my notes on Surgery

 

Kaplan Surgery Intial survey - Airway -

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If patient patient is consci conscious ous and and fully fully normal normal,, normal normal voice, voice, does not need need airwa airway y Patient Patient with hematoma hematoma but but normal normal voice, voice, still needs needs an airwa airway y because because of of the expanding hematoma. se laryngoscope, with anesthesia Pt with with subcut subcute e air !emph !emphesyma esyma"" needs needs an airway, airway, means means in#ury in#ury to trachea trachea or or ma#or bronchus. bronchus. $an%t put a tube blindly, might lead to perforation etc... &ibrotic bronchoscope !with visuali'ation" so we can advance beyond in#ury. Pt is uncon uncons, s, but breathi breathing ng sponta spontaneou neously, sly, but but ma(es ma(es noise)g noise)gurg urgles les when when he breaths. So indication for airway. Also trauma pt who is uncons needs airway even if he is breathing spontaneously. Pt unable unable to move move ext, ext, then became became unconsc unconscious ious.. &irst &irst thing we do is ta(e ta(e care of airway, but we (now he has cervical spine in#ury so we can%t hyperextend nec(. se *berobtic through endotracheal tube. Patient Patient alert, alert, with with facial facial fractur fractures es + drow drowing ing in in his own blood blood + norma normall anatomic pathways not available, so we go through the nec(. o cricothyroidotomy, or percutaneous tracheostomy.

reathing  rauma  rauma Pa Patient tient in shoc( shoc( -

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Is chest involved/ o  If chest is not involved, then we (now the patient is in schoc( because he is bleeding 0hen $hes $hestt is is in invo volv lved ed Are nec( veins distended, or $1P high/ o 2o 3 patient is bleeding  4  4es es 3 either pericardial pericardial tamponade tamponade or pneumothorax pneumothorax Is it hard to breathe/  45S 3 pneumothorax pneumothorax o o 26 3 pericardial pericardial tamponade 7ust 7ust sto stop p blee bleedi ding ng and and rep repla lace ce ble bleed edin ing g 

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If patient is in 58, and we (now where he is bleeding, then stop the bleeding *rst. Pt in shoc(, shoc(, shot shot in abdomen abdomen - near near emerg emerg surg surg center, center, ta(e ta(e him to 68 for laparotomy If you you see the bleedi bleeding, ng, stop stop it it with with direct direct pres pressur sure, e, and start start I1 9uids 9uids.. 71A 71A + spont spont breat breathin hing, g, :1 :1 not diste distend nded, ed, hypot hypotens ensive ive.. 0e (now shoc( is from bleeding o o Patient gets intubated. If we don%t (now where he is bleeding from, *rst start 9uid o resuscitation. ;-< large iv bores. If you you thin( thin( its its peric pericard ardial ial tampon tamponade ade but but not not sure sure,, do ultrasou ultrasound. nd. o  reatment  reatment for pericardial pericardial tamponade Pericardiocentesis, tube or window, or mediostenotomy. o

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=ead rauma -

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Penetrat Penetrating ing in#ury in#ury to to s(ull, s(ull, must must go to to 68. 68. &orei &oreign gn body body should should be removed removed in 68 >inear >inear fractur fracture e can be *xed *xed in 58, comminute comminuted d must must be *xed in 68 68 Pt was was unconsc unconscious ious at site site of accid accident, ent, but awa( awa(e e in 58 58 and he is acting acting normal)neuro exam normal, still needs $ of head. Any pt with lucid interval needs $ of head Si Sign gns s of of s( s(ul ulll ffra ract ctur ure e at at bas base e o 8acoon eyes o &luid dripping from ear, or nose o  his means theres theres big trauma, might have have cervical)spincal cervical)spincal cord in#ury o 2eeds ct of head and nec(. Pt trauma trauma to head, head, loses loses consc conscious ious,, lucid lucid interv interval, al, goes goes uncons unconsciou cious s again, again, now patient has dilated *xed pupil o Acute epidural or acute subdural hematoma >ens shapped hematoma on ct 5pidural if completely normal o Subdural is bigger trauma and usually sic(er $rescent shaped hematoma)semilunar. If patient has subdural on ct and small, and no focal neuro signs, then observe in hospital, chec( I$P  if elevated treat medically  diuretics, mannitol, hyperventilation to decrease icp. $an reduce o; demand or brain also by sedation or hypothermia. hypothermia. Patient Patient with signs signs of al'heim al'heimers ers within within wee(s, wee(s, patient patient has has chronic chronic subdural subdural hematoma. o $t scan, evacuate hematoma.  

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2ec( rauma -

?unshot wounds@ o Patient has wound to nec(, spitting)coughing blood, expanding hematoma near area of thyroid cartilage. o Indications for surgical exploration 

?unshots !middle ofwounds nec(" between mandible and above cricoid cartilage Spitting)coughing Spitting)cou ghing blood means in#ury to larynx)pharynx 5xpanding hematoma 5xceptions o Patient with gunshot wound above the mandible 2eeds angiogram)angiographic angiogram)angiographic assessment of vascular tree and emboli'ation Patient with gunshot above clavicle but below cricoid Angiogram, esophagogram, bronchoscopy lunt tr trauma to ne nec( o Stable, lacerations to face, tenderness in posterior nec( midline  hin( cervical cervical spine)spinal spine)spinal cord in#ury in#ury 

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If theres pain, even if neuro is normal we need $ scan

 

