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diagnostic triad of fungemia?
muscle pain skin rash fever
What is the ankle-brachial index (ABI) below which patients usually start developing rest pain?
0.4
Management of pulsatile mass after CEA?
"Likely pseudoaneurysm - should revise anastomosis to eliminate risk of embolization - culture material - if bifurcation involved, use reversed saphenous vein graft to ICA "
Mechanism of steroids
bind receptor in cytoplasm - go to nucleus
do M or F get splenic artery aneurysms more often? what is the etiology in M vs F?
females more often in females it is medial dysplasia in men it is atherosclerosis
why do patients with jejunoileal bypass or Crohn's develop oxalate stones?
"1) fat malabsorption occurs 2) Calcium binds to intestinal fat 3) calcium usually complexes with oxalate, leading to increased oxalate absorption "
what clinical syndromes are a/w RET proto-oncogene mutations?
"MEN 2A, 2B familial medullary thyroid carcinoma NOT MEN 1 "
what is the most common mechanism leading to bacterial infection in bile? (origin of bacteria)
dissemination from the portal venous system via liver
Which cells release TNF in gram-negative bacteremia?
macrophages - especially from Kupffer cells in liver
most common organism in OPSS?
Strep pneumonia
What type of breast cancer does not occur in men?
"cystosarcoma phylloides does not occur in men (controversial) - arises from lobular elements of breast tissue (lobular CA does occur, however) "
Time course for presentation of MH?
Usually within 30 min of induction - can be delayed up to several hrs
Which nerve roots provide motor innervation to external anal sphincter?
"Supplied by inferior rectal branch of internal pudendal nerve (S2,S3,S4) and perineal branch of S4 "
where does adenocarcinoma of the appendix usually occur? tx for appendiceal adenocarcinoma?
usually occurs at the base tx = right hemicolectomy NOTE: carcinoid tumors of the appendix are usually distal
where in the stomach does gastritis usually occur?
"found in proximal (acid-secreting) portion of stomach, progresses distally "
what component of GCS is the most important?
motor
what marks the transition from the proliferation phase to the remodeling phase of wound healing?
Transition from the proliferative phase to the remodeling phase of wound healing is defined by reaching collagen equilibrium.
What is the risk of esophageal cancer after caustic ingestion relative to normal population? average latency? type of carcinoma?
carcinoma risk 100 - 1000 x population risk 40-year average latency carcinoma type = SCC
Is the prognosis of a patient with a colorectal carcinoma related to size of primary lesion?
no
clinical sign of scaphoid fracture?
tenderness in anatomical snuffbox
How long after antibiotic use can you see C. Diff colitis?
May be seen up to 6 weeks after antibiotic therapy
initial management of cholangitis?
"fluid resuscitation antibiotics allow a 12-24 hours period before attempting intervention - endoscopic drainage, T-tube decompression, PTC all are options "
Cell of origin of medullary thyroid CA?
C cells (parafollicular cells) of thyroid
why is it so important to not miss a scaphoid fx?
proximal scaphoid receives its blood supply from the distal bone - a missed fx can lead to avascular necrosis of proximal scaphoid
characteristics of MEN 2B?
"1) Medullary thyroid cancer (hallmark of MEN 2 = 100%) 2) Pheochromocytomas (40-50%) 3) Neural ganglionomas (100%) - in GI tract, conjunctiva, lips, tongue - megacolon, skeletal abnormalities, markedly enlarged peripheral nerves 4) Marfanoid body habitus "
management of acute adrenal insufficiency?
"normal saline, glucose - patients are hyponatremic, hyperkalemic, hypoglycemic glucocorticoids (hydocortisone 100-300 mg/day) - mineralocorticoids can be given later check ACTH level before steroids to confirm diagnosis "
Do neoplasms that result from caustic ingestion have a better or worse prognosis than other adenocarcinomas?
better
which infectious agent is a/w increased coronary artery disease in heart transplant recipients?
CMV
What type of ulcer is this? Is it associated with high or normal acid output?
Type II Acid secretion high
Earliest sign of uncal herniation?
unilateral (ipsilateral) dilated/fixed pupil
What is the most common malignant liver tumor of early childhood?
hepatoblastoma
What is the best way to identify burn wound sepsis?
quantitative burn wound biopsies
What is the treatment of choice for mild diabetes insipidus?
usually individuals who can ingest water on their own can avoid the development of hypertonicity
how does splenectomy improve platelet counts?
1) decreased platelet consumption 2) decreased synthesis of anti-platelet IgG
most common malignancy in childhood?
leukemia neuroblastoma is most common solid tumor
what is the embryological defect in pancreas divisum? prevalence of this anomaly?
Results from incomplete fusion of ventral duct with dorsal duct during fetal development - present in 5% of patients
antibody produced in ITP is what type?
IgG
What do pheochromocytomas secrete?
"Tumors secrete epi, norepi, or both (most common) - may also secrete dopamine, ACTH, VIP, serotonin "
where does melanoma metastasize to in the SI? (what layer of bowel wall)
submucosa
What electrolyte irregularities are usually seen with stored blood (relative to normal plasma)?
potassium level increased calcium level decreased (due to citrate binding) low pH
What is the most common site of GISTs in the GI tract?
stomach
Treatment for papillary thyroid cancer?
"bilateral, multifocal, or hx of irradiation (high incidence of multifocal neoplsams), or tumor > 1.5 cm TOTAL THYROIDECTOMY - these tumors have high rates of recurrence otherwise, LOBECTOMY + ISTHMUSECTOMY "
Mechanism of malignant hyperthermia
Ca release from sarcoplasmic reticulum
Which layer of the small intestine is the strength layer?
submucosa
how is succinylcholine metabolized?
plasma pseudocholinesterases - hemodialysis breaks down these enzymes; do not use in renal failure
Which cells carry MHC I receptors?
MHC I receptors are located on all nucleated cells - broadly reactive against common components of pathogenic organisms
Blood flow from SMV preferentially flows into what lobe of the liver?
R lobe splenic vein return shows no preference
does H. pylori confer an increased risk for gastric adenocarcinoma?
"yes, 2-6x increased risk "
Reynold's pentad?
RUQ pain fever jaundice hypotension delirium/MS changes
What is the most common cancer diagnosis in women in the US?
breast CA
interleukin 2 is commonly produced by what cell type?
activated T cells
what is the first test of choice to evaluate a suspected insulinoma?
a monitored fast - check serum glucose and insulin levels q4-6 hours - insulin/glucose ratio elevated (> 0.3) in insulinoma - check C-peptide concentration and tox screen (look for oral hypoglycemics) to r/o surrepititious insulin use GLUCOSE TOLERANCE TEST MEANINGLESS
Pharyngeal pouch derivatives from 5th branchial pouch?
5th pouch houses the ultimobranchial bodies - these become the C cells of the thyroid - Ultimobranchial bodies arise from neural crest cells but migrate into 5th pouch
where is secretin secreted from? stimulants to secretion?
Found in S cells of duodenum and jejunum Stimulants: - duodenal acidification; when luminal pH < 4.5 Inhibitors: - intraduodenal secretion of pancreatic bicarbonate
where is nitric oxide stored within cells?
It is not stored within cells -- cells have a basal rate which can be up- or down-regulated. nitric oxide synthase has both a constitutive and an inducible form
ATPs from anaerobic glycolysis
2 and 1 lactate
What complication is associated with overly aggressive correction of hyponatremia?
central pontine myelinolysis (CPM)
what are the boundaries of the gastrinoma triangle? what % of gastrinomas are found here?
"Area defined as: 1) the confluence of the cystic and common bile duct 2) the second and third portions of the duodenum inferiorly, 3) and the neck and body of the pancreas. 90% of gastrinomas are found here "
What is central vs. nephrogenic diabetes insipidus?
defect in production or activity of ADH (Vasopressin) - central: defect in production of ADH - renal: defect in renal response to ADH
Presentation of MH?
"Fever, tachycardia Rigidity, skin mottling Cyanosis, increased end expiratory pCO2 Metabolic acidosis, hyperkalemia "
Mechanism of action of c-kit?
proto-oncogene; product = tyrosine kinase - initiates second messenger system responsible for cell proliferation
What acid-base abnormality exacerbates the cardiac dysrhythmias that may arise as a result of hypokalemia?
alkalosis
do elderly patients heal with more scarring or less scarring?
The elderly heal with less scarring
Rough ER
makes proteins for export
Does fat contain more or less water relative to other body tissues?
"fat contains little water females have more fat:lean mass than males, less body water "
What type of ulcer is this? Is it associated with high or normal acid output?
Type IV Occurs as result of chronic NSAID or aspirin use can occur anywhere in the stomach
How much fluid normally turns over within the pleural space each day?
5-10 liters
what is the dominant cell type in the inflammatory phase of wound healing? what about in the proliferative phase?
inflammatory phase: macrophages proliferative phase: fibroblasts
what is functional residual volume (RV)?
gas in lung at end of maximal expiration
Primary bile duct stones are usually what kind of stone?
"usually brown pigment type - result of bacterial deconjugation of bilirubin diglucoronide -> bilirubin - usually are brown, friable; composed of calcium bilirubinate "
What gene is mutated in poorly differentiated GISTs?
c-kit
what CA is associated with APC? mechanism of activity?
Colorectal carcinoma Familial adenomatous polyposis coli (FAPC) Tumor suppressor gene
do elderly patients develop wound infections occur more commonly or less commonly?
No difference in rate of wound infections.
tx for fat embolism?
"reduce long bone fx - early fixation associated with lower incidence of ARDS otherwise, mainly supportive: - 100% O2 - intubation if PaO2 < 60 - PEEP "
most likely cause of isolated gastric varices?
splenic vein thrombosis from pancreatitis
which interleukin is responsible for inducing hepatic acute phase proteins?
IL-6
Mechanism of renin-AT
"Macula densa senses low NaCl, produces renin which converts angiotensinogen, to Angiotensin I, which is converted to Angiotensin II in the lung by ACE. ATII is a vasoconstrictor and ·'s aldosterone which keeps Na, loses K/H in urine." Y
Which burn medication can generate a metabolic acidosis?
"Mafenide acetate is a carbonic anhydrase inhibitor - interferes with renal buffering, may cause a metabolic acidosis - bicarb wasted, Cl- retained (hyperchloremic metabolic acidosis) "
"In pts with LCIS, how often does cancer develop in ipsilateral vs. contralateral breast?"
"half in index breast, half in contralateral breast "
Sensitivity
ability to detect disease = # with positive test result / # that have disease (true positive).
