HI-YIELD NOTES IN SURGERY [from USMLE clerkship-surgery & Surgical Recall] Blummer’s shelf Metastatic disease to the rectouterine
Metastatic disease to the rectouterine pouch of Douglas or rectovesical
SURGERY SIGNS, TRIADS, AND ETC...
Important triads to remember
ABCD of melanoma
Achalasia triad
Beck’s triad
Bergman’s triad
Cantrell pentalogy
Carcinoid syndrome triad
Carney’s triad
Charcot’s triad in multiple sclerosis
In cholangitis
Cystitis triad
Fat embolism triad
Glucagonoma triad
Grave’s disease triad
Hand-Schuller-Christian triad
Hematobilia triad
Hereditary hemochromatosis triad
HUS triad
Hutchinsons triad of late congenital
syphilis
Hypersplenism triad
Intususception triad
Kartagener’s syndrome triad
Kasabach-Merit syndrome triad
Macklers triad
Meig’s syndrome triad
Meniere’s triad
Miller-Dieker syndrome triad
Multiple myeloma triad
Necrotizing enterocolitis triad
Pellagra [niacin, vitamin B3 - 3 D’s]
Pheochromocytoma triad
Plummer-Vinson syndrome triad
Reiter’s syndrome triad
Renal cell CA triad
Reynold’s pentad
Rubella syndrome triad
Saint’s triad
Sjogren syndrome triad
Somatostatinoma tumor triad
Thrombotic thrombocytopenic
purpura, TTP pentad
Tuberous sclerosis clinical triad
Virchow triad of thrombus formation
Wegener’s granulomatosis triad
Wernicke triad of alcoholic
encephalopathy
Wilm’s tumor triad
Wiskott-Aldrich triad
Whipple’s triad of insulinoma
Important signs to remember
Balance’s sign Dullness to percussion in LUQ and resonance to percussion in R flank seen
w/ splenic rupture or hematoma.
Battle’s sign Echymosis over the mastoid process in patients w/ basilar skull fractures
“Blue dot sign” A blue dot on scrotal skin from a twisted testicular appendage .
Bell clapper deformity Bilateral non-attachment of the testicles by the gubernaculum to the scrotum
pouch creating a “shelf” that is palpable on rectal examination.
Boas sign R subscapular pain resulting from cholelithiasis
Chvostek’s sign Tapping the facial N. in front of ear tragus causes ipsilateral twitching
Courvoiser’s sign A palpable, nontender gallbladder often associated w/ CA in head of the
pancreas or the gallbladder
Asymmetric, border [irregular, color variation, diameter > 0.6
Cullen’s sign Aka periumbilical ecchymoses , indicative of intraperitoneal hemorrhage
cm and dark black color
Dance’s sign Empty RLQ in children w/ ileocecal intussusception
Dysphagia, regurgitation, weight loss
De Musset’s sign Bobbing of head w/ heartbeat
Hypotension, JVD, muffled heart sounds
Duroziez sign Presence of diastolic femoral bruit when femoral artery is compressed
Mental status changes, petechiae, dyspnea seen in fat
enough to hear a systolic sound.
emboli syndrome
Fothergill’s sign Bluish discoloration of skin, differentiates intra from extra-abdominal mass
Omphalocele, diaphragmatic hernia, cleft sternum, absent
pericardium & intracardiac defects Fox’s sign Ecchymosis of inguinal ligament seen w/ retroperitoneal bleeding
Flushing, diarrhea and R sided heart failure Gastrinoma triangle Junction of 2nd and 3rd portions of duodenum, cystic duct, pancreatic duct
Gastric leiomyosarcoma, pulmonary chondromas, extra- Grey-Turner sign Bluish hematoma or flanks echymoses , sign of retroperitoneal hemorrhage
adrenal paraganglioma Hamman’s Crunching sound on auscultation of the heart resulting from emphysematous
Scanning speech, intention tremor, nystagmus sign/crunch mediatinum, seen in Boerhaave’s syndrome and pneumomediastinum.
Jaundice, RUQ pain, fever/chills Hill’s sign Systolic pressure in the legs > 20 mmHg higher than in the arms
Urinary frequency, suprapubic pain, dysuria Homan’s sign Calf pain on forced dorsiflexion of foot in pxs w/ DVT.
Confusion, dyspnea, petechiae Howship-Romberg Pain along the inner aspect of thigh seen in an obturator hernia due to
DM, necrotizing skin erythema, anemia sign nerve compression
Hyperthyroidism, ophthalmopathy, pretibial myxedema Kehr’s sign Severe L shoulder pain in pxs w/ splenic rupture due to referred pain from
diaphragmatic hernia
Calvarial defects, diabetes insipidus, exopthalmos
Macewen’s sign Tapping on the head of a hydrocephalic infant produces a cracked pot sound
Abdominal injury, GIT bleeding, colicky pain
Pemberton’s sign Choking sensation aggravated by raising hand above the head [ thyroid CA ]
Pigment cirrhosis w/ hepatomegaly, skin pigmentation & DM
Phren’s sign Relief of pain by elevation of testicle, may be indicative of epididymitis
Anemia, thrombocytopenia & ARF
Quincke’s sign Alternating blushing and blanching of the fingernails when gentle pressure is
Interstitial keratitis, notched teeth, CN 8 deafness
applied.
Seagesser’s sign Phrenic nerve manual compression causing neck tenderness in splenic
Splenomegaly, reduced cellular blood elements w/ high BM
rupture .
activity, correction of blood cytopenias w/ splenectomy
Shopping cart sign Px may be able to walk further if there is something to lean on [found in
intermittent colicky abdominal pain, billous vvomiting,
spinal stenosis ]
currant-jelly stool
Silk-glove sign Indirect hernial sac in pediatric px, the sac feels like a finger of a silk-glove
Bronchiectasis, sinusitis, situs inversus
when rolled under the examining finger.
Rapidly enlarging cavernous hemangioma, DIC,
Spurling’s sign Radicular pain produced w/ downward pressure on head when neck is
hrombocytopenia
extended and tilted toward the affected side
Emesis, lower chest pain, cervical emphysema
Trousseau’s sign Carpopedal spasm following inflation of shygmomanometer cuff to above BP
R –sided hydrothorax, ascites, ovarian fibroma
for several mins.
Hearing loss, tinnitus, vertigo
Valentino’s sign RLQ pain from perforated PUD due to sucus/pus draining into the RLQ
Seizures, MR, lissencephaly
Westermark’s sign Decrease pulmonary vascular markings on CXR in pulmonary embolus
PAM [Punched-out lytic lesions, Atypical plasma cells,
Monoclonal gammopathy]
Feeding intolerance, abdominal distention & hematochezia Radiologic + Histologic hallmarks & tests to remember
Dermatitis, diarrhea, dementia “apple core” filling defect” on barium L-sided colon CA
Palpitations, headache, episodic diaphoresis “Bamboo spine” in plain films Diffuse Idiopathic Skeletal Hyperostosis/Forestier synd.
Microcytic hypochromic anemia, atrophic glossitis, “beads on string appearance” bile ducts Sclerosing cholangitis
esophageal webs “bent inner tube” or “omega sign” Sigmoid volvulus.
Conjunctivitis, polyarthritis, infection [urethritis or cervicitis] Bird’s beak or steeple sign Achalasia [no gas bubble]
Hematuria, costovertebral pain, palpable mass Boomerang sign Hydrocephalus
Charcot’s triad + shock & mental status changes “calcium sign’ on CXR Thoracic aortic aneurysm
Cataracts, heart defects [PDA, PAH, VSD, TOF] Cork-screw shaped Diffuse esophageal spasm
Cholelithiasis, hiatal hernia and diverticular disease “Dance, target, donut & pseudokidney sign” Intususception
Xerostomia, keratoconjunctivitis sicca, CT / autoimmune dse “Double lumen sign” beaking, string and Carotid dissection
Gallstones, DM, steatorrhea pearl sign” on angiogram
“port wine facial nevus, cortical atrophy and seizures + “egg-shaped heart” on CXR Transposition of great vessels
calcification of cortex appearing as “tram tracks” on x-ray “Ground glass or bubbly lytic lesion” x-ray Fibrous dyspasia
FAT RN [Fever, Anemia, Thrombocytopenia, Renal and “kidney-bean” sigmoid colon & cecum + Volvulus
Neurologic dysfunction] “bird’s beak” colon on x-ray
MR, adenoma sebaceum [perivascular fibromata], seizures. “Lamellated onion-skin” on x-ray Ewing’s tumor
Endothelial injury, stasis, blood hypercoagulability “Lead pipe appearance” on barium IBD [ulcerative colitis]
Acute necrotizing granuloma; focal necrotizing or “Mushroom-like” bony prominence on x-ray Osteochondroma
granulomatous vasculitis; cresentic glomerulosclerosis Neuhausser’s sign/”soap bubble sign” or Meconium ileus
Confusion, ataxia, ophthalmoplegia “ground glass appearance” in RLQ on AXR
Pneumatosis intestinalis on AXR NEC
Flank mass, hematuria, HPN “popcorn-like” lesion on x-ray Pulmonary hamartoma
Pyogenic infections, thrombocytopenic purpura, eczema “Chain of lakes” on pancreatography Chronic pancreatitis
Hypoglycemic attacks [<50 mg/dl], CNS [stupor, confusion, AXR:“Sentinel loop sign & colon cutoff sign” Acute pancreatitis
LOC], attacks precipitated by fasting or exercise & promptly “soap-bubble” appearance Giant cell tumor
relieved by feeding or parenteral glucose “soap-bubble appearance” on x-ray Multiple myeloma.
“stepladder” arrangement on upright film Paralytic ileus
“String sign, shoulder & double tract sign” Pyloric stenosis
“Sunburst patern” of sulfur granules Actinomycoses infection
“Sun burst or sun ray pattern” on x-ray Osteosarcoma
“thumb printing” on barium enema Ischemic colitis
“tram tracks” on x-ray Sturge-Weber syndrome
Allen’s test Test for patency of ulnar artery prior o placing a radial
arterial line or performing an ABG.
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Tinel’s test Tapping over median nerve at wrist produces pain and Brooke’s ileostomy Standard ileostomy that is folded on itself to prude from the abdomen
paresthesia Bassini herniorrhaphy Repair of inguinal hernia by approximating transverses abdominis
SURGICAL SYNDROMES aponeurosis and conjoint tendon to poupart’s lig.
Leriche’s synd. Claudication of buttocks, impotence, atrophy of buttocks McVay herniorrhaphy Repair of inguinal hernia by approximating the ransversus abdominis
Li-Fraumeni synd. Associated w/ breast CA and soft tissue sarcoma aponeurosis and conjoint tendon to cooper’s ligament
Red reaction synd. Syndrome of rapid vncomycin infusion resulting in skin erythema Lichtenstein “tension-free” inguinal hernia repair using synthetic graft maternal
Ogilvie’s synd. Massive non-obstructive colonic dilatation herniorrhaphy
Gardner’s synd. GI polyps w/sebaceous cysts, osteomas, and desmoid tumors Shouldice Repair of inguinal hernia by imbrication of the transversalis fascia,
Eagle-Barret’s Aka prune-belly syndrome, congenital inadequate abdominal musculature herniorrhaphy transversus abdominis, and the conjoint tendon and approximation of
Fitz-Hugh-Curtis Perihepatic gonorrhea syndrome transverses abdominis aponeurosis and conjoint tendon to the inguinal
Heerfordt’s synd. Sarcoidosis w/ parotid enlargement, faial nerve paralysis, and uveitis ligament
Horner’ syndrome Miosis, ptosis, enopthalmos, decreased sweating APR Abdomino-perineal resection; removal of the rectum and sigmoid colon
Tietze’s syndrome Costochondritis of rib cartilage, aseptic, tx w/ NSAIDS through abdominal and perineal incisions [patient is left w/ colostomy] used
for low rectal CA < 8cm from anal verge
Poland’s synd. Absence of pectoralis major and minor muscle, often associated w/ ipsilateral
hand malformation LAR Low-anterior resection; resection of low rectal tumors through an anterior
abdominal incision
Plummer-Vinson Esophageal web, IDA, dysphagia, spoon-shaped nails, atrophic oral and tongue
mucosa Hartmann’s procedure Proximal colostomy, distal stapled-off-colon or rectum that is left in peritoneal
cavity
Carcinoid synd. Bronchospasm, flushing, diarrhea, R-sided heart failure
Mucus fistula Distal end of end of colon is brought to abdominal skin as stoma
Afferent loop synd. Obstruction of afferent loop of a billroth 2 gastrojejunotomy
Kocher maneuver Dissection of duodenum from R sided peritoneal attachment o allow
Short gut synd. Malnutrition resulting from < 100 cm of viable small bowel
mobilization and visualization of the back of duodenum / pancreas
Stewart-Treves Lymphangiosarcoma arising in chronic lymphedema after axillary for breast CA
Puestow procedure Side-to-side anastomosis of pancreas and jejunum [pancreatic duct is filleted
Blind loop synd. Bacterial overgrowth of intestine caused by stasis
open]
Frey’s synd. Flushing, pain, and diaphoresis in auriculotemporal nerve distribution [crocodile
Stamm gastrostomy Gastrostomy placed by open surgical incision and tacked to abdominal wall
tears]
Highly-selective Transaction of vagal fibers to body of stomach w/o interruption of fibers to
Rendu-Osler- Syndrome of GI tract telangiectaasia, and AVA malformations
vagotomy pylorus
weber syndrome
LOA Lysis of adhesions [enterolysis]
Ramsay-hunt synd Painful facial nerve paralysis from herpes-zoster of the ear
Nissen fundoplication 360 degrees wrap of stomach by its fundus around the distal esophagus to
Boerhaave’s synd. Esophageal perforation
prevent GERD and esophageal hiatal hernia
Thoracic outlet Compression of structures exiting from thoracic outlet
Graham patch Placement of omentum w/ stitches over a gastric duodenal perforation
Munchausen synd. Self-induced illness
Heineke-Miculicz Longitudinal incision thru all layers of pylorus to make it non-functional, used
Mikulicz’s synd. Any cause of bilateral enlargement of parotid, lacrimal & submandibular glands pyloroplasty after truncal vagotomy
Nelson’s synd. Functional pituitary adenoma producing excessive ACTH and mass effect
Modified radical Removal of breast, nipple and axillary LN [no muscles are removed]
producing visual disturbances, hyperpigmentation, amenorrhea, w/ elevated mastectomy
ACTH levels
Lumpectomy Removal of breast mass and axillary LN, normal surrounding breast tissue is
SVC syndrome Obstruction of SVC [e.g. tumor, thrombosis] spared
Trousseau’s synd. Syndrome of DV associated w/ CA
TURP – transurethral Femoral artery to popliteal artery bypass using synthetic graft or saphenous
Mirrizzi’s synd. External compression of CHD by gallstone impacted in cystic duct. resection of prostate vein; used to bypass blockage in the femoral artery
Budd-chiari synd. Thrombosis of hepatic veins CABG – coronary Via saphenous vein graft or internal mammary artery bypass grafts to
Mendelson’s synd. Chemical pneumonitis after aspiration of gastric contents artery bypass grafting coronary arteries from aorta [cardiac revascularization]
Millard-Gubler VI & VII nerve palsy, contralateral hemiplegia in pons infarct Hartmann’s pouch Oversewing of a rectal stump after resection of a colonic segment, px is left
Compartment Swelling of injured extremity w/ pain, paresthesia, pallor, pulselessness, w/ a proximal colostomy
syndrome poikilothermia. Ileoanal pull-through Anastomosis of ileum to the anus after total proctocolectomy
DiGeorge Absence of parathyroids and thymic agenesis [chief cells] Whipple’s procedure Removal of GB, CBD, anthrum of stomach, duodenum, proximal jejunum and
Sheehan’s Postpartum infection & necrosis of pituitary leading to hormonal failure head of pancreas [en bloc].
Fitz-Hugh-Curtis Perihepatitis associated w/ chlamydial infection of cervix Rastelli procedure Aorta is rerouted internally to L ventricle across VSD
Felty’s syndrome Rheumatoid arthritis, splenomegaly, and leucopenia or neutropenia
Lutembacher Ostium secundum defect + mitral stenosis WOUNDS
Maffucci syndrome Multiple enchondromas associated w/ multiple hemangiomas  Steps in wound healing
Albright syndrome Polyostotic fibrous dysplasia w/ precocious puberty & darkly pigmented skin 1. coagulation
Sjogren’s Autoimmune exocrinopathy associated w/ rheumatoid arthritis, decreased 2. inflammation
salivary & lacrimal gland secretion & lymphoid proliferation 3. collagen synthesis
4. angiogenesis
5. epithelialization – usually complete by 24-48 hrs
SURGICAL ANATOMY PEARLS 6. contraction
Artery of Adamkiewicz Responsible for anterior spinal syndrome
Cantle’s line Line drawn from IVC to just left of the gallbladder fossa, it separates the  risk of infection for wounds:
R and L lobes of the liver Clean 1.5%
Gerota’s fascia Fascia surrounding the kidney Clean-contaminated 3%
Ilioinguinal nerve Located on top of the spermatic cord Contaminated 10%
Morrison’s pouch The hepatorenal recess, the most of the posterior cavity w/in peritoneal Dirty 30-35%
cavity
Part of GIT w/o serosa Esophagus, middle and distal rectum
Pouch of Douglas Pouch between the rectum and bladder or uterus
 Classic sins of wound infection:
Retroperitoneal GIT Duodenum, ascending and descending colon, and pancreas Calor Heat
Rotter’s LN Lymph nodes in between pectoralis major and minor muscles Rubor Redness
Space of Retzius Preperitoneal space anterior to bladder Tumor Swelling
Submucosa Strongest layer of the small bowel Dolor Pain
T10 Dermatome at umbilicus Functio laesa Loss of function
White lines of Toldt Lateral peritoneal reflections of the ascending and descending colon
Vein of Mayo Vein that overlies the pylorus  5 W’s in post-op fever: wound infection, wind [atelectasis], water [UTI], walking [DVT],
wonder drugs

