SURGERY 3 EVALS COMPILATION Esophagus 50 Stomach 21 Small intestine 11+19 Liver and Gallbladder 40 Pancreas and spleen 50 hest

!all" lungs" mediastinum" pleura #5 ongenital and ac$uired heart disease 40 %rterial disease #5 &horacic aneur'sm and aortic dissection 25 (enous and l'mphatics 25 )eurosurger' #5 Plastic Surger' 25 *rolog' #0 +one in,ections and tumors 40 -and . !rist" congenital" spine 20 /ractures o, LE and *E #5 Esophagus 10 20 #0 40 50 30 40 50 90 100 110 120 1#0 140 150 130 140 150 190 200 210 220 2#0 240 250 230 240 250 290 #00 #10 #20 ##0 #40 #50 #30 #40 #50 #90 400 410 420 4#0 440 450 430 440 *pper thora1 2iddle thora1 Lo!er thora1 ervical &hora1 %bdominal %orta %6'gos vein oronar' vein 7n,erior phrenic vein ircular lesion Linear lesion Granulation tissue obblestone Stricture 8elieved b' antacids 9orsen b' chocolate 9orsen b' bending over +ronchospasm 8elieved b' passage o, bolus %bnormal )ormal -allmar: 2etaplasia *lceration +else' )issen &oupet Laparoscopicall' &ransthoracicall' Smooth" punch out de,ect +ird<s bea: Subcutaneous emph'sema &ertiar' contraction /illing dilation at carinal bi,urcation %rise ,rom mucosa %rise ,rom submucosal glands 2ainl' in lo!er #rd 2ainl' in middle #rd =inc de,icienc' is a ris: ,actor Smo:ing and alcohol are ris: ,actors Leiom'oma is a ris: ,actor +arrett<s is a ris: ,actor Late diagnosis 2ista:en ,or carcinoma in cardia >issolution in;ur' oagulative in;ur' deviates to le,t sta's at midline deviates to le,t 5 cm 20 cm 2 cm thoracic thoracic abdominal abdominal Grade 7 Grade 77 Grade 77 Grade 777 Grade 7( heartburn heartburn regurgitation regurgitation d'sphagia columnar epithelium s$uamous epithelium goblet cells goblet cells s$uamocolumnar ;unction partial ,undoplication complete ,undoplication partial ,undoplication both both leiom'oma achalasia +oerhaave<s cor:scre! traction diverticulum s$uamous cell carcinoma adenocarcinoma adenocarcinoma s$uamous cell carcinoma s$uamous cell carcinoma s$uamous cell carcinoma neither adenocarcinoma s$uamous carcinoma adenocarcinoma al:ali acid

450 )G& 490 )a- ?# 500 ?range ;uice

both none al:ali

Chapter 24 ESOPHAGUS 1. transition from pharynx to esophagus at the lower border of the 6th cervical vertebra = corresponding to the cricoid cartilage anteriorly 2. thoracic portion of esophagus = 20cm 3. 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%o obvious 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 Bo1'ntic cells0A bod' #@ angularisincisuraA antrum 4@ nerves o, latar;etA bod' 5@ cro!<s ,ootA antroAp'loric region 3@ criminal nerve o, GrassiA ,undus 4@ nocturnal acid secretionA more commonl' elevated than da'time secretion 5@ duodenal ulcerA t!ice as common in men compared to !omen 9@ gastric ulcerA same incidence in men and !omen 10@ deep bleeding on the posterior duodenal bulb or the lesser gastric curvature are high ris: lesions" erode large arteries not amenable to nonAoperative treatment" consider earl' operation 11@ Cohnson classi,icationA &'pe # 12@ Pathologic t'pes o, gastric cancer Be1cavated lesions that ma' e1tend into the muscularispropria !ithout invasion o, this la'er b' the actual cancer cellsA t'pe #0 1#@ Stage #a o, gastric aA &4" )0 14@ Stage #+ o, gastric caA &#" )2 15@ (ircho!<s nodeA cervical" supraclavicular and a1illar' l'mph nodes ma' be enlarged 13@ Sister Coseph<s noduleA palpable umbilical nodule pathognomonic o, advanced disease" evidence o, malignant ascites 14@ +lumerA rectal shel, 15@ G7S&A cA:it" P>G/8%" >#4 19@ G7S&A imatinib 20@ Easiest to per,romA Stamm<s gastrostom' 21@ Gastrostom'A complicationD metabolic bone disease Bdi,,erence bet!een gastric and duodenal ulcer0

Chapter 2( S)O*ACH 1. .nterprandial basal acid secretion = 2!( mE+ HCl per hour 2. somatostatin inhibits pepsinogen secretion 3. alarm symptoms % indications for esophagogastroduodenoscopy ' #eight loss ' recurrent ,omiting ' d%sphagia ' 'leeding ' anemia #. tests for /. pylori ' serologic test ' urea breath test ' histologic test ' rapid urease test simplest method when endoscopy is necessary

' culture ' -O) .-C/U0E01 gastric fluid anal%sis $. 0p to ,12 of px with duodenal ulcers( and *1',12 of px w% gastric ulcers have /. pylori infxn 6. pro2imal duodenum = typical location of peptic ulcers in gastrinoma *. rectal shelf of blumer in the pouch of "ouglas 3drop metastasis in gastric 456 +. erosion of submucosal artery in dieulafo%3s lesion bleeding ,. -allory weiss tear caused by forceful ,omiting and&or retching 11. earl% dumping = 1$'31minutes after a meal diaphoretic( wea7( light'headd and tachycardic8 ameliorated by recumbence or saline infusion 9 diarrhea 11. late dumping = 2'3hours ff a meal8 relieved by admin of sugar8 associated w% h%pogl%cemia and h%perinsulinemia anemia most common metabolic side effect in px who have had a gastric bypass for morbid obesity
Sma## I!t$st !$ (c/o Tw !"#$% vomitingA pro1imal obstruction abdominal series closed loop obstructionA * shaped or shaped strangulationA thic:ening o, the bo!el !all ileocecal diseaseA ma;orit' o, small bo!el disease /87E)>A ,oreign bod'" radiation enteritis" in,ectionEin,lammation" epitheliali6ation o, the ,istulous tract" neoplasm" distal obstruction 4@ %denocarcinomaA ,re$uenc' o, #5A40F 5@ 2ec:els diverticulumA 100 cm o, the ileocecal valve 9@ 2ec:el<s diverticulumA 2 ,eet to the ileocecal valve in adults 10@ +leedingA main problem in mec:els 11@ 2 presentationA bleeding" internal obstruction and diverticulitis %ppendi1 1@ broadAspectrum antibiotics 2@ anore1ia #@ vomitingA dEt neural stimulation and presence o, ileus 4@ diarrheaA occurs in some patients 5@ direct rebound tenderness 3@ rovsing<s sign 4@ cutaneous h'peresthesia 5@ psoas sign 9@ obturator sign 10@ 9+ A 10"000A15"000 11@ Plain ,ilms" 12@ hest 1ra' to rule out right lo!er lobe 1#@ +arium enema 14@ Graded compression sonograph' 15@ %rro!head signA thic:ening o, cecum 13@ %lavarado scoring 14@ omputeri6ed sonograph'" *S> 15@ %bnormal location o, appendi1 and their unusual sites o, pain e1ample pregnanc' 19@ &reatment o, appendi1 SMALL INTESTINE Small bo!el obstruction PED 7%PP B,indingsG0 -ernias ?ccult blood &enderness Electrol'te -'po:alemia -'pocalcemia -'pomagnesemia -'permagnesemia /luid loss ase 1@ 2@ #@ 4@ 5@ 3@

>ecreased oral inta:e o, ,luids (omiting Se$uestration in bo!el lumenE!all 8adiologic ,indings >ilated small bo!el loops %irA,luid levels Paucit' o, air in colon Ce;unum vs@ ileum 2ore arterial arcades Larger circum,erence &hic:er !all Lesser ,att' mesenter' Longer vasa recta Lesser aggregates o, l'mphoid ,ollicles 2ec:el<s diverticulum haracteristics B8ule o, 2<s0 2F prevalence 2D1 ,emale predominance 2,t@ pro1imal to ileocecal valve 2'rs belo! B50F0 >ra!ing o, 2ec:el<s LocationD antimesenteric border" 2 ,t pro1imal to ileocecal valve Enterocutaneous /istula H/87E)>I /oreign bod' in ,istula tract 8adiation enteritis 7n,ectionEin,lammation at ,istula origin Epitheliali6ation o, ,istula tract )eoplasm at ,istula origin >istal obstruction

APPEN&I' Se$uence o, events B%P(0 %nore1ia %bdominal pain (omiting Location o, tip o, appendi1location o, pain 8ectocecalD ,lan: or bac: pain 8ectoAilealD testicular pain PelvicD suprapubic pain H(ariations in the anatomic positionElocation o, the appendi1 accounts ,or man' o, the variations in the principal locus o, the somatic phase o, the pain >ra! 2c+urne' point B2E# ,rom the umbilicus in the line dra!n ,rom umbilicus to %S7S0 *se o, %lvarado scaleD to ascertain li:elihood o, appendicitis 7ndicatorsD signs" s'mptoms" lab ,indings 7nterpretationD 0A4D unli:el' 5A3D compatible !E appendicitisJ do & 4A5D high li:elihood o, appendicitis 9A10D almost certainJ operated Lab !or:Aup o, appendicitis and ,or !hat 9+ countD to :no! i, per,orated *rinal'sisD rule out urinar' tract as source o, in,ection Plain radiographD rule out other pathologies *ltrasoundD establish d1 Bloo: ,or appendicolith0 &D loo: ,or arro!head sign Laparoscop'D diagnostic . therapeutic 10 la'ers o, abdominal !all in 8oc:'A>avis incision S:in amper<s ,ascia

Scarpa<s ,ascia E1ternal obli$ue m@ 7nternal obli$ue m@ 7nternal obli$ue aponeurosis &ransversus abdominis &ransversalis ,ascia Prepertioneal ,at Peritoneum >ra! appendi1 Site o, obstructionD origin o, appendi1 Point o, ruptureD distal to point o, osbstruction along

antimesenteric border

Chapter 24 APPE-0.5 1. growth of cecum displaces appendix mediall% toward ileocecal valve 2. amt of lymphoid tissue steady decrease #ith age 3. obstruction of lumen dominant causal factor #. distention of appendix stimulates stretch fibers ,ague dull diffuse pain $. engorgement and ,ascular congestion capillaries and ,enules are occluded 6. involvement of parietal peritoneum shift in pain to the right lower :uadrant *. perforation antimesenteric 'order +. antibiotics 24!4 hours in nonperforated appendicitis ,. a'dominal pain prime symptom 11. dx of appendicitis +uestioned if p2 is not anorectic 11. tenderness maximal at *c6urne%3s point 12. 7o,sing3s sign pain in !;< when palpatory pressure exerted in ;;< 13. abdominal findings may be absent when appendix hangs into the pel,is 1#. if appendix fills on barium enema( appendicitis is excluded8 if it does not fill no determination can be made 1$. graded compression sonography inconclusi,e if appendi2 is not ,isuali8ed and there is no pericecal fluid or mass 16. px w% 5lvarado scale scores of 4!"0 must go to the operating room 1*. rupture distal to the point of luminal obstruction along antimesenteric border 1+. phlegmon matted loops of bowel adherent to the ad)acent inflamed appendix or a periapendiceal abscess 1,. acute mesenteric adenitis after an upper respiratory infxn 21. underde,eloped greater omentum to contain a rupture significant morbidity in children 21. ruptured graafian follicle ' leu7ocytosis and fever are minimal or absent8 pain occurs at midpoint of menstrual cycle mittelschmer& 22. appendicitis most fre:uently encountered extrauterine disease re:uiring surgical tx during pregnancy 23. open appendectomy ' -c =urney 3obli:ue6 or !oc7y "avis 3transverse6 !;< muscle'splitting incision 2#. if 3>6 perforation or gangrene s7in and subcu left open to heal by 2ndary intent or closed in 4!(da%s as dela%ed primar% closure. 2$. 9o#ler!:eir incision= medial extension of incision w% division of anterior and posterior rectus sheath8 for further eval of lower abdomen 26. tx of appendicitis w%palpable%radiograph. documented mass 3abscess%phlegmon6 = conservative therapy w% interval appendectomy ;!"0#ee$s later. 2*. wound infxn in appendectomy = confined to the su'cutaneous tissue 2+. fecal fistula due to sloughing of that portion of the cecum inside a constricting purse'string suture 2,. carcinoid tumor firm( yellow( bulbar mass 31. tx for adeno45 formal right hemicolectom%

Chapter 2< S*A// .-)ES).-E 1. )e)unum contrasted to ileum = larger diam= thic$er #all= more prominent plicae circulares= less fatt% mesenter%= longer ,asa recta

2. ligament of treit8 = demarcates duodenum from )e)unum 3. parasympathethic ,agus nerve #. intra!a'dominal adhesions related to prior abdominal surgery = etiologic factor in up to *$2 of cases of small bowel obstruction $. small bowel obstruction 3sbo6 uncommonl% caused '% neoplasms 6. e2trinsic causes of s.b.o. = adhesions( hernias( carcinomatosis *. abdominal series? radiograph of a'domen!supine( abdomen'upright( chest'upright +. most specific finding for sbo = triad of dilated small 'o#el loops 3@3cm diam6( air!fluid le,els on upright films( A paucit% of air in the colon ,. tx of sbo = stomach continuously evacuated of air and fluid us -G tu'e 11. most intestinal neoplasms are as%mptomatic until they become large 11. sbo caused by small bowel neoplasm = can be a result of intussusception w% the tumor as the lead point 12. hemorrhage = 2nd most common mode of presentation of small bowel neoplasm 31st? partial sbo6 13. carcinoid tumors diarrhea( flushing( hypotension( tachycardia and fibrosis of endocardium and valves of right heart 1#. symptomatic benign neoplasms of s. i. = surgicall% resected or removed endoscopically 1$. chemotherap% = primary therapy if small intestine is diffusely affected by lymphoma terminal ileum = most fre:uently affected segment in radiation enteritis

L ($) a!* ga##+#a**$) 10 20 #0 40 50 30 40 50 90 100 110 120 1#0 140 150 130 140 150 190 200 210 220 2#0 240 250 230 240 250 290 #00 #10 #20 ##0 #40 #50 #30 #40 #50 #90 400 P& means -7>% route 2ost common site o, cholangiocarcinoma hild Pugh percutaneous transhepatic cholangiogram 7( bi,urcation bilirubin %lbumin 7)8 Encephalitis %scites recurrent retainedG testicular atroph' G'necomastia ascarisEclonorchisG holec'stectom'G intraoperative cholangiogram :lats:in<s tumor % 19A9 %/P E% oral contraceptives alcohol -epatitis rupture 2alignanc' 5A/* gastroesophageal bleed esophagus sclerotherap' Ligation hemostasisG >ecompressionG spleen bro!n pigment supersaturation o, bile surger' obstruction o, 'stic duct in,undibulum esophagusG StomachG emph'sematous gallbladder

Stone a,ter 3 mos &ubular" bro!n stone Portal h'pertension in males 2ost common parasite &1 ,or penetrating e1trahepatic in;ur'G 7? means Perihilar &umor mar:ers 8/ ,or adenoma 8/ ,or %denoma leads to hemo ,or cholangiocarcinoma 2ost common mortalit' ?rgan involved ,or K23 Endoscopic modalit' ,or K23 Sengsta:enAbla:emore Sugiura procedure" removal o, Stone least li:el' %n' stone etiolog' 2ost common cause o, e1trahepatic in;ur' +iliar' colic 2iri66i s'ndrome >ilated veins %ir in gallbladder

Chapter >" GA//6/A00E7 1. average capacity = >0!(0m/ 2. fundus contains most of smooth muscles 3. same peritoneal lining that covers the liver covers the fundus and inferior surface of gallbladder #. cystic artery usu. =ranch of right hepatic arter% $. triangle of 4alot boundaries? c%stic duct= common hepatic duct= li,er margin 6. extrahepatic ducts? 7 and / hepatic ducts= common hepatic ducts= c%stic duct= common 'ile duct *. (00 to "000m/ of bile produced by liver per day +. ?.P and somatostatin inhibit contraction ,. blac7 pigment stones small 'rittle 11. both cholesterol and pigment stones almost al#a%s form in the gall'ladder 11. cholec%stectom% definitive tx for acute cholecystitis 12. reynoldBs pentad fe,er= @aundice= 7UA pain= septic shoc$ and mental status changes 13. sclerosing cholangitis results in secondar% 'iliar% cirrhosis 1#. signs and symptoms of 45 of gallbladder indistinguisha'le from those assocB #& cholec%stitis and cholelithiasis 1$. 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 . 777 Location o, dilated vessels in portal h'pertensionD periumbilical area" chest 8is: o, adenoma" not in /)-D malignanc'" rupture *se o, Sengsta:enA+la:emore tube ontrol o, re,ractor' variceal bleeding 2ost common mortalit' in portal hpn Gastroesophageal variceal bleeding ?rgan a,,ectedD esophagus Endoscopes usedD EG>" E(L 2ost important phospholipidD lecithin -elp,ul nitric o1ideD endothelial Substrate o, deo1'cholic acidD cholesterol Sigiura procedureD spleen PE o, male !E portal hpn &esticular atroph' G'necomastia hildAPugh classi,ication Serum bilirubin Serum albumin 7)8 Encephalopath' %scites 8is: ,actor o, - D hepatitis Bviral0" alcohol E1posure to !hat Bin hepatic adenoma0D estrogen Ligaments that attach liver to diaphragm L . 8 triangular lig@ Ligament attaching liver retroperitoneum 8 coronar' lig@ 7nitial imaging o, liverD abdominal *S> +loc: *S>D obesit'" bo!el gas 9hat is in contact !E segment 4% cephaladD diaphragm Location o, bile duct Bc'stic duct0D right . posterior 9hat t'pe o, bilirubin is seen in urineD con;ugated 9hat :ind o, ;aundice is cholangitisD postAhepatic ;aundice -o! man' !ee:s antibiotics in p'ogenic liver abscessD 5!:s 2ore accurate lab tests ,or hepatic s'nthesis evaluationD albumin" aP&& GALL,LA&&ER - ,ILIARY TREE >oes not move !E change in positionD pol'p

Portion o, +> not visuali6edD retroduodenal 8etained stone 4 causes o, gallbladder cancer 5A,luorouracil Secondar' choledochal stones 9hat is 7? D intraAoperative cholangiogram -'dropsD mucus Spheroc'tosisD blac: pigment &o1inD l'solecithin -erpes 6oster 2anagement o, in;ur'D cholec'stectom' ause o, e1trahepatic in;ur'D iatrogenic 2iri66ie<s s'ndromeD in,undibulum

Pa!c)$as a!* sp#$$! Acute pancreatitis 10 Position 20 >o & scan #0 >>1 ,or h'peram'lasemia e1cept 40 /lan: 50 Patient observed to be 30 Least seen in radiograph 40 2nd !ee:" peripancreatic ,luid collection 50 #rd !ee:" dela' & 90 2gt ,or K5 100 Lactescent 110 ourvosier sign e1cept 120 +lumer<s shel, 1#0 ?rgan involved in acute in;ur' 140 21 o, K1# 150 /eeding 130 9h' in K15 140 %P% -EA77 o, 10 150 Give antibiotics ,or K14 190 &rue o, am'lase e1cept 200 >7 e1cept 210 >rug to give e1cept 220 >eh'drated" lab value increased e1cept 2#0 8etching" %+G o, 240 8etching 250 ?n admission" prognostic sign e1cept Pancreatic malignancy 230 2ost li:el' ,ound in 240 +iops' 250 E% and % 19A9 e1cept 290 7nitial radiograph #00 Somatostatin #10 -ereditar' e1cept #20 &)2" & ,or ##0 omplete resection e1cept #40 AAG #50 9?/ shoc: b' assessing Spleen #30 Sic:le cell #40 S A splenectom' #50 S #90 S 400 S A pain 410 S A anemia 420 S A h'dro1'urea e1cept 4#0 %ccessor' spleen 440 Splenic notch 450 9hite pulp 430 8ed pulp 440 Palpable belo! subcostal lateral decubitus !ith :nees ,le1ed no mesenteric in,arctionG ecch'mosis an1ious but l'ing stead' colon cutAo,, leave alone pseudoc'st internal drainage ,at tenderness palpation lung absent breath sound )C& because it b'passes duodenum severe 'es ,or splenectom' i, normal" elevate a,ter 15th hour decrease ,ibrin morphine albumin h'pochloremic metabolic al:alosis 2allor'A9eiss +*) head and uncinate process adenocarcinoma elevated" cholangitis *S" ,or gallstone pancreatic duct lea:age melanoma si6e S2%ES2( Prerenal *? valine to glutamic acid palliative ,or splenomegal'G er'throc'tes both parents se$uestration crises cause ,or splenectom' malignant trans,ormation ,alci,orm ligament in,erior pole increase si6e venous sinus 21 si6e

450 Ligamentous attachment 490 ?riginate ,rom 500 ommon in,ectious organism Ch$st wa##. Lu!gs. M$* ast !um. P#$u)a 1@ +ronchiectasis 2@ ontiguous #@ 'tolog' 4@ 5@ Pleurodesis 3@ +at droppings 4@ Lab !or:er ,or 5 'ears 5@ s:in an characteristicall' be pinched 9@ +ronchiectasis 10@ E1ample o, macrolide 11@ aspo,ungin 12@ &+ 1#@ L'tic 14@ 7nc@ ES8 15@ to avoid &7/ 13@ 2 !ee:s 14@ to prevent undue tension 15@ endotracheal intubation 19@ initiall' drain 20@ Pancoast 21@ 2assive hemopt'sis 22@ 2imic lobar 2#@ &eratoma 24@ Seminoma 25@ Pericardium 23@ )euroblastoma 24@ Sestamibi scan 25@ Stippled in radiograph 29@ Popcorn appearance #0@ 2>8&+ therap' #1@ s$uamous cell ca E1cept #2@ %denoacarcinoma ##@ Solitar' #4@ !ide e1cisional biops' in lesions not more than #5@ stenosis

abdominal !all mesoderm S@ pneumoniae

& & inc@ adenocarcinoma dec@ mesothelioma sclerosis -istoplasmosis r'ptococcus desmoid tumor macrolide a6ithrom'cin cell !all s'nthesis adenosine deaminase in pleural e,,usion plasmac'toma E!ing<s sarcoma !Eo re,erence to sternal notch &7/ #E4 7schemia 1L adenocarcinoma )E 1 +% surgical chemotherap' 2asao:a 777 posterior mediastinum parath'roids malignant hamartoma ri,ampicin" isonia6id peripheral peripheral lungs +% 2cm &ube same si6e as trachea

C/EST 0ALL. LUNGS. ME&IASTINUM. PLEURA +ronchiectasisD & ontiguousD & 'tolog'D inc@ adenocarcinomaJ dec@ mesothelioma PleurodesisD sclerosis +at droppingsD -istoplasmosis Lab !or:er ,or 5 'earsD r'ptococcus an pinchD desmoid tumor +ronchiectasisD macrolide E1ample o, macrolideD a6ithrom'cin aspo,unginD cell !all s'nthesis &+D adenosine deaminase in pleural e,,usion L'ticD plasmac'toma 7nc@ ES8D E!ing<s sarcoma !Eo re,erence to sternal notch 2 !ee:sD &7/ #E4 7schemia 1L PancoastD adenocarcinoma 2assive hemopt'sisD )E 1 2imic lobarD +% &eratomaD surgical

SeminomaD chemotherap' PericardiumD 2asau:a 777 )euroblastomaD posterior mediastinum Sestamibi scanD parath'roids Stippled in radiographD malignant Popcorn appearanceD hamartoma 2>8&+ therap'D ri,ampicin" isonia6id E1ceptD peripheral %denoacarcinomaD peripheral lungs Solitar'D+% 2cmD subglottic space Bnarro!est part o, trachea0 &ube same si6e as trachea
Co!g$! ta# a!* Ac1u )$* /$a)t & s$as$ 1@ 2@ #@ 4@ 5@ 3@ 4@ 5@ 9@ 10@ 11@ 12@ 1#@ 14@ 15@ 13@ 14@ 15@ 19@ 20@ 21@ 22@ 2#@ 24@ 25@ 23@ 24@ 25@ 29@ #0@ #1@ #2@ ##@ #4@ #5@ #3@ #4@ #5@ #9@ 40@ Le,t ventricle 2'1oma %S> h'pertroph' 2oderate stenosis %S cause o, edema %S> L8 (S> L8 7ncrease pulmonar' mar:ing e1cept >ecrease pulmonar' mar:ing 7ntervention o, o% omplication 2( insu,,icienc' B8->0 2( insu,,icienc' B8->0 ardioplegia ma1 ardioplegia 1 month (S> S$uare root sign -/ L8 P>% 7mpt coronar' arter' &?/ sei6ure P>% Egg shaped +oot shaped omplication o, P>% repair Ebstein *nstable angina %+G ardioplegia Partial %(S> Ebstein %S> repair %ortic insu,,icienc' e1cept o% or triatriatum (S> belo! &(J !ithout muscle &?/ d1c e1ept %ortic insu,,icienc' ,ibroma le,t atrium right ventricle 1@0A1@5 arrh'thmia right ventricle biventricular &?/ &?/ resection restenosis 777 tethering o, lea,let E annular dilation # hrs potassium" cold 50F 8( diastolic Merle' + line le,t posteolateral anterior descending abscess pulmonar' arter' to descending aorta &G% 8(hoarseness tricuspid 8( rupture o, pla$ue le,t internal thoracic 7nAsitu gra,t diastolic primum 8( h'pertroph' 4 N 'o thrust distal to branches 2 chamberJ hori6ontalJ L% inlet cardiac catheteri6ation !idened aortic annulus

Co!g$! ta# a!* Ac1u )$* /$a)t & s$as$ (Chapt$) 23425% Patient !atching &(" e1perienced pain !hen he sat up to change the tv channel O )P-% Primar' conduit ,or %+G O le,t 72% ?ther conduits ,or %+G O right 72% and saphenous vein ause o, mitral stenosis O rheumatic heart disease &'pe o, valves used ,or patients at a 'ounger age O mechanical valves 2ost common neoplasm o, the heart O metastatic tumor Hcouer de steinI O constrictive pericarditis

lass 777

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 e1ercise" smo:ing" alcohol" diet" etc@ Esophagus" stomach" gallbladder ardiac catheteri6ationEcoronar' 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<s anomal' O tricuspid valve and 8( %S> O ,oramen ovale Severe L(?&? O e1treme pallorEpoor peripheral per,usion ommon heart de,ect !ith ?% O bicuspid aortic valve /or patients older than 40 O cardiac catheteri6ation Prostaglandin source O placenta Location o, ?% O distal to the le,t subclavian arter' P>% 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$ 10 8 arm S+PD 145J L arm S+PD 1#5 8 P& S+PD 140J L P& S+PD 150 8 >P S+PD 145J L >P S+PD 150 %+7G 7ntermittent claudication e1cept %rachnodact'l' %rterial biops' %cute limb ischemia ma1 time 8upture o, aortic aneur'smG %rc o, 8oilan omplaint in mesenteric ischemia Least complaint in mesenteric ischemia hronic mesenteric ischemia Elevated lipid pro,ile in aortoiliac Pluc:ed chic:en s:in e1cept ure o, 8a'naud omplaint o, %%% Late ,illing endolea: 8enal segment o, aorta )o need ,or long term surveillance o, %%% +rad'cardia /or brad'cardia +Amode +Amode >oppler angle 2a1imum si6e o, aorta 8estrict in pseudo1anthoma %dvantage o, 28% over & %maurosis ,uga1 8a'naud<s *lceration in +ehcet<s Gold standard ,or renal 2+ traditional scale Screen ,or %%% 2ed used in testing renal ,unction >i,,use spasm" lo! ,illing +eveled needle

20 #0 40 50 30 40 50 90 100 110 120 1#0 140 150 130 140 150 190 200 210 220 2#0 240 250 230 240 250 290 #00 #10 #20 ##0 #40

0@93" right hips" :nee" ,oot" thigh 2ar,ans giant cell arteritis 2 !ee:s &a:a'asu" 2ar,an" Giant cell" E>S 72% to S2% abdominal pain vomiting & . angiograph' t'pe 7 nec: none no complaint t'pe 77 % . S2% above renal open repair carotid bi,urcation atropine echogenecit' blac: and !hite 30 # cm calcium ,or elevated crea level vision loss hand penis >S% mar:edl' reduced ultrasound captopril nonocclusive mesenteric ischemia single !all" retrograde

#50 (alves involved in 2ar,an<s

bicuspid . aortic

ARTERIAL &ISEASE6 ANEURYSMS - AORTIC &ISSECTON Gold standard d1D 28% 7odine contrastD & scan %bdominal distention" acidosisD mesenteric ischemia hronicit'D 14 da's or 2 !ee:s 2eaning o, &EED transesophageal endoscop' &EE ,orD ascending aorta 2eaning o, %+7D an:leAbrachial inde1 %+7 0@4D claudication 2 goalsD stabili6e dissection" prevent rupture 2 &1D betaAbloc:ers" direct vasodilators" aAbloc:ers" % E7 Penetrating aortic ulcerD disrupted atherosclerotic pla$ue 2ost common preventable causeD atherosclerosis ompression o, median arcuate ligD celiac trun: Pulsus parado1usD pericardial tamponade 2iddle branch o, aortic archD L common carotid a@ >istal branchD L subclavian a@ Shortest branchD brachiocephalic trun:

Tho)ac c a!$u)7sm a!* ao)t c * ss$ct o! 1@ 2@ #@ 4@ 5@ 3@ 4@ 5@ 9@ 10@ 11@ 12@ 1#@ 14@ 15@ 13@ 14@ 15@ 19@ 20@ 21@ 22@ 2#@ 24@ 25@ discrepancies bet!een pulse %nd blood pressure hronic dissection minimum o, QQ !ee:s 2 8oss procedure" use o!n pulmonar' arter' +orst procedure ,or descending thoracic aorta and arch Prere$uisite ,or open repair o, aneur'sm +P controlG Prere$uisite ,or endovascularJ pro1 and distal at least 2 cm %side ,rom +P" control pain 2eds ,or K5 morphine /entan'l /irst branch brachiocephalic arter' Second branch le,t common carotid arter' &hird branch le,t subclavian arter' Shortest branch brachiocephalic arter' 8espirator' ,indings o, aortic valve insu,,icienc' d'spnea 8ales 7ntramural hematoma" rupture o, vasa vasorum &EE means transesophageal echocardiogram Emergenc' operation i, dissection ,ound in ascending segment o, aorta Pulsus parado1us cardiac tamponade S!i,t diagnostic modalit' & scan Laplace ,ormula tension R pressure 1 radius %side ,rom amphetamine" abusive substance causing dissection cocaine Goal ,or aggressive pharma therap' ,or dissection stabili6e dissection Prevent rupture lassical PE ,inding

V$!ous a!* L7mphat c S7st$m 1@ 2@ #@ 4@ 5@ 3@ 4@ 5@ 9@ 10@ 11@ Goals o, treatment o, l'mphedema minimi6e s!elling Prevent recurrent in,ection L'mphedema praeco1J ares ,oot al, 2inimum compression ,or l'mphedema 20 mm-g %dvance cases o, l'mphedema" !eeping o, ,luid accompanied b' h'per:eratosis (ein i, Giacomini small saphenous vein GS( to common ,emoral vein landmar: pubic tubercle Pierce clavipectoral ,ascia cephalic vein *nnaSs boot # la'ers Sclerotherap' T #mm

12@ 1#@ 14@ 15@ 13@ 14@ 15@ 19@ 20@ 21@ 22@ 2#@ 24@ 25@

Saphenous venous stripping >i,,erence bet!een P%> and P > P > leads to Pigmentation o, (7 is ,rom deposits o, omputeD 90 :g */- maintenance drip 40 :g hirudin bolus 50 :g argatroban 2onitor */2 s'mptoms to be controlled ,or outpatient L299ar,arin is an e1ample o, 9ar,arin blood product &hrombol'tic agent degrades -7&

U2cm c'anosis venous gangrene hemosiderin 1320 unitsEhr 25 mg 130 ugEmin aP&& pain Edema vitamin M antagonist ,resh ,ro6en plasma ,ibrin heparinAinduced thromboc'topenia

V$!ous a!* L7mphat c & s$as$ (Chapt$) 28% 2edia Sural nerve 7ntradermal Pain Pitting edema +lanching 3"400 units 1"440 units L29- BS 0 Secondar' >(& Elastic compression stoc:ing Great saphenous vein -eparinAinduced thromboc'topenia /actor 77 Gelatin" 6inc o1ide" sorbitol" magnesium aluminum silicate" calamine" gl'cerin ongenital l'mphedema L'mphedema praeco1 L'mphedema tarda >ecompression (enograph' ellulitis Protamine sul,ate -epatobiliar' 2edial aspect

N$u)osu)g$)7 Case 1 trauma, patient with ET tube 1@ 7n securing air!a'" QQQ should also be protected 2@ 9orsens &+7 #@ 4@ E is 2" meaning@@@ 5@ E means 3@ 2 is #" meaning@@@ 4@ 2 means 5@ ( means 9@ ( is 10@ &otal score is nec:G h'po1ia h'potension opens to pain e'e opening decorticateE,le1 motor response verbal response 1& 3 &G

11@ Give ,luids 12@ Sei6ure proph'la1is 1#@ 7, 50:g" give QQQ as bolus 14@ Epidural hematoma 15@ Subdural hematoma 13@ %,,ected vessel in epidural hematoma 14@ 2iddle phase o, epidural hematoma 15@ La'er o, scalp lead to massive bleeding 19@ Peptic ulcer ,rom &+7 20@ 2anagement Case 2 patient has tumor, done CT scan (re ealed hydrocephalus! 21@ & sho!ed tumor in tentorium cerebelliJ accdg to location" !hat tumor 22@ -'drocephalus in &J !hat is compressed 2#@ PE s'mptoms consistent !ith tumor location 24@ 25@ )o occurrence o, QQQJ most li:el' based on location 23@ >e1amethasone ,or 24@ -erniation o, QQQ through ,oramen magnum 25@ &he above is part o, 29@ ontents o, cranial vault #0@ #1@ #2@ )ormal 7 P ##@ 2anagement #4@ %dditional diagnostic procedure #5@ 7, compressed" ma' lead to death

normal saline solutionEP)SS phen'toin 550 mg lenti,orm crescent middle meningeal arter' lucid interval aponeurosisEconnective tissueG cushing<s ulcer craniotom' in,ratentorial ,ourth ventricleEcerebral a$ueductG ata1ia )'stagmusEcranial nerve pals' sei6ure vasogenic edema tonsils cerebellum blood S/ +rain tissue 4A14 mm-g (P shuntG 287 brainstem

N$u)osu)g$)7 (Chapt$) 82% 7n,ratentorial Sei6ure +rain tissue" blood" S/ %ta1ia" n'stagmus" cranial nerve palsies (asogenic edema 4A14 mm-g /ourth ventricle (entriculostom' 9hole brain radiation therap' B9+8&0 p)SS phen'toin 550 mg E'e opening response ?pens to pain 2otor response /le1or posturingEdecorticate -'potension" h'po1ia +iconcaveElensElenti,orm rescent 2iddle meningeal arter' (erbal response

NEUROSURGERY &umor causing inc@ 7 PD in,ratentorial S1 o, in,ratentorialD %ta1ial n'stagmus" cranial nerve palsies Sei6ure

(asogenic edema &onsil erebellum ontents o, cranial vaultD blood" S/ brain tissue )ormal 7 PD 4A14mm-g 9hat la'er o, scalp leads to massive bleeding %poneurosis -'drocephalusD (P shunting &raumaD craniotom' 4th ventricle Epidural hematomaD 2iddle meningeal arter' >ecorticate 1 3 omponents o, Glasgo! coma scaleD e'e opening" motor Epidural hematomaD lenti,orm Subdural hematomaD crescent /luid givenD )SS !Eo glucose >oseD 550mg Phen'toin +rainstem -'po1ia -'potension 287 ushing<s ulcer %!a:ensElucid interval

response" verbal response

P#ast c Su)g$)7 (c/o Tw !"#$% 1A2D cause o, cle,t" ,ailure to ,use o,D 1@ medial nasal process 2@ ma1illar' prominence #@ 4FA i, a parent is cle,t 4@ Simonart band 5@ 7ncisive ,oramen 3@ millardA rotation advancement procedure 4@ /urlo!A= plast'" double opposing 5@ Pectoralis ma;or ,lap 9@ 8ectus abdominis ,lap 10@ &rape6ius 11@ Latissimusdorsi ,lap 12@ Palatoplast'A,istula 1#@ &umescent local anesthesia 14@ 8h'tidectom'A ,or hematoma 15@ &8%2 acron'm 13@ Earliest time ,or split Othic:ness gra,t 14@ Earliest repair ,or palatoplast'A 3 months 15@ &8%2 blood suppl'A sup@ Epigastric arter' 19@ Earl' diagnosis ,or cle,t 20@ le,t priorit'A,eeding 21@ 9h'GA cannot generate negative pressure !hen suc:ing /actors o, s:in gra,tingD 22@ 7n,ection 2#@ 2echanical shear ,orce 24@ -ematoma 25@ Seroma PLASTIC/RECONSTRUCTIVE SURGERY &issue e1pansion &ransposition

8otational %dvancement #5mgE:g E'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'er apillar' budsD inosculation )%2 Bcle,t lip vs@ palate0 -'percoagulabilit' hange in laminar ,lo! Subcutaneous *rine outputEvital stats 15monthsG 9monthsG 5 da's a,,eine" smo:ing 8hinoplast'

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!<s triangle le,t lip ,irst 3 months old /ullAthic:ness ,lap O high vascularit' Bgood healing0" ,or cosmesis Bgood cosmetic appearance0 -igh 1 Lo! 2 /ibrin and plasma 7nosculation >'namic territor' Potential territor' %dvancement procedure onditioning O dela' +lepharoplast' O e'elids ervical rh'tidectom' O ,aceli,t Lidocaine ma1 dose O #5 mgE:g O 1450mg 5 da's lass 1 ma1illar' ottle sign O rhinoplast' &issue e1pansion hange in constitution o, blood" altered blood laminar ,lo! 8emove subcutaneous Smo:ing" ca,,eine
U)o#og c Su)g$)7 1@ 2@ #@ 4@ 5@ &rue o, :idne' &rue o, adrenal &rue o, ureter &rue o, prostate &rue o, penis le,t renal vein longer gerota<s ,ascia in,erior R iliac denonvillier<s glans penis

3@ 4@ 5@ 9@ 10@ 11@ 12@ 1#@ 14@ 15@ 13@ 14@ 15@ 19@ 20@ 21@ 22@ 2#@ 24@ 25@ 23@ 24@ 25@ 29@ #0@

&rue o, testis +ladder e1cept %/P and - G Priapism e1cept &esticular cancer 8enal vascular metastasis + G Grade 4 7schemia and necrosis Paraphimosis omplication o, &*8P +P&*8P oude 8e,le1 Posterior urethral in;uries /ournier<s gangrene e1cept +utter,l' sign Epidid'moorchitis *nilateral cr'ptorchidism O bring do!n +P- e1cept &esticular trauma d1 Struvite GG GG

tunica albuginea O non compliant adenocarcinoma Bindustrial solvents0 germ cell and nonseminomatous epinephrine none BinguinalEiliac0 vena cava bladder cancer renal vein laceration distal #rd glans h'ponatremia large" transurethral catheter endoscopic" penile urethra prostatic cremasteric prostate and membranous buc:<s buc:<s ,ascia h'drocele to monitor ,or change d'suria *S> ammonium and magnesium )on contrast & indinavir

,o!$ I!:$ct o!s a!* Tumo)s 1@ 2@ #@ 4@ 5@ 3@ 4@ 5@ 9@ 10@ 11@ 12@ 1#@ 14@ 15@ 13@ 14@ 15@ 19@ 20@ 21@ 22@ 2#@ 24@ 25@ 23@ 24@ 25@ 29@ #0@ #1@ %ntecedent o, osteitis pubis >is:itis harcot<s ;oint /ungal in,ection simulate &+ Sic:le cell anemia 2inimum time 7( antibiotics 9h' drain )e! gro!th 2a;orit' o, cases Spirochete -allmar: o, chronic osteo Empiric therap' 2a1imum time to !ait ,or response to antibi )ot reliable in in,ants 7ntense osteoblastic response Lra' sho!s bone problems )ot true ,or &+ 7nitial in,ection E,,ective barrier &rue o, se$uestrum and involucrum e1cept 2ultiple m'eloma Glomus tumor E!ing<s sarcoma odman<s tumor %damantinoma location ?steoid osteoma e1cept ?steochondroma e1cept Phalanges Solitar' bone c'st location ?steosarcoma metastasis ?steol'tic" least origin o, metastatic bone tumor pelvic surger' childAlumbarAun:no!n &@ pallidum blastom'cosis s@ t'phi 2 !ee:s ,luctuant mass s$uamous cell carcinoma s@ aureus t@ pallidum draining sinus o1acillin 45 hours ,ever periosteal stripping 10A12 da's high grade ,ever metaph'sis epiph'sis involucrum surrounded b' granulation tissue marro! vascular marro! cartilaginous tibia painless surger' is necessar' enchondroma metaph'sis lung prostate

#2@ ##@ #4@ #5@ #3@ #4@ #5@ #9@ 40@

?steoclastoma aside ,rom long bones ?steosarcoma hemo in rhabdom'osarcoma 2ultiple m'eloma 2ultiple m'eloma e1cept %cid phosphatase E!ing<s e1cept &reatment ,or e!ing<s odman<s triangle

sacrum upper tibia useless calcium irradiation onl' palliativeGG maleAprostate sunburstGG radiotherap' belo! the periosteum

,o!$ I!:$ct o!s a!* Tumo)s (/a!*outs% Staph'lococcal (ol:mann<s canals Pus O se$uestrum 7( antibiotics O 2A4 !ee:s Se$uestrectom' O chronic stage ancellous bone source O iliac +rodie<s abscess O ,ibula Epiph'sis" hip capsule O !ithin S$uamous cell carcinoma >is:itis O lumbar Palliation O pain Sul,ur granules O actinom'cosis lutton<s O Treponemapallidum lutton<s O :nee ;oint Gumma O S'philis ?steosarcoma O sunburst pattern &uberculous osteom'elitis Glomus tumor O vascular tissue Chapter 42 O7)HOPAE0.CS 1. *7. most valuable for examination of soft tissues 2. ligaments and meniscus can usually be seen on an -!. 3. evaluation of pelvic in)uries? 5D radiograph( inlet and outlet ,ie#s #. $ simple acetabular fractures? posterior wall( posterior column anterior wall( anterior column and trans,erse fractures $. anterior hip dislocations from forced a'duction or anterior'posterior force to an abducted thigh8 less common than posterior hip dislocation 6. nonsurgical tx of tibial plateau fractures = short term immobili&ation with a long leg cast followed by bracing or immediate cast'bracing with delayed weight bearing *. middle >rd cla,icle = most common site of clavicular fractures +. distal >rd of cla,icle 2nd common site ,. 6an$art lesion tear in the glenoid labrum due to anterior shoulder dislocation 11. Hill!Sachs lesion compression fracture of the posterolateral aspect of the humeral head by the glenoid rim due to anterior shoulder dislocation 11. *onteggia fracture fracture of the ulna with an associated dislocation of the radial head 12. Galea88i fracture fracture in the distal third of the radius with an associated dislocation of the distal radioulnar )oint 13. nightstic$ fracture isolated fracture of the ulna 1#. greenstic$ fracture imcomplete fracture sustained by immature bones due to capacity to undergo plastic deformation without brea7ing

1$. Colles!Pouteau fracture fracture of the distal radial metaphysis with dorsal displacement of the distal fragment8 most common fracture of the distal radius 16. 6arton3s fracture dorsal articular marginal fracture 3distal radius fracture6 1*. /etenneur3s fracture volar =artonBs fracture 3distal radius fracture6 1+. Hutchinson3s or Chauffeur3s fracture fracture of the radial styloid 1,. Pope%e deformit% of arm due to rupture of the long head of the biceps 21. plantar fasciits plantar heel pain 21. stress fracture common cause of forefoot pain or fatigue fracture of the metatarsal 22. 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* : $* T/;% "ands and #rist 1@ /le1or retinaculum ulnar side O pisi,orm and tri$uetrium 2@ &apping !rist O Phalen<s test #@ +asis o, median nerve O radial arter' 4@ *lnar O Bsomething letter G0 canal 5@ ubital tunnel O ulnar nerve 3@ /luctuation o, nail ,old O ,elon 4@ Gilula O distal edge o, distal ro! ro! 5@ Cahss maneuver O inde1 ,inger Congenital 9@ +arlo! O adduct and elevate 10@ S /E O :nee pain 11@ Pavli: O LeggA alvesAPerthes 12@ lub,oot contracted O medial tendon 1#@ 2a1imum time ,or nonsurgical mgt ,or club,oot O 5 mos 14@ ?sgoodASchlatter O an:le pain Spine 15@ (ertebra prominens O 1 13@ Slip disc !ea:en O nucleus polposus 14@ &o vie! dens O lateral vie! 15@ ompression ,racture O middle column 19@ Ce,,erson O lateral segment 20@ Scoliosis most common O degenerative

pisi,orm and hamate &inel<s test Palmaris longus tendon Gu'on<s canal & paron'chia pro1imal edge o, distal ro! E distal edge o, pro1imal small ,inger adduct and depress groin pain congenital hip d'splasia & E %chilles tendon G & :nee pain 4 annulus polposus %P open mouth vie! anterior column &G idiopathic

Co!g$! ta# A+!o)ma# t $s - Su)g$)7 o: th$ /a!* a!* 0) st (/a!*outs% Ce,,erson ,racture O %P 1Ara' image la' shoveler<s O posterior compartment )eurogenic O lumbar spine stenosis Scoliosis Bmost common0 O idiopathic curves +races O useless in 45 scoliosis Loss o, disc height Polio O neuromuscular +arlo!<s test Galea66i<s sign O shortening Per:in<s" Shenton<s Pavli: harness Mite<s O calcaneous %chilles tendon O lengthening +ipartite patella O as'mptomatic /ibula absence

/irst to ossi,' O capitate &rape6oid O inde1 ,inger metacarpal +ears most o, the load O scaphoid />S Gu'on<s canal O ulnar arter' >e Vuervain<s O thumb

;)actu)$s o: UE a!* LE 1@ 2@ #@ 4@ 5@ 3@ 4@ 5@ 9@ 10@ 11@ 12@ 1#@ 14@ 15@ 13@ 14@ 15@ 19@ 20@ 21@ 22@ 2#@ 24@ 25@ 23@ 24@ 25@ 29@ #0@ #1@ #2@ ##@ #4@ #5@ Primar' callus 9ound closure *nion 8ein,orcement 8emodeling 2 'ears QQ are hallmar: o, QQ stage Late 7nnermost in cast %,ter cast /iberglass +rea:ing strength 7ntramedullar' internal ,i1ation ompartment ompartment s'ndrome incision /alls &orsional and dorsi,le1ion e1cept %vulsion in;ur' %chilles Patella -ipD position Substantial blood loss 2ost common hip ,racture 9ith hip dislocation Pelvis 2edial #rd o, clavicle 2iddle #rd o, clavicle Scapula Elbo! e1cept 8adial nerve )ight stic: ,racture 2onteggia 2onteggia Galea66i e1cept olles ,racture e1cept circulator' circulator' metabolic metabolic mechanical mechanical mesench'mal cellsJ circulator' t'pe 7 stoc:ing ta:e 1Ara' elasticit' cortical rods and nail U#0 mm-g ,asciaG S:inG calcaneus calcaneus 5th metatarsal plantar ,le1ion manual reduction posterior intertrochanteric ,emoral nec: ,emoral head lateral anterior elevateG >epress" anterior" posterior glenoid cond'loid humeral sha,t ulnar diaph'sis ,racture o, pro1imal ulna . radial head dislocation radial head dislocation ulnar nerve compression !idening o, ;oint

