complete study guide

8/12/2019 Complete Study Guide

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SURGERY 3 EVALS COMPILATION

Esophagus 50Stomach 21Small intestine 11+19Liver and Gallbladder 40Pancreas and spleen 50hest !all" lungs" mediastinum" pleura #5ongenital and ac$uired heart disease 40

%rterial disease #5&horacic aneur'sm and aortic dissection25(enous and l'mphatics 25)eurosurger' #5Plastic Surger' 25*rolog' #0one in,ections and tumors 40-and . !rist" congenital" spine 20/ractures o, LE and *E #5

Esophagus

1 *pper thora deviates to le,t2 iddle thora sta's at midline# Lo!er thora deviates to le,t4 ervical 5 cm5 &hora 20 cm3 %bdominal 2 cm

%orta thoracic%6'gos vein thoracic

9 oronar' vein abdominal10 7n,erior phrenic vein abdominal11 ircular lesion Grade 712 Linear lesion Grade 771# Granulation tissue Grade 7714 obblestone Grade 77715 Stricture Grade 7(13 8elieved b' antacids heartburn1 orsen b' chocolate heartburn1 orsen b' bending over regurgitation

19 ronchospasm regurgitation20 8elieved b' passage o, bolus d'sphagia21 %bnormal columnar epithelium22 )ormal s$uamous epithelium2# -allmar: goblet cells24 etaplasia goblet cells25 *lceration s$uamocolumnar ;unction23 else' partial ,undoplication2 )issen complete ,undoplication2 &oupet partial ,undoplication29 Laparoscopicall' both#0 &ransthoracicall' both#1 Smooth" punch out de,ect leiom'oma#2 ird


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4 )G& both49 )a- ?# none50 ?range ;uice al:ali

Chapter 24 ESOPHAGUS

1. transition from pharynx to esophagus at the lower border of the 6 th cervical vertebra = correspondingto the cricoid cartilage anteriorly

2. thoracic portion of esophagus = 20cm3. fried food = causes gastric distention causing G !"

#. gastric distention causes unfolding of the sphincter $. pxs can be placed on !"2#$s of simple antacids when first seen with symptoms of heartburn w%oobvious complications

6. l%e & other al$ali can be neutrali&ed with half'strength vinegar( lemon )uice or orange )uice.*. esophageal #e' caused by ingestion of ferrous sulfate+. vomiting not an o'ligator% factor in malory'weiss syndrome,. ma)ority of px w% -allory'weiss syndrome = 'leeding #ill stop spontaneousl%

Stomach (c/o Tw !"#$%

%natom'1@ angle o, hisA ,undus

2@ parietal Bo 'ntic cells A bod'#@ angularisincisuraA antrum4@ nerves o, latar;etA bod'5@ cro!#419@ G7S&A imatinib20@ Easiest to per,romA Stamm


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>ecreased oral inta:e o, ,luids(omitingSe$uestration in bo!el lumen !all

8adiologic ,indings>ilated small bo!el loops%irA,luid levelsPaucit' o, air in colon

Ce;unum vs@ ileumore arterial arcadesLarger circum,erence&hic:er !allLesser ,att' mesenter'Longer vasa rectaLesser aggregates o, l'mphoid ,ollicles

ec:elistal obstruction

APPEN&I'Se$uence o, events B%P(

%nore ia%bdominal pain(omiting

Location o, tip o, appendi location o, pain8ectocecalD ,lan: or bac: pain8ectoAilealD testicular painPelvicD suprapubic pain

H(ariations in the anatomic position location o, the appendi accounts ,or man' o, the variations in the principallocus o, the somatic phase o, the pain>ra! c urne' point B2 # ,rom the umbilicus in the line dra!n ,rom umbilicus to %S7S*se o, %lvarado scaleD to ascertain li:elihood o, appendicitis

7ndicatorsD signs" s'mptoms" lab ,indings7nterpretationD

0A4D unli:el'5A3D compatible ! appendicitisJ do &A D high li:elihood o, appendicitis9A10D almost certainJ operated