Does the initial sodium concentration correlate with the development of central pontine myelinolysis (CPM)?
no
most important cell type in the process of wound healing is?
macrophage
resection margins for gastric CA?
"In contrast to colon cancer, gastric cancer frequently demonstrates extensive intramural spread. Retrospective studies suggest that a line of resection 6 cm from the tumor mass is necessary to ensure a low rate of anastamotic recurrence. "
Best test for distinguishing ATN from prerenal azotemia?
fractional excretion of sodium
what % of people have accessory splenic tissue? where is it usually located?
found in 15-35% of patients most commonly in splenic hilum; also: - gastrosplenic ligament - gastrocolic ligament - splenorenal ligament - greater omentum - mesentery
Where are incisions made for chest escharotomy in a burn patient?
anterior axillary line bilaterally from clavicle to costal margin
Where does the thoracic duct drain into?
into junction between left subclavian and internal jugular veins
"What approach to repair of a traumatic diaphragmatic hernia is preferred when recognition of the hernia is DELAYED, incarcerated viscera present?"
trans-thoracic
mechanism of action of ticlodipine?
Prevents fibrinogen binding to the platelet GPIIb-IIIa complex
Which antibiotic has GI prokinetic qualities? Mechanism?
Erythromycin Stimulates motilin receptors
what does the RET proto-oncogene code for?
tyrosine kinase receptor - several mutations have been defined - mutations can be inherited or de novo - acts as a dominant proto-oncogene
When should the facial nerve be sacrificed during parotidectomy for pleomorphic adenoma of the parotid gland?
should almost never be sacrificed during parotidectomy for benign lesions
What structure demarcates the subclavian artery into its 3 portions?
1st portion: medial to anterior scalene 2nd portion: behind anterior scalene 3rd portion: lateral to anterior scalene
Treatment for hypertrophic subaortic stenosis?
"Maximize diastolic filling by relaxing myocardium, slowing heart rate Inotropes unnecessary, potentially harmful "
what form must Fe be in to be absorbed?
Fe+++ - requires ACID stomach environment
what is the most common extra-abdominal malignancy that metastasizes to the small bowel?
melanoma
What is the Cushing reaction?
Reaction to increased intracranial pressure: 1) hypertension (autoregulation to increase CPP) 2) bradycardia (vagal response to increased BP)
what nerve is entrapped in carpal tunnel syndrome?
median nerve
what is this rash? what is its significance?
necrotizing migratory erythema - pathognomonic for glucagonoma - biopsy of edge of rash may be diagnostic
Which lumbar disc most commonly herniates?
occurs most commonly at L5-S1 or L4-L5
what is the rate-limiting step in catecholamine synthesis?
conversion of tyrosine to dihydroxyphenylalanine (Dopa) by TYROSINE HYDROXYLASE
Treatment for coumadin-induced skin necrosis?
d/c warfarin start heparin
Annular pancreas is a/w what other conditions?
40% have duodenal stenosis/atresia 20% have Down's
HNPCC penetrance?
80% penetrant: less of an indication for prophylactic colectomy
What is the most common benign tumor of esophagus?
leiomyoma
Prospective Cohort study
non random assignment to treatment groups
MEN I characteristics?
1) Parathyroid hyperplasia (95%) 2) neuroendocrine tumors of Pancreas and duodenum (75%) 3) Pituitary adenomas (16-65%) (PPP)
what are the most common causes of Cushing's SYNDROME?
1) exogenous steroid administration 2) Cushing's dz (ACTH from pituitary adenoma) 3) ectopic ACTH production (think small cell lung CA)
What % of liver blood flow comes from portal vein? What % of liver oxygen?
66-75% 50% of oxygen comes from portal 50% comes from hepatic arteries
Which lobe(s) is/are most commonly affected in congenital lobar emphysema?
usually only affects one lobe: - left upper lobe - 41% - right middle lobe - 34% - right upper lobe - 21%
which reactions in the cell are responsible for generation of free radicals in reperfusion injury?
hypoxanthine -> xanthine by xanthine oxidase xanthine oxidase is activated in ischemic endothelial cells
What topical antibiotic medication(s) are painful on application?
mafenide acetate
On which side do you usually see a pleural effusion in Boerhaave's?
Left side
where are the superior parathyroid glands usually located?
just above intersection of recurrent laryngeal nerve and inferior thyroid artery
determinants of myocardial oxygen requirements? which is the most important?
wall tension -- most important heart rate inotropy
which interleukin is responsible for B cell maturation?
IL-4
Pharyngeal pouch derivatives from 3rd branchial pouch?
3rd pouch (dorsal wings): inferior parathyroids 3rd pouch (ventral wings): thymus 3rd pouch contributes to 3 structures: - thymus - L and R inferior parathyroids
Which topical medication has antifungal activity?
silver nitrate
Mechanism of coumadin-induced skin necrosis?
protein C (anti-coagulant protein) has shortest half-life of all K-dependent proteins - functional activity of protein C drops more rapidly than procoagulant proteins - transent hypercoagulability
What is the normal non-protein requirement when using TPN? (kcal/kg in 24 hours)
25 - 35 kcal/kg/day
What nerve/artery is commonly injured with supracondylar fracture of femur?
thrombosis popliteal artery
which direction is the oxy-hemoglobin dissociation curve shifted with carbon monoxide poisoning?
"left LEFT = LATCH, RIGHT = RELEASE "
What type of thyroid cancer has a familial inheritance pattern?
medullary
Cushing syndrome vs. Cushing's disease?
Cushing's syndrome: condition caused by an excess of adrenocortical hormone from ALL causes Cushing's disease: caused by PITUITARY hypersecretion of ACTH
Is it possible to have unilateral gynecomastia?
gynecomastia may be unequal or unilateral
What is the most frequently injured carpal bone?
scaphoid
Risk factors for esophageal SCC?
EtOH tobacco nitrosamines achalasia lye ingestion
which cells are responsbile for generating the contractile force of wound contraction?
Fibroblasts Fibroblasts (like muscle cells) contain actin microfilaments; seen in increased number in contracting wounds.
what % of insulinomas are a/w MEN syndrome? why is this distinction important?
"10% in MEN, possibility of multiple insulinomas is more likely - recurrence rate is higher "
Respiratory quotient of fat metabolism?
Fat metabolism 0.7
[bicarb] vs. [Cl-] at low vs. high levels of pancreatic exocrine secretion?
"Low stimulus: [Cl-] high (110 mEq/L) High stimulus: [Cl-] falls, [bicarb] rises to 140 mEq/L "
most common location of diaphragmatic rupture?
posterolateral left diaphragm
What non-surgical therapies are effective for Dupuytren's contracture?
"no medical therapy is effective - splinting, NSAIDs, steroid injections do not work "
what is the classic clinical presentation of VIPoma?
"watery diarrhea: can be large volume, > 5 liters/day hypokalemia: loss of potassium due to diarrhea achlorhydria/hyochlorhydria aka WDHA syndrome "
which layer of the esophagus is the strength layer?
submucosa
which substance is a/w improved wound healing when given to patients chronically taking corticosteroids?
Vitamin A
Treatment for focal nodular hyperplasia?
observation: biopsy if indicated to r/o other mass - rupture and malignant degeneration are exceedingly rare may be difficult to distinguish from adenoma histologically
how is the diagnosis of VIP made?
"serial measurements of VIP - VIP secretion episodic, often normal; check level while patient having diarrhea - single low VIP level does not rule out the syndrome CT of abdomen/thorax to localize extrapancreatic tumor "
What is the most common gene-related abnormality found in a/w colorectal carcinoma?
amplification of the K-ras proto-oncogene
Pathophysiology (oncogenetic mechanism) of BRCA-1?
functions as tumor suppressor - loss of heterozygosity
What is the most important predictor of malignancy for an incidentaloma?
Size is most important predictor of malignancy - 90% of carcinomas were > 6 cm
which direction is the oxy-hemoglobin dissociation curve shifted with high pCO2?
"right LEFT = LATCH, RIGHT = RELEASE "
Risk of CA from choledochal cysts?
Sabiston's says 20% over 20 years
Indications for esophageal resection for Barrett's?
"1) Grade III dysplasia documented by 2 pathologists 2) Carcinoma 3) Undilatable stricture Otherwise, anti-reflux procedure indicated (controversial) "
What is the role of integrins in neutrophil adherence?
Responsible for firm adhesion step as neutrophil is captured on endothelial surface
Treatment of cystosarcoma phylloides tumors? Do you perform ALND?
"Tx for benign or malignant = wide excision - even benign lesions can recur after incomplete excision - mastectomy for lg lesions in sm breast, recurrences - ALND NOT performed unless biopsy-proven nodal involvement "
Where can you NOT find lymphatics
"Muscle, bone, tendons, brain (loose cell-cell jxns - no basement membrane)"
What causes decreased lung compliance in ARDS?
"The decreased compliance in acute respiratory distress syndrome occurs because the lung is smaller, not stiffer. "
test of choice to rule out splenic vein thrombosis as acause of bleeding esophageal varices?
arteriography with venous phase studies
"Of the cardinal sxs of aortic stenosis, which is the most common initial clinical manifestation?"
angina
What nerve/artery is commonly injured with supracondylar fractures of the humerus?
Brachial artery
What is innervated by the superior laryngeal nerve?
internal branch: innervates laryngeal mucosa ABOVE vocal folds external branch: innervates cricothyroid muscle near the superior pole - damage can cause subtle changes in voice; of particular concern to pts who use their voice for their living
Effect of PEEP on FRC?
increased FRC - highly beneficial in pts with low FRC - may be very detrimental in patients with COPD (high FRC)
what is the most common GI site for lymphoma?
The stomach is the site of more than half of GI lymphomas and is the most common organ involved in extranodal lymphomas.
What is the most common cause of an elevated mixed venous pO2?
wedged pulmonary artery catheter: draws stagnating blood that has equilibrated with lung PO2
Antidiuretic hormone (ADH) is secreted in response to?
hypovolemia (most powerful stimulant) increased serum osmolality
treatment for papillary thyroid CA with positive node?
lobectomy/isthmusectomy or lobectomy (or total thyroidectomy if meets criteria) + IPSILATERAL modified radical neck dissection
Which hormone is the primary determinant of free water in the body?
antidiuretic hormone (ADH)
Criteria for ARDS?
1) pO2/FIO2 < 200 2) cxr findings c/w ARDS 3) PCWP < 18 ref = European Consensus (?)
treatment for FNA of thyroid with results showing Hurthle cells?
"to OR for lobectomy/isthmusectomy if Hurthle carcinoma, return for completion thyroidectomy "
What nerve/artery is commonly injured with posterior dislocation of knee?
