1. 1: ST Bariatric
   1. Presentation
      1. 56 y/o F cc morbid obesity (BMI 43)
         1. comorbidities
            1. depression, fatigue
            2. HL, HTN, hypercholesterolemia
            3. Diabetes
            4. GERD
            5. Obstructive sleep apnea
         2. meds
            1. IBU, ASA, Paroxetine, Simvastatin, HCTZ, Lansoprazole
      2. Progress
         1. Initial visit in january
         2. Wellspan Clinical Weight Loss Program
            1. was able to lose 10 pounds
         3. Psych assessment in office in June
         4. Cadiac assessment.
         5. July 15th surgery with normal recovery
         6. July 23 postop check
            1. DUMPING SYNDROME
      3. psychosocial issues
         1. 35.7% of american adults are obese
         2. ~65% are overweight
         3. $100bn/yr to treat
   2. Dx
      1. BMI >30
   3. Bariatric Surgery
      1. Indicated?
         1. Indications
            1. BMI >40 (class III very severely)
            2. BMI >35 (severely) AND comorbidities
            3. DMII
            4. Pickwickian Syndrome
            5. obesity hypoventillation syndrome
            6. BMI > 30, PaCO2 >45
            7. CO2 narcosis
            8. excessive daytime sleepiness
            9. headaches
            10. increased heart stress → cor pulmonale
            11. Obesity-related Cardiomyopathy
            12. Sleep Apnea
            13. OA interfering with lifestyle
            14. Demonstrated failure on previous diets + counseling & reading assignment
         2. Contraindications
            1. Hx substance abuse
            2. Untreated major depression or psychosis
            3. Binge-eating disorders
            4. End-stage disease of any organ
            5. Inability to commit to long-term weight-loss strategy
            6. Poor surgical candidate generally (incl CHF)
      2. By Rationale
         1. Restriction (more gradual loss)
            1. Vert Band
            2. Lap Band
            3. high complication rate
            4. Contraindicated in portal hypertension, CT disorder, severe esophageal dysmotility
         2. Malabsorption (faster loss, but nutrition problems)
            1. Jejunoileal bypass
            2. Duodenal switch
         3. Combinations available too
            1. Roux-en-Y
            2. About
            3. better resolution of comorbidities than band
            4. faster wt loss
            5. Gold standard
            6. Technique
            7. Cut jejunum 50cm distal to lig treitz
            8. cut a stomach pouch just distal to LES; connect it to distal jejunum
            9. Rest of stomach is left as-is, but the new piece is attached 100-150cm distal to gastrojejunal anastomosis
            10. or 150 if >40BMI
            11. Postoperative Care
            12. First 24h
            13. fluid resuscitation, urine output monitoring
            14. POD1
            15. contrast study optional
            16. no tachycardia or T>100F?
            17. water to liquids
            18. 30mL q 30 minutes
            19. FU in 30d to assess oral intake and ound healing
      3. Effective? (med results in italics)
         1. overall/cause specific mortality down.
            1. strongest in BMI >40; less clear less fat
            2. 29% reduction
         2. Mean EWL 61%
            1. med: 0.1% increase
         3. Diabetes
            1. RYGB 80% of DM pts no longer need meds at 6 mo.
            2. Complete resolution in 77%; improved in 86%
            3. best resolution in duodenal switch operations
         4. HL
            1. Improved in 70%
         5. HTN
            1. resolved in 62%; improved in 79%
         6. Apnea
            1. 86% resolution
         7. Urinary stress incontinence
            1. in women, a coin-toss
      4. Complications/AE (20%)
         1. 1-2% mortality
         2. Dumping syndrome
            1. undigested food empties into jejunum
            2. rapid entry of water into intestine→osmotic diarrhea
            3. nausea, vomiting, bloating, cramping, diarrhea, dizziness, fatigue
            4. hypoglycemia due to dumping ↑↑insulin release from pancreas
            5. fix
            6. low-carb, low simple-sugars, no water during meals
            7. maybe octreotide, PPI
         3. wound infection
         4. G-J stromal stricture
         5. Marginal ulcers
         6. internal hernia
         7. Roux limb ischemia
         8. Blow-out of stomach remnant
         9. Long term micronutrient deficiency
   4. Complications
      1. DMII, CVD, stroke, cancers, OA, liver disease, obstructive apnea, depression
2. 2: MK Head Injury/ Prolonged ICU Stay
   1. Presentation
      1. 25 y/o M with axial load injury sustained during MMA practice
      2. Injuries: closed head injury, SDH
         1. initial CT
            1. L SDH with effacement of foramen monro
            2. Subfalcine/subuncal herniation
            3. 1.5cm L→R midline shift
         2. GCS was 3t in the trauma bay
      3. GCS improved to E2V1M3 = GCS 6 but never got better than that
      4. Course complicated
         1. C Diff
         2. Seizures
            1. cooling blanket
            2. vecuronium
      5. Received trach and PEG tube
   2. Closed Head Injury
      1. Pathophys
         1. Problems
            1. Hematoma
            2. Epidural
            3. Uncommon: MMA laceration., temporal region
            4. blood collects outside dura but within skull
            5. pressure→herniation
            6. subfalcine → cerebral cortex/brainstem herniation → contralateral hemiparesis & decerebrate posturing
            7. pressure → midline shift → CN III compression → ipsilateral fixed dilated pupil
