ABSITE Review
(MC = most common)
-Which coagulation factor is not made by the liver? Where is it made?
Factor VIII, endothelium
-What are the vitamin K dependent factors?
II, VII, IX, X, protein C, protein S
-What does bleeding time detect?
Abnormal platelet function
-What is the mechanism of action of unfractionated heparin?
Binds to thrombin (factor II) and amplifies its activity
-What is the MC congenital bleeding disorder?
Von Willebrands’ disease
-What is the MC inherited thrombotic disorder?
Factor V Leiden
-What is the MC transfusion reaction?
Febrile non-hemolytic reaction
-What causes a right shift on Hgb curve?
Low ph (acidosis), increased temp, increased CO2, increased 2,3 DPG
-What factor deficiency would only affect PT?
Factor 7
-MC bacteria in colon?
Bacteroides
-Which immunoglobulin is transported across the placenta?
IgG
-What is the most toxic part of endotoxin?
Lipid A region on LPS
-MC infection in SICU?
Postop pneumonia
-MC bacteria causing UTI?
E coli
-Most reliable indicator of successful intubation?
Presence of end-tidal CO2
-What are the benefits and side effects of etomidate?
No respiratory depression but may cause adrenal insufficiency
-What medication is used to reverse benzodiazepine overdose?
Flumazenil
-Succinylcholine should be avoided in which patients?
Those with elevated potassium - burns, crush injury
-What is the pathology and first sign of malignant hyperthermia? What is the treatment?
Inability of sarcoplasmic reticulum to re-accumulate calcium in skeletal muscle (defect in ryanodine receptor); First sign is elevated ETCO2; Treatment
involves stopping surgery and anesthesia, actively cooling the patient and giving dantrolene
-What are the signs of local anesthetic toxicity?
CNS symptoms first (metallic taste, circumoral tingling, tinnitus), followed by seizures and shock
-What is the max dose (ml) of 1% lidocaine for a 70 kg patient?
4.5 mg/kg lido without epi, 7 mg/kg lido with epi; 1% solution = 1 gram/100 ml = 10 mg/ml. For a 70 kg pt: 31.5 ml of 1% lido or 49 ml of 1% lido with epi
-What is the max dose of (0.5%) bupivicaine for a 70 kg patient?
2.5 mg/kg without epi, 3 mg/kg with epi. For a 70 kg pt: 35 ml of bupivicaine without epi, 42 ml of buipvicaine with epi
-What is the first muscle to recover from paralysis?
Diaphragm
-What is an anesthetic and analgesic commonly used for quick procedures?
Ketamine
-What enzyme activates all other zymogens?
Trypsin
-What activates trypsin?
Enterokinase
-What is the half life of albumin? Prealbumin?
18 days, 2 days
-What is the respiratory quotient (amount of CO2 produced / amount of O2 used) or RQ for carbs, proteins, fats?
Carbs: 1, proteins: 0.8, fats: 0.7
-What are the approximate daily caloric and protein needs of a patient?
25 kcal/kg/day; 1 gr protein/kg/day
-How is nitrogen balance calculated?
N bal = N in - N out = (gr of prot / 6.25) - (24 hr urine N + 4)
-Initial treatment of hyperkalemia with EKG changes?
Calcium
-What are the mechanisms of action and common side effects of the following immunosuppressants: Cyclosporine, tacrolimus, sirolimus (rapamune),
mycophenolate mofetil (cellcept), azathioprine (imuran)?
Cyclosporine: inhibits IL-2; nephrotoxic, gingival hyperplasia, HTN, hyperkalemia
Tacrolimus: binds FKBP & inhibits IL-2, IL-3, IL-4, IFN gamma; nephrotoxic, CNS toxicity (seizures, headaches, altered mental status), diabetes, HTN,
hyperkalemia
Sirolimus: binds FKBP then FRAP, preventing T cell progression from G1 to S phase; impaired wound healing, HTN, HLD, pneumonitis
Mycophenolate mofetil: inhibits inosine monophosphate dehydrogenase; nausea, diarrhea, bone marrow suppression
Azathioprine: purine analog, prevents DNA replication; bone marrow suppression, hepatitis, pancreatitis
-What is the treatment for post transplant lymphoproliferative disorder?
