ABSITE 2016 Rapid Fire Review Jason Weinberger D.O. Stem Pearls • The provided clinical presentations are the most common for each diagnosis (age, gender, nationality, symptoms, etc.) • A 22 year old female… – Think GYN diagnoses • An alcoholic... – Think klebsiella, dietary deficiencies, liver disease, etc... • A 94 year old... – Think conservative management – Less likely to have to opt for the aggressive surgical option • Ashkenazi Jewish population... – Think Crohn‘s, cystic fibrosis Stem Pearls • Stable or hemodynamically unstable? – If tachycardic or hypotensive you’re forced to act – Never observation and rarely a medical option if unstable – Airway, airway, airway; GCS ≤ 8 = intubate • Is the patient symptomatic or not symptomatic? – If patient is symptomatic, never choose observation and the answer is rarely a medical therapy – If patient is asymptomatic and there’s no obvious malignancy, then think observation/conservative management Other Pearls • For diagnosis questions – evaluate each answer choice and see if it completely fits the clinical description • “Which of these is not like the other ones?” • Radiology picture questions are meant to be easy – Common diagnoses, don’t think Zebras • No calculator is provided so the math is usually easy and straightforward Calculations To Know • • • • • • • • FENA = (U Na/U Crt)/(P Na/PCrt) Parkland = 4mL x Kg x %BSA Serum Osm = 2(Na) + BUN/2.8 + Glucose/18 Free Water Deficit = Kg(0.6) x (Na/140-1) Anion Gap = Na - (HCO3+Cl) CPP = MAP – ICP MV = TV x RR SVR = 80(MAP-CVP)/CO Calculations To Know • O2 Delivery = (1.34xSaO2xHgb) + Pa02(0.0031) • Ca adjustment = For every 1 less than 4, add 0.8 to Ca • Na adjustment = For every 100 over 100mg/dL glucose, add 1.6 to Na Normal Values • • • • • • • Circulating blood volume = ~ 7 mL/kg Resting LES pressure = 10-20 mmHg ICP = 5-15 mmHg CVP = 5-12 mmHg A-a gradient = (Age/4) + 4 Hepatic venous pressure gradient = 5 mmHg Basal gastric acid secretion < 10meq/hr Genetic mutation often associated with melanoma and malignant nevi BRAF mutation Treatment of ovarian vein thrombosis Antibiotics & Anticoagulation Most common complication after pancreaticoduodenectomy Delayed gastric emptying Make the diagnosis: 45 y.o. ♂ with large left breast mass, smooth & leaf-like on exam. Core biopsy with stromal/epithelial elements & < 5 mitoses/hpf Cystosarcoma phylloides Pathophysiology behind dilated pupil after traumatic head injury Ipsilateral temporal herniation compressing C.N. III (oculomotor) Virus associated with the development of Kaposi’s sarcoma HHV-8 Provides innervation to the pectoralis major & minor muscles Medial pectoral nerve Treatment of choice for biopsy proven papillary thyroid cancer of the left lobe with positive ipsilateral node Total thyroidectomy with modified radical neck dissection Pathogenesis of Volkman’s contracture with supracondylar fractures Damage to anterior interosseous artery Make the diagnosis: 28 year old female with hypertension and chain of beads appearance noted in right renal artery Fibromuscular dysplasia Aldosterone : Renin ratio suggestive of an aldosteronoma > 20 Three drugs used to treat mastodynia Evening primrose oil Danazol OCPs Confirmatory test to assess whether fluid is CSF Beta 2 Transferrin Distinguishing factor between ARDS and ventilator associated pneumonia Proteinaceous exudate on BAL Fluid protein : serum protein ratio > .7 Time period for a wound to reach its maximal tensile strength 8 weeks Name the amino acid that is found in every 3 residues in collagen Proline Most aggressive subtype of ductal carcinoma in situ Comedo pattern Desired margin of resection for gastric cancer 5 cm Malignancy associated with exposure to vinyl chloride, thorotrast, and arsenic Angiosarcoma Test used to distinguish insulinoma from factitious hyperinsulinemia C-peptide levels Basophilic nuclear remnants seen on peripheral blood smear of patients s/p splenectomy Howell-Jolly bodies Coronary vessel that determines circulatory dominance as it branches from right coronary or circumflex Posterior descending artery First branch of the external carotid artery Superior thyroid artery Make the diagnosis: Galactocele Most commonly affected portion of the intestine associated with aortoenteric fistula 3rd portion of duodenum Nerve coursing lateral to medial across the anterior scalene Phrenic nerve Make the diagnosis: 75 y.o. ♂ s/p fall with left leg internally rotated, thigh adducted and slightly flexed Posterior hip dislocation (Femoral neck fracture = externally rotated) Most desired site for autologous arteriovenous fistula creation Radiocephalic fistula (Cimeno) Non-dominant extremity Released from terminal ileum in response to a fatty meal and inhibits stomach/gallbladder contraction Peptide YY Name the two arterial vessels supplying the majority of blood to the breast Internal mammary Lateral thoracic Make the diagnosis: Intestinal hamartomatous polyps, skin tumors, breast carcinoma, follicular thyroid cancer, and PTEN mutation Cowden syndrome Located within the duodenum and secrete pepsinogen as well as alkaline mucus Brunner’s glands List at least 4 tests used to work-up a potentially functioning adrenal lesion Serum potassium / sodium Plasma renin : aldosterone ratio Plasma fractionated metanephrines 24 hour urine catecholamines 1 mg dexamethasone suppression test 24 hour urine cortisol Source of liver bleeding not controlled with Pringle maneuver Hepatic veins Make