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326 Cards in this Set
- Front
- Back
What is the first step in work-up for thyroid nodule?
|
FNA
|
|
What is the cause of Grave's disease?
|
TSI (anti-TSH-receptor IgG)
|
|
What is the best medical management of Grave's disease?
|
MMI or PTU
|
|
What is the best definitive therapy for Grave's disease?
|
Radioablation (I131)
|
|
"What is the treatment of Grave's in a pregnant, allergic patient?"
|
Thyroidectomy
|
|
What is the biggest post-surgical complication of thyroidectomy?
|
Transient hypocalcemia
|
|
What is the biggest long-term complication of thyroidectomy?
|
Hypothyroidism
|
|
What are the treatments of thyroid storm?
|
"SSKI (Lugol's), MMI, beta-block"
|
|
"What is the diagnosis -- hyperthyroid symptoms, no exopthalmos or pretibial myxedema"
|
Toxic adenoma
|
|
What is the most common carcinoma of the thyroid? How does it spread?
|
Papillary. Lymph nodes (Palpable - P)
|
|
What is the second most common carcinoma of the thyroid? How does it spread? Catch to diagnosis?
|
Follicular. Blood. Can't use FNA (penetrates capsule).
|
|
What is the best medical treatment for metastatic thyroid cancer?
|
I131
|
|
What must be done in addition to excision for medullary thyroid cancer?
|
Lymph node dissection.
|
|
How can medullary thyroid cancer be followed?
|
Calcitonin levels.
|
|
What gene is blamed for medullary thyroid cancer?
|
RET
|
|
What is the most common cause of hypercalcemia in non-hospitalized pt? Hospitalized?
|
Hyperparathyroidism. Malignancy.
|
|
How can the cause of hyperparathyroidism be localized? Treatment?
|
Sestamibi scan. Parathyroidectomy.
|
|
What is the treatment of SECONDARY hyperparathyroidism?
|
Treat underlying problem… then parathyroidectomy of 3.5 glands.
|
|
"2 first treatments for dangerously high, acute hypercalcemia."
|
Large amount of peripheral IVF's + loop diuretic.
|
|
What is Cushing's DISEASE?
|
Pituitary adenoma producing ACTH
|
|
How can you diagnose Cushing's syndrome? How does Cushing's DISEASE differ?
|
"Dex-suppression test (not with low-dose, suppressed with high doses). Disease has high ACTH"
|
|
What is Conn's disease? What are some signs/symptoms?
|
"Primary hyperaldosteronism. HTN, hypokalemia, low renin levels."
|
|
What is the rule of 10's? What syndrome is this part of?
|
"Pheochromocytoma -- Familial, bilateral, malignant, children, extra-adrenal. MEN-2A/2B"
|
|
How can you make the diagnosis of pheochromocytoma?
|
Plasma-free metanephrines OR urinary metanephrine + normetanephrine + VMA
|
|
How are pt's treated medically before surgery for pheochromocytoma?
|
"Alpha-block --> beta-block (THIS ORDER), large amounts of fluid"
|
|
What is the treatment of an incidentaloma of the adrenal?
|
"If less than 3cm, check for Conn's, Cushing's, or pheochromocytoma with K levels, dex-suppression, catacholamines. Then CXR and CT scan to look for other tumors. If nothing, F/U CT in 6 months. If >3cm, remove because possible adrenal carcinoma."
|
|
What is MEN-1? MEN-2A? MEN-2B?
|
"Parathyroid (remove 3.5 glands), pituitary (PRL), pancreas (ZE, insulinoma, VIP). Thyroid (medullary), parathyroid, pheo. Same as 2A with MARFANOID habitus."
|
|
What is deficient in hereditary spherocytosis? Inheritance? Treatment?
|
Spectrin/ankyrin. Autosomal dominant. Splenectomy.
|
|
What is the primary treatment of ITP? What if non-responsive? What is the best indicator of long-term prognosis?
|
Steroids/immunosuppressives. Splenectomy if non-responsive or refractory to therapy. Initial response to steroid treatment.
|
|
"For a patient needing platelet transfusion during splenectomy for ITP, what is the ideal time to give?"
|
When spleen has been removed.
|
|
"What is a common physiologic response to splenectomy? At what level is it treated, and what is the treatment?"
|
"Thrombocytosis. >1E6, aspirin."
|
|
How long before splenectomy should pt's be immunized. What immunizations?
|
"~2 weeks. HIB, Pneumococcus, Meningococcus."
|
|
What is the most common post-op complication of splenectomy?
|
Atelectasis.
|
|
What is an easy way to screen whether splenectomy has been successful? What if it's not?
|
"Peripheral smear for spherocytes, Howell-Jolly, Acanthocytes, Target cells. Probably have accessory spleen."
|
|
What are some risk factors for breast cancer?
|
"Family history (esp. pre-menopausal), early menarche, late menopause, nullparous, radiation, BRCA, previous biopsy."
|
|
Signs of BRCA-1?
|
Breast + ovarian CA
|
|
Signs of BRCA-2?
|
Breast + male breast CA
|
|
What is the typical screening for breast CA?
|
"Yearly breast exam at 20, yearly mammography at 40"
|
|
What is the best radiographic test for palpable breast lesions? What if they are very fibrous?
