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ABSITE KILLER 2014
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Last updated: 12/31/13
TABLE OF CONTENTS (WITH LINKS)
ABDOMINAL COMPARTMENT SYNDROME:
ACALCULOUS CHOLECYSTITIS:
ACHALASIA:
ACTIVATED PROTEIN C: XIGRIS:
ACUTE PHASE RESPONSE:
ACUTE RENAL FAILURE:
ADRENAL MASS:
AIR EMBOLISM:
AMASTIA:
AMINOCAPROIC ACID: AMICAR:
ANAL CANCER:
ANAL SPHINCTER DYSFUNCTION:
ANEMIA:
ANOVA:
ANTIBODIES:
APPENDICEAL MUCOCELE:
BANKED BLOOD:
BARRETTS ESOPHAGUS:
BASE DEFICIT:
- Lactiferous ducts
- Laparoscopy
- Liver abscess: pyogenic
- Liver cancer (hepatocellular carcinoma)
- Lung abscess
- Lung cancer
- Lupus anticoagulant
- Maintenance fluids
- Malignant hyperthermia
- Malrotation and midgut volvulus
- Mammography
- Mastitis
- Mean arterial pressure (MAP)
- Meconium ileus
- Melanoma
- Meta-analysis
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- Vasodilation
- Ventricular septal defects (VSDs)
- Vitamin D
- Vitamin K
- von Willebrand Disease (vWD)
- von Willebrand Factor (vWF)
- Warfarin
- Wound healing
- Xigris (see Activated protein C)
- Zenkers diverticulum
ACALCULOUS CHOLECYSTITIS:
QUESTION: A 45-year-old man has a 50% total body surface area third-degree burn.
On hospital day 7, fever, marked leukocytosis, and right upper quadrant pain develop.
His blood pressure is 130/80 mmHg and his heart rate is 110 beats per minute.
Ultrasonography shows a distended gallbladder but is negative for gallstones.
Antibiotics are initiated. What is the next step in management?
.
.
.
.
.
.
ANSWER: Hepatoiminodiacetic acid (HIDA) scan
- The presentation is most consistent with acalculous cholecystitis (see response to
question 13). The initial study of choice is US, which can be performed at the bedside.
- If the US findings are negative and the patient is not critically ill, the next study would
be an HIDA scan with morphine.
.
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.
.
QUESTION: What ultrasound findings support a diagnosis of acalculous cholecystitis?
.
.
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.
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QUESTION: What is the initial diagnostic study of choice for acalculous cholecystitis?
.
.
.
.
.
ANSWER: Ultrasound
- US is the initial diagnostic study of choice and can be performed at the bedside in the
intensive care unit.
- In a recent prospective study, US findings were considered positive if three major
criteria were present: wall thickness greater than 4 mm, hydrops, and sludge.
- The sensitivity was only 50% and the specificity 94%.
- In stable patients in whom the diagnosis is unclear after US, an HIDA scan can be
performed with morphine (67% sensitivity and 100% specificity).
- Failure to visualize the gallbladder is the most sensitive and specific finding.
- Leakage into the pericholecystic space suggests perforation.
- An HIDA scan is not recommended in critically ill patients in whom a delay in therapy
can be potentially fatal.
ACHALASIA:
QUESTION: Is achalasia due to increased or decreased ganglion cells?
.
.
.
ANSWER: Achalasia is due to decreased ganglion cells
.
.
.
.
QUESTION: Achalasia results from a problem with ganglion cells in ________'s
plexus
.
.
.
ANSWER: Achalasia results from decreased ganglion cells in Auerbachs plexus
.
.
.
QUESTION: Does achalasia result in absence of peristalsis or increased peristalsis?
.
.
.
ANSWER: Achalasia results in the absence of peristalsis
.
.
.
QUESTION: Does achalasia result in esophageal constriction or dilation?
.
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ANSWER: Achalasia results in esophageal dilation
.
.
.
QUESTION: What image does achalasia look like on Barium swallow?
.
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QUESTION: What is an important side effect of Xigris?
.
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ANSWER:
- The side effects of Xigris is bleeding. (QUESTION)
INCREASED:
- C-reactive protein (an opsonin, activates complement)
- amyloid A and P
- Fibrinogen
- Haptoglobin
- Ceruloplasmin
- Alpha-1 antitrypsin
- Alpha-1 antichymotrypsin
- C3 (complement)
.
.
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.
.
QUESTION: What factors are decreased during the acute phase response?
.
.
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DECREASED
- Albumin
- Transferrin
- Fibronectin
ADRENAL MASS:
QUESTION: What finding on an adrenal mass on CT scan is the most suggestive of
adrenal cancer?
.
.
.
.
.
.
ANSWER: Size > 6cm.
- The size of the adrenal mass on imaging studies is the single most important criterion
to help diagnose malignancy.
- In the series reported by Copeland, 92% of adrenal cancers were >6 cm in diameter.
- Other CT imaging characteristics suggesting malignancy include tumor heterogeneity,
irregular margins, and the presence of hemorrhage and adjacent lymphadenopathy or
liver metastases.
AIR EMBOLISM:
QUESTION: How do you treat an air embolism?
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.
.
ANSWER:
- Although estimated to occur in only 0.2 to 1% of patients, an air embolism can be
dramatic and fatal.
- Treatment may prove futile if the air embolus is larger than 50ml.
- If an embolus is suspected, the patient should immediately be placed into a left lateral
decubitus Trendelenburg position, so the entrapped air can be stabilized within the right
ventricle.
- Aspiration via a central venous line accessing the heart may decrease the volume of
gas in the right side of the heart, and minimize the amount traversing into the pulmonary
circulation.
- Subsequent recovery of intracardiac and intrapulmonary air may require open surgical
or angiographic techniques.
- Prevention requires careful attention to technique.
.
.
.
AMASTIA:
QUESTION: Absence of the breast (amastia) is associated with which genetic
disorder?
.
.
.
.
.
ANSWER: Poland syndrome.
POLAND SYNDROME
- Absence of the breast (amastia) is rare and results from an arrest in mammary ridge
development that occurs during the sixth fetal week.
- Poland's syndrome consists of hypoplasia or complete absence of the breast, costal
cartilage and rib defects, hypoplasia of the subcutaneous tissues of the chest wall, and
brachysyndactyly.
TURNER'S SYNDROME
- Turner's syndrome (ovarian agenesis and dysgenesis) may have polymastia as a
component.
FLEISCHER'S SYNDROME
- Fleischer's syndrome (displacement of the nipples and bilateral renal hypoplasia) may
also have polymastia as a component.
KLINEFELTER'S SYNDROME
- Klinefelter's syndrome (XXY) is manifested by gynecomastia, hypergonadotropic
hypogonadism, and azoospermia.
- There is an increased risk of breast cancer in men with Klinefelter's syndrome.
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ANAL CANCER:
QUESTION: What is the treatment for squamous cell carcinoma of the anal canal?
.
.
.
ANSWER: The treatment for squamous cell carcinoma of the anal canal is the Nigro
protocol
.
.
.
QUESTION: True or false: The treatment of squamous cell carcinoma of the anal canal
is NOT surgery
.
.
.
ANSWER: True. The treatment of squamous cell carcinoma of the anal canal is NOT
surgery. The treatment is the Nigro protocol
.
.
.
QUESTION: The Nigro protocol is made up of which treatment modalities?
.
.
.
ANSWER: The Nigro protocol consists of chemotherapy and radiation therapy
.
.
ANEMIA:
QUESTION: What are the laboratory findings in iron deficiency anemia?
.
.
.
.
.
ANSWER:
- The laboratory findings in iron deficiency anemia are low MCV, low ferritin, high transferrin and high TIBC.
.
.
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.
.
QUESTION: What are the laboratory findings in anemia of chronic disease?
.
.
.
.
.
ANSWER:
- The laboratory findings in anemia of chronic disease are low to normal MCV, normal or high ferritin, and low
TIBC. (TOPIC)
ANOVA:
QUESTION: True or false: ANOVA compares means for more than 2 groups.
.
.
.
ANSWER: True
.
.
.
QUESTION: Does ANOVA use quantitative or qualitative data when comparing the
means of more than 2 groups?
.
.
.
ANSWER: ANOVA uses quantitative data when comparing the means of more than 2
groups
.
.
.
QUESTION: True or false: ANOVA is a t-test for more than 2 groups
.
.
.
ANSWER: True
ANTIBODIES:
QUESTION: Which antibodies can act as opsonins?
.
.
.
ANSWER: IgG and IgM are opsonins
.
.
.
QUESTION: Which antibodies are able to fix complement?
.
.
.
ANSWER: IgG and IgM are able to fix complement. 2 IgGs or 1 IgM is needed to do
this.
.
.
.
QUESTION: Which antibody level decreases after splenectomy?
.
.
.
ANSWER: After a splenectomy, you will have decreased levels of IgM
.
.
.
QUESTION: Which antibody is made first during an immune reaction?
.
.
.
ANSWER: IgM is made first during an immune reaction
.
.
.
APPENDICEAL MUCOCELE:
QUESTION: At the time of laparoscopic surgery for presumed appendicitis, the patient
is noted to have a mucous-filled, distended appendix measuring 3 cm in diameter. There
is no acute inflammation or signs of perforation. What is the best next step in
management?
.
.
.
.
.
ANSWER: Conversion to open appendectomy with pathologic confirmation of a
negative margin at the base of the appendix
- An intact mucocele presents no future risk for the patient.
- However, the opposite is true if the mucocele has rupture and epithelial cells have
escaped into the peritoneal cavity.
- As a result, when a mucocele is visualized at the time of laparoscopic examination,
conversion to open laparotomy is recommended.
- Conversion from a laparoscopic approach to a laparotomy ensures that a benign
process will not be converted to a malignant one through mucocele rupture.
- In addition, laparotomy allows for thorough abdominal exploration to rule out the
presence of mucoid fluid accumulations.
QUESTION: True or false: The presence of a mucocele of the appendix does not
mandate performance of a right hemicolectomy.
.
.
.
.
.
ANSWER: True.
- The principles of surgery include resection of the appendix, wide resection of the
mesoappendix to include all the appendiceal lymph nodes, collection and cytologic
examination of all intraperitoneal mucus, and careful inspection of the base of the
appendix.
BANKED BLOOD:
QUESTION: Which factors are low in banked blood?
.
.
.
.
.
ANSWER:
- Factors that are low in banked blood are 2,3-DPG, and factors V and VIII (labile factors)
.
.
.
.
.
QUESTION: Banked blood results in a shift in the oxygen dissociation curve in which
direction?
.
.
.
.
.
ANSWER:
- Shift in the O2 dissociation curve in banked blood is a left shift. (higher affinity of Hgb to O2).
.
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.
.
QUESTION: What is the effect of 2,3 DPG on the oxygen dissociation curve?
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BARRETTS ESOPHAGUS:
QUESTION: .Barrett's esophagus refers to what type of mucosal change?
.
.
.
ANSWER: Barrett's refers to the change in esophageal epithelium from squamous to
columnar.
.
BASE DEFICIT:
QUESTION: What is the probability of death for a patient with a base deficit of -6?
.
.
.
.
.
ANSWER: 25%.
BILIARY ATRESIA:
QUESTION: What is the most important surgical cause of jaundice in the newborn?
.
.
.
.
.
ANSWER: Biliary atresia
- The most important surgical cause of jaundice in the newborn is biliary atresia, which
is an obliterative process of the extrahepatic bile ducts and is associated with hepatic
fibrosis.
- The infant produces acholic stools and demonstrates a failure to thrive.
- Left untreated, it will progress to liver failure and portal hypertension.
.
.
.
.
.
QUESTION: How is biliary atresia diagnosed?
.
.
..
.
ANSEWR: Nuclear scanning.
- Nuclear scanning after pretreatment with phenobarbital is a useful study.
- One is specifically looking to see whether the radionuclide appears in the intestine,
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QUESTION: Optimal management for an 8-month-old girl with biliary atresia in whom
a Kasai operation (hepatoportoenterostomy) failed would be what?
.
.
.
.
.
ANSWER: liver transplantation.
- The Kasai operation, in which an isolated limb of the jejunum is anastomosed to the
transected ducts at the liver plate, is the operation of choice for biliary atresia.
