SURG NOTES

SKIN & SHIT

• Pyoderma Gangrenosum vs Ecythema gangernosum
• Pyoderma gangernosum ⇒ associated systemic disease (IBD-heme-arthro)
• dx of exclusion
• debridement is avoided due to potential of pathergy induction
• management corticosteroids systemic/local
• Biopsy of margins reveal → neutrophils infiltrate
• Ecythema gangernosum ⇒ Pseudomonas

• Burns
• < 5 days → staph
• > 5 days → Pseudomonas or Candida
 
• Management:
1. Stabilization (ABC)
2. Resusitation (Fluids)
3. Catheterization
4. Burn Care: Irrigation, gentle gauze debridement + application of topical abx + nonstick dressing
 
• What signs in a burn patient warrants a diagnosis of sepsis?
• Any patient with high TBSA burn, should be observed for sepsis. Findings that warrant a diagnosis are:
1. < 36.5C or > 39C
2. Tachycardia (>90) or Tachypnea (>30) or refractory hypotension
3. New Lab abnormalities (Leukocytosis/Leukopenia/Thrombocytopenia)
4. Organ dysfunction (Oliguria - new onset enteral Feeding intolerance - GI hypomobility & ileus)
• If suspected → cultures + empiric antibiotics
• At risk of hypermetabolic syndrome
• TO offset & decrease its risk → start enteral feeding within 24 hours of burn
• Enteral > Parenteral
• Dextrose has low calories

1. Wound care → irrigation and debridement + leave it for secondary repair (EXCEPT FOR COSMETIC causes or deep muscle/blood supply affection)

2. Imaging IF fracture/fb suspected

3. Infection →
1. Tetanus if ≤ 5 years since last vaccination
2. Amoxicillin-clavulinic acid if cat bite, involves face/hand/foot/joint/genitalia, or if immunocompromised or if primary closure is done
3. Consider rabies toxin

• Management depends on high-risk vs low-risk tumors:
• Low Risk (size ≤ 2 cm; on trunk or extremities, EXCLUDING hands & feet)
• High Risk: [ttt → Mohs microscopic surgery]
• Lesions on face, neck, hands, feet, genitalia (especially if ≥ 1cm)
• Any lesion ≥2 cm in any location
• Lesions with aggressive histology or poorly defined borders.

• Sus lesions should undergo full-thickness excisional biopsy with initial margins of 1-3mm of normal tissue.

• Visual Assessment of Melanomas
• ABCDE Criteria (≥1 is sus)
• Asymmetry
• Border Irregularity
• Color variation (within lesion or compared to others)
• Diameter ≥6 mm
• Evolving appearance overtime
 
• 7-Point Check List (≥1 major OR ≥ 3 minor is sus)
• Major → Change in appearance (Color, Size, Shape)
• Minor → Diameter ≥7 mm, Local Inflammation, Bleeding/Crusting, or sensory symptoms
 
• Ugly Duckling Sign → One lesion is significantly different from others on the patient

LUNGS & SHIT

• Pulmonary Contusion < 24hr post-infusion in lung trauma patient
• most likely anterior → anterior infiltration not specified anatomically

• 24-72hr post inticing event (Ortho procedure - Long bone fracture - Pancreatitis)
• Resp Distress (>90%) ⇒ Hypoxemia, Tachypnea, Dyspnea
• Neuro dysfunction (>50%) ⇒ AMS, Seizures, Strokes
• Petechial Rash (<50%)

• Flail Chest
• Happens when >3 continuous ribs in >2 spaces cause an isolated flail chest that moves paradoxically to chest wall during respiration.
• It causes hypoxia via:
1. Impaired generation of negative intrathoracic pressure during inspiration & increased dead space during expiration
2. Associated pulmonary contusion due to Blunt trauma
3. Fracture-related pain
• management → mech ventilator + positive pressure which can force the flail segment to move outwards with the chest during inspiration

• Persistent large air leakage despite secure chest tube in a patient with hx of trauma → check for tracheobronchial injury via bronchoscopy
• Can present as air leakage, persistent pneumomediastinum, pneumothorax, Subcutaneous emphysema DESPITE tube thoracostomy

