ABSITE Review

Introduction

This information is based questions that I have gotten wrong in the past.

Body as Whole

Clinical Management

1. Etiology of hyponatremia in pancreatitis

Third spacing of fluids causing hyponatremia, hypovolemia. Renal losses Una < 20 mEq/l, Uos > 400.

2. Rx of complicated reduction of incarcerated inguinal hernia

3. Antibiotics for pelomorphic gram-positive rods.

C. diphtheriae – exotoxin – tx with high dose PCN.

4. Antmicrobial associated acidosis -

Acute Interstitial Nephritis (AIN)caused by PCN and cepholosporins.

5. {2000} Dx of obturator hernia

Sx. of bowel obstruction, pain and paresthesia of the anterior thigh, older pts with weight loss.Howship-Romberg test, extension and abduction of the thigh produce pain along the medial thigh to the knee

6. {2000} Hypophosphatemia of Refeeding

Refeeding hypophosphatemia occurs commonly in critically ill patients in the ICU. Starvation for a period as short as 48 hours and poor nutritional status predispose to this syndrome. There is rapid uptake of glucose, potassium, phosphate and magnesium into cells. The serum concentration of these agents falls dramatically. In addition, for an unexplained reason, the body swiftly begins to retain fluid, and the extracellular space expands.

7. Treatment of Ventillatory Complications in Burn Victim

8. Diagnostic Tests for a soft tissue sarcoma of thigh

MRI, core biopsy, incisional biopsy longitudinally.

9. Metal Absorbtion post Whipple

proximal small intestine responsible for metal aborption.

10. Treating Hyperkalemia s/p AAA Repair

acute renal failure, follow for EKG changes, Calcium gluconate, kayaxalate, glucose, insulin, bicarb

10.1 ATN

FeNa > 3

Uosm < 350

11. Etiology of hypokalemia in gastric outlet obstruction. (Chloride Responsive)

PUD, gastric polyps, ingestion of caustics, pyloric stenosis, congenital duodenal webs -->

GOO --> vomiting --> dehydration, chloride loss, H+ loss, --> Aldosterone increased -->

increased Na+ resorption at expense of K+ and protons--> increased K losses, increased alkalosis --> shift of K out of cells, Paradoxical Aciduria. Replace with NaCl.

12. Treatment of hyperkalemia

Symptomatic - > Calcium gluconate, calcium carbonate, glucose and insulin

13. Etiology of Succinylcholine induced hyperkalemia

Worse in situation where acetylcholine receptors are up regulated. Duchenne Muscular Dystrophy, Burns, upper motor neuron lesions, spinal cord injuries. muscular trauma- abnormal muscle and rabdo.

14. Tetanus Prophylaxis

15. Hypomagnesemia

apathy, depression, seizures, muscle weakness, tetany, Trousseau's Sign, Chvostek Sign, arrhythmias, a. fib, coronary spasm.

Hard to correct hypokalemia in setting of hypophosphatemia, hypomagnesemia.

16. Complications of Protamine reversal of heparin.

Anaphalactic shock. Vasodilation. hypotension, bradycardia

17. Estimating Blood Loss from hematachezia

Class I <= 15% blood loss - minimal tachycardia

Class II 15-30% blood loss – tachycardia, pulse pressure down, DBP up.

Class III 30-40% blood loss - tachycardia, Mental status changes, SBP down.

Class IV >40% blood loss - life threatening, SBP down, DBP down.

18. Common Effect of Benzodiazepines

paradoxical stimulation

19. Conditions associated with Normal Anion Gap Acidosis: a.k.a. Hyperchloremic Acidosis

Anion Gap = Na⁺ - (Cl^- + HCO₃^-) nl (10-18)

a. diarrhea

b. Renal Tubular Acidosis

Type I: Distal Type – inability to main proton gradient in distal tubules

Type II: Proximal Type – Loss of Bicarb, part of Fanconi Syndrome

Type IV: Hyperaldosteronism, increased renin, volume depletion, hyponatremia, hyperkalemia

c. Carbonic Anhydrase

d. Excessive NS rehydration

e. Administration of HCL

20. Conditions associated with Increased Anion Gap Acidosis. MUDPILES.

M. Methanol

U. Uremia

D. Diabetic Ketoacidosis – increased serum beta-hydroxybutyric acid and acetoacetic acid

P. Paraldehyde

I. Infection

L. Lactic Acidosis

E. Ethylene Glycol

S. Salicylates

21. Spinal cord Injury

Anterior Spinal Cord: Motor (cross high), Pain (cross low), Temperature (cross low)

