Absite Review

Head and Neck

30 year old female develops neck pain following a recent URI.

She has an enlarged and tender thyroid. She is diagnosed with acute thyroiditis

What is the treatment?

• Penicillin

• NSAIDS

• Observation

• Thyroid hormone replacement

Acute thyroiditis

• Involves lymphocytic infiltration of the thyroid

• Usually follows a URI

• Symptoms: fever, tenderness, sore throat, cough, and elevated ESR

• Treatment – NSAIDS

• Usually self-limited (2-3 weeks)

55 year old woman presents with a palpable neck mass and a calcium level of 15. What is

the diagnosis?

• Parathyroid carcinoma

• Parathyroid hyperplasia

• Parathyroid adenoma

• Thyroid nodule

Parathyroids

• The palpable mass and extraordinarily high calcium point to parathyroid carcinoma.

• Superior –4th brachial pouch; Inferior – 3rd

• Blood supply – inferior thyroid artery• Treatment of parathyroid carcinoma involves

enbloc resection of the thyroid and parathyroids. • Most common cause of hypercalcemia is a

parathyroid adenoma followed by hyperplasia.

What tests will determine if a 14 year old with a family history of medullary thyroid cancer

has MENIIb?

• RET protooncogene

• Calcitonin

• Calcium

• thyroglobulin

Stuff to memorize

• MEN 1

pituitary tumors

hyperParathyroidism

neuroendocrine Pancreatic tumors

• MEN II – RET protooncogene

– Hyperparathyroidism (35%)

– Medullary thyroid CA (100%)

– Pheochromocytoma (50%)

– IIB

– Mucosoal neuromas and Marfanoid habitus

Breast

Level III axillary lymph nodesare?

• Inferior to the pectoralis minor

• Medial to the pectoralis minor

• Lateral to the pectoralis minor

• Superior to the pectoralis minor

• Posterior to the pectoralis minor

• Level 1 – lateral to pec minor

• Level 2- inferior to pec minor

• Level 3- medial to pec minor

• Ax dissection is considered complete once level 1 and 2 nodes are taken. Level 3 is not routinely taken.

Treatment of a woman with previous irradiation to chest for Hodgkin’s lymphoma who now presents with invasive ductal

carcinoma of the left breast

• Simple mastectomy and SLN

• Modified radical mastectomy

• Breast conservation therapy

• Chemotherapy, followed by radiation

• Lumpectomy must be followed by radiation.

• Patients with previous history of radiation, collagen-vascular disorders, or another contraindication to radiation are NOT candidates for breast conservation therapy.

Tamoxifen

• Increases risk of endometrial cancer, DVTs

• Competitive estrogen agonist

• Decreases local recurrence and mortality in patients with DCIS and breast cancer

• Give to all women with ER/PR positive status

A 22 year old woman presents with a red, painful breast. She is post partum and breast feeding. What

should be her treatment plan?

• Antibiotics and cessation of breast feeding

• Warm compresses and cessation of breast feeding

• Antibiotics. Continue breast feeding.

• To OR for an I an D.

• Antibiotics and continuation of breast feeding.

Histologic characteristics associated with an increased risk

of breast cancer• Florid epithelial hyperplasia

• Fibrocystic breast disease

• Duct ectasia

• Apocrine metaplasia

Other histologic characteristics associated with an increased risk of breast cancer

• Sclerosing adenosis

• Papilloma

• Atypical hyperplasia

• DCIS

• LCIS

Nutrition

 The most abundant amino acid is?

a. Alanine          

b. Glutamine          

c. Valine

d. Tryptophan

e. Leucine 

A patient  has received 250 ml of 20% fat and a solution consisting of 2,000 ml of 20% dextrose and 5% amino

acid. The total number of calories the patient has

received is:

• 1,800 K cal/day

• 2,210 K cal/day

• 2080 K cal/day

• 2,600 K cal/day

• 2,810 K cal/day

• Protein – 4 kcal/gm

• Carbohydrates - 3.4 kcal/gm

• Fat - 9 kcal/gm

Respiratory Quotient

• Equals carbon dioxide produced/oxygen utilized

• =1 – carbohydrate utilization

• =0.82 - protein utilization

• =0.7 – fat utilization

• = >1 overfeeding and subsequent hypercarbia.

A 75 year old woman underwent a Whipple procedure for pancreatic cancer. Her post op course was complicated by an anastomotic leak. She is still on mechanical ventilation post

op day #26, with two failed attempts at extubation. On reason that could explain this is a respiratory quotient of:

• 0.66• 0.7• 0.8• 0.9• 1.1

Hyperhomocystinemia is a risk factor for premature atherosclerosis and venous thromboembolic disease. Treatment includes all of the following except:1)Folate2)Vit B63)Vit B124)Vit B1

A patient presents with a gunshot wound to the proximal thigh. In the operating room, a 1.5 cm injury to the proximal common femoral artery is identified. Operative repair is:

1)PTFE interposition graft

2)Vein interposition graft

3)Primary end to end anastomosis

4)Ileofemoral bypass

The order of cells arriving at the scene of injury during

Wound healing is:

1)Fibroblasts, Macrophages, Platelets, Neutrophils

2)Macrophages, Platelets, Neutrophils, Fibroblasts

3)Platelets, Macrophages, Neutrophils, Fibroblasts

4)Platelets, Neutrophils, Macrophages, Fibroblasts

• Innervation of the intrinsic muscles of the hand is from:

• 1)Median Nerve

• 2)Ulnar Nerve

• 3)Radial Nerve

• During starvation, the body initially uses which substrate primarily for energy production:

• 1)Fatty Acids

• 2)Keto Acids

• 3)Amino Acids

A patient s/p renal transplant 5 yrs ago presents to the ER with lower abdominal pain and fever. A CT scan of the abdomen and pelvis reveals diffuse bulky retroperitoneal lymphadenopathy. The virus most commonly responsible for this condition is:1)CMV2)BK Virus3)EBV4)Polyoma Virus5)HTLV-1

The oncogene associated with Gastrointestinal Stromal Tumors is:

1)C-kit

2)RET

3)Her-2 Neu

4)K-Ras

5)bcr-abl

Treatment of a Warthin’s tumor of the Parotid gland is:

1)Total Parotidectomy with Facial Nerve Sparing

2)Subtotal (Superficial) Parotidectomy w/ Facial N. Sparing

3)Chemotherapy

4)Parotidectomy and exicsion of al involved tissues

Characteristics of a Keloid include all of the following

except:

1)Increased TGF-B

2)Decreased TGF-B

3)High recurrence rate

4)Do Not Regress Spontaneously

The Best Approximate Measure of Portal Pressure is:

1)Hepatic artery pressure-hepatic venous pressure

2)Hepatic venous pressure3)Hepatic wedge pressure4)Portal vein pressure

40 yo female with non-tender swelling on right side of face, slightly inferior and anterior to ear. Biopsy reveals pleomorphic adenoma.

Best treatment is?

1. Treatment with Nafcillin for 10 days

2. Superficial parotid lobectomy

3. Parotidectomy

4. Treatment with sialagogues

2. Superficial parotid lobectomy

• Most tumors (2/3) of parotid are benign

• Pleomorphic adenoma most common

• Warthin’s tumor is second most common

• Tumors in smaller salivary glands more likely to be malignant

45 yo female with non-tender neck mass anterior to SCM. FNA of mass is non-

diagnostic. Open biopsy returns the diagnosis of thyroid tissue. Your next step is:

1. Do nothing

2. Treatment with radioactive iodine

3. Total thyroidectomy

4. Radical neck dissection

5. Treat with thyroid replacement hormone

4. Radical neck dissection

• Aberrant thyroid tissue is metastatic

• Treatment involves modified or radical neck dissection

19 yo male who fell while snowboarding on to an outstretched hand. What is the most

commonly broken bone in the hand?

1. Lunate

2. Scaphoid

3. Hamate

4. Trapezium

5. Capitate

2. Scaphoid

• Most common broken bone in hand

• Initial x-rays may be non-diagnositic

• Wait two weeks then re-x-ray

24 yo male who gets a metal splinter in his right third finger. Tip of finger becomes

tender and erythematous. What is the best treatment option?

1. Warm soaks

2. Surgical drainage

3. 10 day course of Doxycycline

4. 10 day course of Penicillin

5. Do nothing

2. Surgical drainage

• Felon normally arise from punctures

• Form a localized comparment syndrome

• Untreated they can go on to ischemia and necrosis

30 yo male who was hit on the back of his head by a baseball bat during a bar fight.

Presents to the ER with bilateral “black eyes” and echymosis behind right ear. The most

commonly injured nerve is?

1. CN V

2. CN VIII

3. CN III

4. CN VII

5. CN IX

4. CN VII

• Exits skull through stylomastoid foramen

Patient is diagnosed with basal skull fracture. Initial treatment is?

1. Wait 7 days to see if CSF leak stops on own

2. Immediate surgical repair with dural patch

3. Lumbar drain to lower CSF pressure

4. Antibiotics and wait 7 days

1. Wait 7 days to see if CSF leak stops on own

• Only 5% of CSF leaks will require surgery

• Prophylactic antibiotics have not been shown to demonstrate any benefit

• If after 7 days, a lumbar drain may be helpful, before going to surgery

27 yo female with a history of recurrent abdominal pain. Laparoscopy reveals

“chocolate cysts” on ovaries. At this point, your treatment plan is:

1. Proceed to TAH/BSO

2. Remove scope and begin medical treatment

3. Remove implants with scope

4. Remove implants with scope and then treat medically

4. Remove implants with scope and then treat medically

• Diagnosis is endometriosis

• Medical treatment involves cyclic oral contraceptives and analgesics

• Laprascopic removal may be beneficial

55 yo male with complaint of pneumoturia. The best study to show the etiology is?

1. MRI

2. Cystoscopy

3. CT scan

4. Barium enema

5. IVP

3. CT scan

• Barium enema is diagnostic in less then 50% of cases

• Cystoscopy reveals systitis, hard to determine site of fistula

• MRI does not add any more then CT

• IVP – “unrewarding”

25 yo male at winter X-games who suffers a femoral shaft fracture while competing in Moto-X “Best Trick” event. Treatment

includes:

1. Psych consult for going off a 90’ jump on a supercross bike in the snow

2. Intramedullary rod

3. External fixation

4. Distal femoral traction and casting

2. Intramedullary rod

• Standard of care

10 years after MRM, a woman develops a purplish mass on arm. Next step in

management is?

1. Chemotherapy

2. Wide local excision

3. Forequarter amputation

4. Chemotherapy and radiation

5. Incisional biopsy

3. Forequarter Amputation

• Stewart-Treves Syndrome

• Lymphangiosarcoma post MRM secondary to chronic lymphedema

Organism most commonly causing osteomyolitis in a patient with sickle cell

disease?

1. Staphylococcus aureus

2. Salmonella

3. Shigella

4. H. influenza

2. Salmonella

• Despite controversy, Salmonella is most common world wide

• Regionally, Staph may be more common

How many NCAA titles has University of Texas won?

1. 38 Total (Mens and Womens sports)

2. 3 football AP titles

3. 6 baseball titles

4. Still a LOT less then the Univeristy of Southern California

5. All of the above

5. All of the above

• 84 total titles (Mens and Womens)

• 11 titles in football• 12 titles in baseball• As a country the

University of Southern California ranks 7th in all time Olympic Gold Medals

Drug most commonly associated with TEN (toxic epidermal necrolysis)?

1. Phenytoin

2. Warfarin

3. Trimethiprim/Sulfamethoxazole

4. Penicillin

5. Vancomycin

3. Trimethoprim/Sulfamethoxazole

• TEN associated with sulfa based drugs

• Warfarin necrosis is associated with protein C deficiency

• Why else did I spend time to type this out?!

18 yo male in high speed MVA. Pt with right tib/fib fracture. Presentation of most common nerve injury associated with this fracture is?

1. Numbness on plantar surface

2. Foot drop

3. Unable to plantar flex foot

4. Loss of sensation in third web space

2. Foot drop

• Injury to Peroneal nerve as it wraps around fibular head

32 yo male who develops erythema and a painful ulceration on his arm 2 days after cleaning the garage. Treatment for the

patient?

1. Debridement

2. Skin graft

3. Keflex

4. Dapsone

5. Warm soaks

4. Dapsone

• Pt most likely has Brown recluse spider bite

• Treatment is Dapsone

• Dapsone also for treatment of leprosy

32 yo female with acute onset of RLQ abdominal pain. HR = 120 and BP=85/60.

