Surgery Rotation Notes

 

Surgery Rotation Notes

 Abbreviations  Abbreviations D/C = discharge, discontinue PCA = patient controlled analgesia CS = chem stick (Accu check for glucose) HAL = hyperalimentation TPN = total parenteral nutrition Medications Tylox   (oxycodone (oxycodone HCL – Acetaminophen) for mod-severe pain; capsule Dilaudid  (hydromorphone)  (hydromorphone) for mod-severe pain; IV or suppository Roxicet (oxycodone HCL – Acetaminophen) for med-severe pain; tab  Actiq (Fentanyl) – narcotic agonist analgesic for severe pain; much stronger than Dilaudid Ciprofloxacin (a fluoroquinolone) – inhibit DNA topoisomerase II; tx URI, GI, and UTI; given IV; contraindicated in pregnant women & children b/c damage to cartilage, tendons; antacids ↓  absorption; ↑ warfarin Flagyl   (metronidazole) (metronidazole) – toxic metabolite; antiprotozoan + antibacterial (trichomonas, amebiasis, gardnerella, bacteriodes, clostridium); given IV; disulfiram-like with EtOH, ↑warfarin) Lamisil   (Terbinafine) (Terbinafine) – nail fungal infections; can cause liver damage (not cream form though)

Cipro & Flagyl are given before surgery for G(-) coverage b/c open bowel Cephalosporin is given before surgery for G(+) coverage b/c open skin Vancomycin is given for G(+) coverage Neomycin & Erythromycin is given before surgery (13, 6, & 1 hr before surgery) for G(+) coverage Pentasa – anti-inflam for Ulcerative colitis Remicade – monoclonal antibody for Crohn’s dz Sulfasalazine + Prednisone – tx for Crohn’s dz and Ulcerative colitis Propofol  –  – sedative/hypnotic; IV Versed  (midazolam)  (midazolam) – benzodiazepine for sedation; IV Zofran (ondansetron) – 5HT3 antagonist; tx of nausea/vomiting Phenergan (promethazine HCl) for nausea/vomiting Heparin – prophylaxis of DVTs; always given post surgery; dose = 18 units/kg/hr  Toradol – NSAID NSAID for pain; pain; renal toxicity and possible possible bleeding bleeding from from platelet dysfxn

PCA doses  basal rate / dose / frequency / total allowed in 1 hour (max pushes + basal rate) example 0.4 / 0.3 / 6 / 3.4 Catheters, Drains, and Lines Foley catheter – kept in until patient can ambulate to bathroom; hard to walk around with catheter in PICC line (peripherally inserted central catheter) – inserted into vein in arm and threaded to SVC; used to take blood samples, deliver drugs, or hyperalimentation; less likely to be infected and can be kept for long periods of time compared to IV lines and central lines HL IV – Heparin Lock Intravenous – flushes IV line, maintains patency

 

