital cellulitis: edema of the contents of the orbit including extraocular muscles (treat as above)
    • subperiosteal abscess: globe is displaced inferiolaterally, vision affected
    • orbital abscess: ptosis, chemosis, ophthalomoplegia, vision loss
    • cavernous sinus thrombosis: bilateral eye problems, meningismus

    if surgery is indicated, ethmoidectomy and removal of a portion of lamina papyracea
  359. potts puffy tumor
    soft tissue swelling due to subperiosteal abscess over the frontal sinus

    staph aureus
  360. treatment of sialadenitis
    • IV abx against staph aureus
    • heat application to parotid
    • IV hydration
    • lemon drops
    • surgical drainage of any abscess
  361. contents of foramen ovale
    • V3
    • accesory meningeal artery
    • petrosal nerve
    • emissary vein
  362. most common cause of epiglottitis
    H. influenza
  363. 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
  364. location of most branchial cleft cysts
    second branchial cleft system

    small pit in skin just anterior to the lower third of the sternocleidomastoid muscle
  365. thyroglossal duct cysts:
    embryonic origin?
    • anterior midline of neck
    • failure of thyroglossal duct to regress, improper migration of thyroid
  366. primary lymphatic drainage of the upper lip
    lower lip?
    • preauricular nodes
    • submental and facial/jugular/infraparotid
  367. infections associated with nasopharyngeal carcinoma
  368. treatment for nasopharyngeal carcinoma
  369. infection associated with squamous cell carcinoma of head and neck (mostly oropharynx)
    HPV 16 and 18
  370. bells palsy associated with what infection?
  371. recurrent respiratory papillomatosis
    • associated with HPV,
    • warts on larynx
  372. primary repair after lip excision:
    what percentage of lip can be closed primarily
    <33 percent
  373. branchial cleft cyst orgins
    • 1st: external auditory canal
    • 2nd: tonsilar fossa
    • 3rd: pyriform sinus
    • 4th:
  374. bones that make up the orbit
    • frontal
    • zygoma
    • maxilla
    • palatine
    • sphenoid
    • lacrimal
    • ethmoid
  375. diagnostic criteria for chronic mesenteric ischemia
    • symptoms of disease
    • rule out other causes of abdominal pain and wt. loss
    • moderate to high grade stenosis of at least 2 mesenteric arteries
  376. Le Riche syndrome
    • thigh and buttock claudication
    • sexual dysfunction
    • diminished femoral pulses
  377. patency rate of aortobifem
    85% at 5 years
  378. nerves commonly injured during CEA
    • 1: vagus (recurrent laryngeal), causes hoarseness secondary to vocal cord paralysis
    • 2: hypoglossal, causes tongue deviation to ipsilateral side
  379. steps in management of suspected aortoenteric fistula
    • 1: EGD, especially 3rd and 4th portions of duodenum (look for mass effect, bleeding, visible graft suture line)
    • 2: CT scan
    • 3: Aortography
    • 4: ex-lap
    • 5: extra-anatomical bypass
  380. for asymptomatic carotid stenosis, at what percentage of stenosis should a patient undergo CEA?
    no absolute consensus. fiser says at 80-99% stenosis. some studies show 70-80%. hope they don't ask
  381. when to treat patients with symptomatic cartotid stenosis:
    >70% stenosis
  382. what percentage of popliteal aneurysms are bilateral
  383. types of endoleaks
    • Type I: leak at proximal or distal end of stent graft
    • Type II: lumbar vessels or IMA backbleed into sac
    • Type III: graft has a tear or a piece breaks
    • Type IV: blood leaks out through porous graft
  384. side effect of metronidazole
    peripheral neuropathy
  385. precursor to NO
  386. arginine acts at which receptor to form which molecule
    guanilate phosphate receptor to form cyclic GMP
  387. atrial natriuritic peptide:
    where is it released from?
    what does it cause?
    • released from the atria when stretched.
    • casuses natriuresis and diuresis.
  388. vent stategy for ARDS
    • presure control ventilation
    • increase PEEP to help oxygenation, but not too high--must avoid barotrauma
    • permissive hypercapnea
    • try to keep FIO2 down
  389. formula for oxygen delivery
    cardiac output x [(Hgb x 1.34 x O2 sats) + (0.003 x p02)]
  390. most common organism involved in burn wound sepsis
  391. most common cause of skin graft loss
    seroma or hematoma (prevents neovascularization)
  392. common complication of silvadene
    neutropenia and thrombocytopenia
  393. common complication of silver nitrate
    hyponatremia, hypochloremia, hypocalcemia, hypokalemia, and methemoglobinemia