|
US. Use MRI.
|
|
A pt shows up with microcalcifications associated with a breast mass. What is the next step? Follow-up?
|
"Core biopsy. If benign, f/u 6 months with mammogram."
|
|
What is the treatment for fibroadenoma?
|
"Biopsy, 6 month f/u, excise of growth"
|
|
How are brest cysts diagnosed? Treatment?
|
US. Asipration if painful/complex -- cytology if complex or bloody asiprate.
|
|
What is the most common cause of bloody nipple discharge? Treatment?
|
Intraductal papilloma. Subareolar duct excision.
|
|
What is the treatment of a breast abscess?
|
"US, I&D, abx, stop breast-feeding and pump."
|
|
"Non-lactating woman with red, painful, swollen breast. Treatment?"
|
"Inflammatory breast cancer. Chemo, THEN mastectomy."
|
|
Patient with 'eczema' of the nipple. Next step?
|
Paget's disease of the breast. Nipple biopsy.
|
|
Pt with isolated breast lump needs treatment. Most important prognostic indicator?
|
Lumpectomy + radiation = mastectomy. Lymph node involvement.
|
|
What is the surgery performed in an isolated breast lump with no palpable nodes? What if this is positive?
|
"Lumpectomy + sentinal node dissection. If sentinel node positive, must dissect axillary nodes too."
|
|
What patients with breast cancer get chemo? Who gets tamoxifen? What is its side effect?
|
Node+ or premenopausal. ER+. Blood clots.
|
|
What are some complications of axillary node dissection?
|
"Lymphedema, winged scapula (long thoracic nerve), numbness (intercostobrachial nerve), no adduction (thoracodorsal nerve)."
|
|
What are the 2 most common BENIGN liver tumors? Best visualization?
|
Hemangiomas and FNH. Arteriography.
|
|
Woman using OCPs has spot noticed on her liver. When to remove?
|
Hepatic adenoma. Resect always because RISK of rupture.
|
|
When should hemangiomas of the liver be removed?
|
If symptomatic or extrememely large.
|
|
What is the catch-word for FNH of the liver?
|
CENTRAL SCAR
|
|
What is the treatment of metastasis to the liver?
|
"Resection if <5, radioablation if >5"
|
|
What is the treatment of cystic neoplasms of the liver?
|
"RESECTION if thick walls, calcifications, or septated."
|
|
How are hydatid cysts of the liver diagnosed? What should NEVER be done? Treatment?
|
"Serology. Aspiration. Albendazole, maybe resection."
|
|
What is the treatment of liver pus?
|
"Drainage, insertion of drain, and abx."
|
|
A pt has a abscess that has 'anchovy paste' leaking from it. Treatment?
|
Amoebic abscess. Flagyl.
|
|
What is the medical treatment of symptomatic portal hypertension (ascites)? Surgical?
|
"Beta-block, salt/fluid restriction, lasix + spironolactone. TIPS"
|
|
What is the cause of hepatic encephalopathy? Treatment?
|
High ammonia levels. Protein restriction + lactulose.
|
|
What is the treatment for an acute variceal bleed?
|
Fluid resuscitation + somatostatin + EGD (sclerotherapy)
|
|
What is the treatment for a variceal bleed that has been treated once with EGD but recurs?
|
Fluid resuscitation + somatostatin + EGD (sclerotherapy)
|
|
What is the treatment for variceal bleeds that recur a 3rd time?
|
TIPS after baloon tamponade.
|
|
What are the 2 simple indications for liver transplant?
|
ESLD or fulminant liver failure.
|
|
What is the base cause of gallstone formation?
|
Supersaturation of cholesterol.
|
|
What is biliary colic?
|
Intermittent abdominal pain caused by transient obstruction of cystic duct.
|
|
How does acute cholecystitis differ from biliary colic?
|
Persistent pain caused by impacted cystic duct.
|
|
What is the triad for cholangitis?
|
"Jaundice, RUQ pain, fever/leukocytosis."
|
|
"What is the treatment for acute cholecystitis? What if the patient is septic, or too unstable for surgery?"
|
Lap chole. Percutaneously drain/decompress.
|
|
What is the best diagnostic test for biliary disease?
|
RUQ US
|
|
What diagnostic test for biliary disease can be done for an equivocal RUQ US?
|
HIDA scan (cholecystitis = non-filling of gallbladder)
|
|
What is the usual bug in infected acute cholecystitis?
|
E. coli.
|
|
What is the treatment for choledocholithiasis?
|
"ERCP FIRST, then lap chole."
|
|
What is the treatment for gallstone pancreatitis?
|
NPO + IVFs + analgesia --> possible ERCP --> lap chole when cleared up
|
|
Pt presents with evidence of SBO with air in the biliary tract.
|
Gallstone ileus.
|
|
What does a porcelain gallbladder mean?
|
REMOVE IT -- high incidence of malignancy
|
|
What is the treatment of gallbladder cancer?
|
"Lap chole. If invasion to liver, wedge resection of liver."
|
|
What is the treatment of cholangiocarcinoma of the hepatic bifurcation?