SURGICAL OPERATIONS – MUST KNOW Rapid recall

Billroth 1 antrectomy w/ gastroduodenostomy
Early surgical infections that occur in the 1 st 24 hrs post-op Streptococcus & clostridium
Bilroth 2 antrecomy w/ gastrojejunostomy
are MC due to
Roux-en Y limb Jejunojejunostomy forming a y-shaped figure of small bowel +
MC source of wound infection is Host’s normal flora
gastrojejunostomy

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MC cause of poor wound healing Tissue hypoxia Glucose High Low
MC cause of post-op fever w/in 1st 24 hrs Atelectasis Amylase Low High
RBC count Low High
FLUIDS, ELLECTROLYTES AND NUTRITION WBC count Low High
 Even w/o intake, a person must excrete 800 ml/day in urine waste products.
 Third spacing is the shift of ECF from plasma compartment to elsewhere [interstitial or
transcellular process] Rapid recall
 Normal urine output: 0.5 cc/kg/hr for adults and 1 cc/kg/hr for children. MC cause of shock Hemorrhage
 Hyponatremia = < 130 mEq/L, symptomatic when < 120 mEq/L MC injured abdominal organ in blunt trauma Spleen > liver
 Hypernatremia = > 145 mEq/L MC injured abdominal organ in penetrating trauma Small bowel
 Hypokalemia = < 3.5 mEq/L [ECG – flattened T waves, ST depression, U wave] MC injured solid organ associated w/ penetrating trauma Liver
 Hyperkalemia = > 5 mEq/L [ECG – peak T waves, wide QRS, T wave disappearance w/ sine MC surgical cause of emergency Acute appendicitis
wave pattern] MC level of spinal fracture C5
 Hypocalcemia = < 8 mg/dl [ECG – prolonged QT interval] MC level of subluxation C5 on C6
 Hypercalcemia = > 15 mg/dl MC finding in thoracic great vessel injury Indistinct aortic knob
 Causes of elevated anion gap metabolic acidosis: MUDPILES [Methanol, Metabolism, Uremia, MC thoracic traumatic injury Pulmonary contusion
DKA, Paraldehyde, Iron, INH, Lactic acidosis, Ethylene glycol, Salicylates] MC renal traumatic injury Renal contusion
 Causes of normal anion gap metabolic acidosis: HARD UP [Hyperparathyroidism, Adrenal MC cause of non-traumatic pneumothorax Ruptured pulmonary bleb
insufficiency, RTA, Diarrhea, Uteroenteric fistula, Pancreatic fistulas] MC cause of spontaneous pneumothorax Rupture of subpleural space
MC cause of chylothorax Distal esophagectomy
MC Sx of pneumothorax Chest pain
Rapid recall MC cause of pneumoperitoneum in adults Gastroduodenal perforation
MC fluid disorder DHN In infants Ruptured Meckel’s
MC cause of normovolemic hyponatremia SIADH diverticulum
The 1st organ affected in hypovolemic/cardiogenic shock [both cold shocks] Kidneys Least common GUT injury Ureteral injury
MC cause of hypovolemic shock in 1st 24 hrs after abdominal surgery Hemoperitoneum Clinically apparent tamponade may result from 60-100 ml of blood
MC fluid disorder in surgical px ECF volume deficit Jeferson’s fracture C1 or atlas
Hangman’s fracture C2 or dens
TRAUMA CSF is formed in the choroid plexus at a rate of 150 cc
 Crystalloids include normal saline and LR, while colloids include blood products such as RBC Procedure of choice for px w/ laryngotracheal separation. Tracheostomy
and albumin. Region most vulnerable to injury in spinal trauma Cervical vertebrae
 An enlarging pupil w/ decrease in level of consciousness is suggestive of: uncal herniation Most sensitive test for retroperitoneal injury CT scan
 Retroauriccular ecchymosed [Battle’s sign] and periorbital ecchymoses [Racoon’s eye] is Occlusion of the portal triad manually or w/ an atraumatic Pringle maneuver
suggestive of: Basilar skull fractures vascular clamp. Occlusion should not exceed 20 mins
 A 20 y/o female has a brief loss of consciousness following a head injury. She is awake but is
amnestic for the event and keeps asking the same questions again and again: concussion THERMAL INJURY
 A 21 y/o male w/ head injury has loss of consciousness flowed by a brief lucid interval . He  Burn scar CA called Marjolin’s ulcer is usually squamous cell CA w/c metastasizes via lymph
presents w/ an ipsilateral fixed and dilated pupil and contralateral hemiparesis: epidural node.
hematoma [biconvex or lenticular in shape].  “Rule of nines” in burns:
 Measures to lower ICP: HIVED [Hyperventilation, Intubation, Ventriculostomy, Elevate head, i. Each upper limb = 9%
Diuretics] ii. Each lower limb = 18%
 A 70 y/o male presents to the ED after a whiplash injury. He is ambulating well but has an iii. Anterior and posterior trunk = 18% each
extremely weak handshake: central cord syndrome iv. Head and neck = 9%
 Distraction/seat-belt injury/chance fracture – a horizontal fracture thru the vertebral body, v. Perineum and genitalia = 1%
spinous processes, laminae, pedicles, and tearing of the posterior spinous ligament.  “Rule of palm” – the surface area of the pxs palm is approximately 1% of TBSA used for
 A 19 y/o male, who was stabbed in the chest complaints of dyspnea. Breath sounds on the left are estimating size of small burns.
absent: pneumothorax
 A 25 y/o female presents after a high speed MVC w/ dyspnea and tachycardia. There is focal  Types of burns:
bruising over the R side of her chest. CXR shows a RU lobe consolidation: pulmonary contusion Degree PE Depth Sensation Color Healing
 Criteria for a [+] DPL: 1st Blush Superficial Painful Red 7 days
1. > 10 ml gross blood on initial aspiration Desquamate Thickness
2. > 100,000 RBC 2nd Blister, wet Partial Very painful Glistening 7-21 superficial
3. > 500 WBC thickness pink 21-35 - deep
4. gm stain w/ bacteria or vegetable matter 3rd Charred Full thickness Painless White/black Grafting
5. amylase > 20 IU/L NOTE: Mild [< 10% TBSA], moderate [10-30% TBSA], severe [> 30% TBSA]
6. presence of bile
Classification of severity of hypovolemic shock Rapid recall
Clas Amount Description % blood loss MC compartment requiring fasciotomy Anterior tibial compartment
s MC causes of post-burn pneumonia S. aureus, Pseudomonas
1 750 cc Slight tachycardia, normal BP & UO 15% Common organisms found in burn wound infections S. aureus, Pseudomonas, Strep, C. albicans
2 750-1500 cc tachyC, tachypnea, CRT< 2, orthostasis, ↓ BP, 15-30% MC type of burns in children Scalding injury
agitation, confusion MC complication of electrical burns Peripheral nerve injury
3 1500-2000 cc All of the above, [+] lethargy, & ↓ UO 30-40%
4 > 2000 cc > 40% BREAST
Anatomy
Types of sepsis  Have ligaments that extend from deep pectoral fascia to superficial dermal fascia that provide
SIRS T< 36 or >38, PR>90, RR>20, PaCO2<32, WBC>12,000 or <4,000, bands <10 structural support referred to as cooper’s ligaments.
Sepsis SIRS, [+] known source of infection
Severe Sepsis, [+] organ dysfunction, hypotension but respond to fluid resuscitation
 Boundaries of axilla for dissection:
Shock Sepsis that is refractory to fluid resuscitation Superior Axillary vein
Posterior Long thoracic nerve
Properties of pleural effusion fluid Lateral Latissimus dorsi muscle
Components Transudate Exudate Medial Lateral to, deep to, or medial to pectoral minor muscle
Sp. gravity < 1.016 > 1.016
Protein < 3 gm/dl > 3 gm/dl  Rotter’s nodes lies between the pectoralis major and minor muscles.
LDH < 0.5 > 0.6  Blood supply of breast: axillary A. [via lateral thoracic & thoracoacromial branches], internal
mammary A. [via perforating branches] & intercostal A.

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  A nerves that surgeon must be aware of during axillary dissection: long thoracic, thoracodorsal,  BRCA 1 is associated w/ ovarian CA.
medial and lateral pectoral nerves .  5-10% of breast masses have [-] mammograms
 Levels of axillary LN of breast:  Recommended therapy for breast CA: CAF [Cyclophosphamide, Adriamycin, 5-FU] or CMF
[methotrexate instead of adriamycin]
Level 1 [low] Lateral to pectoral nerve  Prognosis depends more on stage than on histologic type of breast CA.
Level 2 [middle] Deep to pectoral minor  Type of chemotherapy used in breast CA: CMF [cyclophosphamide, methotrexate, 5-FU] or CAM
Level 3 [high] Medial to pectoral minor [cyclophosphamide, adriamycin, 5-FU]
 Chemotherapy for DCIS: tamoxifen after lumpectomy and radiation
Breast pathology
 Developmental disorders of the breast: Reporting mammogram results
Mastitis neonatorum Witch’s milk I No abnormality
Amastia Absent breast II Benign abnormality
Athelia Absent nipple III Probably benign finding
Amazia Nipple is present, glandular tissue is absent IV Suspicious for CA
Polythelia Supranemerary nipples V Highly suspicious for CA
Polymastia Accessory breast tissue

 Skin dimpling in breast CA is due to traction on Cooper’s ligament. Staging of breast CA

 A female w/ 1 or more risk factors for breast CA presents w/ a mass in upper outer quadrant of Stages S.R Description
breast. She’s at risk of cancers occur in the: upper outer quadrant 0 100% DCIS or LCIS
 Axillary V. is responsible for the majority of venous drainage in breast. 1 92% Invasive CA < 2 cm [+] LN, [-] mets
 Venous drainage is largely responsible for metastases to the spine thru Batson’s plexus. 2 87% Invasive CA < 5 cm, [+/-] movable axillary LN, [-] no mets
[communication w/ vertebral veins, route for hematogenous spread to vertebral column and 3 75% Invasive CA > 5 cm, [+] fixed axillary LN, [+] ipsilateral internal mammary LN
hips or any CA w/ skin involvement, pectoral & chest fixation, [-] distant mets
 Long thoracic nerve causes “winging of scapula” in post-mastectomy pxs [serratus anterior 4 13% Any form of breast CA w/ distant mets including ipsilateral supraclavicular LN
muscle]
 Breast exam recommendations: Lobular vs. Ductal CA in-situ
For all ages SBE every month Features Lobular CA in-situ Ductal CA in-situ
20-40 y/o Breast exam 2-3 yrs by physician Age of onset Premenopausal Postmenopausal
> 40 y/o Annual breast exam by physician PE - Palpable mass
[+] hx of breast CA PE every 3-4 mos. for 2 yrs Mammogram - Microcalcification
w/ lobular CA in-situ 2x/yr clinical breast exam, annual mammography Diagnosis Incidental Work-up abnormality
w/ atypia Annual clinical breast exam & mammography Risk In all breast tissue At site of diagnosis
w/ AD pattern 2x/yr clinical breast exam, annual mammography Treatment Observation vs. chemotherapy Lumpectomy + radiation vs. ipsilateral
vs. prophylactic mastectomy simple mastectomy, tamoxifen
 Breast CA mutations:
BRCA 1 Mutation linked w/ breast, ovarian & prostate CA Chr. 17q21 Breast operations
BRCA 2 Mutation linked w/ male & female breast CA Chr. 13q12 Radical mastectomy Resection of all breast tissue, axillary LN, pectoralis major & minor M.
MRM Same as radical mastectomy except pectoralis M. is left intact
 Chemoprevention of breast CA: Simple mastectomy Same as radical mastectomy except pectoralis M. is left intact & NO
axillary node disection
Tamoxifen Decreases the incidence of contralateral breast CA in pxs w/ previous hx Lumpectomy & axillary Resection of mass w/ rim of normal tissue & axillary node dissection,
S/E: hot flushes, vaginal discharge, endometrial CA, DVT, embolism node dissection good cosmetic result
Raloxifen SERM, also used to treat osteoporosis Sentinel node biopsy LN are identified on preoperative scintigraphy & blue dye is injected
 Indications for prophylactic mastectomy:
i. Hereditary breast CA: BRCA 1 & 2 Rapid recall
ii. Strong family of breast CA Hx of female w/ backpain [if reproductive, young age] High risk for breast CA
iii. Personal hx of lobular CA Hx of male w/ backpain High risk for prostate CA
iv. Personal hx of atypia & breast CA Ideal breast self-examination is done at 1 week after menstrual period
v. Women anxious of CA development Most worrisome radiologic feature for breast CA: SpIculated masses w/ microcalcific &
 The smallest breast mass palpable on PE is 1 cm. linear branching calcifications
 A female complains of nipple pain during breastfeeding w/ focal erythema and warmth of breast on Most lethal breast CA Inflammatory carcinoma
PE: mastitis MC histologic type of breast CA in MALES Infiltrating ductal CA
 A 25 y/o female presents w/ painful breast mass several weeks after sustaining breast trauma by a MC cause of bloody nipple discharge in young women Intraductal papilloma
seat belt car injury: fat necrosis MC breast tumor in pxs < 30 y/o Fibroadenoma
 A 20 y/o female presents w/ a well-circumscribed mass in her L breast. It is mobile, nontender and MC cause of green, straw or brownish nipple discharge Fibrocystic disease
has defined borders on PE: fibroadenoma MC cause of breast mass after breast trauma fat necrosis
 A female presents of acute pain in her axilla and lateral chest wall, and a tender cord is identified MC site of breast metastasis lungs > bone
on PE: mondor’s disease [superficial thrombophlebitis of lateral thoracic & thoracoepigastri c V.]
Tumors running and leeping promptly to bone Thyroid, Renal, Lung, Prostate, Breast
 A 35 y/o female presents w/ straw colored nipple discharge and bilateral breast tenderness that
Thrombophlebitis of superficial breast veins Mondor’s disease
fluctuates w/ her menstrual cycle: fibrocystic changes [no ↑risk for breast CA]
Most important factor in prognosis of patients Axillary lymph node status
 A 45 y/o female presents w/ breast pain that does not vary w/ her menstrual cycle w/ lumps in her
Most important prognostic factor in breast CA Stage of disease [axillary node mets]
nipple-areolar complex and a hx of non-bloody nipple discharge : mammary duct ectasia
 A 46 y/o female presents w/ 1 month hx of spontaneous unilateral bloody nipple discharge. Radical
THYROID
compression of the involved breast results in expression of blood at 12 o’ clock position:
Anatomy & embryology
intraductal papilloma
 Thyroid forms at base of tongue a 3 rd wk AOG
 MC invasive breast CA: infiltrating ductal CA [in peri/postmenopausal women]
 Ligament of Berry: ligament that attaches thyroid to the cricoid.
 2ND MC type of invasive breast CA : Infiltrating lobular CA
 The recurrent laryngeal nerve innervates all of the intrinsic muscles of the larynx except the
 20% of infiltrating lobular breast CA have simultaneous contralateral breast CA.
cricothyroid .
 A 65 y/o female presents w/ pruritic pain, scaly rash on her nipple discharge: paget’s disease
 Thyroglossal duct obliterates after 2 nd month.
 A 45 y/o female presents w/ enlargement of her L breast w/ nipple retraction, erythema [peau de
 Thyroid follicles store enough hormones to last 2-3 mos
orange ], warmth, and induration: inflammatory breast CA
 Iodine trapping & T4 synthesis begin by 3-4 mos. AOG.
 Breast CA risk factors: early menarche < 12, late menopause > 55, 1 st pregnancy > 30
 Screening for breast CA: annual mammograms after age 50  Relationships:

4
 Anterior SCM, sternothyroid, thyrohyoid, omohyoid isthmetomy, total or isthmectomy, total thyroidectomy & resection of
Posterior Trachea near-total or near-total central neck thyroid, external
Posterolateral Common carotid A., IJV, vagus nerves thyroidetomy thyroidetomy dissection radiation tx
Prognosis Worse for old age Worse for old age Poor prognosis
 Composed of cuboidal epithelium & central colloid Variants Sclerosis Hurtle cell tumors
 W/in stroma are C cells w/c secrete calcitonin 10-yr SR 74-93% 70% 70-80% Median: 4-5
 Blood supply of thyroid: superior [from 1st branch of external carotid A. at level of carotid mos.
bifurcation] & inferior thyroid A. [from thyrocervical trunk of subclavian A.], thyoridea ima [from
aortic arch or innominate A.]  Risks of thyroid surgery include: recurrent laryngeal nerve injury, hypoparathyroidism, and
 Venous drainage: superior [to IJV], middle [to IJV] & inferior thyroid [to brachiocephalic V.] persistent hyperparathyroidism [w/ subtotal thyroidectomy]
 Innervation: R recurrent & L recurrent [from vagus], & superior + middle symphathetic
ganglia [sympathetic] & vagus N. [parasympathetic]
 Surgical operation for thyroid:
< 1.5 cm w/ no hx of neck radiation Thyroid lobecomy and isthmectomy, near total
exposure thyroidectomy or total thyroidecomy
Nerve injuries > 1.5 cm, bilateral, + cervical node Total thyroidectomy
Superior Sensory Inability to perceive foreign body mets or hx of radiation exposure
laryngeal Motor Unilateral – huskiness & weakness of voice
nerve Bilateral – easy fatigability in speaking, ↓ volume & pitch of voice  Causative agents for thyroiditis: strep pyogenes, staph aureus, pneumococcus pneumoniae
Recurrent Sensory Loss of sensation to lower pharyngeal mucosa
laryngeal Motor Unilateral – unilateral paralysis of vocal cords, hoarse voice Thyroid nodules are likely to be malignant when:
nerve Bilateral – respiratory difficulty 1. occur in young men
2. hx of radiotherapy to head or neck during childhood
Assessment of thyroid function 3. nodule grows rapidly w/ hoarseness or dysphagia
 If T production is increased, both tT4 & fT4 increase & vice-versa 4. not suppressed by L-thyroxine
 If amount of TBG changes, ONLY tT4 changes [NOT fT4] 5. cold nodules on RAI scintiscan
6. nodules appear solid or heterogenous on UTZ
 TT3: useful to confirm dx of early hyperthyroidism
 Pemberton’s sign: choking sensation aggravated by raising hand above the head

Important terms & concepts Subacute vs. Hashimoto’s thyroiditis

Features Subacute thyroiditis Hashimoto’s thyroiditis
Myxedema coma Caused by severe hypothyroidism triggered by stress [infection, alcohol, drugs],
Etiology Viral [mumps, coxsackievirus] Autoimmune disorder
leads to inspiratory or respiratory insufficiency, hypothermia
History/PE Malaise, URI, fever, tender Painless thyroid enlargement, pain
Metyrapone test Test for anterior pituitary hypofunction, blocks cortisol production, evaluates
thyroid, hyper to hypothyroidism & tender, hyper to hypothyroidism
pituitary ACTH production
Evaluation ↓ RAI w/ ↑ T4 & T3, ↓ TSH Antithyroid antibody assay is
Plummer disease Nodular toxic goiter, autonomously hyperfunctioning thyroid gland, normal
generally [+], ↓ T3 & T4, ↑ TSH
thyroid tissue functions are suppressed
Treatment Symptomatic, self-limited Exogenous thyroid hormone
Thyroid storm Extreme hyperthyroidism precipitated by surgery or infection. Sx of high fever,
DHN, tachycardia, w/ high-output cardiac failure & coma. 25% mortality. Tx:
beta-blocker, PTU, iodine, cooling measures Thyroid hormones
L-thyroxine [T4] Triiodothyronine [T3]
Thyroid anomalies: Produced only in thyroid gland 80% from peripheral conversion
Lingual thyroid Thyroid tissue that failed to descend presenting as posterior tongue mass Half life: 7 days 1 day
Lateral aberrant thyroid Mass at lateral thyroid lobe, may manifest as enlarged L thyroid gland Only free hormones are active 3x more potent than T4
Pyramidal lobe Fibrous remnant of thyroglossal duct that persists as finger-like projection 99.7% protein bound
from isthmus More abundant lesser
Thyroglossal duct cyst – Mass btw hyoid bone & isthmus that moves upward on tongue protrusion Bigger Smaller
MC thyroid anomaly Managed by Sistrunk procedure  thyroid enlargement + ↑TH = toxic goiter
 ↑TH + thyroid not enlarged = hyperthyroid
 ↑TH + S/Sx = thyrotoxicosis
Thyroid diseases  Enlarged thyroid = goiter
Refetoff’s syndrome T4 refractoriness
Jod-Basedow syndrome Hyperthyroidism 2◦ to ↑ I2 intake Surgical treatment of Thyroid diseases
Pendred’s syndrome Goiter w/ deafness Grave’s disease Bilateral subtotal thyroidectomy or radioiodide ablation
Plummer’s disease Toxic multinodular goiter Papillary CA Total thyroidectomy
Follicular CA Total thyroidectomy, [+] RAI
 The only anti-thyroid drug that can be given to pregnant pxs : PTU Medullary CA Total thyroidectomy, [+] neck LN dissection
 15% of solitary thyroid nodules are malignant Anaplastic CA Debulking & tracheostomy
 85% of cold nodules have 10-25% chance of malignancy. Thyroid lymphoma Chemotherapy & radiation
 5% of hot nodule have 1% chance of malignancy 1◦ hyperparathyroidism Parathyroidectomy
2◦ hyperparathyroidism Treat underlying cause, parathyroidectomy
Thyroid CA PARATHYROIDS
Features Papillary – MC Follicular Medullary Anaplastic Anatomy & embryology
Risk factors Radiation Dyshormogenesis MEN - risk Iodine deficiency  Superior glands originate from 4th pharyngeal pouch, Inferior glands originate from 3rd
Sex F>M F>M F>M F>M pharyngeal pouch [in conjunction w/ thymus]
S/Sx Painless mass, Painless mass Painful mass, Hard, fixed LN,  Contains chief cells w/ occasional oxyphils, secretes parathormone [calcitonin]
dysphagia, SOB dysphagia, SOB neck pain,  Tubercle of Zuckerkandl: most posterior extension of lateral thyroid lobes
dysphonia  Ligament of Berry: connects thyroid to trachea
Dx FNAB, CT-MRI FNAB, CT-MRI FNAB, [+] FNAB  Vasculature: inferior thyroid A., superior, middle & inferior thyroid V.
amyloid -dxtic
Grossly Encapsulated, hard, Encapsulated, Unilateral, mid- Macroinvasion,  Innervation:
multifocal solitary upper lobes clinically + LN External branch of Cricothyroid M. Causes disability on phonation
Histologic Psammoma Solitary, C cell-origin, Sheets of superior laryngeal N
bodies, orphan- encapsulated sheet of cells, heterogenous Recurrent laryngeal N. Intrinsic muscles R: near subclavian A.
annie eyes amyloid, collagen cells of larynx L: near ligamentum arteriosus
Metastases Lymphatic Hematogenous Lymphatic Aggressive
Tx Lobectomy, Lobectomy & Total D-bulking
Parathyroid pathology

5
  Hypercalcemic crisis : Ca+ > 13 mg/dl. Treat w/ saline, diuretics, & anti-arrhythmic agents Parathyroid Hyperplasia, adenomas Hyperplasia, adenoma Hyperplasia
 A patient complains of tingling around her lips on post-op day 1 S/P total thyroidectomy: Pancreatic Hyperplasia, adenoma,
hypoparathyroidism causing hypocalcemia islets CA
 Parathyroid CA: high Ca+, PTH, & alk phosphatase Adrenal Cortical hyperplasia Pheochromocytoma Pheochromocytoma
Thyroid C-cell hyperplasia Medullary carcinoma Medullary carcinoma
ADRENALS Extraendocrine Mucocutaneous
Anatomy & histology changes ganglioneuromas,
 Located at level of T11 marfanoid habitus
 Vasculature: branches of aorta, inferior phrenic & renal A. Mutant gene MEN I RET RET
 Venous drainage: central V. to IVC [on R] & L renal V. [on L] locus
 Cortex: aldosterone [zona glomerulosa], cortisol [fasciculata], sex steroids [reticularis]

Adrenal pathology
Rapid recall
 CA commonly associated w/ hypercalcemia: breast CA metastases, prostate CA, kidney; lung, Most sensitive test for thyroid function TSH
pancreatic, multiple myeloma Most definitive procedure to assess thyroid malignancy FNAC
MC thyroid anomaly Thyroglossal duct cyst
 Procedures for adrenal diseases: Most aggressive of the thyroid tumors: Anaplastic type [giant & spindle cells]
Cushing’s disease Transphenoidal resection of pituitary adenoma MC site of distal metastasis for follicular CA: Bone
Adrenal adenoma Laparoscopic adrenalectomy Common tumor marker for parathyroid CA HCG
Adrenal carinoma Open adrenalectomy MC ectopic ACTH production Small cell lung CA
Ectopic ACTH Resection of primary lesion MC extra-adrenal site of ACTH production Organ of Zukerkandl [near abdominal aorta]
MC cause of secondary adrenal insufficiency Iatrogenic [glucocorticoid therapy]
 A px w/ known addison’s disease presents w/ acute upper abdominal painw/ peritoneal signs and MC pituitary adenoma Prolactinoma [tx by bromocriptine]
confusion: addison’s crisis MC sign of pheochromocytoma HPN
 MC extra-adrenal location of neuroblastoma: organ of Zuckerkandl [to L of aortic bifurcation of MC Sx of medullary thyroid CA Diarrhea
IMA] MC Sx of Prolactinoma Secondary amenorrhea
MC manifestation of MEN syndrome Hypothyroidism
Adrenal diseases MC manifestation of hypoparathyroidism Tetany
Cushing’s disease Hypercortisolism MC manifestation of primary adrenal insufficiency Skin pigmentation
Addison’s disease Adrenal insufficiency
Conn’s disease Hyperaldosteronism ACUTE ABDOMEN
Primary Conn’s Secondary to excessive aldosterone secretion  Kehr sign [pain referred to L shoulder due to irritation of L hemidiaphragm] is seen in: splenic
rupture
Secondary Conn’s Secondary to increase renin
 Murphy’s sign is seen in: acute cholecystitis
 The pain of appendicitis localizes into: McBurney’s point
Laboratory findings in Cushing’s syndrome
Iatrogenic
hypercortisolism
Pituitary ACTH
hypersecretion
Adrenal cortisol
hypersecretion
Ectopic ACTH
production
Rapid recall
MC cause of free air under the diaphragm Perforated peptic ulcer
ACTH ↓ ↑ ↓ ↑
MC surgical emergency in pregnant women Appendicitis
Urinary free ↑ ↑ ↑ ↑
cortisol MC cause of UGI bleeding PUD
DHEA ↓ ↑ ↑ ↑ MC cause of abdominal pain in elderly Cholecystitis
Blood needed to have melena > 50 cc of blood
MC cause of massive lower GI bleed Diverticulosis
Primary vs. secondary adrenal insufficiency MC cause of occult blood loss Cholangitis
Features Addison’s disease 2◦ adrenal insufficiency MC surgical disease of small bowel Crohn’s disease
ACTH High Low MC cause of LLQ pain Diverticulitis
Cortisol after ACTH challenge Low High MC cause of RLQ pain Appendicitis

PITUITARY ESOPHAGUS [see GIT in IM notes]

Anatomy Anatomy
 Parts; adenohypophysis [from Ratche’s pouch]; anterior lobe while neurohypophysis from neural
primordial]; posterior lobe
 Vetebral levels at w/c the following traverse:
 Anterior lobe lacks direct supply. Portal channels from hypothalamus & posterior pituitary supply it T8 Inferior vena cava
 Posterior pituitary is supplied by middle & inferior hypophyseal arteries [from ICA] T10 Esophagus
 Drains via cavernous sinus to petrosal sinus to jugular veins T12 Aorta