Decrease immunosuppression
-What is the order of appearance of cells after the development of a wound?
Platelets, neutrophils, macrophages, fibroblasts, lymphocytes
-Name the different types of collagens and where they are found.
I - all connective tissue, 90% of all collagen; II - cartilage; III - fetal, healing wounds; IV - basement membrane; V - cornea
-When does the collagen level in a wound plateau?
After approximately 8 weeks no NET change in amount of collagen
-Name of enzymes that cross-link collagen.
Prolyl & lysyl hydroxylase
-What medication can offset the effects of steroids on wound healing?
Vitamin A
-How do keloids differ from hypertrophic scars?
Keloids often recur after excision & violate boundaries of scar (hypertrophic scars do not)
-Cancer that develops in a chronic wound is known as what?
Marjolin’s ulcer
-What are the criteria for diagnosis of ARDS?
Acute onset, PaO2/FIO2 ratio < 200, PA wedge pressure < 18, BL infiltrates on CXR
-What is the diagnosis and treatment of a patient who has significant fluid resuscitation then develops increased peak inspiratory pressures and decreased
urine output?
Abdominal compartment syndrome; decompressive laparotomy
-A patient has blood at the meatus. What is the next step?
Retrograde urethrogram to rule out urethral injury
-What is the first sign of compartment syndrome of the leg?
Decreased sensation of the first webspace due to anterior compartment compression of deep peroneal nerve
-What is the Parkland formula?
Amount of IVF needed in first 24 hours after a 2nd-3rd degree burn of >10-20% TBSA; = (4ml of LR)x(body weight kg)x(%TBSA burn); give half of this total
fluid amount in first 8 hours, rest over 16 hours
-Best way to diagnose burn wound infection
Quantitative bacterial count of biopsy from wound
-Which are the key advantages and disadvantages of the following topical burn antibiotics: 1: silver sulfadiazine (silvadene), 2: mafenide acetate
(sulfamylon), 3: silver nitrate?
1: Painless; limited Pseudomonas coverage, slows re-epithelialization
2: Good Pseudomonas coverage, penetrates eschar; painful and causes acidosis
3: Broad spectrum including fungus; causes black stains and electrolyte disturbances
-Melanoma staging is primarily dependent on what?
Tumor thickness and presence of ulceration
-MC type of melanoma
Superficial spreading melanoma
-In extremity sarcomas, what direction should the incision be oriented for a biopsy?
Longitudinal (will need to resect entire incision if patient needs further operation)
-What is the most important prognostic factor in sarcomas?
Pathologic grade
-What is the MC site of mets from sarcomas?
Lungs
-What is the treatment for gastric mucosa associated lymphoid tissue lymphoma (GALT)?
Treat for H. pylori
-What is the gene defect in hereditary spherocytosis?
Spectrin and ankyrin
-Vaccinations are needed against which organisms after splenectomy?
Streptococcus pneumoniae, Haemophilus influenzae, Neisseria gonorrhoeae
-Which cells secrete calcitonin?
Parafollicular or c cells (neural crest origin); also give rise to medullary thyroid cancer
-What is the pathology in Hashimoto’s thyroiditis?
Antibodies against microsomal fraction of the thyroid cell
-What is the most important prognostic factor in well differentiated thyroid cancer?
Age at diagnosis
-What is the MC cause of hyperparathyroidism?
Single adenoma 85% of the time
-Extremely high serum calcium levels indicate what?
Parathyroid carcinoma
-What is the MC cause of Cushing syndrome?
Iatrogenic; MC endogenous cause is pituitary adenoma (Cushing disease)
-When should adrenal incidentalomas be resected?
If functional or >5 cm
-Why is total thyroidectomy done for I/L follicular thyroid ca?
Helps with post op I radiation ablation
-What is the MC type of thyroid cancer?
Papillary
-What is the MC presentation of hyperparathyroidism?
Incidentally discovered elevated Ca
-Treatment for parotidits?
