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ABSITE 2021 Questions & Answers
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Nerve implicated in Frey syndrome — parasympathetic postganglionic fibers to parotid - ANSWERAuriculotemporal nerve Management recommendations for BRCA and don't want children or any more - ANSWERBSO, bilateral mastectomy, HRT until 50 Next step for spontaneous skin ulceration in arm in post modified radical mastectomy patient - ANSWERIncisional biopsy because likely lymphangiosarcoma/Stewart- Treves syndrome and therapy will be WLE +/- isolated limb perfusion First line treatment for acute limb ischemia of the lower extremity - ANSWERPercutaneous transluminal angioplasty unless long segment or multiple segments, then open approach Technique for SMA embolectomy - ANSWERTransverse incision of proximal SMA, just distal to middle colic, 2-3 fogarty proximal and distal, close with interrupted prolene Is BRCA1 or 2 higher risk for breast cancer? For ovarian cancer - ANSWERBRCA 1 for both Organism associated with human bites - ANSWEREikenella corrodens Organism associated with lymphangitis - ANSWERStrep pyrogenes Management for rhabdomyolysis - ANSWERIV fluids and alkalinization of the urine How is vitamin K synthesized in the body? - ANSWERColonic bacteria Anticoagulation recommendations for mechanical and bioprosthetic valves - ANSWERMechanical must be on vit K anticoagulant w/target INR for aortic and high risk mitral 3 and 2.5 for others, and add low dose asa if low bleeding risk. Surgical aortic: asa for 3 mo, and surgical mitral or tricuspid vit K anticoagulant x3 mo, and low dose asa indefinitely for these if low bleeding risk. Transcatheter aortic: dual anti- plt therapy 3-6 mo and low dose asa indefinitely Pathophysiology of gynecomastia - ANSWERDecreased androgen production and either increased estrogen production or estrogen precursors are the main cause. Also can have decreased androgen to receptor binding and increased androgen binding to sex hormone binding globulin
Octreotide mechanism of action for varices treatment - ANSWERSplanchnic vasoconstriction and decreases portal htn Liver abscess treated with flagyl - ANSWERAmoebic liver abscesses from entamoeba histolytica Liver abscess treated with albendazole - ANSWERHydratid liver cysts Treatment for resectable gallbladder carcinoma - ANSWERTis and T1a (invasion of lamina propria) chole is sufficient. T1b-T3 chole + 4b/5 hepatectomy, and regional lymphadenectomy pH changes by how much with a change in PaCO2 of 10 mmHg - ANSWER0. Contraindications for ketamine - ANSWERAngina/ischemic heart disease because it increases sympathetic nervous system increasing myocardial O2 consumption. Also contraindicated in space-occupying brain lesions and increased IOP MOA of desmopressin - ANSWERStimulates endothelial release of factor viii and vWF MOA of propranolol for asymptomatic prophylactic treatment of esophageal varices - ANSWERNon-selective beta blockers inhibit beta2 receptors inhibiting vasodilation is splanchnic circulation, and they decrease cardiac output with beta 1 blockade Pager-schroetter syndrome - ANSWERExercise induced thrombosis of the subclavian and axillary veins Pathway of beta 2 stimulation - ANSWERGPCR that activates cAMP Receptors that dobutamine activates - ANSWERBeta1 with low dose and beta higher doses SMA site of occlusion for embolic vs thrombotic etiology and pattern of ischemia - ANSWEREmbolic usually distal SMA and causes ischemia from mid-jejunum through transverse colon. Thrombotic is usually proximal SMA and causes ischemia from proximal jejunum through transverse colon. Embolic spares proximal jejunal branches Management of mediastinitis - ANSWEROpen debridement and pectoral muscle flaps What do you give for beta blocker overdose? - ANSWERglucagon What is first line treatment for diltiazem overdose? - ANSWERInsulin -- those refractory can be treated with lipid emulsion therapy or transcutaneous pacing