VP shunt – ventriculoperitoneal shunt; fluid shunted from ventricles in brain to abdominal cavity to reduce intracranial pressure Labs Prealbumin – used as marker for protein-calorie malnutrition; earliest indicator of nutritional status; correlates with patient outcomes; highest ratio of essential:nonessential amino acids Urine analysis – check leukocyte esterase and nitrite levels; also specific gravity Other  Sequential Compression Devices (SCD) - placed on legs to enhance blood circulation to prevent DVTs Silver nitrate – used to cauterize leaky blood vessel (also in hemophiliacs) TPN – total parenteral nutrition; must be administered via PICC line or central line PPN – partial parenteral nutrition (without lipids); can be adminstered via IV line Use quantitative culture to differentiate normal colonization vs infection Small bowel fxn never stops; stomach and large bowel stops after major abdominal surgery Etiology of any disease process: think infection, tumor/mass, obstruction, injury/trauma Patient Care FLUIDS Calculating Fluid Input (shortcuts) 1) Adult input input per day = [(weight [(weight – 20) x 20] + 1500 (i.e. (i.e. for 70kg person, person, 70 – 20 = 50 x 20 = 1000 + 1500 = 2500mL/day 2) Adult Adult input input per hour hour = weigh weightt + 40 = 110mL/ 110mL/hour  hour  Calculating Urine Output 1) Adult expected expected urine urine output = .5 -1 cc/kg/hr ((i.e. i.e. 70kg adult adult should produce produce at least least 35cc/hr or 840 cc/day); needs more fluids if producing less than 30cc/hr or 720 cc/day) 2) Infant/child Infant/child expected expected urine output output = 1-2cc/kg/hr (i.e. (i.e. 10kg child should should produce at lea least st 10cc/hr  or 240 cc/day) 3) Bolus for adults adults (i.e if not not peeing enough) enough) = 10cc/kg 10cc/kg (i.e. (i.e. for 70kg adult, adult, give bolus bolus of 700cc 700cc or 23oz of fluid b/c 30cc in 1oz); in acute distress, can give up to 20cc/kg bolus 4) Bolus for children children in acute acute distress, distress, can give give up to 20cc/kg 20cc/kg (i.e. for 10kg 10kg child, child, give bolus of 200cc or 6.6oz) 5) Bolus should should be normal normal saline saline (NS) or lactated lactated ringer ringer (LR) (LR) Lactate converted to HCO3- in liver (lactate is unstable in solution) Post surgical patients need more fluid than maintenance rate; consider 1.5 maintenance rate BUT, beware of hypernatremia  for 70kg patient, 1.5 maintenance fluid = 3.75L D5 ½ NS = 289mEq of Na+; body needs ~3mEq/kg of Na+ per day = 210mEq for 70kg patient Dextrose included in IV fluids to protect against muscle breakdown caused by gluconeogenesis [hypoglycemia  glycogenolysis until glycogen stores depleted in 1-2days  gluconeogenesis in liver (substrates used are breakdown of muscle proteins into amino acids); need small amount of dextrose to inhibit gluconeogenesis

 

During surgery: vasodilatory state; need to give IV fluids; also body compensates by release of ADH Postop day #1: want ins and outs to be even Postop day #3: fluid in third space goes to intravascular space; check urine output and ↓ if too high Must replace fluid loss from NGT (H20 + electrolytes) due to gastric outlet obstruction with LR: losing HCO3-, Na+, Cl- so LR therapy is appropriate Must replace fluid loss (from NGT or severe emesis) with NS + KCl -losing H+, Na+, K+ from gastric secretions -state ofCl-, hypokalemic hypochloremic metabolic alkalosis with paradoxic aciduria -loss of volume + electrolyte imbalances  reabsorption of Na+ for volume, and other electrolytes for stability -↓Na+  kidneys attempt to reabsorb Na+ but loses K+ in process via Na+/K+ exchanger in collecting duct -Cl- needed for Na+ reabsorption in ascending loop and DCT, but ↓Cl- compromises this process -as K+ ↓, Na+/K+ exchanger function ↓; Na+ reabsorption proceeds in collecting duct but excretes H+ in process via Na+/H+ exchanger  paradoxic aciduria -NS has higher [Cl-] than LR; thus can better help with Na+ reabsorption -KCl provides K+ that ↑ Na+ reabsorption Too much urine 1) iatroge iatrogenic nic – too much fluids fluids given given 2) diabetes diabetes insipi insipidus dus (centra (centrall vs nephrogen nephrogenic) ic) 3) hi high gh outp output ut rena renall failur failure e 4) high blood blood solutes solutes and and glucose glucose (above (above 200, 200, glucosuria) glucosuria) 5) si sick ckle le cel celll anem anemia ia Too little urine 1) ac acute ute tubula tubularr necro necrosi sis s 2) chronic chronic renal renal failure/r failure/rena enall insuffici insufficiency ency 3) obst obstru ruct ctio ion n 4) SIADH Discontinue NG tube when output is low ( 4 wks) 70% ischemia   amputation Symptoms: pain in large muscle groups, i.e. calf muscles; tip of toe has lowest perfusion, so often painful (metatarsalgia)