• Hemothorax management
• Hemothorax + hypotension + tracheal deviation ⇒ MASSIVE HEMOTHORAX (>1500mL)
• Management of hemothorax is chest tube (thoracostomy), which if yields >1500mL or >20mL/kg ⇒ EMERGENT Surgical Thoracotomy

• Bronchial Carcinoid Tumor
• Most common lung tumor is young adults/teens, especially NON-SMOKERS.
• Presentation → Hemoptysis, air way obstruction, recurrent pneumonia
• Dx → Contrast-enhanced tumor with endobronchial component
• Confirmation with bronchoscopy & biopsy

1. tension→ needle decompression & chest tube

2. Spontaneous
1. Small <2cm → O2
2. Large >2cm
1. Stable → needle decompression
2. Unstable → emergency chest tube

• Came from an endemic area + hemoptysis + CXR shows upper lobe opacity

• If patient is stable → Resp Isolation

Algo

 

if bronchoscopy fails → Pulmonary Angio embolization → if fails: Thoracotomy

 

The patient should be placed with the bleeding lung in the dependent position (lateral position) to avoid blood collection in the airways of the opposite lung.

• Can cause
• Atelectasis
• Unilateral hyperinflation with mediastinal shift

• Surgery (anesthesia) + Smoking ⇒ Increases the risk of mucus plugging.
• Causes atelectasis (collapse) → Ipsilateral mediastinal shift, Dullness to percussion, diffuse opacity, narrower rib spacing
• management:
• Minor → Chest Physiotherapy
• Large → Bronchoscopy

• 6hr after transfusion starts → Tachycardia, hypotension +/- fever + CXR shows bilateral pulmonary infiltrates

• Management → Cessation of transfusion + Resp Support

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• Follows Blunt Thoracoabdominal trauma

• CXR shows NGT (correcty positioned along the greater curvature of the stomach) is in the Left-Side of the CHEST not the abdomen. ⇒ CT TO CONFIRM DX.
• ttt ⇒ Surgical Repair (as it can cause intestinal strangulation and death)

• Complications:
• Lung Compression → Few days after trauma, the patient still feels SOB +/- cough
• Bowel Obstruction → Few days after trauma, patient develops NV and Abdominal Pain

• Indications → Cancer, Severe COPD, persistent infection despite medical ttt

• BEST INDICATOR OF POST-OP PULMONARY MORBIDITY /OUTCOMES ⇒ FEV1 & DLCO

URO & SHIT

• Testicular Torsion
• Testicle can be swollen, erythematous, tender + the usual buzzy elevated/horizontal position/absent cremasteric reflex
• Can be associated with mild hydrocele
• heterogenous echotexture → late finding that indicates necrosis

• Varicocele
• Sites:
• Most common left
• Bilateral is also common
• Isolated right side is suspicious for tumor or thrombosis
• Dx → US
• Complications → Infertility & Testicular Atrophy
• ttt →
• Older → NSAIDs + support
• Younger → follow-up for signs of atrophy or semen analysis changes → Gonadal vein ligation

• BPH can recur after TURP as it doesn’t remove all the prostatic tissue
• Physical examination is not reliable & can show a normal prostate, despite having BPH

• Symptomatic Ureteral Stone management
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UTI = dysuria & frequence or pyelonephritis (Fever + CPA tenderness)
AKI = lactic acidosis or high creatinine
 
< 5mm ⇒ Conservative alone (fluids - analgesics)
5-10mm ⇒ alpha 1 antagonist (tamsulosin)
>10 mm ⇒ urological intervention (lithotripsy or stent)

• Patient with MVA + pelvic fracture + blood at meatus. Dx?
Answer
Dx → PUI
• Blood at meatus + high riding prostate due to injury of bulbomembranous junction + inability to void + perineal bruising
• RETROGRADE URETHROGRAPHY must be done BEFORE cathetarization or surgery
• PUI surgery can be delayed (vs AUI cannot)
 

• Peyronie Disease
• Usually resolves over 1-2years
• If active/progressive ⇒ NSAIDs (for pain) + Pentoxifylline (for fibrosis) + Injection of collagenase
• If Refractory ⇒ SURGEYR

HEART & SHIT

• Patient with Valvular Heart Disease undergoing surgery management?
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What are the low vs intermediate vs high-risk surgeries?
• low-risk → cataract
• intermediate-risk → GI surgery WITHOUT resection
• high-risk → transplant surgery

• Surgery Indication of chronic severe MR
• Primary MR valve REPAIR (> prosthetic valve replacement)
• Symptomatic
• LV dilation or LVEF ≤ 60% (regardless of symptoms)

NOTE 1→ MR patients usually have high LVEF as regurgitation causes increased SV, this is why ≤60% is early indicator of LV dysfunction.