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Sur Surgi gica call exp explo lora rati tion on of of nec( nec( o 1ital signs are deterioration 5xpanding hematoma o o Spitting)vomiting blood o ?unshot wounds to middle 'one of nec( If above angle of mandible Arteriographic Arteriograph ic dx and tx If below cricoid cartilage Arteriogram, esophagram, esophagoscopy, bronchoscopy 

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Spinal cord in#uries -

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=emisection o >oss of pain)temp on one side, paralysis and loss of vibration)propiro on the other distal to lesion Anteri Anterior or cor cord d syndr syndrome ome !ant !anteri erior or spin spinal al arter artery" y" o >oss of pain)temp, paralysis on both sides, and preservation of vibratory)position. vibratory)posit ion. !dcml posterior" $en $entr tra al c cor ord d syn syndr dro ome

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=yperextension of nec( pper extremity issues but lower ext spared. 2eed 2eed to do 78I 78I ffor or any any of of tthe hese se St Ster eroi oids ds as so soon on as diag diagno nosi sis sm mad ade e

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$hest rauma -

lunt lunt trauma trauma and and penetr penetratin ating g is the the same same in chest chest due to to bro( bro(en en ribs ribs that that leads to penetration 8ib fractur fracture e + 8x topic topical al anest anesthetic hetic so they they can breath breath norm normal al ension ension pneumo pneumo don%t don%t do do $8, $8, norma normall pneumo pneumo do 8A 8Ay, then then chest chest tube in upper part of chest =emothorax  bleeding usually stops on its own, have to get rid of blood with chest tube in bottom part of chest 

6nce we see drain only drains a little bit we (now were doing good and bleeding has stopped o In the case that drain recovers a ton of bleeding, that means systemic vessel usually intercostal, means bleeding not stopping, so we need surgical intervention  th  thoracotomy oracotomy.. &lail chest  chest tubes, diuretics, 9uid restriction. &ollow with $8 and 5K? she might have contusions lung)hear lung)heartt also in cases of deceleration in#uries. o 7ay even eventually lead to aortic dissection !slowly" !slowly" o If $8 shows wide mediastinum do spiral $ if they match, do surgery. If they don%t match then we do arteriogram i iap aphg hgra ragm gmat atic ic ru rupt ptur ure e o owel sounds in chest, multiple air levels in chest, more common in left. o

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o ?astric tube goes upphes into chest hor horac acic ic su subc bcut utan aneo eous us emph em esym yma a

 

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$aused by@    ransection ransection of esophagus during endoscopy endoscopy    ension ension pneumo pneumothorax thorax !patient will be in shoc(" shoc("    ransactional ransactional in#ury to trachea trachea  need to do *beroptic bronchoscopy to see in#ury and for intubation 

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Abdominal rauma -

lunt trauma@ o Anyone with acute abdomen)signs of peritoneal irritation needs exploratory laparotomy leeding or not o Anyone in bleeding don%t (now where !low cvp." $an%t be head, not enough room If nec( not distended li(e cra'y not bleeding in nec( o $8 !normal", means they aren%t bleeding in the chest Pelvic fracture + chec( by pelvic exam &emur fracture + chec( by pelvic exam Abdomen + if none of the other places bleeding, bleeding most be in abdomen. 0e don%t do exploratory laparotomy unless were sure. o $ scan *rst !if they are hemodynamically stable" If not stable  focus abdominal ultrasound)diagnostic peritoneal lavage o If high cvp thin( pericardial tamponade 

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Pelvic &ractures -

If pat patie ient nt is is hem hemod odyn ynam amic ical ally ly sta stabl ble e o In women in pelvic fracture@ need proctosigmoidscopy exam, pelvic exam !to chec( for in#ury to vagina", and retrograde cystogram. o In men@ in men we have to chec( in#ury to rectum and urethra !retrograde urethrogram *rst" before we rule out bladder damage !then do retrograde cystogram"

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$ase where e woman woman is bleeding bleeding to to death death into into pelvis pelvis !shoc( !shoc( not respond responding ing to to 9uids"wher o $hec( that patient is nto bleeding into abdomen  &AS or P> o Surgery not best answer o sually bleeding from venous plexus so arteriograms are no good o est thing to do is &I lood in urine In case of blunt trauma need to (now about associated bony in#uries o o B. Shot point blan( above pubis  blood in urine  bladder in#ury 2eed surgical exploration o ;. lunt trauma  7ultiple in#uries including pelvic 9acture, then blood in urine If rib fracture  its (idney 

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If not evaluate urethra then evaluate bladder

 

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<. Pelvic fracture, blood in meautus, wants to urinate cant, high riding prostate rethral in#ury  do regrograde urethragram C. 7ale with pelvic fracture, but no blood, and urethral urethral catheter won%t go  stop there is in#ury to urethra D. In bladder cystogram  need ; pics  full and empty !if in#ury is at trigone won%t see in#ury when bladder is full, need to ta(e pics with 

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bladder empty to see extravasation in trigone" E. lunt trauma, blood in urine, rib fracture  (idney in#ury  do $ scan, don%t usually need surgery but $ scan will tell you F. Pt mva, rib fracture, abdominal contusion, hematuria. $t scan shows renal in#uries don%t need surgery. hen E wee(s later develops S6, and 9an( bruit. 8enal artery and vein have formed A1 *stula  leads to $=& $an also have pt develop hypertension months later and that would be due to 8enal artery stenosis G. In child with small trauma and hematuria might mean congenital anomaly, need urological eval, with u)s H. $hild with in#ury to pelvis, no blood in urine or meatus, but has swollen scrotum o u)s, might tell us about testicular rupture rupture B. >arge penile shaft hematoma If penis was erect  fracture  history important !pt might lie" 2eed emergent repair 