Lab !or:Aup o, appendicitis and ,or !hat countD to :no! i, per,orated

*rinal'sisD rule out urinar' tract as source o, in,ectionPlain radiographD rule out other pathologies*ltrasoundD establish d Bloo: ,or appendicolith&D loo: ,or arro!head signLaparoscop'D diagnostic . therapeutic

10 la'ers o, abdominal !all in 8oc:'A>avis incisionS:inamper


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Scarpara! appendiSite o, obstructionD origin o, appendiPoint o, ruptureD distal to point o, osbstruction along antimesenteric border

Chapter 2 APPE- .51. growth of cecum displaces appendix mediall% toward ileocecal valve2. amt of lymphoid tissue steady decrease #ith age3. obstruction of lumen dominant causal factor #. distention of appendix stimulates stretch fibers ,ague dull diffuse pain$. engorgement and ,ascular congestion capillaries and ,enules are occluded6. involvement of parietal peritoneum shift in pain to the right lower :uadrant*. perforation antimesenteric 'order +. antibiotics 24!4 hours in nonperforated appendicitis,. a'dominal pain prime symptom1 . dx of appendicitis +uestioned if p is not anorectic11. tenderness maximal at *c6urne%3s point12. 7o,sing3s sign pain in !;< when palpatory pressure exerted in ;;% route 7(# ost common site o, cholangiocarcinoma bi,urcation4 hild Pugh bilirubin5 %lbumin3 7)8

Encephalitis %scites

9 Stone a,ter 3 mos recurrent10 &ubular" bro!n stone retained11 Portal h'pertension in males testicular atroph'12 G'necomastia

1# ost common parasite ascaris clonorchis14 & ,or penetrating e trahepatic in;ur' holec'stectom'15 7? means intraoperative cholangiogram13 Perihilar :lats:inecompression#1 Sugiura procedure" removal o, spleen#2 Stone least li:el' bro!n pigment## %n' stone etiolog' supersaturation o, bile#4 ost common cause o, e trahepatic in;ur' surger'#5 iliar' colic obstruction o,#3 'stic duct# iri66i s'ndrome in,undibulum# >ilated veins esophagus#9 Stomach40 %ir in gallbladder emph'sematous gallbladder


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Chapter >" GA//6/A E71. average capacity = >0!(0m/2. fundus contains most of smooth muscles3. same peritoneal lining that covers the liver covers the fundus and inferior surface of gallbladder #. cystic artery usu. ranch of right hepatic arter%$. triangle of 4alot boundaries? c%stic duct= common hepatic duct= li,er margin6. extrahepatic ducts? 7 and / hepatic ducts= common hepatic ducts= c%stic duct= common 'ile duct*. (00 to "000m/ of bile produced by liver per day+. ?.P and somatostatin inhibit contraction,. blac7 pigment stones small 'rittle1 . both cholesterol and pigment stones almost al#a%s form in the gall'ladder 11. cholec%stectom% definitive tx for acute cholecystitis12. reynoldBs pentad fe,er= @aundice= 7U pain= septic shoc$ and mental status changes13. sclerosing cholangitis results in secondar% 'iliar% cirrhosis1#. signs and symptoms of 45 of gallbladder indistinguisha'le from those assocB #& cholec%stitis

and cholelithiasis1$. Clats7in tumors perihilar cholangiocarcinomas

LIVER?rigin o, hepatic a@D celiac trun:

on,luence o, portal v@D superior mesenteric v@ . splenic v@Le,t lateral lobeD segments 77 . 777Location o, dilated vessels in portal h'pertensionD periumbilical area" chest8is: o, adenoma" not in /)-D malignanc'" rupture*se o, Sengsta:enA la:emore tube

ontrol o, re,ractor' variceal bleedingost common mortalit' in portal hpn

Gastroesophageal variceal bleeding?rgan a,,ectedD esophagusEndoscopes usedD EG>" E(L

ost important phospholipidD lecithin-elp,ul nitric o ideD endothelialSubstrate o, deo 'cholic acidD cholesterolSigiura procedureD spleenPE o, male ! portal hpn