the diagnosis: 20 y.o. ♂ soccer player complains of aching calf/foot pain with knee flexion and plantar-flexion Popliteal entrapment syndrome Name this procedure: Heller Myotomy / Dor fundoplication Eponym given to the valveless venous plexus responsible for direct hematogenous spread of breast cancer to the spine Batson’s plexus DeBakey classification for an aneurysm encompassing ascending & descending aorta Type 1 Make the diagnosis: 65 y.o. ♂ with SOB, pretibial rash, & bronchoscopy with biopsy consistent with non-caseating granuloma Sarcoidosis Accounts for 3% of the lymphatic drainage in the breast Internal mammary nodes Paraneoplastic syndrome & release of PTH-related peptide associated with this type of lung cancer Squamous cell carcinoma Make the diagnosis: Pneumothorax occurring in temporal relation to menstruation Catamenial pneumothorax Most common failure of AV grafts for dialysis Venous obstruction secondary to intimal hyperplasia Percentage of acinar cell function lost before onset of steatorrhea in chronic pancreatitis 90% Carries the obliterated remnant of the umbilical vein to the undersurface of the liver via the falciform ligament Ligamentum teres Calculate the Child-Pugh score: Albumin - 2.9 Bilirubin – 3.5 INR - 2.5 Encephalopathy - Severe Ascites - Treatable w/ Meds 13 Activates trypsinogen to trypsin Enterokinase Make the diagnosis: Rheumatoid arthritis, hepatomegaly, splenomegaly Felte’s (sp) syndrome Medical treatment of bronchospasm in carcinoid syndrome Aprotinin Most common ectopic tissue found in Meckel’s diverticulum Gastric tissue Best serum & urine test for detection of carcinoid tumor Serum Chromogranin A Urine 5-HIAA Antigen associated with the constellation of ulcerative colitis, sacroiliitis, and ankylosing spondylitis HLA B27 Acquired cause of achalasia and Hirschsprung’s disease Trypanosoma cruzi Most common genetic cause of breast cancer BRCA2 Adjunct to broad spectrum antibiotics and early surgical debridement of necrotizing fasciitis IVIG The proportion of truly nondiseased people who are so identified by the screening test Specificity Number of new cases of a disease in a given population during a specified time period Incidence Three hormone receptors tested for the management of breast cancer Estrogen Progesterone HER2-neu A dilated, aberrant, submucosal vessel which erodes through the overlying epithelium in the absence of a primary gastric ulcer Dieulafoy’s lesion Paralytic with good indication to use in renal or liver failure patients secondary to its metabolic elimination by Hoffman degradation Cisatracurium Make the diagnosis: XXY, hypogonadism, gynecomastia, increased risk of breast cancer Klinefelter’s syndrome Osmotic diuretic and oxygen free radical scavenger Mannitol Most common location of aneurysms in the circle of Willis Bifurcation of anterior cerebral artery & anterior communicating artery Branch of the brachial plexus associated with thumb apposition/abduction and sensory for first 3 fingers on the palmar aspect Median nerve Make the diagnosis: Anterior knee pain in adolescent Tibial tubercle apophysitis Osgood-Schlatter disease Make the next move: During management of melanoma of the upper extremity the sentinel lymph node is positive in the axilla Complete axillary node dissection Levels 1, 2, and 3 Treatment of gastroduodenal artery stump blowout s/p Whipple Angioembolization Central enzyme involved in apoptosis Caspase Duration until a wound reaches its greatest tensile strength 8 weeks, 80% Make the next move: Magnesium IV Rider Provides sensory innervation to the upper esophagus and motor limb of the gag reflex Glossopharyngeal nerve Technique of primary hernia repair best suited for closure of femoral hernia McVay Repair Associated with liquefactive necrosis of the esophagus & deeper penetration/burns Alkaline ingestion Most common complication of popliteal aneurysms Thromboembolism Treatment of septic pelvic thrombophlebitis IV heparin & antibiotics Treatment of primary sclerosing cholangitis in patient with history of ulcerative colitis Liver transplantation Most definitive treatment of a chronic anal fissure after 6 weeks of sitz baths, stool softeners, and conservative management Lateral sphincterotomy Type of hypersensitivity reaction associated with anaphylaxis and the binding of antigens to IgE with mast cell degranulation Type 1 Hypersensitivity Appropriate crystalloid bolus for treating shock in an infant 20 mL/kg Most common type of gallbladder polyp Cholesterol polyp Best test to assess for recurrence in patient with history of medullary thyroid cancer s/p thyroidectomy Calcitonin Make the diagnosis: 45 y.o. ♂ s/p MVC w/ left femur fracture SOB on exam, PaO2 65, & petechial rash Fat emboli syndrome Aberrant innervation of epidermis by postganglionic nerve fibers from the auriculotemporal nerve Frey’s Syndrome (Gustatory sweating) Appropriate T staging for gallbladder carcinoma that on pathology appears to be invading the lamina propria T1a Two best treatment options for Hemophilia A patients with severe bleeding Factor VIII replacement or Cryoprecipitate Virus associated with the following clinical exam finding: HPV Condyloma acumulata Major stimulant of erythropoietin production by the kidneys Hypoxia BRAF enzyme inhibitor used as immune therapy agent in late stage Melanoma patients Vemurafenib Rituximab – CD 20 - NHL Trastuzumab – HER 2-neu – Breast cancer Bevacizumab – VEGF – Colorectal cancer