HI-YIELD NOTES IN SURGERY [from USMLE clerkship-surgery & Surgical Recall] De Musset’s sign Bobbing of head w/ heartbeat

Duroziez sign Presence of diastolic femoral bruit when femoral artery is compressed
SURGERY SIGNS, TRIADS, AND ETC... enough to hear a systolic sound.
Fothergill’s sign Bluish discoloration of skin, differentiates intra from extra-abdominal mass
Important triads to remember Fox’s sign Ecchymosis of inguinal ligament seen w/ retroperitoneal bleeding
ABCD of melanoma Asymmetric, border [irregular, color variation, diameter > 0.6 Gastrinoma triangle Junction of 2nd and 3rd portions of duodenum, cystic duct, pancreatic duct
cm and dark black color Grey-Turner sign Bluish hematoma or flanks echymoses, sign of retroperitoneal hemorrhage
Achalasia triad Dysphagia, regurgitation, weight loss Hamman’s Crunching sound on auscultation of the heart resulting from emphysematous
Beck’s triad Hypotension, JVD, muffled heart sounds sign/crunch mediatinum, seen in Boerhaave’s syndrome and pneumomediastinum.
Bergman’s triad Mental status changes, petechiae, dyspnea seen in fat Hill’s sign Systolic pressure in the legs > 20 mmHg higher than in the arms
emboli syndrome Homan’s sign Calf pain on forced dorsiflexion of foot in pxs w/ DVT.
Cantrell pentalogy Omphalocele, diaphragmatic hernia, cleft sternum, absent Howship-Romberg Pain along the inner aspect of thigh seen in an obturator hernia due to
pericardium & intracardiac defects sign nerve compression
Carcinoid syndrome triad Flushing, diarrhea and R sided heart failure Kehr’s sign Severe L shoulder pain in pxs w/ splenic rupture due to referred pain from
Carney’s triad Gastric leiomyosarcoma, pulmonary chondromas, extra- diaphragmatic hernia
adrenal paraganglioma Macewen’s sign Tapping on the head of a hydrocephalic infant produces a cracked pot sound
Charcot’s triad in multiple sclerosis Scanning speech, intention tremor, nystagmus Pemberton’s sign Choking sensation aggravated by raising hand above the head [thyroid CA]
In cholangitis Jaundice, RUQ pain, fever/chills Phren’s sign Relief of pain by elevation of testicle, may be indicative of epididymitis
Cystitis triad Urinary frequency, suprapubic pain, dysuria Quincke’s sign Alternating blushing and blanching of the fingernails when gentle pressure is
Fat embolism triad Confusion, dyspnea, petechiae applied.
Glucagonoma triad DM, necrotizing skin erythema, anemia Seagesser’s sign Phrenic nerve manual compression causing neck tenderness in splenic
Grave’s disease triad Hyperthyroidism, ophthalmopathy, pretibial myxedema rupture.
Hand-Schuller-Christian triad Calvarial defects, diabetes insipidus, exopthalmos Shopping cart sign Px may be able to walk further if there is something to lean on [found in
Hematobilia triad Abdominal injury, GIT bleeding, colicky pain spinal stenosis]
Hereditary hemochromatosis triad Pigment cirrhosis w/ hepatomegaly, skin pigmentation & DM Silk-glove sign Indirect hernial sac in pediatric px, the sac feels like a finger of a silk-glove
HUS triad Anemia, thrombocytopenia & ARF when rolled under the examining finger.
Hutchinsons triad of late congenital Interstitial keratitis, notched teeth, CN 8 deafness Spurling’s sign Radicular pain produced w/ downward pressure on head when neck is
syphilis extended and tilted toward the affected side
Hypersplenism triad Splenomegaly, reduced cellular blood elements w/ high BM Trousseau’s sign Carpopedal spasm following inflation of shygmomanometer cuff to above BP
activity, correction of blood cytopenias w/ splenectomy for several mins.
Intususception triad intermittent colicky abdominal pain, billous vvomiting, Valentino’s sign RLQ pain from perforated PUD due to sucus/pus draining into the RLQ
currant-jelly stool Westermark’s sign Decrease pulmonary vascular markings on CXR in pulmonary embolus
Kartagener’s syndrome triad Bronchiectasis, sinusitis, situs inversus
Kasabach-Merit syndrome triad Rapidly enlarging cavernous hemangioma, DIC, Radiologic + Histologic hallmarks & tests to remember
hrombocytopenia “apple core” filling defect” on barium L-sided colon CA
Macklers triad Emesis, lower chest pain, cervical emphysema “Bamboo spine” in plain films Diffuse Idiopathic Skeletal Hyperostosis/Forestier synd.
Meig’s syndrome triad R –sided hydrothorax, ascites, ovarian fibroma “beads on string appearance” bile ducts Sclerosing cholangitis
Meniere’s triad Hearing loss, tinnitus, vertigo “bent inner tube” or “omega sign” Sigmoid volvulus.
Miller-Dieker syndrome triad Seizures, MR, lissencephaly Bird’s beak or steeple sign Achalasia [no gas bubble]
Multiple myeloma triad PAM [Punched-out lytic lesions, Atypical plasma cells, Boomerang sign Hydrocephalus
Monoclonal gammopathy] “calcium sign’ on CXR Thoracic aortic aneurysm
Necrotizing enterocolitis triad Feeding intolerance, abdominal distention & hematochezia Cork-screw shaped Diffuse esophageal spasm
Pellagra [niacin, vitamin B3 - 3 D’s] Dermatitis, diarrhea, dementia “Dance, target, donut & pseudokidney sign” Intususception
Pheochromocytoma triad Palpitations, headache, episodic diaphoresis “Double lumen sign” beaking, string and Carotid dissection
Plummer-Vinson syndrome triad Microcytic hypochromic anemia, atrophic glossitis, pearl sign” on angiogram
esophageal webs “egg-shaped heart” on CXR Transposition of great vessels
Reiter’s syndrome triad Conjunctivitis, polyarthritis, infection [urethritis or cervicitis] “Ground glass or bubbly lytic lesion” x-ray Fibrous dyspasia
Renal cell CA triad Hematuria, costovertebral pain, palpable mass “kidney-bean” sigmoid colon & cecum + Volvulus
Reynold’s pentad Charcot’s triad + shock & mental status changes “bird’s beak” colon on x-ray
Rubella syndrome triad Cataracts, heart defects [PDA, PAH, VSD, TOF] “Lamellated onion-skin” on x-ray Ewing’s tumor
Saint’s triad Cholelithiasis, hiatal hernia and diverticular disease “Lead pipe appearance” on barium IBD [ulcerative colitis]
Sjogren syndrome triad Xerostomia, keratoconjunctivitis sicca, CT / autoimmune dse “Mushroom-like” bony prominence on x-ray Osteochondroma
Somatostatinoma tumor triad Gallstones, DM, steatorrhea Neuhausser’s sign/”soap bubble sign” or Meconium ileus
“port wine facial nevus, cortical atrophy and seizures + “ground glass appearance” in RLQ on AXR
calcification of cortex appearing as “tram tracks” on x-ray Pneumatosis intestinalis on AXR NEC
Thrombotic thrombocytopenic FAT RN [Fever, Anemia, Thrombocytopenia, Renal and “popcorn-like” lesion on x-ray Pulmonary hamartoma
purpura, TTP pentad Neurologic dysfunction] “Chain of lakes” on pancreatography Chronic pancreatitis
Tuberous sclerosis clinical triad MR, adenoma sebaceum [perivascular fibromata], seizures. AXR:“Sentinel loop sign & colon cutoff sign” Acute pancreatitis
Virchow triad of thrombus formation Endothelial injury, stasis, blood hypercoagulability “soap-bubble” appearance Giant cell tumor
Wegener’s granulomatosis triad Acute necrotizing granuloma; focal necrotizing or “soap-bubble appearance” on x-ray Multiple myeloma.
granulomatous vasculitis; cresentic glomerulosclerosis “stepladder” arrangement on upright film Paralytic ileus
Wernicke triad of alcoholic Confusion, ataxia, ophthalmoplegia “String sign, shoulder & double tract sign” Pyloric stenosis
encephalopathy “Sunburst patern” of sulfur granules Actinomycoses infection
Wilm’s tumor triad Flank mass, hematuria, HPN “Sun burst or sun ray pattern” on x-ray Osteosarcoma
Wiskott-Aldrich triad Pyogenic infections, thrombocytopenic purpura, eczema “thumb printing” on barium enema Ischemic colitis
Whipple’s triad of insulinoma Hypoglycemic attacks [<50 mg/dl], CNS [stupor, confusion, “tram tracks” on x-ray Sturge-Weber syndrome
LOC], attacks precipitated by fasting or exercise & promptly Allen’s test Test for patency of ulnar artery prior o placing a radial
relieved by feeding or parenteral glucose
arterial line or performing an ABG.
Tinel’s test Tapping over median nerve at wrist produces pain and
Important signs to remember
paresthesia
Balance’s sign Dullness to percussion in LUQ and resonance to percussion in R flank seen SURGICAL SYNDROMES
w/ splenic rupture or hematoma.
Leriche’s synd. Claudication of buttocks, impotence, atrophy of buttocks
Battle’s sign Echymosis over the mastoid process in patients w/ basilar skull fractures
Li-Fraumeni synd. Associated w/ breast CA and soft tissue sarcoma
“Blue dot sign” A blue dot on scrotal skin from a twisted testicular appendage.
Red reaction synd. Syndrome of rapid vncomycin infusion resulting in skin erythema
Bell clapper deformity Bilateral non-attachment of the testicles by the gubernaculum to the scrotum
Ogilvie’s synd. Massive non-obstructive colonic dilatation
Blummer’s shelf Metastatic disease to the rectouterine pouch of Douglas or rectovesical
Gardner’s synd. GI polyps w/sebaceous cysts, osteomas, and desmoid tumors
pouch creating a “shelf” that is palpable on rectal examination.
Eagle-Barret’s Aka prune-belly syndrome, congenital inadequate abdominal musculature
Boas sign R subscapular pain resulting from cholelithiasis
Fitz-Hugh-Curtis Perihepatic gonorrhea syndrome
Chvostek’s sign Tapping the facial N. in front of ear tragus causes ipsilateral twitching
Heerfordt’s synd. Sarcoidosis w/ parotid enlargement, faial nerve paralysis, and uveitis
Courvoiser’s sign A palpable, nontender gallbladder often associated w/ CA in head of the
Horner’ syndrome Miosis, ptosis, enopthalmos, decreased sweating
pancreas or the gallbladder
Tietze’s syndrome Costochondritis of rib cartilage, aseptic, tx w/ NSAIDS
Cullen’s sign Aka periumbilical ecchymoses, indicative of intraperitoneal hemorrhage
Poland’s synd. Absence of pectoralis major and minor muscle, often associated w/ ipsilateral
Dance’s sign Empty RLQ in children w/ ileocecal intussusception

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 hand malformation Puestow procedure Side-to-side anastomosis of pancreas and jejunum [pancreatic duct is
Plummer-Vinson Esophageal web, IDA, dysphagia, spoon-shaped nails, atrophic oral and filleted open]
tongue mucosa Stamm gastrostomy Gastrostomy placed by open surgical incision and tacked to abdominal wall
Carcinoid synd. Bronchospasm, flushing, diarrhea, R-sided heart failure Highly-selective Transaction of vagal fibers to body of stomach w/o interruption of fibers to
Afferent loop synd. Obstruction of afferent loop of a billroth 2 gastrojejunotomy vagotomy pylorus
Short gut synd. Malnutrition resulting from < 100 cm of viable small bowel LOA Lysis of adhesions [enterolysis]
Stewart-Treves Lymphangiosarcoma arising in chronic lymphedema after axillary for breast CA Nissen fundoplication 360 degrees wrap of stomach by its fundus around the distal esophagus to
Blind loop synd. Bacterial overgrowth of intestine caused by stasis prevent GERD and esophageal hiatal hernia
Frey’s synd. Flushing, pain, and diaphoresis in auriculotemporal nerve distribution [crocodile Graham patch Placement of omentum w/ stitches over a gastric duodenal perforation
tears] Heineke-Miculicz Longitudinal incision thru all layers of pylorus to make it non-functional,
Rendu-Osler- Syndrome of GI tract telangiectaasia, and AVA malformations pyloroplasty used after truncal vagotomy
weber syndrome Modified radical Removal of breast, nipple and axillary LN [no muscles are removed]
Ramsay-hunt synd Painful facial nerve paralysis from herpes-zoster of the ear mastectomy
Boerhaave’s synd. Esophageal perforation Lumpectomy Removal of breast mass and axillary LN, normal surrounding breast tissue
Thoracic outlet Compression of structures exiting from thoracic outlet is spared
Munchausen synd. Self-induced illness TURP – transurethral Femoral artery to popliteal artery bypass using synthetic graft or saphenous
Mikulicz’s synd. Any cause of bilateral enlargement of parotid, lacrimal & submandibular glands resection of prostate vein; used to bypass blockage in the femoral artery
Nelson’s synd. Functional pituitary adenoma producing excessive ACTH and mass effect CABG – coronary Via saphenous vein graft or internal mammary artery bypass grafts to
producing visual disturbances, hyperpigmentation, amenorrhea, w/ elevated artery bypass grafting coronary arteries from aorta [cardiac revascularization]
ACTH levels Hartmann’s pouch Oversewing of a rectal stump after resection of a colonic segment, px is left
SVC syndrome Obstruction of SVC [e.g. tumor, thrombosis] w/ a proximal colostomy
Trousseau’s synd. Syndrome of DV associated w/ CA Ileoanal pull-through Anastomosis of ileum to the anus after total proctocolectomy
Mirrizzi’s synd. External compression of CHD by gallstone impacted in cystic duct. Whipple’s procedure Removal of GB, CBD, anthrum of stomach, duodenum, proximal jejunum
Budd-chiari synd. Thrombosis of hepatic veins and head of pancreas [en bloc].
Mendelson’s synd. Chemical pneumonitis after aspiration of gastric contents Rastelli procedure Aorta is rerouted internally to L ventricle across VSD
Millard-Gubler VI & VII nerve palsy, contralateral hemiplegia in pons infarct
Compartment Swelling of injured extremity w/ pain, paresthesia, pallor, pulselessness, WOUNDS
syndrome poikilothermia. • Steps in wound healing
DiGeorge Absence of parathyroids and thymic agenesis [chief cells] 1. coagulation
2. inflammation
Sheehan’s Postpartum infection & necrosis of pituitary leading to hormonal failure
3. collagen synthesis
Fitz-Hugh-Curtis Perihepatitis associated w/ chlamydial infection of cervix
4. angiogenesis
Felty’s syndrome Rheumatoid arthritis, splenomegaly, and leucopenia or neutropenia 5. epithelialization – usually complete by 24-48 hrs
Lutembacher Ostium secundum defect + mitral stenosis 6. contraction
Maffucci syndrome Multiple enchondromas associated w/ multiple hemangiomas • risk of infection for wounds:
Albright syndrome Polyostotic fibrous dysplasia w/ precocious puberty & darkly pigmented skin Clean 1.5%
Sjogren’s Autoimmune exocrinopathy associated w/ rheumatoid arthritis, decreased Clean-contaminated 3%
salivary & lacrimal gland secretion & lymphoid proliferation
Contaminated 10%
Dirty 30-35%
SURGICAL ANATOMY PEARLS
Artery of Adamkiewicz Responsible for anterior spinal syndrome
• Classic sins of wound infection:
Cantle’s line Line drawn from IVC to just left of the gallbladder fossa, it separates the
Calor Heat
R and L lobes of the liver
Rubor Redness
Gerota’s fascia Fascia surrounding the kidney
Tumor Swelling
Ilioinguinal nerve Located on top of the spermatic cord
Dolor Pain
Morrison’s pouch The hepatorenal recess, the most of the posterior cavity w/in peritoneal
Functio laesa Loss of function
cavity
Part of GIT w/o serosa Esophagus, middle and distal rectum
• 5 W’s in post-op fever: wound infection, wind [atelectasis], water [UTI], walking [DVT],
Pouch of Douglas Pouch between the rectum and bladder or uterus
wonder drugs
Retroperitoneal GIT Duodenum, ascending and descending colon, and pancreas
Rotter’s LN Lymph nodes in between pectoralis major and minor muscles
Rapid recall
Space of Retzius Preperitoneal space anterior to bladder Early surgical infections that occur in the 1st 24 hrs post-op Streptococcus & clostridium
Submucosa Strongest layer of the small bowel are MC due to
T10 Dermatome at umbilicus MC source of wound infection is Host’s normal flora
White lines of Toldt Lateral peritoneal reflections of the ascending and descending colon MC cause of poor wound healing Tissue hypoxia
Vein of Mayo Vein that overlies the pylorus MC cause of post-op fever w/in 1st 24 hrs Atelectasis
SURGICAL OPERATIONS – MUST KNOW FLUIDS, ELLECTROLYTES AND NUTRITION
Billroth 1 antrectomy w/ gastroduodenostomy • Even w/o intake, a person must excrete 800 ml/day in urine waste products.
Bilroth 2 antrecomy w/ gastrojejunostomy • Third spacing is the shift of ECF from plasma compartment to elsewhere [interstitial or
Roux-en Y limb Jejunojejunostomy forming a y-shaped figure of small bowel + transcellular process]
gastrojejunostomy • Normal urine output: 0.5 cc/kg/hr for adults and 1 cc/kg/hr for children.
Brooke’s ileostomy Standard ileostomy that is folded on itself to prude from the abdomen • Hyponatremia = < 130 mEq/L, symptomatic when < 120 mEq/L
Bassini herniorrhaphy Repair of inguinal hernia by approximating transverses abdominis • Hypernatremia = > 145 mEq/L
aponeurosis and conjoint tendon to poupart’s lig. • Hypokalemia = < 3.5 mEq/L [ECG – flattened T waves, ST depression, U wave]
McVay herniorrhaphy Repair of inguinal hernia by approximating the ransversus abdominis • Hyperkalemia = > 5 mEq/L [ECG – peak T waves, wide QRS, T wave disappearance w/ sine
aponeurosis and conjoint tendon to cooper’s ligament wave pattern]
Lichtenstein “tension-free” inguinal hernia repair using synthetic graft maternal • Hypocalcemia = < 8 mg/dl [ECG – prolonged QT interval]
herniorrhaphy
• Hypercalcemia = > 15 mg/dl
Shouldice Repair of inguinal hernia by imbrication of the transversalis fascia,
• Causes of elevated anion gap metabolic acidosis: MUDPILES [Methanol, Metabolism, Uremia,
herniorrhaphy transversus abdominis, and the conjoint tendon and approximation of
DKA, Paraldehyde, Iron, INH, Lactic acidosis, Ethylene glycol, Salicylates]
transverses abdominis aponeurosis and conjoint tendon to the inguinal
• Causes of normal anion gap metabolic acidosis: HARD UP [Hyperparathyroidism, Adrenal
ligament
insufficiency, RTA, Diarrhea, Uteroenteric fistula, Pancreatic fistulas]
APR Abdomino-perineal resection; removal of the rectum and sigmoid colon
through abdominal and perineal incisions [patient is left w/ colostomy] used
Rapid recall
for low rectal CA < 8cm from anal verge
MC fluid disorder DHN
LAR Low-anterior resection; resection of low rectal tumors through an anterior
MC cause of normovolemic hyponatremia SIADH
abdominal incision
The 1st organ affected in hypovolemic/cardiogenic shock [both cold shocks] Kidneys
Hartmann’s procedure Proximal colostomy, distal stapled-off-colon or rectum that is left in
peritoneal cavity MC cause of hypovolemic shock in 1st 24 hrs after abdominal surgery Hemoperitoneum
Mucus fistula Distal end of end of colon is brought to abdominal skin as stoma MC fluid disorder in surgical px ECF volume deficit
Kocher maneuver Dissection of duodenum from R sided peritoneal attachment o allow
mobilization and visualization of the back of duodenum / pancreas TRAUMA