NOTE 2 → Patients with severe MR with EF >60% should be considered for repair even if asymptomatic due to expected LV dysfunction progression

• Surgery Indications of severe AS
• Severe AS = [Aortic jet velocity ≥4 m/sec OR Mean Transvalvular pressure gradient ≥40mmHg OR valve area ≤ 1 cm]
• Severe AS + ≥1 of the following:
• Symptomatic
• LV EF <50% (Regardless of symptoms)
• Undergoing another cardiac surgery

• Pregnancy Contraindications [Should be ttt first prior to pregnancy]
1. Symptomatic MS
2. Symptomatic AS
3. Symptomatic HF LVEF <30%
4. Pul HTN
5. Bicuspid Aortic valve with Ascending Aorta enlargement >50mm

• Valvular AR → LSB

• Root dilation AR → RSB

• Types:
• If Mechanical valve → most common is Paravalvular Leak
• If Bioprosthetic valve → most common is Transvalvular Regurgitation (especially TAVI)
• Pannus Valve Obstruction
• Valve Thrombosis (more common in mechanical → stenosis)

• Features → New onset murmur OR HF symptoms OR MAHA OR Systemic thromboembolism (last 2 → mechanical)

• Initial management ⇒ ECHO

• Aortic Dissection Management
Management



• Type?
• Type A → Ascending Aorta involved ⇒ EMERGENCY, refer to surgery NOW
• Type B → Not.
• ttt?
• Pain control
• BB (fast acting → esmolol)
• If SBP > 120 after BB ⇒ Na Nitroprusside
Tuner Syndrome + chest pain that radiates to the back + HTN
Aortic Dissection (due to presence of bicuspid aortic valve & co-Arc)
Complications → spread to mesenteric artery → severe abdominal pain (with low tenderness) + high amylase
Dx → CT Angio

• Blunt Aortic Injury
• Fall > 10 ft (3m) followed by rapid deceleration → BTAI
• EMERGENCY CXR → Widening of mediastinum, Left-sided effusion(can present as decerased breath sounds), change in aortic contour
• Dx → CT angio if stable; TEE if unstable
• Incomplete tear → patient is stable & normotensive/hypertensive
• Can cause false lumen (similar to AD)
• Can cause a flap obstruction (pseudocoarctation) → UL hypertension with LL hypotension/absent pulse
• Expansion to surrounding structures → RLN (hoarseness)
• Complete tear → Sudden death

• Fluoroquinolones are relatively contraindicated in patients with Aortic Aneurysms, or its risk factors (Marfan - ED Syndrome - Severe atherosclerosis - uncontrolled HTN)
• Adverse Effects → Achillis Tendon Rupture - Retinal detachment - Aortic Aneurysm Rupture

1. Free Wall Rupture
• Most common ~5 days post-MI, up to 2 weeks.
• Most commonly affects LV (LAD occlusion) → rupture → Cardiac Tamponade (Beck’s Triad)
• Risk increases with delayed reperfusion or no reperfusion (via cath)
• ECG shows → PEA (pulseless electrical activity) with a junctional rhythm (potentially perfusing rhythm)
• Dx → ECG
• Management → Rapid Pericardiocentesis & surgical repair

• Patient had an MI + developed arrest + got defibrillated + got amiodarone injection. Then LFTs > 1000. What is cause?
Answer
Hepatic Ischemia cause necrosis of Zone III hepatocytes → > 1000 LFTs
Amiodarone causes cholestasis (increased bilirubin) NOT Acute Liver Failure.