- However, in a subset of patients, the Kasai operation is unsuccessful, and they
eventually require liver transplantation for progressive liver failure and recurrent bouts
of cholangitis.
BIOTECHNOLOGY:
Q: What is the difference between southern blotting, northern blotting, and western
blotting? .
.
.
.
A:
- Southern blotting refers to the technique of transferring DNA fragments from an
electrophoresis gel to a membrane support, and the subsequent analysis of the fragments
by hybridization with a radioactively labeled probe.
- Southern blotting is named after E. M. Southern, who in 1975 first described the
technique of DNA analysis.
- It enables reliable and efficient analysis of size-fractionated DNA fragments in an
immobilized membrane support.
- Northern blotting refers to the technique of size fractionation of RNA in a gel and the
transferring of an RNA sample to a solid support (membrane) in such a manner that the
relative positions of the RNA molecules are maintained.
- The resulting membrane then is hybridized with a labeled probe complementary to the
mRNA of interest.
- Signals generated from detection of the membrane can be used to determine the size
and abundance of the target RNA.
- In principle, Northern blot hybridization is similar to Southern blot hybridization (and
hence its name), with the exception that RNA, not DNA is on the membrane.
- Analyses of proteins are primarily carried out by antibody-directed immunologic
techniques.
- For example, Western blotting, also called immunoblotting, is performed to detect
protein levels in a population of cells or tissues, whereas immunoprecipitation is used
to concentrate proteins from a larger pool.
- There is no technique known as Eastern blotting.
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BLEOMYCIN:
QUESTION: What is the main side effect of Bleomycin?
.
.
.
ANSWER: The main side effect of Bleomycin is pulmonary fibrosis
BREAST DEVELOPMENT:
QUESTION: Which of the hormone is primarily responsible for differentiation of the
breast ductal epithelium?
.
.
.
.
.
ANSWER: Progesterone
- Estrogen initiates ductal development, whereas progesterone is responsible for
differentiation of epithelium and for lobular development.
- Prolactin is the primary hormonal stimulus for lactogenesis in late pregnancy and the
postpartum period.
- It upregulates hormone receptors and stimulates epithelial development.
BURNS:
QUESTION: What is the most common infection in patients with large (>35%) severe
burns ?
.
.
.
.
.
ANSWER: Although urinary tract infection is the most common infection in surgery
patients, pneumonia is the leading cause of infection in patients with severe burn
injuries.
- Inhalation injury, decreased immunity, fluid resuscitation causing pulmonary edema,
and requirement for mechanical ventilation all lead to increased risk for pneumonia.
- In some series, 60-70% of all patients with large severe burns get pneumonia.
.
QUESTION: The affinity of carbon monoxide for hemoglobin is how many times greater
than oxygen?
.
.
.
.
.
ANSWER:
- Another important contributor to early mortality in burns is carbon monoxide (CO)
poisoning resulting from smoke inhalation.
- The affinity of CO for hemoglobin is approximately 200-250 times more than that of
oxygen, which decreases the levels of normal oxygenated hemoglobin and can quickly
lead to anoxia and death.
- Unexpected neurologic symptoms should raise the level of suspicion, and an arterial
carboxyhemoglobin level must be obtained because pulse oximetry is falsely elevated.
.
.
.
CARDIAC MYXOMAS:
QUESTION: What is the most common location for cardiac myxomas ?
.
.
.
.
.
ANSWER: Left atrium..
- Myxomas are the most common primary tumor of the heart.
- The majority (60%75%) arise in the left atrium, with most of the remaining in the
right atrium.
- Very few are found in the right or left ventricle.
- Myxomas are gelatinous tumors with a propensity for embolization.
- They can also obstruct or damage the mitral valve, leading to symptoms of heart
failure.
- Diagnosis is made by transthoracic or transesophageal echocardiography.
- Treatment is surgical excision.
- They are benign but have a tendency to recur.
CHOLECYSTOKININ: CCK:
QUESTION: Where is cholecystokinin produced?
.
.
.
ANSWER: Cholecystokinin (CCK) is released by I-cells of the small intestines
.
.
.
QUESTION: What is the effect of cholecystokinin on the gallbladder?
.
.
.
ANSWER: Cholecystokinin stimulates contraction of the gallbladder
.
.
.
QUESTION: What is the effect of cholecystokinin on the sphincter of Oddi?
.
.
.
ANSWER: Cholecystokinin relaxes the Sphincter of Oddi
.
.
.
QUESTION: What is the effect of cholecystokinin on pancreatic enzyme secretion?
.
.
.
ANSWER: Cholecystokinin increases pancreatic enzyme secretion
.
.
.
CHOLEDOCHAL CYSTS:
QUESTION: What is the most common type of choledocha cyst?
.
.
.
.
.
ANSWER: Type I
- Choledochal cysts have been classified into five types.
- The most common is type I, which is fusiform dilatation of the bile duct.
.
.
.
.
.
QUESTION: Multiple diffuse dilatations of the intrahepatic ducts are known associated
with which type choledochal cysts?
.
.
.
.
.
ANSWER: Type IV choledochal cysts = Carolis disease
- Caroli disease is a type V choledochal cyst that causes multiple bile duct dilatations
that are limited to the intrahepatic bile ducts.
- The cysts lead to recurrent bouts of cholangitis and have a risk of malignancy.
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CHOLESTEROL:
QUESTION: What molecule serves as the plasma carrier of cholesterol?
.
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.
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ANSWER:
- The plasma carrier of cholesterol is VLDL.
.
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.
QUESTION: In which organ is cholesterol formed?
.
.
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ANSWER:
- The organ where cholesterol is formed is the liver.
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.
QUESTION: What enzyme is the rate limiting step in cholesterol formation?
.
COHORT STUDY:
QUESTION: Is cohort study a prospective study or a retrospective study?
.
.
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ANSWER: A cohort study is a prospective study
.
.
.
QUESTION Is a cohort study randomized or nonrandomized?
.
.
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ANSWER: A cohort study is nonrandomized
.
.
.
QUESTION: True or false: A prospective cohort study is a non-random assignment to a
treatment group
.
.
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ANSWER: True
.
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COLLAGEN:
QUESTION: True or false. Tensile strength is never equal to prewound strength. It is
only 80% of what it used to be.
.
.
.
ANSWER: True. The tensile strength is never equal to the pre-wound strength
.
.
.
QUESTION: Which type collage is the most abundant?
.
.
.
ANSWER Collagen Type I is the most abundant throughout
.
.
.
QUESTION: Which type collagen is the principal collagen in scar?
.
.
.
ANSWER: Type I collagen is the principal collagen in scar
.
.
.
QUESTION: Which type collagen is the most abundant in a healing wound?
.
.
.
ANSWER: Type III collagen is the principal collagen in healing wound
.
.
COLON CANCER:
QUESTION: What gene mutations are associated with colon cancer?
.
.
.
.
.
ANSWER: The genetic defects and molecular abnormalities associated with the
development and progression of colorectal adenomas and carcinoma are as follows:
- Mutations may cause activation of oncogenes (K-ras) and/or inactivation of tumorsuppressor genes [APC, DCC (deleted in colorectal carcinoma), p53].
- Colorectal carcinoma is thought to develop from adenomatous polyps by accumulation
of these mutations.
.
.
COMPARTMENT SYNDROME:
QUESTION: When performing a four-compartment fasciotomy for compartment
syndrome, medial and lateral incisions are created. Which compartments is opened
through the medial incision? Through the lateral incision?
.
.
.
.
.
.
ANSWER:
- Compartment pressures are relieved in the leg by medial and lateral incisions.
- Through the medial incision, long openings are then made in the fascia of the
superficial and deep posterior compartments.
- Through the lateral incision, the anterior and peroneal compartments are opened.
.
CONDYLOMA ACCUMINATA:
QUESTION: How is the treatment for extensive perianal condyloma accuminata (anal
warts)?.
.
.
.
.
ANSWER:
- Treatment of anal condyloma depends on the location and extent of disease.
- Small warts on the perianal skin and distal anal canal may be treated in the office with
topical application of bichloracetic acid or podophyllin.
- Although 60 to 80% of patients will respond to these agents, recurrence and
reinfection are common.
- Imiquimod (Aldara) is an immunomodulator that recently was introduced for topical
treatment of several viral infections, including anogenital condyloma.
- Initial reports suggest that this agent is highly effective in treating condyloma located
on the perianal skin and distal anal canal.
- Larger and/or more numerous warts require excision and/or fulguration in the
operating room.
- Excised warts should be sent for pathologic examination to rule out dysplasia or
malignancy.
- It is important to note that prior use of podophyllin may induce histological changes
that mimic dysplasia.
.
.
CO2 EMBOLISM:
QUESTION: A 35 year old woman undergoing routine laparoscopic bilateral tubal
ligation develops severe hypotension, tachycardia, and drop in her end tidal CO2. The
anesthesiologist states the patient still has bilateral breath sounds. What is the most
likely diagnosis?
.
.
.
.
.
ANSWER:
- The most likely diagnosis in this patient is CO2 embolism.
- End tidal CO2 specifically reflects the exchange of CO2 from blood to the alveolus.
- A gradual rise in ETCO2 usually reflects impaired exchange from lung collapse or
atelectasis.
- A sudden drop in ETCO2 can be from something simple like disconnection from the
ventilator or something more serious such as an embolus.
- The abrupt drop in ETCO2 following an embolus is from the interruption of CO2
exchange at the alveolar level.
- Because of the hypotension associated with a drop in ETCO2 in the above patient, the
most likely diagnosis is CO2 embolism.
.
.
COX INHIBITORS:
QUESTION: Which drugs irreversibly inhibits platelet COX (cyclooxygenase)? What is
the mechanism of action of ibuprofen, celebrex, clopidogrel, and aspirin.
.
.
.
.
..
ANSWER:
- Arachidonic acid released from the platelet membranes is converted by COX to
prostaglandin G2 (PGG2) and then to prostaglandin H2 (PGH2), which, in turn, is
converted to TXA2.
- TXA2 has potent vasoconstriction and platelet aggregation effects.
- Arachidonic acid may also be shuttled to adjacent endothelial cells and converted to
prostacyclin (PGI2), which is a vasodilator and acts to inhibit platelet aggregation.
- Platelet COX is irreversibly inhibited by aspirin and reversibly blocked by NSAIDs
but is not affected by COX-2 inhibitors.
- Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) and reversibly affects
platelet COX.
- Both aspirin and clopidogrel irreversibly inhibit platelet function, clopidogrel through
selective irreversible inhibition of ADP-induced platelet aggregation and aspirin
through irreversible acetylation of platelet prostaglandin synthase.
- Celebrex is a COX-2 inhibitor and therefore does not affect platelet COX.
.
.
CRYOPRECIPITATE:
QUESTION:When should cryoprecipitate be given to a patient needing a massive
transfusion of packed RBCs?
.
.
.
.
.
.
.
TABLE: COMPONENT THERAPY ADMINISTRATION DURING MASSIVE
TRANSFUSION
FRESH FROZEN PLASMA (FFP)
- As soon as the need for massive transfusion is recognized.
- For every 6 units of red blood cells (RBCs), give 6 units of FFP (1:1 ratio)
PLATELETS
- For every 6 units of RBCs and plasma, give one 6-pack of platelets.
- Six random-donor platelet packs = 1 apheresis platelet unit
- Keep platelet counts >100,000 ul/ during active hemorrhage control
- After first 6 units of RBCs, check fibrinogen level.
- If 100 mg/dL, give 20 units of cryoprecipitate (2g fibrinogen)
- Repeat as needed, depending on fibrinogen level.
DDAVP: DESMOPRESSIN:
QUESTION: What is the mechanism of action of DDAVP?
.
.
.
.
.
ANSWER:
- The mechanism of action DDAVP is that it causes release of vWF.
.
.
.
.
.
QUESTION: What conditions are usually treated with DDAVP?
.
.
.
.
.
ANSWER:
- Conditions treated with DDAVP include uremia, von Willebrand disease, and Aspirin.
DESMOID TUMORS:
QUESTION: What gene is associated with desmoid tumors of the chest wall?
.
.
..
.
.
ANSWER: Adenomatous polyposis coli (APC)
- Desmoid tumors have recently been shown to possess alterations in the adenomatous
polyposis coli / Beta-catenin pathway, and cyclin D1 dysregulation is thought to play a
significant role in their pathogenesis.