Physical exam: 1) Check Check pulses pulses – femoral, femoral, poplite popliteal, al, dorsali dorsalis s pedis 2) Foot exam exam – cool?, cool?, elevation elevation pallor/depen pallor/dependent dent rubor rubor (elevate (elevate leg 3) Lesion – punched punched down? down? Ascending Ascending or local local infection? infection?  Ankle-brachial  Ankle-b rachial index index (ABI): (ABI): ankle pressure/a pressure/arm rm pressure pressure Vessel incompressible = >1 Normal = ~0.95 Claudication = 0.5 – 0.95 Rest pain = 0.2 – 0.5 Tissure loss = < 0.2

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Carotid Artery Disease (CaAD) 50% of strokes cause by CaAD; biggest risk factor for stroke is TIA Transient Ischemic Attack (TIA) by definition last 50% and symptomatic, offer endarterectomy; NNT = 15 to prevent stroke If stenosis >50% and asymptomatic, offer endarterectomy; NNT = 20 to prevent stroke  Assess risk/benefit risk/benefit in each each patient! patient!

 

GI Complications Lecture  ACUTE BLOOD LOSS LOSS Physical Exam: 1) 20 (BUN (BUN b/c absorption absorption of of blood blood by GI tract) 4) Lactic acid acid b/c of anaerobic anaerobic ATP formation formation due to hypotens hypotension ion -1 unit of blood (250mL of packed RBCs) ≈ 3L of crystalloid for resusitation purposes (b/c crystalloid equilibrates with surrounding tissue, but RBCs stay intravascular) -If patient is tachycardic à expect about 10-20% blood loss à ~.5 - 1L loss (if total blood = ~5L) give one unit of blood (250mL packed RBCs or 3L of crystalloid à expect ↓in tachycardia) -If patient’s tachycardia improves but then returns, continue with alternating cystalloid replacement and blood transfusion; if active bleeding à give blood right away, not crystalloid -Resusitation fluid à NS; LR good, but may have problems (K+, etc); no D5 b/c sugar ↑osmolality, combined with extra glucose released by stress hormones (i.e. cortisol)  Assessing  Assessi ng hypervolemia: hypervolemia: look for edema, weight weight gain, gain, distended distended veins, veins, mucosal mucosal membranes membranes What would happen if you took all of your blood out and replaced it after a few minutes (before brain injury normally occurs)  irreversible shock; wouldn’t die immediately b/c brain intact, but renal failure and shock lung would lead you to death in several days Patient comes into ER b/c bleeding from rectum… What do you do? 1) ABCs ABCs to sta stabl bliz ize e 2) Seco Second ndary ary surve survey: y: H&P H&P 3) Determi Determine ne locatio location n of bleedi bleeding: ng: UGI UGI or LGI a. UGI: large large NGT (to decompress decompress and to clear out blood blood for upper upper endoscopy) endoscopy) + upper endoscopy i. Blood Blood in in NGT indica indicates tes UGI blee bleed d ii. Possible to have UGI bleed but no blood blood in NGT NGT (blood (blood in duodenum duodenum sometimes sometimes can’t make it past pyloric sphincter) b. LGI:i.check che ck rectum rectum + colonosco colonoscopy pystudy: + radioactiv radioactive-labele e-labeled RBCbleed + angiogram angio Radioactive-labe Radioact ive-labeled led RBC important important to r/od UGI bleed b/cgram liver, spleen, spleen, and and kidneys will light up on nuclear study (these sites take up lots of blood),

 