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 • Crystalloids include normal saline and LR, while colloids include blood products such as RBC • “Rule of nines” in burns:
and albumin. i. Each upper limb = 9%
• An enlarging pupil w/ decrease in level of consciousness is suggestive of: uncal herniation ii. Each lower limb = 18%
• Retroauriccular ecchymosed [Battle’s sign] and periorbital ecchymoses [Racoon’s eye] is iii. Anterior and posterior trunk = 18% each
suggestive of: Basilar skull fractures iv. Head and neck = 9%
• A 20 y/o female has a brief loss of consciousness following a head injury. She is awake but is v. Perineum and genitalia = 1%
amnestic for the event and keeps asking the same questions again and again: concussion • “Rule of palm” – the surface area of the pxs palm is approximately 1% of TBSA used for
• A 21 y/o male w/ head injury has loss of consciousness flowed by a brief lucid interval. He estimating size of small burns.
presents w/ an ipsilateral fixed and dilated pupil and contralateral hemiparesis: epidural • Types of burns:
hematoma [biconvex or lenticular in shape]. Degree PE Depth Sensation Color Healing
• Measures to lower ICP: HIVED [Hyperventilation, Intubation, Ventriculostomy, Elevate head, 1st Blush Superficial Painful Red 7 days
Diuretics] Desquamate Thickness
• A 70 y/o male presents to the ED after a whiplash injury. He is ambulating well but has an 2nd Blister, wet Partial Very painful Glistening 7-21
extremely weak handshake: central cord syndrome thickness pink superficial
• Distraction/seat-belt injury/chance fracture – a horizontal fracture thru the vertebral body, 21-35 - deep
spinous processes, laminae, pedicles, and tearing of the posterior spinous ligament. 3rd Charred Full thickness Painless White/black Grafting
• A 19 y/o male, who was stabbed in the chest complaints of dyspnea. Breath sounds on the left NOTE: Mild [< 10% TBSA], moderate [10-30% TBSA], severe [> 30% TBSA]
are absent: pneumothorax
• A 25 y/o female presents after a high speed MVC w/ dyspnea and tachycardia. There is focal Rapid recall
bruising over the R side of her chest. CXR shows a RU lobe consolidation: pulmonary MC compartment requiring fasciotomy Anterior tibial compartment
contusion MC causes of post-burn pneumonia S. aureus, Pseudomonas
• Criteria for a [+] DPL: Common organisms found in burn wound infections S. aureus, Pseudomonas, Strep, C. albicans
1. > 10 ml gross blood on initial aspiration MC type of burns in children Scalding injury
2. > 100,000 RBC MC complication of electrical burns Peripheral nerve injury
3. > 500 WBC
4. gm stain w/ bacteria or vegetable matter BREAST
5. amylase > 20 IU/L Anatomy
6. presence of bile • Have ligaments that extend from deep pectoral fascia to superficial dermal fascia that provide
Classification of severity of hypovolemic shock structural support referred to as cooper’s ligaments.
Class Amount Description % blood loss • Boundaries of axilla for dissection:
1 750 cc Slight tachycardia, normal BP & UO 15% Superior Axillary vein
2 750-1500 cc tachyC, tachypnea, CRT< 2, orthostasis, ↓ BP, 15-30% Posterior Long thoracic nerve
agitation, confusion Lateral Latissimus dorsi muscle
3 1500-2000 cc All of the above, [+] lethargy, & ↓ UO 30-40% Medial Lateral to, deep to, or medial to pectoral minor muscle
4 > 2000 cc > 40%
• Rotter’s nodes lies between the pectoralis major and minor muscles.
Types of sepsis • Blood supply of breast: axillary A. [via lateral thoracic & thoracoacromial branches], internal
SIRS T< 36 or >38, PR>90, RR>20, PaCO2<32, WBC>12,000 or <4,000, bands <10 mammary A. [via perforating branches] & intercostal A.
Sepsis SIRS, [+] known source of infection • A nerves that surgeon must be aware of during axillary dissection: long thoracic,
Severe Sepsis, [+] organ dysfunction, hypotension but respond to fluid resuscitation thoracodorsal, medial and lateral pectoral nerves.
Shock Sepsis that is refractory to fluid resuscitation • Levels of axillary LN of breast:
Level 1 [low] Lateral to pectoral nerve
Properties of pleural effusion fluid Level 2 [middle] Deep to pectoral minor
Components Transudate Exudate Level 3 [high] Medial to pectoral minor
Sp. gravity < 1.016 > 1.016
Protein < 3 gm/dl > 3 gm/dl Breast pathology
LDH < 0.5 > 0.6 • Developmental disorders of the breast:
Glucose High Low Mastitis neonatorum Witch’s milk
Amylase Low High Amastia Absent breast
RBC count Low High Athelia Absent nipple
WBC count Low High Amazia Nipple is present, glandular tissue is absent
Polythelia Supranemerary nipples
Rapid recall Polymastia Accessory breast tissue
MC cause of shock Hemorrhage
MC injured abdominal organ in blunt trauma Spleen > liver • Skin dimpling in breast CA is due to traction on Cooper’s ligament.
MC injured abdominal organ in penetrating trauma Small bowel • A female w/ 1 or more risk factors for breast CA presents w/ a mass in upper outer quadrant of
MC injured solid organ associated w/ penetrating trauma Liver breast. She’s at risk of cancers occur in the: upper outer quadrant
MC surgical cause of emergency Acute appendicitis • Axillary V. is responsible for the majority of venous drainage in breast.
MC level of spinal fracture C5 • Venous drainage is largely responsible for metastases to the spine thru Batson’s plexus.
MC level of subluxation C5 on C6 [communication w/ vertebral veins, route for hematogenous spread to vertebral column and
MC finding in thoracic great vessel injury Indistinct aortic knob hips
MC thoracic traumatic injury Pulmonary contusion • Long thoracic nerve causes “winging of scapula” in post-mastectomy pxs [serratus anterior
MC renal traumatic injury Renal contusion muscle]
MC cause of non-traumatic pneumothorax Ruptured pulmonary bleb • Breast exam recommendations:
MC cause of spontaneous pneumothorax Rupture of subpleural space For all ages SBE every month
MC cause of chylothorax Distal esophagectomy 20-40 y/o Breast exam 2-3 yrs by physician
MC Sx of pneumothorax Chest pain > 40 y/o Annual breast exam by physician
MC cause of pneumoperitoneum in adults Gastroduodenal perforation [+] hx of breast CA PE every 3-4 mos. for 2 yrs
In infants Ruptured Meckel’s diverticulum w/ lobular CA in-situ 2x/yr clinical breast exam, annual mammography
Least common GUT injury Ureteral injury w/ atypia Annual clinical breast exam & mammography
Clinically apparent tamponade may result from 60-100 ml of blood w/ AD pattern 2x/yr clinical breast exam, annual mammography
Jeferson’s fracture C1 or atlas
Hangman’s fracture C2 or dens • Breast CA mutations:
CSF is formed in the choroid plexus at a rate of 150 cc BRCA 1 Mutation linked w/ breast, ovarian & prostate CA Chr. 17q21
Procedure of choice for px w/ laryngotracheal separation. Tracheostomy BRCA 2 Mutation linked w/ male & female breast CA Chr. 13q12
Region most vulnerable to injury in spinal trauma Cervical vertebrae
Most sensitive test for retroperitoneal injury CT scan • Chemoprevention of breast CA:
Occlusion of the portal triad manually or w/ an atraumatic Pringle maneuver Tamoxifen Decreases the incidence of contralateral breast CA in pxs w/ previous hx
vascular clamp. Occlusion should not exceed 20 mins S/E: hot flushes, vaginal discharge, endometrial CA, DVT, embolism
Raloxifen SERM, also used to treat osteoporosis
THERMAL INJURY
• Burn scar CA called Marjolin’s ulcer is usually squamous cell CA w/c metastasizes via • Indications for prophylactic mastectomy:
lymph node. i. Hereditary breast CA: BRCA 1 & 2

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 ii. Strong family of breast CA MC breast tumor in pxs < 30 y/o Fibroadenoma
iii. Personal hx of lobular CA MC cause of green, straw or brownish nipple discharge Fibrocystic disease
iv. Personal hx of atypia & breast CA MC cause of breast mass after breast trauma fat necrosis
v. Women anxious of CA development MC site of breast metastasis lungs > bone
• The smallest breast mass palpable on PE is 1 cm. Tumors running and leeping promptly to bone Thyroid, Renal, Lung, Prostate, Breast
• A female complains of nipple pain during breastfeeding w/ focal erythema and warmth of breast Thrombophlebitis of superficial breast veins Mondor’s disease
on PE: mastitis Most important factor in prognosis of patients Axillary lymph node status
• A 25 y/o female presents w/ painful breast mass several weeks after sustaining breast trauma Most important prognostic factor in breast CA Stage of disease [axillary node mets]
by a seat belt car injury: fat necrosis
• A 20 y/o female presents w/ a well-circumscribed mass in her L breast. It is mobile, nontender THYROID
and has defined borders on PE: fibroadenoma Anatomy & embryology
• A female presents of acute pain in her axilla and lateral chest wall, and a tender cord is • Thyroid forms at base of tongue a 3rd wk AOG
identified on PE: mondor’s disease [superficial thrombophlebitis of lateral thoracic & • Ligament of Berry: ligament that attaches thyroid to the cricoid.
thoracoepigastric V.]
• The recurrent laryngeal nerve innervates all of the intrinsic muscles of the larynx except the
• A 35 y/o female presents w/ straw colored nipple discharge and bilateral breast tenderness cricothyroid.
that fluctuates w/ her menstrual cycle: fibrocystic changes [no ↑risk for breast CA]
• Thyroglossal duct obliterates after 2nd month.
• A 45 y/o female presents w/ breast pain that does not vary w/ her menstrual cycle w/ lumps in • Thyroid follicles store enough hormones to last 2-3 mos
her nipple-areolar complex and a hx of non-bloody nipple discharge: mammary duct
• Iodine trapping & T4 synthesis begin by 3-4 mos. AOG.
ectasia
• Relationships:
• A 46 y/o female presents w/ 1 month hx of spontaneous unilateral bloody nipple discharge.
Anterior SCM, sternothyroid, thyrohyoid, omohyoid
Radical compression of the involved breast results in expression of blood at 12 o’ clock position:
intraductal papilloma Posterior Trachea
• MC invasive breast CA: infiltrating ductal CA [in peri/postmenopausal women] Posterolateral Common carotid A., IJV, vagus nerves
• 2ND MC type of invasive breast CA: Infiltrating lobular CA
• 20% of infiltrating lobular breast CA have simultaneous contralateral breast CA. • Composed of cuboidal epithelium & central colloid
• A 65 y/o female presents w/ pruritic pain, scaly rash on her nipple discharge: paget’s disease • W/in stroma are C cells w/c secrete calcitonin
• A 45 y/o female presents w/ enlargement of her L breast w/ nipple retraction, erythema [peau • Blood supply of thyroid: superior [from 1st branch of external carotid A. at level of carotid
de orange], warmth, and induration: inflammatory breast CA bifurcation] & inferior thyroid A. [from thyrocervical trunk of subclavian A.], thyoridea ima
[from aortic arch or innominate A.]
• Breast CA risk factors: early menarche < 12, late menopause > 55, 1st pregnancy > 30
• Screening for breast CA: annual mammograms after age 50 • Venous drainage: superior [to IJV], middle [to IJV] & inferior thyroid [to brachiocephalic V.]
• Innervation: R recurrent & L recurrent [from vagus], & superior + middle symphathetic
• BRCA 1 is associated w/ ovarian CA.
ganglia [sympathetic] & vagus N. [parasympathetic]
• 5-10% of breast masses have [-] mammograms
• Recommended therapy for breast CA: CAF [Cyclophosphamide, Adriamycin, 5-FU] or CMF Nerve injuries
[methotrexate instead of adriamycin]
Superior Sensory Inability to perceive foreign body
• Prognosis depends more on stage than on histologic type of breast CA.
laryngeal Motor Unilateral – huskiness & weakness of voice
• Type of chemotherapy used in breast CA: CMF [cyclophosphamide, methotrexate, 5-FU] or nerve Bilateral – easy fatigability in speaking, ↓ volume & pitch of voice
CAM [cyclophosphamide, adriamycin, 5-FU]
Recurrent Sensory Loss of sensation to lower pharyngeal mucosa
• Chemotherapy for DCIS: tamoxifen after lumpectomy and radiation
laryngeal Motor Unilateral – unilateral paralysis of vocal cords, hoarse voice
nerve Bilateral – respiratory difficulty
Reporting mammogram results
I No abnormality
Assessment of thyroid function
II Benign abnormality
• If T production is increased, both tT4 & fT4 increase & vice-versa
III Probably benign finding
• If amount of TBG changes, ONLY tT4 changes [NOT fT4]
IV Suspicious for CA
• TT3: useful to confirm dx of early hyperthyroidism
V Highly suspicious for CA
• Pemberton’s sign: choking sensation aggravated by raising hand above the head
Staging of breast CA
Important terms & concepts
Stages S.R Description
Myxedema coma Caused by severe hypothyroidism triggered by stress [infection, alcohol, drugs],
0 100% DCIS or LCIS leads to inspiratory or respiratory insufficiency, hypothermia
1 92% Invasive CA < 2 cm [+] LN, [-] mets Metyrapone test Test for anterior pituitary hypofunction, blocks cortisol production, evaluates
2 87% Invasive CA < 5 cm, [+/-] movable axillary LN, [-] no mets pituitary ACTH production
3 75% Invasive CA > 5 cm, [+] fixed axillary LN, [+] ipsilateral internal mammary LN Plummer disease Nodular toxic goiter, autonomously hyperfunctioning thyroid gland, normal
or any CA w/ skin involvement, pectoral & chest fixation, [-] distant mets thyroid tissue functions are suppressed
4 13% Any form of breast CA w/ distant mets including ipsilateral supraclavicular LN Thyroid storm Extreme hyperthyroidism precipitated by surgery or infection. Sx of high fever,
DHN, tachycardia, w/ high-output cardiac failure & coma. 25% mortality. Tx:
Lobular vs. Ductal CA in-situ beta-blocker, PTU, iodine, cooling measures
Features Lobular CA in-situ Ductal CA in-situ
Age of onset Premenopausal Postmenopausal Thyroid anomalies:
PE - Palpable mass Lingual thyroid Thyroid tissue that failed to descend presenting as posterior tongue
Mammogram - Microcalcification mass
Diagnosis Incidental Work-up abnormality Lateral aberrant thyroid Mass at lateral thyroid lobe, may manifest as enlarged L thyroid gland
Risk In all breast tissue At site of diagnosis Pyramidal lobe Fibrous remnant of thyroglossal duct that persists as finger-like
Treatment Observation vs. chemotherapy Lumpectomy + radiation vs. ipsilateral projection from isthmus
vs. prophylactic mastectomy simple mastectomy, tamoxifen Thyroglossal duct cyst – Mass btw hyoid bone & isthmus that moves upward on tongue
MC thyroid anomaly protrusion
Breast operations Managed by Sistrunk procedure
Radical mastectomy Resection of all breast tissue, axillary LN, pectoralis major & minor M.
MRM Same as radical mastectomy except pectoralis M. is left intact Thyroid diseases
Simple mastectomy Same as radical mastectomy except pectoralis M. is left intact & NO Refetoff’s syndrome T4 refractoriness
axillary node disection Jod-Basedow syndrome Hyperthyroidism 2◦ to ↑ I2 intake
Lumpectomy & axillary Resection of mass w/ rim of normal tissue & axillary node dissection, Pendred’s syndrome Goiter w/ deafness
node dissection good cosmetic result Plummer’s disease Toxic multinodular goiter
Sentinel node biopsy LN are identified on preoperative scintigraphy & blue dye is injected
• The only anti-thyroid drug that can be given to pregnant pxs: PTU
Rapid recall • 15% of solitary thyroid nodules are malignant
Hx of female w/ backpain [if reproductive, young age] High risk for breast CA • 85% of cold nodules have 10-25% chance of malignancy.
Hx of male w/ backpain High risk for prostate CA • 5% of hot nodule have 1% chance of malignancy
Ideal breast self-examination is done at 1 week after menstrual period
Most worrisome radiologic feature for breast CA: SpIculated masses w/ microcalcific & Thyroid CA
linear branching calcifications Features Papillary – MC Follicular Medullary Anaplastic
Most lethal breast CA Inflammatory carcinoma Risk factors Radiation Dyshormogenesis MEN - risk Iodine deficiency
MC histologic type of breast CA in MALES Infiltrating ductal CA Sex F>M F>M F>M F>M
MC cause of bloody nipple discharge in young women Intraductal papilloma S/Sx Painless mass, Painless mass Painful mass, Hard, fixed LN,