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5xtremity fractures -

ullet ullet wou wound nd in ante antero rolat latera erall thigh thigh,, wound wound embed embedded ded.. o 2o need for further evaluation. $lean, tetanus, that%s it  no ma#or arteries ull ullet in an ante terromed omedia iall o 2ormal pulses, no hematoma o  his is anatomical anatomical proximity, proximity, and needs to be evaluated. o oppler studies for integrity of vessels ullet ullet anterio anteriomedia mediall thigh, thigh, excep exceptt posteri posterial al latera lateral, l, with with large large expand expanding ing hematoma o 5veidence of arterial in#ury !could also be lac( of pulses" o 2eed surgical exploration for dx,tx. Pat atie ient nt ha has s bul bulle lett wou wound nd in ar arm m o =as hematoma, nerve damage, bony damage o Stabili'e bone, *x artery, then do nerve repair.  his can lead lead to comportantment comportantment syndr syndrome ome due to delay of of arterial *x and then reperfusio reperfusion, n, may need fasciotomy In lo low w vel veloc ocit ity y bul bulle lett wou wound nds s  damage is #ust tra#ectory of bullet =i =igh gh velo veloci city ty !h !hig igh h pow power er ri9e ri9es" s"  big exit wound  damage is beyond tra#ectory o 2eed extensive debriment, and amputation due to extensive damage to tissues 

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$rush in#ury o $hec( potassium, myoglobin in urine, also compartment syndro syndrome me may happen

urns -

7ax is is DJ, DJ, if if burn burn great greater er than than DJ use use D anyw anyways ays =ead is is HJ, HJ, arms arms are are HJ total total each each !C.D each side", side", legs legs are are HJ on on each each surface and thorax is BGJ on each side o &ormula (g  percent  C o =alf in *rst G hrs, ; nd hal *n the last BE hrs o Add ;> of D0 o ;nd day get half as much, third day should be *ne and will see massive diuresis o 6ther thing people are doing B >)hr and ad#ust based on urinary output

isorders of $hildren -

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evelo evelopme pmenta ntall dysplas dysplasia ia of hip)co hip)cong ngeni enital tal dislo dislocat cation ion of hip hip o neven gluteal folds, one hip dislocated with #er( and clic(. o o ultrasound o  reat  reat with abduction splinting, splinting, pavli( pavli( harness harness >eg perves perves diseas disease)ava e)avascul scular ar necrosis necrosis of capital capital fermur fermur epiphysis epiphysis o G year old, (nee pain, limping, gait issues, guarded motion $ould be (nee or hip pain in children with hip pathology o x with xray o  x unclear Sl Slip ippe ped d cap capit ital al fe femo mora rall epi epiph phys ysis is o B< year old obese, pain In groin, limping, sole of foot pointing to other foot. =ip can%t be rotated internally o 6rthopedic emergency)surgical emergency Septic hip o  oddler  oddler has h had ad 9u !febrile !febrile illness", wal(ing wal(ing around around *ne, now refuses ot move leg o Slight abduction and external rotation o $an%t move it o tx> aspirate and drain !emergency" ac acut ute e hem hemat atog ogne neou ous s ost osteo eomy myel elei eiti tis s o febrile illness, no trauma, persistent pain in bone o do bone scan since xray wont show anything yet o treat with antibiotics bow le leg !g !genu va varum" o normal until < gen genu val valgu gum m !(n !(noc oc( (ed (nee (nee"" normal until G o 6steoc 6steochon hondr drosi osis s of tibial tibial tuber tubercle cle !osgo !osgoode ode schl schlatt atter" er" o BC year old in#ured (nee, pain over tibial tubercle, no swelling o if theres no swelling of (nee theres nothing wrong with (nee in 

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immobili'ation of(nee for E wee(s in cast cl club ub fo foot ot !p !pal alat athe hesi sic c gen genuv uvar arus us"" o

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baby born with both feet turned inward o plantar 9exion an(le, eversion of foot, adduction of forefoot and internal rotation of tibia o child would be wal(ing on his toes on the top of foot o treated with serial casts, *xing deformities from distal to proximal before age of B or ; su supr prac acon ondy dyla larr ffra ract ctur ure e of of hum humer erus us o

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can lead to vascular compromise of forarm have to (eep chec(ing pulses)oppler studies

 umors  umors in chi children ldren -

os oste teog ogen enic ic sa sarc rcom oma a !7$ !7$ tu tumo mor" r"  sunburst pattern, ;-< months of bone pain nd ;  most common  large fuisiform tumor)onion s(in  ewing sarcoma !in diaphysis of bones" 

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Adult ortho in#uries -

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Ante Anteri rior or di disl sloc ocat atio ion n of of sho shoul ulde derr o =old arm near body, externally rotated o amage to axillary nerve Pos oste terrior dis dislo loca cati tio on o =appens when there is uncoordinated contractions !electrical burns, sei'ures" o ray won%t show it o =olds arm normal position across body

Pre-6p assesment -

$an% $an%tt do do s sur urge gery ry if 5& L .< .<D D ?oldman%s cr criteria o Age, bed ridden, emergency operation, enter body cavity, 7I recently, arrhythmia, $=&. $=&.  :1 in a non trauma patient  means $=&  operation is very high ris(. &irst getting him out of $=& then do surgery !bbloc(s, diuretics etc" 0ait E months after 7I. $an sometimes do revasculari'ation *rst in patients with unstable angina before doing other surgeries Patient with lung disease  *rst chec( P& esp &51B !if abnormal" then chec( P$6;. If abnormal as( patient to Muit something for G wee(s, improve fevB and pco; medically until &51B improves then surgery. If liver diseae)liver failure $I to do surgery Also need to chec( nutritional de*ciency  if severely malnourished malnourish ed can do hyper alim for D days or so and should be enough. !intensive nutritional nutritional support delivered to ?I tract" 