Pituitary pathology [see IM notes] Pathology

 Microadenoma: > 1 cm diameter while macroadenomas: < 1 cm  Esophageal varices is MC due to: alcoholic cirrhosis
 An alcoholic man presents after severe retching, complaining of retrosternal and upper abdominal
pain: Boerhaave syndrome [full thickness – L side posterolateral wall of distal esophagus] or
Familial syndromes w/ pheochromocytoma Mallory-Weiss syndrome [partial thickness – R side posterolateral wall of distal esophagus]
Syndrome Components  Mediastinal emphysema heard as “crunching” sound w/ heartbeat [Hammon’s crunch ] is
MEN type 2 or 2A Medullary thyroid CA and C cell hyperplasia, pheochromocytomas and characteristic of: Mallory-Weiss syndrome
adrenal medullary hyperplasia, parathyroid hyperplasia  Pharyngoesophageal & epiphrenic diverticula are called pulsion diverticula [false diverticula]
MEN type 3 or 2B Medullary thyroid CA and C cell hyperplasia, pheochromocytomas and while midesophageal are traction diverticula [true diverticula]
adrenal medullary hyperplasia, mucosal neuromas, marfanoid features  Diffuse esophageal spasm is associated w/ risk for IBS & spastic colon
Von hippel-Lindau Renal, hepatic, pancreatic and epididymal cysts, renal cell CA,  FB ingestion is most likely lodged in these anatomic narrowings: above upper esophageal
pheochromocytomas, angiomatosis, cerebellar hemangioblastomas sphincter, near aortic arch & above LES
Von Recklinghausen Neurofibromatosis, cfe au lait spots, schwannomas, meningiomas,
gliomas, pheochromocytomas Characteristic findings in barium swallow:
Sturge-Weber Cavernous hemangiomas of 5th cranial nerve distribution, Bird’s beak or Achalasia [no gas Tx: endoscopic dilatation or esophagomyotomy
pheochromocytomas steeple sign bubble] w/ fundoplication, high risk for SCCA]
Cork-screw Diffuse esophageal Tx: nitrates or CCBs to decrease LES pressure,
MEN syndromes shaped spasm esophagomyotomy is not successful
Type MEN 1 [Wermer] MEN 2 OR 2A MEN 2B OR 3
[Sipple] Clinically significant portal-systemic sites:
Pituitary Adenomas Cardio-esophageal junction Esophageal varices

6
 Periumbilical region Caput medusae  Surgery is indicated when ulcer is refractory to 12 wks of medical tx or if hemorrhage,
Rectum Hemorrhoids obstruction or perforation is present. [TOC = high selective vagotomy – parietal cell
vagotomy or proximal gastric vagotomy]
 A px w/ known PUD has sudden onset of severe epigastric pain. PE reveals guarding and rebound
Types of fistula or atresia tenderness: perforation
A Esophageal atresia w/o TEF  A 53 y/o woman presents due to 3 mos. early satiety, weight loss and non-billous vomiting:
B Proximal esophageal atresia w/ proximal TEF gastric outlet obstruction
C Proximal esophageal atresia w/ distal TEF  A 33 y/o female smoker presents w/ burning epigastric pain improved after eating meals: DU
D Proximal esophageal atresia w/ proximal or distal TEF  A 45 y/o Japanese male smoker presents w/ weight loss and epigastric pain exacerbated by
E “H type” TEF w/o esophageal atresia eating: gastric ulcer
 A 58 y/o woman who is 6 days post-op from a gastrojejunostomy for PUD presents w/ postprandial
Stages of esophageal CA RUQ pain and nausea. She reports that vomiting relieves her suffering : afferent loop syndrome
Stage Description 5-yr SR  Coffee ground refers to an old, brown digested blood found in gastric lavage w/c indicates bleeding
s proximal to the ligament of Treitz.
1 Tumor invades lamina propria or submucosa 80%  GUs are 3x more likely to rebleed than DUs.
2a Invades m. propria or adventitia, [-] LN 33%  Often presents like “umbilicated dimple”: ectopic pancreas
2b Invades m. propria or adventitia, [+] regional LN 33%  Complications of chronic gastritis: gastric atrophy, metaplasia & pernicious anemia
3 Tumor invades adventitia, [+] LN, & adjacent structures 15%
4 Distant metastases 0%  Gastric o perations:
Anthrum Distal subtotal gastrectomy
Midbody Total gastrectomy
Rapid recall Proximal Total gastrectomy
Mc complication of balloon tamponade of esophageal varices Perforation
MC procedure for esophageal diverticula Cervical esophagomyotomy w/
resection of diverticulum. Staging of gastric lymphoma [by Ann-Arbor classification]
Most feared complication of esophageal dilatation Esophageal rupture Stage 1 Disease limited to stomach
MC cause of defective LES Inadequate sphincter pressure Stage 2 Spread to abdominal LN
MC cause of esophageal perforation Iatrogenic Stage 3 Spread to LN above & below diaphragm
MC sign of esophageal atresia Regurgitation of saliva Stage 4 Disseminated lymphoma
MC Sx of esophageal CA Progressive dysphagia
Staging of gastric adenocarcinoma
STOMACH [see GIT in IM notes] Stage Description 5-yr survival
Anatomy s
1 Mucosal involvement 66%
 Innervation: 2 Thru muscularis propria 33%
Anterior gastric wall L vagus N. 3 Any LN involvement, [-] distant mets 10%
Posterior gastric wall R vagus N. 4 Distant mets, extension to adjacent structure 0%
Sympathetic afferents T5-T10 [senses gastric pain]
 Vasculature: Rapid recall
Greater curvature R & L gastroepiploic A. MC site of GI tract lymphoma Stomach
Lesser curvature R & L gastric A. 2nd MC malignant gastric CA Gastric lymphoma
Pylorus Gastroduodenal A. MC type of gastric sarcoma Leiomyoma [hemogenous spread]
Fundus Short gastric A. The only polyps w/ malignant potential Adenomatous polyps
MC location of duodenal ulcer Posterior duodenal wall w/in 2 cm of pylorus
Gastric vs. Duodenal ulcer MC location of gastric ulcer
MC site of ZES
Lesser curvature
Pancreas [neck]
Gastric ulcer Duodenal ulcer
MC non-pancreatic site of ZES Duodenum
Less common Common
MC cause of upper abdominal abscess Left
40-60 y.o 20-45 y.o
MC site of intraabdominal abscess Subphrenic space
Pain aggravated by food Pain relieved by food
Mucosal end artery that causes pressure necrosis Dieulafoy’ lesion
Lesser curvature Duodenal papilla
and erodes into stomach and ruptures.
Blood type “A” Blood type “O”
MC Sx of gastric CA Anorexia & weight loss
Associated w/ malignancy Not associated
Most important prognostic factor in gastric CA Advance stage of the disease
↓ HCO3 production ↑ acid production
SMALL BOWEL
Features suggesting benign gastric ulcer
GI embryology & anatomy
1. gastric folds radiating into base of ulcer
 At 4 th wk, the primitive gut begins to develop where the endoderm becomes intestinal epithelium
2. thick radioluscent edematous collar [Hampton’s line]
& glands, while the mesoderm becomes the CT, muscle & wall of intestine.
3. smooth crater
4. pliable gastric wall in area of ulcer  At 5 th wk, the cranial limb of midgut becomes distal duodenum & proximal ileum, while the
caudal limb becomes the distal ileum to proximal transverse colon
 All of the small intestine is derived from the midgut except for the proximal duodenum w/c is
Classification of gastric ulcers: derived from the foregut.
Types Description Treatment  The small bowel has a total length of 5-10m [ 25 cm duodenum, 100-110 cm jejunum, 15-160
Type 1 Ulcer in lesser curvature at incisura angularis Antrectomy cm ileum]
Type 2 Simultaneous gastric and duodenal ulcer Antrectomy  The entire small bowel is supplied by SMA except the proximal duodenum w/c is supplied by
Type 3 Prepyloric ulcer High selective vagotomy celiac trunk.
Type 4 Ulcer in gastric cardia Subtotal gastrectomy, roux-en-  Jejunum begins & duodenum ends at ligament of Treitz
Y esophagogastrojejunostomy  A 70 y/o male w/ PVD and hyperlipidemia presents w/ severe diffuse abdominal pain. BP is
170/100 and his pulse is 90 bpm. Supine abdominal radiograph shows air w/in the wall of the small
intestine: small bowel infarct
Important S/Sx in adenocarcinoma  A px presents w/ pigmented spots on lips and hx of recurrent colicky abdominal pain : peutz-
Krukenberg’s tumor Metastasis to ovaries jegher’s syndrome
Blumer’s shelf Metastasis to pelvic cul-de-sac , felt on DRE  A 60 y/o male presents w/ a hx of cutaneous flushing, diarrhea, wheezing and an unintentional
Virchow,s node Metastasis to LN palpable in L supraclavicular fossa weight loss: carcinoid syndrome
Sister mary joseph nodules Metastasis to umbilical LN  Appendiceal carinoid < 2 cm: appendectomy while appendiceal carcinoid > 2 cm: R hemicolectomy

 A fasting serum gastrin level > 1,000 pg/ml is pathognomonic for gastrinoma
 Specific disease states:

7
 Peutz-Jeghers syndrome Hamartomatous polyps Cecum R hemicolectomy
Crohn’s disease Adenocarcinoma R colon R hemicolectomy
Gardner’s syndrome Adenoma Proximal/mid transverse colon Extended R hemicolectomy
Familial adenomatous polyposis Adenoma Splenic flexure and L colon L hemicolectomy
Celiac disease Lymphoma, carcinoma Sigmoid or rectosigmoid colon Sigmoid colectomy
Proximal rectum Low anterior resection [LAR]
 MC causes of small bowel adhesions: ABC [Adhesions, Bulge or hernias, and Cancer] Distal rectum Abdomino-perineal resection [APR]
 Air fluid levels in “stepladder” arrangement on upright film are characteristic of paralytic ileus.
 3 hemorrhoid quadrants: L lateral, R posterior and R anterior
Surgical ulcers  Grading of hemorrhoids:
Peptic General term for gastric/duodenal ulcer disease Stage Description Symptoms Treatment
Duodenal Ulcer in duodenum [ductal papilla] 1 Protrudes into lumen, Bleeding Non-resectional
Gastric Ulcer in stomach [antrum] no prolapse measures
Curling’s Gastric ulcer after burn injury 2 Prolapse w/ straining, Bleeding, perception of Nonresectional
Cushing’s Peptic ulcer after neurologic insults spontaneous return prolapse measure
Dieulafoy’s Pinpoint gastric mucosal defect bleeding from underlying arterial malformation 3 Prolapse, needs Blleding, prolapse, mucinous Excision
Marjolin’s SCCA ulceration overlying chronic burn scar manual reduction soilage & pruritus
Apthous GIT ulcer seen in Crohn’s disease 4 Prolapse, can’t be Bleeding, prolapse, mucous Excision
Decubitus Stress ulcer, skin/SQ ulceration from pressure necrosis seen on buttocks/sacrum reduced soilage, pruritus, pain
Venous stasis Skin ulceration on medial malleolus caused by venous stasis of lower extremity
 Paget’s disease of the anus is Adenocarcinoma in situ, and bowen’s disease of the anus is a
squamous CA in situ.
Rapid recall
Longest organ of the GI tract Ileum  Mucosal findings:
Largest immune organ in the body Gut Crohn’s disease Ulcerative colitis
Most prevalent type of immunoglobulin in lumen of GI tract. IgA Apthoid ulcers, granulomas, linear Granular and flat mucosa, ulcers, crypt
MC cause of RUQ pain Cholelithiasis ulcers, transverse fissures, swollen abscess, dilated mucosal vessels,
MC cause of LLQ pain Diverticulitis mucosa, full-thickness wall involvement pseudopolyps, “backwash ileitis”
MC surgical disease of the small bowel Crohn’s disease
MC cause of adult intussusceptions Adenomas Surgical repair for Hirschprung’s disease
MC cause of fistula Previous abdominal surgery Boley Remove aganglionic colon, perform pull-through anastomosis at same time
Duhamel Anterior aganglionic region of rectum is preserved & anastomose to posterior
LARGE BOWEL part of healthy bowel, functional rectal pouch is created, dural barrel side by
Anatomy & embryology side
 Unlike small intestine, colon has taenia coli, haustra & appendices epiploicae Soave Endorectal pull-through, bringing proximal normal colon thru aganglionic
 Retroperitoneal organs of the colon: ascending and descending colon, posterior hepatic and rectum w/c has been stripped of its mucosa but otherwise present
splenic flexures. Swenson 1◦ anastomosis btw anal canal & healthy bowel, rectum is removed
 Intraperitoneal: cecum, transverse and sigmoid colon
 Rectal fascia is composed of Waldeyer’s fascia & Denonvilier’s fascia
 Rectum is 12-15 cm in length and can store approximately 500 cc of feces Duke’s classification of colonic CA
Stages Description
 Blood supply of large intestine A Within mucosa
SMA Ileocolic Cecum B1 Mass extruding into muscularis propria, no nodes
R colic Ascending colon B2 Involvement of entire wall, no nodes
Middle colic Proximal 2/3 of transverse colon C1 Limited wall, [+] nodes
IMA L colic Distal 2/3 transverse colon C2 Entire wall, [+] nodes
Sigmoidal Sigmoid D Distant metastasis [liver, lungs, spine]
Superior rectal Superior 3rd rectum
Internal iliac Middle rectal Middle 3rd rectum
Int. rectal Distal 3rd rectum
Internal pudendal Direct branch Anus Determination of malignant potential of polyps
Size Histology Atypia
< 1 cm 1-3% Tubular 5% Mild 5%
 Innervation: 1-2 cm 10% Tubulovillous 20% Moderate 20%
Sympathetic N. T7-12 [R colon] Inhibits peristalsis > 2cm 40% Villous 40% Severe 35%
L1-3 [L colon & rectum]
Parasympathetic Vagus N. [proximal colon] Stimulates peristalsis
S2-4 [distal colon] R colon vs. L colon vs. Rectal CA
Basis Right colon Left colon Rectal
Pathology Parts Cecum to hepatic flexure Hepatic flexure to sigmoid Sigmoid to rectum
 L sided colon CA present w/ change in bowel habits, obstruction and hematochezia Appearance Bulky, polypoid lesions Scirrous or annular type
 R sided colon CA presents w/ anemia, fatigue and melena. Tumor type Signet-ring cell Signet-ring cell adenoCA
 “Sunburst patern” of sulfur granules on histopathologic examination is characteristic of adenoCA adenoCA
actinomycoses infection. Clinical Mx Anemia Constipation Hematochezia
 “thumb printing” on barium enema is characteristic of ischemic colitis No obstructive Sx More obstructive Sx Less obstructive Sx
 Distended loop of sigmoid colon often in the classic “bent inner tube” or “omega sign” w/ loop Melena Bloody & mucoid stools Fresh blood w/ mucus
aiming toward the RUQ is seen in sigmoid volvulus . Dull, persistent RLQ pain Change in bowel habits w/ [+] tenesmus, crampy
 A 70 y/o male w/ hx of HPN, develops lower abdominal pain 2 days S/P AAA repair. Few hours decrease stool caliber abdominal pain
later, he develops bloody diarrhea: ischemic colitis Other Mx Excessive weight loss Napkin ring lesions Rectal pain, extensive
 “Lead pipe appearance” of colon on barium enema is characteristic of IBD [ulcerative colitis].
 3 MC causes of obstruction of the large bowel: adenocarcinoma, diverticulitis and volvulus
 “kidney-bean” appearance of sigmoid colon and cecum + “bird’s beak appearance of
Frequency of polyps:
colon on xray is characteristics of volvulus. Type Frequency CA potential
 The “apple core” filling defect in descending colon on barium enema is classic for L-sided colon Tubular – most common 75% 5%
CA. Tubulovillous 15% 22%
Villous - ↑ CA r 10% 40%
 Operative management based on location:

8
Rectal CA surgical options: ERCP Passage of endoscope into duodenum & introduction of catheter to ampulla
of Vater & injection of contrast medium into CBD & pancreatic duct
Upper rectum [10-15 cm above anus] Low anterior resection PTCA Passing of needle thru skin & SQ tissues into hepatic parenchyma &
Mid-rectum [5-10 cm above anus] Depends on histology, size, age, sex advancement into a peripheral bile duct
Lower rectum abdomino-perineal resection [APR] or Mile’s procedure
Pathology on liver
Rapid recall  Amebic abscess are classically described as “anchovy paste” in appearance caused by
Entamoeba histolitica.
Widest part of the colon Cecum
 A 27 yo female presents w/ hx of hepatocellular adenoma that resolved after discontinuing OCPs.
MC site of diverticular disease Sigmoid colon
She now wants to get pregnant: hepatocellular adenomas
MC site of distant metastasis from colorectal CA Liver
 Mass of veins extending around umbilicus producing periumbilical bruit [ Cruveilheir-Buumgarten
MC site of diverticulosis Sigmoid colon
bruit] seen in caput medusa.
MC site of anal fissure Posterior midline
MC type of adenomatous polyp Tubular
2nd MC cause of cancer deaths worldwide Colorectal CA Causes of portal HPN
Classic presentation of diverticulosis Massive lower GI bleeding Presinusoidal Sinusoidal Postsinusoidal
MC carcinoma of the anus SCCA [Bowen’s disease] > adenoCA [paget’s] Splenic or portal V. thrombosis, Cirrhosis, granulomatous R heart failure, constrictive
MC Sx of Peutz-Jegher’s syndrome Recurrent colicky abdominal pain schistosomiasis, granulomatous disease pericarditis, hypercoagulability
MC Sx of ulcerative colitis Bloody diarrhea
Most important prognostic factor in colorectal CA LN involvement
Child-Pugh score for liver failure
APPENDIX Variable 1 2 3
Anatomy Bilirubin [mg/dl] <2 2-3 >3
 The appendix buds off from the cecum beginning at 6th wks of life Albumin [mg/dl] > 3.5 2.8-3.5 < 2.8
 Its lymphoid tissue first appears at 2 wks after birth Ascites [clinical] None Easily controlled Poorly controlled
 Luminal capacity is about 0.1 ml [not actual lumen] Neurologic disorder None Minimal Advanced
 Fold of Treves is an ileal fold just proximal to ileocecal valve, contains the antimesenteric fatty PT [secs] <4 4-6 >6
appendage on small bowel.
 Just 0.5 ml raises the appendiceal intraluminal pressure by -60 cm H2O. Anatomy of biliary tree & gallbladder
 Cystic duct comes off the GB & joins the common hepatic duct to form the common bile duct
 Sign’s for appendicitis: [empties into duodenum via ampulla of Vater]
Direct & rebound Tenderness manifested in RLQ  Cystohepatic or Calot’s triangle: inferior border of liver, common hepatic duct, and cystic duct. It
Dunphy’s Increased pain w/ coughing contains the cystic & R hepatic artery
Hamburger sign If a px wants to eat, consider dx other than AP  The infundibulum of gallbladder is called: Hartman’s pouch
Iliopoas Pelvic pain upon extension of the R thigh [signifies retrrocecal  The valves within cystic duct are called spiral valves of Heister
appendicitis]  The GB collects bile directly from liver via small bile ducts called ducts of Luschka
Obturator Pelvic pain upon internal rotation of R thigh [signifies pelvic type AP]
Psoas [+] hyperextension of R thigh will produce RLQ pain [due to direct Pathology of HBT
extension of retrocecal appendix to psoas muscle]  Hydrops of gallbladder is the complete obstruction of the cystic duct by a gallstone, causing the
Rovsing’s Pain in RLQ when palpation pressure is exerted in LLQ [due to gallbladder to fill w/ fluid.
peritoneal irritation]  Charcot’s triad: RUQ pain, fever and jaundice.
Rectal exam [+] pararectal tenderness at the R  Reynold’s pentad: chrarcot’s + CNS Sx and septic shock
 “Beads on a string appearance” of bile ducts is seen in sclerosing cholangitis.
 Risk of rupture of appendicitis is highest w/in 48 hrs [75%]  Cholangiocarcinomas are common located at bifurcation of the R and L hepatic ducts called as:
 MC type of appendiceal tumor: carcinoid Klatskin’s tumor.

HEPATOBILIARY SYSTEM
Anatomy of liver
Types of biliary calculous disease
Stone type Pathogenesis Composition
 Arterial supply: Cholesterol Altered bile components, cholesterol, stasis Cholesterol crystals
Artery Origin Branches of bile
Celiac trunk Aorta L gastric, splenic & common hepatic A. Black Altered bilirubin solubilization Ca+ bilirubinate, bile acids,
Common hepatic A. Proper hepatic A., duodenal A. pigment bilirubin polymers
Brown Bacterial deconjugation of bilirubin, bile Ca+ bilirubinate, bile acids,
 Venous drainage: Left , middle & Right hepatic veins drain into IVC pigment stasis bilirubin polymers, bacteria
 Receives 75% of its blood supply from Portal vein & 25% from hepatic arteries Biliary Bile stasis Ca+ bilirubinate, cholesterol
sludge crystals, mucin gel matrix
 Ligaments of liver:
Falciform ligament Connects anterior abdominal wall to liver, contains ligamentum
teres [obliterated umbilical vein] Staging & treatment of gallbladder adenoCA
Coronary ligament Peritoneal reflection on cranial aspect of liver that attaches it to Stages Description Treatment
diaphragm 1 Mucosal involvement only Cholecystectomy
Triangular ligaments R & L lateral extensions of coronary ligament 2 [+] muscularis layer of GB Radical cholecystectomy [+], wedge resection of
liver around the bed of GB [+] regional LAD
 Normal daily bile output: 500-1,200 ml 3 All layers of wall involved
 Bare area: the posterior section of liver against diaphragm, has NO peritoneal covering 4 Cystic node involvement
 Glissons capsule: peritoneal membrane that covers the liver 5 Distant spread Palliative
 Cantlie’s line [portal fissure]: line hat passes from L side of GB to L side of IVC, divides liver into
R & L lobes Staging of cholangiocarcinoma
 Liver enzymes: AST & ALT [from hepatocytes], alkaline phosphatase [from ductal epithelium] 1 Tumor invading but not thru bile duct wall
2 Tumor invading thru wall & involving perimuscular CT
3 Stage 2, [+] LN involvement
Common procedures of hepatobiliary system: 4 Tumor invading adjacent organs [liver, pancreas, duodenum & vascular organs
Pringle maneuver Compressing the hepatoduodenal ligament to control bleeding from the liver 5 Distant metastatic spread
Liver resection Up to 80% of liver can be removed & still retain adequate function
Sphincterotomy A cut to Sphincter of Oddi to allow passage of tones from CBD into Anatomic variants of choledochal cysts
papillotomy] duodenum. Often done during ERCP 1 Dilatation of CHD & CBD w/ cystic duct entering the cyst. MC type
Kocher incision Incision at the R subcostal margin performed during open cholecystectomy 2 Lateral saccular cystic dilatation

9
3
4
Choledochocele represented by an intraductal cyst
Multiple extra or intrahepatic cysts or both
 Tx of pancreatic CA based on location:
5 Single or multiple intrahepatic cysts Head of pancreas Whipple’s procedure [pancreaticoduodenectomy]
Body or tail Distal resection

Bismuth classification of bile duct injuries or strictures Ranson’s criteria for acute pancreatitis [predicts risk of mortality in pancreatitis]
1 > 2cm of CHD is preserved below the bifurcation On admission [GA LAW] After 48 hrs [C-HOBBS]
2 < 2cm remains Glucose > 200 mg/dl Ca+ < 8 mg/dl
3 Involves hilum w/ preserved continuity btw R & L sides Age > 55 y.o Hct decrease by 10%
4 Destruction of hepatic confluence w/ separation of R & L LDH > 350 IU/L [700/] O2 PaO2 < 60 mmHg
5 Separate inserting sectoral duct w/ or w/o injury to CBD AST/SGOT > 250 IU/dl Base excess > 4 meq/L
WBC > 16, 000/ml BUN increase > 5 mg/L
Sequestered fluid > 6L [base deficit]
Rapid recall Number of risk factors Mortality
Causative agents in bacterial/pyogenic liver abscess E. coli, Klebsiella, Proteus <3 1%
MC antecedent cause of pyogenic liver abscess Liver trauma 3 or 4 16%
MC cause of liver pyogenic abscess Biliary obstruction [thru portal vein] 5 or 6 40%
MC site of liver abscess R lobe [MC type – amebic abscess] >6 70-100%
MC liver nodule Hemangioma Risk of mortality: 20% [3-4 signs], 40% [5-6 signs], 100% [> 7 signs]
MC hepatic malignancy Metastases
MC primary benign liver tumor Hepatic hemangioma
MC benign tumor of liver Cavernous hemangioma Rapid recall
MC primary liver sarcoma Angiosarcoma MC sites of Cystadenocarcinoma Pancreatic body and tail
MC primary liver malignancy Hepatocellular CA MC islet cell tumor Insulinoma [“spells or blackouts” due to hypoglycemia]
Subtype of hepatocellular CA w/c has the best prognosis Fibrolamellar hematoma MC sign of pancreatitis on AXR Sentinel loops
MC primary CA of GB adenoCA
MC primary cancer of HBT Bronchogenic CA SPLEEN
MC cause of portal HPN Cirrhosis from alcoholism Anatomy
MC finding in portal HPN Splenomegaly  Located at LUQ of abdomen btw 8 th & 11th ribs
MC site of obstruction in gallstone ileus Ileocecal valve  Boundaries:
Adenomas of bile ducts are commonly seen in Ampulla of vater Superior L diaphragm leaf
Most sensitive in dx of acute calculous cholecystitis. HIDA scan Inferior Colon, splenic flexure, phrenicocolic ligament
Gold standard for dx of CBD stones ERCP Medial Pancreas [tail], stomach
MC Sx of choledochal cyst Intermittent jaundice Lateral Rib cage
MC Sx of gallbladder CA RUQ pain Anterior Rib cage, stomach
MC Sx in liver cell CA Weight loss & jaundice Posterior Rib cage
MC manifestation of alcoholic liver disease Steatosis Pathology
 Conditions associated w/ splenic rupture include: mononucleosis, malaria, blunt LUQ trauma, and
PANCREAS splenic abscess
Anatomy & embryology
 A 27 y/o HIV [+] female presents w/ fever, waxing and waning mental status and hematuria. CBC
 Begins development during 4 th wk AOG from endoderm of duodenum shows pancytopenia: TTP
 Lies retroperitoneal posterior to stomach, transverse mesocolon & lesser omentum at body of L2
 2 ducts: Wirsung [main duct] & Santorinni [accessory duct] Indications for splenectomy
 Sphincter of Oddi: smooth muscle around ampulla Disease Description & caveats
 Head is closely associated w/ duodenum [anterior & posterior pancreaticoduodenal A.] Trauma Resection w/ hilar involvement, parenchymal damage, active bleeding
 Body & tail are supplied by branches of dorsal pancreatic A. & splenic A. ITP Steroid tx, IV gammaglobulin, plasmapheresis, resection if refractory
TTP Resection if medical Tx failed
 Innervation: Myeloproliferative disease Resection for symptomatic splenectomy
Sympathetic Thoracic sympathetic ganglia to splanchnic N. to celiac ganglia Lymphoma Resection for symptomatic splenomegaly
Parasympathetic From vagal nuclei [for islets, acini & ducts] Hereditary spherocytosis Resection is curative
Felty’s syndrome Resection improves response to infection & treats Sxtic splenomegaly
 Pancreatic anomalies: Splenic abscess CT-guided percutaneous drainage
Heterotrophic Wrong location of pancreatic tissue [stomach, duodenum, meckel’s Parasitic cysts Resection indicated
pancreas diverticulum Sarcoidosis Gaucher’s resection
Pancreas divisum Failure to fuse 2 duct systems [Santorini becomes the main duct] Splenic vein thrormbosis Resection cures the sinistral portal HPN
Annular pancreas Ventral pancreas malrotates & encircles 2nd part of duodenum
Grading & classification of splenic injuries
Pathology Grade Description
 Cullen’s [periumbilicus] and Grey-Turner’s [flank] sign are indicative of severe, hemorrhagic 1 Subcapsular hematoma < 10% SA, capsular tear < 1 cm
pancreatitis. 2 Subcapsular/intraparenchymal hematoma 10-15% SA, laceration 1-3 cm depth
 “Sentinel loop sign” and colon cutoff sign” on AXR is characteristic of acute pancreatitis. 3 Large, > 50% SA, > 5 cm diameter, subscapular/intraperitoneal hematoma, >
 A 32 y/o male who underwent laparotomy for a gunshot wound to the abdomen 2 days ago is found 3cm laceration involving trabecular vessels
to have a tender belly w/o rebound and is leaning forward on his stretcher breathing at a 28/min: 4 Laceration involving hilar or segmental vessels
pancreatitis 5 Hilar avulsion or shattered spleen
 Gallstones are not common cause of chronic pancreatitis.
 Pancreatic calcifications on xray and “chain of lakes” pattern on pancreatography are
Rapid recall
characteristics of chronic pancreatitis. MC cause of hypersplenism Portal HPN
 Whipple’s procedure: removal of GB, CBD, anthrum of stomach, duodenum, proximal jejunum MC primary non-lymphoid tumor of spleen Hemangioma
and head of pancreas [en bloc]. MC presentation of splenic traumatic injury Splenic rupture
 A 30 y/o male complains of feeling faint and confused most notably after he exercises. His Mainstay of tx for TTP Plasmapheresis
symptoms improve after he has a soft drink : insulinoma MC cause of failure to correct thrombocytopenia after Missed accessory spleen
 A 4 y/o male complains of chronic epigastria pain following meals and notices increasing doses of splenectomy
his anti-ulcer medication: Gastinoma or Zollinger-Ellison syndrome
 A 57 y/o male presents w/ a hx of severe watery diarrhea characterized by hypokalemia and HERNIAS AND ABDOMINAL WALL PROBLEMS
achlorhydria: VIPoma or Verner-morrison syndrome or WDHA syndrome. Groin anatomy
 Necrolytic migratory erythema is the skin condition associated with: glucanogoma  Abdominal wall layers: skin, SQ fat, Scarpa’s fascia, external oblique, internal oblique, transversus
abdominis, transversalis fascia [strongest layer] , extra-peritoneal fat & peritoneum

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

11
 Vitelline duct Meckel’s diverticulum 3 Tumor extends across midline Resection & chemotx 40%
Ductus venosus Ligamentum venosus 4 Metastatic disease is found 3 + w/ or w/o radiation 15%
Ductus arteriosus Ligamentum arteriosus 4S Stage 1 & 2 tumor w/ mets to liver, BM, etc. Same as 4 80%



Ductus arteriosus closes w/in 1 st 24 hrs
Ductus venosus closes after 2 wks,
Age of presentation of t he ffg:
 Foramen ovale closes in the 1 st month Pyloric stenosis From 2 wks to 2 mos. of age
Intussusception From 4 mos. to 2 yrs [80%]
 Characterized by “egg-shaped heart” on CXR : transposition of great vessels
Wilm’s tumor Btw 1-4 y.o
 Rastelli procedure: aorta is rerouted internally to L ventricle across VSD
Malrotation Birth to 1 y.o [>85%]
 Ostium primum ASD [aka partial endocardial cushion defect or partial atrioventricular
canal ]. It is common among Down syndrome patients . Neuroblastoma 50% by 2 yrs, > 80% by 8 yrs of age
 Among the supravalvular lesions, the hour-glass type is most amenable to surgical treatment. Hepatoblastoma Younger than 3 y.o
Appendicitis Older than 3 y.o
Pulmonary system
 L: S ratio is a marker of fetal lung maturation. Delayed lung maturation is seen in DM & Rh Rapid recall
isoimmunization
MC cyanotic malformation Tetralogy of fallot [Coeur en sabot]
 L:S ratio < 2: high risk for RDS MC CHD VSD
 Lungs reach full maturity at 8 yrs MC VSD requiring surgery Perimembranous type
 Esophagus & trachea originate from a single diverticulum & divide at 8 wks AOG MC type of VSD Muscular VSD
MC type of ASD Ostium secundum type
Renal system
MC branchial cyst 2nd branchial cleft cyst
 Normal GFR = 50 ml/min/m2 [neonates] & 1—ml/min/m2 [adults]
MC lymphatic malformation in children Cystic hygroma
 Normal urine output = 1-2 ml/kg/hr
MC congenital lung lesion Lobar emphysema
 Urine production starts at 9-12 wks AOG.
2nd MC congenital lung lesion Congenital cystic adenomatoid malformation
 Nephrogenesis is complete by 35 wks.
MC malformation Esophageal atresia w/ TEF
Pediatric pathological diseases MC type of intestinal atresia Duodenal atresia
 A newborn presents w/ respiratory distress and a scaphoid abdomen: diaphragmatic hernia MC site of atresia Papilla of Vater
 An infant has excessive oral secretions, chokes and has apneic episodes during feeding: MC cause of acute intestinal obstruction under 2 y/o Intussusception [MC site – ileocolic]
tracheoesophageal malformation Most frequent congenial GI abnormally Meckel’s diverticulum
 Types of tracheoesophageal malformations: esophageal atresia & TEF, pure esophageal atresia & MC cause of lower intestinal obstruction in neonate Hirschsprung’s disease [Sx: enterocolitis]
H-type TEF MC intra-abdominal malignancy in childhood Wilm’s tumor or nephroblatoma
 Radiologic characteristics of pyloric stenosis: MC site of metastasis of neuroblastoma Lungs
String sign From elongated pyloric channel MC form of cleft palate Total cleft palate
Shoulder sign Bulge of pyloric muscle into the antrum MC site of intussusception Terminal ileum [ileocecal valve]
Double tract sign Parallel streaks of barium in narrow channel MC ectopic tissue in meckel’s diverticulum Gastric mucosa
MC cause of lower GI bleeding in children Meckel’s diverticulum w/ ectopic gastric
 Biliary atresia accounts for 90% of extrahepatic obstruction in neonates. mucosa
 Optimal time of surgery for biliary atresia is at < 8 weeks of age. MC benign liver tumor in children Hemangioma
 “Dance’s sign” - absence of bowel in RLQ [intussusception] MC solid neoplasms in infants Neuroblastoma
 “Target sign” – 2 concentric circles of fat density MC solid tumor in children CNS tumors
 “Target or donut sign ” – single hypoechoic ring w/ hyperechoic center MC cause of SBO in children Hernia
 “Pseudokidney sign” – superimposed hypoechoic [edematous walls of bowel] and hyperechoic MC Sx of AML in children Fatigue
[areas of compressed mucosa] layers MC manifestation of hemophilia A Spontaneous traumatic hemorrhage
 If a meckel’s diverticulum is found w/in a hernial sac, it is called: Littre’s hernia.
 Correction of inguinal hernia is the most frequent surgical intervention in children. ANESTHESIA
 A premature infant born at 33 week’s gestation now at 1 week of age has developed feeding  Spinal anesthesia – needle is inserted at L3-L4 or L4-L5 [at this level cauda equina is present
intolerance, is febrile, and has hematochezia and a distended belly: necrotizing enterocolitis [NEC] and spinal cord has already ended]
 Epidural anesthesia - needle is placed in epidural space [outside CSF] commonly an indwelling
 Pneumatosis intestinalis [gas w/in bowel wall] on AXR is seen in NEC
catheter is left in place.
 Surgical management of cleft lip & palate:  Epinephrine is nor use in this areas: SPF-10 [Scrotum, Penis, Fingers, Toes, Ears and Nose]
Cleft lip
Cleft palate
10 wks-3 mos.
12-18 mo.
Rule of tens : 10 wks age, 10
gm/dl, 10 lbs wt, 10,000
 Commonly used pre-op anesthetic medications:
WBC/mm3 Benzodiazepines Midazolam
Tranquilizer Droperidol
Antihistamine Hydroxyzine, diphenhydramine
 Types of fistula/atresia: Anticholinergic Atropine, scopolamine, glycopyrolate
Type A Esophageal atresia w/o TEF Gastrokinetic metoclopramide
Type B Proximal esophageal atresia w/ proximal TEF H2-blockers Ranitidine
Type C Proximal esophageal atresia w/ distal TEF Alpha-2 agonists Clonidine
Type D Proximal esophageal atresia w/both proximal + distal TEF 5HT antagonists Ondansetron
Type E “H type” TEF w/o esophageal atresia
Rapid recall
 Stages of Wilm’s tumor: Most popular regional anesthesia Subarachnoid block in spinal anesthesia
Stage 1 Limited to kidney and completely Most ideal for hemorrhoidectomy Caudal block
Stage 2 Extends beyond kidney, but completely resected, capsule
invasion and perirenal tissues may be involved OPHTHALMOLOGY
Stage 3 Residual non-hematogenous tumor after resection
Stage 4 Hematogenous metastases [lung, distal LN, brain]
 The red eye diseases :
Stage 5 Bilateral renal involvement Bacterial conjunctivitis Conjunctival redness w/ purulent discharge
Viral conjunctivitis Conjunctival redness w/ serous discharge
Allergic conjunctivitis Clear conjunctival discharge
Stages of neuroblastoma Acute narrow angle Acute pain, cloudy cornea, perilimbal redness, blurred vision
Stages Description Treatment 5-yr SR glaucoma
1 Tumor confined to organ of origin Resection 90% Iritis Perilimbal redness, irregular pupil, pain, decreased vision
2 Extends beyond organ but not across midline Resection & chemotx 80% Corneal ulcer Epithelial defect w/ infiltrate, pain

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 Corneal abrasion Epithelial defect, no infiltrate, pain MC Sx of oropharyngeal CA Persistent sore throat
Orbital cellulitis Periocular swelling, erythematous ocular surface, ↓ vision MC Sx of laryngeal CA Hoarseness
MC manifestation of retinoblastoma Leukoria
 Important terms: Most important prognostic factor in head, neck CA Nodal metastasis
Astigmatism Asymmetric cornea
Esotropia Eyes inward
Exotropia Eyes outward PLASTIC SURGERY
Hypertropia Eyes upward  Axial flaps and their arterial supply:
Hyperopia Farsightedness Forehead flap Superficial temporal A. For intraoral lesions
Diplopia Double vision Deltopectoral 2nd-4th anterior perforators of For head and neck
Strabismus Eye malalignment flap internal mammary A. wounds
Hyphema Blood in anterior chamber of the eye Groin flap Superficial circumflex iliac A. Hand/forearm wounds
Chemosis Edema of conjunctiva
Endophthalmitis
Ptosis
Intraocular infection
Eyelid droop
 Donor sites for skin grafts:
STSG Thigh, buttocks, abdomen, back
Anisocoria Asymmetric pupil diameter
FTSG Inguinal, upper lids, posterior auricular, supraclavicular
Nystagmus Back and forth jerky movement of the eyes
Dacrocystitis Lacrimal sac infection
Mydriasis Pupil dilatation  Types of skin grafts:
Miosis Pupil constriction Split-thickness skin graft Size Location
Myopia Nearsightedness Thin STSG 0.008-0.012 inch Upper ¼ of dermis
Medium STSG 0.013-0.016 Upper ½ of dermis
EARS, NOSE AND THROAT Thick STSG 0.017-0.020 Upper ¾ of dermis
 Menier’s disease is characterized by intermittent vertigo, tinnitus, hearing loss, and aural fullness Full-thickness > 0.020 Both epidermis & dermis
due to excess endolymph.
 Inflammation of the salivary gland: sialadenitis
 Classic Sx of croup/laryngotracheobronchitis: barking [seal-like] non-productive cough Rapid recall
 Le Fort classification: [see figure on surgical recall] MC bacteria in tenosynovitis and paronychia S. aureus
Le Fort 1 Transverse maxillary fracture above dental apices, also traverses MC hand [wrist] tumor Ganglion cysts
the pterygoid plate, palate is mobile, but nasal complex is stable MC cause of carpal tunnel syndrome Synovitis
Le Fort 2 Fracture thru the frontal process of maxilla, thru the orbital floor MC posterior fossa tumor Acoustic neuromas [cerebellopontine angle]
and pterygoid plate, midface is mobile MC site of sinus cancer Maxillary sinus
Le Fort 3 Complete craniofacial separation: differs from II in that it extends MC cell type in head and neck CA Squamous cell CA
thru nasofrontal fracture and frontozygomatic sutures MC dressing material used Alginates [Caltostat]
MC cause of skin graft failure Bleeding or hematoma
 “Tripod” fractures: fronto zygomatic suture, zygomatico maxillary suture, inferior orbital
rim, zygomatic otemporal suture NEUROSURGERY
 Boomerang sign – one of the earliest manifestations of hydrocephalus in w/c temporal tips of
Zones of the neck [see figure on surgical recall] the lateral ventricle appear.
Zone 1 Below cricoid cartilage Selective exploration  Macewen’s sign : tapping on the head of a hydrocephalic infant produces a cracked pot sound.
Zone 2 Cricoid to angle of mandible Surgical exploration  An 83 y/o female w/ a hx of diabetes, HPN and atherosclerosis presents w/ painless, mononuclear
Zone 3 Angle of mandible & up Selective exploration vision loss that lasted a few minutes and has now completely resolved. She has no other
neurologic deficits: amaurosis fugax
Modified Neck dissection  Cerebral hypoperfusion syndrome: unilateral headache due to poor autoregulation w/c can
Type 1 Spinal accessory nerve is preserved cause seizure.
Type 2 Spinal accessory N. & internal jugular N. is preserved  CN III palsy is characterized by blown pupil w/ down and out eyes as seen in uncal herniation.
Type 3 Spinal accessory N. & internal jugular N. & SCM nerves are preserved  CN VIII is affected most frequently in neuroma.
 “Fried egg or chicken wire pattern’ – a fixation artifact not routine seen.
 Tumors arising from paraganglion cells: carotid body tumors, glomus jugulare tumors,
Rapid recall pheochromocytomas
The only muscle not innervated by the vagus. Stylopharyngeus  Common sources of metastatic tumors: bronchogenic lung CA, melanoma, breast CA, renal cell
MC site of angiosarcoma in head & neck Scalp CA, colon adenocarcinoma
MC salivary gland tumors Pleiomorphic adenoma of parotid  Certain metastasis are more likely to hemorrhage: melanoma, renal cell CA, choriocarinoma
MC site of subclinical 2nd primary tumor Esophagus  Most metastases occur in the cerebral hemispheres at gray-white junction or in cerebellum.
MC cause of otitis externa [swimmer’s ear] Pseudomonas [tx w/ amoxicillin, PCN]  Radiosensitive metastasis are characteristic of: small cell lung CA, lymphoma, multiple
MC type of external ear tumor Squamous cell CA [from auricle] myeloma, and germ cell tumors
MC cause of acute otitis media in adults Strep peumoniae & H. influenzae  “Subependymal tubers” or calcific hamartomas + “ash leaf spots” on skin are
MC causes of chronic otitis media S. aureus and P. aeruginosa characteristics of tuberous sclerosis.
MC etiology in infants younger than 6 mos. S. aureus, E. coli, Kebsiella  Surgery for hydrocephalus is usually done at 3-4 mos.
MC cause of bilateral facial nerve palsy Lyme disease [B. burgdorferi]  Presents as “worst headache” of my life: spontaneous subarachnoid hemorrhage
MC cause of unilateral facial weakness/paralysis Bell’s palsy  Postradiation somnolence syndrome: lethargy for a period of 2-6 mos. after treatment
MC encountered vascular mass in nasal cavity Juvenile nasopharyngeal angiofibroma  Spinal diseases [test of choice – MRI]
MC cause of parotid swelling Mumps Spondylosis Degenerative changes in spine, arthritis
MC benign salivary gland tumor Pleiomorphic adenoma [parotids] Spondyloliisthesis Subluxation of 1 vertebral body on another
2nd MC benign salivary gland tumor Warthin’s tumor [parotids] Spondylolysis Fracture or defect in pars interarticularis, mostly
MC malignant salivary gland tumor Mucoepidermoid CA congenital at L5 [spina bifida oculta]
MC parotid malignancy Mucoepidermoid CA
2nd MC submandibular gland malignancy Mucoepidermoid CA  Lumbar spine maneuvers:
2nd MC malignant salivary tumor in adults Adenoid cystic CA Straight leg raise Radicular sx produced w/ leg elevation in supine position
2nd MC parotid malignancy Adenoid cystic CA Crossed straight Radicular sx produced in affected leg w/ elevation of
MC malignancy in submandibular & minor salivary glands Adenoid cystic CA leg raise opposite leg.
Usual causative agent in epiglotitis H influenzae type B
MC salivary gland site of stone formation
MC malignant neck mass in children, adolescents, and
Submandibular gland
Lymphoma
 Cervical spine maneuver:
young adults Spurling’s sign Radicular pain produced w/ downward pressure on head when
MC primary malignant solid tumor of head & neck in kids Rhabdomyosaroma neck is extended and tilted toward the affected side

13
  Herniated disc terminology: 3
2
To speech
To pain
Inappropriate words
Incomprehensible sounds
Flexion [decorticate]
Extension [decerebrate]
Bulge Symmetric extension 1 None None None
Protrusion Asymmetric extension Note: Mild: 13-15; moderate: 9-12; severe < 8
Extrusion Free disc fragment
Degenerated Narrowed disc space
 Differentiating linear skull fractures from normal
plain films findings
Feature Linear fracture Vessel Suture line
 Herniated disc syndromes: groove
Level Motor weakness Reflex affected Density Dark black Grey Grey
C4-5 Shoulder abduction Deltoid Course Straight Curving Follows course of suture lines
C5-6 Forearm flexion Biceps, brachioradialis Branching None Branching Joins other suture lines
C6-7 Forearm, wrist, and finger extension Triceps Width Very thin Thicker than Fx jagged, wide
C7-T1 Wrist and finger flexion Finger jerk
L3-4
L4-5
Quadriceps
Tibialis anterior and extensor hallucis longus
Patellar
Medial hamstring
 Types of subdural hematoma:
L5-S1 Gastrcnemius/soleus Achilles Acute Sx w/in 48 hrs of injury
Subacute Sx w/in 3-14 days
 “Bamboo spine” in plain films – osteophytic growth over intervertebral discs connecting Chronic Sx after 2 weeks or longer
adjacent vertebrae are characteristic: Diffuse Idiopathic Skeletal Hyperostosis/Forestier
syndrome Rapid recall
 Cystic cavitation w/in spinal cord: syringomyelia Gold standard in dx of carotid artery stenosis. Carotid angiogram
 Erb-Duchenne palsy or “Bellhop/Waiter’s tip palsy [C5/6 injury]: arm medially rotated w/ Gold standard in dx of carotid dissection w/c shows Angiogram
wrist and fingers flexed. Klumpke’s palsy [C8-T1 injury]: in an adult w/ insidious progressive “beaking, string and pearl sign, and double lumen sign”
development, think Pancoast tumor. There may be associated Horner’s syndrome. Pathognomonic for neurofibromatosis 2 Bilateral CN 8/acoustic neuromas
 Meralgia paresthetica: entrapment as nerve emerges through inguinal ligament causing lateral MC affected in ependymoma 4th ventricle
thigh paresthesia.
MC adult posterior fossa tumor Hemangioblastoma
 Spinal cord traumatic syndromes, diseases and fractures
MC pathology in pineal tumors Germinoma
Anterior cord Affecs coricospinal and lateral spinothalamic tracts, paraplegia,
“Ghost tumor” and is the great imitator of brain tumor CNS lymphoma
syndrome loss of pain/temperature sensation, preserved
Mainstay of treatment in CNS lymphoma Radiation therapy
touch/vibration/proprioception
MC malignant pediatric brain tumor Primitive neuroectodermal tumors
Central cord Preservation of some lower extremity motor and sensory ability
[PNET]
syndrome w/ upper extremity weakness
MC intracranial tumors in adults Metastatic > gliomas > meningiomas
Brown-Sequard Hemisection of cord resulting in ipsilateral motor weakness and
synd. touch/proprioception loss w/ contralateral pain/ temperature MC intracranial tumors in children Medulloblastomas > astrocytomas >
loss ependymomas
Posterior cord Injury to posterior spinal cord w/ loss of proprioception distally MC primary bone tumors in adults Glioblastoma multiforme
Jefferson’s fx Fracture thru C1 arches from axial loading [unstable fracture] MC location of medulloblastoma Cerebellar vermis [children] or
cerebellar hemispheres [adults]
Hangman’s fx Fracture thru pedicles of C2 from hyperextension
MC site of brain abscess Frontal lobe
Odontoid fx Fracture of odontoid process of C2
MC cranial nerve injury CN 7
Priapism Penile erection seen w/ spinal cord injury
MC type of glioma Ependymoma
Chance fx Transverse vertebral fracture
MC cause of subdural empyema Frontal sinusitis
Clay-Shoveler’s Fracture of spinous process of C7
MC pathogen in spinal epidural abscess Staph aureus
Berry aneurysm Saccular outpouching of vessels in circle of Willis, usually at
bifurcations MC bacteria causing post-neurosurgery meningitis Staph aureus
Cauda equina Herniated disc compressing multiple S1, S2, S3, S4 nerve MC etiology for spinal epidural abscess Staph aureus
syndrome roots, resulting in bowel/bladder incontinence, “saddle MC pathogen in cerebral abscess Streptococcus
anesthesia” over buttocks/perineum, low back pain, sciatica MC etiology of mycoic aneurysm Streptococcus
MC parasitic infection involving CNS Neurocysticercosis
MC fungal infection involving CNS Candidiasis
Acute epidural vs. Subdural hematomas MC site of vertebral osteomyelitis Lumbar
Features Epidural hematoma Subdural hematoma Most lethal & the majority of brain injuries GSW to head
Supratentorial “Ivory vertebrae” is characteristic of Chordoma
Skull fracture 70% 30% MC location of hypertensive intracerebral hemorrhage Putamen
Source of hemorrhage Arterial or venous Venous MC site of spinal injury in children Cervical > thoracic
Vessels involved Middle meningeal A. Ruptured bridging veins MC site of herniated disc at lumbar level L5-S1, then L4-5
Location Temporoparietal Frontoparietal MC site of herniated disc at cervical level C6-7, C5-6
Features Blown pupil [fixed, dilated], classic HA, mental status changes, MC type of fracture to axis Odontoid type 2
“lucid interval” [mins/hrs] contralateral hemipharesis MC cause of subarachnoid hemorrhage [SAH] Trauma
CT scan findings Lens-shaped, convex Crescent-shaped, concaved MC cause of non-traumatic SAH in adults Ruptured berry aneurysm
hyperdensity hyperdensity MC cause of morbidity & mortality in SAH Re-bleeding
Seizures < 25% 75% MC cause acute compression neuropathy. Peroneal
Treatment Neurosurgical evacuation Surgical evacuation MC physical sign of brain metastasis Focal neurologic deficit
Mortality High Low MC sign of epidural hematoma Ipsilateral blown pupil
Infratentorial Most important prognostic factor in neuroblastoma Age at time of diagnosis
Frequency More common Less common
Skull fracture Almost always Frequent CARDIOTHORACIC SURGERY
Source of hemorrhage Venous Venous  Pancoast tumor: tumor at apex of lung or superior sulcus that may involve the brachial plexus,
sympathetic ganglia, and vertebral bodies, leading o pain, upper extremity weakness, and horner’s
 Glasgow coma scale syndrome
 Benign lymphatic tumor is called cystic hygroma while a malignant lymphatic tumor is called
Point Best eye opening Best verbal Best motor
lymphagiosarcoma
s
 “popcorn-like” lesion on x-ray is diagnostic of: pulmonary hamartoma
6 - - Obeys
 Plaque rupture is the main cause of escalation of symptoms. Intermittent closure of dynamic
5 - Oriented Localizes pain
plaques underlies symptoms of unstable angina.
4 Spontaneous Disoriented Withdraws to pain

14
  The intra-aortic ballon pump [IABP] sits in the descending aorta [just distal to where the left  External iliac artery is never involved when cause of aneurysm is atherosclerosis.
subclavian takes off].
 Austin flint murmur: low pitched diastolic rumble secondary to regurgitated blood striking the
anterior leaflet.
Hard signs & soft signs of arterial injury
Hard signs Soft signs
 Anatomic classification of thoracic aortic Hemorrhage Hemorrhage
aneurysms: Distal pulse deficits
Large expanding pulsatile hematoma
Hx of hypotension
Deficit in anatomically related nerves
Debakey type 1 Ascending and descending aorta
Distal ischemia Small, stable, non-pulsatile hematoma
Debakey type 2 Ascending aorta only
Bruit or thrill Proximity of an injury to arterial supply
Debakey type 3 Descending aorta only
Rx: exploration Rx: angiography
 “Tearing or ripping” chest pain radiating to the back is characteristic of thoracic aortic
aneurysm. Rapid recall
 “calcium sign” – reflects separation of intimal calcification from adventitial surface on CXR is seen MC site of peripheral aneurysm Popliteal artery
in thoracic aortic aneurysm MC vascular disorder Varicose veins
 Crawford classification for thoracoabdominal MC site of arterial atherosclerotic occlusion in lower extremities
MC level for non-viable foot
SFA in hunter’s canal
Below knee amputation
aneurysms: MC complaint of chronic arterial ischemia Intermittent claudication
Type 1 Descending thoracic aorta + abdominal Thoracic incision MC manifestation of chronic mesenteric ischemia Postprandial abdominal pain &
aorta proximal to renal arteries weight loss
Type 2 Descending thoracic aorta + abdominal Incision from 6th ICS Best chance of healing particularly in pxs w/ PVD. Above knee amputation
aorta distal to renal arteries into abdomen
Type 3 Distal ½ of descending thoracic aorta + Same as type 2
abdominal aorta proximal to renal arteries
Type 4 Distal ½ of descending thoracic aorta + Retroperioneal incision
abdominal aorta distal to renal arteries from L flank→umbilicus TRANSPLANT
 Definitions:
Mediastinal contents Autograft Donor + recipient are same individual or of same genetic makeup
Superior Aortic arch, great vessels, upper trachea, Allograft Donor + recipient belong to same species but different genetic makeup
esophagus Isograft Donor and recipient are genetically identical [identical twins]
Anterior Thymus, ascending aorta, LN Thymoma, thyroid, germ cell, lymphoma Xenograft Donor and recipient are of different species
Middle Heart, lower trachea & bifurcation, lung Pericardial cysts, lymphoma, mediastinal Orthotopic Transplant graft placed into its anatomic position
hilus, phrenic nerves, LN granuloma, bronchogenic cysts Heterotopic Transplant graft placed at different site
Posterior Esophagus, descending aorta, thoracic duct, Neurogenic tumors Paratopic Donor organ is placed closed o original organ
vagus & intercostals N., sympathetic trunks,
azygos & hemiazygos V., LN  A kidney transplant recipient is seen in the ER for nausea and abdominal pain, fever and elevated
creatinine: acute rejection
 Storage temperature of an organ: 4 degrees Celsius, on ice in a cooler
Rapid recall
MC benign lung tumor Hamartoma  Optimum and maximum times for each organ:
2ND MC benign lung tumor Bronchial adenoma Heart and lungs 4-6 hrs; preferred w/in 5 hrs
MC etiology of chronic mediastinitis Histoplasma capsulatum Pancreas Up to 30 hrs, preferred by 10-20 hrs
MC cause of embolus from the heart Atrial fibrillation Liver 24 hrs; preferred 6-12 hrs
MC site of arterial occlusion by an embolus Common femoral artery Kidney 48 hrs
MC site of arterial occlusion from atherosclerosis: Superficial femoral artery
MC site of abdominal aortic aneurysm Infrarenal artery  L kidney is preferred by surgeons because of its longer renal vein.
MC benign cardiac tumor Myxoma [L atrium]  Pancreatic transplant is placed in abdominal cavity rather than in retroperitoneal space because of
MC malignant cardiac tumor in children Rhabdomyoma a lower incidence of peripancreatic fluid collections and lymphocele.
MC intervention in thoracic trauma Closed tube thoracostomy
MC cause of malignant pleural effusion
MC cause of chylothorax
Lung CA
Lymphoma
Rapid recall
Drug of choice for liver transplant Tacrolimus [FK-506]
2nd MC cause of chylothorax Trauma
MC solid organ being transplanted Kidney
MC type of bronchial gland tumor in lower respiratory tract Adenoid cystic teratoma
MC cause of kidney transplants Diabetes
MC neoplasm of anterosuperior mediastinum Thymoma
MC infectious complication after pancreas transplant UTI
MC primary mediastinal cysts Bronchogenic cysts
MC mediastinal tumor Neuroblastoma [children]
GENITO-URINARY SYSTEM
MC cause of ascending aortic aneurysm Cystic medial necrosis
 Cremasteric reflex: retraction of the testicle as the medial aspect of thish is stroked
MC cause of mitral stenosis. RHD
 Always suspect torsion in px w/ inguinal pain and an empty scrotum.
Most important risk factor for atherosclerosis Systemic HPN
 An adolescent presents w/ acute testicular pain and swelling immediately after a sporting event. He
Most important manifestation in rheumatic fever Rheumatic heart disease
is ill appearing, writhing in pain. He had similar episodes of this in the past: testicular torsion
Type of lung CA arising from non-smokers Adenocarcinoma
 A 40 y/o man presents w/ sudden onset of L-sided flank pain that he rates 10/10. He is writhing,
MC symptom of lung cancer Chronic cough unable to stay still or find a comfortable position: renal colic
Method of choice for centrally-located masses [squamous Bronchoscopy
 During passage of a stone, there are 5 sites where passage is likely to become arrested: calyx of
cell and small cell CA]
kidney, ureteropelvic junction, pelvic brim, ureterovesical junction and vesicle orifice
Method of choice for peripherally located nodules Transthoacic needle biopsy
 Stones < 5-8 mm pass spontaneously
Test of choice for pxs w/ pleural effusion and suspected Thoracentesis
 An 87 y/o man w/ hx of prostate CA presents w/ low back pain: bony metastasis w/ cord
malignancy
compression
 Radical prostatectomy is indicated for stage 2B prostatic CA.
VASCULAR SURGERY
 Peyronies disease: abnormal fibrosis of penis shaft resuling in bend upon erection.
 You are asked to see a px w/ bleeding from an angiogram puncture site. She has an oozing,
 Seminonas are radiosensitive .
pulsatile expanding mass in her groin at the puncture site: expanding hemangioma
 Type of bony lesions seen in metastatic prostate CA: osteoblastic [radiopaque]
 ”blue toe syndrome” is seen in embolism.
 “Bag of worms” = grade 3 varicocoele
 Chronic ischemia MC affects: infrarenal aorta, iliac arteries and superficial femoral artery
 Types of incontinence:
 Infrainguinal disease affects: superficial femoral artery at adductor canal
Stress Loss of urine associated w/ coughing, lifting, exercise, seen
 Size at w/c abdominal aortic aneurysm is considered for surgical repair: 5cm
incontinence most often in women secondary to relaxation of pelvic floor

15
 Overflow Failure of bladder o empty properly, may be caused by and renal pelvis in diagnosing renal calculi
incontinence bladder outlet obstruction or detrusor hypotonicity Procedure of choice in BPH Transurethral prostatectomy
Urge Loss of urine secondary to detrusor instability in pxs w/ stroke, Most sensitive test for early detection of prostatic CA PSA
incontinence dementia and parkinson’s disease Primary method for evaluating renal masses IVP w/ nephrotography
Mixed type Combination of urge & stress incontinence Method of choice for diagnosis & staging of renal cell CA CT scan
Enuresis Bedwetting in children TOC if no evidence of metastasis is seen in renal CA Radical nephrectomy
Mainstay of treatment in bladder CA Simple or radical cystectomy
Whitmore’s staging for prostate CA Classic presentation of bladder CA
MC cause of ARF in surgical pxs
Painless hematuria
Sequestered 3rd space loss [post-op site]
Stage Description
MC cause of ARF in surgical patient Hypovolemia
A CA not detectable by PE but incidentally on surgical specimen
MC histology of prostate CA Adenocarcinoma
B Palpable but confined to prostate
Type of stone NOT seen on x-ray Uric acid
B1: involves 1 nodule w/ normal tissues
B2: involves the gland more diffusely Stone associated w/ UTI Struvite stones
C Palpable tumor extends beyond prostate but no distant mets Stones seen in IBD Calcium oxalate
D Distant mets present Area of prostate where BPH arise Periurethral
D1: to pelvic nodes only Area of prostate where CA arise Periphery
D2: widespread mets MC site of distant metastasis in renal cell CA Lung
MC solid renal tumor of childhood Wilm’s tumor
MC injured urinary organ Kidneys
Surgical staging & treatment for prostate CA Least injured urinary organ Ureters
Stages Description Treatment MC correctable surgical cause of infertility Varicocoele
1 Clinically inapparent tumor, No LN or mets Radical prostatectomy, [+/-] MC Sx of BPH Oliguria & urinary retention
external beam radiation MC Sx of renal stone Flank pain
2 Tumor w/in prostate, no LN or mets Same as 1 MC manifestation of Alport’s syndrome Asymptomatic hematuria
3 Tumor thru prostate capsule, no nodes or mets Radiation tx MC manifestation of amyloidosis Renal involvement
4 Tumor extends into adjacent structures, [+] LN & mets Hormonal tx Most important factor in DM 2 pathogenesis Insulin resistance
MC kidney lesion in DM Nodular glomerulitis
Most important prognostic factor in prostatic CA Grading
Most important prognostic factor in CA of UB Depth of invasion
Staging & treatment of testicular CA Most important prognostic factor in anal CA Stage of disease
Stages Description Treatment
1 Confined to testis into tunica albuginea or Inguinal orchiectomy &
epididymis, no LN or mets radiation to retroperitoneal LN
ORTHOPEDICS
2 [+] LN, no mets, any tumor Same as 1
 Synovial fluid lacks fibrinogen thus it is non-clotting
3 Distant mets, any nodal status, any tumor size Orchiectomy & chemotherapy
 Most stress fractures occur in lower extremities and commonly affect individuals involved in sports
and military recruits “march fracture”
Renal cell CA staging  Incidence of stress fractures by site: metatarsal [50%], calcaneous [25%], tibia [20%], tarsal-
Stages Description 5 yr-SR navicular [common in basketball players]
1 Tumor confined within kidney capsule 60-75%  Study on Salter-Harris fracture on page 467: surgical clerkship book = [SALTR]
2 Invasion thru kidney capsule but confined within Gerota’s fascia 45-65% Salter 1 Thru physeal plate only Separated
3 Involves regional LN or vena cava 25-505 Salter 2 Involves physis and metaphysis Above
4 Distant metastases < 5% Salter 3 Involves physis and epiphysis Lower
Salter 4 From metaphysis thru physis into epiphysis Through
Salter 5 Axial force crushes the physeal growth plate Ruined
Types of nephrolithiasis
Type Freq. Etiology & characteristics Treatment
Ca+ oxalate or 83% Idiopathic hypercalciuria, elevated uric Hydration, thiazides  Fracture healing:
PO4 acid sec. to diet & 1◦ hyperthyroidism. Stage 1 Inflammation & hematoma formation Day 1
Alkaline urine. Radiopaque Stage 2 Hematoma organization Day 2-7
Struvite [Mg-NH4- 9% “Triple-phosphate stones”. Associated w/ Hydration, treat UTI if Stage 3 Callus formation, longest phase Day 8-90
PO4] Proteus. Form staghorn calculi. present Stage 4 Remodeling
Alkaline urine. Radiopaque  A 25 y/o male complains of difficulty breathing. He was noted to be acting a little confused, and that
Uric acid 7% Gout & high-purine diet turnover states. Hydration, alkalinize he has spotty purplish rash. 2 days ago, he sustained a femur fracture after a high speed MVA: fat
Acidic urine. Radioluscent urine w/ citrate embolism syndrome
Cystine 1% Defect in cystine, ornithine, lysine & Hydration, alkalinize  Hallmark finding in compartment syndromes : pain in a conscious and fully oriented person
arginine-COLA]. Hexagonal crystals. urine, penicillamine that is out of proportion to injury or findings.
Radiopaque.  “Sun burst or sun ray pattern” on x-ray is seen in: osteosarcoma [2/3 of distal femur and
proximal tibia], it metastasize to thee lungs
Bladder CA staging [using CT scan of abdomen & pelvis & surgical staging ] 

Enchondromas in multiple bones is called Ollier’s disease.
Still’s disease: rheumatoid arthritis, fever, rash & splenomegaly
Superficial St. 0 CIS, mucosal involvement 1 Tumor < 2.5 cm, no nodes/mets
 “soap-bubble” appearance due to a thin subperiosteal bone shell is seen in: giant cell tumor
St. A Submucosal involvement 2 > 2.5 cm, limited to kidney, no
 “Lamellated onion-skin” appearance on x-ray is characteristic of: Ewing’s tumor
nodes or mets
 “soap-bubble appearance” on x-ray is also seen in: multiple myeloma
Invasive St. B Involvement of UB 3 Extends to IVC, [+] regional LN
muscularis but < 2 cm diameter, & extends  Most likely site of origin for metastatic tumors: BLTKP [Breast, Lung, Thyroid, Kidney, Prostate]
St. C Involvement of perivesical fat past gerota’s fascia  Types of histiocytosis:
Metastatic St. D1 Metastatis to LN 4 Distant mets, [+] LN, > 2cm Letterer-Siwe disease Most severe form [< 2 y.o]. Hepatomegaly, LAD, rash,
St. D2 Mets to bone or other viscera diameter & extends past gerota’s bleeding diathesis, anemia, exopthalmos, DI
of the body fascia Hand-Schuller-Christian dse < 5 y.o. associated ww/ systemic severe illness in children
Eosinophilic granuloma Mildest form , in older age group. Minimal S/Sx
Rapid recall
Classic sign of testicular torsion High-riding testis w/ a horizontal lie  Miscellaneous bone diseases
MC malignancy to affect young men Testicular tumor Legg-Calve-Perthes dse Idiopathic vascular necrosis of femoral head in children
MC testicular tumor Germ cell tumor Slipped capital femoral Migration of proximal femoral epiphysis on the
Most precise method of determining the anatomy of ureter Retrograde pyelogram epiphysis metaphysic in children

16
 Blount’s disease Idiopathic varus bowing of tibia Nightstick fracture Isolated fx of the ulnar shaft
Osgood-Schlatter’s Apophysitis of tibial tubercle resulting from repeated Periarticular fracture Fracture close but not involving the joint
disease powerful contractions of quadriceps Pott’s fracture Fracture of the distal fibula
Intra-articular fracture Fracture thru the articular surface of a bone
Rapid recall Rolando fracture
Scaphoid fracture
Comminuted fracture of the base of the thumb
MC cause by a fall on outstretched hand, snuffbox is tender
MC pathologic condition associated w/ pathologic fx Osteoporosis
Smith’s fracture Distal radius fx w/ volar angulation caused by direct trauma to
MC orthopedic injury Hip dislocation dorsal forearm
MC fractured bone Clavicle Transcervical fracture Fracture thru the neck of the femur
MC fractured long bone Radius, tibia Tibial plateau fracture Intra-articular fracture of the proximal tibia
MC dislocated joint Shoulder joint Torus fracture or Impaction injury in children in w/c cortex is buckled but not disrupted
MC sprained joint Ankle joint buckle fracture
MC site of non-union Middle distal tibia
MC etiology for volkman’s ischemia contracture Compression of anterior aspect of elbow and
upper forearm after a supracondylar fracture in  Miscellaneous hand injuries
childhood Charcot’s joint Joint arthritis from peripheral neuropathy
MC cause of acute hematogenous osteomyelitis Staph aureus Tennis elbow Tendonitis of the lateral epicondyle of the humerus
MC site for acute osteomyelitis Metaphyseal end of a single long bone Turf toe Hyperextension of great toe [tear of tendon of flexor hallucis brevis],
[especially around the knee] seen in football players
MC site of giant cell tumor Around the knee [distal femur and proximal tibia] Shin splints Exercise-induced anterior compartment hyperextension [compartment
MC osteiod forming benign tumor Osteiod osteoma [MC site: diaphysis of long syndrome] seen in runners
tubular bones] Heel spur Plantar fasciitis w/ abnormal bone growth in plantar fascia, seen in
MC benign tumor of the bone Osteochondroma [MC site: metaphysis of long runner and walkers
bones of extremities] Traumatic myositis Abnormal bone deposit in a muscle after blunt trauma, deep muscle
MC primary malignant bone tumor Multiple myeloma contusion, benign
MC pediatric bone tumors Osteochondroma Marjolins ulcer SCCA that arises in chronic sinus from osteomyelitis
MC malignant sarcomas in adults Fibrous histiocytoma, liposarcoma and Bouchard’s nodes Enlarged PIP joints of hand from cartilage/bone growth
leiomyosarcoma HeberDen’s nodes Enlarged DIP joints of hand from cartilage/bone growth
MC site of Ewing’s sarcoma Knee Pannus Inflammatory exudates overlying synovial cells inside the joint
MC site of osteosarcoma 2/3 of distal femur Gamekeeper’s thumb Avulsion of ulnar collateral ligament of 1 st metacarpal joint, usually
Most important indicator whether bone growth is Benign or malignant is the zone of transition associated w/ ski pole injury
MC type of melanoma Superficial spreading [>70%] Mallet finger Rupture of extensor tendon at its insertion into base of distal phalanx
MC malignant sarcomas in children Rhabdomyosarcoma, fibrosarcoma Trigger finger Stenosis of tendon sheath of flexor digitorum + nodule formation
MC type of sarcoma to metastasize to lymph nodes Malignant fibrous histiocytoma
MC sarcoma of retroperitoneum Liposarcoma
MC site of melanoma
MC metastatic site of osteosarcoma
Men [back], in women [legs]
Lungs
 Motor sensation tests of different peripheral nerves
Radial N. Wrist extension , dorsal web space btw thumb and index finger
MC site of solitary fibrous dysplasia Ribs
Ulnar N. Little finger abduction , little finger-distal ulnar aspect
Hallmark finding in fat embolism syndrome: Arterial hypoxemia [PO2 ¸60 mmHg]
Median N. Thumb opposition or thumb pinch , index finger-distal radial aspect
HAND INJURIES Musculocutaneous Arm abduction , deltoid patch on lateral aspect of arm
 The radial nerve does NOT innervate any of the intrinsic muscles of the hand.
 Definitions of fractures: [ see diagram on surgical recall p. 648]
 Clinical maneuvers for testing muscles of the hand Closed fracture Intact skin over fracture/hematoma
Patient maneuver Muscle tested Open fracture or Wound overlying fracture, thru w/c fracture segments are
Bending the tip of the thumb Flexor pollicis longus compound fracture continuity outside environment
Bending each individual fingertip against resistance Flexor digiorum profundus Simple fracture 1 fracture line, 2 bone fragments
while PIPs are stabilized by examiner Comminuted fracture Results in > 2 bone fragments, aka fragmentation
Bring thumb out to side and back Extensor pollicis brevis and Transverse fracture Fracture line perpendicular to long axis of bone
abductor pollicis longus Oblique fracture Fracture line creates an oblique angle w/ long axis of bone
Flexing and extending a fist at the wrist Extensor carpi radialis Spiral fracture Severe oblique fracture in w/c fracture plane rotates along
longus and brevis the long axis of bone, caused by twisting injury
Raising thumb only while rest of the hand is laid flat Extensor pollicis longus Longitudinal fracture Fracture line parallel to long axis of bone
Making a fist w/ little finger extended alone Extensor digiti minimi Impacted fracture Resulting from compressive force, end of bone is driven
into contiguous metaphysis w/o displacement
 Kanavel signs of tensynovitis: STEP [Symmetrical swelling of finger, Tenderness over flexor Pathologic fracture Fracture thru abnormal bone [ex. osteoporitic bone]
tendon sheath, Extension of digit is painful, Posture of digit at rest is flexed] Stress fracture Fracture in normal bone from cyclic loading of bone
 Volkmann’s contracture: contracture of forearm flexors secondary to forearm compartment
syndrome, usually due to brachial artery injury or supracondylar humerus fracture .
 Dupuyren’s contracture: thickening and contracture of palmar fascia Rapid recall
 A 37 y/o female presents w/ pain in her R wrist and fingers, accompanied by a tingling sensation. MC cause of tenosynovitis and osteomyelitis Staph aureus
The pain awakens her from sleep, and she is unable to perform her duties as a word processor: MC cause of osteomyelitis in pxs w/ sickle cell disease Salmonella
carpal tunnel syndrome MC cause of pathologic fracture in adults Osteoporosis
MC cause of hip dislocation High-velocity trauma [ex. MVA]
 Common hand and wrist injuries: MC type of hip dislocation Posterior “dashboard dislocation”
Avulsion fracture In w/c tendon is pulled from bone, carrying w/ it a bone clip MC type of elbow dislocation Posterior [brachial A., ulnar, median]
Boxer’s fracture Fx of neck of 5 th metacarpal sustained in a closed fist injury MC type of shoulder dislocation Anterior [axillary nerve and artery]
Bennet’s fracture Fracture dislocation of base of thumb MC orthopedic tumors in adults Metastasis [prostate – MC, breast,
Boxers fracture Fracture of metacarpal neck “classically” of small finger lung, kidney, thyroid and multiple
Clay shoveler’s Fracture of spinous process of C6-7 myeloma]
Colle’s fracture Dinnerfork deformity, distal radius fx w/ dorsal angulation MC entrapment neuropathy Carpal tunnel syndrome
Jones fracture Fracture at base of 5 th metatarsal diaphysis MC site of compartment syndrome in legs Calf
Galleazzi fracture Distal 1/3 radial fracture w/ dislocation of distal radioulnar joint In arms Anterior compartment
caused by a direct blow to the back of wrist
Hangman’s fracture Fracture of the pedicles of C2 MISCELLANEOUS
Monteggia’s fracture Proximal 1/3 ulnar fx w/ dislocation of radial head caused by direct
blow to posterior ulna
Most common complications of surgical diseases

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MC complication of adult MI Arrhythmia MC indication for laparoscopic splenectomy ITP
MC complication of PUD Bleeding MC indication for surgery in regional enteritis Obstruction
MC complication of meckel’s diverticulum Intestinal obstruction MC indication for surgery in Crohn’s disease SBO
MC complication of diverticulitis Abscess formation MC indication for emergent laparoscopy in NB NEC
Most serious complication of acute MI & MC COD in Ventricular arrhythmia Most important diagnostic procedure for suspected esophageal CA Barium swallow
1st hr after an MI Most direct method of visualizing urethra & UB Cystoscopy
Most serious complication of carotid endarterectomy Perioperative stroke Most reliable method to detect gastric CA Endoscopy
MC urologic complication of Crohn;s disease Ureteral obstruction Most reliable renal imaging study CT scan
MC cardiac complication after thoracic surgery Supraventricular arrhythmias [usually AF] Most reliable indicator of biliary tract disease Biliary UTZ
MC complication of pacemaker insertion Migration of facing electrode Most reliable in identifying colon pathology Barium enema
MC complication of appendectomy Wound infection Most reliable method to confirm esophageal caustic injury Endoscopy
MC complication of pancreaticoduodenal resection Pancreatic fistula Most reliable invasive method to investigate pulmonary disease Bronchoscopy
MC complication of thyroidectomy Wound hematoma Most reliable & complete exam for large bowel Colonoscopy
MC complication after gastrectomy Alkaline reflux disease Most reliable non-invasive method for detecting vascular lesion Duplex scan
MC complication after splenectomy Left lower lung atelectasis Most reliable method to evaluate DVT Venography
MC complication of pulmonary artery cathetherization PVCs Most reliable method to evaluate CAD Angiography
MC complication of heparin therapy Thrombocytopenia Most reliable method to document location & severity of infrainguinal Arteriography
MC complication after varicose operation Ecchymosis arterial occlusive disease
Most serious complication of lower extremity Pulmonary infarct Most reliable procedure in detecting UGIB Arteriography
thrombophlebitis Most reliable method for localizing GU bleeding Direct visualization
Most severe complication of rheumatic fever Endocarditis Most reliable method to dx thoracic aortic aneurysm Chest x-ray
Most severe complication of Kawasaki disease Coronary artery aneurysm Most reliable test for peritonitis Paracentesis
Most severe complication after repair of thoracic Paraplegia Most reliable test to determine presence of intra-abdominal injury DPL
abdominal aortic aneurysm Most reliable test for pheochromocytoma Urinary level of metanephrine
Most severe complication of thyroid surgery Hemorrhage & VMA
Most severe complication of trauma surgery Descending aorta tear Most useful test in establishing the cause of hypercortisolism & in Dexamethasone suppression
Most severe complication of portal HPN Bleeding esophageal varices determining whether cause is pituitary dependent or independent test
Most severe complication of colitis Toxic megacolon Most reliable liver function test in detecting hepatic metastasis Alkaline phosphatase
Most severe complication of Barret’s esophagus AdenoCA Most reliable indicator of thyroid function Free thyroxine index
Most sensitive test of thyroid function TSH assay
Common causes of death in surgical diseases MC screening procedure for colonic CA Occult blood test
MC COD in Alzheimer’s disease Pneumonia MC used contrast study for colorectal CA Air-contrast barium enema
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
MC COD in USA Ischemic hear disease
MC COD in Philippines CVD
MC fatal genetic defect in Caucasians Cystic fibrosis
MC CA among black African countries Cervical & uterine CA
MC perioperative COD following a shunt Hepatic failure [secondary to decrease blood
procedure flow]
MC post-op COD in px undergoing AAA surgery MI
MC post-op COD in repair of aortic dissection Hemorrhage
MC COD after major vascular injury CAD
MC COD after a major pelvic fracture Fat embolism
MC COD in ruptured rectosigmoid colon Peritonitis

Definitive procedures & treatment for common surgical diseases

Most definitive surgery for rectal CA 4 cm above anal verge APR
Most definitive operative tx for lung abscess Pulmonary resection
Most definitive operation for idiopathic pseudoobstruction Subtotal colectomy w/
ileorectal anastomosis
MC procedure for aortic root replacement Composite valve graft
procedure
MC procedure for pancreatic head CA Whipple’s resection
[pancreaticoduodenectomy]
MC procedure to treat BPH TURP
MC procedure for follicular thyroid CA Near-total thyroidectomy
MC procedure for supravesical urinary diversion Cutaneous ureteroileostomy
MC trauma resuscitation fluid Plain LR
MC electrolyte mediated ileus Hypokalimea
Most effective treatment for hypokalimea Hemodialysis
Most characteristic of intestinal obstruction in upright AXR Stepladder appearance
MC abdominal x-ray finding in SBO Air-fluid level in upright film
MC x-ray finding in traumatic thoracic injury Widened mediastinum
MC sign of pancreatitis on AXR Sentinel loop

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