|
Only palliative stenting
|
|
Pt has painless jaundice and palpable gallbladder.
|
Carvosier's sign -- periampullary cancer.
|
|
What is pancreatic divisum?
|
Non-fusion of ventral and dorsal pancreas -- cause of chronic pancreatitis.
|
|
2 most common causes of acute pancreatitis.
|
Alcohol and gallstones.
|
|
Most common cause of mechanical pancreatitis.
|
Gallstones.
|
|
Pt has signs of pancreatitis and results of aspiration show necrotic tissue.
|
Surgical debridement.
|
|
When and how should a pancreatic pseudocyst be treated?
|
After 6 weeks for wall thickening. Ostomy to nearest structure.
|
|
When is surgical intervention required for chronic pancreatitis? Procedure?
|
"Intractable pain. Peustow (pancreaticojejunostomy) if chain-o-lakes, resection of no stricture."
|
|
What is the biggest risk factor for pancreatic CA?
|
Smoking.
|
|
What is the most common location of pancreatic CA?
|
Head of pancreas.
|
|
What is the most common cause of death after resection of pancreatic CA?
|
Recurrence of CA.
|
|
What is the most common cause of islet cell tumor?
|
Non-functioning!
|
|
How can ZE syndrome be diagnosed? What should be the next step?
|
High gastrin levels or rise in gastrin with secretin. Check for MEN-1 syndrome.
|
|
What cells do glucagonomas come from?
|
Alpha cells.
|
|
What is the best number to assess nutritional status?
|
Prealbumin (or albumin)
|
|
What is the number for normal protein requirment? What states raise it?
|
"1.5mg/kg/dy. Burns, sepsis, etc."
|
|
What is the normal calorie need?
|
~30kcal/kg/dy
|
|
What drives the catabolic state during stressful situations?
|
"Cortisol, cytokines, glucagon."
|
|
Why does muscle wasting occur?
|
The liver uses alanine for gluconeogenesis.
|
|
What is the normal RQ ratio? What makes it too high? What is the RQ ratio of fat?
|
0.8. All carb diet. Fat = 0.7
|
|
What kind of nutrition should be given to a patient with hypercholremic metabolic acidosis?
|
Lipids.
|
|
Pt has diarrhea with tube feeds.
|
"Dumping syndrome -- high osmotic load causes pull of water, high sugar, high insulin, then low sugar. Decrease feeds, make more feeds, decrease lipids."
|
|
What amino acid can both decrease sepsis and increase wound healing?
|
Arginine.
|
|
What is the nutritional treatment of a patient with post-op ileus?
|
NGT + 3% amino acids + extra glucose.
|
|
What type of hiatal hernia has high incidence of GERD? Diagnosis?
|
Sliding (type 1). Barium esophogram + EGD.
|
|
What type of hiatal hernia requires surgical treatment? Diagnosis?
|
"Paraesophageal (type 2). Requires EGD, but may suspect with CXR (air behind heart, or NGT above diaphragm)"
|
|
What exactly is achalasia? Diagnosis? Treatment options?
|
"Non-relaxation of LES with dysfunctional peristalsis. Barium swallow (bird's beak) + manometry + EGD. Dilatation, medical, then Heller myotomy."
|
|
What is the most common esophageal diverticulum? Cause? Treatment?
|
Zencker's. Non-relaxation of cricopharyngeus. Ligation of diverticulum + myotomy of cricopharyngeus.
|
|
What is a diverticulum in middle of esophagus called? Cause?
|
Traction diverticulum. Mediastinal inflammation.
|
|
What is the diagnosis in a pt with esophageal dysmotility + very smooth wall esophagus on barium swallow?
|
Scleroderma.
|
|
3 risk factors for squamous cell CA of esophagus? Adenocarcinoma?
|
"Smoking, drinking, nitrosamines. Barrett's."
|
|
What is the treatment of squamous cell CA of the esophagus?
|
"Ivor-Lewis procedure IF NO NODES. Otherwise, palliative care (e.g. stenting)."
|
|
What is the biggest cause of esophageal perforation?
|
"Iatrogenic (e.g. dilation, EGD)."
|
|
"Pt with severe mediastinal pain after retching, air/fluid levels in left chest and pneumomediastinum."
|
"Boerhaave's syndrome -- diagnose with GASTROGRAFFIN, then early repair and drainage."
|
|
What is the best way to evaluate the esophagus after ingesting a caustic agent?
|
EGD.
|
|
What types of ulcers are caused by acid hypersecretion?
|
Types 2 and 3.
|
|
What is the first step in evaluation of suspected ucler disease?
|
EGD and multiple biopsies.
|
|
What is the treatment of H. pylori?
|
Triple therapy for 2 weeks -- PPI + amoxicillin/clarythromycin/metronidazole. F/U in 6 weeks with fecal testing or breath testing + EGD.
|
|
What are some surgical indications for peptic ulcers?
|
"Persistent ulcers despite triple therapy, obstruction, perforation, penetration, bleeding."
|
|
What is the surgical procedure for peptic ulcer disease?
|
Antrectomy + selective vagotomy + Billroth-I/II.
|
|
What procedure must be performed if a patient receives TRUNCAL vagotomy?
|
Pyloroplasty.
