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What are the retroperitoneal structures?
- Suprarenal (aka adrenal glands)
- Colon (ascending and descending only)
What are the branches of the external carotid artery?
"Some Aggressive Lovers Favor Odd Positions More Stimulating"
- Superior thyroid
- Ascending pharyngeal
- Posterior Auricular
- Superficial temporal
What are the branches of the lumbar plexus?
- "I Instantly Get Laid On Fridays"
- "2 from 1, 2 from 2, 2 from 3"
- Iliohypogastric (L1)
- Ilioinguinal (L1)
- Genitofemoral (L1, L2)
- Lateral femoral cutaneous (L2, L3)
- Obturator (L2, L3, L4)
- Femoral (L2, L3, L4)
What are the carotid sheath contents?
"I See 10 cc's in the IV"
- IC: internal cartotid
- 10: vagus nerve
- cc: common carotid
- IV: internal jugular vein
What are the branches of the axillary artery?
"Screw The Lawyers Save A Patient"
- Superior thoracic
- Lateral thoracic
- Anterior circumflex humeral
- Posterior circumflex humeral
What are the dependent pouches of the abdomen where fluid, blood, and pus can collect?
- hepatorenal pouch (supine)
- rectouterine pouch (supine, semi-upright)
What are the 10 most common cancers in adults?
- 1. melanoma
- 2. colorectal adenocarcinoma
- 3. breast adenocarcinoma
- 4. prostate adenocarcinoma
- 5. lung adenocarcinoma
- 6. pancreastic adenocarcinoma
- 7. thyroid carcinoma
- 8. leukemia
- 9. endometrial carcinoma
- 10. renal cell carcinoma
What are the 10 most common cancers in children?
- 1. leukemia
- 2. CNS tumors
- 3. neuroblastoma
- 4. lymphoma
- 5. retinoblastoma
- 7. sarcomas
- 8. bone tumors
- 9. hepatoblastoma
- 10. germ cell tumors
What are the major indications for breast mass excision?
- mass >3cm
- mass growing in size (ultrasound)
- suspicious cytology, atypia
- patient request
What are the important points in HPI of patient with nipple discharge?
- unilateral or bilateral?
- sungle duct or multiple ducts involved?
- spontaneous or expressed?
- bloody or not bloody?
- appearance/color of discharge
What is the differential dx of bilateral milky spontaneous nipple discharge?
- direct nipple stimulation/irritation (e.g. new bra)
- recent lactation with ductectasia
- drugs (e.g. dopamine antagonists; pysch meds)
What are appropriate lab tests to work-up nipple dishcarge?
rule out: hypothyroidism, prolactinoma, pregnancy
- serum TSH levels
- serum prolactin levels
- urine HCG levels (if not premenopausal)
What is an acceptable dose of heparin for DVT prophylaxis?
5000 units BID or TID
What is the differential diagnosis of a pt with a lung cavity with air-fluid levels?
- infected cyst or bulla
- cavitating lung carcinoma
- locaulated empyema
- fungal infection
What clinical conditions commonly lead to a (primary) lung abscess?
- necrotizing pneumonia
- aspiration (stroke, alcoholism, seizure, esophageal disease)
- suppressed cough (stroke, ventilator)
- immunocompromised state (HIV, malignancy, chemo)
What is the chance that a new solitary lung nodule on CXR is malignant?
- 20-40% chance
- risk increases if smoker
What are the general histological types of lung cancer?
- Non-small cell lung carcinoma
- neuroendocrine neoplasms
- bronchial gland carcinomas
What are the general and individual histological types of lung cancer?
- non-small cell lung carcinoma:
- squamous cell
- broncheoalveolar carcinoma
- large cell carcinoma
- neuroendocrine neoplasms:
- classic carcinoid
- atypical carcinoid
- bronchial gland carcinomas:
- adenoid cystic carcinoma
- mucoepidermoid carcinoma
- mucous gland adenoma
What are the different kinds of renal stones based on composition?
- 80%: calcium (w/ oxalate or phosphate); radioopaque
- 10%: magnesium ammonium phosphate; opaque in alk urine
- 6-10%: uric acid; radiolucent (gout, post-chemo, myeloprolif.)
- 1%: cysteine (aut. recessive)
What are common causes of metabolic acidosis with a (high) anion gap?
- Diabetic Ketoacidosis
- Lactic Acidosis
- Ethylene glycol, Ethanol (alcoholoic KA)
What are the common causes of normal anion gap metabolic acidosis?
- Acetazolamide (and other carbonic anhydrase inhibitors)
- Renal Tubular Acidosis
- Uroenteric Fistula
- Pancreaticoduodenal fistula
What are the pathophysiological differences between high anion gap metabolic acidosis and normal anion gap metabolic acidosis?
- high anion gap = production of organic acids
- normal anion gap = production of chloride and/or excretion of bicarbonate
What are the normal antireflux mechanisms?
- barrier: LES
- clearance: esophageal clearance
- passageway: adequately functioning gastric reservoir
What are the operative indications for bowel obstruction?
- any large bowel obstruction
- incarcerated/strangulated hernia
- peritonitis/acute abdomen
- suspected strangulation
- closed loop obstruction
- complete obstruction
- always operate on virgin abdomen
When is it safe NOT to operate on a bowel obstruction?
- SBO due to adhesions
- no signs of strangulation
- obstruction due to adynamic ileus
What are the 4 cardinal signs of bowel strangulation?