    is contradicted in G6PD deficiency
  394. what features make it more likely that parotid tumor is malignant
    • invades both superficial and deep glands
    • involves facial nerve
  395. most common malignant parotid tumor
    mucoepidermoid carcinoma
  396. treatment for mucoepidermoid carcinoma
    • total parotidectomy including facial nerve and
    • if high grade:
    • prophylactic modified radical neck dissection
    • post of XRT
  397. what causes Frey's syndrome
    gustatory sweating

    caused by cross innervation of auriculotemporal nerve and sympathetic fiberes to the skin
  398. nerve most likely injured with submandibular resection
    marginal mandibular
  399. anatomic location for ligation of innominate artery in case of tracheo-innominate fistula
    proximal to the take-off of the right subclavian
  400. most common type of branchial cleft cyst
    type II
  401. describe the location of Type II branchial cleft cysts
    anterior border of sternocleidomastoid, though carotid bifurcation, to tonsilar pillar
  402. most common location for extra-adrenal pheo
    organ of zuckerkandl
  403. what percentage of pheochromocytomas are extra-adrenal
  404. tests for diagnosis of pheo
    24 hour VMA and metanephrines
  405. most sensitive for finding a pheo
    MIBG (131 meta iodo benzyguanidine, a norepinephrine analogue)
  406. most common location for extopic parathyroid gland
  407. actions of parathyroid hormone
    • increase renal absorption of calcium
    • increases osteoclastic release of calcium from bone
    • increases vitamin D hydroxylation in the kidney which increases calcium resorption from the gut
    • causes secretion of phosphate in the kidney
  408. lab values associated with primary hyperparathyroidism
    • elevated PTH,
    • elevated Ca
    • elevated renal cAMP
    • Cl:P04 ratio>33
  409. half life of PTH
    18 minutes
  410. signs of hypercalcemia
    • stones bones moans groans and psychiatric overtones
    • stones: kidney stones
    • bones: bone pain, osteoporosis
    • moans: fatigue
    • groans: constipation
    • psychiatric overtones: lethargy, confusion, depression
  411. contradicted in the treatment of hypercalcemia
    • thiazide diuretics (hydrochlorothiazides)
    • lactated ringers
  412. work up of asymptomatic thyroid nodule
    • thyroid function tests
    • ultrasound
    • FNA
    • if diagnostic: follow appropriate treatment based upon cell type
    • if non-diagnostic: radionuclide study
    • if hot: thyroxine x 6mo, thyroid lobectomy
    • if cold: thyroidectomy or lobectomy
  413. treatment for follicular cell carcinoma
    • if <1cm: lobectomy
    • if >1cm: total thyroidectomy