Popliteal artery thrombosis
what is functional residual capacity (FRC)?
volume of air left in the lungs after a quiet exhalation - equal to ERV + RV
Treatment for a pleomorphic adenoma of the parotid gland?
treat with local excision - superficial parotid lobectomy
What are the first clinical signs/symptoms of hypocalcemia?
perioral tingling paresthesias
What is the enzyme deficiency in homocysteinemia?
Most common form results from reduced activity of cystathionine B-synthase (converts methionine to cystein)
Which enzymes are responsible for degrading collagen during the remodeling phase of wound healing?
matrix metalloproteinases
What are the most common functional neuroendocrine tumors in MEN I?
1) gastrinoma 2) insulinoma
What is the arterial supply to an extralobar pulmonary sequestration? Venous drainage?
arterial supply from systemic arterial supply (thoracic aorta) - artery enters lung through inferior pulmonary ligament (SAME ARTERIAL SUPPLY AS INTRALOBAR) - venous drainage is usually via the systemic venous system
Which parathyroid gland(s) have the most variable location?
the inferior glands
"Pattern of genetic inheritance of BRCA-1, BRCA-2, Li-Fraumeni syndrome?"
All are autosomal dominant
which is more common -- intralobar pulmonary sequestration or extrapulmonary sequestration?
intralobar
What is a Spigelian hernia?
hernia through slit-like defects in fusion of transversalis and internal oblique fascia where it attaches to the lateral border of the rectus sheath at semilunar line - hernia expands laterally BENEATH external oblique aponeurosis
Where do biliary enteric fistulas most commonly occur from/to?
from gallbladder to duodenum (cholecystoduodenal) 70-80% 2nd most common: cholecystocolic
First muscle to recover from paralytic
Diaphragm
What artery is intimately associated with the external branch of the superior laryngeal nerve?
superior thyroid artery (branch of external carotid artery)
Which gene is most closely associated with apoptosis?
p53
Where are pheochromocytomas usually located?
"90% are in adrenal gland, but may be located anywhere along the path of neural crest migration: - organ of Zuckerkandl - urinary bladder - liver hilum - renal hilum - posterior mediastinum - intrapericardial - neck "
Which population group(s) is/are most at risk for esophageal adenocarcinoma?
Much more common in white men
Specificity
ability to state no disease is present = # with negative test result / # without disease (true neg).
What types of colon CA show an increased incidence after cholecystectomy?
cecal carcinomas in women
which type of lung CA frequently cavitates?
lung squamous CA
treatment of hyperphosphatemia?
oral administration of phosphate binders like aluminum hydroxide gel
Which amino acid is preferentially used by tumor cells?
glutamine is selectively utilized by tumor cells - extraction rate of glutamine by tumors is as much as 50% greater than normal cells
What nerve/artery is commonly injured with posterior dislocation of hip?
sciatic nerve injury
where do gastrinomas most commonly occur?
pancreas also in: - gastric antrum - duodenum - spleen - ovary
M:F for ITP?
1:3 female preponderance
What is the impact of aging on FEV1?
FEV1 decreases
Which amino acid is the substrate for nitric oxide synthesis?
arginine
Where is calcitonin produced?
by parafollicular (C cells) of thyroid gland
which interleukin(s) is/are anti-inflammatory?
IL-10
Respiratory quotient of protein metabolism?
Protein metabolism 0.8
local anesthetics have decreased effectiveness in what types of pH?
low pH environments
mechanism of action of endotoxin?
"binds to an acute phase reactant from liver - endotoxin/protein complex which binds to macrophages - macrophages release IL-1, IL-6, TNF "
What is the characteristic pattern of HTN seen with pheochromocytomas?
"Four types of presentation 1) sustained HTN w/o episodic increases 2) mainly normotensive, episodes of HTN 3) sustained HTN + episodic increases 4) non-functioning sustained HTN a/w malignant tumors "
Cytochrome p450 up and down regulated by what drugs
"Act up (anticonvulsant, coumadin, theophylline), CIM D (cimetidine, INH, MAO-I, disulfiram)"
Effect of somatistatin
"Inhibits gastrin, insuling, secretin, ACh -> dec pancreatic and biliary output, stimulated by H+ in duodenum"
Most severely cyanotic developmental heart defect?
transposition of the great arteries
which bacteria are a/w cholangitis?
E. Coli Enterococcus Klebsiella Proteus Pseudomonas Enterobacter (aerobic enterobacteriaceae)
What needs to be ruled out in a patient presenting with a varicocele?
left varicocele: investigate for L retroperitoneal mass - classically associated with renal tumor right varicocele: investigate for IVC occlusion
what % of intussusceptions recur?
5% -- usually within first 24 hours -- pt should be admitted
Where is the brachial plexus relative to the anterior scalene muscle?
The subclavian artery is behind the anterior scalene
are patients with Hashimoto's at increased risk for thyroid malignancy?
slightly increased risk for malignancy (thyroid lymphoma) - no increased risk for other thyroid cancers
Is beta-HCG (bHCG) elevated in seminomatous or non-seminomatous testicular germ cell tumors?
beta-HCG (bHCG) is elevated in 10% of seminomatous tumors; it is classically associated with NSGCTs
What is spinal shock?
flaccidity and loss of reflexes after spinal cord injury prognosis: duration of this state is variable
What is Chvostek's sign?
"Elicitation: Tapping on face at a point just anterior to the ear, just below zygomatic bone Positive response: Twitching of ipsilateral facial muscles, suggestive of neuromuscular excitability caused by hypocalcemia "
What cancer most commonly metastasizes to bone in men?
prostate CA
When do keloids form? When do hypertrophic scars form? Are either likely to subside?
"Keloids typically develop several months after injury; rarely, if ever, subside. Hypertrophic scars develop within the 1st month after wounding; often subside gradually "
What is the ankle-brachial index (ABI) below which patients usually start developing claudication?
0.7
Where does colonic volvulus most often occur? In what direction does the torsion occur?
sigmoid 75-85% counterclockwise cecum 10-15% clockwise SIGMOID = SINISTER
What makes ketamine unique among the drugs used to induce general anesthesia?
Does not cause cardiovascular or respiratory depression
Charcot's triad?
RUQ pain fever jaundice
result of damage to common peroneal nerve?
"foot drop - due to loss of extensor function to ankle and toes - sensory loss DEEP: supplies first web space SUPERFICIAL: skin on distal/anterior leg, most of dorsal surface of the foot, and most of the toes "
Tinel's sign?
production of pain or paresthesia in digits by gentle tapping over the transverse carpal ligament (aka flexor retinaculum) - median nerve is trapped in carpal tunnel under transverse ulnar ligament - positive in carpal tunnel syndrome
What is the most commonly mutated gene in human cancers?
p53
is H. pylori associated with gastric or duodenal ulcers?
BOTH
At what point in the cell cycle do most chemotherapeutics act?
S phase
What is the most specific test for diagnosing biliary dyskinesia?
most specific test is CCK-enhanced cholescintigraphy - assess gallbladder ejection fraction; < 35% is indication for cholecystectomy
"which direction is the oxy-hemoglobin dissociation curve shifted with increased 2,3 DPG concentrations?"
"right LEFT = LATCH, RIGHT = RELEASE "
"is propofol an amnestic, an analgesic, or both?"
amnestic only. no analgesic properties
What is the impact of aging on total lung capacity (TLC)?
"TLC = age independent, unchanged "
Side effects of ketamine use?
increases ICP increases myocardial oxygen consumption (do not use in patients with CAD) auditory/visual hallucinations
where is motilin secreted? when is it secreted (in relation to meal)? action?
secreted by enterochromaffin cells of the mucosa of the upper small intestine - released during the fasting state - increased levels correspond with the onset of the MMC
Does cryptorchidism increase the risk for developing testicular cancer?
Cryptorchidism = increased risk for testicular tumor Orchidopexy is not protective against subsequent testis cancer.
Most common noscocomial infection in surgical patients?
wound infection
Effect of histamine on stomach
acts on parietal cels via cAMP to inc HCl production
where does coumadin-induced skin necrosis usually occur?
"most commonly on extremities, breast, adipose tissues "
3 cardinal signs of urethral injury (in a male)?
high-riding prostate blood at meatus perineal hematoma
what vitamin has some efficacy in reducing the poor wound healing a/w steroid use?
Vitamin A
What is the most common peripheral arterial aneurysm?
popliteal
inheritance of MEN I? of MEN II?
autosomal dominant for both MEN I is on chromosome 11 MEN II is on chromosome 12 men# + 10 = chromosome #
Stimulants to secretion of mucus/bicarbonate from mucus gland cells?
"vagal stimulation, luminal acid "
Are the renal pelvices anterior or posterior to renal arteries?
renal pelvices are posterior to renal arteries
is size a good predictor for metastasis for carcinoids of: SI? appendix?
SI: no appendix: yes - 95% are < 2cm - 2% of patients (all comers) have mets - 1/3 of pts with tumor >2 cm have distant or nodal mets
"if appendix is normal in the face of pt with Crohn's, should you perform appendectomy?"
"yes, as long as the cecum and appendix appear normal - will decrease diagnostic dilemmas in the future - will not affect rate of fistula formation "
What tumor is most commonly associated with a paraneoplastic syndrome?
small cell carcinoma of the lung
What is the origin of the internal mammary artery?
1st portion of subclavian artery
What type of local anesthetics are more likely to induce an allergic reaction?
"Allergic reactions seen more with esters (as opposed to amides). Esters have one 'i' in name (cocaine, procaine, tetracaine). They are metabolized into PABA (allergenic) "
which thyroid carcinomas respond well to radioiodine therapy?
follicular mixed follicular/papillary
in which phase of cell growth are tumors most radiosensitive? resistant?
Cells are most sensitive to effects of radiation in M phase and G2 phase - least sensitive during G1 and S phases
What is the definition of primary vs. secondary adrenal insufficiency?
Primary insufficiency = due to loss of adrenal function Secondary insufficiency = secondary to disease or suppression of hypothalamic- pituitary axis
Is alpha-fetoprotein (AFP) elevated in seminomatous or non- seminomatous testicular germ cell tumors?
alpha-fetoprotein (AFP) is elevated in NSGCTs
what problems are associated with pancreas divisum?
"a/w recurrent pancreatitis, though not that commonly "
Effect of cholesterol on membranes
Increases mobility of proteins
Pathogenesis behind appearance of breast in inflammatory breast dz?