Posterior Spinal Cord: Positional (cross high) and Vibratory Sense (cross high)

21.1 Anterior Spinal Syndrome

Bilateral loss of

22. Chemotherapies

23. Tumor Lytic Therapy: Use of IL-2 to increase NK cells and cytotoxic T-cells to lysis tumors.

Basic Science

1. Parathormone related hypercalcemia and breast CA

PTH-related protein

2. Transmission of nociceptive stimuli

Substance P working on the dorsal horn and spinal cord

3. Mechanism of Aminoglycoside (Gentamicin, Tobramicin) Antiobiotic (binds irreversibly to 30s Ribosome) Resistance results from modification of the the drug. Bacterialcidal.

Clindaycin, tetracycline, erythromycin reversibly bind to ribosome – Bacterial Static

Clindamycin prolongs nueromuscular blockade

4. Mechanisms of altered immunity post-splenectomy.

Encapsulated Bacteria ( H. influenza, N. menigiditis, Strep. Pneumonia), decreased efficiency of opsinization

5. Renal Transplant Donor/Recipient Compatibility

ABO Compatibility

Cross Match to make sure recipient does not have HLA antibodies to against the donor lymphocytes

6. Adoptive Immunotherapy for Tumors

A technique for artificially improving cell-mediated immunity by either artificially increasing the number of specific immunocompetent cells or by altering tumor cells to make them more immunogenic.

IL-2 increasing tumor specific T-cells.

7. Characteristics of Ultrasound Probes

High energy gives greater resolution but decreased penetration.

8. Characteristics of Heparin

enhances ATIII activity

9. Characteristics of Hepatic Acute Phase Response

elevated levels of TNF, IL-6

10. Characteristic multi-drug microbial resistance

11. Definition of Prevalence

Prevalence: The number of people with disease X at a given time.

Incidence: the number of new cases of a diseases or condition in a specific population over a given period of time

11.5 Sensitvity and Specificity

Prevalence = (TP+TN)/(TP+TN+FP+FN)

Sensitivity = TP/(TP+FN)

Specificity = TN/(FP+TN)

Positive Predictive Value = TP/(TP+FP)

Negative Predictive Value = TN/(FN+TN)

12. Infection Associated with defects in cell-mediated immunity.

Viral and bacteria that reside within cells.

13. Malignant Hyperpyrexia = Malignant Hyperthermia

Rapid rise in temperature, hypermetabolism, muscular rgidity

Mutation in the calcium channel of skeletal muscle sacroplasm reticulum.

Triggered by succinylcholine, inhalation agents.

First sign is rising CO₂

Treat with dantrolene

14. Differential of acute renal failure/prerenal azotemia

15. Characteristic of glucose metabolism in GM-neg sepsis.

Initially Insulin dependent uptake leads to hyperglycemia. Hypoglycemia is a late finding.

16. Immunoglobulins found in breast Milk

IgA

17. Characteristic of disseminated intravascular coagulation.

D-dimer elevated

Antithrombin III down

Platelet count down

PT can go either way

Tx: Heparin anticoagulation, Blood products (RBC, platelets, FFP, cryoprecipitate)

18. Asystole due to succinylcholine – Give Atropine

succinycholine: depolarizing neuromuscular blockade causes hyperkalemia leading to cardiac arrest.

Recall Non-depolarizing agents include the “-curoniums” which compete with acetylcholine and are prolonged by aminoglycosides, clindamycin, and tetracyclin.

19..Thromboxane A2 – wound healing

( http://www.emedicine.com/plastic/topic457.htm)

Inflammatory Phase

Thromboxane A2: vasoconstrictor

platelets,

EGF, fibrinogen, histamine, PDGF

neutrophils

leukocytes and macrophages (collegenases, TNF, interleukins)

Proliferative Phase (angiogenesis, epithelialization, granulation tissue)

fibroblasts (collagen

Maturation Phase (contraction)

collagen deposition peaks at 21 days

20. Producer of Von Willebrand S Factor

endothelial cells. VWF binds to platelet glycoprotein Ib

Tx VW dz with desmopressin.

21. Fuel source of neoplastic cells.

Glutamine – fuel source for rapidly growing cells like neoplastic cells, enterocytes, macrophages etc..

22. Anesthetic Complications of Insulin-dependent diabets.

Increased likelyhood of CAD. Possible electrolyte abnormalities.