|
|
"After vagotomy, what is the likely cause of persistent ulcer disease?"
|
"Criminal nerve of Grassi, branch of R Vagus."
|
|
Pt s/p antrectomy + vagotomy has diarrhea and sweating/shaking after meals.
|
"Dumping syndrome -- decrease carbs, increase fluids, increase number of feedings and decrease amount."
|
|
Pt s/p Billroth-I has persistent gastritis.
|
Alkaline reflux gastritis -- revise to Billroth-II.
|
|
What is the most common source of ulcer bleeds?
|
Gastroduodenal artery.
|
|
What is the indication for surgery from variceal bleeds? What if not a good surgical candidate?
|
Only after 2 tries of EGD. Can do angiography with embolization.
|
|
What is the quickest screening method for suspected abdominal perforation?
|
Upright or LEFT lateral decubitus films -- looking for free air under diaphragm or behind liver.
|
|
What is the surgical treatment of a perforated peptic ulcer? What if the patient has chronic ulcer disease?
|
"Oversewing + Graham's patch. If chronic disease, antrectomy + selective vagotomy."
|
|
What is the staging work-up for gastric cancer?
|
"CXR, CT-abdomen/pelvis, laparoscopy + peritoneal washings."
|
|
What is the treatment for GIST? Recurrence?
|
Resection. Imatinib.
|
|
What is the most common type of FUNCTIONAL iselt-cell tumor? What syndrome is it associated with?
|
Gastrinoma (ZE syndrome). Think of MEN-I.
|
|
What are 2 medical treatments of metastatic ZE?
|
PPI + octreotide.
|
|
What hormone signals hunger? From where? Satiety?
|
"Ghrelin, from stomach. Leptin, from adipocytes."
|
|
What are the indications for bariatric surgery?
|
Morbid obesity (BMI>40) or BMI>35 with comorbidities.
|
|
What is the best surgical option of bariatric surgery? What else should be done during procedure? Why? Complications?
|
"Roux-en-Y. Chole, weight loss precipitates stone formation. Anastamotic leak, DVT."
|
|
What structure is Meckel's diverticulum derived from?
|
Ompthalomesenteric duct (Vitelline).
|
|
What is the Rule of 2's?
|
"Meckel's diverticulum -- 2 feet from ileocecal valve, by 2 years old, 2:1 M:F, 2 inches in length, 2 types of tissue (gastric/pancreatic)."
|
|
Should Meckel's be removed if found incidentally?
|
NO.
|
|
What is a good treatment for perianal fistulas from Crohn's disease?
|
Remicade.
|
|
What is the most common presentation of Crohn's disease? Location?
|
Abdominal pain. RLQ (ileocecal).
|
|
What is the most common BENIGN small bowel tumor?
|
Leiomyoma.
|
|
What is the most common malignancy of the small bowel?
|
Adenocarcinoma.
|
|
What is the most common site of carcinoids? What is the treatment?
|
Appendix. Appendectomy if less than 2cm.
|
|
What does the carcinoid syndrome suggest?
|
Suggests metastasis to or past the liver (but also could be high level of 5HT).
|
|
What is the main cause of small bowel obstruction?
|
Abdominal adhesions.
|
|
How can ileus and obstruction be differentiated on film?
|
"Ileus will still have dilated loops and slow follow-through, but air will reach distal colon and rectum."
|
|
What is a good medical treatment for VIPoma?
|
Somatostatin.
|
|
When should a pt with familial polyposis be followed after EGD?
|
6 months with repeat
|
|
What is the most common cause of massive lower GI bleed?
|
Diverticulosis.
|
|
What is the treatment of uncomplicated diverticulitis? When is surgery required?
|
"Bowel rest, abx, IVFs. 2nd incident, less than 40-50, immunocompromised."
|
|
What is the surgical procedure for perforated diverticulitis?
|
Hartmann's procedure (sigmoidectomy + proximal colostomy + Hartmann's pouch).
|
|
What is the surgical procedure for FAP? What other syndrome has the same procedure?
|
Total proctocolectomy + ileal-anal pull-through. UC.
|
|
What is the most likely cause of occult anemia?
|
Right-sided colon cancers.
|
|
What is the main presenting symptom in left-sided colon cancers?
|
Bowel obstruction.
|
|
What is the procedure if you find liver spots during a colectomy for colon cancer?
|
"Biopsy the spots. If mets, can resect 2 months later if <5."
|
|
What is the most important prognostic indicator for colon cancer?
|
Lymph node involvement.
|
|
What is the treatment for rectal cancer?
|
Resection + chemoradiation for ALL tumors (high recurrence).
|
|
"Pt presents with obstructive symptoms, abdominal films show U-loop. Treatment?"
|
Sigmoid volvulus. Decompress with sigmoidoscopy. IVFs and bowel prep. Then resect when clean.
|
|
What is Ogilvie's syndrome?
|
Ileus without obstruction. Treat with NGT and bowel rest.
|
|
What is the treatment of 1st and 2nd degree hemorrhoids?
|
Bulking agents.
|
|
What is the treatment of 3rd degree hemorrhoids?
|
Rubber banding
|
|
What is the treatment of 4th degree hemorrhoids?