"obstruction of lymphatics -> red, thickened, swollen breast "
Branches of vagus
"L. vagus n (anterior) gives hepatic branch, R (posterior) gives celiac branch and the 'criminal nerve of Grassi' which if undivided can keep high acid levels post vagotomy"
Which side of the neck has greater anatomic variance in the position of the recurrent laryngeal nerve?
the right - approaches to the cervical esophagus are therefore usually undertaken from the left side
What are the determinants of cardiac output?
"CO = HR x SV SV = f(preload, afterload, contractility) "
Pathophysiology of congenital lobar emphysema?
"congenital narrowing of bronchus - allows inspiratory air entry, airway collapse narrows bronchial lumen during expiration -> air trapping "
stimulants to gastrin secretion?
vagal stimulation antral distention protein in antrum insulin-induced hypoglycemia...epinephrine stimulates gastrin
Dietary risk factors for gastric adenoCA?
"Diet rich in pickled vegetables, salted fish, excessive dietary salt, and smoked meats Diet that includes fruits and vegetables rich in vitamin C may be protective "
best serum test to assess recurrence in a medullary thyroid patient?
pentagastrin-stimulated calcitonin
what anomaly is this? how often does it occur? presentation?
aberrant right subclavian artery - present in 0.8-1.5% of individuals - usually asymptomatic; may present with dysphagia - a/w non-recurrent right laryngeal
which cytokine is primarily responsible for causing fever in endotoxin-mediated sepsis?
IL-1
for which type(s) of incarcerated hernias is an attempt at reduction contraindicated?
femoral hernias - tighter aperture = more risk of strangulation
Is race a risk factor for LCIS?
12 times more frequent in white than black
Are femoral hernias medial or lateral to femoral vein?
medial
what is the respiratory quotient?
ratio of moles of CO2 produced to moles O2 consumed
Presentation of hyponatremia?
"CNS: lethargy, apathy, disorientation, agitation, coma, weakness, decreased DTRs, szs "
What are the signs of local anesthetic toxicity?
"Low dose: CNS sxs - auditory hallucinations - paresthesias High dose: - convulsions, stupor, coma, respiratory arrest - circulatory collapse, myocardial depression, arrhythmias "
How does LCIS usually present?
Almost never manifests as breast mass; no characteristic appearance on mammography - usually found incidentally on bx of other suspicious mass/mammographic finding - found in 0.8-8% of bxs
"in terms of the RES (liver and spleen), which organ removes non- opsonized bacteria better?"
Spleen removes non-opsonized bacteria better. Liver is highly effective at removing opsonized bacteria.
Howship-Romberg sign?
"pain in the groin extending to the thigh and knee due to compression of obturator nerve - pain radiates to hip joint - pain worse with abduction, extension, or internal rotation of the extremity "
what is the relationship of the inferior thyroid artery to the recurrent laryngeal nerve?
"as long as the nerve is recurrent, there is always a crossing - the artery may be over, under, or between fibers of the recurrent laryngeal nerve "
adverse effects of protamine?
"in diabetics, 1% incidence of anaphylaxis also, rare syndrome of: - pulmonary vasoconstriction - hypotension - transient neutropenia "
Pathophysiology of hyperacute rejection in renal transplant?
"caused by antibody-mediated damage to graft; believed to be due to preformed antibodies reactive against donor antigens - these Ab develop during prior exposure (transfusion, pregnancy) "
What is the most common cause of spontaneous hypothyroidism in adults?
Hashimoto's
Medical treatment for Graves disease?
thionamides: long-term treatment not really an option Beta-blockers 131I ablation: definitive treatment - few side effects - 70% are hypothyroid within 10 years of tx
formula for computing cerebral perfusion pressure?
CPP = MAP - ICP 60 mm Hg = lowest acceptable CPP CPP < 40 imply irreversible brain injury
ATPs from Kreb's cycle
38 from 1 glucose
What are the two terminal branches of the internal mammary?
pericardiophrenic artery superior epigastric artery
test of choice for locating accessory splenic tissue?
technetium sulfur colloid scan
Inheritance pattern of FAP? Penetrance?
Autosomal dominant 100% penetrant
What FEV1 constitutes a significant pre-operative risk factor?
< 1 liter
Most common organism causing osteomyelitis in sickle cell anemia patients?
salmonella
"presentation of adrenal insufficiency
sepsis: fever, septic physiology GI: nausea, vomiting, abd pain, diarrhea neuropsych: apathetic affect electrolyte abnormalities: hyponatremia, hyperkalemia, hypochloremia, hypoglycemia acid/base: metabolic acidosis "
Which virus is associated with post-transplant lymphoprliferative disorder?
EBV
"when performing splenectomy for ITP, at what point in the procedure should a platelet transfusion be initiated?"
after splenic artery is ligated
Treatment for a recluse spider bite?
Dapsone cold therapy inhibits the venom tetanus prophylaxis antibiotics NO steroids debridement and skin grafting may be necessary non-acutely
What is the minimum age for performing a cricothyroidotomy?
"No cric in < 12 yo - up until this age the cricoid ring is the only circumferential support to the trachea, damage to this ring can lead to collapse "
do elderly patients heal wounds more slowly or more quickly?
The elderly heal more slowly
"What nerve injury is associated with a ""claw hand"" deformity?"
ulnar nerve injury - injury weakens intrinsic muscles of hand - innervation to FDP intact - results in unopposed flexion
Membranes of mitochondira
"2 membranes, TCA cycle in inner matrix"
"what layer of the colon is the ""strength"" layer?"
submucosa
What inhibits/activates gastrin secretion?
"stim - amino acids, ACh; inh - protons in duodenum"
Can FNA diagnose medullary CA?
yes
Usual presentation for a patient with hepatic adenoma?
"Although may be symptomatic, most patients have sxs, usually of abdominal pain (as many as 50%). 10 to 33% of patients present with acute bleeding or rupture with intraperitoneal hemorrhage. "
What is the principal collagen type in in scar?
type I
Mechanism of Renal osteodystrophy
Kidney loses Ca & keeps PO4; dec vit D 1-hydroxylation -> secondary hyperparathyroid
Pathophysiology of pupillary dilation in tentorial herniation?
caused by compression of the oculomotor nerve (CN III)
what % of cutaneous neoplasms are melanomas? what % of cutaneous neoplasm deaths are due to melanoma?
3% 65%
what is paradoxical aciduria?
"aciduria in alkalemic pt - severe H+ loss (vomiting) - urine initially alkalotic from renal compensation - contraction leads to alkalosis, retention of Na+ in exchange for K+ excretion - as hypokalemia progresses, K+/H+ exchanger unable to retain acid "
what are the sensory neurotransmitters in the colon?
Mediators of sensory input: - substance P - calcitonin-gene related peptide
Indications for right colectomy for carcinoid tumor in appendix?
1) size > 2 cm (some say 1.5) 2) involvement of regional lymph nodes: some would say do a wide dissection and omentectomy 3) those that involved the base of the appendix: some would say you can do a cecectomy
mechanism of tamoxifen?
estrogen receptor antagonist - binds at NUCLEAR site
tx for hyperparathyroidism/hypercalcemia associated with MEN I?
subtotal (3 1/2) parathyroidectomy or total parathyroidectomy with heterotopic autotransplantation
Most common pathogenic organism in early (6 hours post-op) wound infection?
CLOSTRIDIA
most common benign tumor of liver?
Cavernous hemangiomas of the liver are the most common benign hepatic tumor and are detected in some 2% to 7% of autopsies.
At what compartment pressure is a fasciotomy indicated?
May be needed for compartment pressures > 30 mm Hg - 30-45 watch carefully - greater than 45 usually needs intervention
at what size should an asymptomatic popliteal aneurysm be repaired?
at greater than 2 cm
Where are ribosomes made
nucleolus - no membrane
Which diagnostic test has the highest sensitivity/specificity for GERD?
pH Probe Monitoring
Most common noscocomial infection that causes mortality?
respiratory
Characteristic FNA results for follicular type?
follicular cells unable to determine invasion without tissue sample
Where is the subclavian VEIN relative to the anterior scalene muscle?
The subclavian VEIN is in front of the anterior scalene
How long does a segment of Barrett's need to be before it carries significant risk?
any length of Barrett's carries substantial risk
mechanism of keloid formation?
increased collagen formation
What is the arterial supply to an intralobar pulmonary sequestration? Venous drainage?
arterial supply from systemic arterial supply (thoracic aorta) - artery enters lung through inferior pulmonary ligament (SAME ARTERIAL SUPPLY AS EXTRALOBAR) - venous drainage usually is by the pulmonary veins
what groups of patients are at higher risk for developing thyroid CA?
"1. h/o low dose radiation - 20-35 year latency period - usually papillary, but some are follicular 2. family hx of medullary carcinoma "
"What is the impact of aging on PaO2, PaCO2?"
PaO2 decreases PaCO2 = unchanged
insulin:glucose ratio commonly seen in fasting patient with insulinoma?
> 0.4 (some say 0.3)
"treatment for central, acute diabetes insipidus?"
aqueous pitressin
Incidence
# of newly diagnosed cases in a population I a certain time (usually per year).
Respiratory quotient of CHO metabolism?
Carbohydrate metabolism 1.0
Treatment for an early stage acinic cell cacinoma of the parotid gland?
treat with local excision - superficial parotid lobectomy
What is an MIBG scan? What is it used for?
MIBG resembles norepinephrine and concentrates within pheos. Scan with iodine-131 (131I)-labeled metaiodobenzylguanidine (MIBG) is used when a pheo is confirmed biochemically but CT and MRI fail to localize
Cardinal symptoms of compartment syndrome of an extremity?
"pain out of proportion to injury pain with passive stretching of muscles paresthesia, hyperesthesia loss of motor function diminished or absent pulses "
most abundant glycoprotein in wound healing process?
fibronectin
TNF is primarily produced by what cell type?
activated T cells and macrophages
where are insulinomas usually found?
"equally distributed throughout pancreas - one third in head/uncinate process, one third in body, one third in tail "
Membranes of nuclei
an outer membrane that is continuous w/ rough ER
Prevalence
# of people having disease in population studied (is higher w/diseases that last long time).
Initial treatment for cystosarcoma phylloides?
"wide local excision with 3 cm margins total mastectomy may be required, especially for re-excision "
Treatment for thyroid storm?
beta-blockade steroids PTU/methimazole iodide
what is the principle type of collagen present in scar tissue?
"The principal collagen type scar is type 1, with lesser amounts of type 3 collagen also present. "
Null Hypothesis
No difference exists
is the spleen diminished or enlarged in ITP?
"NOT enlarged - if the spleen is palpable, question your diagnosis "
medical treatment of Hashimoto's?
thyroid replacement to shrink goiter if one present
Role for surgery in treatment of gastric lymphoma?