- Associations with other diseases and conditions are well documented, especially
those with similar alterations in the adenomatous polyposis coli pathway, such as
familial adenomatous polyposis (Gardner's syndrome).
DIABETES INSIPIDUS:
QUESTION: Is diabetes insipidus due to elevated ADH or low ADH?
.
.
.
ANSWER: Diabetes insipidus is due to low ADH
.
.
.
QUESTION Do patients with diabetes insipidus have high urine output or low urine
output?
.
.
.
ANSWER: Patients with diabetes insipidus have high urine output
.
.
.
QUESTION: Do patients with diabetes insipidus have a low urine specific gravity or a
high urine specific gravity?
.
.
.
ANSWER: Patients with diabetes insipidus have a low urine specific gravity
.
.
.
QUESTION: Do patients diabetes insipidus have high serum osmolarity or low serum
osmolarity?
.
.
.
ANSWER: Patients with diabetes insipidus have a high serum osmolarity
.
.
.
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QUESTION: Do patients with diabetes insipidus have high serum Na or low serum
Na?
.
.
.
ANSWER: Patients with diabetes insipidus have a high serum sodium concentration
.
.
.
QUESTION. Do patients with diabetes insipidus have a high urine sodium or a low
urine sodium?
.
.
.
ANSWER: Patients with diabetes insipidus have a low urine sodium
DIAPHRAGMATIC INJURIES:
QUESTION: Diaphragm injuries involve which side of the chest more commonly, right
or left? Are diaphragmatic injuries easy are hard to detect on CT scan?
.
.
.
.
ANSWER:
- Diaphragm injuries are more common with blunt trauma and are more common on the
left (liver projects the right side)
- Diaphragm injuries are hard to find on CT scan unless there is gross herniation
DIVERTICULITIS:
QUESTION: Approximately 5% of patients with complicated diverticulitis develop a
fistula to an adjacent organ. The most commonly involved organ is what?
.
.
.
.
ANSWER: The most commonly involved organ is the bladder.
- Approximately 5% of patients with complicated diverticulitis develop fistulas
between the colon and an adjacent organ.
- Colovesical fistulas are most common, followed by colovaginal and colo-enteric
fistulas.
- Colocutaneous fistulas are a rare complication of diverticulitis.
.
.
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.
.
DNA:
Q: Approximately how many genes are present in the human genome?
.
.
.
.
.
A:
- The human genome has an estimated 25,000 to 30,000 genes, and overall it is 99.9%
identical in all people.
DUODENAL ATRESIA:
QUESTION: A newborn has bilious vomiting. Plain films reveal a distended gastric air
bubble and a markedly dilated proximal duodenum. What is the most likely diagnosis?
.
.
.
.
.
ANSWER: Duodenal atresia
- The history and radiograph findings are consistent with duodenal atresia.
- Duodenal atresia occurs because of failure of vacuolization of the duodenum from its
solid core state.
.
.
.
.
.
QUESTION: What conditions are associated with duodenal atresia?
.
.
.
.
.
ANSWER: Down syndrome, biliary atresia
- It is associated with prematurity, Down syndrome, maternal polyhydramnios,
malrotation, annular pancreas, and biliary atresia.
.
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ECMO:
QUESTION: What are the indications for ECMO in neonates?
.
.
.
.
.
ANSWER:
- In neonates with respiratory distress syndrome, management includes high-frequency
ventilation surfactant and inhaled nitric oxide.
- When those interventions fail, ECLS is used.
- ECLS can be performed by either venovenous or venoarterial cannulation.
- The major indications for ECLS include meconium aspiration, respiratory distress
syndrome, persistent pulmonary hypertension, sepsis, and CDH.
ENDOPLASMIC RETICULUM:
QUESTION: Which type of ER makes cytoplasmic proteins? Which type of ER makes
proteins for export?
.
.
.
.
.
ANSWER:
- The endoplasmic reticulum that makes cytoplasmic proteins is the smooth endoplasmic reticulum.
- The endoplasmic reticulum that makes proteins for export is the rough endoplasmic reticulum.
ERYTHROMYCIN:
QUESTION: Erythromycin increases gastrointestinal motility by which mechanism?
.
.
.
ANSWER: Erythromycin binds the motilin receptor, and activates it to increase
gastrointestinal motility
EXTRINSIC PATHWAY:
QUESTION: Which two factors are involved in the initiation of the extrinsic pathway
(PT)?
.
.
.
.
.
ANSWER: In the extrinsic pathway, tissue factor reacts with factor VII to initiate the
coagulation process leading up to fibrin production
.
.
.
.
.
QUESTION: Summarize the extrinsic pathway: include the lab test associated with it,
the factors involved, and the final product
.
.
.
.
.
ANSWER: Extrinsic path tested with PT. Tissue factor + VII --> activated X --> fibrin
.
.
.
FACTORS:
QUESTION: Which factors are present at low levels in banked blood?
.
.
.
.
.
ANSWER:
- The factors that are at low levels in banked blood are factor V and factor VIII.
.
.
.
.
.
QUESTION: Which factor is not made by the liver?
.
.
.
.
.
ANSWER:
- The only factor that is not made in the liver (but instead is made by the reticuloendothelial cells) is Factor VIII.
.
.
.
.
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FACTOR V LEIDEN:
QUESTION: True or false: The most common risk factor for spontaneous venous thromboembolism is factor
V leiden.
.
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.
ANSWER: TRUE
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QUESTION: Patients with factor V Leiden are predisposed to thrombosis because they
have a genetic mutation in factor V which is what effect made on factor V?
.
.
.
.
.
.
ANSWER:
- A third major mechanism of inhibition of thrombin formation is the protein C system.
- On its formation, thrombin binds to thrombomodulin and activates protein C to
activated protein C (APC), which then forms a complex with its cofactor, protein S, on
a phospholipid surface.
- The APC-protein S complex cleaves factors Va and VIIIa so they are no longer able to
participate in the formation of tissue factor-VIIa or prothrombinase complexes.
- Of interest is an inherited form of factor V that carries a genetic mutation, called
factor V Leiden, that is resistant to cleavage by APC and thus remains active
(procoagulant).
- Patients with factor V Leiden are predisposed to venous thromboembolic events.
.
.
FACTOR VIII:
QUESTION: Factor VIII is the only factor not made in the liver. Where is it made?
.
.
.
ANSWER: Factor VIII is the only factor not made in the liver. It is made by
reticuloendothelial system
.
FATTY ACIDS:
QUESTION: How do short and medium chain fatty acids enter the bloodstream?
.
.
.
.
ANSWER:
- The metabolism of short chain fatty acids and medium chain fatty acids is that they are absorbed by the
intestines by simple diffusion and enter the portal system. (TRICKY)
.
.
.
.
.
QUESTION: How do long chain fatty acids enter the bloodstream?
.
.
.
.
.
ANSWER:
- The metabolism of long chain fatty acids is that they are in the form of micelles in the intestines where they fuse
with enterocytes, then they are carried with chylomicrons, and then enter the bloodstream via the lymphatics.
(Easy, 3)
FIBRIN:
QUESTION: Which factor is involved in cross-linking fibrin to form a fibrin plug?
.
.
.
.
.
ANSWER:
- The factor involved in cross-linking fibrin to form a fibrin plug is Factor XIII (factor 13).
FLAIL CHEST:
QUESTION: In the adult, the hypoxemia seen immediately after a flail chest injury is
due to what?
.
.
.
.
.
ANSWER: The underlying pulmonary contusion.
- In those patients in whom early respiratory failure develops, it is the result of an
underlying pulmonary contusion.
- Pain control is another important element of management. Most patients do not need
fixation of the flail segment.
FUNCTIONAL GENOMICS:
QUESTION: What is functional genomics?
.
.
.
.
.
ANSWER: Functional genomics is a term used to describe a) Transcription of DNA, b)
Translation of RNA, and c) Proteomics. .
- Functional genomics seeks to assign a biochemical, physiologic, cell biologic, and/or
developmental function to each predicted gene.
- Genomics and proteomics are the study of the genetic composition of a living
organism at the DNA and protein level, respectively.
- The study of the relationship between genes and their cellular functions is called
functional genomics.
GALLSTONE ILEUS:
QUESTION: What is the primary surgery for patients with gallstone ileus?
.
.
.
.
.
ANSWER: The primary surgery in this patient is to relieve the small bowel obstruction.
That involves feeling for the gallstone, opening the ileum, and removing the stone. The
secondary procedure, if the patient can tolerate it, is cholecystectomy and closure of the
hole in the duodenum.
GASTRIC LYMPHOMA:
QUESTION: A 50 year old man presents with epigastric pain unrelieved with proton
pump inhibitors. You perform an upper endoscopy and a mass is found in the stomach.
You biopsy it and it comes back lymphoma. Abdominal CT scan shows that the mass is
full thickness and 3/4 of the stomach is involved. What is the most appropriate therapy?
.
.
.
.
.
.
.
.
ANSWER.
- Treatment or gastric lymphoma is chemo-XRT
- Surgery is indicated only for complications of the disease (bleeding, perforation,
obstruction) or possibly for stage I disease limited to the mucosa.
GAStRIC VARICES:
QUESTION: A patient with a history of pancreatitis develops severe bleeding from
gastric varices. You do not see any esophageal varices on EGD. What is the best
treatment for this condition?
.
.
.
.
ANSWER:
- Gastric varices without esophageal varices are most likely from a thrombosed splenic
vein related to pancreatitis and not cirrhosis. Treatment is splenectomy.
- Less than 2-3% of patients with cirrhosis get gastric varices without esophageal
varices.
- Treatment in this patient is splenectomy.
GASTRIN:
QUESTION: What is the molecular mechanism of action of how Acetylcholine and
gastrin cause HCl production?
.
.
.
ANSWER: Acetylcholine and gastrin activate PIP,DAG to increase Ca, which activates
protein kinase C which increases HCl production
ACh or Gastrin --> PIP, DAG, Ca, Protein Kinase C --> HCl production
.
.
.
.
.
QUESTION: Which cells produce Gastrin?
.
.
.
ANSWER: Gastrin is produced by gastric antrum G cells
Mnemonic: Gastric is made by G cells
.
.
.
QUESTION: What molecules stimulate the production of Gastrin?
.
.
.
ANSWER: Peptides and amino acids in the stomach, vagal input with acetylcholine, and
calcium all stimulate gastrin release
.
.
.
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GASTROINTESTINAL BLEEDING:
QUESTION: A 50 year old man has severe hematochezia requiring 6 units of blood in
12 hours. The bleeding is ongoing. His blood pressure in 110/60 and his HR is 110.
You do not find anything on anoscopy. You place an NG tube and get back bile but no
blood. How was the most appropriate next step in your work-up?
.
.
.
.
.
ANSWER:
- This would be considered massive bleeding because of the transfusion requirement.
- You are unlikely to find anything on colonoscopy because there is too much blood.
- You should not go directly to the OR for a subtotal colectomy unless the patient was
hypotensive despite aggressive resuscitation attempts.
- Try to localize the area first. Angiography is the best choice, which will localize the
lesion (and possibly treat with embolization).
- Then take the patient to the OR for colectomy at the appropriate location.
.
GASTROSCHISIS:
QUESTION: The most common anomaly associated with gastroschisis is what?
.
.
.
.
.
ANSWER: Intestina atresia
- Gastroschisis, unlike omphalocele, is not typically associated with systemic or
chromosomal abnormalities.
- It is most commonly associated with intestinal atresia in as many as 15% of cases.
- For this reason, it is imperative that the small bowel be carefully explored at the time
of reduction and repair of the abdominal wall defect.
.
.
.
.
.
.
QUESTION: On what side is the abdominal wall defect in gastroschisis?
.
.
.
.
.
ANSWER: Right side.
- There is an abdominal wall defect to the right of the umbilicus, and the bowel
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GLEEVEC:
QUESTION: What type of leukemia is Gleevec used to treat?
.
.
.
.
.
ANSWER: - The primary function of anticancer chemicals is to block different steps
involved in cell growth and replication.
- These chemicals often block a critical chemical reaction in a signal transduction
pathway or during DNA replication or gene expression.
- For example, STI571, also known as Gleevec, is one of the first molecularly targeted
drugs based on the changes that cancer causes in cells.