Enterochromaffin-like cells secrete what? - ANSWERHistamine Most common location for small bowel lymphoma - ANSWERIleum Where is the hernia sac most often located in an indirect inguinal hernia? - ANSWERDeep to the cremaster muscle, and anterior and superior to the spermatic cord structures Initial management of severe ulcerative colitis - ANSWERResuscitation, NG decompression, systemic steroids (either IV methylpred 20 mg q8 or hydrocortisone 100 mg q8), and +/- IV antibiotics (if fulminant colitis, toxic megacolon, peritoneal signs, and/or signs of systemic toxicity). Only operate if perforation, life threatening bleeding, toxic megacolon, fulminant colitis refractory to medical treatment Types of choledochal cysts and their treatment - ANSWER1) Fusiform dilation of the CBD (90%) -- treat with cyst excision and roux-y hepaticojejunostomy; 2) CBD diverticulum -- treat with cyst excision and closure of the choledochotomy; 3) CBD cyst within the duodenal -- transduodenal marsupialization or cyst excision; 4) multiple extrahepatic cyst +/- intrahepatic cysts (b); 5) Caroli's disease Volatile gas anesthetic with the least myocardial depression - ANSWERNitrous oxide, but doesn't produce enough anesthesia to be used as a single agent. Isoflurane the next best. Adverse effects of halothane - ANSWERHepatic necrosis and ventricular arrhythmias Non-depolarizing paralytic not metabolized by the liver or kidney - ANSWERAtracurium or its cis isomer cisatracurium -- ester hydrolysis and hoffman elimination Axon regeneration growth rate - ANSWER1-2 mm/day Treatment of cecal volvulus - ANSWERRight hemicolectomy and ileocolic anastomosis Treatment for acute limb ischemia - ANSWERIf Rutherford type IIa or less can attempt catheter-directed thrombolysis or if acute thrombosis of chronic disease, but if Rutherford type IIb an embolectomy should be done Best topical antimicrobial for burn MRSA infection - ANSWERMupirocin What is mafenide acetate good for? - ANSWERPseudomonas burn infection and eschar penetration
How does a slipped gastric band look on radiograph? - ANSWERBand is oriented horizontally vs. obliquely (45 degree angle) as it should and fundus is above the band How should the anastomosis btwn the stomach and pseudocyst be done for a cystogastrostomy? - ANSWERRunning suture with full-thickness bites What is included in the preoperative evaluation of a pt with lung cancer? - ANSWERPFTs, PET CT, and mediastinum evaluation either with EBUS or mediastinoscopy Most common site of metastasis for GIST - ANSWERliver Resection margins for a GIST - ANSWERGrossly negative Rate of hepatic artery thrombosis after liver transplant and presentation - ANSWERRate in adults: 5-15%; peds: 10-25%. If presents early: transaminitis and fulminant liver failure. If late, biliary strictures, hepatic abscesses, recurrent bacteremja — can great non-op temporarily but ultimately will need new transplant Trocar placement for lap appy in the second trimester - ANSWEREntry either open Hasson technique supraumbilical 10 mm or left upper quadrant for closer technique and then 5 mm at LLQ and RLQ Indications for resection of fibroadenoma - ANSWERIncreased cellularity, size > cm, anxiety over mass, rapid growth Most common cause of hypermagnesium and treatment - ANSWERRenal failure and treat like hyperkalemia with calcium gluconate or chloride for emergent severe, symptomatic and then increase excretion Surgical management for rectal carcinoid tumors - ANSWER How is a cholangiogram performed? - ANSWERA clip is placed btwn the infundibulum and the cystic duct, and then a linear incision is made in the cystic duct , and a cholangiocatheter is placed in the cystic duct and the biliary system is visualized via fluoroscopy Ischemic monomelic neuropathy - ANSWERRare complication after vascular access procedure, more common in women and diabetics, where blood flow is shunted away from the nerves distal to the arterioveneous fistula resulting in neurological defects. Pulses still present. Requires immediate fistula ligation Bethesda Criteria grading and respective management - ANSWER1: Nondiagnostic -- repeat FNA; 2: Benign -- follow-up with u/s in 6-12 mo; 3: Atypia or FLUS -- repeat FNA; 4: Follicular neoplasm -- lobectomy; 5: Suspicious for malignancy -- usually total thyroid; 6: Malignant -- total thyroid
