High Yield Surgery

Shelf Exam Review

Emma Holliday Ramahi
 Pre-Op Evaluation
• Contraindications to surgery
– Absolute? Diabetic Coma, DKA

– Poor nutrition? albumin <3, transferrin <200,

weight loss <20%.
– Severe liver failure? bili >2, PT >16, ammonia > 150
or encephalopathy
– Smoker? stop smoking 8wks prior to surgery

If a CO2 retainer, go easy on the O2 in the post-op

period. Can suppress respiratory drive.
 Tells you who is at
• Goldman’s Index  greatest risk for surgery
– #1 = CHF
• What should you check? EF. If <35%, no surg.
– #2 = MI w/in 6mo
EKG  stress test 
• What should you check? cardiac cath  revasc.
– #3 = arrhythmia
– #4 = Old (age >70)
– #5 = Surgery is emergent
– #6 = AS, poor medical condition, surg in chest/abd
• What should you check?
Listen for murmur of AS-
Late systolic, crescendo-decrescendo murmur that radiates
to carotids. ↑ with squatting, ↓ with decr preload
 Aspirin, NSAIDs, vit E (2wks)
• Meds to stop:
Warfarin (5 days) – drop INR to
<1.5 (can use vit K)
Take ½ the morning dose of
insulin, if diabetic
• If CKD on dialysis: Dialyze 24 hours pre-op
• Why do we check the BUN and Creatinine?
– What is the worry if BUN > 100?
There is an increased risk of post-op bleeding 2/2
uremic platelet dysfunction.
– What would you expect on coag pannel?
Normal platelets but prolonged bleeding time
 Vent Settings
set TV and rate but if pt takes a
• Assist-control  breath, vent gives the volume.

• Pressure support  pt rules rate but a boost of

*Important for weaning.* pressure is given (8-20).

• CPAP  pt must breathe on own but + pressure

given all the time.

• PEEP  pressure given at the end of

*Used in ARDS or CHF* cycle to keep alveoli open
(5-20).
 You have a patient on a vent…
• Best test to evaluate management? ABG
• If PaO2 is low? increase FiO2
• If PaO2 is high? decrease FiO2
• If PaCO2 is low (pH is high)?  Decr rate or TV
• If PaCO2 is high (pH is low)? Incr rate or TV
• Which is more efficient? TV is more efficient to
change.
*Remember minute
ventilation equation
& dead space*
 Acid Base Disorders
• Check pH  if <7.4 = acidotic.
• Next  Check HCO3 and pCO2:
– If HCO2 is high and pCO2 is high? Respiratory Acidosis
– If HCO2 is low and pCO2 is low? Metabolic Acidosis
• Next  Check anion gap (Na – [Cl + HCO3]), normal? 8-12
• Gap acidosis = MUDPILES
• Non-gap acidosis = diarrhea, diuretic, RTAs (I< II, IV)
• Check pH  if >7.4 = alkalotic.
• Next  Check HCO3 and pCO2:
– If HCO3 is low and pCO2 is low  Respiratory Alkalosis
– If HCO3 is high and pCO2 is high  Metabolic Alkalosis
• Next  Check urine [Cl]
• If [Cl] < 20 Vomiting/NG,
antactids, diuretics
• If [Cl] > 20
Conn’s, Bartter’s Gittleman’s.
 Sodium Abnormalities
• ↓Na = Gain of water
– Check osm, then check volume status.
– ↑volume ↓Na: CHF, nephrotic, cirrotic
– ↑volume ↓ Na: diuretics or vomiting + free water
– Nl volume ↓Na: SIADH, Addisons, hypothyroidism.
– Treatment? Fluid restriction & diruetics
– If hypovolemic? Normal Saline
– When to use 3% saline? Symptomatic (Seizures), < 110
– What would you worry about? Central Pontine Myolinolysis.
• ↑Na = Loss of water
– Treatment? Replace w/ D5W or hypotonic fluid
– What would you worry about? cerebral
edema.
 Other Electrolyte Abnormalities
• Numbness, Chvostek or Troussaeu, prolonged
QT interval. ↓Ca
• Bones, stones, groans, psycho. Shortened QT
interval. ↑Ca
• Paralysis, ileus, ST depression, U waves.↓K
– Treatment? give K (kidneys!), max 40mEq/hr
• Peaked T waves, prolonged PR and QRS, sine
waves. ↑K
– Treatment? Give Ca-gluconate then insulin + glc,
kayexalate, albuterol and sodium
bicarb. Last resort = dialysis
 Fluid and Nutrition
• Maintenance IVFs  D51/2NS + 20KCl (if peeing)
– Up to 10kg s 100mL/kg/day
– Next 10 kgs  50mL/kg/day
– All above 20  20mL/kg/day
• Enteral Feeds are best  keep gut mucosa in tact
and prevent bacterial translocation.
• TPN is indicated if gut can’t absorb nutrients 2/2
physical or fxnal loss.
– Risks = *acalculus cholecystitis*, hyperglycemia, liver
dysfxn, *zinc deficiency*, other ‘lyte probs
 Burn

www.readykor.com/docs/burns_files/burns9.jpg

http://emedicine.medscape.com/arti
http://en.wikipedia.org/wiki cle/769193-media
1st degree /Burn

2nd degree 3rd degree

• Circumferential burns? Consider escharotomy

• Look for singed nose hairs, wheezing, soot in
mouth/nose? Low threshold for intubation
• Patient w/ confusion, HA, cherry red skin?
– Best test? Check carboxyHb (pulse ox = worthless)
– Treatment? 100% O2 (hyperbaric if CO-Hb is ↑↑↑
 Clotting & Bleeding
• Clotting-
– In old people? Think cancer
– Edema, HTN, & foamy pee? Nephrotic syndrome
– In young person w/ +FH Factor V Leiden
– What’s special about ATIII def? Heparin won’t work
– Young woman w/ mult. SABs? Lupus Anticoagulant
– Post op, ↓plts, clots HIT! (If heparin w/in 5-14 days
• What do you treat w/?
Leparudin or agatroban
• Bleeding
– Isolated decr in plts? ITP
– Normal plts but incr bleeding time & PTT? vWD
– Low plts, Incr PT, PTT, BT, low fibrinogen, high Ddimer
and schistocytes? DIC!! Caused by gram – sepsis,
carcinomatosis, OB stuff
 Burn Work up and Tx
• Rule of 9s – Parkland formula-
• Adults- Kg x % BSA x 3-4
Give ½ over the •
1st 8hrs and the • Kiddos- Kg x % BSA x 2-4
rest over next •
• Ringers lactate or
16hrs
normal saline
• NO PO or IV abx. Give topical.
http://img.tfd.com/dorland/thumbs/rule_of-nines.jpg

Silver
• Doesn’t penetrate eschar and can cause
Sulfadiazine
leukopenia?
• Penetrates eschar but hurts like hell? Mafenide
• Doesn’t penetrate eschar and causes hypoK and
HypoNa? Silver Nitrate
 Other Burn Stuff
• Chemical burn, what to do? Irrigate >30min prior to ER
• Electrical Burn, best 1st step? EKG!
• If abnormal? 48 hours of telemetry (also if LOC)
• If urine dipstick + for blood but microscopic exam
is negative for RBCs? Myoglobinuria  ATN
• Then what do you check? K+! (When cells break)
• If affected extremity is extremley tender, numb,
white, cold with barely dopplerable pulses?
Compartment syndrome!!
– Criteria? 5 Ps or compartment pressure >30mmHg
– Treatment? May require fasciotomy. (at bedside!)
 Trauma Drama
• Airway-
– If trauma patient comes in unconscious? Intubate!
– If GCS < 8? Intubate!
– If guy stung by a bee, developing stridor and
tripod posturing? Intubate!
– If guy stabbed in the neck, GCS = 15, expanding
mass in lateral neck? Intubate!
– If guy stabbed in the neck, crackly sounds w/
palpating anterior neck tissues? fiberoptic
broncoscope
– If huge facial trauma, blood obscures oral and
nasal airway, & GCS of 7? cricothyroidotomy
• Breathing-
– So you intubated your patient… next best step?
Check bilateral breath sounds
– If decr on the left?
Means you intubated the right mainstem bronchus
– What to do? Pull back your ET tube
– Next step? Check pulse ox, keep it >90%
 www.imagingpathways.health.wa.gov.au/.../cxr.jpg www.daviddarling.info/images/pneumothorax_rad...

Traumatic Aortic Injury Pneumothorax

img.medscape.com/.../424545-425518-718tn.jpg
upload.wikimedia.org/.../Pulmonary_contusion.jpg

Hemothorax Pulmonary Contusion

 Chest Trauma
• A patient has inward mvmt of the right ribcage
upon inspiration.
– Dx? Flail chest. >3 consec rib fractures
– Tx? O2 and pain control. With what?*
• A patient has confusion, petechial rash in chest,
axilla and neck and acute SOB.
– Dx? Fat embolism
– When to suspect it? After long bone fx (esp femur)
• A patient dies suddenly after a 3rd year medical
student removes a central line.
– Dx? Air embolism
– When else to suspect it? Lung trauma, vent use, during
heart vessel surgery.
• Cardiovascular-
Worry about shock
– If hypotensive, tachycardic?
Hypovolemic/
– If flat neck veins and normal CVP? Hemorrhagic
– Next best step? 2 large bore periph IV- 2L NS or LR over
20min followed by blood.
– If muffled <3 sounds, JVD, electrical alternans,
pulsus paradoxus? Pericardial Tamponade
• Confirmatory test? FAST scan
• Treatment? Needle decompression, pericardial window or
median sternotomy
– If decr BS on one side, tracheal deviation AWAY
from collapsed lung? Tension Pneumothorax
• Next best step? Needle decompression, followed by
a chest tube.
DON’T do a CXR!!!
 Shock
Types of Shock Causes Physical Exam Swan-Ganz Treatment
Catheter
Hypovolemic Loss of circulating blood volume (whole Hypotensive, tachycardic, RAP/ PCWP↓ Crystalloid
blood from hemorrhage or interstitial from diaphoretic, cool, clammy resuscitation
SVR↑
bowel obstruction, excessive vomiting or extremities
diarrhea, polyuria or burn) CO↓
Vasogenic Decreased resistance w/in capacitance Altered mental status, RAP/PCWP↓ Fluid resuscitation
vessels, seen in sepsis (LPS) and hypotension warm, dry (may cause edema)
SVR↓
anaphylaxis (histamine) extremities (early), Late and tx offending
looks like hypovolemic CO↑ (EF↓) organism
Neurogenic A form of vasogenic shock where spinal Hypotensive, bradycardic, RAP/PCWP↓ In adrenal insuff, tx
cord injury, spinal anesthesia, or adrenal warm, dry extremities, w/ dexamethasone
SVR↓
insufficiency (suspect in pts on steroids absent reflexes and flaccid and taper over
encountering a stressor) causes an acute tone. Adrenal insuf will CO↑ several weeks.
loss of sympathetic vascular tone have hypoNa, hyperK
Cardio- Cardiac tamponade or other processes Hypotensive, tachycardic, U/S shows fluid Pericardio-centesis
compressive exerting pressure on the heart so it cannot JVD, decreased heart in the pericardial performed by
fulfill its role as a pump sounds, normal breath space inserting needle to
sounds, pulsus paradoxus pericardial space
Cardiogenic Failure of the heart as a pump, as in SOB, clammy extremities, RAP/PCWP↑ give diuretics up
arrhythmias or acute heart failure rales bilaterially, S3, front, tx the HR to
SVR↑
pleural effusion, decr 60-100, then address
breath sounds, ascites, CO↓ rhythm. Next give
periph edema, vasopressor support
if nec.
 Head Trauma
• GCS  eyes 4, motor 6, verbal 5

tumj.tums.ac.ir
uiowa.edu
prep4usmle.com

Epidural Acute subdural Chronic subdural

Hematoma, edema, tumor can cause increased ICP
Symptoms? Headache, vomiting, altered mental status
Elevate HOB, hyperventillate to pCO2 28-32,
Treatment?
give mannitol (watch renal fxn)
Surgical intervention?
Ventriculostomy
Neck Trauma
Penetrating Trauma  GSW
or stab wound
Zone 3 = ↑ angle of mandible
w/u? Aortography and triple
endoscopy.
Zone 2 = angle of mandible-cricoid
w/u? 2D doppler +/- exploratory
surgery.
Zone 1 = ↓ cricoid
w/u? Aortography
 Penetrating Abdominal Trauma
• If GSW to the abdomen?
Ex-lap. (plus tetanus prophylaxis)
• If stab wound & pt is unstable,
with rebound tenderness &
rigidity, or w/ evisceration?
Ex-lap. (plus tetanus prophylaxis)

If you see this? • If stab wound but pt is stable?

FAST exam. DPL if FAST is equivocal.
Do not pass go, go Ex-lap if either are positive.
directly to • If blunt abdominal trauma pt
exploratory with hypotension/tachycardia:
laparotomy. Ex-lap.
 Blunt Abdominal Trauma
If unstable? Ex-lap.
If stable? Abdominal CT
Spleen or
– If lower rib fx plus bleeding into abdomen liver lac.
– If lower rib fx plus hematuria Kidney lac.
– If Kehr sign & viscera in thorax on CXR Diaphragm
rupture.
– If handlebar sign Pancreatic rupture.
– If stable w/ epigastric pain?
• Best test? Abdominal CT.
• If retroperitoneal fluid is found? Consider duodenal
rupture.
 Pelvic Trauma
FAST and DPL to r/o bleeding in
• If hypotensive, tachycardic  abdominal cavity.
• Can bleed out into pelvis  stop bleeding by fixing fx 
internal if stable, external if not.
• If blood at the urethral meatus and a high riding prostate?
Consider pelvic fracture w/ urethral or bladder injury.
• Next best test? Retrograde urethrogram (NOT FOLEY!)
• If normal? Retrograde cystogram to evaluate bladder
• What are you looking for? Check for extravasation of dye. Take
2 views to ID trigone injury.
If extraperitoneal extravasation?
Bed rest + foley
If intraperitoneal extravasation?
Ex-lap and surgical repair
 Ortho Trauma
• Fractures that go to the OR-
– Depressed skull fx
– Severely displaced or angulated fx
– Any open fx (sticking out bone needs cleaning)
– Femoral neck or intertrochanteric fx

• Common fractures-
– Shoulder pain s/p seizure or electrical shock Post. shoulder dislocation
– Arm outwardly rotated, & numbness over deltoid. Ant. shoulder dislocation
– old lady FOOSH, distal radius displaced. Colle’s fracture
– young person FOOSH, anatomic snuff box tender. Scaphoid fracture
– “I swear I just punched a wall…” Metacarpal neck fracture “Boxer’s
fracture”. May need K wire
– Clavicle most commonly broken where? Between middle and distal 1/3s.
Need figure of 8 device
 Ortho Trauma X-rays

Depressed skull fx Colle’s fx Scaphoid fx

mksforum.net xraypedia.com/files/images/fxapcolles.jpg
orthoinfo.aaos.org/figures/A00012F04.jpg

Clavicle fx Femoral neck fx

en.academic.ru
gentili.net Intertrochanteric fx
download.imaging.consult.com/.../gr5-
midi.jpg
• Fever on POD #1-
– Most common cause, low fever (<101) and non
productive cough? Atalectasis
• Dx? CXR- see bilateral lower lobe fluffy infiltrates
• Tx? Mobilization and incentive spirometry.
– High fever (to 104!!), very ill appearing. Nec Fasc
• Pattern of spread? In subQ along Scarpa’s fascia.
• Common bugs? GABHS or clostridium perfringens
• Tx? IV PCN, Go to OR and debride skin until it bleeds
– High fever (>104!!) muscle rigidity. Malignant
• Caused by? Succ or Halothane Hyperthermia
• Genetic defect? Ryanodine receptor gene defect
• Treatment? Dantrolene Na (blockes RYR and decr
intracellular calcium.
• Fever on POD #3-5-
– Fever, productive cough, diaphoresis
Pneumonia acutemed.co.uk

• Tx? Check sputum sample for culture, cover w/ moxi

etc to cover strep pneumo in the mean time.
– Fever, dysuria, frequency, urgency, particularly in a
patient w/ a foley.
UTI
• Next best test? UA (nitritie and LE) and culture.
• Tx? Change foley and treat w/ wide-spec abx until
culture returns.
• Fever > POD 7-
Central line infection
– Pain & tenderness at IV site
• Tx? Do blood cx from the line. Pull it. Abx to cover staph.
– Pain @ incision site, edema, induration Cellulits
but no drainage.
• Tx? Do blood cx and start antibiotics Simple
– Pain @ incision site, induration WITH drainage.Wound
• Tx? Open wound and repack. No abx necessary Infection
– Pain w/ salmon colored fluid from incision. Dehiscence
• Tx? Surgical emergency! Go to OR, IV abx, primary closure of fascia
– Unexplained fever Abdominal Abscess
• Dx? CT w/ oral, IV and rectal contrast to find it. Diagnostic lap.
• Tx? Drain it! Percutaneously, IR-guided, or surgically.
– Random  thyrotoxicosis, thrombophlebitis, adrenal
insufficiency, lymphangitis, sepsis.
 Pressure Ulcers
• Caused by impaired blood flow  ischemia
– Don’t culture  will just get skin flora. Check CBC and blood cultures.
Can mean bacteremia or osteomyelitis.
– Can do tissue biopsy to rule out Marjolin’s ulcer
– Best prevention is turning q2hrs

– Stage 1 = skin intact but red. Blanches w/ pressure judy-

waterlow.co.
uk

– Stage 2 = blister or break in the dermis

qondio.com

– Stage 3 = SubQ destruction into the muscle

– Stage 4 = involvement of joint or bone. gndmoh.com seejanenurse.wordpress.com

• Stage 1-2 get special mattress, barrier protection

• Stage 3-4 get flap reconstruction surgery
– Before surgery, albumen must be >3.5 and bacterial load must be
<100K
 Thoracic
• Pleural Effusions  see fluid >1cm on lat decu
 thoracentesis!
– If transudative, likely CHF, nephrotic, cirrhotic
• If low pleural glucose? Rheumatoid Arthritis
• If high lymphocytes? Tuburculosis
• If bloody? Malignant or Pulmonary Embolus
– If exudative, likely parapneumonic, cancer, etc.
– If complicated (+ gram or cx, pH < 7.2, glc < 60):
• Insert chest tube for drainage.
– Light’s Criteria  transudative if:
LDH < 200
LDH eff/serum < 0.6
Protein eff/serum < 0.5
ncbi.nlm.nih.gov
• Spontaneous Pneumothorax  subpleural bleb
ruptures  lung collapse.
– Suspect in tall, thin young men w/ sudden dyspnea (or
asthma or COPD-emphysema)
– Dx w/ CXR, Tx w/ chest tube placement
– Indications for surgery = ipsi or contra recurrence,
bilateral, incomplete lung expansion, pilot, scuba, live
in remote area  VATS, pleurodesis (bleo, iodine or
talc)
• Lung Abscess  usually 2/2 aspiration (drunk,
elderly, enteral feeds)
– Most often in post upper or sup lower lobes
– Tx initially w/ abx  IV PCN or clinda
– Indications for surgery = abx fail,
abscess >6cm, or if empyema is present.

www.meddean.luc.edu
 Work up of a Solitary Lung Nodule
• 1st step = Find an old CXR to compare!
• Characteristics of benign nodules:
– Popcorn calcification = hamartoma (most common)
– Concentric calcification = old granuloma
– Pt < 40, <3cm, well circumscribed
– Tx? CXR or CT scans q2mo to look for growth
• Characteristics of malignant nodules:
http://emedicine.medscape.com/
article/356271-media

– If pt has risk factors (smoker, old), If >3cm, if eccentric

calcification
– Tx? Remove the nodule (w/ bronc if central,
open lung biopsy if peripheral. http://emedicine.medscape.com/ar
ticle/358433-media
 A patient presents with weight loss, cough,
dyspnea, hemoptysis, repeated pnia or lung
collapse.
• MC cancer in non-smokers? Adenocarcinoma. Occurs in scars of old pnia
• Location and mets? Peripheral cancer. Mets to liver, bone, brain and adrenals
• Characteristics of effusion? Exudative with high hyaluronidase
• Patient with kidney stones, Squamous cell carcinoma.
constipation and malaise low PTH +Paraneoplastic syndrome 2/2 secretion
central lung mass? of PTH-rP. Low PO4, High Ca
• Patient with shoulder pain, ptosis, Superior Sulcus Syndrome from Small
constricted pupil, and facial edema? cell carcinoma. Also a central cancer.
• Patient with ptosis better after 1 Lambert Eaton Syndrome from small
minute of upward gaze? cell carcinoma. Ab to pre-syn Ca chan
• Old smoker presenting w/ Na = 125, SIADH from small cell carcinoma.
moist mucus membranes, no JVD? Produces Euvolemic hyponatremia.
• CXR showing peripheral cavitation andFluid restrict +/- 3% saline in <112
CT showing distant mets? Large Cell Carcinoma
 ARDS
• Pathophys: inflammation  impaired www.ispub.com/.../ards3_thumbnail.gif

gas xchange, inflam mediator release,

hypoxemia
• Causes:
– Sepsis, gastric aspiration, trauma, low perfusion,
pancreatitis.
• Diagnosis: 1.) PaO2/FiO2 < 200 (<300 means acute lung injury)
2.) Bilateral alveolar infiltrates on CXR
3.) PCWP is <18 (means pulmonary edema is non-cardio

• Treatment: Mechanical ventilation w/ PEEP

 Murmur Buzzwords

• SEM cresc/decresc, louder w/

Aortic Stenosis
squatting, softer w/ valsalva. +
parvus et tardus
• SEM louder w/ valsalva, softer HOCM
w/ squatting or handgrip.
• Late systolic murmur w/ click Mitral Valve Prolapse
louder w/ valsalva and
handgrip, softer w/ squatting
• Holosystolic murmur radiates Mitral Regurgitation
to axilla w/ LAE
 More Murmurs