- STI571 offers promise for the treatment of chronic myeloid leukemia (CML) and may
soon surpass interferon-y as the standard treatment for the disease.
- In CML, STI571 is targeted at the Bcr-Abl kinase, an activated oncogene product in
CML .
- Bcr-Abl is an overly activated protein kinase resulting from a specific genetic
abnormality generated by chromosomal translocation that is found in the cells of patients
with CmL.
- STI571-mediated inhibition of Bcr-Abl-kinase activity not only prevents cell growth
of Bcr-Abl-transformed leukemic cells, but also induces apoptosis.
- Clinically, the drug quickly corrects the blood cell abnormalities caused by the
leukemia in a majority of patients, achieving a complete disappearance of the leukemic
blood cells and the return of normal blood cells.
GLYCOLYSIS:
QUESTION: What is the net ATP made during anaerobic glycolysis of 1 glucose
molecule?
.
.
.
.
.
ANSWER:
- The net ATP made during anaerobic glycolysis is 2 ATPs and lactate.
.
.
.
.
.
.
QUESTION: What is the total ATP made from 1 glucose molecule in aerobic glycolysis
(including Kreb cycle, and oxidative phosphorylation)?
.
.
.
.
.
ANSWER:
- The amount of ATP formed from 1 glucose molecule by the Kreb cycle (plus glycolysis and oxidative
phosphorylation) is 38 ATP.
GLUCONEOGENESIS:
QUESTION: During gluconeogenesis, what is the intermediate molecule in the
conversion of lactate to glucose in the liver?
.
.
.
.
.
ANSWER:
- When lactate from muscle is converted to glucose in the liver via the Cori cycle during gluconeogenesis, the
intermediate is pyruvate. Lactate Pyruvate Glucose.
.
.
.
.
.
QUESTION: Which molecule can act as a substrate for either gluconeogenesis or the
Krebs cycle?
.
.
.
.
.
ANSWER:
- The molecule that is used in gluconeogenesis and also used in the Krebs cycle is pyruvate. (TRICKY)
.
.
.
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GYNECOMASTIA:
QUESTION: Which gastrointestinal condition leads to gynecomastia due to an
increased production of estrogen?
.
.
.
.
.
ANSWER: Hepatocellular carcinoma
GYNECOMASTIA DUE TO ESTROGEN EXCESS
- Estrogen excess results from an increase in the secretion of estradiol by the testicles or
by non-testicular tumors, nutritional alterations such as protein and fat deprivation,
endocrine disorders (hyperthyroidism, hypothyroidism), and hepatic disease
(nonalcoholic and alcoholic cirrhosis).
GYNECOMASTIA DUE TO TESTOSTERONE DEFICIENCY
- Klinefelter's syndrome, aging, and renal failure all cause gynecomastia by a decrease
in testosterone production.
HEMOPHILIA:
QUESTION: What is the treatment of hemophilia A?
.
.
.
.
.
ANSWER:
- The treatment for hemophilia A is factor VIII or cryoprecipitate.
.
.
.
.
.
QUESTION: What is the treatment a duodenal hematoma in a patient with hemophilia
A?
.
.
.
.
.
ANSWER:
- The treatment of duodenal hematoma in a patient with hemophilia A is factor VIII and nonoperative
management.
.
.
.
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.
.
.
.
.
QUESTION: How do you treat a hemophiliac joint effusion?
.
.
.
.
.
ANSWER: Do not aspirate. Treat with ice, range of motion therapy. Give actor VIII.
HEMORRHAGE:
QUESTION: In a patient with ongoing hemorrhage, the risk of death increases 1% every
______ minutes in the ER.
.
.
.
.
.
ANSWER: Every 3 minutes in the ER.
HEMORRHOIDS:
QUESTION: An internal hemorrhoid that prolapses past the dentate line with straining
is what degree hemorrhoid?
.
.
.
.
ANSWER:
- It is a first degree internal hemorrhoid.
- Internal hemorrhoids are located proximal to the dentate line and covered by insensate
anorectal mucosa.
- Internal hemorrhoids may prolapse or bleed, but rarely become painful unless they
develop thrombosis and necrosis (usually related to severe prolapse, incarceration,
and/or strangulation).
- Internal hemorrhoids are graded according to the extent of prolapse.
- First degree hemorrhoids bulge into the anal canal and may prolapse beyond the
dentate line on straining
- Second degree hemorrhoids prolapse through the anus but reduce spontaneously.
- Third degree hemorrhoids prolapse through the anal canal and require manual
reduction.
- Fourth degree hemorrhoids prolapse but cannot be reduced and are at risk for
strangulation.
.
HEMOSTASIS:
QUESTION: What is the first step in the process of hemostasis?
.
.
.
.
.
ANSWER:
- The first step in the process of hemostasis after vessel injury is: vasoconstriction.
HEPARIN:
QUESTION: True or false: Heparin enhances the effect of antithrombin on thrombinmediated conversion of fibrinogen to fibrin
.
.
.
.
.
ANSWER: The answer is TRUE.
- The mechanism of action of Heparin is that it activates ATIII. (TOPIC)
.
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QUESTION: What is the management of a patient on heparin who actively bleeds into
the retroperitoneum?
.
.
.
.
.
ANSWER:
- If a patient on heparin develops active bleeding into the retroperitoneum, the treatment is conservative
management and protamine infusion.
.
.
.
.
.
QUESTION: What are the side effects of heparin?
.
.
.
.
.
HEPATIC ADENOMA:
QUESTION: A 40 year old woman on no medications and without any past medical
problems presents with intermittent abdominal discomfort. She undergoes a contrasted
abdominal CT scan which shows a 4 cm hypervascular liver lesion. Sulfur colloid scan
shows no uptake. AFP is normal. There is no peripheral to central enhancement on the
contrasted CT scan. You diagnose her with a hepatic adenoma. How do you treat a
hepatic adenoma?
.
.
.
.
.
ANSWER:
- A liver mass that is hypervascular, is associated with a normal AFP (likely not
hepatocellular carcinoma), has no peripheral to central enhancement (likely not a
hemangioma), and no uptake on sulfur colloid scan (likely not focal nodular
hyperplasia) is most consistent with adenoma.
- Because she is not on any steroids, (i.e. oral contraceptive pills), the treatment for
the lesion is resection because of the significant risk of rupture and malignant
transformation.
.
.
.
HERNIAS:
QUESTION: What is the most common complication following inguinal hernia repair?
.
.
.
.
.
ANSWER:
- The most common complication following an inguinal hernia repair is urinary
retention.
- Risk factors include males, increased narcotic requirement and age
.
HIATAL HERNIA:
QUESTION: What are the indications for surgical repair of a hiatal hernia in a
symptomatic patient?
.
.
.
.
.
ANSWER: The indications for hiatal hernia repair include:
- Patient desires not to take pills to control reflux for a prolonged period
- Regurgitation and aspiration not controlled with medical therapy
- Persistent symptoms despite medical therapy
Barrett's is not an indication for hiatal hernia repair although the patient should be
placed on a proton pump inhibitor and have their esophagus evaluated for dysplasia and
cancer on a regular basis.
HISTAMINE:
QUESTION: What is the molecular mechanism of action of how histamine causes HCl
production?
.
.
.
ANSWER: Histamine acts on parietal cells via cAMP to increase HCL production
mnemonic: H for Happy cAMPers)
HYPERCOAGULABLE STATES:
QUESTION: What is the most common risk factor for spontaneous venous
thromboembolism?
.
.
.
.
.
ANSWER:
- The most common risk factor for spontaneous venous thromboembolism is factor V leiden.
.
.
.
.
.
HYPERHOMOCYSTEINEMIA:
QUESTION: What is the treatment of hyperhomocysteinemia?
.
.
.
ANSWER:
- The deficiency associated with DVTs and arterial thrombosis (i.e. clots in arteries and veins) is
hyperhomocysteinemia (and lupus anticoagulant).
- Treatment of hyperhomocysteinemia is folic acid & B12.
HYPERKALEMIA:
QUESTION: What is the initial treatment of choice in a patient with hyperkalemia and
arrhythmias?
.
.
.
.
.
ANSWER: A patient that is having arrhythmias as a result of the hyperkalemia should
receive Ca-gluconate 1st to stabilize cardiac muscle cell membranes.
QUESTION: You bring an intubated 30 year old man with a 60% total body surface
burn back to the OR for his 3rd debridement in 3 days and the anesthesiologist gives
him succinylcholine instead of the pancuronium which he was receiving in the ICU.
Shortly after this, his EKG shows T wave abnormalities, then a widened QRS, and then
ventricular fibrillation. You cannot feel a pulse so you start CPR and shock him 3 times
without success. The 1st drug you should give for this problem is what?.
.
.
.
ANSWER:
- Burn patients are at increased risk for hyperkalemia because of myonecrosis and
leaking of potassium into the bloodstream.
- This, combined with succinylcholine which causes potassium release when it
depolarizes the cell membrane, results in hyperkalemia.
- The 1st treatment of choice when hyperkalemia occurs with arrhythmias is calcium
gluconate.
- This stabilizes the myocardial cell membrane and will help stabilize the arrhythmia.
- Dextrose 50% and 10 units of insulin, HCO3-, Kayexalate, dialysis, etc can be used to
help treat hyperkalemia.
QUESTION: What is the first treatment administered to a patient with a potassium level
of 6.3 and flattened P waves on their ECG?
.
.
.
.
.
.
ANSWER:
- The goals of therapy include reducing the total body potassium, shifting potassium
from the extracellular to the intracellular space, and protecting the cells from the effects
of increased potassium.
- For all patients exogenous sources of potassium should be removed, including
potassium supplementation in IV fluids and enteral and parenteral solutions.
- Potassium can be removed from the body using a cation-exchange resin such as
Kayexalate that binds potassium in exchange for sodium.
- It can be administered either orally, in alert patients, or rectally.
- Immediate measures also should include attempts to shift potassium intracellularly
with glucose bicarbonate infusion.
- Nebulized albuterol (10 to 20 mg) may also be used.
- Use of glucose alone will cause a rise in insulin secretion, but in the acutely ill this
response may be blunted, and therefore both glucose and insulin may be necessary.
- Circulatory overload and hypernatremia may result from the administration of
Kayexalate and bicarbonate, so care should be exercised when administering these
agents to patients with fragile cardiac function.
- When ECG changes are present, calcium chloride or calcium gluconate (5 to 10 mL of
10% solution) should be administered immediately to counteract the myocardial effects
of hyperkalemia.
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HYPERPARATHYROIDISM:
QUESTION: What are the typical lab results seen in primary hyperparathyroidism in
terms of Ca, PTH, and urine Ca levels?
.
.
.
.
ANSWER:
- Primary hyperparathyroidism is associated with:
- Autonomously elevated PTH (nl 10-60 pg/ml)
- elevated serum Ca (nl 8.5 - 10.5)
- Elevated (70%) or normal (30%) urine Ca
.
.
.
.
.
.
.
QUESTION: What are the indications for operative treatment of asymptomatic patients
with primary hyperparathyroidism?
.
.
.
.
.
ANSWER:
- Current National Institutes of Health conference guidelines for surgery in
asymptomatic patients include at initial evaluation:
(1) a serum calcium level more than 1 mg/dL above the upper limit of reference
value,
(2) reduced creatinine clearance of more than 30% compared with matched
controls,
(3) an increased urinary calcium excretion of more than 400 mg/day,
(3a) - Presence of kidney stones (nephrolithiasis) detected by abdominal imaging
(4) evidence of bone mass reduction more than 2.5 standard deviations below
matched controls, and
(5) unwillingness or inability to undergo continued follow-up.
HYPOCALCEMIA:
QUESTION: A 23 year old woman undergoes total thyroidectomy for carcinoma of the
thyroid gland. On the second postoperative day, she begins to complain of a tingling
sensation in her hands. She appears quite anxious and later complains of muscle cramps.
What is the most appropriate initial management strategy?
.
.
.
.
.
ANSWER:
- Intravenous calcium infusion is the treatment for severe, symptomatic hypocalcemia,
although, typically, oral calcium supplementation (up to 1 to 2 g every 4 hours) is
sufficient in patients with mild symptoms.
- Since post-thyroidectomy hypocalcemia is usually due to transient ischemia of the
parathyroid glands and is self-limited, in most cases the problem is resolved in several
days.