|
These are incarcerated -- must surgically resect.
|
|
What is the treatment of perianal abscesses?
|
I&D in the OR.
|
|
What is Goodsall's rule? What is the treatment of fistula-in-ano?
|
"Perianal fistulas anterior will open at the pectinate line at a straight radial line, and those posterior will open at the midline in a curved line. Surgical unroofing."
|
|
"A patient had severe pain when pooping, and noticed some BRB on the TP. What other physical finding is associated? Treatment?"
|
"Anal fissure. Skin tags. Bulking, Sitz baths, sphincterotomy."
|
|
What is the first step in work-up for thyroid nodule?
|
FNA
|
|
What is the cause of Grave's disease?
|
TSI (anti-TSH-receptor IgG)
|
|
What is the best medical management of Grave's disease?
|
MMI or PTU
|
|
What is the best definitive therapy for Grave's disease?
|
Radioablation (I131)
|
|
"What is the treatment of Grave's in a pregnant, allergic patient?"
|
Thyroidectomy
|
|
What is the biggest post-surgical complication of thyroidectomy?
|
Transient hypocalcemia
|
|
What is the biggest long-term complication of thyroidectomy?
|
Hypothyroidism
|
|
What are the treatments of thyroid storm?
|
"SSKI (Lugol's), MMI, beta-block"
|
|
"What is the diagnosis -- hyperthyroid symptoms, no exopthalmos or pretibial myxedema"
|
Toxic adenoma
|
|
What is the most common carcinoma of the thyroid? How does it spread?
|
Papillary. Lymph nodes (Palpable - P)
|
|
What is the second most common carcinoma of the thyroid? How does it spread? Catch to diagnosis?
|
Follicular. Blood. Can't use FNA (penetrates capsule).
|
|
What is the best medical treatment for metastatic thyroid cancer?
|
I131
|
|
What must be done in addition to excision for medullary thyroid cancer?
|
Lymph node dissection.
|
|
How can medullary thyroid cancer be followed?
|
Calcitonin levels.
|
|
What gene is blamed for medullary thyroid cancer?
|
RET
|
|
What is the most common cause of hypercalcemia in non-hospitalized pt? Hospitalized?
|
Hyperparathyroidism. Malignancy.
|
|
How can the cause of hyperparathyroidism be localized? Treatment?
|
Sestamibi scan. Parathyroidectomy.
|
|
What is the treatment of SECONDARY hyperparathyroidism?
|
Treat underlying problem… then parathyroidectomy of 3.5 glands.
|
|
"2 first treatments for dangerously high, acute hypercalcemia."
|
Large amount of peripheral IVF's + loop diuretic.
|
|
What is Cushing's DISEASE?
|
Pituitary adenoma producing ACTH
|
|
How can you diagnose Cushing's syndrome? How does Cushing's DISEASE differ?
|
"Dex-suppression test (not with low-dose, suppressed with high doses). Disease has high ACTH"
|
|
What is Conn's disease? What are some signs/symptoms?
|
"Primary hyperaldosteronism. HTN, hypokalemia, low renin levels."
|
|
What is the rule of 10's? What syndrome is this part of?
|
"Pheochromocytoma -- Familial, bilateral, malignant, children, extra-adrenal. MEN-2A/2B"
|
|
How can you make the diagnosis of pheochromocytoma?
|
Plasma-free metanephrines OR urinary metanephrine + normetanephrine + VMA
|
|
How are pt's treated medically before surgery for pheochromocytoma?
|
"Alpha-block --> beta-block (THIS ORDER), large amounts of fluid"
|
|
What is the treatment of an incidentaloma of the adrenal?
|
"If less than 3cm, check for Conn's, Cushing's, or pheochromocytoma with K levels, dex-suppression, catacholamines. Then CXR and CT scan to look for other tumors. If nothing, F/U CT in 6 months. If >3cm, remove because possible adrenal carcinoma."
|
|
What is MEN-1? MEN-2A? MEN-2B?
|
"Parathyroid (remove 3.5 glands), pituitary (PRL), pancreas (ZE, insulinoma, VIP). Thyroid (medullary), parathyroid, pheo. Same as 2A with MARFANOID habitus."
|
|
What is deficient in hereditary spherocytosis? Inheritance? Treatment?
|
Spectrin/ankyrin. Autosomal dominant. Splenectomy.
|
|
What is the primary treatment of ITP? What if non-responsive? What is the best indicator of long-term prognosis?
|
Steroids/immunosuppressives. Splenectomy if non-responsive or refractory to therapy. Initial response to steroid treatment.
|
|
"For a patient needing platelet transfusion during splenectomy for ITP, what is the ideal time to give?"
|
When spleen has been removed.
|
|
"What is a common physiologic response to splenectomy? At what level is it treated, and what is the treatment?"
|
"Thrombocytosis. >1E6, aspirin."
|
|
How long before splenectomy should pt's be immunized. What immunizations?
|
"~2 weeks. HIB, Pneumococcus, Meningococcus."
|
|
What is the most common post-op complication of splenectomy?
|
Atelectasis.
|
|
What is an easy way to screen whether splenectomy has been successful? What if it's not?
|
"Peripheral smear for spherocytes, Howell-Jolly, Acanthocytes, Target cells. Probably have accessory spleen."
|
|
What are some risk factors for breast cancer?
|
"Family history (esp. pre-menopausal), early menarche, late menopause, nullparous, radiation, BRCA, previous biopsy."
|
|
Signs of BRCA-1?