• Soft tissue dehiscence → only superficial tissue is seperated (ms, skin) → no signs of sternal instability
• ttt → local care & debridement + primary closure

• Sternal dehiscence → sternal instability & nonunion, characterized by clicking or rocking of the sternum on palpation.
• EMERGENCY → Sternal Rewiring

• Most common cause of death is Heart Failure, so it is an indication of urgent surgical intervention.
• IE diagnosed → severe MR, causing HF (Acute PE & LL edema)
1. Blood Culture & empirical abx
2. O2
3. Surgical Consultation
• Other indications of surgical consultation are:
• (local damage) HF
• (systemic damage) localized extension of infection → abscess, fistula, HB
• difficult to treat organisms (multi-drug resistant - fungal)
• very high risk of embolism (>1cm vegetation - persistent embolization despite abx)
• Prophylaxis:

To patients with prosthetic/mech valve, px IEC, or CHD (residual or unrepaired)

• Dental or Gingival manipulation (Amoxicillin)
• Resp mucosa incision (tonsillectomy or bronchoscopy w biopsy) ⇒ Amoxicillin
• Skin or Muscle Surgery in infected area (Cellulitis or Abscess) ⇒ Vanocomycin
• GI or GU procedure in infected area (UTI instrumentation or Diverticulitis) ⇒ Ampicillin
• NO NEED FOR PROPHYLAXIS FOR:
• Colonoscopy/Endoscopy
• Vaginal/CS
• Dental X-ray, fillings, orthodontics

VASCULAR & SHIT

• Lower Extremity Proximal DVT
• Risk Factors → Px DVT, Cancer, Immobilization (>3 days), Drug injection, Obesity, pregnancy, COC/HRT
• Drug injection (in femoral artery) can cause iliofemoral DVT
• Features → Swollen Leg, Calf>3cm, pitting edema, collateral veins, Localized tenderness along vein distribution
 
• Management?
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• Upper Extremity DVT
• Risk Factors
1. peripherally inserted CVC (eg. patient taking chemo + has erythema, swelling, no discharge) [to exclude infection]
2. weightlifting → scalene/subclavius muscle hypertrophy
3. repetitive arms motion → injury to the axillosubclavian vein
4. Malignancy
5. Thoracic Outlet Syndrome (Cervical Rib) → injury to the axillosubclavian vein
 
• Manifestations → hours after motion: arm swelling, pain, erythema, warmth, and heaviness
• Nearby superficial veins dilate (as they act as collaterals)
• Pain
• Improves with rest & elevation to heart level
• Worsens with activity & elevation above the head
 
• Dx → Doppler or Duplex
• ttt → 3m of anticoagulant therapy or thrombolysis

• Triad of Bilateral hip, gluteal, and thigh claudications - ED - absent/diminished femoral pulses
• ED (either due to aortoiliac or internal iliac or internal peudendal artery occlusion) warrants a warning of substantial risk of CAD. ED usually precedes symptomatic CAD by 3-5 years.

• Pulsatile mass in the groin are “under the inguinal ligament” that causes anterior thigh pain
• Pain is due to compression of nerve
• Usually associated with AAA

1. AVF → continuous bruit with NO mass
1. ttt: small (observation/US-guided compression); large (surgical repair)

2. Pseudoaneurysm → pulsatile mass with systolic bruit

3. Hematoma → No bruit +/- mass

ENT & SHIT

• Cellulitis of submandibular & sublingual spaces → tender & edematous mouth floor → ‘hard’ & displaced tongue posteriorly ⇒ ACUTE AIRWAY OBSTRUCTION

• associated features → woody/brawny neck with no lymphadenopathy

• Elderly with decreased fluid intake & NPO (pre-op) presenting with severe parotid swelling (pre-auricular tenderness & swelling) + pain on jaw movement +/- radiation to ipsilateral half of face.