            8. BICONVEX or lense shape on CT
            9. Subdural
            10. blood collects between brain surface and dura
            11. tearing of bridging veins
            12. usually presents with a lucid interval
            13. Common, with worse prognosis, due to coexisting brain injury
            14. Hemorrhage
            15. Subarachnoid
            16. Subtopic 1
            17. Diffuse axonal injury
         2. Monro-Kellie Doctrine
            1. If ICP is supposed to be constant, you can't go adding things to the mix
            2. CBF = CPP/CVR
            3. CPP = MAP-ICP
            4. CPP can vary from 50-150; autoregulated by CVR. >70 is fine.
            5. ICP >20 is BAD
            6. body responds by bradycardia, bradypnea, hypertension
            7. Game over when MAP and CPP are both <50mmHg
      2. Clinical
         1. Mgmt
            1. AVOID SECONDARY BRAIN INJURY
            2. Mortality is 75% if hypoxia & hypotension
            3. 1) ABC
            4. 2) neuro assessment c/ pupil exam + GCS calculation
            5. Dilation with sluggish response: early sign of temporal lobe herniation (compression of third nerve against tentorium)
            6. wider pupil is the side with the defect
            7. Glasgow Coma Score
            8. Interpretation
            9. Trend is more important than score
            10. deterioration of 2 or more is significant and indicates worsening condition
            11. Mild: GCS 13-15
            12. Moderate: 9-12
            13. Severe: 8 or less
            14. COMA
            15. 3-4: 97% death or veg state
            16. 5-6: 65% death
            17. 7-8: 28% death
            18. EVM 4-5-6
            19. Eye: 4spont 3command 2pain 1not
            20. Voice: 5a&o 4confused 3inappropriate 2gibberish 1none
            21. Motor: 6commands 5localizes 4withdraws 3decereb 2decort 1none
            22. Intubated folks can be 11T at best.
            23. CT scan
            24. ONLY if the facility can TREAT
         2. Tx
            1. Endotracheal Intubation
            2. Hyperventillation
            3. →cerebral vasoconstriction→↓cranial BV→↓ICP
            4. Careful: prolonged use→cerebral ischemia
            5. Mannitol
            6. decreases brain volume due to edema
            7. AGGRAVATES HYPOVOLEMIA: so make sure patient is otherwise resuscitated
            8. improves renal cortical perfusion
            9. Burr hole
            10. on side of larger pupil. emergency procedure FOR PROFESSIONALS ONLY
            11. Elevate head of bed to support CPP and prevent ↑ICP
   3. Prolonged ICU Stay
      1. Infection Control
      2. Nutrition
         1. hypercatabolic state → 1.5x energy demand.
            1. major proteolysis
         2. 30kcal/kg
            1. Nitrogen
            2. 1g N →6.25g protein
            3. Daily output is 24hUUN +4
         3. Mode
            1. Enteral
            2. better: preserves gut flora
            3. TPN
            4. risks
            5. sepsis via central line infection
            6. may manifest as glucose intolerance
            7. catheter pneumo/hemo/hydrothorax
            8. mild abnormalities in ALT/AST/ALP/Bili--- investigate if >7-14days
            9. absence of nutrients in the bowel→ mucosal atrophy AND acalculous cholecystitis
            10. no lipids in bowel → no GB contraction → sludging from bile stasis
         4. Don't overfeed
            1. excess calories ↑CO2 retention → respiratory insufficiency
            2. hepatic steatosis
      3. The Vent
         1. Patient mode: CMV 0.6L, PEEP 8, FiO2 30%
            1. barotrauma
            2. volotrauma
            3. biotrauma
            4. atelectatic trauma
            5. O2 toxicity
            6. hazardous over 0.8
         2. Modes
            1. CMV
            2. gives the diaphragm a rest. will require sedation/NM block to work fully
            3. patients with good muscles will overbreathe this ventillator
            4. tell by set vent rate being lower than minute vent rate
            5. SIMV
            6. increased work of breathing but patient less likely to overbreathe the vent; good for pts without CV problems
            7. computer makes sure never to ventilate during a natural breath and avoids stacking
            8. Assist Control
            9. vent rate is controlled; patient can still initiate breaths
            10. Pressure Support
            11. augments patient's breathing
            12. used in conjunction with SIMV sometimes
         3. Concepts
            1. IE ratio: time spent inspiring to expiring. Usually 1:2
            2. can improve oxygenation by reversing to 1:2, allowing more time for oxygenation but is uncomfortable
            3. PEEP
            4. good for ARDS but careful not to exceed 10cmH2O
            5. alveolar rupture
         4. Weaning\
            1. SBT well-tolerated for 30-120 minutes? go ahead and think about discontinuation
   4. The Dangers of MMA
      1. Fewer safety rules
      2. no health coverage at the lower levels
3. 3: LB SBO
   1. Presentation
      1. 81 y/o F cc n/v 2d
         1. Last BM 24h prior to adm; no flatus since
         2. PMH: OA, HTN
         3. PSH: hysterectomy, cholecystectomy
         4. Meds: HCTZ, ASA, Verapamil
         5. PE
            1. Vitals: afebrile, hypertensive
            2. ABD: distended, hypoactive BS, tympanic
         6. Labs
            1. WBC 12.8, H&H 16.4 & 45.9
            2. BUN 37, Cr 0.79; ratio: >40
            3. >20 = pre-renal azotemia
         7. Imaging
            1. SBO w/ transition point in LLQ + pelvic ascites
            2. Found some incidental pancreatic Intraductal papillary mucinous neoplasms