Cetuximab – EGFR – Colorectal cancer Inflixmab – TNF-a – Crohn’s Site of action within the nephron for furosemide Thick ascending loop Treatment of squamous cell carcinoma of the vulva with depth < 1mm Wide local excision Syndrome associated with pelvic tumor, abdominal ascites, and right hydrothorax Meig’s syndrome Drug of choice for actinomyces infection (sulfur granules) Penicillin Most commonly injured nerve in parotid surgery Greater auricular nerve #1 cause of colon obstruction in children Hirschsprung’s disease Make the diagnosis: Dermatitis, dementia, and diarrhea Niacin deficiency Pellagra Vitamin B3 deficiency Hematologic condition which has highest risk of OPSI after splenectomy Thalassemia major Most common area for a Zenker's diverticulum Killian’s triangle Between inferior constrictors & cricopharyngeus muscle Most common malignant salivary gland tumor Mucoepidermoid carcinoma Diagnostic test for pancreatic exocrine insufficiency Fecal fat testing Common origin of a replaced right hepatic artery Superior mesenteric artery Treatment of gallbladder carcinoma extending into the muscularis propria Segment 4b/5 hepatic resection Portal lymphadenectomy Make the diagnosis: S/P head injury, high UOP, low specific gravity, high serum sodium Diabetes Insipidus Primary hormonal stimulus for pancreatic bicarbonate secretion Secretin Reflex affected by L4 nerve root compression Patellar reflex Structure commonly injured in anterior shoulder dislocations Axillary nerve Most common extra-adrenal location of a pheochromocytoma Organ of Zuckerkandl Three zones of injury associated with burns Zone of coagulation Zone of stasis Zone of hyperemia Treatment recommendation for cellular atypia on rectal biopsy of patient with known ulcerative colitis Mesalamine Rx Make the oncologic diagnosis: Watery diarrhea, hyperkalemia, & achlorydia VIPoma Treatment for Type 5 choledochal cyst (Caroli's disease) Liver transplantation Type of hypersensitivity reaction associated with binding of autoantibodies to immunoglobulins such as in Hashimoto’s thyroiditis or Grave’s disease Type 2 Hypersensitivity Gene associated with neuroblastoma in children N-myc Surgical treatment for biliary atresia in infants Kasai procedure Hepatoportoenterostomy Cause of intestinal atresias Intra-uterine vascular accidents Most common cause of Cushing's disease Pituitary adenoma (anterior lobe) Cause of hypocalcemia after massive transfusion Citrate binding Medical treatment for a prolactinoma Bromocriptine What are the appropriate surgical margins for resection of a melanoma that has 3mm depth? 2cm wide local excision Make the diagnosis: FNA of thyroid nodule reveals amyloid tissue Medullary thyroid cancer Derived from salmon sperm Used in the reversal of unfractionated heparin Dosed at 1 mg per 100 U/Heparin Risk of hypotension Protamine Consumptive coagulopathy or CHF due to giant liver hemangioma Kasabach-Merritt Syndrome Surgical treatment and approach for leiomyoma in midesophagus Right thoracotomy & enucleation Major pancreatic duct that merges with CBD before draining into duodenum Wirsung’s duct Make the diagnosis: Bilateral diminished motor, pain, and temperature sensation below the level of injury. Preservation of position and vibratory sense. Anterior cord syndrome Most common complication after Heller myotomy Reflux Palliative procedure for chronic pain associated with locally advanced pancreatic adenocarcinoma Celiac plexus block Most common gram positive cause of emphysematous cholecystitis Clostridium welchii Inhalational agent with the least myocardial depression Nitric oxide Most common pathogen associated with mastitis Staph aureus Most common gran negative bacteria associated with human bite infections Eikenella Two essential fatty acids that must be obtained through food sources Linoleic and linolenic acid Milan criteria for liver transplant in patients with hepatocellular carcinoma tumors 1 tumor < 5cm 3 tumors, each less < 3 cm Two primary bile salts Cholic acid & Chenodeoxycholic acid Cardiac arrythmia caused by hypomagnesemia Tosades de Pointes Monoclonal antibody used for treatment of HER2-neu positive breast cancer patients Trastuzumab Most common cause for seizures after massive fluid resuscitation for septic patient Hypernatremia Initial treatment recommend for anal fissure Sitz baths Stool softeners Cause of drooping of lateral lip after submandibular gland excision Injury to marginal mandibular branch of CN VII Most sensitive test for recurrent thyroid cancer after total thyroidectomy & I131 Serum thyroglobulin Make the diagnosis: 60 y.o. ♂ with abdominal pain and leg swelling undergoes endoscopy and many large rugal folds are visualized. Biopsy is consistent with mucous cell hyperplasia. Menetrier’s disease Interpectoral lymph nodes located between the pectoralis major and minor muscles Rotter’s nodes Most potent stimulator of pancreatic enzyme secretion CCK Indication to discontinue antibiotic treatment of spontaneous bacterial peritonitis < 250 PMNs/cc Treatment of flushing and diarrhea associated with Carcinoid syndrome Octreotide Surgical treatment for Type 1 choledochal cyst Excision of cyst Hepaticojejunostomy Only hormone to be secreted by the pancreas in its active form Amylase Medical treatment recommend for FAP patients to decrease burden of adenomas / desmoid tumors Sulindac Tamoxifen Make the next move: Biopsy consistent with dermal lymphatic invasion Neoadjuvant chemo, MRM, adjuvant