T-Tube s/p cholecystectomy Answer: T-tubes are commonly inserted
whenever there is a concern for retained gallstones after a CBD exploration to
decompress the biliary tree. Usually a T-tube cholangiography is done 2 weeks
post-operatively to evaluate any retained stones and for possible removal of
the T-tube. A minimum of 4-6 weeks should pass before any instrumentation is
performed to allow for the tract to mature.
Neck Zones Answer: Zone I is located from the clavicle to the cricoid. Injuries
to this zone may involve lung apex, trachea, brachiocephalic or subclavian
artery and veins, nerve roots and esophagus. Zone II is located from the
cricoid to the angle of the mandible. Injury in this location may involve the
carotid or vertebral arteries, the jugular veins, esophagus or trachea. Zone III
is located from the angle of the mandible to the skull base. Injury to this zone
may result in external or internal carotid injury, jugular injury, cranial nerve
injury or hypopharyngeal injury. Those patients that are hemodynamically
unstable require operative intervention, regardless of zone. Other indications
for operative intervention include hard signs of vascular injury (bruit, thrill,
expanding or pulsatile hematoma) or tracheal injury (subcutaneous air or
bubbling from the wound).
Breast cancer in males Answer: Tamoxifen confers a survival benefit for
males with hormone receptor positive breast cancer. Orchiectomy is a second
line hormonal manipulation in males with estrogen receptor positive,
metastatic breast cancer. In the above case orchiectomy is not indicated
because the patient does not have evidence of metastatic disease
Causes of pseudohyponatremia Answer: Causes of pseudohyponatremia may
lead to treatment that is not directed at the correction of sodium levels, such
as in hyperglycemia, mannitol administration, or radiologic contrast medium.
Cause of isotonic hyponatremia Answer: Isotonic hyponatremia can occur
due to lab testing and is most commonly due to high blood triglyceride levels
1
APPHIA - Crafted with Care and Precision for Academic Excellence.
,Hyponatremia Answer: Treatment of asymptomatic, euvolemic or
hypervolemic hyponatremia is free water restriction and observation of
sodium levels. Hypovolemic hyponatremia is treated with volume resuscitation
with either lactated ringer's solution or normal saline solution. If the patient
were symptomatic, treatment would be correction with hypertonic saline
solution.
Treatment of Hypervolemic hyponatremia Answer: The patient now presents
with acute, symptomatic, hypervolemic, hyponatremia due to excessive water
intake. The appropriate treatment is correction of the sodium deficit with
hypertonic saline. Sodium deficit is calculated based upon actual and desired
sodium level and total body water. The appropriate rate of sodium correction
in this setting is 0.5 mEq/L/hour.
Central pontine myelinolysis Answer: Brain adaptations that reduce the risk of
cerebral edema in chronic hyponatremia make the brain vulnerable to injury if
the hyponatremia is too rapidly corrected. The neurologic manifestations
associated with overly rapid correction have been called the osmotic
demyelination syndrome (ODS, formerly called central pontine myelinolysis or
CPM). This syndrome is caused by rapid correction of sodium deficit at greater
than the appropriate rate of 0.5 mEq/L/hour. The risk is greatest for patients
who have had a low sodium level for greater than 48 hours. Cerebral edema
with brainstem herniation is seen with rapid correction of hypernatremia
Paronychia Answer: Minor skin break down is the most common predisposing
factor for acute paronychia; therefore, people with occupations that are
associated with increased risk of such minor traumas have higher risk of
developing acute paronychia. Staph aureus is the most common pathogen.
Other possible organisms are streptococcus, enterococci and pseudomonas.
Paronychia is the most common hand soft tissue infection. It represents 35%
of all hand infections
Thoracic duct Answer: The thoracic duct is the main lymphatic channel for the
abdomen and chest. Chylomicrons and long-chained fatty acids enter into this
2
APPHIA - Crafted with Care and Precision for Academic Excellence.
,lymphatic system, whereas short and medium-chained fatty acids are
transported in the portal system. It originates at the cisterna chyli at L1-L2 and
courses superiorly through the aortic hiatus. It runs along right of midline until
crossing to the left at T4-T5. The duct then empties in to the left subclavian
vein at the junction with the internal jugular vein.
Undifferentiated spindle cell tumor (malignant fibrous histiocytoma of bone)
Answer: Undifferentiated spindle cell tumor (malignant fibrous histiocytoma of
bone) is an uncommon tumor. The most common site of occurrence is the
proximal tibia and distal metaphyses of the femur. It may also be found in the
pelvis, humerus, and scapula. Radiographic features include loss of normal
trabeculation and cortical destruction. Adjacent soft tissue invasion and mass
formation may occur. MRI with contrast is the imaging study of choice.