- In cases of persistent hypocalcemia, Vitamin D preparations may be necessary.
- There is no role for thyroid hormone replacement or magnesium sulfate in the
treatment of hypocalcemia.
.
.
.
QUESTION: What is the actual serum calcium level in a patient with an albumin of 2.0
and a serum calcium level of 6.6?
.
.
.
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HYPOKALEMIA:
QUESTION: A postoperative patient with a potassium of 2.9 is given 1 mEq/kg
replacement with KCL (potassium chloride). Repeat tests after the replacement show
the serum K to be 3.0. The most likely other electrolyte abnormality to cause this is
what?
.
.
.
.
.
ANSWER:
- The most likely other electrolyte abnormality in this case is hypomagnesemia.
- In cases in which potassium deficiency is due to magnesium depletion, potassium
repletion is difficult unless hypomagnesemia is first corrected.
INCIDENCE:
QUESTION: Define incidence
.
.
.
ANSWER: Incidence is the number of new cases diagnosed over a certain time frame in
a population. This time frame is usually per year. For example, the number of patients in
the US with newly diagnosed breast cancer in 2010.
INHALED ANESTHETICS:
QUESTION: Is the main side effect of Halothane hepatotoxicity or renal toxicity?
.
.
.
ANSWER: Halothane is hepatotoxic
.
.
.
QUESTION: What kind of toxicity is associated with Methoxyflurane?
.
.
.
ANSWER: Methoxyflurane is associated with renal toxicity
INR:
QUESTION: True or false: An INR of more than 1.5 is considered safe for operation
.
.
.
.
.
ANSWER: The answer is TRUE.
- With meticulous hemostatic technique, many operations can be performed on patients
with an INR greater than 1.5.
- Exceptions include operations on the eye or the prostate, neurosurgical procedures, or
a blind needle aspiration.
- In these cases, an INR of less than 1.2 is required.
- Patients who are receiving anticoagulant treatment with warfarin and who require
emergency surgery may be given plasma to immediately reverse the warfarin effect.
- Alternatively, vitamin K may be given orally or subcutaneously at least 6 hr
preoperatively to reverse the effect of warfarin on vitamin K dependent factors.
- The INR should be obtained again before surgery and, if it is not below 1.5, plasma
should be administered.
INTESTINAL ATRESIA:
PATHOPHYSIOLOGY
QUESTION: True or false: Jejunal atresia is due to a fetal mesenteric vascular
accident.
.
.
.
.
.
ANSWER: TRUE.
- Obstruction caused by intestinal atresia can occur at any point along the intestinal
tract.
- Most cases are believed to be caused by in utero mesenteric vascular accidents
leading to segmental loss of the intestinal lumen.
- They are classified into four types based on the severity.
PRESENTATION
QUESTION: Most infants with jejunal atresia present with nonbilious vomiting.
.
.
.
.
.
ANSWER: FALSE.
- Infants with jejunal or ileal atresia present soon after birth with bilious vomiting and
progressive abdominal distention.
- The more distal the obstruction, the more distended the abdomen and the greater the
number of loops on upright abdominal radiograph.
.
.
.
.
.
QUESTION: Jejunal atresia is the most common cause of surgical vomiting in infancy.
.
.
.
.
.
ANSWER: FALSE.
TREATMENT
QUESTION: What is the management of jejunal atresia?
.
.
.
.
.
ANSWER:
- The initial treatment of jejunal atresia is nasogastric tube decompression and fluid
resuscitation.
- Definitive treatment involves surgical resection of the atretic loop and primary reanastomosis.
INTRINSIC PATHWAY:
QUESTION: Summarize the intrinsic pathway: include the lab test associated with it,
the factors involved, and the final product
.
.
.
ANSWER:
- Intrinsic path is tested with PTT.
- Exposed collagen + XII --> XI, IX --> X which activates thrombin to produce fibrin
INTUSSUSCEPTION:
QUESTION: What is the most common pathologic lead point for intussusception in
children?
.
.
.
.
.
ANSWER: Meckel diverticulum
- Infants 6 to 24 months of age with intussusception typically have no pathologic lead
point on pathologic examination, but instead have hypertrophied Peyer patches.
- Conversely, older children have a much higher likelihood of having a pathologic lead
point.
- As such, they have a much greater need for operative intervention to resect the segment
of bowel that includes the pathologic area.
- The most common pathologic lead point for intussusception in children is a Meckel
diverticulum.
- Other causes include polyps, appendicitis, intestinal neoplasms such as
lymphosarcoma, submucosal hemorrhage, foreign body, ectopic pancreatic or gastric
tissue, and intestinal duplication.
LACTIFEROUS DUCTS:
QUESTION: How many lactiferous ducts drain into the nipple of the mature female
breast?
.
.
.
.
.
ANSWER: 15-20
- The breast is composed of 15 to 20 lobes, which are each composed of several
lobules.
- Each lobe of the breast terminates in a major (lactiferous) duct (2 to 4 mm in
diameter), which opens through a constricted orifice (0.4 to 0.7mm in diameter) into the
ampulla of the nipple.
LAPAROSCOPY:
QUESTION: Compared to open procedures, do laparoscopic procedures result in
higher or lower serum cortisol levels?
.
.
.
.
.
ANSWER: Laparoscopic procedures result in higher serum cortisol levels.
- Endocrine responses to laparoscopic surgery are not always intuitive.
- Serum cortisol levels after laparoscopic operations are often higher than after the
equivalent operation performed through an open incision.
LUNG ABSCESS:
QUESTION: What is the most common cause of lung abscess?
.
.
.
.
.
ANSWER: Aspiration
- A lung abscess is usually the result of aspiration that results in a suppurative bacterial
infection, leading to localized pulmonary parenchymal necrosis.
- Patients with a history of alcohol abuse, those with poor dentition and gum disease,
and patients with seizure disorders are at greatest risk.
LUNG CANCER:
QUESTION: What is the most common type of lung cancer in a nonsmoker?
.
.
.
.
.
ANSWER: Adenocarcinoma
- Adenocarcinoma is the most common lung cancer in nonsmokers.
LUPUS ANTICOAGULANT:
QUESTION: What is the laboratory diagnosis of lupus anticoagulant?
.
.
.
.
.
ANSWER:
- The laboratory diagnosis of lupus anticoagulant is long Russel viper venom time.
.
.
.
.
.
QUESTION: What conditions are associated with both arterial and venous clots?
.
.
.
.
.
ANSWER:
- Lupus anticoagulant (and hyperhomocysteinemia) are both associated with arterial and venous clots.
MAINTENANCE FLUIDS:
QUESTION: A 30-kg child has an estimated daily fluid requirement of what ml/hr?
.
.
.
.
.
ANSWER: 70 ml/hr
- Daily maintenance fluids for children can be estimated using the 4-2-1 rule
4 mL/kg/hr for the first 10 kg,
2 mL/kg for the second 10 kg, and
1 mL/kg for any additional kilograms).
- For this child who weighs 30 kg, maintenance fluids calculate to be
4 mL/kg x 10 kg = 40 mL,
2 mL/kg x 10 kg = 20 mL,
1 mL/kg x 10 kg = 10 mL;
40 mL + 20 mL + 10 mL = 70 mL/hr.
MALIGNANT HYPERTHERMIA:
QUESTION: What are the symptoms of malignant hyperthermia?
.
.
.
ANSWER: The symptoms of malignant hyperthermia include: fever, tachycardia,
rigidity
.
.
.
QUESTION: If you suspect a patient has malignant hyperthermia, do you continue the
operation or stop it?
.
.
.
ANSWER: Part of the treatment of malignant hyperthermia is stopping the operation
.
.
.
.
.
.
QUESTION: What is the inheritance pattern of malignant hyperthermia?
.
.
.
.
.
ANSWER: Autosomal dominant.
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MAMMOGRAPHY:
QUESTION: Routine mammography in women over 50 years of age decreases mortality
from breast cancer by approximately how many percentage points?
.
.
.
.
.
.
ANSWER: 33%
- Routine use of screening mammography in women >=50 years of age reduces mortality
from breast cancer by 33%.
- This reduction comes without substantial risks and at an acceptable economic cost.
MASTITIS:
QUESTION: What is the treatment of choice for Zuska's disease (recurrent periductal
mastitis)?
.
.
.
.
ANSWER: Antibiotics, incision, and drainage
- Zuska's disease, also called recurrent periductal mastitis, is a condition of recurrent
retroareolar infections and abscesses.
- This syndrome is managed symptomatically, by antibiotics coupled with incision and
drainage as necessary.
MECONIUM ILEUS:
QUESTION: What is a common condition associated with meconium ileus?
.
.
.
.
.
ANSWER: Cystic fibrosis
- Meconium ileus is a result of cystic fibrosis, in which the meconium becomes thick
and viscous due to deficits in pancreatic enzymes.
.
.
.
.
.
QUESTION: What is the presentation of an infant with meconium ileus?
.
.
.
.
.
ANSWER: Small bowel obstruction, bilious emesis
- It creates a small bowel obstruction, and as such, the infant may present with bilious
vomiting.
- In the most severe forms, it can lead to intestinal perforation.
.
.
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MELANOMA:
QUESTION: A patient presents with a biopsy proven melanoma of the thigh which is
3mm thick on histologic examination. At the time of excision, how wide should the
margins be?
.
.
.
.
.
.
ANSWER:
- Regardless of tumor depth or extension, surgical excision is the management of choice.
- Lesions 1mm or less in thickness can be treated with a 1cm margin.
- For lesions 1 mm to 4mm thick, a 2 cm margin is recommended.
- Lesions of greater than 4mm may be treated with 3 cm margins.
- The surrounding tissue should be removed down to the fascia to remove all lymphatic
channels.
- If the deep fascia is not involved by the tumor, removing it does not affect recurrence
or survival rates, so the fascia is left intact.
META-ANALYSIS:
QUESTION: Does a meta-analysis use one study or several different studies?
.
.
.
ANSWER: A meta-analysis uses different studies
.
.
.
QUESTION: Does a meta-analysis combine or separate the data from different studies?
.
.
.
ANSWER: A meta-analysis combines data from different studies.
MITOCHONDRIA:
Q: Does the mitochondria have 1 or 2 membranes?
.
.
.
A: Mitochondria have 2 membranes
.
.
.
Q: Where in the mitochondria does the Krebs cycle occur?
.
.
.
A: The Krebs cycle occurs on the inner matrix
.
.
.
MOTILIN:
QUESTION: What is the effect of Motilin on the GI tract?
.
.
.
ANSWER: Motilin is a key stimulatory hormone of the GI tract
.
.
.
QUESTION: Where in the GI tract is the motilin receptor found?
.
.
.
ANSWER: The motilin receptor is found primarily in the stomach, duodenum, and colon
.
.
NECROTIZING FASCIITIS:
QUESTION: What physical exam finding is most suggestive of a necrotizing soft tissue
infection and would mandate immediate surgical exploration?
.
.
.
.
.
ANSWER:
- The physical exam finding that is most suggestive of a necrotizing soft tissue infection
includes grayish, turbid semipurulent material ("dishwater pus") that can be expressed,
as well as for the presence of skin changes (bronze hue or brawny induration), blebs, or
crepitus.
- The patient often develops pain at the site of infection that appears to be out of
proportion to any of the physical manifestations.
- Any of these findings mandates immediate surgical intervention, which should consist
of exposure and direct visualization of potentially infected tissue (including deep soft
tissue, fascia, and underlying muscle) and radical resection of affected areas.
NECROTIZING PANCREATITIS:
QUESTION: What type of nutrition has been shown to decrease the rate of pancreatic
abscess in patients with necrotizing pancreatitis?
.
.
.
.
.
ANSWER: Enteral nutrition
- In two small studies, enteral feedings initiated early, using nasojejunal feeding tubes
placed past the ligament of Treitz, have been associated with decreased development of
infected pancreatic necrosis, possibly due to a decrease in gut translocation of bacteria.
- Recent guidelines support the practice of enteral alimentation in these patients, with
the addition of parenteral nutrition if nutritional goals cannot be met by tube feeding
alone.
NEUROBLASTOMA:
QUESTION: A 2-year-old child presents with an abdominal mass, "raccoon eyes," and
"blueberry muffin" skin lesions. This most likely represents what disease?