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Breast + ovarian CA
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Signs of BRCA-2?
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Breast + male breast CA
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What is the typical screening for breast CA?
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"Yearly breast exam at 20, yearly mammography at 40"
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What is the best radiographic test for palpable breast lesions? What if they are very fibrous?
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US. Use MRI.
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A pt shows up with microcalcifications associated with a breast mass. What is the next step? Follow-up?
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"Core biopsy. If benign, f/u 6 months with mammogram."
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What is the treatment for fibroadenoma?
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"Biopsy, 6 month f/u, excise of growth"
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How are brest cysts diagnosed? Treatment?
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US. Asipration if painful/complex -- cytology if complex or bloody asiprate.
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What is the most common cause of bloody nipple discharge? Treatment?
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Intraductal papilloma. Subareolar duct excision.
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What is the treatment of a breast abscess?
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"US, I&D, abx, stop breast-feeding and pump."
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"Non-lactating woman with red, painful, swollen breast. Treatment?"
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"Inflammatory breast cancer. Chemo, THEN mastectomy."
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Patient with 'eczema' of the nipple. Next step?
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Paget's disease of the breast. Nipple biopsy.
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Pt with isolated breast lump needs treatment. Most important prognostic indicator?
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Lumpectomy + radiation = mastectomy. Lymph node involvement.
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What is the surgery performed in an isolated breast lump with no palpable nodes? What if this is positive?
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"Lumpectomy + sentinal node dissection. If sentinel node positive, must dissect axillary nodes too."
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What patients with breast cancer get chemo? Who gets tamoxifen? What is its side effect?
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Node+ or premenopausal. ER+. Blood clots.
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What are some complications of axillary node dissection?
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"Lymphedema, winged scapula (long thoracic nerve), numbness (intercostobrachial nerve), no adduction (thoracodorsal nerve)."
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What are the 2 most common BENIGN liver tumors? Best visualization?
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Hemangiomas and FNH. Arteriography.
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Woman using OCPs has spot noticed on her liver. When to remove?
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Hepatic adenoma. Resect always because RISK of rupture.
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When should hemangiomas of the liver be removed?
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If symptomatic or extrememely large.
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What is the catch-word for FNH of the liver?
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CENTRAL SCAR
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What is the treatment of metastasis to the liver?
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"Resection if <5, radioablation if >5"
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What is the treatment of cystic neoplasms of the liver?
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"RESECTION if thick walls, calcifications, or septated."
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How are hydatid cysts of the liver diagnosed? What should NEVER be done? Treatment?
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"Serology. Aspiration. Albendazole, maybe resection."
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What is the treatment of liver pus?
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"Drainage, insertion of drain, and abx."
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A pt has a abscess that has 'anchovy paste' leaking from it. Treatment?
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Amoebic abscess. Flagyl.
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What is the medical treatment of symptomatic portal hypertension (ascites)? Surgical?
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"Beta-block, salt/fluid restriction, lasix + spironolactone. TIPS"
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What is the cause of hepatic encephalopathy? Treatment?
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High ammonia levels. Protein restriction + lactulose.
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What is the treatment for an acute variceal bleed?
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Fluid resuscitation + somatostatin + EGD (sclerotherapy)
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What is the treatment for a variceal bleed that has been treated once with EGD but recurs?
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Fluid resuscitation + somatostatin + EGD (sclerotherapy)
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What is the treatment for variceal bleeds that recur a 3rd time?
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TIPS after baloon tamponade.
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What are the 2 simple indications for liver transplant?
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ESLD or fulminant liver failure.
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What is the base cause of gallstone formation?
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Supersaturation of cholesterol.
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What is biliary colic?
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Intermittent abdominal pain caused by transient obstruction of cystic duct.
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How does acute cholecystitis differ from biliary colic?
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Persistent pain caused by impacted cystic duct.
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What is the triad for cholangitis?
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"Jaundice, RUQ pain, fever/leukocytosis."
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"What is the treatment for acute cholecystitis? What if the patient is septic, or too unstable for surgery?"
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Lap chole. Percutaneously drain/decompress.
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What is the best diagnostic test for biliary disease?
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RUQ US
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What diagnostic test for biliary disease can be done for an equivocal RUQ US?
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HIDA scan (cholecystitis = non-filling of gallbladder)
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What is the usual bug in infected acute cholecystitis?
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E. coli.
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What is the treatment for choledocholithiasis?
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"ERCP FIRST, then lap chole."
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What is the treatment for gallstone pancreatitis?
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NPO + IVFs + analgesia --> possible ERCP --> lap chole when cleared up
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Pt presents with evidence of SBO with air in the biliary tract.
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Gallstone ileus.
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What does a porcelain gallbladder mean?
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REMOVE IT -- high incidence of malignancy
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What is the treatment of gallbladder cancer?
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"Lap chole. If invasion to liver, wedge resection of liver."