Hydration & antibiotics
-What is Mondor disease and how is it treated?
Superficial thrombophlebitis of breast; treatment is NSAIDs and warm compresses
-What is the MC cause of bloody nipple discharge?
Papilloma
-Atypical Ductal Hyperplasia (ADH) and Atypical Lobular Hyperplasia (ALH) increase breast cancer risk by how much?
4-5 fold
-What factors increase the risk of breast cancer?
Anything that increases estrogen exposure (early menarche, late menopause, nulliparity, first birth after age 30, exogenous estrogen use, family history)
-Which chromosomes are BRCA 1 and BRCA 2 located on?
Chromosome 17 and 13, respectively
-What is unique about inflammatory breast cancer?
Presents with peau d’orange due to lymphatic obstruction; treatment is chemotherapy, then mastectomy and radiation
-A scaly, ulcerated lesion of the breast is due to what condition and what is the treatment?
Paget disease; almost all are associated with underlying breast cancer. Get mammogram.
-What is the treatment for Phylloides tumors?
Wide local excision (no lymphadenectomy needed)
-10 years after axillary lymph node dissection, a woman develops a blue nodule in her arm. What is the diagnosis and treatment?
Angiosarcoma (Stewart-Treves Syndrome), wide resection
-Which pneuomocytes secrete surfactant?
Type II
-What is the MC cause of death from cancer?
Lung cancer
-What is the main therapy for small cell lung cancer?
Chemotherapy
-What is the MC mediastinal tumor overall?
Neurogenic (usually posterior mediastinum)
-What is the MC anterior mediastinal tumor?
Thymoma
-Plan for a lung nodule in smoker?
Operative resection (lobectomy)
-Treatment for a massive air leak s/p chest tube for trauma?
Thoracotomy
-What is the MC primary cardiac tumor?
Myxoma
-What is the first visible sign of atherosclerosis in a vessel?
Fatty streak formation
-What is the initial treatment for a patient with claudication?
Exercise, smoking cessation, statin
-What is the 5 year amputation rate in patients with claudication?
Only 5%
-What GI complication must be watched for after AAA repair?
Colonic ischemia (sigmoid)
-When should the following aneurysms be repaired: 1: renal/hepatic, 2: splenic, 3: popliteal, 4: femoral, 5: iliac, 6: aortic (abdominal)?
1: when found, 2: >2cm or if pregnant or planning to be pregnant, 3: >2cm, 4: >2.5cm, 5: >3cm, 6: >5cm
-What is Page-von Schrotter disease and what is the treatment?
Effort induced compression of subclavian vein (thoracic outlet obstruction); treatment is thrombolytics and anticoagulation, with possible angioplasty to
recanalize vein followed by surgical resection of 1st rib
-What is unique about the layers of the esophagus?
No serosa
-Where do Zenker’s diverticuli occur?
Killian’s triangle – at junction of cricopharyngeus and thyropharyngeus (also MC site of iatrogenic perforation)
-What is the blood supply for a gastric conduit?
R gastroepiploic artery
-When operating for a gastric ulcer, what should always be done?
Biopsy of ulcer rim to rule out cancer
-What is the MC peptic ulcer type? Which type are due to hyperacidity?
MC is type I (along lesser curve). Type II (prepyloric & duodenal) and III (antral) have increased acid secretion
-What are the two MC arterial anomalies of the hepatic blood supply?
Replaced/recurrent R hepatic artery off of SMA; replaced/recurrent L hepatic artery off of L gastric artery
-What is the orientation of the structures in the portal triad?
Bile duct on right, hepatic artery on left, portal vein posterior
-Best test to assess liver function?
INR/PT
-How do you manage a CBD injury if recognized intraop?
Place a drain near the injury then transfer to a hepatobiliary surgeon (other option is RNY hepaticojejunostomy if experienced enough to perform it)
-What is the treatment for an incidentally found hepatic adenoma?
Excise due to risk of rupture and HCC
-MC malignant liver tumor?
Mets
-Treatment for gallbladder carcinoma?