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Post 6p $omplications

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7ali 7align gnan antt hype hypert rthe herrmia mia o 6xygen, 9uids, cool person down, dantrolene, al(alini'e urine to prevent myoglobuniria Post op fever o B. 0ind - day B -- atelectasis o ;. 0ater - day < - I o <. 0al(ing + day D + 1 

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lood gasses that we see after P5 3 hypoxemia with hypocapnia !low po; and low pc;" in pulmonary failure we see low po; and high pco;. o spiral $ scan of chest. C. 0ound + day F + wound infection D. 0onder 0onder - day B + drugs, deep abscess, what did we do ?et a ct scan if fever on day B 7Is happen either during operation or after B-; days. If patient has alarming chest pain thin( of either 7I or P5 depends on timing. efore day D its 7I Post surgery patient can%t get clot busters, can give anticoag !heparin" but not thrombolytics $hanges in e(g are *rst changes seen in post op or during operation for an 7I 

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Aspiration of gastric contants  do bronchoscopy to wash out and remove particles Steroids not helpful after the fact 

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Post op disorientation -

If nothi nothing ng is wro wrong, ng, but but patie patient nt is conf confus used ed do bloo blood d gases gases  lac( of o; to brain A8S o Patient has already been very sic( o >ow Po; with lots of oxygen o Patchy in*ltrates o  x@ P55P, don%t use use high volume, volume, chec( for other other signs of infection)sepsis 

Abdominal distention -

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Paralytic il ileus o  occurs in the *rst few days post op. o Abdominal distention, no passing gas, absent bowel sounds o Prolonged by hypo(alemia 5ar 5arly S S6 6 + mec mechanic anica al ue to adhesions o o sually after paralytic ileus not resolving after D-E days o ray ilated loops of S, and air 9uid levels $on*rmed with $ scan  shows transiotion point b)w proximal dilated and distal collapsed bowel at site of obstruction o 2eed surgery 

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&luid and electrolytes -

=ypernatremia o >ost water !or hypotonic 9uids", became hypertonic. 5very < meM)> that serum sodium is above BC, means B> of water lost o o  x@ D B);2S If hypernatremia happens fast, and produces $2S sx, can correct 

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Muic(er with D0 or DB)< 2S =yponatremia o 0ater has been retained. B. Patient starts with normal 9uid volume, and retains water due to A= $orrection via 9uid restriction ;. Patient is losing lots of isotonic 9uids !usually from ?I", forced to retain water if he has not had enough 9uid replacement 8estore volume with isotonic 9uids 2S or >8. o If it occurs Muic(ly, have to *x with <J or DJ 2S o If it occurs slowly !from SIA=", correction is via 9uid restriction =ypo(alemia o =appens slowly due to KN lost from the ?I or in urine 

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$an happen Muic(ly when KN moves into the cells !seen when KA is corrected" o 8x@ KN replacement  I1 no more than B meM)h =yper(alemia o =appens slowly when (idney can%t excrete KN !(idney failure or aldosterone aldostero ne antagonists" o 8apidly if KN is being dumped from the cells !crush in#uries or dead tissue)acidosis" 8x@ hemodyliasis is ultimate treatment efore that use DJ dextrose and insulin to push KN into cells $an also do 2? suction I1 calcium !fastest correction" 

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iseases of ?i System -

5sophagus o ?58 + If x is uncertain, do p= monitoring with correlation to sx. In long standing ?58, do endoscopy and bx to chec( for barrett%s esophagus If long standing, can%t be controlled with PPI)meds, then we do surgery. Imperative if ulcers)stenosis) or if there are severe dysplastic changes In dysplastic changes resection is needed, o otherwise do laparascopic nissen fundoplication $ancer 

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Progression of dysphagia 0eight loss always seen SM $ell $a, in smo(ers. Adenocarcinoma in long standing ?58 x@ endoscopy and bx, *rst do barium swallow before endoscopy to prevent perforation $ scan assess operability •

 x@ usually palliative palliative surgery surgery 7allory weis tear After prolonged foreceful vomiting right red blood comes up. 5ndoscopy establishes the x  x@ photocoagulation photocoagulation o oerhaave syndrome Prolonged, forceful vomiting leads to esophageal perforation $ontinuous, severe, wrenching epigastric and low sternal pain that is sudden &ever, leu(ocytosis, SI$K pt. x@ $ontrast swallow !gastrogra*n)water !gastrogra*n)water soluble *rst, and then barium if gastrogra*n is negative"  x@ need emergency emergency sur surgical gical repair repair Stomach o ?astric adenocarcinoma adenocarcinoma Seen in elderly. Anorexia, weight loss, and vague epigastric distress x@ endoscopy and bx. $ can help.  x@ surgery surgery is best tx o ?astric lymphoma Similar to gastric adenomcarcinoma adenomcarcinoma  x@ based on chemo chemo or radioation. radioation. Surgery Surgery is done if if possibility possibility of perforation as tumor cells die. 7A>67A can be reversed by eradication of =. pylori. 