chemo/XRT Pathogenesis attributed to development of gastroschisis Intrauterine rupture of umbilical cord Make the diagnosis: Pancreatic cyst with central “starburst” calcification, low CEA in fluid, no mucin Serous cystadenoma Treatment for low-grade gastric MALToma biopsied during endoscopy Eradication of H. pylori Clarithromycin, Amoxicillin, PPI Maximum site of absorption for water and NaCl Jejunum Make the diagnosis: Liver lesion on MRI with central stellate scar and uptake of sulfur colloid on technetium scan Focal nodular hyperplasia Most common cause of anterior mediastinal mass in adults Thymoma Designation of the lymph nodes stationed medial to the pectoralis minor Level 3 Myelinated afferent nerve fibers associated with fast conduction of pain sensation Aδ fibers Most frequent pulmonary site affected by aspiration in the supine position Posterior segment of right upper lobe First line therapy for effort induced thrombosis of subclavian vein Catheter directed thrombolysis Maximum dose of lidocaine if used with epinephrine for local anesthesia 7 mg/kg Long-term complication of lung transplant that eventually leads to organ failure Bronchiolitis obliterans First sign of blood transfusion reaction in the operating room Bleeding Most common cause of testicular atrophy after open inguinal hernia repair Venous thrombosis from excessive cord manipulation Protein mutation often associated with GIST tumors c-Kit Toxic metabolite responsible for liver necrosis during acetaminophen overdose NAPQI Most common organism associated with acute lymphangitis Group A Strep Rate limiting step in cholesterol synthesis HMG CoA reducatase Most important prognostic factor for sarcomas Tumor grade Best predictor of ability to successful extubate a patient Rapid shallow breathing index Tobin index Frequency / Tidal volume Treatment for cyanide poisoning often associated with excessive nitroprusside treatment Thiosulfate Amyl nitrate Anatomic anomaly most often encountered during crural dissection for Nissen fundoplication Replaced left hepatic artery Branch from left gastric artery Medication used to keep a patent ductus arteriosus open prior to pediatric cardiothoracic surgery PGE-1 Treatment of phimosis found at time of preparation for laparotomy Dorsal slit Gene mutation/condition associated with jejunoileal atresia in neonates Cystic Fibrosis CFTR gene Enzyme that converts norepinephrine to epinephrine PMNT Gene mutation that predisposes men to breast cancer risk BRCA 2 Most common nerve distribution affected by thoracic outlet syndrome Ulnar nerve Make the next move: Splenectomy & IV antibiotics Type of thyroid cancer most likely associated with bone metastases Follicular thyroid cancer Source of renin secretion Juxtaglomerular cells Chemotherapy options for unresectable glucagonoma Streptozocin 5-FU Most common site of injury during upper endoscopy Level of the cricopharyngeus Sites of reepithelization at skin graft donor sites Skin edges Hair follicles Medication used post liver transplant to prevent recurrent Hepatitis B infection Lamivudine Four components in Tetralogy of Fallot Pulmonary stenosis Overriding aorta VSD Right ventricular hypertrophy Most common cause of chylous ascites Malignancy / Lymphoma Vascular abnormality associated with Dysphagia Lusoria Anomalous right subclavian artery Make the next move: A 52 y.o. ♀ complains of tachycardia, nausea, diaphoresis, and dizziness that resolves after eating snacks. A diagnosis is made but CT with IV contrast is unable to localize the tumor. Endoscopic ultrasound Most common gene mutation associated with pancreatic cancer K-ras Conduit vessel for CABG with longest patency rates Left internal mammary artery Most common variant of tracheoesophageal fistula Type C Blind ending esophageal pouch Distal tracheoesophageal fistula Make the diagnosis: 55 y.o. ♂ with depression, fatigue, goiter, elevated TSH, and positive antibodies to thyroid perioxidase Hashimoto’s Thyroiditis (Chronic Lymphocytic Thyroiditis) Most common complication of flexible bronchoscopy Hypoxemia Typical metabolic derangement found in patients with pyloric stenosis Hypochloremia Hypokalemia Metabolic alkalosis Most common cause of GI bleed in children Meckel’s diverticulum Best surgical approach for mediastinal biopsy of stations 5 & 6 Anterior mediastinotomy Chamberlain procedure Paraaortic lymph nodes Most common primary chest wall malignancy Chrondrosarcoma Aspect of axillary lymph node dissection that increases likelihood of postoperative lymphedema Dissection superior to axillary vein Topical treatment for hydrofluoric acid burn Calcium gluconate Organism associated with pyogenic liver abscesses in alcoholic patients Klebsiella pneumoniae Chromosome of the BRCA 1 gene mutation 17 Classification of endoleak from separation between stent graft components Type III Treatment of SVC syndrome after failed radiotherapy Endovascular angioplasty and stent placement FEV1 and DLCO contraindications to pneumonectomy FEV1 < 0.8 L DLCO < 60% Recommended surgical treatment for a 5mm wide squamous cell carcinoma of the lower lip WLE with 1cm margin and primary repair SCC > 2cm → XRT as well Two blood product transfusions with no risk of contamination Albumin IVIG Two respective causes of early and late dumping syndrome after gastrectomy with B1 reconstruction Early – Rapid passage of hyperosmolar bolus & fluid shifts Late – Overcompensation of hyperglycemia & insulin surge