After successful fluid resuscitation, your next step is:

1. Emergent celiotomy

2. Discharge to home

3. Transvaginal ultrasound

4. CT scan

3. Transvaginal ultrasound

• Used to determine if pregnancy is intrauterine or otherwise

• Definitive diagnosis is via laparoscopy

• If pt is unstable, emergent celiotomy (laparotomy) is indicated

75 yo female who has fallen and is found to have a mid-shaft humeral fracture. The nerve

most commonly injured?

1. Radial

2. Ulnar

3. Axillary

4. Musculocutaneous

1. Radial nerve

• This nerve controls the extensors of the wrist

• Nerve palsy is not an operative indication, unless following manipulative reduction

8 yo male with femoral shaft fracture. Treatment includes:

1. Intramedullary rod

2. External fixation

3. Distal femoral traction and casting

3. Distal femoral traction and casting

• Pediatric patients are always treated conservatively

35 yo male s/p MVA with hematuria. Pt is hemodynamically stable. CT scan of

abdomen shows a grade 2 renal injury. The best management is?

1. Celiotomy and nephrectomy

2. Celiotomy and renal salvage

3. Non-operative management

4. CBI until hematuria clears

3. Non-operative management

• All grade 1-3 injuries require non-operative management

• Grade 5 requires nephrectomy

• Grade 4 attempt at renal salvage

• Repair of collecting system with absorbable sutures

The correct order that cells arrive for wound healing?

1. PMN, platelets, macrophages, fibroblasts

2. Fibroblasts, platelets, macrophages, PMN

3. Platelets, fibroblasts, PMN, macrophages

4. Platelets, PMN, macrophages, fibroblasts

5. Macrophages, PMN, platelets, fibroblasts

4. Platelets, PMN, macrophages, fibroblasts

• MEMORIZE: ON EVERY YEAR

• Platlets always first to cause hemostasis

• Fibroblasts always last to finalize healing

Source of free oxygen radicals in reperfusion injury?

1. Pyruvate kinase

2. Tyrosine kinase

3. Cytochrome oxidase

4. NADPH oxidase

5. Xanthine oxidase

5. Xanthine oxidase

• From endothelial cells and macrophages

67 yo male, smoker, with 1.5 cm lesion on left lateral aspect of the tongue, no palpable

LAD. Biopsy shows Squamous cell carcinoma. Best treatment is?

1. Wide local excision

2. Excision and radical neck dissection

3. Radiation

4. Hemiglossectomy and lymph node dissection

5. Radiation followed by radical neck dissection

1. Wide local excision

• Up to 2 cm, WLE

• Greater then 2 cm, Excision with radical neck dissection

34 yo female, 1 week postpartum, with acute onset of RLQ abdominal pain. Physical exam reveals a tender ropy mass on palpation. Best

treatment of this patient is?

1. Exploratory laparotomy

2. Appendectomy

3. Discharge with motrin

4. Admit and start on heparin drip

5. Transvaginal ultrasound

4. Admit and start on heparin drip

• Dx: pelvic thrombophlebitis

• If the presentation is not classic, transvaginal ultrasound or CT can be used to make diagnosis

25 yo male with a lesion on glans of his penis and palpable nodes in right groin. He is uncircumsized. Biopsy is squamous cell

carcinoma. Appropriate treatment is?

1. Partial penectomy with post-op chemo

2. Parital penectomy

3. Partial penectomy with post-op radiation

4. Total penectomy with post-op chemo

5. Total penectomy with lymphadenectomy

5. Total penectomy with lymphadenectomy

• With palpable nodes, a lymphadenectomy is required

• Radiation and chemo have been shown to be ineffective

Lance Armstrong, 7-time Tour de France winner, had non-seminomatous testicular

cancer. What tumor marker was elevated?

1. Beta-HCG

2. CA 19-9

3. AFP

4. CA 125

5. CEA

3. AFP

• Choriocarcinoma = beta-HCG

• Seminoma = beta-HCG

• Non-seminomatous tumors = AFP (and sometimes beta-HCG)

A 30 yo female is brought to HUP, at 2 am, after being hit by a car a the corner of 13th and Walnut.

Primary survey is unremarkable. On secondary survey blood is noticed coming from her vagina. Rectal exam reveals a high-riding prostate. What

study is mandatory in this patient?

1. CT scan abdomen

2. Retrograde urethrogram

3. Barium enema

4. Karyotype

5. IVP

2. Retrograde urethrogram

• Blood at meatus or high riding prostate mandate RUG (retrograde urethrogram)

1 year after suffering 2nd and 3rd degree burns to his legs, a 19 yo male has a non-healing

ulcer on his thigh. Initial treatment is?

1. Resection of ulcer with negative margins

2. Full thickness skin graft

3. Wet to dry wound care

4. Split thickness skin graft

1. Resection of ulcer with negative margins

• Marjolin’s ulcer – squamous cell carcinoma

Which of the following cancers has the lowest incidence of bone metastases?

1. Breast

2. Lung

3. Renal

4. Prostate

3. Renal

• This only occurs in less then 30% of patients

All of the following are metablized by either the liver or the kidneys except?

1. Vecuronium

2. Pancuronium

3. Atricurium

4. Succinylcholine

5. Tubocurarine

3. Atricurium

• Hoffman degredation by red blood cells

A 36 yo female on steroids for treatment of sarcoidosis presents with acute appendicitis. After uncomplicated appendectomy, the patient should be

given?

1. Vitamin A

2. Vitamin B6

3. Vitamin B12

4. Vitamin K

5. Vitamin C

1. Vitamin A

• Reduces deleterious effects of steroids on wound healing

One gram of nitrogen contains how many grams of protein?

1. 4

2. 6.25

3. 9

4. 3.4

5. 7

2. 6.25

• Need to memorize

• 4 is kcal per gram of protein

• 3.4 is kcal per gram of glucose in solution

• 9 is kcal per gram of fat

• 7 is the number of Heisman trophy winners USC has (how many does Texas have?)

Match drug with side effects

1. Vincristine

2. Bleomycin

3. Adriamycin

4. Vinblastine

a. Pulmonary fibrosis

b. Bone marrow suppression

c. Cardiac fibrosis

d. Neuropathy

Most common collagen in the body?

1. Type 1

2. Type 2

3. Type 3

4. Type 4

5. Type 8

1. Type 1

• Most common in the body

• Type 2 – cartilage

• Type 3 – wound healing– Low in Ehlers-Danlos

• Type 4 – basement membrane

• Type 8 – eye ball (Descemet's membranes)

Most sensitive test to find a gastrinoma?

1. MRCP

2. CT with IV contrast

3. Secretin stimulation test

4. EGD

5. Somatostatin scintigraphy

5. Somatostatin scintigraphy

• Test of choice for localizing a gastrinoma

• Secretin stim test is the test of choice for diagnosing a gastrinoma

All of the following are involved in change of a colon adenoma to

carcinoma except?

1. APC

2. DCC

3. p53

4. k-RAS

5. c-MYC

5. c-MYC

• All the others are involved in the pathway, except c-myc which is lung, stomach, and breast.

• If asked a question about colon cancer and its gene: answer is always APC.

All the following are associated with a VIPoma except?

1. Hypokalemia

2. Achlrohydria

3. Diarrhea

4. Hyperglycemia

5. Hypocalcemia

5. Hypocalcemia

• WDHA– Watery diarrhea– Hypokalemia– Achlrohydria

• Hyperglycemia

• Hypercalemia– Secondary to PTH-like hormone

34 yo female with long standing odynophagia and presents with the following UGI. The

first step is treatment is?

1. Esophagectomy

2. Heller myotomy

3. Balloon dilation

4. Calcium channel blocker

5. Botox injection

3. Balloon dilation

• This is achalasia.

• If they ask what would you do first, balloon dilation is always first, although we are now doing botox. Remember, the exam is not up to the here and now.

• If balloon dilation fails, heller myotomy.

Blood supply to the neo-esophagus s/p transhiatal esophagectomy?

1. Right gastric

2. Left gastric

3. Right gastroepiploic

4. Left gastroepiploic

5. Gastroduodenal

3. Right gastroepiploic

• How many of these do we do here?

• On just about every year

30 yo male presents with the following growth on the roof of his mouth. Treatment

includes?1. FNA

2. Wide local excision

3. Reassurance

4. Radiation

5. Wide local excision and radiation

3. Reassurance

• This is a torus

• Benign

• Arises in adults– 20/1000 adults

• Treat if it becomes symptomatic– Chisel it off

Match the following:

1. Replaced right hepatic artery

2. Accessory left hepatic artery

3. Bronchial arteries

a. Left gastric

b. SMA

c. Aorta

Describe chronology of activation of pancreatic exocrine enzymes.

Trypsinogen converted to trypsin by enterokinase

Then trypsin converts everything else

What are causes of early and late dumping syndrome?

Early: hyperosmotic load in duodenum with fluid shifts

Late: hypoglycemia from increased insulin

Which vagal nerve gives off the celiac branch?

Right vagal nerve

Name three actions of CCK.

Contracts the gallbladder

Relaxes sphincter of Oddi

Increased pancreatic enzyme secretion

What is the most common post-vagotomy symptom?

Diarrhea (35%)

Not dumping (10%)

Through what mediators do gastrin and Ach induce parietal cell H+ release?

PIP and DAG

Increase Ca

Activate protein kinase C

How does omeprazole work?

Blocks H/K ATPase of parietal cell

What are the different effects on emptying of liquids and solids by proximal vs. truncal vagotomy?

Proximal: increased liquid emptying, no change in solid emptying

Truncal: Both (if do pyloroplasty)

How is dumping syndrome treated?

99% of the time it is fixed with diet (basically the Atkins diet… high fat and protein, low

carbs)

Which vagal nerve gives off the hepatic branch?

Left vagus

Which vagal nerve gives off the criminal nerve of Grassi? What if this is not

divided during vagotomy?

Right vagal nerve

Continued high acid output

Main action of secretin

Nature’s antacid

Secretion of bicarbonate by pancreas

After small bowel resection, what compound causes small bowel mucosal

hypertrophy?

Enteroglucacon

What is the composition of bile?

80% bile salts

15% lecithin

5% cholesterol

Name 2 primary and 2 secondary bile acids

Primary: cholic acid & chenodeoxycholic acid

Secondary (formed by intestinal bacteria): deoxycholic acid & lithocholic acid

What 2 Ig’s are opsonins?

IgG and IgM

What interleuken converts NK cells to LAK (activated)?

IL-2

What interleukin stimulates B cells to become plasma cells?

IL-4

What is endotoxin?

Lipopolysaccharide A from Gram Negative Rods

4 sites of intraabdominal abscesses

Subdiaphragmatic

Subhepatic

Pelvic

Inter-loop

Why do gallstones form?

Increased cholestorol

Or

Decreased bile salts and/or lecithin

Organisms most responsible for immediate post-op necrotizing

wound infection?

Clostridial

B-strep

Is staph aureus coag pos or neg?

Coag positive

Slimey

Where are MHC I and II found and what type of cell do they activate?

MHC I- all nucleated cells, activate CD8 T cells

MHC II- B cells, dendritic cells, monocytes, activate CD4 T helper cells

How do aminoglycosides work?What leads to resistence?

Are they bacteriostatic or bacteriocidal?

Irreversibly bind to ribosome

Decreased active transport

Bacteriocidal

What cells secrete both TNF and IL-1 during intial injury response?

Macrophages / Monocytes

IL-1 (fever)

How do clinda, tetra and erythromycin work? Are they bacteriostatic or

bacteriocidal?

Reversibly bind to ribosome

Bacteriostatic

What compound is the “ileal brake”?

Peptide YY

Secreted by ileum after mixed

meal to inhibit acid secretion

How does vanco work?

Binds to plasma membrane

MMCHow often? Runs from where to where?

Name the 4 phases. What is the key

stimulating hormone for the MMC? Every 90 minutes

Stomach to terminal ileum

I- quiescence

II- gallbladder contraction

III- peristalsis

IV- subsiding electrical activity

Motilin (stimulated by erythromycin)

What does TGF-B do for a wound?

Stimulates fibroblasts

Attracts neutrophils

What causes MRSA resistance?

Change in bacteria binding protein

How do sulbactam and clavulanate work?

Inhibit B-lactamase

How does amphotericin work?What organ is most adversely effected by

ampho?

Alters fungal cell wall by binding sterols

Kidney impairment

When does collagen production begin and max out?

Begins Day 3

Max at Day 21

What can you give to counter the effects of steroids on wound healing?

Vitamin A

What does TxA2 do?

From platelets

Platelet aggregation

Vasoconstriction

What cancers is c-myc associated with?

