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123 Cards in this Set
- Front
- Back
What is follow-up for patients with breast cancer?
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Patients should see their physician 2x a year. Annual CXR and LFTs. Patients with lumpectomy should get mammograms of affected breast every 6 months for 2 years and then yearly.
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What is the 5 year survivial for stage 1 cancer? Stage 2?
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Stage 1 = 93%
Stage 2 = 72% |
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What is the false negative rate for mammograms?
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From 7-20%
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Why is surgery necessary for DCIS? What kind of surgery is done?
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If lesions remain, the 10 year risk for invasive carcinoma is >30%.
For solitary lesion: lumpectomy and radiation - no need for nodes b/c mets are rare. Multifocal: Simple mastectomy |
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What is the treatment for LCIS? Why?
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Surveillance with mammograms every 6 months. Its a malignant disease marker with 15-20% 20 year risk of Cancer. There is NO risk of axillary mets.
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The most common cause of bloody discharge:
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intraductal papilloma - requires surgical biopsy
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After the diagnosis of breast cancer, which two tests should be done to detect metastasis?
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CXR and LFTs
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What is the primary blood supply to the breasts?
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Internal mammary and lateral thoracic
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This stage breast cancer is >2cm has no nodes and no mets.
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Stage I
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This stage breast cancer is <2cm with mobile nodes or 2-5cm with no nodes and no mets.
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IIA
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This stage breast cancer is 2-5cm with mobile nodes or 5+ cm with no nodes and no mets.
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IIB
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This stage breast cancer is 5+cm with mobile nodes or any size cancer with fixed nodes. May also have skin changes, retraction, and lymphadenopathy.
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III
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This stage breast cancer has distant mets
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IV
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What is the standard treatment for stage IV breast cancer?
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Palliative radiation and chemo. Surgery may be for debulking.
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What is the standard treatment for stage III breast cancer?
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Modified radical mastectomy with neoadjuvant therapy (condult radiologist)
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What is the 5 year survival for stage 3 breast cancer? Stage 4?
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Stage 3 = 41%
Stage 4 = 18% |
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What are the risks of a core needle biopsy of the breast?
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Pneumothorax, hematoma, and has a 20% false negative rate
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What are the risks of tamoxifen therapy?
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Increased risk of endometrial cancer (1.5%)
Osteoporosis, DVT, menopausal symptoms |
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What is the treatment for Her2Neu receptor positive Breast CA?
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Trastuzumab (Herceptin)
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What is Valentino's appy?
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Rupture of peptic ulcer that flows down the colic gutters
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Name ten things on on the DDX for RLQ pain:
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Appendicitis, diverticulitis, TOA, Hepatitis, mesenteric lymphadenitis, gastroenteritis, kidney stone, diverticulitis of cecum, PID, ectopic, UTI, IBD, Pancreatitis and PNA
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Describe the clinical appearance of SBO
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Patient is distended, air fluid levels seen on KUB, feculent vomit, typanic abd, dehydrated. Metabolic alkalosis with hypo K and hypo CL.
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If there is crohn's in the cecum why should you not take out the appendix?
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Because it may cause a fistula
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Name the 7 causes of a fistula:
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FRIENDS: Foreign body, Radiation, Infection, Epitheliazation, Neoplasm, Distal obstruction, Stones
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How do you manage a Crohn's SBO?
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First with medical management: NPO, bowel rest, TPN and observation. If not improved in 3 weeks, may need to resect affected colon with anastamosis.
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How do you manage peri-anal disease with Crohn's?
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Drain the peri-rectal abscess and place a seton (hollow plastic tube) in the fistula and give metronidazole
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How do you treat mesenteric lymphadenitis?
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IVF
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How do you treat supperative thrombophlebitis?
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Remove the focus on infection (catheter, section of vein), IV antibiotics, consider surgical intervention.
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28 year old presents with abdominal pain, elevated WBC and large tubular structure in the retroperitoneum after vaginal delivery:
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Suppurative Thrombophlebitis: treat with exploratory celiotomy- find the ovarian vein and excise it
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Why should you do an EKG with increased calcium levels?