obscuring any indication of UGI bleed; also difficult to see rectum on nuclear study; high sensitivity, low specificity ii. Angiogram Angiogram if nuclear nuclear studies studies (+); high high specificity, specificity, low sensitivity; sensitivity; rectum difficult to see iii. Check rectum rectum first first b/c nuclear and angiogram angiogram studies aren’t good here here 4) If continued continued bleeding bleeding per rectum, rectum, clamp off parts parts of colon colon or subtotal/total subtotal/total colectomy colectomy The following types of bleeding require surgical intervention… 1) Localized Localized and identifiable identifiable source source of active bleeding 2) requires between 6-10 units units of blood blood (10 units units = 2500mL 2500mL of packed packed RBCs) RBCs) 3) pati entdcannot ca nnot kept kepital pt al hemodyn hemodynamic amically ally stabl stable e 4) patient reblee rebleed while whi le inbehos hospit Causes of bleeding per rectum: 1) AVM AVM (7 (70+ 0+yo yo)) 2) Divert Diverticu iculos losis is (5 (50-7 0-70y 0yo) o) 3) Color Colorec ectal tal canc cancer er (50+yo (50+yo)) 4) Hemo Hemorr rrho hoid ids s BOWEL OBSTRUCTION Physical exam: 1) Hyperac Hyperactive tive bowel bowel sounds sounds aka “Borbo “Borborygm rygmus” us” (↑in attempts to push blocked substance through); hypoactive later when bowels become distended (overstretches and ↓ overlap of SM fibers) 2) “Tinkle” high-pitch high-pitched ed sounds sounds of bowel b/c b/c high air:volume air:volume ratio; ratio; diagnostic diagnostic of SB obstruction obstruction Causes of SB obstruction: #1 adhesions (from previous abdominal surgery) partial vs full obstruction; watch to see if partial obstruction resolves itself  #2 hernia (incarcerated loop of bowel); also think of femoral hernia in pregnant patients #3 cancer (polyp grows so large it obstructs) Causes of LB obstruction: #1 cancer  #2 diverticulitis/infection #3 volvulus Causes of air in the SB (radiographic findings) 1) GI procedu procedures res (i.e. (i.e. endosc endoscopy) opy) + post post surgery surgery 2) Babies Babies norma normally lly have have lots lots of air in in SB 3) Swallow Swallowing ing air trying trying to to burp burp Dx of SB obstruction 1) KUB/ KUB/fla flatt abdom abdomina inall XR 2) upright upright abdom abdominal inal XR (look (look for for air-fluid air-fluid level levels) s) 3) L lateral lateral decub decubitus itus (look (look for for free free air) 4) CT w/con w/contras trastt after after decom decompres pression sion 5) UGI w/SB w/SB followthr followthroug ough h after decom decompres pression sion Tx: 1) NGT NGT to to deco decomp mpres ress s air  air  2) Replen Replenish ish fluids fluids if a lot is lost lost via via NGT, vomit vomiting ing 3) Gastri Gastric c secr secreti etions ons:: a. ClCl- 6060-11 110m 0mL L  use NS to replenish; could use ½ NS b. K+ 5-1 -10 0mL  use 10KCl to replenish c. H+, Na+  no action

 

d. Need to replenish replenish Cl- and K+ to help help replenish replenish Na+; aciduria aciduria resolves resolves with correction correction of of Cl-, K+, and Na+; refer to Fluids part for better explanation e. “order” mL for mL replacement replacement of fluid loss from from NGT with NS NS 10KCl 10KCl

 

Pediatric Surgery Case 1: 1 month old vomiting for five days  Ask: age age of patient, patient, duration duration of sx, sx, what is is being vomited, fever  fever   Age  limits DDx; Bilious  distal to pylorus; non-bilious  proximal to pylorus Fever  infection Hunger  evaluates how sick patient is Tearing, skin turgor, UOP (diapers), lethargy  evaluates volume status

DDx: pyloric stenosis, overfeeding, reflux, CNS lesions, bowel obstruction, intususseption, volvulus Pyloric Stenosis Sx: one month old, non-bilious emesis, hunger after vomiting, +/- coffee-brown emesis (gastritis due to stasis  some blood in emesis) Signs: Gastric waves, palpable olive (near liver edge) Dx: 4mm thick & 16mm long Rad: UGI  “string sign” (elongated pylorus) + “shoulder sign” (bulge of pylorus into antrum) Tx: 1) stabiliz stabilize e electrol electrolytes ytes:: lose Cl-, Cl-, H+, Na+, Na+, K+  hypokalemic hypochloremic metabolic alkalosis with paradoxical aciduria a. recusitate recusitate with NS NS fluid bolus bolus (20cc/kg) (20cc/kg) + D5 D5 ¼ or ½ NS with 10 or 20KCl 20KCl @ 1.5 maintenance rate; ½ NS b/c want lots of Cl-; 20 KCl b/c want lots of K+ b. monito monitorr UOP UOP (wet (wet dia diaper per)) 2) operate on baby baby after electrolytes electrolytes stable; stable; anesthesia anesthesia causes respiratory respiratory alkalosis alkalosis which which is deadly if patient has underlying metabolic alkalosis; ↓CO2  ↓of CNS respiratory drive   respiratory distress  death 3) pyloric myotomy myotomy open vs vs lap; destroy destroy muscularis muscularis and serosa serosa layer, layer, mucosa intact intact 4) post st--op  TPN for several weeks to allow pylorus to loosen Case 2: 10 month old, lethargic, irritable, not eating well, unusual dark stools DDx: intussusception, gastroenteritis, Hirshsprung’s dz, volvulus, Meckel’s diverticulum, polyps, food allergy (all of these could cause bleeding and thus included in DDx)

Intussusception Sx: irritable, crampy abdominal pain, ↓oral intake, current jelly stool (blood + sloughed mucosa) Signs: (-) BS in RLQ b/c cecum pushed out of RLQ Mechanism: Ileum telescoping into cecum; can get so bad that patient presents with rectal prolapse  Age: 10 month old, old, range = 6 mon – 3 yrs (usually (usually b/c of of hyperplasia hyperplasia of lymphoid lymphoid tissue in distal ileum ileum or Meckel’s diverticulum acting as a lead point); in adults with suspected intussusception, think of cancer or Meckel’s diverticulum as a lead point; if recurrent intussusception, think about lead points (i.e. Meckel’s diverticulum) and do surgery Tx: 1) Flui Fluids ds + Abx Abx 2) Reduction Reduction via barium/air barium/air enema (contraindicated (contraindicated in pts with perforation perforation or or peritoneal peritoneal signs) 3) Reduction Reduction via surgery surgery (squeeze (squeeze colon distally distally so that that SB comes comes out) out) 4) Concurr Concurrent ent appende appendectom ctomy y if surgery surgery is indicated indicated Case 3: 1 wk old, temperature instability (hypothermia), lethargy, distension, bloody stool  Temperature instability  indicates septic state Premature birth  predisposed to NEC NEC (Necrotizing Enterocolitis)

 

Mechanism: post-infection, loss of blood  diversion of blood to critical parts (i.e. brain)  ↓blood flow to intestines  ischemia to mucosa (typically in distal ileum b/c watershed area)  air tracks between mucosa and serosa (pneumotosis); possible infectious etiology Sx: premature baby who has been tolerating feeds but no longer does; often occurs post-infection, thus temperature instability, lethargy; distension, bloody stool Signs: may be able to palpate same loops of bowel on abdominal exam (dead bowel may be fixed) Rad: “soap bubble” pattern on ab Xray; pneumotosis; portal vein gas; free air if perforated  “football sign” Labs: gangrenous bowel  low platelet count + metabolic acidosis (both b/c bleeding) Stage 1: Sx (-) rad findings; Stage 2: (-) rad findings; Stage 3: near death Tx: 1) Indications Indications for surgery surgery : perforation, perforation, fixed loop, portal portal venous venous gas 2) severe cases: cases: if patchy, patchy, gangrenous gangrenous bowel bowel all the way way from ligament ligament of Treitz to midtransverse colon  bowel resection with high jejenostomy and Hartman’s pouch; maintain with TPN and Abx until bowel transplant possible; 5yr survival is 60%; some parents; long term TPN difficult b/c frequent line infections and possible need for liver transplant 3) moderate cases: cases: resect resect dead portions portions of bowel bowel and anastomose anastomose the the remaining remaining parts; create create a proximal ostomy to allow anastomotic areas to heal; may have short bowel syndrome after  4) less severe severe cases: NGT to decompress decompress bowel, bowel, Abx, NPO with with TPN for 2wks to allow allow bowels to to heal (non surgical management); follow CBC (platelets) and Lactic acid (metabolic acidosis)