Breast

Small cell lung

Neuroblastoma

Burkitt’s lymphoma

Growth factors act at the most variable period of the cell cycle. What period is

that?

G 1

What syndrome involving a p53 mutation includes sarcomas, breast ca,

brain tumors and leukemia?

Li Fraumeni syndrome

How big is the bile pool? How often does it recirculate?

How much bile is lost daily?

5 grams in the bile pool

Recirculates every 4 hours

Lose 0.5 grams every day (10%)

What 4 mutations are involved in colon cancer?

APC

p53

DCC

k-ras

K ras associated with what 3 cancers?

Pancreas

Colon

Lung

Ret protooncogene associated with what cancer?

Medullar thyroid cancer

MEN 2A and 2B

Mondor’s disease

Superficial thrombophlebitis of breast veins

Cord-like

NSAIDS

How does gallbladder concentrate bile?

Active resorption of Na and Cl,

so water follows

What does prostacyclin do?

Inhibits platelets

Vasodilation

Bronchodilation

Name 2 risks of taking tamoxifen

Endometrial cancer

DVT

How do quinolones work?

DNA gyrase inhibition

Side effect of vincristine and cisplatin

Neuro (brain) toxicity

Result of injury to thoracodorsal nerve

Paralysis of latissimus dorsi

Weak arm abduction

What does PDGF do for a wound?

Attracts fibroblasts

Increases smooth muscle

What vascular conduit allows direct mets from breast cancer to vertebrae?

Batson’s plexus

Valveless vertebral veins

Amastia, no pectoralis muscles, hypoplastic shoulder

Poland syndrome

Where does breast ca met to?

Bone

Brain

Lung

Initial cytokine response to injury mainly involves what 2 factors?

IL-1 and TNF

Treatment for DCIS

If low grade, small, or negative margins:

Lumpectomy with postop XRT

If high grade, large, or poor margins:

Mastectomy

Treatment for phyllodes tumor (cystosarcome phyllodes)

Usually not malignant

Wide local excision

No need for axillary dissection (sarcomos spread hematogenously, not via lymphatics)

Rarely need mastectomy

BRCA I and II associated with what?

BRCA 1 – ovarian

BRCA 2 – male breast cancer

Indications for XRT after mastectomy

4 positive nodes

Skin or chest wall involvement

Positive margins

Treatment of intraductal papilloma

Not cancer

Resect nipple and draining duct

#1 cause of bloody nipple discharge

How do sarcomas usually spread?

Hematogenously (not via lymphatics)

(that’s why you don’t do an axillary node dissection for phylodes tumor of the breast)

What is the approach to a extremity sarcoma biopsy?

Incisional biopsy

Unless really small (< 4cm)

Once tissue dx of sarcoma, then surgery and postop XRT if high grade, close margins or

> 5cm

What cells mediate GVHD?

T cells

What is the clo test?

Detects urease from H. pylori

How does mycophenolate work?

Blocks purine synthesis

Result of injury to long thoracic nerve

Paralysis of serratus anterior

Winged scapula

Risk factors for gastric cancer

Atrophic gastritis

Polyps > 2 cm

Pernicious anemia

Type A blood

Nitrosamines

Surgical margin for gastric cancer

6 cm

Intramural spread

Why does ileal resection lead to diarrhea?

Less bile salt absorption

More bile salts go to colon

Less colon water absorption

Diarrhea

(also more oxalate stones and less vit B12 absorption)

List the 4 combinations of ER and PR status from best to worst

ER+PR+

ER-PR+

ER+PR-

ER-PR-

What medication helps symptoms of carcinoid syndrome?

Octreotide

What cell cycle phase is most sensitive to radiation?

M phase

Ligation of what nerve leads to numbness of inner aspect of upper arm?

Intercostobrachial

3 most common sites of carcinoid (in order)

A I R

Appendix

Ileum

Rectum

How does prednisone work to treat rejection?

Blocks IL-1 release from macrophages

What is the difference in how papillary vs. follicuar thyroid cancer spread?

Papillary – lymph

Follicular - blood

After excision of thyroid mass, surgical pathology shows amyloid

Medullary thyroid cancer

How does digoxin work?

Increases Ca in heart cells by blocking the Na-K ATPase

Treatment of medullary thyroid cancer?

Total thyroidectomy

Node dissection of positive nodes

What is the first step in working up a thyroid nodule?

FNA

(After H&P, of course)

Bone finding associated with hyperparathyroidism

Osteitis fibrosa cystica

What if urine calcium is not high in suspected hyperparathyroidism?

FHH

Familial Hypocalciuric Hypercalcemia

What is MEN 2B?

Medullary thyroid cancer

Pheochromocytoma

Marfan / mucosal neuromas

What causes hyperacute rejection?

Pre-formed antibodies

Treatment for LCIS

Only a marker…

Nothing

or

Tamoxifen

or

Bilateral mastectomy (if high risk)

What causes acute rejection?

Rejection of foreign MHC antigens

Treatment of acute rejection

OKT 3

How does azathioprine work?

Purine analog

Decreased DNA synthesis

How does cyclosporin work?

Blocks IL-2 production

Rotamase inhibitor

Toxic to kidney

How does FK 506 work?

Blocks IL-2 production

More potent than cyclosporin

How does OKT3 work?

Monoclonal antibody

What is the most common cause of oliguria after kidney transplant?

ATN

(acute tubular necrosis)

How does succinylcholine work?

Depolarizing agent

How does reglan work?

DA blocker

Metyrapone and aminogluththimide produce what?

Medical adrenalectomy

Leuprolide produces what?

Medical orchiectomy

What medicine closes a PDA?

Indomethacin

What 2 types of thyroid cancer cannot be differentiated by FNA?

Follicular

Hurthle cell

What medicine can help people on NSAIDS avoid PUD?

Misoprostil

What blood types are gastric ulcers associate with?

Type I with A

The rest with O

What are the kcal/g breakdowns for carbs / protein / fat?

Carbs 3.4

Protein 4

Fat 9

What is the respiratory quotient? How does it work out for fat vs. carbs?

CO2 produced to O2 consumed

Fat 0.7

Carbs 1

What is the preferred fuel of the colon?

Short chain fatty acids

(n-Butyrate)

What is the preferred fuel of the small bowel?

Glutamine

The number one amino acid in the blood

Glutamine

When fat is absorbed, what goes to the liver vs. lymphatics?

Medium and short chain fatty acids go to liver via portal vein

The rest are converted from micelles to chylomicrons by enterocyte and sent to

lymphatics

Linoleic acid deficiency

Visual changes

Hair loss

Dermatitis

Vitamin A deficiency

Decreased vitamin C stores

Na make up of NSS vs. LR

NSS 154

LR 130

Treatment of hyperkalemia

Calcium

Bicarb

Insulin

Glucose

Kayexalate

Dialysis (if not improving)

Function of Type I and Type II alveoli

Type I - Gas exchange

Type II - Surfactant (only 1%)

Decreases surface tension

Preop FEV1 and Predicted Postop FEV1

Preop FEV1

Pneumonectomy > 2L

Lobectomy > 1L

Wedge > 0.6 L

Predicted Postop FEV1

> 0.8 L

Most common lung cancer

Adenocarcinoma of the lung

Which type of lung cancer secretes PTH-like substance?

Squamous lung cancer

Which type of lung cancer secretes ACTH and ADH?

Small cell lung cancer

What is a Pancoast tumor?

Lung cancer involing symphathetic chain (Horner’s syndrome) and / or ulnar nerve

Is thymectomy indicated in all cases of myethenia gravis?

Yes

Greatly improves symptoms

What percent of patients with myasthenia gravis have a thymoma?

10 %

Does thoracic outlet syndrome usually involve the artery, vein or nerve?

Nerve (ulnar)

Only 1% - 2% involve vessels

8 days after MI, patient develops pan-systolic murmur and is decompensating.

Most likely diagnosis?

Septal rupture

Treatment for SVC syndrome

Radiation

Who gets Takayasu arteritis and what is it?

Young girls

Arteritis of aorta (thoracic and abdominal) and pulmonary artery

What kind of heart valve should a young girl get?

Tissue valve

If may ever get pregnant, cannot put in mechanical valve because patient could not

be on coumadin

How do you treat a thoracic duct injury?

Drain it

NPO for 2 weeks

If not resolved…

R thoracotomy

Ligate thoracic duct as it enters the right chest (next to the aorta)

What is size cut-off for operating on a thoracic aortic aneurysm?

8 cm

Surprisingly, you let it get bigger than a AAA

OR

If it’s symptomatic (i.e. impending rupture)

Describe aortic dissections

Type A - ascending aorta… operate

Type B – not ascending aorta… B-blockers

Most common congenital cardiac defect

Ventricular septal defect (VSD)

Treatment for VSD

Half will close on their own

Fix the rest, or if symptomatic

or failure to thrive

When do you surgically close a PDA?

When indomethacin has not closed a PDA by 6 months

How does an IABP work?

Increases coronary perfusion during diastole

Reduces afterload

(by inflating during diastole)

Skin cell involved in contact hypersensitivity (i.e. latex)

Langerhans cells

What do Merkel cells do?

Mechanoreceptors of skin

Merkel cell carcinoma is a

neuroendocrine tumor

Benign, painful subungal tumor (underneath fingernail)

Glomus cell tumor

Tx: shell it out

Apocrine sweat gland inflammation

Hidadrenitis

Axilla and groin

How are STSGs vascularized?

Imbibition… first few days

Neovascularization… days 2 - 7

Necessary resection margins for melanoma

1cm… <1mm depth

2cm… 1-4mm depth

3cm… >4mm depth

3 most common melanoma organ sites

Skin

Eyes

Rectum

Men (back)

Women (legs)

90% cure rate is associated with what Breslow classification for malignant

melanoma?

0.75mm

4 types of malignant melanoma (starting with worst)

Nodular (early mets)

Superficial spreading

Lentigo maligna

Acral lentiginous

What is the difference between a hypertrophic scar and a keloid?

A keloid grows beyond the original wound edges, a hypertrophic scar does not

Increased collagen production

Failure of collagen breakdown

Indications for a thoracotomy after trauma requiring a tube

thoracostomy?

Instability

Drain more than 1500 initially

Drain more than 200 / hour for 4 hours

Persistent hemothorax despite 2 good tubes

Treatment for traumatic diaphragmatic rupture

Repair through abdomen…

unless happened a long time ago…

then repair through chest (adhesions in the belly to diaphragmatic injury)

What immunologic components are lost after splenectomy?

Tuftsin

Properidin

Fibronectin (nonspecific osponins)

Decreased IgM production

What about spherocytosis gets better after splenectomy?

Anemia

&

Jaundice

How does PEEP work?

Increases FRC

Increases compliance

Keeps alveoli open

Name 4 things that cause a “right shift” of the Hgb:O2 dissociation curve

Increase temperature

Increase CO2

Increase H+

Increase 2,3 DPG

What lab value should always be checked before giving a burn patient silvadene?

WBC count

Silvadene causes neutropenia

What lab abnormalities can be caused by silver nitrate?

Na

Cl

What do you call squamous cell carcinoma that develops in a chronic wound?

Marjolin’s ulcer

What should you know about patients with popliteal artery aneurysms?

Half are bilateral

1/3 also have a AAA

Must resect (can embolize & thrombose)

Operation is exclude and bypass

Splenic artery aneurysm

Most common visceral artery aneurysm

Resect if > 2 cm or if in female who may get pregnant

Resect in men if > 2 cm or symptomatic

AAA 5-year rupture risk

< 5 cm … 20%

5cm – 7 cm … 33%

> 7 cm … 95%

Treatment approach to claudication

NOT SURGERY right away

Smoking cessation

Exercise

Trental

CEA 5-year stroke rates

Asymptomatic >60% stenosis

11% to 5%

Symptomatic >70% stenosis

26% to 9%

Most commonly injured cranial nerve during CEA?

Vagus (X)(from clamp)

Hoarseness

Young woman with high blood pressure

Fibromuscular dysplasia of renal artery

Right renal more likely

Angioplasty

4 stages of atherosclerosis

Type I foam cell

Smooth cell proliferation

Collagen exposure

Thrombosis

Treatment of squamous cell ca of the anus

NOT SURGERY

Chemo & XRT

(surgery-APR- if recurrent)

Amsterdam criteria for Lynch

3 first-degree relatives with colon

cancer over 2 generations with 1 before the age of 50.