&esticular atroph'G'necomastia

hildAPugh classi,icationSerum bilirubinSerum albumin7)8Encephalopath'%scites

8is: ,actor o, - D hepatitis Bviral " alcoholE posure to !hat Bin hepatic adenoma D estrogenLigaments that attach liver to diaphragm

L . 8 triangular lig@

Ligament attaching liver retroperitoneum8 coronar' lig@

7nitial imaging o, liverD abdominal *S>loc: *S>D obesit'" bo!el gashat is in contact ! segment 4% cephaladD diaphragmLocation o, bile duct Bc'stic duct D right . posteriorhat t'pe o, bilirubin is seen in urineD con;ugatedhat :ind o, ;aundice is cholangitisD postAhepatic ;aundice-o! man' !ee:s antibiotics in p'ogenic liver abscessD !:sore accurate lab tests ,or hepatic s'nthesis evaluationD albumin" aP&&

GALL,LA&&ER - ,ILIARY TREE>oes not move ! change in positionD pol'p


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Portion o, > not visuali6edD retroduodenal8etained stone4 causes o, gallbladder cancer5A,luorouracilSecondar' choledochal stoneshat is 7? D intraAoperative cholangiogram-'dropsD mucusSpheroc'tosisD blac: pigment&o inD l'solecithin-erpes 6osteranagement o, in;ur'D cholec'stectom'ause o, e trahepatic in;ur'D iatrogeniciri66ie


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4 Ligamentous attachment abdominal !all49 ?riginate ,rom mesoderm50 ommon in,ectious organism S@ pneumoniae

Ch$st wa##. Lu!gs. M$* ast !um. P#$u)a 1@ ronchiectasis &2@ ontiguous @ 'tolog' inc@ adenocarcinoma4@ dec@ mesothelioma5@ Pleurodesis sclerosis3@ at droppings -istoplasmosis@ Lab !or:er ,or 5 'ears r'ptococcus@ s:in an characteristicall' be pinched desmoid tumor9@ ronchiectasis macrolide10@ E ample o, macrolide a6ithrom'cin11@ aspo,ungin cell !all s'nthesis12@ & adenosine deaminase in pleural e,,usion1#@ L'tic plasmac'toma14@ 7nc@ ES8 E!ing8& therap' ri,ampicin" isonia6id#1@ s$uamous cell ca E cept peripheral#2@ %denoacarcinoma peripheral lungs##@ Solitar' %#4@ !ide e cisional biops' in lesions not more than 2cm

#5@ stenosis &ube same si6e as trachea

C EST 0ALL. LUNGS. ME&IASTINUM. PLEURAronchiectasisD &ontiguousD &'tolog'D inc@ adenocarcinomaJ dec@ mesotheliomaPleurodesisD sclerosisat droppingsD -istoplasmosisLab !or:er ,or 5 'earsD r'ptococcusan pinchD desmoid tumorronchiectasisD macrolideE ample o, macrolideD a6ithrom'cinaspo,unginD cell !all s'nthesis& D adenosine deaminase in pleural e,,usionL'ticD plasmac'toma7nc@ ES8D E!ing


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SeminomaD chemotherap'PericardiumD asau:a 777)euroblastomaD posterior mediastinumSestamibi scanD parath'roidsStippled in radiographD malignantPopcorn appearanceD hamartoma>8& therap'D ri,ampicin" isonia6idE ceptD peripheral%denoacarcinomaD peripheral lungsSolitar'D %2cmD subglottic space Bnarro!est part o, trachea&ube same si6e as trachea

Co!g$! ta# a!* Ac1u )$* $a)t & s$as$

1@ Le,t ventricle ,ibroma2@ ' oma le,t atrium#@ %S> h'pertroph' right ventricle4@ oderate stenosis 1@0A1@55@ %S cause o, edema arrh'thmia3@ %S> 8 right ventricle@ (S> 8 biventricular@ 7ncrease pulmonar' mar:ing e cept &?/

9@ >ecrease pulmonar' mar:ing &?/10@ 7ntervention o, o% resection11@ omplication restenosis12@ ( insu,,icienc' B8-> 7771#@ ( insu,,icienc' B8-> tethering o, lea,let annular dilation14@ ardioplegia ma # hrs15@ ardioplegia potassium" cold13@ 1 month (S> 0F1 @ S$uare root sign 8( diastolic1 @ -/ 8 Merle' line19@ P>% le,t posteolateral20@ 7mpt coronar' arter' anterior descending21@ &?/ sei6ure abscess22@ P>% pulmonar' arter' to descending aorta2#@ Egg shaped &G%24@ oot shaped 8(-25@ omplication o, P>% repair hoarseness23@ Ebstein tricuspid2 @ 8(2 @ *nstable angina rupture o, pla$ue29@ % G le,t internal thoracic#0@ 7nAsitu gra,t#1@ ardioplegia diastolic#2@ Partial %(S> primum##@ Ebstein 8( h'pertroph'#4@ %S> repair 4 N 'o#5@ %ortic insu,,icienc' e cept thrust#3@ o% distal to branches# @ or triatriatum 2 chamberJ hori6ontalJ L%# @ (S> belo! &(J !ithout muscle inlet#9@ &?/ d c e ept cardiac catheteri6ation40@ %ortic insu,,icienc' !idened aortic annulus

Co!g$! ta# a!* Ac1u )$* $a)t & s$as$ (Chapt$) 2 425% Patient !atching &(" e perienced pain !hen he sat up to change the tv channel O ) -% lass 777 Primar' conduit ,or % G O le,t 7 % ?ther conduits ,or % G O right 7 % and saphenous vein ause o, mitral stenosis O rheumatic heart disease &'pe o, valves used ,or patients at a 'ounger age O mechanical valves ost common neoplasm o, the heart O metastatic tumor Hcouer de steinI O constrictive pericarditis


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1 cm # Solution content O potassium %utogra,t source o, diseased %( O pulmonic gra,t Li,est'le modi,ications ,or management o, heart diseases O e ercise" smo:ing" alcohol" diet" etc@ Esophagus" stomach" gallbladder ardiac catheteri6ation coronar' angiograph'" 2> echo &?/ O bootAshaped 8are t'pe o, muscular (S> !ith multiple connections bet!een the right and L(s O HS!iss cheeseI )o@ o, chambers in cortriatum O 2 &!o parts involved in Ebstein% survival O le,t ventricle ,unction &?/ patient position O s$uat

%void in P>% surger' O recurrent lar'ngeal nerve End result o, (S> O L( h'pertroph'

A)t$) a# * s$as$

1 8 arm S PD 145J L arm S PD 1#58 P& S PD 140J L P& S PD 1 08 >P S PD 145J L >P S PD 150% 7 0@93" right

2 7ntermittent claudication e cept hips" :nee" ,oot" thigh# %rachnodact'l' ar,ans4 %rterial biops' giant cell arteritis5 %cute limb ischemia ma time 2 !ee:s3 8upture o, aortic aneur'sm &a:a'asu" ar,an" Giant cell" E>S

%rc o, 8oilan 7 % to S %omplaint in mesenteric ischemia abdominal pain

9 Least complaint in mesenteric ischemia vomiting10 hronic mesenteric ischemia & . angiograph'11 Elevated lipid pro,ile in aortoiliac t'pe 712 Pluc:ed chic:en s:in e cept nec:1# ure o, 8a'naud none14 omplaint o, %%% no complaint15 Late ,illing endolea: t'pe 7713 8enal segment o, aorta % . S % above renal1 )o need ,or long term surveillance o, %%% open repair1 rad'cardia carotid bi,urcation19 /or brad'cardia atropine20 Amode echogenecit'

21 Amode blac: and !hite22 >oppler angle 302# a imum si6e o, aorta # cm24 8estrict in pseudo anthoma calcium25 %dvantage o, 8% over & ,or elevated crea level23 %maurosis ,uga vision loss2 8a'naud


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#5 (alves involved in ar,an


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12@ Saphenous venous stripping U2cm1#@ >i,,erence bet!een P%> and P > c'anosis14@ P > leads to venous gangrene15@ Pigmentation o, (7 is ,rom deposits o, hemosiderin13@ omputeD 90 :g */- maintenance drip 1320 units hr1 @ 0 :g hirudin bolus 2 mg1 @ 0 :g argatroban 130 ug min19@ onitor */- aP&&20@ 2 s'mptoms to be controlled ,or outpatient L - pain