Surgery usually reserved for complications of treatment with chemo or XRT
effects of motilin receptor stimulation?
stimulates gastrointestinal smooth muscle contraction improves gastric emptying not been shown to shorten postoperative hospitalization after gastric resections
What is the most common cause of mitral regurgitation following MI?
infarction of a papillary muscle
Most commonly experienced side effect of truncal vagotomy?
diarrhea
What are the potential complications from untreated choledochal cysts?
obstruction cholangitis carcinoma calculi
what organism is most commonly isolated from bile?
E. Coli also: Klebsiella Proteus Enterobacter Anaerobes in 25-30%: B. Frag Clostridium species
Last muscles to recover from paralytics
neck and face
What types of patients are classically diagnosed with choledochal cysts? (age? gender?)
M:F ratio 1:3 50% present before age 10 80% are detected during childhood
what is the effect of age on the virulence of papillary thyroid CA?
much more virulent in the elderly
Which artery/arteries provide(s) blood supply to the stomach when it is pulled up during esophagectomy?
stomach tube dependent on right gastric and right gastroepiploic arcades
Which type of urinary stone is associated with urinary tract infection?
magnesium ammonium phosphate stones (struvite)
Inheritance pattern of HNPCC? Penetrance?
Autosomal dominant 80% penetrant: less of an indication for prophylactic colectomy
how long after starting coumadin does coumadin-induced skin necrosis usually occur?
usually occurs 3-10 days after treatment - no benefit from stopping drug
How is H. Pylori infection diagnosed?
serologic (IgG antibodies): 80-95% sensitive and specific urea breath test: 94- 98% sensitive and specific EGD: gold standard
Does pyoderma gangrenosum occur in UC or Crohn's?
In both UC and Crohn's Also in: - rheumatoid arthritis - dysproteinemias - leukemia/lymphoma - idiopathic in 50%
What is the effect of aging on lung elasticity?
elasticity is decreased
What is the role of ICAMs in neutrophil adherence?
Responsible for binding to integrins; involved in firm adhesion step of neutrophil capture
Mechanism of the classical pathway of complement activation?
mediates specific Ab responses - initiated by the binding of antibodies to cell surface Ags - subsequent binding of Ab to complement C1q results in active C1s subunits
What extracolonic CA(s) is HNPCC (Lynch II) a/w?
"endometrial, ovarian stomach SI hepatobilitary renal ureteric "
"what is the ""double rupture"" phenomenon with regard to splenic artery aneurysms?"
"The double rupture phenomenon, whereby blood is initially contained within the lesser sac and free hemorrhage eventually occurs into the peritoneal cavity is common with ruptured splenic artery aneurysm. "
Side effect(s) of mafenide acetate?
"1) Painful 2) Interferes with renal buffering, may cause a hyperchloremic metabolic acidosis "
"are patients with Hashimoto's hypothyroid, euthyroid, or hyperthyroid?"
patients may be: - euthyroid - hypothyroid (20%) - hyperthyroid - Hashitoxicosis (5%)
"In what part of the esophagus do leiomyomas most commonly occur (proximal, mid, or distal)?"
Usually arise from inner circular muscle layer in distal and mid thoracic esophagus
which hormone(s) inhibit small bowel motility?
secretin and glucagon somatostatin is both inhibitory and stimulatory
Does the right renal artery pass posterior or anterior to IVC on its way from aorta to kidney?
right renal artery passes behind IVC
Can FNA diagnose Hurthle carcinoma?
no
action of secretin?
stimulates pancreatic secretion of bicarb inhibits gastric emptying
in what % of patients under 10 years does ITP spontaneously regress?
"in 90% - surgical management should be reserved for cases with important clinical consequences of hemorrhage, like intracranial hemorrhage "
treatment for thyroid lesion with follicular cells diagnosed on FNA?
"Any patient with an FNA diagnosis of follicular cells should undergo lobectomy/isthmusectomy, including pyramidal lobe - note: only 20% of these patients will have follicular carcinoma "
Viral agent most commonly responsible for pneumonitis in post- transplant patients?
CMV
Type II Error
Accepts null hypothesis incorrectly - no real difference but thinks there is (not specific)
why do patients develop iron deficiency after partial gastrectomy?
iron absorption is impaired in achlorhydric patients
"what are the two main cell types of the exocrine pancreas, and the function of each?"
"acinar cells: synthesize digestive enzymes, high chloride secretions - stimulated by cholecystokinin ductal cells: secrete bicarbonate - stimulated by secretin NOTE: at high flow rates, high-bicarbonate secretions "
What is the first branch of the internal carotid artery?
ophthalmic artery
what cytokines are elaborated by activated macrophages?
"IL-1, IL-6, TNF "
on what side do inguinal hernias occur most commonly?
right
BMI threshold that constitutes indication for performing a bariatric procedure?
NIH Consensus Panel BMI > 40 ...or... BMI 35 - 40 with high-risk comorbid conditions
"What dietary risk factor for hepatocellular carcinoma may be associated with elevated incidence rates in Africa, Asia?"
aflatoxins
does H. pylori confer an increased risk for gastric MALT?
yes
which lobe of the liver has independent venous drainage?
caudate lobe (segment I)
what nerve is injured in anterior dislocations of the humerus?
axillary nerve
Mechanism of action of clopidogrel bisulfate (Plavix)?
inhibits ADP-induced platelet aggregation - directly inhibits ADP binding to its receptor and of the subsequent ADP- mediated activation of the glycoprotein GPIIb/IIIa complex - irreversibly modifies the platelet ADP receptor
what % of ingunial hernias are indirect vs. direct?
about 2/3 are indirect
which transfusion component(s) has/have a significant amount of vWF?
cryoprecipitate
"Drug of choice for chronic, nephrogenic diabetes insipidus?"
massive doses of desmopressin (no vasoconstrictive properties)
Where is the thoracic aorta usually injured in blunt trauma?
usually just distal to left subclavian artery
"Which recover from NMBA earlier, airway muscles or diaphragm?"
"Muscles have unequal sensitivity to NMBA - diaphragm resistant to NMBA - neck and pharyngeal muscles are most sensitive Pt may spontaneously ventilate, produce large NIF and have airway obstruction when extubated. "
which direction is the oxy-hemoglobin dissociation curve shifted with decreased pH?
"right LEFT = LATCH, RIGHT = RELEASE "
test for von-willebrand's deficiency?
ristocetin cofactor assay - causes platelet aggregation in presence of vWF
What is the most common cause of hypercalcemia in hospitalized vs. non-hospitalized patients?
hospitalized patients: - malignancy - second = primary hyperparathyroidism outpatients: - primary hyperparathyroidism
Which muscle's tendon is pierced by the femoral artery as it exits Hunter's canal to become the popliteal artery?
adductor magnus
Role of parietal cells
produce H+ and intrinsic factor
Stimulation of which adrenergic receptors causes dilation of systemic and pulmonary arteries and systemic veins?
beta 2
What cytokines are associated with apoptosis?
TNFbeta IL-1beta
bacteria implicated in Fournier's gangrene?
"Bacteroides, E. Coli, and Strep "
"characteristic mammographic findings of DCIS, LCIS?"
DCIS: clustered microcalcifications often seen - also seen with invasive breast CA LCIS: no calcifications present
Most common noscocomial infection?
urinary tract infection
what elements are considered in histologic grading of sarcomas?
1) cellular atypia 2) frequency of mitotic figures 3) presence/absence of spontaneous tumor necrosis
Which cells carry MHC II receptors?
"located on macrophages, Kupffer cells (antigen-presenting cells -- APC) - these cells process antigens, present them to T and B cells "
What is the impact of aging on DLCO?
DLCO decreases
Indications for surgical treatment for pyoderma gangrenosum?
"Avoid surgery; pathergic phenomenon may occur, resulting in wound enlargement. Grafting has resulted in PG at harvest site - if tendon/bone exposed, surgery may be necessary - some pts w UC have responded to total colectomy "
Treatment of MH?
"Dantrolene 2.5 mg/kg bolus: reduces Ca release - 10 mg/kg IV over 24 hours continuous infusion Sodium Bicarb D50, insulin to treat hyperkalemia Hyperventilation with 100% O2 Active cooling Avoid CCBs (potential hyperkalemia) "
Initial treatment for low-grade gastric MALT?
eradicating H. Pylori may lead to regression - re-biopsy in 6 weeks
what is functional residual capacity (FRC)?
volume of air left in the lungs after a quiet exhalation - equal to ERV + RV
Most prominent symptom in an extremity compartment syndrome?
pain
What is the correct preoperative pharmacological preparation for a patient with a pheo?
"1) Alpha blockade with phenoxybenzamine - start at 20 mg/day, titrate up by 10 mg/day - start at least 7-10 days pre-op 2) Propranolol start 48 hrs before operation at 30-40 mg/day "
Treatment of LCIS?
Controversial; close surveillance vs. prophylactic bilateral mastectomy tamoxifen: results in 50% reduction in risk of developing breast cancer
what is the malignant potential of Peutz-Jeghers polyps?
Histologically these polyps are hamartomas and not adenomas and therefore offer little risk of malignant transformation.
what is the most common abnormality associated with gastroschisis?
intestinal atresia
when is mafenide acetate used instead of silvadene?
in wounds at high risk for infection in burns involving the external ear
which interleukin mediates the hepatic acute-phase synthetic response?
IL-6 is now recognized as a primary mediator of altered hepatic protein synthesis known as acute-phase protein synthetic response. Glucocorticoids augment the acute-phase response
What is a felon? Treatment?
infection of the pulp of the fingertip that can lead to deep ischemic necrosis because of compartmentalizing septa - pulp space should be drained by dividing septa
is hyperthermia usually an early or a late sign in MH?
usually a late sign
What is the most common viral agent transmitted by blood transfusion?
CMV
Zinc a/w what aspects of wound healing?
important cofactor in multiple enzymatic reactions - deficiency a/w poor epithelialization
conditions that increase incidence of carpal tunnel syndrome?
DM thyroid conditions RA pregnancy
Treatment for divided ureter in proximal 2/3 with > 3 cm of injured ureter?
transureteroureterostomy auto-transplantation interposition of ileum/appendix nephrectomy
What is the role of Vitamin C in wound healing?
"cofactor for hydroxylation of lysine and proline during collagen synthesis without vitamin C, existing scars dissolve "
What is a calcified liver cyst > 5 cm with adjacent daughter cysts on ultrasound or CT most likely to be?
echinococcal liver cyst
What are the most frequent causes of dysphagia after Nissen?