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Can cause short QT intervals with prolonged PR
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What is the medical treatment for hypercalcemia?
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NS to dilute, diuresis with lasix. Then begin calcitonin, Mithramycin and bisohosphonates.
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Name eleven common causes of hypercalcemia:
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Hyperparathyroidism, Sarcoidosis, Vitamin A or D intoxication, Iatrogenic (thiazides), Milk alkali syndrome, metastatic cancer, Paget's disease, Addison's disease, neoplasm
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Name four ways to test for renal artery stenosis:
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Duplex the renal arteries, radioisotope renogram (arteriogram), hypertensive IVP
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What test would you do for Cushings?
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AM/PM cortisol levels and then a low dose/high dose dexamethasone to confirm (pituitary will have suppression with high dose)
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Name five causes of uncontrollable HTN:
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1. Cushing's syndrome
2. Renal artery stenosis 3. Conn's syndrome 4. Coactation of the aorta 5. Pheochromocytoma |
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What test would you do for a pheo?
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I-MIBG scan: scintography using iodine- if greater than 5cm = cancer
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What is the organ of zuckerandl?
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chrommafin body from neural crest cells located at the bifurcation of the abdominal aorta that can be the source of a pheo
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What is a pheochromocytoma?
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neural endocrine tumor of the adrenal medulla that secretes large amounts of catecholamines (epi and norepi)
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What is Conn's syndrome? Why does it cause HTN?
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aldosterone producing adenoma. Aldosterone causes the increased exchange of Na+ for K+ in the kidneys leading to hypernatremia and hypokalemia. Na+ retention leads to plasma volume expansion and hypertension:
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What ratio would you look at in Conn's syndrome?
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Renin: Aldosterone
If this ratio is > 30, this means that there is a lot of aldosterone and not very much renin |
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Name three imaging tests for Conn's:
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1. CT to localize tumor
2. Iodocholesterol scan: scintography of adrenal 3. selective venous sampling of adrenal vein to look for increased aldosterone |
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How do you treat Conn's?
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Spironolactone: it is an aldosterone antagonist
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How much does DCIS increase the risk for breast CA?
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35X
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What two options should be given to women with LCIS?
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Close follow up (6 month mammography) or bilateral simple mastectomy
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What is the Breslow level?
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Gives the five year survival for melaonoma by depth of invasion.
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What are the stages of the Breslow levels? What is the 5 year survival?
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I : >0.75mm >89% survival
II : 0.75-1.5 75% survival III : 1.5 - 2.5 58% survival IV: 2.5-4 46% survival V: >4mm 25% survival |
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What tests for mets should be done with a diagnosis of melanoma?
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LFTs and CXR
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If there is a melanoma of the face, what should be removed?
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The melanotic lesion with adequate margins. Do a superficial parotidectomy and modified radical neck dissection. Avoid the marginal mandibular branch of the facial nerve.
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What is the Halsted theroy of cancer?
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Remove the primary tumor with all lymph node drainage
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Change in mental status is due to ________ until proven otherwise:
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Hypoxia
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What are the two commmon causes of wound infection:
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Group D strep and clostridium
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An SpO2 of 70, 80, and 90 correspond to a PaO2 of what?
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40, 50, and 60. At a PaO2 of 60 the hemoglobin curve drops precipitously
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What size tube do you intubate with? Why? Where should it be placed?
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Size 8 tube becasue its the smallest a scope will fit down, tip of the tube should be 2cm above the carina, which is about the level of the clavicles.
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What is intermittent manditory ventillation?
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Has a predetermined rate but patients can breathe over the vent.
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What should initial vent settings be?
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10-15cc/kg, 10 breaths a min, FiO2 100% and weaned down to <60. PEEP of 5.
Change according to blood gas analysis |
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What are the benefits and draw-backs of PEEP?
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Its good because it keeps pressure in the lungs that keeps alveoli open but is bad because it can cause a PTX, it decreases venous return and cardiac output and can cause hypotension.
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If a patient is allergic to heparin but has a PE, what do you do?
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Place a greenfield or bird's nest filter in the IVC below the renal arteries.
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What is Homan's sign?