21@ Edema22@ ar,arin is an e ample o, vitamin M antagonist2#@ ar,arin blood product ,resh ,ro6en plasma24@ &hrombol'tic agent degrades ,ibrin25@ -7& heparinAinduced thromboc'topenia

V$!ous a!* L7mphat c & s$as$ (Chapt$) 28% edia Sural nerve 7ntradermal Pain Pitting edema lanching 3"400 units 1"440 units L - BS Secondar' >(& Elastic compression stoc:ing Great saphenous vein -eparinAinduced thromboc'topenia /actor 77 Gelatin" 6inc o ide" sorbitol" magnesium aluminum silicate" calamine" gl'cerin ongenital l'mphedema L'mphedema praeco L'mphedema tarda >ecompression (enograph' ellulitis Protamine sul,ate -epatobiliar' edial aspect

N$u)osu)g$)7

Case 1 trauma, patient with ET tube1@ 7n securing air!a'" QQQ should also be protected nec:2@ orsens & 7 h'po ia#@ h'potension4@ E is 2" meaning@@@ opens to pain5@ E means e'e opening3@ is #" meaning@@@ decorticate ,le@ means motor response@ ( means verbal response9@ ( is 1 &10@ &otal score is 3 &


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11@ Give ,luids normal saline solution P)SS12@ Sei6ure proph'la is phen'toin1#@ 7, 50:g" give QQQ as bolus 50 mg14@ Epidural hematoma lenti,orm15@ Subdural hematoma crescent13@ %,,ected vessel in epidural hematoma middle meningeal arter'1 @ iddle phase o, epidural hematoma lucid interval1 @ La'er o, scalp lead to massive bleeding aponeurosis connective tissue19@ Peptic ulcer ,rom & 7 cushinge amethasone ,or vasogenic edema2 @ -erniation o, QQQ through ,oramen magnum tonsils2 @ &he above is part o, cerebellum29@ ontents o, cranial vault blood#0@ S/#1@ rain tissue

#2@ )ormal 7 P 4A14 mm-g##@ anagement (P shunt#4@ %dditional diagnostic procedure 87#5@ 7, compressed" ma' lead to death brainstem

N$u)osu)g$)7 (Chapt$) 82% 7n,ratentorial Sei6ure rain tissue" blood" S/ %ta ia" n'stagmus" cranial nerve palsies (asogenic edema 4A14 mm-g /ourth ventricle (entriculostom' hole brain radiation therap' B 8& p)SS phen'toin 50 mg E'e opening response ?pens to pain otor response /le or posturing decorticate

-'potension" h'po ia iconcave lens lenti,orm rescent iddle meningeal arter'

(erbal response

NEUROSURGERY&umor causing inc@ 7 PD in,ratentorialS o, in,ratentorialD %ta ial n'stagmus" cranial nerve palsiesSei6ure


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(asogenic edema&onsilerebellumontents o, cranial vaultD blood" S/ brain tissue)ormal 7 PD 4A14mm-ghat la'er o, scalp leads to massive bleeding

%poneurosis-'drocephalusD (P shunting&raumaD craniotom'4 th ventricleEpidural hematomaD iddle meningeal arter'>ecorticate13omponents o, Glasgo! coma scaleD e'e opening" motor response" verbal responseEpidural hematomaD lenti,ormSubdural hematomaD crescent/luid givenD )SS ! o glucose>oseD 50mgPhen'toinrainstem-'po ia-'potension87ushing


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8otational%dvancement#5mg :gE'elid reconstructionD blepharoplast'8h'tidectom'D ,aceli,t>'namic territor'Potential territor'onditioning O inc@ reliabilit' o, ,lap/ull thic:ness O epidermis . complete la'er o, dermis&hic:Asplit gra,tsD more primar' contraction" less 2ndar' contraction%dvantage o, ,ull thic:nessD durabilit'" cosmesis)utrition to gra,tD ,ibrin la'erapillar' budsD inosculation)% Bcle,t lip vs@ palate-'percoagulabilit'hange in laminar ,lo!Subcutaneous*rine output vital stats1 months 9months5 da'sa,,eine" smo:ing8hinoplast'

P#ast c a!* R$co!st)uct $ Su)g$)7 (Chapt$) 89% &ransposition O single pivot point 8otational O single pivot point" semicircular %dvancement O urro!