.
.
.
.
.
ANSWER: Neuroblastoma.
- Neuroblastoma is the most common abdominal malignancy in children.
- The presenting symptoms depend on the site of the primary tumor, the presence of
metastatic disease, the age of the patient, and the metabolic activity of the tumor.
- The most common presentation is a fixed lobular mass extending from the flank toward
the midline.
- The tumor can also extend into the neural foramina and cause symptoms of spinal cord
compression.
- It tends to metastasize to cortical bones, bone marrow, and the liver, and patients may
present with localized swelling and tenderness, limp, or refusal to walk.
- Periorbital metastases account for proptosis and ecchymoses, resulting in "raccoon
eyes."
- In infants, liver metastases may expand, causing hepatomegaly.
- Metastatic lesions to the skin produce the blueberry muffin appearance.
NUCLEOLUS:
Q: True or false: The nucleolus has no membrane
.
.
.
A: True
NUCLEUS:
Q: The nuclear membrane is continuous with what other organelle?
.
.
.
.
.
A: The nucleus outer membrane is continuous with the rough endoplasmic reticulum
.
OMEPRAZOLE:
QUESTION: What enzyme does omeprazole inhibit?
.
.
.
ANSWER: Omeprazole inhibits the H/K ATPase
.
.
.
QUESTION: Omeprazole inhibit acid secretion from which cell?
.
.
.
ANSWER: Omeprazole inhibits acid secretion from parietal cells
OMPHALOCELE:
QUESTION: The most common abnormality associated with omphalocele is what?
.
.
.
.
.
ANSWER: Cardiac.
- The incidence of other abnormalities in patients with omphalocele is approximately
60% to 70%.
- Cardiac anomalies are the most common, followed by musculoskeletal,
gastrointestinal, and genitourinary anomalies.
OXALATE STONES:
QUESTION: What is the mechanism of renal oxalate stones after small bowel resection, specifically ileal
resection?
.
.
.
.
.
ANSWER:
- Ileal resection leads to decreased oxalate binding to calcium secondary to increased intraluminal fat.
- Oxalate then gets absorbed in colon, is released in urine, and can cause Ca oxalate kidney stones (hyperoxaluria)
- Normally, fatty acids are absorbed by the terminal ileum, and calcium and oxalate
combine to form an insoluble compound that is not absorbed.
- In the absence of the terminal ileum, unabsorbed fatty acids reach the colon, where
they combine with calcium, leaving free oxalate to be absorbed..
PALLIATIVE CARE:
QUESTION: The primary treatment for dyspnea ("air hunger") in a dying patient is what
medication?
.
.
.
.
.
ANSWER:
- The primary treatment of dyspnea (air hunger) in the dying is opioids, which should be
cautiously titrated to increase comfort and reduce tachypnea to a range of 15 to 20
breaths/min.
- Air movement across the face generated by a fan can sometimes be quite helpful.
- If this is not effective, empiric use of supplemental O2 by nasal cannula (2 to 3L/min)
may bring some subjective relief, independent of observable changes in pulse oximetry.
- Supplemental O2 should be humidified to avoid exacerbation of dry mouth.
- Typical starting doses of an immediate release opioid for breathlessness should be 1/2
- 2/3 of a starting dose of the same agent for cancer pain.
- For patients already on opioids for pain, a 25 to 50% increment in the dose of the
current immediate release agent for breakthrough pain often will be effective in
relieving breathlessness.
PARADOXICAL ACIDURIA:
TOPIC: COND ASSOC PARADOXICAL ACIDURIA
PARAESOPHAGEAL HERNIA:
QUESTION: What is the indication to operate in a patient with a paraesophageal
hernia?
.
.
.
ANSWER For paraesophageal hernias, you always operate since there is a risk of
incarceration and strangulation
PARALYTICS:
QUESTION: Which muscle in the body is the first muscle to recover from paralytics?
.
.
.
ANSWER: The diaphragm is the first muscle to recover from paralytics
.
.
.
QUESTION: Which muscles are the last to recover from paralytics?
.
.
.
ANSWER: The neck and face muscles are the last to recover from paralytics
.
.
.
QUESTION: Which antibiotic prolongs neuromuscular blockade?
.
.
.
ANSWER: Clindamycin prolongs neuromuscular blockade
- mnemonic. Clindamycin will "cling" to the "muscle" to make the blockade last longer.
.
.
PARATHYROID GLANDS:
QUESTION: From which branchial pouch does the inferior parathyroid glands arise?
.
.
.
.
.
ANSWER: The inferior parathyroid glands arise from the third branchial pouch.
PARATHYROIDECTOMY:
QUESTION: What is the difference between subtotal parathyroidectomy and total
parathyroidectomy?
.
.
.
.
.
ANSWER:
- Subtotal parathyroidectomy typically involves resection of three and a half of the four
glands.
- Total parathyroidectomy consists of removing all four enlarged parathyroid glands and
auto transplanting part of one parathyroid gland into the forearm.
- Roughly equivalent results have been obtained with the two procedures, and debate
continues as to which is better.
PHEOCHROMOCYTOMA:
QUESTION: A 20 year old man comes to your office and has a blood pressure of
240/120. He states that he gets headaches sometimes when he lifts. Given the most
likely diagnosis, what is the best lab test to diagnose pheochromocytoma?
.
.
.
.
.
ANSWER:
- The best test for the diagnosis of pheochromocytoma is a 24 hour VMA and
metanephrine collection study.
.
.
.
.
.
QUESTION: What is the most sensitive test to diagnose a pheochromocytoma is
.
..
.
.
ANSWER: Plasma metanephrines.
- Recent studies have shown that plasma metanephrines are the most reliable tests to
identify pheochromocytomas, with sensitivity approaching 100%.
- Urinary metanephrines are 98% sensitive and are highly specific for
pheochromocytomas, whereas VMA measurements are slightly less sensitive and
specific.
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PLASMA MEMBRANE:
QUESTION: What is the percent makeup of lipids and proteins in the plasma
membrane?
.
.
.
.
.
ANSWER:
. The percent breakdown of proteins and lipids in the plasma membrane is 40% lipid, 60% proteins.
PLASMIN:
QUESTION: What is the mechanism of plasmin?
.
.
.
.
ANSWER:
- The mechanism of action of plasmin is degradation of fibrinogen.
.
.
.
.
.
QUESTION: What drug inhibits plasmin?
.
.
.
.
ANSWER:
- The inhibitor of plasmin is aminocaproic acid (Amicar).
POSTSPLENECTOMY SEPSIS:
QUESTION: A 3 year old undergoes splenectomy for hereditary spherocytosis. Six
weeks later, the child returns to the emergency room with a fever of 104, chills, rigors,
and a systolic blood pressure of 60. The child's white blood cell count is 20. Describe
the clinical features and risks of postsplenectomy sepsis.
.
.
.
.
ANSWER:
- The condition is more common in patients who undergo splenectomy for malignancy or
hematologic disease compared to trauma
- Children less than 5 years of age undergoing splenectomy are at higher risk
- The condition is due to a specific lack of immunity to encapsulated organisms
- Postsplenectomy sepsis syndrome is very rare after splenectomy.
- It occurs more commonly in patients undergoing splenectomy for non-traumatic
indications.
- The most common organism involved in PSSS is strep pneumoniae.
- Children <5 are at higher risk.
- The condition is due to a specific lack of immunity to encapsulated organisms (H.
influenzae, N. meningitidis, S. pneumoniae)
POSTTRANSPLANT LYMPHOPROLIFERATIVE
DISORDER: PTLD:
QUESTION: PTLD (posttransplant lymphoproliferative disorder) is caused by what
organism?
.
.
.
.
.
ANSWER: PTLD is caused by Epstein-Barr virus infection. The most severe form of
infection, PTLD can present as a localized tumor of the lymph nodes or GI tract, or
rarely as a rapidly progressive, diffuse, often fatal lymphomatous infiltration.
PREGNANCY:
QUESTION: Does the 2,3-DPG level increase or decrease during pregnancy? What is
physiologic effect of this?
.
.
.
.
.
ANSWER:
- In pregnancy, 2,3-DPG level is increased to enhance release of oxygen to the fetus.
.
.
.
.
.
PREVALENCE:
QUESTION: Define prevalence
.
.
.
ANSWER: Prevalence is the number of patients having the disease in the population
.
.
.
QUESTION: What is the effect of long standing disease on prevalence?
.
.
.
ANSWER: The prevalence is higher in diseases that last a long time
.
.
PROSTACYCLIN:
QUESTION: What is another term for prostacyclin?
.
.
.
ANSWER: Prostacyclin is PGI2
.
.
.
QUESTION: What is the effect of prostacyclin on platelet aggregation
.
.
.
ANSWER: Prostacyclin decreases platelet aggregation
.
.
.
QUESTION: What is the effect of prostacyclin on the vasculature?
.
.
.
ANSWER: Prostacyclin leads to vasodilation
.
.
.
QUESTION: What is the effect of prostacyclin on bronchial relaxation?
.
.
.
ANSWER: Prostacyclin causes bronchial relaxation
.
PROTAMINE:
QUESTION: True or false: Theoretically, 1.28mg of protamine neutralizes 1 mg of
heparin
.
.
.
.
.
ANSWER: The answer is TRUE.
PROTEIN C:
QUESTION: What coagulation factors does Protein C degrade?
.
.
.
ANSWER: Protein C degrades factors V and VIII and fibrinogen
.
.
.
.
.
QUESTION: What is the consequence of protein C or S deficiency?
.
.
.
.
.
ANSWER:
- The consequence of protein C deficiency (or protein S deficiency) is increased risk of spontaneous venous
thromboses.
PROTEIN S:
QUESTION: True or false: Protein S is a vitamin K dependent factor
.
.
.
ANSWER: True
.
.
.
.
.
QUESTION: What effect does Protein S have on Protein C?
.
.
.
.
.
ANSWER: Protein S helps protein C
PT:
QUESTION: Does PT measure the intrinsic pathway or the extrinsic pathway?
.
.
.
.
.
ANSWER: PT measures the extrinsic pathway
.
.
.
.
.
.
QUESTION: What test is the single best test to evaluate synthetic function of the liver?
.
.
.
.
.
ANSWER: PT is the single best test to evaluate synthetic function of the liver
.
.
.
.
.
PTT:
QUESTION: Does PTT measure the intrinsic pathway or the extrinsic pathway?
.
.
.
.
.
.
ANSWER: PTT measures the intrinsic pathway
.
.
.
.
.
.
QUESTION: Collagen is in which state when the intrinsic pathway (PTT) is initiated?
.
.
.
.
.
ANSWER: The intrinsic pathway is activated when collagen is exposed
.
.
.
QUESTION: In the intrinsic pathway (PTT), exposed collagen reacts with which factor
to initiate the process that leads to the formation of fibrin?
.
.
.
ANSWER: Exposed collagen reacts with factor XII to initiate the coagulation process
that leads to the formation of fibrin
.
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PULMONARY EMBOLISM:
QUESTION: What is the most common electrocardiographic change after pulmonary
embolism (PE)?
.
.
.
.
.
ANSWER: Sinus tachycardia
- The most common finding on electrocardiography after a PE is sinus tachycardia
(present in almost one half of patients).
- A heart rate greater than 100 beats per minute in the setting of suspected PE should
further raise concern.
- The classic finding on an electrocardiogram is the S1, Q3, T3 pattern, which consists
of a prominent S wave in lead I and a Q wave and inverted T wave in lead III.
- This electrocardiographic finding indicates right ventricular strain from a large PE,
but it is not commonly present.
- A large PE will lead to an enlargement of the right ventricle causing the
interventricular septum to deviate to the left.
- The right bundle branch stretches, leading to a right bundle branch block..
.
source .
PYLORIC STENOSIS:
QUESTION: What medication, when given in early infancy, is linked to pyloric
stenosis?
.
.
.
.
.
ANSWER: Erythromycin
- Administration of erythromycin in early infancy has been linked to the development of
hypertrophic pyloric stenosis.
- It is linked with early administration of erythromycin.
.
.
.
.
.
QUESTION: True or false: Pyloric stenosis has a familial link in some cases.
.
.
.
.
ANSWER: True
.
.
.
.
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QUESTION: True or false: Surgery requires a full-thickness division of the pylorus into
the mucosa.
.