Immunoglobulin found in breast milk IgA Chemotherapy agent used for residual disease after radical adrenalectomy for adrenocortical carcinoma Mitotane Clark level of depth with invasion up to the papillary-reticular dermal interface Level III Most common sarcoma of the extremity Malignant fibrous histiocytoma Antidote for treatment of a beta-blocker overdose Glucagon Three phases of empyema formation Exudative phase Fibroproliferative phase Organized phase Contains the highest concentration of potassium in the body Saliva Most commonly injured nerve in the tacking of mesh during laparoscopic inguinal hernia repair Lateral femoral cutaneous nerve Femoral branch of genitofemoral nerve Best surgical approach for male breast cancer Modified radical mastectomy Peripheral nerve injury attributed to prolonged lithotomy positioning Common peroneal nerve injury Make the diagnosis: Mediterranean sheep handler reports with complaints of RUQ pain and fevers Hyatid cysts Echinococcal liver abscesses Nerve that innervates latissimus dorsi Thoracodorsal Nerve Most common complication of hemorrhoidectomy Urinary retention Statistical value that lies exactly in the middle of a continuous set of data points Median Make the diagnosis: Sex-linked recessive disorder, deficiency of Factor IX, elevated PTT levels Hemophilia B Christmas disease Most common electrolyte abnormality with DKA Hypokalemia Hormone found to be substantially decreased after sleeve gastrectomy Ghrelin Boundaries of Hesselbach’s triangle Medial border of rectus Inferior epigastric vessels Inguinal ligament GCS of patient localizing to pain, incomprehensible words, opens eyes to pain 9 5/2/2 Used for treatment of uremia in chronic renal failure patients to release vWF and factor VIII from the endothelium DDAVP Most common cause of splenic vein thrombosis Chronic Pancreatitis Next best treatment for this diagnosis? Heparin gtt Most common visceral artery aneurysm Splenic artery Treatment of duodenal hematoma detected on CT after trauma NPO/TPN Most common thyroid cancer Papillary Cause of iron deficiency anemia associated with sliding hiatal hernia Cameron’s Ulcers Name the major extracellular cation and anion Na CL Best test to assess the synthetic function of the liver PT/INR Antibiotic used to bind exotoxin of gram positive infections Clindamycin Immediate action needed in patient with suspected air embolism Placement into left lateral decubitus Trendelenberg position Two electrolyte abnormalities associated with adrenal insufficiency Hyponatremia Hyperkalemia Most common blood transfusion complication Non-hemolytic febrile reaction Complication of bleomycin and amiodarone Pulmonary fibrosis Which zone of the neck is injured? Zone 1 (Cricoid to clavicles) Name the condition: Development of squamous cell carcinoma from chronically healing wounds Marjolin’s ulcers Recommended treatment for recurrent C. Diff infection after failed Flagyl course PO Vancomycin Most important prognostic factor in diagnosis of melanoma Depth of invasion Treatment of hypotensive, pregnant, Jehovah’s witness with splenic rupture Exploratory laparotomy Most important cell in wound healing Macrophage Commonly used antibiotic associated with risk of cholestasis Ceftriaxone Adverse effect of succinylcholine seen in burn patients Hyperkalemia Make the diagnosis: Gastroschisis Most anterior structure in the renal hilum Renal vein Treatment for benzodiazepine overdose Flumenazil Name the condition: Hypercoagulable state Resistance to activated protein C Factor V Leiden Kcal/g for carbohydrates, dextrose, protein, & fat Carbs – 4 Dextrose 3.4 Protein – 4 Fats - 9 Most commonly injured nerve in open inguinal hernia repair Ilioinguinal nerve Three main vessels supplying blood flow below the knee Anterior tibial artery Posterior tibial artery Peroneal artery Name the procedure: Intraperitoneal on-lay mesh for parastomal hernia Sugarbaker repair Equation for respiratory quotient CO2 produced ________________________________ O2 consumed Nerve that innervates serratus anterior Long Thoracic Nerve Best surgical treatment for duodenal stricture in a Crohn's patient Heineke-Mikulicz strictureplasty Most important amino acid substrate used by the liver for gluconeogenesis Alanine Electrolytic composition of lactated ringers Na 130 Cl 109 Lactate 28 K4 Ca 3 Testicular tumor that is most sensitive to radiation Seminoma Three values needed to calculate a potential transplant patient’s MELD score Bilirubin Serum Creatinine INR Most common blood product transfusion with risk of contamination & bacteremia Platelets Make the diagnosis: Cyanosis, VSD, & aortic arch hypoplasia Transposition of Great Vessels Describe the anatomical relationship of the portal triad structures Portal vein – posterior Common bile duct – right/anterior Hepatic artery – left/anterior Most common aerobic bacteria found in the colon E. coli Required amount of lymph nodes for adequate sampling during gastrectomy for adenocarcinoma > 15 Recommended medical treatment of hyperthyroidism in pregnant patient Propylthiouracil (PTU) Three branched chain amino acids Isoleucine Leucine Valine Silver nitrate complication Hyponatremia Pathophysiology associated with Cushing ulcers Elevated ICP Best treatment for cystic duct leak after cholecystectomy ERCP w/ stent Pharmacologic treatment of hepatorenal syndrome Spironolactone Hallmark biochemical feature of refeeding syndrome Hypophosphatemia Most common location for a