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What is the treatment of cholangiocarcinoma of the hepatic bifurcation?
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Only palliative stenting
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Pt has painless jaundice and palpable gallbladder.
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Carvosier's sign -- periampullary cancer.
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What is pancreatic divisum?
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Non-fusion of ventral and dorsal pancreas -- cause of chronic pancreatitis.
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2 most common causes of acute pancreatitis.
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Alcohol and gallstones.
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Most common cause of mechanical pancreatitis.
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Gallstones.
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Pt has signs of pancreatitis and results of aspiration show necrotic tissue.
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Surgical debridement.
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When and how should a pancreatic pseudocyst be treated?
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After 6 weeks for wall thickening. Ostomy to nearest structure.
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When is surgical intervention required for chronic pancreatitis? Procedure?
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"Intractable pain. Peustow (pancreaticojejunostomy) if chain-o-lakes, resection of no stricture."
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What is the biggest risk factor for pancreatic CA?
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Smoking.
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What is the most common location of pancreatic CA?
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Head of pancreas.
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What is the most common cause of death after resection of pancreatic CA?
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Recurrence of CA.
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What is the most common cause of islet cell tumor?
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Non-functioning!
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How can ZE syndrome be diagnosed? What should be the next step?
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High gastrin levels or rise in gastrin with secretin. Check for MEN-1 syndrome.
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What cells do glucagonomas come from?
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Alpha cells.
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What is the best number to assess nutritional status?
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Prealbumin (or albumin)
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What is the number for normal protein requirment? What states raise it?
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"1.5mg/kg/dy. Burns, sepsis, etc."
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What is the normal calorie need?
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~30kcal/kg/dy
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What drives the catabolic state during stressful situations?
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"Cortisol, cytokines, glucagon."
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Why does muscle wasting occur?
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The liver uses alanine for gluconeogenesis.
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What is the normal RQ ratio? What makes it too high? What is the RQ ratio of fat?
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0.8. All carb diet. Fat = 0.7
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What kind of nutrition should be given to a patient with hypercholremic metabolic acidosis?
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Lipids.
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Pt has diarrhea with tube feeds.
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"Dumping syndrome -- high osmotic load causes pull of water, high sugar, high insulin, then low sugar. Decrease feeds, make more feeds, decrease lipids."
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What amino acid can both decrease sepsis and increase wound healing?
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Arginine.
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What is the nutritional treatment of a patient with post-op ileus?
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NGT + 3% amino acids + extra glucose.
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What type of hiatal hernia has high incidence of GERD? Diagnosis?
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Sliding (type 1). Barium esophogram + EGD.
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What type of hiatal hernia requires surgical treatment? Diagnosis?
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"Paraesophageal (type 2). Requires EGD, but may suspect with CXR (air behind heart, or NGT above diaphragm)"
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What exactly is achalasia? Diagnosis? Treatment options?
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"Non-relaxation of LES with dysfunctional peristalsis. Barium swallow (bird's beak) + manometry + EGD. Dilatation, medical, then Heller myotomy."
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What is the most common esophageal diverticulum? Cause? Treatment?
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Zencker's. Non-relaxation of cricopharyngeus. Ligation of diverticulum + myotomy of cricopharyngeus.
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What is a diverticulum in middle of esophagus called? Cause?
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Traction diverticulum. Mediastinal inflammation.
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What is the diagnosis in a pt with esophageal dysmotility + very smooth wall esophagus on barium swallow?
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Scleroderma.
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3 risk factors for squamous cell CA of esophagus? Adenocarcinoma?
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"Smoking, drinking, nitrosamines. Barrett's."
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What is the treatment of squamous cell CA of the esophagus?
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"Ivor-Lewis procedure IF NO NODES. Otherwise, palliative care (e.g. stenting)."
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What is the biggest cause of esophageal perforation?
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"Iatrogenic (e.g. dilation, EGD)."
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"Pt with severe mediastinal pain after retching, air/fluid levels in left chest and pneumomediastinum."
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"Boerhaave's syndrome -- diagnose with GASTROGRAFFIN, then early repair and drainage."
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What is the best way to evaluate the esophagus after ingesting a caustic agent?
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EGD.
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What types of ulcers are caused by acid hypersecretion?
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Types 2 and 3.
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What is the first step in evaluation of suspected ucler disease?
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EGD and multiple biopsies.
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What is the treatment of H. pylori?
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Triple therapy for 2 weeks -- PPI + amoxicillin/clarythromycin/metronidazole. F/U in 6 weeks with fecal testing or breath testing + EGD.
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What are some surgical indications for peptic ulcers?
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"Persistent ulcers despite triple therapy, obstruction, perforation, penetration, bleeding."
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What is the surgical procedure for peptic ulcer disease?
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Antrectomy + selective vagotomy + Billroth-I/II.
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What procedure must be performed if a patient receives TRUNCAL vagotomy?
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Pyloroplasty.
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"After vagotomy, what is the likely cause of persistent ulcer disease?"
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"Criminal nerve of Grassi, branch of R Vagus."
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Pt s/p antrectomy + vagotomy has diarrhea and sweating/shaking after meals.
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"Dumping syndrome -- decrease carbs, increase fluids, increase number of feedings and decrease amount."