            3. small branch, 30% malignancy chance
      2. Progress
         1. admitted july 30th
            1. orders: NPO, IVF, NG tube, abd XR series w/ oral contrast
            2. med consult for HTN
      3. Discharged August 4th
         1. PCP for HTN
         2. EGD + endo US for cysts
            1. cysts aspirated and sent for cytology
   2. SBO
      1. Pathophys
         1. Etiology
            1. Adult
            2. adhesion, hernia, Crohn's, gallstone ileus, tumor
            3. Children
            4. hernia, malrotation, meconium ileus, meckel diverticulum, intussusception, intestional atresia
         2. Mechanical obstruction
            1. ¬absorptive function, ↑luminal accumulation
            2. fluid shift into extravascular space
            3. transudative loss into the peritoneum
            4. Gallstone ileus
         3. Functional Obstruction
            1. Ileus
         4. Early Postoperative SBO
            1. SBO sx w/in 30d of abd operation
            2. nonoperative is favored, CT if no improvement
         5. Complications
            1. strangulation → necrosis → sepsis
            2. ↑amylase, ↑lactate, persistent leukocytosis
            3. free fluid
            4. mesenteric edema
            5. CONSTANT PAIN
            6. vomiting → aspiration → pneumonitis
            7. dehydration → prerenal azotemia → ARI
            8. not only from vomiting, but also from intra→extravascular fluid movement from inflammation → venous congestion→transudate
      2. Clinical
         1. Dx
            1. Presence of bowel movement does not rule out SBO; could just be distal peristalsis
            2. Vomiting? Think proximal SBO
            3. Distension? Think distal SBO
            4. if unresolved, can lead to eventual feculent vomitus
            5. PEx
            6. dehydration
            7. low-grade fever
            8. tachycardia
            9. if persistant after fluid resuscitation, suspect inflammation/ischemia/necrosis
            10. Tenderness
            11. Mild, diffuse tenderness
            12. if SBO is uncomplicated, will improve after NG decompression.
            13. Localized tenderness over distal SB
            14. suggests distension or ischemia
            15. High fever
            16. bowel ischemia
            17. pulmonary complications due to aspiration
            18. DRE
            19. Rectal vault shouldn't contain stool
            20. if stool, suspect ileus over SBO
            21. Lab/Rads
            22. Abd XR to start
            23. Dilated small bowel w or w/o colonic air
            24. stepladder pattern with air-fluid levels
            25. CT if obscure etiology
            26. ileus, IBD, tumor, gallstone ileus
            27. dx transition from dilated to compressed bowel (diagnostic for mech obs)
            28. Upper GI and SB follow-through
            29. differentiates SBO from ileus
            30. use if no improvement with supportive therapy after 24h
            31. Labs
            32. CBC/diff
            33. expect mild leukocytosis in dehydrated patients that should resolve with fluids
            34. if it doesn't resolve with fluids, think complications
            35. amylase
            36. good sign of complicated obstruction
            37. serum electrolyte
            38. urinalysis
            39. ABG for certain patietns
         2. Tx
            1. Uncomplicated SBO from adhesions
            2. NONOPERATIVE
            3. NPO, NG tube, fluid resuscitation, frequent exams and lab/rads
            4. Might drop a foley to monitor urine output
            5. should see improvement in 6-24h
            6. feeling better
            7. ↓NG aspirate
            8. radiographic resolution of distension
            9. Surgical
            10. Always: perioperative broad spectrum ABX
            11. X-lap, division of adhesive bands, resection of ischemic/necrotic bowel
4. 4: WM Cholelithiasis →Pancreatic Pseudocyst
   1. Presentation
      1. 42 y/o F cc longstanding gallstone pancreatitis
         1. PMH
            1. gallstone panc, infected pseydocyst+nec panc
            2. GERD
            3. HTN
         2. PSH
            1. hysterectomy, ERCP, pancreatic stenting, cystogastrostomy tube
         3. meds
            1. medroxyprogesterone, IBU, omeprazole, citalopram, metoprolol
         4. PEx
            1. fertile, female, BMI 33, age 42
         5. Labs
            1. WBC 10.6, H&H 11.2 & 34.8, plt 262
      2. HPI
         1. March
            1. dx gallstone pancreatitis
            2. complicated by pancreatic pseudocyst
         2. April-June
            1. ERCP w/ pancreatic stent: unsuccessful
            2. Repeat ERCP + cystogastrostomy tube
            3. successful, symptoms slowly improved
         3. July 07
            1. 4d hx postprandial epigastric and RUQ pain + nausea
            2. admitted inpt, IVF, clears, lap chole plan
         4. JUly 08
            1. Lap chole
   2. A&P
      1. Size & Shape
         1. Tubular, 10cm long, 5cm diameter
         2. fundus, body, neck cystic duct lined by spiral valves of Heister
      2. Function
         1. Liver makes .5-1L bile/day
            1. increases with H2O and bicarb secretion, enterohepatic recirculation of bile (mostly in terminal ileum)
            2. Contains cholesterol, bile acids, lecithin, conjugated bilirubin, protein
            3. alkalinizes gastric chyme
            4. makes duodenal contents isoosmolar
            5. digests fats & DAKE
            6. Usually 5% lost; >20% ↓bile acid concentration → stone formation, steatorrhea, ¬coagulation via ↓K absorption