    • total thyroidectomy for the following:
    • tumor >1cm
    • extrathyroidal disease (capsular invasion, clinical or positive nodal disease, mets)
    • multicentric dz
    • history of XRT to head/neck/chest
  414. after thyroidectomy, loss of voice pitch is due to injury to which nerve
    superior laryngeal nerve
  415. after thyroidectomy, hoarseness is due to injury to which nerve
    recurrent laryngeal nerve
  416. indications for I-131 ablation
    • tumor >1cm
    • extra-thyroidal dz
  417. nerve to the crichothyroid
    superior laryngeal nerve
  418. describe the course of the RIGHT recurrent laryngeal nerve
    • runs more lateral than the left
    • wraps around the innominate before ascending into the neck
    • is more likely to be non-recurrent than the left
  419. described the course of the LEFT recurrent laryngeal nerve
    • more medial than the right
    • wraps around the aorta before ascending into the neck
  420. nerve that supplies the muscles of the larynx except for the cricothyroid
    recurrent laryngeals
  421. treatment of thyroid storm
    • beta blocker (esmolol drip)
    • lugol's (elemental iodine and potassium iodide)
    • propythiouracil
    • cooling blankets
    • oxygen
    • glucose
    • fluid
    • steroids
  422. what is the wolff chaikoff effect?
    high-dose iodine inhibits action of TSH, inhibits organic coupling of iodide to tyrosine--> less T3 and T4 release
  423. mechanism of action of PTU
    • inhibition of peroxidases that connect iodine to tyrosine forming T4 and T3
    • blocks conversion of T4 to T3 in the periphery
  424. most common endocrine pancreatic tumor
    insulinoma (but not in MEN syndromes)
  425. characteristic of MEN IIa
    • parathyroid hyperplasia
    • medullary thyroid cancer
    • pheochromocytosis
  426. what to treat first with MEN IIa and MEN IIb
  427. characteristics of MEN IIb
    • medullary thyroid cancer
    • pheo
    • marfanoid habitus
    • mucosal neuroma
  428. ca, PTH and urine ca associated with primary hyperparathyroidism
    • elevated ca (8.5-10.5)
    • elevated PTH (>60)
    • elevated or normal urine ca
  429. most common indiction for operation in patients with secondary hyperthyroidism
    bone pain
  430. tamoxifen reduces annual odds of:
    reccurence by how much?
    mortality by how much?
    • recurrence: 50%
    • mortality: 25%
  431. what time of cancer is phyllodes tumor?
    do they metastasize?
    • sarcoma
    • they do not metastasize to lymph nodes
  432. which muscle does long thoracic innervate
    serratus anterior
  433. what muscle does thoracodorsal innervate
    latissimus dorsi
  434. indications for xrt in breast cancer
    • skin or chest wall involvement
    • positive margins
    • tumor >5cm
    • inflammatory ca
    • advanced nodal disease (>4 nodes, extracapsular invasion, fixed nodes (N2-axillary or N3-which are internal mammary fixed nodes)
  435. Type I hypersensitivity reaction:
    mediated by what
    • immediate hypersensitivity
    • mediated by IgE
    • bee stings, peanuts, hay fever
  436. type II hypersensitivity reaction
    mediated by what?
    • IgG or IgM reacts with cell-bound antigen
    • ABO incompatibility, graves, myasthenia gravis
  437. type III hypersensitivity reaction:
    mediated by what?
    • immune complex deposition
    • serum sickness, RA, SLE
  438. Type IV hypersensitivity reactions
    mediated by what?
    • delayed-type, antigen stimulation of previously sensitized T cells
    • TB skin test, contact dermatitis
  439. thoracic outlet syndrom usually affects which nerves of the brachial plexus
    C8-T1 (part most likely to rub the first rib)
  440. incisions made during Ivor Lewis esophagectomy
    abdominal and RIGHT thoracotomy
  441. most common congenital heart defect
  442. most common cyanotic congenital heart defect
    tetrology of fallot
  443. how does squatting help during tet spells
    increases systemic vascular resistance forcing left to right shunt through the VSD
  444. most important factors in myocardial oxygen consumption
    wall tension, followed by rate
  445. most common disease process associated with ascending aortic arch aneurysms
    cystic medial necrosis
  446. most common disease process causing descending aortic aneurysms
  447. patency of IMA to LAD
    90% at 20 years
  448. patency of saphenous vein graft to any coronary
    80% at 5 years
  449. organs/tissues that do not contain lyphatics
    • brain
    • tendons
    • muscle
    • bone
    • cartilage
    • cornea
  450. what should be done for patients who develop an acute neurological event shortly after CEA
    re-exploration in the OR
  451. most commonly injured nerve during CEA
  452. mgmt of gi bleed shortly after AAA repair
    • sigmoidoscopy
    • if necrotic, perform resection, colostomy, hartman's pouch
  453. chief cells secrete
  454. only enzyme secreted by the pancreas in active form
  455. another name for upper espophageal sphincter
    cricopharyngeious muscle
  456. pressures at rest and during swallowing of UES
    • at rest: 70mmHg
    • during early swallowing: 15mmHg
  457. approximate LES pressure at rest and during swallowing
    • at rest: 15mmHg
    • during swallowing: 0mmHg
  458. anatomic and physiologic problem causing Zenkers
    failure of UES to relax
  459. treatment of low grade barrets esophagus
    • PPI
    • frequent surveilance
  460. treatment of small leak after esophagectomy
    • repair the defect
    • then place a muscle, fat, or pleural flap to reinforce repair
    • lay drains
    • NPO x 1 week
    • repeat swallow study
    • feed pt with J tube
  461. treatmen of large leak (necrosis, ususally) after esophagectomy
    • open
    • take down the anastomosis
    • resect the necrotic portion,
    • place drains
    • esophagostomy
    • wait 3 months
    • reconnect patient with colonic interposition
  462. axillary lymph node dissection levels
    • level I: lateral to pec minor
    • level II: beneath pec minor
    • level III: medial to pec minor
    • Rotter's nodes: between pec major and pec minor
  463. borders of axillary lymph node dissection
    • superior: axillary nerve
    • lateral: skin
    • anterior: pec minor
    • posterior: latissimus dorsi (look for thoracodorsal)
    • medial: chest wall (look for long thoracic)
  464. appropriate margins for basal cell carcinoma
    0.3 to 0.5 cm
  465. indications for sentinal node biopsy for melanoma
    • if lesion is > 1 mm deep
    • clinically negative nodes