 

Endocrine Lecture Thyoid nodule workup 1) Hx: painful, painful, sweating, weight weight change, change, bowel fxn, palpitations, palpitations, ap appetite, petite, heat/cold heat/cold intolerance, intolerance, previous surgeries, radiation exposure, family hx (MEN) 2) Physical: Physical: palpation palpation of nodule (mobile, fixed, fixed, firm, soft), soft), exopthalmus, exopthalmus, LN involvement involvement 3) Fine needle needle aspiration aspiration of any neck neck lump; U/S helpful for for guiding needle needle and to to determine determine if cystic vs. solid (solid more indicative of cancer) 4) Labs Labs:: TSH TSH,, free free T4 T4 5) Benign: hyperplast hyperplastic ic thyroid nodule, nodule, colloid cyst; cyst; Malignant: Malignant: papillary, medullary, medullary, anaplastic, anaplastic, lymphoma, metastatic carcinoma a. Dx of most thyroid thyroid cancers cancers are based based on cytoarchitect cytoarchitecture, ure, except except for follicular follicular cancer cancer (must see invasion) b. Prog Progno nosi sis s good good  bad: papillary, follicular, medullary, anaplastic c. Stage Stage importan importantt for progno prognosis sis and and drives drives treatmen treatmentt d. Age determines determines stage stage in thyroid thyroid cancer cancer (i.e. (i.e. 33 diagnostic diagnostic for hyperp hyperparat arathyro hyroidis idism m b. Rule out familial familial hypocalcinuric hypocalcinuric hypercalc hypercalcemia emia with 24hr 24hr urine Ca (don’t (don’t want to remove remove parathyroids in this situation b/c it won’t help them) 4) Rad: a. Sestimibi scan: localizes localizes parathyro parathyroid id producing producing tissue tissue b. U/ U/S S and and CT scan scan help helpful ful too too 5) Tx: Adenoma Adenoma vs Hyperp Hyperplasi lasia a a. Adenoma: Adenoma: remove remove single single adenoma adenoma b. Hype Hyperp rpla lasi sia a i. bx most most normal normal one one to keep keep and remove remove other others s ii. freeze some parathyro parathyroid id tissue tissue and and thaw thaw and reinplant reinplant if needed iii. removal with with autotranspla autotransplantation ntation (placement (placement on SCM or forearm for easy easy access) access) 6) Intraoperative Intraoperative PTH PTH assay: used used in surgery surgery to assess assess amount of PTH PTH remaining remaining

 