"first 2 weeks: traumatic edema first 4-6 weeks: intramural hematoma after 6 weeks: wrap too tight, may need dilation "
How is the diagnosis of central diabetes insipidus made?
water deprivation test: - evaluates pts's ability to concentrate urine in response to increasing plasma concentration - dx made based on plasma osm > 300 with urine osm > 270
ANOVA
analysis of variables - t-test for >2 samples of quantitative data
what is the most sensitive screening test for Cushing SYNDROME?
24-hour urinary free cortisol
What is a Marjolin's ulcer?
"squamous cell carcinoma occurring in a chronic open wound - occurs after an average of 20 years, but may occur within a few years "
Role of chief cells
make pepsinogen (become pepsin - initiates proteolysis)
Smooth ER
?cytoplasmic proteins - or???
Mechanism of action of antidiuretic hormone (ADH)?
"stimulates insertion of water channels into cortical collecting ducts, thick ascending loop "
What is zero-order vs. first-order pharmacokinetics? Which is more common?
Zero Order - rate of elimination is constant - can occur in overdose situations where clearance processes are saturated First Order - half-life does not vary with dose - most drugs obey first-order pharmacokinetics
most common complication a/w hepatic hemangiomas?
anemia risk of rupture is low
Clinical appearance of a posteriorly dislocated hip?
"thigh adducted, internally rotated, flexed "
what CA(s) is/are associated with RAS?
"pancreatic, colon, lung "
second messenger signal for nitric oxide?
nitric oxide binds to receptor (soluble guanylyl cyclase) - guanylyl cyclase makes cyclic GMP - cyclic GMP improves blood flow by relaxing blood vessel walls (cyclic GMP)
Characteristic FNA results for papillary type thyroid cancer?
cleft nuclei/nuclei of different sizes - psammoma bodies (calcium deposits) sometimes
Can FNA diagnose follicular CA?
"no Distinction between follicular adenoma and carcinoma needs to be made on the basis of capsular or vascular invasion, and can be made only using histology. "
which cells in the stomach secrete acid?
parietal cells
Pathophysiologic mechanism of hyperchloremic metabolic acidosis with ureterosigmoidostomy?
"Cl- exchanged for bicarb by colonic mucosa, resulting in loss of bicarb - aggravated by ammonia reabsorption from urine in colon; ammonia is converted to H+ by liver - ureteroileostomy minimizes this problem "
Diagnostic study of choice for intussception?
BE (some say ultrasound...)
Does epithelialization occur more rapidly under moist conditions or dry conditions?
Epithelialization is more rapid under moist conditions than dry conditions.
presentation of uncal herniation
ipsilateral dilated/fixed pupil contralateral spastic arm/leg weakness from compression of motor tract
effect of pH on ionized calcium level?
"Acidosis increases level, alkalosis decreases level - H+ displaces Ca++ from binding proteins "
Venous drainage of intralobar vs. extralobar pulmonary sequestration?
intralobar: usually by pulmonary veins extralobar: usually via systemic venous system EXTRA = EXTRA-PULMONARY
What is normal ICP?
<10 mm Hg
Cystosarcoma phylloides tumors: what % are malignant?
10-25% are histologically malignant - only a fraction of these patients actually develop metastatic disease
Physiology of defect in malignant hyperthermia?
Patients with defect in calcium release from sarcoplasma of skeletal muscle
What disorder is characterized on this plain film?
"sigmoid volvulus - note how volvulus tends to ""point"" to RUQ "
Where is the organ of Zuckerkandl?
"organ of Zuckerkandl: usually located to left of aortic bifurcation, near IMA "
CXR findings with fat embolism?
bilateral fluffy infiltrates - identical to ARDS
"is etomidate an amnestic, an analgesic, or both?"
amnestic only. no analgesic properties
"Which aspect of wound healing is made worse by steroids, but NOT improved by administration of Vitamin A?"
wound contraction
Presentation of hypercalcemia?
"stones bones: decalcification, osteitis fibrosa cystica moans: anorexia/vomiting/nausea/weight loss groans: HA, muscle ache, gastritis, pancreatitis, ulcers psych overtones: fatigue, lethargy, depression "
What part of the GI tract develops polyps in Peutz-Jegher's syndrome?
"hamartomatous polyps throughout the GI tract (stomach, SI, colon), usually by age 20 "
Most frequent leg compartment involved in extremity compartment syndrome?
anterior compartment - numbness in great toe web space may be attributable to pressure on deep peroneal nerve
What are the complications associated with untreated popliteal artery aneurysms?
rupture almost nerve occurs 40% will develop thromboembolic complications if left untreated thrombosis can also occur
what is pancreas divisum? what % have it?
"failure of normal fusion of the pancreas, resulting in two pancreatic ducts that do not join, each of which drains an independent area of the pancreas. 10% have it "
What is neurogenic shock?
"impairment of descending sympathetic pathways in spinal cord - loss of vasomotor tone - loss of sympathetic innervation to the heart - results in venous pooling, bradycardia (inability to mount tachycaria) "
What nerve/artery is commonly injured with posterior dislocation of knee?
Popliteal artery thrombosis
what is the most common autoimmune thyroid disease?
Hashimoto's
What % of patients with Peutz-Jeghers have melanotic pigmentation? Where?
"95% have it usually perioral, periocular, perianal "
initial appearance of collagen occurs at what time period?
48-72 hours (third post-injury day)
technique for approaching felon infections?
two main approaches: - lateral approach: place incision dorsal to IP flexion crease - central approach: appropriate for mid-pad infections
What % of the time is medullary thyroid carcinoma multicentric in MEN 2A and MEN 2B?
always in both
Clinical presentation of homocysteinemia?
Marfanoid body habitus thromobotic vascular disorders ectopia lentis mental retardation osteoporosis
What is the difference between a hypertrophic scar and keloids?
The primary difference between a keloid and a hypertrophic scar is that a keloid extends beyond the boundary of the original tissue injury.
how soon after initiating heparin does heparin-induced thrombocytopenia occur?
"early and late form: - early = 2-5 days: - benign course, may improve - stop heparin if plts < 100K - late = 5 - 10 days: - more severe -- in only 5% of cases - a/w severe arterial embolic complications - stop all heparin "
Is the diarrhea a/w VIPoma usually episodic or constant?
episodic
Indications for surgery for Dupuytren's contracture?
MCP joint: contracture greater than 30 deg PIP joint: any significant contracture (more than 20)
Most common extremity injury associated with vascular injury?
knee dislocation
Treatment for Zenker's diverticulum?
1. cricomyotomy 2. suspension from prevertebral fascia vs. resection/excision
Major side effect(s) of doxorubicin?
"cardiomyopathy -> CHF, EKG changes - MUGA scan/ECHO prior to use to monitor/track EF "
Treatment of congenital lobar emphysema?
"medical: if infant not in respiratory distress, able to feed and grow do not necessarily need surgery surgical: lobectomy "
Gastrin is produced where?
antral G cells
Do femoral hernias appear more commonly on the right or the left?
twice as common on right
most common cause of failure of reversed saphenous vein grafts (early vs. intermediate vs. late)?
early (< 2 months) = technical error intermediate (2 months - 2 years) = intimal hyperplasia late (> 2 years) = arterial atherosclerosis
cause(s) of anemia in renal failure?
retained toxins -> poisoned bone marrow decreased erythropoietin from disease kidney(s) presence of erythropoietin inhibitors
Pathophysiology of myasthenia gravis?
antibodies to post-synaptic ACh receptors
How long after wounding does wound contraction begin? At what point does maximal contraction occur?
4-5 days 12-15 days
Effect of PEEP on pts with pneumonia?
PEEP can actually decrease oxygenation by increasing V/Q mismatch - consolidated lung will not open up with PEEP - PEEP impedes blood flow to lung which is already being oxygenated
EKG fingings with hyperkalemia?
"MILD HYPERKALEMIA 1) peaked T waves SEVERE HYPERKALEMIA 2) P wave flattening -> disappearance 3) prolonged QRS -> sine wave 4) sinus arrest, VFib/VTach "
most common cause of carpal tunnel syndrome? other causes?
usually idiopathic - may be seen after Colles's or Smith's fractures - rheumatoid arthritis - gout - DM - hypothyroidism - amyloidosis
What type of ulcer is this? Is it associated with high or normal acid output?
Type III Acid secretion high
which cytokines have pyrogenic effects?
TNF IL-1 IL-6
In what part of the GI tract is the majority of water absorbed?
ASCENDING colon
Which muscles are innervated by the superficial peroneal nerve?
lateral compartment -- foot evertors - peroneus longus - peroneus brevis
What is the role of selectins in neutrophil adherence?
Responsible for the initial rolling/slowing down of neutrophils as they encounter a site of inflammation
Where in the esophagus does Zenker's diverticulum occur?
cervical esophagus -- posterior - Killian's dehiscence: weak spot between transverse fibers of cricopharyngeus (inferiorly) and oblique fibers of inferior constrictor muscles (superiorly)
Treatment for diagnosed cystosarcoma phylloides after excision for fibroadenoma?
"if found to have after fibroadenoma excision, need to re-excised with wider margins "
Which pancreatic endocrine tumor is associated with watery diarrhea?
VIPoma
Mechanism of action of imatinib mesylate (Gleevec)?
inhibits signal transduction of various tyrosine kinases
What is the embryologic error/defect believed to be responsible for jejunal/ileal atresia?
thought to be the result of interruption of vascular supply to small bowel at fetal stage of development
Classic clinical presentation of OPSS?
"sudden onset of nausea, vomiting, headache, confusion -> coma progression to DIC and shock rapid course, often 12-18 hours "
"In pts with LCIS, what is the most common type of CA that develops?"
"Infiltrating ductal carcinoma is the most common CA. Incidence of infiltrating lobular carcinoma is high in these patients, but ductal is still more common. "
most common growth factor involved in wound healing is?
platelet-derived growth factor (PDGF)
Which direction is the oxy-hemoglobin dissociation curve shifted with blood transfusions?
"1) increased pH -> left shift of curve 2) depressed amt of 2,3-DPG in stored cells -> left shift of curve LEFT = LATCH, RIGHT = RELEASE "
1-year and 10-year patency rates for saphenous vein graft vs. internal mammary grafts during CABG?
1-year10-year -------------------------- SVG80-90%50% IMA98%90%
most common causes of gastric outlet obstruction in adults?
adenocarcinoma of the stomach. duodenal stenosis secondary to peptic ulceration in 20-40%
which direction is the oxy-hemoglobin dissociation curve shifted with increased temperature?
"right LEFT = LATCH, RIGHT = RELEASE "
At what age(s) does gynecomastia usually occur?