• Can be due to dehydration/decreased oral hygiene (dementia patients) or stone or neoplasm

• Dx → clinically + followed by CT to exclude stone/neoplasm

• ttt → abx, hydration, sialagogues, massage

• Any patient with nasal trauma should be evaluated for a septal hematoma (soft swelling; vs hard → deviated septum)
• Complications of nontreated hematoma → Infection (abscess) & avascular necrosis (septal perforation)
• ttt → immediate drainage → anterior packing → ice + NSAIDs + abx & reevaluation later

• Whistling sound post-rhinoplasty is buzzy for septal perforation from a septal hematoma

• Other causes:
• Cocaine use
• Syphilis - TB - Sarcoidosis
• Nose Picking - Wegner’s

NEURO & SHIT

• Diagnostic → CSF-specific proteins (B-2transferrin, B-trace protein)

• To find exact site → Imaging (with intrathecal contrast) or Endoscopy (with intrathecal fluorescein dye)

• Management → Inpatient observation (bed rest - head elevation - frequent neuro exams)
• Complication → Meningitis

• Cocaine.

• Strokes are classically ≥ 60 years & with hx of chronic HTN

• Sympathetic activation → mydriasis, HTN, tachycardia hints to cocaine use

• Meningioma
• Risk Factors
• Ionizing Radiation, Old Age, Female, Genes (NF2)
• Radiation has a latency period of >20 years
• Management:
• Small (<2cm) & asymptomatic ⇒ Observation/Serial Imaging
• Large or Symptomatic or associated brain edema ⇒ Surgery
• Unresectable or Comorbidities ⇒ Radiation

• buzzy keyword is = fluid collection with peripheral enhancement on MRI

• Classic presentation → fever (not always ~50%), focal back pain, neuro findings

• EMERGENCY → IV abx & emergency laminectomy & decompression (<24hr of onset of neurologial deficit)
• if delayed = permanent deficits

• Rear-ended MVA → weakness/decreases sensation in UL > LL.

• management:
1. Cervical X-Ray ⇒ Normal/Cervical Spondylosis
2. Cervical Myelogram is Diagnostic

• ttt → steroids and/or surgery

• screen for associated symptoms:
• RCC → abdominal MRI
• Pheochromocytoma → metanephrines
• Cerebellar hemangioblastomas → MRI brain
• Retinal hemangioblastoma → eye/retinal exam

• Caused by HTN, Aspirin,

• Surgical Decompression IF:
1. Signs of Neurological Deterioration (lethargy, obtunded, coma)
2. Radiological Evidence (≥3 cm, BS compression, Obstructive Hydrocephalus)

• Subfalcine → NO cranial nerve affection/Resp Centers/Coma.
• Symptoms as LL weakness that can progress to bilateral as ACA is compressed

• Uncal → Signs of BS compression (irregular resp, unconsciousness) + IPSILATERAL FIXED DILATED PUPIL

• Tonsillar → Signs of BS compression (irregular resp, unconsciousness) + FIXED MIDPOSITION PUPILS

RENAL & SHIT

• Classic triad is hematuria (IDA), flank pain, and palpable abdominal mass in a smoker (triad present in <10% of patients)

• So, >1 of these warrants an investigation

• Smoker (or other risk factor) + hematuria.

• First → Urinalysis to determine hematuria THEN

• Dx → Flexible Cystoscopy with biopsy (GS) or urine cytology

• Staging → TURBT + Upper UT imaging (IVP, MRI, CT)

• ttt:
• No muscle invasion ⇒ TURBT & intravesical immunotherapy
• Muscle invasion ⇒ radical cystectomy + systemic chemo (Muscle invasion usually means tumor has invaded walls)
• Metastatic ⇒ Systemic Chemo + Immunotherapy

MSK & SHIT

• Patellar Tendon Rupture ⇒ Patella rides high

• Quadriceps Tendon Rupture ⇒ Patella rides low

• Rotator cuff tear
• Tear → pain/limited range of motion with abduction, external rotation, and raising arms overhead
• WAEKNESS is present + drop arm sign
• Usually after a fall on outstretched hand
• Dx:
• Initially → Shoulder X-Ray to exclude fractures
• Diagnostic → MRI of the shoulder
• ttt → surgery within 6 weeks
 

• Rotator cuff impingement/tendinopathy
• Same as tear BUT NO weakness
• Subacromial tenderness is present with normal range of motion
• positive impingement tests

• In patients in DM or Hypothyroidism

• Loss of PASSIVE & ACTIVE ROM (vs arthropathy → loss of active only)

• Pain & weakness → disuse atrophy & loss of swing
• ttt → ROM exercises. NO IMAGING NEEDED.