7) Comp Complic licati ation ons s of remova removall a. hypop hypopar arath athyro yroidi idism sm  hypocalcemia, need Ca+ supplements b. also transien transientt “bon “bone e hunge hunger” r”  hypocalcemia c. icis icisio iona nall hemat hematom oma a  compresses airway  respiratory distress; evacuate hematoma d. recurren recurrentt laryng laryngeal eal nerve nerve injury injury  hoarseness or respiratory distress Pheochromocytoma Workup 1) Hx: Hx: palpi palpitat tation ions, s, ↑BP, headaches, feelings of impending doom family hx 2) Labs: 24hr urine metanephrine metanephrine and normetanephrine normetanephrine 3) Preo Rad: MIB Gagem (nuclear (nuclea medicine test) localizes localizes tissue tissue and and sites of of metastasis metastasis 4) Pr eop pMIBG manag man emen entrt medicine a. phenoxybenzamin phenoxybenzamine e (alpha blocker) blocker) for 3wks 3wks to prevent prevent alpha alpha response response during during manipulation of tumor during surgery b. propano propanolol lol (beta (beta blocker) blocker) the the day before before surgery surgery c. IVF b/c volume depleted depleted and to compensate compensate for hypotension hypotension post surgery surgery 5) 10% rule: rule: bilateral, bilateral, familial, familial, malignant, malignant, extra adrenal, multiple tumors 6) popular site site of extra-adrenal extra-adrenal pheo: pheo: organ organ of Zuckerkandl Zuckerkandl (bifurcation (bifurcation of of aorta) Carcinoid tumor Workup 1) Neuroen Neuroendocr docrine ine tumor tumor secr secretin eting g 5HT 2) Sx: flushing, diarrhea, wheezing, wheezing, valvular valvular heart dz 3) Common sites: sites: end of small small bowel (appendix (appendix), ), anywhere anywhere in GI track, lung, lung, liver mets mets (b/c of venous drainage) 4) Labs a. 24hr urine urine 5-HI 5-HIAA AA (break (breakdow down n product product of 5HT) 5HT) b. serum serum Chromag Chromagran ranin in A (cells (cells stain stain posit positive) ive) c. Octreotide scan (nuclear (nuclear medicine medicine test) test) to localize localize b/c cells cells have octreotide octreotide receptors receptors d. CT sc scan an to loc local aliz ize e 5) Concern about size size of tumor: >2cm >2cm likely spread spread to LN, thus thus requiring requiring larger resection resection 6) Tx: a. 2cm remov removal al of lar large gerr area area  Adrenal Incidentoma  Adrenal Incidentoma 1) Hx: Sx of hypercorti hypercortisol, sol, hyperaldoster hyperaldosteronism, onism, and pheochrom pheochromocytoma; ocytoma; hx hx of cancer (could (could be mets from another breast or lung cancer) 2) Labs a. CXR: CXR: che check ck for for lun lung g cance cancer  r  b. Mammogra Mammogram: m: chec check k for for breas breastt cance cancer  r  c. BMP (K (K+): ↓ in hyperaldosteronism (aldosteromas are usually small b/c symptomatic) d. 24hr urine urine cortiso cortisol: l: check check for Cushing Cushing’s ’s syndrome syndrome e. 24hr urine metanephrine, metanephrine, normetanephrine normetanephrine:: check check for for pheo pheo 3) Tx: a. Rese Resect ct any any funct functio ional nal tumo tumor  r  b. Resect non-func non-functional tional tumors tumors based based on size size (=>3cm, remove remove via via laproscopy) laproscopy) Insulinoma 1) Whipple’s triad: hypoglycemia hypoglycemia + sx sx present during during fasting fasting + improves improves with glucose glucose ZES (Gastrinoma)  PUD 1) gastrinoma gastrinoma triangle: triangle: junction of of cystic duct duct and common common bile duct + head/neck head/neck of of pancreas pancreas + duodenum

 

Glucagonoma 1) diabetes, weight loss, Necrolytic migratory erythema

 