.
.
.
.
ANSWER: FALSE.
- The submucosa and mucosa are not entered.
RADIATION THERAPY:
QUESTION: What phase of the cell cycle is most sensitive to radiation therapy?
.
.
.
ANSWER: The M phase of the cell cycle is the most sensitive to radiation therapy
.
.
.
QUESTION: True or false: Radiation therapy is most effective with high O2 levels
.
.
.
ANSWER: True
.
.
.
QUESTION: If you want to minimize skin damage, do you use higher or lower energy
radiation therapy?
.
.
.
ANSWER: Higher energy radiation therapy leads to less skin damage
.
.
.
QUESTION: What is the pathology seen on histology of tissue that has undergone
radiation therapy?
.
.
.
ANSWER: Pathology of tissue that underwent radiation therapy shows obliterative
endarteritis
.
.
.
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.
.
..
QUESTION: What is the side effect of recombinant factor VIIa (Novoseven)?
.
.
.
.
ANSWER:
- Side effects recombinant factor VIIa: thromboembolic events.
.
.
.
.
REFEEDING SYNDROME:
QUESTION: Refeeding syndrome is associated with which electrolyte abnormalities?
..
.
.
ANSWER:
- Refeeding syndrome occurs when excess calories are given to a starved person
(anorexia).
- Refeeding syndrome is a potentially lethal condition that can occur with rapid and
excessive feeding of patients with severe underlying malnutrition due to starvation,
alcoholism, delayed nutritional support, anorexia nervosa, or massive weight loss in
obese patients.
- With refeeding, a shift in metabolism from fat to carbohydrate substrate stimulates
insulin release, which results in the cellular uptake of electrolytes and therefore low
serum levels of phosphate, magnesium, potassium, and calcium.
- In refeeding syndrome, the electrolyte abnormalities you should expect to see are:
- Hypophosphatemia
- Hypomagnesemia
- Hypokalemia
- Hypocalcemia
.
.
QUESTION: What is the process that results in the hypophosphatemia seen in refeeding
syndrome?
.
.
.
.
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REJECTION:
QUESTION: Graft vs host disease is mediated by which immune cells?
.
.
.
ANSWER: Graft vs host disease is mediated by CD8+ T cells
.
.
.
QUESTION: Hyperacute rejection is due to which part of the immune system?
.
.
.
ANSWER: Hyperacute rejection is due to antibodies
.
.
.
QUESTION: Is hyperacute rejection due to preformed antibodies, antibodies that are
formed after the transplantation, or immune cells?
.
.
.
ANSWER: Hyperacute rejection is due to preformed antibodies.
.
.
.
QUESTION: How do you prevent hyperacute rejection occurring?
.
.
.
ANSWER: You can avoid hyperacute rejection by not transplanting when the
crossmatch is positive
.
.
.
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RENIN:
QUESTION: What is the mechanism of action of renin?
.
.
.
.
.
ANSWER:
- The mechanism of action of renin is conversion of angiotensinogen to angiotensin I.
.
.
.
.
.
QUESTION: What RQ signifies overfeeding? What RQ signifies starvation?
.
.
.
.
.
ANSWER:
- The respiratory quotient (RQ) is the ratio of CO2 produced to O2 consumed.
- An RQ>1.0 means too much carbohydrates, overfeeding.
- An RQ<1.0 means too little carbohydrates, starving.
RHABDOMYOLYSIS:
QUESTION: How do you decrease the risk of renal failure in a patient with
myoglobinuria?
.
.
.
.
.
ANSWER:
- The treatment of renal failure due to myoglobinuria in severe trauma patients has
shifted away from the use of sodium bicarbonate for alkalinizing the urine, to merely
maintaining brisk urine output of 100 mL/h with crystalloid fluid infusion.
- Mannitol and furosemide are not recommended as long as the IV fluid achieves the
goal rate of urinary output.
.
.
.
.
QUESTION: Treatment of patients with severe burn injuries and myoglobinuria consists
of what?
.
.
.
.
.
.
ANSWER: The best treatment for patients with burn injuries and myoglobinuria is fluid
resuscitation and HCO3- to prevent precipitation of the myoglobin.
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RNA:
Q: Where in the cell is ribosomal RNA made?
.
.
.
A: Ribosomes RNA is made in the nucleolus
SARCOMAS:
QUESTION: For extremity sarcoma biopsy, when do you make an excisional biopsy,
and when do you make a longitudinal incisional biopsy?
.
.
.
ANSWER: You can get an excisional biopsy if the sarcoma is <4 cm. Otherwise do a
longitudinal incisional biopsy.
.
.
.
QUESTION: What is the benefit of a longitudinal incisional biopsy?
.
.
.
ANSWER: With a longitudinal incisional biopsy, you have less lymphatic disruption
and it is easier to excise scar if the biopsy positive
.
.
.
QUESTION: In treating soft tissue sarcomas, when is postoperative radiation therapy
indicated?
.
.
.
ANSWER: Postoperative radiation therapy is indicated for: high grade sarcoma, close
margins, or tumor >5 cm
.
.
.
QUESTION: How do soft tissue sarcomas spread?
.
.
.
ANSWER: Sarcomas spread hematogenously, not via lymphatics. Metastases to nodes
is rare.
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SECRETIN:
QUESTION: What is the effect of secretin on the pancreas?
.
.
.
ANSWER: Secretin is the primary stimulus of pancreatic bicarbonate secretion
SENSITIVITY:
QUESTION: What does the sensitivity of a test reflect?
.
.
.
ANSWER:
- Sensitivity reflects ability to detect disease
- [true positives/(true positive + false negatives)]
.
.
QUESTION:: True or false: Sensitivity is the ability of the test to detect disease
.
.
.
ANSWER: True
.
.
.
QUESTION: True or false: Sensitivity is # with disease and positive test result/ # that
have disease
.
.
.
ANSWER: True
QUESTION: What factors are associated with successful weaning of TPN in patients
with short bowel syndrome?
.
.
.
.
ANSWER
- Length of small bowel >200cm
- Presence of ileocecal valve
- Presence of colon
- Pediatric patients adapt better than adult patients.
TABLE - Risk factors for development of short bowel syndrome after massive small
bowel resection
- small bowel length <200cm
- Absence of ileocecal valve
- Absence of colon
- Diseased remaining bowel (eg. Crohn's disease)
- Ileal resection
SILVADENE:
QUESTION:What is the side effect of silvadene?
.
.
.
ANSWER: The side effect of Silvadene is neutropenia
.
.
.
.
.
.
QUESTION: Which one of the burn creams has good activity against candida?
.
.
.
ANSWER: Silvadene has good activity against Candida
.
.
.
QUESTION: Which one of the burn creams has poor eschar penetration?
.
.
.
ANSWER: Silvadene has poor eschar penetration
SILVER NITRATE:
QUESTION: What is the side effect of Silver nitrate?
.
.
.
ANSWER: The side effect of Silver nitrate is hyponatremia and hypochloremia due to
leaching of NaCl
SKIN GRAFTS:
QUESTION: Skin grafts survive in the 1st 48 hours primary by which mechanism?:
.
.
.
.
.
ANSWER:
- Skin grafts survive by imbibition (osmotic exchange of nutrients) for the 1st 48 hours.
- After that, neovascularization takes over.
SOMATOSTATIN:
QUESTION: Somatostatin inhibits the secretion of what molecules?
.
.
.
ANSWER: Somatostatin inhibits gastrin, insulin, secretin, and acetylcholine
.
.
.
QUESTION: What is the effect of somatostatin on pancreatic and biliary output?
.
.
.
ANSWER: Somatostatin decreases pancreatic and biliary output
.
.
.
QUESTION:: What stimulates the release of somatostatin?
.
.
.
ANSWER: Somatostatin is stimulated by acid in duodenum
.
.
.
QUESTION:: What hormone analog is octreotide?
.
.
.
ANSWER: Octreotide is a long acting somatostatin analog
SPECIFICITY:
QUESTION True or false: specificity is the ability to state no disease is present
.
.
.
ANSWER: True
.
.
.
QUESTION: True or false: Specificity is # with no disease and negative test result / #
without disease
.
.
.
ANSWER: True
SULFAMYLON:
QUESTION: What is the side effect of Sulfamylon?
.
.
.
ANSWER: The side effect of Sulfamylon is acidosis due to carbonic anhydrase
inhibition (less H2CO3 -> H2O + CO2)
.
.
.
.
.
.
QUESTION: Which one of the burn creams is painful on application?
.
.
.
ANSWER: Sulfamylon is painful on application
TENSION PNEUMOTHORAX:
QUESTION: A 21-year-old man who was the driver in a head-on collision has a pulse
rate of 140 beats per minute, respiratory rate of 36 breaths per minute, and blood
pressure of 60 mm Hg palpable. His trachea is deviated to the left, with palpable
subcutaneous emphysema and poor breath sounds in the right hemithorax. The most
appropriate initial treatment is to do what?
.
.
.
.
.
ANSWER: Needle decompression
- Advanced trauma life support protocol states that the initial management is to place a
needle in the second intercostal space, midclavicular line, just above the rib using a
4.5-cm (2-inch) catheter (5-cm needle).
- This should be immediately followed by a tube thoracostomy.
TESTICULAR CANCER:
QUESTION: AFP is a marker for which type of testicular cancer?
.
.
.
ANSWER: AFP is a marker for non-seminomatous testicular cancer
.
.
.
QUESTION: beta-HCG is a marker for which type of testicular cancer?
.
.
.
ANSWER: beta-HCG is a marker for non-seminomatous testicular cancer
.
.
.
QUESTION: In the workup of a testicular mass, do you biopsy the mass via
orchiectomy via inguinal incision or via a trans-scrotal incision?
.
.
.
ANSWER: In the workup of a testicular mass, the biopsy is orchiectomy via inguinal
incision. It is NEVER via trans-scrotal.
.
.
.
QUESTION: Which testicular cancer is very radiosensitive? Seminoma or
nonseminoma?
.
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QUESTION: In which Ethnic group would you not expect to find testicular cancer?
.
.
.
ANSWER: Testicular cancer is rare in African-Americans
.
.
.
TETRALOGY OF FALLOT:
QUESTION: What is the most common congenital heart defect causing a right-to-left
shunt?
.
.
.
.
.
ANSWER: Tetralogy of Fallot
- Tetralogy of Fallot is the most common congenital heart defect presenting as a "blue
baby" (cyanosis from a right-to-left shunt).
- The four features include VSD, dextroposition of the heart (overriding aorta), right
ventricular outflow tract obstruction, and right ventricular hypertrophy.
- Most surgeons recommend repair during infancy, but if the patient is unstable and is
younger than 6 months old, Blalock-Taussig shunt placement may be performed.
THROMBIN:
QUESTION: What is the mechanism of action of thrombin?
.
.
.
.
.
ANSWER:
- The mechanism of action of thrombin is conversion of fibrinogen to fibrin and fibrin split products, and
activation of platelets.
THROMBOXANE:
QUESTION: What is the other word for thromboxane?
.
.
.
ANSWER: Thromboxane and TXA2 are interchangeable terms
.
.
.
QUESTION: What cells or cell components secrete thromboxane?
.
.
.
ANSWER: Platelets secrete thromboxane
.
.
.
QUESTION: Does thromboxane increase or decrease aggregation of platelets?
.
.
.
ANSWER: Thromboxane increases platelet aggregation
.
.
.
QUESTION: Does thromboxane cause vasoconstriction or vasodilation?
.
.
.
ANSWER: Thromboxane causes vasoconstriction
.
.
.
QUESTION: What is the effect of thromboxane on the calcium level inside platelets?
.
.
.
ANSWER: Thromboxane triggers release of calcium in platelets
.
.
.
QUESTION: What is the effect of increased calcium levels inside platelets on the
GpIIb/IIIa receptor?
.
.
.
ANSWER: Release of calcium in platelets exposes GpIIb/IIIa receptor on platelets
.
.
.
QUESTION: What is the effect of exposure of the GpIIb/IIIa receptor on platelets?
.
.
.
ANSWER: Exposure of the GpIIb/IIIa receptor on platelets causes platelet-to-platelet
binding and platelet to collagen binding
THYROGLOSSAL CYSTS:
QUESTION: What is the treatment for thyroglossal ysts?
.
.
.
.
.