• Holosystolic murmur w/ late

VSD
diastolic rumble in kiddos
• Continuous machine like PDA
murmur-
• Wide fixed and split S2- ASD

• Rumbling diastolic murmur Mitral Stenosis

with an opening snap, LAE and
A-fib
• Blowing diastolic murmur with Aortic Regurgitation
widened pulse pressure and
eponym parade.
• Bad breath & snacks in Zenker’s diverticulum.
the AM. Tx w/ surgery

• True or false? False. Only contains mucosa

• Dysphagia to liquids & solids. Dysphagia worse w/ hot &
Achalasia. cold liquids + chest pain that
Tx w/ CCB, nitrates, feels like MI w/ NO regurg
botox, or heller
sxs. Diffuse esphogeal spasm.
myotomy
Assoc w/ Chagas dz Tx w/ CCB or nitrates
jykang.co.uk
and esophageal
cancer.
ajronline.org

• Epigastric pain worse after GERD. Most sensitive test is 24-hr pH

eating or when laying down monitoring. Do endoscopy ifst“danger signs”
present. Tx w/ behav mod 1 , then antacids,
cough, wheeze, hoarse. H2 block, PPI.
• Indications for surgery? bleeding, stricture, Barrett’s, incompetent LES,
max dose PPI w/ still sxs, or no want meds.
If hematemesis (blood occurs If gross hematemesis If progressive
after vomiting, w/ subQ unprovoked in a cirrhotic dysphagia/wgt loss.
emphysema). Can see pleural w/ pHTN. Esophageal Carcinoma
effusion w/ ↑amylase Gastric Varices Squamous cell in
Boerhaave’s If in hypovolemic shock? smoker/drinkers in the
Esophageal Rupture middle 1/3.
do ABCs, NG lavage, Adeno in ppl with long
Next best test? medical tx w/ octreotide standing GERD in the
CXR, gastrograffin or SS. Balloon distal 1/3.
esophagram. NO tamponade only if you
edoscopy need to stablize for Best 1st test?
Tx? transport
barium swallow, then
surgical repair if full Tx of choice? endoscopy w/ bx, then
thickness staging CT.
Endoscopic
sclerotherapy or
banding
*Don’t prophylactically
band asymptomatic
varices. Give BB. img.medscape.com
/pi/emed/ckb/onco
logy/276262
 Stomach
http://emedicine.medscape.c
om/article/175765-media

• Acid reflux pain after eating, when laying down- Hiatal Hernia
– Type 1 = Sliding. GE jxn herniates into thorax. Worse for GERD. Tx sxs.
– Type 2 =Paraesophageal. Abd pain, obstruction, strangulation  needs surgery.
• MEG pain worse w/ eating. H.pylori, NSAIDs, ‘roids- Gastric Ulcers
Double-contrast barium swallow- punched out lesion w/ reg margins.
– Work up =
EGD w/ bx can tell H. pylori, malign, benign.
– Surgery if-
Lesion persists after 12wks of treatment.
• Gastric Cancer- Adeno most common. Esp in Japan
– Krukenberg Gastric CA  ovaries Blummer’s Shelf Mets felt on DRE
Virchow’s node L supraclav fossa Sister Mary Joseph Umbilical node
– Lymphoma- HIV MALT-lymphoma- H. pylori
• Randoms-
– Mentriers = protein losing enteropathy, enlarged rugae.
– Gastric Varices = splenic vein thrombosis.
– Dieulafoy’s = massive hematemesis  mucosal artery erodes into
stomach
 Duodenum
• MEG pain better w/ eating Duodenal Ulcers
– 95% assoc w/ H. pylori
– Healthy pts < 45y/o can do trial of H2 block or PPI
– Dx? blood, stool or breath test for H. pylori but endoscopy w/
biopsy (CLO test) is best b/c it can also exclude cancer.
– Tx? PPI, clarithromycin & amoxicillin for 2wks. Breath or stool
test can be test of cure.
• What to suspect if MEG pain/ulcers don’t resolve? ZE Syndrome
– Best test? Secretin Stim Test (find inapprop high gastrin)
– Tx? Surgical resection of pancreatic/duodenal tumor
– What else to look for? Pituitary and Parathyroid problems.
• A patient has bilious vomiting and post-prandial pain.
Recently lost 200lbs on “Biggest Loser”. SMA Syndrome
– Pathophys- 3rd part of duodenum compressed by AA and SMA
– Tx? by restoring weight/nutrition. Can do Roux-en-Y
 Exocrine Pancreas
• MEG pain straight through to the back. Pancreatitis
– Most common etiologies? Gallstones & ETOH
– Dx? Incr amylase & lipase. CT is best imaging test
– Tx? NG suction, NPO, IV rehydration and observation
– Bad prognostic factors- old, WBC>16K, Glc>200, LDH>350, AST>250…
drop in HCT, decr calcium, acidosis, hypox
– Complications- pseudocyst (no cells!), hemorrhage, abscess, ARDs
• Chronic Pancreatitis-
– Chronic MEG pain, DM, malabsorption (steatorrhea)
– Can cause splenic vein thrombosis  which leads to …? Gastric varices!
• Adenocarcinoma-
– Usually don’t have sxs until advanced. If in head of pancreas 
Courvoisier’s sign large, nontender GB, itching and jaundice
– Trousseau’s sign = migratory thrombophlebitis
– Dx w/ EUS and FNA biopsy
– Tx w/ Whipple if: no mets outside abdomen, no extension into SMA or
portal vein, no liver mets, no peritoineal mets.
 Endocrine Pancreas
• Insulinoma- sxs (sweat, tremors, hunger, seizures) + BGL <
– Whipple’s triad? 45 + sxs resolve w/ glc admin
– Labs? insulin ↑, C-peptide ↑, pro-insulin ↑
• Glucagonoma-
– Sxs? Hyperglycemia, diarrhea, weight-loss
– Characteristic rash? necrolytic migratory erythema
• Somatistainoma- img.medscape.com/.../104

– Commonly malignant. see malabsorption, 8885-1093550-244.jpg

steatorrhea, ect from exocrine pancreas malfxn

• VIPoma-
– Sxs? Watery diarrhea, hypokalemia, dehydration, flushing.
– Looks similar to carcinoid syndrome.
– Tx? Octreotide can help sxs
 Gallbladder Acute Cholecystitis
• RUQ pain  back, n/v, fever, worse s/p fatty foods.
– Best 1st test? U/S
– Tx? Cholecystectomy. Perc cholecystostomy if unstable med-ed.virginia.edu

• RUQ pain, high bili and alk-phos. Choledocolithiasis

– Dx? U/S will show CBD stone.
– Tx? Chole +/- ERCP to remove stone
• RUQ pain, fever, jaundice, ↓BP, AMS. Ascending Cholangitis
– Tx? w/ fluids & broad spec abx. ERCP and stone removal.
• Choledochal cysts-
– Type 1? Fusiform dilation of CBD  Tx w/ excision
– Type 5? Caroli’s Dz. Cysts in intrahepatic ducts  needs liver transplant
• Cholangiocarcinoma- rare.
– Risk factors? Primary sclerosing cholangitis (UC), liver flukes and
thorothrast exposure. Tx w/ surgery +/- radiation.
 Liver
• Hepatitis-
– AST = 2x ALT  Alcoholic heptatitis (reversible)
– AST > ALT high (1000s)  Viral hepatitis
– AST & ALT high s/p hemorrhage, surg, or sepsis  Shock liver
• Cirrhosis and Portal HTN-
– Tx- SS and VP vasocontrict to decrease portal pressure, betablockers
also decrease portal pressure.
– Don’t need to treat esophageal varices prophyactically, but
band/burn them once they bleed once.
– TIPS relieves portal HTN but…  worsens hepatic encephalopahty
• Treat with: Lactulose. helps rid body of ammonia.
• Hepatocellular Carcinoma
– RF- chronic hepB carrier > hepC. Cirrhosis for any
reason, plus aflatoxin or carbon tetrachloride.
– Dx w/ high AFP (in 70%), CT/MRI.
– Tx: can surgically remove solitary mass, use rads or cryoablation for
pallation of multiple.
 More Liver
*Women on OCP  palpable abd mass or spontaneous
rupture  hemorrhagic shockHepatic Adenoma www.radswiki.net/main/images/thumb/
3/3e/Hepat...

Dx? U/S or MRI

Tx? D/c OCPs. Resect if large or pregnancy is desired
*2nd MC benign liver tumor. W>M but less likely to rupture. Focal Nodular
No tx needed. Hyperplasia
*Bacterial Abscess.
Most common bugs? E. coli, bacteriodes, enterococcus.
Tx? Surgical drainage and IV abx.
RUQ pain, profouse sweating and rigors, palpable liver. Entamoeba histolytica
Tx? Metronidazole. DON’T drain it.
Patient from Mexico presents w/ RUQ and large liver cysts found
on U/S Enchinococcus.
– Mode of transmission? Hydatic cyst paracyte from dog feces.
– Lab findings? eosinophilia, +Casoni skin test
– Tx? albendazole and surgery to remove ENTIRE cyst,
rupture  anaphylaxis
 Spleen
• Post-Splenectomy 
– Post op thrombocytosis >1mil  give aspirin. img.medscape.com/.../432648-432823-
3042.jpg

– Prophylactic PCN + S. pneumo, H. flu and N. meningitidis vaccines.

• ITP-
– Consider in isolated thrombocytopenia (bleeding gums, petechiae,
nosebleeds).
– Decr plt count, incr megakaryocytes in marrow.
– NO splenomegaly.
– Tx w/ steroids 1st. If relapse  splenectomy.
• Hereditary Spherocytosis-
– See sxs of hemolytic anemia (jaundice, incr indir bili, LDH, decr
haptoglobin, elevated retic count) + spherocytes on smear and
+osmotic frag test. Prone to gallstones.
– Tx w/ splenectomy (accessory spleen too).
• Traumatic Splenic Rupture- www.ezhemeonc.com/wp-
content/upload

– Consider w/ L lower rib fx and intra abd hemorrhage. Can have Kehr’s
sign (irritates L diaphragm).
 Appendix
• pain in umbilical area  RLQ, n/v.
perf. Appendicitis
– Go to surgery if: Clinical picture is convincing.
– If perforated/abscess? drain, abx (to cover e.coli & bacteriodes),
and do interval appendectomy
• Carcinoid Tumor- #1 site: Appendix!
– Carcinoid syndrome sxs? Diarrhea, Wheezing.
– When do they happen? When mets to liver. (1st pass metabolism)
– What else to look out for? Diarrhea, Dementia, Dermatitis
– If >2cm, @ base of appendix, or
w/ + nodes  Hemicolectomy
– Otherwise  Appendectomy is good enough
 Bowel Obstruction
• Small Bowel Obstruction-
– Suspect in hernia, prior GI surgery (adhesions), cancer,
intussusception, IBD.
– Sxs are pain, constipation, obstipation, vomiting.
– 1st test is upright CXR to look for free air. CT can show point of
obstruction.
– Tx w/ IVF, NG tube. Do surgery if peritoneal signs, Incr WBC, no
improvement w/in 48hrs.
• Volvulus- either cecal or sigmoid
– Decompression from below if not strangulated. Otherwise, need
surgical removal and colostomy.
• Post-Op Ileus-
– Also consider if hypoK (make sure to replete), opiates.
– See dilated loops of small bowel w/ air-fluid level.
– Do surgery for perforation. Give lactulose/erythromycin.
• Ogilvie’s syndrome-
– See massive colonic distension. If >10cm, need decompression w/ NG
tube and neostigmine (watch for bradycardia) or colonoscopic
decompression.
 Abdominal Imaging

http://emedicine.medscape.com/article/ http://www.ganfyd.org/index.php?tit http://emedicine.medscape.com/ar

374962-overview le=Small_bowel_obstruction ticle/178948-media

http://emedicine.medscape.co
http://emedicine.medscape.com/article/7 m/article/774045-
74045-diagnlearningradiology.comosis diagnlearningradiology.comosis learningradiology.com
 Hernias
• Umbilical- in kiddos, close spontaneously by age 2. In
adults: 2/2 obesity, ascites or pregnancy.
• Indirect Inguinal- MC  through inguinal ring (lat to
epigastric vessles) in spermatic cord. R>L, more often
congenital (patent proc vaginals)
• Direct Inguinal-  through Hasselbeck’s triangle
(med to epigastric vessles), more often acquired
weakness.
• Femoral- more common in women.
• Tx- emergent surgical repair if incarcerated to
avoid strangulation. Elective if reducible.
 Inflammatory Bowel Disease
• Involves terminal ileum? Crohn’s. Mimics appendicitis. Fe deficiency.
• Continuous involving rectum? UC. Rarely ileal backwash but never higher
• Incr risk for Primary UC. PSC leads to higher risk of cholangioCA
Sclerosing Cholangitis?
• Fistulae likely? Crohn’s. Give metronidazole.
• Granulomas on biopsy? Crohn’s.
• Transmural inflammation? Crohn’s.
• Cured by colectomy? UC.
• Smokers have lower risk? UC. Smokers have higher risk for Crohn’s.
• Highest risk of colon cancer? UC. Another reason for colectomy.
• Associated w/ p-ANCA? UC.
Treatment = ASA, sulfasalzine to maintain remission. Corticosteroids to induce
remission. For CD, give metranidazole for ANY ulcer or abscess. Azathioprine,
6MP and methotrexate for severe dz.
IBD Images & Complications

commons.wikimedia.org
medinfo.ufl.edu/~bms5191/gi/images/cd1a.jpg

http://www.ajronline.org/cgi/con
tent-nw/full/188/6/1604/FIG20

studenthealth.co.uk
 Diverticular Disease
• Diverticulosis-
– False diverticulae (only outpocketings of mucosa)
– Occur 2/2 low fiber diet in areas of weakness where blood
vessels penetrate  bleed
– Complications are bleeding, obstruction, diverticulitis
• Diverticulitis-
– Diverticulum becomes obstructed and forms
abscess/perforates
– LLQ pain, either constipation or diarrhea,
– Look for free air, CT is best imaging to
evaluate for abscess. No Barium enema!
– Tx w/ NPO, NG suction, IVF, broad spec abx & pain control. www.meddean.luc.edu/.../GI/Diverticulit
is2.jpg

– Do colonoscopy: 4-6 weeks later.

– Surgery indicated if: multiple episodes, age <50. Elective is better than
emergency (can do primary anastamosis)
 Colorectal Cancer
• RF
– Genetics? AFP, Lynch Syndrome, HNPCC, Gardners, Cowdens
– Other? UC. Need colonoscopy 8-10yrs after dx
• Sxs
– Right sided cancer = bleeding ourwebdoctor.com

– Left sided cancer = obstruction

– Rectal cancer = pain/fullness, bleeding/obstruction
• Work up DRE, transrectal ultrasound (depth of invasion),
Colonoscopy! CEA to measure recurrance, CT for staging.
• Tx
– For colon- remove affected segments & chemo if node +
– For rectum- upper/middle 1/3 get a LAR, lower 1/3 gets an APR
(remove sphincter, permanent colostomy)
 AAA
• Screening = men 65-75 who have ever smoked. Do abdominal U/S.

• Sxs = pulsatile abdominal mass.

• Tx conservatively if:
if <5cm and asymptomatic, monitor growth every 3-12mo.
• Surgery indicated if: >5cm, growing <4mm/yr
• Rupture =
– severe sudden abdomen, flank or back, shock, tender
pulsatile mass.
– 50% die before reaching the hospital.
• Post-op complications = #1 cause of death  MI
– Bloody diarrhea-Ischemic colitis
ASA
– Weakness, decreased pain w/ preserved vibr, prop- syndrome
– 1-2 yrs later if have brisk GI bleeding  Aortoenteric Fistula
 Mesenteric Ischemia
• Acute Mesenteric Ischemia = surgical emerg!
– Acute abdominal pain in a pt w/ A-fib subtherapeutic
on warfarin or pt s/p high dose vasoconstrictors
(shock, bypass).
– Work up is angiography (aorta and SMA/IMA)
– Tx is embolectomy. If thrombus, or aortomesenteric
bypass.
• Chronic Mesenteric Ischemia =
– Slow progressing stenosis (req stenosis of 2.5 vessels
 Celiac, SMA and IMA).
– Severe MEG pain after eating, food fear and weight
loss. “Pain out of proportion to exam”.
– Dx w/ duplex or angiography.
– Tx w/ aortomeseteric bypass or transaortic mesenteric
endarterectomy.
 Peripheral Artery Disease
• Acute arterial occlusion: 5P’s  no dopplerable pulses.
– Tx w/ immediate heparin + prepare for surgery.
– Surgery (embolectomy or bypas) done w/in 6hrs to avoid
loss.
– Thrombolytics may be possible if: no surg in <2wks,
hemorrhagic stroke.
– Complications = compartment syndrome during reperfusion
period  do fasciotomy watch for myoglobinuria.
• Claudication-
– Pain in butt, calf thigh upon exertion.
– Best test? Ankle-Brachial Index
– Normal- >1
– Claudication & Ulcers- 0.4-0.8, use medical management
– Limb ischemia- 0.2-0.4, surgery is indicated
– Gangrene <0.2, may require amputation
 DVT and PE
• High risk after surgery (esp orthopedic)
• DVT-
– Dx w/ Duplex U/S & also check for PE
– Tx w/ heparin, then overlap w/ warfarin for 5 days, then download.imaging.consult.com/...
continue warfarin for 3-6mo. /gr1-midi.jpg

– Complications- post-phlebotic syndrome = chronic valvular

incompetence, cyanosis and edema
• PE-
– Random signs = right heart strain on EKG, sinus tach, decr
vascular markings on CXR, wedge infarct, ABG w/ low CO2 and
O2.
– If suspected, give heparin 1st! Then work up w/ V/Q scan, then
spiral CT. Pulmonary angiography is gold standard.
– Tx w/ heparin warfarin overlap. Use thrombolytics if severe but
NOT if s/p surgery or hemorrhagic stroke. Surgical
thrombectomy if life threatening. IVC filter if contraindications
to chronic coagulation.
 Work up of a Thyroid Nodule
• 1st step? Check TSH
• If low? Do RAIU to find the “hot nodule”. Excise or radioactive I131
• If normal? FNA
• If benign? Leave it alone.
• If malignant? Surgically excise and check pathology
• If indeterminate? Re-biopsy or check RAIU
• If cold? Surgically excise and check pathology
– Papillary MC type, spreads via lymph, psammoma bodies
– Follicular Spreads via blood, must surgically excise whole thyroid!
– Medullary Assoc w/ MENII (look for pheo, hyperCa). Amyloid/calci
– Anaplastic 80% mortality in 1st year.
– Thyroid Lymphoma Hashimoto’s predisposes to it.
 Work up of an Adrenal Nodule
• #1- check functional status
Diagnosis Features Biochemical Tests
Pheochromocytoma High blood pressure, Urine- and plasma-free
catechol symptoms metanephrines
Primary aldosteronism High blood pressure, low Plasma aldosterone-to-
K+, low PRA* renin ratio
Adrenocortical carcinoma Virilization or feminization Urine 17-ketosteroids
Cushing or "silent" Cushing Cushing symptoms or Overnight 1-mg
syndrome normal examination results dexamethasone test

• #2- if <5cm and non-function  observe w/

CT scans q6mo.
If >6cm or functional  surgical
excision
http://emedicine.medscape.com/article/116587-treatment
 Parathyroid Disease
• Hypoparathryoidism
– Typically comes from thyroidectomy
– Sxs are perioral numbness, Chvortek, Trousseau
– ↓*Ca+, ↑*PO4+, ↓*PTH+
• Hyperparathyroidism-
– Usually asymptomatic ↑Ca, but can present w/ kidney stones,
abdominal or psychiatric sxs
– ↑*Ca+, ↓*PO4+, ↑vitD, ↑*PTH+
– Dx w/ FNA of suspicious nodules. Can use Sestamibi scan.
– Tx w/ surgical removal of adenoma. If hyperplasia, remove all 4
glands and implant 1 in forearm.
• MEN-
– MEN1- pituitary adenoma, parathyroid hyperplasia, pancreatic
islet cell tumor.
– MEN2a- parathryoid hyperplasia, medullary thyroid cancer,
pheochromocytoma
– MEN2b- medullary thyroid cancer, pheochromocytoma,
Marfanoid
 Work up of a Breast Mass
• U/S can tell if solid or cystic. MRI is good for eval dense
breast tissue, evaluating nodes and determining
recurrent cancer.
– Best imaging for the young breast
– U/S good for determining fibroadenoma/cysto-sarcoma
phyllodes.
• Aspiration of fluid if cystic, FNA for cells if solid
– Send fluid for cytology if its bloody or recurs x2
– Fibrocystic change  cysts are painful and change w/
menses. Fluid is typically green or straw colored.
• Restrict caffiene, take vitamin E, wear a supportive bra
• Excisional biopsy if palpable or if fluid recurs
• Mammaographically guided multiple core biopsies
 Breast Cancer
• RF: BRCA1 or 2, person hx of breast cancer, nulliparity, www.pathconsultddx.com/.../gr1-sml.jpg

endo/exogenous estrogen.
• DCIS-
– Either excision w/ clear margins or simple mastectomy if multiple
lesions (no node sampling) + adjuvant RT.
• LCIS-
– More often bilateral. Consider bilateral mastectomy only if +FH,
hormone sensitive, or prior hx of breast cancer
• Infiltrating ductal/lobular carcinoma-
– If small and away from nipple, can do lumpectomy w/ ax node
sampling. Adjuvant RT. Chemo if node +. Tamoxifen or Raloxifen if ER +
– Modified radical mastectomy w/ ax node sampling w/o adjuvant RT
gives same prognosis.
• Paget’s Dz-
– Looks like eczema of the nipple. Do mammogram to find the mass.
• Inflammatory-
– Red, hot, swollen breast. Orange peal skin. Nipple retratction.

riversideonline.com
 Skin Cancer
• Basal Cell Carcinoma-
– Shave or punch bx then surgical removal (Mohs)
• Squamous Cell Carcinoma-
– AK is precursor lesion (tx w/ 5FU or excision) or http://emedicine.medscape.com/article/

keratoacanthoma. 276624-media

– Excisional bx at edge of lesion, then wide local excision.