23. Mediator of Neutrophil Adherence.

Integrins mediate neutrophil adherence. Dapsone may inhibit this. Use Dapsone for Brown recluse Spider.

24. Factors that prolong PT.

Drugs that prolong the prothrombin time – inhibit C₄₅₀.

Allopurinol Disulfiram Omeprazole Amioradone Erythromycin Phenylbutazone Anabolic steroids Fluconazole Piroxicam Cephalosporins Isoniazid Quinidine Chloramphenicol Ketoconazole, Sulfinpyrazone Cimetidine KetoprofenTamoxifen Clofibrate Metronidazole Thyroxine Co-trimazole Naproxen Trimethoprim sulfamethoxazole

Drugs that reduce the prothrombin time– up regulate C₄₅₀

Barbiturates Colestipol Rifampin Carbamazepine Gluthetimide Vitamin K, Cholestyramine Griseofulvin

25. Tumor Marker with greatest sensitivity.

PSA – this is the only one used for screening these days.

26. Characteristics of Anesthetic Agents

Local Anesthetic: esters vs. amides.

Amides: Lidocaine, bupivicaine, mepivicaine, etidocaine - frequent allergies.

Lidocaine overdose: Initial sx are neurologic (excitatory), subsequently CNS depression, Also cardiogenic.

Esters: procaine, cocaine, tetracaine,

In effective in acidic conditions.

Inhaled Anesthetic:

Methoxyflurane: Causes renal dysfunction b/c fluoride molecule

Halothane: hepatotoxicity

27. Primary Substrate of Gluconeogenesis

Pyruvate. Pyruvate can be made from alanine or lactate

28. Characteristics of B lymphocytes.

Stimulated by IL-4 to make antibodies.

29. Blind Loop sydrome --> Bacterial overgrowth --> poor B₁₂ absorption.

30. Lung Squamous Cells Cancer – associated with hypercalcemia by a neoplastic effect. Also be aware of Pancoast Tumors causing Horner's Syndrome (enophthalmos, ptosis, meiosis, and ipsilateral dyshidrosis ).

31. Fetal w/tins: cell-cell adhesion molecules for leukocytes-endothelial interactions.

33. GIST: Size is the most significant prognostic factor.

34. Cell-mediated Immunity: required to fit opportunistic infections. Viruses and intracellular bacteria. (Pneumocystis carinii, fungal infections)

Gastrointestinal

Clinical Management

1. Treatment and Prognosis of Colon CA mets to Liver.

Remove mets if no more than 3 mets in same part of liver, away from major vessels.

Cryo – if not near major vessel that acts as a heat sink.

Radiofrequency ablation if not near a vessel.

2. Hematogenous Spread of CA to Small Bowel

Hematogenous--melanoma, breast, lung, Kaposi

3. Perforated esophageal CA

Operate

4. Diagnosis of acute gastric dilatation

bezoar, volvulus,

5. Treatment of benign esophageal stricture.

Balloon dilation

6. Treatment of c. difficile in pregnancy

PO Vanco

7. Diagnostic test for GB symptoms w/o stones

HIDA Scan

8. Diagnostic Test for Pyogenic abscess of liver

USG, CT Scan <-- fevers, chills, malaise

9. Anti-acid procedures

Vagotomy – decreased pyloric sphincter tone

Truncal Vagotomy w/ pyloroplasty

Parietal Cell Vagotomy

P

10. Rx: Recurrent Adenocarcinoma of Rectum

resection of tumor, possible pelvic exenteration – improves outcome.

11. Gallstone Ileus

12. Rx: Choledochal Cyst

13. Rx. Hiatel Hernia

Type I: sliding – dependent on symptoms

Type II: paraesophageal - repair

Type III:

14. Rx: Ulcerative Colitis

Colectomy to prevent CA

15. Rx: Recent 4 cm pseudocyst

wait 6 weeks after pancreatitis

16: Rx: Pancreatic fistula – loss of bicarb.

17: Dx: biliary stricture 2^nd to pancreatitis

18. Rx: Retained gallstone via T-tube: extract through the tube 4 weeks later under fluoro.

19. Rx Barrett's Esophagus with high grade metaplasia.

Surgery.

20. Treatment of Complicated Laparoscopic Cholecystectomy.

21. Rx: Villous Adenoma/Adenocarcinoma Poly

22. Pancreat Cysts ic: Ressect if suspicious of neoplasm. Mucinous cysts are considered premalignant.

23. Amebic Abscess of Liver: Flagy, Percutaneous drainage.

24. Focal Nodular Hyperplasia of liver: associated with oral contraceptives, not malignant, risk of rupture, associated with AV malformation, “central scar” seen on CT scan.