Pathology commonly shows high-grade lesions (> 90%) and a tumor showing
fibroblasts in a whirling pattern with multinucleated giant cells, inflammatory
cells, and foamy mononuclear giant cells. Neoadjuvant chemotherapy can be
administered in which it can relieve pain and decrease local edema,
contracture, and the size of the soft tissue tumor. Urgent surgical resection is
indicated if at high risk for pathologic fracture. Surgical excision with wide
margin is advised whether or not the patient receives neoadjuvant therapy.
Amputation can normally be avoided.
Pneumocytes Answer: There are three major cell types in the alveolar wall
(pneumocytes):
Type I (Squamous Alveolar) cells that form the structure of an alveolar wall
Type II (Great Alveolar) cells that secrete pulmonary surfactant to lower the
surface tension of water and allows the membrane to separate, therefore
increasing its capability to exchange gases. Surfactant forms an underlying
aqueous protein-containing hypophase and an overlying phospholipid film.
Macrophages that destroy foreign material, such as bacteria.
Pneumocytes Answer: Answer A: Alveoli production continues until
approximately 10 years of age.
3
APPHIA - Crafted with Care and Precision for Academic Excellence.
, Answer B: Type II (Great Alveolar) cells secrete pulmonary surfactant between
24 and 28 weeks.
Answer C: Alveoli production begins at 7 months gestation and continues until
approximately 10 years of age.
Answer D: The pores of Kohn are found in alveolar walls and allow
communication between individual alveoli but do not play a significant role in
carbon dioxide delivery.
Answer E: Alveoli are squamous-lined sacs at the terminal ends of the
respiratory tract that are the sites for gas exchange in the lung.
Peri-operative diabetes control Answer: The doses of insulin and other
hypoglycemic drugs need to be titrated during the perioperative period. The
oral hypoglycemic agents are withheld on the day of surgery and resumed
after the surgery except Metformin. If there is altered renal action, then
Metformin has to be withheld until the renal function stabilizes due to the risk
of lactic acidosis. During this period hyperglycemia is managed with a short-
acting insulin preparation based on blood glucose monitoring. Rapid and
short-acting insulin is withheld when the patient is NPO and covered based on
blood glucose monitoring. Intermediate and long-acting insulin is given at the
normal dose the night before surgery. If there is a morning dose, then half the
normal dose on the morning is given. Some patients use insulin pumps for
glucose management. The pumps have variable delivery rate based on
endogenous insulin production. On the day of surgery, the patient is managed
4
APPHIA - Crafted with Care and Precision for Academic Excellence.
whenever there is a concern for retained gallstones after a CBD exploration to
decompress the biliary tree. Usually a T-tube cholangiography is done 2 weeks
post-operatively to evaluate any retained stones and for possible removal of
the T-tube. A minimum of 4-6 weeks should pass before any instrumentation is
performed to allow for the tract to mature.
Neck Zones Answer: Zone I is located from the clavicle to the cricoid. Injuries
to this zone may involve lung apex, trachea, brachiocephalic or subclavian
artery and veins, nerve roots and esophagus. Zone II is located from the
cricoid to the angle of the mandible. Injury in this location may involve the
carotid or vertebral arteries, the jugular veins, esophagus or trachea. Zone III
is located from the angle of the mandible to the skull base. Injury to this zone
may result in external or internal carotid injury, jugular injury, cranial nerve
injury or hypopharyngeal injury. Those patients that are hemodynamically
unstable require operative intervention, regardless of zone. Other indications
for operative intervention include hard signs of vascular injury (bruit, thrill,
expanding or pulsatile hematoma) or tracheal injury (subcutaneous air or
bubbling from the wound).
Breast cancer in males Answer: Tamoxifen confers a survival benefit for
males with hormone receptor positive breast cancer. Orchiectomy is a second
line hormonal manipulation in males with estrogen receptor positive,
metastatic breast cancer. In the above case orchiectomy is not indicated
because the patient does not have evidence of metastatic disease
Causes of pseudohyponatremia Answer: Causes of pseudohyponatremia may
lead to treatment that is not directed at the correction of sodium levels, such
as in hyperglycemia, mannitol administration, or radiologic contrast medium.
Cause of isotonic hyponatremia Answer: Isotonic hyponatremia can occur
due to lab testing and is most commonly due to high blood triglyceride levels
1
APPHIA - Crafted with Care and Precision for Academic Excellence.
,Hyponatremia Answer: Treatment of asymptomatic, euvolemic or
hypervolemic hyponatremia is free water restriction and observation of
sodium levels. Hypovolemic hyponatremia is treated with volume resuscitation
with either lactated ringer's solution or normal saline solution. If the patient
were symptomatic, treatment would be correction with hypertonic saline
solution.