– Can use rads for tough locations.
• Melanoma-
– Superficial spreading (best prog, most common)
– Nodular (poor prog) http://emedicine.medscape.com/article/1
101535-media

– Acrolintiginous (palms, soles, mucous membranes in darker

complected races).
– Lentigo Maligna (head and neck, good prog)
– Need full thickness biopsy b/c depth is #1 prog
– Tx w/ excision-1cm margin if <1mm thick,
2cm margin if 1-4mm thick, 3cm margin if >4mm
myhealth.ucsd.edu
– High dose IFN or IL2 may help
 Sarcoma
• Soft Tissue Sarcoma-
– Painless enlarging mass. (Don’t confuse w/ bruised muscle.
– Dx w/ biopsy (NOT FNA). Excisional if <3cm otherwise
incisional.
– Tx w/ wide, local excision or ampulation + RT.
– Spreads 1st to the lungs (hematogenously)  can do
wedge resection if only met and primary is under control.
• Liposarcoma-
– 99% DON’T come from lipoma
• Fibrosarcoma/Rhabdomyosarcoma/
Lymphangiosarcoma-
– Hard round mass on extremity. Can occur in areas of
chronic lymphedema
 Work up of a Neck Mass
• 7 days = inflammatory, 7 mo = cancer, 7 yrs =
congenital
– MC is a reactive node, so #1 step is to examine teeth,
tonsils, etc for inflammatory lesion
– If you find a lesion that’s still there in 2 week  FNA it!
– If node is firm, rubbery and “B sxs” are present 
excisional bx looking for Lymphoma
• Hodgkins = lymphocyte predom is good prog factor. Reed
Sternberg cells. lmp.ualberta.ca

• Non-Hodgkins = nodular and well-dif are good prog factor.

• Staging CT, CXR and laparotomy for chemo and XRT treatment
• If midline  thyroglossal duct cyst, move tongue 
mass moves. Remove surgically. cssd.us

• If anterior to SCM  brancial cleft cyst

• If spongy, diffuse and lateral to SCM  cystic hygroma
(Turners, Down’s, Klinefelters)
 ENT Cancers
• Oral Cancer-
– Most freq squamous cell. In smokers & drinkers
– Tx w/ XRT or radical dissection (jaw/neck)
• Laryngeal Cancer-
– Laryngeal papilloma in kiddo w/ stridor or cough
– Squamous cell in adults.
– Tx w/ laryngoscope laser or resection
• Pleomorphic Adenoma-
atlasgeneticsoncology.org

– MC salivary glad tumor. Usually on parotid. Benign but recurs

• Warthlin’s Tumor-
– Papillary cystadenoma lymphomatosum. Benign on parotid
gland.
– Can injure facial nerve (look for palsy sxs in ? Stem)
• Mucoepidermoid Carcinoma-
– MC malignant tumor. Arises from duct. Causes pain and CNVII
palsy
 Pedi-Surg
Baby is born w/ respiratory distress,
scaphoid abdomen & this CXR.
Diaphragmatic hernia
• Biggest concern? Pulmonary hypoplasia
emedicine.medscape.com
• Best treatment? If dx prenatally, plan
delivery at @ place w/
ECMO. Let lungs mature
3-4 days then do surg
Baby is born w/ respiratory
TE- Fistula
distress w/ excess drooling.
• Best diagnostic test? Place feeding tube, take xray, see it
coiled in thorax
 GI disorders Gastroschisis
• Defect lateral (usually R) of *will see high
the midline, no sac. maternal AFP
– Assoc w/ other disorders? Not usually. bms.brown.edu

– Complications? May be atretic or necrotic req

removal. Short gut syndrome
Omphalocele
• Defect in the midline.
Covered by sac.
– Assoc w/ other disorders? Yes bms.brown.edu

Umbilical Hernia
• Defect in the midline. No
bowel present.
– Assoc w/ other disorders? Assoc w/ congenital hypo-
– Treatment? thyroidism. (also big tongue)
images.suite101.com/617141_c
om_picture067.jpg
Repair not needed unless persists past age 2 or 3.
 A vomiting baby
• 4wk old infant w/ non-
Pyloric Stenosis
bileous vomiting and
palpable “olive”
– Metabolic complications? Hypochloremic, metabolic alkalosis
– Tx? Immediate surg referral for myotomy
• 2wk old infant w/ bileous
Intestinal Atresia
vomiting. The pregnancy Or Annular Pancreas
was complicated by poly-
hydramnios.
– Assoc w/? Down Syndrome (esp duodenal) Learningradiology.com

• 1 wk old baby w/ bileous

vomiting, draws up his legs, Malrotation and volvulus
*Ladd’s bands can kink the duodenum
has abd distension.
– Pathophys? Doesn’t rotate 270 ccw around SMA
 Pooping Problems
• A 3 day old newborn has Meconium ileus- consider CF if +FH
still not passed meconium. *gastrograffin enema is dx & tx
Hirschsprung’s- DRE  explosion of poo.
– DDX? (name 2)
bx showing no ganglia is gold standard
• A 5 day old former 33
weeker develops bloody Necrotizing Enterocolitis
diarrhea
– What do you see on xray? Pneumocystis intestinalis (air in the wall)
– Treatment? NPO, TPN (if nec), antibiotics and resection of necrotic bowel
– Risk factors? Premature gut, introduction of feeds, formula.
• A 2mo old baby has colicky
abd pain and current jelly Intussusception
*Barium enema is dx and tx
stool w/ a sausage shapend
mass in the RUQ.
 Urology
• BPH-
– Anticholinergics meds make it worse  foley for acute urinary
retention.
– Medical Tx 1st w/ tamsulosin or finasteride
– Surgical Tx w/ TURP (hyponatremia, retro-ejac)
• Prostate Cancer-
– Nodules on DRE or elevated/rising PSA means  transrectal
ultrasound and bx. Bone scan looks for blastic lesions.
– Tx w/ surgery, radiation, leuprolide or flutamide.
• Kidney Stones-
– CT is best test. If stone <5mm, hydrate and let it pass. If >5mm, do
shock wave lithotripsy. Surgical removal if >2cm.
• Scrotal Mass-
– Transilluminate, U/S, excision! (don’t bx). Know hormone markers!
• Testicular Torsion-
– Acute pain and swelling w/ high riding testis.
– Do STAT doppler U/S  will show no flow (contrast w/ epididymitis)
– Can surgically salvage if <6hrs. Do orchiopexy to BOTH testes.
 Ortho
• Avascular Necrosis- img.medscape.com/.../329097-333364-4215.jpg

– In kids  Leg-Calve-Perthe’s dz in 4-5 y/o w/ a painless

limp and SCFE in a 12-13 y/o w/ knee pain or sickle cell pts
– In adults  steroid use, s/p femur fracture.
• Osteosarcoma-
– Seen in distal femur, proximal tibia
@ metaphysis, around the knee
– Codman’s triangle and Sunray appearance
• Ewing Sarcoma-
img.medscape.com/.../329097-333364-4215.jpg

– Seen at diaphysis of long bones,

night pain, fever & elevated ESR
– Lytic bone lesions, “onion skinning”.
– Neuroendocrine (small blue) tumor
www.learningradiology.com/.../cow279lg.jpg
 Transplant
• Hyperacute Rejection-
– Vascular thrombosis w/in minutes
– Caused by preformed antibodies
• Acute Rejection-
– Organ dysfunction (incr GGT or Cr depending on organ)
w/in 5days – 3mo. Due to T-lymphocytes.
– Technical problems common in Liver  1st check for biliary
obstruction w/ U/S then check for thrombosis by Doppler.
– In heart, sxs come late, so check ventricular bx periodically.
– Tx w/ steroid bolus and antilymphocyte agent (OKT3)
• Chronic Rejection-
– Occurs after years. Due to T-lymphocytes.
– Can’t treat it. Need re-transplantation.
 Anesthesia
• Local- (lidocaine, etc) To prevent systemic absorption  numb
– Why give with epi? tongue, seizures hypotension, bradycardia,
arrhythmias
– No epi where? Fingers, nose, penis, toes
• Spinal-Subarachnoid- (bupivacaine, etc)
– For ppl who can’t be intubated. Can’t give if incr ICP or hypotensive.
• Epidural- (local + opiod)
– If “high block”  blocks heart’s SNS nerves and phrenic nerve.
• General-
– Merperidine: Norperidine metabolite can lower seizure
threshold esp in pts w/ renal failure.
– Succinylcholine: Can cause malignant hyperthermia, hyperK (not
for burn or crush victim)
– Rocuronium, etc: Sometimes allergic rxn in asthmatics

– Halothane, etc: Can cause malignant hyperthermia (dantroline

Na), liver toxicity.
SURGERY SHELF REVIEW
Dr. Dominik Lipinski MD
––––––––––––––––– CV ISSUES –––––––––––––––––
Goldman’s index: cardiac risk factors in surgery –
JVD (#1), recent MI (#2), PVCs and arrhythmias, age
>70, emergency surgery, aortic stenosis
JVD: indicates CHF, #1 CV risk factor overall, give
β-blockers, Ca2+-channel blockers, digitalis, and
diuretics if possible before surgery
MI: previous MI increases risk of post-op MI, so
consult cards and order a stress test
MI within 30 days: very high risk, delay surgery
Family Hx of MI: get a concentrated cardiac FHx,
EKG, and exercise stress test to assess risk factors
↑cholesterol: increased risk of coronary artery
disease, but do not postpone surgery
Premature ventricular contractions: at risk of
arrhythmia due to ventricular dysfunction,
indicated for stress test and echo
Ejection fraction: SV/EDV; normal EF >67%, an
EF<35% increases risk of operative MI
Diabetes: should be NPO 8 hours before surgery,
administer IVF with D5, check glucose morning of
surgery; if glucose >250 → 2/3 of insulin, if glucose
<250 → 1/2 of insulin
Hyperglycemia: ideal glucose is 100-250,
delay surgery until glucose is under control
Diabetic coma: absolute contraindication to
surgery; give IVF, correct acidosis and glucose
↓hct: important to determine underlying cause of
anemia, consider possible colorectal cancer
↑hct: either hypovolemia or polycythemia; if
hypovolemic → delay until hydrated, if polycythemic
→ important to determine underlying cause
Obesity: higher risk of HTN, cardiovascular disease,
post-op atelectasis, type 2 diabetes, DVTs; require
DVT prophylaxis and aggressive post-op pulmonary
care for preventing atelectasis
HTN: diastolic BP >110 is high risk of CV complications,
β-blockers reduce overall risk
Atherosclerosis: can present as acute coronary
syndome or peripheral vascular disease, always
evaluate pt’s cardiac risk factors
CV evaluation: EKG (and compare to old EKG),
persantine thallium stress test, dobutamine echo
LBBB: indicates underlying ischemic heart disease
RBBB: indicates significant pulmonary disease, but
can be normal in up to 10% of pts
Previous CABG: decreases cardiac risk if performed 6
months to 5 years before surgery, effect on cardiac
risk unclear if >5 years
Previous coronary angioplasty: high risk (33%) of
coronary restenosis, so stress test is indicated; if
angioplasty is recent, delay surgery for several
weeks
Angina: indicates coronary artery disease, evaluate
for possible coronary revascularization
AFib: give anticoagulation and β-blockers, and
cardiovert them to normal sinus rhythm
Carotid bruit: indicates carotid stenosis; indicated
for CEA if high grade (>70%) stenosis
Previous stroke: order a carotid duplex study, in
order to assess the carotid arteries
Gangrenous toe: peripheral revascularization is
more urgent than a full cardiac work-up
––––––––––––– RESPIRATORY ISSUES ––––––––––––
Smoking: up to 6× risk for post-op complications due
to compromised ventilation, must quit smoking for 2
months before surgery
COPD: give bronchodilators and try to improve
pulmonary status as much as possible
Severe COPD: very high risk for acute pulmonary
failure with surgery; teach patient about
incentive spirometry, give bronchodilators, and
mobilize post-op to prevent atelectasis
Green sputum: give oral antibiotics, and schedule
surgery after Tx is complete
Bloody sputum: indicates active infection or lung
cancer; requires a full work-up including CXR, CT
scan, and bronchoscopy
–––––––––––– HEPATOBILIARY ISSUES –––––––––––
Acute cholecystitis: presents as fever, RUQ pain,
WBC>15; get U/S → IVF, abx, lap chole w/in 72 hours
Child’s classification: stratifies risk of surgery in pts
with liver failure; measures 3 labs (albumin, bilirubin,
PT) and 3 clinical findings (encephalopathy, ascites,
nutrition)
Child’s group A: 0-5% mortality
Child’s group B: 10-15% mortality
Child’s group C: >25% mortality; not good surgical
candidates until Child’s status is improved
Alcohol use: delay surgery until pt has undergone
withdrawal, since post-op withdrawal syndrome has
a high risk of morbidity/mortality
Liver failure: make sure the pt is in a compensated
state, abstain from alcohol for 6-12 weeks, control
ascites, normalize nutrition status and coagulation
factors
Pressure necrosis on hernia: high risk of rupture
with a high mortality rate, requires urgent repair
Surgery – Preoperative Care
Delirium in liver failure: possible causes include
CNS abnormality, electrolyte imbalance, GI
bleeding, sepsis, or bacterial peritonitis; evaluate
for mental status change, and tap the ascites
Ascitic leakage: high risk of bacterial peritonitis;
manage by sending fluid to lab, giving IV
antibiotics, and urgent hernia repair
Hemorrhoids: suspect portal HTN in pt with
cirrhosis + hemorrhoids, high risk of hemorrhage
Malnutrition: indicated by recent weight loss (#1) or
albumin <3.0 (#2); give 7-10 days of pre-op nutritional
support ideally
––––––––––––––––– GU ISSUES –––––––––––––––––
Dysuria: get urinalysis and urine culture; if positive
for UTI, delay surgery until resolved
Chronic renal failure: delay surgery until pt is stable,
dialysis started, and any other problems resolved
CRF × K+ measurement: needs to be obtained
immediately before surgery, since CRF can result
in rapid electrolyte imbalances
CRF × operative bleeding: renal failure causes
platelet dysfunction secondary to uremia;
give desmopressin or FFP, but not platelets
CRF × operative hypotension: many possible
causes, consider glucocorticoid (aldosterone)
deficiency in a pt who has taken steroids before
Kidney transplant pt: require perioperative steroids
Post-op hyperkalemia: check EKG for peaked T
waves, Tx C BIG K DIe – calcium gluconate, bicarb-
insulin-glucose, kayexalate, and dialysis
–––––––––––––– VALVULAR ISSUES –––––––––––––
Mitral stenosis: elevated LA pressure can lead to
cor pulmonale (PH+RVH); management includes
cards consult, prophyactic abx for endocarditis, can
go to surgery if stable
Mitral stenosis × CHF: high risk of mortality;
requires extensive cardiac work-up, EKG, echo,
and operative monitoring of cardiac status
Aortic stenosis: Sx triad of angina, dyspnea, syncope,
and high possibility of sudden death; requires
cardiac work-up and operative monitoring
Endocarditis prophylaxis: recommended for GI
procedures, GU procedures, and HEENT procedures
Cardiomyopathy: high risk of arrhythmias, CHF,
heart failure, and sudden death; manage with cards
consult and full cardiac work-up
–––––––––––––––––– GI ISSUES –––––––––––––––––
Bowel prep: decreases fecal mass and bacterial
content in the colon → prevents colon surgery
 Surgery – Preoperative Care

complications; put pt on clears day before surgery,

NPO at midnight, and give a cathartic agent

GoLYTELY: an isotonic formula that causes no

change in electrolyte or water balance; fluid
remains in colon and causes a “volume washout”

Fleet’s Phospho-Soda: a sugar-rich, hypertonic

formula that works by drawing fluid into the GI
tract; risks include dehydration, metabolic
acidosis (loss of bicarb); avoid in diabetics

Magnesium citrate: an osmotic agent that draws

fluid into GI tract (mag is poorly absorbed); risks
include dehydration and hypermagnesemia; avoid
in renal failure

–––––––––––––––– OTHER ISSUES –––––––––––––––

Anesthesia of choice: multiple factors involved, so

it’s best to consult an anesthesiologist

Local anesthesia: ↓systemic effects, ↑pain

Spinal anesthesia: ↓pulmonary complications,

↓control over cardiac or vascular mechanisms

General anesthesia: ↑physiologic control,

↑pulmonary complications, ↓HR/BP

Aspirin use: stop aspirin use 7-10 days prior to

surgery, will affect platelet aggregation

NSAIDs use: stop NSAIDs 2 days prior, will affect

platelet aggregation

Cellulitis: active infections are associated with

higher risk of post-op wound infections; delay
surgery until infection is resolved

––––––––––––––– POST-OP FLUIDS ––––––––––––––
Post-op fluid management: replace blood lost
during surgery + provide maintenance IVF + make up
for fluid loss in drains/NG tubes/fistulas
Surgical blood loss: replace in a 3:1 ratio with IVF
(e.g. replace 500mL blood loss with 1.5L NS or LR)
Maintenance IVF: administer D5½NS+KCl,
using the 100/50/20 rule for daily fluid
requirements, or 4/2/1 rule for hourly fluids
Drains/NG tubes/fistulas: fluid loss should be
replaced milliliter for milliliter with regard to
specific electrolyte content
Third space: fluid sequestered into ISF due to
inflammation or injury, mobilized 3-5 days after
recovery → requires decrease in IVF rate
––––––––– OPERATIVE COMPLICATIONS ––––––––
Malignant hyperthermia: T>104 following
anesthesia w/ high risk of myoglobinuria; Tx
dantrolene, 100% O2, and cooling blankets
Bacteremia: T>104 and chills within 1 hour of an
invasive procedure; get blood Cx ×3 and start
empiric abx
Aspiration: complication of awake intubations;
leads to sudden death, chemical pneumonitis, or
secondary pneumonia
Aspiration management: prevent via NPO and
antacids before intubating, Tx BAL and broncho-
dilators (steroids are useless)
Tension PTX: complication of intubation in weak or
traumatized lungs, presents as “difficulty to bag”,
progressive hypotension and JVD; Tx emergent
needle decompression + chest tube
––––––––––– POST-OP COMPLICATIONS ––––––––––
Normal urine output: at least 0.5-1 mL/kg/hr
Post-op urine retention: presents as a need to
void, but inability to do so; Tx straight cath at 6
shours post-op and Foley after 2nd straight cath
UOP = 0: most likely a kinked or plugged Foley
UOP < 0.5: either fluid deficit (bleeding out) or
acute renal failure; give a bolus of 500mL IVF and
if UOP responds, then it’s due to fluid deficit
Post-op hematuria: consider bladder overdistention,
cancer, infection, kidney stones, trauma, prostatitis,
and cyclophosphamide; get urology consult
Post-op fever: consider the five Ws – wind
(atelectasis POD #1), water (UTI POD #3), walking
(DVT POD #5), wound infection (POD #7+), wonder
drug (drug-induced fever)
Atelectasis: partial lung collapse, Dx bilateral
inspiratory crackles, prevent with pulmonary
Surgery – Postoperative Care
toilet and incentive spirometry (can develop into volume depletion (slow) or altered MS (rapid); give
pneumonia on POD #3 if left untreated) D5½NS to correct imbalance
UTI: Dx urinalysis and urine Cx, Tx abx Hyponatremia: due to SIADH or isotonic fluid loss w/
free water resorption, presents as coma and
Urosepsis: UTI + septic shock; presents as cloudy convusions; Tx water restriction and LR/NS
urine, fever, hypotension, and ∆mental status;
Dx urinalysis and urine Cx, Tx empiric abx + IVF Hypokalemia: due to diarrhea or vomiting, give K+ at
a rate of <10 mEq/hr
DVT: Dx doppler studies, Tx heparin
Hyperkalemia: due to renal failure, aldosterone
Wound infection: Dx examine wound site for blockers, or release from dead tissue (crush injury,
erythema and fluctuance; if cellulitis → abx only, ischemic bowel, etc.); Tx C BIG K DIe – calcium
if abscess → drain pus and BID dressing changes gluconate, bicarb-insulin-glucose, kayexalate, and
dialysis
IV infection: Tx remove catheter and
inflammation should resolve, all IV sites should be Metabolic acidosis: pH<7.4 + HCO3<24, Tx correct
rotated every 4 days for prevention underlying problem (e.g. fluid resuscitation)
Suppurative phlebitis: infected thrombus at site Metabolic alkalosis: pH>7.4 + HCO3>24, Tx KCl
of venipuncture; Tx remove catheter and surgical
excision of infected vein to the first non-infected Respiratory acidosis: pH<7.4 + CO2>40 due to
branch, leave wound open, and give IV abx hypoventilation, Tx mechanical ventilation
GI fistula: causes leakage of GI contents from wound Respiratory alkalosis: pH>7.4 + CO2<40 due to
site; Tx NPO, TPN, and protect abdominal wall until hyperventilation caused by pain, fever, sepsis or
body can heal itself early ARDS; Tx correct underlying problem
Non-healing fistula: factors that prevent healing
are FRIEND – foreign body, radiation, infection,
epithelialization, neoplasm, distal obstruction
Fistula × peritonitis: requires surgical exploration
Fistula × abscess: requires percutaneous drainage
Post-op chest pain: consider MI or massive PE
MI: presents as chest pain +/- other classic signs;
Dx CK-MB or troponin I, treat the complications
Massive PE: presents as chest pain, hypoxia, and
prominent JVD; Dx V-Q scan, Tx heparin → IVC
filter if PE recur while anticoagulated
ARDS: presents as hypoxia due to septic shock, Tx
intubation w/ high PEEP and permissive hypercarbia,
then look for source of sepsis
Delirium tremens: presents as hallucinations in an
alcoholic POD #2-3, prevention is key and Tx is
controversial (benzodiazepines if choice is given)
Hepatic encephalopathy: presents as coma in a liver
failure pt s/p TIPS due to NH4+ toxicity
Wound dehiscence: presents as salmon-colored fluid
soaking dressings s/p open laparatomy POD #5;
stabilize wound site, surgical closure at a later date
Evisceration: dehiscence + intestines spilling out;
keep pt in bed and cover bowel w/ sterile dressings,
emergency surgical closure necessary
––––––––––– FLUIDS & ELECTROLYTES ––––––––––
Hypernatremia: every 3 Na+ over 140 indicates 1L
water loss (e.g. Na+ 146 = 2L water loss), presents as
 Surgery – Wound Healing