spontaneous esophageal perforation Distal, left, posterior Procedural absolute contraindication to PEG Lack of transillumination (Light reflex) Make the diagnosis: Weight loss, anemia, glossitis, DVT, pancreatic tail mass Glucagonoma Surgical management of bleeding Meckel’s diverticulum Segmental small bowel resection Contraindicated antihypertensive medication in patients with severe TBI Nitroglycerin Targeted PTH level reduction 10 minutes after excision of abnormal gland 50% Three main stimuli for H+ production in the stomach Ach, Gastrin, Histamine Chemotherapy agent with adverse affect of hemorrhagic cystitis and its recommended treatment Cyclophosphamide Treatment = Mesna Treatment of IgG4 Autoimmune Pancreatitis Steroids Bacteria associated with cat scratch disease in immunocompromised patients Bartonella hensalae Cytokine associated with cachexia in cancer patients TNF-α Hormone that promotes small bowel growth with short gut syndrome Glucagon Like Peptide (GLP) Stage of 1.2 mm depth melanoma with positive inguinal node Stage 3 Procedure for gastric cancer 3cm proximal from pylorus along the lesser curve & 4 cm distal from GE junction Total gastrectomy with esophagojejunostomy Strength layer of the small bowel Submucosa Most common gram negative cause of infected AAA Salmonella Provides the branch for the right gastroepiploic artery Gastroduodenal artery Make the Diagnosis: Pathology: Hyperplastic epithelial proliferation Hypertrophy of the muscularis propria Enlarged Rokitansky-Aschoff sinuses Gallbladder adenomyomastosis First muscle to recover after paralytic reversal Diaphragm Treatment for hemodynamically unstable patient with new onset atrial fibrillation Synchronized cardioversion Best surgical therapy for otherwise healthy 60 y.o. ♂ with history of Barrett’s esophagus that has recent biopsy consistent with high grade dysplasia. Esophagectomy Best surgical therapy for otherwise healthy 60 y.o. ♂ with history of Barrett’s esophagus that has recent biopsy consistent with high grade dysplasia. Esophagectomy Make the diagnosis: 2 weeks s/p transabdominal GSW a patient presents with RUQ abdominal pain, GI bleed, and jaundice Hemobilia Hepatic artery pseudoaneurysm with connection to biliary system Most common pancreatic islet cell tumor associated with MENIN gene mutation Gastrinoma Virus associated with the development of Burkitt’s lymphoma EBV Surgical treatment for traumatic injury to the distal 1/3 of ureter, 3 cm defect Psoas hitch or Boari flap Treatment of annular pancreas Duodenojejunostomy Produced in the zona glomerulosa and secreted in response to hyperkalemia or increased levels of angiotensin II Aldosterone Best test to determine successful endotracheal intubation End tidal CO2 Most common nutritional deficiency after gastric bypass surgery Iron deficiency Blood supply to the superior parathyroid glands Inferior thyroid artery Primary fuel source of brain neurons after 48 hours of starvation Ketones The most common neuroendocrine tumor of the pancreas (also the least malignant) Insulinoma Make the diagnosis: Nausea, vomiting, abdominal distension, and inner thigh pain with internal rotation Obturator hernia Cornerstone of treatment for patient with disseminated intravascular coagulation Correct/treat the underlying cause Estimated energy requirement (kcal/kg/day) for average post-surgical patient 25 kcal/kg/day First clinical sign of local anesthetic overdose Perioral numbness Side effect of sulfamylon/mafenide Metabolic acidosis Most common primary tumor of the heart Myxoma of the left atrium Risk factor for recurrent Crohn’s flares but protective for Ulcerative colitis remission Smoking Most accurate diagnostic imaging in detection of Meckel’s diverticulum 99m Tc-pertechnetate scan Best surgical approach for distal esophageal perforation Left thoracotomy Gene mutation in Lynch Syndrome associated with right sided colon cancers DNA mismatch repair gene hMSH2 hMLH1 Secreted by JG cells of the kidney & cleaves angiotensinogen to angiotensin I Renin Nutritional deficiency associated with development of cardiomyopathy Selenium Cause of hyperacute rejection of organ transplants Presence of antibodies directed toward donor from ABO blood group incompatibility Branchial pouch derivative of the superior parathyroid glands 4th branchial pouch Best treatment option for diagnosis of Merkel cell carcinoma (red/purplish nodule, NSE+) WLE, SLNB, and radiation Make the diagnosis: 45 y.o. ♀ with distal pancreatic lesion with elevated CEA from fluid on EUS Mucinous cystic neoplasm BIRADS classification of a benign lesion 2 Pathophysiology behind Type 2 Heparin-Induced-Thrombocytopenia IgG antibodies bind to heparin/PF4 complexes Ranson’s criteria on admission: Glucose > 200 Age > 55 LDH > 350 AST > 250 WBC > 16 Current state of metabolism with respiratory quotient of 0.7 Ketogenosis (Lipolysis) Treatment for 1 cm carcinoid lesion at the tip of the appendix Observation Most common cause of liver transplant in the U.S. Hepatitis C Earliest identifiable lesion in atherosclerosis Fatty streak First clinical sign of compartment syndrome Numbness in the first toe web space Make the diagnosis: Pain with passive extension Flexor tenosynovitis Indications for bariatric surgery BMI > 40 BMI > 35 with associated comorbidity Treatment for CMV infection s/p kidney transplant Ganciclovir Maximum volume of air that can be expired after maximal inhalation Vital capacity Calculation of ideal