         2. Diverts to gallbladder when Oddi is closed
         3. Concentrates bile absorbing NaCl & H2O
         4. CCK→contracts gb & relaxes Oddi
      3. Pictures
         1. hepatobiliary tree, ending with ampulla of Vater through Sphincter of Oddi
            1. Triangle of Calot (hepatocystic triangle)
            2. Superior: inferior margin of liver
            3. Medial: common hepatic duct
            4. Lateral: Cystic duct
   3. Cholelithiasis
      1. Epi
         1. 1-2% of pts/yr develop symptoms
            1. 2/3 remain free of sx after 20y
      2. Types
         1. 75% western pop: Cholesterol: yellow and soft
            1. Female, fertile, fat, 40s
            2. multiparity, hi-dose Estrogen OC, rapid weight loss, prolonged TPN, malabsorption
            3. 10% pure, 70-80% mixed
            4. enlarge over first 2-3 years, then stabilize
            5. usually radiolucent thus not visualizable
         2. Pigment Stones (most common on Earth)
            1. 20% Black
            2. unconjugated (indirect) Bilirubin from hemolysis, cirrhosis, sclerosing cholangitis
            3. Brown
            4. biliary stasis, infection
            5. Agents
            6. E. Coli/Enterococcus (80% acute; 30% chronic)
            7. usually secondary, arrive only when inflammation present
            8. Protozoa to blame in some alcalculous cholecystitis
      3. Biliary colic
         1. RUQ waxing/waning, dully aching, poorly-localized, postprandial, upper abdominal radiating to back
         2. post-prandial
            1. due to CCK-induced contraction of the inflamed gallbladder
            2. may also awaken patient at night
         3. liver function normal by lab evaluation
            1. if dysfcn, think common duct obstruction
         4. Biliary colic is NOT related to inflammation and is thus distinct from acute cholecystitis
      4. Treatment
         1. none necessary unless biliary colic or cholecystitis
   4. Pancreatic pseudocyst
      1. Pancreatitis→disruption of panc parenchyma → release of enzymes → autolysis & necrosis → "pseudocyst" lined with granulation tissue and filled with digested blood and pancreas
   5. Gallstone pancreatitis
      1. Epi
         1. 60% of all nonalcoholic acute pancreatic cases are gallstone-based
      2. pathophys
         1. Sometimes a large stone; more likely sludge or small stone passage
      3. Clinical
         1. Dx
            1. classic clinical picture of pancreatitis
            2. + amylase and lipase are very high compared to EtOH panc
         2. Treatment
            1. Bowel Rest and IV hydration
            2. lap chole after pancreatitis resolves
            3. if delayed, 25-30% will develop recurrent pancreatitis within 6w period
      4. Complication
         1. Gallstone Ileus
            1. Pathophys
            2. erosion of large gallstone directly into intestinal tract at the duodenum
            3. Clinical
            4. history of gallstone disease + intermittent SBO
            5. air in the biliary tree, sometimes
            6. Dx by CT with oral contrast
5. 5: XX Prophylactic Bilat Mastectomy Due to BRCA-1+ & L Inv Ductal
   1. Presentation
      1. 34 y/o F cc Infiltrating Ductal carcinoma L breast
         1. PMH
            1. meds
            2. MV
         2. PSH
            1. core biopsy L breast mass
            2. salpingectomy for ectopic pregnancy
         3. FHx
            1. HTN
            2. DM
            3. Mother and Sister Br. Ca
      2. Course
         1. Mastectomy w/ Sentinal Node Biopsy
            1. Blue Dye + 99Tc Injected night before
            2. Gamma detector used in OR to locate sentinel node; node excised and sent for frozen
   2. Breast Cancer
      1. Epi
         1. Risk Factors
            1. MOST Women w/ Br Ca did not have risk factors
            2. HRT
            3. RR 2 if >59 y/o
            4. EtOH
            5. RR 1.5 if >2-5/day
            6. LCIS
            7. RR 8-11
            8. Previous Breast Ca
            9. RR 4-5
            10. Hx Proliferative biopsy
            11. ~2; 4-5 if "atypical hyperplasia"
            12. NO RISK
            13. pollution, implatns, exercise, smoking, abortions, antiperspirants, bras
         2. 1 in 8 women
            1. 10% are genetic
         3. Increasing incidence, but earlier detection
      2. Pathophys
         1. Types
            1. LCIS
            2. RR 6-12 for ↑future ductal or lobular carcinoma in either breast
            3. 1% yearly chance of developing invasive
            4. usually an incidental finding
            5. DCIS
            6. Preinvasive. invades in 30-50% in 10y if untreated
            7. presents as mammo microcalcifications, usually no mass
            8. includes comedocarcinoma (has necrotic core), which invades 1/3 of the time
            9. 75% Infiltrating ductal carcinoma
            10. 90% of invasive breast cancerrs; WORST PROGNOSIS
            11. characteristic firm, irregular mass
            12. histo: stellate morphology with reactive fibroplasia
            13. "cords, islands, glands"
            14. 10% Infiltrating lobular Carcinoma
            15. 10% of breast cancers
            16. less well-defined, thus harder to detect
            17. Multifocal and bilateral. "indian file" cells
         2. Mets usually to brain, lung, bone
      3. Evaluation
         1. Preop Eval
            1. H&P
            2. Bilateral Mammo
            3. Chest Radiograph
            4. LFTs
            5. Studies as indicated by sx
         2. Breast Mass Eval
            1. If suggestive of fibrocystic change, recheck in 3mo
            2. Age <30, use ultrasound
            3. >40, mammography +/- US