Scrotal Mass General questions to ask: Tender? Location relative to testicle? Studies: U/S, doppler, transillumination transilluminati on Enlarged scrotum DDx: 1) indirect hernia through patent processus processus vaginalis vaginalis 2) hydr dro ocele a. U/S (+) tr trans ansill illumi umina tion n area b. shows sh ows hypec hynatio pechoic hoic area surroun surroundin ding g testicle testicle c. pain painle less ss,, nonnon-te tend nder  er  d. swelling of scrotum scrotum during during day (not (not swollen swollen in the the morning) morning) 3) Spermat Spermatoce ocele/E le/Epidi pididym dymal al cyst cyst a. Communication Communication between between cyst cyst and epididymis epididymis +/- obstruction obstruction of vas deferens deferens b. Hypo Hypoec echo hoic ic on U/ U/S S c. (+) tr trans ansill illumi umina natio tion n 4) Vario ioc cele a. Varicos Varicositie ities s of pampin pampinifor iform m plexus plexus of veins veins b. Left side side often often affected affected b/c drainage drainage into left left renal renal vein vein c. “worm“worm-lik like” e” appe appeara arance nce d. pulling pulling sensati sensation, on, +/- infertili infertility ty e. Tx: laparascopic laparascopically ally tie off off veins above above inguinal inguinal ligament; ligament; venographic venographic embolization embolization Red, inflammed scrotum DDx: 1) epid epidid idym ymit itis is a. enlar enlarge ged d epid epididy idymis mis b. tender, tender, pain pain relieved relieved by by elevatio elevation n of testicle testicle c. UTI  abnormal UA d. Eleva Elevate ted d whit white e cou count? nt? e. Dopp Doppler ler show shows s ↑ bloo blood d flow flow f. ((-)) tr tran ansi sill llum umin inat atio ion n g. reactive hydrocele hydrocele (fluid (fluid collection collection surround surrounding ing area) h. Tx: Abx, Abx, rest, rest, scrota scrotall elevatio elevation, n, NSAID NSAIDs s 2) testi testicu cular lar torsi torsion on a. kids, kids, young young adults adults usually usually after after strenou strenous s activity activity b. due to poor fixat fixation ion – Bell Bell Clappe Clapperr fixation fixation c. extremel extremely y painful painful b/c b/c can turn turn more than than 360 360 degrees degrees d. Dopp Dopple lerr sh show ows s ↓blood flow e. “donut “donut sign” sign” on on nuclear nuclear medicin medicine e study study f. Operate Operate within within 6 hours; hours; also also fix contr contrala alatera terall side side g. Tx: reduc reduce e in ER ER using using local local anest anestheti hetic c 3) Fournie Fournier’s r’s Necrotiz Necrotizing ing Fasciti Fascitis s a. Alcho Alcholic lics, s, diab diabet etics ics at at risk risk b. Starts Starts as perirec perirectal/ tal/gen genitou itourina rinary ry source source c. Terrible Terrible smell smell because because dead dead tissue tissue receivi receiving ng no perfusi perfusion on d. Can exte extend nd upward upward all all the way way up to clavic clavicle le e. Tx: Abx, repeat debriedment, debriedment, bury testes in thigh thigh or create create new scrotum Scrotum with “blue dot” 1) appendix appendix testis, testis, appendix appendix epididymis epididymis (Mullerian (Mullerian remnants) remnants)

 torsion/twist

 

2) Tx: Tx: reass reassur uranc ance, e, NSAI NSAIDs Ds Squamous cell carcinoma 1) preve prevent nt with with circu circumci mcisi sion on 2) odor, odor, late late pres present entati ation on Phimosis 1) can’t can’t retrac retractt fore foresk skin in 2) undiagnosed undiagnosed diabetics may first first present present with this this symptom symptom 3) Tx : circ circum umci cisi sion on 4) Tx: Paraphimosis: Paraphi mosis: can’t replace replace retracted retracted foreskin foreskin (iatrogenic, (iatrogenic, i.e. placing foley foley and not replacing replacing retracted foreskin) Peyronnie’s dz: trauma, fibrosis of tunica albuginea; Tx with Ca ch blockers, or cholchicine Balanitis: infection on glans penis; associated with STDs Testicular cancer  1) pain painle less ss mass mass 2) Left testicle testicle drains to para-aortic para-aortic LN; Right Right testicle drains drains to interaortocav interaortocaval al LN 3) mets mets to lung lung  cannon ball lesions on CXR; mets to retroperitoneal LN, mets to brains 4) Hydr Hydron onep ephr hros osis is  cancer compresses ureters 5) U/ U/S S sho shows ws solid solid mass mass 6)   ↑risk for cryptoorchidism 7) Germ Germ cell cell >> non-g non-ger erm m cell cell a. Germ cell: seminoma, teratoma, teratoma, embryonal, embryonal, yolk sac, choriocarcin choriocarcinoma, oma, teratocarcin teratocarcinoma oma b. Non-ger Non-germ m cell: leydig, leydig, sertoli, sertoli, gonada gonadalbla lblastom stoma a 8) Adults  seminoma; young  yolk sac 9) Labs: AFP AFP (yolk sac), bHcG bHcG (choriocarcino (choriocarcinoma), ma), LDH, LDH, LFTs, BUN/creatinine BUN/creatinine 10) Studies: U/S, CXR (check for lung met), CT (check for brain met) 11) Tx: inguinal orchiectomy (b/c fast doubling time), radiation therapy (seminoma very sensitive)

 

12) 4) http://depts.washington.edu/surgstus/primer.html  http://depts.washington.edu/surgstus/primer.html  REVIEW Types of shock Pulmonary wedge pressure