• Deeper Infections should be suspected if?
Answer
1. Long Standing wound >1-2 weeks
2. Large Ulcer Size ≥ 2cm
3. Systemic Symptoms (Fever, Chills)
4. Elevated ESR
5. Palpation/Presence of Bone at ulcer base

• Infections are usually → Polymicrobial + can cause OM via contagious spread

• Very common after high velocity tibial fractures

• Presentation → patient had a RTA fracture → fixation therapy → acute OM presentation (recurrent fevers) that are inadequately treated → chronic osteomyelitis (presentation is nonunion + fragmentation of the bone + irregular fracture line)
• Risk Factors of malunion (DM - Impaired blood supply [smoking, atherosclerosis] - corticosteroids - infection [OM])

• SINUS TRACT is buzzy for chronic OM

• ttt → open surgical debridement & biopsy

• Rest pain + pain on weight bearing + aggravated by forced abduction & internal rotation

• Pain site → groin is a big one, thigh, or buttocks

• Skin & labs are negatives for any finding

• Often presents in children age > 10 due to rapid growth

• Defined as Cobb’s angle > 10 degrees

• Foreward ben test shows asymmetry

• 1st step → XRAY to measure cobb’s angle
• 10-30 degrees → follow-up in 6 months
• 30-40 in a child→ brace
• 40-50+ → surgery

• Pain increases with ipsilateral neck flexion & Improves with shoulder abduction

• These signs are specific.

• Greatest risk → recurrence

• Avascular necrosis is NOT common in isolated shoulder dislocation, it is associated however with proximal humerus fracture.

• FOOSH <10 years → buckle fracture in distal radius

• Dx is xray seeing 0)

• Causes → crush injury, long bone fracture, rhabdomyolysis, reperfusion, massive fluid resuscitation
• Presentation or pressure can be normal at first, but as the patient get resuscitated → reperfusion, the syndrome can present

• C/P
• Early → progressive pain that increases rapidly + painwith stretchinh
• Late → decreased sensation + weakness that turns into paralysis +/- loss of pulse (rare)

• Dx → Delta pressure (diastolic pressure - compartment pressure) ≤ 30 confirms the dx

• ttt → Emergency Fasciotomy

• Lytic lesions with concentric layers (Sunburst & Coddman)

• Hx of TP53 (Li fraumeni Syndrome) & RB1 (Retinoblastoma)

• Occurs in older adults with hx of paget & radiation

• Acute → Inflammation & Pain

• Chronic → No pain & inflammation

• Tophus → cortical bone erosions with overhanging edges

• Rhabdo → hyperkalemia

• succinylcholine (depol NM blocker) → hyperkalemia

• management:
1. Weight loss
2. Regular moderate activity & NSAIDs
3. Exercise program to strengthen the Quads

• Saline irrigation of gross debris → wrapped in sterile saline-moistened gauze in a sealed plastic bag → bag is immersed in cool ice water (0 degrees C)
• This decreases metabolism & O2 demand → decreases risk of ischemia
• Direct ice contact increases risk of frostbite

NUTRITION & SHIT

• Diarrhea, Peri-oral pustular rash, Alopecia

• Hypogonadism

• Impaired wound healing, Impaired taste, Immune dysfunction

• Risk Factor ⇒ Malabsorptive disease (Celiac - CD), TPN, diarrhea, gastric bypass, bowel resection.

• Hair Loss/Brittle Hair

• Skin Depigmentation

• Anemia

• Osteoporosis

• Neurological Dysfunction (Peripheal Neuropathy ⇒ ATAXIA, ROMBERG POSITIVE, LOSS OF VIBRATION)

ENDOCRINE

• Cancer Risk Factors should be assessed

• Examination → Size, Mobility, Firmness, and L.Ns

• Serum TSH
• If normal → US
• If > 2cm → FNA (unless cystic)
• If > 1cm → Look for high-risk features (Microcalcifications, Irregular margins, internal vascularity) ⇒ FNA
• If decreased → Radionuclide Scans

Pregnant Women SHOULD NOT receive radioactive iodine, however, FNA is safe.