Functions of the radial nerve - ANSWERextensor compartment of the forearm and sensation to radial 3 1/2 digits of the dorsal surface of the hand Functions of the medial nerve - ANSWERinnervates the anterior forearm (flexor) compartment and thenar muscles. Sensation to the radial 3 digits of the hand on the palmar side Functions of the ulnar nerve - ANSWERsensation to 1 1/2 digits and motor supply of the intrinsic hand muscles, ulnar portion of the flexor carpi ulnaris and ulnar two lumbricals Best way to access the aorta foot injury repair - ANSWERCattel-Brausch for infrarenal and mattox for suprarenal VIPoma are produced by what cell type and where are they located - ANSWERD cells in the pancreas; body and tail What are the incision for escharotomy of the chest to help with breathing with chest burns? - ANSWERBilateral axillary incision from chest to abdomen +/- transverse across at top and bottom to make a box Normal CVP, PWP, CI, and SVR - ANSWER Mechanism of action of mag sulfate as a tocolytic - ANSWERCompetitiveLy inhibits influx of calcium at the motor end plate Layers of the stomach - ANSWERMucosa, muscularis mucosa, submucosa, oblique muscle layer, circular, longitudinal, serosa What layer do you want to see protruding for a pyloromyotomy - ANSWERMucosa Siewart classification for GE junction tumors and their management - ANSWERI: 1- cm proximal to the squamocolumnar Z line and treated with subtotal esophagectomy and subtotal gastrectomy with regional lymphadenectomy; II: 1 cm proximal to Z line to 2 cm distal ("junctional carcinoma") and treat with total gastrectomy and partial esophagectomy with regional lymphadenectomy; III: 2 cm distal to 5 cm distal and same as treatment above (i think) Fourth degree burn - ANSWERInvolve deeper structures such as muscle and bone Fothergill's sign - ANSWERPalpable abdominal mass that remains unchanged with contraction of rectus muscles associated with rectus sheath hematoma Most common inherited thrombophilia - ANSWERFVL Disease most commonly associated with both venous and arterial thrombosis - ANSWERantiphospholipid syndrome
What is cleared more rapidly from the serum, lipase or amylase? - ANSWERAmylase is cleared more rapidly (<48 hr) vs lipase, which is elevated > hr Heerfordt syndrome - ANSWEROr uveoparotid fever -- manifestation of sarcoidosis and manifests as parotid swelling, uveitis, and facial nerve palsy. Biopsy reveals granulomas with focal central necrosis. Treatment is steroids Management of infected pleural space after pneumonectomy - ANSWEROpen drainage thoracostomy (Eloesser flap) and serial packing of the wound with 2-3x day dressing changes a day until sterilization, and then instill antibiotic solution and close chest primarily w/o a chest tube (Clagett method) McVay repair - ANSWER Gene in MRSA that confers ß-lactamase resistance - ANSWERmecA -- encodes a PCN-binding protein 5 yr survival for stage I, IIA, IIB, IIIA, B, C, IV Colon cancer - ANSWERI: 92%, IIA: 87%, IIB:63%, IIIA: 89%, IIIB: 69%, IIIC: 53%, IV: 11% but 40-50% if resectable liver or lung mets Indications for Mohs - ANSWERBCC, melanoma in situ w/5 mm margins, SCC, dermatofibrosarcoma protuberans Fetal circulatory path - ANSWEROxygenated blood goes from the placenta to the single umbilical vein into the IVC. Then goes to right atrium to left thru foramen ovale and blood in the pulm artery goes thru the ductus arteriosum to the the aorta then two umbilical arteries Bismuth-Corbett's classification for cholangiocarcinoma - ANSWERType I: common hepatic duct, II: bifurcation of common hepatic duct, III: secondary ducts of one side, IV: secondary ducts of both sides Primary site of urea production - ANSWERLiver; ammonia to arginine to urea Most common complication of lung transplant - ANSWERBronchiolitis obliterans Paget von schroetter syndrome and treatment - ANSWERVenous thoracic outlet syndrome or effort thrombosis that results in narrowing or occlusion of the subclavian and/or axillary vein. Treatment is initially catheter directed thrombolysis and eventually first rib resection Borders of inguinal canal - ANSWERInf: inguinal ligament; sup: conjoint tendon; anterior: external oblique aponeurosis; post: transversalis fascia Where is the weakness for a direct inguinal hernia - ANSWERTransversalis fascia