4
 dysphagia, SOB dysphagia, SOB neck pain,
dysphonia
Dx FNAB, CT-MRI FNAB, CT-MRI FNAB, [+] FNAB Parathyroid pathology
amyloid -dxtic • Hypercalcemic crisis: Ca+ > 13 mg/dl. Treat w/ saline, diuretics, & anti-arrhythmic agents
Grossly Encapsulated, hard, Encapsulated, Unilateral, mid- Macroinvasion, • A patient complains of tingling around her lips on post-op day 1 S/P total thyroidectomy:
multifocal solitary upper lobes clinically + LN hypoparathyroidism causing hypocalcemia
Histologic Psammoma Solitary, C cell-origin, Sheets of • Parathyroid CA: high Ca+, PTH, & alk phosphatase
bodies, orphan- encapsulated sheet of cells, heterogenous
annie eyes amyloid, collagen cells ADRENALS
Metastases Lymphatic Hematogenous Lymphatic Aggressive Anatomy & histology
Tx Lobectomy, Lobectomy & Total D-bulking • Located at level of T11
isthmetomy, total or isthmectomy, thyroidectomy & resection of • Vasculature: branches of aorta, inferior phrenic & renal A.
near-total total or near-total central neck thyroid, external • Venous drainage: central V. to IVC [on R] & L renal V. [on L]
thyroidetomy thyroidetomy dissection radiation tx • Cortex: aldosterone [zona glomerulosa], cortisol [fasciculata], sex steroids [reticularis]
Prognosis Worse for old age Worse for old age Poor prognosis
Variants Sclerosis Hurtle cell tumors Adrenal pathology
10-yr SR 74-93% 70% 70-80% Median: 4-5 mos. • CA commonly associated w/ hypercalcemia: breast CA metastases, prostate CA, kidney; lung,
pancreatic, multiple myeloma
• Risks of thyroid surgery include: recurrent laryngeal nerve injury, hypoparathyroidism, and • Procedures for adrenal diseases:
persistent hyperparathyroidism [w/ subtotal thyroidectomy] Cushing’s disease Transphenoidal resection of pituitary adenoma
• Surgical operation for thyroid: Adrenal adenoma Laparoscopic adrenalectomy
< 1.5 cm w/ no hx of neck radiation Thyroid lobecomy and isthmectomy, near total Adrenal carinoma Open adrenalectomy
exposure thyroidectomy or total thyroidecomy Ectopic ACTH Resection of primary lesion
> 1.5 cm, bilateral, + cervical node Total thyroidectomy
mets or hx of radiation exposure • A px w/ known addison’s disease presents w/ acute upper abdominal painw/ peritoneal signs
and confusion: addison’s crisis
• Causative agents for thyroiditis: strep pyogenes, staph aureus, pneumococcus • MC extra-adrenal location of neuroblastoma: organ of Zuckerkandl [to L of aortic bifurcation of
pneumoniae IMA]

Thyroid nodules are likely to be malignant when: Adrenal diseases

1. occur in young men Cushing’s disease Hypercortisolism
2. hx of radiotherapy to head or neck during childhood Addison’s disease Adrenal insufficiency
3. nodule grows rapidly w/ hoarseness or dysphagia Conn’s disease Hyperaldosteronism
4. not suppressed by L-thyroxine Primary Conn’s Secondary to excessive aldosterone secretion
5. cold nodules on RAI scintiscan Secondary Conn’s Secondary to increase renin
6. nodules appear solid or heterogenous on UTZ
Laboratory findings in Cushing’s syndrome
Iatrogenic Pituitary ACTH Adrenal cortisol Ectopic ACTH
Subacute vs. Hashimoto’s thyroiditis hypercortisolism hypersecretion hypersecretion production
Features Subacute thyroiditis Hashimoto’s thyroiditis ACTH ↓ ↑ ↓ ↑
Etiology Viral [mumps, coxsackievirus] Autoimmune disorder Urinary free ↑ ↑ ↑ ↑
History/PE Malaise, URI, fever, tender Painless thyroid enlargement, pain cortisol
thyroid, hyper to hypothyroidism & tender, hyper to hypothyroidism DHEA ↓ ↑ ↑ ↑
Evaluation ↓ RAI w/ ↑ T4 & T3, ↓ TSH Antithyroid antibody assay is
generally [+], ↓ T3 & T4, ↑ TSH Primary vs. secondary adrenal insufficiency
Treatment Symptomatic, self-limited Exogenous thyroid hormone Features Addison’s disease 2◦ adrenal insufficiency
ACTH High Low
Thyroid hormones
Cortisol after ACTH challenge Low High
L-thyroxine [T4] Triiodothyronine [T3]
Produced only in thyroid gland 80% from peripheral conversion PITUITARY
Half life: 7 days 1 day Anatomy
Only free hormones are active 3x more potent than T4 • Parts; adenohypophysis [from Ratche’s pouch]; anterior lobe while neurohypophysis from
99.7% protein bound neural primordial]; posterior lobe
More abundant lesser • Anterior lobe lacks direct supply. Portal channels from hypothalamus & posterior pituitary supply
Bigger Smaller it
Ø thyroid enlargement + ↑TH = toxic goiter • Posterior pituitary is supplied by middle & inferior hypophyseal arteries [from ICA]
Ø ↑TH + thyroid not enlarged = hyperthyroid • Drains via cavernous sinus to petrosal sinus to jugular veins
Ø ↑TH + S/Sx = thyrotoxicosis
Ø Enlarged thyroid = goiter Pituitary pathology [see IM notes]
• Microadenoma: > 1 cm diameter while macroadenomas: < 1 cm
Surgical treatment of Thyroid diseases
Grave’s disease Bilateral subtotal thyroidectomy or radioiodide ablation Familial syndromes w/ pheochromocytoma
Papillary CA Total thyroidectomy Syndrome Components
Follicular CA Total thyroidectomy, [+] RAI MEN type 2 or 2A Medullary thyroid CA and C cell hyperplasia, pheochromocytomas
Medullary CA Total thyroidectomy, [+] neck LN dissection and adrenal medullary hyperplasia, parathyroid hyperplasia
Anaplastic CA Debulking & tracheostomy MEN type 3 or 2B Medullary thyroid CA and C cell hyperplasia, pheochromocytomas
Thyroid lymphoma Chemotherapy & radiation and adrenal medullary hyperplasia, mucosal neuromas, marfanoid
1◦ hyperparathyroidism Parathyroidectomy features
2◦ hyperparathyroidism Treat underlying cause, parathyroidectomy Von hippel-Lindau Renal, hepatic, pancreatic and epididymal cysts, renal cell CA,
pheochromocytomas, angiomatosis, cerebellar hemangioblastomas
PARATHYROIDS Von Recklinghausen Neurofibromatosis, cfe au lait spots, schwannomas, meningiomas,
Anatomy & embryology gliomas, pheochromocytomas
• Superior glands originate from 4th pharyngeal pouch, Inferior glands originate from 3rd Sturge-Weber Cavernous hemangiomas of 5th cranial nerve distribution,
pharyngeal pouch [in conjunction w/ thymus] pheochromocytomas
• Contains chief cells w/ occasional oxyphils, secretes parathormone [calcitonin]
• Tubercle of Zuckerkandl: most posterior extension of lateral thyroid lobes MEN syndromes
• Ligament of Berry: connects thyroid to trachea Type MEN 1 [Wermer] MEN 2 OR 2A [Sipple] MEN 2B OR 3
• Vasculature: inferior thyroid A., superior, middle & inferior thyroid V. Pituitary Adenomas
• Innervation: Parathyroid Hyperplasia, adenomas Hyperplasia, adenoma Hyperplasia
External branch of Cricothyroid M. Causes disability on phonation Pancreatic Hyperplasia, adenoma,
superior laryngeal N islets CA
Recurrent laryngeal N. Intrinsic muscles R: near subclavian A. Adrenal Cortical hyperplasia Pheochromocytoma Pheochromocytoma
of larynx L: near ligamentum arteriosus Thyroid C-cell hyperplasia Medullary carcinoma Medullary carcinoma

5
 Extraendocrine Mucocutaneous 1 Tumor invades lamina propria or submucosa 80%
changes ganglioneuromas, 2a Invades m. propria or adventitia, [-] LN 33%
marfanoid habitus 2b Invades m. propria or adventitia, [+] regional LN 33%
Mutant gene MEN I RET RET 3 Tumor invades adventitia, [+] LN, & adjacent structures 15%
locus 4 Distant metastases 0%

Rapid recall Rapid recall

Most sensitive test for thyroid function TSH Mc complication of balloon tamponade of esophageal varices Perforation
Most definitive procedure to assess thyroid malignancy FNAC MC procedure for esophageal diverticula Cervical esophagomyotomy w/
MC thyroid anomaly Thyroglossal duct cyst resection of diverticulum.
Most aggressive of the thyroid tumors: Anaplastic type [giant & spindle cells] Most feared complication of esophageal dilatation Esophageal rupture
MC site of distal metastasis for follicular CA: Bone MC cause of defective LES Inadequate sphincter pressure
Common tumor marker for parathyroid CA HCG MC cause of esophageal perforation Iatrogenic
MC ectopic ACTH production Small cell lung CA MC sign of esophageal atresia Regurgitation of saliva
MC extra-adrenal site of ACTH production Organ of Zukerkandl [near abdominal aorta] MC Sx of esophageal CA Progressive dysphagia
MC cause of secondary adrenal insufficiency Iatrogenic [glucocorticoid therapy]
MC pituitary adenoma Prolactinoma [tx by bromocriptine] STOMACH [see GIT in IM notes]
MC sign of pheochromocytoma HPN Anatomy
MC Sx of medullary thyroid CA Diarrhea • Innervation:
MC Sx of Prolactinoma Secondary amenorrhea Anterior gastric wall L vagus N.
MC manifestation of MEN syndrome Hypothyroidism Posterior gastric wall R vagus N.
MC manifestation of hypoparathyroidism Tetany Sympathetic afferents T5-T10 [senses gastric pain]
MC manifestation of primary adrenal insufficiency Skin pigmentation • Vasculature:
Greater curvature R & L gastroepiploic A.
ACUTE ABDOMEN Lesser curvature R & L gastric A.
• Kehr sign [pain referred to L shoulder due to irritation of L hemidiaphragm] is seen in: splenic Pylorus Gastroduodenal A.
rupture Fundus Short gastric A.
• Murphy’s sign is seen in: acute cholecystitis
• The pain of appendicitis localizes into: McBurney’s point Gastric vs. Duodenal ulcer
Gastric ulcer Duodenal ulcer
Rapid recall Less common Common
MC cause of free air under the diaphragm Perforated peptic ulcer 40-60 y.o 20-45 y.o
MC surgical emergency in pregnant women Appendicitis Pain aggravated by food Pain relieved by food
MC cause of UGI bleeding PUD Lesser curvature Duodenal papilla
MC cause of abdominal pain in elderly Cholecystitis Blood type “A” Blood type “O”
Blood needed to have melena > 50 cc of blood Associated w/ malignancy Not associated
MC cause of massive lower GI bleed Diverticulosis ↓ HCO3 production ↑ acid production
MC cause of occult blood loss Cholangitis
MC surgical disease of small bowel Crohn’s disease Features suggesting benign gastric ulcer
MC cause of LLQ pain Diverticulitis 1. gastric folds radiating into base of ulcer
MC cause of RLQ pain Appendicitis 2. thick radioluscent edematous collar [Hampton’s line]
3. smooth crater
ESOPHAGUS [see GIT in IM notes] 4. pliable gastric wall in area of ulcer
Anatomy
• Vetebral levels at w/c the following traverse: Classification of gastric ulcers:
T8 Inferior vena cava Types Description Treatment
T10 Esophagus Type 1 Ulcer in lesser curvature at incisura angularis Antrectomy
T12 Aorta Type 2 Simultaneous gastric and duodenal ulcer Antrectomy
Type 3 Prepyloric ulcer High selective vagotomy
Pathology Type 4 Ulcer in gastric cardia Subtotal gastrectomy, roux-en-
• Esophageal varices is MC due to: alcoholic cirrhosis Y esophagogastrojejunostomy
• An alcoholic man presents after severe retching, complaining of retrosternal and upper
abdominal pain: Boerhaave syndrome [full thickness – L side posterolateral wall of distal Important S/Sx in adenocarcinoma
esophagus] or Mallory-Weiss syndrome [partial thickness – R side posterolateral wall of distal Krukenberg’s tumor Metastasis to ovaries
esophagus] Blumer’s shelf Metastasis to pelvic cul-de-sac, felt on DRE
• Mediastinal emphysema heard as “crunching” sound w/ heartbeat [Hammon’s crunch] is Virchow,s node Metastasis to LN palpable in L supraclavicular fossa
characteristic of: Mallory-Weiss syndrome Sister mary joseph nodules Metastasis to umbilical LN
• Pharyngoesophageal & epiphrenic diverticula are called pulsion diverticula [false diverticula]
while midesophageal are traction diverticula [true diverticula] • A fasting serum gastrin level > 1,000 pg/ml is pathognomonic for gastrinoma
• Diffuse esophageal spasm is associated w/ risk for IBS & spastic colon • Surgery is indicated when ulcer is refractory to 12 wks of medical tx or if hemorrhage,
• FB ingestion is most likely lodged in these anatomic narrowings: above upper esophageal obstruction or perforation is present. [TOC = high selective vagotomy – parietal cell
sphincter, near aortic arch & above LES vagotomy or proximal gastric vagotomy]
• A px w/ known PUD has sudden onset of severe epigastric pain. PE reveals guarding and
Characteristic findings in barium swallow: rebound tenderness: perforation
Bird’s beak or Achalasia [no gas Tx: endoscopic dilatation or esophagomyotomy • A 53 y/o woman presents due to 3 mos. early satiety, weight loss and non-billous vomiting:
steeple sign bubble] w/ fundoplication, high risk for SCCA] gastric outlet obstruction
Cork-screw Diffuse esophageal Tx: nitrates or CCBs to decrease LES pressure, • A 33 y/o female smoker presents w/ burning epigastric pain improved after eating meals: DU
shaped spasm esophagomyotomy is not successful • A 45 y/o Japanese male smoker presents w/ weight loss and epigastric pain exacerbated by
eating: gastric ulcer
Clinically significant portal-systemic sites: • A 58 y/o woman who is 6 days post-op from a gastrojejunostomy for PUD presents w/
Cardio-esophageal junction Esophageal varices postprandial RUQ pain and nausea. She reports that vomiting relieves her suffering: afferent
Periumbilical region Caput medusae loop syndrome
Rectum Hemorrhoids • Coffee ground refers to an old, brown digested blood found in gastric lavage w/c indicates
bleeding proximal to the ligament of Treitz.
Types of fistula or atresia • GUs are 3x more likely to rebleed than DUs.
A Esophageal atresia w/o TEF • Often presents like “umbilicated dimple”: ectopic pancreas
B Proximal esophageal atresia w/ proximal TEF • Complications of chronic gastritis: gastric atrophy, metaplasia & pernicious anemia
C Proximal esophageal atresia w/ distal TEF • Gastric operations:
D Proximal esophageal atresia w/ proximal or distal TEF Anthrum Distal subtotal gastrectomy
E “H type” TEF w/o esophageal atresia Midbody Total gastrectomy
Proximal Total gastrectomy
Stages of esophageal CA
Stages Description 5-yr SR

6
 Staging of gastric lymphoma [by Ann-Arbor classification] MC cause of fistula Previous abdominal surgery
Stage 1 Disease limited to stomach
Stage 2 Spread to abdominal LN LARGE BOWEL
Stage 3 Spread to LN above & below diaphragm Anatomy & embryology
Stage 4 Disseminated lymphoma • Unlike small intestine, colon has taenia coli, haustra & appendices epiploicae
• Retroperitoneal organs of the colon: ascending and descending colon, posterior hepatic
Staging of gastric adenocarcinoma and splenic flexures.
Stages Description 5-yr survival • Intraperitoneal: cecum, transverse and sigmoid colon
1 Mucosal involvement 66% • Rectal fascia is composed of Waldeyer’s fascia & Denonvilier’s fascia
2 Thru muscularis propria 33% • Rectum is 12-15 cm in length and can store approximately 500 cc of feces
3 Any LN involvement, [-] distant mets 10% • Blood supply of large intestine
4 Distant mets, extension to adjacent structure 0% SMA Ileocolic Cecum
R colic Ascending colon
Rapid recall Middle colic Proximal 2/3 of transverse colon
MC site of GI tract lymphoma Stomach IMA L colic Distal 2/3 transverse colon
2nd MC malignant gastric CA Gastric lymphoma Sigmoidal Sigmoid
MC type of gastric sarcoma Leiomyoma [hemogenous spread] Superior rectal Superior 3rd rectum
The only polyps w/ malignant potential Adenomatous polyps Internal iliac Middle rectal Middle 3rd rectum
MC location of duodenal ulcer Posterior duodenal wall w/in 2 cm of pylorus Int. rectal Distal 3rd rectum
MC location of gastric ulcer Lesser curvature Internal pudendal Direct branch Anus
MC site of ZES Pancreas [neck]
MC non-pancreatic site of ZES Duodenum • Innervation:
MC cause of upper abdominal abscess Left Sympathetic N. T7-12 [R colon] Inhibits peristalsis
MC site of intraabdominal abscess Subphrenic space L1-3 [L colon & rectum]
Mucosal end artery that causes pressure necrosis Dieulafoy’ lesion Parasympathetic Vagus N. [proximal colon] Stimulates peristalsis
and erodes into stomach and ruptures. S2-4 [distal colon]
MC Sx of gastric CA Anorexia & weight loss
Most important prognostic factor in gastric CA Advance stage of the disease Pathology
• L sided colon CA present w/ change in bowel habits, obstruction and hematochezia
SMALL BOWEL • R sided colon CA presents w/ anemia, fatigue and melena.
GI embryology & anatomy • “Sunburst patern” of sulfur granules on histopathologic examination is characteristic of
• At 4th wk, the primitive gut begins to develop where the endoderm becomes intestinal actinomycoses infection.
epithelium & glands, while the mesoderm becomes the CT, muscle & wall of intestine. • “thumb printing” on barium enema is characteristic of ischemic colitis
• At 5th wk, the cranial limb of midgut becomes distal duodenum & proximal ileum, while the • Distended loop of sigmoid colon often in the classic “bent inner tube” or “omega sign” w/
caudal limb becomes the distal ileum to proximal transverse colon loop aiming toward the RUQ is seen in sigmoid volvulus.
• All of the small intestine is derived from the midgut except for the proximal duodenum w/c is • A 70 y/o male w/ hx of HPN, develops lower abdominal pain 2 days S/P AAA repair. Few hours
derived from the foregut. later, he develops bloody diarrhea: ischemic colitis
• The small bowel has a total length of 5-10m [25 cm duodenum, 100-110 cm jejunum, 15-160 • “Lead pipe appearance” of colon on barium enema is characteristic of IBD [ulcerative
cm ileum] colitis].
• The entire small bowel is supplied by SMA except the proximal duodenum w/c is supplied by • 3 MC causes of obstruction of the large bowel: adenocarcinoma, diverticulitis and volvulus
celiac trunk. • “kidney-bean” appearance of sigmoid colon and cecum + “bird’s beak appearance of
• Jejunum begins & duodenum ends at ligament of Treitz colon on xray is characteristics of volvulus.
• A 70 y/o male w/ PVD and hyperlipidemia presents w/ severe diffuse abdominal pain. BP is • The “apple core” filling defect in descending colon on barium enema is classic for L-sided
170/100 and his pulse is 90 bpm. Supine abdominal radiograph shows air w/in the wall of the colon CA.
small intestine: small bowel infarct • Operative management based on location:
• A px presents w/ pigmented spots on lips and hx of recurrent colicky abdominal pain: peutz- Cecum R hemicolectomy
jegher’s syndrome R colon R hemicolectomy
• A 60 y/o male presents w/ a hx of cutaneous flushing, diarrhea, wheezing and an unintentional Proximal/mid transverse colon Extended R hemicolectomy
weight loss: carcinoid syndrome Splenic flexure and L colon L hemicolectomy
• Appendiceal carinoid < 2 cm: appendectomy while appendiceal carcinoid > 2 cm: R Sigmoid or rectosigmoid colon Sigmoid colectomy
hemicolectomy Proximal rectum Low anterior resection [LAR]
• Specific disease states: Distal rectum Abdomino-perineal resection [APR]
Peutz-Jeghers syndrome Hamartomatous polyps
Crohn’s disease Adenocarcinoma • 3 hemorrhoid quadrants: L lateral, R posterior and R anterior
Gardner’s syndrome Adenoma • Grading of hemorrhoids:
Familial adenomatous polyposis Adenoma Stage Description Symptoms Treatment
Celiac disease Lymphoma, carcinoma 1 Protrudes into lumen, Bleeding Non-resectional
no prolapse measures
• MC causes of small bowel adhesions: ABC [Adhesions, Bulge or hernias, and Cancer] 2 Prolapse w/ straining, Bleeding, perception of Nonresectional
• Air fluid levels in “stepladder” arrangement on upright film are characteristic of paralytic spontaneous return prolapse measure
ileus. 3 Prolapse, needs Blleding, prolapse, mucinous Excision
manual reduction soilage & pruritus
Surgical ulcers 4 Prolapse, can’t be Bleeding, prolapse, mucous Excision
Peptic General term for gastric/duodenal ulcer disease reduced soilage, pruritus, pain
Duodenal Ulcer in duodenum [ductal papilla]
Gastric Ulcer in stomach [antrum] • Paget’s disease of the anus is Adenocarcinoma in situ, and bowen’s disease of the anus is a
Curling’s Gastric ulcer after burn injury squamous CA in situ.
Cushing’s Peptic ulcer after neurologic insults • Mucosal findings:
Dieulafoy’s Pinpoint gastric mucosal defect bleeding from underlying arterial malformation Crohn’s disease Ulcerative colitis
Marjolin’s SCCA ulceration overlying chronic burn scar Apthoid ulcers, granulomas, linear Granular and flat mucosa, ulcers, crypt
Apthous GIT ulcer seen in Crohn’s disease ulcers, transverse fissures, swollen abscess, dilated mucosal vessels,
Decubitus Stress ulcer, skin/SQ ulceration from pressure necrosis seen on buttocks/sacrum mucosa, full-thickness wall involvement pseudopolyps, “backwash ileitis”
Venous stasis Skin ulceration on medial malleolus caused by venous stasis of lower extremity
Surgical repair for Hirschprung’s disease
Rapid recall Boley Remove aganglionic colon, perform pull-through anastomosis at same time
Longest organ of the GI tract Ileum Duhamel Anterior aganglionic region of rectum is preserved & anastomose to posterior
Largest immune organ in the body Gut part of healthy bowel, functional rectal pouch is created, dural barrel side by
Most prevalent type of immunoglobulin in lumen of GI tract. IgA side
MC cause of RUQ pain Cholelithiasis Soave Endorectal pull-through, bringing proximal normal colon thru aganglionic
MC cause of LLQ pain Diverticulitis rectum w/c has been stripped of its mucosa but otherwise present
MC surgical disease of the small bowel Crohn’s disease Swenson 1◦ anastomosis btw anal canal & healthy bowel, rectum is removed
MC cause of adult intussusceptions Adenomas
Duke’s classification of colonic CA

7
 Stages Description
A Within mucosa • Venous drainage: Left , middle & Right hepatic veins drain into IVC
B1 Mass extruding into muscularis propria, no nodes • Receives 75% of its blood supply from Portal vein & 25% from hepatic arteries
B2 Involvement of entire wall, no nodes • Ligaments of liver:
C1 Limited wall, [+] nodes Falciform ligament Connects anterior abdominal wall to liver, contains ligamentum
C2 Entire wall, [+] nodes teres [obliterated umbilical vein]
D Distant metastasis [liver, lungs, spine] Coronary ligament Peritoneal reflection on cranial aspect of liver that attaches it to
diaphragm
Triangular ligaments R & L lateral extensions of coronary ligament
Determination of malignant potential of polyps
Size Histology Atypia • Normal daily bile output: 500-1,200 ml
< 1 cm 1-3% Tubular 5% Mild 5% • Bare area: the posterior section of liver against diaphragm, has NO peritoneal covering
1-2 cm 10% Tubulovillous 20% Moderate 20% • Glissons capsule: peritoneal membrane that covers the liver
> 2cm 40% Villous 40% Severe 35% • Cantlie’s line [portal fissure]: line hat passes from L side of GB to L side of IVC, divides liver
into R & L lobes
R colon vs. L colon vs. Rectal CA • Liver enzymes: AST & ALT [from hepatocytes], alkaline phosphatase [from ductal epithelium]
Basis Right colon Left colon Rectal
Parts Cecum to hepatic flexure Hepatic flexure to sigmoid Sigmoid to rectum Common procedures of hepatobiliary system:
Appearance Bulky, polypoid lesions Scirrous or annular type Pringle maneuver Compressing the hepatoduodenal ligament to control bleeding from the liver
Tumor type Signet-ring cell adenoCA Signet-ring cell adenoCA adenoCA Liver resection Up to 80% of liver can be removed & still retain adequate function
Clinical Mx Anemia Constipation Hematochezia Sphincterotomy A cut to Sphincter of Oddi to allow passage of tones from CBD into
No obstructive Sx More obstructive Sx Less obstructive Sx papillotomy] duodenum. Often done during ERCP
Melena Bloody & mucoid stools Fresh blood w/ mucus Kocher incision Incision at the R subcostal margin performed during open cholecystectomy
Dull, persistent RLQ pain Change in bowel habits w/ [+] tenesmus, crampy ERCP Passage of endoscope into duodenum & introduction of catheter to ampulla
decrease stool caliber abdominal pain of Vater & injection of contrast medium into CBD & pancreatic duct
Other Mx Excessive weight loss Napkin ring lesions Rectal pain, extensive PTCA Passing of needle thru skin & SQ tissues into hepatic parenchyma &
advancement into a peripheral bile duct
Frequency of polyps:
Type Frequency CA potential Pathology on liver
Tubular – most common 75% 5% • Amebic abscess are classically described as “anchovy paste” in appearance caused by
Tubulovillous 15% 22% Entamoeba histolitica.
Villous - ↑ CA r 10% 40% • A 27 yo female presents w/ hx of hepatocellular adenoma that resolved after discontinuing
OCPs. She now wants to get pregnant: hepatocellular adenomas
Rectal CA surgical options: • Mass of veins extending around umbilicus producing periumbilical bruit [Cruveilheir-Buumgarten
bruit] seen in caput medusa.
Upper rectum [10-15 cm above anus] Low anterior resection
Mid-rectum [5-10 cm above anus] Depends on histology, size, age, sex
Causes of portal HPN
Lower rectum abdomino-perineal resection [APR] or Mile’s procedure
Presinusoidal Sinusoidal Postsinusoidal
Splenic or portal V. thrombosis, Cirrhosis, granulomatous R heart failure, constrictive
Rapid recall
schistosomiasis, granulomatous disease pericarditis, hypercoagulability
Widest part of the colon Cecum
MC site of diverticular disease Sigmoid colon Child-Pugh score for liver failure
MC site of distant metastasis from colorectal CA Liver Variable 1 2 3
MC site of diverticulosis Sigmoid colon Bilirubin [mg/dl] <2 2-3 >3
MC site of anal fissure Posterior midline Albumin [mg/dl] > 3.5 2.8-3.5 < 2.8
MC type of adenomatous polyp Tubular Ascites [clinical] None Easily controlled Poorly controlled
2nd MC cause of cancer deaths worldwide Colorectal CA Neurologic disorder None Minimal Advanced
Classic presentation of diverticulosis Massive lower GI bleeding PT [secs] <4 4-6 >6
MC carcinoma of the anus SCCA [Bowen’s disease] > adenoCA [paget’s]
MC Sx of Peutz-Jegher’s syndrome Recurrent colicky abdominal pain Anatomy of biliary tree & gallbladder
MC Sx of ulcerative colitis Bloody diarrhea • Cystic duct comes off the GB & joins the common hepatic duct to form the common bile duct
Most important prognostic factor in colorectal CA LN involvement [empties into duodenum via ampulla of Vater]
• Cystohepatic or Calot’s triangle: inferior border of liver, common hepatic duct, and cystic
APPENDIX duct. It contains the cystic & R hepatic artery
Anatomy • The infundibulum of gallbladder is called: Hartman’s pouch
• The appendix buds off from the cecum beginning at 6th wks of life • The valves within cystic duct are called spiral valves of Heister
• Its lymphoid tissue first appears at 2 wks after birth • The GB collects bile directly from liver via small bile ducts called ducts of Luschka
• Luminal capacity is about 0.1 ml [not actual lumen]
• Fold of Treves is an ileal fold just proximal to ileocecal valve, contains the antimesenteric fatty Pathology of HBT
appendage on small bowel. • Hydrops of gallbladder is the complete obstruction of the cystic duct by a gallstone, causing
• Just 0.5 ml raises the appendiceal intraluminal pressure by -60 cm H2O. the gallbladder to fill w/ fluid.
• Sign’s for appendicitis: • Charcot’s triad: RUQ pain, fever and jaundice.
Direct & rebound Tenderness manifested in RLQ • Reynold’s pentad: chrarcot’s + CNS Sx and septic shock
Dunphy’s Increased pain w/ coughing • “Beads on a string appearance” of bile ducts is seen in sclerosing cholangitis.
Hamburger sign If a px wants to eat, consider dx other than AP • Cholangiocarcinomas are common located at bifurcation of the R and L hepatic ducts called as:
Iliopoas Pelvic pain upon extension of the R thigh [signifies retrrocecal Klatskin’s tumor.
appendicitis]
Obturator Pelvic pain upon internal rotation of R thigh [signifies pelvic type AP] Types of biliary calculous disease
Psoas [+] hyperextension of R thigh will produce RLQ pain [due to direct Stone type Pathogenesis Composition
extension of retrocecal appendix to psoas muscle] Cholesterol Altered bile components, cholesterol, stasis Cholesterol crystals
Rovsing’s Pain in RLQ when palpation pressure is exerted in LLQ [due to of bile
peritoneal irritation] Black Altered bilirubin solubilization Ca+ bilirubinate, bile acids,
Rectal exam [+] pararectal tenderness at the R pigment bilirubin polymers
Brown Bacterial deconjugation of bilirubin, bile Ca+ bilirubinate, bile acids,
• Risk of rupture of appendicitis is highest w/in 48 hrs [75%] pigment stasis bilirubin polymers, bacteria
• MC type of appendiceal tumor: carcinoid Biliary Bile stasis Ca+ bilirubinate, cholesterol
sludge crystals, mucin gel matrix
HEPATOBILIARY SYSTEM
Anatomy of liver Staging & treatment of gallbladder adenoCA
• Arterial supply: Stages Description Treatment
Artery Origin Branches 1 Mucosal involvement only Cholecystectomy
Celiac trunk Aorta L gastric, splenic & common hepatic A. 2 [+] muscularis layer of GB Radical cholecystectomy [+], wedge resection of
Common hepatic A. Proper hepatic A., duodenal A. liver around the bed of GB [+] regional LAD

8
 3 All layers of wall involved • A 30 y/o male complains of feeling faint and confused most notably after he exercises. His
4 Cystic node involvement symptoms improve after he has a soft drink: insulinoma
5 Distant spread Palliative • A 4 y/o male complains of chronic epigastria pain following meals and notices increasing doses
of his anti-ulcer medication: Gastinoma or Zollinger-Ellison syndrome
Staging of cholangiocarcinoma • A 57 y/o male presents w/ a hx of severe watery diarrhea characterized by hypokalemia and
1 Tumor invading but not thru bile duct wall achlorhydria: VIPoma or Verner-morrison syndrome or WDHA syndrome.
2 Tumor invading thru wall & involving perimuscular CT • Necrolytic migratory erythema is the skin condition associated with: glucanogoma
3 Stage 2, [+] LN involvement • Tx of pancreatic CA based on location:
4 Tumor invading adjacent organs [liver, pancreas, duodenum & vascular organs Head of pancreas Whipple’s procedure [pancreaticoduodenectomy]
5 Distant metastatic spread Body or tail Distal resection

Anatomic variants of choledochal cysts Ranson’s criteria for acute pancreatitis [predicts risk of mortality in pancreatitis]
1 Dilatation of CHD & CBD w/ cystic duct entering the cyst. MC type On admission [GA LAW] After 48 hrs [C-HOBBS]
2 Lateral saccular cystic dilatation Glucose > 200 mg/dl Ca+ < 8 mg/dl
3 Choledochocele represented by an intraductal cyst Age > 55 y.o Hct decrease by 10%
4 Multiple extra or intrahepatic cysts or both LDH > 350 IU/L [700/] O2 PaO2 < 60 mmHg
5 Single or multiple intrahepatic cysts AST/SGOT > 250 IU/dl Base excess > 4 meq/L
WBC > 16, 000/ml BUN increase > 5 mg/L
Bismuth classification of bile duct injuries or strictures Sequestered fluid > 6L [base deficit]
1 > 2cm of CHD is preserved below the bifurcation Number of risk factors Mortality
2 < 2cm remains <3 1%
3 Involves hilum w/ preserved continuity btw R & L sides 3 or 4 16%
4 Destruction of hepatic confluence w/ separation of R & L 5 or 6 40%
5 Separate inserting sectoral duct w/ or w/o injury to CBD >6 70-100%
Risk of mortality: 20% [3-4 signs], 40% [5-6 signs], 100% [> 7 signs]
Rapid recall
Causative agents in bacterial/pyogenic liver abscess E. coli, Klebsiella, Proteus Rapid recall
MC antecedent cause of pyogenic liver abscess Liver trauma MC sites of Cystadenocarcinoma Pancreatic body and tail
MC cause of liver pyogenic abscess Biliary obstruction [thru portal vein] MC islet cell tumor Insulinoma [“spells or blackouts” due to hypoglycemia]
MC site of liver abscess R lobe [MC type – amebic abscess] MC sign of pancreatitis on AXR Sentinel loops
MC liver nodule Hemangioma
MC hepatic malignancy Metastases SPLEEN
MC primary benign liver tumor Hepatic hemangioma Anatomy
MC benign tumor of liver Cavernous hemangioma • Located at LUQ of abdomen btw 8th & 11th ribs
MC primary liver sarcoma Angiosarcoma • Boundaries:
MC primary liver malignancy Hepatocellular CA Superior L diaphragm leaf
Subtype of hepatocellular CA w/c has the best prognosis Fibrolamellar hematoma Inferior Colon, splenic flexure, phrenicocolic ligament
MC primary CA of GB adenoCA Medial Pancreas [tail], stomach
MC primary cancer of HBT Bronchogenic CA Lateral Rib cage
MC cause of portal HPN Cirrhosis from alcoholism Anterior Rib cage, stomach
MC finding in portal HPN Splenomegaly Posterior Rib cage
MC site of obstruction in gallstone ileus Ileocecal valve Pathology
Adenomas of bile ducts are commonly seen in Ampulla of vater • Conditions associated w/ splenic rupture include: mononucleosis, malaria, blunt LUQ trauma,
Most sensitive in dx of acute calculous cholecystitis. HIDA scan and splenic abscess
Gold standard for dx of CBD stones ERCP • A 27 y/o HIV [+] female presents w/ fever, waxing and waning mental status and hematuria.
MC Sx of choledochal cyst Intermittent jaundice CBC shows pancytopenia: TTP
Indications for splenectomy
MC Sx of gallbladder CA RUQ pain
Disease Description & caveats
MC Sx in liver cell CA Weight loss & jaundice
Trauma Resection w/ hilar involvement, parenchymal damage, active
MC manifestation of alcoholic liver disease Steatosis
bleeding
ITP Steroid tx, IV gammaglobulin, plasmapheresis, resection if
PANCREAS
refractory
Anatomy & embryology
TTP Resection if medical Tx failed
• Begins development during 4th wk AOG from endoderm of duodenum
Myeloproliferative Resection for symptomatic splenectomy
• Lies retroperitoneal posterior to stomach, transverse mesocolon & lesser omentum at body of
disease
L2
Lymphoma Resection for symptomatic splenomegaly
• 2 ducts: Wirsung [main duct] & Santorinni [accessory duct]
Hereditary spherocytosis Resection is curative
• Sphincter of Oddi: smooth muscle around ampulla
Felty’s syndrome Resection improves response to infection & treats Sxtic
• Head is closely associated w/ duodenum [anterior & posterior pancreaticoduodenal A.]
splenomegaly
• Body & tail are supplied by branches of dorsal pancreatic A. & splenic A.
Splenic abscess CT-guided percutaneous drainage
• Innervation:
Parasitic cysts Resection indicated
Sympathetic Thoracic sympathetic ganglia to splanchnic N. to celiac ganglia
Sarcoidosis Gaucher’s resection
Parasympathetic From vagal nuclei [for islets, acini & ducts]
Splenic vein thrormbosis Resection cures the sinistral portal HPN
• Pancreatic anomalies:
Grading & classification of splenic injuries
Heterotrophic Wrong location of pancreatic tissue [stomach, duodenum, meckel’s
Grade Description
pancreas diverticulum
1 Subcapsular hematoma < 10% SA, capsular tear < 1 cm
Pancreas divisum Failure to fuse 2 duct systems [Santorini becomes the main duct]
2 Subcapsular/intraparenchymal hematoma 10-15% SA, laceration 1-3 cm depth
Annular pancreas Ventral pancreas malrotates & encircles 2nd part of duodenum
3 Large, > 50% SA, > 5 cm diameter, subscapular/intraperitoneal hematoma, >
3cm laceration involving trabecular vessels
Pathology
4 Laceration involving hilar or segmental vessels
• Cullen’s [periumbilicus] and Grey-Turner’s [flank] sign are indicative of severe, hemorrhagic
5 Hilar avulsion or shattered spleen
pancreatitis.
• “Sentinel loop sign” and colon cutoff sign” on AXR is characteristic of acute pancreatitis. Rapid recall
MC cause of hypersplenism Portal HPN
• A 32 y/o male who underwent laparotomy for a gunshot wound to the abdomen 2 days ago is
found to have a tender belly w/o rebound and is leaning forward on his stretcher breathing at a MC primary non-lymphoid tumor of spleen Hemangioma
28/min: pancreatitis MC presentation of splenic traumatic injury Splenic rupture
• Gallstones are not common cause of chronic pancreatitis. Mainstay of tx for TTP Plasmapheresis
• Pancreatic calcifications on xray and “chain of lakes” pattern on pancreatography are MC cause of failure to correct thrombocytopenia after Missed accessory spleen
characteristics of chronic pancreatitis. splenectomy
• Whipple’s procedure: removal of GB, CBD, anthrum of stomach, duodenum, proximal jejunum
and head of pancreas [en bloc]. HERNIAS AND ABDOMINAL WALL PROBLEMS
Groin anatomy

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 • Abdominal wall layers: skin, SQ fat, Scarpa’s fascia, external oblique, internal oblique, Parasomal Hernia adjacent to an ostomy
transversus abdominis, transversalis fascia [strongest layer], extra-peritoneal fat & Maydl’s W type of intestinal loop herniates
peritoneum Morgagni Anterior parasternal diaphragmatic hernia
• Innervation: intercostals & upper lumbar nerves Spigelian Sac passes thru spigelian or semilunar fascia
• Inguinal canal boundaries: Sliding hernia Hernial sac partially formed by the wall of a viscus [ex. bladder/cecum]
Anterior wall External oblique aponeurosis Cooper’s Involves the femoral canal and tracts to labia majora in females and
Posterior wall Transverse abdominal M. aponeurosis, transversalis fascia scrotum in males
Medial border Transverse aponeurosis, transversalis fascia Incisional Resulting as a surgical complication
Lateral border Transverse abdominal M. Epigastric Primary defect in linea alba above umbilicus
Inferior rectus Transverse aponeurotic fascia Eventration Loss of integrity of the abdominal wall
Superior rectus Transverse aponeurosis Internal hernia Hernia into or involving intra-abdominal structure
Obturator Hernia thru obturator canal
• Spermatic cord contents: vas deferens & its artery, 1 testicular A., 2-3 veins, lymphatics, Lumbar hernia Petit’s hernia or Grynfeltt’s hernia
autonomic nerves & fat Bochdalek’s Hernia hru the posterior diaphragm, usually on the left
• Ligaments: Femoral hernia Hernia medial o femoral vessels [under inguinal ligament]
Inguinal ligament Stringly brace the myopectineal orifice, constitutes the medial Indirect inguinal Inguinal hernia lateral to Hesselbach’s triangle
border of femoral canal Direct inguinal Inguinal hernia w/in Hesselbach’s triangle
Henle’s ligament The portion of tendon of rectus abdominal M. that curves laterally Hiatal hernia Hernia thru esophageal hiatus
into pecten pubis Umbilical hernia Hernia thru umbilical ring
Hesselback’s ligament Fascial condensation in region of inferior epigastric vessels Internal Hernia thru defect in visceral structure
Perineal Hernia thru floor of perineum
• Vasculature: cremaster vessels arise from inferior epigastric vessels & pass thru posterior wall Sciatic Hernia thru greater sciatic foramen
of epigastric canal via their own foramen. It supplies cremaster muscle & testis tunica Intraparietal Hernia in w/c abdominal contents migrate btw layers of abdominal wall
• Nerves: Hesselbach’s Hernia under inguinal ligament lateral to femoral vessels
Genital N. L1-2 Innervates cremaster vessels to for neurovascular Ventral Incisional hernia on ventral abdominal wall
bundle & may substitute for absence of ilioinguinal N. Parastomal Hernia adjacent to an ostomy [ex. colostomy]
Iliohypogastric, ilioinguinal & genital T12- Innervates the skin of groin, base of penis & medial Properitoneal Intraperitoneal hernia btw peritoneum & transversalis fascia
branch of genitofemoral N. L1 upper thigh
• Anterior vs. posterior hernioplasty
• Femoral canal contents: Nerve, Artery, Vein, Empty space, LN [NAVEL]
Anterior hernioplasty Posterior hernioplasty
• Nerve that travels on the spermatic cord: ilioinguinal nerve
Marcy-simple ring closure Nyhus iliopubic tract repair
• Nerve that travels w/in the spermatic cord: genital branch of genitofemoral nerve Bassini-Shouldice repair – gold standard Cheatie-Henry midline approach
• Anatomical triangles: McVay-Lotheissen ligament repair Stoppa procedure
Hesselbach’s Site of direct Inferior: inguinal ligament; medial: rectus abdominis; Lichtenstein – tension free repair Laparoscopic herniopasty
triangle inguinal hernia lateral: inferior epigastric vessels
Triangle of Superiorly: 12th rib; anterior: internal oblique; floor: • Complications of hernioplasty: ischemic orchitis, testicular atrophy, neuralgia, recurrence
Grynfeltt quadratus lumborum M. • Descriptive terms for hernia:
Triangle of Petit Aka Inferior lumbar Posterior: latissimus dorsi, inferior: iliac creast; floor: Reducible Ability to return the displaced organ to usual anatomic site
triangle inferior oblique & transversus abdominis M.
Incarcerated Swollen or fixed w/in hernial sac, may cause obstruction
Strangulated Incarcerated hernia w/ resulting ischemia
Pathology
Complete Hernial sac and its contents protrude all the way thru the defect
• Diagnostic signs:
Incomplete Defect present w/o sac or contents protruding completely thru it
Sister Mary Nodule that enlarges at umbilicus, sign of advanced GIT
Joseph nodules malignancy
Rapid recall
Grey-Turner sign Bluish hematoma at flanks, sign of retroperitoneal hemorrhage
MC site of abdominal hernias Inguinal canal
Fothergill’s sign Bluish discoloration of skin, differentiates intra from extra-
MC hernias in females Indirect inguinal hernia [tx: McVay repair]
abdominal mass
MC hernia in both sexes Indirect inguinal hernia
Caput medusae Very fine veins, due to portal HPN sec. to cirrhosis or alcoholism
MC inguinal hernia in children Indirect inguinal hernia [R usually]
MC site of direct inguinal hernia Hesselbach’s triangle
• Hernia calendar:
MC organ in inguinal hernial sac in men Small intestine
0-2 yrs Indirect inguinal hernia
MC organ in inguinal hernial sac in women Ovary or fallopian tube
2-20 yrs Hernia is uncommon
20-50 yrs Indirect inguinal hernia
PEDIATRIC SURGERY
> 50 yrs Direct inguinal hernia
Fetal circulation
• Blood from placenta returns to fetus by way of umbilical vein thru the ductus venosus directly
• Surgical repair of hernias: into IVC
Lytle’s repair Narrowing of deep ring by suturing medial wall • Most of saturated blood is shunted directly thru the foramen ovale to the left
Lichtenstein “tension free” repair using mesh • De-saturated blood thru ductus arteriosus enters placental circulation
Bassini’s repair Suturing conjoint tendon to the incurved part of inguinal ligament
Shouldice repair Double breasting of transversalis fascia Cardiovascular changes after birth
Ogilvie’s repair Plication of transversalis fascia • Systemic + pulmonary vascular resistance increases & ductus arteriosus closes
Plug and patch Placing a plug of mesh in hernial defect • Remnants of the following will become:
McVay’s or Cooper’s Conjoint tendon sutured to cooper’s ligament [femoral] Umbilical vein Ligamentum teres
High ligation Ligation and transaction of indirect hernial sac w/o repair of inguinal UmbilicAL artery MediAL umbilical ligament
floor [usually used in children] Urachus Median umbilical ligament
TAPP procedure Trans-abdominal preperioneal inguinal hernia repair Tongue remnant [thyroid] Foramen cecum
TEPA procedure Totally extraperitoneal approach Vitelline duct Meckel’s diverticulum
Ductus venosus Ligamentum venosus
• Strangulation in hernia is highest in femoral [R side mostly in females] > indirect > direct Ductus arteriosus Ligamentum arteriosus
hernia
• Indications for laparoscopic inguinal hernia repair: • Ductus arteriosus closes w/in 1st 24 hrs
1. bilateral inguinal hernia
• Ductus venosus closes after 2 wks,
2. recurring hernia
• Foramen ovale closes in the 1st month
3. need o resume full activity as soon as possible
• Characterized by “egg-shaped heart” on CXR: transposition of great vessels
• Rastelli procedure: aorta is rerouted internally to L ventricle across VSD
• Common types of hernia:
Richter’s Only part of intestinal wall is in the hernia. • Ostium primum ASD [aka partial endocardial cushion defect or partial atrioventricular
canal]. It is common among Down syndrome patients.
Littre’s The hernial sac contains Meckel’s diverticulum
• Among the supravalvular lesions, the hour-glass type is most amenable to surgical treatment.
Petit’s Hernia thru inferior lumbar triangle
Grynfeltt’s Hernia thru superior lumbar triangle
Pulmonary system
Garengoff’s The hernial sac has the appendix • L: S ratio is a marker of fetal lung maturation. Delayed lung maturation is seen in DM & Rh
Pantaloon’s A combination of direct and indirect inguinal hernia isoimmunization

10
 • L:S ratio < 2: high risk for RDS MC site of atresia Papilla of Vater
• Lungs reach full maturity at 8 yrs MC cause of acute intestinal obstruction under 2 y/o Intussusception [MC site – ileocolic]
• Esophagus & trachea originate from a single diverticulum & divide at 8 wks AOG Most frequent congenial GI abnormally Meckel’s diverticulum
MC cause of lower intestinal obstruction in neonate Hirschsprung’s disease [Sx: enterocolitis]
Renal system MC intra-abdominal malignancy in childhood Wilm’s tumor or nephroblatoma
• Normal GFR = 50 ml/min/m2 [neonates] & 1—ml/min/m2 [adults] MC site of metastasis of neuroblastoma Lungs
• Normal urine output = 1-2 ml/kg/hr MC form of cleft palate Total cleft palate
• Urine production starts at 9-12 wks AOG. MC site of intussusception Terminal ileum [ileocecal valve]
• Nephrogenesis is complete by 35 wks. MC ectopic tissue in meckel’s diverticulum Gastric mucosa
MC cause of lower GI bleeding in children Meckel’s diverticulum w/ ectopic gastric
Pediatric pathological diseases mucosa
• A newborn presents w/ respiratory distress and a scaphoid abdomen: diaphragmatic hernia MC benign liver tumor in children Hemangioma
• An infant has excessive oral secretions, chokes and has apneic episodes during feeding: MC solid neoplasms in infants Neuroblastoma
tracheoesophageal malformation MC solid tumor in children CNS tumors
• Types of tracheoesophageal malformations: esophageal atresia & TEF, pure esophageal MC cause of SBO in children Hernia
atresia & H-type TEF MC Sx of AML in children Fatigue
• Radiologic characteristics of pyloric stenosis: MC manifestation of hemophilia A Spontaneous traumatic hemorrhage
String sign From elongated pyloric channel
Shoulder sign Bulge of pyloric muscle into the antrum ANESTHESIA
Double tract sign Parallel streaks of barium in narrow channel • Spinal anesthesia – needle is inserted at L3-L4 or L4-L5 [at this level cauda equina is present
and spinal cord has already ended]
• Biliary atresia accounts for 90% of extrahepatic obstruction in neonates. • Epidural anesthesia - needle is placed in epidural space [outside CSF] commonly an
• Optimal time of surgery for biliary atresia is at < 8 weeks of age. indwelling catheter is left in place.
• “Dance’s sign” - absence of bowel in RLQ [intussusception] • Epinephrine is nor use in this areas: SPF-10 [Scrotum, Penis, Fingers, Toes, Ears and Nose]
• “Target sign” – 2 concentric circles of fat density • Commonly used pre-op anesthetic medications:
• “Target or donut sign” – single hypoechoic ring w/ hyperechoic center Benzodiazepines Midazolam
• “Pseudokidney sign” – superimposed hypoechoic [edematous walls of bowel] and Tranquilizer Droperidol
hyperechoic [areas of compressed mucosa] layers Antihistamine Hydroxyzine, diphenhydramine
• If a meckel’s diverticulum is found w/in a hernial sac, it is called: Littre’s hernia. Anticholinergic Atropine, scopolamine, glycopyrolate
• Correction of inguinal hernia is the most frequent surgical intervention in children. Gastrokinetic metoclopramide
• A premature infant born at 33 week’s gestation now at 1 week of age has developed feeding H2-blockers Ranitidine
intolerance, is febrile, and has hematochezia and a distended belly: necrotizing enterocolitis Alpha-2 agonists Clonidine
[NEC] 5HT antagonists Ondansetron
• Pneumatosis intestinalis [gas w/in bowel wall] on AXR is seen in NEC
• Surgical management of cleft lip & palate: Rapid recall
Cleft lip 10 wks-3 mos. Rule of tens: 10 wks age, 10 gm/dl, Most popular regional anesthesia Subarachnoid block in spinal anesthesia
Cleft palate 12-18 mo. 10 lbs wt, 10,000 WBC/mm3 Most ideal for hemorrhoidectomy Caudal block

• Types of fistula/atresia: OPHTHALMOLOGY

Type A Esophageal atresia w/o TEF • The red eye diseases:
Type B Proximal esophageal atresia w/ proximal TEF Bacterial conjunctivitis Conjunctival redness w/ purulent discharge
Type C Proximal esophageal atresia w/ distal TEF Viral conjunctivitis Conjunctival redness w/ serous discharge
Type D Proximal esophageal atresia w/both proximal + distal TEF Allergic conjunctivitis Clear conjunctival discharge
Type E “H type” TEF w/o esophageal atresia Acute narrow angle Acute pain, cloudy cornea, perilimbal redness, blurred vision
glaucoma
• Stages of Wilm’s tumor: Iritis Perilimbal redness, irregular pupil, pain, decreased vision
Stage 1 Limited to kidney and completely Corneal ulcer Epithelial defect w/ infiltrate, pain
Stage 2 Extends beyond kidney, but completely resected, Corneal abrasion Epithelial defect, no infiltrate, pain
capsule invasion and perirenal tissues may be involved Orbital cellulitis Periocular swelling, erythematous ocular surface, ↓ vision
Stage 3 Residual non-hematogenous tumor after resection
Stage 4 Hematogenous metastases [lung, distal LN, brain] • Important terms:
Stage 5 Bilateral renal involvement Astigmatism Asymmetric cornea
Esotropia Eyes inward
Stages of neuroblastoma Exotropia Eyes outward
Stages Description Treatment 5-yr SR Hypertropia Eyes upward
1 Tumor confined to organ of origin Resection 90% Hyperopia Farsightedness
2 Extends beyond organ but not across midline Resection & chemotx 80% Diplopia Double vision
3 Tumor extends across midline Resection & chemotx 40% Strabismus Eye malalignment
4 Metastatic disease is found 3 + w/ or w/o radiation 15% Hyphema Blood in anterior chamber of the eye
4S Stage 1 & 2 tumor w/ mets to liver, BM, etc. Same as 4 80% Chemosis Edema of conjunctiva
Endophthalmitis Intraocular infection
Age of presentation of the ffg: Ptosis Eyelid droop
Pyloric stenosis From 2 wks to 2 mos. of age Anisocoria Asymmetric pupil diameter
Intussusception From 4 mos. to 2 yrs [80%] Nystagmus Back and forth jerky movement of the eyes
Wilm’s tumor Btw 1-4 y.o Dacrocystitis Lacrimal sac infection
Malrotation Birth to 1 y.o [>85%] Mydriasis Pupil dilatation
Neuroblastoma 50% by 2 yrs, > 80% by 8 yrs of age Miosis Pupil constriction
Hepatoblastoma Younger than 3 y.o Myopia Nearsightedness
Appendicitis Older than 3 y.o
EARS, NOSE AND THROAT
Rapid recall • Menier’s disease is characterized by intermittent vertigo, tinnitus, hearing loss, and aural
MC cyanotic malformation Tetralogy of fallot [Coeur en sabot] fullness due to excess endolymph.
MC CHD VSD • Inflammation of the salivary gland: sialadenitis
MC VSD requiring surgery Perimembranous type • Classic Sx of croup/laryngotracheobronchitis: barking [seal-like] non-productive cough
MC type of VSD Muscular VSD • Le Fort classification: [see figure on surgical recall]
MC type of ASD Ostium secundum type Le Fort 1 Transverse maxillary fracture above dental apices, also traverses
MC branchial cyst 2nd branchial cleft cyst the pterygoid plate, palate is mobile, but nasal complex is stable
MC lymphatic malformation in children Cystic hygroma Le Fort 2 Fracture thru the frontal process of maxilla, thru the orbital floor
MC congenital lung lesion Lobar emphysema and pterygoid plate, midface is mobile
2nd MC congenital lung lesion Congenital cystic adenomatoid malformation Le Fort 3 Complete craniofacial separation: differs from II in that it extends
MC malformation Esophageal atresia w/ TEF thru nasofrontal fracture and frontozygomatic sutures
MC type of intestinal atresia Duodenal atresia

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 • “Tripod” fractures: frontozygomatic suture, zygomaticomaxillary suture, inferior orbital • Cerebral hypoperfusion syndrome: unilateral headache due to poor autoregulation w/c can
rim, zygomaticotemporal suture cause seizure.
• CN III palsy is characterized by blown pupil w/ down and out eyes as seen in uncal herniation.
Zones of the neck [see figure on surgical recall] • CN VIII is affected most frequently in neuroma.
Zone 1 Below cricoid cartilage Selective exploration • “Fried egg or chicken wire pattern’ – a fixation artifact not routine seen.
Zone 2 Cricoid to angle of mandible Surgical exploration • Tumors arising from paraganglion cells: carotid body tumors, glomus jugulare tumors,
Zone 3 Angle of mandible & up Selective exploration pheochromocytomas
• Common sources of metastatic tumors: bronchogenic lung CA, melanoma, breast CA, renal cell
Modified Neck dissection CA, colon adenocarcinoma
Type 1 Spinal accessory nerve is preserved • Certain metastasis are more likely to hemorrhage: melanoma, renal cell CA, choriocarinoma
Type 2 Spinal accessory N. & internal jugular N. is preserved • Most metastases occur in the cerebral hemispheres at gray-white junction or in cerebellum.
Type 3 Spinal accessory N. & internal jugular N. & SCM nerves are preserved • Radiosensitive metastasis are characteristic of: small cell lung CA, lymphoma, multiple
myeloma, and germ cell tumors
Rapid recall • “Subependymal tubers” or calcific hamartomas + “ash leaf spots” on skin are
The only muscle not innervated by the vagus. Stylopharyngeus characteristics of tuberous sclerosis.
MC site of angiosarcoma in head & neck Scalp • Surgery for hydrocephalus is usually done at 3-4 mos.
MC salivary gland tumors Pleiomorphic adenoma of parotid • Presents as “worst headache” of my life: spontaneous subarachnoid hemorrhage
MC site of subclinical 2nd primary tumor Esophagus • Postradiation somnolence syndrome: lethargy for a period of 2-6 mos. after treatment
MC cause of otitis externa [swimmer’s ear] Pseudomonas [tx w/ amoxicillin, PCN] • Spinal diseases [test of choice – MRI]
MC type of external ear tumor Squamous cell CA [from auricle] Spondylosis Degenerative changes in spine, arthritis
MC cause of acute otitis media in adults Strep peumoniae & H. influenzae Spondyloliisthesis Subluxation of 1 vertebral body on another
MC causes of chronic otitis media S. aureus and P. aeruginosa Spondylolysis Fracture or defect in pars interarticularis, mostly
MC etiology in infants younger than 6 mos. S. aureus, E. coli, Kebsiella congenital at L5 [spina bifida oculta]
MC cause of bilateral facial nerve palsy Lyme disease [B. burgdorferi]
MC cause of unilateral facial weakness/paralysis Bell’s palsy • Lumbar spine maneuvers:
MC encountered vascular mass in nasal cavity Juvenile nasopharyngeal angiofibroma Straight leg raise Radicular sx produced w/ leg elevation in supine position
MC cause of parotid swelling Mumps Crossed straight Radicular sx produced in affected leg w/ elevation of
MC benign salivary gland tumor Pleiomorphic adenoma [parotids] leg raise opposite leg.
2nd MC benign salivary gland tumor Warthin’s tumor [parotids]
MC malignant salivary gland tumor Mucoepidermoid CA • Cervical spine maneuver:
MC parotid malignancy Mucoepidermoid CA Spurling’s sign Radicular pain produced w/ downward pressure on head when
2nd MC submandibular gland malignancy Mucoepidermoid CA neck is extended and tilted toward the affected side
2nd MC malignant salivary tumor in adults Adenoid cystic CA
2nd MC parotid malignancy Adenoid cystic CA • Herniated disc terminology:
MC malignancy in submandibular & minor salivary glands Adenoid cystic CA Bulge Symmetric extension
Usual causative agent in epiglotitis H influenzae type B Protrusion Asymmetric extension
MC salivary gland site of stone formation Submandibular gland Extrusion Free disc fragment
MC malignant neck mass in children, adolescents, and Lymphoma Degenerated Narrowed disc space
young adults
MC primary malignant solid tumor of head & neck in kids Rhabdomyosaroma
MC Sx of oropharyngeal CA Persistent sore throat
MC Sx of laryngeal CA Hoarseness • Herniated disc syndromes:
MC manifestation of retinoblastoma Leukoria Level Motor weakness Reflex affected
Most important prognostic factor in head, neck CA Nodal metastasis C4-5 Shoulder abduction Deltoid
C5-6 Forearm flexion Biceps, brachioradialis
C6-7 Forearm, wrist, and finger extension Triceps
PLASTIC SURGERY C7-T1 Wrist and finger flexion Finger jerk
• Axial flaps and their arterial supply: L3-4 Quadriceps Patellar
Forehead flap Superficial temporal A. For intraoral lesions L4-5 Tibialis anterior and extensor hallucis longus Medial hamstring
Deltopectoral 2nd-4th anterior perforators of For head and neck L5-S1 Gastrcnemius/soleus Achilles
flap internal mammary A. wounds
Groin flap Superficial circumflex iliac A. Hand/forearm wounds • “Bamboo spine” in plain films – osteophytic growth over intervertebral discs connecting
adjacent vertebrae are characteristic: Diffuse Idiopathic Skeletal Hyperostosis/Forestier
• Donor sites for skin grafts: syndrome
STSG Thigh, buttocks, abdomen, back • Cystic cavitation w/in spinal cord: syringomyelia
FTSG Inguinal, upper lids, posterior auricular, supraclavicular • Erb-Duchenne palsy or “Bellhop/Waiter’s tip palsy [C5/6 injury]: arm medially rotated w/
wrist and fingers flexed. Klumpke’s palsy [C8-T1 injury]: in an adult w/ insidious progressive
• Types of skin grafts: development, think Pancoast tumor. There may be associated Horner’s syndrome.
Split-thickness skin graft Size Location • Meralgia paresthetica: entrapment as nerve emerges through inguinal ligament causing lateral
Thin STSG 0.008-0.012 inch Upper ¼ of dermis thigh paresthesia.
Medium STSG 0.013-0.016 Upper ½ of dermis • Spinal cord traumatic syndromes, diseases and fractures
Thick STSG 0.017-0.020 Upper ¾ of dermis Anterior cord Affecs coricospinal and lateral spinothalamic tracts, paraplegia,
syndrome loss of pain/temperature sensation, preserved
Full-thickness > 0.020 Both epidermis & dermis
touch/vibration/proprioception
Central cord Preservation of some lower extremity motor and sensory ability
Rapid recall
syndrome w/ upper extremity weakness
MC bacteria in tenosynovitis and paronychia S. aureus
Brown-Sequard Hemisection of cord resulting in ipsilateral motor weakness
MC hand [wrist] tumor Ganglion cysts
synd. and touch/proprioception loss w/ contralateral pain/
MC cause of carpal tunnel syndrome Synovitis temperature loss
MC posterior fossa tumor Acoustic neuromas [cerebellopontine angle] Posterior cord Injury to posterior spinal cord w/ loss of proprioception distally
MC site of sinus cancer Maxillary sinus Jefferson’s fx Fracture thru C1 arches from axial loading [unstable fracture]
MC cell type in head and neck CA Squamous cell CA Hangman’s fx Fracture thru pedicles of C2 from hyperextension
MC dressing material used Alginates [Caltostat] Odontoid fx Fracture of odontoid process of C2
MC cause of skin graft failure Bleeding or hematoma Priapism Penile erection seen w/ spinal cord injury
Chance fx Transverse vertebral fracture
NEUROSURGERY
Clay-Shoveler’s Fracture of spinous process of C7
• Boomerang sign – one of the earliest manifestations of hydrocephalus in w/c temporal tips of
Berry aneurysm Saccular outpouching of vessels in circle of Willis, usually at
the lateral ventricle appear.
bifurcations
• Macewen’s sign: tapping on the head of a hydrocephalic infant produces a cracked pot sound.
Cauda equina Herniated disc compressing multiple S1, S2, S3, S4 nerve
• An 83 y/o female w/ a hx of diabetes, HPN and atherosclerosis presents w/ painless, syndrome roots, resulting in bowel/bladder incontinence, “saddle
mononuclear vision loss that lasted a few minutes and has now completely resolved. She has anesthesia” over buttocks/perineum, low back pain, sciatica
no other neurologic deficits: amaurosis fugax
Acute epidural vs. Subdural hematomas

12
Features Epidural hematoma Subdural hematoma MC sign of epidural hematoma Ipsilateral blown pupil
Supratentorial Most important prognostic factor in neuroblastoma Age at time of diagnosis
Skull fracture 70% 30%
Source of hemorrhage Arterial or venous Venous CARDIOTHORACIC SURGERY
Vessels involved Middle meningeal A. Ruptured bridging veins • Pancoast tumor: tumor at apex of lung or superior sulcus that may involve the brachial plexus,
Location Temporoparietal Frontoparietal sympathetic ganglia, and vertebral bodies, leading o pain, upper extremity weakness, and
Features Blown pupil [fixed, dilated], classic HA, mental status changes, horner’s syndrome
“lucid interval” [mins/hrs] contralateral hemipharesis • Benign lymphatic tumor is called cystic hygroma while a malignant lymphatic tumor is called
CT scan findings Lens-shaped, convex hyperdensity Crescent-shaped, concaved lymphagiosarcoma
hyperdensity • “popcorn-like” lesion on x-ray is diagnostic of: pulmonary hamartoma
Seizures < 25% 75% • Plaque rupture is the main cause of escalation of symptoms. Intermittent closure of dynamic
Treatment Neurosurgical evacuation Surgical evacuation plaques underlies symptoms of unstable angina.
Mortality High Low • The intra-aortic ballon pump [IABP] sits in the descending aorta [just distal to where the left
Infratentorial subclavian takes off].
Frequency More common Less common • Austin flint murmur: low pitched diastolic rumble secondary to regurgitated blood striking the
Skull fracture Almost always Frequent anterior leaflet.
Source of hemorrhage Venous Venous • Anatomic classification of thoracic aortic aneurysms:
Debakey type 1 Ascending and descending aorta
• Glasgow coma scale Debakey type 2 Ascending aorta only
Points Best eye opening Best verbal Best motor Debakey type 3 Descending aorta only
6 - - Obeys
5 - Oriented Localizes pain • “Tearing or ripping” chest pain radiating to the back is characteristic of thoracic aortic
4 Spontaneous Disoriented Withdraws to pain aneurysm.
3 To speech Inappropriate words Flexion [decorticate] • “calcium sign” – reflects separation of intimal calcification from adventitial surface on CXR is
2 To pain Incomprehensible sounds Extension [decerebrate] seen in thoracic aortic aneurysm
1 None None None • Crawford classification for thoracoabdominal aneurysms:
Note: Mild: 13-15; moderate: 9-12; severe < 8 Type 1 Descending thoracic aorta + abdominal Thoracic incision
aorta proximal to renal arteries
• Differentiating linear skull fractures from normal plain films findings Type 2 Descending thoracic aorta + abdominal Incision from 6th ICS
Feature Linear fracture Vessel groove Suture line aorta distal to renal arteries into abdomen
Density Dark black Grey Grey Type 3 Distal ½ of descending thoracic aorta + Same as type 2
abdominal aorta proximal to renal arteries
Course Straight Curving Follows course of suture lines
Type 4 Distal ½ of descending thoracic aorta + Retroperioneal incision
Branching None Branching Joins other suture lines
abdominal aorta distal to renal arteries from L flank→umbilicus
Width Very thin Thicker than Fx jagged, wide
Mediastinal contents
• Types of subdural hematoma:
Superior Aortic arch, great vessels, upper trachea,
Acute Sx w/in 48 hrs of injury
esophagus
Subacute Sx w/in 3-14 days Anterior Thymus, ascending aorta, LN Thymoma, thyroid, germ cell, lymphoma
Chronic Sx after 2 weeks or longer
Middle Heart, lower trachea & bifurcation, lung Pericardial cysts, lymphoma, mediastinal
hilus, phrenic nerves, LN granuloma, bronchogenic cysts
Rapid recall
Posterior Esophagus, descending aorta, thoracic Neurogenic tumors
Gold standard in dx of carotid artery stenosis. Carotid angiogram duct, vagus & intercostals N., sympathetic
Gold standard in dx of carotid dissection w/c shows Angiogram trunks, azygos & hemiazygos V., LN
“beaking, string and pearl sign, and double lumen sign”
Pathognomonic for neurofibromatosis 2 Bilateral CN 8/acoustic neuromas Rapid recall
MC affected in ependymoma 4th ventricle MC benign lung tumor Hamartoma
MC adult posterior fossa tumor Hemangioblastoma 2ND MC benign lung tumor Bronchial adenoma
MC pathology in pineal tumors Germinoma MC etiology of chronic mediastinitis Histoplasma capsulatum
“Ghost tumor” and is the great imitator of brain tumor CNS lymphoma MC cause of embolus from the heart Atrial fibrillation
Mainstay of treatment in CNS lymphoma Radiation therapy MC site of arterial occlusion by an embolus Common femoral artery
MC malignant pediatric brain tumor Primitive neuroectodermal tumors MC site of arterial occlusion from atherosclerosis: Superficial femoral artery
[PNET] MC site of abdominal aortic aneurysm Infrarenal artery
MC intracranial tumors in adults Metastatic > gliomas > meningiomas MC benign cardiac tumor Myxoma [L atrium]
MC intracranial tumors in children Medulloblastomas > astrocytomas > MC malignant cardiac tumor in children Rhabdomyoma
ependymomas MC intervention in thoracic trauma Closed tube thoracostomy
MC primary bone tumors in adults Glioblastoma multiforme
MC cause of malignant pleural effusion Lung CA
MC location of medulloblastoma Cerebellar vermis [children] or MC cause of chylothorax Lymphoma
cerebellar hemispheres [adults]
2nd MC cause of chylothorax Trauma
MC site of brain abscess Frontal lobe
MC type of bronchial gland tumor in lower respiratory tract Adenoid cystic teratoma
MC cranial nerve injury CN 7
MC neoplasm of anterosuperior mediastinum Thymoma
MC type of glioma Ependymoma
MC primary mediastinal cysts Bronchogenic cysts
MC cause of subdural empyema Frontal sinusitis
MC mediastinal tumor Neuroblastoma [children]
MC pathogen in spinal epidural abscess Staph aureus
MC cause of ascending aortic aneurysm Cystic medial necrosis
MC bacteria causing post-neurosurgery meningitis Staph aureus
MC cause of mitral stenosis. RHD
MC etiology for spinal epidural abscess Staph aureus
Most important risk factor for atherosclerosis Systemic HPN
MC pathogen in cerebral abscess Streptococcus
Most important manifestation in rheumatic fever Rheumatic heart disease
MC etiology of mycoic aneurysm Streptococcus
Type of lung CA arising from non-smokers Adenocarcinoma
MC parasitic infection involving CNS Neurocysticercosis
MC symptom of lung cancer Chronic cough
MC fungal infection involving CNS Candidiasis
Method of choice for centrally-located masses [squamous Bronchoscopy
MC site of vertebral osteomyelitis Lumbar
cell and small cell CA]
Most lethal & the majority of brain injuries GSW to head Method of choice for peripherally located nodules Transthoacic needle biopsy
“Ivory vertebrae” is characteristic of Chordoma
Test of choice for pxs w/ pleural effusion and suspected Thoracentesis
MC location of hypertensive intracerebral hemorrhage Putamen malignancy
MC site of spinal injury in children Cervical > thoracic
MC site of herniated disc at lumbar level L5-S1, then L4-5 VASCULAR SURGERY
MC site of herniated disc at cervical level C6-7, C5-6 • You are asked to see a px w/ bleeding from an angiogram puncture site. She has an oozing,
MC type of fracture to axis Odontoid type 2 pulsatile expanding mass in her groin at the puncture site: expanding hemangioma
MC cause of subarachnoid hemorrhage [SAH] Trauma • ”blue toe syndrome” is seen in embolism.
MC cause of non-traumatic SAH in adults Ruptured berry aneurysm • Chronic ischemia MC affects: infrarenal aorta, iliac arteries and superficial femoral artery
MC cause of morbidity & mortality in SAH Re-bleeding • Infrainguinal disease affects: superficial femoral artery at adductor canal
MC cause acute compression neuropathy. Peroneal • Size at w/c abdominal aortic aneurysm is considered for surgical repair: 5cm
MC physical sign of brain metastasis Focal neurologic deficit • External iliac artery is never involved when cause of aneurysm is atherosclerosis.

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 A CA not detectable by PE but incidentally on surgical specimen
Hard signs & soft signs of arterial injury B Palpable but confined to prostate
Hard signs Soft signs B1: involves 1 nodule w/ normal tissues
Hemorrhage Hemorrhage B2: involves the gland more diffusely
Distal pulse deficits Hx of hypotension C Palpable tumor extends beyond prostate but no distant mets
Large expanding pulsatile hematoma Deficit in anatomically related nerves D Distant mets present
Distal ischemia Small, stable, non-pulsatile hematoma D1: to pelvic nodes only
Bruit or thrill Proximity of an injury to arterial supply D2: widespread mets
Rx: exploration Rx: angiography
Surgical staging & treatment for prostate CA
Rapid recall Stages Description Treatment
MC site of peripheral aneurysm Popliteal artery 1 Clinically inapparent tumor, No LN or mets Radical prostatectomy, [+/-]
MC vascular disorder Varicose veins external beam radiation
MC site of arterial atherosclerotic occlusion in lower extremities SFA in hunter’s canal 2 Tumor w/in prostate, no LN or mets Same as 1
MC level for non-viable foot Below knee amputation 3 Tumor thru prostate capsule, no nodes or mets Radiation tx
MC complaint of chronic arterial ischemia Intermittent claudication 4 Tumor extends into adjacent structures, [+] LN & mets Hormonal tx
MC manifestation of chronic mesenteric ischemia Postprandial abdominal pain &
weight loss
Best chance of healing particularly in pxs w/ PVD. Above knee amputation
Staging & treatment of testicular CA
Stages Description Treatment
1 Confined to testis into tunica albuginea or Inguinal orchiectomy &
epididymis, no LN or mets radiation to retroperitoneal LN
TRANSPLANT 2 [+] LN, no mets, any tumor Same as 1
• Definitions: 3 Distant mets, any nodal status, any tumor size Orchiectomy & chemotherapy
Autograft Donor + recipient are same individual or of same genetic makeup
Allograft Donor + recipient belong to same species but different genetic makeup Renal cell CA staging
Isograft Donor and recipient are genetically identical [identical twins] Stages Description 5 yr-SR
Xenograft Donor and recipient are of different species 1 Tumor confined within kidney capsule 60-75%
Orthotopic Transplant graft placed into its anatomic position 2 Invasion thru kidney capsule but confined within Gerota’s fascia 45-65%
Heterotopic Transplant graft placed at different site 3 Involves regional LN or vena cava 25-505
Paratopic Donor organ is placed closed o original organ 4 Distant metastases < 5%

• A kidney transplant recipient is seen in the ER for nausea and abdominal pain, fever and Types of nephrolithiasis
elevated creatinine: acute rejection Type Freq. Etiology & characteristics Treatment
• Storage temperature of an organ: 4 degrees Celsius, on ice in a cooler Ca+ oxalate or 83% Idiopathic hypercalciuria, elevated uric Hydration, thiazides
• Optimum and maximum times for each organ: PO4 acid sec. to diet & 1◦ hyperthyroidism.
Heart and lungs 4-6 hrs; preferred w/in 5 hrs Alkaline urine. Radiopaque
Pancreas Up to 30 hrs, preferred by 10-20 hrs Struvite [Mg-NH4- 9% “Triple-phosphate stones”. Associated w/ Hydration, treat UTI if
Liver 24 hrs; preferred 6-12 hrs PO4] Proteus. Form staghorn calculi. present
Kidney 48 hrs Alkaline urine. Radiopaque
Uric acid 7% Gout & high-purine diet turnover states. Hydration, alkalinize
Acidic urine. Radioluscent urine w/ citrate
• L kidney is preferred by surgeons because of its longer renal vein.
Cystine 1% Defect in cystine, ornithine, lysine & Hydration, alkalinize
• Pancreatic transplant is placed in abdominal cavity rather than in retroperitoneal space because
arginine-COLA]. Hexagonal crystals. urine, penicillamine
of a lower incidence of peripancreatic fluid collections and lymphocele.
Radiopaque.
Rapid recall
Bladder CA staging [using CT scan of abdomen & pelvis & surgical staging]
Drug of choice for liver transplant Tacrolimus [FK-506]
Superficial St. 0 CIS, mucosal involvement 1 Tumor < 2.5 cm, no nodes/mets
MC solid organ being transplanted Kidney
St. A Submucosal involvement 2 > 2.5 cm, limited to kidney, no
MC cause of kidney transplants Diabetes
nodes or mets
MC infectious complication after pancreas transplant UTI
Invasive St. B Involvement of UB 3 Extends to IVC, [+] regional LN
muscularis but < 2 cm diameter, & extends
GENITO-URINARY SYSTEM
St. C Involvement of perivesical fat past gerota’s fascia
• Cremasteric reflex: retraction of the testicle as the medial aspect of thish is stroked
Metastatic St. D1 Metastatis to LN 4 Distant mets, [+] LN, > 2cm
• Always suspect torsion in px w/ inguinal pain and an empty scrotum.
St. D2 Mets to bone or other viscera diameter & extends past
• An adolescent presents w/ acute testicular pain and swelling immediately after a sporting event. gerota’s fascia
of the body
He is ill appearing, writhing in pain. He had similar episodes of this in the past: testicular
torsion
Rapid recall
• A 40 y/o man presents w/ sudden onset of L-sided flank pain that he rates 10/10. He is writhing,
Classic sign of testicular torsion High-riding testis w/ a horizontal lie
unable to stay still or find a comfortable position: renal colic
MC malignancy to affect young men Testicular tumor
• During passage of a stone, there are 5 sites where passage is likely to become arrested: calyx
of kidney, ureteropelvic junction, pelvic brim, ureterovesical junction and vesicle orifice MC testicular tumor Germ cell tumor
• Stones < 5-8 mm pass spontaneously Most precise method of determining the anatomy of ureter Retrograde pyelogram
and renal pelvis in diagnosing renal calculi
• An 87 y/o man w/ hx of prostate CA presents w/ low back pain: bony metastasis w/ cord
compression Procedure of choice in BPH Transurethral prostatectomy
• Radical prostatectomy is indicated for stage 2B prostatic CA. Most sensitive test for early detection of prostatic CA PSA
• Peyronies disease: abnormal fibrosis of penis shaft resuling in bend upon erection. Primary method for evaluating renal masses IVP w/ nephrotography
• Seminonas are radiosensitive. Method of choice for diagnosis & staging of renal cell CA CT scan
• Type of bony lesions seen in metastatic prostate CA: osteoblastic [radiopaque] TOC if no evidence of metastasis is seen in renal CA Radical nephrectomy
• “Bag of worms” = grade 3 varicocoele Mainstay of treatment in bladder CA Simple or radical cystectomy
• Types of incontinence: Classic presentation of bladder CA Painless hematuria
Stress Loss of urine associated w/ coughing, lifting, exercise, seen MC cause of ARF in surgical pxs Sequestered 3rd space loss [post-op site]
incontinence most often in women secondary to relaxation of pelvic floor MC cause of ARF in surgical patient Hypovolemia
Overflow Failure of bladder o empty properly, may be caused by MC histology of prostate CA Adenocarcinoma
incontinence bladder outlet obstruction or detrusor hypotonicity Type of stone NOT seen on x-ray Uric acid
Urge Loss of urine secondary to detrusor instability in pxs w/ stroke, Stone associated w/ UTI Struvite stones
incontinence dementia and parkinson’s disease Stones seen in IBD Calcium oxalate
Mixed type Combination of urge & stress incontinence Area of prostate where BPH arise Periurethral
Enuresis Bedwetting in children Area of prostate where CA arise Periphery
MC site of distant metastasis in renal cell CA Lung
Whitmore’s staging for prostate CA MC solid renal tumor of childhood Wilm’s tumor
Stage Description MC injured urinary organ Kidneys
Least injured urinary organ Ureters

14
MC correctable surgical cause of infertility Varicocoele MC site of osteosarcoma 2/3 of distal femur
MC Sx of BPH Oliguria & urinary retention Most important indicator whether bone growth is Benign or malignant is the zone of transition
MC Sx of renal stone Flank pain MC type of melanoma Superficial spreading [>70%]
MC manifestation of Alport’s syndrome Asymptomatic hematuria MC malignant sarcomas in children Rhabdomyosarcoma, fibrosarcoma
MC manifestation of amyloidosis Renal involvement MC type of sarcoma to metastasize to lymph nodes Malignant fibrous histiocytoma
Most important factor in DM 2 pathogenesis Insulin resistance MC sarcoma of retroperitoneum Liposarcoma
MC kidney lesion in DM Nodular glomerulitis MC site of melanoma Men [back], in women [legs]
Most important prognostic factor in prostatic CA Grading MC metastatic site of osteosarcoma Lungs
Most important prognostic factor in CA of UB Depth of invasion MC site of solitary fibrous dysplasia Ribs
Most important prognostic factor in anal CA Stage of disease Hallmark finding in fat embolism syndrome: Arterial hypoxemia [PO2 ¸60 mmHg]

HAND INJURIES
• The radial nerve does NOT innervate any of the intrinsic muscles of the hand.
ORTHOPEDICS • Clinical maneuvers for testing muscles of the hand
• Synovial fluid lacks fibrinogen thus it is non-clotting Patient maneuver Muscle tested
• Most stress fractures occur in lower extremities and commonly affect individuals involved in Bending the tip of the thumb Flexor pollicis longus
sports and military recruits “march fracture” Bending each individual fingertip against resistance Flexor digiorum profundus
• Incidence of stress fractures by site: metatarsal [50%], calcaneous [25%], tibia [20%], tarsal- while PIPs are stabilized by examiner
navicular [common in basketball players] Bring thumb out to side and back Extensor pollicis brevis and
• Study on Salter-Harris fracture on page 467: surgical clerkship book = [SALTR] abductor pollicis longus
Salter 1 Thru physeal plate only Separated Flexing and extending a fist at the wrist Extensor carpi radialis
Salter 2 Involves physis and metaphysis Above longus and brevis
Salter 3 Involves physis and epiphysis Lower Raising thumb only while rest of the hand is laid flat Extensor pollicis longus
Salter 4 From metaphysis thru physis into epiphysis Through Making a fist w/ little finger extended alone Extensor digiti minimi
Salter 5 Axial force crushes the physeal growth plate Ruined
• Kanavel signs of tensynovitis: STEP [Symmetrical swelling of finger, Tenderness over flexor
• Fracture healing: tendon sheath, Extension of digit is painful, Posture of digit at rest is flexed]
Stage 1 Inflammation & hematoma formation Day 1 • Volkmann’s contracture: contracture of forearm flexors secondary to forearm compartment
Stage 2 Hematoma organization Day 2-7 syndrome, usually due to brachial artery injury or supracondylar humerus fracture.
Stage 3 Callus formation, longest phase Day 8-90 • Dupuyren’s contracture: thickening and contracture of palmar fascia
Stage 4 Remodeling • A 37 y/o female presents w/ pain in her R wrist and fingers, accompanied by a tingling
• A 25 y/o male complains of difficulty breathing. He was noted to be acting a little confused, and sensation. The pain awakens her from sleep, and she is unable to perform her duties as a word
that he has spotty purplish rash. 2 days ago, he sustained a femur fracture after a high speed processor: carpal tunnel syndrome
MVA: fat embolism syndrome • Common hand and wrist injuries:
• Hallmark finding in compartment syndromes: pain in a conscious and fully oriented person Avulsion fracture In w/c tendon is pulled from bone, carrying w/ it a bone clip
that is out of proportion to injury or findings. Boxer’s fracture Fx of neck of 5th metacarpal sustained in a closed fist injury
• “Sun burst or sun ray pattern” on x-ray is seen in: osteosarcoma [2/3 of distal femur and Bennet’s fracture Fracture dislocation of base of thumb
proximal tibia], it metastasize to thee lungs Boxers fracture Fracture of metacarpal neck “classically” of small finger
• Enchondromas in multiple bones is called Ollier’s disease. Clay shoveler’s Fracture of spinous process of C6-7
• Still’s disease: rheumatoid arthritis, fever, rash & splenomegaly Colle’s fracture Dinnerfork deformity, distal radius fx w/ dorsal angulation
• “soap-bubble” appearance due to a thin subperiosteal bone shell is seen in: giant cell tumor Jones fracture Fracture at base of 5th metatarsal diaphysis
• “Lamellated onion-skin” appearance on x-ray is characteristic of: Ewing’s tumor Galleazzi fracture Distal 1/3 radial fracture w/ dislocation of distal radioulnar joint
• “soap-bubble appearance” on x-ray is also seen in: multiple myeloma caused by a direct blow to the back of wrist
• Most likely site of origin for metastatic tumors: BLTKP [Breast, Lung, Thyroid, Kidney, Prostate] Hangman’s fracture Fracture of the pedicles of C2
• Types of histiocytosis: Monteggia’s fracture Proximal 1/3 ulnar fx w/ dislocation of radial head caused by direct
Letterer-Siwe disease Most severe form [< 2 y.o]. Hepatomegaly, LAD, rash, blow to posterior ulna
bleeding diathesis, anemia, exopthalmos, DI Nightstick fracture Isolated fx of the ulnar shaft
Hand-Schuller-Christian dse < 5 y.o. associated ww/ systemic severe illness in children Periarticular fracture Fracture close but not involving the joint
Eosinophilic granuloma Mildest form, in older age group. Minimal S/Sx Pott’s fracture Fracture of the distal fibula
Intra-articular fracture Fracture thru the articular surface of a bone
• Miscellaneous bone diseases Rolando fracture Comminuted fracture of the base of the thumb
Legg-Calve-Perthes dse Idiopathic vascular necrosis of femoral head in children Scaphoid fracture MC cause by a fall on outstretched hand, snuffbox is tender
Slipped capital femoral Migration of proximal femoral epiphysis on the Smith’s fracture Distal radius fx w/ volar angulation caused by direct trauma to
epiphysis metaphysic in children dorsal forearm
Blount’s disease Idiopathic varus bowing of tibia Transcervical fracture Fracture thru the neck of the femur
Osgood-Schlatter’s Apophysitis of tibial tubercle resulting from repeated Tibial plateau fracture Intra-articular fracture of the proximal tibia
disease powerful contractions of quadriceps Torus fracture or Impaction injury in children in w/c cortex is buckled but not
buckle fracture disrupted
Rapid recall
MC pathologic condition associated w/ pathologic fx Osteoporosis • Miscellaneous hand injuries
MC orthopedic injury Hip dislocation Charcot’s joint Joint arthritis from peripheral neuropathy
MC fractured bone Clavicle Tennis elbow Tendonitis of the lateral epicondyle of the humerus
MC fractured long bone Radius, tibia Turf toe Hyperextension of great toe [tear of tendon of flexor hallucis brevis],
MC dislocated joint Shoulder joint seen in football players
MC sprained joint Ankle joint Shin splints Exercise-induced anterior compartment hyperextension [compartment
MC site of non-union Middle distal tibia syndrome] seen in runners
MC etiology for volkman’s ischemia contracture Compression of anterior aspect of elbow and Heel spur Plantar fasciitis w/ abnormal bone growth in plantar fascia, seen in
upper forearm after a supracondylar fracture in runner and walkers
childhood Traumatic myositis Abnormal bone deposit in a muscle after blunt trauma, deep muscle
MC cause of acute hematogenous osteomyelitis Staph aureus contusion, benign
MC site for acute osteomyelitis Metaphyseal end of a single long bone Marjolins ulcer SCCA that arises in chronic sinus from osteomyelitis
[especially around the knee] Bouchard’s nodes Enlarged PIP joints of hand from cartilage/bone growth
MC site of giant cell tumor Around the knee [distal femur and proximal tibia] HeberDen’s nodes Enlarged DIP joints of hand from cartilage/bone growth
MC osteiod forming benign tumor Osteiod osteoma [MC site: diaphysis of long Pannus Inflammatory exudates overlying synovial cells inside the joint
tubular bones] Gamekeeper’s thumb Avulsion of ulnar collateral ligament of 1st metacarpal joint, usually
MC benign tumor of the bone Osteochondroma [MC site: metaphysis of long associated w/ ski pole injury
bones of extremities] Mallet finger Rupture of extensor tendon at its insertion into base of distal phalanx
MC primary malignant bone tumor Multiple myeloma Trigger finger Stenosis of tendon sheath of flexor digitorum + nodule formation
MC pediatric bone tumors Osteochondroma
MC malignant sarcomas in adults Fibrous histiocytoma, liposarcoma and
leiomyosarcoma • Motor sensation tests of different peripheral nerves
MC site of Ewing’s sarcoma Knee Radial N. Wrist extension, dorsal web space btw thumb and index finger

15
 Ulnar N. Little finger abduction, little finger-distal ulnar aspect MC COD in USA Ischemic hear disease
Median N. Thumb opposition or thumb pinch, index finger-distal radial aspect MC COD in Philippines CVD
Musculocutaneous Arm abduction, deltoid patch on lateral aspect of arm MC fatal genetic defect in Caucasians Cystic fibrosis
MC CA among black African countries Cervical & uterine CA
• Definitions of fractures: [see diagram on surgical recall p. 648] MC perioperative COD following a shunt Hepatic failure [secondary to decrease blood
Closed fracture Intact skin over fracture/hematoma procedure flow]
Open fracture or Wound overlying fracture, thru w/c fracture segments are MC post-op COD in px undergoing AAA surgery MI
compound fracture continuity outside environment MC post-op COD in repair of aortic dissection Hemorrhage
Simple fracture 1 fracture line, 2 bone fragments MC COD after major vascular injury CAD
Comminuted fracture Results in > 2 bone fragments, aka fragmentation MC COD after a major pelvic fracture Fat embolism
Transverse fracture Fracture line perpendicular to long axis of bone MC COD in ruptured rectosigmoid colon Peritonitis
Oblique fracture Fracture line creates an oblique angle w/ long axis of bone
Spiral fracture Severe oblique fracture in w/c fracture plane rotates along Definitive procedures & treatment for common surgical diseases
the long axis of bone, caused by twisting injury Most definitive surgery for rectal CA 4 cm above anal verge APR
Longitudinal fracture Fracture line parallel to long axis of bone Most definitive operative tx for lung abscess Pulmonary resection
Impacted fracture Resulting from compressive force, end of bone is driven Most definitive operation for idiopathic pseudoobstruction Subtotal colectomy w/
into contiguous metaphysis w/o displacement ileorectal anastomosis
Pathologic fracture Fracture thru abnormal bone [ex. osteoporitic bone] MC procedure for aortic root replacement Composite valve graft
Stress fracture Fracture in normal bone from cyclic loading of bone procedure
MC procedure for pancreatic head CA Whipple’s resection
Rapid recall [pancreaticoduodenectomy]
MC cause of tenosynovitis and osteomyelitis Staph aureus MC procedure to treat BPH TURP
MC cause of osteomyelitis in pxs w/ sickle cell disease Salmonella MC procedure for follicular thyroid CA Near-total thyroidectomy
MC cause of pathologic fracture in adults Osteoporosis MC procedure for supravesical urinary diversion Cutaneous ureteroileostomy
MC cause of hip dislocation High-velocity trauma [ex. MVA] MC trauma resuscitation fluid Plain LR
MC type of hip dislocation Posterior “dashboard dislocation” MC electrolyte mediated ileus Hypokalimea
MC type of elbow dislocation Posterior [brachial A., ulnar, median] Most effective treatment for hypokalimea Hemodialysis
MC type of shoulder dislocation Anterior [axillary nerve and artery] Most characteristic of intestinal obstruction in upright AXR Stepladder appearance
MC orthopedic tumors in adults Metastasis [prostate – MC, breast, lung, MC abdominal x-ray finding in SBO Air-fluid level in upright film
kidney, thyroid and multiple myeloma] MC x-ray finding in traumatic thoracic injury Widened mediastinum
MC entrapment neuropathy Carpal tunnel syndrome MC sign of pancreatitis on AXR Sentinel loop
MC site of compartment syndrome in legs Calf MC indication for laparoscopic splenectomy ITP
In arms Anterior compartment MC indication for surgery in regional enteritis Obstruction
MC indication for surgery in Crohn’s disease SBO
MISCELLANEOUS MC indication for emergent laparoscopy in NB NEC
Most important diagnostic procedure for suspected esophageal CA Barium swallow
Most common complications of surgical diseases Most direct method of visualizing urethra & UB Cystoscopy
MC complication of adult MI Arrhythmia Most reliable method to detect gastric CA Endoscopy
MC complication of PUD Bleeding Most reliable renal imaging study CT scan
MC complication of meckel’s diverticulum Intestinal obstruction Most reliable indicator of biliary tract disease Biliary UTZ
MC complication of diverticulitis Abscess formation Most reliable in identifying colon pathology Barium enema
Most serious complication of acute MI & MC COD in Ventricular arrhythmia Most reliable method to confirm esophageal caustic injury Endoscopy
1st hr after an MI Most reliable invasive method to investigate pulmonary disease Bronchoscopy
Most serious complication of carotid endarterectomy Perioperative stroke Most reliable & complete exam for large bowel Colonoscopy
MC urologic complication of Crohn;s disease Ureteral obstruction Most reliable non-invasive method for detecting vascular lesion Duplex scan
MC cardiac complication after thoracic surgery Supraventricular arrhythmias [usually AF] Most reliable method to evaluate DVT Venography
MC complication of pacemaker insertion Migration of facing electrode Most reliable method to evaluate CAD Angiography
MC complication of appendectomy Wound infection Most reliable method to document location & severity of Arteriography
MC complication of pancreaticoduodenal resection Pancreatic fistula infrainguinal arterial occlusive disease
MC complication of thyroidectomy Wound hematoma Most reliable procedure in detecting UGIB Arteriography
MC complication after gastrectomy Alkaline reflux disease Most reliable method for localizing GU bleeding Direct visualization
MC complication after splenectomy Left lower lung atelectasis Most reliable method to dx thoracic aortic aneurysm Chest x-ray
MC complication of pulmonary artery cathetherization PVCs Most reliable test for peritonitis Paracentesis
MC complication of heparin therapy Thrombocytopenia Most reliable test to determine presence of intra-abdominal injury DPL
MC complication after varicose operation Ecchymosis Most reliable test for pheochromocytoma Urinary level of metanephrine
Most serious complication of lower extremity Pulmonary infarct & VMA
thrombophlebitis Most useful test in establishing the cause of hypercortisolism & in Dexamethasone suppression
Most severe complication of rheumatic fever Endocarditis determining whether cause is pituitary dependent or independent test
Most severe complication of Kawasaki disease Coronary artery aneurysm Most reliable liver function test in detecting hepatic metastasis Alkaline phosphatase
Most severe complication after repair of thoracic Paraplegia Most reliable indicator of thyroid function Free thyroxine index
abdominal aortic aneurysm Most sensitive test of thyroid function TSH assay
Most severe complication of thyroid surgery Hemorrhage MC screening procedure for colonic CA Occult blood test
Most severe complication of trauma surgery Descending aorta tear MC used contrast study for colorectal CA Air-contrast barium enema
Most severe complication of portal HPN Bleeding esophageal varices
Most severe complication of colitis Toxic megacolon
Most severe complication of Barret’s esophagus AdenoCA

Common causes of death in surgical diseases

MC COD in Alzheimer’s disease Pneumonia
MC COD in premature infants Hyaline membrane disease
MC COD in MI Arrhythmia
MC COD in dialyzed CKD px Heart disease
MC COD among hospitalized px w/ acute MI Cardiogenic shock
MC COD in cystic fibrosis Respiratory failure
MC COD in DM MI [IHD]
MC COD in Mallory-Weis syndrome Massive hemorrhage at EG junction
MC COD in Marfan’s syndrome Dissecting aortic aneurysm
MC COD in HPN AMI [2nd=lenticulostriate stroke, 3rd = CRF]
Most important COD in pxs w/ HPN CHF
MC COD in SLE Lupus nephropathy type 4 [diffuse proliferative]
MC COD in CML Blast crisis
MC COD in sickle cell anemia Pneumococci & Hib

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