            4. review previous images
            5. All solid masses require FNA or core biopsy
            6. algorithm
            7. Triple Test (if all three benign, then 100% True Negative)
            8. Clinical Exam
            9. Imaging (mammo and/or US)
            10. FNA
         3. H&P
            1. Previous breast problems, biopsies, mammography
            2. FHx breast, ovarian cancer
            3. suggestive if in multiple generations, multiple 1st degree relatives, pre-menopausal ca, bilateral ca, ovarian ca, multiple other ca in family
            4. TRAUMA TO BREAST
            5. GYN hx
            6. menstrual history
            7. pregnancies
            8. OCP, HRT
            9. Age
            10. abnormalities <30 are mostly fibrocystic
            11. postmenopausal ▲ should scare
            12. Bone Pain
            13. Bone scan if there's a tumor
         4. Imaging
            1. Mammography
            2. two views: craniocaudal; mediolateral oblique
            3. 10% false negative (higher in younger); 10-15% false positive
            4. 0.2 rads/dose (2 mSv)
            5. a little less than 1y environmental radiation
            6. BI-RADS categories
            7. 1 is negative, 2 benign, 3 probably benign, 4 suspicious, 5 likely malignancy
            8. US
            9. good for women under 30 to Dx cystic change (solid mass vs cyst, simple vs complex)
            10. benign if good borders, central enhancement, absence of echoes
            11. Bad if poor margins, echoes/shadows, "taller than wide"
            12. 99.5% NPV
         5. Biopsy
            1. FNA for cytology
            2. 65-98% sensitive; 99.8% specific
            3. Core biopsy or open biopsy for histology
            4. stage I and II tumors need CBC, XR, LFTs
            5. Image-guided has better accuracy
            6. 20% of biopsies come back carcinoma
            7. Even benign ones should have 6mo FU mammo
         6. staging/histologic
            1. Stage via TNM
            2. T
            3. Tis
            4. CIS
            5. T1
            6. 2cm or less
            7. T2
            8. 2-5cm
            9. T3
            10. >5cm
            11. T4
            12. involvement of skin, chest wall
            13. OR inflammatory
            14. N
            15. N0 negative
            16. N1 1-3
            17. N2 4-9
            18. N3 10 or more
            19. M
            20. M0 for none; M1 for distant
            21. Integration
            22. Stage 0 and 1 are no tumor or tiny without nodes
            23. Stage 2 is small with node or big without node
            24. Stage 3 is big/mult tumors with or without nodes
            25. Stage 4 has mets
            26. Estrogen receptor?
            27. Her-2-neu oncogene
            28. poor prognosis
            29. however, likely response to Herceptin
      4. Treatment
         1. Lumpectomy
            1. Contraindicated if dermal lymph involvement, unwillingness to take rads
            2. ~6w course of rads to follow
            3. Rads indications
            4. invasive cancer
            5. DCIS
            6. May improve survival in all node+ women
         2. Mastectomy
            1. Simple
            2. prophylactic IF high-risk biopsied lesions + strong family history OR BRCA positive
            3. Axillary Dissection
            4. Since lymph drains axillary/pec minor nodes 1(lateral)→2(medial)→3(deep), biopsy 1 first to see if spread
            5. sentinel biopsy
            6. Modified Radical (simple + axillary)
            7. Indications
            8. Multicentric cancer
            9. Residual cancer post-adjuvant (chemo/hormone) therapy
            10. Radical
            11. Breast, skin, pecs, axilla
            12. horrible disfigurement and functional impairment. use only if Ca. infiltrates the pec major
            13. No stat sig difference in survival between mastectomy and breast-conserving therapy
         3. BCT
            1. Contraindications
            2. >2 primary tumors in separate quadrants
            3. Diffuse malignant-looking microcalcifications
            4. Previous breast rads
            5. Pregnancy (unless post-delivery rads)
            6. Collagen vascular disease
         4. Chemotherapy
            1. Indicated in node=positive disease or tumors >1cm
            2. Triple Cocktail
            3. Cyclophosphamide
            4. Doxorubicin
            5. CARDIOTOXIC
            6. 5-FU
            7. Alternately
            8. doxo + cyclophosphamide
            9. next, taxane
            10. Hormone Therapy
            11. Tamoxifen
            12. For ER=positive tumors in postmenopausal women
            13. Decreases recurrence AND ↓40% incidence of contralat ca
            14. but no additional benefit after 5y of continued Rx
            15. AE: hot flashes
            16. Newer aromatase inhibitors
            17. ¬circulating estrogen by 90%
         5. Reconstruction
            1. Proven benefit to psych, social, emotional, functional domains
            2. Immediate vs delayed
            3. immediate
            4. pro
            5. better psychosocial benefit
            6. streamlined surgical process
            7. possibly more aesthetic
            8. con
            9. longer op time
            10. higher complication rate, esp with TRAM flap
            11. big tumors or invasive ones are difficult
            12. contraindications
            13. advanced disease >stage 3
            14. rads postop
            15. active smoking, obesity, cardiopulm disease
            16. delayed
            17. pro