ANSWER: Sistrunk procedure
- The classic treatment of thyroglossal duct cyst is the Sistrunk procedure, which
involves complete excision of the cyst in continuity with its tract, the central portion of
the hyoid bone, and the tissue above the hyoid bone extending to the base of the tongue.
.
THYROID STORM:
QUESTION: What is the most appropriate initial treatment for thyroid storm?
.
.
.
ANSWER:
- Beta-blockers are used in the initial treatment of thyroid storm.
- Treatment of thyroid storm includes:
- Beta blockers (esmolol drip usually)
- Lugol's (KI)
- Propylthiouracil
- Cooling blankets
- Oxygen
- Glucose
- Fluid
- Steroids (Cortisol 100 mg Q8H)
TRACHEA:
QUESTION: What is the approximate length of the trachea distal to the subglottic
space?
.
.
.
.
.
ANSWER: 10-13 cm
- The trachea is composed of cartilaginous and membranous portions, beginning with
the cricoid cartilage, the first complete cartilaginous ring of the airway.
- The cricoid cartilage consists of an anterior arch and a posterior broad-based plate.
- Articulating with the posterior cricoid plate are the arytenoid cartilages.
- The vocal cords originate from the arytenoid cartilages and then attach to the thyroid
cartilage.
- The subglottic space, the narrowest part of the trachea with an internal diameter of
approximately 2 cm, begins at the inferior surface of the vocal cords and extends to the
first tracheal ring.
- The remainder of the distal trachea is 10.0 to 13.0 cm long, consists of 18 to 22 rings,
and has an internal diameter of 2.3 cm.
TRACHEOSTOMY:
QUESTION: If you see massive bleeding from a trach, what artery is involved?
.
.
.
ANSWER: If you see a massive bleed from a tracheostomy site, the innominate artery
is involved.
.
.
.
QUESTION: If you see massive bleeding from a trach, what kind of fistula could the
patient have developed?
.
.
.
ANSWER: Bleeding from a trach site could represent a tracheo-innominate fistula
.
.
.
QUESTION: When making a tracheostomy, how can you avoid creating a tracheoinnominate fistula or injuring the innominate artery?
.
.
.
ANSWER: You can avoid injuring the innominate artery by making the tracheostomy no
lower than 3rd tracheal ring.
.
TRANSFUSION REACTIONS:
QUESTION: What is the mechanism of acute hemolysis?
.
.
.
.
.
ANSWER:
- The mechanism of acute hemolysis is ABO incompatibility.
.
.
.
.
.
TRANSLATION:
Q: Where in the cell does translation of mRNA into proteins occur?
.
.
.
.
.
A: The process of decoding information on mRNA to synthesize proteins is called
translation. Translation takes place in ribosomes composed of rRNA and ribosomal
proteins.
ULCERATIVE COLITIS:
QUESTION: The risk of colon cancer in a patient who was diagnosed with ulcerative
colitis 20 years ago is approximately what percentage?
.
.
.
.
.
.
ANSWER
- Risk of malignancy increases with pancolonic disease and the duration of symptoms is
approximately 2% after 10 years, 8% after 20 years, and 18% after 30 years.
- Unlike sporadic colorectal cancers, carcinoma developing in the context of ulcerative
colitis is more likely to arise from areas of flat dysplasia and may be difficult to
diagnose at an early stage.
.
.
.
.
.
UMBILICAL HERNIAS:
QUESTION: What is the most important initial therapy for a patient with portal
hypertension, ascites, and a tense umbilical hernia?
.
.
.
.
.
.
ANSWER:
- Medical therapy to control the ascites.
- Treatment and control of the ascites with diuretics, dietary management, and
paracentesis is the most appropriate initial therapy.
- Patients with refractory ascites may be candidates for transjugular intrahepatic
portocaval shunting or eventual liver transplantation.
- Umbilical hernia repair should be deferred until after the ascites is controlled.
.
.
.
.
.
QUESTION: True or false: Most umbilical hernias in adults are congenital.
.
.
.
.
QUESTION: When should you offer operative repair to a patient with ascites secondary
to cirrhosis who presents for elective umbilical hernia repair?
.
.
.
.
.
ANSWER: You should offer repair to this patient if they are leaking ascites from the
hernia or at risk of doing so.
- One criterion supporting the surgical repair of an umbilical hernia is that patients are
leaking ascites, and thereby,placing them at higher risk of peritonitis..
- It is of utmost importance to minimize ascites preoperatively.
- Repair of an umbilical hernia without adequate control of ascites preoperatively
contributes to a 73% recurrence rate.
.
.
.
.
.
QUESTION: How do you manage ascites prior to umbilical hernia repair in a patient
with cirrhosis and ascites?
.
.
.
.
.
ANSWER: Medical control of ascites entails fluid and salt restriction, diuretics, and
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QUESTION: What operation can you perform prior to umbilical hernia repair in patient
with cirrhosis and ascites to reduce their ascites?
.
.
.
.
.
ANSWER: You can perform TIPS. Transjugular intrahepatic portosystemic shunt may
be used preoperatively to reduce the production of ascites.
.
.
.
.
.
.
QUESTION: What are the complications of umbilical hernia repair in patient with
cirrhosis and ascites?
.
.
.
.
ANSWER: Surgery on these patients is complicated by the risk of hemorrhage
secondary to variceal disruption, peritonitis, postoperative ascites leak, and hepatic
decompensation.
- Therefore,such a surgical undertaking should be considered only in select patients.
QUESTION: True or false: The repair of umbilical hernias in patients with cirrhosis is
associated with a high rate of recurrence.
..
.
.
ANSWER: True.
- The high rate of recurrence is secondary to the production of ascites and nutritional
deficiencies, resulting in muscular wasting and fascial thinning.
- Repair of an umbilical hernia without adequate control of ascites preoperatively
contributes to a 73% recurrence rate..
.
.
.
.
QUESTION: What percentage of patients with cirrhosis develop an umbilical hernia?
.
.
.
.
.
ANSWER: Up to 20% of patients with cirrhosis develop a hernia of the anterior
abdominal wall.
.
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UREMIA:
QUESTION: What is the treatment for uremic bleeding in a patient with chronic renal
failure?
.
.
.
.
.
ANSWER:
- The initial treatment for coagulopathy in chronic renal failure is DDAVP, which takes only 1 hour to take effect.
- The definitive treatment, if you have more time to spare (i.e. you do not need to perform an emergency operation and
there is no active bleeding), is hemodialysis.
- Other options include cryoprecipitate (has lots of vWF and factor VIII), erythropoietin, and estrogen.
.
.
.
.
.
QUESTION: What is the best test to assess risk of bleeding in patients with uremia?
.
.
.
.
ANSWER:
- The most useful laboratory test to assess both risk of bleeding and response to therapy in patients with uremia is
bleeding time.
QUESTION: The appropriate duration of antibiotic therapy for nosocomial urinary tract
infection is how many days?
.
.
.
.
ANSWER:
The presence of postoperative UTI should be considered based on urinalysis
demonstrating WBCs or bacteria, a positive test for leukocyte esterase, or a
combination of these elements.
- The diagnosis is established after more than 10^4 CFU/mL of microbes are identified
by culture techniques in symptomatic patients, or more than 10^5 CFU/mL in
asymptomatic individuals.
- Treatment for 3-5 days with a single antibiotic that achieves high levels in the urine is
appropriate.
- Postoperative surgical patients should have indwelling urinary catheters removed as
quickly as possible, typically within 1 to 2 days, as long as they are mobile.
VASODILATION:
QUESTION: What are the mediators of vasodilation?
.
.
.
.
ANSWER:
- The mediators associated with vasodilation are nitric oxide, prostacyclin, adenosine.
VITAMIN D:
QUESTION: The production of Vitamin D starts in which part of the body?
.
.
.
ANSWER: Vitamin D is made initially made in the skin
.
.
.
QUESTION: Once Vitamin D is made in the skin, where is it next processed and what
change is made to it?
.
.
.
ANSWER: Vitamin D is initiated in the skin, and then processed in the liver with the
modification of 25-OH.
.
.
.
QUESTION: After it leaves the liver, where is Vitamin D finalized, and what is the
modification done to it?
.
.
.
ANSWER: Vitamin D is made into its active form in the kidney. The modification is 1OH.
.
.
VITAMIN K:
QUESTION: True or false: The effects of vitamin K reversal take 48hr
.
.
.
.
.
ANSWER: The answer is FALSE.
- Patients who are receiving anticoagulant treatment with warfarin and who require
emergency surgery may be given plasma to immediately reverse the warfarin effect.
- Alternatively, vitamin K may be given orally or subcutaneously at least 6 hr
preoperatively to reverse the effect of warfarin on vitamin K dependent factors.
- The INR should be obtained again before surgery and, if it is not below 1.5, plasma
should be administered.
.
.
.
.
.
QUESTION: What are the vitamin K dependent factors?
.
.
.
ANSWER: Vitamin K dependent factors are II, VII, IX, and X; protein C and S. The
mnemonic is 1972.
.
.
.
QUESTION: True or false: Protein C is vitamin K dependent factor
.
.
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.
.
.
.
.
QUESTION: Which type of von Willebrand disease responds to ddAVP?
.
.
.
ANSWER: Type I and III have low amounts of vWF, responds to ddAVP
.
.
.
QUESTION: What is the other name for DDAVP?
.
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WARFARIN: COUMADIN:
QUESTION: True or false: Warfarin (coumadin) inhibits the activity of vitamin Kdependent factors (II, VII, IX, and X)
.
.
.
.
.
ANSWER: The answer is TRUE.
- With meticulous hemostatic technique, many operations can be performed on patients
with an INR greater than 1.5.
- Exceptions include operations on the eye or the prostate, neurosurgical procedures, or
a blind needle aspiration.
- In these cases, an INR of less than 1.2 is required.
- Patients who are receiving anticoagulant treatment with warfarin and who require
emergency surgery may be given plasma to immediately reverse the warfarin effect.
- Alternatively, vitamin K may be given orally or subcutaneously at least 6 hr
preoperatively to reverse the effect of warfarin on vitamin K dependent factors.
- The INR should be obtained again before surgery and, if it is not below 1.5, plasma
should be administered.
QUESTION: Which deficiency leads to skin necrosis after starting warfarin therapy?
.
.
.
.
.
ANSWER:
- The deficiency that leads to skin necrosis after starting warfarin is protein C deficiency.
.
.
.
.
.
QUESTION: Which drugs increase the effect of coumadin?
.
.
.
.
ANSWER:
- Drugs that affect coumadin metabolism by increasing its effect are cephalosporins, fluoroquinolones,
amiodarone, quinidine, etc.
.
.
.
.
.
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WOUND HEALING:
QUESTION: The peak number of fibroblasts in a healing wound occurs at what day
after injury?
.
.
.
.
ANSWER: The peak number of fibroblasts in a healing wound occurs 6 days after
injury.
.
.
.
.
.
.
QUESTION: What is the order of cell migration to a wound? Put these cells in the right
order: Fibroblasts, Macrophages, Platelets, PMNs
.
.
.
ANSWER: Cells to wound (in order): platelets, PMNs, macrophages, fibroblasts
(dominant by day 5)
.
ZENKERS DIVERTICULUM:
QUESTION: The most important step in treatment of a patient with a Zenker's
diverticulum is:
.
.
.
.
.
ANSWER:
- The most important step in treatment of Zenker's diverticulum is performing a
cricopharyngomyotomy.
- The anatomic problem with a Zenker's diverticulum is failure of the UES to relax with
swallowing.
- The diverticulum is usually resected but in some situations when the diverticulum
would be too hard to remove, it can be suspended upward such that it drains into the
esophagus.
.
.
.
.
QUESTION: What is the name of the triangle that Zenker's diverticulum occurs in?
.
.
.
ANSWER: Zenker's diverticulum occurs in Killians triangle
.
.
.
QUESTION: Is Zenker's diverticulum due to decreased pressure or increased pressure?
.
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REFERENCES
Schwartz's Principles of Surgery .
Rush Review of Surgery .
The Practice ABSITE Question Book .
PURCHASE KEY
DATE
KEY
10/07/13
723KY2023W-3262303JS-272-4MDY2-371-3N2-172-3WY1-3M
12/31/13
37452937363-37203S731-373-27937-312-3MD-382-3829-33