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7id and lower ?I -

Small bowel 7echianical obstruction obstruction o ue to adhesions. $olic(y ab pain, protrated vomiting, progressive distention, no passage of gas)feces. &irst will have high pitched bowel sounds. ray istended loops of S, air 9uid levels  @ 2P6, 2? suction, I1 9uids Surgery is done if conservative mgmt. fails w.in ;C hrs if  

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complete, a few days if partial. Strangulated obstruction obstruction

 

Starts as mechanical obstruction, then patient gets septic !fever, wbc, pain, peritoneal irritation, sepsis etc" 5758?52$4 S8?584 $arcinoid syndrome Small bowel carcinoid tumor with liver mets &lushing of face, diarrhea, whee'ing, 8= valve damage !:1" ;C hours urine for D=ydroxyindolacetic acid !D=IAA" 

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?I bleeding -

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7$ from from upper upper gi which which is from from nose to to ligamen ligamentt of treit' treit'.. 6nly 6nly ;DJ are are from from colon or rectum, and minority occur in #e# or ileum. ?I bleeding from colon is due to angiodusplasia, polyps, diverticulosis o or cancer o 0hen young person has ?I bleed most commonly its from upper ?I or hemmorhoids if present o In old person it could be from anywhere 1omiting blood leed from upper ?I. Same if its blood recovered by 2? tube in a o patient who has rectal bleeding !upper gi again"  hen we do ?I endoscopy. $hec( mouth and and nose *rst 7elena Indicates digested blood and usually upper ?I. o o Start with upper ?I endoscopy 8P8 o $an be from anywhere in ?I o &irst if patient is actively bleeding pass 2? tube and aspirate gastric contents If there is blood it must be upper ?I bleed If no blood is retrieved !9uid is white)no bile, then theres no bleeding from nose to pylorus.  hen follow with upper ?I ?I If no blood retrieved and 9uid is green !bile" then entire upper ?I is excluded. o If there is still active bleeding and we%ve exluded upper ?I $hec( hemorrhoids !anoscopy" *rst $olonoscopy $olonoscop y not helpful during heavy active bleeding If heavy bleeding do angiogram If small bleeding do tagged red cell study.    agged agged blood will will pool somewhere, somewhere, then we can do angiogram. o Patients with recent hx of bleeding with no active In young pts start with endoscopy In older do both endoscopy and colonscopy In child + thin( mec(els, start with technetium scan !for ectopic gastric mucosa" 

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Acute Abdomen

 

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Perforation o Sudden onste, constant, generali'ed, severe. Signs of peritoneal irritation !tenderness, guarding, rebound" o o &ree air under diagphragm in upright xray con*rms 5758?52 S8?584 o 6bstruction o $ould be due to duct obstruction + ureter, cystic, or common duct 6nset of colic(y pain Patient moves constantly to *nd comfort Ischemic process o $ombines severe ab pain with blood in the lumen of gut Prima imary per eriito toni nittis o Suspect in child with nephrosis and ascites or adult with ascites who has mild generali'ed acute abdomen 0ill also have fever, wbc. $ultures of ascetic *ld yield single organism.  x@ antibiotics !26 !26 S8?584" S8?584" o ?ene ?enera rali li'e 'ed d acu acute te abdo abdome men n o  x is exploratory exploratory laparotomy laparotomy if its not not primary peritonitis peritonitis o 8ule out things that mimic acute abdomen *rst + 7I !ecg", lower lobe o o

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pneu !cxr", P5, or things that don%t reMuire surgery !pancreatitis" Acute pan pancreat eatitis o In alcoholic with upper acute abdomen o 8apid onset of in9ammatory process, pain is constant, epigastric, radiates to bac(, n)v)retching. n)v)retching. o x@ serum)urinary amylase, lipase. $ if dx not clear.  x@ npo, ngt, iv 9uids. 9uids. o iliary tract d' o &at women, forties, *ve children, right upper Muadrant ab pain. Acute di diver veritic iticul ulit itis is o Acute ab pain in >>O. 7iddle age or older o &ever, wbc, physical *ndings of peritoneal irritation in >>O. 

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x@ npo, $ scan is dianogstic  @ iv, antibiotics. ant ibiotics. 7ost cool down, if they do not, will reMuire emergent surgery. 8adiologically 8adiolo gically guided percutaneous draingge of abscess may precede resection. 5lective surgery surgery for those who have had at least ; attac(s 1ol olvu vulu lus s of sigmo igmoiid o In old people. Signs of intestinal obstruction, severe ab distention o x@ 8A4 is diagnostic Shows air9uid levels in small bowe, distdend colon, huge air *lled loop in 8O that tapers down toward >O  parrot%s bea(. o  x@ proctosigmoidscopic proctosigmoidscopic exam resolves resolves acute problem. problem. 8ectal 8ectal tube is left in o

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cases need elective sigmoid resection 7es 7esent enter eriic isc is8ecurrent chem hemia

 

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In old. evelop acute abdomen in person with a*b or recent 7I x is late because old people don%t have impressive acute abs !minimal sx" Source is usually clot that brea(s oQ and lodges in the S7A sually dx is late + when there is blood in lumen and acidosis sepsis has developed. In early cases arteriogram and embolectomy save the day 