body weight for a male 50 kg + 2.3 kg for each 1” > 5’ Most common form of transmission for infections with Prevotella Saliva Most common site of arterial occlusion from atherosclerotic disease in the lower extremity Distal SFA Hunter’s canal Most common complication of long-term TPN administration Central line associated infection Necessary diagnostic study for liver transplant patient with rising LFT’s POD#3 Hepatic ultrasound Rule out hepatic artery thrombosis Make the diagnosis: Sudden onset upper abdominal pain Recurrent retching with inability to vomit Inability to pass NGT Gastric volvulus Borchardt Triad Best treatment for splenic vein thrombosis and isolated gastric varices Splenectomy Necessary cofactor for hydroxylation and cross-linking of proline and lysine during collagen synthesis Vitamin C Make the next move: POD#1 s/p mastectomy a 65 y.o. ♀ complains of acute abdominal pain. She’s bradycardia, hypotensive, tachypneic, and upper abdomen is distended/tympanic. Placement of nasogastric tube Lower extremity compartment most sensitive to compartment syndrome Anterior compartment *contains deep peroneal nerve* Best test for T-staging of esophageal and rectal neoplasms Endoscopic Ultrasound Recommendation for ulcerative colitis patient with rectal biopsy showing high grade dysplasia Proctocolectomy with ileoanal pouch Additional malignancy risk associated with BRCA 1 gene mutation in females Ovarian cancer Consider prophylactic BSO Make the diagnosis: Elevated bilirubin & alk phos ERCP w/ beading of hepatic ducts History of ulcerative colitis Primary sclerosing cholangitis Incision of choice to repair a Stanford Type A aortic dissection Median sternotomy Most common parasitic cause of appendicitis Ascaris lumbricoides Make the Diagnosis: Patient with history of DM and chronic renal failure Calciphylaxis Best surgical procedure for atrial fibrillation patient with ten hours of left leg ischemia and US showing occlusion at SFA/profunda bifurcation Femoral embolectomy and calf fasciotomy Anesthetic with both analgesic and amnestic effect Ketamine Targeted receptor for opioid analgesics Mu receptor Indicated for Stage 1 breast cancer patients who are treated with breast conservation therapy to decrease local recurrence risks Radiation therapy Make the diagnosis: Upper abdominal distension, nausea, vomiting after a re-do Nissen fundoplication Vagal nerve injury *left vagus nerve anterior to stomach* Unmyelinated afferent nerve fibers associated with slow conduction of pain sensation Group C fibers Recommended treatment for Riedel’s thyroiditis Steroids *Fibrous stroma present* Mechanism of action for Infliximab used in treatment of Crohn’s patients TNF-α inhibitor Two types of gastric ulcers associated with increased acid secretion Type 2 – Duodenum & antrum of stomach Type 3 - Prepyloric Complication of hepatic adenomas Spontaneous rupture w/ intraperitoneal hemorrhage Make the diagnosis: Liver lesion, elevated neurotensin levels, negative AFP Fibrolamellar liver cancer Plastics technique used for release of scar contracture across joint Z-plasty Three vaccinations recommended 2 weeks prior to elective splenectomy Pneumococcal (Pneumovac 23) Meningococcal Haemophilus influenza B Diagnostic imaging required for 2 week old infant with bilious vomiting Upper GI series *rule out malrotation* Components of the Nigro protocol for SCC of anal canal 5-FU Mitomycin Radiation Make the Diagnosis: Patient with history of glucagonoma Necrolytic migratory erythema Hormone secreted by D cells of the gastric antrum in response to acidic environment Somatostatin Make the diagnosis: 45 y.o. ♀ with palpable neck mass, abdominal pain, serum Ca2+ 16 mg/dL Parathyroid carcinoma Most common breast lesion in adolescents and young adults Fibroadenoma Make the diagnosis: Recurrent pneumonia, aberrant pulmonary tissue surrounded by normal lung tissue and pleura, central arterial & venous supply Intralobar pulmonary sequestration Neurologic defect associated with mid-shaft humerus fracture Radial nerve injury Name the procedure: Suturing of the transversus abdominis and internal oblique aponeurosis (conjoint tendon) to the inguinal ligament Bassini Repair Most likely circuit issue during laparoscopy if IAP is 3 mmHg and flow rate is 0 Tank is empty Make the next move: HOD#3 s/p MVC a 65 y.o. ♀ sodium drops from 140 to 122 meq/L. Nursing staff notices altered mental status and now seizure-like activity. Administration of 3% saline Two hormones secreted by the posterior pituitary lobe ADH Oxytocin Make the diagnosis: Eczematous lesion on nipple with likely underlying DCIS or ductal carcinoma Paget’s disease of the breast Make the next move: 40 year old ♂ presents with an ill-defined mass of the right thigh that on imaging measures 5 cm in greatest dimension Core needle biopsy Name the two most commonly injured nerves during carotid endarterectomy Hypoglossal nerve Vagus nerve Three common locations of the hemorrhoidal pillars Left lateral Right anterior Right posterior Make the Diagnosis: Mondor’s disease Superficial thrombophlebitis of the breast Most common coagulopathy in chronic Crohn’s patient with previous surgical history Vitamin K deficiency First line treatment for hemobilia Angiogram & embolization Clotting factor with the shortest half-life Factor 7 Make the diagnosis & proper staging: 35 y.o. ♀ with night sweats & weight loss Cervical lymph node with Reed-Sternberg cells PET with increased activity in neck & spleen Stage IIIB Hodgkin’s Lymphoma Most common adjuvant chemotherapy regimen for Stage III colorectal cancers FOLFOX 5 FU + Leucovorin + Oxaliplatin Intra-operative medication used during cholangiogram if distal CBD tapering visualized IV Glucagon First line therapy for chronic venous leg ulcers Compression therapy Most common malignancy within a thyroglossal duct cyst Papillary thyroid cancer Most important component of the Glasgow Coma Scale in regards to neurologic prognosis Motor response Complication associated with patients s/p cricothyroidotomy Subglottic stenosis Immediate treatment for this patient who recently started Coumadin Heparinization Appropriate T-staging for a 3cm breast cancer T2 Depth of melanoma at which SLNB is always recommended ≥ 1 mm Required post-op predicted FEV1 prior to pulmonary resection 800 mL Accounts for 75% of splenic parenchyma and phagocytizes circulating blood Red pulp Most common location of an accessory spleen Splenic hilum Most common congenital abnormality requiring splenectomy Hereditary Spherocytosis Primary management of thrombocytopenic purpura Plasmaphersis Two types of vascular formations at the splenic hilum Distributive & Magistral Vasculature structure anterior to aorta but posterior to the superior mesenteric artery Left renal vein Loops around right subclavian artery Non-recurrent in 1% of population Right recurrent laryngeal nerve Order of subclavian region structures anterior to posterior Anterior → Posterior Subclavian vein Anterior scalene Subclavian artery Brachial plexus Middle scalene First branch of the external carotid artery Superior thyroid artery Superior arterial supply of the left adrenal gland Inferior phrenic artery Metaplasia associated with Barrett’s esophagus Squamous to columnar metaplasia Synthesized into nitric oxide by vascular endothelial cells and causes vasodilatation Arginine Topical burn treatment that is often painful and associated with acidosis Mafenide / Sulfamylon Nutritional deficiency associated with neuropathy and elevated glucose levels Chromium Most sensitive test for diagnosis of GERD 24 hour pH testing Most important step in treatment of Zenker’s diverticulum Cricopharyngeal myotomy Most common configuration of tracheoesophageal fistula Type C Most common complication after inguinal hernia repair Urinary retention Eponym given to inner thigh pain with internal rotation Howship Romberg Sign Obturator Hernia Borders of the femoral canal Inferior/Posterior – Cooper’s ligament Superior – Iliopubic tract Lateral – Femoral vein Lumbar hernia bordered by the 12th rib, internal oblique, and lumbosacral aponeurosis Grynfelt’s hernia Point at which the inferior epigastric artery enters the rectus sheath Linea semicircularis Arcuate line Genetic syndrome associated with hamartomatous polyps and brain gliomas Turcot’s Syndrome Fracture of the hand frequently associated with avascular necrosis Scaphoid fracture Inhalational agent associated with elevated LFT’s Halothane Nerve root associated with weakened dorsiflexion (foot drop) L5 Electrolytic inhibited by local anesthetics Sodium Progressive palmar fascia proliferation, most commonly 4th & 5th digit, associated with DM/ETOH Dupuytren’s Contracture Most common composition of a kidney stone Calcium oxalate Most common site of metastases for prostate cancer Bone Medication that causes a hormonal orchiectomy Leuprolide LH antagonist Optimal treatment of ureter trauma, distal 1/3rd, 1.5 cm defect Reimplantation to bladder Associated with renal cell carcinoma, CNS tumors, and pheochromocytoma VHL Syndrome Type 1 Fuel supply for colonocytes Short chain fatty acids Butyrate Gene mutation associated with FAP and most common cause of death after colectomy APC gene chromosome 5 Periampullary tumors Treatment of recurrent cloacogenic carcinoma of the anal canal APR Gene mutation associated with syndrome of right sided colon cancer, increased risk of ovarian/endometrial cancers, autosomal dominant penetrance DNA mismatch repair gene Lynch syndrome Most accurate measure of assessment of cardiac preload Left ventricular end diastolic volume Complication of Cepacol (Benzocaine) spray and its treatment Methemoglobinemia Methylene blue Vasopressor that increases cAMP and provides inotropic / vasodilator effects Milrinone Phosphodiesterase inhibitor Most common cause of prolactinoma Pituitary adenoma Nerve traversing lateral to medial across the anterior scalene Phrenic nerve Second most common type of benign salivary gland tumor, most common to be bilateral Warthin’s tumor Less aggressive form of melanoma commonly found on the head/neck region of elderly Lentigo maligna Counteracts effects of steroids on wound healing Vitamin A Adrenal gland hemorrhage after meningococcal infection Waterhouse-Friderichsen Syndrome Viral infection associated with post-transplant lymphoproliferative disorder EBV – PTLD Cytokine used as indicator of injury severity and upregulates acute phase hepatic proteins IL-6 TNF – Fever, vasodilatation, produced by macrophages IL 1 – Fever, stimulates TNF IL 2 – T cell activating factor, maturation of cytotoxic T cells IL 3 – Growth of blood cell precursors IL 4 – B cell activating factor, IgE production IL 6 – Acute phase protein upregulation IL 8 – Chemotaxis IL 10 – Inhibition of cytokine production Variant of liver cancer associated with elevated neurotensin levels and normal AFP Fibrolamellar hepatocellular carcinoma