––––––––––––––– WOUND HEALING ––––––––––––– Prophylactic abx: recommended for any clean-
contaminated or contaminated procedures,
Primary intention: close approximation of wound insertion of prosthetic material, immunosuppression,
edges via sutures or staples or poor blood supply; give single dose 1 hour pre-op
and single dose post-op
Primary intention timing: epithelialized by POD
#2, max collagen in 5-7 days, avoid weight-lifting
for 4-6 weeks, complete healing by 6 months
(only 60-80% of original strength)

Secondary intention: contamined wounds left open

to prevent abscess formation; granulation tissue
forms first, then contraction via myofibroblasts,
then finally a delayed epithelialization

Third intention: wound initially left open, then

delayed primary closure afterwards

Secondary/tertiary intention timing: much more

delayed than healing by primary intention

Healing growth factors: PDGF, TGF-β, FGF, EGF

Suture knot: hard, knot-like structure below wound

site; absorbable sutures will resolve with time, non-
absorbable sutures can be taken out under lido/epi

Stitch abscess: infected suture that intermittently

drains pus, should be taken out under lido/epi

Incisional hernia: presents as bulging at wound site

with increased abd pressure (e.g. coughing), needs
to be repaired surgically

Red/sensitive scar: assuming no wound infection, it

could be completely normal; observe for 6 months
before considering surgical revision

Hypertrophic scar: raised scar within site of incision;

observe until scar is stable, then steroids + excision

Keloid: raised scar that extends beyond site of

incision; will grow back if excised

–––––––––––––– WOUND INFECTION ––––––––––––

Wound infection: red and tender area on incision

site; Tx drainage and BID wet-to-dry dressing
changes, no antibiotics unless cellulitis is spreading

Post-infection management: observation is slow

and can result in contractions; other options
include skin grafting (must have <105 bacteria per
gram of tissue) or healing by third intention

Wound types: clean, clean-contaminated,

contaminated, infected

Clean wounds: no entry into GI, GU, or

respiratory tracts; <1% infection rate, Tx primary
closure

Clean-contamined wounds: enters GI, GU, or

respiratory tract in a controlled manner;
<10% infection rate, Tx primary closure

Contaminated wounds: major wound

contamination (e.g. bowel spillage or stab
wounds); Tx secondary closure

–––––––––––––––– LUNG CANCERS ––––––––––––––
Coin lesion: solitary pulmonary nodule on CXR;
DDx primary lung cancer, granuloma (TB or fungal),
hamartoma, metastatic cancers
Coin lesion management: first thing is always to
get an older CXR for comparison studies → if
suspicious, sputum cytology and CT scan
Benign coin lesions: calcification = granuloma,
bull’s-eye shape, popcorn shape = hamartoma,
air-crescent sign = aspergilloma, Southwest
region = coccidioidomycosis, Ohio river valley =
histoplasmosis
Indeterminate coin lesions: resection indicated
Malignant coin lesions: spiculations or 20+ pack-
year smoking = primary lung cancer, multiple
lesions = metastatic cancer; resection indicated
Lung cancer management: first thing is always CXR
→ if suspicious, sputum cytology and CT scan → if
still suspicious, bronchoscopy and mediastinoscopy
w/ biopsy (“tissue is the issue”)
NSCLC staging: stage I is local, stage II involves hilar
LN, stage III involves distal LN, stage IV is metastatic
cancer
NSCLC Tx: stage I/II → first get spirometry and
V/Q scans to see if pt is a surgical candidate,
then do pneumonectomy or sleeve lobectomy;
stage III/IV → chemotherapy and radiation
Surgery contraindications: FEV1 <800mL,
mediastinal LN involvement, distal metastases
SCLC staging: limited stage involves ipsilateral lung
only, extensive stage involves contralateral lung
SCLC Tx: chemotherapy and radiation
Pancoast tumor: superior sulcus tumor at the apex
of the lung; presents as Horner syndrome – ipsilateral
ptosis, miosis, anhidrosis, flushing due to loss of
sympathetic tone (invades superior cervical ganglia)
Pancoast tumor Tx: two stages – irradiation for 6
weeks to shrink tumor, then surgical resection
Bronchial adenoma: tumors that arise from within
bronchi and cause obstruction; MC lung cancer in a
nonsmoker under 30 y/o, Sx hemoptysis and
atelectasis, Dx CT scan and bronchoscopy (beware
of possibility of bleeding)
Bronchial adenoma Tx: lobectomy is curative
Mesothelioma: cancer arising from pleural
mesothelium, shipyards and asbestos exposure are
risk factors, Dx CT scan shows thick pleural walls
Mesothelioma Px: not responsive to medical
therapy, most pts have <1 year to live w/o surgery
Mesothelioma Tx: extrapleural pneumonectomy
is curative, but high rate of morbidity/mortality
–––––––––––––––– LUNG DISEASES ––––––––––––––
Pleural effusion: fluid build-up in pleural space,
cancer in older pt until proven otherwise; DDx CHF,
bronchogenic carcinoma, mesothelioma, empyema,
pneumonia, TB effusions
Pleural effusion management: get thoracentesis
and culture pleural fluid, and a pleural biopsy
Spontaneous PTX: rupture of apical blebs in healthy
young people causes sudden chest pain and dyspnea;
Tx thoracostomy on water-seal drainage
Recurrent/persistent PTX: indicated for thorascopic
excision of blebs, and pleurodesis (either scraping or
talc application) causing pleural adhesions
Bilateral PTX: dangerous situation, indicated for
pleurodesis to prevent future recurrences
Empyema: collection of pus within pleural cavity;
presents with cough, fever, chest pain, and pleural
effusion on CT scan; MCC is Staph aureus
Empyema Tx: initiate appropriate antibiotics,
insert chest tube, evacuate pus collection, then
re-expand the lung
––––––––––––––– HEART DISEASES ––––––––––––––
Unstable angina: progressive ischemia of
myocardium resulting in increasing angina at rest
and an ischemic EKG pattern
Unstable angina management: cardiac catheter
and evaluate for potential revascularization, Tx
bypass or angioplasty
Ejection fraction: SV/EDV; normal EF is 67%, EF <50%
is abnormal, EF <35% is high-risk for operative MI
Coronary artery disease: blockage of coronary
arteries, high risk of sudden death due to ventricular
arrhythmias; Tx bypass or angioplasty
Left main disease: blockage of only LCA, worst Px
Three-vessel disease: blockage of LAD/RCA/LCX
Coronary artery bypass: open via median
sternotomy, isolate internal thoracic artery (best
choice) or greater saphenous vein, put on bypass
and stop the heart, sew grafts to arteries, restart the
heart and close up
CABG mortality: 3% overall, greater in high-risk
pts but they benefit the most from the surgery
Coronary angioplasty: insertion of stent to prolong
patency of clogged coronary arteries, 33% rate of
restenosis in 1 year
Cardioplegia solution: solution used to stop heart
mid-diastole to protect it from ischemia and provide
a motionless field; often used with hypothermia to
prolong time of safe ischemia (up to 2.5 hours)
Surgery – Cardiothoracic Surgery
Off-bypass coronary surgery: grafting of ITA or GSV
to coronary arteries without bypass in order to avoid
complications of bypass (e.g. general inflammatory
response); reserved for high-risk pts
Dilated cardiomyopathy: dilation of myocardium
causes systolic dysfunction leading to progressive
dyspnea and fatigue, often preceded by viral URI
DCM Px: 1/3 recover, 1/3 stay the same, 1/3 die
DCM Tx: β-blockers will improve heart function,
but heart transplant is indicated (requires
chronic immunosuppression)
Heart transplant: remove donor heart and isolate in
hypothermic cardioplegia solution, remove recipient
heart on bypass, suture donor heart in recipient;
MCC of death are infection due to immuno-
suppression, and accelerated coronary artery
atherosclerosis
Constrictive pericarditis: presents as dyspnea,
hepatomegaly, and ascites due to diastolic failure;
Dx cardiac cath shows “square root sign”, Tx
surgical correction
––––––––––––– VALVULAR DISEASES ––––––––––––
Valvular disease management: first detected on
auscultation → get an echocardiogram
Valve replacement: mechanical valves (durable
but require anticoagulation) and porcine valves
(nonthrombogenic but will deteriorate over time)
Aortic stenosis: angina, dyspnea, syncope, and high
risk of sudden death; Dx harsh mid-systolic murmur,
MCC is congenital bicuspid aortic valve with
dystrophic calcification, Tx valve replacement when
symptomatic
Aortic regurgitation: presents as loud, blowing
diastolic murmur and bounding pulses; if chronic →
valve replacement when symptomatic, if acute →
emergent valve replacement and long-term abx
Mitral stenosis: presents as dyspnea and fatigue,
caused by rheumatic fever, results in cor pulmonale
(RVH+PH) and AFib; Tx valve repair or replacement
Mitral regurgitation: presents as dyspnea and
fatigue, caused by MVP, Dx high-pitched holosystolic
murmur; Tx annuloplasty (preferred) or valve
replacement
Mitral prolapse: eccentric closure of mitral leaflets;
common in women, precedes severe disease in men
––––––––––– MEDIASTINAL DISEASES –––––––––––
Anterior mediastinal mass: thymomas, lymphomas,
teratomas, other metastatic germ cell neoplasms
Thymoma: often presents with progressive
muscle weakness secondary to myasthenia gravis,
Tx surgical removal via median sternotomy
Lymphoma: Tx radiation and chemotherapy
 Surgery – Cardiothoracic Surgery

Teratoma: contains hair and teeth, Tx surgical

removal via median sternotomy

Middle mediastinal mass: lymphomas, bronchogenic

cysts, pericardial cysts

Bronchogenic cysts: develop from foregut

remnants, Tx surgical removal via thoracotomy

Pericardial cysts: typical water bottle appearance,

Tx surgical removal via thoracotomy

Posterior mediastinal mass: neurogenic tumors

(MCC is neurilemoma)

Neurilemoma: dumbbell-shaped tumor found

adjacent to vertebral bodies, develops from
nerves and nerve sheathes, Tx surgical removal
via thoracotomy

–––––––––––––– CAROTID DISEASES –––––––––––––
Atherosclerosis: systemic disease that has multiple
manifestations (stroke, TIA, CAD, MI, mesenteric
ischemia, AAA, PVD); presence of any one of these
should raise suspicion for the others
Stroke: a neurologic deficit that doesn’t resolve
within 24 hours, Tx t-PA only within 3 hours
Stroke management: carotid duplex study,
observation for improvement; CEA is not
indicated until pt has stabilized
Transient ischemic attack: brief neurologic deficit
that fully resolves within 24 hours; due to thrombo-
embolus from internal carotid arteries
TIA management: physical exam (check carotid
bruids, neuro, cardiovascular) + carotid duplex;
Tx aspirin or carotid endarterectomy
TIA × amaurosis fugax: emboli from carotid
travels to retina causing transient blindness;
Dx fundoscopic exam reveals Hollenhorst plaque,
a bright shiny spot in a retinal artery
TIA × aphasia: emboli from left carotid travels to
speech center located in left hemisphere
CEA: indicated for >70% carotid stenosis with either
neurologic sx or asymptomatic bruits; complications
include 1-3% risk of perioperative stroke, or injury to
facial, vagus, or hypoglossal nerves
Post-CEA management: start aspirin, encourage
lifestyle modifications (e.g. diet and exercise, quit
smoking) since patient is still high-risk for MI
Asymptomatic carotid bruit: get a carotid duplex
study, indicated for CEA if >70% stenosis
–––––––––––– PERIPHERAL DISEASES –––––––––––
Subclavian steal syndrome: presents as nothing at
rest, but arm claudication and CNS sx with arm
activity due to subclavian artery atherosclerosis; Dx
arteriogram, Tx bypass surgery
Arterial embolus: presents as the 6 P’s – pain, pallor,
parasthesias, poikilothermia, pulselessness, paralysis;
clot source is usually Afib or recent MI
Embolus Tx: requires urgent revascularization
within 6 hours; give heparin and go to OR for
balloon catheter embolectomy +/- fasciotomy
Embolus post-op: start warfarin for anti-
coagulation, then get CT scan or aortography to
search for source of emboli
Compartment syndrome: revascularization of
acutely ischemic limb results in ischemia-reperfusion
injury, causing muscle edema within fascial compart-
ment and the 6 P’s
Compartment syndrome Tx: fasciotomy
Ankle-brachial index: ratio of BP in arm vs. leg;
ABI >1.0 is normal, ischemic ABI is 0.6-0.8
(claudication) or 0.3-0.5 (rest pain)
Doppler tracing: normally triphasic due to systolic
flow → elastic recoil → diastolic flow; ischemic
signal is either biphasic (mild) or monophasic (severe)
Claudication: exercise-induced ischemia that causes
reversible calf pain, MCC is an atherosclerotic SFA
Claudication management: if mild → not
indicated for surgery, so exercise and lifestyle
changes are recommended; if severe → get
Doppler tracing, then arteriogram to localize
Claudication Px: 1/3 improve on a non-op exercise
program, 1/3 stay the same, 1/3 get worse
Aortoiliac stenosis: presents as triad of claudication
+ absent femoral pulse + impotence
Aortoiliac stenosis Tx: depends on case;
bilateral loss of femoral pulse → aortofemoral
bypass graft, single segment iliac stenosis →
angioplasty, high risk pt → lifestyle changes
Severe claudication: presents as claudication + rest
pain or foot ulcers, common in diabetics; get a
vascular work-up and arteriogram to determine level
of occlusion, and assess general medical status
SFA stenosis Tx: reverse GSV to SFA graft
Iliac stenosis Tx: surgical revascularization or
balloon dilation
SFA + iliac stenosis Tx: both of the above, either
at the same time or sequentially (iliac first)
SFA + popliteal stenosis Tx: femoropopliteal
bypass to the best artery continuous with the
foot, failure likely in distal and severe disease
Multiple obstructions Tx: reconstruction may not
be possible, limb amputation indicated
Bypass pre-op: 10% risk of MI, arrhythmias, or heart
failure; requires evaluation of cardiac status (get
dipyridamole-thallium scintigraphy to rule out CAD)
Pre-op reveals <30% ejection fraction: high risk of
post-op heart failure
Pre-op reveals CAD: cancel or delay surgery,
perform a less invasive procedure, pre-op CABG
or PTCA, or intensive intraoperative monitoring
Pre-op reveals recent MI: delay surgery for 3 mo
Bypass post-op: daily duplex studies to check for
graft stenosis, give aspirin, educate on lipid control
and foot care; MCC death is CAD
Trash foot: post-op embolization of atherosclerotic
debris following bypass results in cyanotic toe;
Tx heparinization of clot and long-term aspirin use
–––––––––––– ABDOMINAL DISEASES –––––––––––
Surgery – Vascular Surgery
AAA: presents as painless pulsatile abdominal mass;
management is getting ultrasound and CT scan, then
elective graft repair if aorta is >5 cm
AAA repair post-op: major fluid shifts (third-space
loss on POD#1/2, third-space mobilization on
POD#3), cardiac problems due to aortic clamping,
and impotence due to damage of hypogastric
circulation or autonomic nerves around IMA
Ruptured AAA: presents as pulsatile mass, back and
abdominal pain, and hypotension; if unstable → OR,
if stable → get CT scan or ultrasound, then OR
Ruptured AAA repair: clamp aorta at level of
diaphragm to stop bleeding, then proceed with
repair; 80% risk of death by bleeding out in the OR
AAA repair × bloody diarrhea: indicates ischemic
colitis due to interrupted IMA; Dx sigmoidoscopy,
Tx bowel rest if limited to mucosa, colectomy and
colostomy if full-thickness involvement
AAA repair × delayed fever: indicates vascular
graft infection via S. aureus or S. epidermidis;
Dx CT scan, Tx graft removal, debridement, and
IV antibiotics
AAA repair × UGI bleed: indicates aortoduodenal
fistula, usually a small bleed followed 1-2 days
later by massive bleeding; Dx CT scan, Tx graft
removal and GI repair
Mesenteric ischemia: presents as postprandial abd
pain, weight loss, and multiple abd bruits due to
atherosclerosis of celiac trunk or SMA
Mesenteric ischemia management: Dx
mesenteric angiogram, Tx revascularization;
follow-up with aspirin and evaluation for other
atherosclerotic diseases
Aortic dissection: presents as acute onset tearing
chest/back pain due to severe HTN (200/140), CXR
shows widened mediastinum
Aortic dissection management: Dx MRI, spiral CT,
transesophageal echo, or arteriography; if
ascending aorta → go to OR for surgical repair, if
descending aorta → β-blockers
–––––––––––––– VENOUS DISEASES –––––––––––––
Deep venous thrombosis: presents as acute onset
dull leg pain, unilateral swelling, and Homans’ sign
DVT risk factors: Virchow’s triad – stasis,
endothelial damage, and hypercoagulability
DVT management: Dx duplex ultrasound, Tx
therapeutic heparin or LMWH, followed by long-
term warfarin therapy (follow INR)
Post-thrombotic syndrome: occurs in 10% of DVT pts,
presents as severe leg edema and ulceration around
ankle area due to chronic venous HTN
 Surgery – Vascular Surgery

Post-thrombotic syndrome management:

prevention via chronic use of support hose, heal
ulcers if they’ve already developed

DVT prophylaxis: indicated if pt is at risk for DVT;

includes leg compression devices and subcutaneous
low-dose heparin

DVT prophylaxis for hip fx: fondaparinux and leg

compression devices

Pulmonary embolus: presents as acute onset chest

pain, dyspnea, and hyperventilation (↓PCO2), due to
DVT embolization into lung → wedge-shaped area of
lung infarction, S1Q3T3 on EKG

PE management: get EKG to rule out MI, ABGs

(shows ↓PCO2), CXR, and pulse oximeter;
mismatch on a V/Q scan is diagnostic, Tx identical
to DVT Tx

Recurrent PE: due to failure of heparin therapy;

indicated for IVC interruption with a metal filter

Anticoagulation: therapeutic/high-dose heparin or

LMWH for Tx DVT/PE, low-dose for prophylaxis;
IVC filters when anticoagulation fails or is contra-
indicated

Anticoagulation × HIT: rare heparin side-effects

include thrombocytopenia and paradoxical
arterial clots, d/c heparin immediately

Anticoagulation × skin necroses: rare side-effect

of warfarin therapy, start warfarin along with
heparin to prevent this from happening

Anticoagulation × UGI bleed: life-threatening

condition that requires immediate d/c, give pt a
metal filter instead for PE prophylaxis

Phlegmasia cerulea dolens: presents as acute onset

leg edema with pain and cyanosis due to venous
outflow obstruction, high risk of nerve damage and
venous gangrene

PCD management: elevate leg and immediate

anticoagulation, then order duplex ultrasound
and pelvic CT scan to confirm the Dx

–––––––––– OTHER VASCULAR DISEASES –––––––––

Temporal arteritis: presents as severe, unilateral

headache, visual changes, and nodularity of
temporal artery; give high-dose steroids right away
to prevent blindness