            18. guaranteed margins before reconstruction
            19. better perfusion
            20. con
            21. more surgery
            22. fewer options
            23. worse aesthetics
            24. types
            25. Implants
         6. Complications
            1. Surgical
            2. infection
            3. seroma/hematoma
            4. 5-12% local recurrence after breast-conserving therapy; 5-10% after modified radical
            5. Axillary dissection
            6. lymphedema
            7. ¬range of motion
            8. gotta take BP from OTHER ARM
            9. Nerve Damage
            10. LTN
            11. Winged scapula
            12. TD
            13. Lat dorsi paralysis
            14. ICB
            15. loss of sensation to upper forearm skin
      5. Prognosis
         1. Proven
            1. Tumor size, node status
            2. Her-2, hormone receptor status
         2. Controversial
            1. S-phase, Ki-67, tumor ploidy, grade
6. 6: NP Polytrauma, Burn, STSG
   1. Presentation
      1. 25 y/o M unrestrained passenger
         1. Injuries
            1. RUE Burn
            2. ~3% SA, full-thickness inv. mm w/ eschar
            3. TBI
            4. EDH/SDH w/ midline shift
            5. Fractures
            6. multiple spinal
            7. multiple ribs
            8. Orbital floor fractures
            9. R elbow
            10. Skull fx
            11. Bilateral pulmonary contusion
      2. Progress
         1. Multiple surgeries
            1. Craniotomy
            2. x-lap
            3. IVC Filter
            4. wound infection → washoiut
            5. Excisional debridement and vac dressings
            6. debridement and STSG
   2. Thermal Injury
      1. Signs
         1. dry, red, blistery → INTUBATE
         2. face & upper torso burns
         3. carbonaceous sputum
      2. Leads to
         1. pharyngeal/laryngeal edema
         2. exposure to combustion products → tracheobronchitis
         3. Complications
            1. Neuro: delirium
            2. Polumonary: resp failure
            3. CV: VTE, supporative thrombophlebitis
            4. GI
            5. ↓splanchnic blood flow→
            6. stomach/duodenal ulcers
            7. acalculous cholecystitis
            8. pancreatitis
            9. hepatic dysfcn
            10. Stress ulcers
            11. preventable by early feeding?
            12. Renal
            13. ATN from poor resuscitation or myoglobinuria
            14. Infection
            15. foley caths, sinusitis/otitis from NG tube
         4. Compartment syndrome
            1. >35mmHg confirms dx but it's usually clinical based on decreased sensation
            2. do not trust decreased pulses or cap refill
            3. careful about myoglobin-induced ARF
            4. aggressive fluids
      3. Pathophys
         1. CO
            1. Shifts O2 dissociation curve left
            2. Exposure
            3. >30% COHgb will → significant CNS dysfcn
            4. exposure: 3 minutes in a fire
            5. >60% → coma and death
            6. Fix
            7. Natural dissociation
            8. t 1/2 on room air is 250 minutes
            9. t1/2 on 100% O2 is 50 minutes
         2. Heat
         3. Inflammatory Edema
            1. Fluid Loss
            2. seen systemically with burns >20% of body
            3. replacement
            4. Parkland Formula
            5. 24h volume = 3 to 4 mL/kg/%burn, half in the first 8h (2-3mL/kg for kids)
            6. LR solution + 5% dextrose to help with colloid problems
            7. Assessing effectiveness
            8. Urine outpout
            9. 0.5mL/kg/h; 1-2 mL for infants
            10. average it out across 2-3h
      4. Treatment
         1. Measuring
            1. Surface Area
            2. RULE of NINES
            3. Palm = 1%
            4. Picture
            5. Rule of Nines
            6. Burn Depth
            7. Burn depth chart
         2. Dressings
            1. Useless
            2. NO STEROIDS for burns >10% BSA
            3. Silver sulfasalazine doesn't penetrate burn and is useless
            4. Silver nitrate doesn't penetrate either
            5. Broad spectrum abx select for the resistant organism
            6. Others
            7. Pigskin for flat clean wounds; endogenous growth factors encourage epithelialization
         3. When to transfer
            1. Any age >20% TBSA; 10% if not 10-50y/o
            2. any partial or full burn over a sensitive/important area
            3. Chemical, electrical. &c other trauma
            4. Anyone requiring long-term support
7. 7: MK Acute Appendix
   1. Appendix
      1. Presentation
         1. 37 y/o M cc abd pain
            1. 3 day history, localizing into the RLQ
            2. PE
            3. fever, RLQ tenderness w/ guarding and rebound
            4. Imaging
            5. CT consistent with appendicitis
         2. Progress
            1. operative
            2. Lap to open appendectomy due to retrocecal position and reactive fibrosis
            3. ruptured, gangrenous appendix found
            4. found a fecalith intra-operatively
            5. postop
            6. uncomplicated. discharged two days later after return of BF and pain gone
      2. Anatomy
         1. Blood Supply from SMA→ileocolic a→appendiceal a via the mesoappendix
         2. avg size, 11cm; ~8mm diameter; 74% retrocecal
         3. ~200 lymphoid follicles; most populous btw 10-20y
      3. Problems
         1. Appendicitis
            1. Acute
            2. Epi
            3. 10,000 deaths/year; 5% of the population, mostly 5-35 y/o
            4. older/younger ↑↑ chance of perforation (up to +20%)