Cholecystectomy alone for T1 lesion (confined to muscular layer), add en bloc hepatic resection with regional lymphadenectomy for T2 and T3 lesions
-MC liver malignancy in kids?
Hepatoblastoma
-How is the main pancreatic duct formed?
Duct of Wirsung from the fusion of the ventral bud duct and the distal portion of dorsal bud duct (proximal dorsal bud duct becomes the minor pancreatic
duct or duct of Santorini)
-What is the most potent stimulator of pancreatic HCO3 secretion?
Secretin
-Which chemotherapeutic agent increases survival in pancreatic cancer?
Gemcitabine
-What lab should always be checked in patients with pancreatic endocrine tumors?
Calcium to rule out MEN 1
-What is the MC functioning pancreatic tumor?
Insulinoma
-Are most pancreatic endocrine tumors benign or malignant?
90% of insulinomas are benign; all others are usually malignant
-Which pancreatic endocrine tumor causes necrotizing migratory erythema?
Glucagonoma
-What is the primary fuel of SB enterocytes?
Glutamine
-Treatment for gallstone ileus?
Enterotomy and removal of stone (usually at terminal ileum); avoid cholecystectomy in most patients as they are often critically ill
-What is the MC presentation of Meckel's diverticulum in kids? adults?
Kids: bleeding; Adults: obstruction
-How are appendiceal carcinoids managed?
Appendectomy alone if <2 cm and located at tip of appendix; otherwise right hemicolectomy
-What is the primary fuel source of colonocytes?
Short chain fatty acids (butyrate, propionate, acetate)
-When doe patients with ulcerative colitis need their first colonoscopy?
Within 10 years after diagnosis
-A polypectomy is adequate treatment for colon cancer in which cases?
No submucosal invasion, no lymphovascular invasion, and margins > 2 mm
-Familial adenomatous polyposis (FAP) is due to a mutation in what gene & what chromosome?
APC tumor suppressor gene on chromosome 5q
-What is the second leading cause of death in FAP patients?
Cancer in a duodenal polyp (need EGD every 2 years)
-HNPCC is due to a defect in what gene?
DNA mismatch repair genes (MLH1, MSH2)
-What is first and second MC cause of lower GI bleeding?
Diverticulosis then colonic angiodysplasia or AVM
-Where do most anal fissures occur?
90% in posterior midline (if not, suspect Crohn’s disease)
-What is the treatment for tumors of the anus
Nigro protocol (5-FU, mitomycin, and radiation)
-An elderly woman has a SBO and hip pain that radiates down the medial thigh. What is the diagnosis?
Obturator hernia (Howship-Romberg sign)
-Clean transaction of lower ureter, plan?
Psoas hitch
-Treatment for an extraperitoneal bladder rupture?
Foley
-What are the 5 types of tracheo-esophageal fistulas?
Type A: atresia only; Type B: EF before atresia; Type C: MC, atresia + distal TEF; Type D: double TEF; Type E: TEF only, no atresia.
-What is the initial management of a child with hypertrophic pyloric stenosis?
IVF and correction of electrolytes (get HCO3 < 30); then pyloromyotomy
-What is the differential diagnosis of bilious emesis in a newborn?
ALWAYS rule out malrotation with midgut volvulus immediately! Other causes include duodenal atresia, SB atresia, annular pancreas, meconium ileus,
NEC, Hirschsprung’s disease, imperforate anus
-What is the treatment for biliary atresia?
Kasai portoenterostomy; if diagnosed after 60 days old, liver transplant is primary treatment
-What is the MC choledochal cyst type, how is it managed and why?
Type I (cyst of entire CBD); treatment is excision with RNY hepaticojejunostomy to prevent future cancer
-How does omphalocele differ from gastroschisis?
Omphalocele occurs in midline, has a sac, normal bowel, and high incidence of associated anomalies (& higher mortality); gastroschisis is associated with
intestinal atresia
-When should umbilical hernias be repaired in children?
If not resolved by age 4-5 years old
-MC solid organ tumor in children?
Neuroblastoma
-What is the fluid resuscitation protocol in kids?
Bolus 20ml/kg up to two times, if still hypotensive, give 10ml/kg RBCs