Term
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Definition
1. History:
2. Physical:
3. Tests:
-HPI-painful? relation to menses?
-PMH/FH- unopposed exposure to estrogen: NAACP- (nulliparity, age of menses-younger than 13, age of menopause-older than 55, cancer of breast in self or family, pregnancy with first child->30 yo) --SH/Meds- OCPs?
Head to toe, including:
-Breast: skin changes, nipple discharge, inflammatory symptoms, axillary/supraclavicular nodes, peau d’ orange, how many lumps
-Pelvic
-Rectal (The only contraindications for a rectal are no finger, no a-hole, acute MI or fatal arrhythmia)
a. Ultrasound in the office and/or FNA to check for fluid (if no fluid comes back = solid)
b. Mammogram: to look at other breast and other areas of same breast for occult malignancy (false negative rate = 15%) (U/S only in pts below 30)
c. Core Needle Bx: if aspirate and totally goes away with no blood and no recurrence for 6 weeks it is a normal cyst
d. Excisional biopsy in OR: if palpable mass still present after aspiration, if cyst recurs within 6 weeks, or if bloody fluid comes back
**Request ER and PR to be included in Path Report!
4. Clincally Stage the Patient: LFTs, CXR, changes in mental status = CT, bone pain = bone scan
Staging: 1. tumor <2cm with no nodes: 5 year surival is most people
2. tumor >2cm and <5cm or mobile nodes : 2/3 survival after 5 years 3. tumor >5cm or fixed nodes: 1/3 survival after 5 years
4. distant mets: hardly anyone survives after 5 years
5. Options for Surgery:
a. Lumpectomy + sentinel node bx + radiation
b. Modified Radical Mastectomy (breast and axillary nodes): can do this for level 1 and 2 nodes
(1 = lateral to pec minor, 2 = posterior, 3 = medial)
c. Radical Mastectomy: ONLY if imaging shows the tumor involves the pectoral fascia or male breast cancer
Discussion of options 1 and 2:
*Survival is the same.
* Local recurrence is increased in lumpectomy, but cosmetically it saves the breast.
*Radiation is a downside – 5 days of the week for 6 weeks, and radiation can cause other cancers. *If you have local recurrence after lumpectomy you can not do radiation again.
*Modified radical mastectomy is one operation and can have radiation with local recurrence.
*Patient returns in one week: Path shows 10/15 nodes + for metastatic disease – (still stage 2 b/c mobile nodes). Positive nodes = systemic disease, tx with chemo – CMF (Cyclophosphamide, Methotrexate, 5-FU) or CAM (Cyclophosphamide, Adriamycin, 5-FU) - refer to oncology. If ER+, tx with Tamoxifen. Tamoxifen can increase the risk of endometrial ca (1.5% risk - 2 x 0.8) and cause osteoporosis, 2x DVT risk, and other menopausal symptoms.
Sister freaks out (age 33): Do an H&P. Women need baseline mammogram at 35-40 yo, then every other year 40-45, every year >50. A mammogram gives 2 rads (as few as 65 rads can induce malignancy therefore do NOT DO mammograms on young girls b/c would cause more breast ca from radiation). You should get a mammogram on her b/c she is within 5 years of sister’s age when diagnosed with breast cancer. Using Gales Criteria, give high-risk patients Tamoxifen prophylaxis for 5 years (and no more) to decrease risk by 50%.
2) DCIS: 25 yo female with strong hx of breast cancer gets a mammogram that shows abnormal area in right upper outer quadrant
1. H&P: unremarkable
2. U/S: shows it is solid
3. Stereotactic Breast Bx (mammogram-guided): cellular debris

4. Needle localizing excisional bx w/ mammography: DCIS - risk of recurrent invasive cancer is 35x that of normal
5. Surgical Options with DCIS:
a. Lumpectomy with radiation (do not need sentinel bx because in situ)
b. Simple mastectomy (breast only)
**with these 2 treatments, the chance of positive nodes is 3-4%***
3) LCIS: What if pathology messed up? actually LCIS. The risk of recurrent invasive cancer is 10-15% in either breast over the next 15 years
1. Surgical Options with LCIS:
a. bilateral simple mastectomy
b. excise lesion and follow closely
*Overview of Treatments:
Non-inflammatory Breast Cancer:
1. Lumpectomy + Radiation + Sentinel Node biopsy (for Stages I and II)
2. Modified Radical Mastectomy
3. Radical Mastectomy (only if chest wall involved)
4. “Salvage” Mastectomy if local recurrence after a lumpectomy + radiation
+/- Chemo (CMF or CAM) if nodes are + +/- Tamoxifen if cancer is ER+
Inflammatory Carcinoma of the Breast: Chemotherapy first! (Then XRT and/or mastectomy if needed)
DCIS: a. Lumpectomy with radiation (do not need sentinel bx because in situ)
b. Simple mastectomy (breast only) +/- Tamoxifen or XRT
LCIS: a. bilateral simple mastectomy
b. excise lesion and/or follow closely +/-Tamoxifen
*Staging: I: Tumor <2cm, no nodes
IIa: Tumor <2cm, mobile nodes OR tumor 2-5cm, no nodes
IIb: Tumor 2-5cm, mobile nodes OR tumor >5cm, no nodes
IIIa: Tumor >5cm, mobile nodes OR any size tumor with fixed axillary nodes IIIb: Skin Changes, Chest Wall fixation, OR ipsilateral internal mammary nodes IV: distant mets, including ipsilateral supraclavicular nodes |
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Term
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Definition
1) RLQ PAIN: 23 yo with RLQ pain x 10 hours, emesis x 2, increasing in intensity
1. History:
2. Physical: 3. DDX:
HPI- Type, quality of pain, and duration of pain? Ever had it before? Radiation of pain? Aggrevating/Relieving factors? ROS- hematemesis, n/v/d, change in eating and/or bowel habits, urinary symptoms, last menses, vaginal discharge
PMH/PSH, FH, SH, Meds, Allergies
Vitals
Abdominal (I, A, P, and Percuss) - rebound? distention?, signs of infection?, PELVIC & RECTAL
Female: Ectopic pregnancy, PID, Ovarian Torsion, TOA, mittelschmerz
GU: UTI, Pyelonephritis, Kidney Stone
GI: Appendicitis, Diverticulitis of Cecum, IBD, Gastroenteritis, Valentino’s Appendicitis, Omental Torsion, Mesenteric Lymphadenitis, Pancreatitis
Liver: Hepatitis, Cholecystitis
Lung: Pneumonia

*NOT in DDX: SBO= distended, air/fluid level, fecalent vomit, tympanic, dehydrated, metabolic alkalosis with hypoK+ and hypoCl; Ischemic Colitis= pain way out of proportion to physical exam
4. Tests: CBC, CMP, amylase/lipase, b-HCG, U/A, Type and Screen
5. Images: (The diagnosis is made by physical exam, so really these are unnecessary!!!) - CXR, AXR
6. Preop: IVFs, Anaerobic-covering antibiotics
7. Exploratory Lap:
Normal Appendix: take it out anyway to rule out appendicitis in future
Mesenteric lymphadenopathy that shows reactive hyperplasia on frozen section =Mesenteric
Lymphadenitis - give IVFs
Mass in tip of appendix (Carcinoid): if <2cm just take out appendix, if >2cm do a right hemicolectomy (will only have symptoms of carcinoid if it has mets, otherwise the serotonin is detoxifed in the liver via the portal vein
TOA: unilateral salpingo-oophrectomy with hysterectomy
Crohn’s in ileum (uncomplicated): do NOT take out appendix if cecum involved because you can get a fistula. A fistula is an abnormal connection between 2 epithelial surfaces. Do not get fistulas with FRIEND (foreign body, radiation, infection, epitheliazation of tract, neoplasm, distal obstruction). Clue on physical exam that you have Crohn’s is perianal pathology esp fistula in ano NOT at 12 or 6 o’clock. Resect Crohn’s and perianal disease goes away. Treat Crohn’s with steroids.
Meckel’s: amputate at the base
2) SUPPURATIVE THROMBOPHLEBITIS: 25 yo female with RLQ pain 48 hours after SVD
1. History/Physical Exam: + involunary guarding, + rebound, no discharge, no CMT, tender in RLQ, Heme – 2. Labs: CBC, CMP, type and cross (results: wbc 28 with left shift)
3. DDX: see #1 above
4.Tests: 1)AbdominalSeries: normal
2) Abdominal/Pelvic CT: large tubular structure in retroperitoneum
5. Operation: Exploratory Celiotomy – find large right ovarian vein with suppurative thrombophlebitis due to uterus sitting on it and bacterial colonization. Need to excise the vein
3) DIVERTICULITIS: 60yo with LLQ x 8h, increasing in intensity, +n/v 1. History:
2. PE: tender, heme -, no fever, + involuntary guarding
3. Tests: 1) Abdominal Series: normal
2) CT: diverticulitis in sigmoid with pericolic abscess by left colon
3) (Colonoscopy had the symptoms been bleeding without signs of pain/inflammation – Do NOT do in acute setting bc of perforation risk!)
4. Pre-Procedure: IVFs, NPO, Broad-spectrum Antibiotics with Gram (-) Coverage, NG suction as needed
4. Operation: 1st choice: percutaneous drainage with abx - let inflammation calm down and then in 2-3 weeks do a prep + resection + primary anastomosis. Abx need to cover Gm- and anaerobes so use Cefotetan and Gentamycin.
2nd choice: If you can’t do percutaneous drainage (ie in the case of perforation, obstruction, etc), open pt and drain abscess. Do a diverting colostomy with either a mucus fistula or Hartmann’s pouch (stapled rectal stump). **Do Hartmann’s only if you have a short distal portion to avoid blind loop syndrome. Short = nothing longer than sigmoid. Do a
diverting colostomy b/c don’t want to do a primary anastomosis on an unprepped colon. 4) MI & DUODENAL PERFORATION: 40yo with acute episode of epigastric pain, emesis x 1
1. Hx: HPI - appearance of emesis, hx of alcohol? , hx of abd pain?, PMH/PSH, FH, SH, Meds, Allergies 2. Exam: + rebound, no radiation, no Murphy’s, do a rectal, decreased bs, + involuntary guarding
• •
•
• •
•

3. ABCs: 4. DDX:
5. Tests:
Oxygen?, NG tube, IVF, Foley, Type & cross
PUD, gastritis, MI, pancreatitis, biliary colic, gastric volvulus, Mallory-Weiss
Abdominal series - free air in left abdomen Bedside EKG: acute MI, CKMB & tropins are +
6. Plan: Start nitro drip, swan ganz to check filling pressure, B-blocker, Antibiotics, go to OR
7. In OR: See perforated duodenal ulcer - Graham patch (Omental
patch) If there is no omentum do a serosal patch.
Other options: 1. Graham Patch + Highly selective vagotomy
2. Truncal vagotomy and pyloroplasty incorporating the ulcer
3. If gastric perforation – Antrectomy incorporating ulcer
*Close the abdomen and the anethesiologist tells you the BP is 50. Use an introaortic balloon pump (attched to an EKG) in femoral artery-aorta. When in systole the balloon is collapsed, in diastole the balloon is inflated. This gives a diastolic kick to get blood in coronaries (increasing preload) and creates a suction in systole to decrease afterload. |
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Term
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Definition
1)BLEEDING ESOPHAGEAL VARICES: Drunk male, vomiting BRB, passed out, BP of 75 in ER
1. ABCs: A/B: Intubate and ventilate b/c loss of protective reflex Give O2,
NGT-blood stops after 1L C: 2 large bore IVs (2L LR)
2. Exam: Normal except rectal is Heme +, EGD(Esophagogastroduodenoscope?) shows actively bleeding esophageal varices + gastritis
3. Labs: CBC, CMP, LFTs (if alcoholic), Type & Cross, Tox screen, Blood alcohol level -Hemoglobin returns as 3 - give 1u of PRBCs to increase hemoglobin by 1 (get up to 10)
4. Tx: 1) Sclerotherapy: using sodium morrhuate, if not available...
2) Balloon Tamponade with Sengstaken-Blakemore: puts balloons in esophagus and stomach, works using pressure, leave in as little time as possible b/c necrosis risk
3) Rubber Bands
4) Vasopressin (risk = MI)
5) Somatostatin
6) Portocaval Shunt (must do this early) – (risk=encephalopathy)
*Asides: 1) Pathophys of cirrhotic liver- scar tissue impedes blood flow in portal vein, increased pressure in portal system gets shunted to splenic vein - short gastrics - esophageal plexus, also in
umbilical vein (caput medusa), inferior rectal vein (hemorrhoids), and retroperitoneal
2) Pathophys of encephalopathy: gut bacteria normally detoxified in liver, Check this by
measuring arterial ammonia
3) Child’s Classification: predicts operative mortality
A: no ascites, bili <2, no enceph, alb >3.5, good nutrition (measure with transferrin, prealbumin), operative mortality is the same as if not cirrhotic
B: easily controlled/mild ascites, bili 2-3, alb 3-3.5, mod. Nutrition, no encephalopathy, operative mortality = additional 15% to mortality of the operation itself
C: ascites, alb <3, bili .3, encephalopathy, bad nutrition, mortality is 40% + mort of op itself, MC op for class C is TIPS (transjugular intrahepatic portosystemic shunt)- stent placed intrahepatically between the hepatic vein and branch of portal vein, used to bide time before transplant
4) Do NOT shunt class Cs! Do TIPS as a bridge to transplant

5) MC reason for liver transplant- Nash nonalcoholic cirrhosis d/t obesity (fatty liver) 5. F/u in 6mo: 2nd EGD shows red whale sign (impending variceal hemorrhage), class B, done drinking
*indications to shunt: 1) stopped drinking, 2) NOT class C, 3) determine if blood in portal vein goes to
or from liver (retropedal is bad b/c increased incidence of encephalopathy, want hepatofugal flow). Test this with color dopler of portal vein. Or you can measure portal pressure indirectly with hepatic vein wedge pressure, if <24 do NOT shunt b/c poor portal inflow.
*Shunt Choices: 1) portocaval (highest risk enceph, best for ascites)
2) distal splenorenal shunt (Warren Shunt): selective L-sided shunt that does NOT decrease portal pressure, lowest risk of encephalopathy b/c only splenic flow diverted
3) Mesocaval and H-graft are in between the above two with risks and benefits
2) COLON CANCER: 55 yo w/ dark tarry stools and Hgb = 7
1. Hx: HPI – change in eating or bowel habits, weakness/fatigue, PMH/PSH, FH- colon ca, polyps, SH – diet? 2. Physical: normal except rectal is heme+
3. Labs: CBC, CMP- albumin 2.5, low Ca2+, Hgb 7, so give 3u of blood to get Hgb to 10,
4. Tests: Colonoscopy: prepare with bowel prep (4L Golytely over 4-8h). It shows cancer in midtransverse colon. Biopsy: adenocarcinoma
5. Further workup: CEA level
Clinically Stage with LFTs and CXR
6. Pre-op: 1) Labs (Hgb =9 - give PRBCs). Risk for PRBCs: AIDS, CMV, bleeding, transfusion reaction, immunosuppresion can make cancer worse, PT/PTT
2) Golytely Colonic Lavage or Fleets
3) PO antibiotics – 1g Neomycin and 1g Erythromycin * 3 doses 4) 24hr preop IV antibiotics – cefoxitin, cefotetan, or unasyn
*Dukes Staging of Colon Cancer:
A: invasion of submucosa
B: Invades muscularis (1), through muscularis (2)
C: + nodes
D: distant mets
**Aside: colon cancer spread proximally**
TNM Staging:
I: Invades submucosa or m. propria (T1-2 N0 M0) II: through m. propria (T3-4, N0, M0)
III: + nodes (any T, N1-3, M0)
IV: distant mets (any T, any N, M1)
7. Operation: Right and transverse colectomy + mesocolon resection (lymphatic drainage) +primary anatomosis. Then irrigate with sterile water to lyse cancer cells. If there is a lesion on right lobe of liver, bx it, then do a wedge resection. (If there are < 4 isolated lesions in one live lobe, you increase 5 yr survival by 20%). Also consider BSO to avoid recurrence in ovaries.
8. Post-op monitoring: Get a CEA 6 weeks after surgery.
3) ANAL FISSURE: 22yo with pain that lasts for hours upon defecation with BRBPR 1. History:
2. Exam: + sentinal tag at 6 o’clock (if a tag is NOT at 6 or 12 o’clock = Crohn’s), too painful for DRE or Proctoscope
3. Dx: Rectal fissure (a tear)
4. Tx: 1) Medical: stool softeners, sitz baths, high fiber diet
2) Surgical: lateral internal spincterotomy, don’t cut external spinchter (incontinence) |
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Term
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Definition
1) 50yo female with halitosis (bad breath), c/o food getting “stuck” and emesis after eating, difficulty swallowing liquids as well

a. History/Physical
b. Tests: 1) Esophagoscopy: shows undigested food
2) Barium Swallow: dilated esophagus with corkscrew appearance & bird beak sign
3) Manometry confirms the dx of achalasia (increased pressure in the LES and inability of LES to relax)
c. Dx: Achalasia - failure of LES to relax with swallowing and loss of peristalsis. (This disease is mimicked by Chagas due to Trypanosoma cruzi).
d. Treatments: 1) Esophagomyotomy- cut hypertensive outer muscle, or... 2) Balloon dilation of LES
2)
b. Tests:
c. Tx:
3)
b. Tests:
c. Tx:
3) CCBs (Medical tx of reflux)
4) Belsey Mark IV 270 fundoplication 5) Botox
a. History/Physical: CC: “My food gets stuck”
1) Esophagoscopy with bx shows grade 2 esophagitis and Barrett’s
**Grading of Esophagitis: 1-erythema, 2-linear ulceration, 3-circular ulceration, 4-stricture**
If low grade Barrett’s: Nissen to control reflux If high grade Barrett’s: Esophagogastrectomy
a. History/Physical: CC: “My food gets stuck”
1)Esophagoscopy w/ bx shows grade 4 esophagitis with hiatal hernia and no Barrett’s Nissen + Balloon dilation to dilate stricture
4)
previous radiation as well as other symptoms – dysphagia, wt loss, hoarseness, etc.
a. History/Physical: CC: “My food gets stuck”, ask about risk factors- tobacco, alcohol, reflux, Barretts,
b. Tests: 1) Esophagoscopy w/ bx show fungating mass that is Squamous Cell Carcinoma c. Tx: Metastatic workup: CXR, LFTs, bone scan, CT
Esophagectomy (take out ALL of esophagus b/c will have skip areas). Then do a stomach swing (gastric pull-up). Can also bring up small intestine or colon but check colon for cancer first! |
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Term
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Definition
1) PANCREAS PROBLEMS: 60yo markedly jaundiced, lost 10lbs, itching x 4-6 weeks
1.History: PMH: Diabetes? Gallstones? Infection? SH: Alcohol? Smoking?
2. Exam: Courvosier’sign? (Palpable, nontender distended gallbladder)
3. Labs: CBC, CMP with fractionated bili, amy/lip, hepatitis panel
-results: bili 10 (mostly direct), increased alk phos, LFTs mildly elevated
4. Tests: U/S - shows dilated gallbladder and dilated common bile duct
CT -shows mass in head of pancreas obstructing the common bile duct
Transduodenal bx so that leakage goes into duodenum
5. Management:
a) If pancreatic cancer at head of pancreas: Whipple- pancreaticoduodenectomy, cholecystectomy, truncal vagotomy, antrectomy, choledochojejunostomy, pancreticojejunostomy, and gastrojejunostomy. A Whipple provides palliation b/c chemo and radiation do nothing. Whipple is also good for cholangiocarcinoma - 5 year survival is 40%.
If cancer is in the body or tail – Distal pancreatectomy

**If the pancreatic cancer is unresectable due to bv involvement, liver involvement, or biliary obstruction do a palliative stent with ERCP. The downside to the stent is infection b/c luminal
obstruction in CBD and have to change it q 3 months.**
b) If chronic pancreatitis: Roux en Y choledochojejunostomy. This is a bypass from the CBD to the jejunum and it prevents alkaline gastritis (as compared to a Bilroth). Treat alkaline gastritis with
cholestyramine to decrease bile acid pool, or Ca2+ which chelates bile acids.
*If chronic pancreatitis obstructing pancreatic duct: Longitudinal Pancreaticojejunostomy (Puestow) or Distal Pancreaticojejunostomy (Duval)
2) ADENOCARCINOMA OF THE OVARY AND BILIARY DYSKINESIA: 44yo female with epigastric pain after eating fattening foods
1. Hx: only significant for not having a period for 4 months 2. Physical:
3. Tests: Abdominal u/s - shows mass on ovary
4. Op for Ovarian Ca: TAH BSO
Periaortic lymph node dissection
Lavage
Omentectomy
Bilateral diaphragmatic bx to check for lymph node involvement
*She returns with same symptoms: do a CCK-HIDA scan (nl ejection % = >40%) if lower it’s biliary dyskinesia - take out gallbladder |
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Term
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Definition
1) CAROTID STENOSIS: 65 yo male with carotid bruit on right
1. Hx: asymptomatic (no fainting or weakness), Amaurosis Fugax? PMH-stroke? 2. Exam: benign except carotid bruit
3. Tests: Doppler Flow Study - shows right carotid with 80% stenosis
1 year risk of stroke:
4. Preop:
a. Cardiac Work-up- EKG and stress test (EKG while on treadmill or use cardiolyte/thallium if can’t use treadmill). The idea is to make the heart work harder to try to find any area of ischemia. Exercise the heart to dilate arteries and veins - need more blood flow to sustain. If you have a fixed impediment you get ischemic when at rest. If cardiac work-up shows ischemia of heart, do a cardiac cath. If this shows 80% blockage (atherosclerosis) of left main coronary artery do a CABG.
b. Labs: Coags (best test is a hx of bleeding/bruising), CBC, BMP, CXR
c. Head CT if symptomatic? 5. Anesthesiologist:
a. Prophylactic Antibiotics
b. Heparin (100u/kg)
c. Dopamine to keep pressure up.
d. Alpha-blocker such as Clonidine preoperatively e. Have a Nitro drip ready for HTN crisis.
5. Operation: CEA.

Medical Management
Surgical Management
Asymptomatic
12%
6% (50% risk reduction)
Symptomatic
27%
9% (2/3 risk reduction)

**Pathophys of HTN crisis- carotid body is clamped off therefore it thinks you are hypoTN b/c no blood is getting there - signal to adrenals to increase catechols and increase BP. You need to turn carotid body off by injecting it with lidocaine which inhibits action potential of nerves and therefore carotid body can’t communicate.
*Complication after surgery: pt not moving left side of body. Need to do a duplex of carotid artery. Open pt and explore- hope to find an intimal flap so that you can scrape off intima at intima/media junction.
*Asides: If asymptomatic with 60% stenosis- operate
There are NO internal carotid branches in the neck
Use prophylactic abx for: prothesis/FB (dacron) and dirty places (colon)
2) ABDOMINAL AORTIC ANEURYSM: 65yo male’s KUB shows egg shell mass in mid abdomen (Causes: atherosclerosis, collagen vascular disease, salmonella, syphillis, TB); other possible symptoms – vague back or
abdominal pain
*DDx: acute pancreatitis, aortic dissection, mesenteric ischemia, MI, perforated ulcer, diverticulosis, etc.
1. Tests: U/S – shows 4.6cm infrarenal AAA = watchful waiting Arteriogram to assess renal/iliac involvement
a) <5cm is low risk to rupture - follow q 3 months to monitor growth
b) >5cm - operate
c) if it grows > 1⁄2 cm in 6 months - operate
*At the next u/s is it 6cm -operate
2. Pre-op workup (If rupture or leak – no preop or diagnostics, go straight to laparotomy): cardiac workup, CXR, BMP to evaluate renal function and acid/base status, peripheral vascular exam (pulses), prophylactic abx w/in 30min of incision to have peak levels in tissue at time of cutting, and bowel prep. Bowel prep is important b/c when you ligate the IMA (in this operation you ligate the IMA and lumbars in the aneurysm) if the marginal artery gives out you can get ischemic colitis 2-3 days out. You will also get translocation of bacteria which will infect the graft.
3. Options for surgery:
a. Prosthetic Graft Placement wrapped in native aneurysm adventitia
b. Endovascular Repair via femoral catheter placed stents (for poor surgical candidates)
c. Aortobi-iliac or Aortobifemoral graft (if iliacs are severely occluded or iliac aneurysms are also present)
*Early Complication: pt returns 1 wk later with BRBPR, Diarrhea, and Abdominal Pain -- Colonic Ischemia (due to sacrifice of IMA during surgery and lack of good collateral blood flow); Tx with resection of necrotic colon, Hartmann’s Pouch or Mucous Fistula, and End Colostomy
*Late Complication: pt returns 4 months later in ER due to hematemesis (decreased BP, increased HR) a. DDX: Dieulafoy’s ulcer (gastric mucosal defect bleeding from underlying AV malformation),
esophageal varices, PUD, aortoenteric fistula
b. ABCs: 2 large bore 16-guage Ivs in arms give 2L isotonic fluid
**Garr’s Rule of 7 tubes: 2 IVs, 2 chest tubes, NGT, ET tube, foley (need UOP at 0.5cc/kg/hr)**
c. History and Physical, then EGD (endoscopy)
d. Dx: Aortoenteric fistula (fistula between aorta and duodenum) due to graft infection. MC organism is slime-producing staph epidermis. The slime forms biofilms which inhibit abx. The cause of this could be not enough intraoperative abx.
e. Management:
1) Endoscopy in OR
2) CT – look for gas bubbles, fluid (signs of graft infection) 3) Take out infected graft
4) Irrigate with betadine peroxide

5) Extra-anatomic bypass - Axillobifem (graft from axillary a. to femoral a. then femoral to other femoral) to stay out of infected area
3) ACUTE ARTERIAL EMBOLUS: 60yo diabetic who’s right leg is colder than left x 1 day
1. History: “6Ps: Pain, Paralysis, Pallor, Paresthesia, Polar, Pulselessness”
2. Physical: pulses not palpable in either foot, right foot colder than left, HR is irregularly irregular
3. Tests: 1) ABIs - left is 0.4, right is 0.0. (ABIs are not accurate in diabetics b/c vessels are calcified & do not contraact with BP cuff. It’s more accurate to do toe pressures, and anything below 75 indicates ischemia. 2) Doppler: no flow from knee down on right (no pain b/c diabetic neuropathy) 3) EKG: A-fib
4. Management: Go to OR. You don’t need cardio clearing in an emergency. a. Anticoagulate with heparin.
b. Slow his ventricular response with Digoxin (it’s an inotrope that decreases conduction time at AV node). c. Arteriogram if possible?
d. Put a Fogarty (balloon catheter) in femoral artery, place it past the emboli, inflate balloon, and pull it back to remove emboli.
4) VENOUS STASIS ULCER: 40yo farmer with prior leg injury now has ulcers on medial malleolus that won’t heal
1. History:
2. Exam: edema over entire leg, palpable pulses
3. Labs: CBC, CMP, coags - all normal
4. Tests: 1) Doppler - shows good flow and no DVT.
**Pathophys of venous stasis ulcer: DVD? destroys veins - recanalization of veins - poor valves with leakage - venous insufficiency – increased hydrostatic pressure, and increased interstitial pressure – decreased tissue perfusion of end organ (skin)**
2) Biopsy ulcer due to concern of Marjolin’s ulcer (squamous cell carcinoma ulceration overlying chronic osteomyelitis or burn scar)
5. Tx: 1) Medical: Unna boot with zinc, dressings changes, elevate to decrease interstitial pressure, compression stockings that go above knee
2) Surgical: Linton procedure: subfascial ligation of veins |
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Term
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Definition
1) PULMONARY EMBOLUS/HYPOXIA: 30 yo female 36o s/p TAH with change in mental status (***change in mental status is due to hypoxia until proven otherwise***)
1. ABCs
A: Intubate: Use size 8 endotracheal tube because this is the smallest size a bronchoscope will fit in. The tip of the tube should be 2cm above the carina. This corresponds to the level of the clavicles on
CXR. The tube should go down 22cm.
B: Ventilator: Use intermittent mandatory ventillation (IMV). This is a mode with intermittent mandatory ventilation at a predetermined rate; patients can also breathe on their own above the mandatory rate without help from the ventillator. Initial ventilator settings: Mode: IMV, Tidal

Volume: 10-15cc/kg, Rate: 10 breaths/min, Fi02: 100% and wean down (it takes about a day to get O2 toxicity, can prevent this with a FiO2 < 60), PEEP: 5cm H20. From these parameters, change according to blood-gas analysis. Bonus: PEEP is good because it keeps pressure in the lungs to keep alveoli open, it’s bad because it can cause PTX, decreased venous return, decreased CO,
hypotension. a ventilator if:
1. PaO2 < 60
2. PaCO2 > 60 (only if NOT a COPD pt)
3. Loss of protective reflexes (i.e. drunk, high, unconscious)
4. RR > 30-35
5. Your clinical judgement tells you to
***Put a patient on
C: Check BP, vitals
2. Initial Tests (simultaneous with ABCs):
3. Physical Exam:
a) Pulse ox (before intubation): O2 sat= 70% therefore PaO2 is 40
***A PaO2 of 40,50,60 corresponds roughly to an O2 sat of 70.80,90 respectively***At a PaO2 of 60 the Hb-O2 curve dips, therefore
needs O2 sat at 90 or above***
b) ABG: Returns as pO2 = 40 and pCO2 = 40
Vital Signs: T 992, HR 115, RR 35
Head-to-toe: Look for wound infection (bacteria = group D strep and clostridium), check nail beds and perioral region for cyanosis, listen to lungs (in this case she has bilaterally decreased breath sounds in both lung bases)
Homan’s, Check for asymmetry of legs
4. Further Tests/Imaging:
a. CXR (diagnostic and to check ET tube placement): bilateral basilar atelectasis, Westermark’s
Sign? (wedge-shaped, hyperlucent area due to decreased pulmonary vasculature)
b. Spiral Contrast CT scan: of chest to check for PE
c. V-Q Scan?
d. PulmonaryArteriogram?
e. EKG – cor pulmonale? Flipped T waves or ST depression? f. Duplex Ultrasonography: to check for DVT
6. Management:
a. ABG: about 20 minutes after first ABG to check stats (in this case PaO2 is now 90)
b. Medication:
1. Heparin to prevent further clotting (100u/kg). Follow the PTT which you want at 1.5-2x normal, or INR between 2-3. (bonus: you can NOT use a thrombolytic agent if
a patient has had surgery in the last 2 weeks) Consider thrombolytics if pt is unstable. Follow with 3-6 months of Coumadin
2. If allergic to heparin, put a Greenfield or Birds Nest filter in the IVC. Put it below the renal arteries.
3. If no filter available, use Miles Clips on the IVC below the renal arteries (the clips have small holes to let some blood through). You can only use these clips if you have an intact azygous system that drains into the IVC above the renal art.
2) FLAIL CHEST AND SPLENIC INJURY: Jockey kicked by horse in left chest, dyspnea, increased RR 1. ABCs: A: Intubate, NGT
B: PEEP as needed, in case of pulmonary contusion
If tension pneumo (JVD, anxiety, etc)- Thoracentesis with 12 guage needle in 2nd space, midclavicular line - O2 sats go from 84 to 92. Make sure you get all the blood out to avoid a fibrothorax. Then put in 1 chest tube in 4th space in midaxillary line.
C: 2 large bore IVs, Foley

2. PE: Decreased breath sounds of left, crepitus, flail chest (negative pressure sucks chest in with inspiration) 3. Labs: CBC (Hgb 10), CMP, type and cross
4. Tests: 1) CXR: get this after putting in chest tubes
2) Chest CT: broken ribs
3) Abd/Pelvis CT: peri splenic hematoma
5. Tx: 1) Epidural to minimize pain (don’t do a big dose of PCA b/c will decrease respiratory drive) or intercostal blocks (inject below the rib where the nerve is)
2) Pulmonary toilet, Diuretics, minimize fluid intake, pain control to avoid pneumonia secondary to pulmonary contusion.
*Complication: Later on pt’s BP drops to 70. 2 boluses of IVFs do not bring it back up. You are worried about a spleen bleed so go to OR and do a splenectomy. Do an autotransplantation by mincing (chopping) part of the
spleen into small pieces and putting them into a pocket made out of omentum. |
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Term
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Definition
1) HYPERCALCEMIA: Middle age female with no energy, decreased excitement, high Ca, low PO4, normal
albumin (It’s important to know albumin level b/c if it’s low you bump it up and bump Ca up with it.)
1. Hx: HPI: Duration of symptoms?, causative events for depression? PMH: hx of psych issues?
Meds:
2. Physical Exam:
3. Labs: CMP (High Ca, low PO4, high Cl), EKG because of increased Ca (findings include short QT interval, prolonged PR)
4. DDX: “CHIMPANZEES”.
C = calcium supplementation IV
H = hyperparathyroidism: 1o: 85% adenoma, 10% hyperplasia, 5% cancer
2o: Due to renal failure, not absorbing Ca b/c not converting 25 vit D to 1,25 vit D) 3o: occurs when 2o is corrected b/c parathyroid continues its
autonomous function I = iatrogenic (thiazides)
M = metastatic cancer (#1 is breast)/milk alkali syndrome (chugging Mylanta) P = paget’s disease of bone
A = addison’s disease/acromegaly
N = neoplasm (colon, lung, breast, prostate, multiple myeloma)
Z = think Zollinger Ellison b/c can have hyperCa from MEN 1 (not from ZE). As an aside the #1 pit tumor is prolactinoma, #1 pancreas tumor is gastrinoma (60% malignant), 10% of insulinomas are
malignant, 80% of glucagonomas are malignant
E = excessive vitamin D E = excessive vitamin A
S = sarcoidosis

5. Management of hyperCa crisis: NS to dilute out intravascular volume and diuresis with Lasix. Then begin calcitonin, bisphosphonates, or mithramycin
6. Narrow down DDX: Check PTH - if PTH and Ca are high, it’s probably 1o hyperCa.
7. Treatment:
Primary HPTH - Exploratory Neck Surgery: Give IV methylene blue first to stain the PT glands blue. If you see 1 big gland it’s adenoma, if you see 2 or more big glands it’s hyperplasia. Most sensitive test during surgery is your eyes. Can also inject with Technitium and use gamma probe. If you only see 3 glands and they are all normal you need to find the missing adenoma.
a. PT Hyperplasia – Remove all PT glands and leave at least 30mg of PT tissue placed in non- dominant forearm muscles
b. PT Adenoma – Remove adenoma, send for frozen section, biopsy all abnorm enlarged PT glands c. PT Carcinoma – Remove carcinoma, ipsilateral thyroid lobe, and all enlarged lymph nodes
*If missing a gland, you can: a. Do a thyroid lobectomy, close pt, wait for path report OR
b. Do a sestamibi washout to light up PT glands, OR c. CT scan - see if missing gland is in thymus - if so- thymectomy
Secondary HPTH – Correct Ca and PO4, then renal transplant
Tertiary HPTH – Correct Ca and PO4, remove all PT glands and reimplant 30mg in forearm muscles if refractory to medical treatment |
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Term
| 2) HYPERTENSION: 25 yo marine recruit with BP of 210/120, HR 140, EKG shows SVT |
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Definition
1. History: HPI:
Any symptoms- HA, Blurry vision?
FH:
Meds: Patient responds he had been on ACE inhibitor and B-blocker since this was discovered
but THE MEDS ARE UNABLE TO CONTROL THE HTN 2. Physical: Flank bruits?
3. DDX: 1. RAS: a. Duplex of renal arteries
b. See if 1 kidney is losing more salt than other
c. do a hypertensive IVP and if 1 kidney lights up later than other = RAS (invasive) d. arteriogram (invasive)
Tx: a. Invasive non-surgical: Percutaneous Renal Transluminal Angioplasty
(PRTA)/stenting
b. Surgical : Resection, bypass, vein/graft interposition, or endarterectomy *Do
NOT use ACE inhibitors !
2. Cushings:
1. look for buffalo hump, striae, central obesity, moon facies, copper skin, etc.
2. disease vs syndrome: first get AM/PM cortisol, then do low dose/high dose dex to
make the distinction. (disease: no cortisol suppresion with low dose, + suppression with high dose. vs syndrome: which shows no suppression with low or high dose)
3. Tx: Adrenal Adenoma – unilateral adrenalectomy
Adrenal Carcinoma – Surgical excision if possible
SH: Drugs?
Ectopic ACTH-producing tumor – surgical 3.Coarctation: get ABIs (nl is 1 or greater), CXR (will show rib notching), Echo, Cardia Cath
Tx: Resection with end-to-end anastomosis, subclavian artery flap, patch graft (rare), Interposition graft, Endovascular repair (adults only)
4. Pheo: “Classic Triad – Palpitations, HA, episodic diaphoresis”131I-MIBG
Labs: Urine – VMA, metanephrine, normetanephrine, Urine/serum- epinephrine, norepi Tumor Localization: CT, MRI, (MetaIodoBenzelGuanidine), PET Scan
excision if possible
>5cm = cancer, <5cm = not cancer
Bonus: organs of Zuckerkandl: major site of extra-adrenal pheo (around abd aorta) Tx: a. a-blockade with phenoxybenzamine or prazosin (increases intravascular volume and dilutes catecholamine-induced vasoconstriction)
b. Surgery: tumor resection with early ligation of venous drainage (to minimize catecholamine release)
5. Conn’s: <1% are malignant (answer) (*How to differentiate between 1 and 5: Give Captopril and then measure renin and aldosterone. If low renin and high aldosterone, it’s Conn’s. If low renin and low aldosterone it’s RAS.)
a. Labs: CMP- hypoK+, high aldosterone level, normal or decreased renin b. Imaging: CT scan to localize the tumor
c. Further studes for Conn’s: i. Iodocholesterol scan
ii. Selective
venous sampling of an adrenal vein to see if one
adrenal makes more aldosterone than the other. If R = L, it’s hyperplasia (not cancer or adenoma)
Saline Infusion Test – decreases aldosterone levels in normal but not in Conn’s
Spironolactone because it is an aldosterone receptor antagonist
iii.
pts
Preop:
3) MEN 2A: 30yo female recently diagnosed as HTN with no risk factors, hard to control
1. DDX for HTN: Conn’s, Cushing’s, Pheo, RAS, Coarctation
2. Labs: electrolytes (Ca comes back as 12), albumin normal, need to check thyroid with calcitonin! 3. Tests:
1) + MIBG lights up left renal artery
2) + CT shows mass in left adrenal medulla
3) + 24 hour urinary catecholamine and VMAs 4) EKG – nl
4. Prepare for op:
1) *-blocker and *-blocker to normalize BP, (if already *-blocked don’t *-block b/c you will greatly increase BP)
2) IV tone will decrease, therefore you need a Swan Ganz Catheter (measures LVEDV) and IV volume to get a good wedge pressure.
**Saline Load Protocol- infuse 2L isotonic fluid, check wedge presssure and stop with 2L or 18mmHg to get good CO and good IV volume**
3) Type & Cross for the 3 adrenal veins
4) Anesthesiology Drugs: pressors, good IVs for fluids
*Asides: 10% rule, only need 2 out of the 3 criteria for MEN 2a to call it MEN 2a, and MEN 2a does NOT change plans for removing the pheochromocytoma b/c any other surgery will kill them
4) NECK MASS: 25yo female with neck mass that moves with swallowing.
1. History: HPI – Voice change? Dysphagia? PMH – Neck Radiation? FH- Thyroid CA? MEN II? 2. Exam: rubbery hard mass, no lymphadenopathy
3. Labs: CBC, CMP (need), TSH, free T4, bHCG - all normal except 4 months pregnant
4. Tests: 1) FNA shows many follicular cells
2) U/S: solid
3) Can NOT do radioactive iodide uptake b/c pregnant
5. Operation: Lobectomy, frozen section says follicular carcinoma - do total thyroidectomy
d. Treatment:
Surgery: Adenoma – Unilateral adrenalectomy Unilateral Hyperplasia –
(lap)
Unilateral adrenalectomy (lap)
Spironolactone (no surgery)
retention for exchange of K in distal tubules, resulting in fluid retention and hypertension
Bilateral Hyperplasia – e. Physio of Conn’s: aldosterone causes Na

*Complication: 12 hours later pt says she feels like she is being stuck with pins and needles, Her Ca2+ is 6 d/t parathyroid damage. Give calcium gluconate until symptoms resolve. Patient will need to be on Synthroid and Ca2+ with vitamin D
6. Follow-up: 6 weeks (or in this case, after delivery?) for radioactive iodide scan to make sure all is clear; if lung mets are seen, treat with radioactive iodide
7. Begin Synthroid. |
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Term
| BURNS: 30yo w/ 2o & 3o burns to 45% TBSA, stridor/coughing up carbonaceous sputum |
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Definition
1. ABCs:
A: i) size 8 orotracheal tube to 22 (at clavicles on CXR)
ii) CXR (to check OT tube placement)
iii) NG tube (Pts with >20%TBSA burns often develop paralytic ileus – vomiting – aspiration risk -- pneumonia
B: Ventilator on IMV with 100% O2, 2 chest tubes if PTX (If on vent > 2 weeks, need to trach to prevent tracheoinnominate fisula (brachiocephalic a))
C:
i) Defibrillator on 300 for V-fib + epinephrine ii) 2L IVs in saphenous vein (if arms burned)
iii) Parkland: TBSA x 4 x wt – give 1⁄2 in first 8o & 1⁄2 in next 16 o
iv) If you notice the hands starting to turn black (vascular compromise), do a mediolateral escharotomy to relieve pressure of ongoing edema & restore circulation, no anesthesia
v) Foley (UOP of 30cc/hr)
2. Labs: ABGs 20min after intubation, CBC, CMP, U/A – myoglobin (can clog renal tubules, flush out with isotonic fluids and alkanalize urine), carboxyhemoglobin ( for cherry red color)
3. Management:
a. Debridement/early excision of burns (except deep wounds of palms, soles, genitals, and face) and
apply topical abx (Do NOT give systemic Abx b/c will get superinfection, only use topical - any of the following)
i. Sulfamylon: painful b/c penetrates eschar and irritates nerve endings, causes metabolic acidosis b/c it’s a CA inhibitor
ii. Silvadene: transient neutropenia
iii. Silver Nitrate: metabolic alkalosis due to hypoK+ and hypoNa+, turns everything black iv. Bacitracin: possible allergy, limited to Gm+
v. Betadine: possible allergy, can kill tissue by desiccating wound (drying it out) vi. Acetic Acid: possible acidosis if abnormal kidneys
b. Take to burn unit:
i. Turn heat up to 98.6 o
ii. Bronchoscopy to evaluate upper airway burns and wash out carbanaceous material to prevent atelectasis and pneumonia (bronchoscopy is both diagnostic and therapeutic)
iii. Evaluate degree of burn wound excision with IV fluorescein (if glows = perfused, if not = excision is
inadequate)
iv. 3-7 days out – excision of deep wounds of palms, soles, genitals, and/or face
v. Skin grafts- NOT on night of burn b/c need to resuscitate with proper fluids first, let edema resolve around POD 3 before applying skin grafts (usually > 1week after injury)
 |
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Term
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Definition
1) MELANOMA: Male with 2.1cm mole on forehead that itches and bleeds with scratched
1. Hx: sun exposure?
2. Physical: mole and a rubber mass in zone 2 (anterior SCM) that does not move with deglutition (swallowing – therefore not they thyroid)
3. Breslow Classification of microstaging:
I. *<0.76mm
II. *>0.76, <1.5cm III. >1.5cm, <3cm IV.*>3cm
4. What do you do?
1. Punch Biopsy: shows malignant melanoma with depth of 2.1mm
2. Needle bx of LN shows malignant melanoma (identify LN via sentinel node biopsy)
3. Clinically stage with LFTs and CXR (bone scan/CT/MRI if symptomatic)
4. Excision Rule: excise 1 cm in margin for every mm in depth. Therefore excise with 2.1cm margins and excise down to outer layer of investing fascia (i.e. pericranium fascia if on
forehead, fascia lata on thigh, fascia of rectus on belly) + Lymphadenectomy if palpable
5. Based on Halstead Theory of cancer – remove primary tumor with all LN drainage
?Therefore do a superficial parotidectomy and modified radical neck dissection. (A radical dissection takes CN 11 whereas modified radical leaves it). Make sure to avoid the marginal
mandibular branch of the facial nerve. ?
Possible adjuvant – IFN – a2B if + nodes or >4mm melanoma
2) MALIGNANT MELANOMA IN AN EXTREMITY: irregular, raised, itchy mole on thigh 1. History/Physical
2. Tests: 1) Punch bx shows 2.8mm melanoma
3. Preop: stage pt with LFTs and CXR
4. Operation: Resect with 2.8cm margins down to deep fascia. Do a sentinel node bx by injecting lymphazurine at site of lesion and holding gamma probe to blue node. If positive, do an inguinal node dissection. Take out lymph drainage in Quadrangle of Hansen and rotate sartorius muscle to cover femoral vessels
5. Adjuvant Tx: Limb perfusion chemotherapy-circulate chemo in the leg ONLY by using femoral artery and vein and a bypass pump |
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Term
|
Definition
1) Pyloric Stenosis: 1st born WM with projectile vomiting x12 hours
a. DDX: Pyloric stenosis
Duodenal atresia (caused by an ischemic insult during development of failure of recanilization) Volvulus/malrotation (cecum in RUQ)
Annular pancreas (pancreatic head around 2nd part of duodenum due to failure of proper rotation)

b. Exam: Calm baby down in dark room with tangential light and look for peristaltic waves that end in the midline, palpate the olive
c. Tests: U/S or upper GI with barium
1. Gastrograffin is water soluble in the peritoneal cavity, but causes pneuminitis in the lungs 2. Barium won’t hurt the lungs but is bad in the peritoneal cavity
d. Operation: pyloromyotomy- incision in RUQ, find pylorus, cut through both mucle layers and separate the two sides so that they move independently of each other
2) Duodenal Atresia: 37 week preemie with double bubble
a. DDX: Annular pancreas (tx = Duoduodenostomy)
Duodenal atresia (tx =Duoduodenostomy or Duodenaljejunostomy) Duodenal web (tx = webectomy)
b. Imaging: upper GI will shows complete failure of contrast to pass through duodenum
3) Inguinal hernia: Hernia lateral to Hesselbach’s Triangle into the internal inguinal ring and down the inguinal canal due to patency of the processus vaginalis. Repair by cutting skin, scarpa’s and external oblique fasica through external ring, then find hernia sac anteromedially and due a high ligation at the neck at the internal ring, resect the sac and allow sac stump to retract into peritoneal cavity
4) Hemangioma, Umbilical hernias: do nothing
5) CF: ground-glass abdomen w/ failure to pass meconium, do gastrograffin enema
6) Omphalocele
*Sac covers extruded viscera *Pentalogy of Cantrell: “D COPS”-
diaphragmatic defect, cardiac, omphalocele, percardium, sternal cleft
*Diagnose with fetal u/s
*Defect can be very large
Gastroschisis
*No sac
*Not assoc with other anomalies
*Dx with fetal u/s *Defect ~ 2-4cm
7) Diaphragmatic hernia: preemie in resp distress, scaphoid abd. & paradoxic chest motion a. Tests: Get ABGs and a CXR.
b. Operation:
c. Complications: After fixing the hernia a common late complication after “honeymoon period” is R to L shunting due to hypoplastic lung. Next step is ECMO (heart-lung bypass) to let the lung mature. Do this with carotid and jugular. You must anticoagulate to prevent stroking out. Baby will live on one carotid and jugular for rest of life b/c other is ligated. |
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Term
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Definition
*Wedge Pressue is an indirect measurement of LVEDV, it shows how well LV is filling
*Beck’s Triad: hypotension, JVD, muffled heart sounds
*In neurogenic shock you lose sympathetic tone, get an increase is venous capacitance, venous pooling and CVP
Neurogenic shock
heart acts like nothing is wrong b/c you cut nerves from the heart
asystole, a kind of cardiogenic shock, wedge pressure is zero |
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Term
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Definition
incarcerated or strangulated hernia
involves only one sidewall of the bowel
spon. reduces==>gangrenous bowel and perf. w/i the abdoment without signs of obstruction |
|
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Term
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Definition
| hernia involving a meckel's diverticulum |
|
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Term
|
Definition
| hernia through the linea semilunaris or spigelian fascia, aka spontaneous lateral ventral hernia |
|
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Term
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Definition
| hernia sac exists as both a direct and indirect hernia straddling the inferior epigastric vessels |
|
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Term
|
Definition
| hernia through Grynfeltt-Lesshaft triange ( super lumbar triangle) |
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