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=epatobiliary -

he liver o Primary hepatoma 6nly in people with cirrhosis evelop vague 8O pain, weight loss. 7ar(er 3 alpha-fetoprotein. $ scan will show location)extent 8esection if possible o 7et to liver 7ore common than primary. &ound by $ while treating primary, or if $5A rising in those with colon cancer If met is con*ned to one lobe, and slow growing can do lobe resection. o =epaticadenomas $omplication of 6$P. endency to rupture and bleed massively in abdomen $ is dx, and emergent surgery needed o Pyogenic liver abscess $omplication of biliary tract d', esp acute ascending cholangitis. &ever, wbc, tender liver x@ $ scan.  x@ Percutaneous Percutaneous drainage. drainage. Amebic abscess o 75I$6 Similar to pyogenic  x@ metronida'ole metronida'ole $an begin empiric tx in those clinically suspected, if they improve its continued, if it does not improve then drainage is done. :aundice o =emolytic :aundice ncon#ugated !indirect" only. 2o bile in urine. 0or(up to determine what is (illing 8$s o =epatocellular #aundice 5levation of both bilis. =igh >&s, and small increase in Al( P  

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7$ + hepatitis o serologies to determine cause of hepatitis *rst •

 

6bstructive #aundice 5levations of both, increase in >&s, very high Al( P. &irst )S for dilatation of biliary ducts If caused by stones !the stone obstructing the duct is not usually seen" but stones are seen in ? In malignant obstruction >arge, thin walled, distended gb is seen !$ourvoisier terrier sign" o 6bstructive #aundice by stones &at &emale &orty fertile =igh al( phosph, dilated cuts on u)s, non dilated ? full of stones. o 58$P to con*rm dx, do sphincterotomy to remove $ stone &ollow with cholecystectomy o 6bs #aundice by tumor sually adenocarcinoma of head of pancreas, adenocarcinoma of ampulla of vater or cholangiocarcinoma from $ itself. If suspected tumor on )S then do $ scan. &ollow with percutaneous bx If $ is negative  hen do 58$P 58$P !ampulla cancers cancers cause obstruction when they are small and not seen on $, but can be seen on 58$P, and cholangiogram will show intrinscit tumors from the duct or any pancreatic tumors not seen in $. ?allbladder o Asymptomatic ?allstones are left alone o iliary colic 0hen stone temp occludes cystic duct $olic(y pain in 8O, rads to 8 shoulder, and beltli(e to the bac(.    riggered riggered by ingestion of of fatty food N 2)1 26 signs of peritoneal irritation irritation or systemic signs. Self limited - B-< B-< min x@ )S establishes dx of gallstones and elective cholecystectomy is indicated o Acute cholecystitis Starts as biliary colic but stone stays in cystic duct and then in9amm obstructs ?. Pain is constant, fever, 0$, with signs of peritoneal irritation in 8O. x@ )S !gallstones, thic( walled gb, pericholecystic 9uid  x@ 2? suction, 2P6, I1, antibiotics R cool down most cases then do elective cholecystectomy. o

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If they do not respond)can%t cool down, then we need to do emergent cholecystectomy.

 

If pt is very sic( might need to do percutaneous percutaneous transhepatic cholecystostomy temporarily. o Ascending cholangitis Stones reached common duct + producting partial obstruction and ascending infection 7uch sic(er + temp BC-BD, chils, high 0$,  S5PSIS 1584 =I?= A>K P=6SP=  @ I1 antibiotics, emergency decompression of common duct by 58$P or percutaneous through liver !P$"  hen must do cholecystectomy o iliary pancreatitis pancreatitis 0hen stones become impacted distally in the ampulla 6bstructing both pancreatic and biliary ducts. Stones pass spontaneously, get mild and transitory episode of cholangitis ?et manifestations of pancreati pancreatitis tis !elevated amylase)lipase." amylase)lipase." u)s shows gallstones in gb  @ 2po, ng, iv 9uids. &ollowed by cholecystectomy 7ay need ercp and sphncterotomy to dislodge stone Pancreas o Acute pancreatitis $omplication of gallstones, or alcoholics alcoholics.. o Acute edematous pancreatitis In alcohlic or pt with gallstones. 5pigastric midab pain starts after heavy meal or heavy drin(ing $onstant, radiates to the bac(, 2)1, and continued retching after stomach is empty 5levated amylase)lipase  diagnostic. Key *nding to establish edematous nature is elevated hematocrit. •

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 x@

Pancreatic rest 2po, ng, iv 9uids Acute hemorrhagic pancreatitis egins edematous, but low hematocrit. 0b$, increased blood glucose, and low serum calcium. 2ext morning hematocrit is evne lower, serum calcium stays low even with replacement, 2 increases and we have metabolic acidosis develop. 7ay die, due to multiple pancreatic abscesses and bleeding. aily $ scans and drain abscess  x@ I1 imipenem if signs of infection infection Pancreatic abscess • •

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Some one not getting $ scanned, and has persistent fever, 0$ about B days after pancreatitis.

 

Imaging will then reveal collections of pus =ave to drain percutaneous percutaneous and tx with imipenem)meropemen. Psuedocyst >ate seMuel of acute pancreatitis or abdominal trauma D wee(s after initial problem. $ollection of pancreatic #uice outside pancreatic duct and pressure sx. @ $ or )S  x@ If E cm or smaller or present for les sthan E wee(s can be observed If larger than E cm or older than E wee(s + they might rupture)bleed o    reat reat with drainage of cyst cyst + percutanously percutanously or endoscopic $hronic pancreatitis 8epeated episodes of pancreatitis !usually alcoholic" evelop calci*ed pancreas >eads to steatorrhea, diabtes, constant epigastric pain.  x@ Insulin, pancreatic en'ymes Pain is resistant 58$P may help  

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reast -

7amm 7ammog ogra raph phy y sta start rted ed at age age C C 5arl 5arlie ierr if if &=x &=x,, b but ut not not bef befor ore e age age ; &ibroadenomas Seen in young women, *rm, rubbery mass, moves easily. o o x@ 5ither &2A or sonogram 

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o 8emoval is optional if symptomatic ?i ?ian antt #uve #uveni nile le *br *broa oade deno noma mas s o In young adolescents. adolescents. o 8apid growth, need to remove to avoid deformity $4sto 4stosa sarrcoma coma phyl phyllo lode des s o In late ;s, grow over many years, become large and can distort breast. o enign but can become malignant sarcomas. o $2 or incisional bx is needed !&2A not enough" o 7S 857615 &ib ibro rocy cyst stic ic chan change ges, s, cyst cystic ic mast mastit itis is o <s-Cs. goes away with menopause o ilateraly tenderness tenderness related to menstrual cycle. 7ultiple lumps that

come and go.