–––––––––––– ESOPHAGEAL CANCERS –––––––––––
Dysphagia: management includes barium swallow
and esophagoscopy w/ biopsy; DDx achalasia,
Zenker diverticulum, esophageal cancers, strictures
Esophageal cancer: SCC in upper 2/3 due to cigs and
EtOH, adenocarcinoma in lower 1/3 due to Barrett’s,
Sx progressive dysphagia and weight loss
EC management: esophagoscopy and biopsy,
then staging via endoscopic ultrasound and CT
scan, then specific Tx
EC staging: stage I invades submucosa only, stage
II invades muscularis +/- LN, stage III invades
adventitia + adjacent structures, stage IV is
metastatic
EC prevalence: adeno MC in US, SCC elsewhere
EC Tx: upper 1/3 – chemo and radiation only;
middle 1/3 – chemo and radiation to shrink the
tumor, then esophagectomy; lower 1/3 –
esophagectomy and proximal gastrectomy; never
operate on stage IV cancer
Advanced esophageal cancer: Sx severe dysphagia
and chronic cough (due to aspiration from TE fistula),
management is palliative care b/c surgery won’t help
––––––––––– ESOPHAGEAL DISEASES –––––––––––
Zenker diverticulum: pulsion diverticulum that
develops at upper esophagus due to abnormal
coordination of cricopharyngeal constriction;
Sx dysphagia, regurgitation, and bad breath
Zenker management: Dx barium swallow, Tx
cricopharyngeus myotomy
Traction diverticulum: diverticulum at middle
esophagus due to LN traction, indicates cancer
Esophageal motility disorders: achalasia (only one
treated surgically), nutcracker esophagus, spasms,
hypertensive LES
Achalasia: hypertonic and non-relaxing LES w/
poorly relaxing esophagus, Sx dysphagia of
liquids > solids
Achalasia management: Dx bird’s beak on barium
swallow and ↑LES pressure on manometry, Tx
Heller myotomy
Nutcracker esophagus: painful swallowing due to
high amplitude action potentials, Tx nifedipine
Diffuse esophageal spasms: uncoordinated 3°
peristalsis, Tx medically
Hypertensive LES: high LES pressure at baseline
but relaxes with swallow, Tx medically
Acute epigastric pain: DDx acute pancreatitis, GERD,
PUD (gastric ulcers or duodenal ulcers), cholelithiasis,
gastroenteritis
Pain × PMHx: gallstones or alcoholism = acute
pancreatitis (order amylase/lipase levels), NSAIDs
or steroid use = PUD
Esophageal varices: present as UGIB due to portal
HTN, often alongside coagulopathy (liver failure)
EV management: band the bleeding varices,
correct any coagulopathy, IV octreotide to lower
portal pressure → if bleeding continues, repeat
endoscopic banding → if bleeding continues,
TIPS or gastric balloon tamponade
EV follow-up: β-blockers to lessen chance of
rebleeding; good liver function → elective TIPS,
bad liver function → liver transplant
Mallory-Weiss syndrome: presents as UGIB due to
retching lacerating the lower esophagus, bleeding
usually stops spontaneously
Boerhaave syndrome: presents as epigastric pain
and fever due to retching perforating the esophagus;
Dx contrast swallow, Tx emergent surgical repair
Instrumental perforation: presents as retrosternal
pain, fever, and pneumomediastinum s/p upper GI
endoscopy; Dx contrast swallow, Tx surgical repair
GERD: presents as heartburn, regurgitation,
waterbrash (sour taste), dysphagia, cough
GERD Tx: PPIs → if it persists after six weeks, do
EGD w/ biopsy to see what’s going on
Normal EGD: PPIs or elective lap Nissen
Esophagitis: multiple, nonulcerating erosions in
stomach; mild to moderate esophagitis → PPIs
for 8-12 weeks, severe esophagitis → lap Nissen,
uncontrollable bleeding esophagitis → subtotal
gastrectomy
Barrett esophagus: intestinal metaplasia of
esophageal epithelium; no dysplasia → Tx PPIs or
lap Nissen; low-grade dysplasia → Tx lap Nissen +
annual surveillance; high-grade dysplasia → Tx
esophagectomy
Lap Nissen fundoplication: wraps fundus of stomach
around LES to keep it in abdominal cavity (must
check for intact esophageal peristalsis first); contra-
indicated in morbidly obese (gastric bypass instead)
Hiatal hernia: hernia from abdominal cavity, through
diaphragm, into chest cavity
Type 1 hiatal hernia: sliding hernia, risk of reflux
esophagitis, Tx PPIs
Type 2 hiatal hernia: paraesophageal hernia, risk
of incarceration/strangulation, Tx surgical repair
Type 3 hiatal hernia: presence of both types 1+2,
Tx surgical repair
–––––––– GASTRIC/DUODENAL DISEASES ––––––––
Peptic ulcer disease: gastric ulcers, duodenal ulcers
Surgery – Upper GI Surgery
PUD surgery indications: intractability,
perforation, obstruction, bleeding
Duodenal ulcers: caused by ↑acid secretion; most
commonly in 1st part of duodenum, DU in 2nd-4th part
indicates Zollinger-Ellison syndrome (gastrinoma)
DU types: posterior ulcers bleed due to gastro-
duodenal artery, anterior ulcers perforate
DU Tx: triple therapy → if ulcer persists, surgery
is indicated (HSV > TV+P >> TV+A), also get serum
gastrin levels to rule out Z-E syndrome
Perforated DU: CXR shows free air under
diaphragm; use omentum to patch the ulcer
(Graham patch), then stop acid w/ PPIs or HSV
Perforated DU × sepsis: complete Graham patch
as soon as possible, give PPIs and IV abx, then
monitor in ICU and plan surgery for a later date
Bleeding DU: due to posterior ulceration into
GDA; Tx oversew the ulcer, then stop acid w/ PPIs
Gastric ulcers: caused by ↓mucosal protection; type I
– lesser curvature at incisure, type II – duodenum
and stomach, type III – pylorus, type IV – GE junction
GU Tx: PPIs → if ulcer persists after six weeks, do
endoscopy and multiple marginal biopsies for
possibility of gastric cancer; if ulcer persists after
18 weeks, surgery is indicated
GU surgery: wedge resection or distal
gastrectomy (due to possibility of cancer), TV+P
for types II and III due to ↑acid production
Bleeding GU: Tx excision rather than oversewing
Gastric cancers: lymphoma, adenocarcinoma, GIST
(e.g. sarcomas and lipomas)
Gastric adenocarcinoma: often spreads to left
supraclavicular (Virchow’s) node and ovaries;
Tx proximal → total gastrectomy, if distal →
distal gastrectomy w/ anastomosis; take out D1
LN at lesser curvature
Linitis plastica: infiltrating carcinoma with desmo-
plastic reaction causing stomach to look fixed
and rigid; Tx total gastrectomy w/ splenectomy
Gastric lymphoma: first determine cancer stage
(CT scan, LN biopsy, and bone marrow Bx);
Tx partial thickness → radiation, full thickness →
surgical resection
GIST: any soft tissue tumor of stomach; Tx wedge
resection w/ 1 cm negative margins (no LN)
Gastric varices: present as UGIB due to portal HTN,
Tx uncontrollable bleeding w/ TIPS or splenectomy
instead of banding
 Surgery – Pancreatic/Hepatic Surgery

––––––––––––– GB/BILIARY DISEASES ––––––––––––
Biliary disease progression: cholelithiasis → biliary
colic → acute cholecystitis; choledocholithiasis →
ascending cholangitis or gallstone pancreatitis
Cholelithiasis: presents as nausea, vomiting, RUQ
pain w/o fever; only 15-20% are symptomatic
Cholelithiasis in pregnancy: manage non-op if
possible (hydration and pain meds), elective lap
chole can be done after delivery
Biliary colic: fatty meal → CCK release → gall
bladder contraction against non-lodged stone
resulting in transient RUQ pain for <6 hours; labs are
usually normal if episode has passed
Cholecystitis: presents as fever, WBC>15, RUQ pain
>6 hours; MC bacteria are E. coli, Bacteroides fragilis,
Klebsiella, Enterococcus
Cholecystitis management: Dx abdominal U/S,
order CBC and LFTs, Tx lap chole within 72 hrs
Cholecystitis in elderly: elderly pts respond to
sepsis with hypothermia and ↓WBC
Cholecystitis antibiotics: ciprofloxacin (Cipro)
and metronidazole (Flagyl) to cover GNR and
anaerobes; abx not indicated for cholelithiasis
Cholecystectomy indications: symptomatic
cholelithiasis, acute cholecystitis, and cholangitis;
do not operate on asx stones
Cholecystectomy complications: nicking the CBD
(jaundice) or right hepatic artery (hepatitis)
Post-op biliary leak: presents as Charcot’s triad;
get an U/S and HIDA scan → Tx biliary drainage
and temporary stent during ERCP
–––––––––––––––––– JAUNDICE –––––––––––––––––
Jaundice: elevated bilirubin and yellowing of skin;
three types – hemolytic, obstructive, hepatocellular
Hemolytic jaundice: ↑bilirubin (direct <20%),
search for what’s killing the RBCs
Hepatocellular jaundice: ↑bilirubin (direct 20-50%)
and ↑AST/ALT, consider HBV/HCV and alcoholism
Obstructive jaundice: ↑bilirubin (direct >50%) and
↑alk phos, caused by CBD stones and cancers
Painless jaundice: caused by biliary obstructive
tumors (ampullary cancer, duodenal cancer,
cholangiocarcinoma, pancreatic adenocarcinoma)
Painless jaundice management: Dx CT scan then
ERCP, Tx Whipple if no mets or local invasion
Painless jaundice × occult bleed: indicates
ampullary cancer, get CT scan then Whipple
–––––––––––– PANCREATIC DISEASES –––––––––––
Pancreatic head mass: check for metastases, then
perform Whipple if no mets
Pancreatic adenocarcinoma: presents as obstructive
jaundice, get a CT scan; cancer in head → Tx Whipple,
in body or tail → distal pancreatectomy, mets or
local invasion → palliative care (no surgery)
Acute pancreatitis: presents as epigastric pain
boring through to the back w/ ↑lipase/amylase;
amylase levels do not correlate with severity
Pancreatitis causes: I GET SMASHED – Idiopathic,
Gallstones (#1), EtOH (#2), Trauma, Steroids,
Mumps, Autoimmune, Scorpion sting, Hyper-
triglyceridemia (#3), Hypercalcemia, ERCP, Drugs
Chronic pancreatitis: presents as constant epigastric
pain, steatorrhea, and diabetes in a chronic alcoholic;
Tx insulin and pancreatic enzyme replacement
––––––––––––––– LIVER DISEASES ––––––––––––––
Liver cyst: simple cyst, leave it alone
Echinococcal cyst: multilocular cyst w/ calcified walls
due to parasite Echinococcus granulosus; inject
hypertonic saline inside cyst and carefully excise it
Liver abscess: multiple/small bacterial abscesses →
IV antibiotics; single/large bacterial abscess → perc
drain; amebic abscess (Mexicans) → metronidazole
Liver cancers: hepatic adenoma, focal nodular
hyperplasia, hemangioma, hepatoma
Hepatic adenoma: often presents as hypovolemic
shock and distended abdomen, related to OCPs
and anabolic steroid abuse; Tx d/c OCP → if it
persists, resect due to possibility of rupture
FNH: Dx central stellate scar or sunburst pattern
on CT scan, no OCP relationship, leave alone even
if symptomatic
Hemangioma: leave alone even if symptomatic,
never spontaneously rupture, do not needle
biopsy due to possibility of rupture
Hepatoma: presents as vague RUQ pain and mass
related to HBV/HCV and cirrhosis w/ ↑αFP; Dx CT
scan then Tx resection w/ negative margins
indicated as long as there’s no mets
Portal HTN: Sx esophageal varices, caput medusa,
hemorrhoids; Tx TIPS (connect portal vein to hepatic
vein to relieve pressure) as a “bridge to liver txp”

Post-op obstruction: presents as Charcot’s triad Edematous pancreatitis: get amylase/lipase,

due to stricture or retained stone; get an U/S and
HIDA scan → Tx biliary drainage and choledocho-
jejunostomy
Choledocholithiasis: presents as transient jaundice
and ↑alk phos; Dx U/S shows dilated bile ducts +/-
ERCP, Tx lap chole w/ CBD exploration
Acute cholangitis: presents as Charcot’s triad
(jaundice, fever, RUQ pain) or Reynold’s pentad
(shock, ∆MS) due to choledocholithiasis
Acute cholangitis management: IVF, antibiotics,
and U/S → ERCP to decompress biliary tree →
finally lap chole w/ CBD exploration
GB polyps: <2 cm observe, >2 cm take it out due to
risk of adenocarcinoma
GB adenocarcinoma: presents as mass in GB fossa;
Dx CT scan, Tx open chole + hilar LN resection + liver
resection w/ negative margins
Porcelain GB: dystrophic calcification of GB has 50%
risk of adenocarcinoma, take it out
then NPO, IVF, pain meds
Hemorrhagic pancreatitis: presents as MSOF,
ARDS, and hemodynamic instability; send to ICU
for resuscitation and serial CTs
Ischemic pancreatitis: Dx no blood flow to
pancreas on contrast CT, Tx IV abx and resection
Gallstone pancreatitis: if amylase returns to
normal → lap chole + cholangiogram; if
complicated → ERCP to remove stone
Pancreatic abscess: presents as septic shock 2 weeks
after acute pancreatitis; Dx dynamic CT scan, Tx perc
drain + antibiotics
Pseudocyst: abdominal pain and early satiety 5
weeks after acute pancreatitis, Tx cystogastrostomy
only if it’s symptomatic and has been present for 6+
weeks (must get Bx w/ frozen epithelial section and
see no epithelial lining before the ostomy since
epithelium indicates cancer)

––––––––––– SMALL BOWEL DISEASES –––––––––––
Small bowel obstruction: presents as colicky abd
pain, nausea/vomiting, and constipation; MCC are
adhesions from previous surgery and hernias
SBO management: get KUB → Dx air-fluid levels
and dilated loops; Tx NPO, NG suction, IVF, and
initially observation
SBO × electrolyte imbalance: “hypokalemic,
hypochloremic metabolic alkalosis” due to emesis
SBO × bloody diarrhea: indicates obstructive
tumor or ischemic bowel; Dx sigmoidoscopy →
observe if mucosal, resection if full-thickness
SBO × flatus: indicates partial SBO since gas can
get through, more likely to resolve w/o surgery
SBO × diarrhea: indicates partial SBO due to fecal
impaction and severe constipation
SBO × inguinal hernia: requires urgent hernia
repair to relieve strangulation
SBO × melanoma: melanoma is the MC tumor
that metastasizes to intestine, surgery indicated
since these don’t resolve spontaneously
SBO × other cancers: surgery indicated since
these don’t resolve spontaneously
SBO × peritonitis: presents as rebound tender-
ness, ↑WBC, fever, or metabolic acidosis due to
necrotic bowel; indicated for ex lap
SBO × adhesions: indicated for ex lap → lysis of
adhesions
SBO × closed loop obstruction: usually due to
adhesive band occluding two segments of bowel;
indicated for ex lap → lysis of adhesions,
resection of any dead bowel, and “second look”
operation if bowel viability is indeterminate
SBO × pneumoperitoneum: indicates perforation
due to ischemic or overdistended bowel;
indicated for ex lap → dead bowel resection
Nicked bowel during LOA: small hole → primary
repair, large or multiple holes → bowel resection;
high risk of leakage and EC fistula formation
Uncertain about SBO: get an upper GI series w/ small
bowel follow-through, barium contrast will stop at
site of obstruction if SBO exists
Mesenteric ischemia: presents as postprandial abd
pain, weight loss, SBO, and multiple abd bruits
usually due to atherosclerosis of celiac trunk or SMA
Mesenteric ischemia management: Dx
mesenteric angiogram, Tx revascularization;
follow-up with aspirin and evaluation for other
atherosclerotic diseases
Mesenteric ischemia × peritonitis: presents as
rebound tenderness, ↑WBC, fever, or metabolic
acidosis due to necrotic bowel; ex lap indicated
Mesenteric ischemia × AFib: indicates emboli
shooting from left atrium to celiac trunk or SMA
Mesenteric ischemia × ↑hct: polycythemia due to
severe dehydration requires IV fluid resuscitation
Mesenteric ischemia × CHF: ischemia may be
secondary to a low-flow, nonocclusive state;
indicated for mesenteric vasodilation and
improve cardiac output
Mesenteric ischemia × aortic dissection:
dissected aorta can occlude mesenteric vessels;
Dx angiography, Tx surgical repair
Mesenteric ischemia × ↓BP: either ischemic
bowel causing septic shock, or hypotension
causing low-flow, nonocclusive ischemia
Left colon necrosis: bowel resection → anastomosis
if stable, otherwise colostomy and Hartmann pouch
Long segment necrosis: bowel resection → small
bowel syndrome requiring chronic TPN or transplant
Short segment necrosis: bowel resection →
anastomosis, “second look” operation if bowel
viability is indeterminate
Small punctate necroses: indicates multiple small
emboli or low-flow state; bowel resection →
anastomosis, “second look” operation if bowel
viability is indeterminate
Bowel ischemia but no necrosis: try to revascularize
the bowel via removing or bypassing the occlusion
Low-flow but no necrosis: non-op management of
hemodynamic status, surgery should be avoided
––––––– INFLAMMATORY BOWEL DISEASE –––––––
Inflammatory bowel disease: Crohn’s disease and
ulcerative colitis; presents as crampy abdominal pain,
bloody diarrhea, and recent weight loss
IBD management: colonoscopy to determine if
it’s UC, Crohn’s, or something else → abdominal
CT scan for confirmation of IBD
Crohn’s disease: inflammatory disease involving full
GI tract with skip lesions (terminal ileum is MC site),
Bx shows full thickness + noncaseating granulomas +
creeping fat, Dx terminal ileum string sign on CT scan
Crohn’s management: IV steroids and 5-ASA
(sulfsalazine) for acute flare-ups
Crohn’s × SBO: due to stenotic terminal ileum;
manage with NPO, TPN, and observation → if it
fails to resolve, surgical stricturoplasty indicated
Crohn’s × perianal disease: metronidazole
Surgery – Lower GI Surgery
Crohn’s × rectal disease: rare, indicated for
subtotal colectomy and ileostomy
Ulcerative colitis: inflammatory disease involving
rectum and continuous proximal extension, Bx
shows mucosal involvement + crypt abscesses +
pseudopolyps, Dx lead pipe sign on CT scan
UC management: IV steroids and 5-ASA
(sulfsalazine) for acute flare-ups, annual
colonoscopy for possibility of cancer
UC × severe dysplasia: total proctocolectomy,
ileal pouch formation, and ileo-anal anastomosis;
no further cancer surveillance needed
Pouchitis: presents as fever, bloody diarrhea, and
pain on defecation s/p ileal pouch formation for UC;
Tx metronidazole
Toxic megacolon: presents as fever, bloody diarrhea,
pain, and abdominal distention in a pt w/ UC
TM management: get KUB for confirmation, then
NPO, IVF, NG suction, IV steroids and abx;
improves → no surgery, stays the same or gets
worse → surgery necessary
TM × perforation: shows free air on upright CXR,
indicated for total colectomy and ileostomy w/
Hartmann pouch
TM × impending perforation: shows pneumatosis
on CT scan, indicated for surgery (see above)
––––––––––––––– APPENDICITIS –––––––––––––––
Appendicitis: presents as RLQ pain, low grade fever
and leukocytosis; MCC lymphoid hyperplasia
Appendicitis management: get CT scan or U/S
(U/S is cheaper); if uncomplicated → app’y, if
abscess (↑↑fever/↑↑WBC) → perc drain, interval
app’y
Appendicitis in kids: children with appendicitis
present more often with a ruptured appendix
Appendicitis in elderly: older pts usually don’t
have classic presentation of appendicitis, but
rather vague abdominal complaints, sepsis,
altered MS, or failure to thrive
Appendicitis in pregnancy: enlarged uterus can
push appendix upwards → RUQ pain; appy can
be performed safely w/o risk to mom or child
RLQ pain × dysuria: indicates appendicits, UTI, or
appendiceal abscess next to bladder
RLQ pain × minimal dysuria: likely appendicitis
RLQ pain × hematuria: indicates severe UTI or a
kidney stone
RLQ pain × h/o PID: could be appendicitis, recurrent
PID, or an ectopic; PID confirmed by cervical or
adnexal tenderness, or cervical discharge (get gyn
consult and stain discharge)

RLQ pain × h/o gastroenteritis: could be appendicitis
but likely gastroenteritis
RLQ pain × R pelvic tenderness: likely retrocecal
appendicitis, go to the OR
RLQ pain × BPH Sx: likely bladder outlet obstruction
due to enlarged prostate, Tx Foley catheter
RLQ pain × h/o IBD: IBD can present similarly to
appendicitis, get colonoscopy and CT scan and
manage appropriately
RLQ pain × crampy pain/diarrhea: indicates IBD,
constipation, or cancer rather than appendicitis
RLQ pain × corticosteroids: steroids can mask all Sx
of inflammation, be cautious since most steroid pts
won’t present until perforation occurs
App’y findings: inflamed appendix, perforated
appendix, normal appendix, inflamed cecum,
fecalith, carcinoid tumor, other tumors
Inflamed appendix: take it out
Normal appendix: take it out anyways unless
cecum is inflamed, check other areas for
abnormalities (terminal ileum for Crohn’s or
Meckel’s, perforated gastric or duodenal ulcer,
ovaries, etc.)
Inflamed appendix/cecum: take them both out
via right colectomy
Inflamed appendix + fecalith: confirms
appendicitis
Perforated appendix: take it out, I/D the abscess,
and leave a drain in to prevent wound infection
Appendiceal carcinoid: <2cm appendectomy,
>2cm right hemicolectomy; can present w/
carcinoid syndrome due to liver metastasis
Terminal ileal carcinoid: resection and check the
rest of bowel for other carcinoids; can present
w/ carcinoid syndrome due to liver metastasis
––––––––––––––– DIVERTICULITIS –––––––––––––––
Diverticulosis: presents as LGIB, 85% stop
spontaneously, may develop into diverticulitis
Diverticulitis: presents like left-sided appendicitis,
get CT scan and manage non-op if possible (IVF, NPO,
IV antibiotics) even with signs of LLQ peritonitis
Diverticulitis f/u: colonoscopy to confirm
presence of diverticula and absence of cancer
Surgery indications: uncontained perforation
that presents as 4-quadrant peritonitis or
pneumoperitoneum (air under diaphragm)
Elective surgery indications: recurrent episodes
(2x in 6 months, 3x in a year)
Diverticulitis complications: abscess (Tx perc drain),
obstructions, fistula (pneumaturia or fecaluria, Tx
surgical separation of colon from bladder)
––––––––––– LARGE BOWEL DISEASES ––––––––––
Pseudomembranous colitis: watery diarrhea and
↑↑WBC due to clindamycin-related C. diff overgrowth;
Dx stool toxin or colonoscopy, Tx stop clindamycin
and start metronidazole or vancomycin
Colon cancer screening: anyone above 50 y/o should
get yearly fecal occult blood test (flex sig and
colonoscopy also used, but less commonly)
Polyps: tubular/pedunculated have a stalk,
sessile/villous are flattened; progression from polyp
to cancer takes ~10 years
Pedunculated polyp: polypectomy w/ biopsy →
if dysplasia is not localized to head of polyp, then
segmental colectomy
Sessile polyp: biopsy → if any high grade
dysplasia, then colectomy
Benign polyps: juvenile, Peutz-Jeghers,
inflammatory, hyperplastic; leave these alone
Colon cancer: left side obstructs, right side bleeds;
Dx “apple core” lesion on barium enema, 99%
garden variety (∆MCC, ∆DCC, ∆RAS, ∆p53) and 1%
familial inheritance (FAP, HNPCC)
Stage I/II: localized cancer, Tx colectomy
Stage III: LN involvement, Tx colectomy and
chemo (5-FU + levimasole, only stage that chemo
will improve survival rates)
Stage IV: distal metastasis, Tx palliative chemo
unless there is a resectable mass in liver or lung
Colectomy: requires 12-14 LN removal for adequate
procedure; requires pre-op bowel prep and abx
Post-op wound infection: open fascia to make
sure it’s intact, then local wound care
Post-op feculent leak: indicates anastomotic leak,
get abd CT scan to check for undrained collection,
then NPO/IVF is sufficient for most cases
Post-op feculent vomit: indicates either post-op
ileus (due to leakage) or mechanical obstruction;
Tx NPO/IVF and NG tube
Post-op abscess: Dx CT scan, Tx perc drain
Post-op constipation: indicates either stricture or
cancer recurrence; Dx colonoscopy
FAP: ∆APC on chromosome 5p, autosomal dominant,
presents as >100 polyps in colon; Tx either total
proctocolectomy, or total abdominal colectomy +
strip anal mucosa + ileoanal anastomosis
Gardner syndrome: FAP + polyps in stomach (not
premalignant) and duodenum (premalignant);
Surgery – Lower GI Surgery
FAP pts should always get upper endoscopy and
remove the duodenal polyps
HNPCC: ∆MLH or ∆MSH mismatch repair genes →
microsatellite instability, Tx total abdominal
colectomy + ileorectal anastomosis
Colon cancer recurrence: f/u with colonoscopy, CEA
marker, CXR for lung mets, and LFTs for liver mets
–––––––––––– ANORECTAL DISEASES –––––––––––
All anorectal diseases: first step in management is to
scope and rule out cancer
Hemorrhoids: presents as blood streaks in stool and
extreme pain (external); Tx scope to r/o cancer →
fiber/stool softeners → if it keeps bleeding, excision
or banding
Non-healing hemorrhoids: indicates anal canal
cancer; Tx chemoradiation (5-FU) → APR if it
persists or recurs
LAR vs. APR: LAR is low anterior resection (high in
rectum), APR is abdominoperineal resection (low in
rectum)
Rectal cancer: Dx colonoscopy to r/o cancer, then
endoscopic U/S for staging → Tx depends on stage
Rectal cancer T1: transanal resection
Rectal cancer >T1: neoadjuvant chemoradiation
for 6 weeks to shrink the tumor → then LAR with
2cm distal margins → APR if margins not possible
Anal cancer: presentation is non-specific (bleeding,
pain, drainage, itching) and requires biopsy
Small anal cancer: Tx resection w/ negative
margins
Large anal cancer: often mistaken as “non-
healing hemorrhoids”, Tx chemoradiation (Nigro
protocol) → APR if it persists or recurs
Perirectal abscess: Tx I&D → 40% will develop a
fistula according to Goodsall’s rule (anterior straight
tract, posterior curved tract) → Tx fistulotomy
Pilonidal abscess: abscess in sacrococcygeal area of
lower back, Tx I&D and removal of hair
Anal fissure: presents as pain and blood with BM
due to increased sphincter tone; Tx fiber/stool
softeners → if it won’t heal, botox → still won’t heal,
lateral internal sphincterotomy
Recurring anal fissure: probably Crohn’s; biopsy
first for possible cancer, then Tx metronidazole if
biopsy reveals Crohn’s
Rectal prolapse: presents as rectal protrusion
following defecation; internal prolapse → high-fiber
diet to normalize BM, external/bleeding prolapse →
rectopexy or LAR
 Surgery – Lower GI Surgery