"Occurs during three phases of life, when there is excess estrogen relative to testosterone: 1) neonatal 2) adolescence 3) senescence "
What nerve/artery is commonly injured with distal radius fracture?
Median nerve compression
Kanavel's four signs of flexor tenosynovitis?
1) flexed posture of affected digit 2) tenderness along the sheath with erythema 3) pain on passive extension of DIP joint 4) fusiform swelling (sausage-like finger)
"is ketamine an amnestic, an analgesic, or both?"
both
What is a proto-oncogene -- mechanism?
cancer-related gene that can become activated by mutational changes
What is Trousseau's sign?
"Elicitation: Inflate BP cuff above systolic pressure for several minutes Positive response: Muscular contraction including flexion of the wrist and MCP joints, hyperextension of fingers, flexion of thumb on palm, suggestive of neuromuscular excitability "
can antibiotic resistance develop to topical antibiotics?
yes
Most common form of cancer in males 15-35?
testicular cancer
Which topical medication leeches electrolytes (Na and K) from wounds?
silver nitrate
What is the most common site of esophageal perforation during upper endoscopy?
at level of cricopharyngeus - site of anatomical constriction
what % of total body weight is water in men vs. women?
men: 60% women: 50%
Which electrolytes are depleted severly during refeeding syndrome? Which is most dramatic and clinically significant?
"During re-feeding, hypokalemia, hypomagnesemia, hypophosphatemia occurs - hypophosphatemia may be especially clinically significant -> muscle weakness, respiratory insufficiency "
"In pts with LCIS, what is the risk of breast cancer?"
Marker for future malignancy in EITHER breast (up to nine-fold increase); - 13% risk in first decade after diagnosis - 26% in second decade - 35% risk in 35 years (risk higher in younger pts) roughly 1% per year
characteristics of MEN 2A?
1) Medullary thyroid cancer (hallmark of MEN 2 = 100%) 2) Pheochromocytomas (42%) 3) Hyperparathyroidism (parathyroid hyperplasia)(25-35%) (MPH)
What is a tumor suppressor genes -- mechanism?
"contribute to tumorigenesis when mutated or deleted - examples: p53, APC, BRCA-1, BRCA-2 "
Treatment for divided ureter in distal 1/3 with > 3 cm of injured ureter?
reimplant ureter to bladder fix bladder to psoas minor muscle (psoas hitch) Boari flap: a tubed bladder flap
how long after initiating coumadin do you usually see coumadin- associated rash?
3-8 days
What are the main stimulants to renin release?
stimulants: - decreased plasma sodium - decreased BP in afferent arterioles - hyperkalemia
What is the treatment for variceal bleeding in a patient with splenic vein thrombosis?
splenectomy
where does Boerhaave's syndrome usually occur?
"nearly always occurs in its left posterior distal portion (""weak spot"") "
Pharyngeal pouch derivatives from 4th branchial pouch?
4th pouch develops into superior parathyroids
Mechanism of activity of amrinone/milrinone?
phosphodiesterase inhibitors cAMP-mediated
"Can Chvostek's sign be positive with hypomagnesemia, normal calcium level?"
yes
What are the stimulants of bile flow?
secretin stimulates ductal secretion (bicarbonate) CCK stimulates hepatocellular component
Respiratory quotient of glucose conversion to fat?
Glucose conversion to fat 8.0
which stomach cells secrete acid?
parietal cells
Cervical esophageal blood supply?
inferior thyroid arteries
Composition of Plasma membrane
"60% protein, 40% lipid"
What is the most common type of fistula in diverticular disease?
colovesical
Can FNA diagnose papillary CA?
"yes psammoma bodies, intranuclear cytoplasmic inclusions (Orphan Annie nuclei) are seen on FNA "
What drug(s) has/have demonstrated efficacy in closing fistulas associated with Crohn's disease? mechanism?
infliximab - monoclonal antibody to TNF-alpha
What % of breast CA patients have p53 mutation?
< 1% of breast cancer patients have p53 mutation
where are bile acids reabsorbed?
"ACTIVE: in the SI PASSIVE: deconjugation of bile acids in SI/colon - deconjugation raises pKA of bile acids, enables resorption - passive nonionic diffusion occurs in distal SI + colon "
what CA(s) is/are associated with BRCA-1?
Lifetime risk for breast CA: 80-85% - 50% by age 50 - slightly higher than with BRCA-2 Lifetime risk for ovarian CA: 40-60% - significantly higher than with BRCA-2
What gene-related defect is most often a/w pancreatic carcinoma?
K-ras in 65-100% often asked
what is the most common hernia in men? women?
inguinal hernia is most common in both
do you do an ALND for malignant cystosarcoma phylloides?
"ALND NOT performed in absence of biopsy-proven nodal involvement,even for malignant phylloides tumors Axillary metastases are uncommon "
How is cis-atracurium metabolized?
Hoffman spontaneous degradation in plasma - clearance not prolonged in hepatic/renal dysfunction
possible choices for C. Diff colitis?
IV or PO flagyl PO vanco po flagyl is first line vanco for critically ill patients
blood supply to superior parathyroids? inferior parathyroids?
inferior thyroid artery supplies BOTH sets of parathyroids in the majority of cases
Is the respiratory quotient high or low in situations of overfeeding?
high
gene implicated in MEN?
"RET - proto-oncogene - associated with MEN IIa, IIb, FMTC "
IL-1 is commonly produced by what cell type?
macrophages
what is the normal bacterial composition of feces?
"anaerobes:aerobes = 100-300:1 bacteroides/fusobacterium predominate - some enterococcus, E. Coli "
Meta-analysis
Review and statistical combination of data from different studies
Vitamin deficiency seen in blind loop syndrome?
"bacterial overgrowth in loop leads to bacterial consumption of B12, megaloblastic anemia "
appearance of duodenal atresia on plain film?
double bubble sign due to gastric bubble + bubble bounded by pylorus and obstruction
most common right-to-left shunt in infants? (most common cyanotic malformation)
tetralogy of Fallot
What electrolyte imbalance frequently accompanies a VIPoma?
hypercalcemia - these tumors often secrete PTH
most common pituitary adenoma in MEN I? tx?
prolactinoma bromocriptine controls prolactin secretion and can shrink tumor mass
which tumor marker(s) are secreted by medullary thyroid carcinomas?
calcitonin almost always elevated carcinoembryonic antigen (CEA) elevated in 80%
Which LFT value is most commonly elevated in biliary obstruction?
alk phos
Overall risk of breast CA? What % of women will die from the disease? Risk for a woman with no risk factors?
Lifetime risk for all women 12.2% 3.6% will die from the disease Lifetime risk for a woman with no risk factors = 4%
Most common bug implicated in endocarditis in an IVDA? most commonly involved valve?
Staph Aureus tricuspid (50%) aortic (25%) mitral (20%)
correct margin for melanoma in situ? larger lesions?
in situ .5 cm 1-4 mm thick: 1 cm margin is advisable >4 mm thick: 2 cm margin recurrence more dependent on thickness at time of diagnosis
Type III Error
Wrong conclusion - not supported by data
indications for surgery for carpal tunnel syndrome?
thenar atrophy weakness failure to respond to conservative therapy
in what % of patients with ITP do platelet counts return to normal after splenectomy? what are the predictors of success of splenectomy?
80% of ITP patients have normal platelet counts post-splenectomy 90% of those who had a good response to steroids 60% of those who failed steroids
What is the primary energy source for colonocytes?
"In contrast to glutamine in the small intestine, short chain fatty acids are primary energy source for colonocytes. "
what is the most common functional tumor of the endocrine pancreas? least common?
most common: insulinoma least common: somatostatinoma
management of burns to the auricle?
"Twice daily cleansing and application of mafenide acetate - avoid pressure on burned auricle from pillows, etc "
Usual presentation of DCIS?
"most commonly no breast mass (but can, unlike with LCIS) usually a cluster of microcalcifications on mammo "
What is an oncogene -- mechanism?
"genes that become oncogenic when amplified, mutated, or overexpressed; NOT when deleted - promote transformation of normal cells -> tumor cells by activating growth "
What is the main amino acid fuel for enterocytes?
glutamine
Are Peutz-Jeghers polyps premalignant? What is the mgt of Peutz-Jegher pts?
"no They are, however, at an increased risk for colonic CA - mgt should be aggressive endoscopic removal of polyps - increased risk not enough to warrant prophylactic colectomy "
maximum collagen synthesis occurs at what time period? when does collagen synthesis plateau?
7-21 days synthesis plateaus at 7 days post-injury
treatment of choice for hepatic adenoma?
"For asx patients or patients with minimal sxs, surgery is treatment of choice. Tumors have the tendency to bleed and a small chance of coexisting malignancy. "
Which lung tumors arise centrally?
1. Squamous cell carcinoma 2. Small cell carcinoma 3. Large cell (non-small cell) can be central OR peripheral
most common bugs a/w catheter sepsis?
Staph Epi Staph A Yeast
what are the stimulants to gastric acid secretion? 2nd messengers for each mechanism? which cells secrete acid?
stimulants: 1. histamine (cAMP/protein kinase C) 2. acetylcholine (IP3/protein kinase C) 3. gastrin (IP3/protein kinase C) parietal cells Hi-CAMP
Symptoms of Malignant hyperthermia
"Fever, tachy, rigid, acidosis. 1st sign on inc end tidal CO2 - often not pts 1st exposure to anesthesia"
How is the diagnosis of Graves disease made?
1) Anti-TSH-receptor abs almost always positive 2) radioactive iodine scanning = increased uptake diffusely distributed over the entire gland
What % of pts with esophageal adenoCA have Barrett's? What % of patients with Barrett's develop adenocarcinoma?
62% 7-20%
what is the mechansim of activity of RAS?
"encodes plasma membrane GTP-binding proteins - mutations abolish GTPase activity of G proteins, leading to a constitutively activated protein "
What is usually the earliest sign in onset of MH?
unexplained rise in end-tidal CO2 levels
Treatment for SCC of anal canal?
"chemo radiation - biopsy 6-8 weeks after completion of therapy - progression should prompt use of second-line chemoradiation therapy (cisplatin), possible APR if tumor is in situ, surgical excision "
Treatment of gallstone ileus?
"proximal enterotomy, stone extraction - check entire SB for stones (present in 10% of patients) - no operation on biliary fistula should be undertaken at initial procedure, as this doubles mortality rate "
what are the two terminal branches of the gastroduodenal artery?
right gastro-epiploic artery superior pancreaticoduodenal
what is the most common form of skin cancer?
basal cell carcinoma (BCC)
are insulinomas usually malignant or benign?
> 95% are benign
calcitonin - stimulants to secretion?
secretion is stimulated by calcium and pentagastrin
source of fever in atelectasis
Alveolar macrophages
Whipple's triad? what is the test of choice for diagnosing insulinoma?
1) hypoglycemic symptoms with fasting 2) blood glucose of 50 or less 3) reversal of symptoms with glucose treatment test of choice is insulin:glucose ratio of > 0.3
blood supply to head of pancreas?
superior pancreaticoduodenal (from GDA) inferior pancreaticoduodenal (from SMA)
when should prophylactic colectomy be performed on FAP patients? what % of pts with FAP develop CRC by age 20?
shortly after diagnosis all patients with FAP will develop colon cancer if left untreated 5%
what immunoglobulin is present most abundantly in breast milk?
IgA is most abundant
what CA is associated with DCC? mechanism of activity?
Carcinomas of colon and stomach Mechanism = tumor supression (loss of cell adhesion molecule) Deleted in Colon Cancer
Appropirate crystalloid bolus for treating shock in an infant?
20 cc/kg
Where in the US is the brown recluse spider found?
native only to the South and central Midwestern states
Most common causes of primary adrenal insufficiency?
"In general, autoimmune disorders most common cause In ICU, hemorrhage most common cause Other causes: - Waterhouse-Friedrichsen: adrenal hemorrhage, meningococcal sepsis - mets to adrenal - TB infection of adrenals "
What is another (common) name for pleomorphic adenoma of the parotid gland?
mixed tumor
What are the sources for vitamin K intake?
"present in edible vegetables, especially in green leaves produced by intestinal bacteria "
Non-parametric statistics
for qualitative data analysis - nominal (named - s.a. color) ordinal (scale - pain)
Which population is at risk for femoral hernias?
"Multiparous females - with lax tissue supports, pregnancy causes stretching of femoral septum which normally covers the mouth of the femoral canal "
drug of choice for clostridial myonecrosis (C. Perfringens)?
penicillin G clindamycin if PCN-allergic
what happens when melanoma metastasizes to the SI?
intussusception can occur
What are the cardinal symptoms of aortic stenosis?
angina (50% 4 yr survival); most common manifestation syncope (50% 4 yr survival) CHF/dyspnea (50% 2 yr survival); worst prognosis
How is the diagnosis of Hashimoto's made?
antibodies to human thyroid peroxidase are positive in 90% antithyroglobulin antibodies are positive in 20-50%
electrolyte abnormality most often a/w ileus?
hypokalemia
Intrinsic factor mechanism
binds vit B12 -> absorbed in terminal ileum - pernicious anemia
What % of primary hyperaldosteronism is adenoma vs. hyperplasia?
65+% - unilateral adenoma 30% - bilateral hyperplasia (unilateral hyperplasia is reported) 5% - bilateral adenomas
What metabolic derangement occurs with ureterosigmoidostomy?
Hyperchloremic metabolic acidosis
How many half-lives does it take for a drug to reach steady-state concentration (given first-order pharmacokinetics)?
4-5 half-lives
What is the impact of aging on residual volume (RV)?
RV decreases
Management of hydrofluoric acid burns?
patients often experience life-threatening hypocalcemia - use subeschar injection of 10% calcium gluconate - intravenous calcium support - limited exposures can be managed with irrigation and topical calcium gluconate gel
How long after cessation of regular steroids use is a patient susceptible to adrenal insufficiency?
previous administration of steroids may result in adrenal insufficiency for up to one year
What % of patients with a popliteal artery aneurysm have a co- existing AAA?
40% of patients have a co-existing AAA
Treatment for extra-peritoneal bladder rupture (no associated injuries)?
foley catheter drainage - cystogram in 7-10 days
What % of popliteal artery aneurysms are bilateral?
50-70% are bilateral
What is the most common type of choledochal cyst?
Type I accounts for approximately 80% of cases
Effect of vagal activity on stomach
stimulates ACh and gastrin -> release PIP/DAG -> inc Ca ->activate protein C -> inc HCl production
What type of ulcer is this? Is it associated with high or normal acid output?
Type I Acid secretion normal or low; ulcers due to lack of mucosal protection
What is the best drug to cause a calciuria?
lasix
Treatment for carcinoid tumor of the rectum?
"< 2 cm, no invasion into muscularis: transanal excision > 2 cm or invasion: APR or LAR "
where is calcium absorbed? is absorption active or passive?
absorbed in duodenum (actively) and jejunum (passively)
What bugs are not covered by silvadene cream?
some pseudomonas species enterobacter cloacae
Does heparin-induced thrombocytopenia occurs more often with unfractionated or fractionated heparin?
less frequently with fractionated than with unfractionated
Where is the subclavian ARTERY relative to the anterior scalene muscle?
The subclavian ARTERY is behind the anterior scalene
Appropriate mgt of choledochal cysts?
excision with clean margins biliary drainage with Roux-en-Y NOTE: some will treat type II with excision and reconstruction of bile duct wall
"Of the cardinal symptoms of aortic stenosis, which has the worst prognosis?"
CHF/dyspnea (50% 2 yr survival); worst prognosis
What is the most common cause of thyrotoxicosis?
Graves disease
What test is used to rule out surreptitious insulin administration?
C-peptide
what is FEV1?
volume of gas exhaled in one second with maximum expiratory effort
Classic triad for presentation of intussusception?
"vomiting: may become bilious abd pain: intermittent; in between bouts, child may act normal blood per rectum: ""currant jelly"" stool with mucus and blood classic triad occurs in < one-third of patients: "
cardinal signs of fat emboli syndrome?
1) petechial rash 2) respiratory distress (hypoxia on ABG) 3) cerebral signs
Type I error
Rejects null hypothsis incorrectly - there is difference but not detected (not sensitive enough)
Pathophysiologic mechanism of p53?
"tumor suppressor; multiple effects - regulates cell growth, acts as a transcription factor - regulates apoptosis "
where are VIPomas most often located? best test to localize tumor?
distal pancreas - these tumors are almost always distal; can perform distal pancreatectomy
What % of pheochromocytomas are unilateral vs. bilateral?
90% are unilateral
Three late sequelae of electrocution injury
cataracts delayed hemorrhage cholelithiasis
management of scaphoid fracture?
"long arm thumb cast, repeat x-rays in 2 weeks "
What adjuvant therapy has a role in treatment of melanoma?
interferon for stage III disease (nodal metastases)
What is the most common cause of cancer death in the US?
lung CA
Mechanism of the alternate pathway of complement activation?
"does not require antibodies to inititate the cascade, but is initiated by foreign cell surface components "
What electrolyte abnormality(ies) can be associated with colorectal villous adenomas?
"hypokalemia -- due to diarrhea, secretion of mucus metabolic alkalosis due to volume loss, secretion of potassium-rich mucus "
Where are carcinoid tumors located in the appendix?
75% are in distal third 15% are in middle third 10% are in base
what CA(s) is/are associated with BRCA-2? lifetime risk for breast CA?
"Lifetime risk for breast CA: 80% Lifetime risk for ovarian CA 20% (less than BRCA-1) Others: male breast CA, prostate, pancreatic "
Is reflux a risk factor for developing esophageal SCC?
no
What is a Type I vs. a Type II error?
Type I: false-positive (null hypothesis incorrectly rejected) Type II: false-negative (null hypothesis not disproved when in should be)
most common cause of gram-negative bacterial sepsis in hospitalized patients?
urinary tract infections
What is the clinical presentation of unilateral recurrent laryngeal nerve injury?
"dyspnea vs. hoarseness (or both), depends on position of injured cord - if injured cord apposed -> dyspnea - otherwise, may be more hoarseness "
Treatment for medullary thyroid CA?
"total thyroidectomy, central node dissection - recommend parathyroidectomy with autotransplantation to allow for better node dissection - single vs. bilateral neck dissection if nodes are clinically involved "
What is the normal value for respiratory quotient?
0.82
Is gynecomastia a risk factor for male breast CA?
no
What is the treatment for neurogenic shock?
IV fluid resuscitation judicious use of vasopressors (phenylephrine) atropine for hemodynamically significant bradycardia adequate perfusion may be maintained without normalizing blood pressure
What is the impact of aging on vital capacity (VC)?
VC decreases
Mechanism of action of fluroquinolones?
interferes with bacterial DNA gyrase
Histopathologic findings in achalasia?
1. loss of ganglion cells in myenteric plexus 2. degenerative changes in vagus nerve 3. changes in dorsal motor nucleus of the vagus
Which pancreatic enzyme(s) is/are secreted in active form?
"lipase and amylase all others are secreted as zymogens, activated by duodenal enterokinase or by trypsin (which started off as trypsinogen before activation by enterokinases) "
What approach to repair of a traumatic diaphragmatic hernia is preferred in the context of ACUTE injury?
trans-abdominal
Definition of Barrett's?
"Change in esophageal epithelium that can be recognized by endoscopy AND is confirmed to have intestinal metaplasia by biopsy. Metaplasia, with goblet cells, is required by definition. Metaplasia without visual changes is normal. "
"Rate limiting step in cholesterol formation (in liver, steroid precursor)"
HMG Co-A Reductase - statin target
Which muscles are innervated by the deep peroneal nerve? What is the result of injury to the deep peroneal nerve?
anterior compartment -- extensors of foot and toes - tibialis anterior - extensor digitorum longus - extensor hallucis longus INJURY = FOOT DROP
What nerve/artery is commonly injured with fracture of the mid- shaft humerus?
radial nerve
Treatment of malignant hyperthermia
"dantrolene, stop operation/anesthetic, supportive"
electrolyte abnormalities seen with adrenal insufficiency?
hyponatremia hyperkalemia hypochloremia hypoglycemia metabolic acidosis
which more commonly presents as a palpable breast mass -- DCIS or LCIS?
DCIS occasionally presents as a breast mass LCIS almost never manifests itself as clinically apparent mass. Usually found incidentally on biopsy of other more suspicious mass/mammographic finding
Treatment of homocysteinurea?
"dietary supplement with pyridoxine, folate, cobalamin "
Mechanism of action of aminoglycosides?
"binds to 30s ribosomal subunit, inhibits transcription "
Treatment of hepatic hemangiomas?
"low risk of rupture - observation is indicated for asymptomatic patients, esp for lesions < 4 cm - surgical excision may be considered for symptomatic masses - embolization moderately effective "
In what types of patients are ketamine contraindicated?
increased intracranial pressure (trauma) CAD psychiatric patients
What cancer most commonly metastasizes to bone in women?
breast

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