  466. increasing the power decreases the potential for what type of error
    • type II error: accepting the null hypothesis when it is not true.
    • saying a difference does not exist when a difference actually does exist.
  467. where are most gastric cancers located?
  468. receptor associated with GIST
  469. chemo for GIST
    gleevec (tyrosine kinase inhibitor)
  470. margins for GIST resection
    1 cm
  471. how do gastric leiomyosarcomas spread?
    as most sarcomas do: hematogenous
  472. types of gastric ulcers
    • type 1: lesser curve, along body, due to decreased mucosal protection
    • type 2: 2 ulcers-lesser curve and duodenal, due to increased acid
    • type 3: prepyloric, due to increased acid; high bleeding risk
    • type 4: lesser curve along cardia
    • type 5: associated with NSAIDS
  473. what is the lesion that is a precursor to gastric lymphoma?
  474. how to treat MALT
    h. pylori erradication: triple therapy--bismuth, amoxicillin, metronidazole or tetracycline
  475. chemo for gastric lymphomas or non-regressing MALT
    CHOP: cyclophosphamide, doxorubicin (adriamiacin), vincristine, prednisone
  476. test for echinococcal cysts
    casoni skin test
  477. how to treat echinococcal cyst
    albendazole first to kill parasite. never stick a needle in it--risk of anaphylactic shock
  478. treatment for schistosomiasis abscess
  479. how to treat ameobic liver abscess
  480. budd chiari syndrome
    • caused by occlusion of hepatic veins
    • classically presents with:
    • abdominal pain
    • ascites
    • hepatomegaly
  481. best test for hepatic vein thrombosis
    mesenteric angiogram with venous phase contrast
  482. radiographic findings for hemangioma
    • peripheral to central enhancement
    • hypervascular on CT, MRI
  483. radiographic finding for focal nodular hyperplasia
    • uptake on sulfer colloid scan
    • central stellate scar
    • hypervascular on CT, MRI
  484. rare complication of hemagioma
    consumptive coagulopathy and CHF (kasabach-merrit syndrome)
  485. radiographic finding for hepatic adenoma
    • liver mass with no uptake on sulfer colloid scan
    • hypervascular
  486. what is the treatment for hepatic adenoma in people not on steriods/OCP's
    resection due to risk of malignant transformation and rupture
  487. most common variant of originn of left hepatic artery
    left gastric artery
  488. surgical treatment of gallstone ileus
    • ex-lap
    • open ileum
    • remove stone
    • close ileum
    • cholecystectomy
    • repair duodenal hole
  489. stages of gall bladder cancer
    • stage I: limited to mucosa
    • stage II: into muscularis
    • stage III: through the wall of the gallbladder, may have spread into lymph nodes and nearby tissue
    • stage IV: metastatic
  490. treatment for stage I gallbladder cancer
    cholecystectomy alone
  491. surgical treatment of stage II gallbladder cancer
    • cholecystectomy
    • wide resection at liver bed around segments 4 and 5
    • may need whipple, lobectomy
    • 2-3 cm margins
  492. surgical treatment of stage III or IV gallbladder cancer
    some stage III's can be removed, but most cannot. no surgical treatment for stage IV
  493. klatskins tumors
    cholangiocarcinoma of the upper third of bile ducts
  494. mirizzi syndrome
    compression of common hepatic duct by large stone that can also erode into the duct from the cystic duct or gall bladder
  495. charcot's triad
    • fever,
    • RUQ pain
    • jaundice
  496. reynold's pentad
    charcot's plus mental status change and shock
  497. endocrine function of the pancreas
    • alpha: glucagon
    • beta: insulin
    • delta: somatostatin
    • PP or F: pancreatic polypeptide
    • islet: VIP, serotonin, neuropeptide Y, grp
  498. work-up of RUQ pain and nausea after lap chole
    • LFT's
    • CBC
    • ultrasound
    • perc drain any fluid collections
    • if bile, perform ERCP
  499. treatment for cystic duct stump leak after lap chole
    ERCP, sphincterotomy, stent
  500. spontaneous closure is least likely in fistula originating from
  501. stomach
  502. GI diverticula do not occur where?
    in the rectum
  503. coag abnormalities with von willebrand's
  504. uring sodium in the setting of SIADH: high or low?
  505. DNA replication occurs at which phase of the cell cycle
    S phase
  506. Li Fraumeni:
    what kind of cancers are associated?
  507. location of most esophageal leiomyomas
    distal 1/3 of espophagus
  508. meckels diverticulum:
    true diverticulum?
    embryonic origin
    rule of twos
    • true diverticulum
    • remnant of the omphalomesenteric duct (aka vitelline duct or yolk stalk)
    • 2 feet from ileocecal valve
    • 2 inches long
    • 2% of population has them
    • 2% are symptomatic
    • 2 years old is most common age of presentation
    • 2 types of tisse: gastric and pancreatic
    • 2 times more boys than girls
  509. hormone secreted by the adrenal medulla
  510. response of beta islet cells to catecholamine release
    inhibition of insulin secretion
  511. how does the hypothalmus cause fever
    • in response to stress
    • IL-1, IL-6, and TNF all stimulate PGE2 synthesis
    • PGE2 interacts with the hypothalmus, causing it to increase temperature in the body
  512. which transplant drugs cause nephrotoxicity
    calcineurine inhibitors: tacrolimus and cyclosporine
  513. side effect of rapamycin
    thrombocytopenia and hypercholesterolemia
  514. side effects of mycophenolate
    • bone marrow toxicity
    • gastroenteritis
  515. which transplant drug can cause post-transplant diabetes
  516. transplant drug associated with hirsutism and gingival hypersplasia
  517. transplant drugs that are neurotoxic
    cyclosporine and tacrolimus
  518. regarding hangman's fractures:
    caused by?
    describe fracture
    • extension and distraction injury
    • posterior elements of C2 are fractured
    • type I: treat with rigid collar
    • type II: treat with traction, halo for 3 months
    • type III: treat with immediate surgery.
  519. jefferson fracture
    • C1 burst fracture
    • caused by axial loading
  520. odontoid fractures
    • type I: odontoid above the base, stable
    • type II: occur at the base, UNSTABLE, need halo or surgery
    • type III: base and extend into vertebral body, unstable, need halo
  521. treatment for neck trauma
    • if symtomatic
    • Zone I: angio first, then neck exploration
    • Zone II: neck exploration in symtomatic patient
    • Zone III: angio first, then neck exploration