25. Gastric Ulcers

Type I: Inferior Lesser Curvature. Associated with achlorhydria)

Type II: 2 spots (gastric and duodenal). Assoc. w/ acid hypersecretion.

Type III: Pyloric and prepyloric ulcer. Assoc. w/ acid hypersecretion.

Type IV: Juxtacardia

Type V: NSAID induced.

26. Enterocutaneous Fistula

Low Output: <200 cc/day

Moderate: 200 – 500 cc/day

High Output: > 500 cc/day

FRIENDS

F: Foreign body.

R: Radiation

I: Inflammation -Crohn's

E: epithelialization

N: Neoplasm

D: Distal Obstruction

S: Sepsis

Basic Science

1. Characteristic of migrating motor complex of the gut

Happens every 90 minutes while fasting possibly stimulated by motilin.

http://www.gastroresource.com/GITextbook/en/chapter6/6-3.htm

2. Slow Wave: up to 3/minute, generated by myeteric plexuses

3. Pathways of visceral abdominal pain.

Stomach: T5-T7

Biliary Tract: T6-T8

Kidney: T10-L1

Colon: T10-L1

4. Factors stimulating acid secretion

Neural --> Vagus --> oxyntic cells--> acetylcholine --> Ca influx.

Hormonal --> Gastrin --> oxyntic cells (gastrin receptor) --> Ca influx

Paracrine --> Histamine --> oxyntic cells (H2 receptors) --> cAMP

5. Gastric Cell Types

Chief Cells --> secrete pepsinogen

Parietal Cells (Oxyntic Cells)

H+

Intrinsic Factor --> bind B12 -> absorbed in distal ileum

G- Cells --> located in Antrum --> secrete gastrin, inhibited by somatostatin

6. Preferred source of energy for coloncytes

short chained fatty acids (butyric acid)

7.

false diverticulum between thyropharyngeal and crycopharengeal muscles

Associated with GERD & hiatel hernia

Sx: w/ dysphagia, halitosis, regurg of undigested food, noisy swallowing and aspiration.

Rx: crycopharygeus myotomy.

8. Pathophysiology of GB emptying after fatty meal.

CCK elevation

9. Hepatitis B serology

10. Stimulants of the Pancreas: Secretin and CCK

11. Composition of Primary Common Bile Duct Stones: Calcium bilirubinate, browner and softer vs. cystic stones tend to be cholesterol..

Cardiovascular and Respiratory

Clinical Management

1. Angioplasty Long Term Patency

Patency of angioplasty is shorter than bypass surgery

2. Thoracic Outlet Syndrome

Neurologic: compression of brachial plexuses, parathesias, weakness, cold sensation.

Arterial: Numbness of arms and hands, tingling, positional weakness, positional loss of pulse.

Venous: Swelling of fingers and hands, heaviness of upper extremity

3. Popliteal Aneurysms

75% have aneurysm elsewhere – mostly AAA.

Thromboemboli – most common complication

4. Signs and Symptoms of Aortic Stenosis: Sortness of breath, loss of consciousness. L. ventricular stenosis. Murmer 10% risk of mortality in non-cardiac surgery.

5. Carotid Atherosclerosis

Symptomatic (NASCET) >= 70%: 26% --> 9% stroke risk at 2 years.

Symptomatic 50-69%: 25 to17% reduction of stroke risk

Asymptomatic (ACAS) , >60% stenosis, 11% to 5.1% stroke risk at 5 years.

Asymptomatic (ACST) 60%-99% stenosis, 11.8% to 6.4% stroke or death rate.

6. Steal Syndorme - usually an inflow problem.

7. Indomethacin closes ductus arteriosus.

Basic Science

1. Physiologic Effect of PEEP.

Increasing PEEP increases PaO2, decreases cardiac filling, increases compliance.

2. Components of Total Capacity

3. Physiology Effects of Isopreteronol

β1>>β2

Increased Ionotropy

Increased Chronotropy

Increased Cardiac Consumption

Vasodilation

4. Risk factors for ATN post arteriography dye load

5. Mechanism of White Clot Syndrome

"Heparin-Induced Thrombocytopenia (HIT) Syndrome" or "White Clot Syndrome".