chemical dissolution (usually with Coke) but endoscopic removal if unsuccessful. If bezoars made of vinyl gloves, surgery Incretin effect - ANSWERThe augmentation of insulin secretion after oral glucose vs IV glucose GLP-1 and GLP-2 - ANSWERGLP-1 is a gut hormone that stimulates insulin secretion, gene expression, and beta cell growth. Together with gut hormone glucose-dependent insulinotropic polypeptide (GIP), they're responsible for the incretin effect. GLP-2 is an enteroendocrine peptide released in response to luminal nutrients and maintains small bowel adaptative responses to resection improves nutrient absorption Activity of gastrin - ANSWERActivates enterochromaffin cells to secrete histamine which stimulates acid secretion How long does it take for the stomach, small bowel, and colon take to regain function after abdominal surgery? - ANSWER24 hr, 3 days, and 5 days respectively Contraindications for strictureplasty - ANSWERMalnutrition, malignancy, multiple in a short segment, fistula/abscess, hemorrhagic stricture, excessive tension, perforation 2nd greatest cause of death after colorectal cancer in FAP pts - ANSWERDesmoid tumors Treatment for unresectable desmoid tumors - ANSWERHormonal therapy with tamoxifen +/- NSAIDs Preferred imaging modality for desmoid tumors - ANSWERMRI Levamisole MOA - ANSWERAt first anti-heminthic thru activating nACh receptors to cause nematode spastic contraction but also stimulates dendritic cell maturation and T cell activation MOA of doxorubicin - ANSWERTopoisomerase inhibitor Most common cause of exudative pleural effusion - ANSWERmalignancy Location and sx of somatostatinoma - ANSWERHOP and sx include abdominal pain and weight loss and some have diabetes/glucose intolerance, steatorrhea/diarrhea, cholelithiasis Treatment of esophageal leiomyoma - ANSWEREnucleation if symptomatic Management of an iatrogenic ureter injury - ANSWERIf within 7 days and good surgical candidate: primary repair. If after: nephrostomy tube or stent (stent can be used if there's still continuity)
When using the stomach as a conduit for esophagectomy, how can you get more length if needed? - ANSWERKocher maneuver -- medial rotation of the duo Gastroschisis and omphalocele location and etiology - ANSWERGastroschisis is located to the right of the umbilicus and etiology is unknown. Omphalocele is failure of closure of the umbilical ring and is thru the umbilicus PNETs that can be enucleated - ANSWERInsulinoma and gastrinoma <2 cm not abutting the pancreatic duct or not on the duo wall for gastrinoma Braden Walker grading of pressure ulcers - ANSWERI: Unblanching erythema; II: extends to dermis; III: Extends to subcutaneous tissue; IV: involves muscle, bone, or fascia. Unstageable has an eschar that needs to be removed to determine depth Management of blisters from frost bite - ANSWERIf stage II with clear or milky filled blisters: open and drain but if stage III: hemorrhagic and should be kept closed. stage II with clear or milky filled blisters: open and drain to release prostaglandins with needle aspiration but if stage III: hemorrhagic and should be kept closed as deeper injuries should not be uproofed Bassini repair - ANSWERClose the inguinal floor by suturing the conjoint tendon to the inguinal ligament from the pubic tubercle medially to the internal ring laterally McVay repair - ANSWERMesh-free repair that can repair femoral hernias too. Sutures the conjoint tendon to coopers ligament with last stitch incorporating the inguinal ligament Anti-Xa level that's within therapeutic range - ANSWER0.7 u/ml What is the Baux score and how do you calculate - ANSWERIt's a score that predicts mortality based off age, percent TBSA burned, and inhalation injury. =£TBSA + age + 17(inhalation injury, yes =1, no=0). 113 is LD Number of bronchopulmonary segments in each lung lobe - ANSWERLUL: 2, Apicoposterior and anterior; lingula: 2, superior and inferior; LLL: superior, anteriomedial, lateral, posterior; RUL: anterior, apical, posterior; Middle: medial, lateral; RLL: superior, medial, lateral, anterior, posterior Duct of Santorini vs Wirsung - ANSWERWirsung is the main pancreatic duct that drains into the major papilla inferiorly draining the uncinate and part of the head. Santorini is the accessory draining into the minor papilla superiorly the rest Pressure of the UES and LES at rest and during swallow - ANSWERUES at rest is 50-70 mmHg and 10-20 at rest. LES is 10-20 at rest and 0 with swallow First line treatment to reverse tPA and second line - ANSWER1st: cryo; 2nd: aminocaproic acid