–––––––––––––––– GI BLEEDING ––––––––––––––––

Hematemesis: bloody vomiting, always UGIB

Melena: coffee ground blood in stool, usually UGIB

but can also be from ascending colon

Hematochezia: BRBPR, can be either UGIB or LGIB;

NG tube aspirate/lavage → LGIB if –blood/+bile,
UGIB if +blood, indeterminate if –blood/–bile

UGIB: GI bleeding proximal to Ligament of Treitz,

management is EGD

UGIB in ICU pt: most likely a stress ulcer

LGIB: GI bleeding distal to Ligament of Treitz, 85%

stop spontaneously; MCC are AVM, diverticulosis,
and colon cancer

LGIB management: must localize site of bleeding

w/ tagged RBCs (<1 cc/min) or angiography (>1
cc/min); if not currently bleeding, get upper and
lower endoscopy since localization won’t help

LGIB surgery indications: “hemodynamic

instability despite transfusion”, loss of 4-6 units in
24 hrs or 8-10 units in 48 hrs

LGIB scenario: GI bleed stops spontaneously →

get colonoscopy to determine cause and rule out
possibility of colon cancer → coagulate if AVM,
leave alone if diverticulosis

LGIB scenario: unstable patient, massive BRBPR,

no imaging to localize site of bleeding → total
colectomy since 85% of bleeding is from the colon

LGIB in kids: indicates Meckel’s diverticulum, Dx

technetium uptake into ectopic gastric mucosa

Dx tagged RBCs: sensitive for LGIB at 0.1 cc/min, but

not specific for localizing site of LGIB; bladder always
lights up first so ignore that part

Dx angiogram: less sensitive for LGIB at 1.0 cc/min,

but more specific for localizing site of LGIB; allows
for smaller LGI resection in surgery if necessary

––––––––––––– OTHER GI DISEASES ––––––––––––

Sigmoid volvulus: twisting of sigmoid colon around

mesentery results in closed-loop obstruction; Tx
“detorse” the colon via rigid scope and rectal tube,
then elective sigmoid colectomy

Cecal volvulus: twisting of cecum; Tx right

colectomy since detorsion usually won’t work

Ogilvie’s syndrome: pseudoobstruction and massive

colon dilation w/o mechanical obstruction; Tx
endoscopic decompression or neostigmine if >11 cm
due to possibility of cecal perforation

Constipation: do a rectal exam to make sure stool

isn’t impacted, then give enemas from below

–––––––––––––– THYROID DISEASES–––––––––––––
Thyroid embryology: derivative of foramen cecum
from the base of the tongue
Thyroglossal duct cyst: remnant of thyroglossal
duct as a mobile midline neck mass, Dx at 1-2 yo
due to neck fat, Tx Sistrunk operation (take out
cyst, trunk, and medial portion of hyoid bone)
Thyroid nodule management: first get TSH levels →
if euthyroid, get FNA for cancer Dx; otherwise, work
up for hypo- or hyperthyroidism
Risk of malignancy: solid nodules, cold nodules
(lack of radioiodine uptake), size > 1.5 cm
Colloid nodule: benign nodule, manage medically
Hyperthyroidism: Graves’ disease (most common),
toxic adenoma (#2), toxic multinodular goiter (#3)
Graves’ disease (diffuse toxic goiter): auto-
immune disease due to IgG against TSH-R causing
exophthalmos, pretibial myxedema, and
hyperthyroidism; more common in women
Graves’ disease Tx: oral radioiodine (no surgical
risks) or surgery (won’t become hypothyroid)
Thyroid storm Tx: β-blockers, antithyroid drugs
Antithyroid drugs: propylthiouracil (PTU) and
methimazole block peroxidase, PTU also blocks
peripheral conversion of T4 to T3
Toxic adenoma: Dx hot nodule on scan with
peripheral suppression, Tx lobectomy if >2 cm,
radio-iodine if <2 cm
Toxic multinodular goiter: Tx surgical excision if
>2cm, radio-iodine if <2 cm
Hypothyroidism: chronic/Hashimoto thyroiditis
(most common), subacute/De Quervain thyroiditis,
acute bacterial thyroiditis
Hashimoto thyroiditis: autoimmune disease with
lymphocytic infiltration, Tx Synthroid
Hashimoto thyroiditis antibodies: anti-TSH,
anti-microsomal, anti-thyroglobulin, anti-
peroxidase
De Quervain thyroiditis: subacute, painful
granulomatous inflammation following viral URI,
Tx observation (condition will self-resolve)
Acute thyroiditis: painful, swollen, tender thyroid
mass due to Staph/Strep infection, Tx I&D
Thyroid cancers: 80% papillary, 10% follicular, 4%
medullary, 1% anaplastic; FNA can be used to Dx
papillary and medullary but not follicular (must see
capsular invasion to DDx adenoma vs. carcinoma)
Papillary cancer: associated with radiation,
lymphatic spread, best Px overall, Bx shows
Orphan Annie nuclei with psamomma bodies
Papillary cancer Tx: total thyroidectomy w/
central LN excision → modified radical neck
dissection if LN are positive for cancer
Follicular cancer: endemic to iodine-deficient
regions, hematogenous spread, 2nd best Px
Follicular cancer Tx: hemilobectomy with biopsy
because 80% are benign adenomas and 20% are
malignant carcinomas, total thyroidectomy if Bx
reveals malignant carcinoma
Medullary cancer: AD inheritance with MEN2A/2B
syndromes, Δret proto-oncogene, both lymphatic
and hematogenous spread, Bx amyloid deposits,
3rd best Px
Medullary cancer Tx: total thyroidectomy for
both cancer and ret+ prophylaxis w/ central LN
excision → modified radical neck dissection if LN
are positive for cancer
Anaplastic cancer: rare, worst Px
Anaplastic cancer Tx: palliative (e.g.
tracheostomy)
Thyroid lymphoma: associated w/ chronic
Hashimoto’s thyroiditis, Tx radiation therapy
Post-thyroidectomy f/u: take patient off T4 for 6
weeks (use T3 instead for its shorter T½), increase
TSH level, and make sure total thyroidectomy was
performed; give radioactive iodine exam after 6
weeks to check if any metastases will light up
Positive for metastases: get CT scan, macro →
excision, micro → oral radio-iodine therapy
Papillary cancer f/u: follow thyroglobulin levels
Follicular cancer f/u: follow thyroglobulin levels
Medullary cancer f/u: 24-hour urine for VMA or
metanephrines (MEN syndrome can present with
pheochromocytoma), follow calcitonin levels
Modified radical neck dissection: like radical neck
dissection, but spares sternocleidomastoid muscle,
CN XI, and internal jugular vein
Thyroid cancer Px: MACIS system – Metastasis (non-
lymph nodal), Age (<45 is better), Completeness of
resection, Invasion, Size (>2 cm has worse Px)
Thyroid surgery risk factors: superior laryngeal
nerve (soft/deep voice), recurrent laryngeal nerve
(hoarseness unilateral, dyspnea bilateral), para-
thyroid glands (hypoparathyroidism)
––––––––––––– PARATHYROID DISEASES –––––––––
Parathyroid glands: 30-50 mg each, brownish-yellow
color, sinks in water (to differentiate from fat)
Parathyroid embryology: 3rd branchial pouch
becomes inferior glands and thymus, 4th becomes
superior glands
Surgery – Endocrine Surgery
DiGeorge syndrome: congenital absence of both 3rd
and 4th branchial pouches → hypocalcemia, thymic
aplasia
PTH: secreted from chief cells; three functions –
renal ↑Ca++/↓P, bone ↑Ca++/↑P, stimulates 1α-
hydroxylase to activate vitamin D for indirect GI
resorption of Ca++
Osteitis fibrosa cystica: rapid, painful loss of bone
due to HPTH; “moth eaten skull”
Calciphylaxis: calcium deposition in soft tissue due
to HPTH
Multiple myeloma: punched-out lesions of bone due
to a B-cell neoplasm
Hypercalcemia Sx: kidney stones, painful bones,
abdominal groans (peptic ulcers, pancreatitis,
cholelithiasis), psychic overtones (↓mental status)
Hypercalcemia DDx: parathyroid adenoma (MCC
outpatient), metastases to bone (MCC inpatient)
1° HPTH: ↑PTH/↑Ca++/↓P, most sensitive test is Cl:P
ratio >33:1; causes include 90% adenoma, 9% hyper-
plasia, 1% carcinoma
1° HPTH management: straight to surgery if
symptomatic (4-gland exploration or minimally
invasive surgery), no imaging necessary
4-gland exploration: open exploration of neck
area; adenoma → take it out; hyperplasia → take
3½ glands out, or take all 4 out and auto-
transplant ½ gland back in; carcinoma → en bloc
resection of parathyroid and ipsi thyroid lobe
Minimally invasive surgery: needs positive
Sestamibi scan pre-op, big/abnormal gland during
exploration, and intra-operative decrease in PTH
levels by >50% following excision
2° HPTH: ↑↑PTH/↓Ca++/↑P, due to renal failure
2° HPTH management: medical management, 3½
gland excision if complications exist
3° HPTH: ↑PTH/↑Ca++/↓P, found in renal transplant
pts whose parathyroid glands work autonomously
3° HPTH management: 3½ gland excision if HPTH
persists for 1 year following transplant
Sestamibi scan: “lighting up” in parathyroid gland is
85% accurate for Dx parathyroid adenoma
Hypercalcemic crisis: Ca++>15 indicating carcinoma;
Tx flush with NS, then drain with furosemide (Lasix),
then treat the underlying cause
Parathyroid nodule: probably a thyroid nodule,
unless Ca++ ~15 indicating parathyroid carcinoma
2nd operation s/p adenoma removal: requires
localization studies, don’t just go back in there
 Surgery – Endocrine Surgery

Missing parathyroid glands: check thymus (MC
location/15%), up and down neck, open carotid
sheath, retro-esophageal area, esophageal groove,
and inside the thyroid gland itself
Median sternotomy: only indicated if pt is in a life-
threatening hypercalcemic crisis
–––––– MULTIPLE ENDOCRINE NEOPLASIA ––––––
Pituitary Cushing: due to ↑ACTH secretion,
suppressable by high dose dexamethasone;
Dx MRI, Tx transsphenoid hypophysectomy
Adrenal Cushing: due to ↑cortisol secretion
(causes ↓ACTH); Dx CT scan, Tx adrenalectomy
Ectopic Cushing: due to ↑ACTH secretion usually
from SCLC, not suppressable by high dose dexa

MEN1 (Wermer): pituitary adenoma, pancreatic Adrenal gland tumors: aldosteronoma, cortisoloma,
endocrine cancer (MC gastrinoma), parathyroid sex hormone-secreting tumor, pheochromocytoma,
hyperplasia incidentaloma

MEN1 Tx: excise parathyroid first since hyper- Aldosteronoma: presents as ↑Na, ↓K, ↓H, ↓renin;
calcemia can cause ↑gastrin levels; if Z-E can’t be Dx CT scan for mass (if no mass present or ↑renin,
controlled w/ PPIs → total gastrectomy since think RA stenosis), Tx adrenalectomy (adenoma)
MEN gastrinomas are multifocal or aldactone (hyperplasia)

MEN2A (Sipple): parathyroid hyperplasia, Cortisoloma: presents as adrenal Cushing’s, Tx

pheochromocytoma, thyroid medullary cancer adrenalectomy

MEN2B: pheochromocytoma, thyroid medullary Sex hormone-secreting tumor: Tx adrenalectomy

cancer, mucosal neuromas, Marfanoid habitus
MEN2A/2B Tx: excise pheochromocytoma first
since it can be life-threatening
Gastrinoma: give PPIs → if acid persists, get serum
gastrin levels → <200 absent, >500 present, 200-500
indeterminate and requires secretin stimulation test
→ if paradoxical ↑gastrin w/ secretin, present → get
CT scan to localize and cut it out
VIPoma: presents as “rice water” diarrhea; get CT
scan to localize and cut it out
Insulinoma: presents as hypoglycemia, Dx ↑C-
peptide levels or monitored fasting (to see if they’re
“faking it”); get CT scan and cut it out
Glucagonoma: presents as new-onset diabetes and
migratory rash from lower body upwards, Dx
glucose challenge test; get CT scan and cut it out
Metastatic glucagonoma: give somatostatin and
streptozocin since surgery is contraindicated
Pheochromocytoma: presents with HA, HTN,
palpitations, etc.; Dx 24 hour urinary VMA or
metanephrines, Tx α-blockers (phenoxybenz-
amine) then β-blockers then adrenalectomy
Intraoperative hypotension: give IVF
Incidentaloma: make sure it’s not secreting
hormones then work-up based on size; <5 cm →
leave alone, >5 cm → resection + check other organs
since adrenals are common site of metastasis
Aortic coarctation: presents as HTN in arms but
normal BP in legs; get CXR (scalloping of ribs) then
confirm w/ spiral CT, then surgical correction
Renovascular HTN: presents as HTN + abd bruits,
secondary to fibromuscular dysplasia (young women)
or atherosclerosis (old men) of the renal arteries;
get a doppler of renal vessels, then either balloon
dilation or surgical correction

Nesidioblastosis: presents as hypersecretion of

insulin in a newborn; Tx 95% pancreatectomy

–––––––––– OTHER ENDOCRINE DISEASES –––––––––

Pituitary adenoma: prolactinoma (#1), null cell tumor

(#2), ACTH (#3), GH (#4); may present as bitemporal
hemianopsia ◐◑ due to optic chiasm compression

Prolactinoma: presents with galactorrhea and

amenorrhea, Tx bromocriptine

Null cell tumor: doesn’t secrete anything

Cushing syndrome: presents as truncal obesity, abd

striae, buffalo hump, hyperglycemia, osteoporosis,
HTN, and immunosuppression due to ↑cortisol

Cushing causes: MCC is exogenous steroid use;

intrinsic causes include pituitary adenoma,
adrenal adenoma, and ectopic secretion of ACTH

––––––––––––––– SKIN CANCERS –––––––––––––––
Skin cancers: basal cell carcinoma (50%), squamous
cell carcinoma (25%), malignant melanoma (15%);
management is full-thickness incisional biopsy at
border of the lesion
Basal cell carcinoma: raised waxy lesion or non-
healing ulcer in upper face, doesn’t spread; Tx local
excision w/ 1 mm margins
Squamous cell carcinoma: non-healing ulcer in lower
face, spreads to LN; Tx local excision w/ 1 cm margins
and LN excision
SCC risk factors: draining fistulas, arsenic
exposure
Keratoacanthoma: variant of SCC that grows
rapidly and then dies off spontaneously
Dysplastic nevus: atypical mole, precursor of
malignant melanomas, requires close observation
Melanoma: ABCDE – Asymmetric, irregular Borders,
different Colors, Diameter >5mm, Evolving; Px
related to depth, highly metastatic and will be found
in weird places
Ulcerated melanoma: 1/3 reduction in survival
Depth <0.75 mm: Tx excision w/ 1 cm margin,
good prognosis
Depth 0.76-3.99 mm: Tx excision w/ 2 cm margin,
palpable LN → removal, no palpable LN →
sentinel LN biopsy w/ elective removal
Depth >4 mm: Tx excision w/ 2 cm margin,
remove palpable LN, pt will likely die from mets
Melanoma × LN involvement: remove regional LN,
then complete staging for mets (CXR, CT scan, LFTs,
brain MRI)
Melanoma × metastases: Tx radiation and
chemotherapy (interferons)
Lentigo maligna melanoma: superficial, spreading
melanoma on the face, good prognosis overall, Tx
excision w/ narrow margin
Acral lentiginous melanoma: melanoma on pale
areas of dark-skinned pts (sole of feet, palm of hand),
worst prognosis due to depth
Subungual melanoma: melanoma under fingernail or
toenail, Tx DIP amputation
Melanoma on face: Tx excision w/ smaller margins
for cosmetic purposes, consult plastic surgery
Melanoma in anus: all mucosal melanomas have bad
prognosis, Tx APR w/ palpable LN excision
Melanoma × SBO: presents as abd distention,
nausea and vomiting due to metastatic melanoma in
peritoneal cavity; Tx ex lap w/ excision
Surgery – Skin/Soft Tissue Surgery
–––––––––––––––– SARCOMAS –––––––––––––––– Hernia surgery types: open (Bassini, McVay,
Shouldice, Lichtenstein), laparoscopic (TAPP, TEP)
Sarcomas: present as firm, painless masses; Px
depends on size, grade, and distant metastases (no Bassini repair: inguinal ligament to conjoint
LN since sarcomas spread hematogenously) tendon, high tension, fixes direct and indirect
hernias
Sarcoma management: Dx incisional biopsy
parallel to resection margins, chest CT for mets, McVay repair: Cooper’s ligament to conjoint
Tx resection w/ 1 cm negative margins tendon; fixes direct, indirect, and femoral hernias
High-grade sarcomas: Tx radical amputation w/ McVay repair w/ relaxing incision: cut
post-op radiation therapy transversus abdominis aponeurosis to relax
tension on sutures
Sarcoma × lung mets: get chest CT to characterize
lesion and look for others → needle biopsy for Shouldice repair: inguinal ligament to reinforced
confirmation → Tx thoracic wedge resection transversalis fascia in two layers
Sarcoma × liver mets: biopsy for confirmation → Tx Lichtenstein repair: tension-free repair w/ mesh;
hepatic wedge resection or formal lobectomy fixes direct, indirect, and femoral hernias
––––––––––––––––– HERNIAS ––––––––––––––––– TAPP and TEP: TransAbdominal PrePeritoneal
and Totally ExtraPeritoneal lap procedures;
Hernia surgery indications: all abdominal hernias have steep learning curve and unproven results
due to possibility of strangulation, except sliding
esophageal hernias (Tx PPIs) and umbilical hernias in Hernia surgery complications: damage to genital
pts <2 yo (simple observation) branch of genitofemoral nerve, ilioinguinal,
iliohypogastric, or lateral femoral cutaneous nerves
Umbilical hernia management: <2cm watch, causing pain and sensory defects
>2cm fix, fix if it doesn’t regress before kinder-
garten regardless Hernia surgery post-op: avoid lifting for 6 weeks so
incision site has time to regain strength
Hernia × SBO: presents as abdominal distention,
nausea, and vomiting due to incarcerated or
strangulated hernia; Tx emergent hernia repair
Hernia × strangulation: presents as firm/tender
mass w/ fever, ↑WBC, metabolic acidosis; Tx
emergent hernia repair
Indirect hernia: through internal ring lateral to
inferior epigastrics vessels, due to patent processus
vaginalis; most common hernia overall (even in
women and elderly)
Indirect hernia in kids: high incidence of
bilaterality, repair is limited to high ligation of sac
w/o abdominal wall repair
Direct hernia: medial to inferior epigastric vessels,
due to weakening abdominal wall; more common in
elderly
Femoral hernia: below inguinal ligament into
femoral triangle, more common in women, highest
risk of strangulation (50% of all strangulations)
Sliding hernia: involves other viscera as part of the
hernia wall (e.g. bladder, cecum, sigmoid colon),
important to recognize sliding hernias as not to
injure any contained structures
Ventral hernia: hernia through incision site at linea
alba; Tx primary closure (small) or mesh repair (large)
Rare hernia causes: anything that increases
abdominal pressure – obesity, COPD, ascites, BPH
causing bladder obstruction, constipation, ascites;
these require further evaluation before surgery

–––––––––––– BREAST MANAGEMENT –––––––––––
Breast cancer screening: monthly self-exam, yearly
breast exam, yearly mammogram if >40 y/o (earlier if
there is a strong family Hx)
Breast mass on exam: first, get mammogram to
characterize mass and rule out other masses →
get core needle biopsy → excisional biopsy if
needle inadequate
Abnormality on mammogram: ‘probably benign’
→ follow-up; ‘suspicious’ → core needle biopsy,
excisional biopsy if needle inadequate
Breast cancer risk factors: family Hx (#1), BRCA1 and
BRCA2 genes, old age
MC breast masses: <25 fibroadenoma, 25-50 fibro-
cystic change, >50 infiltrating ductal carcinoma
–––––––––– BENIGN BREAST DISEASES –––––––––
Fibroadenoma: firm, mobile, rubbery mass in young
women; Dx FNA and U/S, Tx elective removal
Giant juvenile fibroadenoma: seen in teens with
rapid breast growth; Tx excision to avoid breast
deformity
Phyllodes tumor: huge, benign tumors that distort
the breast; Dx core or incisional biopsy since FNA is
insufficient, Tx excision w/ negative margins
Fibrocystic change: multiple, bilateral lumps that
vary with menstrual cycle; if dominant or persistent
lump → aspiration → excisional biopsy if mass
recurs or persists
Sclerosing adenosis: Tx careful observation or
prophylactic bilateral simple mastectomy; not
precancerous, but is a risk factor of cancers
Atypical ductal hyperplasia: Tx excision; not
precancerous, but high risk of becoming a cancer
Intraductal papilloma: presents as bloody nipple
discharge; Tx galactogram/ductogram-guided
excision (due to small risk of carcinoma)
Acute mastitis: breastfeeding women get
Staph/Strep infection through cracks in nipple w/
yellowish discharge, Tx antibiotics and warm
compresses, may develop into breast abscess
Breast abscess: pus pocket in lactating women;
Tx I&D and biopsy to rule out possible cancer
Periductal mastitis: subareolar infection in smokers,
both males and females affected
Gynecomastia: breast tissue hypertrophy in males;
common in puberty (will resolve spontaneously) and
older men (excision if it doesn’t regress on its own)
Dystrophic calcification: presents as breast lump
following trauma, but work up as a cancer until
proven otherwise (trick question!)
Surgery – Breast Surgery
–––––––– MALIGNANT BREAST DISEASES –––––––
Breast cancer buzzwords: family history, ill-defined
or fixed mass, skin or nipple retraction, peau
d’orange, nipple eczema, and palpable axillary LN
Breast cancer Tx: identical for all cancers (except
inflammatory, LCIS, DCIS); depends on cancer stage
Stage I-II: lumpectomy w/ 1 cm negative margins
+ axillary LN samping + post-op radiation; or
modified radical mastectomy
Stage III-IV: systemic chemotherapy
Axillary LN involvement: Tx chemotherapy if pre-
menopausal, tamoxifen if post-menopausal
Breast cancer × pregnancy: work-up and Tx is
identical, except no chemo during 1st trimester
and no radiation anytime; if stage III or IV,
chemoradiation is essential and abortion may be
necessary
Breast cancer × men: work-up and Tx is identical
Paget’s disease: presents as “crusty” nipple eczema,
indicates underlying infiltrating ductal carcinoma
Inflammatory cancer: resembles cellulitis w/ peau
d’orange, “tumor cells in dermal lymphatics”, Tx
requires pre-op chemo
DCIS: Tx simple mastectomy
LCIS: Tx careful observation or prophylactic bilateral
simple mastectomy; not precancerous, but is a risk
factor of breast cancers
–––––––– POST-SURGERY COMPLICATIONS –––––––
Small ipsilateral nodule: local recurrence until
proven otherwise, work-up like any other mass
Contralateral finding: most likely a new primary
cancer, work-up like any other mass
Elevated LFTs: indicates liver mets, get abd CT scan
Back pain: indicates bone mets, get bone scan then
X-ray
Pathologic fracture: indicates bone mets, get bone
scan then X-ray
Sensorimotor defects: indicates spine mets, get MRI
Severe headache: indicates brain mets, get MRI
New-onset seizures: indicates brain mets, get MRI
New-onset coma: indicates acute hypercalcemia due
to bone mets, get a renal panel for confirmation

–––––––––––– TRAUMA EVALUATION ––––––––––––
Evaluation of trauma pt: primary survey, get an
“ample” Hx, secondary survey
Primary survey: initial evaluation of trauma pt;
ABCDE – airway, breathing, circulation, disability
(neurological), environment/exposure
Ample Hx: things to ask a trauma pt – allergies,
meds, previous illnesses, last meal, events
surrounding injury
Secondary survey: full inspection of trauma pt
following clearance of life-threatening issues,
continual reassessment is necessary for changes
Airway: determine if airway is clear, quickest way to
evaluate is to see if pt can talk; use intubation,
cricothyroidotomy, or tracheostomy if obstructed
Blunt trauma to neck: consider possibility of
laryngeal edema developing into airway
obstruction
Breathing: evaluate via lung auscultation, CXR, and
pulse oximetry
Circulation: stop external hemorrhage, 2 large-bore
IV lines (14 or 16-gauge) w/ 2L crystalloid, followed
by packed RBC (type O–) if necessary
Cardiac tamponade: presents with Beck’s triad –
JVD, muffled heart sounds, hypotension;
Tx subxiphoid pericardiocentesis and go to OR
Hypovolemic shock: class I <15% and lactic acid;
class II 15-30% and ↑HR; class III 30-40% and ↓BP;
class IV >40% with lethargy and anuria
Hypovolemic shock Tx: 2 large-bore IV lines and
2L crystalloid infusion, resuscitation measured by
urine output, HR, BP, and mental status
Hypovolemic shock Tx unresponsive: search for
underlying cause, ex lap or thoracotomy may be
indicated for continuous internal bleeding
Closed head injury: brain edema and ischemia
causes Cushing reflex – peripheral vaso-
constriction (↑BP), bradycardia (↓HR), and
respiratory depression (↓RR)
Circulation × pregnancy: ↑HR is normal and may
not indicate shock, ↓hct of 31-35% is normal, best
evaluated laying on her left side
Disability: evaluate with GCS; 15 max, ≤8 coma, 3
nearly dead
Disability × awake: stabilize C-spine, palpate
posterior neck for tenderness, assess extremities
for motor/sensory function, and get lateral C-
spine imaging
Disability × comatose: C-spine cannot be cleared,
so precautions must continue
C-spine injury: suspected with neurological Sx,
radiological abnormalities, or C-spine tenderness;
intubation requires extreme caution
Priapism: indicates fresh spinal cord injury; check
for anal sphincter tone, bradycardia, and possibly
neurogenic shock
––––––––––––––– HEAD TRAUMA –––––––––––––––
Head trauma evaluation: begin with primary survey
(ABCs) → rapid neuro exam if stable → if any neuro
sx, get head CT and neurosurg consult
Rapid neuro exam: check pupils, cranial nerves,
peripheral motor/sensory function, and rate level of
consciousness via GCS
EDH: head CT shows convex lens hematoma;
presents as LOC → lucid interval → LOC →
ipsilateral fixed/dilated pupil, Tx craniotomy
SDH: head CT shows crescent moon hematoma,
high risk for brain herniation; Tx head elevation,
hyperventilate, sedate, mannitol + furosemide
Diffuse axonal injury: head CT shows blurred
gray-white junction and small punctate
hemorrhages; management is prevention of ↑ICP
Head trauma × hypovolemic shock: look for another
source of bleeding
Basal skull fx: raccoon eyes, hemotympanum,
otorrhea, rhinorrhea, ecchymosis behind the ear
(Battle’s sign); neurosurg consult is indicated
––––––––––––––– NECK TRAUMA –––––––––––––––
Neck stab wound: begin with primary survey (ABCs),
then careful exam for injured structures
Surgery indications: expanding hematoma,
deteriorating vital signs, coughing blood,
subcutaneous emphysema, all GSW and stab
wounds in zone 2 (zones 1+3 can be observed if
stable)
Stab × zone 1: below cricoid (includes lung);
observation and pre-op angiogram if stable,
otherwise exploration of neck is necessary
Stab × zone 2: between mandible and cricoid;
exploration of neck is mandatory
Stab × zone 3: above mandible; observation and
pre-op angiogram if stable, otherwise exploration
of neck is necessary
Stab × dysphagia: suggests injury to the
esophagus, Dx esophagoscopy or barium
swallow
Stab × hoarseness: suggests injury to the airway,
larynx (voicebox), or recurrent laryngeal nerve;
Dx laryngoscopy or exploration
Surgery – Acute/Critical Care Surgery
Stab × hemiparesis: suggests injury to the carotid
artery; get angiogram and either vascular or
neurosurg consult
Neck GSW: exploration of neck is mandatory in zone
2, observe if stable in zones 1+3
Neck blunt trauma: at risk of carotid dissection (Tx
anticoagulation) or laryngeal edema (Tx intubation)
––––––––––––––– SPINAL TRAUMA ––––––––––––––
Spinal cord injury management: get MRI to look at
spinal cord, then immediate high-dose steroids
Hemisection syndrome: always due to stab
wounds in posterior neck area, presents as ipsi
DCML/motor loss and contra ACL loss
Anterior cord syndrome: usually seen w/
vertebral burst fractures, presents as bilateral
ALS/motor loss but intact DCML
Central cord syndrome: usually seen w/ whiplash
(e.g. rear end collisions), presents as UE burning
pain and paralysis, but LE nerves intact
––––––––––––––– CHEST TRAUMA ––––––––––––––
Rib fx: painful breathing leads to shallow breaths →
atelectasis → pneumonia, Tx local nerve block
Chest stab wounds: suspect HTX or PTX, chest tube
insertion is indicated
Infraclavicular stab wounds: suspect injury to
subclavicular artery or vein, Dx angiogram if pt is
stable or urgent exploration if unstable
Nipple-level stab wounds: suspect additional
injury to diaphragm/abdominal organs, ex lap
indicated for abdominal organ damage
PTX: air in pleural space; insert a finger to make sure
of pleural space, then insert a chest tube, remove
when lung is fully inflated and no air leak present
Small PTX: simple observation is okay if it’s
asymptomatic, no free fluid present, not
expanding, and no other significant injuries
Sucking chest wound: seal with occlusive
dressing, insert chest tube in different location
Nonfunctioning chest tube: chest tube is in the
wrong location or not working properly;
reposition or replace chest tube
Continuous air leak into chest tube: major airway
injury with disruption of bronchus or trachea
Tension PTX: mediastinal shift, hypotension, JVD,
absent breath sounds, and hyperresonant to
percussion; Tx emergent needle aspiration and
chest tube insertion (do not wait for CXR or ABG)
HTX: blood in pleural space, go to OR if chest tube
drains 1.5L or >200 mL/hr for 3 hours

HTX × hypotension: suspect blood loss in left
chest, indicated for left chest tube insertion
Thoracic GSW: GSW is managed differently due to
unpredictable path of bullets vs. knife, mark both
entrance/exit sites and get imaging
Thoracic blunt trauma: suspect HPTX, chest tube
insertion is indicated; emergent thoracotomy if >1.5L
or >200mL/hr blood is extracted from tube
Aortic transection: presents as widened media-
stinum on CXR, confirm w/ aortic angiography or
chest CT → go to OR if transected
Flail chest: presents w/ paradoxic chest wall
movements due to multiple rib fx, suspect lung
contusions and aortic transection; manage by
inserting bilateral chest tubes and serial ABGs
Pulmonary contusions: presents as deteriorating
ABGs and “white out” of lungs on CXR; Tx colloid
(not crystalloid) + diuretics + fluid restriction
Ruptured diaphragm: CXR reveals stomach in left
chest; rapid eval of non-abd injuries → go to OR
Ruptured trachea/bronchi: presents as
continuous air leak into chest tube and
subcutaneous emphysema; go to OR
Air embolus: presents as sudden death in an
intubated/respirator pt; management is immediate
Trendelenburg position + cardiac massage
Fat embolus: presents as RDS and petechiae in
neck/axilla due to bone marrow embolization from
long bone fx; management is respiratory support
––––––––––––– ABDOMINAL TRAUMA –––––––––––
Abdominal GSW: mandatory OR for ex lap for all
GSW below nipple level
Abdominal stab wound: mandatory OR if stab
wound penetrates peritoneum (e.g. protruding
viscera, peritonitis, hemodynamic instability);
otherwise, digital exploration and observation
Abdominal blunt trauma: mandatory OR if signs of
peritonitis or hemodynamic instability despite
transfusion; otherwise, CT scan can be done safely
before proceeding
Trauma × flat/nontender abd: observe if no
mechanism, imaging if mechanism exists
Trauma × severe abd pain: suspect peritoneal
irritation due to blood or intestinal contents, Dx
FAST or CT → indicated for ex lap if positive
Trauma × tire mark across abd: indicates severe
direct trauma, high suspicion of internal injury
Trauma × coma: abd imaging mandatory since
physical exam is impossible on a comatose pt
Trauma × perforated viscera: CXR reveals free air
in abdomen; rapid eval of non-abd injuries →
repair perforated viscera in the OR
Trauma × hypotensive w/o hemorrhage:
indicated for FAST or DPL → ex lap in OR if
positive; CT scan inappropriate for unstable pts
Trauma × hypotensive w/ pelvic fx: suspect
vascular injury from branch of internal iliac, Dx
FAST, Tx control by embolization
Dx DPL/FAST: diagnostic peritoneal lavage (DPL)
or ultrasound (FAST) useful for quick Dx of
internal free fluid → positive DPL/FAST is
indicated for ex lap; may be false negative in
retroperitoneal injuries
Dx CT scan: useful for stable pts, avoid in
unstable or severely injured pts
Splenic laceration: ex lap if unstable, preserve
spleen if possible to avoid post-splenectomy sepsis,
avoid blood transfusion if possible, splenectomy
requires vaccination for SHiN bacteria
Liver laceration: ex lap if unstable, observe if stable
Mesentery injury: difficult to detect on CT so
mechanism must evoke suspicion, co-exists with
bowel injury since mesentery is tougher than bowel
Renal laceration: stable → angiography and planned
operative repair; unstable → IV pyelo to detect if
two kidneys present, then OR for nephrectomy
Hematoma in SMA region: suggests major injury to
abd aorta, major aortic branches, pancreas, or
duodenum; stable → angiography and assessment
before operation, unstable → urgent ex lap
Pancreatic transection: mandatory ex lap; minor
injury → debride and drain, major injury → resection
of devitalized pancreatic tissue and repair of
duodenal injury
Duodenal hematoma: common in kids hitting abd on
bicycle handlebars, hematoma causes GI obstruction;
Tx NPO/IVF, will resolve spontaneously in 5-7 days
Blood in ex lap: stop bleeding by packing all four
quadrants with gauze packs → attack injuries in
order of severity and attempt hemostasis → inspect
remainder of abd contents and repair injuries
Triad of death: acidosis, coagulopathy, hypothermia
Hemorrhage × hypothermia: can lead to
coagulopathy due to platelet dysfunction and
PT/PTT prolongation; rewarming indicated
Hemorrhage × low platelets: loss of platelets due
to hemorrhage puts pt at risk for coagulopathy;
platelet transfusion indicated
Hemorrhage × metabolic acidosis: results from
decreased tissue perfusion causing lactic acidosis;
crystalloid infusion indicated
Surgery – Acute/Critical Care Surgery
Hemorrhage × abd distention: bleeding into abd
cavity can lead to abd compartment syndrome,
which can cause decreased renal blood flow
(oliguria) and dyspnea (elevated diaphragm)
↓CO/↓CVP: hypovolemic shock, neurogenic shock
(e.g. spinal cord trauma, anaphylaxis)
↓CO/↑CVP: cardiogenic shock (e.g. CHF, MI, tension
PTX, pericardial tamponade)
––––––––– RETROPERITONEAL TRAUMA ––––––––
Retroperitoneal zones: central is zone 1, flank is
zone 2, pelvis is zone 3
Surgery indications: all zone 1 hematomas, zone 2
and 3 hematomas only if penetrating trauma
Zone 1 (central hematoma): may involve injury to
major vascular structure, indicated for ex lap
Zone 2 (flank hematoma): no exploration
warranted unless penetrating trauma, because
peritoneum will tamponade bleeding
Zone 3 (pelvic hematoma): no exploration
warranted unless penetrating trauma, because
peritoneum will tamponade bleeding
––––––––––––– UROLOGIC TRAUMA ––––––––––––
Urologic surgery indications: all GSW, stab wounds,
and other penetrating injuries
Urethral injury: presents as blood on meatus, scrotal
hematoma, and “high-riding” prostate; get a
retrograde urethrogram and suprapubic catheter
instead of Foley (may compound injury)
Bladder injury: associated w/ seatbelt trauma in
adults; get a retrograde cystogram and post-void
films, then surgical repair
Renal injury: associated w/ blunt trauma to back and
lower rib fx; get CT scan, manage non-op if possible
Scrotal hematoma: manage non-op unless testicle is
ruptured (seen on U/S)
Penis fx: associated w/ cowgirl sex; insert a
suprapubic catheter then repair surgically
–––––––––––––––– LIMB TRAUMA –––––––––––––––
Penetrating limb trauma: no vascular injury → give
tetanus PPx and clean wound; vascular injury
present → arteriogram if stable, OR if unstable
Combined limb trauma: order of repair is bone first,
then vascular repair, nerve last; fasciotomy required
to prevent compartment syndrome
Limb GSW: may require extensive debridements and
amputation if unsalvageable
Crushing limb trauma: high risk of myoglobinuria
leading to acute renal failure; Tx IV fluids + mannitol
+ acetazolamide to maintain a high urine output

––––––––––––––––––– BURNS ––––––––––––––––––
Burn assessment: determine depth of burn, type of
burn, and body surface area (%BSA) burned
First-degree burns: epidermis only, painful
Second-degree burns: extends into dermis,
causes pain and blistering, may develop into
third-degree burns w/o proper management
Third-degree burns: full thickness, painless
Burn management: tetanus PPx, IV pain meds,
topical agents (silver sulfadiazine is default, mafenide
acetate for deep penetration, triple abx ointment for
the eyes)
Rule of 9’s: estimates %BSA burned; head and upper
extremities are 9% each; anterior trunk, posterior
trunk, and lower extremities are 18% each; and
perineum is the last 1%
Parkland formula: estimates fluid replacement in
burn victims, LR volume = %BSA × kg × 4mL/kg;
give 50%LR in first 8 hours, 50%LR in next 16 hours
Fluid for infants: 20 mL/kg if BSA>20%
Chemical burns: alkaline burns are worse than acids
Chemical burn management: massive tap water
irrigation, don’t try acid-base neutralization,
except in ingestion – orange juice for alkali, milk
for acids
Electrical burns: may appear benign on surface, but
masks large amounts of interior damage to muscles,
nerves, and vessels; at risk of cardiac injury
(arrhythmias) and muscle injury (myoglobinuria)
Electrical burn management: IV fluids + mannitol
+ acetazolamide to maintain a high urine output
Inhalation burns: suspected with carbonaceous
sputum, facial burns, singed facial/nasal hairs,
hoarseness, etc. due to smoke inhalation
Inhalation burn management: confirm w/
fiberoptic bronchoscopy and order serial ABGs;
high COHb levels → Tx 100% O2
Circumferential burns: rapidly become thick and
contracted, causing restricted ventilation in the
chest and ischemia in extremities; Tx escharotomy
Scalding burns in kids: consider child abuse
Burns × methemoglobinemia: Sx chocolate-brown
blood, central cyanosis of trunk, arrhythmias,
seizures, coma; Dx ABGs (pulse ox is unreliable), Tx
IV methylene blue
––––––––––––––– BITES & STINGS ––––––––––––––
Bite management: all require tetanus PPx
Dog bites: rabies PPx only required if bite was
unprovoked and dog isn’t available for brain Bx
Surgery – Acute/Critical Care Surgery
Snake bites: don’t always result in envenomation; if
signs of venom evident (pain, swelling, discoloration)
then draw blood for labs and Tx anti-venin
Bee stings: may present as anaphylactic shock
(“warm and pink”) secondary to allergic response;
Tx stinger removal and epinephrine
Spider bites: black widows have neurotoxins, brown
recluses have necrotoxins
Black widow spiders: present w/ severe muscle
cramps, acute abdomen, and nausea/vomiting;
give IV calcium gluconate + muscle relaxants
Brown recluse spiders: present as an ulcerated
lesion; excise ulcer and skin graft
Human bites: requires extensive irrigation and
debridement due to high amounts of bacteria
––––––––––––––––– NUTRITION ––––––––––––––––
TPN: indicated for nutrition when gut is non-
functional or not availble, requires personalization of
formula for nutrition status
TPN × fever: examine catheter site for infection,
obtain cultures from catheter site and blood;
if –bacteria → change catheter site, if +bacteria
→ change catheter site and start antibiotics
TPN × metabolic coma: hyperglycemic,
hyperosmolar, nonketotic coma is commonly due
to excessive osmolar diuresis in hyperglycemia
TPN × elevated LFTs: very common (up to 30%),
TPN can cause fatty liver, structural liver damage,
and even cirrhosis with prolonged TPN
TPN × dry/scaly skin: indicates free fatty acid
deficiency, Tx FFA administration
Nitrogen in TPN: positive nitrogen balance is the
goal, since negative nitrogen balance indicates a
catabolic state; severity of injury correlates with a
higher amino acid requirement
BEE: basal energy expenditure, equal to (body
weight × 25 kcal/kg/day)
Nondepleted pts: 1.2× BEE calories needed; good
nutritional status before surgery
Depleted pts: 1.2-1.5× BEE calories needed;
malnourished before surgery
Hypermetabolic pts: 1.5-2× BEE calories needed;
severely stressed catabolic state due to trauma,
burns, sepsis, cancer, etc.
Macronutrients: carbs (4 kcal/gm), protein (4
kcal/gm), fat (9 kcal/gm), etoh (7 kcal/gm)