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Pt s/p Billroth-I has persistent gastritis.
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Alkaline reflux gastritis -- revise to Billroth-II.
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What is the most common source of ulcer bleeds?
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Gastroduodenal artery.
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What is the indication for surgery from variceal bleeds? What if not a good surgical candidate?
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Only after 2 tries of EGD. Can do angiography with embolization.
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What is the quickest screening method for suspected abdominal perforation?
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Upright or LEFT lateral decubitus films -- looking for free air under diaphragm or behind liver.
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What is the surgical treatment of a perforated peptic ulcer? What if the patient has chronic ulcer disease?
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"Oversewing + Graham's patch. If chronic disease, antrectomy + selective vagotomy."
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|
What is the staging work-up for gastric cancer?
|
"CXR, CT-abdomen/pelvis, laparoscopy + peritoneal washings."
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What is the treatment for GIST? Recurrence?
|
Resection. Imatinib.
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What is the most common type of FUNCTIONAL iselt-cell tumor? What syndrome is it associated with?
|
Gastrinoma (ZE syndrome). Think of MEN-I.
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What are 2 medical treatments of metastatic ZE?
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PPI + octreotide.
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What hormone signals hunger? From where? Satiety?
|
"Ghrelin, from stomach. Leptin, from adipocytes."
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What are the indications for bariatric surgery?
|
Morbid obesity (BMI>40) or BMI>35 with comorbidities.
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What is the best surgical option of bariatric surgery? What else should be done during procedure? Why? Complications?
|
"Roux-en-Y. Chole, weight loss precipitates stone formation. Anastamotic leak, DVT."
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What structure is Meckel's diverticulum derived from?
|
Ompthalomesenteric duct (Vitelline).
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What is the Rule of 2's?
|
"Meckel's diverticulum -- 2 feet from ileocecal valve, by 2 years old, 2:1 M:F, 2 inches in length, 2 types of tissue (gastric/pancreatic)."
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Should Meckel's be removed if found incidentally?
|
NO.
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What is a good treatment for perianal fistulas from Crohn's disease?
|
Remicade.
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What is the most common presentation of Crohn's disease? Location?
|
Abdominal pain. RLQ (ileocecal).
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What is the most common BENIGN small bowel tumor?
|
Leiomyoma.
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What is the most common malignancy of the small bowel?
|
Adenocarcinoma.
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What is the most common site of carcinoids? What is the treatment?
|
Appendix. Appendectomy if less than 2cm.
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What does the carcinoid syndrome suggest?
|
Suggests metastasis to or past the liver (but also could be high level of 5HT).
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What is the main cause of small bowel obstruction?
|
Abdominal adhesions.
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How can ileus and obstruction be differentiated on film?
|
"Ileus will still have dilated loops and slow follow-through, but air will reach distal colon and rectum."
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|
What is a good medical treatment for VIPoma?
|
Somatostatin.
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When should a pt with familial polyposis be followed after EGD?
|
6 months with repeat
|
|
What is the most common cause of massive lower GI bleed?
|
Diverticulosis.
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What is the treatment of uncomplicated diverticulitis? When is surgery required?
|
"Bowel rest, abx, IVFs. 2nd incident, less than 40-50, immunocompromised."
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|
What is the surgical procedure for perforated diverticulitis?
|
Hartmann's procedure (sigmoidectomy + proximal colostomy + Hartmann's pouch).
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|
What is the surgical procedure for FAP? What other syndrome has the same procedure?
|
Total proctocolectomy + ileal-anal pull-through. UC.
|
|
What is the most likely cause of occult anemia?
|
Right-sided colon cancers.
|
|
What is the main presenting symptom in left-sided colon cancers?
|
Bowel obstruction.
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|
What is the procedure if you find liver spots during a colectomy for colon cancer?
|
"Biopsy the spots. If mets, can resect 2 months later if <5."
|
|
What is the most important prognostic indicator for colon cancer?
|
Lymph node involvement.
|
|
What is the treatment for rectal cancer?
|
Resection + chemoradiation for ALL tumors (high recurrence).
|
|
"Pt presents with obstructive symptoms, abdominal films show U-loop. Treatment?"
|
Sigmoid volvulus. Decompress with sigmoidoscopy. IVFs and bowel prep. Then resect when clean.
|
|
What is Ogilvie's syndrome?
|
Ileus without obstruction. Treat with NGT and bowel rest.
|
|
What is the treatment of 1st and 2nd degree hemorrhoids?
|
Bulking agents.
|
|
What is the treatment of 3rd degree hemorrhoids?
|
Rubber banding
|
|
What is the treatment of 4th degree hemorrhoids?
|
These are incarcerated -- must surgically resect.
|
|
What is the treatment of perianal abscesses?
|
I&D in the OR.
|
|
What is Goodsall's rule? What is the treatment of fistula-in-ano?
|
"Perianal fistulas anterior will open at the pectinate line at a straight radial line, and those posterior will open at the midline in a curved line. Surgical unroofing."
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|
"A patient had severe pain when pooping, and noticed some BRB on the TP. What other physical finding is associated? Treatment?"
|
"Anal fissure. Skin tags. Bulking, Sitz baths, sphincterotomy."
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