Treatment for intersphincteric abscess - ANSWERInternal drainage and cutting of the internal sphincter Light's criteria - ANSWERPleural protein to serum ratio >0.5, pleural LDH to serum ratio of >0.6, and pleural LDH >2/3 of upper limit of normal How to repair a cardiac laceration - ANSWERPledgetted non-absorbable sutures in horizontal mattress to avoid coronary vessels Mortality rate for ruptured aortic aneurysm repair endovascularly and open? - ANSWER25% and 50% respectively Light's criteria - ANSWERpleural protein:serum protein of >0.5, pleural LDH to serum of 0.6, or pleural LDH 2/3 of upper limit of normal in serum How should a traumatic cardiac laceration be repaired - ANSWERPledgetted non- absorbable suture in a horizontal mattress fashion to avoid coronaries Positive DPL - ANSWERAspirate 10 ml of gross blood, enteric contents,bacteria. Instill 1 L of saline and get 100K RBCs, 500 mm^3 WBCs, elevated amylase, and again enteric contents and bacteria Margins for an extremity sarcoma - ANSWER2 cm When does collagen synthesis peak? - ANSWER21 days Which PNETs are more likely to be malignant? - ANSWERFunctional, glucagonoma, VIPoma Recommended margins for phyllodes tumors - ANSWER1 cm Treatment of encephalopathy in liver failure - ANSWERRifaximin will prevent formation of ammonia from decreasing bacteria in the gut that form ammonia or lactulose to increase excretion or decrease protein intake (60 g is recommended usually) Amount of overlap needed for mesh on normal abdominal wall for lap VHR - ANSWER4 cm Rotter nodes - ANSWERNodes btwn pectoralis muscles, can be site of metastatic spread for breast cancer Is radioactive iodine increased or decreased during acute thyroiditis? - ANSWERDecreased Most common site of perforation during colonoscopy - ANSWERSigmoid colon Does marasmus or kwashiorkor have anasarca - ANSWERKwashiorkor
Components of the fraility score, and what score is increased preop risk - ANSWERDecreased grip strength, weight loss >10 lb, slow walking speed, low energy expenditure, and self-reported exhaustion. ≥2 is increased risk Most common benign hepatic mass - ANSWERhemangioma Gardner Syndrome: associated findings and gene - ANSWERAssociated gene is APC. Characterized by adenomas throughout the GI tract (colon, ileal, duodenal) desmoid tumors, osteomas Treatment for ethylene glycol toxicity - ANSWERFomepizole to inhibit metabolism. Can also give etoh to competitively inhibit metabolism and dialysis What is the vascular supply and configuration of the CBD? - ANSWERBlood supply is segmental coming from branches of the cystic, hepatic, and gastroduodenal arteries, which meet to form collaterals that run in the 3 and 9 o'clock positions When do you increase the frequency of a medication? The amount? - ANSWERWhen the trough is low, and when the peak is low respectively Turcot Syndrome: gene and associated findings - ANSWERAPC, DNA mismatch repair. Colon adenomas and brain tumors (GM and medulloblastoma) Muir-Torre syndrome: associated gene and findings of syndrome - ANSWERhMLH1, hMSH2; sebaceous adenomas and colon cancer (can also have GU malignancies and BCC) Genes associated with juvenile polyposis - ANSWERSMAD4 and BMPR1A Compartments of the forearm - ANSWERSuperficial and deep flexor on the ventral aspect and extensor on the dorsal aspect Fluid resuscitation for electrical injuries - ANSWERKeep UOP 2 ml/kg/hr Obligate glucose users - ANSWERRBCs, WBCs, adrenal medulla, peripheral nerves von Willebrand Disease types and treatment - ANSWERI: mild deficiency; II: qualitative defect; III: near complete absence. I & II can be treated with vWF as first line; III should get factor VIII/vWF concentrate. Only type II is AD. How should femoral hernias be repaired? - ANSWERMost should be repaired with a tissue repair of the femoral canal, most common being McVay: suturing conjoint tendon to Cooper's ligament. Bismuth-Strasburg classification of bile duct injuries - ANSWERA: cystic duct leak or leak from small ducts of liver bed; B: occlusion of aberrant right hepatic duct; C: transection of aberrant right duct; D: partial (<50%) transection of major bile duct; E1:
