SURGERY ORAL REVALIDA

1. PERITONITIS

2. INGUINAL HERNIA

3. OBSTRUCTIVE JAUNDICE

4. TRAUMATIC BRAIN INJURY

5. GASTRIC CANCER
6. HEMORRHOIDS

7. SMALL BOWEL OBSTRUCTION

8. APPENDICITIS

9. CHOLANGITIS

10. ACUTE CHOLECYSTITIS

11. BREAST CANCER

12. PEPTIC ULCER DISEASE

13. THYROID CANCER
14. LARGE BOWEL OBSTRUCTION
15. BLUNT THORACOABDOMINAL
TRAUMA
16. BURN INJURIES
 PERITONITIS
 Chief ➢ Abdominal pain (diffuse)
Complaint
 Family ◼ History of Cirrhosis or Ascites
History / ◼ History of Renal failure on peritoneal dialysis, NSAID use
Past Medical
History
 Review of ◼ Fever, Nausea/Vomiting, Diarrhea, Anorexia, Chills, Constipation,
Systems ◼ Hematochezia, Hematemesis, Melena
 Physical ❖ Assessment of RF
Examination ❖ Abdomen: (+) abdominal tenderness, pain diffuse and unremitting,
(+) guarding, (+/-) hypoactive bowel sound, no shifting dullness
 Differential 1. Appendicitis
Diagnosis 2. Aortic aneurysm
3. Obstruction
4. Diverticulitis
 Diagnostics ✓ Abdominal X-ray (supine, upright), Chest X-ray (CXR)
✓ Complete blood count (CBC), Platelet count (PC)
✓ Alanine aminotransferase test (ALT), Aspartate aminotransferase test (AST)
✓ Blood urea nitrogen (BUN), Creatinine
✓ Amylase, Lipase
✓ Alkaline phosphatase level test (ALP), Lactate dehydrogenase test (LDH)
 Management ⚫ Admit
⚫ Fluids
⚫ Medical treatment:
a. Antibiotics (Metronidazole & Piperacillin/Tazobactam)
b. Proton pump inhibitor (PPI)
c. Analgesic
⚫ Definitive treatment: Laparotomy – (+) perforation, (+) multiple abscess, (+) abscess in
proximity to vital structures such that percutaneous drainage is hazardous
 Notes ⚫ Peritonitis- microbial contamination of peritoneal cavity
⚫ Classification
1. PRIMARY- invasion via hematogenous dissemination form distant source of
infection
- or direct inoculation
- ex: patient w/ ↑ ascites
patient treated for renal failure via peritoneal dialysis
2. SECONDARY- perforation or severe infection of an intra-abdominal organ
- ex: appendicitis, perforated GIT
3. TERTIARY- common immunocompromised
- wasn’t able to sequester the initial secondary peritoneal infection.
- Etiology: E faecalis & faecium, Staph epidermis, Candida, Pseudomonas
 INGUINAL HERNIA
 Chief Complaint ➢ Inguinoscrotal mass
 Family History / ◼ COPD, Ascites, Pregnancy
Past Medical ◼ CT disorder, Smoking,
History ◼ Previous surgery, Strenuous exertion
 Review of ◼ Pain/discomfort when coughing or straining
Systems ◼ Improves when lying down
◼ Nausea/Vomiting, Fever, Red/purple discoloration, Hyperemia in the groin
--- Complicated
 Physical ❖ (+) Bulge on groin
Examination ❖ (+) Resonance – loop of bowel, bowel sound
❖ (+) Transillumination: light behind scrotum
-cystic: shines through
- solid: light is blocked
❖ (+) Cough impulse
 Differential 1. Hydrocoele, Varicocele
Diagnosis 2. Torsion of testis
3. Lipoma of spermatic cord
 Diagnostics ✓ History & Physical Examination: gold standard
✓ Ultrasound: if in doubt
 Management ⚫ Asymptomatic: treat conservatively; Pain reliever
⚫ Symptomatic: Elective surgery
⚫ Strangulated: Urgent surgery
*Operative techniques: Mesh use, Open repair, Laparoscopic repair

*from another source

⚫ Initial management
- pain reliever, Trendelenburg position (head down, tilt of 35-45 degreee),
Taxis maneuver (hernia reduction)
⚫ Complications if not treated:
- Incarceration
- Laceration
- Strangulation

*Strangulated Hernia
- skin discoloration
- fever
- signs of obstruction
- signs of peritonitis
- necrosis
 Notes Inguinal Hernia
- protrusion of organ or tissue through a defect in surrounding wall
- main concern: strangulation --- blood supply interruption --- necrosis

*Epidemiology:
- more common in male (F: superficial inguinal ring opening is smaller)
- right sided > left

*Etiology:
- congenital: patent processus vaginalis
- acquired: weakness on abdominal wall
*Risk factors:
- family history
- inherent abdominal wall weakness
- upright posture
- chronic increased in intraabdominal pressure
- connective tissue disorder
- smoking
- previous RLQ surgery
- strenous exertion
- loss of shutter and sphincter mechanism

*Classification:
a. Direct
- occurs in the floor of inguinal canal through Hesselbach triangle (Med: lateral border of
rectus abdominis, Lat: inferior epigastric vessel, Inf: inguinal ligament)
- does not traverse the internal ring
- medial or inferior to inferior epigastric vessel
b. Indirect
- passes through internal ring and down the inguinal canal
- can extend to scrotum
- commonly strangulates
- lateral or superior to inferior epigastric vessel
c. Femoral
- situated on femoral ring

*Classification based on Symptom:

a. Asymptomatic
b. Minimal symptomatic: do not interfere to daily normal life
c.Reducible: can be returned to usual anatomical site
d. Irreducible/Incarcerated: cannot be reduced and may cause obstruction
e. Strangulated: non-reducible and shows sign of strangulation
Incarceration --- Ischemia --- Necrosis
 OBSTRUCTIVE JAUNDICE
 Chief Complaint ◼ (+) Jaundice
◼ (+) Globular abdomen (distention)
 Family History / ◼ Old age, Male, History of gallstone, Schistosomiasis, Pancreatic cancer
Past Medical
History
 Review of ◼ Intermittent fever, Anorexia, Pruritus, Weight loss, Nausea/Vomiting
Systems ◼ Abdominal pain, Bloatedness,
◼ Alcoholic gray stool, Dark urine
 Physical ❖ General: NRD, VS
Examination ❖ Skin: Jaundice
❖ HEENT: Icteric sclerae
❖ Abdomen: (+) Distention, (+) Tenderness (RUQ), (+/-) Caput medusa
❖ Digital Rectal Exam: Blummer shelf
❖ Neuro Exam: Altered mental status
 Differential 1. Malignancy: old age, weight loss, alcoholic stool
Diagnosis 2. Pancreatic mass
3. Viral hepatitis
4. Cirrhosis
 Diagnostics ✓ Complete blood count (CBC)
✓ ALT, AST, ALP
✓ Bilirubin
✓ Creatinine
✓ PT, PTT
✓ TPAG
✓ SE
✓ Ultrasound, CT scan
✓ MRCP, ERCP
 Management ⚫ NPO
⚫ Fluid replacement
⚫ Medical treatment: Antibiotics (Cefuroxime and Metronidazole), Omeprazole
⚫ Definitive treatment
a. Cholangitis: ERCP drainage
b. Tumor: if it is resectable - Whipple’s procedure (head of pancreas, gallbladder,
duodenum, portion of stomach, lymph node involved)
c. Palliative:Choledochojejunectomy, Chemotherapy
 TRAUMATIC BRAIN INJURY
 History ➢ (+) Trauma (vehicular accident)
 Review of ◼ Loss of consciousness, Nausea/Vomiting, Diziness
Systems ◼ Chest/Abdominal pain
 Physical ❖ GCS (E4V5M6)
Examination ❖ Eyes: Dilated, Anisocoric, (+/-) Raccoon eyes, Battle sign
❖ Neuro Exam: Motor/Sensory/Reflexes/ CN
 Differential 1. Epidural hematoma – (+) lucid interval, loss of consciousness, dilated pupil on side of
Diagnosis injury, weakness on contralateral side; convex bleed on CT scan
2. Subdural hematoma – concave bleed on CT scan, “moon”, crescent-shaped
3. Subarachnoid hemorrhage – severe headache, arachnoid
4. Intracerebral bleed – ischemic vs. hemorrhagic
 Diagnostics ✓ Skull xray, CT scan
✓ Chest X-ray
✓ CBC, BT, PT, PTT
 Management ⚫ ER (ABCDE) – indications for “E” intubation, hook to 02
⚫ then NPO
⚫ Treatment
a. Antibiotics, Keto, Omeprazole, Tetanus antitoxin (ATS) for wound, Mannitol
b. Insert indwelling Foley catheter (IFC)
c. WOF: Neurodegeneration
⚫ Signs for Possible Craniectomy:
a. >30cc bleed
b. GCS deterioration
c. >1cm thickness
d. Midline shift >5mm
 GASTRIC CANCER
 Chief Complaint ➢ Abdominal pain
 Family History / ◼ Family history of Cancer
Past Medical ◼ Previous history of Pylori infection, Gastric polyp, Surgery, Pernicious anemia,
History Smoking, Alcohol, Obesity
◼ Old age, Diet increase in nitrosamine
 Review of ◼ Malaise, Anorexia, Nausea/Vomiting, Weight loss
Systems ◼ Hematemesis, Melena, Dysphagia, Dyspepsia
 Physical ❖ (+) Leser trelat sign (Seborrheic keratosis)
Examination ❖ GIT: (+/-) Mass on palpation, (+) Tenderness on epigastrium
❖ DRE: (+) Blummer shelf (metastasize)
❖ Others: (+) Lymphadenopathies – Virchow, Iliac node, Sister mary joseph node,
Troisier sign
 Differential 1. Peptic ulcer disease
Diagnosis 2. Gastroesophageal reflux disease
3. Esophageal cancer
 Diagnostics ✓ Esophagogastroduodenoscopy (EGD), Biopsy, Endoscopic ultrasound
✓ Labs: CBC, PC, BT, PT,PTT, BUN, Creatinine, TPAG, CEA
 Management ⚫ Surgery
*Based on location of tumor:
a. Distal - distal subtotal gastrectomy
b. Middle - total
c. Proximal - total or proximal subtotal
*Standard surgical treatment:
- resection of all tumor with 4-6cm, grossly negative margins, with en bloc removal
of adjacent lymph node and involved organs
a. Radical total gastrectomy - remove stomach with Roux-en-Y limb sewn on
esophagus
b. Radical subtotal - remove distal 75% of stomach, pylorus with 2cm of proximal
duodenum, greater and lesser omentum, associated lymph node
⚫ Chemotherapy
⚫ Palliative
a. Gastrojejunostomy
b. Tube jejunostomy
c. Chemotherapy
d. Radiotherapy
 HEMORRHOIDS
 History ➢ Protruding anal mass
➢ History of straining/constipation
➢ Protrusion when coughing or upon exertion
➢ (+/-) Bleeding, (+/-) Pain
 Review of ◼ Constipation, Fecal incontinence, Obstipation, Blood streaked stool, Weight loss
Systems
 Physical ❖ DRE: (+) Anal mass,Ppalpable tissue mass on 3, 7, 11 o’clock,
Examination (+) Blood on tactating finger
 Differential 1. Rectal prolapse
Diagnosis 2. Rectal cancer
3. Colon polyps
4. Anal fissure/abscess
5. Inflammatory bowel disease
 Diagnostics ✓ Protoscopy, Anoscopy, Proctosigmoidoscopy
✓ Labs: CBC, SE, PT,PTT,CEA
 Management ⚫ Supportive:
a. Minimize straining
b. Warm sitz bath (40C) for 15mins
c. Increase fluid intake, Increased fiber diet
⚫ Medical:
a. Hydrocortisone
b. Phlebotonics - Diosmin + Hesperidine
⚫ Non-invasive:
a. Rubber band ligation (RBL)
b. Sclerotherapy
⚫ Surgical: Excision hemorrhoidectomy
⚫ If admitted and for OR:
a. Treatment: Metronidazole, Omeprazole, Ketorolac
b. Bowel preparation: Castor oil, Dulcolax
*Grade:
I- not beyond anal verge – diet modification
II- spontaneous reduction – high fiber, RBL, sclerotherapy
III- manual reduction – (+) surgery
IV- irreducible
*Types:
Internal, External – demarcation: dentate line
Mixed
 SMALL BOWEL OBSTRUCTION
 Chief Complaint ➢ Obstipation
 Review of ◼ Abdominal pain, Abdominal distention
Systems ◼ Vomiting (proximal- bilious, large volume) (distal- feculent, decrease volume)
◼ Fever, Nausea, Weight loss
 Physical ❖ GIT: (+) Distended abdomen, (+) Abdominal tenderness,
Examination (+) High pitched bowel sound: negative because of fatigue
❖ Look for surg. incision
❖ Distention more pronounce if obstruction is distal
❖ Hyperachie BS at the beginning later becomes (-) → fatigue & atony
❖ “water clipping into large hollow container”
❖ Succussion splash – slushing sound after sudden movement
❖ Manifestation of Strangulation (FeL2T2)
- Fever, Leukocytosis, Localized abdominal tenderness, Tachycardia/Tachypnea
 Differential 1. Paralytic ileus
Diagnosis 2. Chron’s disease
3. Large bowel obstruction
4. Neoplasm
 Diagnostics ✓ Abdominal xray upright
- Triad: Rectal gas, Air fluid bowels, Dilated small bowel loops (>3cm)
- String-of-beans sign, Coffee-bean sign
✓ CXR, CT with contrast
✓ CBC, SE, Urinalysis (Spec. gravity)
 Management a. NPO - bowel rest
b. Fluid replacement
c. Decompression - NGT
⚫ Conservative treatment
- 75% partial, 36% complete SBO can be treated non-operatively
- improves
- SBO 2o to post-op adhesion- non-surg unless with strangulation
- Surg for non-resolving
⚫ Good prognosis
Medical treatment: Antiemetics, Analgesic, Antibiotics; WOF: congestion
⚫ Surgical treatment: Explorative laparotomy
*Peritonitis
*Strangulation - fever, leukocytosis, abdominal tendernes, tachycardia
 Pathophysiology ⚫ Obstruction → Gas/Fluid accumulation → ↑Intraluminal pressure → Intestinal ischemia
 Category ⚫ Mechanism of Obstruction
- Functional – ineffective motility, physical obstruction
- Mechanical – physical blockage of lume
⚫ Duration
- Acute- abrupt onset, progressive, does not resolve w/ trxt
- Chronic- recurring w/ interval resolution
⚫ Extent
- Partial – narrowed, permits transit of some intestinal contents.
- Complete – totally obstructed.
⚫ Location
- Proximal- pylorus→ proximal jejenum
- Intermediate- mid jejenum → mid ileum
- Distal- distal ileum → even colon
⚫ Type of Obstruction
- Simple- single point – prox. dilation, distal compresson
- Closed-loop – occluded on 2 points
 - entrapped by single constricture lesion
- Strangulated – blood flow is compromised, tissue necrosis & gangrene

 Etiologies: ⚫ Adhesion: post-op mc

⚫ Hernias
⚫ Volvulus
⚫ Ext. mass effect (abscess, annular pancreas)
⚫ Congenital
⚫ Inflammatory dse (Crohn’s, Diverticulitis)
⚫ Neoplasms, Trauma
⚫ Ileus- most freq differential for SBO

PROXIMAL BOWEL DISTAL SMALL BOWEL

(open loop) (open loop) (closed loop)
⚫ Pain - intermittent, intense, colicky - int. to constant -progressive, int to constant,
rapidly worsens
- relieved by vomiting
⚫ Vomiting - large vol, bilious, frequent - ↓vol, ↓freq, feculent w/ time - may be prominent
⚫ Tenderness - epigastric, peri-umbilical, mild - diffuse, progressive - diffuse, progressive
⚫ Distention - (-) - moderate - marke - often absent
⚫ Obstipation - (+/-) - (+) - (+/-)

SBO Ileus
⚫ Common to both N/v, obstipation, (-) flatus, distention
⚫ Pain Crampy Minimal
⚫ BS N or ↑ (-) or ↓
⚫ Radiograph Gas in SI only Gas in SI & colon
 APPENDICITIS
 Chief Complaint ➢ Right lower quadrant pain
 Family History / ◼ Age (20-30yrs old), More common in male
Past Medical
History
 Review of ◼ Periumbilical or diffuse pain – localized at right lower quadrant
Systems ◼ Anorexia, Nausea and Vomiting, Fever, Weakness
 Physical ❖ (+/-) Fever, (+) Tachycardia
Examination ❖ Murphy’s triad: Pain, Vomiting, Fever --- in sequence
❖ Abdomen: (+) Direct/rebound tenderness on Mc Burney’s point,
(+) Dunphy sign - pain when cough, (+) Rovsing’s sign - RLQ pain on palpation,
(+) Iliopsoas - pain on leg extension, (+) Obturator - pain upon internal rotation of
flexed thigh
 Differential 1. Acute gastroenteritis
Diagnosis 2. Acute mesenteric lymphadenitis (children)
3. Diverticulitis (adult)
4. Pelvic inflammatory disease (PID)
5. Ectopic pregnancy (female)
6. Urinary tract infection (UTI)
 Diagnostics ✓ CBC, UA
✓ Ultrasound: target sign (thick-walled, non-compressible, luminal structure in RLQ)
: signs of AP (wall thickening >0.5mm and periappendiceal fluid)
✓ CXR: to rule out lobar pneumonia
 Management ⚫ Non-surgical
a. Bowel rest
b. Fluids
c. Medical treatment: Antibiotics (Metronidazole, Cefoxitin, Ciprofloxacin), PPI, Pain
reliever, Percutaneous drainage
⚫ Surgical
a. Open appendectomy: early, non-perforated
b. Lower midline laparotomy: perforated/complicated

*Stages
a. Congestive
b. Suppurative
c. Gangrenous
d. Perforation

*Alvarado Score
-Migrating pain -1 Interpretation:
-Anorexia -1 9-10 – almost certain
-Nausea/Vomiting -1 7-8 – high likelihood
o
-Elevated temperature (>36.3 ) -1 4-6 – further imaging
-RLQ pain/tenderness (R iliac fossa) - 2 < 3 – low likelihood
-Rebound tenderness -1
-Leukocytosis (>10 x 109) -2
-Shift to the left of WBC -1

*from another source

*Indications for Incidental AP:
- children going chemotherapy
- disabled
- Chron’s disease
 - travel to remote areas

*Laparoscopic:
- faster healing
- aesthetic
- faster recovery
- less hospital stay

*Indication for patient to eat: borborygmi

*Indications for Discharge:

- no vomitting,
- able to eat
- able to pass out stool

*Prognosis:
- Uncomplicated: resolve spontaneously and it may progress to complicated appendicitis
- Complicated (if not treated): generalized peritonitis --- sepsis --- death

*Follow-up:
- immediately after surgery if with SSI
- long-term complication: post-operative adhesion
- WOF signs of obstruction: abdominal distention, inability to pass stool, nausea/vomiting
 Notes Acute Appendicitis
- inflammation of appendix caused by obstruction of appendiceal lumen
- most common acute surgical abdomen
- more common in males; 20-30 yrs old
- etiologies: fecalith (most common), increased intraluminal pressure, hypertrophy of
lymphoid tissue, inspissated barium, vegetables and fruit seeds, internal worms (Ascaris)

Pathophysiology:
closed loop distention --- anterior N secretion of mucosa --- rapid distention - stimulation of
visceral nerve pain fibers --- bacterial multiplication --- occlusion of lymphatics, venules,
capillaries --- engorgement and congestion (+ nausea/vomiting) --- RLQ pain --- absorption
of necrotic tissue and toxins (fever, tachycardia, increased WBC) --- progressive distention
 CHOLANGITIS
 Chief Complaint ➢ Right upper quadrant pain
 Family History / ◼ History of common bile duct stone
Past Medical History ◼ Fatty and salty food
 Review of ◼ Fever, Chills, Nausea and Vomiting
Systems ◼ Epigastric – RUQ pain
 Physical ❖ Jaundice, Icteric sclerae
Examination ❖ Abdomen: Flat, NAB, (+) Direct tenderness on palpation
❖ Charcot’s triad: Fever, Pain, Jaundice
❖ Reynold’s pentad: Fever, Pain, Jaundice, Altered mental status, Septic shock
 Differential 1. Pancreatic head cancer
Diagnosis 2. Cholangiocarcinoma
3. Periampullary cancer
4. Viral hepatitis
5. ALD
 Diagnostics ✓ CBC, PC
✓ ALT, AST, ALP
✓ Amylase, Lipase
✓ SE, Creatinine
✓ PT, PTT
✓ Hepa profile
✓ HBT of biliary tree
✓ ERCP
✓ MRCP
 Management ⚫ Antibiotics: Cephalosporin, Metronidazole
⚫ Biliary decompression: drainage
⚫ Laparotomy cholecystectomy once stable
*Grading
a. I (Mild) - respond to initial management
- treated with antibiotics; if does not respond to antibiotics: biliary drainage
b. II (Moderate) - does not respond to initial management, no organ dysfunction
- ERCP/MRCP; definitive treatment: remove cause of cholangitis
c. III (Severe) - associated with atleast one organ dysfunction
- appropriate organ support; ERCP/MRCP; remove cause
 ACUTE CHOLECYSTITIS
 Chief Complaint ➢ Right upper quadrant pain
 Review of ◼ Biliary colic (RUQ pain after fatty meal)
Systems ◼ Bloatedness
◼ Relieved by NSAIDS
◼ Pain unremitting, persist for several days
◼ Fever, Anorexia, Nausea and Vomiting
 Physical ❖ Abdomen: (+) Focal tenderness or guarding on RUQ, (+) Murphys sign - inspiratory
Examination arrest on deep palpation in right subcostal area, (+) Boas sign - hyperesthesia on right
subscapular area
 Differential 1. Cholangitis
Diagnosis 2. Choledocholithiasis
3. Acute pancreatitis
 Diagnostics ✓ HBT and Pancreatic ultrasound
- diagnostic test of choice
- enlarged gallbladder, thickening of wall >5mm, gallbladder stone, ultrasound
murphy’s sign
✓ CBC
✓ Amylase, Lipase
✓ PT,PTT
✓ Bilirubin, SE, Creatinine
 Management ⚫ NPO then IVF
⚫ Medical treatment: Antibiotics (3rd gen), NSAIDs for analgesia, PPI, H2RB for acidity
⚫ Definitive treatment: Laparotomy cholecystectomy

*Complications:
- Gangrenous cholecystitis
- Gallstone pancreatitis
- Hydrops of liver
- Cholangitis

*Incision: Kocher
- starts midline 2.5-5cm below xiphoid
- ends laterally 2.5cm below costal margin
 Notes Acute Cholecystitis
- acute infection of gallbladder due to obstruction of cystic duct
- 90-95%: stone
- Acalculous: critically ill and biliary stasis

*Pathophysiology:
Obstruction --- Gallbladder distention --- Inflammation --- Edema
2013 TOKYO GUIDELINES
A. LOCAL Sign C. Imaging- positive
1. Murphy Sign
2. RUQ pain Interpretation
B. SYSTEMIC Sign  Suspected – 1A + 1B
1. Fever  Definite – 1A + 1B + 1C
2. ↑ CRP
3. ↑ WBC
 BREAST CANCER
 Chief Complaint ➢ Breast mass/lump
 Family History / ◼ (+) Cancer on family members
Past Medical ◼ OB score, OCP use, Menarche, Menopause
History ◼ Alcohol use
◼ Number of offspring, Breastfeeding
 Review of ◼ Erythema, Nipple change, discharge and retraction-due to shortening of Cooper’s
Systems suspensory ligament
◼ Fever, Weight loss
◼ Pain, Mass size, shape, mobility, margin
 Physical ❖ Chest: (+) Mass, Enlargement, Asymmetry, Ulceration/Erythema of skin
Examination ❖ Axillary mass: “peau d’ orange”-blocked lymphatics
 Differential 1. Benign
Diagnosis
 Diagnostics ✓ Mammography – not palpable
^MAS (Microcalcification, Asymmetric thickening, Solid mass)
^BIRADS Category:
0 (Incomplete): additional imaging needed
1 (N finding): routine screening
2 (Benign): routine screening
3 (Probably benign, <2% risk of malignancy): very high probability of benign
finding, short interval follow-up 6 months, then every 6-12months for 1-2yrs
4A (Low suspicion, 3-10%): needle biopsy
4B (Intermediate, 11-50%): needle biopsy
4C (Moderate, 51-94%): needle biopsy
5 (Highly sensitive, >95%): appropriate action
6 (Malignant): assure treatment is completed

✓ Ductography
^Indication: nipple discharge, contains blood

✓ MRI - for women (+) BRCA mutations

✓ Ultrasound - used to resolve equivocal mammographic findings and guide for biopsies
^Breast cyst: well-circumscribed, smooth margins, echo-free center
^Benign mass: weak internal echoes, well-differentiated anterior and posterior margins
^Breast cancer: irregular walls and (+) acoustic enhancements
^Lymph node involved with cancer: cortical thickening, change in shape, size >10mm,
(-) fatty hilum, hypoechoic internal echoes

✓ Biopsy
^Aspiration or needle (FNAB)
^Core needle (CNB): diagnostic technique of choice for pre-operative systemic therapy
^Incisional: fast, frozen section available
^Excisional: can evaluate margins
^Needle directed excisional: for non-palpable abnormalities
^Stereotactic biopsy: accurate image guidance and require special mammography
equipment

✓ CXR
✓ Ca 15-3
 Management ⚫ Surgical
a. BCS/BCT: Lumpectomy
*BCT - Lumpectomy, SLN dissection, Radiation
b. MRM: removal of breast with preservation of PM; remove lymph node
⚫ Chemotherapy
⚫ Radiotherapy
⚫ Hormonal: Tamoxifen - pre-menopausal; Aromatase inhibitor - post-menopausal

*from another source

⚫ Early invasive (Stage I-II)
- breast conservation
- with or without adjuvant chemotherapy
- lumpectomy, axillary lymph node status assessment (SLNB), radiotherapy
⚫ Advanced (Stage III)
- neoadjuvant then BCS or
- MRM with adjuvant chemotherapy/radiotherapy
- anti-estrogen therapy
⚫ Distant metastasis (Stage IV)
- palliative anti-estrogen
- palliative chemotherapy
⚫ Locoregional recurrence (S/P MRM, S/P BCS)
- excision with chemotherapy and hormonal
- MRM with chemotherapy and hormonal

*Types of Mastectomy:
a. Simple (Total)
- most common type
- remove entire breast (including nipple and areola)
- lymph node or muscle not included
b. MRM
- preserves pectoralis major and removal of axillary lymph node
c. Radical
- removes entire breast, axillary lymph node and both pectoralis major
d. Partial
- removes cancerous part and some N (example lumpectomy and quadrantectomy)
e. Skin sparing
- all breast and nipple-areola complex including skin overlying biopsy site
f. Nipple sparing
- skin sparing and preservation of NAC
g. Subcutaneous
- removes tissue through incision under breast then leaves skin, areola and nipple intact

*BCS and Segmental mastectomy

- BCS and moderate dose radiotherapy
- goals: survival equivalent to mastectomy, cosmetically acceptable, low rate of recurrence

*Endocrine therapies:
a. Surgical ablation
b. Estrogen
c. Androgen
d. Anti-estrogen
e. Progestins
f. Hydroxylase/Aromatase inhibitor
g. LHRH analogue
 Notes *Risk factors:
a. Hormonal- female (1:100), early menarche (<8yrs old), obesity, late menopause (>55 yrs
old), prolonged OCP use, aging
b. Non-hormonal- genetic (BRCA 1 & 2), radiation, alcohol use (increased E3 level),
dietary fat (increased estrogen)

*Breast Cancer Risk assessment:

^Gail Model- age at menarche, number of breast biopsies, age at first live birth, number of
first degree relatives with breast cancer

*Breast Cancer Risk management:

a. Screening mammogram - baseline at 35, annual beginning at 40 yrs old
b. Chemoprevention - Tamoxifen and Raloxifene (Selective estrogen receptor modulator)
c. Prophylactic mastectomy

*BRCA mutations:
a. BRCA 1 - c17q, 90% lifetime risk, poorly differentiated, (-) hormone receptor
b. BRCA 2 - c13q, 85% lifetime risk for breast cancer, well-differentiated, (+) hormone
receptor

*Risk management for BRCA mutation carriers:

- Prophylactic mastectomy and reconstruction
- Prophylactic oophorectomy and HRT
- Intensive surveillance
- CBE every 6 months
- Mammogram yearly beginning at 25 yrs old
- Breast MRI
- Chemoprevention

*Pathology:
a. Lobular
b. Ductal
- Most invasive arise in terminal duct lobular unit
- Most common histologic type: invasive ductal carcinoma (70-80%)

*Classification:
- Paget’s disease
- Invasive ductal carcinoma
- Medullary
- Mucinous
- Papillary
- Tubular
- Invasive lobular: signet-ring cancer

*Molecular subtypes:
a. Luminal A - (+) ER, PR and (-) HER2/neu
- hormone responsive, most common subtype, less aggressive, good prognosis
b. Lumina B - (+) ER, PR and (+) HER2/neu
- worse than A
c. HER2/neu enriched - (-) ER, PR and (+) HER2/neu
- highly aggressive, increased recurrence, decreased survival
d. Basal-like - (-) ER, PR, HER2/neu; (+) cytokeratin 5,6 and (+) EGPR
- aggressive, high grade and mitotic rate
*Hx, PE, ROS
✓ RF
✓ breast mass, enlargement, asymmetry
✓ nipple change, discharge, retraction
- due to shortening of the Cooper’s
suspensory ligament
✓ ulceration or erythema of skin
✓ axillary mass → peau d’ orange –
blocked lymphatics
✓ ulceration
mastalgia → (+) pain – benign
*Dx
1. Mammography
(MAS – Microcalcification
-- Assymetic Thickening
-- Solid mass)
- specific features:
▪ solid mass +/- stellate features
▪ assymetric tissue thickening
▪ clustered microcalcification
- disav: young & dense breast
BIRADS Category
0- Incomplete – additional imaging neede
1- N finding- routine screening
2- Benign- routine screening
3- Prob. benign, <2% risk of malignancy
- very high prob of benign finding
- short interval ff-up (6mos)
- then every 6-12 mos for 1-2 yrs
4A- Low suspicion (3-10%) biopsy
4B- Intermediate (11-50%) (needle)
4C- Moderate (51-94%)
4- Highly suggestive (>95%)
- appropriate action
6- Proven malignant – assure trxt is complete
2. Ductography
Indication: nipple discharge, contains blood
3. MRI- for women (+) BRCA mutations
4. UTZ- used to resolve equivocal mammographic findings.
-guide for biopsies
• BREAST CYST- well circumscribed, smooth margins, echo
free center.
• BENIGN MASS- weak internal echo
- well defined ant. & post. margins
• BREAST CA- irreg walls
- (+) acoustic enhancements
• Lymph Node Involved w/ CA
- conical thickening
- change in shape
- size> 10 mm
- (-) fatty hilum
- hypoechoic internal echoes
*Biopsy
1. Aspiration or Needle (FNAB)
2. Core Needle (CNB)- dx technique of choice for pre-operative
systemic therapy
3. Incisional- fast, frozen section available
4. Excisional- more complete evaluation
- can evaluate margins
5. Wire or Needle directed excisional – for non-palpable
abnomalities
6. Stereotache biopsy – accurate image guidance
- require special mammography equipment
*Mngt:
1. Early Invasive (Stage I-II)
- breast conservation SA (BCS)
- +/- adjuvant chemo
▪ lumpectomy
▪ axillary LN status assessement (SLNB)
▪ radiotherapy
2. Advanced (Stage III)
- neoadjucant (actinomycin containing) then BCS
- MRM ↑ adjuvant chemo/RT
- anti-estrogen therapy
3. Distant Mets (Stage IV)
- palliatve anti-estrogen
- palliative chemo
4. Locoregional recurrence (S/P MRM, S/P BCS)
- excision + chemo + hormonal
- MRM + chemo + homonal
*BCS & Segmental Mastectomy
- BCS + mod dose RT
- Goals:  survival equivalent to mastectomy
 cosmetically acceptable
 low rate or recurrence
*Types of Mastectomy
1. SIMPLE (TOTAL) - mc type
- remove ENTIRE BREAST (+ nipple areola)
- LN or muscle NOT removed
2. MRM
- preserves pectoralis major + removal of axillary LN
a) Patey- removes PM
b) Madden & Auchincloss- preserves PM
c) Scanlon- transect & repair
3. RADICAL
- removes entire breast, axillary LN & both PM
4. PARTIAL- removes cancerous part & same N
-ex: lumpectomy, quadrantectomy
5. SKIN SPARING
- all breast + nipple-areola complex + skin overlying
biopsy site
6. NIPPLE SPARING - skin sparing + preservation of NAC
7. SUBCUTANEOUS
- removes tissue through incision under breast
- leave skin, areola & nipple intact
*Endocrine Therapies
1. Surgical Ablation – Oophorectomy,
- Adrennectomy
- Hypophysectomy
2. Estrogen- DES
3. Androgens- Fluoxymestrone
4. Antiestrogen- Tamoxifen
5. Progestins- Megestrol acetate
- Medroxyprogesterone acetate
6. Hydroxylase/Aromatase inhibitor
- aminoglutethimide, anastrade,
- letrozole, exemestane
7. LHRH analogue- Leuprocide
 PEPTIC ULCER DISEASE
 History ➢ NSAID/Aspirin use
➢ H.pylori infection
➢ (+) Epigastric pain, burning sensation
 Family History / ◼ Smoker
Past Medical ◼ Alcoholic
History
 Review of ◼ Abdominal pain: epigastric, Bloatedness
Systems ◼ Nausea and Vomiting, Weight loss
◼ Melena, Coffee ground emesis
 Physical ❖ (+) Tenderness on epigastric area
Examination *Gastric:
- Pain while eating, food worsens pain, decreased gastric acid
*Duodenal:
- Pain 2-3 hours postprandial, alleviated by food, awakens patient at night, decreased
bicarbonate, increased hydrogen ions
 Differential 1. Pancreatitis
Diagnosis 2. GERD: with chest pain/radiation
3. MI: with chest pain/radiation
4. Acute cholangitis
 Diagnostics ✓ EGD
✓ H. pylori testing (urea breath test),
✓ Labs (CBC, PT, PTT, SE)
 Management ⚫ Medical treatment
a. Triple therapy for H. pylori: PPI, Clarithromycin, Amoxicillin/Metronidazole
b. Acid neutralizing agents: PPI, Antacid, H2RB
c. Opioid analgesic: Tramadol
⚫ Surgical treatment
a. Emergency exploration
b. Omental patch + Biopsy
⚫ Post-operative (Liquid - Soft - Diet as tolerated)
⚫ Supportive
a. Smoking cessation
b. Alcohol avoidance
c. NSAID withdrawal
*Complications of PUD:
- Bleeding
- Perforation
- Obstruction
 THYROID CANCER
 History ➢ Anterior neck mass
➢ Decreased iodine intake
➢ Radiation exposure
 Family History / ◼ History of neck cancer
Past Medical
History
 Review of ◼ Palpitation, Tremors, Easy fatigability, Cold/Heat intolerance, Feeling of anxiety
Systems ◼ Hoarseness, Dysphagia, Dyspnea, Weight loss
 Physical ❖ Thin
Examination ❖ EENT: (+) Exophthalmos, Sparse hair
❖ Neck: Location, size, mobility
CLAD
 Differential 1. Thyroglossal duct cyst
Diagnosis 2. MNTG
3. Colloid adenomatous goiter
 Diagnostics ✓ Thyroid ultrasound
✓ Thyroid profile: if euthyroid - FNAB
✓ Iodine scan
✓ FNAB
 Management ⚫ Medical treatment
a. Propanolol: regulate heart rate, decreased peripheral conversion of T4 to T3
b. PTU
c. Methimazole
⚫ Surgical treatment
a. Malignant: total; then offer RAI after
b. Multinodular: total
c. One lobe: lobectomy + isthmus
⚫ Post-operative
a. Hormone replacement
b. Monitor thyroglobulin
*Complications:
- Bleeding: leads to obstruction
- Hypocalcemia: Ca2+ gluconate
 LARGE BOWEL OBSTRUCTION
 Chief Complaint ➢ Obstipation (no passage of stool)
 Family History / ◼ Old age
Past Medical History
 Review of Systems ◼ Abdominal distention, Abdominal pain
◼ Changes in caliber of stool
◼ Nausea and Vomiting, Weight loss, Fever, Anorexia
 Physical ❖ Abdomen: Abdominal distention, Absent bowel sounds,
Examination Hyper-resonance, (+) Tenderness on abdomen
❖ DRE: GST, No mass, (-) Fecal material on tactating finger
❖ Fever
 Differential 1. Volvulus
Diagnosis 2. Paralytic ileus
3. Diverticulitis
 Diagnostics ✓ Abdominal x-ray
✓ CBC, UA
✓ SE, Crea
 Management ⚫ Non-surgical
a. Fluid replacement
b. NPO (bowel rest)
c. NGT suction
d. Antibiotics: Cefoxitin, Metronidazole, Omeprazole
⚫ Surgical
*Indications:
- Complete obstruction with sign of ischemia and clinical deterioration
- Persistent partial obstruction (more than 3-5 days)
- Suspected intestinal strangulation
*Surgical bowel decompression
- Resection
- Stoma creation if bowel passage not restored
 BLUNT THORACOABDOMINAL TRAUMA
 APPROACH TO ⚫ PRIMARY SURVEY
PATIENT ✓ Airway
- first priority
- ensure patency, airway protection
- cleared of any debris, blood, foreign body
- O2
- application of hard cervical collar
- manual airway maneuvers – to lift tongue
- jaw thrust
- chin lift
• Indications for “E” ET
- acute airway obstruction
- hyperventilation
- ↓ O2 despite supplemental O2
- altered mental status (GCS <8)
- cardiac arrest
- severe hemorrhagic shock
• Other options
1. Orotracheal
2. Nasotracheal
3. Cricothyroidectomy- craniofacial trauma
4. Tracheostomy- last resort, laryngeal fractures

✓ Breathing & Ventilation

- assess HR, O2 sat
- inspect ext. signs of trauma, asymmetric chest exp.
- palpate chest wall injury
- auscultate BS
✓ Circulation
- evidence of bleeding
- adequacy of circulation – pulse, color of skin, capillary refill
- palpable CAROTID pulse: SBP > 60 mmHg
- palpable FEMORAL pulse: SBP > 70 mmHg
- palpable RADIAL pulse: SBP > 80 mmHg
- pale skin, CRT > 2secs- poor peripheral perfusion

❖ Approach to Shock
1. Differentials
2. Venous access- IV, 2 large bore (g14-16)
- venous cutdown (basilic/saphenous)
- central line (IJ, subclavian, femoral)
- intraosseous route
3. Initial fluid resuscitation- direct P, tourniquets, typing
- surgical intervention
✓ Disability & Neuro Status
- GCS
- pupillary size, motor & sensory, glucose level
 MOTOR 6 VERBAL 5 EYE OPENING 4
6 Obey
5 Localize Oriented
4 Withdraw Confused Spontaneous
3 Decorticate (Flex) Incoherent/Inappropriate To speech
2 Decerebrate (Extend) Incomprehensible To pain
1 None None None

❖ Mgmt:
- airway competence
- supportive: seizure control, treat hypoglycemia
- treat ↑ICP

✓ Environmental Control & Exposure

- patient’s clothing must be disrobed while avoiding hypothermia
- look at areas not initially assessed
 CHEST TRAUMA ❖ Mgmt:
• Needle Thoracentesis- tension pneumothorax
• Pericardiocentesis- cardiac tamponade
• CTT- 4-5th ICS MAL
- indication: hemothorax, pneumothorax
* Emergent thoracotomy- incision over 5th rib into 4th ICS beginning sternum ext to
posterior axillary line
1.TENSION - build up of air in pleural space due to lung laceration
PNEUMOTHORAX - mediastinum to contralateral side (tracheal deviation)
❖ CM: resp. distress, hyperexpanded chest, ↓BS on affected side, dist. neck vein,
hypotension
❖ Mgmt:
- Immediate: Needling (2nd ICS MCL)
- Definitive: Chest tube thoracostomy (4-5th ICS MAL)