            5. Pathophys
            6. Obstruction: 60% lymphoid hyperplasia; 35% fecalith
            7. Obstruction→lymph blockage→ischemia→necrosis/bacterial overgrowth
            8. can perforate
            9. Clinical
            10. Presentation/Eval
            11. RLQ pain w/ anorexia, nausia, sometimes vomiting
            12. anorexia is the sine qua non
            13. McBurney's Pt: (1/3 from ASIS to umbilicus).
            14. rebound and percussive tenderness from peritonitis
            15. signs
            16. Rosving's sign
            17. RLQ pain on palpating LLQ (or even heel tap)
            18. Psoas Sign
            19. pain w/ R hip extension or flexion
            20. good for retrocecal dx
            21. Obturator Sign
            22. pain w/ passive rotation of flexed R hip
            23. good for the 20% w/ pelvic appy
            24. Imaging
            25. US
            26. noncompressible tubular structure with focal tenderness
            27. >6mm in diameter
            28. ~85% sensitive, ~94% specific
            29. CT
            30. Distension of appendix/nonfilling with contrast, inflammatory ▲ in surrounding fat, abscess, free fluid
            31. False positive: ~5%
            32. Alvarado Score
            33. Signs
            34. 2x: RLQ tenderness
            35. Rebound Tenderness
            36. T >99.1
            37. Symptoms
            38. RLQ migration
            39. Anorexia
            40. N/V
            41. Lab Values
            42. 2x: Leukocytosis
            43. Left Shift
            44. Ten point scale
            45. 1-4: UNLIKELY
            46. 96% sensitive to rule out; no imaging needed
            47. 5-6: POSSIBLE
            48. CT abtomen (for 4, too)
            49. 7-8: PROBABLE
            50. consult surgery
            51. 9-10: DEFINITE
            52. complications
            53. In pregnant pts
            54. appendix will be displaced cephalad & preg leukocytosis may mask
            55. careful-- perforation → 35% fetal loss
            56. Abscess
            57. nonoperative treatment
            58. percutaneous radiologic drainage + abx
            59. do appendix after 6-8 wks, but most pts won't even develop recurrent appendicitis
            60. DDx
            61. gastroenteritis
            62. PID
            63. Pyelonephritis
            64. IBD
            65. endometriosis
            66. ovulatory pain (Mittelschmerz)
            67. ruptured/hemorrhagic ov cyst
            68. Diverticulae (meckel's or otherwise)
            69. Ileitis
            70. cholecystitis
            71. perforated PUD
            72. Tx
            73. IV Fluid
            74. Abx
            75. covering colonic flora
            76. 2g ceph
            77. broad spectrum PCN
            78. fluoroquinolone + metro
            79. DC post 24h if appendix not burst
            80. Continue until afebrile, normocytosis, regained GI fcn
            81. Surgery
            82. Open
            83. mm splitting over McBurney's point
            84. Deliver Colon & appendix
            85. Divide blood supply via transillumination of the mesoappendix
            86. Ligate @ base, invert if questionable tissue integrity.
            87. Lap
            88. Pros/Cons
            89. less post-op pain
            90. more abscesses if the appendix turns out to be perforated.
            91. Complications
            92. post-op wound infection
            93. Pelvic abscess
            94. if perforated
            95. fecal fistula
            96. think Crohn's if so
            97. appendiceal remnants
            98. perforation
            99. sometimes general, sometimes limited to the omentum
            100. bact spread through portal system
            101. pylephlebitis→air in portal system / liver abscess
            102. Quick & Dirty
            103. Dx
            104. Clinical. CBC-diff and UA (WBC/RBC due to adjacent irritation)
            105. Image &c if there are questions
            106. Rx
            107. Lap appy
            108. Preop: 2gcef/PCN or fluoroquin/Metro. D/C if no perf/fever.
            109. if palpable abscess, CT, I&D, consider return for lap appy in 6-8w.
            110. Postop
            111. Worry about wound infection, pelvic abscess if perforation, fecal fistula in Crohn's
            112. If incomplete resection, possibility of recurrence from remnants.
            113. Chronic
8. 8: Gangrene/Amputation
   1. Presentation
      1. 68 y/o M cc dry gangrene of LE phalanx
         1. PMH
            1. HTN
            2. HL
            3. DMII w/ poor control
         2. PSH
            1. Carotid endarterectomy
            2. CABG
         3. PEx
            1. small R LE phalanx complete dry gangrene
            2. R calf ulcer w/ wet gangrene on vac therapy
      2. Course
         1. "Uncomplicated" recovery w/ d/c to SNF
   2. Claudication/PVD
      1. Pathophys
         1. whys and wherefores
            1. why
            2. atherosclerosis, often assoc w/ coronary and carotid artery disease
            3. could also be Buerger's, cystic adventitial disease, extraluminal compression
            4. occlusion decreases distal pressure via Poiseuille's law
            5. poiseuille's law
            6. Radius has a quartic exponential effect on pressure
            7. clinically not important until >50% obstruction
            8. decreased perfusion ↓O2 delivery → anaerobic metabolism without clearing away of waste products → lactic acidosis → pain (also pain from nerve ischemia)
            9. Risk factors
            10. SMOKING, HTN, HL
            11. 40-60 y/o
            12. Diabetes
            13. independent and prognostic RF
            14. half of PVD is DM
            15. Neuropathy can cloud Dx of rest pain
            16. Infection can ↑p(tissue loss)
            17. Definition
            18. Arterial stenosis → LE ischemia
            19. Acute: pain, pallor, pulselessness, neuroPathy
            20. Chronic: LE pain on exercise that quits with rest
            21. location
            22. superficial femoral > iliac , tibial arteries