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3@ &rue o, testis tunica albuginea O non compliant@ ladder e cept adenocarcinoma Bindustrial solvents@ %/P and - G germ cell and nonseminomatous9@ Priapism e cept epinephrine10@ &esticular cancer none Binguinal iliac11@ 8enal vascular metastasis vena cava12@ G bladder cancer1#@ Grade 4 renal vein laceration14@ 7schemia and necrosis distal # rd

15@ Paraphimosis glans13@ omplication o, &*8P h'ponatremia1 @ P- large" transurethral catheter1 @ &*8P endoscopic" penile urethra19@ oude prostatic20@ 8e,le cremasteric21@ Posterior urethral in;uries prostate and membranous22@ /ournieris:itis childAlumbarAun:no!n#@ harcot


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#2@ ?steoclastoma aside ,rom long bones sacrum##@ ?steosarcoma upper tibia#4@ hemo in rhabdom'osarcoma useless#5@ ultiple m'eloma calcium#3@ ultiple m'eloma e cept irradiation onl' palliative# @ %cid phosphatase maleAprostate# @ E!ing


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1$. Colles!Pouteau fracture fracture of the distal radial metaphysis with dorsal displacement of thedistal fragment8 most common fracture of the distal radius

16. 6arton3s fracture dorsal articular marginal fracture distal radius fracture1*. /etenneur3s fracture volar artonBs fracture distal radius fracture1+. Hutchinson3s or Chauffeur3s fracture fracture of the radial styloid1,. Pope%e deformit% of arm due to rupture of the long head of the biceps2 . plantar fasciits plantar heel pain21. stress fracture common cause of forefoot pain or fatigue fracture of the metatarsal22. tarsal tunnel s%ndrome compression of the tibial nerve8 vague symptoms num'ness and tingling

on plantar aspect of foot

a!*s - 0) st. Co!g$! ta# & so)*$)s. Sp !$ (Mo* : $* T/;%

"ands and #rist 1@ /le or retinaculum ulnar side O pisi,orm and tri$uetrium pisi,orm and hamate2@ &apping !rist O Phalen


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3 . 'o#el surger% increases ris7 of c. difficile colitis31. internal hemorrhoid = may prolapse or bleed but rarely becomes painful unless thrombosed or

w%necrosis32. anal fissure = spasm of internal anal sphincter 33. lateral location of anal fissure evidence of underlying dis crohnBs( / E( syph( tb( leu7emia3#. perianal a'scess most common8 painful swelling at anal verge3$. ischiorectal a'scess horse'shoe abscess36. Goodsall3s rule transverse line dividing perineumF to anterior and posterior to identify internal

opening of fistulas in ano3*. fistulas w% external opening anteriorly short radial tract3+. fistulas w%external opening posteriorly cur,ilinear fashion to the posterior midline3,. exceptions to goodsallBs rule greater than >cm from anal margin

Amputat o!. P)osth$s$s a!* ,)ac$s ( a!*outs%6 Spo)ts M$*. So:t T ssu$ I!


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Most common pathogen in children pneumococcus Common in adults liver, ascites 100,000 Indwelling catheter except Bacteriodes fragilis Indwelling catheter after 5 days esser sac left lo!e of the liver "xcept povidone#iodine Morrison$s pouch stomach Most common site of perforation cecum %eritonitis delayed head in&ury 'yphoid ileitis hematoche(ia %ost#op lea)age 5#* days %erforation 1+ hours pH decrease low fran) peritonitis anastomosis -#ray air#fluid level .ehr$s sign left su!phrenic 'empori(ation /' tu!o#ovarian etroperitoneal ureter Highest mortality in perforation duodenum Most common in children )idney

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