Treatment of Hypervolemic hyponatremia Answer: The patient now presents
with acute, symptomatic, hypervolemic, hyponatremia due to excessive water
intake. The appropriate treatment is correction of the sodium deficit with
hypertonic saline. Sodium deficit is calculated based upon actual and desired
sodium level and total body water. The appropriate rate of sodium correction
in this setting is 0.5 mEq/L/hour.
Central pontine myelinolysis Answer: Brain adaptations that reduce the risk of
cerebral edema in chronic hyponatremia make the brain vulnerable to injury if
the hyponatremia is too rapidly corrected. The neurologic manifestations
associated with overly rapid correction have been called the osmotic
demyelination syndrome (ODS, formerly called central pontine myelinolysis or
CPM). This syndrome is caused by rapid correction of sodium deficit at greater
than the appropriate rate of 0.5 mEq/L/hour. The risk is greatest for patients
who have had a low sodium level for greater than 48 hours. Cerebral edema
with brainstem herniation is seen with rapid correction of hypernatremia
Paronychia Answer: Minor skin break down is the most common predisposing
factor for acute paronychia; therefore, people with occupations that are
associated with increased risk of such minor traumas have higher risk of
developing acute paronychia. Staph aureus is the most common pathogen.
Other possible organisms are streptococcus, enterococci and pseudomonas.
Paronychia is the most common hand soft tissue infection. It represents 35%
of all hand infections
Thoracic duct Answer: The thoracic duct is the main lymphatic channel for the
abdomen and chest. Chylomicrons and long-chained fatty acids enter into this
2
APPHIA - Crafted with Care and Precision for Academic Excellence.
,lymphatic system, whereas short and medium-chained fatty acids are
transported in the portal system. It originates at the cisterna chyli at L1-L2 and
courses superiorly through the aortic hiatus. It runs along right of midline until
crossing to the left at T4-T5. The duct then empties in to the left subclavian
vein at the junction with the internal jugular vein.
Undifferentiated spindle cell tumor (malignant fibrous histiocytoma of bone)
Answer: Undifferentiated spindle cell tumor (malignant fibrous histiocytoma of
bone) is an uncommon tumor. The most common site of occurrence is the
proximal tibia and distal metaphyses of the femur. It may also be found in the
pelvis, humerus, and scapula. Radiographic features include loss of normal
trabeculation and cortical destruction. Adjacent soft tissue invasion and mass
formation may occur. MRI with contrast is the imaging study of choice.
Pathology commonly shows high-grade lesions (> 90%) and a tumor showing
fibroblasts in a whirling pattern with multinucleated giant cells, inflammatory
cells, and foamy mononuclear giant cells. Neoadjuvant chemotherapy can be
administered in which it can relieve pain and decrease local edema,
contracture, and the size of the soft tissue tumor. Urgent surgical resection is
indicated if at high risk for pathologic fracture. Surgical excision with wide
margin is advised whether or not the patient receives neoadjuvant therapy.
Amputation can normally be avoided.
Pneumocytes Answer: There are three major cell types in the alveolar wall
(pneumocytes):
Type I (Squamous Alveolar) cells that form the structure of an alveolar wall
Type II (Great Alveolar) cells that secrete pulmonary surfactant to lower the
surface tension of water and allows the membrane to separate, therefore
increasing its capability to exchange gases. Surfactant forms an underlying
aqueous protein-containing hypophase and an overlying phospholipid film.
Macrophages that destroy foreign material, such as bacteria.
Pneumocytes Answer: Answer A: Alveoli production continues until
approximately 10 years of age.
3
APPHIA - Crafted with Care and Precision for Academic Excellence.
, Answer B: Type II (Great Alveolar) cells secrete pulmonary surfactant between
24 and 28 weeks.
Answer C: Alveoli production begins at 7 months gestation and continues until
approximately 10 years of age.
Answer D: The pores of Kohn are found in alveolar walls and allow
communication between individual alveoli but do not play a significant role in
carbon dioxide delivery.
Answer E: Alveoli are squamous-lined sacs at the terminal ends of the
respiratory tract that are the sites for gas exchange in the lung.
Peri-operative diabetes control Answer: The doses of insulin and other
hypoglycemic drugs need to be titrated during the perioperative period. The
oral hypoglycemic agents are withheld on the day of surgery and resumed
after the surgery except Metformin. If there is altered renal action, then
Metformin has to be withheld until the renal function stabilizes due to the risk
of lactic acidosis. During this period hyperglycemia is managed with a short-
acting insulin preparation based on blood glucose monitoring. Rapid and
short-acting insulin is withheld when the patient is NPO and covered based on
blood glucose monitoring. Intermediate and long-acting insulin is given at the
normal dose the night before surgery. If there is a morning dose, then half the
normal dose on the morning is given. Some patients use insulin pumps for
glucose management. The pumps have variable delivery rate based on
endogenous insulin production. On the day of surgery, the patient is managed
4
APPHIA - Crafted with Care and Precision for Academic Excellence.