These activated platelets begin adhering to the wall of the blood vessel at the site of bleeding, and within a few minutes they form what is called a “white clot.” (A clump of platelets appears white to the naked eye.)

Red clot has fibrin in it and has captured RBCs

HIT caused by antibodies IgG

6. Definition of Oxygen Delivery.

DO2 = CO X CaO2 = CO X (SaO2 X Hg X 1.3 + .0031 X PaO2)

7. Anatomy of Internal Mammary Artery

Branch off the subclavians, run along sternum.

GU, Head & Neck, Skin, Musc., Nerv. Sys

Clinical Management

1. Brown Recluse Spider Bite

Treat with Dapsone ( check G-6-DP levels first )

2. Treatment of Transitional Cell Cancer of Bladder

Immunotherapy

Infusion of BCG virus

Chemotherapy mitomycan, adriamycan,

Surgery for Stage II or III

3. Treatment of Basal Cell Cancer of Shin

4. PID antibiotics

5. Metastatic Melanoma to Axillary Node

5.5 Precursors to Skin Malignancy include actinic keratoses and lentigo maligna.

6. Metastatic Ovarian CA

Debulking Operation

7. Rupture of Plantaris Muscle

Differentiate from achilles tendon rupture

Elastic Support

8. Treatment of Parotid Mass

FNA

Pleomorphic Adenoma – benign encapsulated

Adenolymphoma (Warthin's Tumor) – partial parotidectomy w/ negative margins

9. Treatment of Preop Phimosis

Suprapubic catheter

If emergency, dorsal slit of foreskin.

10. Hand Injuries

scaphoid at high risk for avascular necrosis b/c branch from radial artery.

Perilunate Dislocation: most common

11. Rx: Squamous cell cancer of penis

Local excision (if limited to foreskin, partial or complete penectomy

12. Nerve Injuries

(see http://cpmcnet.columbia.edu/dept/ps/2006/academics/year1/anat/anat_exam3_bplesions.pdf )

Wrist Drop: Radial nerve injury – often compressed in in axilla or upper arm

Winged Scapula:

Erb-Duchenne Palsy (porters tip): Injury to upper brachial plexus.

Claw Hand: Ulnar nerve injury, often trauma to medial epicondyle of humerus

Basic Science

1. Nerve affect in compartment syndrome

Endocrine, Hematic, Lymphatic, Breast

Clinical Management

1. Role of splenectomy in lymphoma/leukemia

Indications for Splenectomy

Trauma

hereditary spherocytosis, thalassemia major, and certain forms of immune thrombocytopenic purpura (ITP)

Hodkin's Disease for staging

2. Treatment of thrombocytopenia purpura

medical treatment (plasma phoresis, FFP transfusions, glucosteriods)

3. Treatment of gynecomastia associated with anabolic steroids.

Clomid: antiestrogen

4. Timing of platelets for splenectomy for ITP.

5. Treatment of Breast CA

6. Treatment of Thyroiditis

antithyroid med: PTU, Tapazole

Beta blocker

Lugol's solution (Iodine prep.)

Radioactive Iodine/Surgery (pregnant women)

7. Etiology of swelling post fem-pop bypass surgery.

8. Characteristic of local Hodgkin's Disease

most common mediastinal tumor. Cough chest pain, fever

9. Primary Hyperparathyroidism: High PTH, High Ca, Low Phosphate, Hyperphosphaturia, hyperalkaline phosphase, High Uric acid,

10. Cushing's Syndrome. central body obesity, glucose intolerance, hypertension, excess hair growth, osteoporosis, kidney stones, menstrual irregularity, and emotional liability.

Basic Science

1. Mechanism of Calcitonin

inhibit bone resorption by reducing osteoclast activity

increased urine output of calcium and phosphate.

32 aa protein

can be stimulated by gastrin - “gastrin stim test”

2. MEN Syndromes

3. Metastatic spread of breast CA goes to lungs, bones, brain, bowel.

4. Parathyroid evolved from 3^rd brachial pouch (lower pair) and 4^th brachial pouch (upper pair). Thyroid evolved from thyroid primordium and descends anterior to the GI system attached to the tongue. (Thyroductal cyst.)

5. Pituitary: Adenohypothesis (Anterior Pituitary Lobe): portal blood flow from hypothalamus, on neurons

Neurohypothesis: (Posterior Pituitary Lobe): Axons only, no blood brain barrier, vasopressin, oxytocin

Craniopharyngiomas: calcified cystic lesions, remnant of Rathke's Pouch.