- acute abdominal pain --> peritonitis
What are the most common causes of adynamic ileus?
- generalized peritonitis (e.g. perforated organ)
- acute pancreatitis
- electrolyte abnormalities (e.g. hypokalemia)
- postoperative ileus
- infection (e.g. diverticulitis, appendicitis, PID, sepsis)
- thoracic causes (e.g. pneumonia, fx ribs)
- retroperitoneal disorders (e.g. ureter, spine)
- drugs (e.g. opiates, CCB, psychotropics)
What are the most common causes of large bowel obstruction?
- colon cancer
What are the 3 main contributors to postoperative wound dehiscence with laparotomy?
- inadquate wound closure
- increased intra-abdominal pressure
- deficient wound healing
What are the BI-RADS categories?
- Breast Cancer nodules on Mammogram:
- I: definitely benign, annual screening
- II: probably benign, annual screening
- III: probably benign but could be malignant, f/u <1yr, 2% risk
- IV: suspicious for malignant, 23-34% risk
- V: probably malignant, 95% risk
- VI: definite malignancy already proven with biopsy
What are the most common causes of postoperative fever?
- "Wind, Water, Wound, Walk, Weird"
- POD #1: pneumonia, atelectasis
- POD #3: UTI (esp. with Foley)
- POD #5: wound infection
- POD #7: DVT
- POD #9+: abscess, drug reaction, transfusion rxn
What is the order of the "reconstructive ladder"?
- direct wound closure (primary, secondary)
- local flap
- distant flap
- free flap
What is the difference between a skin graft and a skin flap?
- graft = receives new blood supply from host
- flap = own vascular supply, more risk of rejection
What can cause/keep open fistulas?
- Foreign body
- Distal obstruction
What separates a thyroid adenoma from a thyroid carcinoma?
capsular and/or vascular invasion
What are important prognostic factors in well-differentiated thyroid cancer?
- Age (>45 yo)
- Extrathyroidal invasion
- Size (>4cm)
What are the methods of surveillance for recurrent thyroid cancer?
- Physical examination
- Thyroglobulin levels
- Radioactive iodine scan
What are the causes of hypercalcemia?
- calcium supplements
- hyperparathyroidism, +/- renal failure
- sarcoidosis/granulomatous disease
- paraneoplastic syndrome
- multiple myelosis
- adrenal insufficiency
- drugs (diuretics, thiazide, lithium)
- milk alkali syndrome
- Vit. D toxicity
- benign familial hypercalcemic hypocalciuria
- Paget's disease
What are the symptoms of hypercalcemia?
- "Bones, Stones, Thrones, Groans, and Moans"
- bones: fractures, osteoporosis
- stones: renal stones, renal colic, pancreatitis
- Thrones: polyuria, incontinence, constipation
- Groans: lethargy, depression, confusion, coma
- Moans: headache, myalgia, hyporeflexia
What are the symptoms of hypocalcemia?
- Neuro: circumoral parasthesia, depression, confusion, Chvostek's sign, Trousseau's sign, seizures
- MSK: tetany, hyperreflexia, cramps, osteomalacia
- CV: ECG changes, arrhythmia
What are the causes of hypocalcemia?
- Vit. D deficiency
- chelation of calcium
- osteoblastic metastases
- toxic shock syndrome
What are the common causes of hypoparathyroidism?
- pseudohypoparathyroidism (familial)
What are the indications for AAA surgical repair?
- >5.5. cm
- aortocaval fistula
- aortoenteric fistula
- increased growth rate
What are the recommendations for AAA screening/surveillance?
- all men >65 yo or >55 yo with FHx
- all women >65 yo with FHx or tobacco hx
- >3.5 cm: U/S 3 yrs
- 3.5-4.5 cm: U/S annually
- 4.5-5.5 cm: U/S 6 mo
What are the levels of the CEAP classification?
- classification of venous insufficiency severity:
- C0 = no evidence
- C1 = superficial/reticular spider veins only
- C2 = simple varicose veins only
- C3 = ankle edema (not foot edema)
- C4 = skin pigmentation in gaiter area (lipodermatosclerosis)
- C5 = healed venous ulcer
- C6 = open venous ulcer
What are the basic MVA injury history questions?
- seat belt used?
- air bags deployed?
- extraction and transport times?
What are the general concerns of MVA trauma?
- tension pneumothorax
- myocardial contusion
- injury to thoracic aorta
- intraabdominal injury
- ruptured diaphragm
What are the absolute indications for surgery in a pt with blunt injury following MVA?
- peritoneal signs
- hemodynamic instability with +FAST or +DPL
(relative indication: free fluid in abdomen on CT scan with no solid organ damage)
What are positive signs on a DPL?
- DPL = diagnostic peritoneal lavage
- RBC >100,000/uL
- WBC >500/uL
- increased amylase (vs serum)
- +bile, bacteria, food, stool
How can you clinically estimate amount of blood loss preop?
Class I: <15% of blood volume lost; vital signs are normal; slight anxiety.
Class II: 15-30% of blood volume lost; pulse >100 per minute; blood pressure normal; decreased pulse pressure; tachypnea; output 20-30 ml/hour; moderate anxiety; capillary refill time increased
Class III: 30-40% of blood volume lost; pulse >120; blood pressure decreased; respiratory rate 30-40/min; output 5-15 ml/hour; anxious and confused.
Class IV: over 40% of blood volume lost; pulse >140; blood pressure very low; narrow pulse pressure; negligible urine output; confused, lethargic.
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