Cerebral Perfusion Pressure

MAP – ICP

Want 70

Cushing’s triad with high ICP

Hypertension

Bradycardia

Kussmaul respirations (slow, irregular)

Glasgow Coma Scale

6, 5, 4

Motor – 6

Verbal – 5

Eyes – 4

Brown Sequard

½ spinal cord transection

Lose motor on that side

Lose pain & temp on other side

Central Cord Syndrome

Feel legs

Don’t feel arms

C-spine hyperextension

Bilateral parotid tumors

Warthin

Intrinsic coagulation pathway

PTT

Vitamin K inhibits…

2,7,9,10

Protein C and Protein S

Protein C and S do what?

Degrade factors 5 and 8

Factor 8 only factor not made in liver

Treatment of vW disease?

Cryo

Vw factpr

Factor 8

Hemophilia: 2 types

A-8

B-9

(Christmas Disease)

Long PTT

How does heparin work?

Binds Anti-Thrombin (AT) 3

Old male with acute abdomen, thickened sigmoid colon on CT, and pneumaturia. What is diagnosis?

1. Diverticulitis

2. Ulcerative Colitis

What is management of hepatic flexure T2N1M0 carcinoma after R colectomy?

1. RT

2. 5FU with levam

3. no further therapy

2.5 cm hemangioma of eyelid in newborn. What is management?

– Do nothing– Give steroids– Embolize– RT– Excise

Young woman with sudden onset of lower abdominal pain, hypotension and tachycardia. Abd is tender and sl. protuberant. What is dx?

– Ruptured ectopic pregnancy– rupture ovarian cyst– ruptured liver adenoma– ruptured splenic art aneurysm

17 year old boy with sudden onset of tender, high riding testicle. Low grade fever. Very tender scrotum. What is therapy?

– b/l scrotal exploration– u/l scrotal exploration– appy

How many calories are in 1000cc of 10% dextrose and 5% amino acids, 1000cc of 10% lipids

• 2400

• 2200

• 1840

• 1440

Answer

• 10% dextrose = 100g = 340 cal. 5% amino acids = 50g = 200 cal. 10% lipids = 100g = 99 cal.

What is the lesion in Peutz-Jahger syndrome?

– Hamaratoma– Adenoma– Hemangioma– Lipoma

where is second most common location of pheo outside of adrenal?

– abdominal aorta– thoracic aorta, behind the arch– sacral plexus– bladder

Where does ovarian ca spread to first?

– pelvic nodes– paraaortic nodes– diaphragm– omenturm– peritoneum

What organ does not have lymphatic drainage?

– kidney– liver– colon– skeletal muscle– Lung

Flushing and diarrhea, small bowel LAD, liver mets. What are sx from?

– Serotonin– Bradykinin– Somatostatin

Which cell is most abundant in a 10 day old wound?

• Monocytes

• Macrophages

• PMNs

• Fibroblasts

Wound Healing

• Inflammatory Phase 0- 3days: PMN predominant in this phase - they begin to arrive immediately, attaining large numbers within 24 hours. The process of clearing the wound of debris usually takes several days, but the time varies depending on the amount of material to be cleared. The PMNs are followed temporarily by macrophages, which appear in wounds in significant numbers within 2 or 3 days.

– Lymphocytes also appear in wounds in small numbers during the inflammatory phase.

• Proliferative Phase 3-21 days - Fibroblasts proliferate in response to growth factors to become the dominant cell type during this phase. Type III collagen predominant in the wound

• Remodelling Phase > 3 weeks - type III collagen replaced with type I collagen, capillary density gradually diminishes, and the number of fibroblasts is reduced. During the maturation phase, the proteoglycan content returns to a level that closely approximates that of normal skin.

Tensile strength of a 4 week old wound is due to?

• ???

Answer:

• cross linking of collagen, quantity of collagen• Hydroxylation requires ascorbic acid (vitamin C)

– necessary for stabilization + cross-linkage of collagen– Collagen cross-linking occurs in the extracellular space as the

collagen molecules aggregate into larger structures. – These intra/intermolecular bonds provide strength and stability– As wound matures, fibrils cross-link to form large cables of

collagen, providing increased tensile strength – During the initial phase of wound healing, there is a relative

abundance of type III collagen in the wound. With remodeling, the normal adult ratio of 4:1 (type I > type III) collagen is restored.

S/P emergency AAA, now has 20cc of clear yellow urine in foley, what is the

management?

Answer:

• fluids, swan placement, renal scan, urinary sodium, urine specific gravity

• you should think of ATN and exclude active bleeding/low intravscular volume.

• Renal failure caused by ATM s/p ruptured AAA MUCH MORE COMMON – occurs ~21% of survivors of operation in one series. – Unfortunately, mortality rate associated with this complication

remains high, varying from 50% to 70% despite acute HD & nutritional support.

s/p thyroidectomy 4 hours ago, wound was dry upon closing and all 4 PTH were seen as well as both laryngeal nerves, now pt has stridor, what is the management?

• Open the wound at bedside then take back to OR

• Don’t forget about tracheomalacia (gives stridor also)– requires orotracheal intubation or tracheostomy –

– occurs in large goiters (results of the pressure softening of the tracheal cartilages) caused by the impingement on the tracheal lumen by the large goiter.

S/P CEA 2 weeks ago, now with a pulsatile neck mass, with some leakage via the wound, what is the initial management?

• take back to OR immediately

• open the neck incision in the office

• U/S of the neck

• aspirate in office

• angiogram

Answer

• Pt could get an US but without compression of the mass – if it is a wound infection/seroma with transmitted pulsations from the carotid artery is obvious that you should not deal with it in the office – an angiogram in the OR should follow if you see an aneurism or pseudoaneurism on US.

• Carotid aneurysms in general, and specifically aneurysms of the internal carotid artery, are sometimes technically difficult to repair. With previous operative or accidental trauma, the scarring may be dense and the dissection technically demanding. Obviously, the neural structures in the field must be protected, especially the vagus nerve, and the internal jugular vein should not be sacrificed unless absolutely necessary.

Patient with secondary hyperparathyroidism found 3 of 4 PTH glands on a thorough neck exploration, cannot find the 4th, what do you do?

• Median sternotomy

• sestamibi scan

• close pt and check PTH, Ca Levels

Recurrent cancer in the anastamosis after a LAR, 4 cm proximal to the dentate line, what is the management?

• Chemo

• XRT

• APR

• transanal excision

Pt with hypokalemia, watery diarrhea has a pancreatic lesion seen on CT, what is the most likely diagnosis?

• Insulinoma

• Glucagonoma

• Gastrinoma

• VIPoma

• somatostatinoma

Answer•WDHA syndrome (watery diarrhea, hypokalemia, and either achlorhydria or hypochlorhydria) & the

pancreatic cholera syndrome (half of the patients have some degree of hyperglycemia and hypercalcemia, and cutaneous flushing can be observed in a minority). Patients characteristically present with intermittent severe diarrhea, typically of a watery nature, averaging 5 L/d.

•Diag of exclusion (of other causes of diarrhea)•Because VIP secretion can be episodic in patients with VIPomas, several fasting VIP levels should

be measured because a single low VIP level does not rule out the syndrome.•In most reported cases, the abdominal CT scan identified the tumor, and further imaging studies,

such as visceral angiography or portal venous hormone sampling, were unnecessary.

Parameter Description___________________________________Symptoms Watery diarrhea Weakness Lethargy NauseaDiagnostic tests Hypokalemia Achlorhydria Serum VIP levelsAnatomic localization Most in body or tail of pancreas

How do you treat pain S/P whipple/ chronic pancreatitis?

• stellate ganglion injection

• celiac plexus injection

• Intrathecal morphine-PCA

Answer• Percutaneous, radiologically guided injection of the celiac ganglia with neural

ablative agents has been used in patients with chronic pancreatitis, based on the success of this approach in patients with pancreatic cancer. The procedure is not usually effective long-term in chronic pancreatitis, with pain relief lasting 6 months in fewer than half of treated patients. Repeated injection is not usually successful.

• Nonnarcotic analgesics should be used initially. If pain is progressive, increases in dose or frequency of these agents should be attempted before narcotics are prescribed. Eventually, most patients with chronic pancreatitis require narcotic pain relief; addiction is common and makes evaluation of treatments aimed at pain relief difficult.

• Enzyme replacement - exogenous enzyme administration as a treatment for pain has been proposed, based on the concept of negative-feedback inhibition of pancreatic secretion. Although initial controlled trials suggested that improvement in pain can occur as a result of enzyme replacement, especially in patients with idiopathic pancreatitis, disappointing results have also been reported.

GI Hormones

• Cholecystokinin (CCK) – Peptide; acts both as a neurotransmitter and as a true hormone. Molecular forms

include peptides with 8, 33, 39, and 58 amino acids. CCK is found in high concentrations in both the brain and the gut. In the GI tract, CCK immunoreactive cells are primarily located in the mucosa of the duodenum and jejunum, and CCK is released from the mucosa in response to luminal fats and proteins. Following CCK release from the duodenum and jejunum, the gallbladder contracts and the sphincter of Oddi relaxes, emptying bile into the duodenum. CCK acts in a synergistic fashion with secretin to stimulate pancreatic exocrine secretion. Postprandial levels of CCK probably act in a physiologic way to delay gastric emptying.

• Secretin – 27– AA peptide. in same structural family as glucagon, VIP, and gastric inhibitory

peptide. Secretin is found in the S cells of the duodenum and jejunum. It is a true hormone, released in response to acid in the duodenum when luminal pH falls below 4.5. Intraduodenal secretion of pancreatic bicarbonate neutralizes duodenal pH, diminishing the release of secretin. The amount of secretin released after a meal is sufficient to stimulate pancreatic secretion. Other biologic functions of exogenously infused secretin appear to have little or no physiologic role.

GI Hormones• Somatostatin

– paracrine peptide, occurs in 2 different forms: 14 & 28 AA peptides. Has been localized in multiple areas of the CNS, PNS, and gut. May act as a neurotransmitter and may also act as a paracrine agent in the pancreatic islets and in the mucosa of the stomach . Somatostatin containing D cells have also been found in small quantities throughout the gut mucosa. It has been hypothesized that somatostatin has a regulatory role along with motilin in controlling motility by means of the migrating motor complex. It is believed that motilin activates the migrating motor complex and that this effect is counteracted by somatostatin. In addition, somatostatin is released during a meal and regulates the release of gastric acid and gastrin by a paracrine inhibitory mechanism. Somatostatin may also have a similar effect in autoregulating pancreatic exocrine secretion.

• Gastric inhibitory polypeptide (GIP) – 42 AA peptide, structurally related to the glucagon family. Thought to function

as a true hormone and is localized in highest concentration in the mucosa of the duodenum and jejunum. GIP is also found in small quantities in the antrum and terminal ileum. Physiologically, GIP may regulate insulin release by augmenting the insulin response to an oral meal (incretion effect). It does not affect the insulin response to intravenous nutrients.

GI Hormones• Motilin

– 22 AA peptide localized in enterochromaffin cells of the mucosa of the upper small intestine that may have a physiologic role in regulating the migrating motor complex. It is released during the fasting state, and increased levels correspond with the onset of the migrating motor complex. The initiation of motilin release during the migrating motor complex appears to be cholinergic dependent. ERYTHROMYCIN HAS MOTILIN LIKE ACTIVITY

• Neurotensin– 13 AA neurotransmitter found in the central nervous system and gut. Specific

endocrine cells, or N cells, that contain neurotensin are found in the ileal mucosa. Smaller quantities are found in the jejunum, stomach, duodenum, and colonic mucosa. Neurotensin is released by a mixed meal and fats, and carbohydrates and protein release much smaller increments. It has been proposed that neurotensin has a physiologic role in fat-initiated changes in gastric acid secretion, gastric emptying, pancreatic secretion, and intestinal motility.

GI Hormones Final…

• Pancreatic glucagon and enteroglucagon – belong to the family of peptides that includes secretin, VIP, and GIP. The

smaller peptide, glucagon, has 29 amino acids, whereas the larger enteroglucagon molecule contains 37 amino acids. Both pancreatic and enteric glucagon are formed from a common prohormone, glicentin, which has 69–amino acid residues. Glucagon functions in opposition to insulin to promote glycogenolysis, lipolysis, gluconeogenesis, and ketogenesis. Glucagon may also be important in the stress response to trauma. Enteroglucagon is found in the ileum and colon and may regulate intestinal mucosa cell turnover.

• Peptide YY (PYY) – proposed hormone in the same family as neuropeptide Y and pancreatic

polypeptide. It has 36–amino acid residues and is found predominantly in the mucosa of the terminal ileum and right colon. It is released in response to a mixed meal and to fats. Postprandial concentrations of PYY inhibit acid secretion, perhaps by blocking acetylcholine release at the vagal cholinergic nerve ending. It is not clear whether the action of PYY on pancreatic secretion or gastric emptying is truly physiologic.

2 liver mets with a pancreatic lesion VIPoma, what is the mgmt?

• Liver wedge resection only

• Distal pancreactomy

• Streptozotocin and 5FU

• Somatostatin

6cm right liver cyst c capsule and several 1cm nearby cysts, fever. What is

management? – albendazole– perc drainage– marsupization– R. hepatectomy

Answer• Simple cysts of liver: common, benign, can become symptomatic lesions if they enlarge. Can cause biliary

obstruction, hepatic failure if multiple; TX: follow w/o intervention if asx; if mass effect: marsupializtion/resection. DO NOT FNA b/c cyst will recur.

• Infectious cysts of liver: include hydatid, amebic, chronic abscesses; distinguished from simple cysts by presence of septa/calcifications;

Pyogenic Hepatic Abscess: rare; if spread hematogenously usually unifocal; if spread 2ndary to biliary obstruction usually multifocal; Si/Sx: fever, chills, abd pain, wt loss, abnl LFTs, inc WBCs; make dx w/CT scan (preferred) or U/S. If unifocal/multifocal abscess seen percutaneous aspiration* (allows causative org to be ID and can modify appropriate abx rx) [most likey dx in above pt]

*unless indication that abscess may be amebic

1. Amebic Hepatic Abscess: due to invasion w/Entamoeba histolytica, spread by fecal-oral route, causes amebic colitis or abscess; Si/Sx: acute onset of fever, abd pain, abnl LFTs, get serologies for amebic infxn because cannot tell difference btwn pyogenic abscess on exam/imaging alone. TX: metronizdazole 750 mg TID; superinfxn can occur if attempt at aspiration made; only aspirate cyst if pt unresponsive to medical mgmt/ if abscess large enough that there is risk of rupture

Hydatid dz of Liver: Echinococcus; humans ingest eggs in contaminated food; grow slowly and produce sx due to enlargement: abd pain, biliary obstruction, jaundice; on CT scan, calcification and daughter cysts w/in parent cyst suggests echinococcus; must get serologic testing. TX: classically operative: remove cyst w/o disseminating any of organism drain cyst then inject parasiticidal fluid into cyst; cyst contents and pericystic wall removed carefully; administer scolicidal agent benzimidazole albendazole. Studies have shown percutaneous drainage of cysts and albendazole to be just as effective as surgical excision w/fewer side effects therefore should be considered as first choice of tx

Woman with recently diagnosed MEN II (?I) presents with confusion, bradycardia, widened T, short QT. What is management?

– fluid and lasix– IV phos– Hypertonic saline– Urgent head CT– Immediate neck exploration

Discussion

HYPERCALCEMIA (Greenfield p260-261, p1302-1305; Way p309)• Most common causes: hyperparathyroidism and malignancy; Si/Sx: Neuromuscular

effects early: muscle fatigue, weakness, bone and jt pain; Psych: personality d/o, psychoses, confusion, depression, coma; CV effects: hypertension; EKG changes: shortened QT interval; GI sx: N/V, abd pain, constipation, pancreatitis, inc gastric acid secretion w/ulcer formation; Renal: nephrolithiasis, nephrocalcinosis, gout, pseudogout, polydipsia, polyuria

• MEN I: tumors of parathyroid, pituitary, and pancreas, adrenocortical tumors, carcinoid tumors and multiple lipomas

• MEN II: hyperparathyroidism w/medullary CA of thyroid and pheochromocytomas• TX of severe hyperCa2+: (Ca2+ > 14.5 mg/dL) IV isotonic saline given to expand ECF,

inc urine flow, and enhance Ca2+ excretion and dec serum Ca2+ level; Lasix and IV NaSulfate also inc renal excretion of Ca2+

• Once hyperCa2+ treated, establish dx of hyperparathyroidism; localize parathyroid tumor w/ U/S or sestamibi scan, then cervical exploration and parathyroidectomy should be performed in the well hydrated pt.

pt with head injury. Na=118. More frequent convulsions. What is management?

– isotonic fluid– hypertonic fluid– antispasmodics– fluid restriction– fluid and lasix

Discussion

HYPONATREMIA • Tx dept on severity of sx, which include primarily CNS sx:

weakness, fatigue, muscle cramps, mental confusion, anorexia, N/V, HA, leading to delirium frank seizures coma

• Infusion of hypertonic saline solution is rarely indicated because it can ppt circulatory overload, but indicated only in pts w/severe hypoNa+ (PNa<120 meq/L) which can produce mental obtundation with seizures; rate of correction should not exceed 1-2 meq/L/hr because may cause permanent brain dmg due to central pontine myelinolysis; tx goal is to get serum Na+ above 125 meq/L or achieve resolution of sx

Woman s/p RT for cervical cancer has recto vaginal fistula. What is first line management

– colostomy– local flap– LAR

Discussion

• Tx dept on location of fistula and size; fistulae created by Crohn’s dz/ irradiation rarely heal spontaneously– Low, simple fistula/some mid-rectovaginal fistulae: endorectal

advancement of anorectal flap– High fistulae/some mid-rectovaginal fistulae: transabd approach; if

healthy tissue, can repair with mobilization of rectovaginal septum, division of fistula, layer closure of rectal defect w/o bowel resection

– If local tissue dmged by irradiation/infxn/inflammatory dz: extended LAR w/ coloanal anastamosis

• Complex rectovaginal fistulae: require diverting colostomy then closed 2-3 mo after successful repair vs. permanent colostomy

In bacteremia, TNF

– Peaks at 6 hrs– Is stimulated by endotoxin– Is inhibited by IL-1

Post liver txp, pneumonia c incusion bodies: rx?

– gancyclovir– Bactrim– INH and rifampin– Cipro

Answer

• Pneumonia with inclusion bodies PCP

• seen in immunocompromised txp pts, dx by direct lung bx, Tx: bactrim

A woman is 3 months post-partum, she presents with ascites & jaundice. Dx by?

– liver bx– cavogram with hepatic venous phase– ERCP– CT with iv contrast in venous phase

Discussion

BUDD-CHIARI SYNDROME • Caused by hepatic venous obstruction; classic presentation: abd pain, ascites,

hepatomegaly; occlusion of hepatic v cause pressure in ctrl v, therefore get centrilobular congestion, necrosis, and w/chronic dz get fibrosis and cirrhosis leading to portal HTN and ascites

• Most common cause in Western population: hypercoaguable states: assoc w/polycythemia vera, myeloproliforative d/o, paroxysmal nocturnal hemoglobinuria, defects in coagulation cascade and with inc estrogen states like pregnancy and use of OCP

• SX: hepatomegaly, RUQ pain, N/V, ascites, sequelae of cirrhosis, portal HTN, variceal bleeding, encephalopathy

• DX: U/S eval of liver and vasculature w/ sensitivity of 85-95%; duplex scanning can reveal location of obstruction and flow in veins

• Gold standard of DX: angiography—gives detailed info on location and degree of obstruction

• Tx: surgical decompression w/ portosystemic shunt

After Whipple, what deficiency would you see?

• Fe

• Zinc

• B12

• Bile Salts

Discussion

• With pancreatic insufficiency, as may be seen post-Whipple, zinc absorption and retention may become impaired, with low levels of zinc noted in the plasma. Copper levels in the fingernails and the plasma may rise.

A woman is found to have a 4cm small cell lymphoma of the stomach underneath a chronic

nonhealing ulcer bed. Proper management is ? • H.Pylori Trx

• Gastrectomy

• Excision of the ulcer with 2cm margins

Discussion• For an ulcer in the stomach that is biopsy positive for lymphoma the treatment of choice

would be to excise the ulcer and the underlying malignancy. This would entail a total gastrectomy. Lesions that are distal can be treated by subtotal gastrectomy however, as has been reported in up to 30% of patients, the lymphoma extends into the duodenum distally or the esophagus proximally, therefore frozen section must be done on the margins and that is why a total gastrectomy with roux en y anastamosis is better. Proximal tumors get total gastrectomy. The complications of bleeding, obstruction, and perforation, can be avoided with gastric resection, (all of which have been reported to occur with increased frequency during chemotherapy and radiation therapy whether these modalities are used preoperatively, postoperatively, or as primary therapy). The treatment of primary gastric lymphoma is controversial. At one time, surgery offered the only diagnostic approach and was the only treatment modality available, but developments in radiologic and endoscopic diagnosis as well as advances in chemotherapy and radiation therapy have led to the use of these modalities as alternatives to surgical intervention. Because primary gastric lymphomas are curabl by complete surgical resection alone, those who favor surgery argue that all patients with gastric lymphoma should undergo surgical exploration unless systemic involvement is demonstrated.

Answer

• Most VIPomas have been located in the distal pancreas, where they are amenable to resection by distal pancreatectomy. If no tumor is found in the pancreas, a careful exploration of the retroperitoneum including both adrenals should be performed. Metastatic disease to the lymph nodes and the liver have been reported in half of all cases. In the presence of metastatic disease, safe palliative debulking of the metastatic tumor is indicated, but not pancreatectomy.

• In patients with recurrent or unresectable VIPoma, octreotide therapy is used to reduce circulating VIP levels and control diarrhea.

• Chemotherapy specific for VIPoma patients has not been studied prospectively, although small numbers of patients have appeared to partially respond to streptozocin, combination chemotherapy or interferon.

80 yo woman with pain in medial thigh and a palpable pelvic mass that’s tender. What is

dx? • Lymphoma

• Femoral hernia

• Obturator hernia

• Colon Cancer

Answer

• The patient may present with evidence of compression of the obturator nerve, resulting in pain in the medial aspect of the thigh. This was described by John Howship and is called Howships sign. Reduction in the contents and inversion of the hernia sac are the initial steps in the surgical treatment of obturator hernias

A pregnant woman with thyrotoxicosis is refractory to medical therapy. The best management would be:

• subtotal thyroidectomy and propranolol

• propranolol alone

• subtotal thyroidectomy

Discussion

• Pregnancy and thyrotoxicosis. Because PTU inhibits T4 to T3 conversion, crosses the placenta less readily, and is concentrated to a lower extent in the mother's milk than MMI, use of PTU is preferred over that of MMI in pregnant patients. Isolated cases of aplastica cutis induced by MMI have been reported. Long-term treatment with propranolol is not recommended because low birth weight can result. In addition, postnatal bradycardia and poor responses to hypoxia have been noted in newborns of mothers treated with propranolol. If adequate control of hyperthyroidism is not possible, subtotal thyroidectomy should be considered, which is best performed during the second trimester.

An elderly man has a 1cm penis SCC, what is the management?

• Partial penectomy

• total penectomy and groin dissection

• total penectomy and RT to groin.

• 5-Fu topical ointment

Discussion• Poor personal hygiene and retained phimotic foreskin have been implicated in the

etiology of penile carcinoma. Penile cancer is extremely rare in men circumcised at birth. Squamous cell carcinoma of the penis occurs most commonly in the sixth decade of life. Small penile cancers limited to the prepuce can be treated with circumcision alone. Partial penectomy with at least a 2-cm margin of normal tissue is used to treat smaller (2 to 5 cm) distal penile tumors. The remaining penis should be long enough to permit voiding in the standing position. The 5-year cure rate for patients who undergo partial penectomy is 70 to 80%. Larger distal penile lesions or proximal tumors require total penectomy and perineal urethrostomy. Many patients will have inguinal lymphadenopathy at presentation. However, inguinal lymph node enlargement before excision of the primary tumor may be the result of infection and not metastatic disease. Thus, clinical assessment of the inguinal region should be delayed 4 to 6 weeks, during which time the patient is given antibiotics. If inguinal lymphadenopathy persists or subsequently develops, there is a high likelihood of metastatic lymph nodal disease and ilioinguinal lymphadenectomy should be performed. However, if inguinal lymphadenopathy resolves, prophylactic lymph node dissection may not be necessary depending on the grade of the primary lesion. Radiation of the primary tumor and regional lymph nodes is an alternative to surgery in patients with small (2 cm), low-stage tumors. The advantage of radiotherapy over surgery is preservation of the penis. However, control rates are slightly lower than those of surgical excision.

A woman has pain in the C8-T1 distribution exacerbated by abducting her arm. Which is

the most likely cause?