            23. if just below inguinal ligament, it's femoropopliteal occlusive disease
            24. within adductor canal "hunter's"
         2. Locations
            1. Femoropopliteal occlusive disease
            2. often mild/subclinical due to collaterals of the profunda femoris artery
            3. Aortoiliac occlusion
            4. Leriche Syndrome
            5. impotence
            6. absence of femoral pulses
            7. LE claudication
            8. muscle wasting on the buttocks
            9. Superficial Femoral Artery Occlusion
            10. calf but not thigh pain (thigh gets collateral from profunda femoris)
      2. Clinical
         1. Dx
            1. Symptoms
            2. Claudication
            3. Claudication is extremely reproducible; same load produces same sx
            4. from latin claudatio (to limp)
            5. Outcomes
            6. framingham: 5% get amputated in 5y
            7. 50% improve with just smoking cessation and a walking program
            8. Rest Pain
            9. pain in toes and metatarsal heads while laying down at night
            10. DDx: charlie horses
            11. pain is due to nerve ischemia
            12. Outcomes
            13. 50% will need amputation if untreated
            14. Ulceration
            15. minor traumas from poor foot care/poor shoe fit
            16. painful unless DM peripheral neuropathy
            17. Charcot foot deformity & dryness
            18. differentiate from venous ulcers which appear at gaiter zone and have venous pooling/red blood cell extravasation → orange-brown skin discoloration & lipodermasclerosis
            19. Gangrene
            20. Dry
            21. mummification
            22. Wet
            23. gangrene + ongoing infectin
            24. Physical Exam
            25. Look for other Vascular disease
            26. Auscultate Bruits
            27. Precordial gallops, murmurs
            28. pulsatile masses/bruits in abdomen
            29. LE exam
            30. distal loss of hair
            31. mm atrophy
            32. Severe PVD: Buerger's sign
            33. toes/soles go pale when raised even by about 15-30 degrees
            34. Palpation of pulses
            35. presencew and character at femoral artery, popliteal, dorsalis pedis, and posterior tibial
            36. ABI
            37. Ratio of doppler signals of ankle SBP and brachial SBP
            38. writ large, <.8 is claudication; <0.4 is rest pain/tissue loss
            39. I to III: ABI decreases from 0.8 by halves until 0.2
            40. IV to VI: ulceration, gangrene, major gangrene
            41. <0.5 ABI is considered severe
            42. Call Rest Pain "Metatarsalgia"
            43. Doppler
            44. Normal Triphasic Form
            45. Forward flow of systole
            46. Reversal via vascular bed resistance/snap
            47. Resumption of forward flow during diastole
            48. Biphasic & Monophasic with progressive stenosis
            49. Duplex/Color scanning
            50. meh.
            51. Diagnostic MRA (mag resonance arteriography) or contrast arteriography or CT angiography
            52. Indicated for: lifestyle-limiting claudication, rest pain, or gangrene
            53. Complications
            54. contrast reactions, nephropathy, puncture (fem artery) hemorrhage
            55. pseudoanyeurism, thrombosis
            56. DDx
            57. Musculoskeletal Pain
            58. present at rest
            59. Neurogenic Pain
            60. usually not located in big mm groups and is unrelated to exercise
            61. do a sensory exam and examine straight-leg raised lifts
            62. Spinal Stenosis Pain
            63. relieved by sitting down or bending forward
            64. radiates down limb
            65. takes about 5min to go away
            66. Treadmill Tests
            67. Claudicators WILL drop ABI when symptoms occur while others won't.
         2. Tx
            1. Lifestyle Therapy
            2. 50% get better by quitting smoking and regimented exercise/walking
            3. Cilostazol (PDE-III inhibitor) → 30-50% improvement
            4. everyone should get ß-blocker, statin, ACE-inhibitors to ¬atherosclerosis
            5. Interventions
            6. RISKY. Complications abound
            7. Indications
            8. Gangrene/Tissue Loss
            9. Rest pain w/ multi-level LEPVOD
            10. Endovascular Treatment
            11. percutaneous transluminal angioplasty
            12. 1y Restenosis rate between 20% and 50%
            13. renal vessels 11-26% bad at 1y; iliac 7-32%.
            14. infrapop/tibial: 50-60% bad at 1y, but good for poor surg candidates & those with important ulcers
            15. can be cut down some with stenting
            16. Surgery
            17. Bypass
            18. Outcomes
            19. Proximal (aortoiliac)
            20. 90% patency @ 5y
            21. Distal (fem/tib)
            22. 65% patent @ 5y
            23. Profundoplasty not useful in gangrene or tissue loss, or even for ulcers. Gotta do arterial bypass.
            24. Saphenous vein and prosthetics don't do so well for pop artery bypass
            25. high risk patients can get extra-anatomic bypass: axillary-femoral and fem-fem, tunneled in subQ tissue
            26. lower than for aortofemoral grafts
            27. complications
            28. immediate: bleeding, thrombosis, hematoma
            29. pseudoanyeurism
            30. aortoduodenal fistula
            31. aortic graft can erode into duodenumIII & spill gut stuff into aorta.
            32. Endarterectomy
            33. standard treatment for caroted bifurcation stenosis
            34. 'cause it's really just that one place, compared to LEPVOD which can be extensive
            35. Amputation
            36. severe rest pain or gangrene + not revascularization candidates
            37. even if you can save the leg with bypass, you may need to take the foot
            38. The distal the better
            39. toe:
            40. 25-50% of toe amputations progress to bigger amputations
            41. 25% wound failure