    • if asymptomatic
    • Zone I: angio first, then neck exploration
    • Zone II: observation
    • Zone III: observation
  522. MOA cyclophosphamide
    alkylating agent
  523. chemo drugs: microtubule inhibitors
    • vincristine
    • vinblastine
  524. moa methotrexate
    dihydrofolate reductase inhibitor
  525. moa 5FU
    thymidyl synthetase inhibitor
  526. chemo drugs that cause bone marrow suppression
    • carboplatin
    • vinblastine
  527. hepatic adenoma:
    1. imaging characteristics
    2. resection criteria
    1. hypodense, Tc labeled scan picks up central scar, hypervascular, peripheral blood supply

    2. due to risk of rupture, resect all that are 4cm or bigger, symptomatic , do not regress after cessation of birth control,
  528. best choice of paralytic in pt with hepatic failure and renal failure


    plasma ester hydrolysis and Hoffman elimination, does not require the kidney or liver to metabolize
  529. paralytic that uses hoffman elimination
  530. what to do with traumatic injury to the neck or distal pancreas (to the left of mesenteric vessels)
    distal pancreatectomy preserving the spleen if possible
  531. what to do with extensive injuries to the head of the pancreas
  532. TRALI:
    1. when does it usually occur
    2. findings on cxr
    3. does it have elevated PCWP
    4. mortality rate
    5. when does it usually resolve
    • 1. 2-6 hours after transfusion
    • 2. similar to ards
    • 3. no elevation of PCWP
    • 4. 5-8%
    • 5. improvement in 2-8 days
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