Discussion

• Thoracic outlet syndrome (TOS) refers to compression of the subclavian vessels and nerves of the brachial plexus in the region of the thoracic inlet. These neurovascular structures of the upper extremity may be compressed by a variety of anatomic structures, such as bone (cervical rib, long transverse process of C7, abnormal first rib, osteoarthritis), muscles (scalenes), trauma (neck hematoma, bone dislocation), fibrous bands (congenital and acquired), or neoplasm. . In over 90% of cases, neurogenic manifestations are reported. Ulnar nerve (C8-T1) involvement is associated with motor weakness and atrophy of the hypothenar and interosseous muscles, as well as pain and paresthesia along the medial aspect of the arm and hand, the fifth finger, and the medial aspect of the fourth finger. Symptoms of subclavian artery compression include fatigue, weakness, coldness, ischemic pain, and paresthesia.

An elderly woman has aerobilia and a small bowel obstruction. What is the best management?.

• Ileal enterotomy and close without doing chole• enterotomy and cholecystectomy with

fistulectomy• ileocecal bowel resection• cecal enterotomy

Answer

• The best management of gallstone ileus is to remove the stone via a enterotomy, close the fistula tract between the gallbladder and the bowel (usually duodenum) and get out. The gallbladder will be taken care of at a future operation. Here, from the answers given, I would put enetrotomy and close without doing chole.

What is first identified in a lap Nissen to identify the GE junction?

• Right crus

• Left crus

• anterior vagus

• posterior vagus

Answer

There are 2 approaches to identify the GE junction at the start of a Lap. Nissen.

1. involves dissecting the L crus first – advantage is early division of the gastrosplenic ligament

avoidance of splenic injury as a result of traction on the short gastrics. (Cameron)

2. involves dissecting the R crus first

The ureter is hit in a low impact GSW to the belly and there is urinary extravasation. What is best procedure? • ureteroureterostomy

• ileal conduit with bowel

• ureterostomy to abdomen

Discussion

• Grading system- I Hematoma/ II Laceration <50%/ III Laceration>50%/ • IV Complete transection <2cm devascularization/ Avulsion >2cm

devascularization• High impact GSW and or an unstable patient deserve a staged repair, with

tying off the ureter and perc. nephrostomy. This patient has a low impact GSW so primary repair if the patient is stable is indicated.

• The procedure of choice depends on the location of the injury. A ureteroureterostomy is preferred with transection of the upper 2/3 of the ureter. If the distal 1/3 is injured then a Boari flap (tubulization of the bladder) or the psoas hitch ( tack the bladder to the psoas to bring it up to the ureter. If there is enough length of the ureter a ureterneocystostomy is done. The other 2 procedures mentioned in this question are not used in the acute setting. (Cameron)

• The answer is ureteroureterostomy.

After a lap chole you do a gram and can see distal CBD but no proximal filling. After dye + changing patients position you still don’t see any.

What is next step? • Intraop ERCP

• close and get CT

• close and get LFTs

• open

Answer

• OPEN, CBD injury must explore and repair. (Cameron)

While changing a central line a tremendous amount of air gets into the proximal port.

What is your first move? • Put patient in trendelenberg with left side

down

• begin amrinone

• Intubate

• give 100% O2.

Answer

• Put patient in trendelenberg with left side down, and attempt to aspirate air directly from the venous line. In dire circumstances a needle through the chest wall into the right ventricle to attempt to aspirate the air. (Marino)

Cells that die in embryogenesis, thymocytes that die from corticosteroids, and cells that die from

RT all die from? • O2 deprivation

• Anti-inflammatory effects

• Apoptosis

• Programmed cell death

Answer

• Apoptosis is programed cell death. It is responsible for numerous physiologic and pathologic events. Including: embryogenesis, hormone-dependent involution in the adult (endometrial cells during menses), cell deletion inproliferating cell populations (intestinal crypt epithelia), death of immune cells, pathologic atrophy of hormone dependent cells (prostatic atrophy after castration and loss of lymphocytes in the thymus after steroids), cell injury in viral disease, cell death from radiation, chemo and hypoxia.

• (Robbins Pathologic Basis of Disease)

Which hepatic lesion needs to be resected?

• 6 cm hepatocellular adenoma

• 6 cm focal nodular hyperplasia

• 6 cm hamartoma

• 6 cm hemangioma

Answer

• The above are all benign liver lesions. Indications for resection are as follows: symptoms, hemorrhage or risk of malignant transformation , inability to exclude malignancy. Hepatic adenomas should be resected due to the propensity to rupture or undergo malignant degeneration. The other benign tumors should not be resected unless they meet one of the above criteria. (Cameron)

Characterize LES:

Length/ Normal, resting Pressure?

LES is 3 to 5 cm in length Normal resting pressure within ranges from 10 to 20 mm Hg

Full thickness burns to chest,back, and upper extremities.

Now with rising CO2. • Escharatomy

• Increase TV

• Increase Resp Rate

• Increase PEEP

Discussion• When deep second- and third-degree burn wounds encompass the circumference of an extremity,

peripheral circulation to the limb can be compromised. Development of generalized edema beneath a nonyielding eschar impedes venous outflow and eventually affects arteriaFl inflow to the distal beds. This can be recognized by numbness and tingling in the limb and increased pain in the digits. Arterial flow can be assessed by determination of Doppler signals in the digital arteries and the palmar and plantar arches in affected extremities. Capillary refill can also be assessed. Extremities at risk are identified either on clinical examination or on measurement of tissue pressures greater than 40 mm Hg. These extremities require escharotomies, which are releases of the burn eschar performed at the bedside by incising the lateral and medial aspects of the extremity with a scalpel or electrocautery unit. The entire constricting eschar must be incised longitudinally to completely relieve the impediment to blood flow. The incisions are carried down onto the thenar and hypothenar eminences, and along the dorsolateral sides of the digits to completely open the hand if it is involved . If it is clear that the wound will require excision and grafting because of its depth, escharotomies are safest to restore perfusion to the underlying nonburned tissues until formal excision. If vascular compromise has been prolonged, reperfusion after an escharotomy may cause reactive hyperemia and further edema formation in the muscle, making continued surveillance of the distal extremities necessary. Increased muscle compartment pressures may necessitate fasciotomies. The most common complications associated with these procedures are blood loss and the release of anaerobic metabolites, causing transient hypotension. If distal perfusion does not improve with these measures, central hypotension from hypovolemia should be suspected and treated.

• A constricting truncal eschar can cause a similar phenomenon, except the effect is to decrease ventilation by limiting chest excursion. Any decrease in ventilation of a burn patient should produce inspection of the chest with appropriate escharotomies to relieve the constriction and allow adequate tidal volumes. This need becomes evident in a patient on a volume control ventilator whose peak airway pressures increase.

Succinylcholine question. Young man in OR for third debridement in for days for

severe burns. Has arrest. Next step?

• Glucose and Insulin

• Epinephrine

• IV Calcium

• Hemodialysis

Discussion• Succinylcholine is known to produce life-threatening elevations in serum potassium in

some clinical conditions: • • Burned patients may be susceptible to excessive potassium release beginning 24 hours

after the injury and persisting for up to 2 years. Although the magnitude of the hyperkalemic response in burn patients does not correlate well with the magnitude of the burn, it is recommended that succinylcholine be avoided in patients suffering burns exceeding 8 per cent body surface area.

• • Patients with extensive neuromuscular disorders, particularly denervation syndromes (spinal cord lesions, progressive muscle wasting disorders), are known to be susceptible to exuberant potassium release with succinylcholine.

• • Patients with severe intra-abdominal infections persisting longer than 1 week have also been reported to have a hyperkalemic response to succinylcholine.

• Although succinylcholine produces little elevation of serum potassium levels in normal individuals (up to 0.5 mg/dL), it seems reasonable to avoid succinylcholine in situations in which hyperkalemia may exist, such as cardiac glycoside poisoning or hydrofluoric acid exposure. Muscle cell membrane instability in any clinical setting associated with rhabdomyolysis is likely a setup for hazardous potassium release with succinylcholine. Rhabdomyolysis has been reported with toxicity due to sympathomimetics, phencyclidine, doxylamine, heroin, and envenomation by scorpions, Latrodectus spiders, and crotalids

Trx of Hyperkalemia:

• Hyperkalemia due to succinylcholine (in burn patients b/c of hyperkalemia) Treat with atropine, insulin and glucose, bicarb. However, electrolyte abnormalities in burn pts are avoided by decreasing the potassium in enteral feedings and giving oral bicarb solutions (Bicitra). Severely burned pts actually require exogenous potassium b/c of the aldosterone response that leads to potassium wasting. Thus hyperkalemia is RARE in burn patients even with some renal insufficiency.

Increasing end tidal CO2 over 2 minutes in a lap chole pt, what is the management?

• Evacuate CO2

• Increase Tidal Volume

Question #1

• Optimal rate of glucose administration for a patient on TPN is:– A. 10-20 gms/kg/hr– B. 8-10 gms/kg/hr– C. 5-6 gms/kg/hr– D. 1-2 gms/kg/hr

Answer #1

C

Question #2

• Protein absorption occurs in:A. Duodenum

B. Jejunum

C. Ileum

D. Colon

Answer #2B

Question #3

• A characteristic of 3-week old blood is:– A. Hypokalemia– B. Elevated pH– C. Hypocalcemia– D. Elevated 2-3 DPG

Answer #3

• C

Question #4

• The operative finding associated with transfusion of mismatched blood:

A. hypoxia

B. rigors

C. tachycardia

D. generalized bleeding

Answer #4

• D

Question #5

• The pre-transplant crossmatch involves:– A. recipient serum and donor lymphocytes– B. recipient lymphocytes and donor plasma– C. recipient globulins and donor macrophages– D. recipient macrophages and donor globulins

Answer #5

• a

Question #6

• Acute renal failure 6 weeks post-transplant is the result of:– A. T cells– B. B cells– C. IgG– D. macrophages

Answer #6

• A

Question # 7

• The initial step in managing a case of suspected necrotizing fascitis is:– A. Hyperbaric oxygen therapy– B. Immediate operative debridement– C. High dose penicillin IV– D. Bacterial smears of the wound

Answer # 7

• D

Question #8

• In ambient conditions, the most important determinant of oxygen content is:– A. elevated pH– B. 2,3 DPG levels– C. elevated temperature– D. Hemoglobin concentration

Answer #8

• D

Question #9

• Sodium Thiopental was inadvertently injected into the radial artery at the wrist. The complication that could be expected is:– A. vasodilation and shock– B. vasoconstriction, thrombosis and necrosis– C. convulsions and coma– D. cardiac arryhtmia and cardiac arrest

Answer # 9

• B

Question #10

• The non-depolarizing agent that has a predictable rate of metabolism is:

• A. D-tubocurarine

• B. atracurium

• C. vecuronium

• D. pancuronium

Answer #10

• B

Question #11

• The topical antibiotic, use in burn treatment, which causes metabolic acidosis is:– A. silver sulfadiazine– B. silver nitrate– C. mafenide acetate– D. gentamicin cream

Answer #11

• C

Question #12

• The most effective initial treatment for an obtunded patient with a serum calcium of 14 mg is:– A. calcitonin– B. IV phosphate– C. mithramycin– D. saline and IV lasix

Answer #12

• D

Question #13

• An indication for emergency thoracotomy following a GSW to the chest is:– A. unaccounted hypotension– B. initial chest tube drainage > 800 cc– C. clotted hemothorax– D. persistent chest tube drainage > 200cc/hr

Answer #13

• D

Question #14

• Treatment of sigmoid colon CA with bladder invasion is:– A. total colectomy, partial cystectomy– B. pelvic exenteration– C. sigmoid resection and wide excision of

bladder fistula– D. total cystectomy, sigmoid resection, and

ileal loop

Answer #14

• C

Question #15

• Gastroschisis is:A. Genetic defect resulting in an abdominal wall

defect

B. Presence of a peritoneal sac

C. Associated with multiple congenital anomalies

D. The result of an intrauterine umbilical vein rupture

Answer #15

• D

Question #16

• Treatment of acinic cell carcinoma of the parotid is:– A. Total parotidectomy– B. Total parotidectomy and ipsilateral radical

neck– C. Superficial parotidectomy– D. Excision of the tumor and radiation therapy

Answer #16

• C

Question #17

• Treatment of a malignant melanoma 2 mm in depth is:– A. Excision with 1 cm margins and interferon

alpha– B. Excision with 4 cm margins and

prophylactic node dissection– C. Excision with 2 cm margins and sentinel

node biopsy– D. Excision with 1 cm margins

Answer #17

• C

Question # 18

• Proper treatment for a 3 cm papillary thyroid cancer with tumor involving 4 lymph nodes is:– A. ipsilateral lobectomy with resection of involved lymph nodes

– B. total thyroidectomy

– C. total thyroidectomy, central compartment node dissection, and berry-picking all hard or enlarged lateral cervical lymph nodes

– D. total ipsilateral lobectomy, near total lobectomy on the contralateral side, and resect involved lymph nodes

Answer #19

• C

Question #19

• Thyroid storm is treated with:

A. Beta blockers

B. Aspirin

C. benzodiazepines

D. Dilantin

Answer #19

• A

Question #20

• Treatment for elevated homocysteine levels is:– A. Niacin– B. Folate– C. Thiamine– D. Riboflavin

Answer #20

• B

42 y/o Women w/breast mass and biopsy finds “dermal lymphatic

invasion” What is the next step?

A. Chemo

B. Lumpectomy/XRT

C. Mastectomy

D. Observation

42 y/o Women w/breast mass and biopsy finds “dermal lymphatic

invasion” What is the next step?

A. Chemo

B. Lumpectomy/XRT

C. Mastectomy

D. Observation

42 y/o Women w/breast mass and biopsy finds “dermal lymphatic

invasion” What is the next step?

A. Chemo

B. Lumpectomy/XRT

C. Mastectomy

D. Observation

30 year old female develops neck pain following a recent URI.

She has an enlarged and tender thyroid. She is diagnosed with acute thyroiditis

What is the treatment?

• Penicillin

• NSAIDS

• Observation

• Thyroid hormone replacement

Treatment of a woman with previous irradiation to chest for Hodgkin’s lymphoma who now presents with invasive ductal

carcinoma of the left breast

1. Simple mastectomy and SLN

2. Modified radical mastectomy

3. Breast conservation therapy

4. Chemotherapy, followed by radiation

54yo male presents w/fever, confusion, nausea, RUQ tenderness,

wbc 14. All are required except?

1. IVF

2. ABX

3. Drainage of the blockage

4. OR for Ex Lap

Which of the following require surgery?

• 3cm Hemangioma

• 3cm Hepatic Adenoma

• 3cm FNH of the liver

• 3cm Liver Cyst

45 yo female with non-tender neck mass anterior to SCM. FNA of mass is non-

diagnostic. Open biopsy returns the diagnosis of thyroid tissue. Your next step is:

1. Do nothing

2. Treatment with radioactive iodine

3. Total thyroid lobectomy

4. Total thyroidectomy, and neck dissection

5. Treat with thyroid replacement hormone

Which cytokine is responsible for the hypothalamus fever response?

1. TNF-α

2. TGF-β

3. IL-1

4. Thromboxane A2

5. IL-2

What upper extremity injury is associated with an axillary artery

injury?

1. Anterior Shoulder Dislocation

2. Proximal Humerus Fracture

3. Humeral Shaft Fracture

4. Volkmann’s contracture

5. Ulnar Fracture

19 yo male who fell while snowboarding on to an outstretched hand. What is the most

commonly broken bone in the hand?

1. Lunate

2. Scaphoid

3. Hamate

4. Trapezium

5. Capitate

55 year old woman presents with a palpable neck mass and a calcium level of 15. What is

the diagnosis?

1. Parathyroid carcinoma

2. Parathyroid hyperplasia

3. Parathyroid adenoma

4. Thyroid nodule

65 y/o smoker with DM presents with claudication. All are indicated

except?

1. PVR/ABI’s

2. Trental

3. Angiogram

4. Exercise

5. Smoking cessation

S/P CEA 6 month ago, now with a neck mass and some leakage via the wound, what is the

initial management?

1. take back to OR immediately

2. open the neck incision in the office

3. U/S of the neck

4. aspirate in office

5. angiogram

The Best Approximate Measure of Portal Pressure is:

1. Hepatic artery pressure

2. Hepatic venous pressure

3. Hepatic wedge pressure

4. Portal vein pressure

The number one risk factor for developing HCC?

1. Hepatitis A

2. Hepatitis B

3. Hepatitis C

4. Hepatitis D

Prophylactic antibiotics should be given?

1. 2 hours preop

2. 1 hour preop

3. At the time of induction

4. At the time of Skin incision

DX of diaphragmatic hernia is made with?

1. Chest X ray

2. UGI

3. CT Scan

4. EGD

   Obtaining respiratory quotient of 0.70 indicates which of the following:

 1. Lipogenesis2. mixed fuel utilization3. Fat utilization4. reliance on carbohydrate calories5. proteins used as fuel

Pt with hypokalemia, watery diarrhea has a pancreatic lesion seen on CT, what is the most

likely diagnosis?

1. Insulinoma

2. Glucagonoma

3. Gastrinoma

4. VIPoma

5. somatostatinoma

HERNIATED DISC

• A Patient presents with DECREASED SENSATION OF THE ANTERIOR CALF, DORSUM OF THE FOOT AND GREAT TOE, ALONG WITH DECREASED DORSIFLEXORS OF THE FOOT. What disc is involved ?

1. S1 NERVE ROOT L5-S1 DISC2. L5 NERVE ROOT L4-L5 DISC3. L4 NERVE ROOT L4-L5 DISC4. L5 NERVE ROOT L5-S1 DISC

A 75 year old woman underwent a Whipple procedure for pancreatic cancer. Her post op course was complicated by an anastomotic leak. She is still on mechanical ventilation post

op day #26, with two failed attempts at extubation. On reason that could explain this is a respiratory quotient of:

1. 0.66

2. 0.7

3. 0.8

4. 0.9

5. 1.1

80 yo woman with pain in medial thigh and a palpable pelvic mass that’s tender. What is

dx?

1. Lymphoma

2. Femoral hernia

3. Obturator hernia

4. Colon Cancer

The most significant SE of Pancuronium is?

• Hyperkalemia

• Hypokalemia

• Renal dysfunction

• Sympathetic stimulation

• Hyperthermia

Indication for a fem pop?

1. Claudication of one block

2. SFA occlusion

3. Popliteal outflow occlusion

4. Gangrene of the two toes and two vessel run-off to the foot.

83yo w/CHF, COPD has a 2cm adenocarcinoma of the colon 3cm above the dentate line. Best Tx?

1. APR

2. Local Excision

3. Chemo

4. Chemo/XRT

5. XRT

Most common symptom after a vagatomy?

1. Dumping

2. Diarrhea

3. Obstruction

4. Recurrent ulcers

What tumor is associated with migratory erythematous skin lesions

of the leg?

1. Gastrinoma

2. Glucagonoma

3. Insulinoma

4. VIPoma

Four days after an acute MI, the patient becomes unstable. PE

reveals a holosystolic murmur. Etiology?

1. ASD

2. Aortic Valve rupture w/wide open AI

3. Ruptured papillary muscle

4. Perforated of Left Ventricle and Tamponade

SPLENIC TRAUMA

• UNLESS HEMODYNAMICALLY UNSTABLE WITH GREATER THAN 50% BLOOD VOLUME TRANSFUSED, SAVE THE SPLEEN, ESPECIALLY IN CHILDREN

Fuel sources

• Primary fuel source of the small intestine is glutamine

• Primary fuel source of colonocytes are branched chain fatty acids

1. Which cytokine is responsible for the hypothalamus fever response?

• TNF-α

• TGF-β

• IL-1

• Thromboxane A2

• Prostacyclin

• IL-1 released from macrophages and responsible for fever• TNF-α release from macrophages is stimulated by

endotoxin, and induces an inflammatory reacton– Endotoxin - lipopolysaccharide A from gram negative bacteria

• TGF-β stimulates fibroblasts and is responsible for excessive fibrosis

• Thromboxane A2 is released from activated platelets, resonsible for platelet aggregation and vasoconstriction

• Prostacyclin causes platelet inhibition, vasodilation, and bronchodilation

2. Which cell is considered most essential in wound healing?

• Platelet

• Neutrophil

• Macrophage

• Fibroblast

• The order of infiltrating cells in wound healing is platelets, polymorphonuclear cells, macrophages, and fibroblasts

• Leukocyte recruitment is initially by selectins on the leukocyte and endothelial cell, and then by endothelial cell ICAM and leukocyte integrins

• Macrophages are activated by PDGF and considered essential to appropriate wound healing

• Fibroblasts are the dominant cell by day 5– The healing wound contains Collage Type I and Type III– Collagen production begins on day 3 reaches a maximum/constant amount

at day 21; subsequent wound strength is increased by greater crosslinking

3. Which topical burn treatment is associated with neutropenia?

• Topical Calcium

• Silvadene

• Sulfamylon

• Silver Nitrate

• Topical, subcutaneously injected, or intravenous calcium used for hydrofluoric acid burns

• Silvadene has a risk of neutropenia, good activity against Candida, and poor eschar penetration

• Sulfamylon (mafenide acetate) has good eschar penetration and a broad spectrum of activity– Painful application; metabolic acidosis due to carbonic

anhydrase inhibition• Silver Nitrate leeches electrolytes to cause

hypokalemia, hyponatremia, and hypochloremia

4. What is the appropriate treatment when a biopsy of a gastric mass is read

as a MALT lymphoma?

• Chemotherapy

• Radiation Therapy

• Surgical Resection

• H. Pylori Treatment

• MALT is a precursor to gastric lymphoma

• Monoclonal B cells

• Associated with Helicobacter pylori infection

• Antibiotic treatment highly effective for low-grade MALT lymphoma

5. Which of the following is not a characteristic of cholecystokinin (CCK)?

• Causes gallbladder contraction

• Relaxes the sphincter of Oddi

• Stimulates pancreatic release of bicarbonate

• Stimulates pancreatic enzyme release

• CCK is released from I cells in the intestinal mucosa– Causes gallbladder contraction, sphincter of Oddi relaxation, and

increased pancreatic enzyme secretion• Secretin released from S cell throughout the small bowel

and is the primary stimulus of pancreatic bicarbonate secretion– High flow rate = high pancreatic bicarbonate concentration, low

Chloride concentration– Slow flow allows bicarbonate/chloride exchange so low pancreatic

bicarbonate concentration, high Chloride concentration.

6. Which colorectal cancer syndrome is associated with mutations in DNA

mismatch repair genes?

• Familial Adenomatous Polyposis

• Familial hereditary nonpolyposis colon cancer

• Gardner Syndrome

• Turcot Syndrome

• Hereditary Non Polyposis Colon CA (AKA Lynch syndrome) is associated with DNA mismatch repair gene mutations– Lynch I is limited to colonic tumors– Lynch II associated with ovarian, bladder, stomach, and endometrial

cancer.– Appropriate treatment is proctocolectomy

• Familial Adenomatous Polyposis is autosomal dominant, associated with the APC gene, and cancer by the age of 40– Patients Need a total procto-colectomy prophylactically.– Patients also at risk for duodenal cancer

• Gardner syndrome is FAP with osteomas and desmoid tumors• Turcot syndrom is FAP with brain tumors (autosomal recessive)

7. Chemotherapy and radiation is the appropriate initial therapy for which

form of anal cancer?

• Adenocarcinoma

• Squamous Cell Carcinoma

• Bowen Disease

• Malignant Melanoma

• Anal squamous cell carcinoma is treated with the Nigro protocol (ChemoRx and XRT)– APR indicated for recurrent or residual disease

• Adenocarcinoma treated with local resection versus APR• Bowen disease is carcinoma in situ and treated with wide

local excision• Melanoma not responsive to chemo/XRT and treated with

wide local excision or APR– Both have poor survival rates (< 20%)

8. What is the likely injury in an MVC trauma patient with an adducted,

internally rotated, and shortened leg?

• Anterior Hip Dislocation

• Posterior Hip Dislocation

• Femoral Neck Fracture

• Anterior Knee Dislocation

• Posterior Knee Dislocation

• 90% of Hip dislocations are posterior– Patients hit their knee on the dashboard in an MVC and present with internal

rotation, flexed, adducted thigh– Risk of sciatic nerve injury and AVN of the femoral head without prompt

reduction• Patients with anterior hip dislocations present with a frog leg (external

rotation, abduction).• Femoral neck fractures present with shortened limb and external rotation

– These injuries have a risk of non-union and AVN of the femoral head• Anterior knee dislocations associated with hyperextension, posterior knee

dislocation occurs when the proximal tibia is driven posteriorly– Complete neurovascular exam mandatory– Arteriography required for all patients with a history of ischemia or diminished

pulses

9. What upper extremity injury is associated with an axillary artery

injury?

• Shoulder Dislocation

• Proximal Humerus Fracture

• Humeral Shaft Fracture

• Scaphoid Fracture

• Volkmann’s contracture

• Dupuytren’s contracture

• Shoulder dislocation associated with axillary nerve injury• Proximal humerus fracture is associated with axillary artery injury• Humeral shaft fractures are associated with radial nerve injuries• Scaphoid fracture is associated with a tender snuffbox

– Clinical suspicion requires a cast up to elbow or screw fixation even with a negative x-ray

• Volkmann’s contracture is an ischemic fracture associated with a supracondylar humerus fracture (compromised anterior interosseous artery) and forearm flexor compartment syndromes

– Median nerve injury– Treatment is fasciotomy

• Dupuytren’s contracture of the palmar fascia is curling of the fingers and is not associated with trauma

– Treatment is steroids and PT, possible surgical division of the thickened fascial bands

10. What is not a sign of malignant hyperthermia?

• Fever

• Tachycardia

• Rigidity

• Increase in end tidal CO2

• Alkalosis

• Malignant Hyperthermia occurs due to calcium release from the sarcoplasmic reticulum

• Associated with fever, tachycardia, rigidity, and acidosis– first sign is usually increased end tidal CO2

• Treatment is dantrolene, stopping the operation and anesthetic, and supportive care

• Usually occurs when it is not the patient’s first exposure to an anesthetic agent

11. What is not part of the Cushing Triad associated with elevated ICP?

• Hypertension

• Bradycardia

• Seizures

• Respiratory Irregularity

• Cushing’s triad with associated with increased ICP is hypertension, bradycardia, and Kussmaul respirations (slow, irregular).

• Cerebral perfusion pressure = CPP = MAP – ICP

• Goal in head trauma patients is maintain CPP at ~ 70

The most likely cause of an identified macrocytic anemia in a surgical practice is:

A - Inadequate folic acid intake

B - Vegetarian diet

C - 5 yrs post-op total gastrectomy

D - 2 yrs post-op right colectomy

The treatment for elevated homocysteine levels is:

A - Folate

B - Niacin

C - Thiamin

D - Riboflavin

During the irreversible phase of coagulation, the release of platelet granules is activated by:

A - von Willebrand factor

B - Sub-endothelial collagen

C - Thromboxane A-2

D - Platelet factor 4

Hyperacute rejection is mediated by:

A - Lymphocyte activated killer cells

B - T8 cells

C - T4 cells

D - Preformed antibodies

Burn Antibiotics

• Silver Sulfadiazine (silvadene) – does not penetrate eschar, painless, transient neutropenia

• Sulfamylon (mafenide acetate) – penetrates eschar, painful, carbonic anhydrase inhibitor - -Metabolic acidosis

• Silver Nitrate – Electrolye leaching

Respiratory Quotient

• Equals the ratio of the volume of CO2 produced to the volume of O2 consumed

• Carbohydrate RQ = 1.00

• Fat RQ = 0.7

• Protein RQ = (roughly) 0.82

• RQ of brain is 0.97 to 0.99

Nitric Oxide (NO)

• Produced by nitric oxide synthase from L-ARGININE

• NO acts via cGMP

Reperfusion Injury

• Source of FREE RADICALS is XANTHINE OXIDASE

Antibodies

• IgG – most common

• IgM – pentad, J-Chain, primary response

• IgD – B Cell Surface

• IgA – secretions - Including BREAST MILK

• IgE – hypersensitivity, parasitic

Parotid Tumors

• “Superficial parotidectomy is indicated for all parotid tumors, unless deep lobe extension is noted, in which case, total parotidectomy is performed with sparing of the facial nerve.”

Parathyroids

• Sup glands originate from 4th branchial pouch, inf from 3rd pouch

• Blood supply from inf thyroid arteries

MEN• MOST COMMON PANCREATIC MASS IN

MEN IS GASTRINOMA (o/w INSULINOMA)• MEN I:• 3Ps: Pancreatic, Pituitary, Parathyroid• Tumor marker is calcium as 100% get

hyperparathyroidism• MEN II: - Medullary Thyroid c ELEVATED

CALCITONIN• a) Medullary Thyroid, Pheo, Parathyroid

hyperplasia• b) Meduallry Thyroid, Pheo, Mucosal

neuromas & marfanoid habitus

PEEP

• Increases PaO2

• Increases FRC

• Use in mechanically ventilated patients to increase SaO2

Pulmonary Sequestration

• Pulmonary parenchyma (0.515cm) not connected to tracheobronchial tree, outside normal investment of visceral pleura, thought to come from aberrant outpuching of foregut (separate from nl lung outpouching)

Pulmonary Sequestration• - Usually present with recurrent

pneumonia• - Males 3-4:1 females• - 85% in thorax, 63% between diaphragm

and lower lobe• - Intralobar

– o Arterial supply aorta– o Venous drainage pulmonary vein

• - Extralobar– o Arterial supply systemic– o Venous drainage systemic

5 Veins to save

Right RenalPoplitealPortalSuprarenal IVCSMV

Choledochal Cysts

• Most Common - Type 1 - involves CBD - Requires hepaticojejeunostomy - risk is MALIGNANCY

• Type 4 and 5 require transplantation

Anal Pain

• Three causes:

• Fissure - most common, painful

• Thrombosed external hemorrhoid

• Perianal, Perirectal Abscess - may not be most painful, but most dangerous

Easy Points

• Review general abdominal anatomy

• STATISTICS

9mo old undergoes RIH complicated by continuous oozing from wound despite pressure.

Reoperation reveals diffuse oozing. The most likely congenital defect causing this would be in

• Factor VIII

• Factor IX

• Von Willebrand’s factor

• bradykinin

vW disease

• Most common congenital bleeding disorder

• Prolonged bleeding time (ristocetin test)

• vWF links platelets to collagen (GpIb receptor)

• Decreased circulating vWF (type I, III) - cryoprecipitate, ddAVP

• Ineffective vWF (type II)- cryoprecipitate

50yo male is 4 hours s/p resection of pheochromocytoma. His BP is 80/40 with low

urine output. CVP measures 14. The most appropriate therapy next is

• Transfuse 2U PRBC

• Exploratory celiotomy

• Dopamine

• norepinephrine

Pheochromocytoma

• Preop- volume replacement for hypotension, phenoxybenzamine (alpha blocker) first to avoid hypertensive crisis

• Follow cautiously with beta blocker for tachyarrhythmias, hypertension

• Postoperative hypotension Rx- fluids and pressors (levophed)

50yo male has a 5 cm left adrenal mass and low plasma renin activity, high plasma aldosterone,

high urine potassium. What acid base disturbance would you predict?

• metabolic acidosis

• Respiratory alkalosis

• Metabolic alkalosis

Hyperaldosteronism

• Sodium retention, potassium wasting, HTN

• Best test is urine aldosterone following Na load

• High serum Na, low serum K, high urine K

• Medical rx- spironolactone, K repletion, CCB

Which topical burn treatment is associated with neutropenia?

• Topical Calcium

• Silvadene

• Sulfamylon

• Silver Nitrate

BURNS

• Silvadene has a risk of neutropenia, good activity against Candida, and poor eschar penetration

• Sulfamylon (mafenide acetate) has good eschar penetration and a broad spectrum of activity– Painful application; metabolic acidosis due to carbonic anhydrase

inhibition

• Silver Nitrate leeches electrolytes to cause hypokalemia, hyponatremia, and hypochloremia

A 100 kg Dutch man is burned 50% BSA in a smelting accident. At what

infusion rate should the LR start?

• 80 cc/hr• “encourage PO”• 1250 cc/hr• 8000 cc/hr

Parkland formula

• Use for burns > 20 % BSA

• 4 cc/kg/hr * % BSA in first 24 hours, half over first 8 hours

• Use LR

• Urine output best indicator 0.5-1.0 cc/kg/hr

One week later, one arm wound which was not excised appears to be third degree despite topical silver

sulfadiazene. The likely etiology is

• Pseudomonas

• Staph. Epidermidis

• Adverse reaction to silver sulfadiazine

• He is still burning

Burn wound infection

• Peripheral edema

• Conversion to deeper burn

• Wound/skin discoloration

• Rapid eschar separation

• Wound biopsy gold standard

• Think Pseudomonas

60yo female undergoes lap cholecystectomy for symptomatic cholelithiasis. Pathology comes back

gall bladder cancer invading through the mucosa and muscular layer. Further treatment is

• Not indicated at this time

• Excision of port sites and observation

• Resection of GB fossa and regional lymphadenectomy

• radiation

Gall bladder

• Organisms- E. coli, Klebsiella, Enterococci

• Biliary dyskinesia- <25% excretion after 2 hours during CCK HIDA

• Incidental GB cancer after chole- confined to muscular layer (stage I), no further Rx. If it does, segment IV/V resection

• GB polyp- chole if >1cm

24 yo male who gets a metal splinter in his right third finger. Tip of finger becomes tender and

erythematous. What is the best treatment option?

1. Warm soaks

2. Surgical drainage

3. 10 day course of Doxycycline

4. 10 day course of Penicillin

5. Do nothing

Felon

• Felon refers to infection of terminal joint space of a finger

• normally arise from punctures

• Form a localized comparment syndrome

• Untreated they can go on to ischemia and necrosis

30yo schizophrenic undergoes laparoscopic inguinal hernia repair for recurrent hernia. He comes to the

office three weeks later complaining of numbness of his scrotum on one side. You suspect

• Genitofemoral nerve injury• Ilioinguinal nerve injury• He missed this month’s haldol shot• He has contracted a “social” disease

Laparoscopic inguinal herniorrhaphy

• Indicated for bilateral or recurrent inguinal hernia

• Genitofemoral nerve injury (loss of cremaster, scrotum or thigh numbness)

• Ilioinguinal nerve injury associated with open repair

• Urinary retention common early postoperatively

During laparotomy for SBO in a 70yo woman, you find a 3 cm cystic mass on the left ovary. After you

relieve the bowel obstruction, your next step is

• Tell the resident to close and head to the club for your 2pm tee time

• Oopherectomy with frozen section

• Bilateral oopherectomy

• TAH/BSO

Incidental ovarian mass

• Risk of ovarian CA

• If postmenopausal, resect and get a frozen, may need TAH/BSO

• If premenopausal, controversial- usually need partial oopherectomy with frozen

70yo male smoker has a prominent popliteal pulse. Duplex ultrasound shows 2 cm popliteal artery

aneurysm. He is asymptomatic. You counsel the patient that treatment is

• Not indicated at this time given small size• Indicated because of limb loss associated with

thrombosis• Indicated given a high incidence of mycotic

aneurysm in this location• smoking cessation will result in improvement

Popliteal artery aneurysm

• High incidence of other aneurysms (bilateral, femoral, AAA)- need to screen

• Complications are emboli and thrombosis

• Surgery if symptomatic or >2cm

• Procedure- ligate and bypass or interposition graft

60yo male user of smokeless tobacco has an asymptomatic lateral neck mass. H&P is

otherwise unremarkable. Next step would be

• Oral clindamycin

• Panendoscopy with biopsies, neck and chest CT

• Perform excisional biopsy

50yo male develops unilateral right calf and foot swelling after his tenth revision of a R fem-distal

bypass for rest pain. Duplex shows no DVT. You surmise the cause is likely

• Lymphocele

• Edema 2/2 reperfusion of an ischemic limb

• Graft thrombosis

• The graft is just that good

The arterial supply of the gastric tube used following esophagectomy is

• right gastroepiploic artery

• right gastric artery

• Artery of Adamkowicz

The correct order that cells arrive for wound healing?

1. PMN, platelets, macrophages, fibroblasts

2. Fibroblasts, platelets, macrophages, PMN

3. Platelets, fibroblasts, PMN, macrophages

4. Platelets, PMN, macrophages, fibroblasts

5. Macrophages, PMN, platelets, fibroblasts

50yo male has a 5 cm adenocarcinoma of the LUL without distant metastasis. His FEV1

currently is 1.0 L (35% predicted). You next recommend

• Mediastinoscopy with LN sampling

• Left upper lobectomy

• Quantitative V/Q scan

• One way ticket to Amsterdam

Preop FEV1 and Predicted Postop FEV1

Preop FEV1

Pneumonectomy > 2L

Lobectomy > 1L

Wedge > 0.6 L

Predicted Postop FEV1

> 0.8 L

A 30 yo attorney is brought to HUP, at 2 am, after being hit by a car a the corner of 13th and Walnut.

Primary survey is unremarkable. Secondary survey reveals blood at the urethral meatus. What is your

next move?

1. T pod

2. Retrograde urethrogram

3. IVP

4. Place the largest foley in the Trauma bay without lube

Blood at the urethra equals

retrograde urethrogram

CPP= mean BP – ICPWant 60-70 mm Hg

When in doubt, always answer…

• Glutamine

• IL-2 for immunology questions

• APC for colon cancer