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A sign of DVT: pain in the calf with dorsiflexsion of the foot while the knee is at 90 degrees
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Signs of DVT:
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One large leg, Doppler legs, spiral contrast CT of chest
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What causes duodeal atresia?
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Vascular insult during development that causes failure of recannalization
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Why does a child with pyloric stenosis have aciduria?
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Due to intractable vomiting, kidneys save Na+ at the expense of H+. They don't exchange it for K+ because K+ is low and they're trying to save that too.
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What tests should be done for pyloric stenosis?
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U/S or upper GI with barium.
Gastrograffin is water soluble in the peritoneal cavity but causes pneumonitis. Barium is bad in the peritoneal cavity |
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What causes an inguinal hernia in children?
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Patency of the proccussus vaginalis
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What is a gastroschisis?
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Abdominal wall defect, no surrounding sac, not associated with other anomalies, small defect, diagnosed with prenatal U/S
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What is omphalocele?
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Abdominal wall defect in which the sac covers extruded viscera, associated with diapgragmatic defect, cardiac problems, pericardium and sternal cleft (Pentalogy of Cantrell)
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What pre-op medications are given to a patient undergoing CEA?
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Prophylactic antibiotics (foreign body), heparin, and dopamine to keep BP up. Give an alpha blocker pre-operatively and have nitro drip ready for HTN crisis.
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Why does a patient have a HTN crisis with CEA?
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Carotid body is clamped, body thinks you're hypotensive, releases signal to increase catecholes and blood pressure. Should inhibit carotid body with lidocaine.
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Why is a bowel prep important in repair of a AAA?
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Because you ligate the IMA which provides blood to watershed areas of the colon (splenic flexure). If there is ischemia of the bowel, patient gets ischemic colitis 2-3 days post-op. Translocation of bacteria will infect the graft.
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What preparation is important for a AAA repair:
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Get EKG and stress test, do pre-op antibiotics (foreign body) and bowel prep.
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What is Dieulafoy's ulcer?
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large tortuous ateriole in the stomach that erodes and bleeds and can cause gastric hemorrhage.
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What are options for AAA repair?
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1. Open repair with direct transabdominal approach
2. Retroperitoneal approach 3. Endograft repair |
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What is the major drawback of endovascular repair of AAA?
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Endoleak: occurs in 20% of patients. Need compliant patient for good followup.
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What is an aortoenteric fistula? What causes it?
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Fistula between the aorta and duodenum caused by slow growing graft infection with S. epidermidis.
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How do you approach fixing an aortoenteric fistula?
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Endoscopy in the OR, CT to look for gas bubbles or fluid, take out the infected graft, irrigate with betadine and perfirm exta-anatomic bypass (axillobifem)
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How do you prepare a patient pre-op for removal of a pheo?
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1. alpha blocker and then beta blocker
2. Intravascular tone will decrease - need swan ganz to measure wedge 3. Type and cross for the 3 adrenal veins 4. pressors, good IVs for fluids |
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What is MEN1?
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Tumos associated with menin gene defect: Pituitary, parathyroid and pancreas
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What is Men 2a?
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Tumors associated with the Thyroid, parathyroid, and adrenals
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Men2b:
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Tumors associated with submucosa, medullary thyroid, and adrenal
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Why do a trach if patient is on vent for > 2 weeks?
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To prevent tracheoinnominate fistula (bracheocephalic artery)
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What defibrillator settings are needed for V-fib?
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300 and have epi ready. This is for burn patients that may have arrythmias
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What should urine OP be in a burn patient?
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30cc/hr
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Why is myoglobin not good for kidneys? How do you fix this?
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It clogs the renal tubules. Flush with isotonic fluids and alkinalize the urine.
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Name 6 things to put on burns:
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1. Sulfamylon
2. Silvadene 3. Silver Nitrate 4. Bacitracin 4. Betadine 6. Acetic Acid |
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What are the drawbacks of sulfamylon?
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painful- irritates nerve endings
Causes metabolic acidosis because its a CA inhibitor |
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What are the drawbacks of silvadene?
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Transient neutropenia
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What are the drawbacks of silver nitrate?