• Patient underwent thyroidectomy + radioactive iodine treatment + has been taking levothyroxine started having new increase in Tg (thyroglobulin) levels.
• This is a sign of cancer recurrence
Explanation
Tg is produced by thyroid tissue (gland/cancer) → this patient has no thyroid → so new increase in Tg ⇒ recurrence of cancer.
• Patient is taking levothyroxine for 2 reasons:
1. Replace thyroid gland function
2. negative feedback on pituitary to decrease TSH → decrease stimulation of thyroid tissue growth/cancer recurrence
• How to test for recurrence?
• Stop Levothyroxine or give TSH → decrease negative feedback → increase in TSH → increase Tg

• Primary ttt is → surgical resection
• If small (<2cm) & no evidence of nodal involvement or contralateral thyroid abnormalities ⇒ partial/lobectomy
• If larger ⇒ Total thyroidectomy
• If nodal involvement or extrathyroidal invasion ⇒ Lymph nodal dissection (regional/central compartment)

• AFTER SURGERY → Levothyroxine is given + radioiodine ablation is used in patients with high risk of recurrence (Large - invasion - metastasis - incomplete resection)

• Usually seen in patients with burns, sepsis, trauma/hge

• no ttt indicated, unless glucose (>180-200) then short-acting insulin is administed to maintain glucose in slight hyperglycemia

• High Serum Calcium, Low Serum Phosphate, High PTH, High urinary calcium

• Next Step after dx ⇒ Parathyroid Imaging & Parathyroidectomy (of PTH adenoma)

BREAST

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Simple Cyst → thin-walled, fluid filled cyst

Complex Cyst → thick-walled, solid components

 

NOTE → US is the preferred imaging modality in women <30 years of age.

• Common after breast surgery & trauma (seat belt)

• Can mimic breast cancer → dimpling & skin retraction + fixed irregular mass + calcification of mammogram

• US → hyperechoic mass (correlates with benign etiology)

• Biopsy → fat cells and foamy histiocytes

• ttt → excision then reassure & routine follow-up

• Dx → IBC

PEDS NECK MASSES

1. Midline?
• Moves with tongue → Thyroglossal Cyst
• DOESN’T move with tongue → Dermoid Cyst

1. Lateral?
• Single mass anterior to SCM → Branchial Cleft Cyst [ttt → resection]
• Multiple & Tender → Reactive Adenopathy
• Necrotic/Violaceous Discoloration → M.avium lymphadenitis

1. Posterior?
• Cystic Hygroma

POST-OP COMPLICATIONS

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Immediate

• Tissue trauma → observe & symptomatic ttt
• Fever & Leukocytosis last < 3 days.

• MH → Dantrolene & cooling.

• Causes: Complications (ureteric injury), increased surgery duration, increased bowel manipulation (laparotomy)

• Ileus > 72 hrs post-op → AXR shows uniformly dilated bowels + decreased sounds + abdominal pain & vomiting
• Vomiting results in hypokalemic hypochloremic metabolic alkalosis
• ttt → bowel rest & serial examinations

OPHTHALMOLOGY

• Dx confirmed with → gonioscopy (to visualize angle) & tonometry (to measure IOP)

• ttt → topical & systemic IOP lowering drugs
• Later → Laser iridotomy

• Large ⇒ Extrusion of Vitreous

• Small & No FB visualized ⇒ Eccentric/Peaked/Teardrop pupil (fixed)

• Management → Eye Shield + Ophthalmologic consultation

• “Rock hard induration of eyelids” + RAPD + vision loss following trauma.

• Emergency Orbital Decompression MUST be done before imaging or any other intervention

• If injury is severe → enucleation of they eye to pevent sympathetic ophthalmia

• if some recovery is expected → follow-up; if condition develops → steroids & biologics

• Usually > 60 years of age.

• Can present in younger patients with: DM, trauma, steroids use, external radiation, HIV infection

• ttt → Laser remval

HERNIA

• Delaying surgery DOESN’T increase risk of complications

• Most patients will require surgery within the next 10 years

• note that femoral hernia are NON-PULSATILE MASSES