2. OPEN - sucking chest sound

PNEUMOTHORAX - free communication bet. pleural space & atmosphere

❖ Hx/PE/ROS
- resp. distress, “sucking, blowing sound”, hypoxia, hypocarbia
❖ Mgmt:
- Immediate: Temporary closure (tape)
- Definitive: Closure of chest wall defect & tube thoracostomy remote fr. wound

3. MASSIVE - >1500 ml or >25h

HEMOTHORAX
❖ Hx/PE/ROS: respiratory distress, hypotension, ↓BS & dullness to affected side
❖ Mgmt: volume replacement, tube thoracostomy
❖ Thoracotomy if >1.5 after 1 hour
>200 ml/hr cont. blood loss
4. FLAIL CHEST - ≥ 3 ribs are fractured on at least 2 locations
❖ Hx/PE/ROS:
- resp. distress
 - paradoxical mov’t of free floating chest wall
- paradoxical chest motion
- subcut. emphysema
- pain at fracture site
❖ Mgmt:
- intubation w/ P ventilation
- pain mgmt.
- chest tube, pulmonary inlet, surgical fixation
5. PULMONARY - blunt trauma to chest
CONTUSION
- radiologic dx
❖ CM: dyspnea, hemoptysis, hypoxemia
Mgmt: Adequate oxygenation, ventilatory support
6. TRACHEO- - massive air leak
BRONHIAL INJURY
❖ CM: dyspnea, dysphagia, coughing, stridor, failure to resolve even (+) CT tube,
pneumomediastinum, HAMMAN Sign
Mgmt: Definitive ‘E’ flexible broncoscopy
7. CARDIAC - blood accumulates in pericardium
TAMPONADE
❖ CM:
(TRAUMATIC)
BECK TRIAD- Hypotension, Neck vein distention, Muffled heart sound
KUSSMAUL SIGN- ↑ jugular venous distention on inspiration
PULSUS PARADOXUS- ↓ systemic BP on inspiration
 BLUNT ABDOMINAL TRAUMA
- VA, direct blows, fall, assaults & crush injury
• Dx:
1. Peritoneal Lavage- gold standard for evaluation of intraabdominal trauma
2. FAST
3. CT Scan of Abdomen- (+) FAST, hemodynamically stable patient
• Mgmt: Laparotomy
Indications: Peritoneal signs, (+) DPL, (+) FAST or CT Scan, Unstable
 BURN INJURIES
 ASSESSMENT ❖ BURN SIZE ❖ BURN DEPTH
ESTIMATION 1st degree (Epidermal) – epidermis & upper dermis
a) “Rule of - dry, no blisters
Nines/Wallace” -guide - painful, erythematous
for fluid resuscitation 2 degree (Partial Thickness) – epidermis & part of
nd

- 9% each arm dermis

- 15% each thigh & leg - moist blebs, (+) blisters
- 9% head - mottled white to pink,
- 9% chest cherry red
- 9% abdomen - very painful
- 9% lower back & 3 degree (Full thickness) – epidermis, dermis, SC
rd

buttocks tissue
- 1% genitalia & - dry w/ leathery eschar
perineum - charred vessels
- ↓sensation, intact deep P
b) Lund & Browder-
sensation
more accurate for
4th degree – damage to underlying tissue
children
- prolonged contact
- little or no pain
- graft needed
❖ Jackson Zones of Burn Injury
• COAGULATION Zone- central area, most severe burn, (-) capillary blood flow
• STASIS Zone- surrounds coagulation area, mod. degree
• HYPEREMIA Zone- outermost, contain viable tissue
 Mgmt: ❖ Minor burns – PT <15% in adults ❖ Moderate or Major or Critical Burns
< 10% in children <10 ❖ Moderate: PT 15-25% adult
y/o 10-20% children,
in adults >50 elderly
y/o FT 2-10%
- superficial thickness ❖ Major: PT >25% adult
- FT <2% > 20% children, elderly
❖ Mgmt: ❖ Mgmt:
✓ cool wound w/ tap water ✓ use sterile gloves
✓ tetanus prophylaxis ✓ suspect inhalation injury
✓ wound care, debridement, ✓ intubate if ≥50% BSA
analgesic ✓ fluid resuscitation
✓ send home ✓ IFC, NGT
✓ get baseline weight
✓ tetanus, H2-blocker
✓ escharotomy
 FLUID RESUSCITATION - mcc of mortality w/in 48 hrs is inadequate resuscitation.
1. PARKLAND/BAXTER FORMULA (Initial 24h) ❖ Topical Antimicrobial
IVF req’t= TBSA burned x Wt (kg) x 4ml/kg 1. Bacitracin – gram (+)
= D5LR 2. Mafenide – BS, Anticlostridial
- half given during 1st 8 hrs 3. Mupirocin – anti-MRSA
- remaining half over subsequent 16 hrs 4. Nystatin – anti-fungal
2. GALVESTON FORMULA
- for children
- 5,000 ml/BSA/% TBSA + 2000
ml/BSA/% TBSA
D5LR
- half- 1st 8 hrs
- half- next 16 hrs
3. FOR THE 2ND 24 HR PORTION
- colloids
- optimal MAP= 60 mmHg
- UO: Adult – 0.5 ml/kg/hr
Children- 1-1.5 ml/kg/hr
❖ Wound Dressing
- debride, remove dead skin, unroof
blisters
5. Silver nitrate – BS
6. Silver sulfadiazine – BS, antipseudomonal
7. Dalkin solution – BS
(15 ml zonrox + 985 ml PNSS) – against MRA, VRE,
Viruses, molds & yeast
❖ Definitive Mgmt
- excision of burn wound, skin grafting
- nutrition, pain control
- rehab, mgmt. of complication
❖ Complications
- burn wounds sepsis – mcc of death
- ARDS, DVT
- abdominal compartment syndrome (due to massive
resuscitation)
- stress ulcers (Curling ulcers
❖ Criteria for Discharge
- no existing complication
- fluid resuscitation completed
- adequate pain tolerance
- adequate nutritional intake
- no anticipated septic complications