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Metabolic alkalosis due to hypo K and hypo Na, turns everything black
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Name 6 ways to stop bleeding esophageal varices:
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1. sclerotherapy : using sodium morrhuate
2. Balloon tamponade 3. rubber band ligation 4. vasopressin 5. Somatostatin 6. Portocaval shunt |
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What causes hepatic encephalpathy? How do we test for it?
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Its caused by bacteria normally detoxified in the liver
Test for it by measuring arterial ammonia |
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What are Child's criteria?
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Predicts operative mortality in patient's with cirrhosis. Measures ascites, bili, albumin, and encephalopathy
A: no symptoms and no increased risk B: well controlled ascites, moderate lab values, 15% increase C: Ascites, encephalopathy, bad nurtrition, 40% mortality |
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What is TIPS?
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transjugular intrahepatic portosystemic shunt: stent placed intrahepatically between the hepatic vein and branch of the portal vein. Is a temporary bridge to transplant
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If a mass is detected at the head of the pancreas on CT, how do you biopsy it?
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Transduodenal biopsy so that leakage goes into the stomach
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Where is the head of the pancreas?
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Above the portal vein
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Whipple procedure removes what?
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distal 1/2 of the stomach (antrum), head of the pancreas, duodenum, gallbladder, cystic duct, common bile duct, proximal jejunum and regional lymph nodes.
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Whipple is also a good procedure for what other carcinoma?
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Cholangiocarcinoma (5 year survival is 40%)
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If pancreatic cancer is unresectable in a patient with symptoms, what can be done?
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Relieve biliary obstruction with a stend placed with ERCP.
Stents are frequently infected and need replacement q3 months. |
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Surgical solution to chronic pancreatitis?
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Roux en Y choledochojejunostomy: bypass from the CBD to the jejunum. This prevents alkaline gastritis.
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How do you medically treat alkaline gastritis
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Cholestyramine to decrease bile acid pool or Calcium to chelate bile acids
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What tests should be done to clincally stage colon cancer?
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CXR and LFTs and pre-op CEA level
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What preparation should be done for a bowel resection for colon cancer?
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Check labs, do bowel prep, give antibiotics (neomycin and erythromycin)
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What post-op test should be done 6 weeks s/p colon cancer resection?
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CEA
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Richter's hernia
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incarcerated or strangulated hernia involving one side of the bowel
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Littre's hernia
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hernia involving Meckel's diverticulum
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Spigelian hernia
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hernia through the linea semilunaris (spontaneous lateral ventral hernia)
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Pantaloon hernia:
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hernia sac is both direct and indirect and straddles the inferior epigastric vessels
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Grynfeltt's hernia
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hernia through superior lumbar triangle
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Petit's hernia
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hernia through inferior lumbar triangle
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Bochdalek's hernia
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hernia thorugh posterior diaphragm - usually left
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Morgagni;s hernia
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anterior parasternal diaphragmatic hernia
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Cooper's ligament
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pectineal line of pelvis
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Poupart's ligament
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attaches from the ASIS to the pubic tubercle
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Nissen
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wraps fundus 360 around LES
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Belsey Mark IV:
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270 degree wrap around the LES
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Toupe
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180 degree wrap around les
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hill repair
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posterior gastropexy: uses the arcuate ligament to re-establish the intra-abdominal position of the distal esophagus
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Collis-Nissen
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cut the stomach to lengthen the esophagus
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Heller Myotomy
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Used for achasia
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Bassini
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repair for inguinal hernia, sutures pouparts ligament to the transversus abdominus aponeurosis/conjoint tendon
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McVay
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Cooper's ligament sutured to transversus abdominis aponeurosis
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Wound infection in the first 24 hours is caused by
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Group D strep and Clostridium
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How do you kill clostridium
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PCN
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Treatment for acute hyperkalemia
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IV calcium is cardioprotective, sodium bicarbonate, glucose and insulin, albuterol, kayexalate, dialysis
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Name 6 complications after surgery
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1. Death
2. hemorrhage 3. loss of function 4. pain 5. scarring 6. Infection |
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The biggest risk of giving packed RBCs is _________
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bleeding- dilutional effect on platelets
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