 

7ammogram is theonly thing needed if no persistant or dominant mass If theres a mass need to do aspiration If 9uid is clear and mass goes away, that%s it If mass persists or recurs need bx, If bloody 9uid, must send to cytology In Intr tra aduc ducta tall pa papillo illoma ma o

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In young women !<s" bloody nipple discharge 2eed to do mammogram, but papillomas will not show up too small. o ?alactogram may guide resectio resection n In*l In*ltr trat atin ing g duct ductal al car carci cino noma ma o 7$ breast cancer. $IS $annot metasta'ie !no axillary sampling needed" but high incidence of o recurrence. o 2eed only local excision o If many lesions can do total simple mastectomy o

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5ndocrine System -

hyroid o  hyroid nodules nodules In euthyroid pts thin( of cancer. x@ &2A If benign do notintervene If malignant or indeterminate must do thyroid lobectomy.    otal otal thyroidectomy thyroidectomy should should be done in follicular follicular cancers cancers In hyperthyroid patients Almost never cancer but might reason for hyperthyroid o labs S= !low", C !high" 2uclear scan will show if nodule is the source    reated reated w with ith radioactive iodine or if they they have a hot adenoma can be treated with surgical excision of aQected  

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lobe =ype =yperrpar ara ath thyr yro oidis idism m o sually due to *nding high calcium in labs 8epeact calcium and chec( for low phosphorus and rule out bone o cancer !mets" o If *ndings persist do P= determination o 5lective intervention is #usti*ed even if asymptomatic HJ have single adenoma + removal is curative. $ushing o =airy face, buQalo hump, obesity, stria, thin wea( extremeties. 6steoporosis, 7, =2, mental instability. o x@ Start with overnight low dose dexamethasone supprestion supprestion 

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!suppression at low levels rules out disease"

 

If theres no suppression do ;C hour urine-free cortisol. If elevated due high dose suppression Suppresion at high doses means its pituitary adenoma 2o suppression at high doses means adrenal adenoma or paraneoplastic paraneoplas tic syndrome !ectopic acth"  hen do imaging imaging studies !78I !78I for pit, $ $ scan for adrenal" adrenal"  x@ removal of tumor tumor 

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Surgical =ypertension -

Pri rima mary ry hype hypera rald ldos oste terrnois noism m o $an be due to adenoma or hyperplasia o &indings@ hypo(alemia in a hypertensive pt not on diuretics =ypernatremia, metabolic al(alosis. =igh aldo, and low levels of renin If appropriate response to postural changes !increase in aldo when standing" suggest hyperplasia If no response then its an adenoma Adrenal $ scan locali'es, and then do surgical removal Pheochromoc mocyto ytoma o  hin, hyperactive hyperactive women, attac(s of headache, perspiration, perspiration, palpitations, pallor 0hen pts are seen attac( has subsided and pressure might be normal o o Start with ;C hour urinary vanillulmandelic vanillulmandelic acid !17A", metanephrines or free urinary catecholamines o &ollow with $ of adrenal glands)readionuclide studies for extaadrenal sites o Surgery reMuires prep with alpha bloc(ers $oar $oarct cta ati tio on of aorta o Seen in 7$ in young pts, =2 in arms, normal pressure)low pressure in legs. o $8 + scalloping of ribs o Spiral $ can with I1 dye !$A" is diagnostic o Surgical correction is curative 8enovascular = =2 2 o ; groups, both are resistant to usual medications, have faint bruit over fnlan( or upper abdomen o @ uplex scan of renal vessels and $A o B. 4oung women with *bromuscular dysplasia  @ balloon dilatation dilatation and stending stending o ;. 6ld men with arteriosclerotic occlusive disease  x is controversial controversial due systemic systemic disease disease from atheroscler atherosclerosis osis   

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Pediatric + &irst ;C hours -

5sophageal atr atresia o Shows up shortly after birth when *rst feeding is attempted. o

2? tube is passed, will coil up in upper chest on xrays.

 

7$ I sblind pouch in the upper esophagus and a *stula beween >5 and tracheobronchial tree. o $hec( for 1A$58 o  x@ Surgical Surgical repair, if it needs to be be delayed do gastrostomy gastrostomy to protect protect lungs from acid Imperforate an anus o 2oted on physical exam, part of 1A$58 anomlies o

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If no *stula present need to do colostomy if it%s a high pouch. If pouch close to anus can do primary repair right away. oub ouble le bub bubbl ble ea and nd gree green n vomi vomitt o >arge air 9uid level in the stomach, and a smaller one to its right in *rst part of duodenum uodenal atresia, annular pancreas or malrotation 7alrotation is emergency x with contrast enema or upper ?I. Intestinal at atresia o Shows up with green vomit o 25?AI15 double bubble but has multiple air 9uid levels in abdomen o

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&ew days old to ; months old -