––––––––––––– PEDIATRIC SURGERY ––––––––––––
VACTERL syndrome: vertebral, anal atresia, cardiac,
TE fistula, esophageal atresia, renal, limbs (radius);
presence of any of these requires checking for the
others
Esophageal atresia: presents as excess salivation,
choking spells, coiling NG tube, and often a TE
fistula; Tx surgical repair (if delay is necessary,
gastrostomy)
Anal atresia: high rectal pouch → colostomy then
delayed repair, low rectal pouch → repair, if ano-
fistula present → delay repair since further
growth may correct condition
Congenital diaphragmatic hernia: presents as RDS
due to hypoplastic left lung; Dx CXR shows bowel in
left chest, Tx intubation w/ low-pressure ventilation
Gastroschisis: midline hernia to left of umbilical cord
tearing through peritoneum; Tx closure if small, silo
if large, and TPN for a month since GI doesn’t work
Omphalocele: midline hernia through the cord with
peritoneal covering; Tx closure if small, silo if large
Biliary vomiting: indicates SBO distal to ampulla of
Vater; DDx duodenal atresia, intestinal atresia
annular pancreas, or malrotation
Malrotation: presents as biliary vomiting and
double-bubble on X-ray; Dx contrast enema or
upper GI study, Tx emergency surgical correction
Intestinal atresia: presents as biliary vomiting and
multiple air-fluid levels on X-ray, aka apple-peel
atresia due to vascular accident in utero
Necrotizing enterocolitis: presents as feeding
intolerance, abd distention, and ↓platelets in
premies; Tx NPO, IVF, TPN, IV abx → surgical repair if
signs of intestinal necrosis/perforation present
Pyloric stenosis: presents as non-bilious projectile
vomiting in first-born boys; Dx palpable epigastric
olive, Tx rehydration and pyloromyotomy
Biliary atresia: presents as progressive jaundice in a
1-2 month old due to lack of CBD; Dx HIDA scan +
phenobarbital (to stimulate GB contraction), Tx liver
transplant
Hirschsprung’s disease: presents as chronic
constipation due to lack of nerves in distal colon,
rectal exam can decompress bowel; Dx X-ray shows
distended proximal colon, Tx surgical pull-through
Intussusception: presents as colicky abd pain that
lasts 1 minute then resolves, and currant jelly stools;
Dx/Tx barium or air enema (surgery if it doesn’t work)
Child abuse: presents as retinal hemorrhages, SDH,
multiple healed fx, and scalding burns; call child
protective services
Meckel’s diverticulum: presents as LGIB in a child,
Dx technetium uptake for ectopic gastric mucosa
Vascular rings: presents as stridor, RDS, crowing
respiration, and dysphagia in an infant due to
compression of trachea and esophagus; Dx barium
swallow and bronchoscopy, Tx surgical correction
Cardiac anomalies: all require prophylactic anti-
biotics for subacute bacterial endocarditis
L→R shunts: all present with murmurs and late-
onset cyanosis due to Eisenmenger syndrome
(pulmonary HTN reversing direction of shunt)
ASD: presents as low-grade systolic murmur,
fixed S2, and frequent colds; Dx echo, Tx surgery
VSD: presents as pansystolic harsh-sounding
murmur with failure to thrive; Dx echo, Tx surgery
PDA: presents with machinery-like murmur, often
seen with congenital rubella syndrome; Dx echo,
Tx indomethacin or surgery
R→L shunts: all present with murmurs and early-
onset cyanosis
Tetralogy of Fallot: presents as cyanosis and
clubbing in a 5 y/o child who squats for relief;
Px determined by degree of pulmonary stenosis,
Dx echo shows RVH, Tx surgery
Transposition of great vessels: presents as life-
threatening cyanosis in a newborn; Dx echo, Tx
surgery
–––––––––––––– OPHTHALMOLOGY –––––––––––––
Strabismus: misaligned eyes due to uncoordinated
extraocular muscles; Tx surgical extraocular muscle
manipulation to prevent ambylopia
Amblyopia: vision impairment usually due to
strabismus in kids, Tx eyepatch the good eye to
develop the impaired one
Retinoblastoma: presents as a leukocoria in a baby,
Tx surgical enucleation (remove the eye)
Narrow-angle glaucoma: presents as severe eye pain,
headache, “seeing halos around lights”, eye feels as
hard as a rock; Tx iridotomy (give pilocarpine, aceta-
zolamide, or mannitol as first aid)
Orbital cellulitis: presents as cellulitis of eyelids w/
fixed/dilated pupil and limited eye ROM; get CT scan
then drain the pus
Chemical burns of eye: irrigate w/ plain water ASAP,
at hospital – irrigate w/ saline, remove corrosive
particles, and test pH before sending home; alkaline
burns are worse than acid burns
Retinal detachment: presents as flashes and floaters,
and a dark curtain being pulled down over the eye;
Tx emergency laser “spot welding”
Amaurosis fugax: emboli from carotid travels to
retina causing transient blindness; Dx fundoscopic
exam reveals Hollenhorst plaque, a bright shiny spot
in a retinal artery
Surgery –Subspecialty Surgery
Embolic occlusion of retinal artery: presents as
sudden unilateral loss of vision; Tx breathe into
paper bag and repeatedly press on eye to shake clot
into a more distal branch of retinal artery
––––––––––––– OTOLARYNGOLOGY ––––––––––––
Neck masses: three types – congenital, inflammatory,
neoplastic; differentiate via onset and resolution
Congenital neck masses: thyroglossal duct cyst
(midline), branchial cleft cyst (lateral), cystic
hygroma (base of neck)
Thyroglossal duct cyst: remnant of thyroglossal
duct as a mobile midline neck mass, Dx at 1-2 yo
due to neck fat, Tx Sistrunk operation (take out
cyst, trunk, and medial portion of hyoid bone)
Branchial cleft cyst: lateral mass at anterior edge
of SCM, may have a small opening and blind tract
Cystic hygroma: dilated lymphatic duct at base of
neck, common in Turner syndrome, get CT scan
to find extent of mass before surgical removal
LN DDx: cancers are large (>2 cm), painless, fixed,
insidious onset, unusual site; infectious LN are small
(<2 cm), painful, rapid onset, mobile, normal site
Lymphomas: presents with multiple swollen LN,
fever, and night sweats; get excisional biopsy, then
Tx chemo
Supraclavicular metastases: MC primary sites are
pancreas and stomach; get excisional biopsy for Dx
Head/neck SCC: presents as persistent hoarseness,
painless ulcer in floor of mouth, or unilateral earache;
risk factors are EtOH, smoking, and AIDS
SCC management: get triple endoscopy to look
for primary tumor → biopsy tumor → CT scan to
determine stage; Tx resection, radical neck
dissection, cisplatin-based chemo
Acoustic neuroma: presents as unilateral deafness
due to Schwann cell proliferation on CN VIII, get MRI
Facial nerve tumor: presents as gradual-onset
unilateral facial paralysis (sudden-onset is Bell’s
palsy), get MRI
Parotid tumors: present as masses around angle of
mandible, two types – pleomorphic adenomas
(benign, painless) and mucoepidermoid carcinomas
(malignant, painful)
Parotid tumor management: get FNA or formal
superficial parotidectomy (open biopsy contra-
indicated due to CN VII)
Foreign bodies: any toddler w/ unilateral ENT sx
(earache, rhinorrhea, wheezing) has a toy stuck in
there; do endoscopy under anesthesia to remove
Ludwig angina: abscess in floor of mouth due to
tooth infection, Tx I&D and tracheostomy

Bell’s palsy: sudden CN VII paralysis for no evident
reason, Tx antivirals immediately
CN VII trauma: sudden CN VII paralysis following
facial trauma, will resolve spontaneously
Cavernous sinus thrombosis: presents as diplopia in
a pt w/ sinusitis due to nerve (CN III/IV/VI) injury, Tx
antibiotics, CT scan, and drainage of abscess
Epistaxis: nosebleed has different causes and
management depending on pt’s age
Epistaxis × children: due to nosepicking, Tx local
pressure and phenylephrine nasal spray
Epistaxis × teens: either cocaine abuse and septal
perforation (requires packing) or juvenile
nasopharyngeal angiofibroma (surgical resection)
Epistaxis × elderly: due to HTN; requires packing,
BP control, and often surgical ligation of vessels
Vertigo: dizziness can be attributed to diseases of
inner ear or brain itself
Vertigo × inner ear: “room is spinning”, Tx
meclizine, phenergan, or diazepam
Vertigo × brain: “room is stable, but patient is
spinning”, do a neurologic work-up
––––––––––––––– NEUROSURGERY ––––––––––––––
CNS diseases: vascular (sudden onset), metabolic
(hours), infectious (days-weeks), tumors (months),
degenerative disease (years)
Vascular CNS diseases: TIA, ischemic stroke,
hemorrhagic stroke, subarachnoid hemorrhage
TIA: brief neurologic deficit that fully resolves
within 24 hours; due to thromboembolus from
internal carotid arteries
TIA management: carotid duplex, then aspirin
and elective CEA (if >70% stenosis)
Ischemic stroke: a neurologic deficit that doesn’t
resolve within 24 hours due to thromboembolus
from internal carotid arteries, Tx t-PA within 3
hours, otherwise observe and rehab
Hemorrhagic stroke: severe headache and
neurologic deficit that doesn’t resolve within 24
hours in uncontrolled HTN; Dx CT scan, Tx rehab
and control of HTN
SAH: “worst headache of my life” due to rupture
of Charcot-Bouchard aneurysm in lenticulostriate
arteries; Dx CT scan to confirm SAH, then arterio-
gram to locate aneurysm, then surgical clipping
CNS abscess: presents as space-occupying lesions
but short-onset (weeks) and w/ nearby infections
(otitis media, mastoiditis); get CT scan then resect
CNS tumors: presents as space-occupying lesions
and progressive headache over months; get MRI
then resect (give mannitol, hyperventilate, and high-
dose steroids while waiting)
Frontal lobe tumors: present as disinhibition,
anosmia (CN I), ipsilateral blindness (CN II), and
contralateral papilledema
Craniopharyngioma: presents as GH deficit and
bitemporal hemianopsia ◐◑ in a kid, Dx calcified
lesion in sella turcica
Prolactinoma: presents as amenorrhea and
galactorrhea in a young woman, consider
possibility of MEN1 syndrome, Tx bromocriptine
Acromegaly: presents as huge hands, feet,
tongue, and jaws in a tall man due to ↑GH; Dx get
somatomedin C levels and MRI, then resection
Nelson syndrome: presents as bitemporal
hemianopsia ◐◑ and hyperpigmentation in an
adult due to pituitary microadenomas that grew
to full size; Dx MRI then Tx surgical resection
Pituitary apoplexy: presents with typical pituitary
adenoma sx, then sudden onset headache and
CNS sx due to bleeding into tumor; Dx MRI then
emergent steroid replacement
Pinealoma: presents as loss of upper gaze and
“sunset eyes” due to compression of vertical
gaze center in superior colliculi
Brain tumors in kids: present as cerebellar sx and
headaches relieved by knee-chest position, due to
posterior fossa lesions; Dx MRI, Tx resection
Spinal cord tumors: present as back pain in
someone who’s been treated for other cancers
(spine is a common site of mets); Dx MRI, Tx neuro-
surgical decompression
Neurogenic claudication: presents with pain on
exertion and relief with rest, but pain is position-
dependent and pulses are intact; Dx MRI, Tx neuro-
surgical decompression
Trigeminal neuralgia: severe facial pain lasting 60
seconds; Dx MRI to r/o organic cause, then Tx anti-
convulsants (radiofrequency ablation as backup)
Reflex sympathetic dystrophy: presents as severe
pain months after a crush injury w/ sympathetic
overload (cold, cyanotic, moist); Dx sympathetic
block, Tx surgical sympathectomy
–––––––––––––––––– UROLOGY –––––––––––––––––
Testicular torsion: presents as severe testicular pain
and “high riding testicle with horizontal lie” due to
twisting of the cord; Tx emergent surgical detorsion,
then orchiopexy (do not do any Dx tests)
Epididymitis: presents like testicular torsion but w/
fever, pyuria, and cord is also tender; Dx U/S to rule
out torsion, then Tx antibiotics
Obstructive UTI: presents as sepsis (fever, chills,
flank pain) in someone passing a kidney stone;
Surgery –Subspecialty Surgery
surgical emergency that requires immediate
decompression (stent or perc nephrostomy) in
addition to IV antibiotics
Lower UTI: presents as dysuria and cloudy, stinky
urine but no fever, chills, or flank pain; common in
young women, give antibiotics
Pyelonephritis: UTI that has ascended to the kidneys,
presents with fever, chills, flank pain; Dx urologic
work-up and Tx antibiotics
Prostatitis: presents as fever, chills, dysuria, back
pain, and tender prostate on rectal exam; give anti-
biotics and don’t do any more rectal exams
Urologic workup in kids: indicated for traumatic
hematuria and UTIs, since it may indicate congenital
abnormalities otherwise undiagnosed
Congenital malformations: posterior urethral valves,
hypospadias, epispadias, vesicoureteral reflex, low
implantation of ureter, ureteropelvic obstruction
Posterior urethral valves: presents as anuria in a
newborn boy; cathereterize to empty bladder,
then Dx voiding cystourethrogram, Tx resection
Hypospadias: presents as urethral opening on
ventral side of penis, never circumcise since
prepuce is needed for surgical correction
Epispadias: urethral opening on dorsal penis
VUR: presents as dysuria, fever, chills, and flank
pain in kids due to ascending UTI; give antibiotics
and Dx IV pyelo and voiding cystogram to look for
reflux, long-term abx until child “grows out of it”
Low implantation of ureter: asymptomatic in
boys, “wet with urine all the time” in girls b/c
ureter drips into vagina instead of bladder; Dx
physical exam or IV pyelo, Tx surgical correction
Ureteropelvic obstruction: usually asymptomatic,
but presents with colicky pain with large diuresis
(e.g. colicky pain following “beer drinking binge”)
Hematuria: always get IV pyelo (CT scan if allergic or
poor renal function) and cystoscopy to r/o cancers
Urologic cancers: renal cell carcinoma, transitional
cell carcinoma, prostatic cancer, testicular cancer
RCC: presents as hematuria, flank mass/pain, and
paraneoplastic syndromes (PAPER – PTHrP, ACTH,
prolactin, EPO, renin); get CT scan if suspected,
Tx surgical resection
Bladder TCC: presents as painless hematuria in
smokers; get IV pyelo and cystoscopy, then Tx
surgical resection, then lifelong f/u for high-rate
of local recurrence
Prostatic cancer: asymptomatic, detected as
rock-hard nodule on rectal exam; get U/S-guided
needle biopsy, then TURP or radiation therapy
(Tx flutamide and leuprolide if metastatic)
 Surgery –Subspecialty Surgery

Testicular cancer: presents as painless testicular

mass that doesn’t transilluminate; get radical
orchiectomy w/ biopsy, then f/u αFP or βHCG for
recurrence (Tx cisplatin or radiation if metastatic)

BPH: presents as dribbing, nocturia, and difficulty

voiding in an old man; put in Foley for 3 days, and Tx
α-blockers (tamsuosin), 5αR-blockers (finasteride)
+/- surgical prostate resection

Post-op urine retention: presents as a need to void,

but inability to do so; Tx straight cath at 6 hours
post-op and Foley after 2nd straight cath

Stress incontinence: presents as urine leaking w/

abd pressure due to weakened pelvic floor in a
multigravid woman; Tx surgical repair of pelvic floor

Kidney stones: presents as colicky flank pain and

hematuria +/- radiation to inner thigh, Dx plain X-rays;
Tx analgesics, fluids, and observation (<3 mm) or
shockwave lithotripsy (>3 mm)

Impotence: two types – organic and psychogenic,

management depends based on etiology

Psychogenic impotence: sudden onset w/o

traumatic cause, specific to partner or situation;
Tx psychotherapy

Organic impotence: sudden onset (trauma) or

gradual onset (atherosclerosis, diabetes); first-
line Tx is PDE5-blockers (sildenafil, Viagra)

–––––––––––– TRANSPLANT SURGERY –––––––––––

Transplant donors: almost everyone including brain-

dead pts, Hep and HIV pts to each other, metastatic
cancer pts for corneas

Transplant rejection: hyperacute (minutes), acute

(days/months), chronic (years)

Hyperacute rejection: preformed ab’s against donor

organ causes vascular thrombosis within minutes;
never seen since type-and-cross prevents this from
happening

Acute rejection: HLA mismatch causes macrophage

attack on donor tissue with lymphocytic infiltrate,
confirmed by biopsy

Liver rejection: indicated by elevated LFTs, first

step is to get U/S and Doppler to rule out biliary
obstruction and vascular thrombosis

Heart rejection: indicated by progressive heart

failure; management is getting routine ventricular
biopsies and Tx steroid bolus + OKT3

Chronic rejection: gradual deterioration of organ

function due to polymorphisms, irreversible and no
Tx available

–––––––––––– PEDIATRIC DISEASES ––––––––––––
Congenital hip dysplasia: presents as uneven gluteal
folds, posterior dislocating hips (with “snapping”) in
a newborn; Dx U/S since hip isn’t calcified for X-ray,
Tx splinting
Avascular necrosis of femoral head: presents in a kid
w/ limping, hip pain, and limited hip ROM; Dx X-ray,
Tx cast + crutches
Hip dislocation: presents as a chubby kid limping
due to groin pain, hip has limited internal rotation;
Dx X-ray, Tx pin femoral head back in place
Septic hip: presents in toddlers who refuse to move
hip following a septic illness; Dx hip aspiration unter
anesthesia, Tx perc drain
Osteomyelitis: presents in kids w/ severe localized
bone pain following a septic illness; Dx bone scan
since X-ray will be false negative, Tx antibiotics
Genu varum: aka bowlegs, <3 y/o observe since it’s
normal, >3 y/o surgical correction
Genu valgus: aka knock-knee, observation okay
Osgood-Schlatter disease: presents in teens w/
persistent pain over tibial tubercle, aggravated by
quad contraction; Tx immobilization in cast
Club foot: presents as bilateral inverted feet in a
newborn; Tx serial plaster casts on adducted
forefoot → hindfoot varus → equinus
Scoliosis: laterally curved spine, common in teenage
girls; Tx spine brace until mature, surgery if severe
––––––––––––––– BONE TUMORS –––––––––––––––
Osteosarcoma: presents as low-grade knee pain in a
10-25 y/o, X-ray shows Codman’s triangle and
sunburst appearance; consult a specialist
Ewing sarcoma: presents as low-grade epiphyseal
pain in a child, X-ray shows onion skinning, due to
t(11;22); consult a specialist
Metastatic bone cancers: usually from breast (lytic)
and prostate (blastic), causing bone pain and patho-
logic fx; Dx bone scan, Tx chemoradiation
Multiple myeloma: plasma B-cell tumor results in
CRAB – hyperCalcemia, Renal failure, Anemia, and
Bone pain (X-ray shows punched-out lesions); Dx
urinary Bence-Jones protein, Tx chemotherapy
–––––––––––– ORTHOPEDIC TRAUMA ––––––––––––
Fractures: all require 2 X-rays (90° from each other)
including joints above and below fractured bone;
anticoagulation of choice is fondaparinux + leg
compression devices
Clavicular fx: typically between mid-to-distal third of
clavicle; Tx figure-of-eight device for 4-6 weeks
Surgery – Orthopedic Surgery
Anterior shoulder dislocation: presents w/ outward Open fx: require cleaning and reduction within 6
rotated arm + deltoid numbness due to axillary palsy hours to prevent ischemia of distal limb
Posterior shoulder dislocation: rare, presents w/ Gas gangrene: presents as tender, swollen,
internally rotated arm held close to body discolored wound site w/ crepitus following a
penetrating injury; Tx high-dose penicillin G,
Colles fx: distal radial fx in osteoporotic women hyperbaric oxygen, and debridement
falling on outstretched hand; Tx reduction + cast
Monteggia fx: diaphyseal fx of proximal ulna + radial
dislocation, following direct trauma to ulna
Galeazzi fx: diaphyseal fx of distal radius + ulnar
dislocation, following direct trauma to radius
Scaphoid fx: presents as wrist pain and tender
anatomic snuffbox in a young person falling on
outstretched hand; Tx thumb spica cast
Metacarpal neck fx: presents as swollen and tender
hand after punching a wall; Tx splint or plate
Hip fx: presents as shortened and externally rotated
hip in an osteoporotic woman; Tx depends on
location of fx
Femoral neck fx: may lead to avascular necrosis of
femoral head; Tx prosthetic replacement of head
Intertrochanteric fx: less likely to cause avascular
necrosis; Tx ORIF
Femoral shaft fx: Tx intramedullary rod fixation,
high risk of hypovolemic shock and fat embolisms
Knee injury: all severe knee injuries present w/
swelling, and first step in management is an MRI
Unhappy triad: injury to ACL, MCL, and medial
meniscus following blow to lateral leg; Tx surgical
repair
ACL tear: presents as swelling, pain, and positive
anterior drawer sign; Dx MRI, Tx immobilization
and rehab
Meniscal tear: presents as pain, swelling, and
“clicking” of knee w/ forceful extension; Tx
arthroscopic repair to salvage meniscus
Tibial stress fx: presents as localized tibial pain in a
soldier following a long march; Tx cast and f/u X-ray
in 2 weeks
Leg fx: common in pedestrian vs. car accidents; Tx
cast for easily reduced fx, intramedullary nailing
otherwise, high risk of compartment syndrome
Achilles tendon rupture: presents as “popping noise”
in ankle following exertion w/ pain and swelling; Tx
cast or surgery
Ankle fx: common after falling on inverted or
everted foot; Tx ORIF
––––––––– ORTHOPEDIC EMERGENCIES –––––––––
Pain under cast: remove cast to examine