COLON. RECTUM - ANUS 2 t'pes o, stool . de,ine 2elenaD dar: redJ pro1imal G7& bleeding -ematoche6iaD bright redJ distal G7& bleeding Procedure o, >8E . rationale Position on bed !hen in le,t lateral decubitus

/acing !all" ceiling 7n contact !E bed" ,ree edge o, bed >ra! cloc: position o, mass >i,,erentiate internal . e1ternal hemorrhoids >o endoscop' becauseW 2illiganA2organ B?pen0 -emorrhoidectom' %llo!ed to heal b' secondar' intention %cute . long term complications o, hemorrhoidectom' %cuteD urinar' retention" in,ection" bleeding hronicD incontinence" anal stenosis" ectropion &'pes . ma1imum lengths o, endoscopes %noscop'D 5cmJ vie!s anal canal Proctoscop'D 25cmJ vie!s rectum . distal sigmoid /le1ible sigmoidoscop'D 30cmJ vie!s sigmoid olonoscop'J 100A130cmD vie!s colon" up to (iscious triad o, anal ,issureD pain" spasm" ischemia >ra! location o, ileostom' . colostom'

terminal ileum

Chapter 2 CO/O-= 7EC)U*= A-US 1. midgut = small intestine( ascending colon( proximal transverse colon 2. hindgut = distal transverse colon 9 proximal anus 3. covered by serosa = intraperitoneal colon and proximal 1%3 of rectum #. lac7 serosa = mid and lo#er rectum $. cecum = widest portion of colon8 thinnest muscular wall8 most vulnerable to perforation 6. epicolic lymph nodes found on bowel wall *. paracolic inner margin of bowel ad)acent to arterial arcades +. intermediate around mesenteric vessels ,. main at origin of superior and inferior mesenteric arteries 11. sentinel l%mph nodes first 1'# nodes to drain a specific segment of colon 11. ,al,es of Houston = 3 distinct submucosal folds 12. #alde%er3s fascia = rectosacral fascia 13. denon,illiers3 fascia = separates rectum from prostate and seminal vesicles in men( and from vagina in women 1#. columns of morgagni = longitudinal muscle folds surrounding the dentate line8 into which anal crypts empty 1$. inferior rectal ,ein = drains into internal iliac vein 16. EB coli most common aerobe8 6acteroides most common anaerobe 1*. rectoanal inhi'itor% refle2 distention of rectum causes reflex relaxation of internal anal sphincter 1+. anoscopes = +cm8 examines anal canal 1,. endorectal ultrasound evaluates depth of invasion of neoplastic lesion 21. 4 5 detect early recurrence of colorectal ca 21. une2plained iron def anemia indication for colonoscopy 22. internal hemorrhoid painless bright'red rectal bleeding w% bowel movements 23. combination of 3 doses of neom%cin and er%throm%cin = bowel preparation8 decreases post'op infxn by decreasing bacterial load of colon 2#. complicated diverticulitis? ' #& a'scess ' o'struction ' diffuse peritonitis Cfree perforationD ' fistulas 'et colon and ad@acent structures 2$. melanin spots on buccal mucosa and lips = peut8!@eghers s%ndrome 26. H-PCC & /%nch3s s%ndrome = autosom. dominant8 colorectal ca develops at an early age 2*. sigmoid ,ol,ulus? ' bent inner tube ' coffee bean appearance ' birdBs bea7 2+. CB difficile pseudomembranous colitis 2,. clindam%cin first antimicrobial agent assoc. w% pseudomem. 4olitis

31. 'o#el surger% increases ris7 of c. difficile colitis 31. internal hemorrhoid = may prolapse or bleed but rarely becomes painful unless thrombosed or w%necrosis 32. anal fissure = spasm of internal anal sphincter 33. lateral location of anal fissure evidence of underlying dis 3crohnBs( /.E( syph( tb( leu7emia6 3#. perianal a'scess most common8 painful swelling at anal verge 3$. ischiorectal a'scess horse'shoe abscess 36. Goodsall3s rule transverse line dividing perineumF to anterior and posterior to identify internal opening of fistulas in ano 3*. fistulas w% external opening anteriorly short radial tract 3+. fistulas w%external opening posteriorly cur,ilinear fashion to the posterior midline 3,. exceptions to goodsallBs rule greater than >cm from anal margin Amputat o!. P)osth$s$s a!* ,)ac$s (/a!*outs%6 Spo)ts M$*. So:t T ssu$ I!<u) $s a!* =o !t & so)*$)s (Chapt$) 83% acute vascular diseases O arteriosclerosis" thromboangiitisobliterans ,ingers and metacarpals amputation" important elements O grasp" pinch" hoo: malignant tumor measures be,ore amputation O resection" irradiation pro1imal to metatarsals O ma;or amputations S% - ,oot O s'me amputation P&+ O patellar tendon 8eplantation O upper limb Should be done to stump ,or prosthesisAma:ing A G /ore$uarter amputation O removal o, scapula and most o, clavicle %mputation in children" overgro!th O humerus" tibia" ,ibula -emiApelvectom' O anadianAt'pe hip disarticulation ?rthoses O ,or relie, o, stress on !ea:ened tissues &homas brace O nec: ?rthotist O braceAma:er (arus O L L 8everse Lachman<s O P L +as:etball in;ur' O % L" 2 L" medial meniscus Loc:ed :nee O menisci Shoulder impingement O supraspinatus tendon Mnee O anterior peripatellar approach Shoulder displacementEdislocation O anterior on,irmator' test O 287Earthroscop' Chapter ( SU7G.CA/ .-9EC).O-S 1. for bowel surgery clear li:uid diet for 12'2# hours prior to colonic resection( concurrent with using a cathartic preparation and ingesting large amts of fluid to flush the contents of colon 2. antimicrobial agents 2ndar% importance to effective surgery w%regard to tx of surg. infxn 3. proph%la2is admin of antimicrob. agent prior to initiation of surg. procedure #. empiric therapy = limited to short course of drug 33'$ days6 $. Cefa8olin prophylaxis for breast surgery 6. >!( da%s = antibiotic therapy for perforated or gangrenous appendicitis *. EB coli = most common aerobic bacteria causing hepatic abscess

I!t)aa+*om !a# I!:$ct o!s (Sa+ sto! Chapt$) 32%

Hematogenous route Most common pathogen in adults E. coli

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 /'0 tu!o#ovarian 1etroperitoneal ureter Highest mortality in perforation duodenum Most common in children )idney