2ecr 2ecrot oti' i'in ing g ent enter eroc ocol olit itis is o In premature infants when they are *rst fed o &eeding intolerance, ab distention, rapidly dropping platelet count o  x@ stop feeding, feeding, broad spectrum spectrum antibioitics, antibioitics, iv 9uids 9uids and nutrition nutrition 2eed surgery if they develop@  abdominal wall erythema, air in the portal vein, intesintal pneumatosis  pneumoperitononeum pneumoperitononeum 7econium Il Ileus o abies who have cystic *brosis !mother might have it also" o evelop feeding intolerance, bilious vomiting o ray shows multiple dilated loops of bowel and ground glass appearance o x@ ?astrogra*n enema is diagnostic and therapeutic =ype =ypert rtro roph phic ic pylo pylori ric c sten stenos osis is o 2onbilious pro#ectile pro#ectile vomiting after each feed. aby is hungry and wants to eat o Palpable Palpa ble olive si'e mass in ruM If no mass, do u)s o o  x@ 8ehydrate and correct al(alosis  hen ramstedt ramstedt pyloromyotomy pyloromyotomy or balloon dilatation. dilatation. iliary at atresia o E-G wee( old babies with persistent increasing #aundice o serologies and sweat test then do =IA scan o 

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If =IA scan shows up everywhere in biliary tree then it%s not biliary atresia, but if dye is stuc( in liver then he does have it o 0ill need surgery and maybe liver transplant =irsc =irschsp hsprun rung g d' !agang !aganglio lionic nic megaco megacolon lon o $hronic constipation o 8ectal exam may lead to explosive expulsion of stool and 9atus and relief of abdominal distention 

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rays show distended proximal colon !normal" and Rnormal-loo(ing distal colon !aganglionic part" x@ full thic(ness bx of rectal mucosa

>ater in infancy -

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Intussuception o In E-B; month olds + colic(y ab pain o >asts B min and then (id goes bac( to normal until another episode o 7ass on right side, empty 8>O, current #elly stools o  x@ barium or air air enema diagnostic diagnostic and therapeutic therapeutic 7ec 7ec(el div diver erit itic icul ulu um o >ower gi bleed in (ids. o o radioisotope scan for gastric mucosa

6phthalmology $hildren -

Amblyopia o 1ision impairment due to interference with the processing of images by brain during *rst E to F years of life. Seen in child with strabismus. o if its not corrected early on there will be permanent cortical blindness !even though eye is perfectly normal" Strabismus o x@ re9ection from a light comes from diQerent areas of the cornea in each eye Should be surgically corrected at dx to prevent amblyopia o If it develops later in infancy we will see an exaggerated convergence  hen use correctiv corrective e glasses o  rue  rue strabis strabismus mus does not resolve resolve on its own 0hite pu pupil in in a baby o Is an emergency + might be due to retinoblastoma or congenitall cataract o Should be attended to to prevent amblyopia 

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6pth in adults -

?laucoma o Acute angle Severe eye pain or frontal headache + starting in the evenining or when pupils have been dilated for a while 

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Pt may halos around lights Pupil is report mid3dilated and does not react to light

 

$ornea is cloudy with greenish hue 5ye feels hard as a roc(  x@ 5mergency + drill hole in iris with laser to provide route for drainage $an also administer carbonic anhydrase inhibitors !iamox" and topical beta bloc(ers or alpha-;-agonist 7annitol or pilocarpine can also be used 6rbital c ce ellulitis o 5mergency o 5yelids are hot, tender, red, pt is febrile. o Key *nding@ eyelids are rpied open and pupil is dilated and *xed with limited motion Pus in orbit o x@ emergency $ and drainage $hemical burns o 8eMuire massive irrigation o After prying it open and washing for an hour transports to 58. o $ontinue irrigation with saline, corrosive particles are removed before patient is sent home and p= is tested to ma(e sure its all gone 8etinal de detachment 5megerncy o o Pt reports seeing 9ashes or having 9oaters in the eye !more 9oaters, means its worse" o  x with laser Rspot welding welding to protect remaining retina 5mbo 5mboli lic c occ occlu lusi sion on of ret etin inal al a. 5megerncy but not much can be done o o 6ld patient, sudden loss of vision in 625 eye. After < min damage is I885versible o ?et patient to breathe into paper bag, someone press hard on eye and release 1asodilate and sha(e the clot to more distal location   

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2eurosurgery - IA o Sudden, transitory loss of neurologic function o sually due to high grade stenosis of the internal carotid o Predictors of stro(e, need elective carotid endarterectomy - Ischemic st stro(e o Sudden onset without headache o 2eurologic de*cits present for more than ;C hours o Assessment by $ scan and therapy for rehab o $an treat with t-pa if used with H min to < hours !up to E hours/" &irst do $ scan to rule out exntesive infarcts or hemorrhage. 

6rgan transplant -

=ype =yperracute ute re# e#ec ecti tio on

 

1ascular thrombosis that occurs within minutes + due to preformed anitbioties. Prevented by A6 matching and lymphocytotoxic cross motch 2ot seen clinically Acute re re#ection o After the *rst D days, within < months o 6ccur even if pt is on immunosuppression o

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Signs of organ dysfunction $on*rmed with bx o In case of liver &irst rule out biliary obstruction by u)s and vascular thrombosis by oppler oppl er.. o  x@ &irst line therapy is bolus of steroids If that doesn%t wor( can use anti-lymphocyte agents but are very toxic $hronic re# re#e ection o Seen months to years after transplant o ?radual loss of function  

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Irreversible